Instrumentation for Basic Oral Surgery

Elevators :

Work principles of elevetors : 1. Lever principle [Link] principle

[Link] and axle principle
- Cryer elevators :
- Its head is triangular in shape
- Its function is ( wheel and axle ) rotation
to elevate the roots .
- when to use it ? Cryer elevators
when we have an empty socket ( No root inside)
and the other root of the tooth is still in its socket ,
so we use it to remove this root.

- NOTE :
NEVER EVER use cryer elevator to extract upper 3rd molars ... WHY ?
→ in order not to cause tuberosity fracture .

 [Link] :
If you are given 2 cryers ; How to determine which one is left cryer and which one is
the right ?
→ Hold the cryer& look at the tip ( at the triangle ) , make the convexity toward you " so you can
seethe smooth side = the convex side of the tip " , then see for which side the tip is directed ( to your
right or to the left ) ..

-if the tip directed to the left so it's ( left cryer ) .

-if the tip is directed to the right so it's ( right cryer ).

 Example :
look at the adjacent photo , it's a left cryer elevator .
- the convexity of the tip toward us , the tip is directed to
the left side ( to ur left , not the patient's left ) ... so (Left
cryer elevator ) .
How to use cryer elevators ?
- we put the tip of it in the empty socket ( the concavity of the tip should face the root that
we want to remove ).
- wheel and axle principle.

Warwick James Elevators :

- 3 Types : straight , right , left

- Mainly used to extract and luxate upper 3rd molars .
- Wheel and axle principle as cryers .
- How to use it ?
we adapt the concave surface of the tip on the mesiobuccal surface of the tooth
( upper 3rd molar ) , then we push buccally and backward.

 The left pic : from left to right :

left warwick james , straight warwick , right warwick

NOW , how to determine which is right & which is left .. the same way as cryer
elevators :)
- Examples :

Left warwick james elevator. Right warwick james elevator :

coz the concavity of the tip is curved toward
your left , so when you rotate it the convexity
will be curved toward the right , so it’s right .

 Straight elevators :
- Work principles : ( Lever & Wedge principles ).
- different types with different shapes of blades.
- The coupland chisel is one type of the straight elevators

The proper way to hold straight elevator :

(most imp.)
index on the shank
( Hemostat = Mosquito = artery forceps Needle holder
has parallel serration has a cross serration ; to aid instabilization of
the needle . ( double/cross serrated )
Its head = long and thin Its head is shorter and straight
mostly curved - some of them are straight

(Hemostat)

Needle
Holder

Artery foreceps Needle Holder

(Hemostat)

 Notes :
 Both have locking mechanism
 Use your thumb and ring finger in holding the instrument , stabilize the shank with your index finger
 we use hemostat to hold ( artery or vein )
( to clamp a bleeding vessel until it closes = to control hemorrhage ).
 Other uses for Hemostats :
Removal of debris, pieces , root tips.
( we catch the needle within the first quarter or third ) .

 The proper way to hold the ( Needle Holder ) & the ( Needle)?
 - NOTE :
Regarding the extraction foreceps , we have 2 styles : ( look at the pic.s below ) :
-English style = British = when the foreceps has an angle of 90˚ .
- American style = mostly curved " not 90 ˚ " .

 The proper way to hold:

upper foreceps : lower foreceps :

American style English style

Foreceps :
Upper foreceps :

- Upper anterior foreceps :

lookat the beaks , there is space between them , they
don't touch each others , that's how we differentiate it
from upper remaining roots foreceps .
- The handle and the beaks are at the same level
,meaning that there is no curvature in beaks .

curved / NO space =posterior R.R

straight / NO space = anterior R.R

- Upper remaining root foreceps :

- For anterior R.R : it is straight ( no angle)
- For posteriorR.R : not straight " has an angle "
 - Upper posterior remaining roots foreceps :
narrow beaks that close intimately.

- Upper premolar foreceps :

Note : the beaks , NO notches at all .
it's Universal = used for both sides right & left . ( because there is no furcation ) .

- Upper molars foreceps :

lookat the beaks , there is one

notch on one side ( on the side
that should be adapted on the
tooth buccally between the MB
and DB roots ).
 Again , Always look at the beaks and notice the notches if they are present :
- upper molar foreceps = 1 notch buccally
- lower molar foreceps = 2 notches ( buccally and lingually) .

→ for the premolars , either upper or lower → ( NO notches at all ).

 So whenever you see 2 notches , this foreceps is a ( lower molar foreceps ).

Lower ( 2 notches ) Upper ( 1 notch )

 Upper third molar foreceps :

has NO notches on its beaks , why ?

 lower anterior foreceps :

there is space between its beaks ,
beaks don't touch each others.
 Lower remaining roots foreceps :
( Lower root extraction forceps )
NO space between its narrow beaks
, beaks do touch each others.

 ( Lower premolar forceps ) :

NO notches on its beaks

 ( Lower molar forceps ) :

( 2 notches on its beaks , one notch lingually , one buccally )

English style
  ( Lower molar forceps ) :
American Style

(coz the angle is not 90˚ )

and for sure there is 2 notches .
Lower ( 2 notches)

 ( Cowhorn extraction forceps ) :

- engages very deep within the furcation .
- we use it If there was no good amount of
remaining tooth structure

 Bone Rongeurs( Bone crushers = Bone Cutters ) :

" bone cutting foreceps " with spring loaded handles .
- to remove ( crush ) small bony spicules or inter-radicular bone that might
cause injury to the patient , procedure called alveoloplasty.
 Bone file : ( rasp )
-has a broad and serrated end with a parallel bevels.
- it smoothen down the bone in the pull stroke fashion.

- NOTE : ONLY pull strokes ,

not push nor push & pull . ( [Link] )

Scalpel

No. #3 reusable handle

(most commonly used).
disposable plastic handle

Scalpel = blade + handle

#10 Blade : for common extra-oral incisions , ( in the skin anywhere extraorally ).
#11 Blade :lance ( ‫ ) الحربة‬like shape for incision & drainage of abscesses .
#12 Blade : sickle like ( curved ) , to access the distal sites & to do suture removal .
#15 Blade : the most commonly used one intra-orally , for : ( flaps , excisions, biopsies..).
 How to hold the scalpel ?
By Pen Grasp .

- Why ? good tactile sensation

and good control.

 Periosteal elevators :

1- (No. 9 Molt periosteal elevator) : has :

-small , sharp,pointed end : to elevate the

Inter-dental papilla before reflecting the whole flap .

- broad rounded end : tocontinue the

elevation of the periosteum from bone .

 Movement : - Twisting (to elevate the papilla) .

- Push strokes (main strock ) .
- Pull strokes (might cause tearing to the soft tissue).

2- Howarth Periosteal Elevator : One aspect is round ( like periosteal elevator )[1]
the other side is a chisel or other modification [2].
1 2

2 1
  Austin Retractor :  Minnesota Retractor :
(Right angle retractor ), to has a double step , the first end reflect
retract cheek , tongue or flaps. and retract the flap , and the other step
is for retraction of the cheek.

 Langenbeck Retractor ( right angle retractor) :

has a long arm with a finger area to aid in stabilization ,Used mainly in major sur-
geries in the hospitals .

 Seldin Retractor ( right angle retractor) :

looks like theperiosteal elevator , but it is blunt so itaids in reflection of small flaps .

 Bowdler Henry rake retractor : has a tooth end

  Weider retractor (Heart shaped serrated)
(Right angle retractor , retract the tongue
posteriorly).

 Malleable retractor (bendable) :

(Universal retractor) can be bend
to fit any area.

 Towel clip :
mainly to fix the towels , maybe used to re-
tract the tongue , hold the tip of the tongue ...

→ Also we can fix the tip of the tongue in

surgeries by : ( Zero-silk suture ).

 Grasping soft tissues :

- Adson forceps (or pickup) :

during suturing or tissue stabilization.
- Stillies foreceps (Pickup) :
(longer than Adson) .

- Allis tissue forceps :

- To grasp thick tissue(excisionof tissue)(Biopsy).

- Never be used on tissue that is to be left in
the mouth (tissue destruction - crushing injury)
coz it has multi-tooth interdigitation in its tip.

- Mallet and Chisel :

- hammering of the bone and teeth .
→ we don't use it in wisdoms .

- Curette :
Removal of soft tissue(peri-apical
granuloma , granulation tissue after extraction ).

- Mitchell trimmer :One end looks like curette[1]

the other end looks like a sickle[2]

1 2
 Periotomes :
- Used to sever the periodontal ligaments to facilitate tooth
removal.
- Useful before immediate implantation to preserve bone.

 Root tip pick (Apexo) :

- has a very thin head ; to remove the small tips of roots
down in the socket

 Crane pick elevators :

- To remove deep roots
 Suture Needles :

- Mostly we use curved needles .

sometimes we use straight needles especially extra-orally.

- Mostly we use the cutting type , which has a triangular cross section.
sometimes we use the non-cutting type which has a round cross section ,
but it dulls easily .

Always try to use a (Reverse cutting type ) , the cross section of it is reversed to the
back , it's better than the ( forward "usual " cutting type ) , why ?

Because in the forward or usual type of cutting , if we hold the flap with the needle, it
will cut all the way until the end of the flap because it is a forward cutting , But if it is
reversed it will hold the tissue , it stops with the same direction of our movement , it
holds the tissue rather than cutting it all the way to the end .

 Reverse cutting needle

cross section

 Conventional cutting
needle

 Reverse cutting  Conventional cutting

needle needle
 Now regarding oral suture materials , I asked [Link] about them , he explained
briefly and said you should read about them , so I put here some general infor-
mation from the internet … it's up to you! 

Suture Materials


Absorbable Non-Absorbable

Synthetic Natural Synthetic Natural

Multi-filament Monofilament Multi-filament

Monofilament Monofilament
or or
Multi-filament Multi-filament

- Size : Commonly we use 3-0 or 4-0 intra-orally .

- 4-0 size is smaller than 3-0 size
- Skin sutures are removed in 5 days , while intraoral sutures in 7 days .

- Natural sutures = may cause tissue reaction or inflammatory reaction .

from animals or plant tissue .
ex. Silk , Catgut .

- Synthetic sutures = less reaction , less inflammatory reaction .

- absorbable synthetic , ex. : polyglycolic acid, polylactic acid, Monocryl and
polydioxanone .
- non-absorbables , ex. " nylon, polyester , PVDF and polypropylene.

- Absorbable = They are broken down by various processes including hydrolysis

( in synthetic materials )and proteolytic enzymatic degradation (in natural sutures ).
( gradually digested by enzymes in the tissue).

- Multi-filament sutures = several filaments twisted or braided (‫ )مجدولة‬together.

 Type of suture

Suture size

Length of suture Structure = multi

Needle
type & length

Needle profile  Silk Suture : Natural suture composed of a protein

called fibroin , it's Non-Absorbable suture .

shape of needle = ( 1/2 circle needle )

- Thread ( suture) color = violet

- structure = Braided = multi

Vicryl (polyglactin 910)

suture : is an absorbable,
synthetic suture.

 By the way , there are several

shapes of needles :
- Straight
- 1/4 circle
- 3/8 circle
- 1/2 circle.
- 5/8 circle
- compound curve
- half curved (1/2 curved )
- J shape

^^ ‫صب‬
ّ ‫ ما حدا يع‬.. ‫ أب تو يو‬sutures ‫كمان مرة ؛ معلومات ال‬ 
  Mouth Prop (Gag)
Either : plastic box or metallic.
- sometimes used in pediatrics to hold the mouth opened , especially in the GA.
- We put these mouth props (gag) in the mouth in the side that we don't work on.

 Side-action mouth prop = Molt mouth gag :

- is used to open the patient's mouth " like the plastic ones "
- used to prop mouth open during extraction procedures and
reduce TMJ trauma for sedated patients.

 Kidney dish & Galley pot :

to carry anything like bony grafts , tissues , teeth or any material we want.
 The most imp. thing in this file :p
is to know How to determine clinically which is right & which is left ( foreceps or
elevators ) .

→ Regarding upper posterior ( molar ) foreceps :

By looking at the beaks of the foreceps ; you will see that there is a notch on one
side and there is nothing on the other , the notch is made to adapt between the
two buccal roots of the upper molars ( mesiobuccal root & distobuccal root ) , the
part of the beak without notch will be adapted on the palatal side of the tooth .

You can see the video , it was explained ..

 Yalla zay el3anjad : test yourself , wel answers mshaglabeen..

side view of the same collection
 Not the END ..

Making one person smile can change the world ..

Maybe not the whole world but at least their own world ! ')

Your colleague : Mais Alsoud