Frank Colyer

(1)UPPER TEETH.—For the removal of teeth in the maxilla the patient should be placed at such a level that the arm of the operator can, if necessary, embrace the head of the patient with comfort. The operator should stand at the right side of the patient, and slightly in front, the first finger and thumb being placed on either side of the alveolus (fig. 16). In the event of the patient becoming restless, the arm should be shifted so as to encircle the head and hold it firmly.

(a) Upper Incisors.—The roots of both the upper central and lateral incisors are usually cone shaped, the anterior surface being the arc of a greater circle than that of the posterior. Forceps for the removal of these teeth ought therefore to have the blades made in a corresponding manner (see fig. 17). The lateral incisor is smaller than the central, and has at times a root somewhat flattened. In removing upper incisors the posterior blade is applied first, care being taken to

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Fig. 16.

see that the edge of the instrument passes between the gum and the tooth. To dislodge these teeth a firm inward movement should be made in a direction towards the palate, this movement being followed by one in an outward direction. If this fails to dislodge the tooth from its attachments, a firm rotary motion, first to the right and then to the left, may be tried (the amount of rotation necessary being only about an eighth of the circle represented by the circumference of the root). Rotation is generally recommended in the first instance for the extraction of these teeth, but the inward movement is, I think, best, the teeth yielding more readily and with less laceration of the soft tissues.

The extraction of the roots of these teeth does not as a rule present much difficulty. When moderately sound the instrument shown in fig. 17 may be used, but in those instances where the root is much decayed, and lies well below the gum margin, a rather finer pair will be found more serviceable. The manner of removal is similar to that used when the crown is standing.

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Fig. 17.

(b) Upper Canines.—These teeth, like the incisors, are single rooted, but the difference between the curve of the anterior and posterior surfaces is greater. The roots too are much longer, more firmly implanted, and hence require more force in their removal. Forceps similar in pattern to those used for incisors may be used, the severance of the tooth from its attachments being brought about by force applied in an inward, followed by an outward, direction. The root being more or less three sided, rotation cannot well be adopted.

The roots of canine teeth are to be removed in the same manner as that adopted for the whole tooth.

(c) Upper Bicuspids.—The first bicuspid has usually one root flattened and more or less longitudinally grooved on its mesial and distal surfaces. If this grooving is much marked, it results in a greater or less division of the root into two slender terminations. Whether such bifurcation exists or not can seldom be determined before operation and would not modify the method adopted, but the tendency to this variation should be borne in mind and the lateral movement be very gently applied. The internal and external surfaces of the root are for all practical purposes of equal curvature.

The second bicuspid has usually only one root, which is not so flattened in the antero-posterior diameter as the first. There is also not the same tendency to grooving or bifurcation of the root as there is in the first bicuspid.

The blades of forceps for the bicuspids should be equal segments of the same circle; they should also be bent at an angle with the handles, so that the latter may clear the lower lip. The forceps shown in fig. 18 is a useful pattern. In removing an upper bicuspid, the inner blade of the forceps should be applied first. For severing the tooth from its attachments a slight inward movement should first be made, followed by an outward one. If this fails to cause the socket to yield, the inward movement may again be made, followed by an outward one, and repeated if necessary. The removal of the tooth from its socket is to be carried out by force applied in a downward and outward direction. It is well to remember that the force applied to the inward should always be slight compared to that used in the outward direction. The removal of bicuspid roots is carried out in a manner similar to that for the whole tooth.

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Fig. 18.

(d) Upper Molars.—The first upper molar has three roots, one internal towards the palate (palatine), and two external (buccal); of the three the palatine is the largest, sub-cylindrical in form, and often curved. The two buccal roots are placed in an anterior and posterior position, the latter being in a plane internal to the anterior one; both these roots are somewhat flattened, and of the two the anterior is the larger. The roots of the second molar are similar in shape to the first, but are usually smaller. The third molar, when normal, has three roots, but very frequently these are all fused together so as to form an abrupt tapering cone, the point of which is often curved.

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Fig. 19.

Owing to the disposition of the roots different forceps will be required for the removal of upper molars on the right and left side. Of the blades, the outer or buccal should possess two grooves, the anterior being the broader and placed in a more external plane. This blade should also have a slight projection between the grooved surfaces to adapt itself to the space between the buccal roots. The inner or palatal blade should possess only one groove. A well-made pair of upper molar forceps should fit the neck of a first upper permanent molar accurately. The blades should be bent at an angle with the handles, so that when in use the latter may clear the lower lip (fig. 19). The palatine blade should be applied first, and in bringing the outer blade into place the point should be kept over the groove on the buccal side of the tooth, as this groove is a guide to the space between the outer roots. To sever these teeth from their attachments force must be applied first slightly inwards and then outwards, the movements being repeated if necessary, the removal of the tooth from the socket being carried out by exerting force in a downward and outward direction. Too much outward movement leads to undue bending or fracture of the external alveolar plate.

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Fig. 20.

In removing the third molars it is advisable not to have the patient’s mouth opened to the fullest extent, as the tension of the tissues of the cheek will thereby be lessened and a clearer view of the outer side of the tooth thus gained. The application of the forceps is of the utmost importance, as one is liable, unless care is taken, to include some of the soft tissue between the blades and the tooth and so cause a painful laceration. Force applied inwards and then outwards is generally sufficient to loosen these teeth, their removal being carried out by a downward and outward movement.

Forceps similar to those shown in fig. 19 may be used for the removal of the third molars, but most operators use patterns the blades of which are similar segments of the same circle (fig. 20).

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a b c d
Fig. 21.

(a) Normal upper first permanent molar. (b) Oblique rooted upper first permanent molar. (c) Normal upper second permanent molar. (d) Oblique rooted second permanent molar.

There is an abnormality of the upper molars which may with advantage be mentioned here. In this deformity the posterior buccal root is situated in a plane much internal to the anterior—in other words, it is an exaggeration of the normal arrangement. Such teeth have been termed by Mr. Booth Pearsall “oblique rooted” (fig. 21). The abnormality is met with most frequently in the third molar, sometimes in the second, rarely in the first. The difficulty encountered in extracting these teeth is that the outer blade of the forceps tends to slip round. Oblique-rooted teeth can at times be diagnosed by noting an undue prominence of the alveolus over the anterior buccal root, and are best removed with forceps similar to that shown in fig. 20.

In cases where a portion of the crown remains and the decay extends well below the gum on either the palatal or buccal side, ordinary molar forceps should be discarded and root forceps employed; useful patterns are shown in figs. 18, 22 and 23. The removal of teeth in this condition is carried out as follows, and for the sake of description it will be supposed that the decay extends deeply on the palatine side. One blade of the forceps should be first applied to the buccal side of the tooth and to the root which is considered the stronger; the inner blade should then be applied to the palatine root care being taken to insinuate it between the alveolus and the root. The forceps should then be pushed well upwards until a firm hold of the root is obtained. A firm inward movement should then be made, as this will allow the inner blade to pass still higher up the palatine fang and insure steadiness should the blades tend to ride upon the surface of the root. An outward movement should next be made, but to nothing like so great a degree as that used in extracting molars with the whole of the crown standing. This inward and outward movement is to be repeated until the tooth is freed, the force being principally applied in the inward direction.

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Fig. 22.

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Fig. 23.

For the removal of roots towards the back of the mouth.

When the more extensive decay has taken place on the buccal side the order of proceeding is slightly different. The first blade to be applied should be the palatine, the outer blade being closed upon whichever of the buccal roots is considered the stronger.

The extractive force should be applied first outwards and then inwards, these movements being repeated if necessary, the principal force being outwards, as the object in view is to prevent the instrument slipping off the more decayed side.

When a molar is so decayed that but little of the crown remains, but all the roots are still united, root forceps are indicated. In such a case the inner blade is to be applied to the palatine root first, the outer blade being closed upon the stronger of the buccal fangs. Inward followed by outward movement should be employed, the point to bear in mind being to use force towards the side of the tooth which is considered the weaker. In the majority of such cases the three roots come away together, but even if this does not happen, one or perhaps two will be removed, the remainder being subsequently removed with but little difficulty.

In cases where the resistance presented by the roots is very great and an unsuccessful attempt has been made with ordinary root forceps, an instrument with a buccal blade similar to that shown in fig. 24 may be used. The inner blade is first applied, the outer one being brought so as to come, if possible, into the space between the buccal roots. A firm hold of the roots having been gained, an attempt to extract should be made by force applied in an inward and outward direction; this failing, sufficient pressure should be put upon the handles to split the roots asunder. The sharp outer blade of the forceps will then pass between the divided buccal roots on to the palatine root, which can thus readily be brought away. A pair of ordinary upper root forceps should be employed for removing the buccal roots.

If all the three roots of a molar are separate, their extraction presents but little difficulty, a slight rotary movement generally sufficing.

In all cases where there is a fear of a molar fracturing, root in preference to ordinary forceps should be used.

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Fig. 24.

(2) LOWER TEETH.—For the removal of lower teeth the patient should be placed on a low level, the head being kept a little forward and the chin depressed. The position of the operator will naturally differ with the tooth to be removed

Fig. 25.

and also with the instrument to be used. With teeth on the right side, when hawk’s-bill pattern forceps or elevators are used, the operator should stand behind and to the right of the patient, the left arm being brought round the patient’s head. The thumb of the left hand should be placed on the inner side and the first finger on the outer side of the alveolus of the tooth to be removed, and the three remaining fingers under and supporting the chin. In placing the fingers in the mouth, care should be taken to keep the wrist well down so as not to impede the entrance of light (fig. 25).

When removing the anterior teeth or those on the left side of the mouth, the operator should stand on the right side and slightly in front of the patient. The left hand should be placed as follows: the second finger on the lingual side, and the first on the labial side of the alveolus of the tooth to be extracted, the thumb being placed under the chin (fig. 26).

When employing forceps of the straight pattern shown in fig. 30, the operator should stand as shown in fig. 26, but it will be found difficult to place the fingers of the left hand on either side of the alveolus, indeed they can only well be used for retracting the cheek and supporting the jaw.

In removing teeth from the lower jaw, the operator should be careful, in raising the tooth from the socket, to guard against a sudden separation of the tooth from its attachments which might result in damage to the upper teeth.

(a) Lower Incisors.—These teeth each have a single root which is much flattened laterally. For their removal, forceps similar to those shown in fig. 27 should be used, the blades being equal segments of the same circle. The lingual blade should be applied first, the loosening movement being made by taking the tooth slightly inwards and then outwards, the final extractive force being upwards and outwards.

The removal of lower incisor roots is carried out in a similar manner.

(b) Lower Canines.—The lower canines have normally one root, which is flattened laterally. In comparison with the incisors, the root is stronger and longer. The removal of a lower canine is carried out in a manner similar to that employed for a lower incisor, but as the tooth presents more resistance, a greater amount of force is usually required.

(c) Lower Bicuspids.—The lower bicuspids have normally one root which is conical in shape. In the first bicuspid the conical shape of the root is not so marked as in the second, the outer aspect being the arc of rather a larger circle than the posterior. Forceps similar to those shown in fig. 27 may be used, the blades for all practical purposes being equal in size and shape. The lingual blade of the instrument should be applied first, the severing of the tooth from its attachments being carried out by a slight rotary movement around the long axis of the tooth first in one direction and then in the other; should this not succeed, a slight inward followed by an outward movement may be tried, the tooth being raised from its socket by force applied in an upward and slightly outward direction.

The roots of lower bicuspids are to be removed in a manner similar to that required for the extraction of a whole tooth. When the root lies much below the level of the gum the extraction is often troublesome owing to the difficulty in gaining a hold with the blades of the forceps; in such cases, if an attempt with forceps has failed, the straight elevator may be employed.

(d) Lower Molars.—Lower molars have two roots, placed anteriorly and posteriorly. The roots are much flattened and have a tendency to curve backwards, this being well marked in the second and especially so in the third molar; a fusion of the two roots is at times met with in the second and frequently in the third molar. A section of a lower molar at the neck shows both the buccal and lingual aspects to be composed of two segments of a circle touching each other at one extremity; the anterior segment being slightly the larger (fig. 28). Each blade of the forceps used for these teeth should possess two grooves,

separated by a projection which fits into the division between the anterior and posterior roots; for all practical purposes the blades may be made of the same size, so that one instrument will suffice for both sides of the jaw. The instrument best adapted for the removal of these teeth is shown in fig. 29, though some operators prefer the shape illustrated in fig. 30. The advantages of the former over the latter may be briefly summed up as follows:

(1) A clear view of the tooth and its surroundings can be obtained during the whole period of removal.

(2) Force can be applied with greater advantage.

(3) The alveolus can be easily embraced by the fingers, or by the finger and thumb of the left hand.

(4) In removing the tooth from the socket a slight backward movement can be employed.

One disadvantage of shape fig. 29 is that it is difficult to employ much inward movement, and therefore, for teeth lying inwards, namely, with the crown directed towards the tongue, hawk’s-bill-shaped forceps cannot easily be used.

Another disadvantage is that the extent of inward movement is limited by the proximity of the upper teeth, and in case of trismus it is often better to use straight forceps (fig. 30). In cases where there are also much swelling and rigidity of the cheek the straight forceps cause less inconvenience to the patient.

In removing lower molars with forceps, the inner blade should be first applied and then the outer, care being taken to get the points of the blades between the interspace of the roots. For severing these teeth from their attachments, a slight inward movement should be first made, followed by one well outwards, this inward and outward movement being repeated if necessary. The removal of the tooth from its socket is carried out by force used in an upward and outward direction. The upward force exerted upon lower teeth should always be well under control, as not infrequently the resistance is very suddenly overcome, and, if such precaution is not taken, there is danger of striking the upper teeth with considerable force.

As previously pointed out, the roots of these teeth are at times curved a little backwards so that it is often needful in removing the teeth from their sockets to twist the forceps in a curved direction backwards.

In the removal of the second molar too much outward movement is not permissible, as the outer alveolus is often very dense.

The third molar is best removed with a straight elevator. A glance at the illustration of this tooth (fig. 31) will show that the roots have a well-marked curve backwards, in addition to which the bone forming the socket of this tooth is stronger than is the case with the anterior molars. The removal of the third molar has therefore to be accomplished by using force in a direction upwards and backwards, in other words, in a curve similar to the arc of the circle formed by the roots. This movement cannot well be carried out with forceps, but is easily accomplished with the elevator as follows (it being assumed that the second molar is in place):—Hold the elevator as shown in fig. 13, and insert the blade between the anterior surface of the root and the alveolus, keeping the flattened side of the instrument as far as possible parallel with the root surface. Then force the blade downwards in a direction towards the apex of the root; following this, rotate the handle away from the direction in which the tooth is to be moved. This has the effect of both raising the tooth in its socket and displacing it backward. The edge of the elevator which is to be brought into contact with the surface of the root should be sharp so as to cut somewhat into the cementum. Should this prove insufficient the handle should again be raised and the flattened surface of the instrument brought parallel with the anterior surface of the root and the extractive movement repeated until the tooth is completely raised from its socket.

In using the elevator, especial care must be taken to protect the tongue with the fingers or thumb of the left hand, so as to prevent a slip, which might result in puncture of the tongue, or of the operator’s finger.

With the third lower molar there is a tendency for the gum to adhere tenaciously to the posterior part of the neck of the tooth. When this happens it is better to simply raise the tooth from its socket with the elevator or forceps, as the case may be, and then cut the gum away with a curved pair of scissors. By this method a severe laceration of the gum may at times be avoided.

When the third molar is isolated owing to the absence of the second molar, the elevator may still be employed for its removal, on the right side the first finger, and on the left side the thumb of the left hand being used as the fulcrum. In such cases, however, many operators prefer to use ordinary lower molar forceps.

The removal of lower molars when a portion of the crown is standing, but the decay has progressed below the gum on either the buccal or the lingual aspect, is carried out with root forceps of shape shown in fig. 27. A condition similar to this in upper molars and the method indicated for their removal were referred to on page 27. The principles enumerated there apply equally to the removal of lower molars, so that it will not be necessary to repeat them. The main points to bear in mind are, to apply the blades of the forceps to the stronger root, and to use the principal force in the direction of the weaker wall.

Where the roots of molars are still united, root forceps should be used, the blade being first applied to the lingual surface of the stronger root. A firm hold having been obtained, the root may be removed by employing force in a manner similar to that employed with ordinary molar forceps. In this way both roots will usually come away together. If, however, only one root is extracted, the remaining one can easily be removed, either with the same forceps or a curved elevator. The curved elevator (fig. 49) may be employed either by placing it against the root, and so forcing it into the socket of the root already removed, or by placing the blade in the socket of the extracted root, forcing the point of the instrument through the intervening bone and then elevating the remaining root.

With roots of lower molars which present great resistance, forceps with cutting blades may be used (fig. 32). The blades are inserted on the lingual and buccal aspects of the arch in such a manner that the points pass into the space between the roots. The handles are then closed and an attempt is made to remove the roots in the ordinary way, but should this prove unsuccessful the handles must be forcibly closed, so as to divide the roots which can then, as a rule, be removed with ordinary root forceps.

The value of splitting roots in a case similar to that shown in fig. 33 is apparent, for, as will be seen, it allows each root to be removed in the line of its inclination.

In those cases where the roots are separated their removal is carried out with root forceps, an inward and outward movement being usually sufficient.

The roots of third molars are best removed with a straight elevator. The modus operandi is similar to that used in extracting the whole tooth.

At times the lower molar teeth are much tilted in such a way that the crown surface stands towards the tongue.—Under such conditions their removal is best carried out with instruments of the pattern shown in fig. 30, since the handles of forceps of the hawk’s-bill pattern when applied would come in contact with the upper teeth, and thus impede the inward movement which is so necessary for the removal of teeth in this position.

The Temporary Teeth.—For the removal of upper incisors and canines, a small pair of straight forceps of the pattern shown in fig. 34 should be used. The first upper temporary molars are best removed with a pair of forceps like fig. 35.

The lower incisors and canines require a small pair of hawk’s-bill forceps similar to the shape shown in fig. 27. For the lower temporary molars, a small pair of forceps similar to that illustrated in fig. 29 should be used.

In removing the temporary teeth, care must be taken not to drive the forceps up too high, for fear of injuring the permanent teeth; this is more especially to be noted in connection with the temporary molars, as the roots of these teeth practically embrace the crowns of the bicuspids. Generally speaking, if a temporary molar fractures in the attempt to remove it, the portion of tooth remaining in the jaw should be left alone unless it can be brought away quite easily.

Roots in the condition shown in fig. 36 are best removed with an elevator as follows: the thumb of the right hand being placed on an adjacent tooth so as to gain a hold, the point of the elevator should be placed below the end of the root and force applied. In a few cases it may be necessary to cut the gum with a lancet before using the elevator.

Small pieces of the temporary teeth which persist and become wedged in between the permanent teeth can be best removed with an excavator or a similar suitable instrument.