The Extraction of Individual Teeth.
(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
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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).
[Illustration: 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.
[Illustration: FIG. 22.]
[Illustration: 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.
[Illustration: 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
[Illustration: 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).
[Illustration: FIG. 26.]
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.
[Illustration: FIG. 27.]
(_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.
[Illustration: FIG. 28.]
(_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,
[Illustration: FIG. 29.]
[Illustration: FIG. 30.]
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.
[Illustration: FIG. 31.]
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.
[Illustration: FIG. 32.]
_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.
[Illustration: FIG. 33.
(_a_) Lower molar with divergent roots. (_b_) The dotted lines show the
direction in which the root can be removed if the tooth is divided as
suggested in the text.]
_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.
[Illustration: FIG. 34.]
[Illustration: FIG. 35.]
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.
[Illustration: FIG. 36.]
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.