Instruments used in tooth extraction

Dental elevators The elevator is the second most important instrument (after the dental forceps) with which tooth extraction is achieved . It is composed of three parts: the handle, the shank, and the blade. The shape of blade differs for each elevator type, and each is used as the need dictates.

Classification of dental elevator. According to the shape: 1- straight elevators. 2- angular elevator. 3- cross bar elevators.(where handle is at right angle to the shank)

Indications for the use of dental elevator 1- used to luxate and remove teeth which cannot be engaged by the beaks of the forceps such as impactions, malposed teeth, extensively decayed tooth and drifted teeth. 2- used to remove roots, fractured or carious. 3- used to loosen teeth prior to the application of forceps. 4- used to split multirooted teeth which have had grooves cut in them.

Elevators can be used to facilitate extraction with forceps by: Breaking down the periodontal attachment. Allowing access to the forceps at a more apical level. Expanding the bony socket.

Principles of elevator Fulcrum Point of application The line of withdrawal

Principles of using dental elevators 1- Wedge principle: here the elevator is forced between the root of tooth and the investing bony tissue parallel to the root. 2- Lever principles : mostly used in elevators is lever of 1st order where fulcrum is in between effort and resistance . it depend on the distance of the load and resistance from fulcrum. We should increase the distance of effort from fulcrum to get more advantage.

3- Wheel and Axle principle. Produced when the elevator engages a purchase point Using the bone as a fulcrum, rotating the handle Transmits rotation from tip of elevator to tip of the root.

Elevators are used in the lever and fulcrum principle to force the tooth or root along the line of withdrawal. The line of withdrawal is the path along which the tooth or root will move out of its socket with the least application of force to it . This line of least resistance is primarily determined by the root pattern.

Precaution to be followed in using elevators. A- never use the adjacent tooth as a fulcrum since this will damage or even luxated the adjacent tooth. B- always use finger guard to protect the patient tissues since slipping of the instrument point into the soft tissue might cause perforation of the mucosa. C- force applied through the instrument should be under control: failing to do so would cause fracture of the maxillary tuberosity, mandible or alveolar process. D- the instrument tip should deliver the force in the correct direction to avoid the accidental forcing of the tooth into the maxillary sinus.

The elevator grip is between the thumb and forefinger and to apply only gentle rotation , since any straight elevator can exert a fracturing force if incorrectly used with a crowbar action.

The fulcrum used for the elevation of teeth should always be a bony one . the use of an adjacent tooth as a fulcrum is only permissible if that tooth is to be extracted at the same visit. Elevators may be forced down the periodontal membrane either mesially, buccaly or distally to the tooth being extracted.( not lingually or palataly)

The elevator should be grasped in the fingers and forced down the periodontal membrane at an angle of 45 degree to the long axis of the root . the tip of the index finger rests against the alveolar bone and enables the operator to have complete control over the instrument.

1- Straight elevator

Straight Elevator. This is the most commonly used type of elevator for the removal of teeth and roots, in both the upper and lower jaws . The handle is pear-shaped, and big enough to be held comfortably in the hand for the surgeon to apply pressure to the tooth to be luxated . The shank is narrow and long and connects the handle to the blade. The blade has two surfaces: a convex and a concave one. The concave surface is placed buccally, either perpendicular to the tooth or at an angle, and always in contact with the tooth to be luxated. The elevator is held in the dominant hand, and the index finger is placed along the blade almost reaching its end. The end of the blade is left exposed and is seated between the socket and the tooth to be luxated

in straight elevator the blade is curved at its cutting end. It comes in 3 sizes, No.1 (narrow) No.2 (moderate) No.3 (broad)

2- Coupland chisel elevators This type is a straight elevator consisting of handle, shank but the blade is straight at its cutting end. It comes in 3 sizes, No.1 (narrow) No.2 (moderate) No.3 (broad)

3- winters elevators (Elevators with T-shaped or Crossbar Handles). This type of elevator is used only in the lower jaw for removal of a root of a molar, after the other root has already been removed with the straight elevator. Each of these elevators is composed of the handle, shank, and blade. The shank is connected to the middle of the handle, giving the elevator a T-shaped appearance, while the connection of the shank to the blade is angled, and the blade end is sharp-tipped.

The blades on this pair of elevators face in opposite directions, and the appropriate one is used according to the root that has to be removed. One elevator is used to remove the mesial root, and the other for the distal root, for each side of the lower jaw. In certain cases, the T-shaped elevator may be used to remove a whole third molar of the lower jaw. The tip of the elevator is placed into the root bifurcation buccal to the tooth, using the external oblique ridge as a fulcrum.

Winter ’s elevators They are of 2 types, long and short. The long winter's elevator is used to remove deeply seated mandibular molar roots. The short type is used to remove roots highly seated in the alveolus

winters elevator. Wheel and axle Adjacent empty socket Mandibular molars Needs sharp tip i.e. no purchase point

4- Cryers elevators (Pair of angled elevator suitable for extracting roots in the mandible and for upper 3rd molars).

Cryer Elevator Wheel and axle Adjacent empty socket Mandibular molars roots and upper 3rd molar tooth. Have sharp tip i.e. no purchase point

Cryers elevators Have a similar shape to curved Warwick James elevators but with a larger, short and sharp pointed triangular head.

5- apexo elevator (Double-Angled Elevators) : are mainly used to 1- remove root tips in both jaws. 2- They are also very useful instruments for the extraction of impacted third molars of the upper jaw.

They are angled elevators with long blades and the fine ones are specially used to remove very deeply seated root apices or bony spicules or fragments. They also come as right or left.

6- Miller Elevator Wheel and axle Impacted maxillary thirds NOT erupted maxillary thirds Place at MB of third molar and roll to the distal

7- Warwick James elevators These have either straight or curved tips.

8- Desmotomes a-straight b- curved.

desmotomes These instruments are used to sever the soft tissues attachment and are either straight or curved . the straight desmotomes is used for upper anterior teeth, while the curved desmotome used for the rest of the teeth.

The choice of different elevators for different tasks is according to: Amount of space available. Position and availability of a solid fulcrum or bone. Position of a strong application point on the root. Direction of movement required

An elevator must not be applied mesially to a lower first molar in an attempt to loosen it . because the lower 2nd premolar have a single conical root and may be dislocated from its socket by force transmitted through the inter dental septum between the two teeth.

The point of application of an elevator is determined by the shape of the root. If the root is straight or conical it will move upwards if force applied to its buccal surface ( buccal application). If the apex of the root points distally the elevator must be applied to the mesial surface of the root (mesial application). If the root apex curved mesially a distal application is called for to elevate the tooth upwards and for wards out of its sockets.