Armamentarium in exodontia

a seminar on Armamentarium in exodontia

1. Armamentarium in Exodontia Presented by- Dr Rayan Guided by- Dr Veerendra Kumar

2. Contents INTRODUCTION OBJECTIVES HISTORY DIAGNOSTIC INSTRUMENTS INSTRUMENTS USED TO ATTAIN SURGICAL ASEPSIS ANESTHETIC ARMAMENTARIUM INSTRUMENTS TO GAIN SURGICAL ACCESS INSTRUMENTS FOR RETRACTION INSTRUMENTS FOR EXTRACTION INSTRUMENTS FOR SUTURING INSTRUMENTS FOR BONE REMOVAL INSTRUMENTS FOR BONE DEBRIDEMENT INSTRUMENTS TO KEEP MOUTH OPEN MISCELLANEOUS INSTRUMENTS

3. Introduction A surgical instrument is a specially designed tool or device for performing specific actions and carrying out desired effects during a surgery or operation. Most surgical instruments are made of high grade steel,either stainless tungsten carbide or chrome plated

4. Objectives Optimal surgical field Optimal visibility Decreased strain to the surgeon

5. History One of the earliest dental tools is a  drill . The first dental drill appeared in 7000 BC and was an invention of Indus Valley Civilization . The history of extraction foreceps is very old and goes back to Aristotle (384-322 BC) where he described the mechanism of oral surgery foreceps Archimedes studied and discussed the priciples of lever about 100 years after Aristotle

6. Until the 16 th century, dedicated dentists did no exist and dentstry was practiced by general physicians and barbers. A number of tools were invented for performing this procedure, most commonly used for extraction was the Dental Pelican.

7. Dental key

8. George Tiemann & Co. has supplied fine surgical instruments since 1826

9. Diagnostic instruments Mouth mirrors/ Odontoscopes Parts : mirror shank and handle Types : Flat, concave, double sided, front surface

10. Uses : Indirect vision Retract cheeks, lips and tongue Reflection of light

11. Probes In detection of caries Palpation

12. Tweezer Parts : Beak, body and handle Types : serrated, non serrated and locking type Uses : carry cotton, guaze or peanuts

13. Instruments used to attain surgical asepsis Cheatle’s Forceps Long angulated Used to pick up other sterile instruments Stored in a container containing sterile solution

14. Swab Holder Instrument with long blades,with an oblong tip Blades have central fenestrations and transverse serrations Uses : To hold swab and clean the area Swab oral cavity and throat in an unconscious patient To hold tongue and give traction in unconscious patient

15. Towel clips The tips of the instrument are pointed,curved towards each other and overlap Types : Pinchter type Beckhaus type Schadel Uses : Hold corners of drapes Hold tongue Stabilize suction tubes, cables etc to drapes

16. Towel clamps BACKHAUS JONES SCHAEDEL

17. Use of Towel clip

18. Draping

19. Anesthetic armamentarium The syringe Types Non disposable Disposable “safety” syringes

20. Cartridge type syringe CORK SCREW PISTON REGULAR

21. Safety syringes

22. 1.Needle Parts:- bevel,shaft,hub,syringe adapter,cartridge penetration end. Guage :-25,27 and 30 are used in dentistry .

23. Instruments used to gain surgical access Surgical scalpels The instrument used for making an incision is called a scalpel Commonly held in a pen grasp for making incisions Parts : Blade and a blade handle

24. Bard Parker Blade Handle Available in various sizes,commonly used is number 3 The handle has a receiving slot for the blade Blades No. 10 – For skin incisions No. 11 – For stab incisions No. 12 – For mucogingival procedures No. 15 – For intraoral surgery

25. Technique for insertion of BP Blade Technique for removal of BP Blade

26. Disposable s calpel

27. Blade remover

28. Dissecting Scissors These have a blunt nose for undermining the tissues Pointed sharp tips Side cutting edge for cutting the tissues

29. Tissue dissecting scissors Mayo HM straight Mayo HM curved

30. Tissue dissecting scissors Met zenbaum HM Standard Met zenbaum HM Slim

31. Tissue dissecting scissors Fox HM straight Fox HM curved

32. Instruments for retracting tissues Periosteal elevators It is a double ended instrument with a sharp end and a broad end Most commonly used Molt no 9, Howarth ’ elevator and Ward’s elevator

33. Uses : R elease papilla Elevate the mucoperiosteal flap Soft tissue retractor Method of reflection Prying motion Push stroke Pull stroke

34. Tongue depressor It is a L shaped blade like instrument Used for depressing the tongue or retracting the cheeks

35. Austin retractor Short right angled instrument Used 3 rd molar impaction surgeries for retraction of mucoperiosteal flap and cheek

36. Minnesota Retractor Wide, bent, tongue blade like instrument Used to hold cheeks and lips out of the way from operating field

37. Instruments used for extraction of teeth Dental extraction foreceps PARTS:- BEAKS HINGE HANDLE

38. Maxillary Anterior Foreceps DESCRIPTION:- •The handle,hinge and beaks are in the same plane. •Both the beaks are symmetrical. They are broad with sharp rounded edge. The beaks come together at the edges when the handles are closed completely. •The handles are straight with serration on the outer surface.

39. METHOD TO USE:- To extract maxillary central incisor,lateral incisor and canines. The tooth is held firmly at CEJ Since these teeth have a conical root,the tooth is extracted with a rotatory movement.

40. Maxillary premolar foreceps The beaks are at a slight angulation to the hinge and handles. This is for better access in the premolar region of the oral cavity. The handles are straight or may droop slightly. The beaks are symmetrical with the edges sharp and rounded . When the handles are closed completely,there is a small gap between the edges of the beaks.

41. METHOD TO USE:- •To extract maxillary first and second premolars. •The first premolar usually has 2 roots,so buccal and palatal traction is given for extraction. •The second premolar has conical root. Rotational forces are given for extraction.

42. Maxillary molar foreceps The beaks are symmetrical. One beak is fitted with a pointed projection which is meant to engage the buccal trifurcation. The other beak has a rounded edge to engage on the CEJ of the lingual root. Gap between the beaks is more than that of premolar forceps. Available in pairs

43. METHOD TO USE :- • Extraction of 3 rooted maxillary first and second molars. •The pointed beak is engaged on the buccal trifurcation and the rounded beak on the palatal CEJ. •Once apical force is applied to ensure a good grip on the tooth,buccal and palatal traction is given for extraction.

44. Maxillary Cowhorn Foreceps DESCRIPTION :- • The beaks are at an angle to the hinge and handles. • It has asymmetrical beaks with one beak which is cylindrical and tapering to end in a pointed tip. The other beak has a forked end to engage the palatal root. • It is also available in pairs.

45. USES:- Extraction of grossly carious first and second maxillary molar. It gives a firm grip on the tooth where a normal maxillary molar forceps is likely to crush the grossly carious crown. In some teeth it may even fracture the furcation to separation the roots so that individual roots may be removed separately. Once a good grip of the tooth is obtained,buccal and palatal traction is given to extract the tooth.

46. Bayonet Root Foreceps Contra angled design of the handles and beaks. Specially made to obtain good access in the posterior region and also to avoid injury to the lower lip The beaks of the root forceps are narrow. Used for extraction of maxillary roots.

47. Maxillary Third Molar Foreceps Beaks design is similar to bayonet root forcep . Beaks are broad and symmetrical with rounded edge. Its design provides good access to the maxillary third molar region

48. Directions Since the maxillary 3rd molar has 3 roots which are fused with no clear demarcated trifurcation,the beaks used are symmetrical to engage the CEJ bucally and palatally

49. Mandibular Anterior foreceps DESCRIPTION:- •Beaks are perpendicular to the handles. •Beaks are narrow, symmetrical and have a concave sharp edge. •The beaks converge at the edge when the handles are closed completely.

50. METHOD OF USE:- • To extract all mandibular anterior teeth . •Tooth is held firmly at CEJ and firm rotation movement with the forcep is required for extraction

51. DESCRIPTION:- •Beaks are slightly broader than the mandibular anterior forceps. •Beaks do not converge completely when the handles are closed. •Symmetrical beaks with concave sharp edges. Mandibular premolar foreceps

52. METHOD OF USE :- • To extract mandibular premolars. •Mandibular premolars have a single conical root, so after holding the tooth firmly at the CEJ with a good apical force,rotational forces are given extraction.

53. Mandibular molar foreceps DESCRIPTION :- • Beaks are perpendicular to the handles. • Beaks are symmetrical with a pointed projection on both the beaks . • This projection engages in the bifurcation between the mesial and distal roots of the mandibular molar . Beaks are broad and do not converge completely when the handles are closed .

54. METHOD OF USE:- • The beaks are engaged with pointed projections engaged in the furcation. •Lingual and buccal traction is given to luxate the tooth.

55. Mandibular Cowhorn Foreceps DESCRIPTION:- •Beaks are perpendicular to the handles. •Both the beaks have a symmetrical design. The beaks are cylindrical with a gradual taper to end in a pointed tip. •The beaks do not converge completely when the handles are closed to accommodate the tooth.

56. METHOD OF USES:- •Used for the extraction of grossly carious mandibular molars where an ordinary molar forceps may crush the remaining weakened crown structure.

57. Elevators INDICATIONS FOR USE:- 1.To remove fractured root fragments(fractured at apical,middle or gingival 1/3rd). 2.To luxate grossly carious teeth before engaging a forcep . 3. To remove intraradicular bone. 4.To split teeth once a bur groove has been placed.

58. Parts of a elevator HANDLE SHANK BLADE

59. Working Principles Of Elevation LEVER PRINCIPLE :- • The elevator is the lever of the 1st class position of the fulcrum is between the effort and resistance.

60. Long arm is 3/4th of the total length and short arm is 1/4th of the total length, to get mechanical advantage of 3.

61. WEDGE PRINCIPLE • In this principle elevator is pushed between the root and the investing bony tissue parallel to long axis of tooth by hand pressure or by mallet force. •It is used in conjunction with lever principle .

62. Sharper the angle of the wedge less the effort required to overcome a given resistance. •formula=( ExI = Rxh )or(R/E=I/H). •Mechanical advantage of this principle is 2.5.

63. 3.WHEEL AND AXLE PRINCIPLE:- •In this principle,effort is applied to the circumference of a wheel,which turns the axle so as to raise a weight. •It can also be used in conjunction with lever and wedge principle.

64. Formula=( EffortXradius of wheel= resistanceXradius of axle)(R/E= Rw /Ra). •Mechanical advantage of this principle is 4.6.

65. Straight Elevator Description:- •Large peer shaped handle with a straight shank and a blade which has a concave/convex surface and an inclined plane. •The blade has a deep concave groove on 1 side and tip is sharp and straight.

66. METHOD TO USE:- •Working of this elevator is based on wedge principle and 1 st order lever principle. •The elevator is placed at an 45degree angle to the long axis to the tooth with concavity of the blade facing the tooth to be extracted. •The crest of the interceptal bone is used as fulcrum . •It may also look like parallel to the long axis of the tooth when it is wedged into the PDL space to luxate the tooth.

67. Apexo Elevators DESCRIPTION:- •“Offset” or angulated elevator as the blade is at an angle to the shank. • The blade is narrow with a deep concavity on one side & end in a sharp pointed tip. • It is available in pairs

68. METHOD TO USE:- • To remove fractured root fragments at the cervical, middle 1/3rd or apical 1/3rd. •The pointed tip & concave surface of the blade is wedged between the tooth fragment & the alveolar bone from the mesial & distal aspect with a slight pushpry motion. •Based on wedge principle.

69. Cryer’s Elevators DESCRIPTION:- •“Offset blade” as the blade is at an angle to the shank and handle . •Blade is curved and triangular in shape with a pointed tip. •It is available in pairs

70. USES:- •To remove impacted molars. The pointed tip is placed in the buccal furcation to luxate the tooth from the socket. •Rotational forces are used on the wheel and axle principle. •To remove fractured root tips in mandibular molars. •To extract mandibular molar root stumps when both the roots are present but one is fractured at a lower level than the other or when the bifurcation is intact.

71. To assist in removal of the erupted maxillary 3rd molar.the elevator is placed with the buccal fulcrum on the alveolar bone Sometimes a bur hole may b drilled onto the tooth to be luxated . The pointed tip of the elevator is engaged into the burhole to get a good purchase point and the tooth is removed

72. DESCRIPTION:- “Offset blade” design where the blade is at an angle to the shank and handle . The blade appears similar to the Cryer’s elevator. The handle as a crossbar design as it is perpendicular to the shank. •The blade is curved and triangular in shape. Winter’s Crossbar

73. USES:- Used with rotational forces based on wheel and axle principle. Used for removal of impacted mandibular teeth. Used with caution for removal of impacted mandibular third molars as the force may cause fracture of the angle region of the mandible. Used for removal of root fragments of mandibular molars. Not used in maxillary arch.

74. Instruments used for Suturing Tissues Mayo- Hegar Needle holder It is a straight instrument with a short working tip. The working tip has cross hatched serrations with a single vertical serration. The handle has a catch/lock.

75. G egar O lsen needle holder Has a built in scissors Saves operating time

76. Deans suture cutting scissors They maybe straight or curved, angulated or non angulated They have long handles and short cutting edgess

77. Tissue holding foreceps Types – Plain Toothed Uses Plain forceps are used to hold delicate structures Toothed foreceps are used to hold tough structures Used to hold needles while suturing tissues

78. Sutures and Needles Classification of sutures Suture material Absorbable Nonabsorbable monofilament Surgical gut polyamide collagen polypropolene monocryl Stainless steel multifilament Polyglycolic acid silk Polyglactin 910 linen polyamide polyester

79. Commonly used needles & threading procedure ROUND BODY CUTTING REVERSE CUTTING

80. Instruments of Bone Removal Rongeurs foreceps It has a short and a sharp working tip. It has a spring type mechanism Used to trim projecting, uneven, overhanging bone

81. MEAD BEYER

82. Chisels and Osteotomes Chisel is a monobeveled instrument It has a heavy cylindrical handle For cutting, the bevel is placed away from the bone For chipping it is placed towards the bone Osteotome is bibeveled and is used for splitting of bone

83. Mallet Can be made of, rubber, nylon or stainless steel Stainless steel are preferred as they can be sterilized Used to deliver controlled force on chisel or osteotome

84. Bone Files It is a double ended instrument. It has serrations on the working tip Used to smoothen bone after extraction or during alveoloplasty Used in a pull stroke

85. Burs They remove bone most efficiently Made of carbide or stainless steel Available in various shapes and sizes Uses Smoothening and removing bone Sectioning teeth

86. Instruments used for wound debridement Surgical curettes These are spoon shaped instruments. Come in various sizes and in straight or angled tips Used to clean out sockets after extraction

87. Bone Scoop It is similar to a curette Primarilly used to scoop out contents from an abscess cavity It can also be used to scoop out cancellous bone

88. Instruments used to keep M outh O pen Mouth Props Types: R ubber or metal Consists of a vertical block having a concave surface Usually comes in a set of three or four Placed in between maxillary and mandibular teeth to keep the mouth open

89. Fergusons Mouth Gag The instrument has serrations that rest on the occlusal surface of upper and lowe teeth The handle has a catch that is fixed at the required opening Uses : Surgeries of oral cavity,pharynx Sedated patients

90. Heisters Mouth Gag It has 2 flat blades that are applied,placed between upper and lower teeth Mouth is opened by turning the key Uses : Trismus Physiotherapy

91. Miscellaneous Instruments Suction Apparatus It is a vaccum pump suctioning device. Electrically operated with a help of a motor Can be mounted on a trolley Single or two bottles can be connected

92. Suction tip These are instruments which are introduced into the surgical field. Types – Plastic or metal They help keep the surgical field clean by sucking away blood, debris, cystic fluid, pus etc.

93. Suction cannula FRAZIER YASARGIL YANKAUER

94. Basic extraction tray set up

95. Surgical extraction tray set up

96. Newer Techniques Physics Foreceps Developed by Golden in 2004 U ses first-class lever mechanics One handle of the device is connected to a “bumper ,” which acts as a fulcrum during the extraction.

97. Bumper is placed approxiamately at the level of mucogingival junction. The beak of the extractor is positioned on the lingual or palatal root of the tooth and into the gingival sulcus B eak and bumper design that allows for efficient atraumatic extractions using only wrist movement. When this technique is first attempted, a conscious effort must be made to retrain your hands to not squeeze the instruments and to not pull with your arm.

98. Vertical extraction systems Benex extractors

99. Easy X- Trac system

100. Sonosurgery Air driven sonic instruments Works at a frequency of 6khz Dimensions (0.25 mm thick, 2.4-3.5 mm wide, and 10 mm long)

101. Refrences Haider SM, Latif W, Oral & Maxillofacial Surgery; A historical review of the development of the surgical discipline, International Journal of Surgery (2018), doi : 10.1016/ j.ijsu.2018.02.051. Contemporary Oral and Maxillofacial Surgery, Sixth Edition- Hupp, James R Petersons principals of Oral and Maxillofacial surgery,Third edition- Michael Miloro , G.E Ghali,Peter Larson Oral and Maxillofacial Surgery - Jonathan_Pedlar_John_W_Frame

102. Principles and Practice of Single Implant and RestorationsTooth Extraction and Site Preservation-Nicholas Caplanis , Jaime L.Lozada,Juan Mesquida BASIC GUIDE TO DENTAL INSTRUMENTS - Carmen Scheller Papadimitriou, D. E. V., Geminiani , A., Zahavi , T., & Ercoli , C. (2012). Sonosurgery for atraumatic tooth extraction: A clinical report. The Journal of Prosthetic Dentistry, 108(6), 339–343. doi:10.1016/s0022-3913(12)00169-2

103. Thank You