How to use Mandibular Extraction Forceps – Anterior, Premolar and Molar

Mandibular Extraction Forceps as the name suggests are used to extract the Mandibular or Teeth of the Lower Jaw. The Mandibular Extraction forceps are divided into types based on the teeth which they are used to extract. Each Forceps has three parts – Handle, Hinge and Beak. In Mandibular Forceps the Beak is at a right angle to the Handle. The Forceps are also manufactured based on the working hand of the operator – Left Handed and Right Handed Forceps.  The types of Mandibular Forceps are as follows –

• Anterior Forceps:
• Premolar Forceps:
• Molar Forceps:
• Cowhorn Forceps:
• Third molar Forceps:
• Mandibular Root Tip Forceps:

There are two types of Forceps based on the position of the Beak in relation to the handle –

American Type Forceps: It has a hinge that is directed in a horizontal direction with the handles of the forceps (Regular Molar and anterior Forceps)

English Type Forceps: It has a hinge that is directed vertically to the handles of the forceps (Third Molar Forceps)

Principles of Forceps use in Extraction:

The goal of Forceps use in Extraction of Teeth is –

• Expand the bony socket using the wedge-shaped beak of the forceps and movement of the tooth with the forceps
• Removal of the tooth from the socket

How to Use Lower Mandibular Extraction Forceps:

Follow all the basic steps which we do before preparing for Extraction

Diagnosis: It is important to diagnose the problem with the tooth and to determine if there is any chance to save the tooth using Root Canal Treatment and convey it to the patient. Take proper IOPA before going for any Surgery, as we do not know what lies under the bone.

Take History: Ask for any Systemic conditions and any medications which the patient might be using – Diabetes, High Blood Pressure, underlying heart conditions, Kidney disease, Allergies etc. Change the treatment plan accordingly – For Ex. use plain LA without Adrenaline in patients with heart disease or High Blood Pressure.

Operator and Patient Chair Position: Make sure that the operator and Patient Chair positions are properly set as it helps in maintaining the force being exerted and proper technique, the position changes depending on the tooth involved, the side and the Jaw involved – Chair positions in Dentistry (you can follow this post for the patient position, Chair position and Operator position).

Local Anesthesia: Administer Local Anesthesia – nerve block or infiltrations as required for the particular tooth and its condition. Check for all the Signs of Anesthesia before proceeding with the procedure.

Isolate the tooth: It is important to isolate using cotton rolls of any cheek retractors etc which allows the operator better visibility for the procedure.

Elevate the Soft Tissue: The soft tissue attachments to the tooth to be extracted needs to be elevated or detached from the tooth. If this is not done it might lead to tearing of the soft tissue while extraction thus leading to delayed healing and wound closure.

Give Support: Before you start to engage the tooth using an Extraction Forceps it is important to support the Mandible or Maxillary arch using your non working hand. Support the

Engage the Tooth: It is important to engage the tooth with the proper Forceps, it is always important to Engage or hold the tooth below the CEJ (Cemento enamel Junction), if the tooth is held at the crown portion and movements given there are chances that the crown might fracture. When the forceps engage beyond the CEJ the centre of gravity is in the centre of the tooth. By giving slight Apical force, the expansion of the Bony Socket happens, this is termed as Wedging. (Apical Force: After Engaging the forceps, slightly pushing the forceps towards the gums or root of the tooth)

Give Rotatory Movements: After engaging the tooth with the forceps, different movements should be given to different teeth.

Anterior teeth – After Engaging the tooth, give Apical pressure to expand the socket and then give alternating Buccal and Lingual Forces, now give rotatory movements to expand the socket from all sides. The last movement should be Rotatory + slight Coronal pull to pull the tooth out of the socket.

Canine – Same as Anterior teeth – Rotatory movements followed by Luxating.

Premolars: Engage the tooth, apply Apical pressure -> Apply Buccal and Lingual forces to Expand the socket -> Rotate the tooth in the socket (Rotate with caution if there are two roots) -> Tractional forceps are applied once you feel the socket is properly expanded to pull the tooth out of the socket.

Molars: After Engaging the Beaks of the forceps in the Furcation area of the Mandibular Molars, give slight Apical Force, this will slightly widen the periodontal ligament and expand the socket, the second force should be Buccal Force – after engaging the tooth the forceps should be moved towards the Buccal side this will expand the buccal plate at the crest of the ridge. The third force should be Lingual Force – similar movement should be given as done with the Buccal movement, this movement expands the linguocrestal bone, Excess force should be avoided as the Lingual plate is narrower in comparison to the Buccal plate. Buccal and Lingual movements can be used alternatively to expand the socket.

The fourth movement is the Rotational Force  – As the name suggests, rotate the tooth slightly in the socket clockwise or anticlockwise (This should be done with care as multiple roots tend to break if excess force is applied). The final force is Tractional force where the tooth is lifted out of the socket once expansion of the socket is sufficient.

A Diagnostic Xray before tooth extraction is always advisable as we can prepare for any anomalies in the tooth shape and structure.