erupted lower third molars are some of
the easiest teeth to remove in the mouth
and some of the most difficult teeth to
remove in the mouth and just like any
other tooth now the thing is as we move
posterior lis we need to remember that
the access for these gets more difficult
visibility gets more difficult and we're
getting closer to some of the vital
structures in the jaw now these are
important things to know because if we
run into complications things can be a
little bit more difficult to deal with
and maybe a little more serious so we
need to have good confidence we need to
be very comfortable extracting teeth
before we get into this type of
extraction so we're going to look at how
we do this right away in this video the
first thing to look at is we need a good
pan or a good PA to show us where that
nerve canal is in relation to the roots
of that tooth typically we're in the
clear when they're erupted like this but
we still want to be sure and we want to
make sure we can see the entire apex of
that tooth now as we get going on this
what we're gonna do is we're gonna start
with our periosteal elevator and again
we want to stay fairly clear if the
lingual tissues throughout this
extraction don't crush the tissues make
sure you have good visibility when
you're placing a forceps or when you're
poking with your periosteal we want to
start on the buccal right between the
third molar and second molar I will
often use the concavity of that
periosteal in this direction to sink it
in between the teeth and pry away and
that will move the papilla away from the
bone to allow you to get your elevator
deeper in between these teeth and allow
you to prevent the crushing of that
tissue as you begin to elevate on that
tooth now we're going to encircle the
tooth with this periosteal so basically
we're going to be going all the way
around pushing to bone making sure that
we're severing all those PDL fibers that
we can access with this instrument once
we've done that we're then going to move
to our elevator this is the els x3
elevator I love it I use it all the time
it's a luxating elevator so it has a
very thin tip on it which allows me to
use it like a lock cedar working it
ethically down the route or as an
elevator where I can be more
perpendicular to the tooth it's a great
instrument you can't apply excessive
forces to these because you will chip
them I've got a few in my kits where
I've done that and you get a feel for it
over time so there's no right or wrong
elevator
to use here just use what you're
comfortable with this is what I happen
to use so you've reflected our papilla
we're gonna start elevating we want to
get good access back here we're going to
insert and try to get a purchase on the
mesial aspect of that tooth so it can be
the mesial-buccal it could be the mesial
lingual or straight mesial wherever you
can get to and you're gonna start
twisting that elevator a little bit and
pushing as you move deeper so as you
move deeper what I'm usually doing is
I'm usually rotating the top edge of
that elevator toward the tooth now the
reason that I do that is I try to keep
the bottom edge on the bone and I try to
use the top edge to lever on the tooth
to get it moving when I do that I'm kind
of avoiding leaning back on the adjacent
tooth so I say tend to get less leverage
off the adjacent tooth when I move in
that direction
the final motion of elevation once
things are loose typically then I will
rotate it up and sort of away from the
tooth to lift it out of the socket so
that's something to keep in mind it also
protects that adjacent tooth so we're
gonna start working at this lots of
times you'll get these lifted a little
bit so you're kind of working in this
direction we're making this motion or
removing ethically and we're kind of
twisting and moving almost anteriorly I
guess with our hand as well so doing
this motion and as we do that we're
getting deeper and deeper in there we
start to lift the tooth but maybe it's
not coming what do we do next the next
thing that we do is we can take this
thin edge of this elevator and now that
we have a little bit of clearance
between the tooth and that buccal shelf
of bone which is so sturdy look at all
that bone there we're going to insert it
in that buccal groove and we're gonna
begin to push down in there till we get
another purchase and then we can lift
from the buccal aspect of that tooth and
most times this is all we need to
deliver that tooth out through the
lingual now this is an easy way to do it
it gets you in under the fur keishon of
that tooth to lift it out if we have
elevated and elevated and we're not
getting much for movement and things are
pretty stiff maybe the tooth lifting a
bit but not coming out we can then move
to our force up and our forcep that we
would typically use back here or that I
typically use is the 222 for set now I
like the 23 cow horn typically
four molars and I will use it if I have
a patient that can open really wide but
this forcep has quite an angulation to
the the teeth I guess or to the jaws of
the four set now that allows us to get
good access back there the patient
doesn't have to open as wide as with the
cow horn and it can grip very tightly on
that tooth and lots of times these teeth
may have conical roots or maybe not be
bifurcated and we don't always have an
area for the cow horn to sink into so
what we'll do is we'll apply this on our
tooth it a bit and now we've got good
leverage on there I'll often use that
underhand grip where you can then start
to move and lean it in both directions
buccal lingual and begin our rotations
and then we can typically deliver this
tooth either to the buccal or the
lingual most times molars will deliver
to the lingual because you can see the
difference in the bone the buccal bone
is so thick the lingual is so thin that
you'll usually have it coming to the
lingual doesn't matter just make sure
that you're not forcing it you will feel
as you get going which way that tooth
wants to come out
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