L7&8 Oral Surgery Dr Amera Alkaisi

29/11/2021

Elevators

Instrument used to elevate or luxate the teeth or roots from their bony socket in closed or
surgical methods to force a tooth or root along the line of withdrawal. It is very important in
removal of teeth.

Line of withdrawal
Is the path along which the tooth or root will move out of its socket when minimal force is
applied to it .This line is primarily determined by root pattern (long axis).

Point of application
Is the site on the root at which force must be applied to effect delivery? It is determine
by the line of withdrawal. We have buccal point of application, mesial and distal.

Parts of elevators
1. Handle: The part to be grasped by the operator
2. Shank: The part between the handle and the blade
3. Blade: The part that engages the crown or root to transmit the force to the tooth, bone or
both. The working side of the blade is either concave or flat

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 Mechanical principle of action of elevators

1. Lever and fulcrum

Most commonly used principle
¨ Elevator is a lever of the first class
¨ Fulcrum is between effort and resistance.
¨ In order to get mechanical advantage, effort arm must be longer than resistance arm.
Used to force the tooth or root out of the socket along the path of least resistance (line of
withdrawal). Ex straight elevator

2. The insertion of wedge

The elevator is inserted between the tooth root and bony socket wall, causing the tooth to
rise in the socket. Ex: coupland elevator, straight elevator and Apexo.

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3. Axel and Wheel
The wheel and axle is a simple machine the effort is applied to the circumference of a
wheel which turn the axle so as to raise a weight. It could be used as a sole work principle
in removing the teeth, it is also used in conjunction with a wedge or lever principles Cryer’s
elevator

Indications of elevators
• To break down the periodontal attachment
• To luxate and remove full teeth which cannot be engaged or grasped by forceps peak
(impacted and malposed tooth).
• Badly carious teeth or teeth with heavy filling.
• To remove roots fractured at gingival line, at mid length and apical third of roots.
• To loosen teeth prior to the application of forceps.
• To split teeth which has been cutted (grooved).
• To remove intra radicular (interseptal) bone.

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 • Any tooth resisting normal extraction by forceps.

Common types of elevators

1. Straight elevators
• It is three part in the same line with blind round blade.
• Used to luxate an erupted tooth placed perpendicular to the long axis at the alveolar
ridge on the mesial aspect of the tooth, with the rounded side of it’s tip resting on bone
• It is rotated away from the tooth creating a scooping action to elevate the tooth.
• For roots: we place it parallel to the long axis of roots between socket wall and the
root and worked toward the apex
• Socket may be used for fulcrum if addition leverage is necessary.

2. Coupland chisel elevator

• It is the same straight elevator with difference in it’s blade being straight and
sharp.
• It comes in sizes No I, II and III.
• Used to cut bone to create point of application and to separate the roots.
• This elevators are forced between the root of the tooth and the investing bony tissue
parallel to the long axis of the tooth

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3. Cryers (east – west elevator)
• It’s blade is triangular in shape, sharp and pointed forming an angle with the shank.
• There are pair of instruments mesial and distal designed to fit the root surface.
• It is used for removing fractured roots of molars.
• The elevator is placed in the empty socket of the tooth being extracted with the tip
facing the root to be removed in the adjacent socket. Rotatory motion will deliver the
root.
• The interradicular septum is engaged near the apex of the socket.
• Care should be taken that the point does not invade mandibular canal (in lower teeth)
a rotatory motion will cut through and cut the septum.
• This elevator is used on bifurcation in buccal side and elevating upward using buccal
plate as a fulcrum for removal of partially mobile mandibular third molars.

4. Apexo elevator
• They are three types mesial, distal and straight.
• The working blade is long and form an angle with the shank
• It has surfaces convex and concave, pointed with sharp margins.
• It is used for the removal of apical fragment of root deeply present in the socket
of the lower jaw mainly
• They can be used for removing root mass of the lower molar after fracture of the
crown.

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5. War-wick james elevator
• It is a light duty elevator like cryer elevator
• There are two angle (mesial and distal) and one straight
• The blade is short with rounded end and the handle is flattened
• It is used for extraction of retained root, deciduous teeth and anterior lower teeth,
when there is less resistance area as upper right and left third molar.

6. Winters elevator
• It’s working end the same as that crayer elevator but the handle is at right angle to the
shank so it’s called winters cross bar handle elevator.
• They are powerful and great force may be applied (sufficient to fracture the mandible).
So it must be used with care.

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Choice of elevators according to:
o Remaining tooth structure
o Space available
o Availability and position of solid fulcrum
o Direction of the required movement
Rules of Use of Elevators
Ø Palm grip
Ø Don’t use the neighboring • • • • tooth as a fulcrum
Ø Don’t use the buccal or lingual plate of bone as a fulcrum, only in a special situation
Ø Use the left hand for reflection, guard and support
Ø Take care of the surrounding vital structures
Ø Follow respectfully, root curvature

Principles to be applied in protection

1. Support patient jaw to prevent dislocation of mandible

2. Protect other tissues in the oral cavity against potential tissue damage, i.e
accidental slipping and plunging of the point of elevator in adjacent or distal soft
and hard tissues. Important when using WEDGE type elevators
3. Careful and continuous control of direction of force, so it is directed into bone
surrounding the tooth or against the tooth being luxated
4. Surrounding immediate operating area with fingers.
Maxilla: Grasp dental arch with index finger and thumb so that alveolus is in
between
Mandible: First and second fingers should straddle alveolus and thumb placed
below mandible, supporting it and off setting downward pressure of elevator
which may dislocate mandible
5. This placing of fingers, buccally, labially and lingually gives operator
immediate information, whether or not pressure is being created on adjacent
teeth which are not to be extracted

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 6. Adjacent teeth should never be used as fulcrums unless they are to be extracted
as well
7. This position also means that if the working point of elevator slips, it will affect
the operator’s finger rather than patient’s surrounding soft tissue, nerves and
blood vessels
Grasping and application
1. Put the elevator in the palm of your hand and grasp it by your fingers with your index
finger extended right up to the working blade and forced down the periodontal
membrane at an angle of 45° to the long axis of the root,
2. The tip of index finger rest against the elevator to control the elevator,
3. The point of application of the elevator that is the site on the root where the force to be
applied to deliver the tooth or root is determined by the line of withdrawal of the tooth
or root.
4. If the root is straight and conical it will move upward and slight lingually if force
applied buccally, buccal application.
5. If the apex of the root points distally the elevator should be applied mesially because
the line of withdrawal is upward and backward.
6. Distal application of elevator withdrawal is upward and forward out of the socket
7. When the elevator applied, the instument is rotated along the long axis of the tooth, so
that the lower edge of the blade engages upon the cementum covering the root surface
and move the tooth out of the socket.
8. Elevators mostly used for 2nd and 3rd molars. the apices of these teeth are distally
inclined so mesial application of the elevator is indicated.
9. Teeth with fused roots a buccal point of application can be created by using bur and
dril 45° with the long axis of the root.
10. Thefulcrum should be always bony one, so use the alveolar bone as a fulcrum and the
adjacent tooth can only be used as a fulcrum if that tooth is also to be extracted in
the same visit.
11. Place the concave surface of the working blade against the tooth.
12. Use your left hand to retract soft tissue from the site of application of the elevator to
protect them from injury by acceidental slipping of elevator.
13. Start with smaller elevator and move to larger as tooth luxate
14. Do not apply too much force if the tooth resist luxation. The difficulty must be found
before procceding further,because extraction of high force may lead to further fracture
of roots, teeth , alveolar bone and jaw and slipping of elevator lead to serious injury in
oral and nieghbouring vital structures as maxillary sinus, cheek or pharynx or even the
orbit.
15. Avoid using elevator adjacent to conical root as lower right and left 4th premolars, it
may be luxate or dislodges when you use elevator luxate adjcent tooth.
16. Be careful when you use elevator adjacent to heavily restoed teeth.
17. In multirooted teeth divergent roots must be separated, creating a space between
them and then elevate toward one another. the same way for converge one, because
unproper use of elevator lead to further fragmentation or crushing of the socket wall.

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Complication of using elevator
Ø The tip of the instrument may fractures and remains in the socket, causing infection
which delay healing, so that at the end or postoperative, elevator must be checked.
Ø Injury to the soft tissues such as tongue, floor of the mouth or palate caused by
slipping of the elevator.
Ø Wrong application or excessive force may lead to fracture of the jaws especially
the lower, crushing of the alveolar bone or fragmentation.
Ø Loosening or extracting the adjacent teeth
Ø Fracture of the maxillary tuberosity as in extraction of the upper 8.

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Ø Spread of the infection may occur when we use elevator in a tooth with periapical
abscesses.
Ø Accidental penetration of maxillary antrum and soft tissues (may perforate greater
blood vessels
Ø Uncontrolled force may lead to displacement of root into maxillary sinus,
submandibular space, infratemporal fossa and buccal soft tissue or inferior dental
canal
Problems arise from
• Improper positioning of elevator
• Too much force is applied
Precautions
§ Never use adjacent tooth as fulcrum, unless it is to be extracted also
§ Never use buccal plate at the gingival line as fulcrum ,except in special situation
§ Never use lingual plate at gingival line as fulcrum
§ Always use finger guards for protection against slipping
§ Controlled forces and pressure exerted in the correct direction
§ Always elevate from mesial side of tooth
§ When cutting through interseptal bone, not to engage adjacent tooth root and
force it out of socket
§ Excessive forces damage or displace adjacent teeth.
§ It must be kept in mind that this is the initial step in extraction process and that
forceps is the major instrument for tooth luxation and removal.

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