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S.M. ORAL SURGERY STUDY GUIDE

PRINCIPLES OF BIOPSY 2

PRE-CANCER SCREENING 3

COMPLICATIONS IN EXODONTIA 3

PREVENTION 3

SOME ISSUES 4

EXTRACTION COMPLICATIONS 4

PRINCIPLES OF SIMPLE TOOTH EXTRACTION 5

STAGES OF FORCEPS EXTRACTION 6

UBC POST OP INSTRUCTIONS 7

PRINCIPLES OF SURGICAL TOOTH EXTRACTION 8

MUCOPERIOSTEAL FLAPS 8

TYPES OF SUTURES 9

REMOVING ROOTS 10

MULTIROOTED TEETH 11

INSTRUMENTS 12

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Principles of Biopsy Biopsy = Taking of living tissue for Lab examination

2 Main Types:

- These apply to both hard tissue (bone) and soft tissue

Incision Biopsy = Partially excise lesion to obtain a representative sample Excise “normal” tissue with the lesion for histological comparison (always) Avoid:

- Anatomical structures (vessels, glands, nerves etc) - Too small of a sample (5mm is kinda the low end of size) - Crushing the tissue with forceps

Excision Biopsy = Completely excise the entire lesion Excise “normal” tissue with the lesion as a histological comparison

- Benign lesions: Margin of 1-2mm - Malignant lesion: Margin of 4-8cm

Some other types

Aspiration Removal of tissue/fluid by inserting a needle into tissues Usually just done by a histopathologist (needs lots of experience to do it properly)

- Solid Mass sample – Fine Needle Aspiration Biopsy - Fine bore (22G) needle

- Cystic Mass – Removal of cyst fluid - Wide bore (14G) needle - Fluid Aspirate can tell us: Appearance, odour, light microscopy, Protein electrophoresis

Exfoliative Cytology Removal of superficial layer of cells (epithelium usually) for microscopy examination - Brush Biopsy - Useful for determining presence of Candidal hyphae

Technique: - Smears taken with wooden/metal spatula or dental plastic instrument - Spread evenly on the center of 2 glass slides - Fix immediately

Microbial Biopsy Swab of pus/infected tissue sent to lab for microscopy, culture and antibiotic sensitivity testing - Slow Process (usually requires overnight incubation at lab, sometimes up to 4 weeks), not really used in dentistry

Pus Technique: - Collect in a sterile syringe or bottle rather than swab - Avoid contamination (obviously) - If there is a delay -> store in fridge at 4-8o - Mention any suspected pathogen to lab (TB etc)

Technique

1. LA

- Infiltrations will ↓ local bleeding 😊 But it it is too close to the site, LA might contaminate the sample

2. Select Representative tissue

- Adjacent to “normal” tissue, include some normal tissue for comparison

3. Incise Tissue

- Use elliptical shape -> this allows you to suture the wound closed without weird “dog ears” at the ends

- For highly vascular areas that are difficult to cut (FOM), can use a CO2 laser

- Consider local anatomy! Vessels, Nerves, Salivary ducts in the area

4. Remove biopsy

- To avoid issues, in general practice we will usually biopsy benign lesions <1cm. Anything iffy just refer

- Can add a single suture tied to 1 side to help lab orient the tissue (“This side up”)

5. Close wound

6. Send sample to pathology lab (Within 2 days)

- Lay the sample with epithelium upward on a piece of paper or cardboard

- Place this in 10x its volume of 10% formaldehyde/saline in a clearly labelled specimen transport container

and specimen bag

7. Await Results

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Special Techniques

Receiving lab must give you warning before you prepare the sample so you know what to do.

- Frozen Sections

o Ordered in the OR when a lesion is suspected of being malignant -> If it is found to be malignant, surgery happens right away

- Immunostaining

o DON’T place these sample in Formaldehyde, use Michelle’s Medium instead so the staining will work

Pre-Cancer Screening A few methods exist

Indications for screening:

- Examine mouths of high risk Pt’s

- Highlight early stage asymptomatic lesions

- Confirm the presence of suspicious lesions

OroScreen

- This is a Toluidine Blue product -> (not Dx though)

- Quick (< 5 mins), used as an adjunct to a complete head/neck cancer exam

1. Rinse w/ 1% acetic acid solution

2. Rinse with toluidine blue 1% disclosing solution

3. Rinse again w/ 1% acetic acid solution (removes excess stain)

4. Examine to identify stain retention by the affected tissues

5. Bring patient back after 10-14 days for a 2nd OroScreen test

o If it’s positive the 2nd time = Indication for a biopsy

Velscope

- Hand-held device, adjunct screening for early detection of soft tissue dysplasia

- Pretty sensitive (if you know how to use it), but not at all specific: Cancer looks the same as Candidiasis etc

- Dr. Matthew hates it

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Complications in Exodontia Peri-Operative Post-Operative

- Primary hemorrhage (Can’t stop bleeding initially) - Tooth Fracture - Tooth Aspiration - Tooth Displacement into anatomical space (sinus etc) - Jaw Fracture (too much force, especially with extracting 8’s)

- Osteonecrosis - Osteoradionecrosis - Secondary Hemorrhage (Bleeds again once a clot was already

formed at appointment)

Prevention - Better than a cure! -> Finesse, not force

- Ensure a thorough pre-operative assessment and Tx plan -> Know your limits, surgery within in

- If you need to refer, do so OVER TELEPHONE rather than by letter

Follow proper steps

1. Careful assessment of Med Hx

o Identify risky patients (previous major diseases (head and neck cancer), Current and past drug Hx (Bisphosphonates!)

o Dental Hx (Prior difficult extractions, Post extraction hemorrhage, Radiotherapy to jaws, Issues with LA)

2. Thorough clinical and radiographic exam

3. Detailed surgical planning

4. Careful and timely explanation of the procedure pre-operatively (Informed consent) -> 5% of cases might have transient/temporary post op. issues

o Consent in form of a signed, written consent t least 24 hrs prior

o Pt must be able to understand the Tx, fully informed, given opportunity to ask questions

o Discuss advantages/disadvantages of alternative managements (including no Tx)

o Discuss anesthesia and side effects/complications (drug reactions)

5. Follow basic surgical Principles -> (Good lighting, Soft Tissue retraction and reflection, Adequate suction)

6. Follow other principles -> (Asepsis, Atraumatic handling of tissues, Hemostasis, Thorough debridement of wound after procedure to prevent

infection)

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Final Checks before Extraction

- Confirm Tx plan, check all teeth, identify the tooth/teeth to be extracted

- Re-Check

- Verbalize Tx plan with assistant (They might correct some big mistakes)

- Check teeth to be extracted on chart if multiple teeth are to be removed for Ortho purposes

Some issues Local Anesthesia Problems - Double check expiry date of LA

- Use your landmarks, make sure you are injecting in the proper stop - Aspirate! - Inject slowly

Soft Tissue Injuries Almost always due to - ↓ attention to mucosal delicacy - Rushing - Use of excessive force

Tear of mucosal flap Most common soft tissue injury during oral surg. - Often from inadequately sized envelope flap -> forcibly retracted = tearing at 1 end of incision

Avoid by: - Creating adequately sized flap - Controlling retraction force - Create releasing incisions

Management - Stop procedure and ↑ length of incision to gain better access - Reposition carefully after surgery - Can result in poor and delayed healing

Puncture Wound When sharp instruments (elevators usually) slip from surgical field - Typically from uncontrolled force - Use finger rest or support from other hand!

Management - Apply direct pressure to wound if there is bleeding - Leave would open and unsutured

Stretch, Burn or Abrasion Abrasions or burns can happen from shank of a bur rubbing on soft tissue or sharp edges of metal retractor - Cannot really Tx this. Just keep it clean - Heals in 4-7 days without scarring -> Rub salt water on wound multiple times a day

Management: 5-10 days for skin abrasions -> Cover with antibiotic ointment

Extraction Complications Root Fracture Most common problem with extractions

- Preventable if you have good technique or use an open technique (remove bone) - Remove the root tips asap

What if the roots are curved, divergent, dilacerated or hyper-cementosed? - Use a surgical transalveolar approach

Root Displacement into Maxillary Sinus

Caused by uncontrolled upwards pressure from extraction forceps or elevators - Most often w/ conical single rooted premolars, and palatal roots of molars - #1 root is the Palatal root from Max. 1st Molar

Remove displaced roots/teeth in sinus ASAP (otherwise give antibiotics until you can do it) - Maxillary molar root is the most common to be displaced

<2mm = no Tx -> ensure a good blood clot and take sinus precautions

- Precautions ↓ changes in sinus air pressure that would dislodge the clot (no blowing nose, sneezing, sucking, smoking

2-6mm -> Figure of 8 suture to hold retention of Surgicel, Gelfoam or PRF. Sinus Precautions, Antibiotics for 5 days Management:

- Identify the size of root lost -> Take radiograph to determine position and size (ideally 2 radiographs 90o to each other)

- Assess if there is an infection of the tooth or periapical tissues - Assess pre-operative condition of the sinus

If the frag. Is small (2-3mm) and there is no pre-existing sinus condition: - Irrigate through small opening with saline rinse at the apex of socket -> Then suction the irrigating solution. This

might flush the root apex through the socket - Confirm radiologically that the tip has been removed - If this doesn’t work, you can leave the root tip in the sinus. If it isn’t infected, probably wont cause a problem

Oroantral Communication Close the extraction site with a figure 8 suture over the socket Provide antibiotics and nasal spray to prevent infection

- Find Hx of Sinusitis -> can cause poor healing, or a chronic communication leading to fistula

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Sinus Precautions for 10-14 days: = Aim is to prevent changes in maxillary sinus air pressure that would dislodge the clot

- Open mouth w/ sneezing - No sucking (straws or cigarettes) - Avoid nose blowing - If a smoker can’t stop -> small puffs - See Pt at 48-72 hour intervals

Rx: - Penicillin (or other antibiotic) - Systemic decongestant for 7-10 days - No antihistamines! They dry our the mucosa

Tooth displacement into Tissue space

Unerupted Upper 3rd Molars when elevated can slip behind maxillary tuberosity into infratemporal space (Maye migrates into neck even)

- Make sure you always place instruments behind upper 3M and have direct vision to prevent this -> Laster Retractor

Mandibular 3Ms can have their roots pushed through thin lingual plate and into FOM - Refer to oral surgeon for removal

Tooth Displacement into Inferior Alveolar Canal

If roots fracture -> Lift out of the socket Create channel of bone adjacent and under to the retained root with a fine diamond bur Take Radiographs in 2 planes

Aspirated Root/Tooth Protect the airway with 4/4 Gauze or C-Sponge -> stop the issue before it even happens If the tooth is inhaled:

- Usually in the R. Main bronchus (Larger and steeper) - Send to Emerge for an X-Ray - Refer via Telephone (more instant)

Fractured/Damaged teeth DON’T USE AN ADJACENT TOOTH AS A FULCRUM - So easy to damage teeth or resto’s

Broken Resto’s = Most common Adjacent tooth injury - Warn Pt pre-operatively of the risk to adjacent teeth/resto’s - Careful with angulation of elevators - Use controlled and appropriate forces with forceps etc

*If break off a resto -> Repair the resto BEFORE you finish the extraction* - Blood will contaminate the prep if you keep going. AND the resto material can contaminate the open socket

Dry Socket = Delayed healing not associated with infection - Caused by excess fibrinolytic activity (Lysis of blood clot and exposure of bone)

Add medicated gauze to cleaned out wound -> Ingredients: Eugenol (obtunds pain from bone), Topical LA

Extracting wrong tooth Avoid! Double check before you pull it out! If you fuck up… IMMEDIATELY replace the tooth into the socket (before the tooth dries out)

- If its mobile, use ortho bonding/straight wire for 4 weeks

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Principles of Simple Tooth Extraction Indications - Unrestorable caries -> Softens crown’s structure = prone to snapping (use physics forceps)

- Periodontal Disease -> ↑ mobility of teeth - Orthodontic Tx - Failed endo therapy -> Usually brittle and hard to extract without breaking - Associated pathologies (Odontogenic cyst or neoplasm)

Pt Assessment Hx - Tooth extraction could be life threatening! Make sure they have no other medical issues that may complicate matters - Past experience may have traumatised Pt - Review meds!

Dental and Med Hx: - Allergy to any dental drugs or materials? - Previous difficulties w/ extraction - Post op bleeding or infection - Hypertension - Type 1 DB - Bleeding disorders - Anticoagulant therapy (Warfarin, Apixaban (direct Factor X inhibiting anticoagulant)) - Immunosuppressant therapy - Co-existing cardiac disease or prosthetic heart values -> Ab prophylaxis?

Clinical Exam - General build (Racial variation in bone density etc) - Bone Structure (older patients have brittle and sclerotic bone) - Mouth Opening (Trismus, or small mouths will make things tricky)

Radiographs - Must evaluate surrounding structures to assess the risk of unanticipated damage (Nerve damage, jaw fracture etc)

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**Weird trivia note: Phillipinos typically have 3 roots with their mandibular 1st molars -> Straanggee

- Also good luck putting this bitch out

Tools of the trade

Forceps 150 -> Maxillary teeth (Premolars, canines, incisors) 151 -> Mandibular teeth (Premolars, Canines, Incisors)

Elevators Straight - Coupland - No. 301

Triangular Patterns - Warwaick-James elevators - Cryer Elevators

Aims of Simple Extractions

- Teeth are attached to bone through a Gomphosis joint -> Fibrous attachment of periodontal fibers from alveolar bone to the tooth root

o Periodontal fiber groups:

▪ Alveolar Crest fibers

▪ Horizontal Fibers

▪ Apical fibers

▪ Oblique Fibers

▪ Inter-Radicular fibers

- The Whole purpose of extraction is the dislocate this fibrous joint

Pain and Anxiety

- Obviously pulling teeth will hurt -> Ensure profound analgesia to prevent

traumatic experience

o Pt Anxiety can ↑ the perception of pain. Be Calm and confident!

- May consider Conscious sedation if the patient is particularly anxious

o Triazolam is ideal for our procedures -> ½ life is only 2-3hrs 😊

o Lorazepam is NOT ideal -> ½ life is 2-3 days, effects lasting way

too long for what we are doing

- Nitrous Oxide or IV Sedation are options also

Stages of Forceps Extraction Teeth are never Pulled!

3 Orchestral movements:

1. Grasp tooth -> Grasp the whole crown and 1-2mm of root beyond CEJ to ↓ chance of fracture

2. Expansion of bony socket -> Apply buccal and lingual force (mostly buccal) to expand the alveolar plate

3. Delivery -> Use a lateral traction force to remove the tooth! If you pull upward, you risk smashing the opposing

arch. Control the force

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Forces

Apical Pressure Breaks the periodontal seal -> Helps your forceps grasp below the CEJ

Forces to Break Perio fibers Buccal Force -> Expand the buccal plate of bone Lingual Force -> Expand lingual crest of bone Rotational Force -> Overall expansion of socket Traction Force -> Delivers the tooth

Forces for teeth

Max. Teeth Bucco-Palatal forces

Mand. Teeth Buccal + Lingual Forces

Buccal + Lingual Forces

Rotational + Buccal Forces Figure of 8 movement

So the Extraction is complete! Now what?

- Examine Tooth morphology -> Make sure all roots are present, check for rough spots on roots

- Compress alveolar bone -> brings it back to normal after all the dilation you did

- Place bite pack -> 2x2 gauze for 30 mins or until bleeding has stopped

- Give Post op instructions

- Ensure haemostasis

Dismiss the patient

- Ensure they have your number

- CALL Pt within 24 hours to check up -> Dr. Matthew will call you to ask how they are doing

UBC Post Op Instructions

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Indications to leave retained roots - ↑ risk of displacing the root (into Max. antrum or Inferior Alveolar Canal) - ↑ risk of damaging adjacent nerve or vessels - Patient is soooo over it

Indications to remove the roots - Could compromise ortho or pros. Tx - Irreversible Pulpitis - You have good access - Patient is compliant

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Principles of Surgical Tooth Extraction Simple Vs. Surgical

Simple Extraction Forceps and Elevators only - Closed, Non-surgical

Surgical Extraction Requires the opening/removal of tissue - Open, complex extraction - Reserved for extreme situations only - Opens the buccal plate to remove tooth

Less morbidity though!

Indications for Surgical Extraction

- Need for excessive force to extract tooth (Crowding, Dense bone, Jaw Fracture, Brittle tooth)

- Inability to remove a tooth with forceps -> Leading to uncontrolled force

o Reflect soft tissue flap, remove some bone, section the tooth/roots and extract in sections

- Thick Dense bone

o If cannot expand the buccal cortical plate -> ↑ chance of root fracture

- Hypercementosis

o Cementum continued to deposit on tooth = large bulbous root that is hard to pull out of socket opening

- Short Clinical Crown + Signs of severe attrition (bruxism)

o ↑ chance that tooth is surrounded by dense heavily bone

Patient Assessment

Prior to surgery you need to assess the Pt:

- Med Hx

- Suitability for Extraction (Level of Co-Operation, Previous Experience, Apprehension and confidence in you)

- Surgical Access (Small Mouth? Trismus?)

- Radiographs -> PA or Pan, or CBCT to see adjacent structures (like the IAN, or Max. sinus)

- Analgesia -> Do you do a block or infiltration?

Mucoperiosteal Flaps Envelope Flap Just a simple horizontal incision, peeled off from the periosteum

- Edentulous Pt: Envelope made along the scar at the crest of the ridge -> Limited vital structures here, so the incision can be long AF

- If they have been edent. For a while, the mental nerve may have migrated into the area = Caution still

Envelope + 1 Releasing Incision

(3 Corner Flap)

Place a vertical incision from one end of the horizontal envelope - Functions to ↓ the stress on the envelop and ↓ risk of tearing - ↑ access and visibility for deeper regions in the envelope

Envelope + 2 Releasing incision

(4 Corner Flap)

Vertical releasing incision made at either end of the envelope incision - ↑ assess and visualization

Ensure it is narrower at the Coronal portion of the flap vs the base -> Ensures good blood supply to the flap

Semilunar Incision Avoids marginal attached gingiva when working on the root apex - Most useful when you only need a limited amount of access

Takes a long time to heal -> Will look terrible at first, but after some time will heal very well

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Y-incision Useful on palate -> Removal of palatal tori - 2 Anterior limbs function as releasing incisions for ↑ access - Avoid nasopalatine nerve + Greater Palatine nerve

Pedicled Flap Indicated to keep good blood supply to the socket and promote healing - Heavy Smokers who have ↓ healing response - The denuded bone of the palate will look terrible until soft tissues grows back over it

Flap Design Points

- Air on the side of bigger when making a flap

o If you go too small you ↑ tension and ↑ chance of necrosis. You also ↓ chance of having to make another flap

o Sharp incisions heal faster than torn tissue, not worth the risk to make your flap too small

- Ensure adequate access for instruments and visualization

- Retract the flap away from the operative field -> Minnesota Retractor

- Soft Tissue heals ACROSS the incision (not along) -> So length doesn’t realllllyyyy matter, its going to heal at the same rate as a smaller incision

- Appropriate Length estimation: Extend 2 teeth anterior and 1 tooth posterior to surgical area

o If an anterior releasing incision is planned, only 1 tooth anterior extension is needed

- Always include the periosteum with the flap (the thin white tissue covering bone)

o Retract the flap from the bone using a Molt #9 Pereosteal elevator

Minnesota Retractor Molt #9 Periosteal Elevator

Where do you make your releasing incisions?

DO THIS 😊 NOPE -> Risk papilla necrosis NOPE -> Risk Recession

Types of Sutures Single interrupted This is the principle technique. Used most frequently for the suturing we will do

Horizontal mattress Helps to appose displaced mucosa post extraction Helps apply tension to mucosa after an extraction that lead to gingival bleeding

Figure of 8 Horizontal Mattress

This is used to secure haemostatic agents placed within a socket post extraction

Vertical Mattress Brings together underlying surface of oral mucosa (for deep incisions)

Continuous Lock Placed after multiple tooth extractions instead of placing many single interrupted sutures

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Removing Roots Bone Removal - Helps to mobilize tooth

- Use bone cutting bur after reflecting flap-> FG 70-02 OS - Bone removed ½-2/3rd the length of the tooth root

DON’T use a regular high-speed turbine that you would use for Resto’s -> Risk of surgical emphysema if air enters tissues DON’T let the bone overheat (denatures alkaline phosphatase enzyme needed for bone healing) -> Denatures at 55o

Sometimes you just need to remove bone to create a purchase point for your elevator between the root and the alveolar bone

Luxation Delivers tooth - When enough bone is removed, straight elevator can be used down the palatal aspect of the tooth to pop

it out buccally - MAKE SURE you have a solid finger rest -> or you might slip and put the elevator

through their FOM (which would be both bad and embarrassing, and would take up your lunch hour)

Delivery w/ forceps Once the bone is removed, and the tooth root luxated buccaly -> Use forceps to remove the root - If you use a bone rauncher to elevate the tooth Dr. Matthew will kill you

Wound Debridement This is the final cleaning and tidying of the operating site before wound closure - Not necessary for simple extractions unless debris is present - Remove all loose bone, soft tissue, done dust, other debris and irrigate with sterile fluid

Can use: - Elevator - Bur - Mosquito artery forceps - Sterile saline irrigation

Wound Closure 2 main categories of sutures - Resorbable and Non-Resorbable - Typically we use “gut” sutures intraorally -> This is resorbable, but can be immersed in chromic acid to ↑

handling and ↓ resorption rate Suture gauge

- 12/0 -> Fine suturing of microvasculature - 3/0 or 4/0 -> Typical for intraoral use - 0/0 -> THICCCC for suturing abdominal wall

Resorbable vs non-resorbable - Pt typically prefer resorbable (don’t need to come back etc), but sometimes its better to place a non-

resorbable to ensure they come back for you to assess healing

Sequence of Knots

1. 1st knot always repositions the flap -> Specifically the position of the interdental papilla 2. Additional sutures ensure the flap stays in place -> Suture from buccal to lingual

Resorbable Non-Resorbable

- Can be left to resorb over several weeks - Gut is the resorbable material of choice

(plain is hard to handle, so we use chromic gut)

- Made of silk most often - Remove after 7-10 days - These encourage plaque retention, which ↓

wound healing - Gore-tex sutures don’t encourage plaque

retention, but are $$$$

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Multirooted Teeth Can divide up the tooth with a bur to convert a multirooted tooth into 2 or 3 single rooted teeth

Mandibular OR

If you break the crown off first

Maxillary Mercedes Technique:

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Instruments Name Picture/Use Name Picture/Use

Periosteal Elevator – Molt #9

Detach Periosteum from bone/neck of tooth Straight Elevator (301, 1, 34)

Loosen tooth or root from bony socket

Angular Elevators (Cryer, Potts, Crane)

Loosen tooth or root from bony socket -> Cryer -> Potts

-> Crane

Root Tip Picks (Angled or Straight)

Loosen Small root fragments from bony socket

-> Angled

-> Straight

Surgical Curettes (Angular, Molt)

Remove tissue or debris from bony sockets -> Angled

-> Molt

Hemostat Securely hold small items, clamp blood vessels, remove small pieces of tooth/bone

Needle Drivers Hold Suture Needle -> Like hemostat, but with concave area inside each beak

Suture Resorbable -> Plain/Chromic gut, Polyglycolic Acid Non-resorbable -> Silk, Polyester, Nylon, Polypropylene Sizes in Dentistry: 3-0, 4-0, 5-0 -> Smaller # = wider diameter

Scalpel -> #11 -> #12

-> #15

Rongeurs (Side Cutting, End Cutting)

Bone Chisel and Mallet

Cut and contour bone -> Remove sharp edges of alveolar crest and remove exostoses Side Cutting

End Cutting

Bone File (Straight or cross cut or curved)

Smooth bone for better contour of alveolar ridge (after rongeur) Tissue Scissors (Dean, Iris, Kelly)

Cut and Remove excess or diseased soft tissue -> Dean -> Iris

-> Kelly

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Towel Clamps Scary looking tool used only to hold surgical drapes and secure tubing to drapes

- Randomly also used to remove metal temporary crowns

Tissue Retractor (Austin, Senn, Selden

Deflect and retract periosteum from bone -> Austin

-> Senn ->Selden

Tongue and Cheek Retractor

(Minnesota, Shuman, Weider)

Hold back tongue and cheek away from surgical site -> Minnesota -> Shuman

-> Weider (AKA: The Sweetheart)

Surgical Aspirating Tips

(Byrd Self Cleaning, Cogswell, Frazier,

Yankeur Tonsil Aspirator)

Maintain clear working field by removing saliva, blood, debris -> Byrd Self Cleaning -> Cogswell

-> Frazier -> Yankeur Tonsil. Placed in throat during GA

Tissue Forceps (Adson, Allison)

Grasps and stabilizes soft tissue flaps during suturing and reconstructive procedures

-> Adson -> Allison

Maxillary Forceps Mandibular Forceps

#99 (Max. Anteriors + Premolars)

#101 (All Deciduous Teeth

+ Man. Anteriors)

#103 (Man. Anteriors and

Premolars) #101 #103

#150 (Max. Anteriors and Premolars

Universal (R +L) #151 (Man. Anteriors +

Premolars)

(Universal R+L)

#18R / L + #53 R/L (Right Max. 1st and 2nd Molar)

Round Beak contours lingual root Pointed back contours bifurcation of buccal roots *#53 = straight handle*

#15 + #17 (Man 1st + 2nd Molars)

*#17 has straight handle

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#88R/L (Max. 1st and 2nd molar)

Bayonet Beak Beak w/2 projections contours lingual root

#16 / #23– Cowhorn (Ma. 1st + 2nd molars)

` ** #23 has straight handle

#210 (Max. 3rd Molars)

Universal (L + R) #222 (Man. 3rd Molars)

#65 + #69 (Max. Overlapping Anteriors /

Root Tips)

Very Narrow beaks

-> #69 doesn’t have contra-angled head

#74 (Man. Root Tips)