| Contents | Post-Test |
This course will give you a working knowledge of oral surgery based on forty years of my experience in the field of dentistry. The course deals with routine extractions and soft-tissue surgeries a practitioner faces and teaches how to handle some of the problems that arise out of them. This does not replace established techniques and common sense in handling surgery cases. It is recommended that you establish a good working relationship with a specialist in oral surgery for consultations and learn other surgery techniques.
Some patients come into your office expecting an extraction to take them out of pain. This becomes a problem when the offending tooth does not need to be extracted. Root canal therapy is the treatment of choice, but the patient’s mind says extraction. This can become a liability issue if you extract a tooth you could retain with root canal therapy.
This patient has no difficulty with the concept of extraction if this becomes the treatment of choice. This patient usually has several teeth in his mouth requiring attention. He is only in your office because one of them is hurting.
The object of this first visit is to take the patient out of pain. This may be an extraction, but often this is an open-and-drain of the tooth or tissue case. You cannot numb a tooth sufficiently with local anesthetic to extract it when the tooth is infected or has inflammation over the root.
The other type of patient takes care of his teeth, but he is now faced with an extraction. Usually the tooth has lost bone support from extreme occlusal stress resulting in a very mobile tooth. Extraction becomes the only treatment of choice. Usually the tooth will exhibit swelling over the roots indicating infection in the periodontal ligament. Antibiotics are the treatment of choice after the tooth has been taken out of occlusion.
Losing a tooth is a very emotional experience for most people. You are dealing with a dis-figurement of their face. This is especially true when you are extracting an anterior tooth. An immediate replacement of the extracted tooth with a stayplate helps alleviate this stress. The stayplate may be a temporary replacement to allow healing before the final restoration is placed, or it may become the replacement appliance for the patient.
The first appointment is always to relieve the patient of pain. Treatment should only be started after this has been accomplished. This includes extracting the tooth after the emergency is treated. The patient’s pain usually results from infection, clenching, or nerve exposure.
An older female Spanish patient came to my office complaining of pain in teeth number six through eleven. Her maxillary arch was edentulous except for the six anterior teeth. She had a full compliment of lower teeth. These were in fair shape except the lower anterior teeth had a mobility of two with moderate bone loss.
Upon taking X-rays, her remaining maxillary teeth were diagnosed. The teeth number six and eleven were strong in the root area, but the crown portions had extensive decay through to the pulp chamber and below the tissue. The remaining four anterior teeth exhibited extensive bone loss, and had a mobility of three.
The patient decided to have the six anterior teeth extracted and replace them with a maxillary denture. The suggestion of an immediate denture was refused because the patient wanted to save the extra cost of a reline.
Since tooth number six was causing her discomfort (exposed nerve), it was decided to extract this one first. The extensive decay caused the tooth to fracture below the tissue when pressure was ap-plied. A flap was made and a trough was placed around the tooth exposing more of it.
Elevator pressure fractured the weak decayed tooth further below the tissue. The cuspid root was firm, but the incisal portion was extremely weak from the decay extending deep below the alveolar bone. Another trough was placed and the tooth was extracted using elevators.
A suture was placed and the patient was sent home with post-operative instructions in Spanish. She was no longer bleeding and she was in good spirits. Two hours later the patient was called. Her daughter said she was bleeding profusely.
The patient returned to the office dripping blood from the extraction site. The stack of dripping water blood clots were removed from the extraction site and a pressured two-by-two gauze was applied. The bleeding stopped after a few minutes of pressure, and the patient was sent home.
The patient had obviously been rinsing her mouth with water trying to remove the blood from her mouth. This caused the blood to only partially clot. The rinsing continued until the surgical site had a stack of weak blood clots extending a half inch from the surgical site. The multi-blood clots remained fragile and continued to bleed until there was a steady flow. The patient returned for more extractions. She was nervous. Her four anterior teeth hurt from clenching. They would be too sensitive to extract. She needed something simple to build her confidence. Tooth number eleven provided this. It was a simple extraction. The patient did not experience any pain, and the postoperative results were good.
The patient returned for the four remaining anterior teeth. These were not difficult. They all had a mobility of two or greater. They were slightly sensitive from clenching, but it was acceptable. The patient pointed to her teeth and said to take them all out. She seemed ready psychologically to have the anterior teeth extracted.
She was numbed with a painless injection, and the teeth were removed. There were no bleeding problems. No sutures were needed. The extractions were painless. It appeared everything was normal.
We had her remain in her chair for a few minutes to make sure she felt okay before we sent her home. The receptionist spoke to her in Spanish and reiterated the postoperative instructions. A few minutes later they told me she was lying on the couch in the waiting room.
I did not want her in the waiting room with problems and helped her back to the chair.
She said she was light-headed and felt sick to her stomach. I knew if we could have her concentrate on something other than her extractions, she would feel better. We were not quick enough. The patient was going to empty her stomach. We led her to the bathroom where she took care of the problem. My assistant remained with her in case she decided to faint.
After the bathroom episode, the patient was feeling good, and we sent her home. This was an emotional response to having her front teeth extracted. In retrospect it would have been better to have done an immediate denture. This would have lessened the patient’s traumatic emotion from losing her front teeth. Unfortunately, the patient wanted the tissue to heal first to avoid a reline.
Teeth should not be extracted unless there is a valid reason for doing so. This is especially true with the extraction of the third molars. If the tooth is functioning well in the patient’s mouth, the tooth should remain. If the tooth is a source of infection, it should be removed.
All of the extraction techniques described here are done with a local anesthetic.
This includes teeth six through eleven and teeth twenty-two through twenty-seven.
Anesthetic is given with the painless infiltration method. The labial tissue is allowed to fall on the needle and a small amount of anesthetic is given. When the tissue is numb, more anesthetic is given. Then the labial portion of the gingiva is blanched with anesthetic. This is taken around the tooth following the blanching until the gingiva is numb.
This requires a fair amount of pressure to move the blanching. To insure against forcing anesthetic into a vessel, aspirating is essential. Then only small amounts of anesthetic are given at any one time. The gingiva is generally free of large vessels, but occasionally vessels do extend into the gingiva. This is enough to warrant aspiration of the anesthetic. If this is done correctly, the patient will not feel the injections.
When the tissue is numb, the gingiva is pushed away from the tooth with the pointed edge of the periosteal instrument. The pointed edge should be against the tooth or bone to avoid ripping the tissue.
Once the tissue is retracted free from the tooth, a straight anterior forceps is used to clasp a maxillary tooth, and a lower bent pedo-forceps is used to clasp a mandibular tooth. The bent forceps gives a great deal of leverage for moving the mandibular teeth.
The goal of the extraction is to remove the tooth without excessive injury to the alveolar bone. The tooth can be moved labially and lingually, and it can be twisted from side to side. It does not require excessive pressure to accomplish this. You will be using all of the directions to remove the tooth. Unless the tooth is extremely mobile, you will not be taking the tooth out using only one direction.
The labial plate of alveolar bone over the tooth is the concern here. Excessive labial pressure will fracture it. This is a judgment call. Using the anterior forceps, a maxillary anterior tooth should be pushed slowly labially and then slowly lingually with no intention of extraction at this point. You are only trying to give the tooth some movement. This is especially important for the maxillary cuspid where it is very easy to fracture the labial alveolar bone. Placing your finger over the labial bone will help in determining how much pressure to give here.
Using the forceps, you take a firm grip on the tooth and twist it mesially and then distally. You are trying to loosen the tooth. You may need to remove distal and mesial contacts of the tooth you are extracting to allow room for the twisting. The process is repeated. Labial, lingual, and twisting motions are used until the tooth is loose and ready for extraction.
Taking a firm grip on the tooth with the forceps, you give the tooth a twisting and pulling pressure to remove it. The maxillary laterals usually have a distally curved root. This should be taken into consideration during the pulling pressure.
Sometimes the shape of the mandibular anteriors will dictate a labial pressure during the extraction process. Care should be given to the labial bone during this labial pressure. More effort should be given to the straight pulling action as opposed to the labial movement.
The direction you will extract the tooth will be determined by the prior loosening movements. You will find that the tooth moves more in one direction than another. This is your path of extraction. When there is no definite path of extraction, then a twisting-pulling action will extract most teeth without damaging the anterior labial bone.
It is good to notice the direction of the extraction to avoid striking the other teeth in the mouth when the tooth is suddenly extracted. It is also wise to notice where your elbow is going before you extract the tooth.
After the tooth is extracted, it is good to squeeze the socket closed. The twisting, labial, lingual movements usually expand the thin labial plate. Using a two-by-two gauze, you place it over the extraction site and squeeze the labial plate. This will also stop any bleeding. A suture is very seldom needed in simple extractions.
Many orthodontists ask for the first bicuspids to be extracted. Usually the mandibular bicuspid root converge to a point allowing you to extract it like an anterior cuspid. The tooth is numbed with the painless technique of infiltration and blanching. The sharp pointed side of the periosteal instrument is used to push back the gingiva and expose the tooth.
The tooth is loosened with a buccal, lingual, and twisting motion. Taking the lower pedo-anterior bent beak forceps, the tooth is clasped firmly. The tooth is twisted mesially with constant pressure, and then distally with constant pressure. The tooth is pushed lingually with constant pressure and then it is pushed buccally with constant pressure. The idea is to loosen the tooth until you find the direction of extraction. This is repeated until the tooth is loose.
You may want to relieve the mesial and distal contacts of the tooth to be extracted with a long thin diamond bur to allow room for the twisting action. This is especially important when you are trying to extract a tooth from crowded anterior teeth. This will give you room to move the tooth.
When the direction of the extraction is found, the loose tooth can be extracted with a twist-pull action. Usually the shape of the root allows the tooth to come straight up, but occasionally the second bicuspid has a distal curved root. Then the direction of extraction is more distally.
An attempt should be made to preserve the buccal bone and tissues. A two-by-two is used to squeeze the buccal alveolar bone back in place and stop the bleeding unless the orthodontist wants the bone left expanded to allow movement of the other teeth into the location.
Occasionally there is a double-rooted mandibular bicuspid. This is handled like a maxillary bicuspid extraction. You cannot twist a double-rooted tooth without fracturing the roots. If you find the tooth is not moving during the twisting motion, you’re probably dealing with a double-rooted tooth.
The maxillary bicuspids usually are two-rooted. Occasionally the first bicuspid has a single root, but it would be advisable to treat it as a double-rooted tooth. The X-ray may not pick up the second root. The maxillary bicuspid roots are thin and fragile. The roots may curve toward each other, or they may remain straight. In either situation the tooth cannot take any twisting action.
The bicuspid is numbed with the infiltration and blanching method. The periosteal instrument is used to loosen the tissue around the tooth. The anterior forceps are locked on the buccal and lingual surfaces of the tooth. The tooth is loosened by moving the tooth buccally and lingually. It is a steady pressure buccally and then a steady pressure lingually.
When the tooth is loose, it is extracted by pulling it straight out. Care should be taken to insure nothing will obstruct the sudden release of the tooth. If the tooth does not come out on the first attempt, the buccal and lingual pressures are resumed.
Care must be taken to avoid any twisting pressure when the tooth is extracted. It has to be a straight pressure, or the roots will fracture and remain in the bone. The extraction pressure is steady. You do not use strong muscles here. If the tooth remains after moderate pressure, then you need to resume the buccal and lingual pressure to loosen it more.
If this does not work, or if you can only move the tooth a small amount with the buccal and lingual motion, then you should consider splitting the roots. If the X-rays show the roots are separated, then splitting the tooth is an option. Teeth cannot be split if the roots are not separated. Usually it is a tooth with extremely curved roots that requires splitting, and is in danger of being fractured.
The tooth should be loosened with the buccal and lingual pressure method before you split the tooth to give some movement to the roots. The crown portion of the tooth is removed with a #557 bur leaving a three-millimeter ridge above the tissue. Using the #557 bur, you can split the roots (mesial-distal) through the floor of the pulp chamber. Using a flat bone chisel as an elevator, split the roots by twisting the elevator in the bur groove. A slight cracking sound will tell you it is split.
The groove needs to be deep enough or you will fracture the root in the alveolar bone. Using a small root pick or elevator, the lingual root is eased buccally and the buccal root is eased lingually. No attempt should be made to extract the roots until the roots are loosened from the alveolar bone. It is very easy to fracture a root in the alveolar bone when a forceps is used at this point.
When the root is loosened, the anterior straight pedo-forceps is used to withdraw the root. You need to find the path of extraction and carefully work the root in that direction. That may require removing part of the exposed root. You cannot force a root out with extreme pressure without fracturing it. A fracture usually occurs when the path of extraction is ignored. This is a slow-easing process.
If a root fracture occurs, then you can be thankful that you had loosened the roots first before attempting the extraction. The small root picks are the instruments of choice to free the roots from the alveolar bone. If the root is already partially extracted when it fractures, then a pointed explorer works well to ease the fractured root out. Care should be taken to avoid pushing the root back into the socket. A good light helps here.
A gingiva flap may be necessary to see the fractured root. Using a #15 blade, a vertical incision is placed in the gingiva mesial to the extraction site. This incision should be at least two millimeters beyond the embrasure to give a good closure. The periosteal instrument eases the tissue from the alveolar bone allowing good access to the site. It may be necessary to release the gingiva on the tooth behind the extraction site to give better access.
Once the root is extracted, a suture is placed to close the buccal vertical flap. Before the excess suture is cut, it can be extended to the lingual to draw up the lingual tissue. Care should be taken to avoid distorting the buccal tissue upon bringing the lingual tissue into the suture. A distal suture is placed to secure the distal portion of the gingiva flap.
If the gingiva flap is extended to the posterior tooth to give more room, then another suture needs to be placed to include this tooth. The suture extending from the buccal to the lingual on the distal of the extraction site is extended to the embrasure of the distal tooth. Going between the teeth through the embrasure, the buccal tissue is taken into the suture. Returning to the lingual following the same path, you find the tail of the suture. The suture is tied off and cut. This will give you a good approximation of the tissue against the bone on the buccal and lingual sides.
This can be one of the easiest or one of the most difficult extractions to accomplish. Usually the mandibular molars are bi-rooted, but they can be single- or triple-rooted as well. Molar extractions are the results of excessive bone loss, extensive infection, or extensive loss of tooth structure from decay exposure.
Instruments Needed
Converging single-root molars are easy to extract; they are usually the second or third molars. The painless mandibular injection is given. When the tongue is numbed, the blanching injection technique can be started on the lingual side of the tooth and carried over to the buccal side. If the tooth has periodontal involvement, the anesthetic can be injected into the periodontal ligament after the blanching is completed.
The periosteal instrument is used to release the tissue from the tooth. It is important to take the periosteal instrument to the bone. The tooth needs to be free of the attached tissue. This will avoid tearing the tissue upon extraction. Using the mandibular forceps, the tooth is moved buccal-lingually, and then twisted mesial-distal. This should establish the path of extraction allowing an easy removal of the tooth.
Care should be exercised in reading the X-ray. A converging single root may be a multi-rooted tooth that appears to be a single root. A converging multi-rooted tooth is one of the most difficult to extract because the roots create a square at the apical.
If the tooth does not move with the elevators, or the forceps, the apical portion of the tooth is multi-rooted. The roots are diverging at the apical end. The roots do not come to a point; instead, they form a box. The small roots (usually there are four) are fused. Each root has its own position in the bone creating a box. The X-ray will show a flat end on the roots instead of a point.
This tooth is impossible to move with the ordinary methods. This is a good one to send to a specialist. You cannot split the tooth for any advantage. You can only twist it back and forth until it is loose enough to be extracted. Any heavy pressure will only fracture the tooth making the extraction of the roots more difficult.
This can be very frustrating. The tooth is loose, but it will not follow any path of extraction. You end up sectioning the root out of the socket. Using a #557 bur, you remove the crown portion of the tooth with a horizontal cut and a flat-bone chisel. The root is sectioned with a groove cut buccal-lingual. A flat-bone chisel snaps the roots. If the fracture is good, the roots are split. Usually the first fracture removes a portion of the root requiring another groove.
The box needs to be split before the roots can be extracted. This may require several grooves with the bur. Once the roots are split, the loose roots can be extracted with a small root pick or explorer.
This extraction requires patience and time. At any point the extraction site can be sutured over the remaining roots and referred to a specialist. The patient will not feel any pain from the remaining roots left in the socket. It is not recommended to ignore the roots and leave them in the socket. It can become a site for infection.
The bi-rooted mandibular molar roots are usually curved toward each other making a forceps extraction difficult. The only direction the tooth can be moved is buccal-lingually. When the tooth is sufficiently numbed, the extraction can begin.
The periosteal instrument is used to remove the tissue from the tooth. When the tooth is exposed, the mandibular molar forceps is placed firmly on the tooth. The tooth is rocked buccal-lingually to loosen it. It is tempting to proceed with the extraction when the path of extraction moves to the buccal. Sometimes this is successful when there is a large amount of bone loss, but usually you sacrifice buccal alveolar bone (fracture) in the process.
Using a #557 bur, you remove the crown portion of the tooth three millimeters above the tissue. You want to leave enough tooth structure to place a forceps on. A buccal-lingual bur cut through the floor of the pulp chamber between the roots will separate them. The cut should not be taken into the buccal or lingual alveolar bone. A large flat-bone chisel is placed in the bur cut and twisted. This splits the tooth and the roots.
The pedo-anterior forceps is placed on the distal root. It is important to extract the distal root first because it is usually less curved and the path of extraction is easier. The root is twisted mesial-distal and pushed buccal-lingually. The path of extraction will be established and the root can be extracted.
If the root’s path of extraction is toward the mesial root, the split may need to be enlarged. The pedo-forceps may not allow a mesial path of extraction. A large elevator is placed on the distal of the root. The incisal edge of the elevator is pushed mesially. This should dislodge the root and allow the pedo-forceps to extract the root.
If the curvature of the root is extreme, the root can be sectioned. A large elevator on the distal portion of the root can hold the root in place while a #557 bur removes a section of the root. This allows for more of the root to move into the extraction path. It may be necessary to cut the root a second time to remove the root.
Once the distal root is removed, the mesial root has room for its path of extraction. The pedo-anterior forceps is placed on the mesial root. The root is twisted mesial-distally and pushed buccal-lingually. Once the root is loose, a large elevator is placed on the mesial of the root. The incisal edge is pushed distally. After the root moves, the elevator is relocated to ease the mesial root out.
The mesial root of the mandibular molar is occasionally bi-rooted. These can be difficult to detect. You will usually discover the second root when the mesial root does not move in the extraction process and you take another X-ray to discover why. The X-ray should be taken on a slight angle mesial-distal to see the second root.
The distal root of the tri-rooted mandibular molar is handled the same as the bi-rooted mandibular molar. The difficulty is the mesial root. The two roots will prevent any twisting motion and very limited buccal-lingual movement.
The pedo-anterior forceps is placed on the mesial root, and moved buccal-lingually to establish some movement. A steady pressure in both directions will loosen the root slightly.
The large elevator is placed on the mesial side of the root. Moving the incisal edge into the root will loosen it more. You are not attempting to extract the tooth, but if it comes up you will take it. The process is repeated until the root is as loose as it will go.
Using the #557 bur, a groove is placed between the two roots mesial-distally. The cut needs to be deep enough to separate the roots. A flat-ended bone chisel is placed between the roots and twisted slightly. This should separate the roots. Be careful of the pressure placed on the roots, it is very easy to fracture off a root.
Using the periosteal instrument, move the buccal root to determine the direction of extraction. If the root is suddenly very loose, a pedo-anterior forceps can lift the root out of the socket. If the root is still firm, it will need to be worked with the periosteal and elevators to loosen it.
You cannot extract the root with a forceps if the root is firm in the bone. It will result in a fracture most of the time. The root needs to be worked until the path of extraction is established. Once the path is established, the root can be worked in that direction. The forceps is used to ease the root out only.
Pressure is applied. If the root does not move, the path of extraction is wrong. Some times the path of extraction is to the mesial. A groove is placed on the distal and pressure is applied with an elevator or periosteal instrument.
At this point you are using root picks and the periosteal instrument to dislodge the root. It takes patience and a light touch to ease the root from the alveolar bone. If you find you are not able to give this, it is time to close up and try another day. The patient will be happier.
The remaining root will not cause the patient any discomfort. Sutures are placed to draw the tissue together. You need to wait at least a week or longer to re-enter the site. The bruised tissues need to heal. You will be surprised to see how easy the extraction of the root becomes when you re-enter the site when the patient and you are feeling better.
If the path of extraction is found, more pressure can be applied.
A trough placed on the mesial side of the mesial root will give you leverage for an elevator. This may be the path of extraction, or it may only loosen the root more. An other trough can be placed on the distal side of the mesial root. Pressure is applied. If the root moves, this may be the path of extraction.
Excessive force to push the root in any direction will only result in fracturing the root and possibly the alveolar bone. A steady push or pull is all that is needed. It is a feel you develop. The root is pushed in one direction and then another to loosen it. The alveolar bone is flexible. It will expand to a point, then it will fracture. It is best to avoid an alveolar bone fracture.
This occurs very rarely. It is handled the same as a three-root tooth. The tooth needs to be loosened as much as possible before the tooth is split buccal-lingually and mesial-distally. The key to removing the multi-roots is the loosening of the tooth before the splitting. The smaller the tooth or root, the less leverage you can place. Most of the loosening needs to be done before the splitting.
The roots of a fully exposed mandibular third molar usually are curved to the distal. The path of extraction will be distal. The tooth is numbed with the painless mandibular block and blanching of the tissue around the tooth. Care should be exercised on the buccal because the buccal gingiva is usually thin in this area. The tissue still needs to be numb, but less pressure is used.
The periosteal instrument is used to free the tissue from the tooth. The distal buccal area can be difficult, but the tissue must be free in this area to avoid tearing the tissue upon extraction.
A small elevator is placed mesial to the tooth. The cutting edge of the elevator pushes the tooth toward the distal. This is followed with a larger elevator. There is little danger of fracturing the thick alveolar bone. The tooth usually moves very easily toward the distal. An anterior pedo-forceps is used to finish turning the tooth out toward the distal. Before taking the tooth out, the distal should be checked for any attached tissue. This needs to be removed before lifting the tooth out.
The bone behind the mandibular third molar may not allow a distal movement of the tooth. The roots show this is the correct path of extraction, but the bone is too high on the distal portion of the tooth. The distal portion of the tooth needs to be removed before the tooth can be extracted.
The elevators are placed on the mesial. Pressure is applied to loosen the tooth before the groove is placed. The tooth can be loosened more with the lower molar forceps. Place the beaks on the buccal and lingual sides of the tooth and apply pressure. This is a loosening attempt. Buccal-lingual and twisting motions will further loosen the tooth.
A #557 bur is used to make a buccal-lingual groove through the tooth slightly distal to the midline of the tooth and angled (slanted) toward the distal. A flat bone chisel is placed in the groove and twisted. The distal portion of the tooth will fracture off.
If enough of the tooth fractures off, you will be able to move the loose tooth distally. It may lock up with the bone a second time requiring another groove and fracturing of the tooth. The tooth will work itself through the curvature of the root following the path of extraction.
The object is to reduce tooth structure and not alveolar bone to remove the tooth. When the tooth is loosened prior to the extraction, the fractured roots are easier to manage.
A third molar with a mesial root curving toward the distal and a straight distal root needs to be split. Each root has a different path of extraction. The tissue is retracted, and a small elevator is placed on the mesial of the tooth. The cutting edge pushes the molar distally.
This is not to extract the tooth, though the tooth might continue to come out. This is the path of extraction for the mesial root. Occasionally the distal root has a slight curve you may not see in the X-ray. The larger elevator is placed and pressure is applied. If the tooth continues to move, then this is the path of extraction.
Assuming the tooth did not move, the mandibular forceps is placed on the buccal-lingual. Pressure is applied to loosen the tooth further. You might find a buccal-distal roll of the forceps to be the path of extraction. At the very least the tooth is loosened from all of these attempts.
The tooth needs to be split before it can be extracted. A horizontal groove is placed and the crown is snapped off with the twisting of the flat-bone chisel in the groove. A buccal-lingual groove is placed between the roots extending below the floor of the pulp chamber. The flat-bone chisel is placed and twisted splitting the roots.
The anterior pedo forceps is placed on the distal root. The distal root is moved buccal-lingually and twisted until the path of extraction is found. You may need to remove more tooth structure to allow room for the twisting. Once the distal root is extracted, the mesial root is moved distally with the large elevator.
If the root has an acute curve, it may need to be split to allow room for its removal. The elevator holds the root in place as the #557 bur removes a portion of the protruding root. When more room is established the remaining root is removed.
A mesial root with a mesial curve is rare, but it does occur. The path of extraction is to the mesial. It would be advised to loosen this tooth with the buccal-lingual and twisting movements. The distal root is split and removed with anterior pedo forceps.
The anterior pedo forceps is placed on the mesial root. A buccal-lingual and twisting movements are used to loosen it and find the path of extraction. This is not heavy pressure. When the path of extraction is found, more pressure can be applied. It might help to remove mesial tooth structure to allow access to the mesial path of extraction.
This is not an easy extraction. You do not want to fracture the root deep in the socket and compound your problem. When the root is loose enough it will follow the path of extraction.
The root may fracture from the twisting and pulling movements and leave the apical portion of the root in place. There is not a magic formula to removing the root tip. It will require patience and time.
A trough can be placed with a #557 bur around the root to allow room for the root tip to move. A root pick is placed on the distal to work the root tip toward the path of extraction. This is made more difficult because of the small space you are working in. This is definitely one tooth you might want a specialist to handle.
It is always good to plan your extraction from the X-ray before the surgery is started. It will prevent many mistakes. Parenthesis is always a possibility, especially if the inferior alveolar nerve is in close proximity to the apical portion of the root. A specialist should be considered if there is any danger of injury to the nerve. All root picks, elevators, burs, or explorers should not be allowed to venture deep into sockets with close proximity to the inferior alveolar nerve.
There is usually a reason for the third molar to be impacted. The most common cause is the lack of room. This causes the mesial crown portion of the third molar to become locked below the distal-enamel junction of the second mandibular molar. The partially erupted third molar creates a pocket for debris and infection to settle in. A good regiment of antibiotic is necessary before the extraction procedure is started.
The X-ray shows the path of extraction will be to the distal because the third molar roots are curved distally. A painless mandibular block is given. When the lingual nerve takes hold (the tongue is numb), the tissue is anesthetized from the lingual to the buccal and distal. Good anesthesia is important.
The #15 blade makes an incision through the tissue over the impacted tooth. The impacted third molar is not always directly distal to the second molar. Often the impacted tooth is more buccal to it. Usually you will see the mesial part of the impacted crown projecting above the bone.
The buccal and lingual tissue flaps need to be carried to the mesial third of the second molar. If the flap is carried far enough to the distal and mesial of the extraction site, you will not need a relief tissue incision. The alveolar bone needs to be exposed on both sides of the impacted tooth.
The single-rooted impacted mandibular molar is not a difficult extraction. The root is usually distal. Enough bone needs to be removed over the impacted tooth to expose the crown and three millimeters of root unless the tooth is nearly vertical. The X-ray shows the crown portion of the impacted tooth needs to be free of the second molar before the tooth can be extracted to the distal.
Using the #557 bur, the bone is removed and a buccal-lingual groove is placed in the crown portion of the tooth. This groove needs to go deep, but you do not want to leave the tooth. The groove will start at the distal edge of the crown and go straight down through the pulp chamber, and into the mesial portion of the tooth. The groove should extend buccal-lingually a fair distance. A flat-bone chisel is inserted into the groove and twisted. The crown portion of the tooth will fracture off.
If the groove is deep enough, the fractured-off portion of the crown can be removed with a root pick or periosteal instrument. This will leave you with a four to six millimeter space to work the remaining tooth out. You may need to remove more of the tooth to work the impacted tooth free of the socket.
Using a periosteal or root pick, the remaining root is eased forward and up. A trough can be placed with a #557 bur on the impacted root at the distal bone-cement margin. An elevator can use this trough for leverage to move the root forward. The path of extraction is forward and up.
A root pick can be placed in the socket next to the mesial side of the root. Easy movement of the root pick can rock the tooth upward. Using the two positions for leverage, the remaining root can be eased out of the socket. Care should be exercised to avoid damage to the inferior alveolar nerve.
This is essentially the same procedure as single-rooted tooth except you have two roots requiring another groove to split the roots. The crown-fractured portion is removed exposing the bottom of the pulp chamber.
Another buccal-lingual groove is placed between the distal and mesial roots. Depending on the angle, this groove is placed more distal to reach the bifurcation. If the tooth is on an angle, the groove must be on an angle. The bone chisel is placed and the roots are fractured apart.
The trough is placed on the distal root of the impacted tooth next to the alveolar bone. An elevator is inserted and pressure is applied to move the distal root mesial and apically (down). If there is not enough room for the extraction of the distal root in the socket, the root will need to be cut again and removed in pieces.
The mesial root is eased from the socket with a root pick, periosteal instrument, or explorer. The path of extraction will be mesial and incisally (up).
We are moving into an area that you might want to refer to a specialist before attempting an extraction of a horizontal impacted tooth. The X-ray shows a horizontal boney impacted tooth behind the second molar.
Taking an X-ray of this area can be difficult. Using a snap-a-ray to hold the X-ray film, the film is placed lingual to the second molar. The patient closes down on the snap-a-ray and then opens slightly. While the patient holds this position, the snap-a-ray and film are moved further distally. The patient bites down to hold the snap-a-ray and the X-ray is taken.
If the patient has a gagging reflex from this, you can try again when the patient is numb. If this is still a problem, the patient should hold his breath while the X-ray is being taken.
The patient is numbed with the pain-free mandibular injection followed by gingiva injections from the lingual to the buccal. The patient needs to be numbed.
Using a #15 blade, a centered incision is made to the alveolar bone distal to the impacted molar. The incision is carried forward (mesial) to the distal of the mandibular second molar.
A periosteal instrument is used to lift the tissue from the alveolar bone and tooth. If the tooth is not exposed, you will not find the normal thick tendon-type tissue. The tissue flap should be large enough to expose enough bone to extract the crown portion of the impacted tooth. If the flap is taken forward to the mesial third of the second molar, you may avoid a vertical relief.
The tissue covering the alveolar bone on the lingual side of the mandible is very thin. Extra care in this area will avoid tearing the tissue. You will find the tissue very easy to separate from the alveolar bone. It does not take heavy pressure. A heavy hand in this area may send the periosteal instrument slipping deep into the floor of the mouth.
Using a #557 bur and water, the alveolar bone is removed from the occlusal surface to expose the crown portion of the tooth. Three or four millimeters of bone distal to the second molar should be preserved to keep the second molar intact.
The impacted tooth may be buccal to the midline. When the tooth is found, the remaining bone covering the crown portion is removed. The further distal you take the tooth exposure, the deeper the bone becomes.
You do not need to uncover the root of the tooth. The impacted tooth will be split and removed in parts. A groove is placed at the cementum-enamel junction. It needs to be deep enough to insure a good split. A flat-bone chisel is placed in the groove and twisted. The crown portion splits off leaving the impacted roots.
Impacted teeth are usually already loose. If the split is good, the crown portion moves easily with a root pick or periosteal instrument. If the alveolar bone opening is too small to extract the crown portion of the tooth, the crown portion of the tooth can be split again with a groove mesial-distally, or the alveolar bone opening can be enlarged. The second split preserves the alveolar bone. The alveolar bone exposure should attempt to preserve bone on the buccal and lingual. It is always better to split the crown portion of the tooth a second time.
When the crown portion of the tooth is extracted, a small trough is placed on the distal portion of the impacted root where the root meets the alveolar bone. This gives you a leverage point for the root pick or periosteal instrument to move the root toward the mesial. The root should move easily.
If the root seems to be difficult to move, the path of extraction is slightly different than the one you are using. Create another leverage point, and apply pressure. When the correct path of extraction is found, the root moves easily.
The root may need to be split a second time to retrieve the root through the alveolar bone exposure. Another groove is placed on the root at the alveolar bone margin. The root pick is inserted to hold the root while the bur groove is being placed in the exposed root. The root is sectioned with a twist of the flat-bone chisel and another portion of the root is removed.
The remaining portion of the root is easily removed by slipping the root mesially. The area is aspirated. The sutures are placed to hold the tissue flaps in place. A few minutes of holding the tissue against the alveolar bone will help the tissue to reattach.
This is another extraction you might want to refer to a specialist. The approach is similar to the horizontal bone impaction. The only difference is the positioning of the tooth. The crown portion of the tooth lies close to the thin buccal alveolar bone. Instead of splitting the crown portion of the tooth off, you make two splits after the root is exposed. The alveolar bone is removed similar to the mesial-distal horizontal impaction, except the root is exposed opposed to the crown portion of the tooth.
The first groove is placed through the exposed portion of the root (lingual), and the second groove is placed through the exposed portion of the crown at the cementum-enamel junction (buccal). The flat-bone chisel is placed and twisted in both grooves. The exposed portion of the root is retrieved through the alveolar bone opening. You may need to make another split in the remaining root and crown portions of the tooth to retrieve them. It is always better to reduce the size of the tooth you are retrieving and conserve alveolar bone tissue.
The roots and crown portions move very easily. The encapsulated tissue around the impaction allows room for the tooth to be extracted.
Most post-operative problems can be avoided by not allowing the patient to leave the office until the patient is swallowing normally and the bleeding has stopped. Then once the patient is home, a phone call should be made to see how the patient is doing. This will stop the late- night emergency phone calls and visits.
The patient should bite on something soft on the opposite side of the mouth. This will keep the teeth apart in the surgical area and relieve the pain. A mild pain reliever (Tylenol) is all that is usually needed.
patient rinses with salt water, peroxide, or does not swallow his saliva. The liquid re- moves the blood clot and leaves exposed alveolar bone behind.
If the patient ceases the above activities, the pain will usually stop. If the pain continues, then a new clot must be created. This can be accomplished by curetting the surgical site creating a blood flow in the area. A two-by-two is held over the site to allow the blood to clot. This can be repeated the next day if it becomes necessary.
If the pain continues, the surgical site can be reopened, curetted to insure a good blood supply, and sutured. This usually stops the pain. The patient will also realize that it is not in his best interest to rinse the area.
Some specialists believe the use of reabsorbed sutures will reduce the incident of a dry socket. The idea is to protect the blood clot. All healing comes from the blood supply that forms the blood clot.
The patient is instructed to hold the two-by-two gauze over the site and squeeze the tissue together. If this is not working, the patient will need to return to the office.
If you see a dripping blood clot, you will know the patient has been rinsing the site. The dripping blood clot is wiped from the surgical site. A two-by-two gauze is placed and squeezed against the site. This is held until the bleeding stops.
If the site is bleeding profusely, you can assume the patient tore a suture or injured the site. This usually happens when the patient tries to eat while he is numb. Holding a two-by-two and squeezing it in place will stop the bleeding.
The supernumerary teeth usually lay lingual and apical to the anterior maxillary (eight and nine) central teeth. There can be one supernumerary tooth or two supernumerary teeth placed together in opposite directions. They can be impacted in a close approximation with the central roots or be impacted further posteriorly in the palate. Occasionally they are impacted labial to the central roots.
Usually a raise in the boney palate will indicate where the supernumerary is located. If there is no rise in the bone, then the supernumerary is located with a series of three X-rays. If the supernumerary appears to move some distance side to side in comparison to the central roots, then the supernumerary is on the labial. If the supernumerary appears to remain in the same location between the central roots, then the supernumerary is on the lingual.
The question of when to take the supernumerary tooth out is important. They are usually dis-covered early in the child’s development. They are not causing the child any pain. The main concern is the developing maxillary incisors.
Personally I feel the permanent central incisors need to be fully developed before the super-numerary is removed. There is always the chance the surgery will interfere with the continued growth of the roots. Any displacement of teeth resulting from waiting can be corrected later with orthodontics.
The pain-free infiltration injection is given followed by the blanching technique. This will numb the area. An anterior palatal block can be given after the blanching injections to insure numbing. This block should not be given straight into the incisive canal. The possibility of picking up a vessel or injuring the greater palatine nerve can be avoided by placing the injection on the bone beside the canal. The anesthetic will infiltrate to the site and numb the greater palatine nerve.
The blanching technique should be carried past the maxillary cuspids on each side of the mouth. Using a periosteal instrument, the tissue is retracted from the palatal bone from cuspid to cuspid. Care should be taken in the incisive canal area to avoid injury to the greater palatine nerve. This area can be avoided since the supernumerary is usually located anterior to the canal.
The supernumerary will appear as a rise in the palatal bone lingual to the maxillary roots. Usually a portion of the crown is exposed above the bone.
A #557 bur is used to remove the bone and expose the crown and part of the root. The more distal you take the bone opening, the thicker the bone becomes. A slight bur groove is placed below the crown portion of the supernumerary tooth. A root pick is placed and pressure is applied. Occasionally the supernumerary will move, but usually the larger crown portion of the supernumerary tooth is wedged in the bone.
The bur groove is deepened. The flat-bone chisel is placed and twisted. The crown snaps free of the root. The crown portion is eased from the socket with a root pick. The root is eased into the space created by the removal of the crown. A leverage point may be needed to ease the remaining smaller root forward into the larger crown space.
Two supernumerary teeth are sometimes easier than one. The procedure is the same as for one supernumerary tooth. Usually you do not need to section them. The teeth are smaller allowing for more movement in the socket. The crown portions are reversed giving the crown of one tooth and the root of the other tooth at one end and the crown and root at the other end.
The supernumerary with the visible crown portion is extracted first to allow more room for the crown of the other supernumerary buried deeper in the bone to be extracted. A root pick or ex-plorer is used to ease the supernumeraries from the socket. This usually is an easy extraction.
When the supernumeraries are removed, the socket is suctioned clean and the sutures are placed. The suture should start at the embrasure on the lingual side, pass through the lingual tissue, through the embrasure, and into the labial tissue. The needle is reversed. The thread side of the needle is pushed back through the embrasure and tied off with the tail of the suture left in the lingual tissue. This is the basic suturing technique.
This can be extended to another tooth or several other teeth. The suture starts on the lingual by passing through the lingual tissue. The needle is pushed through the embra- sure, but not into the labial tissue. Instead, the thread encircles the tooth and the needle is pushed through the next embrasure and into the lingual tissue. A good bite of lingual tissue is taken, and the needle is reversed. The thread side of the needle re-enters the embrasure. The needle passes through to the labial side, and re-enters the original embra- sure using the thread side of the needle. The tail of the thread is found and tied off.
This can be extended to as many other teeth as you wish, but you may want to take a bite of the labial tissue to give the lingual tissue more support if you take the suture to more teeth. The suture can become loose when it is not tucked back into the tissue on the labial side.
Finger pressure should hold the lingual tissue against the bone for two minutes to achieve adhesion of the tissue to the bone. The tissue has a tendency to balloon after it has been retracted. This is a relatively pain-free procedure during and after the surgery.
The cuspid is impacted in bone. The orthodontist wants to attach a bracket on the tooth, and pull the tooth into occlusion with a spring wire. The cuspid may be impacted in labial alveolar bone above the deciduous cuspid, or it may be buried deep in the palatal bone.
Usually the alveolar bone is protruding over the cuspid on the labial making it easy to locate. Palatally impacted cuspids are more difficult. Sometimes the tissue is raised where the cuspid is partially erupted in the palatal bone.
X-rays can help in locating palatal cuspid impaction. A two-inch film of the palatal can give a good indication of where the cuspid is located. The orthodontist requesting the surgery has head X-rays and a panorax of the teeth. All of these should position the cuspid for you. The surgical procedure will vary according to the position of the cuspid.
Instruments Needed
A cuspid impaction in the labial alveolar bone above the deciduous cuspid is exposed with a labial flap. A vertical incision is placed with a #15 blade from the distal portion of the lateral incisor through the gingiva and slightly into the mucosa. It is good to avoid the vessels in the mucosa if possible. This incision or the tissue flap my need to be extended if the cuspid cannot be reached easily.
The location of the labial gingiva incision is important for the closure of the flap. The start of the incision needs to be on the distal portion of the lateral tooth to avoid the embrasure. The flap can be sutured to the gingiva attached to the lateral tooth before the thread is taken to the lingual. It makes a nice finish for the flap and adds strength to the closure.
The #15 blade releases the gingiva in the embrasure. Two periosteals are used. One periosteal holds the tissue and gives tension to the flap. The other periosteal eases the gingiva and mucosa off the alveolar bone.
When the flap reaches the crown portion of the cuspid impaction, it can stop. The bone is removed over the crown portion of the cuspid with a #557 bur and water. There is usually an envelope of tissue separating the tooth from the bone. Using a little care, injury to the cuspid can be avoided during the bone removal. If this becomes a concern, a periosteal can be placed between the bone and the tooth.
The crown does not need to be fully exposed. You are only interested in placing the bracket. The exposed crown is dried and the bracket is luted on. The gold chain attached to the bracket extends below the tissue to the cuspid site and is attached to the orthodontic arch wire.
The impacted crown is exposed by using a large round bur to remove enough of the bone to place the orthodontic bracket. The flap of tissue over the exposed crown is removed with a pair of scissors where the crown protrudes to allow the bracket to be placed outside the tissue flap. The bracket can be placed now or later after the flap has been closed.
The flap is sutured to the gingiva next to the lateral. Instead of cutting the suture, the suture is extended to the lingual through the embrasure. The needle takes a bite of the lingual tissue and re-turns back through the embrasure thread end first. The suture is tied off with the tail of the thread and cut. Another suture may be needed to hold the flap to the gingiva.
This suture is placed at the distal embrasure to bring the tissue up tight to the bone. The needle takes a bite of the flap, and passes through the embrasure to the lingual. The needle takes a second bite of lingual tissue and returns to the labial via the embrasure. The tail of the suture is found and the thread is tied off.
When you are finished, the crown portion of the impaction is exposed above the tissue with a bracket luted on. The tissue flap is held against the bone a moment to encourage the tissue to adhere to the bone.
A two-by-two X-ray will help locate the impacted tooth. Occasionally the impacted tooth may be partially protruding from the bone, or the impaction is causing the bone to protrude over it. Usually the impaction is lingual to the lateral and central incisors. Fortunately the crown portion of the impaction is usually near the surface of the bone or protruding from it.
The incisors are anesthesized with the painless infiltration technique on the labial. The blanching technique takes the anesthetic to the lingual. The incisive canal and the naso-palatine nerve are located. The blanching technique takes the anesthetic to the area. The needle is placed to the bone beside the incisive canal and aspirated. The anesthetic is given slowly. You might still be in a vessel.
The tissue is retracted after it is cut loose from the embrasures with a #15 blade. Two periosteals are used to ease the flap off the bone. A rise in the bone will indicate the location of the impaction. If there is no rise in the bone, then your best calculation of its location will suffice. An exploratory opening is placed in the bone with a #557 bur to locate the tooth. Usually you will open into a tissue sac surrounding the impaction.
When you are certain of the position of the impaction, the crown portion of the impacted cuspid can be exposed for the bracket. The chain attached to the bracket is extended in the direction the orthodontist wants the tooth to move. The gold chain goes under the tissue and comes out of the tissue at the arch wire location the orthodontist desires. The chain is tied off and the flap is sutured. The tissue is held in place for a few minutes to allow the tissue to begin its re-attachment process.
Instruments Needed
This can be a difficult tooth to extract. The pain-free infiltration injection technique is given to numb the tooth. The blanching technique is used to numb the lingual. It is good to take the numbing low on the lingual root.
The maxillary posterior molar is usually three-rooted. The two buccal roots are smaller and curve toward each other. The single lingual root is larger and curves toward the buccal.
A periosteal instrument is used to free the gingiva around the tooth. The alveolar bone around the buccal roots needs to be exposed. A maxillary molar forceps is placed over the tooth and pressure is applied (back and forth) buccal and lingually. A periodontal-involved tooth will move some distance and may be extracted if the path of extraction is found.
The roots in sound alveolar bone tissue will move only slightly. You will be splitting the tooth. The more movement the tooth makes, the easier will be the root extraction. A fair amount of pressure is applied to move the tooth buccal-lingually, but you are not trying to extract the tooth.
Once the tooth is slightly loose, the crown portion of the tooth is removed. This is done by placing a horizontal groove in the crown portion of the tooth a few millimeters above the gingiva tissue with the #557 bur. If a flat-bone chisel is placed in the groove and twisted slightly, the crown will pop off.
If only a part of the crown comes off with the twisting of the elevator, another groove is placed. This is done until the crown is removed. You want to leave enough tooth structure above the tissue to give the pedo-anterior forceps leverage.
The lingual root split is done next. A groove is placed mesial-distal through the center of the tooth with a #557 bur. The groove needs to go through the floor of the pulp chamber to be effective.
The groove does not need to endanger the tooth on the mesial or distal side of the extraction. A small amount of tooth structure can remain. It is the groove through the floor of the pulp chamber that is important. It needs to separate the buccal roots from the lingual root.
If the groove is too short, the lingual split will leave part of the lingual root attached to the tooth and the technique will not work. If the groove is too far lingually, the lingual split will fracture off a portion of the lingual tooth structure and leave the lingual root imbedded in the alveolar bone. If the groove is too far to the buccal, you will fracture off the buccal plate leaving the lingual attached to the buccal roots.
When the groove is correctly placed, a flat-bone chisel is placed in the groove and twisted. The tooth will fracture and separate the lingual root from the buccal roots. A pedo-anterior forceps is placed on the lingual root. A slight twisting action will tell you the separation is made.
If you find a loose piece of tooth structure in your forceps, you can assume you misplaced the mesial-distal groove. You will need to expose more tooth structure in the groove area and attempt to place another groove. The lingual root needs to be separated from the buccal roots. You will separate it now, or you will separate it later. Note again where the lingual root is located. If the fracture piece is from the lingual, you can assume the first groove was too far lingually.
Place the second groove deeper and more to the buccal. Using the flat elevator, the lingual root is split from the buccal roots. Place the pedo-anterior forceps on the buccal roots. If you note movement in the roots, you can assume the split is made. If the lingual root is not split off from the buccal roots, you will not be able to split the buccal roots correctly.
Lower the tissue on the buccal and note where the buccal roots enter the alveolar bone. The next groove will go between the buccal roots. Care should be taken to avoid injury to the buccal alveolar bone when this cut is made. The groove should go below the bifurcation if possible.
The flat-bone chisel is placed in the groove and slightly twisted. A cracking noise will tell you the roots are apart. If the groove was not placed deep enough or in the correct position, a piece of tooth structure will fracture off leaving the roots attached. Another groove is placed taking the groove deeper in the correct position.
Using the small and large elevators, the mesial root is moved distally. If the roots are curved, you may need to remove more tooth structure before the mesial root can be extracted. Care should be taken to avoid snapping the fragile buccal roots. This is all easy pressure. The pedo-anterior forceps is used after the mesial root is loosened by the elevators. The distal root is removed after the mesial root is extracted. When the path of extraction is found, the distal root can be lifted from the alveolar bone.
Possible Problems
This should be an easy extraction after the buccal roots are removed. Place a pedo-anterior forceps on the buccal-lingual. The root is slightly twisted mesial-distal to loosen the root and then the root is eased toward the path of extraction. This is usually toward the buccal. This root is fairly strong and can handle more pressure than the buccal roots. You can strengthen the twisting action if the root is resistant to the extraction. This will finish the extraction.
A suture for a single extraction should be a drawstring suture to bring all the tissues together. The tissues are pushed back into place with finger pressure and held for a few minutes to stop the bleeding and allow the tissues to reattach themselves to the bone.
Possible Problems
An attempt should be made to remove the root with elevators and root pick, but usually you will not find a good leverage point to work from. A trough can be placed around the tooth with a #557 bur to remove any sharp edge lodged in the bone and to give a purchase point for the elevators and picks to work from. You need to find the path of extraction and ease the root in that direction. It will usually be toward the buccal. You will need to note in the X-ray where the sinus floor is located. You do not want to be punching a hole in the sinus floor with the trenching.
A suture extends through the mesial-buccal tissue and extends to the distal-lingual. The suture takes a bite of tissue and comes back to the distal-buccal. Another bite of tissue is taken and the suture goes to the mesial-lingual where it takes the final bite of tissue. The suture draws up the tissue and is tied off. This suture will keep the tissue approximate to the alveolar bone and can be removed very easily.
The suture should be kept in place for three to four days before it is removed. A longer period does not aid the healing, but it does increase the possibility of the suture being buried in the healing tissue.
This is also an opportunity to check the extraction site.
This is the result of the extraction site losing its blood clot. This usually results from the patient rinsing with water after the extraction, surgical instruments not sterilized properly, or the doctor’s surgical skills damaging the blood supply from the bone. The bare bone can be painful. Another blood clot needs to be established by allowing blood to flow into the site. The blood does not need to come from the site. The tissue next to it can be nicked allowing the blood to fill the site. A two-by-two is placed and held until the blood starts to clot.
Give this technique a few days. If the simple process does not give a blood supply, the patient needs to be numbed. The tissue is reopened, the bone is scraped of necrotic tissue, and the patient’s blood is allowed to fill the site. The blood supply does not need to come from inside the site. Another suture is placed and the tissues are kept in place with finger pressure until a blood clot starts to form.
Using absorbing sutures tend to prevent dry sockets. This may be due to the tissue not being disturbed.
Maxillary third molar teeth with roots curving toward the buccal can be very easy to extract. Your patients will be amazed how fast you extracted this wisdom tooth. We are assuming the tooth is numbed with the painless technique. The blanching anesthetic should continue into the lingual numbing the lingual root.
The periosteal instrument is used to loosen the tissue around the tooth. This is an important step. The distal tissue can be difficult to reach. If it is not loosened enough, the tissue will tear leaving a gapping hole to repair.
The roots of a maxillary third molar usually curve toward the buccal making the path of extraction toward the buccal. It is still a good idea to test the path of extraction by placing an elevator on the mesial and pushing the tooth distally slightly. If it moves easily, then the path of extraction is to the distal. If the tooth moves, but it shows some resistance, the path is most likely to the buccal or distal-buccal.
Taking a maxillary forceps, the tooth is clasped buccal-lingually. Using moderate force, the tooth is twisted to the buccal. It will usually pop out of the socket. If the tooth does not move with moderate pressure, then the path of extraction is more to the distal. You can try again with a more distal twist.
If the tooth does not move with the buccal twist, the path of extraction is all the way to the distal. The large elevator is place on the mesial side of the tooth. The cutting edge is pushed distally. Care must be exercised at this point to avoid taking a large chuck of the distal alveolar bone with the extraction. The tooth should move distally easily.
This can be an elevator extraction, but bone conservation is important. A pedo-anterior forceps clasps the tooth and eases it out of the socket. The patient may need to close his mouth slightly to allow room for the tooth to be extracted.
The maxillary third molar occasionally exhibits a large distal root. You will not be moving this tooth distally without taking excessive amounts of alveolar bone with it. Ideally this tooth should be sectioned and removed in two parts, but the location makes this very difficult. The buccal-lingual movements should be continued. Often the tooth can still be extracted with a buccal twist. This is not brute strength to force the extraction. This is only a loosening technique before sectioning the tooth if it does not come off easily with the buccal twist.
A horizontal distal-mesial cut with a #557 bur on the lingual side of the tooth a few millimeters above the gingiva will begin the sectioning. Place a flat-bone chisel into the groove and slightly twist it. This will remove the crown portion of the tooth. Another groove is placed buccal-lingually between the mesial and distal roots. The groove should extend through the pulp chamber floor. A flat-bone chisel is placed in the groove and twisted slightly. This splits the distal and mesial roots.
Place the pedo-anterior forceps buccal-lingually over the mesial root and ease the root toward the buccal. This should be the path of extraction. The distal root is eased toward the mesial following the path of extraction. You may need more room to remove the distal root. This can be gained with bur cuts on the crown portion of the distal root.
Any of these procedures can fracture a root leaving it in the alveolar bone. If the tooth is loosened before the extraction, the removal of the roots will be easier.
It is a question of light in this area. If you can see it, you can do it. The mirror reflecting the overhead lights helps. Some offices use a light filament from their hand piece to see better. Small root picks and explorers are the instruments of choice for third molar root tip extractions. You keep moving the root tips until you find the path of extraction. It takes patience and time. Once the roots are loosened, a good suction tip will extract them. This can be very hard or relatively easy depending on how loose the root tips are.
The maxillary third molar root tips are very fragile and very small. They fracture very easily. It is best to always find the path of extraction in the loosening of the tooth before any pressure is applied to extract them. Then if a fracture occurs, the root tips are loose, and easier to extract.
If you hear a cracking noise during the extraction process, the alveolar bone distal to the tooth is fractured. The piece is removed with the tooth and the tissue is sutured into place. The alveolar bone distal-buccal to the maxillary third molar is usually very thin, and subject to a fracture. The tooth is eased out of the socket. It does not take brute force.
The buccal twist will extract this tooth most of the time, but the pressure is being applied to the thicker buccal bone. The distal-buccal or the distal path of extraction needs to be done with a lighter hand.
The all-elevator approach to extracting a locked maxillary third molar toward the distal will give you fractured root tips and fractured alveolar bone. This procedure is not brute force. When the tooth will not move with moderate pressure, the path of extraction is not correct.
The most difficult tooth to extract is a decayed root-canaled maxillary molar with its roots in the maxillary sinus. Root-canaled teeth are extremely brittle. They cannot take even medium pressure without fracturing. It is very easy to find yourself with a fractured root perched in the maxillary sinus. Any excessive pressure will punch the root tip on through the thin alveolar bone and into the sinus.
You need to establish a relationship with a specialist before attempting to remove a root tip in this situation. The root tip can be eased out of the sinus, but the chance to punch it on through is extremely high.
The root tip is held in place because it remains too large to push on through. If the root continues to fracture, this can change very quickly. If the root tip punches on through the alveolar bone, it is best to close up the site and refer the patient to a specialist. To retrieve the root once it has punched on into the sinus, you will need to place a window in the sinus above the cuspid, or, if you are lucky, you can retrieve it through the sinus opening already established by making the opening larger with a #557 bur.
The patient should be informed of this possibility before the surgery begins. The more root extending into the maxillary sinus, the more is the likelihood of losing the root tip in the sinus. A good initial distal-mesial split through the floor of the pulp chamber after the tooth has been loosened helps to prevent the problem, but the possibility of a lingual root fracture is always present. A patient with an extremely large sinus with an extremely thin alveolar bone around the maxillary tooth should be referred to the specialist.
Post-Operative Instructions
A man in his late thirties came into the office with toothache in the upper left maxillary molar. He complained of his left sinus draining into his nose and throat. This caused him to blow his nose constantly.
X-rays were taken. Upon inspection the crown portion of the tooth was badly decayed. The pulp chamber was exposed. A major attempt was made to establish the root canals, but they had closed off preventing root canal therapy. The non-vital tooth was extremely brittle from drying out over a period of time.
This left extraction as the only option to relieve the man of his pain and sinus problem. The maxillary sinus was extreme large. The alveolar bone was paper thin on both sides of the tooth and enclosed the roots. The tooth could not be moved with the forceps. The periodontal membrane was paper thin or nonexistent.
The mesial-distal groove was made, and the flat-bone chisel was placed. The chisel was twisted, but the lingual root would not budge. The groove was extended taking it through the tooth. The flat chisel was tried a second time. This resulted in fracturing the lingual root separating it from the buccal roots.
A groove was placed between the buccal roots. The flat chisel was placed and twisted. The buccal roots fractured. The groove was deepened to insure the split was made. Pressure was applied and the buccal root fractured deeper.
The tooth had not moved in any of these attempts. Now all three separated roots remained in the sinus with a very thin layer of bone around each of them. It was obvious that the alveolar bone would come with the extraction of the roots.
The patient was referred to a specialist. The roots were extracted by the specialist, but the sinus was exposed in the process. A gold foil was placed over the large sinus exposure and the tissue was sutured to close the site. Usually the gold foil would remain until the sinus tissue closed the exposure from the inside, and extruded the foil to the surface of the site. The gold foil could then be picked out of the tissue.
In our case the patient continued to cough. He attempted to remove the drainage against better advice. This dislodged the foil from the site. It had to be replaced three times before the man finally cooperated.
Referring this problem patient prevented a possible suit. He received the best medical treatment available for a very difficult extraction for a very difficult patient.
Today the treatment of choice for a sinus exposure is to close the site and allow the sinus membrane to heal itself from the inside. You may need to relieve tissue on each side of the site to achieve an adequate closure.
This can be done with a vertical flap through the attached gingiva. Using the tissue from the buccal or lingual side, the site is closed. The tissue on the buccal side is thinner and easier to work with. It may be enough to achieve the closer.
Using a #15 blade, two vertical incisions are made through the gingival. One is on the mesial and one is on the distal side of the extraction site. The vertical flap is eased off the bone with the two periosteal technique. The loose vertical flap is lifted over the site and sutured to the lingual side. The tissue flap may need to be straightened with scissors to make it fit snug. If more tissue is needed, a vertical flap is made on the lingual. It is important the sinus opening is closed tightly.
Another way to accomplish this is to place parallel mesial-distal incisions in the attached gingiva just above the mucosa on both sides of the site. The gingiva tissue is loosened to the incision with a periosteal instrument. The loose tissue closes the site, and sutures are placed.
The patient is placed on a good antibiotic therapy to cover the potential of infection. He should be warned against coughing and blowing his nose. This will aggravate the site by putting pressure on the closure.
With good patient cooperation, the site usually heals completely with no complications. If the site is extremely large or the patient is not cooperating completely, the gold foil technique should be considered.
This is usually a full-denture or partial-denture case. The teeth may be fractured, decayed, in solid bone, or periodontally involved. Some of the teeth may be below the tissue. If this is a periodontic case, the teeth will be relatively loose, but the tissue will be full of granulation tissue. If the teeth are worn and exposed, the teeth may be dry and brittle. The periodontic ligament will be very thin making the extractions difficult.
I would restrict the extractions to quadrants. This will allow time for problems and not overdose the patient with anesthetic. You want to restrict the anesthetic well below the toxic level. The type of anesthetic you are using will dictate this.
It would be helpful if you could put the patient through four quadrants of scaling and curettage before extractions to clean up the tissue. This is difficult to sell when the patient is interested in a denture.
Tissue with granulation absorbs a large amount of anesthetic and the excessive bleeding takes the local anesthetic out of the tissue. This requires you to work quickly and keep your surgery site small. You do not want to extract more than a quadrant of teeth at one sitting.
The site is numbed with nerve blocks, infiltration and blanching techniques. You can expect the granulation tissue to absorb a large amount of the anesthetic. The anesthetic should be taken as deep as possible around the loose teeth to ensure anesthesia and to control the bleeding.
The teeth are extracted in the order of taking the tooth most distally first. This leaves the site clean for the anterior teeth. If the bleeding is extensive, the extractions should be restricted to two or three teeth. Once the bleeding is controlled, and the sutures are placed, the next three teeth can be extracted. This keeps you from being overwhelmed. The bleeding is controlled by removing the excessive granulation tissue.
The tissue is eased off the alveolar bone around the sockets with two periosteal instruments. One periosteal holds the tissue while the other one eases the tissue off. You are making an envelope flap in a sense. The granulation tissue is removed with the scissors. More tissue may need to be removed to give you a good closure.
The bone is smoothed by easing a bone file into the enveloped flap and pulling the blades across the bone. It may require a large #2 round bur to remove excessive bone. Move your finger over the loose flap. If you feel a sharp ridge, you need to file the bone more to make it smooth for the denture.
The tissue on the buccal and lingual sides is brought together. If the tissue alignment matches, the suturing can begin. If the tissue alignment is off, you should use the scissors to correct it.
The suturing can be done several different ways. Only the basic single thread suturing will be discussed here. The suturing should start midway between the ends of the flap.
The needle takes a bite of the buccal tissue at the midpoint of the flap. The tissue and needle are brought to the lingual. A bite of lingual tissue is taken and the thread is tied off. The second suture is taken at the next midpoint either on the distal or mesial of the first suture. The single suturing continues from midpoint to midpoint. This will keep your flap straight.
When the suturing is complete, the flap is held in place with a two-by-two gauze and finger pressure. This allows the tissue to begin its adhesion to the bone.
When the first three teeth are under control, the remaining teeth can be extracted in the quadrant. The bleeding can be controlled by removing the granulation tissue. An envelope flap is made and the bone is smoothed with a bone file. The sutures are placed and the flap is held in place with a two-by-two gauze and finger pressure.
No matter how much you smooth the bone after the extraction, the site may still heal with sharp edges of alveolar bone pushing into the tissue. This seems to be more prevalent when granulation tissue is present and the alveolar bone is fragile.
This is the result of the reabsorption process of the infected bone. The thin and thick alveolar bone reabsorbs at different rates leaving behind sharp edges of bone. This will require laying a tissue flap at a later appointment and removing the sharp edges before the denture can be constructed.
The submandibular tori is a growth of bone on the lingual side of the mandible. It is usually located lingually between the cuspid and first molar teeth on both sides of the mouth. The start of the tori can be detected when the patient is four of five years old and continues to grow in the patient until it is removed.
The growth is at the base of the tori. The bone is pushed out from the alveolar bone. The blood vessel and nerves usually do not occupy the tori making its removal easier. The tori can grow to be very large occupying the floor of the mouth.
The tissue over the tori is stretched very thin. A slight injury from a denture or partial does not heal well because of lack of blood supply to the area. To avoid this problem the tori is usually removed before a denture or partial is constructed.
The tori has no adverse complications to the patient other than its size. It usually is not removed unless it is extremely large or you are contemplating placing a denture or partial denture.
The patient is numbed with the inferior alveolar block along with the infiltration and blanching technique. You need to numb the buccal enough to place a suture on the buccal portion of the flap. If teeth are still present, the blanching needs to be taken into the embrasures.
The #15 blade is used to place an incision distal-mesial on the alveolar ridge. If teeth are involved, the embrasures need to be released with the blade. The tissue is eased from the alveolar bone using the two periosteal method. One periosteal holds the tissue while the other periosteal works the tissue loose from the alveolar bone keeping the blade side to the bone.
Care needs to be exercised when the thin tissue is removed from the tori to avoid placing a tear. You want to end up with a long envelope flap. A relief vertical incision might be needed in the central incisor area to avoid taking the flap to the non-numbed side of the mouth. The tori must be worked clear of the tissue.
A periosteal with a wide spatula is placed between the bone and tissue. A number two large round bur is used to reduce the boney tori. The flat periosteal protects the tissue during the bone removal. Use plenty of water to avoid burning the bone and reduce the bone to the desired shape.
When the reduction is completed, you should run your finger over the closed flap to check for any sharp spots on the bone. Usually you will pick up one or two sharp points at the floor of the mouth. If the bur is too large to smooth the bone in this area, a bone file can be used. The cutting teeth of the file work by pulling the file toward you. The file is eased into the flap to avoid tearing a hole in the tissue.
The tissue envelope is sutured to the buccal gingiva. In the edentulous area the needle takes a bite of the tissue at the center of the envelope and brings the lingual flap to the buccal tissue. A bite is taken of the buccal tissue and the thread is tied. The second suture is placed between the end of the flap and this suture. Each suture is placed at the center of the remaining open flap. The idea is to always place the suture in the center of the remaining envelope flap until the envelope is closed. This will give you an even displacement of tissue along the envelope flap.
If teeth are involved in the envelope flap, the flap is closed at the distal of the last tooth. The flap of tissue is brought up to the teeth matching the embrasures. Next, the needle takes a bite of the lingual flap at the embrasure, moves through the embrasure, and takes a bite of the buccal tissue. The needle is reversed, and the thread side of the needle returns through the embrasure. The tail of the thread is found and the suture is tied off. The reverse side of the needle (thread) prevents damage to the thread already in the embrasure. Sometimes it helps to take the needle all the way through the tissue before entering the embrasure with the needle. Your angle can be more acute making the passage easier through the embrasure.
If more then one tooth is involved, the suture is taken to the next embrasure rather than return through the same one. A bite of the lingual flap is taken and the needle returns through the em-brasure thread side first. Returning to the original embrasure the needle passes through thread side first and is tied with the thread tail.
Several teeth can be involved in this type of suture, but the risk of having a loose suture increases with the number of teeth involved in the suture. It does not hurt to tie off after two or three teeth.
When the suture is completed, a two-by-two gauze is placed over the surgery site. Finger pressure is applied to the lingual side of the flap for a few minutes. This will press the tissue to the alveolar bone and help the tissue to reattach. It will also stop any bleeding from the tissues.
A patient came into the office requiring a tori to be removed on the lingual of both sides of the mandible. The tori prevented him from wearing his mandibular denture. He was numbed with the inferior alveolar injection and the infiltration and blanching technique. The surgery went very well. The sutures were placed. The patient was given the post-surgery instructions and sent home.
Two hours later the patient called back complaining, “The sutures had come untied.” He was brought back to the office. Sure enough, all of the sutures were untied and laid perfectly across the tissue except one. The closure had split open and some of the tissue was torn.
The patient said all he did was rinse with water because his mouth was dry. He was corrected in his home care and the sutures were replaced. My assistant suggested the patient probably tried in his denture after the surgery was completed.
Upon further questioning, the patient admitted he had tried in the mandibular denture to see how it would fit after the surgery. The normal pain he would have felt was not there because he was numb. The tissue was opened and the sutures received undue pressure.
Fortunately, the sutures became untied instead of tearing the tissue. The tissue was fragile in this area. It was difficult to place tight sutures without tearing the tissue. The sutures were doubled knotted this time around.
The patient called two days later complaining of pain. He said the sutures had come out again. This time the sutures were gone. When he returned to the office, he had lost ten square millimeters of tissue, leaving denuded bone over the lower right bicuspid area.
The bone was in the early stages of new tissue growth. The area behind this had a loose buccal flap of tissue being pushed off the alveolar bone where the surgery was not done. When the patient said he could lift the tissue with his tongue, I realized the problem. The patient had been pushing the tissue and sutures loose with his tongue. He said all he was doing was shoving his tongue forward and proceeded to demonstrate.
This is a growth of bone at the posterior portion of the hard palate. Usually this is not removed unless it is very large or it interferes with a denture. The tissue over the growth of bone is very thin making it subject to injury when a denture is placed.
Prior to starting the procedure an impression should be taken for the plastic splint. It should be made to fit in the surgery site after the tori is removed. This will keep the tissue tight against the bone after the sutures are placed.
The patient is numbed with an injection beside the greater palatine foramen. It is good to avoid a direct injection into the foramen and damaging the greater palatine nerve. The foramen can be found on the hard palate with finger pressure distal-lingual to the second molar.
A direct injection into the palate can be painful. A more indirect approach might be better. A painless infiltration injection can be given on the buccal side of the upper right and left second molars. Using the blanching technique, the injection can be taken to the lingual and the greater palatine foramen on each side. It is not necessary for the needle to penetrate directly into the greater palatine foramen. A close proximity to the foramen will achieve the desired results.
Using a #15 blade, an incision is made distal-mesial across the center of the tori and extended beyond the tori six or more millimeters on both sides. You should avoid extending the incision into the soft palate.
Relief incisions bisect the first incision at the center of the tori and extend toward the lingual side of the maxillary molars. This relief incision seldom extends more than a few millimeters from the boney tori. Essentially, you will have two incisions creating a “T” across the center of the boney tori. The two-periosteal technique is used to ease the tissue off the tori. The tissue is very fragile. The tori needs to be fully exposed. You may need to extend the relief incisions. You will want to avoid cutting the vessels near the greater palatine foramen.
A #2 round bur is used to remove the tori using plenty of water. A bone file is used to smooth the sharp boney edges left by the bur. There are usually no vessels in the tori. If you start to find vessels, you are passing the tori.
When the tissue flaps are closed, run your fingers over the site to find any sharp edges and to evaluate the reduced tori. You are only interested in making the palate smooth. A small rise of tissue is acceptable.
Sutures are placed drawing the tissue together. You usually do not need to remove excess tissue to align the flaps. The stretched tissue seems to shrink upon being excised. The tissue is pressed to the bone with the plastic appliance made before the surgery started. The appliance remains until the patient returns for the suture removal.
The sutures are usually removed four to five days after the surgery. The site is evaluated. Usually the tissue is snug to the bone and the appliance can be removed. The tissue would eventually adhere to the bone without the appliance, but it will take more time and not heal as well.
This is the removal of the apical portion of the root (tooth) with surgery. It is usually done in conjunction with root canal therapy and you wish to remove the apical periodontal cyst (sac) attached to the root. The dense squamous cell cyst usually contains fluid and cholesterol-filled lumen.
If it is a periapical granuloma, the cyst will consist of granulation tissue, endothelium-lined capillaries, proliferating fibroblasts, and delicate collagen fibers. You will find lymphocytes, plasma cells, lipid-filled macrophages, and cholesterol spaces.
The patient is covered with a regimen of antibiotics before the surgery is started. This avoids excessive swelling after the surgery is completed.
The painless infiltration method of injections is given. The blanching technique should take the anesthetic to the lingual and into the hard palate above the tooth where you are doing the apioectomy.
The #15 blade places a vertical incision on the labial gingiva mesial to the surgical site keeping the incision mesial to the embrasure. This will give you good visualization of the surgical site. The incision should extend through the hard gingiva and slightly into mucosa above the gingiva. This incision can extend further into the mucosa if the procedure warrants it to reach the apical portion of the tooth. Care needs to be taken to avoid the blood vessels in the area.
The embrasures are released with the #15 blade distal to the incision for at least two teeth. If the tissue flap needs to be larger to accommodate the surgery, additional teeth may be involved.
The two-periosteal technique is used to ease the tissue from the alveolar bone to reveal the surgical site. A root canal file is measured against the X-ray to determine the length of the tooth. The measure file is placed in the surgical site to determine the location of the apical portion of the root. If the tooth has been draining fluid, the site will be evident. The bone will be soft and easily curetted.
The #557 bur removes the alveolar bone in this area. The goal of the surgery is to remove the apical portion of the root, curette out the cyst, and seal the gutta-percha in the canal or canals. The bone cut should start a few millimeters incisal to the apical end of the root. The flat periosteal is used to hold the tissue away from the #557 bur. When the root is located, the bone can be removed more apically to reveal the cyst.
Usually the cyst wraps around the apical portion of the root and extends incisally several mil-limeters. The entire cyst’s fibrous capsule needs to be removed from the site to prevent the cyst from reoccurring. A small surgical spoon is used to ease the cystic material from the site.
The portion of the root extending into the cyst is removed with the #557 bur angled toward the incisal. This allows better visualization of the canals and it is easier to place the bur in the tight flap. The cystic walls are curetted and all of the debris is removed. The gutta percha in the canal is sealed with a warm ball burnisher. The tissue flap is sutured back into position using the embrasures as guides.
The vertical incision is sutured first. The needle carrying the thread takes a bite of the loose flap. The loose flap is approximated to the firm gingiva, and the needle takes a bite of the firm gingiva. The suture is tied off, but not cut. The needle is taken through the embrasure and a bite of the lingual tissue is taken. The needle, thread first, passes back through the embrasure. The thread is tied off with the thread tail and the first suture is completed.
The vertical incision is sutured as needed to complete the closure. The remaining tissue flap is approximated to the embrasures and sutured to place using the two-tooth method or the single-tooth method. It is important to reenter the embrasures with the needle thread end first.
Sometimes it is easier to take a bite of the loose tissue flap, and take the needle all the way through the tissue before attempting the embrasure. The curvature of the needle makes it difficult to push through the embrasures at times.
A middle-aged man came into the office with a periapical cyst on the lower right second bicuspid. The tooth structure of the crown portion of the tooth was good. A small decayed lesion exposed the pulp chamber and led to the infection and cyst. The cystic sac was well developed. The patient was asymptomatic.
Antibiotics were given for seven days. The open canal was closed with a small cotton ball and temporalized with cement. The patient did not experience any pain from the closure. He came back two days later for the endo-apioectomy procedure.
The painless injections were given numbing the surgical site and the lingual side of the tongue. The temporary was removed. The root canal was cleaned, enlarged, and filled with gutta percha. The patient was ready for the apioectomy.
A vertical incision was made through the gingiva over the distal portion of the lower right cuspid. The tissue between the embrasures was cut and the buccal gingiva was retracted from the cuspid to the distal of the first molar. Other than the vertical relief cut over the cuspid, it was an envelope buccal flap. The fragile tissue below the gingiva was eased from the bone until the mental nerve was revealed protruding from the mental foramen. The elasticity of the nerve allowed the tissue to be moved away from the bone three millimeters.
The surgical site was determined with a root canal file. Using a #557 bur, an exploratory hole was drilled in the alveolar bone. The periosteal instrument remained in front of the mental nerve protecting it from the drill. The vertical relief had to be lengthened to allow more room for the bur. The mental nerve could be seen in the flap. Care was taken to avoid pressure on the mental nerve when the tissue was retracted.
The root and the cyst were found. The apical portion of the root was removed and the cystic sac was curetted from the site with a small spoon. The site was cleaned and the sutures were placed. The patient’s recovery was good with no after effects.
This was a very risky surgery. Injury to the mental nerve was always a possibility. Extracting the tooth and placing a three-unit bridge may have been the treatment of choice.
Two interesting notes:
This is a surgical procedure to remove the soft-tissue wall of a pocket. The technique is not used excessively since the introduction of the reverse-bevel technique. It still has its place in the removal of gingival hyperplasia due to the drug dilantin and in the removal of necrotic tissue due to necrotizing ulcerated gingivitis.
Four quadrants of scaling and curettage need to be done prior to the surgery to remove the granulation and necrotic tissues. It will reduce the bleeding during the surgery procedure. This is not necessary for gingival hyperplasia cases.
To control the excessive bleeding, the surgery should be limited to one or two sections at one time. This is dividing the teeth into six sections instead of four quadrants with the anterior teeth being one section. The surgery results are better when the surgery is continuous across the anterior teeth.
In gingival hyperplasia cases the surgery can be divided up into fewer sections. It is still rec-ommended to keep the anterior section continuous to achieve better results.
The surgery should be kept in the attached gingiva. An opening in the mucosa is difficult to close with a periodontal dressing without excessive blood seepage.
The pocket marker is used to find the pocket depth. The cotton plier side of the pocket marker is inserted into the gingiva pocket and marker side is pressed through the tissue. This leaves a hole marking the depth of the pocket. The depth is marked on the lingual and buccal side of all the teeth being treated.
Using the periodontal knife #7 (pointed toward the incisal), a forty-five-degree angle incision is made through the gingiva tissue at the hole left by the marker.
The buccal incision is carried from the distal of the last molar to the mesial of the first bicuspid. This incision can be carried on across the anterior to include the distal of the opposite cuspid. It is important to carry the surgery across the anteriors.
The periodontal knife #8 is inserted into the inter-proximals to free the excised tissue from the teeth allowing the whole piece to be lifted off. The excessive bleeding due to granulation tissue in the inter-proximals will be reduced once the granulosa tissue is removed.
Following the marks on the lingual, the periodontal knife #7 (pointed toward the incisal) makes a forty-five-degree incision from the distal of the last molar to the distal of the opposite cuspid matching the first incision. The periodontal knife #8 is worked into the inter-proximals and the excised tissue is lifted off.
The electro-surge is grounded and the “L”-shaped tip is used to remove tissue tags and shape the remaining tissue. The aspirator is placed next to the surgery site to reduce the smell of burning tissue while the electro-surge is in use. If the angulation of the incision is good, the electro-surge is used sparingly. The electro-surge is used for clean up with the “L”-shaped tip. If you wish to use the electro-surge for the surgery, or to remove the distal molar tissue, the thin loop-shaped tip should be used.
It is always a good practice to move with the loop before cutting with it. This is essential when you are using it in difficult places to reach, such as the distal molar areas. The loop is used with a light touch. Taking more than one stroke with the loop is okay.
The wound is covered with a periodontal dressing. The powder and liquid are mixed into a thick paste. The more powder that can be incorporated into the liquid, the easier will be the manipulation of the dressing. The idea is to absorb as much powder as possible into the liquid, and roll the paste into long, narrow round strips. The long round strips of dressing are placed along the buccal and lingual side of the teeth, and pressed to place with a two-by-two using finger pressure.
The dressing is pushed into the inter-proximal with the two-by-two gauze and finger pressure. If the dressing is sticking to everything including the two-by-two, the dressing needs more powder incorporated into it. If the dressing is bulging over the teeth, the dressing strip is too thick and needs to be thinner. Once the dressing is in place, a Hollenbeck instrument is used to push the dressing into the inter-proximals. The goal is to cover the surgery area. It is not necessary to extend the dressing high over the teeth or beyond the gingiva.
The bite should be checked to ensure the anterior teeth can touch. The two-by-two gauze and finger pressure can contour the dressing. You may need to remove some of the excess or replace the dressing with another smaller strip. Once the dressing dries, it becomes very hard.
When the final periodontal dressing is removed, the teeth are cleaned thoroughly with an ultrasound hand-piece and a scaler to remove the hard pieces of dressing sticking to the teeth.
The gingivectomy of hyperplastic tissue due to dilantin will not be a bleeding problem, and surgery sessions can be divided up into maxillary and the mandibular sections. If the conditions warrant, the surgery sessions can be divided up into more sessions. It is important to carry the surgery across the anteriors (six to eleven or twenty-two to twenty-seven) to give a clean look to the anterior teeth.
Usually the placing of a periodontal dressing over the affected gingiva after the debris has been removed will cure the condition. If the ulcerated tissue does not clean up, then the gingivectomy is the treatment of choice.
The patient is numbed with the pain-free injections and scaling is done to remove all of the debris from the teeth left from the previous periodontal dressing. Usually the ulcerated tissue will not have gingiva pockets, and only the necrotic tissue is removed. The ulcerated tissue is removed with the number #7 and #8 knives. The inter-proximals are worked clean of the necrotic tissue, and the periodontal dressing is placed.
This surgical procedure is used to re-contour vertical bone loss around a periodontal-involved tooth or teeth, and to remove the periodontal pocket by reattaching the gingiva.
Extreme pressure from the opposing tooth or teeth-clenching results in this condition. The tooth becomes loose during clenching and tightens up when the patient stops the clenching. The movement of the tooth causes the bone around the tooth to break down leaving a vertical collar devoid of bone around the tooth. The constant movement of the tooth creates stress causing the gingiva and periodontal ligament to break down and pull away from the tooth. This allows the squamous cell epithelium to grow over the tissue preventing the gingiva from reattaching.
The object of this surgery is to lay a tissue flap to remove the vertical bone around the affected tooth and to remove the squamous cell epithelium from the tooth side of the gingiva. This will allow the exposed gingiva tissue to reattach to the alveolar bone and tooth. This procedure removes the periodontal pocket, but it will also leave the tooth with a root exposure above the tissue. The patient needs to be made aware of this before the surgery.
The following procedures are necessary before the surgery is started:
Assuming the gingiva tissues are free of granulation tissue and infection, the patient is numbed with the pain-free injections. The blanching technique takes the numbing to the lingual and buccal.
Two vertical incisions are made through the buccal gingiva and into the mucosa slightly. The blade needs to go all the way to the bone. One of the vertical incisions is made mesial to the surgical site, the other vertical incision is made distal to the surgical site. The incision is mesial or distal to the embrasure. You want to leave solid tissue to suture with later. An embrasure incision will leave narrow and thin tissue.
The reverse bevel incision is taken to the alveolar bone. It runs along the gingiva from the distal vertical incision to the mesial vertical incision two millimeters below the incisive gingiva. The #15 blade cut (pointed down) is on a fifty- to seventy-degree angle and follows the contour of the gingiva into the embrasures. The angle will vary depending on where you are in the mouth. Two millimeters of gingiva around the teeth should remain after this cut. It is important that the #15 blade extends all the way to the alveolar bone to separate the collar of gingiva from the gingiva tissue flap.
The idea is to remove the squamous cell epithelium on the teeth’s side of the gingiva. Presently the gingiva is not attached to the teeth because the gingiva is pushed away from the teeth with the growth of the squamous cell epithelium. The reverse bevel cut will remove the squamous cell epithelium and allow a new attachment of the gingiva to the bone and teeth.
The remaining two millimeters of tissue around the teeth is removed with a periodontal curette or a #8 periodontal knife. The main bleeding at this point is coming from this remaining tissue around the teeth. When this tissue is removed, the bleeding is usually controlled.
Two more vertical incisions with the #15 blade are made on the lingual side of the teeth opposite the buccal incisions. The incisions are placed through the attached gingiva and extend into the palate approximately the same distance as on the buccal side.
The reverse bevel incision runs along the gingiva from the distal vertical incision to the mesial vertical incision two millimeters below the incisive gingiva. The #15 blade incision is on a fifty-to sixty-degree angle and follows the contour of the gingiva into the embrasures. The angle will vary depending on where you are in the mouth. The #15 blade incision is not as severe for the lingual side because the tissue is thicker.
The remaining two millimeters of tissue around the teeth is removed from the lingual side of the teeth with a periodontal curette. You should be able to remove the tissue between the embrasures. All of the gingiva attached to the teeth should be removed with the curette.
The alveolar bone should be exposed around the teeth at this point. This will allow the remaining gingiva tissue to be eased from the bone with the two periosteal technique. This is not a difficult procedure if all of the (collar) tissue is removed from the teeth first. When the bone is exposed on the buccal and lingual sides and all of the gingiva in the flap area is free of the alveolar bone, you are ready for the alveolar bone contouring. A large #2 round bur is used to shape the alveolar bone around the teeth. The vertical alveolar bone should be removed leaving a good slope to the tooth. This may result in a reduction of bone in the embrasures.
The embrasures may not allow for an ideal alveolar bone shape, but a good alluvial fan shape coming out of the embrasures on each side is obtainable. Right and left bone chisels can help define this shape. By placing the corner of the chisel in the embrasure, the other edge is pressed against the alveolar bone and moved back and forth to shape the bone. The #2 round bur removes the hard areas to reach with the chisel. A light touch with the bur can contour the bone quickly. The bone is finished off with a bone file to smooth over any rough edges.
The flap is approximated to the bone. The loose gingiva flap is pushed into the embrasure and trimmed as necessary to fit. The sutures are started in the distal area first to take advantage of the loose tissue in a difficult area. The vertical cut on the buccal is sutured first. Instead of cutting off the thread after the knot is tied, the suture is taken through the embrasure to the lingual. The thread goes around the tooth and enters the mesial embrasure. Coming back to the buccal side, the needle takes a bite of the gingiva tissue. The needle returns to the embrasure thread first, goes around the tooth, and enters the previous embrasure thread first. Coming out of the embrasure, the thread is tied off with the tail of the suture. The remaining distal vertical incision is closed with other sutures as needed.
The same procedure is followed moving toward the mesial. If you are dealing with one or several teeth the procedure works well. You are suturing on the buccal side and taking the thread around the teeth on the lingual. The mesial vertical incision is sutured in a like manner. The suture is tied off and taken through the embrasure. If the buccal flap does not require another suture, a bite of lingual tissue can be taken. The needle is returned thread first to the buccal side and tied off.
The vertical incisions on the lingual are sutured in a like manner. The idea is to keep the sutures stress free. The lingual threads circle the buccal side of the tooth and suture on the lingual. This has a drawing effect on the flap and brings it into a close approximation with the bone. The tissue is held in place with a two-by-two gauze and finger pressure for a few minutes to aid in the re-attachment of the gingiva. The sutures should remain for four to five days unless you need to place a perio-pack.
Surgery on children is the same as on adults except you are dealing with smaller tissues. The patient is numbed with a pain-free injection. The anesthetic is taken from the lingual to the buccal with the blanching technique.
The periosteal instrument is used to loosen the tissue around the tooth. Since the second mandibular bicuspid is erupting below this tooth, the mesial and distal roots will be curved and very thin. It is very easy to fracture the thin roots. The usual path of eruption is to the buccal, but this will cut through the gingiva leaving a gapping wound. It is kinder to the tissues to split the tooth with a buccal-lingual groove, then extract the mesial and distal roots separately. The roots can be eased from the socket with the periosteal instrument.
You may still find that the path of extraction is to the buccal, but the damage to the gingiva will be less after the tooth is split. A suture is needed if the tissue warrants it.
The maxillary frenum needs to be removed if it is preventing the space between the anterior teeth number eight and nine from closing. The maxillary lip is lifted to detect the frenum movement between the teeth. If there is no movement, the surgery may not be necessary.
The patient is numbed with the painless infiltration method. When the patient is numb, the maxillary lip is raised to reveal the extent of the frenum. The hemostat is placed against the gingiva and takes hold of the frenum. This is a good bite of tissue that goes the length of the frenum into the mucosa.
Lifting the hemostat slightly, a scissor is used to cut the frenum along the gingiva and into the mucosa. The scissor’s cut is below and to the end of the hemostat. The cut needs to be tight to the gingiva. The second scissor cut is along the top of the hemostat and meets the first cut. The hemostat is lifted away taking the frenum tissue with it. If any of the frenum tissue is still attached, it needs to be cut free with the scissors. The loose mucosa will fall away leaving a gapping wound. If the scissor cut remains close to the surface of the mucosa, there will not be excessive bleeding.
Some in the profession would leave the mucosa as it is and allow the tissue to heal from this point. I feel it should be sutured. I do not like leaving gaping holes.
The needle takes a bite of tissue on one side of the widest part of the wound and takes another bite on the other side of the wound. The wound is drawn together and tied off. A suture is placed in the middle of the remaining wound on each side of the suture. It may take another suture in the mucosa to close off the wound. The sutures are removed three to four days later to prevent the sutures from becoming embedded in the healing tissue.
It is mandatory to obtain written permission from the patient before the surgery is started. If a complication in the surgery occurs (a root punched into the sinus), the patient should be made aware of the difficulty in retrieving it. If the patient does not want to seek a specialist at this point, it should be noted in the chart. If the patient wants you to attempt the retrieval, it would be advisable to obtain this in writing.
A good health history should be taken before the surgery is started. The following are areas of concern:
Any questions regarding the patient’s health should be referred to the patient’s physician with a simple fax form. Below is an example of one:
| Dentist Name | ||
| Address, Phone | ||
| Fax number | ||
| To: Doctor | ||
| Phone: | ||
| We need a medical clearance before we can do a dental procedure on the following patient: | ||
| Date of birth: | ||
| Patient: | ||
| The planned procedure may consist of extractions, soft tissue surgeries, prophylaxes, endodontics (root canals), fillings, crowns, or dentures. We are concerned in the following areas: |
||
| 1. Is the patient physically able to withstand the above-mentioned dental work? | Yes | No |
| 2. Can we administer epinephrine 1/100,000 in 1.8ml capsules, local anesthetic? | Yes | No |
| 3. Do we need to premedicate (antibiotic) before each dental appointment? | Yes | No |
| 4. If the patient is on a blood thinner (coumadin, plavix), can we stop it for three days? | Yes | No |
| 4. If the patient is on a blood thinner (coumadin, plavix), can we stop it for three days? | Yes | No |
| 5. Please list any other comments pertinent to this patient. | Yes | No |
|
We greatly appreciate your help in providing us with this information. Thank you. Sign: ________________________________ Dentist Name |
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Dental surgery does not require a large inventory of instruments making it a very low overhead procedure. A general dentist should do as much of his own surgery as he feels capable of doing. Whenever surgery is referred out of the office, it diminishes the general dentist’s ability to directly benefit the patient. A good relationship with a specialist will give the general dentist confidence to attempt more complicated surgery procedures.
It is recognized that the dentistry is an art form with a technique base. Each practitioner must develop his own ability to use the techniques and methods available. What works well in one person’s hands may not work well in another person’s hands. It is the practitioner’s responsibility to choose the correct techniques or methods that work well for him. It is the responsibility of each practitioner to recognize his abilities and keep his surgery skills in line with them. This article does not preclude the use of other surgical techniques and methods currently in practice.