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Full text of "Contemporary Oral and Maxillofacial Surgery,4th Ed Part II Principle of Exodontia"

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Principles of 



Larry J. Peterson 


Chapter outline 

Design Parameters for Soft Tissue Flaps Types of 
Mucoperiosteal Flaps Technique for Developing a 
Mucoperiosteal Flap Principles of Suturing 

Indications for Surgical Extraction 

Technique for Open Extraction of Single-Rooted 

Technique for Surgical Removal of Multirooted 
Teeth Removal of Small Root Fragments and Root 
Tips Policy for Leaving Root Fragments 
Treatment Planning 
Extraction Sequencing 
Technique for Multiple Extractions 

rhe removal of most erupted teeth can be 
achieved by closed or forceps delivery, but 
occasionally this technique does not suffice. 
The surgical, or open, extraction technique is the 
method used for recovering roots that were fractured 
during routine extraction or teeth and cannot be 
extracted by the routine closed methods for a variety of 
reasons. In addition, removal of multiple teeth during 
one surgical session requires more than the routine 
removal of teeth as described in Chapter 7. Small flaps 
are usually required for recontouring and smoothing 

This chapter discusses techniques for surgical tooth 
extraction. The principles of flap design, development, 
management, and suturing are explained, as are the 
principles of surgical extraction of single-rooted and 
multirooted teeth. Also discussed are the principles 
involved in multiple extractions and concomitant 


The term local flap indicates a section of soft tissue that 
(1) is outlined by a surgical incision, (2) carries its own] 
blood supply, (3) allows surgical access to underlying tis- 
sues, (4) can be replaced in the original position, and (5] 
can be maintained with sutures and is expected to heal, 
Soft tissue flaps are frequently used in oral surgical, 
periodontic, and endodontic procedures to gain access to 
underlying tooth and bone structures. To perform a tooth 
extraction properly the dentist must have a clear under- 
standing of the principles of design, development, and 
management of soft tissue flaps. 

Design Parameters for Soft Tissue Flaps 

To provide adequate exposure and promote rapid healing, 
the flap must be correctly designed. The surgeon must re- 


Principles of Complicated Exodontia ■ CHAPTER 8 157 


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FIG. 8-1 A, Flap must have base that is broader than free gingival margin. B, If flap is too narrow at 
base, blood supply may be inadequate, which may lead to flap necrosis. 

FIG. 8-2 A, to have sufficient access to root of second premolar, envelope flap should extend 
anteriorly, mesial to canine, and posteriorly, distal to first molar. B, If releasing incision (i.e., three- 
cornered flap) is used, flap extends mesial to first premolar. 

member that several parameters exist when designing a 
flap for a specific situation. 

When the flap is outlined, the base of the flap must usually 
be broader than the free margin to preserve an adequate blood 
supply. This means that all areas of the flap must have a 
source of uninterrupted vasculature to prevent ischemic 
necrosis of the entire flap or portions of it (Fig. 8-1). 

The flap must be of adequate size for several reasons. 
Sufficient soft tissue reflection is required to provide nec- 
essary visualization of the area. Adequate access also must 
exist for the insertion of instruments required to perform 
the surgery. In addition, the flap must be held out of the 
operative field by a retractor that must rest on intact bone. 
There must be enough flap reflection to permit the retractor 
to hold the flap without tension. Furthermore, soft tissue 
heals across the incision, not along the length of the 
incision, and sharp incisions heal more rapidly than torn 
tissue. Therefore a long, straight incision with adequate 
flap reflection heals more rapidly than a short, torn inci- 
sion, which heals slowly by secondary intention. For an 
envelope flap to be of adequate size, the length of the flap 
the anteroposterior dimension usually extends two teeth 
anterior and one tooth posterior to the area of surgery 
(Fig. 8-2, A). If a relaxing incision is to be made, the 

incision should extend one tooth anterior and one 
tooth posterior to the area of surgery (Fig. 8-2, 6). 

The flap should be a full-thickness 
mucoperiosteal flap. This means that the flap 
includes the surface mucosa, submucosa, and 
periosteum. Because the goal of the surgery is to 
remove or reshape the bone, all overlying tissue must 
be reflected from it. In addition, full-thickness flaps 
are necessary because the periosteum is the primary 
tissue responsible for bone healing, and replacement 
of the periosteum in its original position hastens that 
healing process. In addition, torn, split, and macerated 
tissue heals more slowly than a cleanly reflected, full- 
thickness flap. 

The incisions that outline the flap must be made 
over intact bone that will be present after the surgical 
procedure is complete. If the pathologic condition has 
eroded the buccocortical plate, the incision must be at 
least 6 or 8 mm away from it. In addition, if bone is to 
be removed over a particular tooth, the incision must 
be sufficiently distant from it so that after the bone is 
removed, the incision is 6 to 8 mm away from the bony 
defect created by surgery. If the incision line is 
unsupported by sound bone, 

158 PART II 

Principles ofExodontia 

FIG. 8-3 A, When designing flap, it is necessary to anticipate how much bone will be removed so 
that after surgery is complete, incision rests over sound bone. In this situation, vertical release was one 
tooth anterior to bone removal and left an adequate margin of sound bone. B, When releasing inci- 
sion is made too close to bone removal, delayed healing results. 

It tends to collapse into the bony defect, which results 
in wound dehiscence and delayed healing (Fig. 8-3). 

The flap should be designed to avoid injury to local 
vital structures in the area of the surgery. The two 
most important structures that can be damaged are 
both located in the mandible; these are the lingual 
nerve and the mental nerve. When making incisions in 
the posterior mandible, especially in the region of the 
third molar, incisions should be well away from the 
lingual aspect of the mandible. In this area the lingual 
nerve may be closely adherent to the lingual aspect of 
the mandible, and incisions in this area may result in 
the severing of that nerve, with consequent prolonged 
temporary or permanent anesthesia of the tongue. In 
the same way, surgery in the apical area of the 
mandibular premolar teeth should be carefully 
planned and executed to avoid injury to the mental 
nerve. Envelope incisions should be used if at all 
possible, and releasing incisions should be well 
anterior or posterior to the area of the mental nerve. 

Flaps in the maxilla rarely endanger any vital 
structures. On the facial aspect of the maxillary 
alveolar process, no nerves or arteries exist that are 
likely to be damaged. When reflecting a palatal flap, 
the dentist must remember that the major blood 
supply to the palatal soft tissue comes through the 
greater palatine artery, which emerges from the 
greater palatine foramen at the posterior lateral aspect 
of the hard palate. This artery courses forward and 
has an anastomosis with the nasopalatine artery. The 
nasopalatine nerves and arteries exit the incisive 
foramen to supply the anterior palatal gingiva. If the 
anterior palatal tissue must be reflected, both the 
artery and the nerve can be incised at the level of the 
foramen without much risk. The likelihood of 
bothersome bleeding is small, and the nerve 
regenerates quickly. The temporary numbness usually 
does not bother the patient. However, vertical- 
releasing incisions in the posterior aspect of the 
palate should be avoided, because they usually sever 
the greater palatine artery within the tissue, which 
results in bleeding that may be difficult to control. 

Releasing incisions are used only when necessary and 
not routinely. Envelope incisions usually provide the 
adequate visualization required for tooth extraction in 
most areas. When vertical-releasing incisions are 
necessary, only a single vertical incision is used, which 
is usually at the anterior end of the envelope component. 
The vertical-releasing incision is not a straight vertical 
incision but is oblique, to allow the base of the flap to be 
broader than the free gingival margin. A vertical-releasing 
incision is made so that it does not cross bony 
prominences, such as the canine eminence. To do so would 
increase the likelihood of tension in the suture line, which 
would result in wound dehiscence. 

Vertical-releasing incisions should cross the free 
gingival margin at the line angle of a tooth and should not 
be directly on the facial aspect of the tooth nor directly in 
the papilla (Fig. 8-4). Incisions that cross the free margin 
of the gin-giva directly over the facial aspect of the tooth 
do not heal properly because of tension; the result is a 
defect in the attached gingiva. Because the facial bone is 
frequently quite thin, such incisions will also result in 
vertical clefting of the bone. Incisions that cross the 
gingival papilla damage the papilla unnecessarily and 
increase the chances for localized periodontal problems; 
such incisions should be avoided. 

Types of Mucoperiosteal Flaps 

A variety of intraoral tissue flaps can be used. The most 
common incision is the envelope, or sulcular, incision, 
which produces the envelope flap. In the dentulous 
patient the incision is made in the gingival sulcus to the 
crestal bone, through the periosteum, and the full- 
thickness mucoperiosteal flap is apically reflected (see Fig. 
8-2, A). This usually provides sufficient access to perform 
the necessary surgery. 

If the patient is edentulous, the envelope incision is 
made along the scar at the crest of the ridge. No vital 
structures are found in this area, and the envelope inci- 
sion can be as long as is required to provide adequate 
access. The tissue can be reflected buccally or lingually as 
necessary for the removal of a mandibular torus. 

Principles of Complicated Exodontia 



FIG. 8-4 A, Correct position for end of vertical-releasing incision is at line angle (mesiobuccal angle in 
this figure) of tooth. Likewise, incision does not cross canine eminence. Crossing such bony promi- 
nences results in increased chance for wound dehiscence. B, These two incisions are made incorrectly: 
(1) incision crosses prominence over canine tooth, which increases risk of delayed healing; incision 
through papilla results in unnecessary damage; (2) incision crosses attached gingiva directly over facial 
aspect of tooth, which is likely to result in soft tissue defect and periodontal deformity. 

If the envelope incision has a vertical-releasing inci- 
sion, it is a three-cornered flap, with corners at the poste- 
rior end of the envelope incision, at the inferior aspect of 
the vertical incision, and at the superior aspect of the 
vertical-releasing incision (Fig. 8-5). This incision pro- 
vides for greater access with a shorter envelope incision. 
When greater access is necessary in an apical direction, 
especially in the posterior aspect of the mouth, this inci- 
sion is frequently necessary. The vertical component is 
more difficult to close and may cause some mildly pro- 
longed healing, but if care is taken when suturing, the 
healing period is not noticeably lengthened. 

The four-cornered flap is an envelope incision with 
two releasing incisions. Two corners are at the superior 
aspect of the releasing incision, and two corners are at 
either end of the envelope component of the incision 
(Fig. 8-6). Although this flap provides substantial access 
in areas that have limited anteroposterior dimension, it is 
rarely indicated. When releasing incisions are necessary, a 
three-cornered flap usually suffices. 

An incision that is used occasionally to approach the 
root apex is a semilunar incision (Fig. 8-7). This incision 
avoids trauma to the papillae and gingival margin but 
provides limited access, because the entire root of the 
tooth is not visible. This incision is most useful for peri- 
apical surgery of a limited extent. The horizontal compo- 
nent of the semilunar incision should not cross major 
prominences, such as the canine eminence. 

Two incisions are useful on the palate: The first is the 
Y incision, which is named for its shape. This incision is 
useful for surgical access to the bony palate for removal 
of a maxillary palatal torus. The tissue overlying the 
torus is usually quite thin and must be reflected 
carefully. The anterolateral extensions of the midline 
incision are anterior to the region of the canine tooth. 
They are anterior enough in this position that they do 
not sever major branches of the greater palatine artery; 
therefore bleeding is not usually a problem (Fig. 8-8). 

Another flap that is used occasionally on the palate is 
the pedicle flap. This flap mobilizes from one area and 

FIG. 8-5 Vertical-releasing incision converts envelope incision 
into three-cornered flap. 

FIG. 8-6 Vertical-releasing incisions at either end of envelope 
incision convert envelope incision into four-cornered flap. 

then rotates to fill a soft tissue defect in another area. 
The pedicled palatal flap is used primarily for closure 
of oroantral communications (see Chapter 19). 

Technique for Developing a Mucoperiosteal Flap 

Several specific considerations are involved in 
developing flaps for surgical tooth extraction. The 
first step is to incise the soft tissue to allow 
reflection of the flap. The 


Principles ofExodmitiu 

FIG. 8-7 Semilunar incision, designed to avoid marginal 
attached gingiva when working on root apex. It is most useful 
when only small amount of access is necessary. 


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FIG. 8-8 Y incision is useful on palate for adequate access to 
remove palatal torus. Two anterior limbs serve as releasing 
incisions to provide for greater access. 

FIG. 8-9 Scalpel handle is held in pen grasp for maximal 
control and tactile sensitivity. 

no. 15 blade is used on a no. 3 scalpel handle, and it 
is held in the pen grasp (Fig. 8-9). The blade is held 
at a slight angle to the teeth, and the incision is made 
posteriorly to anteriorly in the gingival sulcus by 
drawing the knife toward the operator. One smooth 
continuous stroke is used while keeping the knife 

blade in contact with bone throughout the entire 
incision (Figs. 8-10 and 8-11). 

FIG. 8-10 No. 15 blade is used to incise gingival sulcus. 

The scalpel blade is an extremely sharp instrument, 
but it dulls rapidly when it is pressed against bone, such 
as when making a mucoperiosteal incision. If more than 
one flap is to be reflected, the surgeon should change 
blades between incisions. 

If a vertical-releasing incision is made, the tissue is api- 
cally reflected, with the opposite hand tensing the 
alveolar mucosa so that the incision can be made 
cleanly through it. If the alveolar mucosa is not tensed, 
the knife will not incise cleanly through the mucosa and 
a jagged incision will result. 

Reflection of the flap begins at the papilla. The sharp 
end of the Woodson elevator or the no. 9 periosteal ele- 
vator begins a reflection (Fig. 8-12). The sharp end is 
slipped underneath the papilla in the area of the 
incision and turned laterally to pry the papilla away 
from the underlying bone. This technique is used along 
the entire extent of the free gingival incision. If it is 
difficult to elevate the tissue at any one spot, the 
incision is probably incomplete, and that area should be 
reincised. Once the entire free edge of the flap has been 
reflected with the sharp end of the elevator, the broad 
end is used to reflect the mucoperiosteal flap to the 
extent desired. 

If a three-cornered flap is used, the initial reflection is 
accomplished with the sharp end of the Woodson eleva- 
tor on the first papilla only. Once the flap reflection is 
started, the broad end of the periosteal elevator is insert- 
ed at the middle corner of the flap, and the dissection is 
carried out with a pushing stroke, posteriorly and apical- 
ly. This facilitates the rapid and atraumatic reflection of 
the soft tissue flap (Fig. 8-13). 

Once the flap has been reflected the desired amount, 
the periosteal elevator is used as a retractor to hold the 
flap in its proper reflected position. To accomplish this 
effectively the retractor is held perpendicular to the bone 
tissue while resting on sound bone and not trapping soft 
tissue between the retractor and bone. The periosteal 

Principles of Complicated Exvdontia 



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FIG. 8-1 1 A, Knife is angled slightly away from tooth and incises soft tissue, including periosteum, at crestal bone. B, 
Incision is started posteriorly and is carried anteriorly, with care taken to incise completely through interdental papilla. 

vator therefore is maintained in its proper position, and 
the soft tissue flap is held without tension (Fig. 8-14). 
The Seldin elevator or the Minnesota or Austin 
retractors can be used in a similar fashion when broader 
exposure is necessary. The retractor should not be 
forced against the soft tissue in an attempt to pull the 
tissue out of the field. Instead the retractor is positioned 
in the proper place and held firmly against the bone. By 
retracting in this fashion, the surgeon primarily focuses 
on the surgical field rather than on the retractor; 
thereby the chance of inadvertently tearing the flap is 

Principles of Suturing 

Once the surgical procedure is completed and the 
wound properly irrigated and debrided, the surgeon 
must return the flap to its original position or, if 
necessary, arrange it in a new position; the flap should 
be held in place with sutures. Sutures perform multiple 
functions. The most obvious and important function 
that sutures perform is to coapt wound margins; that is, 
to hold the flap in position and approximate the two 
wound edges. The sharper the incision and the less 
trauma inflicted on the wound margin, the more 
probable is healing by primary intention. If the space 
between the two wound edges is minimal, wound 
healing will be rapid and complete. If tears or 
excessive trauma to the wound edges occur, wound 
healing will be by secondary intention. 

Sutures also aid in hemostasis. If the underlying 
tissue is bleeding, the surface mucosa or skin should 
not be closed, because the bleeding in the underlying 
tissues may continue and result in the formation of a 
hematoma. Sur-face sutures aid in hemostasis but only 
as a tamponade in 

FIG. 8-12 Reflection of flap is begun by using sharp end 
of periosteal elevator to pry away interdental papilla. 

a generally oozing area, such as a tooth socket. 
Overlying tissue should never be sutured tightly in an 
attempt to gain hemostasis in a bleeding tooth socket. 
Sutures help hold a soft tissue flap over bone. This 
is an extremely important function, because bone 
that is not covered with soft tissue becomes 
nonvital and requires an excessively long time to 
heal. When muco-periosteal flaps are reflected from 
alveolar bone, it is important that the extent of the 
bone be recovered with the soft tissue flaps. Unless 
appropriate suture techniques are used, the flap may 
retract away from the bone, which exposes it and 
results in delayed healing. 

162 PAItTO ■ Principles of Exodontia 

FIG. 8-13 When three-cornered flap is used, only anterior papilla 
is reflected with sharp end of elevator. Broad end is then used with 
push stroke to elevate posterosuperiorly. 

FIG. 8-15 A, Figure-eight stitch, occasionally placed over top of 
socket to aid in hemostasis. B, This stitch is usually performed to 
help maintain piece of oxidized cellulose in tooth socket. 

FIG. 8-14 Periosteal elevator (Seldin elevator) is used to reflect 
mucoperiosteal flap. Elevator placed perpendicular to bone and 
held in place by pushing firmly against bone, not by pushing it 
apically against soft tissue. 

Sutures may aid in maintaining a blood clot in the 
alveolar socket. A special stitch, such as a figure-eight 
stitch, can provide a barrier to clot displacement (Fig. 
8-15). However, it should be emphasized that suturing 
across an open wound socket plays a minor role in 
maintaining the blood clot in the tooth socket. 

The armamentarium includes a needle holder, a 
suture needle, and suture material. The needle holder 
of choice is 15 cm in length and has a locking handle. 
It is held with the thumb and ring finger through the 
rings and with the index finger along the length of the 
needle holder to provide stability and control (Fig. 8- 

The suture needle usually used in the mouth is a 
small three-eighths to one-half circle with a reverse 
cutting edge. The cutting edge helps the needle pass 
through the relatively tough mucoperiosteal flap. 
Needle sizes and shapes have been assigned numbers. 
The most common needle shapes used for oral surgery 
are the FS-2 and X-l (Fig. 8-17). 

Sutures are made of a wide variety of materials and 
come in several sizes, each designed for a particular 
purpose. The two basic types of suture material are (1) 
resorbable (i.e., the body is capable of easily breaking the 
material down) and (2) nonresorbable. In general, 
resorbable sutures do not require removal, whereas 
nonresorbable sutures do. 

Three types of resorbable sutures are commonly used 
for oral and maxillofacial surgery: (1) gut, (2) polyglycol- 
ic acid, and (3) polyglactin. Gut is fabricated from the 
submucosa of sheep intestines or the serosa of beef intes- 
tines. Plain gut is susceptible to rapid digestions by pro- 
teolytic enzymes produced by inflammatory cells. Treat- 
ing the gut suture with basic chromium salts produces 
chromic catgut, which is more resistant to proteolytic 
enzymes. Plain gut sutures retain their strength for 
approximately 5 days, whereas chromic gut sutures 
maintain their strength for 7 to 9 days. Polyglycolic acid 
and polyglactin sutures do not enzymatically break 
down. Rather, they undergo slow hydrolysis, eventually 
being resorbed by macrophages. Polyglycolic and 
polyglactin sutures have the advantage of being less 
stiff than gut sutures and are more likely to remain tied. 
However, they may last too long and are more costly 
than gut sutures. 

Resorbable sutures are highly reactive compared with 
nonresorbable sutures; that is, resorbable sutures evoke 
an intensive inflammatory reaction that may impede 
wound healing, occasionally to a clinically significant 
extent. This is the reason that neither plain nor chromic 
gut is used for suturing the surface of a skin wound. 

The most commonly used nonresorbable sutures in 
oral and maxillofacial surgery are silk, nylon, polyester, 
and polypropylene. Nonresorbable sutures are either 
monofilament or multifilament. The multifilament form 
increases the strength of the suture, but also increases 
suture abrasiveness and is more likely to allow bacteria to 
"wick" into the wound. Silk and polyester sutures are 
available only in multifilament form. Polypropylene is 
produced only as a monofilament, whereas nylon comes 
as both a monofilament and a multifilament form. 

All nonresorbable sutures have some reactivity. Of the 
commonly used nonresorbable sutures, silk revokes the 
most intensive inflammatory reaction and nylon is 
the least reactive. In situations in which it is important to 

Principles of Complicated Exodontia 



FIG. 8-16 Needle holder is held with thumb and ring finger. Index finger extends along instrument for stability and 

minimize wound inflammation, such as any facial lacer- 
ation, nylon is usually the cutaneous suture of choice. 

Sutures are available in various sizes that range from the 
largest diameter, 7, down to the smallest extremely fine 
suture size, 11-0. The increasing number of 0's correlates 
with decreasing suture diameter and strength. For exam- 
ple, size 1 -0 suture is larger in diameter than size 2-0, size 
3-0 is larger than 7-0, etc. Because suture material is foreign 
to the human body, the smallest diameter of suture suffi- 
cient to keeping a wound closed properly should be used. 
Generally the size of the suture is chosen to correlate with 
the tensile strength of the tissue being sutured. Most oral 
and maxillofadal surgeons use 3-0 or 4-0 suture. 

The technique used for suturing is deceptively diffi- 
cult. The use of the needle holder and the technique that 
is necessary to pass the curved needle through the tissue 

are difficult to learn. The following discussion 
presents the technique used in suturing; practice is 
necessary before suturing can be performed with skill 
and finesse. 

When the envelope flap is repositioned into its 
correct location, it is held in place with sutures that 
are placed through the papillae only. Sutures are not 
placed across the empty tooth socket, because the 
edges of the wound would not be supported over 
sound bone (Fig. 8-18). When reapproximating the 
flap, the suture is passed first through the mobile 
(usually facial) tissue; the needle is regrasped with the 
needle holder and passed through the attached tissue 
of the lingual papilla. If the two margins of the wound 
are close together, the experienced surgeon may be 
able to insert the needle through both sides of the 
wound in a single pass. However, it is best to use two 
passes in most situations (Fig. 8-19). 



Principles ofExodontia 

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FIG. 8-17 Needle used in oral surgery is 3/8-circle cutting needle. 
Middle needle is FS-2, and tower needle is X-1. 

FIG. 8-18 A, Flap held in place with sutures in papillae. B, 
sectional view of suture. 


When passing the needle through the tissue, the nee- 
dle should enter the surface of the mucosa at a right 
angle, to make the smallest possible hole in the mucosal 
flap (Fig. 8-20). If the needle passes through the tissue 
obliquely, the suture will tear through the surface layers 
of the flap when the suture knot is tied, which results in 
greater injury to the soft tissue. 

When passing the needle through the flap, the sur- 
geon must ensure that an adequate bite of tissue is taken, 
to prevent the suture from pulling through the soft tissue 
flap. Because the flap that is being sutured is a muco- 
periosteal flap and should not be tied tightly, a relatively 
small amount of tissue is necessary. The minimal amount 
of tissue between the suture and the edge of the flap 
should be 3 mm. Once the sutures are passed through 
both the mobile flap and the immobile lingual tissue, 
they are tied with an instrument tie (Fig. 8-21). 

The surgeon must remember that the purpose of the 
stitch is merely to reapproximate the tissue, and therefore 
the suture should not be tied too tightly. Sutures that are 
too tight cause ischemia of the flap margin and result in 
tissue necrosis, with tearing of the suture through the tis- 
sue. Thus sutures that are too tightly tied result in wound 
dehiscence more frequently than sutures that are loosely 
tied. As a clinical guideline, there should be no blanching 
or obvious ischemia of the wound edges. If this occurs the 
suture should be removed and replaced. The knot should 
be positioned so that it does not fall over the incision 
line, because this causes additional pressure on the inci- 
sion. Therefore the knot should be positioned to the side 
of the incision. 

If a three-cornered flap is used, the vertical end of the 
incision must be closed separately. Two sutures usually 
are required to close the vertical end properly. Before the 
sutures are inserted, the Woodson periosteal elevator 
should be used to elevate slightly the nonflap side of the 
incision, freeing the margin to facilitate passage of the 
needle through the tissue (Fig. 8-22). The first suture is 
placed across the papilla, where the vertical release inci- 
sion was made. This is a known, easily identifiable land- 
mark that is most important when repositioning a three- 
cornered flap. The remainder of the envelope portion of 
the incision is then closed, after which the vertical com- 
ponent is closed. The slight reflection of the nonflap side 
of the incision greatly eases the placing of sutures. 

The sutures are left in place for approximately 5 to 7 
days. After this time they play no useful role and, in fact, 
probably increase the contamination of the underlying sub- 
mucosa. When sutures are removed, the surface debris that 
has collected on them should be cleaned off with a cotton- 
tipped applicator stick soaked in peroxide, chlorhexidine, 
iodophor, or other antiseptic solution. The suture is cut 
with sharp, pointed suture scissors and removed by pulling 
it toward the incision line (not away from the suture line). 

Sutures may be configured in several different ways. 
The simple interrupted suture is the one most commonly 
used in the oral cavity. This suture simply goes through 
one side of the wound, comes up through the other side 
of the wound, and is tied in a knot at the top. These 
sutures can be placed relatively quickly, and the tension 
on each suture can be adjusted individually. If one suture 
is lost, the remaining sutures stay in position. 

Principles of Complicated Exodontia ■ CHAPTERS 165 

FIG. 8-19 When mucosal flap is back in position, suture is passed through two sides of socket in separate passes 
of needle. A, Needle is held by needle holder and passed through papilla, usually of mobile tissue first. B, Needle 
holder is then released from needle; it regrasps needle on underside of tissue and is turned through flap. C, 
Needle is then passed through opposite side of soft tissue papilla in similar fashion. D, Finally, needle holder 
graspsneedle on opposite side to complete passing of suture through both sides of mucosa. 

FIG. 8-20 A, When passing through soft tissue of mucosa, needle should enter surface of 
tissue at right angle. B, Needle holder should be turned so that needle passes easily through 
tissue at right angles. C, If needle enters soft tissue at acute angle and is pushed (rather than 
turned) through tissue, tearing of mucosa with needle or with suture is likely to occur (D). 

166 PARTn ■ Principles of Exodontia 

FIG. 8-21 Most intraoral sutures are tied with instrument tie. A, Suture is pulled through tissue 
until short tail of suture (approximately 1 1/2 to 2 inches long) remains. Needle holder is held 
horizontally by right hand in preparation for knot-tying procedure. B, Left hand then wraps 
long end of suture around needle holder twice in clockwise direction to make two loops of 
suture around needle holder. C, Surgeon then opens needle holder and grasps short end of 
suture near its end. D, Ends of suture are then pulled to tighten knot. Needle holder should 
not pull at all until knot is nearly tied, to avoid lengthening that portion of suture. E, End of first 
step of surgeon's knot. The double wrap has resulted in double overhand knot. This increases 
friction in knot and will keep wound edges together until second portion of knot is tied. F, 
Needle holder is then released from short end of suture and held in same position as when 
knot-tying procedure began. Left hand then makes single wrap in counter-clockwise direction. 


Principles of Complicated ExodonHa ■ CHAPTER 8 167 


FIG. 8-21 — cont'd G, Needle holder then grasps short end of suture at its end. H, This portion of knot is completed by 
pulling this loop firmly down against previous portion of knot. I, This completes surgeon's knot. Double loop of first pass 
holds tissue together until second portion of square knot can be tied. J, Most surgeons add third throw to their instrument 
tie. Needle holder is repositioned in original position, and one wrap is placed around needle holder in original clockwise 
direction. Short end of suture is grasped and tightened down firmly to form second square knot. Final throw of three 
knots is tightened firmly. 

A suture technique that is useful for suturing two 
papillae with a single stitch is the horizontal mattress 
suture (Fig. 8-23). A slight variation of that suture is the 
figure-eight suture, which holds the two papilla in posi- 
tion and puts a cross over the top of the socket so that 
may help hold the blood clot in position (see Fig. 8- 

If the incision is long, continuous sutures can be 
used efficiently. When using this technique, a knot 
does not have to be made for each stitch, which makes it 
quicker to suture a long-span incision. The continuous 
simple suture can be either locking or nonlocking (Fig. 8- 
24). The horizontal mattress suture also can be used in a 
running fashion. A disadvantage of the continuous 
suture is that if one suture pulls through, the entire 
suture line becomes loose. 



Surgical extraction of an erupted tooth is a technique 
that should not be reserved for the extreme situation. A 
prudently used open extraction technique may be more 
conservative and cause less operative morbidity than a 

closed extraction. Forceps extraction techniques that 
require great force may result not only in removal of 
the tooth but also of large amounts of associated bone 
and occasionally the floor of the maxillary sinus (Fig. 
8-25). The bone loss may be less if a soft tissue flap is 
reflected and a proper amount of bone removed; it may 
also be less if the tooth is sectioned- The morbidity of 
fragments of bone that are literally torn from the jaw 
by the conservative closed technique exceeds by far 
the morbidity of controlled surgical extraction. 

Indications for Surgical Extraction 

It is prudent for the surgeon to evaluate carefully 
each patient and each tooth to be removed for the 
possibility of an open extraction. Although the vast 
majority of decisions will be to perform a closed 
extraction, the surgeon must be aware continually that 
open extraction may be the less morbid of the two. 

As a general guideline, surgeons should consider 
performing an elective surgical extraction when they 
perceive a possible need for excessive force to extract a 



Principles ofExodontia 

FIG. 8-22 A, To make the suturing of three-cornered flap easier, 
Woodson elevator is used to elevate small amount of fixed tissue 
so that suture can be passed through entire thickness of 
mucoperios-teum. B, When three-cornered flap is repositioned, 
first suture is placed at occlusal end of vertical-releasing incision. 
Papillae are then sutured sequentially, and finally, if necessary, 
superior aspect of releasing incision is sutured. 

The term excessive means that the force will probably 
result in a fracture of bone, a tooth root, or both. In 
any case the excessive bone loss, the need for 
additional surgery to retrieve the root, or both can 
cause undue morbidity. The following are examples of 
situations in which closed extraction may require 
excessive force. 

The dentist should strongly consider performing an 
open extraction after initial attempts at forceps 
extraction have failed. Instead of applying 
unnecessarily great amounts of force that may not be 
controlled, the surgeon should simply reflect a soft 
tissue flap, section the tooth, remove some bone, and 
extract the tooth in sections. In these situations the 
philosophy of "divide and conquer" results in the 
most efficient extraction. 

If the preoperative assessment reveals that the 
patient has heavy or especially dense bone, 
particularly on the buccocortical plate, surgical 
extraction should be considered. The extraction of 
most teeth depends on the expansion of the 
buccocortical plate. If this bone is especially heavy, 
then adequate expansion is less likely to occur and 
fracture of the root is more likely. Dense bone in the 
older patient warrants even more caution. 

Whereas young patients have bone that is more 
elastic and more likely to expand with controlled 
force, older patients usually have denser, more highly 
calcified bone that is less likely to provide adequate 
expansion during luxation of the tooth. 

Occasionally, the dentist treats a patient who has 
very short clinical crowns with evidence of severe 
attrition. If such attrition is the result of bruxism (a 
grinding habit), 

FIG. 8-23 A, Horizontal mattress suture is sometimes used to close 
soft tissue wounds. Use of this suture decreases number of individ- 
ual sutures that have to be placed; however, more importantly, it 
compresses wound together slightly and everts wound 
edges. B, Single horizontal mattress suture can be placed across 
both papillae of tooth socket and serves as two individual sutures. 

it is likely that the teeth are surrounded by dense, heavy 
bone with strong periodontal ligament attachment (Fig. 
8-26). The surgeon should exercise extreme caution if 
removal of such teeth is attempted with a closed tech- 
nique. An open technique usually results in a quicker, 
easier extraction. 

Careful review of the preoperative radiographs may 
reveal tooth roots that are likely to cause difficulty if the 
tooth is extracted by the standard forceps technique. 
One condition commonly seen among older patients is 
hyper-cementosis. In this situation, cementum has 
continued to be deposited on the tooth and has formed a 
large bulbous root that is difficult to remove through the 
available tooth socket opening. Great force used to 
expand the bone may result in fracture of the root or 
buccocortical bone and in a more difficult extraction 
procedure (Fig. 8-27). 

Roots that are widely divergent, especially the 
maxillary first molar roots (Fig. 8-28) or roots that have 
severe dilaceration or hooks, also are difficult to remove 
without fracturing one or more of the roots (Fig. 8-29). 
By reflecting a soft tissue flap and dividing the roots 
prospectively with a bur, a more controlled and planned 
extraction can be performed and will result in less 
morbidity overall. 

If the maxillary sinus has expanded to include the 
roots of the maxillary molars, extraction may result in 
removal of a portion of the sinus floor along with the 
tooth. If the roots are divergent, then such a situation is 
even more likely to occur (Fig. 8-30). 

Teeth that have crowns with extensive caries, 
especially root caries, or that have large amalgam 
restorations are candidates for open extraction (Fig. 8- 
31). Although the root primarily grasps the tooth, a 
portion of the force is applied to the crown. Such 
pressures can crush and shat- 

Principles of Complicated Exodcmtia 



FIG. 8-24 When multiple sutures are to be placed, incision can be closed with running or continuous 
suture. A, First papilla is closed and knot tied in usual way. Long end of suture is held, and adjacent 
papilla is sutured, without knot being tied but just with suture being pulled firmly through tissue. B, 
Succeeding papillae are then sutured until final one is sutured and final knot is tied. Final appearance is 
with suture going across each empty socket. C, Continuous locking stitch can be made by passing long 
end of suture underneath loop before it is pulled through tissue. D, This puts suture on both deep 
periosteal and mucosal surfaces directly across papilla and may aid in more direct apposition of tissues. 

ter the crowns of teeth with extensive caries or large 
restorations. Open extraction can circumvent the need 
for extensive force and result in a quicker, easier extrac- 
tion. Teeth with crowns that have already been lost to 
caries and that present as retained roots should also be 
considered for open extraction. If extensive periodontal 
disease is found around such teeth, it may be possible to 
deliver them easily with straight elevators or Cryer eleva- 
tors. However, if the bone is firm around the tooth 
and no periodontal disease exists, the surgeon should 
consider an open extraction. 

Technique for Open Extraction of 
Single-Rooted Tooth 

The technique for open extraction of a single-rooted 
tooth is relatively straightforward but requires 
attention to detail, because several decisions must be 
made during the operation. Single-rooted teeth are 
those that have resisted attempts at closed extraction or 
that have fractured at the cervical line and therefore 
exist only as a root. The technique is essentially the 
same for both. 

The first step is to provide adequate visualization and 
access by reflecting a sufficiently large mucoperiosteal 
flap. In most situations an envelope flap that is extended 
two teeth anterior and one tooth posterior to the tooth 
to be removed is sufficient. If a releasing incision is 
necessary, it should be placed at least one tooth anterior 
to the extraction site (see Fig. 8-2). 

Once an adequate flap has been reflected and is 
held in its proper position by a periosteal elevator, the 
surgeon must determine the need for bone removal. 
Several options are available: First, the surgeon may 
attempt to 

FIG. 8-25 Forceps extraction of these teeth resulted in removal 
of bone and tooth, instead of just tooth. 

reseat the extraction forceps under direct 
visualization and therefore achieve a better 
mechanical advantage and remove the tooth with no 
bone removal at all (Fig. 8-32). The second option is 
to grasp a bit of buccal bone under the buccal beak 
of the forceps to obtain a better mechanical advantage 
and grasp of the tooth root. This may allow the 
surgeon to luxate the tooth sufficiently to remove it 
without any additional bone removal (Fig. 

1 70 PART II 

i'rinciples of'Exoiimtia 

FIG. 8-26 Teeth that exhibit evidence of bruxism may have denser 
bone and stronger periodontal ligament attachment, which make 
them more difficult to extract. 

FIG. 8-27 Hypercementosis of root makes forceps delivery difficult. 

FIG. 8-29 Severe dilaceration of roots may result in fracture of root 
unless surgical extraction is performed. 

FIG. 8-28 Widely divergent roots increase likelihood of fracture 
of bone, tooth root, or both. 

FIG. 8-30 Maxillary molar teeth "in" floor of maxillary sinus increase 
chance of fracture of sinus floor, with resulting sinus perforation. 

8-33). A small amount of buccal bone is pinched off and 
removed with the tooth. 

The third option is to use the straight elevator as a 
shoehorn elevator by forcing it down the periodontal lig- 
ament space of the tooth (Fig. 8-34). The index finger of 
the surgeon's hand must support the force of the elevator 
so that the total movement is controlled and no slippage 
of the elevator occurs. A small wiggling motion should be 
used to help expand the periodontal ligament space, 
which allows the small straight elevator to enter the 
space and act as a wedge to displace the root occlusally. 

The fourth and final option is to proceed with bone 
removal over the area of the tooth. The surgeon who 
makes the decision to remove some buccal bone from the 

Principles of Complicated Exodontia 



FIG. 8-31 Large caries or large restorations may lead to fracture 
of crown of tooth and therefore to more difficult extraction. 

tooth may use either the bur or the chisel. If the bone is 
thin, a chisel is convenient and frequently requires 
hand pressure only. However, most surgeons currently 
prefer a bur to remove the bone. The width of buccal 
bone that is removed is essentially the same width as 
the tooth in a mesiodistal direction (Fig. 8-35). In a 
vertical dimension, bone should be removed 
approximately one-half to two-thirds the length of the 
tooth root (Fig. 8-36). This amount of bone removal 
sufficiently reduces the amount of force necessary to 
displace the tooth and makes removal relatively easy. 
Either a small straight elevator (Fig. 8-37) or a forceps 
can be used to remove the tooth (Fig. 8-38). 

If the tooth is still difficult to extract after removal of 
bone, a purchase point can be made in the root with the 
bur at the most apical portion of the area of bone 
removal (Fig. 8-39). This hole should be about 3 mm in 
diameter and depth to allow the insertion of an 
instrument. A heavy elevator, such as a Crane pick, can 
be used to elevate or lever the tooth from its socket (Fig. 
8-40, A). The soft tissue is repositioned and sutured (Fig. 
8-40, B). 

The bone edges should be checked; if sharp, they 
should be smoothed with a bone file. By replacing the 
soft tissue flap and gently palpating it with a finger, the 
clinician can check edge sharpness. Removal of 

FIG. 8-32 Small envelope flap can be reflected to expose 
fractured root. Under direct visualization, forceps can be seated 
more apically into periodontal ligament space, which eliminates 
need for bone removal. 

FIG. 8-33 If root is fractured at level of bone, buccal beak of 
forceps can be used to remove small portion of bone at same 
time that it grasps root. 



Prirtcipk's of 'Exoclontia 

FIG. 8-34 Small straight elevator can be used as shoehorn to lux- 
ate broken root. When straight elevator is used in this position, hand 
must be securely supported on adjacent teeth to prevent inadver- 
tent slippage of instrument from tooth and subsequent injury to 
adjacent tissue. 

FIG. 8-37 Once appropriate amount of buccal bone has been 
removed, shoehorn elevator can be used down palatal aspect of 
tooth to displace tooth root in buccal direction. It is important to 
remember that when elevator is used in this direction, surgeon's 
hand must be firmly supported on adjacent teeth to prevent slip- 
page of instrument and injury to adjacent soft tissues. 

FIG. 8-35 When removing bone from buccal surface of tooth or 
tooth root to facilitate removal of that root, mesiodistal width 
of bone removal should be approximately same as mesiodistal 
dimension of tooth root itself. This allows unimpeded path for 
removal of root in buccal direction. 

FIG. 8-36 Bone is removed with bone-cutting bur after 
reflection of standard envelope flap. Bone should be removed 
approximately one half to two thirds length of tooth root. 

FIG. 8-38 After bone has been removed and tooth root luxated 
with straight elevator, forceps can be used to remove root. 

i'rimiph's of Complicated Exvdontki 



FIG. 8-39 If tooth root is quite solid in bone, buccal bone can 
be removed and purchase point made for insertion of elevator. 

with a rongeur is rarely indicated, because it tends to 
remove too much bone. 

Once the tooth is delivered, the entire surgical field 
should be thoroughly irrigated with copious amounts of 
saline. Special attention should be directed toward the 
most inferior portion of the flap (where it joins the 
bone), because this is a common place for debris to set- 
tle, especially in mandibular extractions. If the debris is 
not removed carefully by curettage or irrigation, it can 
cause delayed healing or even a small subperiosteal 
abscess in the ensuing 3 to 4 weeks. The flap is then 
set in its original position and sutured into place with 
3-0 black silk sutures. If the incision were properly 
planned and executed, the suture line will be 
supported on sound, intact bone. 

Technique for Surgical Removal of Multirooted Teeth 

If the decision is made to perform an open extraction 
of a multirooted tooth, such as a mandibular or 
maxillary molar, the same surgical technique used for 
the single-rooted tooth is generally used. The major 
difference is that the tooth may be divided with a bur 
to convert a multirooted tooth into several single- 
rooted teeth. If the crown of the tooth remains intact, 
the crown portion is sectioned in such a way as to 
facilitate removal of roots. However, if the crown 
portion of the tooth is missing and only the roots 
remain, the goal is to separate the roots to make them 
easier to remove with elevators. 

Removal of the lower first molar with an intact 
crown is usually done by sectioning the tooth 
buccolingually and thereby dividing the tooth into a 
mesial half (with mesial root and half of the crown) and 
a distal half. An envelope incision is also made, and a 
small amount of crestal bone is removed. Once the 
tooth is sectioned, it is luxated with straight elevators to 
begin the mobilization process. The sectioned tooth is 
treated as a lower premo-lar tooth and is removed with 
a lower universal forceps (Fig. 8-41). The flap is 
repositioned and sutured. 

The surgical technique begins with the reflection of 
an adequate flap (Fig. 8-42, A and B). The surgeon 
selects either an envelope or three-cornered flap as the 

FIG. 8-40 A, Stout elevator, such as Crane pick, is then 
inserted into purchase point, and tooth is elevated from its 
socket. B, The flap is repositioned and sutured over intact bone. 

ment for access and personal preference dictate. 
Evaluation of the need for sectioning roots and 
removing bone is made at this stage, as it was with 
the single-rooted tooth. Occasionally, forceps, 
elevators, or both are positioned with direct 
visualization to achieve better mechanical advantage 
and to remove the tooth without removing the bone. 

However, in most situations a small amount of 
crestal bone should be removed, and the tooth should 
be divided. Tooth sectioning is usually 
accomplished with a straight hand piece with a 
straight bur, such as the no. 8 round bur, or with a 
fissure bur, such as the no. 557 or no. 703 bur (Fig. 8- 
42, C). 

Once the tooth is sectioned, the small straight 
elevator is used to luxate and mobilize the sectioned 
roots (Fig. 8-42, D). The straight elevator may be used 
to deliver the mobilized sectioned tooth (Fig. 8-42, E). 
If the crown of the tooth is sectioned, upper or lower 
universal forceps is used to remove the individual 
portions of the sectioned tooth (Fig. 8-42, F). If the 
crown is missing, then straight and triangular 
elevators are used to elevate the tooth roots from the 

Sometimes, a remaining root may be difficult to 
remove, and additional bone removal (as is described for 
a single-rooted tooth) may be necessary. Occasionally, it 
is necessary to prepare a purchase point with the bur and 
to use an elevator, such as the Crane pick, to elevate the 
remaining root. 



Principles of ExodonLia 

FIG. 8-41 If lower molar is difficult to extract, it can be sectioned into single-rooted teeth. A, Envelope incision is reflected, and 
small amount of crestal bone is removed to expose bifurcation. Drill is then used to section the tooth into mesial and distal 
halves. B, Lower universal forceps is used to remove two crown and root portions separately. 

After the tooth and all the root fragments have been 
removed, the flap is repositioned and the surgical area 
palpated for sharp bony edges. If any are present, they 
are smoothed with a bone file. The wound is 
thoroughly irrigated and debrided of loose fragments of 
tooth, bone, calculus, and other debris. The flap is 
repositioned again and sutured in the usual fashion 
(Fig. 8-42, G). 

An alternative method for removing the lower first 
molar is to reflect the soft tissue flap and remove 
sufficient buccal bone to expose the bifurcation. Then 
the bur is used to section the mesial root from the tooth 
and convert the molar into a single-rooted tooth (Fig. 
8-43). The crown with the mesial root intact is 
extracted with no. 17 lower molar forceps. The 
remaining mesial root is elevated from the socket with a 
Cryer elevator. The elevator is inserted into the empty 
tooth socket and rotated, using the wheel-and-axle 
principle. The sharp tip of the elevator engages the 
cementum of the remaining root, which is elevated 
occlusally from the socket. If the interradicular bone is 
heavy, the first rotation or two of the Cryer elevator 
removes the bone, which allows the elevator to engage 
the cementum of the tooth on the second or third 

If the crown of the mandibular molar has been 
lost, the procedure again begins with the reflection of 
an envelope flap and removal of a small amount of 
crestal bone. The bur is used to section the two roots 
into mesial and distal components (Fig. 8-44, A). The 
small straight elevator is used to mobilize and luxate 
the mesial root, which is delivered from its socket by 
insertion of the Cryer elevator into the slot prepared 
by the dental bur (Fig. 8-44, B). The Cryer elevator is 
rotated in the wheel-and-axle manner, and the mesial 
root is delivered occlusally from the tooth socket. The 
opposite member of the paired Cryer instruments is 
inserted into the empty root socket and rotated 
through the interradicular bone to engage and deliver 
the remaining root (Fig. 8-44, C). 

Extraction of maxillary molars with widely 
divergent buccal and palatal roots that require 
excessive force to extract can be removed more 

prudently by dividing the root into several sections. 
This three-rooted tooth must be divided in a pattern 
different from that of the two-rooted mandibular 
molar. If the crown of the tooth is intact, the two buccal 
roots are sectioned from the tooth and the crown is 
removed along with the palatal root. 

The standard envelope flap is reflected, and a small 
portion of crestal bone is removed to expose the trifurca- 
tion area. The bur is used to section off the mesiobuccal 
and distobuccal roots (Fig. 8-45, A). With gentle but firm 
bucco-occlusal pressure, the upper molar forceps delivers 
the crown and palatal root along the long axis of the 
root (Fig. 8-45, B). No palatal force should be delivered 
with the forceps to the crown portion, because this 
results in fracture of the palatal root. The entire 
delivery force should be in the buccal direction. A 
small straight elevator is then used to luxate the buccal 
roots (Fig. 8-45, C), which can then be delivered either 
with a Cryer elevator used in the usual fashion (Fig. 8- 
45, D) or with a straight elevator. If straight elevators are 
used, the surgeon should remember that the maxillary 
sinus might be very close to these roots, so apically 
directed forces must be kept to a minimum and 
carefully controlled. The entire force of the straight 
elevator should be in a mesiodistal direction, and slight 
pressure should be applied apically. 

If the crown of the maxillary molar is missing or frac- 
tured, the roots should be divided into two buccal roots 
and a palatal root. The same general approach as before is 
used. An envelope flap is reflected and retracted with a 
periosteal elevator. A moderate amount of buccal bone 
is removed to expose the tooth for sectioning (Fig. 8-46, 
A). The roots are sectioned into the two buccal roots 
and a single palatal root. Next the roots are luxated 
with a straight elevator and delivered with Cryer 
elevators, according to the preference of the surgeon 
(Fig. 8-46, B and C). Occasionally, enough access to the 
roots exists so that a maxillary root forceps or upper 
universal forceps can be used to deliver the roots 
independently (Fig. 8-46, D). Finally, the palatal root is 
delivered after the two buc-cal roots have been 
removed. Often much of the inter- 

Principles of 'Complicated Exodontia ■ CHAPTERS 175 

radicular bone is lost by this time; therefore the small 
straight elevator can be used efficiently. The elevator is 
forced down the periodontal ligament space on the 
palatal aspect with gentle, controlled wiggling motions, 
which causes displacement of the tooth in the buccooc- 
clusal direction (Fig. 8-46, E). 

FIG. 8-42 A, This primary second molar cannot be removed by 
closed technique because of tipping of adjacent teeth into 
occlusal path of withdrawal and of high likelihood of ankylosis. B, 
Envelope incision is made, extending two teeth anteriorly and one 
tooth posteriorly. C, Small amount of crestal bone is removed, and 
tooth is sectioned into two portions with bur. D, Small straight 
elevator is used to luxate and deliver mesial portion of crown and 
mesial root. E, Distal portion is luxated with small straight 
elevator. F, No. 1 51 forceps is used to deliver remaining portion of 
tooth. G, Wound is irrigated and flap approximated with gut 
sutures in papillae. 

Removal of Small Root Fragments and Root Tips 

If fracture of the apical one third (3 to 4 mm) of the 
root occurs during a closed extraction, an orderly 
procedure should be used to remove the root tip from 
the socket. Initial attempts should be made to extract 
the root fragment by a closed technique, but the 
surgeon should 

176 PART 11 ■ Principles of Exodontia 

FIG. 8-43 A, Alternative method of sectioning is to use bur to remove mesial root from first molar. 

B, No. 178 forceps is then used to grasp crown of tooth and remove the crown and distal root. 

C, Cryer elevator is then used to remove mesial root. Its point is inserted into empty socket of distal 
root and turned in wheel-and-axle fashion, with sharp point engaging interseptal 
bone and root and elevating mesial root from its socket. 

FIG. 8-44 A, When crown of lower molar is lost because of fracture or caries, small envelope flap is reflected and small amount of 
crestal bone is removed. Bur is then used to section tooth into two individual roots. B, After small straight elevator has been used to 
mobilize roots, Cryer elevator is used to elevate distal root. Tip of elevator is placed into slot prepared by bur, and elevator is turned to 
deliver the root. C, Opposite member of paired Cryer elevators is then used to deliver remaining tooth root with same type of 
rotational movement. 

Principle* of Complicated Exodontia ■ CHAPTERS 177 

FIG. 8-45 A, When intact maxillary molar must be divided for judicious removal (as when extreme 
divergence of roots is found), small envelope incision is made and small amount of crestal bone is 
removed. This allows bur to be used to section buccal roots from crown portion of tooth. B, Upper 
molar forceps is then used to remove crown portion of tooth along with palatal root. Tooth is deliv- 
ered in buccoocclusal direction, and no palatal pressure is used, because it would probably cause frac- 
ture of palatal root from crown portion. C, Straight elevator is then used to mobilize buccal roots and 
can occasionally be used to deliver these roots. D, Cryer elevator can be used in usual fashion by plac- 
ing tip of elevator into empty socket and rotating it to deliver remaining root. 

begin a surgical technique if the closed technique is not 
immediately successful. Whichever technique is chosen, 
two requirements for extraction are critically important: 
excellent light and excellent suction, preferably with a 
suction tip of small diameter. It is impossible to remove a 
small root tip fragment unless the surgeon can clearly 
visualize it. It is also important that an irrigation syringe 
be available to irrigate blood and debris from around the 
root tip so that it can be clearly seen. 

The closed technique for root tip retrieval is defined as 
any technique that does not require reflection of soft 
tissue flaps and removal of bone. Closed techniques are 
most useful when the tooth was well luxated and 
mobile before 

the root tip fractured. If sufficient luxation occurred 
before the fracture, the root tip often is mobile and 
can be removed with the closed technique. However, 
if the tooth was not well mobilized before the 
fracture, the closed technique is less likely to be 
successful. The closed technique is also less likely to be 
successful if the clinician finds a bulbous 
hypercementosed root with bony interferences that 
prevent extraction of the root tip fragment. In addition, 
severe dilaceration of the root end may prevent the use 
of the closed technique. 

Once the fracture has occurred, the patient should 
be repositioned so that adequate visualization (with 
proper lighting), irrigation, and suction are achieved. 
The tooth 

178 PART II ■ Principles of Exwkmtk 

FIG. 8-46 A, If crown of upper molar has been lost to caries or has been fractured from roots, small 
envelope incision is reflected and small amount of crestal bone is removed. Bur is then used to section 
three roots into independent portions. B, After roots have been luxated with small straight elevator, 
mesiobuccal root is delivered with Cryer elevator placed into slot prepared by bur. C, Once mesiobuc- 
cal root has been removed, Cryer elevator is again used to deliver distal buccal root. Tip of Cryer ele- 
vator is placed into empty socket of mesiobuccal root and turned in usual fashion to deliver tooth root. 
D, Maxillary root forceps can be occasionally used to grasp and deliver remaining root. Palatal root can 
then be delivered either with straight elevator or with Cryer elevator. If straight elevator is used, it is 
placed between root and palatal bone and gently wiggled in effort to displace palatal root in buc- 
coocclusal direction. E, Small straight elevator can be used to elevate and displace remaining root of 
maxillary third molar in buccoocclusal direction with gentle wiggling pressures. 

socket should be irrigated vigorously and suctioned 
with a small suction tip, because the loose tooth 
fragment occasionally can be irrigated from the socket. 
Once irrigation and suction are completed, the 
surgeon should inspect the tooth socket carefully to 
assess whether the root has been removed from the 

If the irrigation- suction technique is unsuccessful, 
the next step is to tease the loose root apex from the 
socket with a root tip pick. A root tip pick is a delicate 
instrument and cannot be used as the Cryer elevator 
can to remove bone and elevate entire roots. The root 
tip pick is inserted into the periodontal ligament 
space, and the root is teased out of the socket {Fig. 8- 
47). Neither excessive apical or lateral force should be 
applied to the root tip pick. Excessive apical force 
could result in displacement of the root tip into other 
anatomic locations, such 

as the maxillary sinus. Excessive lateral force could result 
in the bending or fracture of the end of the root tip pick. 

The root tip also can be removed with the small straight 
elevator used as a shoehorn. This technique is indicated 
more often for the removal of larger root fragments than 
for small root tips. The technique is similar to that of the 
root tip pick, because the small straight elevator is forced 
into the periodontal ligament space, where it acts like a 
wedge to deliver the tooth fragment toward the occlusal 
plane (Fig. 8-48). Strong apical pressure should be avoided, 
because it may force the root into the underlying tissues. 

This is more likely to occur in the maxillary premolar 
and molar areas, where tooth roots can be displaced into 
the maxillary sinus. When the straight elevator is used in 
this fashion, the surgeon's hand must always be supported 
on an adjacent tooth or a solid bony prominence. This 

Principles of Complicated Exodontia ■ CHAPTERS 175 

FIG. 8-47 A, When small (2 to 4 mm) portion of root apex is frac- 
tured from tooth, root tip pick can be used to retrieve it. B, Root tip 
pick is teased into periodontal ligament space and used to luxate 
root tip gently from its socket. 

support allows the surgeon to deliver carefully controlled 
force and to decrease the possibility of displacing tooth 
fragments or the instrument. The surgeon must be able to 
visualize clearly the top of the fractured root to see the 
periodontal ligament space. The straight elevator must be 
inserted into this space and not merely pushed down into 
the socket. 

If the closed technique is unsuccessful, the surgeon 
should switch without delay to the open technique. It is 
important for the surgeon to recognize that a smooth, 
efficient, properly performed open retrieval of a root 
fragment is less traumatic than a prolonged, time-con- 
suming, frustrating attempt at closed retrieval. 

Two main open techniques are used to remove root 
tips. The first is simply an extension of the technique 
described for surgical removal of single-rooted teeth. A 
soft tissue flap is reflected and retracted with a periosteal 
elevator. Bone is removed with a chisel or bur to expose 
the buccal surface of the tooth root. The root is buccally 
delivered with a small straight elevator. The flap is repo- 
sitioned and sutured (Fig. 8-49). 

A modification of the open technique just described 
can be performed to deliver the root fragment without 
removal of the entire buccal plate overlying the tooth. 
This technique is known as the open-window technique. A 
soft tissue flap is reflected in the usual fashion, and the 
apex area of the tooth fragment is located. A dental bur is 
used to remove the bone overlying the apex of the tooth 
and expose the root fragment. An instrument is then 
inserted into the window, and the tooth is displaced out 
of the socket (Fig. 8-50). 

The preferred flap technique is the three-cornered flap 
because of a need for more extensive exposure of the api- 
cal areas. This approach is especially indicated when the 
buccocrestal bone must be left intact. An important and 
common example is the removal of maxillary premolars 
for orthodontic purposes, especially in adults. 

FIG. 8-48 A, When larger portion of tooth root is left behind after 
extraction of tooth, small straight elevator can sometimes be used 
as wedge, or shoehorn, to displace tooth in occlusal direction, it is 
important to remember that pressure applied in such fashion should 
be in gentle wiggling motions; excessive pressure should not be 
applied, B, Excessive pressure in apical direction results in displace- 
ment of tooth root into undesirable places, such as maxillary sinus. 

Policy for Leaving Root Fragments 

When a root tip has fractured, when closed approaches of 
removal have been unsuccessful, and when the open 
approach may be excessively traumatic, the surgeon may 
consider leaving the root in place. As with any surgical 
approach, the surgeon must balance the benefits of surgery 
against the risks of surgery. In some situations the risks of 
removing a small root tip may outweigh the benefits. 

Three conditions must exist for a tooth root to be left 
in the alveolar process. First, the root fragment must be 
small, usually no more than 4 to 5 mm in length. Second, 
the root must be deeply embedded in bone and not 
superficial, to prevent subsequent bone resorption from 
exposing the tooth root and interfering with the prosthe- 
sis that will be constructed over the edentulous area. 
Third, the tooth involved must not be infected, and there 
must be no radiolucency around the root apex. This 
lessens the likelihood that subsequent infections will 
result from leaving the root in position. If these three 

ISO PARI II ■ Principles ofExwIontia 

FIG. 8-49 A, If root cannot be retrieved by closed techniques, 
soft tissue flap is reflected and bone overlying root is removed 
with bur. B, Small straight elevator is then used to luxate root 
buccally by wedging straight elevator into palatal periodontal 
ligament space. 

conditions exist, then consideration can be given to 
leaving the root. 

For the surgeon to leave a small, deeply embedded, 
noninfected root tip in place, the risk of surgery must 
be greater than the benefit. This risk is considered to 
be greater if one of the following three conditions 
exists: First, the risk is too great if removal of the root 
will cause excessive destruction of surrounding tissue; 
that is, if excessive amounts of bony tissue must be 
removed to retrieve the root. For example, reaching a 
small palatal root tip of a maxillary first molar may 
require the removal of large amounts of bone. 

Second, the risk is too great if removal of the root 
endangers vital structures, most commonly the inferior 
alveolar nerve, either at the mental foramen area or 
along the course of the canal. If surgical retrieval of a 
root may result in a permanent or even a prolonged 
temporary anesthesia of the inferior alveolar nerve, 
the surgeon should seriously consider leaving the root 
tip in place. 

Finally, the risks outweigh the benefits if attempts at 
recovering the root tip can displace the root into tissue 
spaces or into the maxillary sinus. The roots most often dis- 
placed into the maxillary sinus are those of the maxillary 
molars. If the preoperative radiograph shows that the bone 
is thin over the roots of the teeth and that the separation 
between the teeth and maxillary sinus is small, the prudent 
surgeon will choose to leave a small root fragment rather 
than risk displacing it into the maxillary sinus. Likewise, 
roots of the mandibular second and third molars can be dis- 
placed into the submandibular space during attempts to 
remove them. During retrieval of any root tip, apical pres- 
sure may displace teeth into tissue spaces or into the sinus. 

If the surgeon elects to leave a root tip in place, a strict 
protocol must be observed. The patient must be informed 
that, in the surgeon's judgment, leaving the root in its posi- 
tion will do less harm than surgery. In addition, radi- 
ographic documentation of the root tip's presence and posi- 
tion must be obtained and retained in the patient's record. 
The fact that the patient was informed of the decision to 
leave the root tip in position must be recorded in the 
patient's chart. In addition, the patient must be recalled for 
several routine periodic follow-ups over the ensuing year to 
track the fate of this root. The patient should be instructed to 
contact the surgeon immediately should any problems 
develop in the area of the retained root. 


If multiple adjacent teeth are to be extracted at a single 
sitting, slight modifications of the routine extraction 
procedure must be made to facilitate a smooth transition 
from a dentulous to an edentulous state that allows for 
proper rehabilitation with a fixed or removable prosthesis. 
This section discusses those modifications. 

Treatment Planning 

In most situations where multiple teeth are to be 
removed, preextraction planning regarding replacement 
of the teeth to be removed is necessary. This may be a full 
or removable partial denture or perhaps placement of a 
single or multiple implants. Before the teeth are extracted, 
the surgeon should communicate with the restorative 
dentist and make a determination of the need for such 
items as interim partial immediate dentures. The discus- 
sion should also include mention of needs for any other 
type of soft tissue surgery, such as tuberosity reduction, 
and hard tissue surgery, such as removal of undercuts in 
critical areas. If dental implants are to be placed at some 
later time, it may also be desirable to graft the extraction 
socket so that healing will be more complete and rapid. In 
some situations, dental implants may be placed at the same 
time as the teeth are removed, which would require the 
preparation of a surgical guide stent to assist the surgeon 
in aligning the implants appropriately. 

Extraction Sequencing 

The order in which multiple teeth are extracted deserves 
some discussion. Maxillary teeth should usually be re- 

Principles of Complicated Exodontia ■ CHAFFER 8 181 

FIG. 8-50 A, Open-window approach for retrieving root is indicated when buccocrestal bone must 
be maintained. Three-cornered flap is reflected to expose area overlying apex of root fragment being 
recovered. B, Bur is used to uncover apex of root and allow sufficient access for insertion of straight 
elevator. C, Small straight elevator is then used to displace tooth out of tooth socket. 

moved first for several reasons. First of all, an infiltration 
anesthetic has a more rapid onset and also disappears 
more rapidly. This means that the surgeon can begin the 
surgical procedure sooner after the injections have been 
given; in addition, surgery should not be delayed because 
profound anesthesia is lost more quickly in the maxilla. 
In addition, maxillary teeth should be removed first, 
because during the extraction process debris such as por- 
tions of amalgams, fractured crowns, and bone chips may 
fall into the empty sockets of the lower teeth if the lower 
surgery is performed first. In addition, maxillary teeth are 
removed with a major component of buccal force. Little 
or no vertical traction force is used in removal of these 
teeth, as is commonly required with mandibular teeth. 
Therefore mandibular extractions that follow maxillary 
extractions are usually easier to perform. A single minor 
disadvantage for extracting maxillary teeth first is that if 
hemorrhage is not controlled in the maxilla before 
mandibular teeth are extracted, the hemorrhage may 

interfere with visualization during mandibular surgery. 
Hemorrhage is usually not a major problem, because 
hemostasis should be achieved in one area before the sur- 
geon turns his or their attention to another area of sur- 
gery, and the surgical assistant should be able to keep the 
surgical field free from blood with adequate suction. 

Extraction usually begins with extraction of the most 
posterior teeth first. This allows for the more effective use 
of dental elevators to luxate and mobilize teeth before the 
forceps is used to extract the tooth. The two teeth that are 
the most difficult to remove, the molar and canine, 
should be extracted last. Removal of the teeth on either 
side weakens the bony socket on the mesial and distal 
side of these teeth, and their subsequent extraction is 
made easier. 

In summary, if a maxillary and mandibular left quad- 
rant is to be extracted, the following order is recom- 
mended: (1) maxillary posterior teeth, leaving the first 
molar; (2) maxillary anterior teeth, leaving the canine; 



Principles of Exodontia 

FIG. 8-51 A, This patient's remaining teeth are to be extracted. 
The broad zone of attached gingiva is demonstrated in adequate 
vestibular depth. B, After adequate anesthesia is achieved, soft tis- 
sue attachment to teeth is incised with no. 15 blade. Incision is car- 
ried around necks of teeth and through interdental papilla. C, 
Woodson elevator is used to reflect labial soft tissue just to crest of 
labioalveolar bone. D, Small straight elevator is used to luxate 
teeth before forceps is used. Surgeon's opposite hand is reflecting 
soft tissue and stabilizing mandible. E, Teeth adjacent to mandibu- 
lar canine are extracted first, which makes extraction of remaining 
canine tooth easier to accomplish. 


(3) maxillary molar; (4) maxillary canine; (5) mandibular 
posterior teeth, leaving the first molar; (6) mandibular 
anterior teeth, leaving the canine; (7) mandibular molar; 
and (8) mandibular canine. 

Technique for Multiple Extractions 

The surgical procedure for removing multiple adjacent 
teeth is modified slightly. The first step in removing a 
single tooth is to loosen the soft tissue attachment 
from around the tooth (Fig. 8-51, A and B). When 
performing multiple extractions, the soft tissue 
reflection is extended slightly to form a small envelope 
flap to expose the cre-stal bone only (Fig. 8-51, C). 
The teeth are luxated with 

the straight elevator (Fig. 8-51, D) and delivered with forceps 
in the usual fashion (Fig. 8-51, E). If removing any of the 
teeth is likely to require excessive force, the surgeon should 
remove a small amount of buccal bone to prevent fracture 
and bone loss. 

After the extractions are completed, the buccolingual 
plates are pressed into their preexisting position with 
firm pressure (Fig. 8-51, F). The soft tissue is repositioned, 
and the surgeon palpates the ridge to determine if any 
areas of sharp bony spicules or obvious undercuts can be 
found. If any exist, the bone rongeur is used to remove the 
larger areas of interference, and the bone file is used to 
smooth any sharp spicules (Fig. 8-51, G). The area is 
irrigated thoroughly with sterile saline. The soft tissue is 

Principles of Complicated Rxodontia ■ CHAPTER 8 

FIG. 8-51 — cont'd F, Alveolar plates are compressed firmly 
together to reestablish presurgical buccolingual width of alveolar 
process. Because of mild periodontal disease, excess soft tissue is 
found, which will be trimmed to prevent excess flabby tissue on 
crest of ridge. G, Rongeur forceps is used to remove only bone that 
is sharp and protrudes above reapproximated soft tissue. H, After 
soft tissue has been trimmed and sharp bony projections removed, 
tissue is checked one final time for completeness of soft tissue sur- 
gery. I, Tissue is closed with interrupted black silk sutures across 
papilla. This approximates soft tissue at papilla but leaves tooth sock- 
et open. Soft tissue is not mobilized to achieve primary closure, 
because this would tend to reduce vestibular height. J, Patient 
returns for suture removal 1 week later. Normal healing has 
occurred, and sutures are ready for removal. The broad band of 
attached tissue remains on ridge, similar to what existed in preoper- 
ative situation (see A). 

inspected for the presence of excess granulation tissue. If 
any is present it should be removed, because it may pro- 
long postoperative hemorrhage. The soft tissue is then 
reapproximated and inspected for excess gingiva. If the 
teeth are being removed because of severe periodontitis 
with bone loss, it is not uncommon for the soft tissue 
flaps to overlap and cause redundant tissue. If this is the 
situation, the gingiva should be trimmed so that no over- 
lap occurs when the soft tissue is apposed (Fig. 8-51, H). 
However, if no redundant tissue exists, the surgeon must 
not try to gain primary closure over the extraction sock- 
ets. If this is done the depth of the vestibule decreases, 
which may interfere with denture construction and wear. 
Finally, the papillae are sutured into position (Fig. 8-51,1 

and J). Interrupted or continuous sutures are used, 
depending on the preference of the surgeon. 

In some patients a more extensive alveoloplasty after 
multiple extractions is necessary. Chapter 13 has an in- 
depth discussion of this technique. 


Berman SA: Basic principles of dentoalveolar surgery. In LJ 
Peterson, editor: Principles of oral and maxillofacial surgery, 
Philadelphia, 1992, JB Lippincott. 

Brown RP: Knotting technique and suture materials, Br J Surg 
79:399, 1992. 

Cerny R: Removing broken roots: a simple method, Aust Dent) 
23:351, 1978.