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Manual of Minor Oral Surgery for the General Dentist - LEK4R|26/3/2008 4:58:19 MM) 

2608_Koerner_FM 4/17/06 1:20 PM Page i 

Manual of 

Minor Oral Surgery 

for the General Dentist 

2608_Koerner_FM 4/17/06 1:20 PM Page ill 

Manual of 

Minor Oral Surgery 

for the General Dentist 

Edited by 
Karl R. Koerner 



2608_Koerner_FM 4/17/06 1:20 PM Page iv 

Karl R. Koerner, BS, DDS, MS, is an editor of and 
contributor to Manual of Oral Surgery for General 
Dentists (Blackwell Publishing) and has co-authored 
Color Atlas of Minor Oral Surgery, 2nd ed. (Mosby) 
and Clinical Procedures for Third Molar Surgery, 2nd 
ed. (PennWell). He also is editor of and contributor 
to a Dental Clinics of North America (Saunders) vol- 
ume on basic oral surgery. Dr. Koerner has produced 
video programs and contributed articles to publica- 
tions such as General Dentistry, Dentistry Today, 
Dental Economics, and the Journal of Public Health 

Dr. Koerner is a past president of the Utah Dental 
Association and a former delegate to the ADA House. 
He has served as Utah Academy of General Dentistry 
(AGD) president, is a Fellow in the AGD, and has 
membership in the International College of Dentists. 
He is licensed in Utah to administer IV sedation and 
licensed to practice dentistry in Utah, Idaho, and 
California. His practice is now limited to oral surgery. 

Dr. Koerner has been teaching clinical courses on oral 
surgery to other dentists in the United States and 
abroad since 1981. In 2002, he joined Clinical 
Research Associates (CRA) in Provo, Utah, as an 
evaluator and clinician and began teaching their 
"Update" courses throughout the country and abroad. 
Since 2002, he has co-presented more than 90 courses 
for CRA and serves on their advisory board. 

© 2006 by Blackwell Munksgaard, 
published by Blackwell Publishing, a Blackwell 
Publishing Company 

Blackwell Publishing Professional 

2121 State Avenue, Ames, Iowa 50014-8300, USA 

Tel;+1 515 292 0140 

Europe and Asia 

All rights reserved. No part of this publication may 
be reproduced, stored in a retrieval system, or trans- 
mitted, in any form or by any means, electronic, 
mechanical, photocopying, recording or otherwise, 
except as permitted by the UK Copyright, Designs 
and Patents Act 1988, without the prior permission 
of the publisher. 

The right of the Author to be identified as the Author 
of this Work has been asserted in accordance with the 
Copyright, Designs and Patents Act 1988. 

North America 

Authorization to photocopy items for internal or 
personal use, or the internal or personal use of specific 
clients, is granted by Blackwell Publishing, provided 
that the base fee of $.10 per copy is paid directly to 
the Copyright Clearance Center, 222 Rosewood 
Drive, Danvers, MA 01923. For those organizations 
that have been granted a photocopy license by CCC, 
a separate system of payments has been arranged. 
The fee code for users of the Transactional Reporting 
Service is ISBN-13: 978-0-8138-0559-7; ISBN-10: 
0-8138-0559-7/2006 $.10. 

Library of Congress Cataloging-in-Publication Data 

Manual of minor oral surgery for the general dentist / 
edited by Karl R. Koerner. 
p. ; cm. 

Includes bibliographical references and index. 

ISBN-13: 978-0-8138-0559-7 (alk. paper) 

ISBN-10: 0-8138-0559-7 (alk. paper) 

1. Dentistry, Operative. 2. Mouth — Surgery. 
3. Dentistry. [DNLM: 1. Oral Surgical Procedures. 
2. Surgical Procedures, Minor. WU 600 M294 
2006] I. Koerner, Karl R. 

Editorial Offices: 

9600 Garsington Road, Oxford OX4 2DQ 

Tel: 01865 776868 

RK501.M34 2006 
617.6'05— dc22 


Blackwell Publishing Asia Pty Ltd, 
550 Swanston Street, Carlton South, 
Victoria 3053, Australia 
Tel: +61 (0)3 9347 0300 

Blackwell Wissenschafts Verlag, Kurfurstendamm 57, 
10707 Berlin, Germany 
Tel: +49 (0)30 32 79 060 

For further information on 

Blackwell Publishing, visit our Dentistry Subject Site: 

The last digit is the print number: 987654321 

2608_Koerner_FM 4/17/06 1:20 PM Page v 


Contributors vii 
Preface ix 

Chapter 1 Patient Evaluation and Medical History 3 

Dr. R. Thane Hales 
Chapter 2 Surgical Extractions 19 

Dr. Hussam S. Batal and Dr. Gregg Jacob 
Chapter 3 Surgical Management of Impacted Third Molar Teeth 49 

Dr. Pushkar Mehra and Dr. Shant Baran 
Chapter 4 Pre-Prosthetic Oral Surgery 8 1 

Dr. Ruben Figueroa and Dr. Abhishek Mogre 
Chapter 5 Conservative Surgical Crown Lengthening 99 

Dr. George M. Bailey 
Chapter 6 Endodontic Periradicular Microsurgery 1 37 

Dr. Louay Abrass 
Chapter 7 The Evaluation and Treatment of Oral Lesions 20 1 

Dr. Joseph D. Christensen and Dr. Karl R. Koerner 
Chapter 8 Anxiolysis for Oral Surgery and Other Dental Procedures 221 

Dr. Fred Quarnstrom 
Chapter 9 Infections and Antibiotic Administration 255 

Dr. R. Thane Hales 
Chapter 10 Management of Perioperative Bleeding 277 

Dr. Karl R. Koerner, and Dr. William L. McBee 
Chapter 1 1 Third World Volunteer Dentistry 295 

Dr. Richard C. Smith 

Index 319 

2608_Koerner_FM 4/17/06 1:20 PM Page vll 


Number in brackets following each name is the 
chapter number. 

Louay M. Abrass, DMD [6] 

Assistant Clinical Professor, Department of 

Endodontics, Boston University School 

of Dental Medicine 
Adjunct Assistant Professor, Department of 

Endodontics, University of Pennsylvania 

School of Dental Medicine 
Private Practice Limited to Endodontics in 

Boston and Wellesley, Massachusetts 

George M. Bailey, DDS, MS [5] 
Associate Professor, University of Utah 

Medical School and Creighton School of 

President and Lecturer CPSeminars 
Private Practice Periodontics 

Shant Baran, DMD [3] 

Resident, Department of Oral and 

Maxillofacial Surgery, Boston University 
School of Dental Medicine and Boston 
Medical Center, Boston, Massachusetts 

Hussam S. Batal, DMD [2] 

Assistant Professor, Department of Oral 
and Maxillofacial Surgery, Boston 
University, Boston, Massachusetts 

Joseph D. Christensen, DMD [7] 
Private General Practice, Salt Lake City, 

Ruben Figueroa, DMD, MS [4] 
Oral and Maxillofacial Surgeon 
Assistant Professor, Director Predoctoral 
Oral and Maxillofacial Surgery, Director 
Oral Surgery Clinic, Boston University, 
Henry Goldman School of Dental 
Medicine, Boston, Massachusetts 

R. Thane Hales, DMD [1,9] 
Founder and Director of the Wasatch 

Surgical Institute 
International Lecturer and Clinician, Private 

Practice, Ogden, Utah 

Gregg A. Jacob, DMD [2] 
Private Practice, Summit Oral and 

Maxillofacial Surgery, PA., Summit, 

New Jersey 

Karl R. Koerner, DDS, MS [Editor, 7, 10] 
International Lecturer and Clinician 
Private General Practice Limited to Oral 

Surgery, Salt Lake City, Utah 
Formerly Consultant and Instructor for 

Clinical Research Associates, Provo, Utah 

William L. McBee, DDS [10] 
Private Practice Limited to Oral and 
Maxillofacial Surgery, Provo, Utah 


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Pushkar Mehra, BDS, DMD [3] 

Director, Department of Dentistry and Oral 

and Maxillofacial Surgery, Boston 

Medical Center 
Director, Department of Oral and 

Maxillofacial Surgery, Boston University 

Medical Center 
Assistant Professor, Department of Oral and 

Maxillofacial Surgery, Boston University 

School of Dental Medicine, Boston, 


Abhishek Mogre BDS [4] 
Current Advanced Standing DMD Student 
Vice President Predoctoral Association of 
Oral and Maxillofacial Surgery, Boston 
University, Henry Goldman School of 
Dental Medicine, Boston, Massachusetts 

Dr. Fred Quarnstrom, DDS [8] 

Clinical Faculty of Dentistry, University of 

British Columbia 
Affiliate Assistant Professor, University of 

Washington School of Dentistry 
Dental Anesthesiologist also in General 

Dental Practice, Seattle, Washington 

Richard C. Smith, DDS [11] 
Chairman of Ayuda Incorporated 
Private General Practice (Retired), Westlake 
Village, California 

2608_Koerner_FM 4/17/06 1:20 PM Page ix 


This handbook is a guide for the general 
dentist who enjoys doing oral surgery. A 
broad range of knowledge and expertise in 
this area is found among dentists. Some 
have had extensive experience and training 
through general practice residencies, mili- 
tary or other postgraduate programs, or a 
mentoring experience with a more experi- 
enced dentist; others have had only minimal 
instruction and training in dental school. 

Dental school oral surgery training varies 
widely based on individual school require- 
ments for graduation. In addition, some 
schools offer elective or extramural experi- 
ences, others do not. Even in the same 
dental school class, a few students might 
have the opportunity to perform extensive 
exodontia, but others will remove only a 
few teeth before moving on to private prac- 
tice. This handbook is meant to diminish 
the discrepancy between experienced and 
inexperienced generalists and provide an 
information base for the interested clinician. 
This book presents a review of procedures 
and principles in each of several clinical 
surgical areas; this review will enable a 
dentist to perform according to established 
standards of care. 

It is assumed that the reader possesses 
fundamental knowledge and skills in oral 
anatomy, patient/operator positioning for 
surgery, the care of soft and hard tissue dur- 
ing surgery, and basic patient management 
techniques. Therefore, the authors have 
skipped to the crux of each procedure, 
addressing such things as case selection, 
step-by-step operative procedures, and the 

prevention and/or management of compli- 
cations. This handbook will help dentists 
perform procedures more quickly, smoothly, 
easily, and safely — thereby greatly minimiz- 
ing doctor frustration and patient dis- 

The procedures covered in this book are 
also done by oral and maxillofacial surgeons 
and/or periodontists and endodontists. 
There are times that the patient would be 
better served by being referred to the spe- 
cialist, such as when the patient is extremely 
apprehensive, medically compromised, an 
older patient with dense bone, or has other 
mitigating circumstances. This book will 
help readers more clearly understand the 
scope of each procedure and more accurately 
define their capabilities and comfort zones. 

Procedures described are mainly dento- 
alveolar in nature, such as "surgical" extrac- 
tions, the removal of impacted wisdom 
teeth (mainly in younger patients), pre- 
prosthetic surgery, apicoectomy and retrofll 
cases, surgical crown lengthening, and 
biopsy. Supportive topics include patient 
evaluation and case selection and the man- 
agement of problems such as bleeding and 
infection. One chapter involves logistical 
considerations and the use of basic surgical 
principles for those volunteering services in 
a third-world setting. 

This book is a ready reference for the 
surgery-minded general practioner. Within 
these pages, the authors share many pearls 
gleaned from years of experience and train- 
ing to increase the readers' confidence and 


2879_Koerner_Chap 01 4/17/06 1:22 PM Page 3 

Chapter 1 

Patient Evaluation and 

Medical History 

Dr. R Thane Hales 


The purpose of this book is to provide the 
general dentist with specific information 
about oral surgery procedures that are per- 
formed daily in general dentists' offices. 
Some advanced information is also given to 
provide the more experienced general dentist 
the opportunity to further his or her skills 
and knowledge. 

The ability of a general dentist to perform 
these procedures is based on a number of 
factors. Some dentists have a great interest in 
surgery, while others have very little interest. 
Some dentists have had a general practice 
residency or other postgraduate training or 
experience; others may not have had the op- 
portunity. Some are in areas that have little 
or no support from a specialist, which makes 
some surgery mandatory in their practices. 
Currently, it is accepted that regardless of 
who performs dental procedures, be they a 
generalist or a specialist, the standards of care 
are the same. If a general dentist wants to in- 
clude the removal of third molars in his or 
her practice, he or she will usually need more 
training than that provided in dental school. 

Just having the desire to do this procedure 
will not, in and of itself, qualify a person. 
The best thing a general dentist can do is to 
first obtain additional training. Surgical ex- 
pertise is improved by taking postgraduate 
courses. The clinician then learns to diagnose 
the less complicated procedures and does 
them with supervision until they are per- 
formed well. State laws do not discriminate 
between a general dentist and a specialist. A 
license gives the same perogative to a gener- 
alist that an oral surgeon has to extract teeth. 
Therefore, the generalist has a greater re- 
sponsibility to acquire training and knowl- 
edge if he or she expects to do more complex 
procedures. This responsibility includes not 
only receiving instruction in step-by-step 
surgical techniques, but also the medical 
management of such patients and any com- 
plications that might arise. 

Surgical skill is only part of the equation. 
The judgment of the practitioner in making 
appropriate decisions regarding the patient's 
total condition is vital when doing surgical 
procedures. Anxiety management should be 
addressed before the surgical procedure is 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 4 


started. Will sedation be needed to accom- 
plish the treatment? Some patients require 
sedation in order to make them feel com- 
fortable about the surgery. The dentist who 
doesn't fully understand the many facets of 
treating an extremely anxious and medically 
compromised patient should find an appro- 
priate network of specialists in medicine 
and/or dentistry and then use a multidisci- 
plinary team approach. 

Dentists must never forget the human el- 
ements of kindness, compassion, and caring. 
The patient wants to be treated just like any 
person would want to be treated. Dentists 
need to have enough insight into the pa- 
tients' fears and concerns to be able to calm 
and reassure them that they can handle any 
and all contingencies with competence. A 
little compassion and empathy go a long way 
in today's "rushed" society. 

Humanism and compassion are the two 
most important factors by which a patient 
judges a dentist's skill. Especially in the mind 
of the patient, the technical aspect of surgery 
is secondary to the surgeon's ability to man- 
age pain and anxiety. It is a given that a sur- 
geon has the ability to handle tissues with 
great skill, care, and judgment; the proper 
handling of and respect for tissues will en- 
able them to heal more quickly and without 
as many complications. 

Medical History 

The most important information that a cli- 
nician can acquire is the medical history of a 
patient. If any problem is expressed in the 
history, a skilled clinician should be able to 
decide whether the patient is capable of un- 
dergoing the procedure. The dentist should 
be fully able to predict how medical prob- 
lems might interfere with the patient's ability 
to heal and whether they might react to the 
anesthetic, antibiotics, or other medications. 
The doctor needs to have a detailed ques- 
tionnaire that covers all major medical prob- 
lems that could exist in a patient and a space 

on the form for any other condition not 
mentioned. The questionnaire must make 
sure that the doctor is advised of any com- 
plications a patient may have had in the 
past. The doctor then must be able to fully 
evaluate the patient's situation relative to the 

In the process of getting medical informa- 
tion or even biographical data, the doctor 
should observe the patient for any illogical 
statements or inconsistent responses that 
might need further evaluation. A bright, 
well-trained assistant is priceless in a private 
practice — especially during the filling out of 
patient forms and in helping to acquire ac- 
curate medical information. He/she should 
bring to the attention of the doctor any 
problem on the form that might influence 
the procedure. The assistant must also high- 
light medical problems and mark the outside 
of the chart with a coded warning that the 
patient is at medical risk. 

All medical questionnaires should include 
a history and description of the patient's 
chief complaint. Patients should fill out the 
form in their own words and give as much 
information as they can about their prob- 
lems. The clarity of this information, accom- 
panied by careful and skillful questioning by 
the doctor, can help him or her form a rea- 
sonable diagnosis. If the patient is unable to 
competently give this information, then all 
aspects of the information should be suspect. 
A diagnosis can be moved to the next step 
only if there is a complete and reliable review 
of the patient's status. The form should in- 
clude a statement of confidentiality reassur- 
ing patients that records will be protected. 
The only people having access to the records 
will be the doctors in the practice or the 
patient's physician (with permission of the 
patient). A signature line is also required to 
verify that the patient has understood the 
questions and that they have been answered 

Specifically, the medical history form 
should include medical problems patients 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 5 


might have that would compromise their 
safety (unless proper steps are taken by the 
dentist). The cardiovascular system is a main 
consideration. Any history of angina, my- 
ocardial infarction, murmurs, or rheumatic 
fever should be taken seriously, and appro- 
priate steps should be taken to protect the 
patient. Other illnesses like hepatitis, asthma, 
diabetes, kidney disease, sexually transmitted 
disease, seizures, artificial joints, heart valves, 
and specific allergies should be noted. 
Allergies that should be addressed are mainly 
those to medications and other items used in 
a dental office, such as latex. The use of any 
anticoagulants (which now include some of 
the common herbal compounds), corticos- 
teroids, hypertension medication, and other 
medications should be thoroughly reviewed. 1 
Female patients, even young unmarried fe- 
males, should be asked whether there is any 
possibility that they are pregnant. The med- 
ical history should be updated annually. A 
good hygienist or assistant should interview 
the patient to find out whether there has 
been any change since the patient's last visit. 
The hygienist should then record the 
changes on the chart and bring them to the 
attention of the doctor. 

After the medical history form is filled 
out, the doctor sits with the patient and re- 
views the form in detail. It is crucial that the 
patient understands everything they are talk- 
ing about. This is a good time to evaluate the 
patient s ability to respond and comprehend 
his or her condition. Any signs of nervous or 
psychological behavior should be noted. The 
interview should help determine whether the 
patient is responsible enough for the physi- 
cian to trust the information the patient has 
given on the medical form. If there is any 
doubt, a responsible family member should 
be consulted, and when necessary, a call to 
the patient's physician should be made. 

Form 1 . 1 shows a typical medical history 
form. Each provider must take responsibility 
for the content of his or her own forms. 
Another important legal paper that has 

proven worthwhile is the consent to proceed 
form (Form 1.2). It gives added protection 
to the office staff. 2 


The dentist is, of course, subject to HIPPA 
(Health Insurance Portability and Account- 
ability Act of 1996) regulations. HIPAA 
requires that all health plans, including the 
Employee Retirement Income Security Act 
(ERISA), health care clearinghouses, and any 
dentist who transmits health information in 
an electronic transaction, use a standard for- 
mat. Those plans and providers that choose 
not to use the electronic standards can use a 
clearinghouse to comply with the require- 
ment. Providers' paper transactions are not 
subject to this requirement. The security reg- 
ulations, which the Department of Health 
and Human Services released under HIPPA, 
were conceived to protect electronic patient 
health information. Protected patient health 
information is anything that ties a patient's 
identity to that person's health, health care, 
or payment for health care, such as X-rays, 
charts, or invoices. Transactions include 
claims and remittances, eligibility inquiries 
and response, and claim status and response. 
Self-training kits can be purchased from the 
American Dental Association. Electronic 
processing has become the standard and, in 
many ways, makes the provider's life much 

Physical Examination 

The clinician or a well-trained hygienist or 
assistant should begin the exam with the 
measurement of vital signs. This both serves 
as a screening device for unsuspected 
medical problems and gives a good baseline 
for future evaluations. The technique of 
measuring blood pressure and pulse rate is 
shown in Figure 1.1. 

Despite elevated blood pressure being 
common, the devices to examine this critical 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 6 

Medical History 

Patient's Name Date of Birth 

Physician's Name Phone number 

Please answer the following questions as completely as possible 

1 . Do you consider yourself to be in good health? YES NO 

2. Are you now or have you been under a physician's care within the past year? YES NO 

If yes, specify the condition being treated: 

Do you take any medication, including birth control pills? YES NO 
Please specify name and purpose of medication: 

4. Do you have or have you ever had any heart or blood problems? YES NO 

5. Have you ever been told that you have a heart murmur? YES NO 

6. Do you require antibiotic medication before treatment for a heart condition? YES NO 

7. Do you now have or have you ever had high blood pressure? YES NO 

8. Have you ever been diagnosed as being HIV positive or having AIDS? YES NO 

9. Have you ever had hepatitis or liver disease? YES NO 

10. Have you ever had rheumatic fever, asthma, blood disorder, 

diabetes ; rhermatism ; arthritis ; tuberculosis ; venereal disease ; heart attack 

kidney disease ; immune system disorder ; any other diseases 

If so, specify: 

11. Do you bleed easily? YES NO 

12. Have you ever had any severe or unusual reaction to, or are you allergic to, any drugs, including the following: 
Penicillin Ibuprofen 

Aspirin Codeine 

Acetaminophen Barbiturates. 

Are you taking any of the following medications? 

Antibiotics Digitalis or heart medication. 

Anticoagulants (Blood thinners) Nitroglycerin 

Aspirin Antihistamine 

Tranquilizers Oral contraceptives 


13. Do you faint easily? YES NO 

14. Have you ever had a reaction to dental treatment or local anesthetic? YES NO 

15. Are you allergic to any local anesthetic? YES NO 

16. Do you have any other allergies? YES NO 

If yes, please describe: 

17. Have you ever had a nervous breakdown or undergone psychiatric treatment? YES NO 

18. Have you ever had an addiction problem with alcohol or drugs? YES NO 

19. Women: Are you or could you be pregnant YES NO 
Are you breast feeding now? YES NO 

20. Are you in pain now? YES NO 

21 . When did you last see a dentist? 

22. Who was your last dentist? 

23. Are your teeth affecting your general health? YES NO 

24. Do you have or have you had bleeding or sensitive gums? YES NO 

25. Have you ever taken Fen Phen or similar appetite-suppressant drugs? YES NO 

26. Do you smoke? If yes, how many cigarettes a day YES NO 

27. Do you drink alcohol? If yes, how often YES NO 

I hereby certify that the answers to the forgoing questions are accurate to the best of my ability. Since a change in my medical 
condition or in medications I take can affect dental treatment, I understand the importance of and agree to take the responsibil- 
ity for notifying the dentist of any changes at any subsequent appointment. 

Signature Date 

(Patient, legal guardian, or authorized agent of patient) 

Form 1-1 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 7 

Consent to Proceed 

I herby authorize Dr. and/or such associates or assistants as s/he may 

designate to perform those procedures as may be deemed necessary or advisable to maintain 
my dental health or the dental health of any minor or other individual for which I have 
responsibility, including arrangement and/or administration of any sedative (including nitrous 
oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s) including those related to 
restorative, palliative, therapeutic, or surgical treatments. 

I understand that the administration of local anesthetics may cause an untoward reaction or 
side effects, which may include, but are not limited to, bruising; hematoma; cardiac stimulation; 
muscle soreness; and temporary or, rarely, permanent numbness. I understand that occasionally 
needles break and may require surgical retrieval. 

I understand that as part of dental treatment, including preventive procedures such as 
cleanings and basic dentistry including fillings of all types, teeth may remain sensitive or even 
possibly quite painful both during and after completion of treatment. After lengthy appointments, 
jaw muscles may also be sore and tender. Gums and surrounding tissues may also be sensitive 
or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek, 
or other oral tissues of the mouth to be inadvertently abraded or lacerated during routine dental 
procedures. In some cases sutures or additional treatment may be required. 

I understand that as part of dental treatment, items including, but not limited to, crowns, 
small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory 
system) or swallowed. This unusual situation may require a series of x-rays to be taken by a 
physician or hospital and may, in rare cases, require a bronchoscope or other procedures to 
ensure safe removal. 

I do voluntarily assume any and all possible risks, including the risk of substantial and 
serious harm, if any, that may be associated with general preventive and operative treatment 
procedures in hopes of obtaining the potential desired results, which may or may not be 
achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature 
and purpose of the forgoing procedures have been explained to me if necessary and that I have 
been given the opportunity to ask questions. 

Patient Name. 

(Patient, legal guardian, or authorized agent of patient) 


Form 1-2 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 8 



Figure 1-1. Blood pressure and pulse. Mercury 
sphygmomanometers are still considered a gold 
standard for blood pressure, but most offices now 
use digital equipment. 

vital sign are frequently not accurate. The 
dentist must routinely calibrate blood pres- 
sure equipment against a standard mercury 
instrument and update the training of staff 
members periodically to ensure accuracy 
Even when automated devices are used, 
those responsible for recording blood pres- 
sure must be properly trained, to reduce 
human error. 

Of the millions of people who have hy- 
pertension, a large percentage are unaware. 
The dental team can be instrumental in dis- 
covering this significant and life-threatening 
health problem. Current studies note that 
nearly one-third of the U.S. population has 
hypertension — defined as a systolic blood 
pressure higher than 139 mm Hg or a dias- 
tolic blood pressure higher than 89 mm Hg. 
Another one-quarter of the U.S. population 
has prehypertension — defined by a systolic 
blood pressure between 120 and 139 mm 
Hg and a diastolic blood pressure between 
80 and 89 mm Hg. (Note: Recent public 
health trends are in the direction of advocat- 
ing even more conservative values than those 
mentioned here and in Table 1.1.) 

Normal to various high values are illus- 
trated in Table 1.1. 

Systolic and diastolic blood pressures, as 
opposed to pulse pressure, remain the best 

Table 1-1. Blood pressure classification 

Systolic BP 

Diastolic BP 





1 20-1 39 



1 40-1 59 


Stage 1 mild 



Stage 2 moderate 



Stage 3 severe 

BP = blood pressure. 

means to classify hypertension. The risk of 
stroke begins to increase steadily as blood 
pressure rises from 1 15/75 mm Hg to higher 

About 15 to 20 percent of patients with 
stage I hypertension have elevated blood 
pressure only in the office setting of a health 
care provider. This type of transient hyper- 
tension is more common in older men and 
women, and antihypertensive treatment in 
these patients may reduce office blood 
pressure but not affect ambulatory blood 

When the blood pressure reading is mild 
to moderately high, the patient should be 
referred to their primary care physician for 
hypertensive therapy. The patient should be 
monitored on each subsequent visit before 
treatment. If needed, the operator can use 
anxiety control protocol (see Table 1 .2 later 
in this chapter). 

When severe hypertension exists, defer 
treatment and refer the patient to a primary 
care or emergency room physician. These 
patients can be walking potential stroke 

A pulse rate should be taken and 
recorded. The most common method is to 
use the tips of the middle and index fingers 
of the right hand to palpate the radial artery 
at the patient's wrist. See Figure 1.1. 

The heart rate is determined by counting 
the number of pulses for 30 seconds and 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 9 


then multiplying that number by two. This 
yields the number of beats per minute. If 
there is a weakened pulse or irregular 
rhythm, elective treatment should not be 
performed unless the operator has received 
clearance by the patient's physician. 

Head and Neck Examination 

The physical evaluation of a dental patient 
will focus on the oral cavity and surrounding 
head and neck region, but the clinician 
should also carefully visually evaluate the rest 
of the patient for abnormalities. 

The physical evaluation is usually accom- 
plished in four primary ways: inspection, pal- 
pation, percussion, and auscultation (listen- 
ing with a stethoscope to the sounds made by 
the heart, lungs, and blood). The dentist 
should also examine skin texture and look 
for possible skin lesions on the head, neck, 
and any other exposed parts of the body. 
Submandibular lymph nodes and those on 
the neck should be palpated. Include exami- 
nation of the hair, facial symmetry, eye move- 
ments and conjunctiva color, and facial 
masses. Inspect the oral cavity thoroughly, in- 
cluding the oropharynx, tongue, floor of the 
mouth, and oral mucosa for any abnormal- 
looking tissue or indurated areas. 

Suspicious Lesions 

All suspicious lesions should have a biopsy. 
According to the guidelines of the American 
Dental Association, any lesion that has an 
abnormal appearance and a duration of 14 
days or more should be biopsied. The speci- 
men should be sent to an oral pathology lab- 
oratory. Labs that specialize in the histologi- 
cal examination of excisional and incisional 
biopsies usually provide specimen jars at no 
charge. Dentists must take the lead in this 
effort. Red and white lesions or a combina- 
tion of both types are particularly suspicious 
and must be taken seriously. See Figure 1.2. 
Oral cancer is usually very invasive and de- 

Figure 1-2. Squamous cell carcinoma on the 
lateral border of the tongue. 

structive. It can be found in people without 
the characteristic risk factors of tobacco and 
alcohol use and even in children. A thorough 
exam is mandatory. 

Anxiety Control 

The incorporation of good anxiety-reducing 
methods is essential. See Table 1.2. 

Common Diseases and 
Conditions Affecting Dental 

When the evaluation is completed, the clini- 
cian should have a good idea of the condi- 
tion of the patient. As dental treatment poses 
no risk to most people, the dentist may be- 
come complacent when presented with a 
high-risk patient and not perform the neces- 
sary steps to completely analyze the situa- 
tion. A careful and systematic approach must 
be used to deal with medically compromised 
patients. Only in this way can potential 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 10 



Table 1-2. Antianxiety protocol 

1 . Administration of a hypnotic agent to promote 
sleep the night before the appointment for sur- 
gery. (Ambien 1 mg) 

2. Administer sedative agent for anxiety control 2 
hours before surgery. 

3. Make a morning appointment with little or no 

4. Give frequent verbal reassurances with other 
distracting conversations not related to the 

5. Warn the patient before doing anything that is 

6. Keep surgical instruments and needles out of 

7. Administer nitrous oxide oxygen. 

8. Administer local anesthetics carefully and use 
those of sufficient duration and intensity. 

9. Use epinephrine 1 :1 00,000, but no more than 
4 ml, for a total adult dose of 0.04 mg in any 
30-minute period. 

1 0. Administer intravenous sedation if available, 
with sufficient monitoring incorporated by 
licensed personnel. 

1 1 . After surgery give verbal and written instructions 
on postoperative care. 

12. Write prescriptions for effective analgesics. 

13. Give reassurance and get information about 
whom to call if problems arise. 

1 4. Call the patient at home that evening to see 
how they are doing and whether there are any 
questions or problems. 

complications be managed or avoided. 
Following are a few of the most common 
diseases and conditions that a clinician will 

Cardiovascular Disease 

The progressive narrowing of the arteries to 
the heart leads to a difference in myocardial 
oxygen demand and supply. This demand 

can be further increased by exertion, diges- 
tion, or anxiety during surgical procedures. 
When the muscle of the heart becomes is- 
chemic, it can produce pressure in the chest 
with pain radiating to the arms, neck, or jaw. 
Other symptoms include sweating and a 
slowed heart rate. This condition is called 
angina pectoris. Angina is usually reversible 
if the proper medications and oxygen are ad- 
ministered quickly. Oxygen, nitroglycerin, 
and aspirin should be available in the office. 

If, during the examination, the dentist 
determines that the patient has experienced 
obstruction of the arterial blood flow to the 
heart, certain precautions must be taken. 
The practitioner's responsibility to the pa- 
tient is to have necessary medications on 
hand and initiate preventive measures even 
before treatment is begun. This will reduce 
the chance that a surgical procedure will pre- 
cipitate an anginal episode. If the patient is 
easily prone to this condition, supplemental 
oxygen is recommended. Oral sedation or 
nitrous oxide can be helpful to relax these 
patients. If anginal pain is a problem during 
a dental appointment, the operator should 
activate the Emergency Medical System (call 
911). The patient's physician should be con- 
sulted prior to subsequent appointments. 

Giving a local anesthetic with epinephrine 
to a patient with a history of cardiac prob- 
lems has always been controversial, but gen- 
erally, the benefits outweigh the risks. 
Endogenous adrenalin surges in response to 
pain stimulation can be equal to or more 
dangerous than the small amount of vaso- 
constrictor. It is recommended, however, 
that with these patients, the dose not exceed 
4 ml of local anesthetic and an epinephrine 
concentration of 1:100,000, for a total adult 
dose of .04 mg per 30-minute period. 1 

Monitoring of the vital signs should be 
done at regular intervals during surgery. 
Verbal contact should be ongoing and 
unforced. Always have a fresh bottle of 
nitroglycerin and a good supply of oxygen 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 11 



Many scenarios should alert the dentist 
that the patient is having more than angina. 
The following symptoms could indicate a 
heart attack or myocardial infarction (MI). 
Among them are the following: 

1 . The chest pain does not go away. 

2. The chest pain goes away but comes 

3. The chest pain worsens. 

If these symptoms persist, the dentist 
must get the patient to an emergency room 
or call the Emergency Medical System (911). 

Myocardial Infarction (MI) 

Care must be taken with patients who have a 
history of MI. The blockage of a coronary 
artery must be recognized and treated imme- 
diately. The infarcted area dies, becomes 
nonfunctional, and eventually necrotic. The 
myocardium around the infarction is slightly 
damaged but usually heals. It may form a 
nidus that can precipitate abnormal 

The management of a patient with a his- 
tory of MI is as follows (as recommended by 
the American Heart Association): 

1 . Consult the patient's physician. 

2. Defer all elective procedures for at least 
six months after an infarction. After clear- 
ance from the patient's physician, imple- 
ment the antianxiety protocol. Give 
supplemental oxygen during each dental 

3. Have nitroglycerin available. If oral sur- 
gery is needed, consider referring the pa- 
tient to an oral and maxillofacial surgeon. 

Heart Bypass Grafts 

Bypass graft patients should also be sched- 
uled for dental treatment no sooner than six 
months after surgery. This is the routine un- 
less there have been complications during 

healing — then it could be longer. Always 
keep the anxious patient as relaxed as possi- 
ble. Carefully monitor the vital signs 
throughout treatment. A pulse oximeter is a 
great instrument to have attached to any 
patient with a history of heart disease. If the 
office is equipped with a heart monitoring 
device (or EKG), it should be used to detect 
any arrhythmias. 

Congestive Heart Failure 

This disease of the heart occurs when the 
myocardium is unable to act as an efficient 
pump. The heart cannot deliver the output 
necessary to maintain the circulatory system, 
and the blood begins to pool and back up. 
The major effect is seen in the pulmonary 
system, the hepatic system, and the mesen- 
teric vascular beds. 

The symptoms of congestive heart failure 
are orthopnea, ankle swelling, and dyspnea. 
Orthopnea is a shortness of breath when the 
patient is lying down. The patient feels some 
comfort in sleeping with the upper body ele- 
vated to enhance breathing. These patients 
are usually on a variety of medications to re- 
duce fluids. Diuretics and digitoxin are ad- 
ministered to increase cardiac output. The 
patient may also be taking beta blockers or 
calcium channel antagonists to control the 
work load of the heart. 

Patients who are generally well controlled 
with their medication can undergo routine 
dental surgery or other treatments. The den- 
tist should initiate anxiety control and give 
supplemental oxygen during surgery. 

Any clinician who serves the medically 
compromised heart patient must be well 
qualified to handle emergencies. If not, he or 
she should refer the patient to a specialist. 

Liver Dysfunction 

The patient who suffers from hepatic dam- 
age, usually from some infectious disease or 
alcohol abuse, will need to be given special 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 12 



consideration. This would include a reduc- 
tion in dose or total avoidance of drugs that 
are metabolized in the liver. This requires the 
prescribing dentist to be cognizant of the 
metabolic processes of the drug he or she 
prescribes. The patient may be prone to 
bleeding because of the fact that many coag- 
ulation factors produced in the liver are 
diminished. A partial prothrombin time 
(PTT) or a prothrombin time (PT) is useful 
in evaluation, especially in the severely liver- 
damaged patient. Many patients with liver 
disease are infectious but can be managed 
with routine universal precautions. 


Diabetes is classified into insulin-dependent 
and non-insulin-dependant patients. Insulin- 
dependent diabetics usually have a history of 
diabetes from childhood or early adulthood. 
The underproduction of insulin is the major 

Elevated serum glucose short-term is 
not dangerous to the diabetic, but hypo- 
glycemia from not eating after an insulin 
load can cause disorientation and possible 
diabetic or insulin shock. This state must be 
treated with a glucose load in order to stabi- 
lize the patient. A drink of orange juice 
when the patient is conscious is effective. 
Emergency kits should provide a safe mode 
of delivery for the needed glucose. To man- 
age an insulin-dependent diabetic, do the 

1 . Make certain the diabetes is well con- 
trolled. Consult the patients physician 
before treatment is initiated. 

2. Place the patient on an anxiety reduc- 
tion protocol if necessary but do not use 
deep sedation. 

3. Do not schedule long procedures and 
make short morning appointments. 

4. Ask the patient before proceeding what 
he or she has eaten and whether he or 
she has balanced it with insulin. 

5. Monitor the patient's vital signs con- 

6. Have the patient eat a normal breakfast 
with the normal insulin dose. 

7. Make sure that the patient is advised to 
adjust the insulin dose to the caloric in- 
take after the surgery. Difficulty in eat- 
ing may cause some alteration in bal- 
ance. Consult the patient's physician if 

8. Watch for signs of hypoglycemia. 

9. Keep in touch with the patient on the 
development of infection. Do what is 
necessary to prevent infection. If any is 
noticed, treat it aggressively. 

10. Have a source of glucose available in the 
office (orange juice, glucose package, 
etc.). 1 

In a non-insulin-dependant diabetic, all 
dental procedures can be performed without 
special precautions — unless the diabetes be- 
comes uncontrolled/ Table 1.3 shows the 
symptoms of hypoglycemia. 


Bleeding disorders are discussed in Chapter 10. 


The most common type of seizure an epilep- 
tic patient will have is a grand mal episode. 
These episodes occur when an area of the 
brain is depolarizing (firing) spontaneously. 
Ask the patient the following questions 
before treatment: 

• What type of seizures do you have? 

• What is the medication you are taking? 

• What is the aura you experience before the 

The drugs that are taken by an epileptic 
are CNS depressants. The most common are 
Dilantin, Phenobarbital, Tegretol, and 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 13 



Table 1-3. Signs of diabetic hypoglycemia 

Frequent urination 
Excessive thirst 
Extreme hunger 
Unusual weight loss 


Increased fatigue 
Blurry vision 

During the medical history find out the 
frequency, severity and duration of the 
episodes from the patient and family mem- 
bers/ Usually the seizures last one to three 
minutes. If one lasts five minutes or more, it 
can be life-threatening. After an epileptic 
episode of one or two minutes, the patient 
will be extremely tired and usually disori- 
ented. The only thing you can do during the 
convulsions is protect the patient from in- 
jury. No attempt is to be made to move the 
patient to the floor. Insert any mouth props 
before the procedure (tied with floss). Do 
not try to insert a mouth prop during an 
episode, as you may damage the teeth or 
gingiva. These patients should be scheduled 
for treatment within a reasonable time after 
the seizure-control medicine is taken. 
Consult with a family member and release 
them to a responsible adult. 


The concern for the pregnant female is not 
only her welfare but the care of the fetus. 
Potential genetic damage from drugs and ra- 
diation are serious concerns. It is always best 
to defer surgery for the pregnant patient 
until after delivery. 

The patient who requires surgery and/or 
medication during pregnancy is at best in a 
high-risk situation and should be treated as 
such. Drugs are rated by the FDA as to their 
possible effect on the fetus. These classifica- 
tions are A, B, C, D, and X. A classification 
drugs are the safest. D and X are the least 
safe. The most likely to have a teratogenic 
effect are the D and X drugs, but doses of 

C and even B drugs should be used with ex- 
treme caution.^ 8 ' ^ 

Drugs considered the safest are acetamin- 
ophen, penicillin, codeine, erythromycin, 
and cephalosporin. Aspirin and ibuprofen 
are contraindicated because of the possibility 
of postpartum bleeding and prolonging of 
the pregnancy/ 

Avoid keeping the near-term patient in a 
supine position, as that position can com- 
press the vena cava and limit blood flow. Do 
not treat any pregnant patients in their first 
or last trimester unless absolutely necessary. 
Even then, it is prudent to consult the pa- 
tient's physician. 


Obviously, the doctor must not prescribe 
medications that are known to enter breast 
milk and potentially affect infants. Only a 
few drugs commonly used in dentistry could 
harm an infant. Some of these include hy- 
drocortisones, tetracyclines, metronidazole, 
and aminoglycosides. 

Acceptable drugs delivered during breast- 
feeding can be administered according to the 
age and size of the baby. The older the child, 
the less chance of a problem with the drug. 
The duration of the medication is also a fac- 
tor. Any drug given long-term must be 
avoided unless prescribed by the mother's 
physician. Any drug that is commonly ad- 
ministered to an infant should be fine to ad- 
minister to a breast-feeding mother, but the 
duration should be shortened. 8 See Table 
1 .4 for a list of drugs that can be used spar- 
ingly and of those that would harm a breast- 
fed infant. 

Basic Life Support 

It is essential that all office personnel attend 
a training program in basic life support. A 
brief review of the technique is appropriate 

The acronym for treating emergencies is 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 14 



Table 1-4. Breast-feeding mothers and drugs 

Drugs that can be 
used sparingly 

Drugs that are potentially 
harmful to the infant 














Chloral hydrate 





PABC and D. This acronym is used in all 
emergencies — not just heart attacks. 

P Position 

A Airway 

B Breathing 

C Circulation 

D Definitive treatment 

A brief description of each letter is as 

P, Positioning the Patient 

Positioning the patient is the first step. The 
right position is the one that is most com- 
fortable for the patient, if conscious. For car- 
diac arrest, the patient needs to be flat on his 
or her back. If asthmatic, patients probably 
will want to sit up, which helps their ability 
to breathe. If a patient is conscious, he or she 
can tell you what position feels the best. If 
the patient is unconscious, place the patient 
horizontally with the feet slightly elevated. 
The most common reason the patient loses 
consciousness is low blood pressure. With 
the feet elevated slightly, the patient can re- 
ceive a larger flow of blood to the head and, 
thus, stimulate the brain. The patient can 
still breathe in the horizontal or supine posi- 
tion, but the head must be on the same 
plane as the heart, not lower. 

A, Airway 

The second letter in the acronym is for air- 
way. Airway management is critical in an un- 
conscious patient. The head is tilted back, 
and the chin is lifted. One hand is placed on 
the forehead, with two fingers of the other 
hand on the mandible to rotate the head 
back. The tongue is attached to the 
mandible so that when you pull the 
mandible forward, the tongue also moves 
forward. This opens the airway so the pa- 
tient can breathe, or so you can breathe for 
the patient. Make sure that no obstructions 
are in the mouth or throat. 

B, Breathing 

The person attending must place his or her 
ear one inch away from the patients nose. 
Watch the chest and see whether it is mov- 
ing. The chest may move, indicating that the 
patient is trying to breathe, but it does not 
mean the patient is breathing. The patient 
might have an obstruction. It is crucial that 
you feel air coming through the mouth or 
nose. In a cardiac arrest, the patient must be 
supine but not have the heart higher than 
the head. The legs can be elevated slightly to 
increase the blood flow to the brain, but if 
the heart is higher than the head, breathing 
becomes more difficult. 

If the patient is not breathing, it is called 
apnea. The rescuer must provide supple- 
mental breathing to the victim to oxygenate 
the blood. 

C, Circulation 

Maintain the head tilt and check for the 
carotid pulse. Knowing how to check the 
carotid pulse is critical. Studies have shown 
that the carotid pulse is missed 40 percent of 
the time by medical personnel and para- 
medics. To locate the carotid artery, maintain 
head tilt and place the fingers on the Adam's 
apple or thyroid cartilage. The fingers are 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 15 



1-3. Carotid pulse. The carotid pulse is 

dD nprrpnt of thp timp 


missed 40 percent of the time. 

then, with moderate pressure, slid down the 
neck toward the rescuer, into a groove on the 
side of the neck formed by the sternocleido- 
mastoid muscle. The carotid artery is located 
in that groove. See Figure 1.3. The pulse 
should be checked for 10 seconds. If a pulse 
is not felt, start compressions immediately. 
You are now circulating oxygenated blood to 
the victim's brain. With the 2005 American 
Heart Association changes, a lay rescuer does 
not assess signs of circulation before begin- 
ning chest compressions. 

D, Definitive Treatment 

The final part of the equation is the diagno- 
sis of the problem. If the doctor can diag- 
nose the problem, then, if trained to do so, 
he or she can give the patient the appropri- 
ate medication. However, remember that 
drugs do not save the patient; proper life 
support does. If the dentist is not trained in 
Advanced Cardiac Life Support (ACLS), 
then it is best to continue with basic life sup- 
port until help arrives. 

Clinical signs are what the doctor can see, 
and symptoms are what the patient tells you. 
Signs and symptoms of concern are as follows: 

1 . Altered consciousness 

2. Respiratory depression 

3. Allergic reaction 

4. Chest pain^ 1, 10 ) 

Basic Life Support, CPR 

The following is a step-by-step outline of 
cardiopulmonary resuscitation. This list is 
for review but is not intended to replace for- 
mal training. 

Cardiopulmonary Resuscitation (CPR) 

1. Call 911 

Check the victim for unresponsiveness. If 
there is no response, call 911 and return 
to the victim. Ask for assistance. In most 
locations, the emergency dispatcher can 
assist you with CPR instructions. If you 
are not alone, have someone else call and 
you begin CPR. 

2. Breathe 

Clear the mouth of any foreign objects. 
Tilt the head back, lift the chin up, and 
listen for breathing. Put your ear one inch 
from the victims nose and mouth. If the 
patient is not breathing normally, pinch 
his or her nose, cover the mouth with 
yours, and blow until you see the chest 
rise. Give two breaths. All breaths should 
be given over 1 second with sufficient vol- 
ume to achieve visible chest rise. 

Figure 1-4. Listen for breathing. 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 16 



Figure 1 -5. Breathe two breaths for two sec- 
onds each. 

Figure 1-6. Chest compressions. 

3. Chest Compressions 

If the victim is unconscious and unre- 
sponsive, begin chest compressions. Push 
down on the chest 1 1/2 to 2 inches, 30 
times right between the nipples. On a 
small child or infant, compress the chest 
1 to 1.5 inches. Compress the chest at the 
rate of 100/minute. The rescuer should 
then breathe twice for every 30 compres- 


Continue administering CPR until help 
arrives. Paramedics will continue life support 
and transport to a medical center or emer- 
gency room. 

Figure 1-7. Heimlich maneuver. Repeat abdomi- 
nal thrusts. 


When a patient has a foreign body lodged 
in the throat, it is important to act immedi- 
ately. Most of the time the dentist is able to 
quickly remove the object before it gets too 
far into the trachea to see. If patients strug- 
gle, they will usually grab the throat. This is 
the universal sign for choking. The following 
steps are to be followed for adults as well as 

First Aid for a Choking Conscious Adult 
and for Children (1—8 years old) 

Determine whether the person can speak or 
cough. If not, proceed to the next step. 
Perform an abdominal thrust (Heimlich ma- 
neuver) repeatedly until the foreign body is 
expelled. See Figures 1.7 and 1.8. A chest 
thrust may be used for markedly obese per- 
sons or those in the late stages of pregnancy. 
If the adult or child becomes unresponsive, 
perform CPR; if you see an object in the 
throat or mouth, remove it. 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 17 



Figure 1-8. Floor position for abdominal thrusts. 

Figure 1-9. Epinephrine syringe. This is the 
only drug that should be preloaded in an emer- 
gency kit. 

Emergency Kit 

Several emergency kits on the market con- 
tain the basic drugs and apparatus to help in 
certain emergencies. 

Epinephrine is the only drug that is of 
immediate help with anaphylaxis but it must 
be given within the first few minutes of 
symptoms. This is the only drug you should 
have in a preloaded syringe. See Figure 1.9. 

Figure 1-10. Emer- 
gency kit. 

2879_Koerner_Chap 01 4/17/06 1:22 PM Page 18 



Epinephrine can be administered into the 
thigh muscle right through the clothing if 
necessary. Each minute that passes without 
epinephrine when a patient is experiencing 
anaphylactic shock considerably lessens the 
chances of recovery. You can give 1 cc of 
1 : 1 000 epinephrine up to three times in 
intervals of five minutes. Also administer 
oxygen. Do not leave the patient until help 


A good emergency kit should include the 

1 . Ammonia inhalants 

2. Tourniquet 

3. CPR pocket mask 

4. Epinephrine in a preloaded syringe 

5. Diphenhydramine 

6. Albuterol inhaler 

7. Syringes 

8. Nitrolingual spray or nitroglycerin 

9. Aspirin 

10. Glucose 

1 1 . CPR pocket mask 


Many medical problems can and do occur 
with dental treatment. Prevention is the key 
to successful and uneventful procedures. We 
must know our patients and be clearly aware 
of their health status. Each patient who has 
health concerns in their medical history 

must be evaluated thoroughly. If the clini- 
cian is not aware of the effect surgery or 
routine dental treatments will have on the 
patient, then a consultation with the 
patient's physician is mandatory. We must 
be prepared for possible medical problems 
and have a good understanding of basic life 
support measures. 


1. L. Peterson, E. Ellis, J. Hupp, M. Tucker. 
Contemporary Oral and Maxillofacial Surgery, 4 th 
edition. St. Louis: Mosby, 2003. 

2. Adapted from Professional Insurance Exchange 
standard consent to proceed form, March, 2005. 

3. American Dental Association Health Insurance 
Portability and Accountability Act, HIPPA, re- 
quirements at 

4. L. Barclay, C. Vega. The American Heart 
Association Updates Recommendations for Blood 
Pressure Measurements. Medscape Medical News,, Dec, 2004. 

5. S.F. Malamed. Emergency Medicine. Millennium 
Productions DVD, 2003. 

6. Basic Life Support for Healthcare Providers, 
American Heart Association, 1997. 

7. J. Little, D. Falave, C. Miller, N. Rhodus. Dental 
Management of the Medically Compromised Patient, 
6th edition. St Louis: Mosby, 2002. 

8. T.W. Hale, Medications and Mother s Milk: A 
Manual of Lactational Pharmacology, 11th ed. 
Pharmasoft Publishing L.P., Amarillo, TX, 2004. 

9. Pregnancy categories for prescription drugs, FDA 
Drug Bull. 1982. 

10. S. F. Malamed. Medical Emergencies in the Dental 
Office, 5th edition. St. Louis: Mosby, 1999. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 19 

Chapter 2 

Surgical Extractions 

Dr. Hussam S. Batal and Dr. Gregg Jacob 


The purpose of this chapter is to review the 
principles of surgical extractions. This chapter 
provides the dentist with general surgical 
principles and techniques that can be used 
for evaluation and treatment. Basic extraction 
techniques are discussed in the context of 
surgical extraction only. Surgical extraction 
is defined in this chapter as extraction of a 
tooth that requires the elevation of a soft tis- 
sue flap, bone removal, and/or sectioning of 
the tooth. Despite the fact that the majority 
of extractions performed in the dental office 
are forceps extractions, surgical extractions are 
frequently indicated when forceps extractions 
are inadequate for a variety of reasons. 

In most cases, an adequate preoperative 
assessment will allow the dentist to predict 
the difficulty of the extraction. Combining 
good clinical and radiographic evaluations 
will allow the dentist to determine the best 
approach for the extractions. However, even 
with the best assessment, approximately 10 
percent of forceps extractions will become 
complicated and require some form of surgi- 
cal extraction. 

Surgical extractions should not be re- 
served only for the most extreme situations. 

When used appropriately, surgical extrac- 
tions may actually be more conservative and 
cause less morbidity than forceps extractions. 
For example, in some cases, excessive force 
might be required to extract a tooth, result- 
ing in the fracture of roots, adjacent bone, or 
both. In general, surgical extractions should 
be considered when strong force might be 
needed to remove a tooth. Using surgical 
extraction techniques instead will allow for 
the controlled removal of bone or the sec- 
tioning of tooth, leading to a more pre- 
dictable outcome. 

General Principles 

Dentists performing surgical extractions 
should have a clear understanding of 
anatomical structures in the surgical site. 
When considering the surgical extractions of 
teeth, several principles should be followed. 
These principles include proper preoperative 
evaluation, proper development of a soft tis- 
sue flap so that adequate access and visualiza- 
tion are obtained, creation of an adequate 
path of removal, use of controlled force to 
decrease the risk of root or bone fracture, 
and proper reapproximation of the soft tissue 


2879_Koerner_Chap 02 4/17/06 1:23 PM Page 20 



Table 2-1 . Indications for the extraction of teeth 

1 — Dental caries 

2 — Periodontal disease 

3 — Orthodontic reasons 

4 — Prosthetic reasons 

5 — Teeth associated with pathology 

6 — Radiation therapy 

7 — Chemotherapy 

8 — Malpositioned teeth compromising periodontal 
health of adjacent teeth 

9 — Teeth with serious infection 
1 — Economics 

1 1 — Teeth in line of a jaw fracture 
1 2 — Unrestorable fractured teeth 

flap. An understanding of these principles 
and adherence to sound surgical techniques 
will ensure the successful surgical extraction 
of teeth and uneventful healing of the surgi- 
cal site. 

Preoperative Evaluation 

The extraction of teeth is one of the most 
commonly performed surgical procedures. 
Table 2. 1 presents the main indications for 
tooth removal. 

A thorough review of the patient's med- 
ical history, social history, medications, and 
allergies is mandatory prior to any surgical 
procedure. The dentist should perform thor- 
ough preoperative clinical and radiographic 
evaluations of the tooth to be extracted. A 
careful preoperative evaluation allows the 
dentist to predict the difficulty of the extrac- 
tion and minimizes the incidence of compli- 
cations. Good clinical and radiographic eval- 
uations will allow the dentist to anticipate 
any potential problems and modify the sur- 
gical approach accordingly for a more favor- 
able outcome. 

Clinical Exam 

When a clinical evaluation of the tooth to be 
extracted is performed, many factors need to 

Table 2-2. Clinical factors predicting the 
difficulty of extractions 

1 — Extensive loss of coronal tooth structure 

2 — Thickness of the buccal plate 

3 — Limited access to the area of extraction 

4 — Limited access to the tooth in the dental arch 

5 — Increased age of the patient 

6 — History of past root canal therapy 

be taken into consideration. Some of them 
present a "red flag" or predictor of difficulty 
See Table 2.2. 

Access to the Surgical Site 

Access to the tooth might be impeded, caus- 
ing the dentist to have difficulty with the 
instrumentation needed for extraction. 
Difficult access can result from a limited 
mouth opening that minimizes access and 
visibility in general, but especially to the pos- 
terior teeth. Depending on the degree of 
access limitation, even a simple forcep ex- 
traction might need to be surgically removed 
because of the inability to apply forceps. The 
most common causes for restricted mouth 
opening are odontogenic infections affecting 
the masticator spaces and temporomandibu- 
lar joint disorders. Other less common rea- 
sons include microstomia and muscle fibro- 
sis due to radiation therapy or burns. 

Difficult access can also result from the 
location of the tooth in the dental arch. 
Access to the maxillary third molar might be 
difficult even in a patient with no restriction 
to the mouth opening. This is because when 
the patient fully opens, the coronoid process 
moves into the area of the maxillary third 
and second molars, limiting instrumentation 
access. Access into this area can be improved 
by having the patient close slightly and move 
the mandible laterally to the side of the 
tooth to be extracted. This will move the 
coronoid process away from the surgical site 
and improve access. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 21 



Figure 2-1. Severe crowding in the dental arch 
can limit access to the application of a forcep. 

Another cause of difficult access is severe 
crowding in the dental arch limiting avail- 
ability of the clinical crown of the tooth. 
This type of limited access is most com- 
monly seen in the mandibular anterior and 
premolar teeth. Attempts at forceps extrac- 
tions in such cases can result in damage to 
adjacent teeth. See Figure 2.1. 

Condition of the Tooth 

The presence of extensive caries or large 
restorations weakens the tooth and often re- 
sults in crown fracture during forceps extrac- 
tions. See Figure 2.2. In addition, the pres- 
ence of extensive caries can make adapting 
the beaks of the forceps difficult, especially if 
the caries is on the buccal or palatal/lingual 
aspect of the tooth. In such cases, a surgical 
extraction should be performed so that the 
beaks of the forceps can be seated as apically 
as possible, beyond the area of the caries on 
sound tooth structure. 

Condition of the Bone 
Surrounding the Tooth 

The extractions of most teeth depend on the 
expansion of the buccal bone. If the buccal 
bone is especially thick or dense, adequate 
expansion is less likely, increasing the risk of 
tooth fracture at the time of extraction. The 

bone in older patients tends to be more 
dense compared to the bone in younger pa- 
tients. Patients with a grinding habit often 
have thick, dense bone. The presence of ob- 
vious buccal exostoses also makes expansion 
of the buccal bone difficult. See Figure 2.3. 
Consideration should be given to surgical 
extraction if a tooth is surrounded by thick, 
dense bone to decrease the risk of tooth frac- 
ture during extraction and to ensure a more 
predictable outcome. 

Figure 2-2. Extensive dental caries weakens the 
coronal tooth structure. Since this can result in 
crown fracture during the extraction, these teeth 
are better approached surgically. 

Figure 2-3. Significant exostoses can limit the 
amount of buccal bone expansion. These teeth 
are best approached by a surgical extraction. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 22 



Radiographic Evaluation 

Radiographic evaluation of the tooth to be 
extracted is critical. A radiograph of diagnos- 
tic quality provides important information 
that cannot be obtained from a clinical eval- 
uation. Periapical and panoramic radi- 
ographs are the most commonly used radi- 
ographs. A good-quality panoramic 
radiograph provides information about the 
general condition and anatomy of the teeth 
and their relationship to adjacent anatomic 
structures. However, it lacks the detail that 
can be provided by a good-quality periapical 
radiograph. The panoramic radiograph is the 
most commonly used radiograph for the 
evaluation of third molars. Occasionally an 
occlusal radiograph can be used to assess the 
buccolingual or buccopalatal location of an 
impacted tooth, such as an impacted cuspid. 
The dentist performing radiographic eval- 
uation of the tooth to be extracted should 
consider several factors including the relation- 
ship of the tooth to adjacent anatomical 
structures, the tooth anatomy, and the condi- 
tion of the surrounding bone. See Table 2.3. 

Anatomy of the Tooth 

The number of roots on the tooth should be 
evaluated, and any variation from normal 
should be noted. See Figure 2.4. The length 
and shape of the roots should be evaluated. 
The shorter and more conical the roots, the 
easier the extraction. The longer, thinner, 
and more curved the roots, the more diffi- 
cult the extraction and the higher the risk of 
root fracture. See Figures 2.5 and 2.6. Teeth 
with dilacerated roots can be extremely diffi- 
cult to extract, and a surgical extraction 
should be performed for such teeth. 

For multirooted teeth, the degree of root 
divergence should also be evaluated. The 
greater the degree of divergence, the greater 
the difficulty of extraction. See Figure 2.7. 
Compare the dimension at the point of 
maximum divergence of the roots to the di- 

Table 2-3. Radiographic factors predicting the 
difficulty of extraction 

1 — Severely divergent roots 

2 — Root dilacerations 

3 — Endodontically treated teeth with or without post 

and core 
4 — Increased number of roots present 
5 — Evidence of external or internal resorption 
6 — Presence of hypercementosis/bulbous roots 
7 — Long roots 
8 — Dense bone 
9 — Horizontal root fracture 

Figure 2-4. A lower second molar with anom- 
alous roots (white arrow). Careful evaluation of a 
periapical radiograph will allow the operator to 
note any variation in anatomy and thereby deter- 
mine the correct surgical plan. 

Figure 2-5. Teeth with thin long roots or dilacer- 
ations of the root are best approached surgically 
to decrease the chances of root fracture. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 23 



Figure 2-6. Another example of teeth with thin 
long roots. 

Figure 2-7. The greater the degree of diver- 
gence of the roots, the greater the difficulty of 
the extraction. These molars should be sectioned 
to develop a path of withdrawal for each root 

mension of the tooth at the crest of bone. If 
the dimension at the point of maximum 
divergence of the roots is greater than the 
dimension of the tooth at the crest of bone, 
then the extraction can be expected to be 
more difficult. Sectioning of the tooth will 
probably be required to create an adequate 
path of withdrawal. See Figure 2.8A,B. 

Relationship of the Tooth to 
Anatomic Structures 

The relationship of the tooth to be extracted 
to anatomic structures such as the maxillary 

Figure 2-8A. When evaluating this periapical 
radiograph, a measurement is made at the widest 
portion of the root (double-headed white arrow) 
and compared to a measurement at the contact 
points of the crown (double-headed dark arrow). 
If the root measurement is greater than at the con- 
tact points, this indicates an inadequate path of 
withdrawal. Also note the curvature on the mesial 
root (single white arrow). This tooth is best ap- 
proached by sectioning the tooth between mesial 
and distal roots. Some bone should be removed 
from the buccal in the furcation area (white trian- 
gle) before tooth sectioning. 

Figure 2-8B. On the lower first molar, the distal 
root should be removed first (white arrow), and 
then the mesial root (black arrow). This sequence 
will prove easier because of the curvature on the 
mesial root. 

sinus or inferior alveolar nerve should be 

Maxillary Sinus 

Great variation exists in the relationship of 
the maxillary posterior teeth to the maxillary 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 24 



Figure 2-9. A first molar with a minimal relation- 
ship to the maxillary sinus. The tooth is totally 
surrounded by bone. 

sinus: The roots might be completely en- 
cased by bone with minimal relationship to 
the maxillary sinus (see Figure 2.9), or the 
maxillary sinus might extend into the furca- 
tion area of the roots with paper-thin bone 
separating the roots from the maxillary sinus. 
See Figure 2.10. In general, the degree of 
maxillary sinus pneumatization increases 
with advancing age and with loss of maxil- 
lary posterior teeth. Various degrees of maxil- 

Figure 2-10. A first molar with a pneumatized 
sinus into the furcation area (angled white arrow). 
Also note the curvature of the mesiobuccal root 
(white straight arrow). There is also close proximity 
of the premolar roots to the sinus (small double- 
ended arrow). This tooth is best approached sur- 
gically by sectioning off the palatal root and then 
dividing the mesiobuccal and distobuccal roots to 
decrease the chance of sinus communication and 
improve the path of removal. 

Table 2-4. Teeth at risk for sinus exposure 

1 — Lone standing maxillary molar with pneumatized 
maxillary sinus 

2 — Roots projecting into a severely pneumatized 
maxillary sinus and minimal coronal bone visible 

3 — Long divergent bulbous roots with a pneuma- 
tized sinus into the trifurcation area 

4 — Teeth with advanced periodontal disease but 
with no mobility; also teeth with the maxillary 
sinus extending into the trifurcation area 

lary sinus involvement can result from the 
removal of maxillary posterior teeth. This 
can vary from the displacement of a root tip 
into the maxillary sinus to the development 
of an oroantral communication or fistula. 

Teeth at the greatest risk for sinus expo- 
sure or communication (see Table 2.4) are 
best approached by surgical extraction. Flap 
reflection with sectioning of teeth along with 
possible buccal bone removal can minimize 
the chance of sinus exposure or root dis- 
placement into the sinus. 

Inferior Alveolar Neurovascular Bundle 

Evaluation of the proximity of the inferior 
alveolar neurovascular bundle is especially 
critical prior to extractions of mandibular 
third molars. Extractions of mandibular 
third molars are associated with the highest 
risk of injury to the inferior alveolar nerve. 
Appropriate evaluation of the relationship of 
the mandibular third molars to this nerve, 
and an altered surgical approach, decreases 
the risk of complications. See Figure 2.11. 

Condition of the Tooth 

Evaluate the tooth for the presence of inter- 
nal or external resorption. If extensive re- 
sorption is present, fracture of the root can 
be expected at the level of the resorption. 
Surgical extraction is usually needed for the 
removal of such teeth. See Figure 2.12. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 25 



Figure 2-11. This tooth has a close relationship 
between the mandibular molars and the mandibu- 
lar canal. As long as the operator does not instru- 
ment apical to the sockets, there should be no 
injury to the inferior alveolar nerve. 

A tooth that has been endodontically 
treated can be difficult to extract for several 
reasons. See Figure 2.13. Unless the tooth 
was endodontically treated recently, it tends 
to be very brittle and fractures easily. 
Furthermore, an endodontically treated 
tooth often has a large restoration or a 
crown, further complicating the extraction. 
Therefore, a tooth that has been endodonti- 
cally treated is often best managed with a 
surgical extraction. 

The tooth should also be evaluated for 
the possibility of ankylosis. The periodontal 
ligament space around the tooth should be 
visible. Otherwise, the tooth might be anky- 
losed. An ankylosed tooth should be ap- 
proached as a surgical extraction. 

A tooth with hypercementosis (see Figure 
2.14) can be difficult to extract due to an 
inadequate path of withdrawal. A surgical 
extraction should be performed so that an 
adequate path of withdrawal can be created 
to facilitate the extraction. 

Condition of the Bone 

The bone surrounding the tooth to be ex- 
tracted should be carefully evaluated. A radi- 
ograph of good quality should allow an as- 

Figure 2-12. Internal resorption of tooth #9. 
Depending on the extent of the internal resorption, 
the tooth can fracture at the level of the resorption 
during extraction, requiring surgical removal of the 
root tip. 

Figure 2-13. Endodontic treatment can make 
teeth brittle and prone to fracture during re- 
moval — requiring surgical extraction. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 26 



Figure 2-14. Hypercementosis on a maxillary 
second premolar with a bulbous root. 

sessment of the relative density of the bone. 
Bone that appears relatively radiolucent is 
less dense and is more likely to expand, 
making the extraction easier. However, bone 
that is relatively radiopaque is more dense 
and less likely to expand, making the extrac- 
tion more difficult. 

Flap Design, Development, and 

Before beginning any surgical extraction we 
should review the appropriate design and 
execution of that procedure. A well-designed 
treatment plan will enable potentially diffi- 
cult surgery to be performed efficiently and 
painlessly for both the patient and the treat- 
ing dentist. Paramount to any surgical treat- 
ment plan is the development of an appro- 
priate surgical flap. Adequate flap design 
plays a vital role in exposure and access for 
the surgical extraction of teeth. Good surgi- 
cal principles and techniques will help to 
avoid tissue trauma and subsequent delayed 

The dentist must consider a number of 
factors simultaneously in preparing for a sur- 
gical extraction. First and foremost are the 
indications for flap development, as the in- 
appropriate decision to lay a flap might lead 
to unnecessary trauma, swelling, and dis- 
comfort for the patient. Conversely, not 

laying a flap when needed might also com- 
plicate the surgery and lead to a more diffi- 
cult procedure for the patient. The general 
indications for flap reflection include the 

• To allow for complete access and visualiza- 
tion of the surgical field. 

• To allow for bone removal and tooth 

• To prevent unnecessary trauma to soft tis- 
sue and bony structures. 

After the decision to raise a flap has been 
made, the treating dentist must decide on 
the type and design of the flap. In the design 
process, several factors should be taken into 
consideration, including vascular supply to 
the flap, regional anatomy, underlying bony 
anatomy, health of the tissues to be incised, 
and the ability to place an incision in a dis- 
crete and cosmetic location that can be 
repositioned postoperatively in a tension-free 

Generally, most surgical extractions will 
require the elevation of a full-thickness mu- 
coperiosteal flap. This flap includes the over- 
lying gingiva, mucosa, submucosa, and un- 
derlying periosteum in one piece. In order to 
properly develop this type of flap, one must 
create sharp, discrete, full-thickness incisions 
that extend completely to the underlying 
bone. See Figure 2.15. Sharp incisions made 
in this fashion will allow the effective eleva- 
tion of a full-thickness flap without tearing 
the periosteum or gingival tissue — thus 
avoiding unnecessary bleeding into the surgi- 
cal field or delayed healing of the flap. 

When considering flap design, the sur- 
geon must decide which flap will allow the 
most effective visualization and execution of 
the surgical procedure while maintaining 
minimal invasiveness. A few basic surgical 
principles must be kept in mind. First, when 
outlining the flap, the base must be broader 
than the apex to allow for maintenance of an 
adequate, independent blood supply. See 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 27 



Figure 2-15. When making an incision, the #15 
blade should be carried down to the bone in a 
full-thickness fashion. 

Figure 2.16. If this basic principle is violated, 
the flap risks devascularization and necrosis 
with delayed healing. Second, the margin of 
the flap should never be placed over a bony 
prominence, as this may prohibit tension- 
free repositioning. This could lead to a 
postoperative dehiscence and healing by 
secondary intention with likely scarring. 
Similarly, the coronal aspects of the releasing 
incisions should be placed a safe distance of 
roughly six to eight millimeters mesial and 
distal to the extraction site, thus ensuring 
that postoperatively, the incisions will lie 
over intact bone. See Figures 2.17A and 
2.17B. If this is not accomplished, the flap 

Figure 2-16. This picture shows a trapezoidal or 
four-cornered flap. The base of the flap (double- 
ended blue arrow) should be wider than the 
coronal aspect of the flap (double-ended white 
arrow) to allow adequate blood supply (single- 
ended white arrows). 

might collapse into the bony defect, resulting 
in likely dehiscence and delayed healing. 
Additionally, the flap must be designed to 
avoid underlying vital structures such as the 
mental or lingual neurovascular bundles in 
the mandible or the superior alveolar bun- 
dles in the maxilla. 

In soft tissues around the lower third mo- 
lars, incisions should be well away from the 
lingual aspect of the ridge to avoid accidental 
severance of the lingual nerve, which may lie 
supraperiosteally in this tissue. Likewise, api- 
cal to the mandibular premolars lies the 
mental nerve. Incisions should be well ante- 
rior and/or posterior to this structure to 

Figure 2-1 7A. Avoid making a releasing incision 
too close to or directly over the area of the ex- 
traction. An incision near a bony defect can result 
in a dehiscence and delayed healing. In this ex- 
ample, the release is too close to the tooth being 

Figure 2-1 7B. The correct design. Releasing in- 
cisions should be 6-8mm anterior and/or posterior 
to the extraction site. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 28 



Figure 2-18. Avoid releasing incisions in the 
area of the mental nerve, as depicted here. 

avoid accidental iatrogenic damage. See 
Figure 2.18. Also, an incision placed too 
high in the maxillary posterior mucobuccal 
fold could allow penetration into the area of 
the buccal fat pad. This becomes more of a 
surgical annoyance than a true complication. 
If this should occur, the pad can be reposi- 
tioned easily, and the mucosa can be closed 
postoperatively; however, it will create a 
visual obstruction to the surgical field during 
the procedure. 

When a palatal incision is necessary, at- 
tention must be paid to the greater palatine 
and incisive neurovascular bundles. The 
greater palatine artery provides the major 
blood supply to the palatal tissue, and there- 
fore, releasing incisions should be avoided in 
this area. Anteriorly, if tissue must be re- 
flected in the area of the incisors, transection 
of the incisive artery usually will not lead to 
significant bleeding, and the nerve tends to 
regenerate quickly. In addition, the altered 
sensation subsequent to this nerve's severance 

Table 2-5. Flap Design Considerations 

Figure 2-19. Envelope flap. Ideally, this type of 
flap should be extended one tooth posterior and 
two teeth anterior to the one being extracted in 
order to provide adequate reflection with minimal 
tension on the flap. 

usually does not lead to significant morbidity 
for the patient. A good understanding of this 
underlying regional anatomy is mandatory 
to avoid inadvertent damage or exposure of 
vital structures. See Table 2.5. 

With the preceding information kept in 
mind, the next decision is the design of the 
mucoperiosteal flap to be used. Intraorally, 
there are a number of flap designs to choose 
from, including the simple crestal envelope 
(see Figure 2.19); crestal envelope with one 
releasing incision (three-corner flap) (see 
Figure 2.17B); crestal envelope with two 
releasing incisions (four-corner flap) (see 
Figure 2.16); or semilunar design (see 
Figure 2.20.) 

For surgical extractions, the most com- 
mon flap is the sulcular envelope (with or 
without a releasing incision). For this flap, a 
full-thickness incision is created intrasulcu- 
larly around the buccal and lingual aspects 
of the teeth. The papillae are kept within 


Result if not avoided 

Incision over bony prominences 

Incising through papillae 

Incision over facial aspect midcrown 

Incision not placed over sound bone 

Vertical incision in area of mental foramen 

Lingual releasing incision in the posterior mandible 

Vertical releasing incision in the posterior palate 

Tension, dehiscence, and delayed healing 

Dehiscence, periodontal defect 

Dehiscence, periodontal defect 

Collapse and delayed healing 

Injury to the mental nerve 

Injury to lingual nerve 

Bleeding, injury to the greater palatine artery or vein 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 29 



Figure 2-20. Semilunar flap. 

the body of the flap, which is reflected 
apically in a full- thickness fashion. This 
flap provides great access to the coronal 
part of the tooth, allowing better visualiza- 
tion, instrumentation, bone removal, and 
tooth sectioning when needed. In addition, 
it can be easily converted into a three-corner 
flap if additional access is needed to the api- 
cal area. 

Generally speaking, most surgical extrac- 
tions can be performed without a releasing 
incision; however, occasionally additional re- 
flection is necessary for tension-free visualiza- 
tion. The release can be created at either the 
mesial or distal end of an envelope, but in 
most cases, it is placed anteriorly and re- 
flected posteriorly. See Figures 2.2 1 A— E. 
Recall that this incision must run obliquely 
as it extends toward the vestibule to allow 
the coronal end of the incision (apex of the 
flap) to be narrower than the base (vestibular 
end of the flap). The releasing incision 
should be located at a line angle of a tooth 
and should not directly transect a papilla (see 
Figure 2.22) or cross over a bony promi- 
nence like the canine eminence in the max- 
illa. Papillary transection can lead to necrosis 
and loss of papillae postoperatively, thereby 
causing cosmetic and periodontal problems. 
Again, incising over a bony prominence 
should be avoided. When a procedure begins 
with a short envelope flap, the use of a re- 
lease provides greater access, especially to the 
apical area. This is occasionally necessary in 
the posterior regions of the mouth, particu- 

Figure 2-21 A. Three-corner flap with the re- 
lease anterior to the papillae (including the papilla 
in the flap). The releasing incision can also be 
placed posterior to the papilla (papilla not in- 
cluded in the flap). 

Figure 2-21 B. A periosteal elevator is used to 
reflect the flap. Reflection is started with the sharp 

larly in the maxilla, where visualization is 
often difficult. 

When a release is necessary, it is very rare 
that a four-corner flap (two releases) will be 
needed. However, occasionally, with frac- 
tured roots in the posterior maxilla near 
the sinus, this flap design is beneficial — 
especially if there is the potential for an oral- 
antral communication requiring the ad- 
vancement of tissue for primary tension-free 
closure. Semilunar incisions are of limited 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 30 



Figure 2-21 C. Once started, reflection can be 
continued with the wider end. 

Figure 2-21 D. The flap is held out of the way 

with a Seldin retractor. 

benefit in surgical extractions, as they pro- 
vide limited access to the apical region of 
teeth. They are used more often for periapi- 
cal surgery Since this flap design is rarely 
used with extractions, it will not be discussed 
further in this chapter. 

After all of the preceding information is 
considered, the technique for developing a 
surgical flap is relatively straightforward. 
Since the most common flap used for surgi- 
cal extractions is the sulcular envelope with 
or without a release, this is the technique 
that will be described. Most incisions are cre- 
ated using standard #15 and/or #12 blades. 

Figure 2-21 E. To reposition the flap against the 
bone, the releasing incision portion is approxi- 
mated first, then the papillae. 

Figure 2-22. Releasing incisions should not 
transect the papilla (white line). Also, releasing 
incisions should not be placed in the midbuccal 
surface of the tooth (black line). 

The incision is created intrasulcularly down 
to the alveolar bone. It begins at the disto- 
buccal line angle, one tooth posterior to the 
tooth being extracted. The incision runs an- 
teriorly in a single stroke. If an envelope flap 
is planned, the incision should be extended 
two teeth anterior to the tooth to be ex- 
tracted. When a three-corner flap is planned, 
the incision is carried one tooth anterior, 
and a releasing incision is made to include 
or exclude the papilla in the design of the 

If a release is used, it is begun at the sul- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 31 



cus and extends in an anteroapical direction 
toward the vestibule. A standard Seldin or 
other broad retractor is used to tense the 
alveolar mucosa to allow a clean, smooth in- 
cision without tearing the tissue. When the 
incision is completed, reflection usually is 
conducted with the sharp end of a periosteal 
elevator. Reflection is begun at the anterior 
sulcular extent of the incision. The elevator 
is positioned underneath the full-thickness 
flap and run posteriorly along the sulcus, 
reflecting all of the papillae and buccal tissue 
down to the alveolar bone. The papillae are 
reflected by simply inserting the elevator 
against the alveolus and rotating the in- 
strument — and concurrently the papillae — 

The crestal gingiva is always reflected first 
along the entire extent of the incision prior 
to reflecting the mucosa more apically If any 
area of the crestal incision is difficult to re- 
flect or it appears that the incision is not 
completely down to the alveolus, the blade is 
re-inserted to ensure a smooth full-thickness 
incision in the sulcus. Next, the sharp end of 
the periosteal elevator is run along the release 
incision against bone, and the tissue is ele- 
vated in a posteroapical direction — always 
in a full- thickness style. To ensure full- 
thickness, the periosteal elevator must always 
remain against the alveolar bone as the flap is 
reflected. When the anterior portion of the 
flap is raised, it is often helpful to place the 
broad end of a retractor under the flap and 
against the alveolus to assist in visualization 
while the remainder of the tissue is swept 
posteroapically At this point, the broad end 
of the periosteal elevator is normally used to 
complete the reflection of the flap into the 
depth of the vestibule. 

Following the surgical removal of the 
tooth, the final step is closure of the flap in a 
tension-free manner. If the flap has been de- 
signed and executed well, this portion of the 
procedure should be straightforward and 
done by repositioning the tissue using su- 
tures to hold the tissue in place. 

Creating an Adequate Path of 

Establishing a proper path of removal is 
one of the main principles in removing 
erupted or impacted teeth. Failure to 
achieve an unimpeded path of removal re- 
sults in a failure to remove the teeth. This 
is commonly achieved either by sectioning 
the tooth or removing bone with a surgical 
handpiece next to the root to allow for 
delivery. The preferred sequence is to ini- 
tially section the tooth, which will convert 
a multirooted tooth into single-root com- 
ponents. Elevation of each root separately 
will allow for removal of the tooth in the 
majority of the cases. If needed, bone 
can be removed to achieve a path of with- 
drawal. This sequence will preserve the 
most alveolar bone around the extraction 
socket. This preservation is important, 
especially when dental implants are 

Occasionally, reversing this sequence is 
needed (bone removal and then sectioning)- 

especially when the location of the furcation 
cannot be visualized. In these instances, bone 
should be removed on the buccal aspect to 
expose the furcation and allow sectioning of 
the tooth. 

Use of Controlled Force 

A key aspect of extracting teeth is the use of 
controlled force during elevation and forceps 
extractions. The dental surgeon needs to 
keep in mind that slow, steady movement 
should be used during extractions. Excessive 
force during extractions can result in the 
fracture of the tooth and possibly the alveo- 
lar bone. When the tooth cannot be ex- 
tracted with reasonable force, the tooth 
should be surgically extracted. This is com- 
monly accomplished by sectioning multi- 
rooted teeth and/or removing buccal bone, 
or a combination of both, to allow con- 
trolled removal of the tooth. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 32 



Technique for Surgical Extraction 
of a Single-rooted Tooth 

The surgical extraction of a single-rooted 
tooth is relatively straightforward. After an 
adequate flap has been reflected and is held 
in proper position, the need for bone re- 
moval is assessed. Often, the improved visu- 
alization and access afforded by the flap 
makes bone removal unnecessary. This is be- 
cause after a flap has been reflected, elevators 
can be used more effectively, and forceps can 
be seated more apically, creating a better me- 
chanical advantage. The tooth then can be 
extracted without bone removal. 

If bone removal is indicated, the tooth 
and, if necessary, a small portion of buccal 
bone may be grasped with the forcep. The 
tooth then is removed along with that small 
portion of buccal bone. See Figure 2.23. 
Other options when bone removal is neces- 
sary include removal of buccal bone using a 
bur or a chisel. The width of the bone re- 
moved should be approximately the same as 
the mesiodistal dimension of the root, and 
the most common vertical length of the 
bone removed is usually approximately one- 

Figure 2-23. A forcep is shown being used to 
remove the root with a small portion of the 

third to one-half the length of the root. The 
tooth then can be extracted using a straight 
elevator and/or a forcep. See Figure 2.24. 
It is important to keep in mind that the 
amount of bone removed should be just 
enough to allow the extraction of the tooth. 
Excessive removal of bone should be 
avoided. This is especially critical in a 
patient who is treatment planned for 

If extraction of the tooth is still difficult 
after bone removal, a purchase point can be 
made. The purchase point should be made 
as apically as possible on the root, to create a 
better mechanical advantage. The purchase 
point should be large enough that an instru- 
ment such as a Crane pick or Cogswell B 
can be inserted and used to extract the 
tooth. See Figure 2.25. Adjacent bone is the 
fulcrum for the elevator. 

After the extraction of a tooth, the surgi- 
cal site should be inspected. All bony 
spicules should be removed, and all sharp 
bony edges should be smoothed. Sharp bony 
edges are assessed by replacing the flap and 
palpating it with a finger. A rongeur or a 
bone file may be used to smooth any sharp 
bony edges. 

Figure 2-24. When adequate bone has been 
removed with a bur or chisel, the root is luxated 
and removed with an elevator, or a forcep can be 
seated onto sound root structure for its removal. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 33 



Figure 2-25. The placement of purchase point 
has three essential requirements: 1) The purchase 
point should be placed close to the level of the 
bone. 2) The purchase point should be deep 
enough to allow for placement of a Crane pick. 
3) Enough tooth structure (3 mm) should be left 
coronal to the purchase point to prevent tooth 
fracture during elevation. 

The surgical site then should be thor- 
oughly irrigated with copious amounts of 
saline to remove all the debris. Special atten- 
tion should be paid to the area at the base of 
the flap, as debris tends to collect in this 
area. Debris that is not removed can cause 
delayed healing or infection of the surgical 
site. The flap then is repositioned and su- 
tured in position. 

Technique for Surgical Extraction 
of a Multirooted Tooth 

The technique for the surgical extraction of a 
multirooted tooth is essentially the same as 
that for a single-rooted tooth. The main 
difference is that a multirooted tooth can 
be divided with a bur to convert it into 
multiple single-rooted teeth to facilitate its 

After an adequate flap has been reflected 
and held in proper position, the need for 
sectioning of the tooth and bone removal are 
assessed. As in the case for a single-rooted 
tooth, the improved visualization and access 

afforded by the flap might make bone re- 
moval and tooth sectioning unnecessary. In 
such cases, the more apical (to the bone 
level) application of elevators and forceps 
allows for a more effective extraction. The 
tooth then can often be extracted without 
sectioning or bone removal. 

If further measures are deemed necessary 
in order to remove the tooth, it is preferable 
to initially section the tooth without remov- 
ing any bone. Using this approach will either 
eliminate the need for bone removal or de- 
crease the amount of bone removal. As in 
the case for a single-rooted tooth, it is im- 
portant that the amount of bone removed be 
just enough to allow the extraction of the 
tooth or root. Excessive removal of bone 
should be avoided, especially in a patient 
who desires implants. 

Bone removal prior to sectioning of the 
tooth is usually not necessary when the fur- 
cation of the tooth can be visualized after re- 
flection of the flap. Sectioning of the tooth is 
accomplished with a bur. The roots are then 
separated. The roots are elevated and ex- 
tracted with root forceps. 

After the extraction of a tooth, the surgi- 
cal site should be inspected. All bony 
spicules should be removed, and any sharp 
bony edges should be smoothened. Sharp 
areas of bone are assessed by replacing the 
flap and palpating it with a finger. A rongeur 
or a bone file may be used to smooth these 

The surgical site then should be thor- 
oughly irrigated profusely with saline to re- 
move bone or tooth chips — especially in the 
fold at the base of the flap. As mentioned, 
with single-rooted teeth, such debris can 
cause delayed healing or infection. The flap 
then is repositioned and sutured in position. 

Case 1: Surgical Extraction of a 
Mandibular Molar 

A flap is reflected. A bur then is used to 
section the tooth into mesial and distal seg- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 34 



ments. Adequate space should be created in 
the furcation area (by bone removal) to allow 
for an adequate path of removal. The mesial 
segment is first elevated with a straight eleva- 
tor and removed with a forcep. If the root 
fractures or if there is inadequate mobility of 
the mesial segment, bone can be removed on 
the buccal aspect to facilitate the extraction. 
After the mesial segment has been extracted, 
the distal segment is elevated with a straight 
elevator and extracted with a forcep. 
Alternatively, the distal segment can be ex- 
tracted using a Cryer elevator. The Cryer ele- 
vator takes advantage of the space created by 
the extraction of the mesial segment. All 
sharp bony edges are then smoothed, the 
area is irrigated, and the flap is repositioned 
and sutured. See Figures 2.26A— M. 

Case 2: Surgical Extraction of a 
Maxillary Molar 

A flap is reflected. A bur is used to cut off 
the crown of the tooth horizontally. The 
roots are then sectioned between the palatal 
root and the two buccal roots. The two buc- 
cal roots are then sectioned into a mesiobuc- 
cal root and a distobuccal root. If the maxil- 

Figure 2-26A. Surgical extraction of a lower 
molar. Commonly an envelope flap is reflected 
with a periosteal elevator. Soft tissue is being 
detached and reflected on the buccal and the 

Figure 2-26B. The flap is retracted and held in 
position with the help of a Seldin retractor. 

Figure 2-26C. This drawing shows a bur ready 
to remove a small amount of bone on the buccal 
surface of the tooth down to the furcation. Expos- 
ing the furcation allows visibility and access to 
use the bur for a section cut between the roots. 

lary sinus extends into the furcation area of 
the tooth, care must be taken when section- 
ing the tooth. The bur should extend just 
short of the furcation area and not into the 
furcation and the sinus. The straight elevator 
is used to complete the separation between 
the buccal and palatal roots. The straight ele- 
vator is then placed in between the 
mesiobuccal and distobuccal roots to com- 
plete the separation between the buccal 
roots. The straight elevator then can be used 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 35 

Figure 2-26D. This is a photograph showing 
how a small amount of bone can be removed on 
the buccal to the furcation, thus facilitating the 
section cut that has been made into the tooth. 

Figure 2-26E. The tooth is sectioned with a 
fissure bur on a surgical drill. The sectioning 
should extend into the furcation area and about 
three quarters of the way through the tooth in a 
bucco-lingual dimension — avoiding the lingual 
plate. Note the cut extending into the furcation 
area (red arrow). Also, in the drawing, some buc- 
cal bone has been removed. 

Figure 2-26F. A straight elevator is used to sep- 
arate the mesial from the distal root. The elevator 
should be placed as apically as possible and 
rotated toward the part to be fractured. 

Figure 2-26G. If the elevator is placed too far 
coronally before being rotated this will commonly 
result in fracture of the crown only and, therefore, 
should be avoided. The X on the mesial part of 
the crown indicates enamel that might break off 
from the elevator being positioned too high. 


2879_Koerner_Chap 02 4/17/06 1:23 PM Page 36 



Figure 2-26H. After separating the mesial and 
distal roots, each root is elevated separately. 

Figure 2-261. After removal of one of the roots, 
the remaining root can be removed by luxation/ 
elevation with a straight elevator. 

to luxate the buccal roots. Following this, the 
buccal roots are extracted using a bayonet 
forcep or a fine-tip rongeur. Finally, the 
palatal root is removed in a similar manner. 
See Figures 2.27A-N. 

Considerations for the Removal 
of Root Tips 

No matter how experienced and careful the 
practitioner, roots fracture during extrac- 
tions. If root fracture occurs during an ex- 

Figure 2-26J. This figure shows a clinical view 
of a lower first molar mesial root being luxated by 
a straight elevator. 

Figure 2-26K. Alternatively, an east/west eleva- 
tor could be used. 

traction, the practitioner should make a de- 
termination as to whether the root tip can be 
left in place or whether it should be re- 
moved. If removal of the root tip is indi- 
cated, the operator must be comfortable 
with removing it. Otherwise, appropriate re- 
ferral should be made. 

If a small root tip fractures during extrac- 
tion, if attempts at retrieval of the root tip 
are unsuccessful, and if further attempts at 
retrieval of the root tip are excessively trau- 
matic, then consider leaving the root tip in 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 37 



Figure 2-26L. An extraction forcep also could 
be used. 

Figure 2-26M. The area is irrigated, especially 
under the flap, and then sutured. 

place. The risks of continued, more aggres- 
sive attempts at retrieval of the root tip 
might outweigh the benefits. 

Certain conditions must exist for a root 
tip to be left in place. The root tip must be 
small — less than 4 to 5 mm in length. In ad- 
dition, it must be deeply embedded in bone 
and not near the crest of bone, so that subse- 
quent bone resorption will not expose the 
root tip and interfere with the prosthesis that 
will be constructed to replace the extracted 

Figure 2-27A. Surgical extraction of an upper 
molar. After failed attempts with a forcep, a flap 
was reflected, and a fissure bur was used to sec- 
tion through the crown. 

Figure 2-27B. The sectioning was completed 
by using a straight elevator. Note that when sec- 
tioning the crown, the dentist should leave 
enough coronal tooth structure for extraction of 
the roots. 

tooth. The root tip should also not be in- 
fected, which could cause subsequent flair- 
ups. If these conditions exist, then consider 
leaving the root tip in place. See Table 2.6. 
In leaving a root tip, the risks of retrieval 
of the root tip must be greater than the ben- 
efits. One condition in which the risks out- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 38 



Figure 2-27C. Removing the crown better facili- 
tates sectioning of the roots as shown here. 

Figure 2-27D. The tooth is sectioned into two 
buccal roots and a palatal root (inverted T or Y). 

weigh the benefits in retrieving a root tip 
might be the need for a large amount of 
bone removal in order to retrieve a root tip. 
Another might be if retrieval of the root tip 
endangers anatomic structures such as the 
inferior alveolar neurovascular bundle or the 
maxillary sinus. 

If a root tip is to be left in place, the pa- 
tient must be informed that the risks of re- 
trieval of the root tip outweigh the benefits. 

Figure 2-27E. A straight elevator can be placed 
between the buccal roots and the palatal root to 
complete the break. 





\ ^V 

Figure 2-27F. Drawing of a straight elevator in- 
serted between the buccal roots and the palatal 

The reason for this is that there is the possi- 
bility of a future complication with the re- 
tained root segment. The fact that the pa- 
tient was informed that a decision has been 
made to leave the root tip must be recorded 
in the patient's record. 

Radiographic documentation of the root 
tip should be obtained and recorded in the 
patient's chart. The patient should also be in- 
structed to contact the practitioner immedi- 
ately should any problems develop in the 
area. It is also prudent to schedule a follow- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 39 



Figure 2-27G. Similarly, the straight elevator 
can also be placed and turned while between the 
buccal roots to facilitate complete separation of 
those two roots. 

Figure 2-27H. Drawing showing positioning of 
the straight elevator between the buccal roots. 

Figure 2-271. The straight elevator is placed 
mesially to pry out the mesiobuccal root, using 
adjacent bone as a fulcrum. 

Figure 2-27 J. Because the mesiobuccal root 
was adequately luxated, a forcep can be used to 
remove the root. 

Figure 2-27K. An elevator could also have 
been used on the distobuccal root as shown in 
the drawing. 

up evaluation of the root tip six months or 
so in the future. 

Surgical Technique for the 
Removal of Root Tips 

Good lighting, access, and suction are critical 
for the successful removal of root tips. Most 
complications, such as displacement into ad- 
jacent anatomical structures like the maxil- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 40 



Figure 2-27L. A forcep could have been used 
on the distobuccal root as well. 

Figure 2-27M. In this view, with the mesiobuc- 
cal root removed, the operator can concentrate 
on the distobuccal root. This root is elevated into 
the space that was created by removing the 
mesiobuccal root. Careful evaluation should be 
made regarding the location of the maxillary sinus 
in the furcation area. 

lary sinus, arise from attempts at removal of 
root tips under poor conditions. 

A systematic approach is key in the re- 
moval of root tips. The practitioner should 
evaluate the part of the tooth that has been 
removed and determine the location and size 
of the fractured segment. This is especially 

Figure 2-27N. The palatal root is then elevated 
and extracted with a root forcep. 

Table 2-6. Indications for Leaving a Root Tip 

1 — Small root tip less than 4 mm in size 

2 — No evidence of periapical pathology or infection 

associated with root tip 
3 — Inability to visualize root tip 
4 — Removal of root tip will cause destruction to 

adjacent structures 
5 — Proximity to the inferior alveolar nerve 
6 — Proximity to the maxillary sinus 
7 — Ill-feeling patient 
8 — Uncontrolled hemorrhage 

critical for a multirooted tooth. If the loca- 
tion and size of the root tip cannot be deter- 
mined clinically, a radiograph (preferably a 
periapical radiograph) should be obtained. 
For small root tips (less than 4 to 5 mm 
in length), the irrigation-suction technique 
may be used for retrieval. This technique is 
useful only if the tooth was well-luxated and 
mobile before the root was fractured. The 
socket is irrigated vigorously and suctioned 
with a fine suction tip. In this way, the root 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 41 



tip may occasionally be irrigated from the 
socket and retrieved with the suction. 

If the irrigation-suction technique is un- 
successful, a root tip pick may be used to re- 
trieve the root tip. The root tip pick is in- 
serted into the periodontal ligament space 
and the root tip gently teased out of the 
socket. Care must be taken not to exert ex- 
cessive apical or lateral force when using the 
root tip pick. Excessive apical force could re- 
sult in the displacement of the root tip into 
other anatomic locations such as the maxil- 
lary sinus or the mandibular canal. Excessive 
lateral force could result in bending or frac- 
ture of the root tip pick. 

An endodontic file might also be used in 
the retrieval of root tips. The file can be in- 
serted into the canal to engage the root tip. 
The root tip is subsequently removed by 
grasping the endodontic file with a hemo- 
stat. This technique is useful only if the root 
tip has a visible canal and if it does not have 
a severe dilaceration that prevents access to 
the canal. 

If attempts at removal of the root tip 
using the preceding techniques are unsuc- 
cessful or if visualization or access is im- 
paired, and if a flap has not been reflected, 
one should be reflected at this time to facili- 
tate retrieval. 

Following the reflection of a flap, bone 
may be removed from the buccal aspect of 
the root tip until it is exposed. It then can be 
retrieved with a root tip pick or a straight 

Alternatively, the bone overlying the buc- 
cal aspect of the apex (on the outer buccal 
plate) of the root tip may be removed. In 
order to locate the exact location of the apex 
of the root tip, a periodontal probe is used to 
measure the distance from the crest of the 
bone to the root tip. This measurement is 
transferred to the bone. The size of the root 
tip is also measured on a periapical radi- 
ograph. A window or fenistration then is cre- 
ated in the bone at the apex of the root tip. 
The tip can be retrieved by inserting a root 

tip pick through this window. This tech- 
nique is especially useful when bone on the 
buccal aspect is thin and must be preserved, 
such as when implants or orthodontic move- 
ment of a tooth into the area are planned. 
See Figures 2.28A-D. 

Figure 2-28A. To remove a small, inaccessible, 
buccal root tip in the maxillary arch, a flap should 
be reflected with adequate exposure to the 
tooth's apical portion. 

Figure 2-28B. The location of the root tip is 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 42 



Figure 2-28C. This measurement is transferred 
to the buccal bone, and a window is created 
through which a root tip pick or similar instrument 
can push the root tip coronally. 

Figure 2-28D. Clinical example of the proce- 
dure only using a semilunar flap. 

Technique for Extractions of 
Multiple Teeth 

It is common for a patient to require ex- 
tractions of multiple adjacent teeth or of all 
remaining teeth. If this is the case, certain 
principles should be followed so that the 
transition from a dentulous state to an eden- 
tulous state is as smooth as possible. The 
goal is to allow proper functional and es- 
thetic rehabilitation with removable or fixed 
prostheses after the extractions. 

The order in which the teeth should be 
extracted is important. In general, maxillary 
teeth should be extracted before mandibular 
teeth for several reasons. Local anesthetics 
tend to have a more rapid onset and a 
shorter duration of action in the maxillary 
arch. This means that surgery in the maxil- 
lary arch can begin sooner after the adminis- 
tration of local anesthetics, but also it means 
that the surgery should not be delayed. In 
addition, extractions of maxillary teeth first 
prevent debris, such as portions of teeth or 
restorations, from falling into mandibular 
extraction sockets if extractions of the 
mandibular teeth were performed first. 
Adequate hemostasis should be achieved in 
the maxillary arch before starting extractions 
in the mandibular arch. This improves visu- 
alization during extractions of mandibular 
teeth. Extractions should also progress from 
a posterior to an anterior direction. This 
allows for the more effective use of straight 
elevators in luxating and mobilizing the 
teeth before using forceps to extract them. 
However, since the canine tends to be the 
most difficult tooth to extract due to its long 
root, it should be extracted last. Extractions 
of the teeth on either side of the canine 
weaken its bony housing, potentially making 
the canine easier to extract. 

In cases of extractions of multiple adja- 
cent teeth or of all remaining teeth, the re- 
flection of a flap improves access and visibil- 
ity during the extractions. This allows for the 
more effective use of straight elevators and 
forceps, making the extractions easier. 
Reflection of a flap also allows for bone re- 
moval and sectioning of teeth if needed. 

Selective alveoloplasty is usually required 
following extractions of multiple adjacent 
teeth or of all remaining teeth. This is espe- 
cially true in the area of the canine promi- 
nence. The goal of the alveoloplasty is to re- 
move all sharp bony edges. Areas of large 
undercuts should also be removed in patients 
who are to receive removable prostheses. 
Unjudicious removal of bone should be 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 43 



avoided. Adequate height and width of the 
alveolar ridge should be maintained as much 
as possible to allow for proper rehabilitation. 
The alveoloplasty may be performed with a 
rongeur or bur, with the final smoothing 
performed with a bone file. 

The surgical sites then should be thor- 
oughly irrigated with saline. As mentioned 
previously, attention should be paid to the 
area at the base of the flap, as debris tends to 
collect there. The flap then can be replaced 
and sutured in position. An attempt should 
not be made to obtain primary closure of the 
surgical sites by advancing the flap toward 
the extraction sockets. This will only de- 
crease the vestibular depth, which is to be 
maintained — especially if the patient is to re- 
ceive a denture. If the flap has excess tissue at 
the time of closure, this excess tissue should 
be trimmed off. See Table 2.7. 

Principles of Flap Closure 

When the surgical procedure is completed 
and the surgical site has been irrigated, the 
flap can be sutured. Suturing the flap holds 
it in position and reapproximates the wound 

Various types of suture needles and suture 
material are available. Some common suture 
types used intraorally include silk, chromic 
or plain gut, or vicryl. With respect to size, 
recall that the larger the number, the thinner 
the suture. For instance, a 2-0 silk is thicker 
than a 5-0 silk. The most common type of 
suture used for the closure of a surgical ex- 
traction envelope flap is either a 3-0 or 4-0 
chromic gut. This type of suture is re- 
sorbable and normally will take anywhere 
from one to two weeks for resorption. 

A number of techniques can be used to 
successfully close a flap including a simple or 
interrupted technique, a running stitch with 
or without locking, and mattress style either 
vertically or horizontally. Each of these tech- 
niques has a place in appropriately closing an 
incision; however, the majority of envelope 

Table 2-7. Multiple Extractions Sequence 

1 — Maxillary teeth 

2 — Mandibular teeth 

3 — Posterior to anterior 

4 — Achieve hemostasis prior to moving from one 

quadrant to the next 
5 — Reflection of a minimal buccal flap will facilitate 

extractions and allow for alveloplasty. 
6 — Alveloplasty 
7 — Irrigation 
8 — Suturing 
9 — Postoperative instructions 

flaps are closed with a standard interrupted 
suture technique. 

Certain principles must be followed when 
suturing the surgical site. It is important that 
the suture needle is perpendicular to the sur- 
face of the mucosa as it penetrates the mu- 
cosa. This creates the smallest possible hole 
in the soft tissue and decreases the risk of 
tearing the soft tissue as the knot is tied. An 
adequate bite or width of soft tissue must 
also be taken to prevent the suture from 
pulling through and tearing the soft tissue. 
When tying the knot, it must be kept in 
mind that the purpose of the suture is to 
reapproximate the tissue. The knot, there- 
fore, should not be tied too tightly. A knot 
that is too tight can cause ischemia of the 
soft tissue, resulting in soft tissue necrosis 
and wound dehiscence. In addition, the knot 
should not be positioned directly on the 
wound margin, as this causes additional pres- 
sure on the knot. Rather, it should be posi- 
tioned to the side of the margin. The knot 
should have three throws so that it does not 
become undone. The suture material can 
then be cut. Nonresorbable sutures are gener- 
ally left in place for approximately 5—7 days. 

Envelope Flap Closure 

For the surgical extraction of a single tooth 
with reflection of an envelope flap, reposi- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 44 



tion the envelope flap into its correct loca- 
tion and suture the papillae. This is done by 
first passing the suture through the buccal 
gingival just apical to the base of the papilla 
and continuing the suture under the inter- 
proximal contact and out through the lin- 
gual gingiva. In many cases, it is not possible 
to obtain a good bite in the lingual tissue, 
and if this is the case, the suture needle is 
then grasped and a second pass is made from 
the lingual and extended back beneath the 
contact point and out the buccal. This su- 
ture is then tied using a standard knot. The 
entire process is repeated on the other papil- 
lae. The papillae adjacent to an extraction 
socket may be approximated using the sim- 
ple interrupted sutures. See Figure 2.29. 

A figure-eight suture or a horizontal mat- 
tress suture should be used if the extraction 
socket is packed with material to aid in he- 
mostasis. For the figure-eight suture, the su- 
ture is passed through the buccal portion of 
the first papilla. It is then brought diagnon- 
ally across the socket and passed through 
the lingual or palatal papilla on the opposite 
side of the socket. The suture is then passed 
diagonally again through the lingual papilla 
toward the buccal. The knot is tied on the 
buccal aspect of the ridge. See Figure 

For the horizontal mattress suture, the su- 
ture is passed through the buccal portion of 
the first papilla. The suture is then passed 
through the lingual or palatal papilla. Then 

Figure 2-29. Interrupted sutures. 

Figure 2-30A. Figure-eight suture. This is com- 
monly used when the socket is packed with 
Gelfoam™ or Surgicel™. The needle is passed at 
the distobuccal papilla. 

Figure 2-30B. Through the mesiolingual papilla. 

Figure 2-30C. Through the mesiobuccal papilla. 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 45 



Figure 2-30D. Through the distolingual papilla. 

Figure 2-30E. Then the suture is tied. 

from the lingual side of the arch, the suture 
is passed through the lingual or palatal por- 
tion of the papilla on the other side of the 
socket. The needle is directed buccally 
through the last remaining papilla — from its 
inside to the outside (buccal). The knot can 
then be tied. See Figure 2.31. 

Closure of a Three-corner Flap 

The papilla at the site of the releasing inci- 
sion should be sutured first. In order to facil- 
itate the suturing at the site of the releasing 
incision, the soft tissue at the nonfliap (fixed) 
side of the releasing incision may be lifted up 
slightly. The papillae on the remainder of the 
envelope portion of the flap should then be 
reapproximated. The anterior release is in- 
spected. Many times it is necessary to place 

Figure 2-31 . Sequence of placement of the hor- 
izontal mattress suture. 

an additional stitch or two to ensure that the 
flap has enough support to prevent normal 
masticatory forces from displacing it post- 
operatively. See Figure 2.32. Usually, how- 
ever, only two sutures are required to reap- 
proximate the releasing incision. 

Figure 2-32. Closure of a three-corner flap. 
The releasing incision is closed first to reorient the 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 46 



Continuous Suture 

The simple continuous suture can be either 
locking (see Figure 2.33A-E) or non- 
locking (see Figure 2.34). For the simple 
continuous suture, the first papilla is reap- 
proximated, and the knot tied in the usual 
fashion. The short end of the suture is then 
cut while leaving the long end of the suture 
intact. The adjacent papilla is then sutured, 
without tying a knot, but merely reapproxi- 
mating the tissue as the suture is being 
placed. Succeeding papillae are then sutured 
in the same fashion until the final papilla is 
sutured and the knot tied. The final appear- 
ance is of the suture going across each extrac- 
tion socket. The advantages of the simple 
continuous suture is that it takes less time to 
perform, and there are fewer knots — usually 
making it more comfortable for the patient. 
The disadvantage of the simple continuous 
suture is that if one suture pulls through, the 
entire suture line becomes loose. 

Technique for Extractions of 
Teeth Using Periotomes 

A periotome is a fine, straight elevator with a 
sharp, narrow blade that is designed to slice 
the periodontal ligament and displace the 

Figure 2-33A. Continuous locking suture. 
Initially a simple interrupted suture is tied. Only the 
short end of the suture is cut. 

Figure 2-33B. Then the needle is passed 
through the adjacent buccal and lingual papillae. 

Figure 2-33C. A loop is created. That loop is 
twisted, and a needle is passed through it, after 
which the loop is pulled tight. 

tooth as the instrument is manipulated api- 
cally. It is not a true dental elevator since it is 
not inserted and rotated to expand the bone 
and subluxate a tooth. It is, however, used 
when the postextraction site is to be recon- 
structed with a dental implant. The goal in 
these cases is to remove a tooth with mini- 
mal alveolar expansion or alteration in the 
bony housing. This is especially true if im- 
mediate implant placement is planned and 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 47 



Figure 2-33D. The procedure is repeated until 
the last pass, where a final loop is made — which 
is used to place the final knot. This last loop func- 
tions as the short end of a simple interrupted 

Figure 2-33E. Final continuous locking suture. 

trauma to the surrounding alveolar bone 
must be avoided. The periotome is used by 
inserting the blade into the periodontal liga- 
ment space and gently rocking the instru- 
ment buccopalatally while applying gentle 
apical pressure. In this way, the periodontal 
ligament is cut, allowing the tooth to be gen- 
tly lifted out of the socket without trauma or 
damage to the alveolar bone. Straight peri- 
otomes are indicated for use on single-rooted 
teeth, and angled periotomes are indicated 
for use on multirooted or posterior teeth. 

Figure 2-34. Continuous suture. 

Common Mistakes during 
Surgical Extractions 

The principles of surgical extraction as dis- 
cussed previously should be followed to de- 
crease the incidence of complications. 
Common mistakes that are made during ex- 
tractions of teeth include attempting a forcep 
extraction when the preoperative evaluation 
had indicated that a surgical extraction was 
required, poor flap design, inadequate reflec- 
tion of a flap, use of uncontrolled force, in- 
adequate seating and adaptation of the for- 
ceps, attempting the removal of root tips 
without adequate access and visualization, 
inadequate irrigation of the surgical site prior 
to reapproximation of the flap, and poor 
reapproximation of the flap. 

If the preoperative evaluation indicates 
that a surgical extraction, rather than a for- 
cep extraction, is required, the practitioner 
should proceed with the surgical extraction. 
Attempts at extracting the tooth with a for- 
cep in this situation might result in loss of 
valuable coronal tooth structure that would 
have facilitated the surgical extraction of the 
tooth. Using forcep extraction when a surgi- 
cal extraction is indicated could also lead to 
excessive trauma of the soft tissue, fracture of 
the tooth, fracture of the adjacent bone, and 
patient fatigue from the extended length of 
the procedure. 

When designing a flap, principles should 
be followed as discussed previously. Poorly 
designed flaps lead to complications such as 
wound necrosis, wound dehiscence, peri- 

2879_Koerner_Chap 02 4/17/06 1:23 PM Page 48 



odontal defects, damage to the papillae, and 
prolonged healing time. 

The flap must be adequately reflected to 
permit adequate access and visibility during 
the extraction. Inadequate flap reflection 
could lead to excessive tension on the flap or 
a tear that is difficult to reapproximate. 
Inadequate flap reflection also prevents in- 
struments from being seated properly. 

The use of uncontrolled force in the ex- 
traction of a tooth should be avoided. Slow, 
deliberate movements, instead of rapid, jerky 
movements, should be used to expand the 
bone. Excessive force should not be used as 
it leads to fracture of the tooth or adjacent 
bone. If heavy force seems necessary to ex- 
tract a tooth, bone should be removed or 
the tooth sectioned (in cases of multi-rooted 
teeth) to allow for a more controlled ex- 

The forcep should be adequately seated 
and adapted for a successful extraction. It 
should be placed as apically as possible and 
reseated periodically during the extraction. 
The beaks of the forcep should be shaped to 
adapt to the root of the tooth. If it doesn't, a 
different forcep should be used. The beaks of 
the forcep should be held parallel to the long 
axis of the tooth so that the forces generated 
are delivered along the tooth's long axis. This 
provides maximal effectiveness in expanding 
the bone. If a cowhorn forcep is used, the 
beaks should be properly seated in the area 
of the furcation, so that the tooth that is 
being extracted is squeezed out of the socket. 
Buccolingual movement should be avoided 
until the beaks of the cowhorn forcep are 
properly seated. 

Attempting the removal of root tips with- 
out adequate access or visualization should 
be avoided. This is especially important in 
the maxillary arch as complications such as 
root displacement into the maxillary sinus 
can occur if excessive apical pressure is used. 
If access to and visualization of the root tip is 
inadequate, further reflection of the flap or 
bone removal should be performed. 

Adequate irrigation of the surgical site 
prior to reapproximation of the flap is criti- 
cal. As discussed previously, debris tends to 
collect at the base of the flap. This area 
should be thoroughly irrigated prior to repo- 
sitioning of the flap. Inadequate irrigation of 
the surgical site can lead to an infection, 
which will require the surgical site to be re- 
opened for irrigation and debridement. 

Proper reapproximation of the flap is im- 
portant to prevent wound necrosis, wound 
dehiscence, periodontal defects, damage to 
the papillae, and an extended healing time. 
Adhering to proper suturing techniques is 
important. The flap should always be held in 
position without tension. 


1. J. R. Hooley, and D. B. Golden. Surgical 
Extractions. Dental Clinics of North America 
38 (2): 217-236. 1994. 

2. H. Dym and O. E. Ogle. Atlas of Minor Oral 
Surgery. Philadelphia, PA: W.B. Saunders. 2001. 

3. L. J. Peterson. Principles of Complicated Exodontia. 
In Contemporary Oral and Maxillofacial Surgery, ed- 
ited by Larry J Peterson, 3rd edition. St Louis: 
Mosby, pp. 178-214, 1998. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 49 

Chapter 3 

Surgical Management of 
Impacted Third Molar Teeth 

Dr. Pushkar Mehra and Dr. Shant Baran 


Removal of impacted third molars or "wis- 
dom teeth" is one of the most common sur- 
gical procedures performed in a dental office. 
Impaction refers to the lack of eruption of a 
tooth into the dental arch within the ex- 
pected time. The tooth becomes impacted 
because eruption is prevented by a physical 
barrier such as an adjacent tooth, dense 
overlying bone, or excessive soft tissue. 
The National Institutes of Health (NIH) 
Consensus Development Conference, held 
in 1979, established a series of guidelines 
that provides information for clinicians who 
treat patients with impacted third molars. 
Teeth most often become impacted because 
of inadequate arch length (total alveolar arch 
length is less than the total dental arch 
length). The most common impacted teeth 
are maxillary and mandibular third molars, 
followed by maxillary canines and mandibu- 
lar premolars. 

As a general rule, all impacted teeth 
should be evaluated for treatment, which 
could mean either observation, removal or 
surgically assisted eruption. Dentists must 

use knowledge acquired from their educa- 
tion, training, and experience and combine 
it with clinical and radiographic examina- 
tions before deciding whether to retain or re- 
move the impacted teeth. For the most part, 
removal of impacted teeth is indicated unless 
a specific contraindication exists. This phi- 
losophy is based on the fact that removing 
impacted teeth becomes more difficult and 
complicated with advancing age. A funda- 
mental precept of the philosophy of den- 
tistry is "prevention of problems." Preventive 
dentistry indicates that impacted teeth be re- 
moved before complications arise. 1-5 

Certain standards of care and expectations 
have been established for all dental and sur- 
gical procedures, and third molar surgery is 
no exception. Whether a general dentist or a 
specialist performs the surgery, these stan- 
dards remain the same. The patients benefit 
from an accurate diagnosis, good presurgical 
planning, sound execution of surgery, and 
well-managed postoperative care. This chap- 
ter discusses the basic principles for manage- 
ment of impacted third molars. It is de- 
signed to provide a basic framework for the 


2879_Koerner_Chap 03 4/17/06 1:24 PM Page 50 



dental surgeon interested in performing 
third molar surgery and provides informa- 
tion that will help in assessing surgical diffi- 
culty and managing impacted third molar 
patients in their practices. 

Indications for Third Molar 

Many indications for removal of impacted 
third molars exist. 1_9 However, elective re- 
moval of third molar teeth should not be 
performed if potential risks outweigh the 
benefits of surgery. The following paragraphs 
list certain conditions that are routinely con- 
sidered as indications for removal of third 


Pericoronitis is an infection of the soft tissue 
that usually occurs around the crown of a 
partially impacted tooth (see Figure 3.1). 
This infection is caused by the normal flora 
of the oral cavity as the presence of bacteria 
in excessive pericoronal soft tissue presents a 
challenge to the delicate balance between 
host defense and bacterial growth. Transient 
decreases in host defenses can precipitate a 
bacterial surge and subsequently cause infec- 
tion that results in moderate to severe pain 
and/or trismus. If left untreated, the infec- 
tion may spread to adjacent head and neck 
fascial spaces. Recurrent trauma from trau- 
matic of an opposing maxillary molar often 
causes the area around the mandibular third 
molar to swell, which leads to a vicious cycle 
of further traumatic occlusion and continued 
infection. Another common cause of peri- 
coronitis is entrapment of food under the 
operculum. This provides a haven for strep- 
tococci and the anaerobic oral microbes to 

Initial treatment should include mechani- 
cal debridement to cleanse the area, prescrib- 
ing oral rinses such as chlorhexidine to re- 
duce bacterial load, and the use of antibiotics 

Figure 3-1. Photograph showing pericoronitis 
around an impacted third molar tooth. Note the 
erythema of the gingival surrounding the third 

with oral flora coverage. Patients should be 
instructed in the use of strict oral hygiene 
measures. Early intervention is advantageous 
because of the potential for rapid spread 
from this area to fascial spaces, which would 
require hospitalization and, possibly, major 
invasive surgery. 

Periodontal Disease 

Periodontal disease of the adjacent second 
molar is often a concern when an impacted 
third molar is present (see Figure 3.2). 
Retention of an impacted third molar can 
compromise the bone housing the second 
molar and might predispose it to periodontal 
defects. This situation can progress to clinical 
recession and pocketing — leading ultimately 
to possible root caries and/or mobility. 


Due to its posterior position, a third molar 
presents a hygiene challenge to the most 
meticulous of patients. A third molar that is 
not in its correct position relative to the arch 
creates a more cumbersome situation with 
regard to hygiene. The susceptibility of such 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 51 



Figure 3-2. Radiograph showing severe bone 
loss around the second molar secondary to perio- 
dontal disease caused by an impacted third molar. 

a third molar to carious involvement is, 
therefore, high, and it is not uncommon to 
see this in clinical practice (see Figure 3.3). 
Even when an obvious communication of 
the tooth may not exist with the oral cavity, 
the potential still exists for subsequent bacte- 
rial invasion. Dental caries and pulpal necro- 
sis contribute to an increasing number of 
third molar extractions with increasing age. 9 

Root Resorption 

As with periodontal disease, the mere pres- 
ence of an impacted third molar in close 

proximity to a second molar predisposes the 
second molar to a myriad of problems. One 
problematic situation is that of resorption of 
the roots of the second molar. Root resorp- 
tion associated with an impacted third molar 
is common in the 21- to 30-year age group, 
and the most common site for root resorp- 
tion is the middle third of the distal surface 
of the adjacent second molar. 10 This presen- 
tation may, unfortunately, result in extrac- 
tion of the second molar, which is news not 
often pleasing to the patient. 

Removable Prostheses 

When planning treatment for dentulous pa- 
tients with removable prostheses, close 
attention should be paid to the presence of 
impacted third molars. Retention of these 
teeth under such prostheses may lead to their 
"eruption." Continued pressure over these 
areas caused by the prosthesis can initiate re- 
modeling of the bone overlying the tooth, 
eventually leading to ulceration of the soft 
tissue and exposure of the previously 
unerupted tooth. The patient is then at risk 
for a problem that could present at at any 

Figure 3.4 shows a radiograph of a 70- 
year-old patient with third molars exposed to 
the oral cavity due to prolonged denture 
wear. This patient had recurrent episodes of 

Figure 3-3A,B. Radiographs showing caries on the distal aspect of the second molar secondary to 
an impacted third molar. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 52 



Figure 3-4. Radiograph of a 70-year-old patient with third molars exposed to the oral cavity due to 
prolonged denture wear. This patient had recurrent episodes of pericoronitis and was treated by removal 
of the offending teeth. Performing third molar extractions in this kind of patient is complex due to the 
presence of an atrophic mandible. There is increased risk of jaw fracture and inferior alveolar nerve in- 
jury during surgery. 

pericoronitis and was treated by removal of 
the offending teeth. Performing third molar 
extractions in this type of patient is more 
complicated due to the presence of an at- 
rophic mandible. There is increased risk of 
jaw fracture and inferior alveolar nerve in- 
jury during surgery at this age. 


Certain types of tumors and cysts have 
been associated with the follicles of impacted 
teeth. Although the overall incidence of 
odontogenic cysts and tumors is not particu- 
larly high, the correlation between pathology 
and impacted teeth cannot be ignored. It 
is recommended that if impacted teeth 
have pathology associated with them, they 
should be removed, and the pathologic 
cyst or tumor sent for histopathological 

Figure 3. 5 A shows a panoramic radi- 
ograph of an impacted third molar in a 
17-year-old female with a pericoronal radi- 
olucency, causing root resorption of the 
second molar. Upon histopathological exam- 
ination, this radiolucency was found to be an 

Figure 3.5B shows a panoramic radi- 
ograph of a 46-year-old male with an im- 
pacted maxillary molar, which has been dis- 
placed superiorly and posteriorly toward the 
infratemporal fossa by expansion of an asso- 
ciated dentigerous cyst. The patient required 
a Le Fort 1 osteotomy procedure for removal 
of the impacted tooth and cyst. 

Management of Dental Crowding/ 
Adjunct to Orthodontic Treatment 

Patients who undergo orthodontic treatment 
spend a great deal of time and money in 
pursuit of attractive looking teeth. The pres- 
ence of impacted wisdom teeth may interfere 
with orthodontic movement and is suspected 
to provide a long-term mesially directed 
force that may contribute to relapse. The re- 
moval of impacted third molars may also 
create some additional space in the posterior 
jaws for orthodontic distalization of teeth. 
Consideration should be given to removal of 
any impacted wisdom teeth prior to initiat- 
ing orthodontic treatment or, in some cases, 
upon completion. The orthodontic treat- 
ment plan, age of the patient, and stage of 
development of the teeth are some factors 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 53 



Figure 3-5A. Panoramic radiograph of an impacted third molar in a 17-year-old female with a peri- 
coronal radiolucency causing root resorption of the second molar. Upon histopathological examination, 
this radiolucency was found to be an ameloblastoma. 

Figure 3-5B. Panoramic radiograph of an impacted third molar in a 46-year-old male with a large peri- 
coronal radiolucency in the maxillary sinus area. The impacted third molar has been displaced into the 
sinus and towards the infratemporal fossa. Upon histopathological examination, this radiolucency was 
found to be a dentigerous cyst. 

that might dictate the timing. The NIH 
consensus conference concluded that al- 
though significant orthodontic reasons exist 
for the early removal of third molars, the 
practice of early surgical enucleation of third 
molar buds between the ages of 7 to 9 years 
is not recommended. 1 1 

Preparation for Orthognathic 

When a patient is being evaluated for or- 
thognathic surgery, the presence of impacted 
teeth should be noted. In patients where a 
mandibular sagittal split osteotomy is recom- 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 54 



mended, the presence of such teeth may 
complicate the surgery. It is recommended to 
remove such teeth at least 6—9 months prior 
to undertaking such a surgery to permit 
adequate healing of the bone. The newly 
formed bone will allow for a more pre- 
dictable bone separation during surgery as 
well as providing more osseous bulk for rigid 
fixation and stability. 

In the authors' experience, impacted maxil- 
lary third molars can be removed safely con- 
comitandy during a maxillary Le Fort I os- 
teotomy procedure. Access for removal of the 
third molar is unrivaled, and usually the ex- 
tractions are a relatively straightforward proce- 
dure. Some surgeons, however, prefer that the 
third molars be removed prior to surgery if 
the surgeon is osteotomizing the maxilla in 
multiple segments. Removal of the third mo- 
lars approximately three to six months prior 
to this orthognathic surgery is often sufficient 
to avoid subsequent surgical complications. 

Management of Facial Pain 

Patients may present complaining of radiating 
pain stemming from the area of an impacted 
third molar. Due to the proximity of the tem- 
poromandibular joint (TMJ) and associated 
musculature, the third molars may be a possi- 
ble source of pain. However, it should be em- 
phasized that the third molars may not be the 
source of the pain. If the patient has no ab- 
solute contraindications as outlined later in 
this chapter, removal of the impacted teeth 
may be considered. The patient should be 
informed of the risks of undertaking such a 
procedure with no clear resolution in sight. 
Patients should understand the possibility of 
not experiencing relief despite removal of the 
impacted teeth. 

Prevention of Pathologic Mandible 

Although the purpose of the alveolus is to 
house the teeth, the presence of teeth invari- 

ably lessens the osseous bulk. When a tooth 
is embedded within the mandible, it occu- 
pies space that would otherwise be bone 
contributing to its strength. If the position 
of the impaction is such that it permits min- 
imal continuity of bone, it might represent a 
point of weakness. This situation could pre- 
dispose an individual to fracture of the 
mandible in the area of the impaction 
(Figure 3.6). Moreover, the presence of such 
a tooth complicates the treatment of a 
mandibular fracture. Therefore, it has been 
suggested that these impactions be removed 
prior to such incidents. Although iatrogenic 
fractures may occur during removal, the in- 
cidence is low, and a controlled setting with 
a systematic approach minimizes this as a 

Figure 3-6. Panoramic radiograph demonstrat- 
ing a left mandibular angle fracture which runs 
through the impacted third molar area. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 55 



Contraindications to Removal of 
Impacted Third Molars 

The removal of teeth comes with a number 
of risks and potential complications. One rea- 
son to consider not removing impacted wis- 
dom teeth is that the potential for subjecting 
a patient to these complications outweighs 
the potential gain achieved by their removal. 

Damage to Adjacent Structures 

A number of vital structures surround third 
molars, and with varying degrees of im- 
pactions come varying degrees of risk to 
these areas. Careful clinical and radiographic 
analysis is required to assess the proximity of 
the teeth to these structures of concern as 
well as an understanding of the extent of 
surgery required to remove these teeth. This 
analysis plays a significant role in determin- 
ing the extent of morbidity associated with 
any procedure. If, after careful evaluation, it 
is determined that extensive damage may 
occur from the removal of such teeth, then 
a decision to remove them may not be 

Figure 3.7 shows a radiograph of a 48- 
year-old male with clinically asymptomatic 
third molars. The impacted teeth were dis- 

Figure 3-7. Deeply impacted mandibular third 
molar in very close proximity to the inferior alveo- 
lar nerve in a 48-year-old male. Note the dense 
bone overlying the impacted tooth. In view of the 
difficulty of the surgery, age of the patient, and 
asymptomatic nature of the impaction, elective 
extraction was not recommended. 

covered on routine panoramic radiographic 
examination. No surgical treatment was rec- 
ommended. Clinicians must understand that 
surgical removal of the impacted lower tooth 
in this patient would risk serious complica- 
tions including, but not limited to, nerve in- 
jury and jaw fracture. 

In contrast to the preceding scenario, 
Figure 3.8 shows a panoramic radiograph of 
a 3 9 -year-old male with symptomatic im- 
pacted second and third molars ("kissing 
molars"). Like the case in Figure 3.7, these 
extractions are very difficult, and in an 
asymptomatic patient, a very strong case can 
be made for close observation without sur- 
gery. However, this patient had recurrent 
bouts of infection, and consequently, despite 
the risks of surgery, the teeth were removed. 
Due to the extent of surgery, the procedure 
was performed in a hospital setting, and the 

Figure 3-8A. Panoramic radiograph of a 39- 
year-old male with symptomatic impacted second 
and third molars ("kissing molars"). 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 56 



Figure 3-8B. The patient had recurrent infec- 
tions so despite the risks of surgery, the impacted 
teeth were removed. The procedure was per- 
formed in a hospital setting. A bone graft was 
harvested from the hip and placed into the large 
surgical defect to augment the weakened 
mandible. Maxillomandibular fixation (wiring of 
jaws) was applied for four weeks postoperatively 
to prevent jaw fracture. 

patient was bone grafted and placed into 
maxillomandibular fixation for four weeks 
postoperatively to prevent jaw fracture. 

Age of Patient 

Age might become a significant factor in de- 
ciding whether or not to remove an impacted 
wisdom tooth. There exists some controversy 
as to the most optimal time for removal. A 
general consensus, however, does exist in one 
area: "Removal of third molar teeth should 
be deferred until one can determine whether 
or not they may remain impacted." 

The surgeon must understand that al- 

though third molars can be removed at any 
age, surgery itself is easier and associated 
with less morbidity when performed in pa- 
tients who are in their late teens or early 
20's. 1 ' 3, 11, 13, 14 w/i m re g ar d to advanced 

age, older patients tend to respond less favor- 
ably to the removal of teeth, particularly im- 
pacted third molars. Bone becomes increas- 
ingly calcified with age, leading to rigidity, 
and becomes less forgiving of the forces re- 
quired to remove these teeth. This yields a 
situation in which more bone must be sacri- 
ficed, and the procedure becomes more trau- 
matic. In the case of asymptomatic im- 
pactions, an approach is favored that requires 
the watchful eye of the general dentist and 
frequent radiographic checks to rule out 

Medical Compromise 

Oftentimes, practitioners may find them- 
selves so focused on the patient s dental con- 
dition that they neglect the patient's medical 
condition. A thorough review of the patient's 
medical history must be performed and the 
patient informed of any issues that may pre- 
clude the removal of a tooth or the need for 
further preoperative preparation. Removal of 
asymptomatic impacted teeth must be 
viewed as "elective." If a patient has uncon- 
trolled cardiovascular or respiratory condi- 
tions, immune compromise, or a significant 
coagulopathy, serious consideration must be 
given to deferring surgery in these cases. In 
nonelective cases, further preoperative prepa- 
ration, involvement of the patient's physi- 
cian, and possible hospitalization may be 

Surgical Instrumentation 

When a dentist attempts any procedure, 
having the correct instruments can make the 
difference between success and complication. 
This is particularly true with surgical proce- 
dures. The following armamentarium is sug- 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 57 



gested as a "basic template" for the surgical 
removal of third molars: 

• #15 Bard-Parker blade 

• Periosteal elevator (example: #9 Molt) 

• Retractors 

- Flap (example: Seldin, Minnesota, 

— Cheek (example: Minnesota, Bishop, 

• Dental elevators 

— Straight (preferably one each of a small, 
medium, and large size) 

- East- West 

— Crane pick 

- Pott's or Miller's (if required) 

• Bone file 

• Extraction forceps 

— Upper universal 

— Lower universal 

• Rongeurs 

- End cutting 

- Side cutting (if needed) 

• Needle holder 

• Suture scissors 

• Suture (resorbable or nonresorbable) 

• Rotary instrument for cutting bone and 

- Drill 

— Burs (round, straight, or cross-cut fissure) 

The exact choice of equipment may vary 
among practitioners. Various blades, suture 
material, retractors, and elevators are avail- 
able, and it is recommended that operators 
use those with which they are most comfort- 
able. The rotary instruments chosen should 
be of the type that do not exhaust air into 
the surgical field, which will minimize com- 
plications such as intraoperative or postoper- 
ative air emphysema and/or foreign body en- 

Presurgical Considerations 

After it is decided to perform the surgery, 
several factors need to be addressed prior to 

commencing the procedure. Attention to 
these areas will allow the surgery to proceed 
more smoothly and safely. 

Informed Consent 

When planning for the surgical removal of 
third molars, one must always inform the 
patient of the risks that are involved and the 
potential complications that may arise. These 
should be explained to the patient in terms 
that the patient can comprehend, highlight- 
ing aspects that may be of particular concern 
in each respective case. 

It should be discussed that during any 
procedure, a time of discomfort or pain is to 
be expected, and appropriate medication 
will be provided. Infection can arise post- 
operatively with any surgical procedure, as 
can "dry socket." Damage to adjacent struc- 
tures can occur, but to prevent this, the ut- 
most care should be exercised. When maxil- 
lary third molars are to be extracted, sinus 
exposure is often possible. When extracting 
mandibular teeth, issues involving the infe- 
rior alveolar, mental, and lingual nerves 
should be discussed. The neural aspect 
should be stressed because of its associated 
morbidity — despite its rare occurrence. 
There are times where noninfected root tips 
might be retained given that retrieval can 
cause further harm with little benefit. The 
patient should be made aware of this. 

Informed consent is a vital aspect of one's 
practice. When a patient is caught off-guard 
by an unexpected mishap, it can lead to 
unnecessary stress for the patient and practi- 
tioner. Patients have the right to be in- 
formed, and it is the professional's responsi- 
bility to use their knowledge to guide the 
patient through decisions about which they 
know very little. 

Radiographic Examination 

Thorough radiographic analysis is imperative 
in assessing difficulty and planning the surgi- 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 58 



cal approach. Panoramic radiographs are the 
"workhorse" in impacted third molar sur- 
gery, and in the authors' opinion they should 
be obtained for all surgical cases. They con- 
veniently demonstrate a large area of the face 
in one view. The relation of third molars to 
the inferior alveolar nerve and approximate 
proximity of maxillary teeth to the sinus can 
be evaluated, as can potential pathology that 
would otherwise be missed in more focused 
fields. This is not to discount the use of 
other dental radiographs. Greater detail can 
be visualized in periapical films, and the 
bucco-lingual dimension can be appreciated 
only with occlusal films. In extremely com- 
plex cases, computerized tomography (CT) 
scans or magnetic resonance imaging (MRI) 
scans might be indicated, as they may pro- 
vide more detailed information about hard 
and soft tissue structures, respectively. 
Oftentimes, the clinician may need to use a 
combination of radiographs and other 
modalities to arrive at a diagnosis or plan. 

Mandibular Third Molar 

Mandibular impactions are classified based 
on three criteria: angulation, position relative 
to the anterior ramus, and position relative 
to the occlusal plane. 

Assessing Difficulty 

These classification systems are not mutually 
exclusive, and when used together, can aid 
the surgeon in assessing difficulty and extent 
of surgery, and also to plan a surgical ap- 
proach for patients with impacted mandibu- 
lar third molars. 

Angulation refers to the angle of the long 
axis of the third molar relative to the long axis 
of the second molar. A mesioangular direc- 
tion is the most common impaction and is 
one in which the crown of the molar is tilted 
mesially. The second most frequent is the ver- 
tical impaction in which the long axis re- 

mains parallel to that of the second molar, 
but the tooth has not erupted. A severe mesial 
inclination may occur, leading to a perpendi- 
cular relationship of the second and third 
molars; this is referred to as a horizontal im- 
paction. Finally, if the crown of the third 
molar faces away from the second molar, it is 
known as a distoangular impaction. 

The Pell and Gregory system of classify- 
ing impacted third molar teeth (see Figure 
3.9) uses the position of the tooth relative to 
the anterior ramus and occlusal plane. When 
classifying teeth relative to the anterior 
ramus, if the mesio-distal dimension of the 
third molar is completely anterior to the an- 
terior aspect of the ramus, the molar is re- 
ferred to as Class 1 . Class 2 is a situation in 
which approximately half of the crown re- 
mains covered by the bone of the anterior 
ramus. Class 3 presents with the entire 
crown posterior to the anterior ramus. It is 
fair to say that Class 3 will likely present a 
greater challenge than a Class 1 impaction. 

The other aspect of the Pell and Gregory 
classification is the position of the tooth rela- 
tive to the occlusal plane (see Figure 3.9). 
Class A depicts a situation in which the oc- 
clusal surface of the third molar is flush with 
the second molar. Class B describes a tooth 
that has its occlusal surface located between 
the occlusal plane and the cervical line of the 
second molar. In the Class C impaction, the 
third molar presents with its occlusal surface 
below the cervical line of the second molar. 
Again, a class C impacted tooth will be 
deepest in bone and can be expected to be 
surgically more difficult than Class A and B 
impacted teeth. 

Facial Form 

Facial form has been implicated as an addi- 
tional factor in assessing difficulty (see Figure 
3.10). This stems from anatomy and can 
highlight specific concerns potentially influ- 
encing surgical access. Patients exhibiting a 
square or compact facial form tend to have 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 59 

Figure 3-9. Pell and Gregory classification of third molar impactions. 

—fcc^a-^V V jk 


"T* ' " ?" 1 ?^^ m 


^^T^ JSK fS£ 


Figure 3-10. Different types of facial form can affect difficulty of surgery. A. Tapering facial form. B. 
Compact facial form. 


2879_Koerner_Chap 03 4/17/06 1:24 PM Page 60 



zygomatic arches that are relatively low and 
maxillary tuberosities that are in close prox- 
imity to the coronoid process when in an 
open-mouth position. These factors make 
surgical access to maxillary third molars 
more difficult than in a patient with a taper- 
ing facial form whose zygomatic arches are 
high and whose coronoid processes do not 
encroach upon the tuberosities. With regard 
to the mandible, patients with a tapering fa- 
cial form tend to have an anterior ramus that 
is more lateral when compared to the square 
form. These observations may seem trivial 
but can make a difference in technique, 
instrumentation, and modification of 

Root Morphology 

Root morphology plays a major role in de- 
termining the degree of difficulty in the re- 

moval of impacted teeth. The first factor is 
the length of roots. In general, the most op- 
timal time for removal of impacted teeth is 
when the roots are one-third to two-thirds 
formed (Figure 3.1 1 A). At this stage the 
roots are generally blunt and rarely fracture 
during removal. They are also not embedded 
as deep as teeth with fully formed roots and, 
thus, are most likely more distance away 
from vital structures when compared to teeth 
with long, fully formed roots. If the roots are 
not developed at all, the extraction is usually 
more difficult since the tooth tends to rotate 
within its own crypt during elevation (Figure 

The next factor to take into consideration 
is whether the roots are fused into a conical 
shape or whether the roots are separate and 
distinct. Teeth with fused conical roots are 
easier to remove than teeth with separate, di- 
vergent roots (see Figure 3.1 1C). Root cur- 

Figure 3-1 1 . Root morphology affecting complexity of surgery. A1 ,A2. Roots are approximately 1/3 to 
2/3 developed, therefore, these are easier extractions. B. Roots have not developed — may be a difficult 
extraction. C. Conical roots morphology — easier extractions. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 61 



Figure 3-11. (continued) D1,D2. Dilacerated roots— more difficult extractions. E1,E2. Bulbous 
roots — more difficult extractions. 

vatures must be assessed. Dilacerated roots 
can complicate a relatively simple extraction 
procedure, as the curved root will often frac- 
ture in the apical dilacerated portion (see 
Figure 3.1 ID). The direction of curvature 
also is important and must be assessed in re- 
lation to the direction of delivery of the 
tooth. Teeth with bulbous roots often require 
extensive bone removal for successful re- 
moval (see Figure 3.1 IE). 

Miscellaneous Considerations 

Certain other factors like density of the over- 
lying bone, size of follicular sac, proximity to 
the second molar, and relationship to vital 
structures (inferior alveolar nerve, maxillary 

sinus, and so on) must also be taken into 
consideration, as they can help in determin- 
ing the difficulty of the extraction. Figure 
3.12 shows an extracted third molar in 
which the mandibular canal traversed 
through the roots. 

Surgical Technique 

Although the surgery itself, in large part, dic- 
tates the postoperative course, certain ac- 
commodations can potentially improve it. 
Patients undergoing third molar surgery may 
benefit from gross debridement of the peri- 
odontal tissues. A healthy environment can 
create more optimal conditions for healing. 
Preoperative rinsing with chlorhexidine glu- 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 62 



Figure 3-12. An extracted third molar demon- 
strating the course of the mandibular canal 
through the tooth roots. 

conate, an antimicrobial rinse, has been 
shown to improve the postoperative course, 
specifically lowering the incidence of alveolar 
osteitis, or dry socket. Anecdotal "evidence" 
suggests that patients with a history of peri- 
coronitis have benefited from preoperative 
antibiotic prophylaxis with a continued post- 
operative course. Ultimately, the removal of 
impacted third molars consists of local anes- 
thetic administration, flap design, bone re- 
moval, luxation, sectioning of teeth, tooth 
delivery, and closure. 


When preparing for any extraction, adequate 
and profound anesthesia is paramount. The 
preferred technique for maxillary third molar 
extractions is buccal infiltration and a palatal 
nerve block in the area of the greater palatine 
nerve. Inferior alveolar nerve blocks com- 
bined with long buccal infiltration are the 
preferred anesthesia for mandibular third 
molar extractions. 

The anesthetic standard upon which den- 
tal recommendations are based is 2 percent 
Lidocaine with a 1:100,000 concentration of 

epinephrine in a 1.8-ml cartridge. However, 
other types of anesthetic may be used as per 
the surgeons preference. Each preparation 
and type of anesthetic has its own time of 
onset, duration of action, and specific toxic- 
ity levels, and attention should always be 
paid to such characteristics. Occasionally, cir- 
cumstances may dictate the use of a local 
anesthetic preparation without epinephrine. 
In these cases, one can expect somewhat 
more bleeding intraoperatively due to lack of 
vasoconstrictive properties of epinephrine. 
Since patient comfort is the ultimate goal, 
many surgeons inject a long-acting local 
anesthetic either preoperatively or postopera- 
tively. Bupivicaine, at a 0.5 percent concen- 
tration, is routinely administered for this 

Flap Design 

The type of flap used in third molar surgery 
is classified as full thickness, which describes 
an incision that is made from the epithelial 
surface to the underlying bone. A periosteal 
elevator is then placed with the concave sur- 
face against the bone to raise the mucope- 
riosteum from the bone. 

The surgeon may find numerous classifi- 
cations of flap design and varying nomencla- 
ture in articles and textbooks. However, in 
the setting of impacted third molar surgery, 
three main types of flap designs exist, and 
basically, all are modifications of one of the 
following flap designs (see Figure 3.13): 

1 . Flaps without a releasing incision (enve- 
lope flaps) 

2. Flaps with an anterior releasing incision 
(three-cornered or triangular flaps) 

It should be noted that these designs are 
not meant to limit the operator but are 
meant to provide a basic foundation from 
which to work. Based on experience and 
preference, surgeons might use a myriad of 
modifications of these fundamental flaps. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 63 



Figure 3-13. Common flap designs for mandibular third molar surgery. A. Short envelope flap. B. 
Long envelope flap. C. Short triangular flap. D. Long triangular flap. 

Practitioners are encouraged to use a tech- 
nique that they are comfortable with, pro- 
vided the following fundamentals are not vi- 
olated (see Figure 3.14): 

• The base of the flap should be larger than 
the apex. Essentially, the releasing inci- 
sion (s) should be divergent in relation to 
the site of exposure so as to not under- 
mine the blood supply of the raised flap. 

• The flap should be raised and released in 
such a manner as to prevent tearing of the 
flap. Tearing might lead to a compromised 
blood supply and necrosis. 

• The ratio between the height of releasing 
incision(s) and length of base should not 
exceed 2:1. 

Envelope flap: This flap can further be 
divided into a short envelope (see Figure 
3.13A) or a long envelope flap (see Figure 

When exposing a mandibular impacted 
tooth, the envelope flap begins with a distal 

Figure 3-14. Basic principles of flap design: The 
base of the flap should be wider than the apex of 
the flap. The releasing incision(s) should be diver- 
gent in relation to the site of exposure so as to not 
undermine the blood supply of the raised flap. The 
ratio between the height of releasing incision(s) 
and length of base should not exceed 2:1 . 

incision. This incision should be placed buc- 
cally, because most impacted teeth are found 
buccally positioned in the jaws, and there is 
a decreased chance of complications like ia- 
trogenic injury to the lingual nerve, bleed- 
ing, and so on. The distal incision com- 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 64 



mences at the external oblique ridge area 
posteriorly, and the the incision should be 
placed anteriorly at the distobuccal line angle 
of the second molar tooth or even just lin- 
gual to this area. More lingually placed inci- 
sions may increase the possibility of lingual 
nerve injury. Kiesselbach et al 15 found that 
in approximately 17 percent of the popula- 
tion, the lingual nerve lies at or above the 
alveolar crest. Thus, if the tissue lingual to 
the correctly placed incision line is violated, 
it could cause lingual nerve injury. The inci- 
sion is then carried anteriorly intrasulcularly 
around the second molar (short envelope 
flap) or further anteriorly as desired (long 
envelope flap). 

Three-cornered (triangular) flap: Very 
often, a fully submerged impaction will re- 
quire more exposure than an envelope can 
provide. In such cases, a three-corner flap 
may be necessary. A three-corner flap is an 
envelope flap with the addition of a verti- 
cally oriented releasing incision. For a lower 
impacted third molar, the incision is started 
similarly to the envelope flap. A retractor is 
used to palpate the external oblique ridge 
and then tense the tissue. A #15 blade is 
placed at the point where retractor meets 
tissue, and an incision made to the disto- 
buccal corner of the second molar. From 
this point, two variations exist (see Figures 
3.13C and 3.1 3D): The releasing incision 
can be made posterior to the second molar 
(short triangular flap) or anterior to the 
second molar (long triangular flap). In both 
cases, the releasing incisions must be made 
at an obtuse angle to maintain a wide base 
for adequate perfusion of the triangular 

As with any surgical procedure, access is 
of paramount importance. Although not all 
impactions require the elevation of a full- 
thickness mucoperiosteal flap, the limited 
visibility in the posterior oral cavity com- 
pounded by the nature of an impaction 
often mandates its use. A fresh, sterile blade 
should always be used. The envelope flap is 

the most common but often may not pro- 
vide sufficient access in the posterior of the 
oral cavity. Releasing incisions should, how- 
ever, be used judiciously. Although some- 
times unavoidable, extending a releasing 
incision into unattached mucosa is not opti- 
mal and may complicate repositioning of 
the flap. 

The authors have consistently found that 
one of the most common mistakes made by 
clinicians with limited experience is that they 
design flaps with limited visibility and inade- 
quate surgical access for instrumentation. 
One must remember that in general, enve- 
lope flaps give lesser exposure and access 
when compared to flaps with releasing inci- 
sions. It is sometimes prudent to start with 
flaps with large access and visibility (for ex- 
ample: a long envelope flap versus a short 
envelope flap). However, the greater the 
amount of elevated tissue, the greater will be 
the degree of postoperative discomfort. 
Thus, the caveat is to exercise prudent sur- 
gery: to have enough visibility for adequate 
access without compromising the procedure 
and to discourage unnecessary reflection of 
tissue. As the surgeon gains more experience, 
it is only natural that he or she will modify 
flap length and design for each individual 
case based on clinical and radiographic ex- 
amination, personal preference, and the op- 
erator's level of expertise. 

Bone Removal 

After careful reflection of soft tissue with a 
periosteal elevator, a bur should be used to 
expose the crown of the tooth, from the buc- 
cal. Careful attention should be paid to pro- 
tecting the soft tissues of the flap, the lip, 
and the cheek. If the surgeon is intently fo- 
cused on the tooth, damage to these struc- 
tures can occur very easily. The goal of bone 
removal is to create a path for the delivery of 
the tooth, but not entirely at the expense of 
the alveolus. 

The first step of bone removal provides 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 65 



Figure 3-1 5A. Bone removal for a mesioangular 
impacted mandibular third molar surgery. Bone re- 
moval from the occlusal aspect. 

Figure 3-1 5B. Bone removal from the buccal 

exposure and visualization of the tooth sur- 
face. This includes bone removal from the 
occlusal aspect (see Figure 3. 15 A) and then 
from the buccal aspect to expose the tooth 
(see Figure 3.15B). Distal bone also can also 
be removed if needed. Bone is not removed 
from the lingual except when using the 
"lingual split-bone" technique of third 
molar removal. This technique is not com- 
monly used in the United States and is not 
recommended because of the high incidence 

Figure 3-1 5C. Troughing of bone on the buccal 
aspect with a straight handpiece. 

Figure 3-1 5D. Troughing of bone on the buccal 
aspect with a surgical high-speed handpiece. 

of surgical trauma and lingual nerve injury 
as compared to the standard buccal ap- 

After the tooth has been exposed, the 
next step in bone removal is troughing (see 
Figures 3.15C and 3.15D). Troughing refers 
to bone removal into bone adjacent to the 
tooth, which provides a ledge of bone for use 
as a fulcrum for tooth elevation purposes. 
The trough should be made wide enough to 
accommodate a straight elevator but not so 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 66 



wide as to permit spinning of the instru- 
ment. This can be accomplished by cutting 
the buccal bone at its interface with the 
tooth. Directing the bur in a manner parallel 
to the long axis of the tooth will create a 
groove while removing minimal buccal bone. 
This will begin to free the tooth from its os- 
seous housing without relinquishing me- 
chanical advantage. The depth of the groove 
should be extended to approximate the "fur- 
cation" of the tooth. This generally corre- 
sponds to the length of the cutting surface of 
a fissure bur. The practitioner should not 
take too much comfort in being on the buc- 
cal, with its great leeway for cutting, because 
the inferior alveolar canal may be positioned 

Troughing is generally confined to the 
buccal and, occasionally, the distal. The dis- 
tal should be approached with great care. 
Owing to the potential crestal position of 
the lingual nerve, one should exercise cau- 
tion along the distal and not venture past 
mid-distal. Also, given that the lingual nerve 
is entirely soft-tissue borne, an instrument 
should be placed along the distal bone, en- 
suring no contact of the bur with soft tissue. 
Cutting bone on the mesial side of the third 
molar should be avoided, as it can violate the 
second molar or create a periodontal defect if 
the interdental bone is sacrificed. 


When the crown of the tooth has been ex- 
posed and an appropriate amount of bone 
has been removed, an attempt to elevate the 
tooth from the socket may be made, keeping 
in mind the anatomy of the area and the vec- 
tor of the directed force. In some instances, 
this may allow removal. If not, consideration 
should be given to sectioning the tooth. 

Tooth Sectioning and Delivery 

Tooth sectioning refers to splitting of the 
tooth from its buccal aspect, using a rotary 

instrument with irrigation. Initially, a groove 
is made with a bur. The groove does not 
need to penetrate the entire tooth. This is to 
avoid injury to the lingual soft tissues and 
the lingual nerve. In many cases, the lingual 
surface of the tooth is in very close proximity 
to a very thin lingual cortical plate. It is not 
uncommon that there may be accidental 
perforation of the rotary bur through the 
plate, thereby injuring the soft tissues includ- 
ing the lingual nerve. Thus, most surgeons 
will invariably stop their bur cut slightly 
short of the lingual surface of the tooth, and 
instead, use a straight dental elevator to frac- 
ture (split) the last remaining lingual aspect 
of the tooth into the desired portions. A nar- 
row straight elevator is usually placed within 
the cut, and the blade rotated toward the as- 
pect to be removed. 

Mesioangular impactions are the most 
common type of mandibular third molar 
impaction. In many instances of a mesioan- 
gular impaction, the mesial aspect of the 
third molar may lie beneath the distal con- 
tour of the second molar. This poses a me- 
chanical obstacle to delivery of the crown. A 
bur may be used to section the tooth in a 
number of ways that might permit removal 
of the crown followed by a path for removal 
of the roots (see Figure 3.16). One simple 
method is to longitudinally split the tooth 
into mesial and distal halves (see Figure 
3.16A). Occasionally, the mesial aspect of 
the crown may still be trapped under the 
second molar and might require an addi- 
tional cut (see Figure 3.16B). Many surgeons 
prefer to make a transverse cut parallel to the 
cementoenamel junction (CEJ) of the third 
molar, thereby separating the crown from 
the root trunk (see Figure 3.16C). The 
crown can be grasped with a forceps or 
ronguer. Another attempt should be made to 
elevate the remainder of the tooth. If unsuc- 
cessful, further troughing of the bone sur- 
rounding the roots may be considered. If a 
furcation exists, a second cut may be placed 
to split the roots from one another, facilitat- 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 67 



Figure 3-1 6A. Sectioning options for mandibu- 
lar mesioangular third molar impactions. This view 
shows a cut longitudinally through the furcation. 

Figure 3-1 6B. Same as 16A, but with an addi- 
tional cutting of the mesial crown, which is 
wedged under the second molar. 

ing removal by creating two single roots (see 
Figure 3.16D). 

One important principle to remember 
while making cuts within teeth is to keep the 
width of the cut as close as possible to the 
width of the dental elevator. This will pro- 
vide for a clean separation of the crown from 
the root trunk. After the elevator is placed 
into the surgically made groove, the surgeon 
should give it a controlled twist. He/she will 


*J —v ^L 



t y 



^VA ""Ov 

Figure 3-1 6C. Crown and root separation. The 
crown is removed and then the root is delivered 
into the original crown space. 

Figure 3-1 6D. Crown removal as in option 16C, 
but then the roots are divided longitudinally 
through the furcation and moved into the crown 
space for removal. 

feel the tooth separate into the two segments 
as planned. An often overlooked option for 
tooth delivery is the use of the drill to place 
a purchase point in the buccal surface of the 
tooth structure. It should be deep enough to 
engage with a Crane pick or Cogswell B ele- 
vator without further fracturing the tooth. 
With correct placement and appropriately 
directed force, these instruments can exert a 
substantial rotational force (given a small 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 68 



lever-arm) that can elevate the most stub- 
born of teeth. 

Horizontal impactions are treated much 
the same way as mesioangular impactions. A 
few adjustments are made based on the incli- 
nation. For instance, one usually elects to re- 
move the crown prior to the root(s). This re- 
quires a cut wider superiorly than inferiorly to 
free the crown for withdrawal. On occasion, 
distal bone of the ascending ramus may need 
excision. This should be attempted cautiously. 
Protecting the lingual soft tissues is of para- 
mount importance. Fortunately, the lingual 
nerve is entirely in soft tissue. With careful use 
of the drill and shielding of the lingual soft 

tissue by placing a retractor on bone, one may 
safely relieve small amounts of distal bone. 
The drill should approach, but never touch, 
the distolingual corner of the third molar. 
These modifications will aid in extracting hor- 
izontal impactions but may also be used for 
other types of impactions as well. Figure 3.17 
shows common sectioning techniques for re- 
moval of horizontally impacted third molars. 
Another common presentation is the ver- 
tical impaction of a lower third molar. A 
vertical impaction requiring removal often 
encroaches on the roots of the second molar 
and should be approached carefully. If the 
crown is clear of any undercuts, delivery can 

Figure 3-17. Common surgical technique for the removal of horizontally impacted mandibular third mo- 
lars. A. Bone is removed from the superior surface of the tooth and from the buccal — and also perhaps 
from the occlusal aspect of the crown if there is sufficient bone thickness distal to the second molar. 
B. Crown is sectioned from root, and then removed. C. Roots are delivered together. Occasionally, a 
purchase point can be made to facilitate delivery. D. Roots have been split and delivered separately. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 69 



be accomplished by either elevating the tooth 
and/or placing a purchase point to allow for 
delivery with a crane pick. Oftentimes the 
crown is either limited by the distal of the 
second molar anteriorly or by the ascending 
ramus posteriorly The operator might elect 
to section the roots vertically if a furcation 
exists. This allows for removal of the unen- 
cumbered portion, thereby creating a space 
into which the trapped segment may be di- 
rected. Occasionally, relieving bone along the 
distal of the crown is necessary to allow deliv- 
ery. This should be performed with the ut- 
most care owing to the likely presence of the 
lingual nerve near the lingual crest. As earlier 

described, careful use of the drill and shield- 
ing of the lingual soft tissue by placing a re- 
tractor on bone will enable one to relieve 
small amounts of distal bone. An alternative 
is to remove the distal portion of the crown 
in an oblique fashion, leaving the mesial for 
leverage. One may elect to remove the entire 
crown horizontally from the buccal if a sub- 
stantial amount of distal bone would other- 
wise be required for removal. This would 
allow delivery of the crown followed by the 
root trunk because of clearance created. 
Figure 3.18 shows common sectioning tech- 
niques for removal of vertically impacted 
third molars. 

Figure 3-18. Common surgical technique for re- 
moval of vertically impacted mandibular third mo- 
lars. A. Bone is removed on the occlusal, buccal, 
and distal aspects. B. After sectioning lengthwise 
through the tooth the posterior aspect is delivered 
first with purchase point and an elevator. C. The 
mesial part of the tooth is delivered with a straight 
elevator using rotary and a lever-type of motion. 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 70 



Distoangular impactions can, at times, 
present a challenge for even the most experi- 
enced surgeon. When facing such a tooth, 
one must thoughtfully weigh the risks and 
benefits — knowing full well that this is often 
the most difficult type. Due to the inclina- 
tion, both access and delivery are compro- 
mised. The same principles apply — soft tis- 
sue reflection, hard tissue removal, and 
sectioning of tooth structure. What differs is 
the approach to sectioning. One always 
tries to remove portions that present a me- 
chanical obstacle, creating a pathway for re- 
moval. This is the "divide and conquer" ap- 
proach. The sequence of sectioning may 
differ. In the distally inclined tooth, the 

ramus will be the obstacle to withdrawal. 
Because one cannot remove the ramus, 
adopt a strategy that employs removing 
crown and bone or sectioning of roots in a 
manner that permits delivery. Figure 3.19 
shows a common sectioning technique for 
removal of distoangularly impacted teeth. 
Many times, removal of the distal portion of 
the crown is sufficient to clear any under- 
cuts, but such a tooth will still require a 
substantial amount of force for delivery. 
Frequently, placing a purchase point as 
apically as possible and attempts at luxation 
from within that purchase point will 
provide enough leverage to deliver the 

Figure 3-19. Common surgical technique for 
the removal of distoangularly impacted mandibu- 
lar third molars. A. Bone is removed on the oc- 
clusal, buccal, and distal aspects. More distal 
bone removal is usually required in these cases. 
B. The crown of the tooth is sectioned from the 
root and delivered with straight elevators. C. A 
purchase point is made and an elevator is used to 
deliver both roots. Sometimes, roots may need 
to be split into separate halves and delivered 

2879_Koerner_Chap 03 4/17/06 1:24 PM Page 71 




Upon removal of all tooth fragments, careful 
examination of the socket is warranted to 
ensure the complete removal of the tooth 
and fragments, as well as to inspect for 
any associated pathology. Prior to re- 
approximating the soft tissues, thorough 
irrigation of the socket and also irrigation 
beneath the raised flap should be done to 
flush any fragments or debris that may pre- 
dispose the patient to infection — especially 
subperiosteal abscess formation. 

Prior to suturing, certain "housekeeping" 
operations might need attention. One must 
ensure the safe and complete removal of any 
follicle if it is visualized. Enucleation or thor- 
ough curettage followed by removal with a 
hemostat should be accomplished. 
Unerupted teeth will usually present with a 
follicle, and often the mesial and lingual as- 
pects require attention. Retained follicles 
have the potential to develop into pathologi- 
cal cysts and tumors. Removal should be 
done with care due to the proximity of the 
adjacent structures including nerves. Infected 
or granulomatous tissue should also be 
treated in this fashion. Bone contour should 
also be evaluated, and any sharp edges, tooth 
fragments, or loose bone fragments should 
be eliminated with a ronguer and/or bone 
file. This will permit better soft tissue ap- 
proximation and an improved postoperative 
course. Irrigation should be performed once 
again before closure. 

When suturing a flap, one must first align 
known landmarks such as corners of the re- 
lease and/or papillae, if involved. This will 
provide the best closure due to the internal 
anatomy having changed postextraction and 
will be less likely to cause an advancement of 
the flap while suturing. The choice of suture 
material is at the discretion of the practi- 
tioner, although 3-0 chromic gut suture on a 
reverse cutting, half-circle needle is com- 
monly used owing to its rapid breakdown 
and ease of manipulation in the oral cavity. 

Maxillary Third Molar Impactions 

In comparing the removal of maxillary to 
mandibular impactions, there are similarities 
but also some salient differences. Both the 
similarities and the differences need to be 
well-understood by the operator. 


When discussing maxillary third molars, the 
classification system is modified to exclude 
the position relative to the ramus since this 
anatomic marker is irrelevant. The only sig- 
nificance of the relative position of the tooth 
to the ramus is in assessing access. 

Generally speaking, with regard to diffi- 
culty, the same angle of impaction yields the 
opposite degree of difficulty in the maxilla 
when compared to the mandible. Mesio- 
angular impactions pose a greater challenge 
compared with distoangular impactions in 
the maxilla, whereas in the mandible, the sit- 
uation is reversed. Also, the bucco-lingual di- 
mension of the alveolus limits the position- 
ing of the mandibular third molar lingually, 
but maxillary impacted third molars can, in 
some cases, be quite palatally positioned. 

When compared with mandibular im- 
pacted third molars, maxillary procedures 
tend to be more straightforward. The aspect 
that complicates matters the most in maxil- 
lary impactions is that visibility can be a 
greater limiting factor. With that in mind, a 
prudent practitioner should approach the ac- 
cess preparation somewhat more aggressively. 

Flap Design 

Envelope and triangular flaps are also used 
for maxillary surgery (see Figures 3.20A— D). 
As with mandibular surgery, either the short 
or long versions of the flaps can be used. A 
new, sterile #15 blade should be used for the 
incision. The posterior extension of the inci- 
sion will be determined by the relative posi- 
tion of the tooth to the tuberosity. The inci- 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 72 



Figure 3-20A. Envelope flap showing the extent 
of the nearly linear incision. 

Figure 3-20B. When the envelope flap is re- 
flected, this is the access that is achieved. 

sion is begun on the anterior aspect of the 
tuberosity distal to the second molar. This 
slightly buccally positioned crestal incision is 
extended anteriorly to include the gingiva 
surrounding the first and second molar 
(envelope flap) or just the second molar 
(triangular flap). 

As previously indicated, visibility is greatly 
reduced in the maxilla, and the use of a re- 
leasing incision is encouraged — especially for 
the surgeon with limited experience and for 
full bony impactions. By maintaining a 
wider base with the release, one can hope to 
overcome the obstacle of limited visibility. 
Frequently, another complicating factor in 
this surgery is the coronoid process of the 

Figure 3-20C. This drawing shows the outline 
of a typical triangular flap. 

Figure 3-20D. When the triangular flap is re- 
flected, this is the access that is achieved. It 
allows greater visibility than the envelope flap. 

mandible. As the mouth is opened, it trans- 
lates anteriorly and often comes to lie buc- 
cally opposite to the impacted maxillary 
third molar. If this anatomic structure limits 
visibility or access, the mouth opening 
should be reduced, and then the surgeon 
should have the assistant manually shift and 
stabilize the lower jaw toward the surgical 

Utilizing a periosteal elevator and the ap- 
propriate leverage, a full-thickness mucope- 
riosteal flap is reflected, elevating in an ante- 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 73 



rior to posterior direction. The same soft tis- 
sue precautions as in mandibular surgery 
should be used. Attention must be paid to 
protecting the soft tissues with adequate re- 
traction. It is wise to reflect some of the 
palatal soft tissue, especially the crestal por- 
tion, as this will aid in smooth delivery of 
the tooth. 

Bone Removal 

The buccal bone in the maxilla is less dense 
than in the mandible; therefore, removal of 
bone is often more conservative. In general, 
unlike mandibular third molar surgery, im- 
pacted maxillary teeth require bone removal 
only on the buccal and occlusal aspects. It is 
rare to ever remove significant distal bone. 
Bone can sometimes be removed either with 
hand instruments like a sharp periosteal ele- 
vator or, alternatively, with rotary instru- 
ments. The aim of bone removal is to visual- 
ize most of the crown of the tooth and 
establish access for extraction instruments. A 
straight dental elevator may be applied to 
assess mobility and access. 

Tooth Sectioning, Luxation, and 

The practitioner should be cognizant of the 
presence of the maxillary sinus and tuberos- 
ity and be careful with the forces directed 
superiorly or posteriorly. An attempt should 
be made to place the elevator from the 
mesiobuccal and engage the tooth from a 
point that will permit movement of the 
tooth in a distobuccal and buccal direction. 
Consideration should be given to the use of 
a curved elevator that is meant to engage the 
interproximal contour of the tooth and im- 
part a force from the palatal. See Figure 
3.2 1 A and B. 

Due to the location of the maxillary third 
molar, a vertical vector of force for luxation 
is necessary, and a slightly misdirected force 
can have drastic consequences. The potential 

Figure 3-21 A. Surgical technique for extraction 
of maxillary impacted third molars. If the tooth is 
not visualized once soft tissue has been reflected, 
bone is removed from the buccal and occlusal 
aspects. This can be accomplished with hand 
instruments (such as a periosteal elevator) or with 
rotary instruments. 

Figure 3-21 B. The tooth is delivered with 
straight elevators applied on the mesiobuccal with 
rotational and lever types of motions. The tooth is 
always delivered in a distobuccal and occlusal 

to dislodge the maxillary third molar superi- 
orly is a very likely one. Therefore, the 
careful placement of a Seldin retractor poste- 
rior to the tuberosity is advised. This pro- 
vides a tactile sense of how posterior and 
superior one s force is being directed, a me- 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 74 



chanical barrier to aid in preventing displace- 
ment, as well as the potential for a wedge 
effect that forces the tooth toward the oral 

It should be stressed that maxillary third 
molars are known to have the most anom- 
alous root morphology Although many pres- 
ent with conical formations, others have 
rather strange root arrangements. Tooth sec- 
tioning is generally not required for max- 
illary third molar surgery. However, when 
the need arises to section a maxillary third 
molar, one must consider the direction the 
tooth is to be delivered. The presence of a 
second molar prohibits an anterior path and 
the dense palatine bone is quite unforgiving, 
and forces directed in this direction are 
marred by complications. If a trifurcation 
exists, then the procedure can be similar to 
that of any maxillary complicated exodontia 
in which a "T" formation will split the three 
roots and facilitate removal. If such a furca- 
tion does not exist, as is often the case, re- 
moval of the distal portion of the crown in 
an oblique fashion will provide enough clear- 
ance to allow the molar to escape in a disto- 
buccal direction. 

In the case of a distoangular impacted 
maxillary wisdom tooth, a few modifications 
might be required. The steps outlined 
throughout this discussion are sufficient to 
address this situation, but a few anatomic 
concerns need be covered. With a distoangu- 
lar maxillary impacted third molar, the 
crown often undermines the tuberosity and 
poses a significant risk of fracture and the 
loss of tuberosity bone. This could become a 
concern for the patient later in life, if den- 
tures are necessary, and it can also predispose 
the patient to a maxillary sinus exposure. 
Understanding these implications necessitate 
a slightly modified approach. One hopes to 
deliver the tooth in the direction in which it 
faces; that is, posteriorly. If tuberosity must 
be relieved to allow this, it is preferable to do 
this conservative excision (with minimal 
bone removal) rather than risk fracture of 

the entire segment. Consideration should 
also be made to sectioning the crown from 
the root trunk, as done in many other in- 
stances. This may allow for root removal 
with posterior elevation. If relief of buccal 
bone is indicated, it should be done judi- 
ciously so as to not eliminate all leverage 

When fracture of a bone segment such as 
buccal cortex or tuberosity is expected, one 
should attempt to reflect the least amount of 
soft tissue so as to preserve blood supply. If 
the operator anticipates such a fracture, 
avoiding reflection of the overlying perios- 
teum will preserve the blood supply to the 
detached segment and will provide the best 
chance of survival postoperatively. If the 
overlying tissue has been reflected and a frac- 
ture is subsequently noted, removal of the 
fractured segment is advocated due to the 
high incidence of postoperative infection 
stemming from the retained fragment. 


As described earlier, upon completion, 
thorough examination of the socket fol- 
lowed by irrigation of the area beneath 
the flap is advised so as to flush any and all 
debris. Closure of the flap then is accom- 
plished with the same principles described 
in the removal of mandibular teeth, begin- 
ning with approximating known markers. 

Postoperative Management 

It is important for patients to understand 
what to expect during the postoperative 
course. Unexpected events can hamper one's 
recovery. If adequate preoperative consulta- 
tion appointments and informed consent are 
an integral part of the treatment planning, 
then the patient knows approximately what 
they will experience during the postoperative 

Patients should expect moderate discom- 
fort following surgical removal of impacted 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 75 



third molars and should be informed of 
such. In the authors' experience, recovery 
after removal of impacted mandibular third 
molars is far more complex than recovery 
from maxillary third molar surgery Ade- 
quate analgesic medication should be pre- 
scribed, and if indicated, the proper use of 
antibiotics should be employed. Patients 
should also be informed of specific activities 
and foods that they should avoid. The post- 
operative period can be marred by many 
complications, the most notable of which are 
pain, infection, dry socket, slow healing, and 
the formation of bony splinters. Smoking 
should be discouraged completely, and 
preferably avoided, for as long as the socket 
remains open. Forceful spitting may dislodge 
the blood clot and disrupt healing, as can 
the use of straws. Patients should be in- 
structed to avoid these practices. Ice applica- 
tion for the first 24-48 hours is highly en- 
couraged as it minimizes swelling and pain. 
After three days, warm moist heat com- 
presses can be used to aid in the resolution 
of soft tissue swelling, decreasing joint stiff- 
ness, and increasing jaw mobility. A diet 
comprised of cold and soft foods is prefer- 
able as long as the socket areas remain ten- 
der. Hot and spicy foods tend to irritate the 
surgical sites. Caution should be used to not 
consume foods that are extremely brittle or 
flaky as they may remain in the sockets — 
precipitating pain and slow healing. Careful 
rinsing with saline should be encouraged be- 
ginning the following day to ensure cleans- 
ing of the areas without aggressive mechani- 
cal irritation. A follow-up appointment 
should always be given for all impacted third 
molar surgery patients. 

Management of Postoperative 

Many postoperative complications are 
avoided by performing careful surgery. Still, 
some occur, even with the most meticulous 

Damage to Soft Tissue 

Soft tissue damage can take the form of a 
tear or puncture in the flap or an abrasion or 
laceration of the lip or mucosa during the 
course of the procedure. The reason for 
such injuries is usually excessive retraction of 
the flap. If one sees that the tissue is tensing 
and providing resistance, consideration 
should be given either to extending the flap 
or to making a releasing incision. Inad- 
vertent tearing of a flap markedly increases 
postoperative pain and delays healing. 
Furthermore, parts of a torn flap are prone 
to necrosis. 

Puncturing of flaps often results from 
inappropriately controlled forces caused by 
the slippage of an instrument. This can 
also predispose a patient to the issues 
noted previously. The careful use of instru- 
ments and the knowledge that these unto- 
ward events can happen will help in their 

Placing one's fingers along the shank of 
an elevator, using finger rests when indi- 
cated, and having adequate jaw and facial 
support (with the operator's other hand or 
an assistant) all can aid in preventing such 

The lips and mucosa can be iatrogeni- 
cally harmed during the course of a sur- 
gical procedure. Retraction for a long 
period of time can cause splitting of the 
commisure of the lips. Heating of rotary 
instruments (the drill) can cause burns on 
the lips. Care must be taken to use a bur- 
guard and appropriately shield the soft 
tissue from the handpiece. These burns 
and/or abrasions must be treated palliatively 
with moisturizing ointments. Lacerations, if 
encountered, should be evaluated for the 
need of sutures. The typical healing period 
for such injuries is 5 to 10 days. In rare 
cases, such problems might require plastic 
surgical repair and should be referred to a 
specialist for evaluation and definitive 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 76 



Pain and Swelling 

Postoperative swelling is often expected with 
the surgical removal of third molars, par- 
ticularly when the procedure requires soft tis- 
sue manipulation, bone removal, and a sig- 
nificant amount of time. Swelling is 
generally noted to worsen through the sec- 
ond day after the procedure and typically be- 
gins to subside soon after. Persistent or in- 
creasing swelling beyond three days warrants 
a re-evaluation. 

Patients often encounter some degree of 
pain or discomfort after these procedures. 
Generally, they will require approximately 
two to three days of narcotic analgesic med- 
ication followed by a brief course of over- 
the-counter analgesics. It may be a good idea 
to prescribe nonsteroidal anti-inflammatory 
medications like ibuprofen since they de- 
crease inflammation and provide analgesia — 
thereby decreasing narcotic use and potential 
abuse. Severe pain persisting beyond the first 
few days that begins to worsen after initial 
improvement needs reexamination by the 


Dentoalveolar procedures are usually not 
marred by postoperative infections, but 
whenever soft tissue flaps are elevated or 
bone is removed, the susceptibility to infec- 
tion increases. The prudent practitioner will 
try to incorporate practices that will help 
minimize such risks. These steps include care 
not to tear a flap, thorough irrigation when 
removing bone with a drill, and copious irri- 
gation prior to closure of the soft tissue. 

Infections are rare within the first two 
days but might present after the third or 
fourth day. Persistent or worsening edema, 
erythema, increasing tenderness, and onset 
of trismus are signs that warrant investiga- 
tion. These signs may also present as part of 
the normal healing process so differentiating 
between the two is essential to prevent a 

poor outcome. Fever, chills, and worsening 
trismus with dysphagia/odynophagia often 
signify potentially serious infection and re- 
quire immediate evaluation. 

The use of prophylactic antibiotic treat- 
ment or preoperative antibiotic mouth 
rinses is a highly debated topic. Opinions 
vary, and results of studies echo these varying 

The offending microorganisms in den- 
toalveolar infections are usually a mixed oral 
flora with streptococci predominating. 
Unless a contraindication exists, empirical 
treatment of oral infections with an oral 
antibiotic (Pen VK or amoxicillin — 
clindamycin if allergic to penicillins) should 
be initiated and continued for one full week. 
If the swelling presents with a fluctuant char- 
acter, incision and drainage with placement 
of drains should be considered with con- 
comitant administration of antibiotics. These 
patients should be observed closely and fre- 
quently to ensure resolution. Referral to a 
specialist is indicated if the infection worsens 
or does not respond to usual treatment. 

Alveolar Osteitis (Dry Socket) 

The phenomenon of alveolar osteitis, other- 
wise known as dry socket, has been attrib- 
uted to multiple factors including smoking, 
difficulty of extraction, bacterial contamina- 
tion, birth control pills, and aberrant host 
healing. These predisposing factors may or 
may not be present. In any given case, it is 
difficult to determine the cause. Simple ex- 
tractions can also suffer from alveolar 

The exact pathophysiology of dry socket 
is not known, but numerous theories have 
been given. Patients often present after the 
third or fourth postoperative day has passed 
and complain of sudden, progressively wors- 
ening of pain in the affected area. A charac- 
teristic mal-odor may be accompanied by a 
foul taste. There is an absence of fever, 
edema, erythema, or lymphadenopathy 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 77 



Examination of the socket yields an open 
socket with no clot present, with the area 
being extremely tender. 

The treatment of alveolar osteitis is aimed 
at establishing the comfort of the patient. 
The process is self-limiting and must run its 
course. Pain relief often requires careful irri- 
gation of the socket with saline an obtun- 
dant dressing inside the socket, and the 
short-term use of a narcotic analgesic. A 
number of commercially available obtundant 
preparations exist for these situations. These 
preparations usually contain a combination 
of anesthetic, eugenol, and balsam of pine or 
balsam peru. Other commercial variants 
exist, and their ingredients should be 
checked and used accordingly. A small strip 
of gauze conservatively covered with one of 
these preparations should be placed inside 
the affected socket. The act of placement 
can be painful, but relief sets in within 

Patients treated for these symptoms 
should be seen 24 to 48 hours later for re- 
moval of the packing. Replacing the dressing 
is often the prudent choice for most patients. 
Many patients require two to three packings 
before experiencing complete relief. 


Some postoperative bleeding may be ex- 
pected for up to 72 hours after a surgical 
procedure. This takes the form of "oozing" 
rather than pulsatile bleeding. Pulsatile 
bleeding warrants an evaluation in an emer- 
gency setting. Oozing beyond 72 hours may 
not be a benign finding, rather, it may be a 
sign of an underlying coagulopathy. If local 
measures are not successful, a medical and 
hematological work-up may be indicated. 

Local measures to control bleeding post- 
operatively are similar to those used intra- 
operatively Intraoperative options include 
the use of direct pressure, sutures, local he- 
mostatic agents like Gelfoam (absorbable 
gelatin sponge), Surgicel (regenerated oxi- 

dized cellulose), topical thrombin, and colla- 
gen. A figure-eight suture is usually placed 
for retention. 

Direct pressure is the mainstay of control- 
ling bleeding, regardless of location. Firm, 
direct, digital pressure or biting on moist 
gauze over the site will provide adequate he- 
mostasis in the majority of cases. Bleeding 
that appears after a few days have transpired 
will still often respond to direct pressure with 
gauze or with a tea bag. The tannic acid in 
tea has been anecdotally noted to have suc- 
cess in providing hemostasis. The previously 
mentioned measures (Gelfoam etc.) are 
also at one's disposal, but care must be taken 
because to treat a socket with more than di- 
rect pressure will often require the adminis- 
tration of local anesthesia to ascertain the 

If bleeding continues, the placement of 
sutures may be indicated. If the soft tissue is 
not firmly bound to the bone, this may be 
the cause of bleeding and will often respond 
well when reapproximated. 

Patients with good general health will 
generally respond to such measures. If such 
minimal treatment does not reveal the 
source, referral for further medical or surgical 
treatment is indicated to avoid ongoing 
problems. Patients who have systemic med- 
ical issues that predispose bleeding or are 
taking medication that prevents adequate he- 
mostasis may require surgical intervention. 

Damage to Teeth and/or Adjacent 

Third molar surgery presents the challenge 
of having the most limited accessibility of all 
extractions, hence raising the associated risk 
of damage to adjacent structures. Adjacent 
teeth are always at risk due to the nature of 
the luxating forces applied during instru- 
mentation, and therefore, the careful use of 
applied force is mandatory. Examination of 
the adjacent teeth and opposing teeth should 
be done, noting those teeth with extensive 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 78 



caries, extensive restorations, and those with 
root canal therapy. Although all teeth are 
subject to these forces and may succumb, 
these characteristics increase their susceptibil- 
ity The patient should be made aware of 
this. Patients should be notified if a problem 
arises (that is, fractured adjacent tooth, 
crown coming loose, and so on), and steps 
should be taken to rectify it. 

Nerve Dysfunction 

Although rare, inferior alveolar or lingual 
nerve dysfunction is one of the most devas- 
tating complications that can arise from the 
removal of a mandibular tooth. Most nerve 
injuries are usually preventable. Careful diag- 
nosis, treatment planning, and sound surgi- 
cal principles can be of paramount impor- 
tance in preventing these injuries. The 
authors recommend that all patients under- 
going surgical removal of impacted third 
molars should receive a follow-up appoint- 
ment one week postoperatively. During this 
evaluation, nerve function should always be 
evaluated. If a sensory deficit exists, the area 
of deficit should be noted. Sensory deficits 
associated with the removal of teeth warrant 
evaluation by a specialist. Treatment and 
thorough evaluation of nerve injuries is be- 
yond the scope of this text. 

Displacement of Teeth or Roots 

Nothing is quite as unnerving to a practi- 
tioner as realizing that the tooth or fragment 
that is being extracted is no longer visible. In 
the mandible, third molar roots can displace 
into the submandibular space or into the in- 
ferior alveolar canal. Maxillary teeth or their 
roots can be displaced into the maxillary 
sinus, the infratemporal space, or the buccal 

Mandibular teeth or their roots can be 
displaced through the lingual cortical plate 
into the submandibular space if there is a 
thin cortex and significant force. If such a 

situation is suspected, one should place an 
index finger along the lingual aspect of bone 
and attempt to locate the fragment. 
Oftentimes, compression from an apical po- 
sition can propel the fragment back up and 
facilitate retrieval; otherwise a lingual dissec- 
tion may be necessary. This procedure risks 
injury to the lingual nerve and has the po- 
tential for excessive bleeding from the floor 
of the mouth. In the authors' experience, 
this should only be attempted if the practi- 
tioner has significant surgical experience. 
Usually, a referral should be considered. 

Displacement of a tooth, root, or frag- 
ment into the maxillary sinus is managed 
differently. Upon discovery of displacement, 
one should review the previous condition of 
the tooth. If the tooth was not infected and 
the fragment is relatively small, leaving the 
root in place can be considered if minimal 
attempts at recovery prove fruitless. Larger 
fragments or those with preexisting apical 
pathosis require removal. Radiographs 
should be attained to ascertain position. 
Thorough irrigation and suction will im- 
prove visibility. Irrigation and suction of the 
socket may flush the fragment out. The suc- 
tion tip and trap should be checked to en- 
sure this. The oroantral communication 
within the extraction socket should never be 
enlarged. If minimal exploration proves un- 
successful, access via a Caldwell-Luc proce- 
dure may be necessary. This procedure to ac- 
cess the maxillary sinus should be performed 
by a specialist. 

If referral is necessary, the patient should 
be informed and be placed on sinus precau- 
tions: avoid smoking and using straws for 
drinking. Sneezing or nose blowing should be 
with the mouth open. An antibiotic like 
amoxicillin, clindamycin, or a comparable 
cephalosporin should be prescribed for ap- 
proximately 10 days. Decongestants should 
also be prescribed along with nasal saline 
sprays to help maintain a patent sinus ostium. 

Displacement into the infratemporal 
space is a situation that requires surgical re- 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 79 



trieval and should be performed only by a 
specialist in a hospital setting. Specialized ra- 
diography and equipment is needed for this 

Occasionally, a tooth or fragment might 
be lost down the posterior oropharynx. If 
noted, the patient should be placed mouth- 
down and encouraged to cough. Suction 
should be placed to facilitate recovery of the 
fragment. If unsuccessful at retrieval, either 
aspiration or swallowing of the fragment has 
occurred. If violent coughing or difficulty 
breathing is encountered, this likely indicates 
aspiration. EMS must be activated, and basic 
life support principles should be followed. If 
these signs do not develop, it is likely that 
the fragment was swallowed and will pass 
within two to four days. The standard of 
care is to refer the patient to an emergency 
room, where chest and abdominal radi- 
ographs can be performed. 

Oroantral Communication 

An oroantral communication describes a sit- 
uation in which the integrity of the mem- 
brane lining of the maxillary sinus has been 
disrupted. This can be noticed during a pro- 
cedure which requires immediate closure, 
or it can develop up to a few weeks post- 
operatively. Patients will complain of conges- 
tion, diffuse face pain on the affected side, 
and the sensation of liquid entering the nose 
while drinking. 

If an oroantral communication is sus- 
pected upon removal of a maxillary molar, 
the practitioner should occlude the patient's 
nose and ask the patient to gently express air 
through the nose with his or her mouth 
open. With direct vision and a mouth mir- 
ror, one should look for air bubbles and/or 
condensation of the reflective surface of the 
mirror and also attempt to hear any passage 
of air. If a perforation is suspected, patients 
should be placed on sinus precautions and 
an antibiotic with sinus flora coverage (see 
the "Tooth Displacement" section). The 

communication within the extraction socket 
should never be enlarged iatrogenically by 
instrumentation. Small perforations (<5 
mm) generally heal by themselves in cooper- 
ative patients. Large perforations require sur- 
gical repair and are best referred to a special- 
ist. Description of the surgical procedures for 
repair of oroantral communications are be- 
yond the scope of this text. 

Jaw Fracture 

Jaw fractures, although uncommon, can 
complicate impacted third molar surgery. 
The clinician must be cognizant of the fac- 
tors listed here, as these could predispose this 
unfortunate complication: difficult (deeply 
impacted teeth) extractions, older-age pa- 
tients, atrophic jaws, systemic disease affect- 
ing bones (for example, osteoporosis), associ- 
ated jaw pathology causing weakening of 
bone (for example, bone defect due to a 
cyst), and use of inappropriate surgical tech- 
nique (excessive extraction force or extensive 
bone removal). With careful treatment plan- 
ning and the execution of sound surgical 
techniques, the majority of jaw fractures can 
be prevented. 

Dentists should be aware of the fact that 
after surgical bone removal, the defect re- 
models for a few weeks before final bone 
deposition starts to takes place. This initial 
remodeling includes osteoclastic cell 
activity — which further weakens bone for 
approximately four weeks after surgery. Thus, 
it is more common to see a jaw fracture in a 
postoperative patient at 2—4 weeks after sur- 
gery rather than immediately postsurgery 
Patients at high risk for postoperative jaw 
fracture (for example, those patients requiring 
extensive bone removal) must be closely fol- 
lowed and should be instructed to stay on a 
full-liquid diet or, preferably, put in maxillo- 
mandibular fixation (wiring of jaws) to de- 
crease the chance of a jaw fracture. 

If a jaw fracture occurs during surgery, it 
must be recognized clinically and a baseline 

2879_Koerner_Chap 03 4/17/06 1:25 PM Page 80 



postoperative radiograph (panorex) taken. 
The patient should be informed of the oc- 
currence and instructed to stay on a liquid 
diet with minimal jaw function. All patients 
with jaw fractures should be referred imme- 
diately to an oral and maxillofacial surgeon 
for definitive treatment. Antibiotics (peni- 
cillin or clindamycin) and chlorhexidine oral 
rinses should be prescribed. 

Maxillary fractures are generally confined 
to alveolar process fractures and can usually 
be treated with splinting of segments with 
composite-wire splints, with or without 
maxillo-mandibular fixation. However, 
mandibular fractures most often extend into 
basal bone and may need more complex 


1. A.F. Fielding, A.E Douglas, and R.D. Whitley. 
Reasons for early removal of impacted third mo- 
lars. Clin Prev Dent 3:19 . 1981. 

2. E.C. Hinds, and K.F. Frey Hazards of retained 
third molars in older persons: report of 1 5 cases. / 
Am Dent Assoc 101:246. 1980. 

3. R.A. Bruce, G.C. Frederickson, and G.S. Small. 
Age of patients and morbidity associated with 
mandibular third molar surgery. J Am Dent Assoc 
101:240. 1980. 

4. G.W Pederson. Oral Surgery. Philadelphia, PA: 
W.B. Saunders Company. 1988. 

5. L.J. Peterson. Principles of management if im- 
pacted teeth. In Contemporary Oral and 

Maxillofacial Surgery. L.J. Peterson (ed), 3rd edi- 
tion, pp. 215-48. St. Louis: Mosby Year Book. 

6. Amercian Association of Oral and Maxillofacial 
Surgeons. Position paper on impacted teeth. 
Chicago: AAOMS. 1983 and 1989. 

7. K.R. Koerner. The removal of impacted third mo- 
lars: principles and procedures. In Basic Procedures 
in Oral Surgery. Dent Clin North Am, pp. 255. 
Philadelphia, PA: W.B. Saunders Company. 1994. 

8. H. Dymm. Management of impacted third molar 
teeth. In Atlas of minor oral surgery, pp. 80-92. 
Philadelphia, PA: W.B. Saunders Company. 

9. A. Khanooja, and M.P. Powers. Surgical manage- 
ment of impacted teeth. In Oral and Maxillofacial 
Surgery (vol 1). R.J. Fonseca (ed), pp. 245-80. 
Philadelphia, PA: W.B. Saunders Company. 2000. 

10. D. Nitzan, J.T. Keren, and Y. Marmary Does an 
impacted tooth cause resorption of an adjacent 
one? Oral Surg Oral Med Oral Pathol 51: 22 1 . 

1 1 . NIH Consensus Development Conference for re- 
moval of third molars. J Oral Surg 38: 235. 1980. 

12. M.H. Amler. The age factor in human extraction 
wound healing. 35: 193. 1977. 

13. K.R. Koerner. Clinical procedures for third molar 
surgery. St Louis, MO: PennWell Books. 1986. 

14. T.P. Osborn, G. Frederickson, LA. Small, et al. A 
prospective study of complications related to 
mandibular third molar surgery. / Oral Maxillofac 
Surg 43: 767. 1985. 

15. J.E. Kiesselbach, andJ.G. Chamberlain. Clinical 
and anatomic observations on the relationship of 
the lingual nerve to the mandibular third molar 
region. / Oral Maxillofac Surg 41:565. 1 984. 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 81 

Chapter 4 

Pre-prosthetic Oral Surgery 

Dr. Ruben Figueroa and Dr. Abhishek Mogre 


Patients who are partially or completely 
edentulous will have esthetic and biome- 
chanical concerns that need to be addressed 
before prostheses can be fabricated. The re- 
habilitative goal of an edentulous patient is 
to restore oral function and facial form. 
Approximately 1 percent of the American 
population, including 35 percent of those 
above age 65, are edentulous, and millions 
are partially edentulous. 

After the natural dentition is lost, the pa- 
tient can have an alveolar ridge with irregu- 
larities, undercuts, scarring, and insertion of 
perioral muscles that interfere with the sta- 
bility of the prosthesis. Changes in the soft 
tissues are related to the degree of underlying 
jaw atrophy. Subsequent to extractions, na- 
ture steps in to begin the process of alveolar 
ridge resorption. This process is rapid follow- 
ing extractions and then slows down to 
achieve a balance between osteoblastic and 
osteoclastic activity. Over a period of years, 
patients often end up with an edentulous 
bony ridge that lacks adequate prosthetic 
support. Immediate and late consequences of 
edentulism require a careful evaluation of the 
intraoral supporting structures in order to 

provide proper rehabilitation and to mini- 
mize the ongoing process of bone loss. 

Irregular alveolar ridges, undercuts, tori, 
large maxillary tuberosities, and shallow 
vestibules are some of the problems that can 
interfere with dental prosthetic rehabilita- 
tion. This chapter covers surgical techniques 
to solve some of these problems. 

Patient Evaluation 

The patient evaluation is the most important 
aspect of treatment. Before any surgical or 
prosthetic procedures are performed, it is 
important to evaluate the patient's overall 

The evaluation begins by obtaining a de- 
tailed understanding of the patient's medical 
and dental history (including any previous 
success or failure associated with dental treat- 
ment) and a thorough physical examination 
of the patient. During this initial evaluation, 
it is important to obtain a clear picture of 
the patient's chief complaint and his or her 
expectations in order to determine whether 
you can meet those expectations. The med- 
ical history should provide information on 
the presence of any risk factors for surgery 


2879_Koerner_Chap 04 4/17/06 1:25 PM Page 82 



including medical conditions that might af- 
fect bone or soft tissue healing. 

The extraoral examination should include 
an assessment of any facial deformities, such 
as previous trauma or surgeries, that might 
affect treatment. The intraoral examination 
includes an assessment of remaining teeth, 
bone, and soft tissue covering denture- 
bearing areas, muscle attachments, jaw rela- 
tions, and the presence of soft tissue or bony 

Intraoral Examination 

An intraoral examination of osseous struc- 
tures includes visual inspection, palpation, 
and radiographic examination, as well as 
looking at stone models of the mouth. 
During the visual inspection, an assessment 
of ridge contours, height, undercuts, and 
muscle attachments as well as soft tissue 
health is determined. Palpation of the 
denture-bearing areas might reveal sharp 
bony areas that need surgical correction. A 
radiographic examination is necessary in the 
diagnosis of any underlying bony pathology. 
Retained roots along with radiolucent and/or 
radiopaque lesions have to be identified and 
differentially diagnosed in order to plan ap- 
propriate treatment. Retained roots that are 
embedded in the bone, but asymptomatic, 
are usually left untouched. Attempts to re- 
move them are usually only partially success- 
ful, and the bony defect left behind can be 
more problematic for denture retention and 
comfort than simply leaving them alone. 
However, patients should be informed of the 
presence of roots and the rationale of not re- 
moving them surgically. 


The maxillary denture-bearing area is evalu- 
ated for undercuts or bony protuberances on 
the buccal and palatal sides. Of particular in- 
terest are palatal tori and tuberosity hypertro- 
phy. Any areas that interfere with the inser- 

tion of the maxillary denture should be cor- 
rected surgically. It is important to evaluate 
posterior tuberosity notching for its impor- 
tance in denture stability and posterior seal. 


The mandibular ridge is evaluated for ridge 
form and contour, irregularities, buccal exos- 
toses, and tori (see Figures 4.1 and 4.2). Be 
careful when examining severe mandibular 
bone resorption since in these cases the ridge 
cannot be assessed by visual inspection 
alone. Muscle attachments as well as a lack 
of vestibule may obscure the actual underly- 
ing bone anatomy. Using palpation, one 

Figure 4-1. The arrows are showing massive 
mandibular tori. Tori are found bilaterally on the 
lingual side in the premolar canine area. 

Figure 4-2. The arrows are pointing towards 
bony exostoses. Exostoses are usually found buc- 
cally, in contrast to tori, which are located lingually. 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 83 



should palpate and identify the mental fora- 
men and the mental neurovascular bundle, 
especially if it is located on the superior as- 
pect of the mandibular ridge, since this situ- 
ation is prone to neurosensory disturbances. 

Maxilla/ Mandible Relationship 

The relationship between the arches is ex- 
tremely important. During examination, an- 
teroposterior and vertical relationships along 
with the possibility of any skeletal asymme- 
try should be evaluated. This evaluation 
must be done with the patient in a normal 
resting position. Overclosure of the man- 
dible might give the impression of a pseudo 
Class III malocclusion. Lateral cephalometric 
radiographs with the patient closing down in 
a normal position are helpful to determine 
anteroposterior relationships of the jaws. 
Interarch distance, particularly in the poste- 
rior area, should be carefully evaluated. In 
addition, any amount of vertical excess in 
the tuberosity region, either bony or soft tis- 
sue, might impinge on the space necessary 
for the placement of dentures. 

Soft Tissue Importance 

Soft tissue covering the denture-bearing area 
needs to be carefully evaluated. The health 
and quality of soft tissue is one of the most 
important determinants of success with 
complete dentures. Ideally, there should be 
healthy keratinized tissue, which is firmly at- 
tached to the underlying bone. The presence 
of any hypermobile, fibrous tissue is inade- 
quate for providing a stable denture-bearing 
area (see Figure 4.3). 

The vestibular area should be free of in- 
flammation secondary to an existing or previ- 
ous ill-fitting denture. Tissues at the depth of 
the vestibule should lack any irregularities in 
order to provide maximal peripheral seal. The 
vestibular assessment should include an eval- 
uation of muscle attachments. Muscle attach- 
ments that come onto the bony ridge might 

Figure 4-3. The arrows are showing hyperplas- 
tic tissue over the maxillary ridge. This tissue will 
make the denture base unstable. 

Figure 4-4. A labial frenum extending toward 
the alveolar crest, thus interfering with buccal 
flange extension. 

interfere with denture retention due to the 
loss of peripheral seal during speech and mas- 
tication (see Figure 4 A). The linguovestibular 
area of the mandible should be inspected to 
determine the location of mylohyoid muscle 
and genioglossus muscle attachments in rela- 
tion to the crest of the ridge. The myohyoid 
and genioglossus muscles will elevate during 
tongue movement, so if their attachments are 
high, they will cause movement and displace- 
ment of the lower denture. 

Treatment Planning 

After recording the medical/dental history 
and completing the physical examination, a 
treatment plan should be formulated. This 
will always precede any surgical intervention. 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 84 



Benefits and possible complications of the 
surgery should be discussed with the patient. 
Alternative treatments, such as implant- 
supported dentures, should be presented 
when indicated. Surgical procedures in- 
volving bone contouring or augmentation 
should be addressed first, followed by soft tis- 
sue procedures. 

The following surgical procedures will be 
presented in this chapter: 

Immediate dentures 


Maxillary tuberosity reduction 

Maxillary torus 

Mandibular tori 

Epulus fissuratum 

Papillary hyperplasia 


Labial frenectomy 

Lingual frenectomy 

Palatal graft 

Ridge augmentation 


The following is a list of basic surgical in- 
struments needed to perform pre-prosthetic 

#15 and #11 surgical blades 

Bard Parker scalpel handle 

Molt periosteal elevator 

Seldin retractor 

Tissue forceps (pickups) 

Chisel and mallet 

Blumenthal bone rongeurs 

Straight fissure bur 

Large round or oval nongouging bur 

Dean scissors 

Needle holder 

Bone file 

Allis forcep 

Immediate Dentures 

Many patients can be treated with an imme- 
diate denture on the day of their extractions. 

However, this procedure requires careful 
planning before performing extractions and 
insertion of the dentures. Inflamed and 
bleeding gingival tissue with heavy deposits 
of plaque and calculus are a definite predis- 
position for postoperative bleeding and in- 
fection. Patients with severe periodontal dis- 
ease and inflammation of the gums should 
be treated by scaling and root planing before 

In rare cases and with adequate planning, 
all remaining teeth can be extracted in one 
patient appointment, with the denture being 
inserted the same day. More commonly, it is 
recommended that complicated extractions 
(that is, posterior teeth) should be done and 
the ridges be allowed to heal before taking 
final impressions. Considerable alveolar ridge 
changes occur after such extractions that 
would affect retention and adaptability of 
the denture. 

The sequence of extractions is an impor- 
tant aspect of overall treatment. Usually, 
mandibular and maxillary molars are re- 
moved first, leaving premolars for the assess- 
ment and maintenance of vertical dimen- 
sion. About two months later, when 
fabrication of the immediate denture is com- 
plete, extraction of the remaining teeth is 
performed and the denture is inserted. 

At the time of the extractions, contouring 
of the ridge can be done as planned on the 
patient's model. A clear surgical stent can be 
positioned to determine any pressure points 
that need further bone reduction. Care must 
be taken not to pull sutures too tightly. 

Following surgery, pain medication 
should be prescribed. Antibiotics are usually 
unnecessary unless there is evidence of infec- 
tion or if the patient has other medical indi- 
cations. The patient is instructed not to re- 
move the denture (s) until follow-up the next 
day. During this next-day appointment, the 
dentist will remove and clean the dentures 
and perform any needed denture adjust- 
ments. Sutures should be removed in five to 
seven days. 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 85 



Table 4-1. Immediate Dentures Treatment Sequence 



1 . Prophylaxis prior to extractions 

2. Complicated extractions 

3. Extractions of maxillary and mandibular molars 

4. Final impressions 

5. Model surgery 

6. Construction of clear surgical stent 

7. Extraction of remaining teeth 

8. Denture insertion 

Minimize bleeding and infection probabilities 
Bony changes may affect final impressions and 

denture fit 
After extractions allow six weeks for healing before 

making final impressions 

Remove teeth that are visible above the gingiva, 
contour gingival tissue, and remove undercuts 

Will guide the surgeon during the procedure for 
alveolar contouring 

Minimal alveolar contouring should be necessary 

Denture adjustments 


Alveoplasty is contouring of the alveolar 
ridge to remove any irregularities and under- 
cuts. Most alveoplasties are performed on the 
maxilla and anterior mandible. The goals are 
to provide a stable base for the prosthesis 
and preserve as much alveolar bone as possi- 
ble. Always be conservative when removing 
bone. Remember that if the patient desires 
to have implants in the future, every little bit 
of preserved bone counts. 

Surgical Technique for an Alveoplasty in 
an Edentulous Patient 

After adequate local anesthesia is obtained, a 
crestal incision is made over the area. A verti- 
cal release incision should be made when 
there is a risk of tearing the soft tissue flap. 
Be careful with anatomical structures such as 
the mental nerve and always maintain a 
wide-base flap. A thin ridge in the anterior 
mandible presents a challenge because it is 
possible to end up in the floor of the 

Use a periosteal elevator to raise a full- 
thickness flap. Keep the pointed edge of the 
elevator against bone at all times to mini- 

mize tissue perforation. If a vertical release 
incision was made, start the reflection where 
it joins the crestal incision. Reflect the flap 
enough to identify the areas needing to be 
smoothed. When the full-thickness flap is re- 
flected, use a Seldin or Minnesota retractor 
to retract and protect the flap. 

Contouring of the bone is accomplished 
with a bone file, rongeurs, and/or round bur 
mounted on a slow-speed handpiece. 
Undercuts and sharp edges are eliminated, 
but the contouring does not have to be per- 
fectly smooth. Frequently reposition the flap 
and try to feel the bone (with a gloved finger 
through soft tissue) for irregularities. Never 
perform digital palpation of the bone di- 
rectly because some irregularities are minimal 
and will not be noticeable or significant 
enough to remove with the flap in position. 
Use the bone file for final contouring and 
smoothing of the bone. Before suturing, irri- 
gate the area — especially at the bottom of 
the flap, where bone debris frequently accu- 
mulates. When the alveoplasty is finished, 
the flap is repositioned to its original posi- 
tion and sutured with interrupted or contin- 
uous sutures. Analgesics should be pre- 
scribed, but antibiotics are usually not 
necessary (see Figures 4. 5 A— B). 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 86 



Figure 4-5A. The arrow in the picture shows a 
severe loss of inter-ridge distance. There is no 
space to restore the edentulous span. 

Figure 4-5B. Increased inter-ridge distance 
after alveoloplasty. 

Maxillary Tuberosity Reduction 

A maxillary tuberosity can increase in the 
vertical dimension, decreasing the vertical 
space between the maxilla and the mandible. 
The resultant problem is not having enough 
space for the denture base. To determine 
adequacy of the space, a dental mirror 
should be placed between the tuberosity and 
the ascending ramus of the mandible. If it 
fits and the patient is not uncomfortable 
with the pressure of the mirror in place, then 
there is enough space. A maxillary tuberosity 
could also have significant undercuts that 
would interfere with the path of denture 


• Decreased intermaxillary space 

• Decreased freeway space 

• Severe undercut that interferes with den- 
ture fabrication steps (including impres- 
sion techniques) and denture insertion 

• Mobile soft tissue that interferes with 
denture stability 

Presurgical radiographs should be taken. 
The ideal radiograph for this purpose is a 
panoramic film. This kind of film will show 
the proximity of the maxillary sinus and will 
help determine whether the enlargement is 
fibrous or bony in nature. Usually a commu- 
nication with the maxillary sinus during sur- 
gery is of no consequence because primary 
soft tissue closure is easy to obtain. 

Fibrous Tuberosity 

The objective of the correction of a fibrous 
enlargement is to surgically reduce the en- 
larged tuberosity and create enough vertical 
space for the denture. Wedge resection is the 
technique of choice. After the area is prop- 
erly anesthetized, an elliptical incision is 
made down to the bone with a #15 scalpel 
blade. Wedge incisions should start on the 
crest of the ridge at the junction of the nor- 
mal ridge with the fibrous tissue. The inci- 
sions extend posteriorly toward the hamular 
notch, removing one third of the bulbous 
mass. The wedge of tissue is grasped with an 
Allis forceps and freed from the cortical bone 
with sharp and blunt dissection. When the 
wedge is removed, the operator proceeds 
with the submucous lateral resections with a 
#15 blade. Submucous cuts are made parallel 
to the bony surface on either side, being 
careful not to perforate the flaps. The buccal 
and palatal flaps are repositioned and 
trimmed until they meet without overlap- 
ping and with no tension. When removing 
tissue, always preserve the vestibule and at- 
tached gingiva. Close with continuous 3.0 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 87 



sutures. Prescribe analgesics as needed, but 
antibiotics are usually not necessary. 

Bony Tuberosity 

With a #15 blade, a single crestal incision is 
made starting at the hamular notch and com- 
ing forward to 10 mm beyond the intended 
area of reduction. At the anterior end of the 
crestal incision a vertical release incision is 
made. The angle of the release incision 
should be approximately 135° to the crest to 
provide a wide-based flap. This full-thickness 
flap is reflected with a periosteal elevator — 
remembering to keep the pointed edge 
against bone. In areas of an undercut, care 
should be taken not to perforate the flap. 
Reflect enough to expose the bone area to be 
removed. Use a Seldin or similar retractor to 
reflect and protect the flap. Contouring of 
the bone can be performed with a side- 
cutting roungeur or a large oval bur (such as 
a bone bur, available through companies like 
Brasseler). After the cortical bone is removed, 
be careful with the underlying medullary 
bone since it is softer. Lack of caution could 
lead to a postoperative defect. Reposition the 
flap to visualize the result and evaluate the 
area. Finish contouring with a bone file and 
irrigate with normal saline. Any excess tissue 
can be trimmed away with scissors. Be careful 
to preserve the vestibule and hamular notch, 
which are important for denture retention. 
If you have a communication with the 
maxillary sinus, irrigate the area well and 
then suture without tension. The patient 
should be informed of the communication 
and instructed not to blow his or her nose, 
sneeze, or cough unless the mouth is open. 
Antibiotics (Amoxicillin 500 mg tid for 
seven days) and a nasal decongestant should 
be prescribed. 

Maxillary Torus 

A maxillary torus consists of a sessile mass of 
cortical bone in the middle of the palate. 

Most often, maxillary tori do not need surgi- 
cal removal. Satisfactory dentures can be 
constructed over most of them. However, 
there are some situations where their removal 
is indicated: 

• Constant trauma 

• When they prevent a good postdam seal 
or have large undercuts that interfere with 
impression techniques 

• Speech impediment 

• Psychological phobia 

A radiographic evaluation should be per- 
formed in order to determine the proximity 
of the nasal cavity and the maxillary sinus. 
Lateral radiographs will generally supply this 
information. One of the possible complica- 
tions of this procedure is the exposure of the 
nasal cavity, creating an oronasal communi- 


A maxillary impression is made, and a cast is 
poured. The torus is removed from the cast 
and a clear stent is made. The stent will pro- 
tect the area, prevent hematoma formation, 
and provide postoperative comfort to the pa- 
tient. The authors recommend using the 
stent, even though some surgeons do not 
consider it essential. 

Local anesthesia with a vasoconstrictor is 
administered for the greater palatine and the 
nasopalatine nerves. Infiltration is suggested 
around and into the torus to facilitate eleva- 
tion of the thin mucoperiosteum. Allow 
enough time for the anesthesia and vasocon- 
strictor to work. 

A #15 blade is used to make an incision 
in the form of a Y in order to expose the 
bone of the torus. Reflection of the flap is 
performed with a periosteal elevator — being 
careful not to tear the extremely thin mu- 
cosa. The flap is then held open with 3-0 silk 

After the entire torus is exposed, it is 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 88 



scored (depth cuts) with a fissure bur in a 
crisscross pattern, using copious irrigation. 
The depth of the cuts should be approxi- 
mately 1.0 to 2.0 mm down from the level 
of the horizontal palatal shelf (toward the 
oral cavity). After the cutting pattern has 
been established, a chisel and a mallet are 
used to remove the individual segments. (If 
the operator is uncomfortable using the 
chisel/mallet method, a bur can be used.) 
Stay superficial in order to avoid perforation 
into the nasal cavity. The final smoothing of 
the bone is accomplished with a large oval 
bur and copious irrigation. There is no need 
to remove the entire torus. The area is irri- 
gated and sutured with 3.0 silk or chromic 
gut using interrupted sutures. The stent is 
tested intraorally, and if unstable, it can be 
relined with soft tissue relining material. The 
stent can be made from thermoplastic mate- 
rial with a vacu-form device, or alternatively, 
an acrylic stent may be fabricated by a lab. 

The stent is retained for 48 hours, after 
which it is removed by the surgeon in order 
to clean and inspect the surgical area. It can 
be worn during the healing period of ap- 
proximately two weeks, but after the first 48 
hours, the stent should be removed after 
each meal for cleansing. 

It is not unusual for the palatal flap to 
slough off. This is not a problem, and granu- 
lation tissue will eventually cover the defect 
with secondary epithelialization (see Figures 

Figure 4-6A. A palatal torus that interferes with 
fabrication of a maxillary denture. 

Figure 4-6B. This picture shows an outline of a 
surgical incision for torus removal. The incision is 
placed over the torus and extended beyond its 
anterior/posterior borders. The typical incision 
appears like two Ys joined in the midline. 

Figure 4-6C. Flaps are reflected and the torus is 

Figure 4-6D. The bony torus is outlined in the 
above picture. 

2879_Koerner_Chap 04 4/17/06 1:25 PM Page 89 

Figure 4-6E. Tori are surgically removed in small 
segments. An attempt to remove a palatal torus in 
one piece could lead to a perforation into the 
nasal cavity. The outline shows the surgeon's 
choice of sectioning the torus before its removal. 

Figure 4-6F. The excised bony torus is shown. 

Figure 4-6G. Tori can be removed using hand 
instruments, rotary instruments, or both. The pic- 
ture shows the appearance of the site after sur- 
gery. It is not necessary to completely remove the 
bony growth. The extent of removal can be as- 
sessed by frequent closing of the flaps and feeling 
the area for sharp edges of bone. 

Figure 4-6H. Surgical templates can be used to 
create pressure for hemostasis and provide a 
method of delivering soft tissue liners as a sur- 
gical dressing. In this case, since the patient 
was also scheduled for full arch extractions, a 
complete upper clear surgical template was fabri- 
cated. An immediate denture could also have 
been used. 

Figure 4-61. Flaps are then closed with sutures. 

Figure 4-6J. This eight weeks postoperative 
picture shows healthy mucosa and excellent 


2879_Koerner_Chap 04 4/17/06 1:25 PM Page 90 



Mandibular Tori 

Mandibular tori are usually bilateral and lo- 
cated on the lingual aspect of the mandible. 
They are normally found in the premolar 
and molar area. Before construction of a 
mandibular removable denture, they fre- 
quently need to be removed. The mucosa 
covering them is thin and prone to irritation 
and ulceration. 


Local anesthesia consists of inferior alveolar 
nerve blocks and infiltration subperiosteally 
over the torus (which helps with dissection). 
An incision is made along the crest of the 
ridge, extending the equivalent of two teeth 
beyond the torus on each end. In dentate 
patients, the incision is placed in the lingual 
gingival sulcus. Release incisions are usually 
not necessary. 

With extreme care, a full-thickness enve- 
lope flap is raised. Because the mucosa is 
thin, perforation of the flap can easily occur, 
with the consequence of delayed and painful 
postoperative healing. The flap is extended 
below the torus enough to place a Seldin re- 
tractor, which will protect the area while the 
torus is being removed. With a fissure bur, 
create a groove on the superior margin of the 
torus where the torus meets the mandible. 
The depth of the groove is approximately 
halfway through the vertical dimension of 
the torus. If the torus is large, create some 
additional vertical cuts to help facilitate re- 
moval. A monobevel chisel is then placed 
into the groove that was created with the 
angle facing the mandible. While the chin is 
being supported manually, the chisel is 
tapped with the mallet. Alternatively, the ini- 
tial bur cut can be extended all the way 
through the vertical dimension of the torus, 
following which it can be removed with a 
needle holder. After the torus is removed, its 
surface is smoothed with a bone file or a 
large, round nongouging bur. At all times 
protect the flap with the retractor. 

The surgical area is irrigated with normal 
saline. Close with either interrupted or con- 
tinuous 3-0 silk or Vicryl sutures. Using 
moist gauze, the operator can place digital 
pressure on the flap for a few minutes to 
help initiate fibrin adhesion and prevent 
subsequent hematoma formation. 

Even when careful, postoperative bleeding 
with hematoma formation is a possible com- 
plication. Bleeding in the floor of the mouth 
could pose a threat to the airway (see Figures 

Ridge Augmentation with 
Hydroxyapatite (HA) 

The basic concept behind using particulate 
hydroxyapatite (HA) for bone augmentation 
is that HA is a dense nonresorbable material 
that seems to show negligible foreign body 
reaction. It is placed subperiosteally by a spe- 
cial technique called subperiosteal tunneling. 
There is evidence that during the healing 
process, bone forms around particles of HA 
that are in contact with alveolar bone. Remain- 
ing, more internal HA particles are densely 
suspended in a connective tissue matrix that 
does have some vascularization. The amount 
of bone augmentation depends on how care- 
ful the operator is to minimally stretch and 
tunnel the periosteum. The disadvantage of 
this technique includes particle escape and 
movement and a lack of adequate density as 
compared to autogenous bone grafts. 

Epulis Fissuratum 

Epulis fissuratum is a hyperplastic growth of 
the mucosa secondary to denture irritation. 
This constant irritation eventually develops 
submucosal fibrosis. This condition inter- 
feres with denture stability and comfort. Pa- 
tients usually see great benefit from surgical 
treatment. However, before surgery either 
the patient should discontinue wearing the 
denture for two weeks or the dentist should 
relieve the denture in the area(s) of irritation. 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 91 



Figure 4-7A. Outline of a mandibular torus. 
Mandibular tori can create undercuts, thereby 
making denture fabricaton and insertion cumber- 
some. The mucosa covering the torus is thin and 
prone to pressure ulceration from dentures. 

Figure 4-7B. Mandibular torus after surgical 
exposure. An incision was made over the crest of 
the ridge, extending the equivalent of two teeth 
beyond the torus on each end. 

As a result of this chronic irritation, there 
is often also a loss of underlying bone. If 
there is significant bone loss after removal of 
the epulis, the patient might not have an ap- 
propriate vestibular depth, and retention of 
the denture could be compromised. During 
the evaluation appointment, the patient 
should be informed of this possibility. 

Surgical Technique 

Local anesthesia with vasoconstrictor should 
be used. If excessive infiltration is done, the 
anatomy of the epilis fissuratum will be dis- 
torted. Identify the epulis and use as many 

Figure 4-7C. The torus is removed and the sur- 
face smoothed. Smoothness can be checked by 
replacing the flaps and then feeling for rough bony 

Figure 4-7D. This postsurgical result shows a 
great improvement in the shape of the mandibular 
ridge and absence of any undercuts. 

Allis forceps as necessary to grasp the tumor- 
like growths. The surgeon holds the forceps, 
and the assistant retracts the lip to ensure 
that the lip muscles are not excised. The su- 
perior border of the epulis is incised first 
with a #15 blade, electrosurgery or laser. 
The epulis is raised by the surgeon, and then 
the inferior cut is made. Both incisions are 
made superficial to the periosteum. The en- 
tire mass is removed. It is important to retain 
as much healthy attached mucosa as possi- 
ble. Bleeding points are controlled with 
electrocautery or laser. The removed tissue 
should be sent for histopathologic exami- 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 92 



Primary closure is not necessary in all 
cases, and it should be avoided whenever 
possible. Primary closure tends to roll the lip 
inward, decreasing the amount of vermillion 
that shows. The denture should be trimmed 
as needed and lined with soft tissue reline 
material after surgery. This dressing should 
be removed in 48 hours and the denture 
cleaned. The denture can be relined again if 
necessary. It takes about six weeks for com- 
plete healing — after which the denture can 
be remade or relined. Pain medication 
should be prescribed, and antibiotics are usu- 
ally not needed. 

Papillary Hyperplasia 

Papillary hyperplasia or denture stomatitis is 
generally secondary to ill-fitting dentures. 
Other factors that contribute to this condi- 
tion are poor oral hygiene, fungal infections, 
and around-the-clock denture use. 

This condition is not premalignant but 
inflammatory in nature, and total full- 
thickness removal of the mucosa is not 
needed. Before performing invasive surgical 
treatment, the maxillary denture should have 
a soft reline, and the patient should be in- 
structed not to wear the denture at night. 
Suspected candidiasis should be treated with 
appropriate antifungal agents. If this conser- 
vative therapy is not successful, surgical ther- 
apy should be considered. 

Surgical Technique 

Local anesthesia with vasoconstrictor is used 
to block the greater palatine and nasopala- 
tine nerves. A biopsy specimen should be 
taken, avoiding the area of the greater pala- 
tine vessels. Removal of the hyperplastic tis- 
sue can be accomplished with an antral 
curette. Scraping of the tissue is performed 
until the dense white tissue (corium) below 
the epithelium is exposed. 

Electrocautery with a loop electrode can 
also be use for the removal of the hyperplas- 

tic tissue. Care should be taken not to burn 
the perioral tissues. Always leave the perios- 
teum intact. Mucoabrasion with a large, 
nongouging round bur mounted on a slow- 
speed handpiece could also be used. Irriga- 
tion should be performed when using the 
handpiece/bur technique. 

Laser surgery is perhaps the most ideal 
technique to use for removing this hyper- 
plastic tissue. As it removes redundant tissue, 
it coagulates the blood at the same time. 
Adjacent areas should be covered with moist 
sponges for protection. 

Following excision, the denture should be 
relined with a soft material (for example, 
Coe-Comfort) for hemostasis and to prevent 
discomfort. Healing by secondary epitheli- 
azation is usually completed within three to 
five weeks. Pain medication is recom- 
mended, but antibiotics are usually not 


The goal of a vestibuloplasty is to remove 
unwanted muscle insertions into the alveolar 
ridge. This is done by exposing bone at the 
place where these muscles formerly attached. 
The vestibuloplasty surgical technique re- 
quires an adequate amount (height) of alveo- 
lar bone. The basic problem here is usually 
not the lack of bone but rather that the shal- 
low vestibule prevents the denture flange 
from extending to provide adequate stability 
and retention. If the patient does not have 
enough bone height, then a ridge augmenta- 
tion procedure might need to be done before 
the vestibuloplasty. 

During the presurgical evaluation it is 
important to evaluate the proximity of 
anatomical structures such as nerves and the 
location of muscle insertions. A panoramic 
radiograph will help to evaluate the bone 
height and identify structures such as the 
mental foramen. 

Nerve blocks and infiltration should be 
used to obtain profound anesthesia and he- 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 93 



mostasis. The incision is placed at the junc- 
tion of attached and unattached mucosa 
with a #15 blade. A partial-thickness flap is 
raised with the blade or Dean scissors, pre- 
serving the periosteum. Any muscle fibers at- 
tached to the periosteum should be removed. 
Small perforations of the periosteum will not 
cause major problems but should be 
avoided. The mucosal edge is sutured to the 
bottom of the dissected area. 

The resulting denuded periosteum may 
be handled in different ways. If the operator 
decides to let it heal by secondary intention, 
the relapse rate is about 50 percent. Another 
method is to graft the area with palatal mu- 
cosa, a collagen membrane, or cadaveric mu- 
cosal membrane. Grafts should be perforated 
with the tip of a #1 1 blade after suturing in 
order to prevent blood clots from forming 
between the graft and the periosteum. Light 
pressure on a graft is desirable in order to 
prevent blood clot formation, and also to 
immobilize the graft. This can be accom- 
plished with the patient s denture after it 
has been relieved and a soft tissue relining 
material placed inside. One should be careful 
that the soft tissue relining material does not 
get lodged under the graft. Another alterna- 
tive would be the use of a soft clear splint 
kept in place with two titanium screws. 
Screws are simple to place and to remove. 
The denture or splint should not be re- 
moved for a week. 

When the splint is removed, the grafted 
tissue will look white and avascular. This is 
normal. It usually means that the superficial 
layer of the graft has been lost, but one 
should not worry because the rest of the 
graft will be vital. Angiogenesis into the graft 
occurs within 48 hours, and healing takes up 
to 5—6 weeks (see Figures 4.8A— F). 

Labial Frenectomy 

Frenal attachments consist of thin bands of 
fibrous tissue attached to the bone. If the 
frenum is close to the crest of the alveolar 

Figure 4-8A. The arrow is pointing towards 
unattached alveolar mucosa and a shallow labial 
vestibule. These conditions affect denture stability 
and retention. 

Figure 4-8B. The recipient site is prepared 
with a partial-thickness flap. The periosteum is 
preserved, but any muscle or fatty tissue is re- 
moved in order to have a nonmovable graft after 

ridge, it can interfere with the extension of 
the denture flange and, consequently, with 
retention and comfort. 

Surgical Technique 

Three surgical techniques are effective in re- 
moving labial frenal attachments. Simple ex- 
cision and Z-plasty techniques are effective 
when the mucosal and fibrous band is rela- 
tively narrow. When the frenal attachment 
has a wide base, a localized vestibuloplasty 
with secondary epithelialization is preferred. 
Local anesthesia with a vasoconstrictor is 
infiltrated. Avoid injecting excessive anes- 
thetic solution because it might obscure the 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 94 



Figure 4-8C. Outlined areas represent a palatal 
graft donor site. 

Figure 4-8D. Palatal grafts of the required size 
are obtained from the donor site. Yellowish areas 
in the graft represent fatty tissue, which should be 
removed before adapting the grafts to the recipi- 
ent site. 

Figure 4-8E. The arrows are showing palatal 
grafts sutured in place. There is a corresponding 
increased depth of the labial vestibule. 

Figure 4-8F. Three months postsurgical picture 
showing excellent vestibular depth and healthy 
keratinized tissue. 

anatomy. It is convenient to have an assistant 
to elevate and evert the lip. 

For the simple excision technique, a nar- 
row elliptical incision is done around the 
frenum down to the periosteum. The 
frenum is removed with sharp and blunt dis- 
section from the underlying periosteum and 
soft tissue. The margins of the incision are 
undermined with Dean scissors. The first su- 
ture is placed at the maximum depth of the 
vestibule including both edges of the mucosa 
and the underlying periosteum. This suture, 
called an anchor suture, will maximize the 
depth of the vestibule. The remainder of the 
incision should be sutured with interrupted 
sutures. Sometimes, part of the wound can- 
not be closed primarily and is left to granu- 
late secondarily (see Figures 4. 9 A and 

For the Z-plasty technique, the lip is 
everted to expose the frenum, and with a 
#15 blade, an incision is made along the 
frenum. At each end of the incision, two 
small incisions are made in a Z fashion. The 
two flaps are undermined and rotated to 
close the original vertical incision in a hori- 
zontal manner. This technique minimizes 
the amount of vestibular ablation as seen 
after the previously described simple tech- 
nique (see Figures 4.10A-C). 

The final method is the vestibuloplasty 
with secondary epithelialization. In cases 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 95 



Figure 4-9A. The arrow points to a high labial 
frenum attachment in a child. Such freni can lead 
to development of a diastema between the central 

Figure 4-9B. The frenal attachment is corrected 
by simple excision technique. The arrow points to 
the part of the wound that was sutured. Below 
this area, sutures could not be placed because 
soft tissue could not be closed. It is left to heal by 
secondary intention. It is important to remove the 
fibrotic tissue between the centrals. 

with a broad frenum attachment, a semi- 
lumar supraperiosteal incision is made at the 
junction of free and attached mucosa. The 
flap is undermined supaperiosteally and su- 
tured to the periosteum, thus increasing the 
depth of the vestibule. Healing takes place 
by secondary epithelialization, and a denture 
with a soft liner is placed over it. 

Figure 4-1 OA. The labial frenum in the picture 
interferes with denture border extension and 

Figure 4-1 OB. The lines represent a Z-plasty 
technique. Areas marked as A and B indicate two 
flaps that will be surgically repositioned, thereby 
eliminating the frenum. 

Figure 4-1 OC. Surgical correction of this promi- 
nent frenum attachment shows the dramatic 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 96 



Lingual Frenectomy 

Tongue-tie or ankyloglossia causes difficulty 
in denture construction due to the overex- 
tension of fibrous lingual attachments, 
which sometimes may be up to the crest of 
the ridge. They can also create difficulty in 

Surgical Technique 

Local anesthetic with vasoconstrictor is used 
to infiltrate the area. A traction suture is 
placed through the tip of the tongue and 
then is used to stretch the tongue superiorly 
toward the palate. Bleeding can be mini- 
mized by clamping a hemostat at the base of 
the frenum for a few minutes before making 
a horizontal incision. Care should be taken 
to avoid injury to the submandibular gland 
ducts. As the incision is made, the tip of the 
tongue is simultaneously stretched to check 
the range of movement. The margins are un- 
dermined and are then sutured back with 
3-0 chromic gut. The patient should be ad- 
vised to not move the tongue very much 
during healing (see Figures 4.1 1A and 

Palatal Graft 

The hard palate is a useful donor site for 
grafting small defects in the oral cavity. It 
provides keratinized tissue around implant 
collars that lack attached gingival, for cover- 
ing an area of vestibuloplasty (see previous), 
and to correct gingival recession. 

Surgical Technique 

The area to be grafted should be prepared 
first. Measure the defect with a ruler or 
calipers to determine the size and shape of 
the graft or construct a template. A template 
can easily be made from the sterile cardboard 
in a suture envelope. 

Local anesthesia is given at the donor site. 
Infiltration of local anesthetic with a vaso- 

Figure 4-11 A. An abnormal position of a lingual 
frenum close to the tip of the tongue can restrict 
its movement. The condition is called tongue-tie. 
The arrow is showing such a condition. 






Figure 4-1 1B. The tongue is corrected surgi- 
cally by a procedure called lingual frenectomy. 
The arrow shows an immediate postsurgical im- 
provement in the range of tongue movement. 

constrictor is preferred for hemostasis. It 
should be allowed to work at least 5—7 min- 
utes before harvesting the graft. The ideal 
sites for the donor tissue are between the first 
premolar and the second molar. This area is 
free of anterior rugae and is thick enough to 
perform a partial-thickness flap procedure. 
The greater palatine artery runs closely at- 
tached to the periosteum above the second 
molar and should be avoided. To judge the 
depth of the incision, a #15 blade can be 

2879_Koerner_Chap 04 4/17/06 1:26 PM Page 97 



used and sunk to the depth of the bevel (1 
mm). After outlining the incision, begin re- 
moving the graft from one of the anterior 
corners. If difficulty is encountered, one trick 
is to increase the depth of one of the anterior 
corners by 1 mm. Begin harvesting with a 
#15 blade, lifting the edge with Adson tissue 
pickup. Sharp dissection can be accom- 
plished with a blade or Metzenbaum scissors. 
The graft is carefully dissected suprape- 
riosteally away from underlying tissue and 
removed. The donor site is inspected for any 
bleeding, which can be controlled with elec- 
trocautery. Collagen may be placed to fur- 
ther control bleeding. If the patient wears a 
denture, soft tissue conditioner can be added 
to this area within the denture to increase 
pressure and provide hemostasis. If dissection 
has been performed without injury to the 
greater palatine artery, bleeding will be 

Inspection of the graft is done, and any 
fatty and/or glandular tissue is removed with 
scissors. This is important for the nutrients 
to reach the graft from the host bed. The 

graft is adapted to the host site and sutured 
to snugly fit. Stability and adaptation of the 
graft are essential for success. The graft 
should have gentle pressure placed by push- 
ing with a moist piece of gauze. This pro- 
motes graft adhesion to the recipient site and 
also helps prevent hematoma, which could 
lead to graft failure. After the graft is su- 
tured, small stab incisions could be made 
with a #1 1 blade into the graft so as to allow 
drainage. Angiogenesis occurs within 48 
hours, and complete healing takes up to five 
weeks (see Figures 4.8C— E). 


Pre-prosthetics is an important part of oral 
and maxillofacial surgery. This chapter in- 
cludes basic and simple pre-prosthetic sur- 
geries that can be performed routinely — 
even by the general dentist. The purpose of 
the authors is to simplify the subject in a 
way that will provide greater confidence to 
the generalist wanting to perform these 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 99 

Chapter 5 

Conservative Surgical Crown 


Dr. George M. Bailey 


Crown lengthening procedures are an indis- 
pensable part of restorative dentistry, pocket 
maintenance, and enhanced oral esthetics. 
However, the surgical procedure itself is fre- 
quently avoided due to the perceived com- 
plex interplay between technique, tooth sta- 
bility, and esthetics. Part of the problem is a 
slightly erroneous concept regarding the 
relationship between the tooth and soft 
tissue attachment. This chapter explores the 
clinical realities of that relationship, the indi- 
cations for crown lengthening, the various 
surgical procedures that are available for 
crown lengthening, and specific surgical 

Biologic Width 

In order to develop conservative crown 
lengthening techniques, it is necessary to 
fully understand the relationship between 
the tooth and the soft tissue structures that 
support and protect it. The main rationale 
that answers the question "Why do crown 
lengthening?" lies in the term biologic 

width, a concept that is both clinical and 

The term biologic width was first intro- 
duced as "an epithelial attachment and the 
connective tissues which extend vertically 
from the bottom of the sulcus to the crest of 
the bone." 1 Additional findings indicated 
that there is a proportional relationship be- 
tween the depth of the gingival sulcus, the 
epithelial attachment — now called the junc- 
tional epithelium (JE), the connective tissue 
fibers, and the crest of the alveolar bone 
around the tooth (see Figure 5.1). 

This same study also measured this rela- 
tionship, showing that in healthy gingiva, 
the sulcus is approximately 1 mm deep (ob- 
viously a very healthy environment), the JE 
is 1 mm, and the connective tissue overlying 
the alveolar bone is 1—2 mm in vertical 
thickness. 2 These studies have thus set the 
clinical basis for crown lengthening and 
suggest that there should be at minimum a 
3-mm space between the restoration margin 
and the alveolar bone to accommodate the 
biologic width. 

More recent findings by Vacek et al. basi- 


2879_Koerner_Chap 05 4/17/06 1:26 PM Page 100 



Sulcus < 



Figure 5-1. Normal relationship of the biologic 

cally verified these original relationships but 
indicated a wider range of measurements 
and suggested to the clinician the impor- 
tance of measuring these values for the indi- 
vidual patient rather than assuming that all 
measurements are the same. The high vari- 
ability of biologic structures from one pa- 
tient to another must be kept uppermost in 
mind in treatment. 

The author's clinical experience is that the 
connective tissue portion of the measure- 
ment overlying the bone is most often 2 mm 
or greater, with a sulcus depth in excess of 1 
mm in a healthy site. Similar observations 
have led some to indicate that as much as 
5.5 mm between the bony crest and the 
restorative margin/sound tooth structure 
must exist for proper restorative procedures 
(2 mm connective tissue, 1 mm junctional 
epithelium, 2 mm sulcus, and 0.5 mm for 
soft tissue rebound). 

It is this enhanced distance that is of con- 
cern for the clinical dentist since the issues of 
adequate tooth support and esthetics come 
into play. This distance ranging from a very 
conservative 3 mm to as much as 5.5 mm 
exposed root is a frequent deterrent to per- 

forming surgical crown lengthening. It is also 
important to remember that the term bio- 
logic width is as much a proportional rela- 
tionship as it is just a vertical measurement. 
Additionally, biologic width appears to be a 
changing reality that is altered by the pres- 
ence of inflammation, hormones, medica- 
tions, tooth position, and age, just to name a 
few. It should be known that the original 
work was performed on human cadavers and 
not living patients. 5 

A clinical reality known to all in dentistry 
but seldom defined is that there is also a 
horizontal measurement to the biologic 
width. The chronic inflammation around an 
over-contoured crown with excessive labial- 
lingual dimensions, even though the vertical 
relationship of the biologic width is intact, is 
an all too common reminder of this princi- 
ple. Figure 5.2 is a clinical example of a 
restoration that seemingly did not violate 
the vertical dimensions of the biologic 
width but is over-contoured on the labial, vi- 
olating the horizontal dimensions and pro- 
ducing inflammation and spontaneous 

A final note regarding biologic width con- 
cerns other terms that are commonly and in- 
terchangeably used to describe it. Although 
these are presented for the sake of linguistic 
accuracy, they do not have a tremendous 
negative clinical impact if used as synonyms 
(see Figure 5.3). 

The foregoing was basically a discussion 
about average histological entities that are 

Figure 5-2. Inflammation when the horizontal 

width is violated. 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 101 



Dentogingival Uni t 

•Junctional Epithelium 
•Gingival Fibers 

Attachment Apparatus 

•Junctional Epithelium 
•Principle Fibers 
• Cementum 
•Alveolar Bone 

Figure 5-3. The dentogingival unit with junctional epithelium and gingival fibers. 

determined by microscopic methods that 
are not readily available to clinical dentistry 
It is important that the clinician use these 
measurements only as a guide and evalu- 
ate each clinical situation on its own 

A Treatment Plan for Surgical 
Crown Lengthening 

Treatment planning for all procedures in 
dentistry follows similar steps leading up to 
the procedure itself. The process becomes 
nearly intuitive with the experienced practi- 
tioner. So much so that that person might 
need to pause and think if asked how the 
final decision was obtained, even though he 
or she probably used a step-by-step approach. 
Table 5.1 indicates a typical process lead- 
ing to a decision for surgical crown length- 
ening. It is meant as a directional guide only 
since each case has a myriad of modifying 
clinical factors. The individual elements with 
expanded information are presented in the 
following sections. 


Medical advances have sustained lives and in 
general improved the lives of our patients. 
However, determining the true medical sta- 
tus of the patient and the influence of med- 
ications on the body in general and the oral 
cavity in particular has become exceedingly 
complex. It is beyond the scope of this chap- 
ter to enter into the myriad possibilities of 
medications, medical conditions, and their 
influence on surgical crown lengthening pro- 
cedures. Each practitioner should become 
knowledgeable in this area before any surgi- 
cal procedure is undertaken. A localized sur- 
gical endeavor with a high degree of success 
can become disastrous if the body cannot 
heal properly. 

Oral Cavity 

As with all clinical determinations, the visual 
and tactile senses combine with experience 
to provide the most accurate diagnosis. Table 
5.2 summarizes some of the common clini- 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 102 



Table 5-1. A Treatment Plan for Surgical Crown Lengthening 

Data Collection 

Medical — determination of influence of medical status/medications on crown lengthening. Potential of patient 

to successfully undergo surgery. Limitations imposed by medical conditions. 
Oral — periodontal probings/sounding measurements, radiographic interpretations, notation of inflammation, 

amount of keratinized tissue, esthetic and structural concerns, and deviation from normal. 


A collation of all data into a statement of the problem (for example, subgingival decay 2 mm below the bony 
crest with insufficient space for the biologic width, which requires surgical crown lengthening before 
restorative procedures). 

Presurgical Procedures 

Consultation — presentation to the patient of the diagnosis; indicated corrective procedure(s); options, if any, 
and the pros and cons of each; explanation of the procedure; prognosis if performed; potential conse- 
quences if not; how procedure is performed; time requirements; postsurgical expectations; financial 
considerations; how the surgical procedure fits into the overall dental plan; and other items the patient 
needs to know and understand. 

Debridement and Oral Hygiene — necessary cleaning procedures and oral hygiene techniques to reduce 
inflammation. Also includes proper use of antibiotics and other antimicrobials. 

Informed Consent Form — serves as a legal document and as a review for the patient. 

Surgical Procedures 

Operator/ Set Up — includes gathering necessary instruments, organizing clinical data, and creating a sterile 

surgical environment 
Surgery — performing the actual surgical procedure, remembering always the goal of the technique. 


Immediate Postoperative — instructions to the patient on the care of the surgical site, dietary requirements, 
prescribing appropriate antibiotics and analgesics, and setting sequences for follow-up appointments. 

Monitoring the Healing — when the patient is seen, what is done, and the time before restorative or other 
procedures can be accomplished is dependant on the type of surgery performed (for example, flap or 
gingivectomy, overall patient healing, and other factors). 

Restorative Procedures 

Determination of when restorative procedures can be effectively completed without negating the surgical 
result. Also applies to orthodontics. 

cal methods for determining biologic width 

Periodontal Probings 

Periodontal probings should be accom- 
plished and recorded for not only the 
tooth/teeth in question but also the adjacent 

areas; particularly those that are healthy and 
can be used as comparative references. 
Notation from the probings should indicate 
pseudopockets, those with increased prob- 
ings because of gingival enlargement versus a 
true pocket caused by inflammation. The 
preceding should also be differentiated from 
a true violation of the biologic width. 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 103 



Table 5-2. Clinical Indications of Biologic Width Violations 


Pain is frequently elicited upon gentle probing around a restoration 


Especially diagnostic when the surrounding areas are free of pathology. 

Direct Measurement 

Under local anesthetic, a periodontal probe is pushed vertically from 
the sulcus through the attachment tissues (JE and connective 
tissue) until the underlying bone is contacted. A measurement of 
2 mm or less apical to the restoration margin/decay/fracture may in- 
dicate insufficient biologic width to maintain health, although there 
are many clinical variations. This process should be compared with 
similar measurements on adjacent healthy teeth. 







Figure 5-4. Sounding: the total sounding depth - suclus depth = biologic width. 


See Table 5.2 and Figure 5.4. Using a peri- 
odontal probe to determine the actual posi- 
tion of the bone remains the most accurate 
clinical method available. Once again, the 
total clinical probing depth (usually taken 
from the gingival margin to the alveolar 
bone) minus the pocket (sulcus) depth 
equals the vertical height of the biologic 
width. Local anesthetic is needed to provide 
adequate comfort for this procedure. 

Although this technique actually perfo- 
rates the sulcus and the underlying tissues, 
properly done there appears to be no sus- 
tained clinical damage. As with the general 
probings, adjacent healthy environments 
should be sounded and recorded as reference 

An important addition to the preceding is 
a horizontal measurement of the associated 
gingival tissues. This measurement can be 
useful in determining whether excision of 
the tissue is indicated or an internal beveled 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 104 



flap with apical positioning is necessary. The 
periodontal probe is pushed horizontally 
through the gingival tissues until the tooth 
or the alveolar bone is encountered and then 
recorded. Similar horizontal measurements 
are made through surrounding healthy tis- 
sues. Since one of the objectives of crown 
lengthening is to produce tissues that are 
similar in horizontal thickness to those that 
are healthy, this is a particularly important 

Radiographic Measurements 

Radiographic evaluations are fairly accurate 
in determining interproximal bone levels and 
then, by extrapolation, adding in the vertical 
necessities for the biologic width. However, 
bone position on the labial and palatal as- 
pects and possible biologic width violations 
in these areas are lost due to superimposition 
of oral structures (see figures 5.5 and 5.6). 

Conventional periapicals/bite-wings 
should be taken via the paralleling technique 
to achieve the greatest accuracy. Use of a ra- 
diographic grid placed over a periapical x-ray 
before exposure can improve radiographic 
measurement accuracy 7 (see figure 5.7). 

Digital radiographs have improved diag- 
nostic interpretations since the image can be 
manipulated, magnified, and colorized to en- 

Figure 5-5. Paralleling technique. Periapical x- 
ray showing extension of decay into the biologic 
attachment area. 

Figure 5-6. X-ray indicating violation of biologic 
width from extension of crown margin. 

hance bone level identification; density de- 
terminations can be performed; reverse im- 
ages can be created; subtraction radiographic 
images can be created; and so on. Digital ra- 
diography can greatly enhance the ability to 
determine bone/attachment relationships. As 
digital radiography technology advances, this 
may become a primary tool for bone loca- 
tion and its relationships with the overlying 
soft tissues (see Figure 5.8A-C). 8 

With both types of radiographs it is im- 
portant to have x-rays of the surrounding 
areas with which to compare against the tar- 
get area. 

Radiographs can also be important in de- 
termining whether the lesion in a tooth is 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 105 



Figure 5-7. Use of measurement grid in a radi- 

decay or resorption. The differentiation is 
important since stopping resorption is gener- 
ally less predictable than stopping decay 
This difference might lead to a treatment 
method other than trying to retain the tooth 
such as extraction and restorative tooth re- 
placement (see Figures 5.9 and 5.10). 

Subjective Considerations 

An important part of data collection leading 
to a definitive diagnosis and treatment plan 
involves the motivations of the patient. 
Surgical procedures of all types produce 
wariness in our patients not commonly evi- 
dent in routine dental procedures. An opin- 
ion should be formed prior to any surgery 

Figure 5-8A. Digital radiograph of a lower molar 

Figure 5-8B. Digital manipulation of the original 
radiograph, such as seen here with increased 
brightness and contrast, enables the operator to 
see another type of view. This can enhance clini- 
cal diagnostic capabilities 

Figure 5-8C. Here is a digital radiograph with 
image reversal (positive view). This is especially 
good when looking at the alveolar crest of bone 
and furcations. 

about the feelings of the patient relative to 
the surgical procedure itself. 

Does the patient agree with the need for 
this procedure and/or want to have it per- 
formed? Can the patient emotionally un- 
dergo a surgical procedure? What is the per- 
ception of this patient's ability to tolerate 
pain? Are the patient's final outcome expec- 
tations realistic? What if these expectations 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 106 



Figure 5-9. Radiographic evidence of resorption 
into the biologic width. X-ray shows relationship 
of resorption to the bony crest, shows endodontic 
involvement, and shows a low probability of 

are not met? Are there any phobias that 
might prohibit a successful surgical proce- 
dure such as needles, the sight of blood, 
and so on? Can the patient devote the 
requisite time for the procedure and the 
postoperative healing? 

This is just a small sampling of questions 
that need to be answered before any surgery 
It is important to have the patient with us 
not only medically but also emotionally A 
positive attitude is a well-known necessity for 
all surgical procedures. 

The Diagnosis 

The importance of a definitive diagnosis can 
never be understated. The diagnosis embod- 
ies a mental organization of all the data col- 
lected and then put into a concise directed 
whole that includes the totality of one's edu- 
cation and experience. It should be consid- 
ered the most important part of the treat- 
ment process since it is the director of 
technique and probable outcome. No 
amount of technical wizardly can compen- 
sate for an erroneous diagnosis. 

The wife of one of my dental continuing 
education course participants once ap- 
proached this author with some thoughts on 
the importance of the diagnostic process. 

Figure 5-1 OA. Consider the consequences of 
crown lengthening in this case. 

Figure 5-1 OB. Radiograph of tooth in 5-1 OA 
prior to fracture. There was decay around the 
post, a deep sliver of tooth (distal) came out with 
the crown, and the tooth is short from a previous 
apico. This tooth is not a good candidate for sur- 
gical crown lengthening. 

She (eminent and successful in her own 
field) was of the opinion that dentists were 
missing the point about the diagnostic pro- 
cedure. She wondered why there was a ten- 
dency in dentistry to monetarily give away 
the diagnosis and charge so much for the 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 107 



technical procedure. In her field, the opinion 
(diagnosis) represented the totality and ex- 
pertise that only she could give — thus, the 
diagnosis was more important than the ac- 
tual procedure itself. Diagnosis sets the stage 
for everything else. 

The definitive diagnosis leading to the 
need for surgical crown lengthening can en- 
compass many factors but usually breaks 
down to just two statements: 1) a violation 
of the biologic width or 2) excessive gingival 
enlargement. Both of these two clinical situ- 
ations will be explored in depth below. 

Presurgical Procedures 

Before the actual surgery procedure is per- 
formed, there are several factors that must be 
considered. They are all important in favor- 
ably influencing the outcome of a case. 

Oral Hygiene 

The two major indications for surgical 
crown lengthening, biologic width violations 
and gingival enlargement, both display char- 
acteristics of inflammatory periodontal dis- 
ease. It is well established that meticulous 
oral hygiene is a necessary part in the control 
of this inflammation. It is also well known 
that surgical procedures in the oral cavity 
without control of the oral bacteria struggle 
at best. 9 " 11 

The patient should receive proper oral 
hygiene instructions and demonstrate an 
ability/willingness to keep the area free of 
bacteria prior to surgery. This is especially 
important when the surgical site is in an es- 
thetic zone. Surgical healing in a highly in- 
flamed area generally lacks predictability as 
to the final position of the soft tissue. 12 


Ideally, a thorough debridement (the term 
used to include both hand instrumentation 
and mechanical cleaning methods) coupled 

with proper oral hygiene should precede the 
surgical procedure by three weeks. This pe- 
riod of time gives full soft tissue healing and 
can enhance predictability of the final posi- 
tion of the soft tissue after a surgery. This is 
also the time in which to evaluate the pa- 
tient's ability and willingness to maintain the 
surgical area and keep it healthy. 


Proper use of antimicrobials, which includes 
oral rinses, local release antimicrobials, and 
systemic antibiotics, may help to reduce in- 
flammation presurgically If indicated, these 
products can enhance the predictability of 
the final position of the soft tissue margin, 
an important issue when esthetics is in- 
volved. "The bang for the buck" occurs 
when antimicrobials are used concomitantly 
with proper oral hygiene and debridement, 
as indicated previously. 

A Final Show and Tell 

When the preceding has been accomplished 
and the surgical site is as healthy as it is 
likely to become, a final evaluation with the 
patient should be considered. Most patients 
have a limited understanding of oral 
anatomy (the why of the procedure) and 
might have forgotten or misunderstood the 
process and the intended final outcome. 

This is the point in the process at which 
to visually show in the patient's own mouth 
what the procedure will accomplish and 
what it is likely to look like postsurgically 
This can also be demonstrated via models, 
alterations of the patient's own models, pho- 
tographs, and computer-generated designs. 
The intent and the need are to enhance the 
patient's understanding and truly have them 
with us in the process. Since many crown 
lengthening procedures are done largely for 
esthetic purposes, the show and tell becomes 
doubly important. Sometimes the patient's 
expectations are beyond reality. 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 108 



This is also a time to answer questions, to 
allow the patient to express concerns, and to 
build confidence in the patient before the ac- 
tual procedure. Most surgical crown length- 
ening is limited to small areas and is viewed 
by the dentist as a minor procedure. It is 
well to remember at this point the tongue- 
in-cheek definition of a minor surgery — any 
surgery that is performed on anyone other 
than oneself. Most patients view minor sur- 
geries as something more major. 

Informed Consent 

The informed consent form is usually given 
immediately before beginning the surgical 
procedure. Informed consent forms are more 
than just a perceived legal requirement. As 
important as it is as a legal document, in- 
formed consent is an invaluable tool to make 
certain that the doctor and the patient are 
on the same page. A consent form given to 
the patient already in the dental chair with 
the surgical procedure looming over them 
can be quite intimidating to the patient. 

Properly worded, the consent form can 
both serve the legal necessities and give the 
patient a final review. The patient should 
have the opportunity to ask final questions 
and receive clarifications. All too frequently 
the patient scribbles a hurried signature and 
dismisses the document as an irritation 
rather than an invitation for dialogue. 

Form 5-1 is a typical consent form for a 
surgical crown lengthening procedure. Since 
there are many local, national, and interna- 
tional legal requirements, this sample should 
be viewed as a formation guide only. There 
are forms available from local dental soci- 
eties, continuing education courses, or legal 

Gingival Hypertrophy and Crown 

As described previously there is a propor- 
tional relationship between the sulcus depth 

and the soft tissue attachment above the 
alveolar bone, which is necessary to maintain 
health around the tooth. An increased 
pocket depth due to increased gingival 
height (gingival hypertrophy or clinically 
noted as gingival enlargement), even though 
the soft tissue attachment is within normal 
limits, violates that relationship. This pro- 
duces a pocket that may lead to periodontitis 
and/or create esthetic problems. Orthodontic 
appliances, medications, and genetics may 
play significant roles in producing gingival 

Orthodontics and Gingival 

Young patients in orthodontic braces com- 
monly produce gingival hypertrophy. This is 
more a result of poor oral hygiene and chang- 
ing hormones than irritation from the brack- 
ets themselves. However, some studies have 
shown that orthodontic appliances and the 
food and plaque accumulation on them 
changes the microbiology in the sulcus, mak- 
ing gingivitis more common than in those 
not in braces (see Figures 5.1 1 and 5.12). 15 ' 16 

Clinical and radiographic measurements 
generally indicate a normal biologic width, 
but with greatly increased sulcus depth due 
to gingival hypertrophy. Initially the increase 
in gingival size can easily be reduced by de- 
bridement and enhanced oral hygiene. If 
not rapidly reduced by these nonsurgical 
methods, the gingival tissues become fibrotic 
and will need surgical crown lengthening 

Some gingival enlargements during ortho- 
dontic treatment might be extensive enough 
to inhibit normal tooth eruption and/or 
prohibit normal orthodontic movement. A 
common problem encountered is gingival 
growth into diastemas, which prevents nor- 
mal orthodontic closure. Gingival hypertro- 
phy has become a major issue in dentistry 
with the increase in the numbers of young 
patients undergoing orthodontic treatment. 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 109 

Patient Information / Consent for Crown Lengthening 

1 . I have been informed and I understand the purpose and the nature of the periodontal 
surgical procedure(s). 

2. Dr. has carefully examined my mouth. Alternatives (if any) have been explained. 

3. I have been informed of possible risks and complications that may be involved with the 
surgery, which may include: pain, swelling, infections, medication/anesthetic reactions, and 
damage to other oral structures. 

4. I understand that if nothing is done, there is likely to be continuing inflammation and bone 

5. I understand that restoring the tooth or teeth may not be possible without crown lengthen- 
ing procedures. 

6. I understand that there is no method to accurately predict the healing capabilities in each 
patient and that there is no guarantee of success. 

7. I understand that such factors as smoking, hormonal disorders, medications, and other 
systemic disorders may affect the overall outcome. 

8. I agree to report to the doctor for postoperative examinations as instructed. 

9. To my knowledge, I have given an accurate report of my physical and mental health 
history. I have also indicated on the health history any allergic reactions, diseases, 
medications, herbs, and any past problems with surgical procedures. 

10. I request and authorize dental procedures for me, including crown lengthening surgery. 
I understand that during and following the contemplated procedure or treatment, 
conditions may become apparent which warrant, in the judgment of the doctor, additional 
or alternative treatments. I also approve any modification in design, materials, or care, if it 
is felt this is for my best interest. 

Signature of Doctor Signature of Patient 

(If patient is unable to sign or is a minor, 
signature of parent or legal guardian) 

Date Relationship to Patient 


Form 5-1 


2879_Koerner_Chap 05 4/17/06 1:26 PM Page 110 



Figure 5-11. Gingival enlargement in orthodon- 
tics. The gingival enlargement in this young per- 
son is due to orthodontic braces, poor oral hy- 
giene, and probably hormonal factors. This 
enlargement is a violation of the proportional 
relationship of the biologic width concept, even 
though the actual biologic width is intact. 

Figure 5-12. After crown lengthening proce- 
dures. This shows healthy gingiva and a return to 
a normal biologic width relationship, indicating 
that the main issue was gingival enlargement 
and not a vertical loss of junctional epithelium/ 
connective tissue/bone. 

Gingival Enlargement from 

Drug-induced gingival enlargement is now a 
well-known side affect of many medications. 
In the past only a limited number of drugs 
such as phenytoin (Dilantin) were known to 
cause gingival changes. 17 An explosion in 
new medications has produced a long list of 
drugs that can cause significant and sus- 
tained gingival hypertrophy. These include 
but are certainly not limited to immunosup- 

Figure 5-13. Medication-induced gingival hy- 
pertrophy. These gingival enlargements were 
produced by a calcium channel blocker taken for 
high blood pressure. Gingival hypertrophy caused 
by one medication is not substantially clinically 
different from other medication-induced enlarge- 
ments, although some medications may produce 
more rapid growth of the gingival tissues. 

pressants, anticonvulsants, and calcium 
channel blockers (see Figure 5.13). 

As a class, the clinician is most likely to 
encounter gingival enlargement from the 
calcium channel blockers than other medica- 
tions since they are prescribed for a wide 
range of cardiovascular problems. 18-20 
Clinically, the appearance and treatment of 
the gingival enlargements does not differ 
from one drug category to another. 

Gingival hypertrophy from drug induc- 
tion poses three distinct problems for the 

1 . The hypertrophy may occur and enlarge 
even in the presence of good oral hygiene. 
Although good oral hygiene may reduce 
the speed of gingival enlargement, most 
studies and clinical experience indicate 
that good hygiene cannot prevent it. The 
author s clinical experience is that the pa- 
tient can significantly inhibit gingival 
growth with good oral hygiene and fre- 
quent debridements but usually cannot 
totally prevent the process. This is partic- 
ularly frustrating to the patient since there 
are few preventive measures other than to 
not take the medication. Alternative drugs 
that do not produce gingival enlargement 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 111 



may be explored in consultation with the 
patient's physician. However the cessation 
of one medication and introduction of 
another is frequently a long process with 
an additional list of side affects. 

2. The entire mouth may be involved. 
Normally, most crown lengthening needs 
are limited to one or two teeth. With 
medication-induced gingival enlargement, 
much of the mouth may be affected, mak- 
ing the surgical procedure (s) much more 
complex. The esthetic and function prob- 
lems for the patient can be significant. 

3. The surgical crown lengthening procedure 
may need to be repeated, sometimes fre- 
quently. As long as the patient is on the 
offending medication, hypertrophy is 
likely to continue. Cessation of medica- 
tion intake may reduce the gingival size. 
However, this usually requires several 
months to a year if a reduction is to occur. 

Crown lengthening procedures in patients 
with drug-induced gingival enlargement re- 
quire a careful evaluation of the patient's 
medical status, the ability to heal from a sur- 
gical procedure, and an interaction between 
the physician and the dentist. This then be- 
comes more complicated than the treatment 
of a single tooth biologic width violation. 

Genetic Factors in Gingival 

This section is presented only to indicate 
that genetics frequently is a factor in hyper- 
trophy Some of the examples are so rare 
that they bear repeating only to the point that 
they do exist. Some of these rare gingival en- 
largements are connected to overall systemic 
issues, which may make surgical treatment 
difficult to manage or even dangerous to the 
patient. Most patients should be in the hands 
of skilled specialists. The role of most dental 
practitioners in these rare forms of gingival 
enlargement is to differentiate them diagnosti- 
cally from other forms of hypertrophy. 

For most practitioners, the role of genetics 
is significant only in determining why tissue 
regrowth occurs after the surgical procedure. 
Since these traits tend to follow a familial 
line, the dentist may be able to form a clini- 
cal opinion about regrowth potential before 
the crown lengthening by examining other 
family members. The presence of similar 
gingival enlargements in others of the same 
family is a good indicator of the role of ge- 
netics. Unfortunately this evaluation is usu- 
ally made after the surgical healing indicates 
significant tissue regrowth. There are cur- 
rently no clinically viable genetic tests to as- 
sist the dentist (see Figure 5.14). 

Operatory Set- Up and Patient 

The next step as we draw closer to the sur- 
gery is to make sure adequate attention has 
been given to preparing the surgical suite (op- 
eratory). The following two sections review 
important aspects of this phase of treatment. 


In the past, only cursory attention was given 
to sterility issues in surgical procedures per- 
formed in the oral cavity. This was largely 

Figure 5-14. Genetic-induced gingival enlarge- 
ment. Other family members have similar gingival 
enlargement with an absence of other factors that 
can produce hypertrophy. 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 112 



due to the misperception that the mouth 
was a bacterially contaminated environment 
that could not or need not be controlled. 

In addition it has also been argued that 
one cannot control the sterility of the aver- 
age dental operatory to the level of a hospital 
surgical suite. Although these are essentially 
correct statements, contamination of the oral 
cavity by bacteria from without or contami- 
nation of deeper structures in the oral cavity 
during a surgical procedure, however minor, 
can have serious consequences. The stan- 
dard of care is to treat the oral cavity surgi- 
cally with as high a level of sterility as one 
can achieve in the dental operatory. 

All surgical instruments should be steril- 
ized, and the dentist should become familiar 
with, practice, and incorporate into the den- 
tal office strict sterile techniques. The basic 
tenet is that only sterile surfaces should con- 
tact sterile surfaces. Most surgeries require 
that an additional staff member not involved 
in the sterile environment be available to get 
instruments, charts, and other items not part 
of the sterile triangle, which is that area in 
the immediate vicinity of the doctor, the as- 
sistant, and the patient. 

Sterile gowns for the dental staff and the 
patient as well as surgical packs (either laun- 
derable or single-use disposable) should be 
part of the normal surgical setup. The den- 
tist and dental staff can receive training in 
how to create sterile surgical packs from vari- 
ous continuing education sources or from a 
local hospital. 

A frequent weak link in dental office 
sterility is the water source. Many culinary 
water sources worldwide have high bacterial 
counts, which, when used during surgical 
procedures, may inject infective microorgan- 
isms directly into surgical sites. 

In addition, the numerous small-diameter 
tubes in dental carts can concentrate bacteria 
and allow a significant bacterial biofilm to 
form in the tubes, even from culinary water 
sources considered to have low bacterial 
counts. These bacteria are then forced into 

the surgical site during rinsing procedures. 
There is mounting evidence that these con- 
taminants may have significant infective 
properties, particularly in patients who have 
decreased immune response mechanisms. 
True sterile water sources should be used 
during oral surgical procedures. 

Surgical Instruments 

Table 5.3 lists some the instruments com- 
monly used in the various types of crown 
lengthening procedures. Since there are so 
many individual preferences among sur- 
geons, the instruments are listed under six 
broad categories — diagnostic, debridement, 
incising, reflection (for flap surgeries), bone 
resection (where indicated), and closure — 
with a few examples of each category listed. 

A common layout for surgical instrumen- 
tation is to place the instruments on the 
surgical tray in the order used. Surgeries 
typically require more instruments/supplies 
on a tray in the operatory than many other 
dental procedures. It may be necessary to 
obtain a larger tray, such as a Mayo tray, to 
contain them in a sterile environment. 
Instruments spread over many surfaces invite 
contamination and instrument dropping (see 
Figure 5.15). 

Crown Lengthening-Gingival 

This type of crown lengthening is primarily 
a "subtraction" procedure that eliminates re- 
dundant or excessive soft tissue. The main 
considerations for its implementation are 
presented in the following sections. 

Surgical Indications 

Surgery may be indicated for the following 
conditions of gingival enlargement: 

1 . A suprabony pocket (a pocket that is 
caused solely by gingival enlargement): 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 113 

Table 5.3 Common Surgical Instruments for Crown Lengthening 












Mouth mirrors 


Scalpel handle 

High-speed hand- 

Needle holder 

Periodontal probe 

Ultrasonic scaler 


piece with #4, 

Suture (see discussion) 

Furcation probes 

such as #15, 

#8 round 

Suture scissor 


#1 5c, or #12 
Kirkland knife 
Orban knife 
Curved scissors 

carbide burs 
Rhodes chisel 
Wedelestadt chisel 
Bone files 

Flap Reflection 





Of choice, many available Add a fine-tip surgical 

2x2 gauze 

Kirkland knife 

Add some long-acting drugs 

evacuator in addition 

Cheek retractor such 

such as bupivicaine and 

to the saliva tip 

as a Bishop 


Hemostatic gauze 
Ice packs 

Figure 5-15. Typical surgical tray setup. Note the oversized tray to contain the instruments in one sin- 
gle sterile area. Tray is covered with a sterile cover. Instruments are arranged in the approximate order in 
which they will be used. 


2879_Koerner_Chap 05 4/17/06 1:26 PM Page 114 



These are common during orthodontic 
procedures and from certain medications 
(see previous discussion). Although these 
pockets may have an intact biologic 
width, they still represent potential 
bacterial traps which can lead to bone 

2. A soft tissue enlargement that prohibits 
proper restorative/orthodontic procedures: 
Oftentimes these enlargements are the 
result of an inflammatory process associ- 
ated with carious lesions or a defective 

3. An esthetically unacceptable tissue en- 
largement, especially in the anterior areas: 
The so-called delayed passive eruption 
(actually a very active process) whereby 
soft tissue is significantly coronal to the 
CEJ (the gummy smile) is a typical exam- 
ple. Many of these enlargements are of a 
horizontal nature and do not represent a 
pocket or bacterial trap per se. These hor- 
izontal enlargements are sometimes 
known as soft tissue pearls. Note: All of 
the preceding presupposes that proper 
oral hygiene and nonsurgical debridement 
have not resolved the gingival enlarge- 
ments. Nonsurgical approaches should 
precede any surgery. 

Surgical Techniques 

The gingivectomy and the flap technique are 
the two most commonly used surgical meth- 
ods when the issue is gingival hypertrophy. 
Both have advantages, appropriate applica- 
tions, and disadvantages, which will be de- 
tailed later in this chapter. Both should be 
viewed as tools, which are most appropriate 
or least appropriate in a given clinical situa- 
tion rather than as an either/or technique. 
The given clinical situation and the experi- 
ence of the surgeon usually dictate which 
technique is used. The internal thinning of 
gingival enlargements (internal beveled inci- 
sion/flap) will be covered in the section deal- 
ing with flap surgery. 


The gingivectomy technique was the domi- 
nant surgical technique in periodontics prior 
to the introduction of the flap and osseous 
contouring methods. Since then it has been 
relegated to a minor role, that role largely 
being excision of gingival enlargements in 
the course of crown lengthening procedures. 

By definition gingivectomy means the 
excision of the gingiva. Gingivectomies have 
or are performed via lasers (most commonly 
the CO 2 and Nd:YAG lasers), electrosurgery 
chemicals (usually a paraformaldehyde or 
potassium hydroxide solution, although 
there are several private formulations), and 
the scalpel. There are enthusiastic adherents 
to each method, with each having a list of 
pros and cons. The overall outcome of each 
of the techniques appears to be coequal, with 
the final result more dependent on the clini- 
cal abilities and experience of the dentist 
using that method than on the method itself. 
Since the scalpel is a universally available 
item, it will be the featured instrument in 
this chapter. 

Presurgical Considerations of the 
Gingivectomy Technique 

A distinct advantage of the gingivectomy is 
its relative simplicity. Tissue is excised to the 
shape and contour desired or needed. How- 
ever, a gingivectomy produces a fairly large 
surface wound that tends to produce a dis- 
proportionate amount of postoperative 
discomfort and hemorrhage. The lasers and 
electrosurgical units control well the hemor- 

The excision of the enlargement also re- 
moves some of the keratinized tissue in the 
reshaping process, which, if excessive, might 
lead to insufficient keratinized tissue to pro- 
tect the tooth. This then may require 
mucogingival replacement procedures. Prior 
to using the gingivectomy as a technique, 
the clinician should ascertain whether or not 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 115 



sufficient keratinized tissue will remain to 
maintain health. If not, an alternate method 
should be considered, most likely a flap tech- 
nique. If the gingivectomy is still deemed the 
most appropriate method even if protective 
keratinized tissue is lost, then the eventuality 
of soft tissue grafting should be included in 
the pretreatment planning. 

The Gingivectomy Technique 

Figure 5.16 shows the basic procedure of a 
gingivectomy. The following steps expand on 
the separate points: 

1 . Anesthetic. An anesthetic of choice is 
used for either local infiltration and/or 
block anesthesia, as the situation dictates. 
Generally the gingival tissues are directly 
injected with 1:50,000 epinephrine to 
better control hemorrhage. 

2. Sounding. General pocket probing and 
diagnostic sounding are performed to ver- 
ify the position of the alveolar bony crest 
(review Table 5.2 and Figure 5.4). 
Horizontal sounding is done at this point 
also to help guide the amount of buccal- 
lingual tissue reduction necessary. 

3. Incision. The incision can be made with 
a scalpel handle containing an insert such 
as a #15, #15-C, or #12 blade. There are 
periodontal knives such as the Kirkland, 
Orban, and Buck knives that can also be 

The incision is made at the point nec- 
essary to accomplish the restorative or es- 
thetic goals. For example, make the inci- 
sion apically far enough to expose the 
decay in the tooth for restorative proce- 
dures or to excise enough tissue so that it 
esthetically matches the surrounding areas 
(esthetic sculpting). 

The incision most commonly used is a 
beveled incision at approximately a 45- 
degree angle to the tooth, recreating a 
normal festooning shape. This incision 
penetrates the entire gingival thickness 

until the tooth surface is contacted. A 
similar incision at a similar beveled angle 
is made on adjacent teeth as needed to 
provide a normal contour. 

An alternative method is to make the 
incision at the desired point with the in- 
cising instrument at a 90-degree angle to 
the tooth. This creates a soft tissue ledge, 
which can then be smoothed out with a 
scalpel, scissors, electrosurgery or high- 
speed rotary instruments such as a course 
diamond or carbide bur. 

With the gingivectomy technique tis- 
sue can be removed as close to the bone 
as necessary without removing the soft 
tissue covering (periosteum). If the bone 
needs to be exposed to accomplish the de- 
sired goal, then a full-thickness flap tech- 
nique with osseous resection should have 
been chosen. Exposing the bone usually 
creates an extended healing time. 

A point that we can learn about the 
gingivectomy technique is that the entire 
biologic width is oftentimes removed 
without any clinical consequences. 
That is to say, that the entire attachment 
tissues (JE, connective tissue that form 
the biologic width, and the sulcus) are 
totally removed, but they regenerate 
without significant hypertrophy. This 
means that the body re-forms this unit 
apically by controlled bone loss. This will 
be the basis for the discussion on flap 
techniques in crown lengthening that 
4. Tissue Removal and Shaping. The ex- 
cised tissue collar is removed from the 
tooth, and the surgical area is shaped to 
match normal physiologic contours. The 
festooning can be done with a sharp 
scalpel, scissor, high-speed rotary burs, or 
other instruments/devices. The surround- 
ing undisturbed areas can be used as a vi- 
sual template for this process. Be certain 
to remove any soft tissue tags directly 
against the tooth surface since these irreg- 
ularities produce unwanted tissue growth 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 116 



Figure 5-16A-G. Localized gingivectomy show- 
ing initial sounding with the incision made at a 90- 
degree angle to the tooth and then shaped with a 
sharp #8 round carbide bur and scissors. The inci- 
sion could or can be at a 45-degree angle with 
similar results. Hemostatic gauze has been ap- 
plied, and a three-week result is shown. 

up the tooth. This is also the time to 
thoroughly clean the tooth surface, a 
process that enhances healing generally. 
Ultrasonics are particularly useful in the 

cleaning process since the water coolant 
acts as a lavage in the surgical area. 
5. Protecting the Site and Controlling 
Hemorrhage. Since this is an open 

2879_Koerner_Chap 05 4/17/06 1:26 PM Page 111 



Table 5-4. Postoperative Patient Care for Crown Lengthening Procedures 

Gingivectomy Technique 

Flap Procedures 

Apply a hemostatic gauze or medical-grade 

cyanoacrylate directly to the surgical site. Apply 

additional sustained positive pressure with gauze 

and ice packs 

Patient maintains the compresses for at least 

two hours 

An alternative is to apply a periodontal dressing 

Patient topically applies chlorhexidine (CHX) to the 

area twice daily. Brushing should not touch the 

gingival areas (stimulates tissue regrowth) 

Avoid chewing in the surgical site, but do maintain 

a high nutritional and fluid intake 

Approriate antibiotics/analgesics 

Appropriate antibiotic coverage 

Positive pressure with gauze and ice packs 

Patient maintains the compresses for at least two 

An alternative is to apply a periodontal dressing 
Patient topically applies chlorhexidine to the 
surgical site twice daily. No brushing or flossing in 
the surgical area 

Avoid chewing in the surgical site, but do main- 
tain a high nutritional and fluid intake 
Suture removal at one week with a continuation 
of CHX for an additional week 

wound, the site may need to be protected 
with a periodontal dressing or a cyano- 
acrylate adhesive (which also has slight 
hemostatic properties). There is also a va- 
riety of hemostatic gauze strips available 
that effectively control bleeding and that, 
when combined with sustained positive 
pressure, can eliminate the need for bulky 
periodontal packings. 18 

6. Postoperative Care. Although postopera- 
tive care for a surgical technique rarely 
earns a spot equal to the technique itself, 
this author believes that the postoperative 
care given for a gingivectomy may largely 
determine the final result. Since this is an 
open wound, irritation from bacteria, oral 
hygiene, and chewing may cause undue 

Table 5.4 summarizes typical post- 
operative care and instructions for a gin- 
givectomy technique. 

7. Healing Summary. If the excision of gin- 
gival hypertrophy was to facilitate restora- 
tive procedures or to commence or finish 
orthodontic procedures, then it is impor- 
tant to know when the surgical site will 
be ready for those procedures. Healing 
studies parallel what is seen clinically with 

the exception of the production of a sta- 
ble sulcus. Surface epithelization and 
keratinization appears to be complete 
in about four weeks, according to re- 
search and clinical observation. The re- 
establishment of the biologic width is at 
about eight weeks. 22 

The greatest frustration for the patient 
and dentist trying to complete the restorative 
process after a gingivectomy is more likely to 
be the absence of a sulcus rather than one 
that is too deep. A general clinical experience 
is that a normal stable sulcus after a gingivec- 
tomy in which tissue was removed to the 
bone (the most common occurrence) may 
not occur for up to six months. Restoring a 
surgical area too soon may expose the gingi- 
val margin as the sulcus forms. This occur- 
rence is dependant upon many factors that 
may be difficult to determine. Where possi- 
ble restorative procedures should be delayed 
until there is evidence of a stable sulcus. 

Gingivectomy Summary 

The gingivectomy technique can be applied 
to the majority of the cases requiring surgical 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 118 



Figure 5-17. Gingival hypertrophy around den- 
tal implants caused by a combination of genetics 
and irritation from a removable device. Mentally 
plan the incision point/angle of incision and soft 
tissue reshaping. The dotted line shows the posi- 
tion of alveolar bone, and the solid line indicates 
the position of the mucogingival junction. 

crown lengthening. By following basic surgi- 
cal and postoperative guidelines, the gin- 
givectomy can create a consistently pre- 
dictable surgical result. Only those cases 
where the decay or a root fracture is below 
the bony crest, as distinguished from those 
that are supracrestal biologic width viola- 
tions, need flap procedures. And as will be 
seen under the flap procedure section, the 
majority of the flap procedures require little 
or no osseous removal to provide a healthy 
environment. See Figure 5.17. 

Esthetic Sculpting 

Esthetic sculpting is the term commonly ap- 
plied to the removal of excessive gingival tis- 
sue largely for aesthetic rather than health or 
functional reasons. This so-called gummy 
smile problem is noted when the soft tissue 
is significantly coronal to the position ex- 
pected for the age group, giving the appear- 
ance that the teeth are submerged into the 
gingival tissues. In the adult, the expected 
gingival position would be at or near the ce- 
mentoenamel junction (CEJ). Figure 5.18 
shows a clinical situation in which the gin- 
giva covers nearly one-half of the distance 
between the CEJ and the incisal edge in an 

adult patient. The tissues are otherwise 

Because the vertical dimension of the 
teeth is covered with gum tissue, there is the 
appearance that the teeth are short, square, 
and squatty. This appearance is most trou- 
blesome to the patient when it occurs in the 
anterior teeth, the upper anterior teeth in 
particular. Although a pseudo-pocket is pres- 
ent in these situations, it is uncommon for 
these to degenerate periodontally since oral 
hygiene procedures are not compromised, 
and a healthy attachment apparatus is gener- 
ally present. The issue is mainly esthetics. 
This should not, however, deter the dentist 
from suggesting a procedure that could im- 
prove the general appearance. 

Presurgical Consultation 

Elective surgical procedures in dentistry usu- 
ally require more explanations by the dental 
staff and an enhanced understanding by the 
patient than nonelective procedures. The fact 
that the impending surgery is elective means 
that it is the patient's option. The conse- 
quence of not having the surgery done is 
probably not related to oral health, just 

A second consideration is that esthetic 
sculpting in the upper anterior may quickly 
and dramatically alter a patient's appearance. 
This sudden change is most likely a positive 
one, but it does nonetheless change the 
image that the patient may have had of 

The author remembers a young patient 
who was excited about getting rid of her 
gummy smile, which she stated she had al- 
ways hated. At the end of the procedure, she 
burst into tears when she saw the change 
and was inconsolable, although family mem- 
bers and the dental staff praised the positive 
changes. Two days later she contacted the of- 
fice and apologized for her behavior and en- 
thusiastically proclaimed how much she 
loved the new look. The rapid change to 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 119 



Figure 5-18A-F. Esthetic sculpting. 

how she had seen herself for so many years 
was initially an emotional shock. 

Dental models, photographs of previous 
patients, a potential final look as generated 
by computer programs, and cautious testi- 
monials are frequently needed. Usually this 
should be a soft-sell approach so that the pa- 
tient does not feel pressured. The other side 
of the equation is that the satisfied patient is 
frequently an enthusiastic advocate for the 

Clinical Evaluations 

Sounding to bone should be accomplished 
so that an accurate mental picture of the 
bone position can be made (review Figure 
5.4 and Table 5.2). An evaluation of how 
much keratinized tissue will remain must 
also be determined. If the excision of the 
gingival tissue is likely to leave insufficient 
keratinized tissue to maintain health, then 
the need for soft tissue grafting should be 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 120 



part of the treatment plan or another tech- 
nique chosen, such as an apically positioned 
flap procedure. Since this an elective sur- 
gery there is also the option not to do the 

Appropriate x-rays (see the previous dis- 
cussion) are cross-referenced with the sound- 
ings and other clinical observations. The po- 
sition of the lip line and the extent of the 
smile should also be noted. A wide smile and 
a high lip line may necessitate extending the 
excision of tissue into the posterior areas for 
a better esthetic result. Restoration margins 
that might be uncovered may need to be re- 
placed postsurgically 

Surgical Procedure 

Most of the aesthetic sculpting surgical pro- 
cedures are gingivectomies as previously 
stated. Occasionally a flap procedure is indi- 
cated when tooth structure beyond the alve- 
olar bone needs to be exposed. 

An appropriate anesthetic is administered. 
Since this is a gingivectomy procedure with 
excision of what is sometimes large amounts 
of surface tissue, 1:50,000 epinephrine in- 
jected directly into the tissues is a help in 
hemorrhage control. Dry 2X2 gauze 
should be in ready supply. Unfilled gauze 
more quickly absorbs blood than does the 
filled variety. 

Since this procedure typically involves 
several adjacent teeth it is usually advanta- 
geous to identify the lead tooth, the one 
which will determine the height and shape 
of the others. This may be a tooth that al- 
ready has a normal height or contour and to 
which the others must be matched, or it may 
be a tooth that, due to its position or rota- 
tion, is the limiting factor for the process. 
Figure 5.18 indicates how one tooth be- 
comes the lead for the others. 

A beveled or 90-degree incision is made 
midfacial at the desired apical level of the 
lead tooth, and the incision is carried into 
the mesial and distal interproximal areas. 

The excised tissue is then removed. The sur- 
geon should be careful not to extend the in- 
cision lingually beyond the contact point of 
the teeth since to do so usually causes verti- 
cal recession in the interproximal areas and 
produces an unaesthetic space devoid of tis- 
sue (the euphemistic "bullet hole" or "black 

If the patient is able to view the surgical 
procedure, it is helpful to have them com- 
ment on the initial height of the lead tooth. 
Remember that one can always remove more 
tissue but replacing it is difficult. Therefore, 
a conservative approach is best until the de- 
sired result is achieved. 

Similar procedures are performed on the 
adjacent teeth. The author has found that 
starting with the central incisors in the mid- 
line (unless there is a different lead tooth) 
and then proceeding laterally produces the 
best results. There are distinct advantages to 
facing the patient when doing the initial in- 
cisions since this gives the most realistic view 
of the process. Comments from staff mem- 
bers and others who may be in the operatory 
are invaluable. 

Some clinicians advocate that up to 25 
percent additional tissue be removed to com- 
pensate for tissue regrowth. Regrowth of this 
magnitude has not been routinely noted by 
this author. Because of this clinical observa- 
tion, consider making the final tissue posi- 
tion at the desired height. Additional tissue 
removal may lead to an excessive display of 
tooth structure and may needlessly remove 
keratinized tissue. 

After the apical height of all teeth is estab- 
lished, the tissue bulk on the labial can be 
thinned into the embrasures to achieve the 
desired scallop and shape. This can be done 
with scissors and rotary burs, at the surgeons 
discretion. Electrosurgical units and lasers 
should be used with great caution since they 
can inadvertently cause recession or bone 

Remember the caution stated previously 
about removing tissue beyond the contact 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 121 



point. This rule is violated only if restorative 
procedures, such as veneers or crowns, are to 
be placed since they need additional lateral 
width and additional space to the lingual. 

Postoperative Care 

Refer once again to Table 5.3 for a summary 
of postoperative procedures. Uncontrolled 
hemorrhage can lead to clot organization 
and an irregular surface. Use of hemostatic 
gauzes, sustained positive pressure (normal 
gauze rolled up like a pencil over the hemo- 
static gauze), and an ice pack with applied 
pressure for 1—2 hours is quite effective. 

Chlorhexidine is topically applied to the 
area twice daily to control the oral bacteria. 
The patient should be instructed not to di- 
rectly brush the gingival areas for two weeks 
since this irritation delays healing, increases 
discomfort, and may cause irregular gingival 

Systemic antibiotics are not routinely 
used, being common only where antibiotic 
prophylaxis for systemic purposes is indi- 
cated. The chlorhexidine applied to the area 
controls the bacterial population until nor- 
mal oral hygiene procedures can be resumed. 

The patient is typically seen in one week 
for reevaluation. Any small tissue regrowths 
can be removed at this time if necessary with 
a minimum of discomfort since nerve end- 
ings are not fully established. The patient is 
seen again at three weeks, at which time 
normal oral hygiene is reinstituted. Another 
evaluation is made at six weeks, assuming 
that a normal healing course has occurred. 
Maintenance for gingivectomies should 
include a three-month recall prophylaxis 
with tissue evaluations in the surgical area 
for the first year postoperatively and then as 

Esthetic Sculpting Summary 

Esthetic sculpting is a predictable procedure 
that can produce enhanced esthetics for pa- 

tients exhibiting a smile with excessive tissue. 
Dentistry is much more than a technical dis- 
cipline concerned only with oral health. It is 
well-established that a portion of the mental 
psyche revolves around physical appearance, 
either real or perceived. The teeth and gum 
relationships contribute greatly to that over- 
all personal perception. Although listed as an 
elective procedure, more and more patients 
are requesting it for personal reasons. 

A Conservative Flap Procedure 
for Crown Lengthening 

The majority of cases requiring surgical 
crown lengthening can be handled by the 
gingivectomy techniques as previously de- 
scribed. The limited numbers requiring a 
flap procedure can be done with less bone 
removal and better esthetics by understand- 
ing and applying the actual necessities of the 
biologic width rather than the perceived re- 
quirements as dictated by studies of the past. 
This approach also takes into account 
changes in restorative methods and materials 
that do not require extensive exposure of the 
tooth surface. 

Revisiting the Biologic Width 

Clinical crown lengthening procedures are 
guided by research on the proportional rela- 
tionships among the sulcus, junctional ep- 
ithelium, and the connective tissue overlying 
the alveolar bone. Traditionally, clinicians 
have been instructed to allow between 3 and 
5.5 mm of vertical height between the 
restorative margin and the alveolar bone for 
the preceding clinical structures. This rep- 
resents a significant problem in that most 
surgical procedures must remove supporting 
bone to fulfill these objectives. This may 
compromise tooth support and/or alter facial 
esthetics (see Figure 5.19). 

Although the following represents the au- 
thor's personal clinical experiences, the con- 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 122 



Figure 5-1 9A. Reviewing the suitability of a 
tooth for crown lengthening. There is adequate 
attached gingiva in this case. If crown lengthening 
is performed, the tooth will most likely end up with 
a longer clinical crown, which, depending on the 
patient's smile line, could have adverse esthetic 

elusions have been universally the same. This 
is less a challenge to established studies and 
more a support for clinical realities for 
achieving the proportional relationships es- 
tablished by that research. Basic premises are 
given here: 

1 . The total amount of sound tooth struc- 
ture that needs to be exposed is substan- 
tially less today due to improved restora- 
tive techniques and materials. Most 
restorative dentists need only a couple of 
millimeters of sound tooth above the gin- 
gival margin in order to complete the 
restorative procedure. 

2. Bone removal is necessary only when 
there is a restorative need below the bony 
crest or a need to esthetically expose more 
tooth than is allowed by an excision of 
soft tissue only (gingivectomy). Both of 
the preceding are relatively uncommon 
occurrences. After flap reflection (except- 
ing the preceding two examples), there is 
usually enough space between the tooth 
margin and the bone to apically position 
the flap without bone removal. This rep- 
resents either an inflammatory degenera- 
tion or the natural space occupied by the 
biologic width. See Figure 5.17. 

Figure 5-1 9B. The radiograph shows good os- 
seous support for the proposed crown lengthen- 
ing. However, the tooth should be provisionalized 
until after the endodontic treatment has proved to 
be successful, and then the periodontal surgery 
can be performed. 

Figure 5-1 9C. Model of this case, with vertical 
measurements denoting the biologic width. 

3. If the soft tissue flap is placed at the bony 
crest, the body will automatically provide 
the height necessary for the biologic 
width, presumably by biologic resorption 
of enough bone to accommodate it. 
Clinical experience verifies this phenome- 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 123 



non. Consider the gingivectomy case in 
which the soft tissue is removed to the 
bone. A stable final healing result without 
coronal soft tissue regrowth shows a nor- 
mal sulcus and normal attachment (as re- 
vealed via sounding techniques), again 
presumably due to physiologic resorption 
of bone to allow such. The summary 
point is that if a soft tissue flap is placed 
at or coronal to the crest of bone, the 
body will resorb adequate bone to estab- 
lish a sulcus and biologic attachment 
without the bone removal advocated by 
traditional means. So rather than remov- 
ing bone to allow space for the 3 -mm bi- 
ologic width, place the flap directly at the 
bony crest and let the body form the req- 
uisite space below the flap. This can pre- 
serve at least 3 mm of bone, improve 
tooth stability, and provide enhanced es- 
thetics (see Figure 5.20). 

Surgical Indications for a Flap 

Flap procedures in crown lengthening may 
be indicated over the gingivectomy tech- 
niques in the following cases: 

1 . When only a limited amount of attached 
keratinized tissue is present in the pro- 
posed surgical site. In those cases in which 
removal of keratinized tissue by the gin- 
givectomy would likely create mucogingi- 
val defects and/or create the need for soft 
tissue replacement procedures, a flap 
procedure might be the indicated 
method. A reflected flap with apical 
positioning can preserve and actually 
enhance the amount of keratinized tis- 
sue available by secondary intention 

2. When restorative needs are apical to the 
osseous crest and there is an obvious need 
to remove bone. This may be deep caries, 
resorption, or fracture of the clinical 
crown or root. This represents a severe 

Figure 5-20A. Crowns on teeth numbers 8 and 
9 with overextended margins into the biologic 
width and accompanying chronic inflammation. 

Figure 5-20B. Probing reveals the pocket 

Figure 5-20C. It is not uncommon with cases 
such as this for the body to physiologically (via in- 
flammation) resorb bone in an attempt to regain 
the needed biologic width. 

condition and may necessitate tooth re- 
moval if too far apical to the bony crest. 
3. When the alveolar bone is healthy and at 
the normal height but procedures require 
the soft tissue height to be more apical 
than is possible with tissue excision (gin- 
givectomy). This is the case when restora- 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 124 



tive or esthetic needs must extend beyond 
the CEJ. This is found when the clinical 
crown height is genetically short and/or 
the esthetic needs require crown height 
beyond the CEJ, such as in preparation 

r veneers or crowns. 

Flap Presurgical Evaluations 

Flap procedures are decidedly more complex 
than gingivectomies. They introduce the 
need for suture and suturing techniques to 
maintain a moveable flap in position. Thus, 
the clinician must know and understand the 
varieties and merits of each suturing tech- 
nique. In addition there may be the need to 
remove bone, which demands knowledge 
about alveolar bone, tooth support, and the 
physiology of bone healing. 

Since crown lengthening is a localized 
procedure surrounded by normal and usually 
healthy tissues, any flap procedure must take 
into account the potential effect flap dis- 
placement may have on these tissues and the 
overall esthetic impact. Decisions must also 
be made regarding flap design and the exten- 
sion into healthy areas. 

Bone removal may be necessary in order 
to accomplish the final goal. Tooth stability 
issues must, therefore, be addressed — that is, 
how much bone to remove, how much bone 
can be removed, and the impact on the in- 
tegrity of the tooth. Radiographic analysis, 
thus, becomes important. Localized bone re- 
moval generally requires more decisions, sur- 
gical skill, and presurgical evaluation than a 
flap procedure that encompasses much of a 

It is at this point that the clinician should 
make the decision to treat or refer to a spe- 
cialist. The decision to refer or not is usually 
made on the basis of perceived clinical fac- 
tors, potential complicating issues, and the 
skill and experience of the treating dentist. 

As with the other crown lengthening pro- 
cedures, the target area should be made as 
healthy as possible via proper oral hygiene 

and debridement procedures well before the 
surgical procedure is performed. Healthy tis- 
sues heal more predictably during surgical 
healing than do those that are inflamed. 

The Flap Technique in Surgical 
Crown Lengthening 

This section details the more complicated, 
serious, and aggressive type of crown 
lengthening. It requires more knowledge 
and experience to diagnose and treat suc- 


Since flap procedures generally require more 
time to perform than the gingivectomy and 
may be perceived by the patient as a major 
surgery, sedative techniques may be indi- 
cated. Local anesthetic is administered into 
the surgical site and also to an area distant 
from the actual flap since reflection tech- 
niques produce some pressure to the sur- 
rounding tissues. It is generally useful to 
inject anesthetic containing 1:50,000 epi- 
nephrine directly into the tissues to help 
control any hemorrhage. 

Sounding Techniques 

These are performed with a periodontal 
probe to determine the topography of the 
underlying bone. This should also be per- 
formed laterally into adjacent nonsurgical 
areas. The intent of sounding in flap crown 
lengthening procedures is to help produce a 
mental image of the bony topography. A 
knowledge of the shape and position of the 
bony crest is even more important in flap 
procedures than it is in gingivectomies. 

Flap Design 

See Figure 5.21. Flap design is the intended 
path of the incision. For crown lengthening 
there are three elements that determine the 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 125 



Figure 5-21 A. Preoperative view from the 

Figure 5-21 B. Preoperative view from the 

Figure 5-21 C. Flap design (proposed flap inci- 
sions). The flap design is as such to allow full clo- 
sure of interproximal soft tissue. 

overall path of the incision (s). These are pre- 
sented in the following paragraphs. 

The first consideration is to choose an in- 
cision path that will help maintain the maxi- 
mum amount of the keratinized tissue. If 

Figure 5-21 D. Flap reflected away from bone to 
allow visualization, debridement, and apical repo- 
sitioning of soft tissue. 

Figure 5-21 E. Flap apically repositioned and 
sutured in place. No bone was removed and yet 
there is adequate tooth structure above the gingi- 
val margin for restorative purposes. 

there is only a minimal amount of kera- 
tinized tissue available, then the incision 
should be in the sulcus or no greater than 
0.5—1.0 mm below the free gingival margin. 
This maintains the maximum amount of 
keratinized tissue and at the same time al- 
lows the flap to be elevated. 

A second guiding principle is the need to 
thin bulky tissues. If the need is to just de- 
tach thin soft tissue from the bone, then the 
blade angle ranges from 45 degrees to almost 
parallel with the long axis of the tooth, either 
in the sulcus or slightly apical to the gingival 
margin. If the tissue is bulky and needs to be 
thinned internally, then an internal bevel in- 
cision can largely accomplish this at the same 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 126 



Figure 5-21 F. Buccal view of healing at four 

Figure 5-21 G. Occlusal view of healing at four 

time that the tissue is released from the un- 
derlying bone. 

The third element in flap design is to 
create a flap that will cover the maximum 
amount of bone but at the same time allow 
the flap to be placed where needed. Each 
clinical situation requires its own unique 
flap design. Since it is not possible to de- 
scribe or diagram every case, the principles as 
stated previously become the guides for the 

Internal Bevel Incision 

The internal beveled incision is a basic part 
of most flap surgeries. The intent of the in- 
ternal bevel incision in crown lengthening is 
to thin the tissue of the flap so that it forms 
a flap margin that will adapt to the tooth 
and bone in a normal relationship. 

It consists of three separate incisions (see 
Figure 5.22). The first incision (also called a 
reverse-bevel incision since the blade-to- 
tissue angle is the reverse of the gingivec- 
tomy) is designed to thin the tissues inter- 
nally, leaving the surface keratinization 
intact — just the opposite of the gingivec- 
tomy The blade, which can be a #15, #15-c, 
#11, or one of the #12 series blades, is in- 
serted into the tissue until bone is contacted. 
This is at an angle that will leave the external 
tissue flap at the desired thickness. This is 
then carried into the interproximal areas. 
Since this path of incision usually leaves 
thicker tissue interproximally than on the 
labial surfaces, a second incision is required 
to internally thin the interproximal tissues 
before flap reflection. 

The final incision is used to detach the re- 
maining tissue from the tooth. The point of 
the scalpel blade or other thin surgical in- 
strument is placed in the sulcus vertically 
along the long axis of the tooth. This inci- 
sion is forced to the alveolar bone crest, ef- 
fectively detaching the collar of tissue next to 
the tooth. 

This technique is best understood from 
diagrams since written descriptions tend to 
make it more complex than it really is. Study 
Figure 5.22 for a visual approach to under- 

The internal-bevel incision approach can 
also be used to thin gingival hyperplasia 
rather than using the gingivectomy tech- 
nique described previously. This miniflap 
procedure retains the surface tissue intact 
and may allow the flap to be collapsed onto 
the bony crest and the surface of the tooth 
in a manner that may produce a better es- 
thetic/functional result than excision of the 
surface tissue. The dental practitioner should 
have the knowledge and ability to perform 
both where indicated. 

Restated, the flap design (incision) should 
allow coverage of as much bone as possible 
with the soft tissue flap, allow the flap to be 
placed where needed, provide an appropriate 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 127 



First Incision 

Second Incision 

Figure 5-22. Three incisions of the internal-beveled incision technique. 

thickness of soft tissue, and preserve kera- 
tinized tissue. It is well to mentally review 
the preceding principles in each clinical case 
before the initial incision. The final flap de- 
sign usually determines many elements in 
the final product. 

The previously described incisions and 
flap design produce a flap that when elevated 
is called an envelope flap. Although this may 
be sufficient to expose adequate tooth struc- 
ture for minor violations of the biologic 
width, deep caries and/or a deep coronal 
fractures require that the flap be positioned 
more apical than is possible with a envelope 
flap. This may require vertical incisions, also 
called vertical releasing incisions. 

These incisions can be made at one or 
both ends of the flap as the situation de- 
mands. They allow the entire flap to be 

placed apically without loss of keratinized 
tissue. These vertical incisions are usually 
made at the line angles of teeth so that clo- 
sure of the vertical incisions is not over the 
radicular surface of a tooth and so that the 
papillae are retained. Incisions are made to 
bone, extending apically beyond the 
mucogingival junction into the vestibule far 
enough that the flap can be elevated and po- 
sitioned apically without excessive muscle 
tension. See Figure 5.23. 

Flap Elevation 

Flap elevation can be accomplished via two 
methods or a combination of both: 

1 . Split- thickness flaps are created at the 
same time as the flap design incisions are 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 128 



Figure 5-23. Vertical releasing incisions with a 
full mucoperiosteal flap. Note how the interproxi- 
mal tissue and the position of the alveolar bone 
have been retained (no bone has been surgically 

done, as indicated previously. All or a por- 
tion of the keratinized attached tissue is 
elevated to the mucogingival junction 
using blunt dissection (a periosteal eleva- 
tor, Kirkland knife, or similar instrument) 
producing a full-thickness mucoperiosteal 
flap. This miniflap is gently retracted and 
with a scalpel or similar sharp surgical 
blade placed parallel with the underlying 
bone; the tissue is incised vertically into 
the vestibule, leaving a portion of the 
connective tissue on the bony surface. 
Split-thickness flaps may offer the ability 
to tightly suture the mobile portion of the 
flap against the alveolar bone. 

2. Full- thickness flaps are created by blunt 
dissection, separating the mucoperios- 
teum from the bone. This full-thickness 
flap is necessary when bone removal is 
needed to expose an additional amount of 
the tooth. An incision is made intra- or 
subsulcular to bone. The entire mucope- 
riosteum is reflected with a periosteal ele- 
vator or similar instrument. This full- 
thickness reflection is extended into the 
vestibule far enough to allow the flap to 
be positioned where desired without undo 
muscle tension. Review Figure 5.23. 

3. A combination of the preceding two 
methods (partial thickness and full thick- 
ness) is useful when bone must be re- 
moved and yet the flap rigidly held in 

position. Initially a full- thickness mucope- 
riostial flap is elevated by blunt dissection 
apically, exposing the requisite amount of 
tooth or bone. The incision is then con- 
tinued into the vestibule, creating a split- 
thickness flap, as described previously. 

Surgical Site Evaluation 

When the flap has been elevated, the tooth 
and bone interface should be examined. This 
is the important time to determine whether 
the tooth is restorable. Occasionally the ex- 
tent of carious destruction or amount of re- 
sorption is such that the tooth cannot be re- 
stored. There may be also an undetected root 
fracture not visible by clinical methods. Flap 
entry with direct visualization is frequently 
the only method to determine these things. 
Alternative methods may then be needed 
such as extraction. 

A thorough evaluation of the bony sup- 
port should also be accomplished. Does any 
bone need to be removed to accomplish the 
objectives? If so, how much needs to be re- 
moved, and what are the consequences for 
the tooth support and general esthetics? 
Does the flap need to be elevated an addi- 
tional distance laterally or apically? In sum- 
mary, should alternative techniques be con- 


Debridement is the term that covers all tech- 
niques used to clean the tooth and remove 
inflammatory products. These can be me- 
chanical instruments such as ultrasonics and 
rotary burs or hand instruments such as 
curettes and surgical tools. All can be used 
coequally at the individual dentist's discre- 
tion. A bacteria- and inflammation-free envi- 
ronment heals quickly, predictably, and with 
reduced postoperative pain. 

The tooth should be cleaned free of all 
plaque and calculus deposits. The end-point 
determination (when the process is com- 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 129 



plete) is the same as with scaling and root 

Granulation tissue (a combination of bac- 
teria, their inflammatory products, and par- 
tially destroyed soft tissue and bone) is now 
removed from the alveolar bone. This is es- 
pecially important at the bone-tooth inter- 

Some granulation tissue is usually present 
on the underneath side of the soft tissue flap. 
This can be removed with a pair of sharp 
curved scissors or a carefully placed scalpel. 

These procedures have now replaced an 
inflammatory wound having a diminished 
capacity to heal with a surgically created 
wound that has an enhanced healing ability. 
The entire surgical site should now be thor- 
oughly flushed with a sterile solution such as 
sterile water or sterile saline. This flushing 
action can greatly reduce postoperative infec- 
tions and should be a part of all surgeries. 

Bone Removal 

The vast majority of crown lengthening cases 
need little or no bone resection/removal. In 
those cases that do need some bone re- 
moved, this can be accomplished by a variety 
of burs and hand instruments. 25 Review 
Figures 5.19-5.21, and 5.23. 

Rotary burs, in either high-speed or low- 
speed handpieces, can be used to remove the 
majority of the bone. Most commonly #4 
and #8 carbide or diamond round burs are 
used. Most studies indicate that the sharp 
carbide bur produces less heat and trauma 
when applied to the bone than a diamond 
bur. In any case there should be a copious 
water stream applied to cool the bur/bone 
and flush the debris away. 

Round rotary burs are initially and care- 
fully used to remove the requisite amount of 
bone immediately adjacent to the tooth. 
Only enough bone needs be removed from 
around the tooth to allow the restorative 
procedures to be performed or to allow ade- 
quate tooth height for esthetic needs. As 

mentioned several times already, there only 
need to be 1—2 mm of tooth above the gin- 
gival margin to accomplish most restorative 

There is also a class of end-cutting burs 
available that can remove the bone next to 
the tooth. 2 These burs have some advan- 
tages over the round burs in that they are 
less likely to nick the tooth during bone 

The round burs are then used to create 
and shape natural physiologic contours 
around the tooth and into the interproximal 
areas (sometimes called sluicing). The intent 
of this osseous shaping is to create a form to 
which the soft tissue flap can adapt. A gen- 
eral principle is that the shape of the bone 
determines the form of the soft tissue. 

Hand instruments are typically used to re- 
fine and remove small amounts of bone im- 
mediately adjacent to the tooth. These hand 
instruments are generally kinder to the root 
surface than the burs. These can be sharp 
curettes or specialized-for-the-process instru- 
ments such as the Rhodes back action chisel. 

Flap Stabilization 

The flap can now be manually placed to ver- 
ify that the flap design/incisions will allow 
the soft tissue to be placed where intended. 
Any minor reshaping of the flap can be done 
with curved scissors, scalpel, or other devices. 

Stabilizing the flap in the intended posi- 
tion throughout the healing phase is one of 
the mandatory principles of surgical crown 
lengthening. Most of the stabilization is ac- 
complished via sutures, the next topic. 
Suturing is commonly presented as a short 
statement — "and the flap is sutured in 
position" — giving the impression that it is a 
minor procedure all in dentistry intuitively 
know and understand. The realities are 
that the suturing techniques and to a lesser 
degree the type of suture used may deter- 
mine the success and failure of the entire 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 130 



Typically, the coronal portion of the flap 
is positioned and sutured first, and then any 
vertical incisions are closed. The reader 
should always remember that there is also an 
infinite variety of ways to accomplish the de- 
sired goal. 

Suture Types 

Dentists the world over have and do success- 
fully use a wide variety of suture materials. 
What is used seems to be determined by 
availability and/or personal experience. The 
successful use of a specific suture material 
seems to be related more to technique than 
specific type. An explosion of different su- 
tures made from many different materials 
make strict cataloging of sutures less precise 
than before. The categories presented in this 
section have many suture types that fit al- 
most as neatly in one category as another. 
The following is presented as a guide more 
than a specific recommendation. 

Absorbable (resorbable) sutures are ei- 
ther from synthetic or biologic sources. They 
offer the advantage of not needing to be re- 
moved and as a class show less irritation 
where they contact the tissue. They also 
show little tendency to wick bacteria into the 
surgical site. They may suffer from a dissolu- 
tion either more or less rapid than wanted. A 
secure knot usually requires several reversing 
ties and sustained tension on the suture ends 
to prohibit the knot from unraveling 
(known as suture memory). 

Nonresorbable sutures, of course, are 
those that require removal. This group in- 
cludes such diverse materials as silk (perhaps 
the most used material worldwide), stainless 
steel, and a large group of synthetic formula- 
tions. Sutures such as silk are easy to tie and 
maintain the knot well without multiple ties. 
However, silk wicks significant bacteria into 
the suture penetration site, which can be a 
concern in thin tissues. The foregoing is 
meant to stimulate investigation into the 
various sutures available, how to use them in 

clinical situations, and the relative merits 
of each. This, as with oral hygiene proce- 
dures, is an area that can enhance general 
surgical treatment when the proper choices 
are made. 

Suturing Techniques 

The gingival flap, whether split-thickness or 
full-thickness mucoperiosteal, must be held in 
an immobile position until it is biologically 
anchored to the underlying connective tissues 
or bone. This is the role of the suturing. As 
with the sutures themselves, several tech- 
niques can nicely accomplish this task. An ex- 
perienced surgeon may use several different 
suturing methods in a single surgical site, 
thus emphasizing that there is likely no single 
universal method; only the proper applica- 
tion of techniques. The suturing methods 
that follow are those most likely to surface in 
a discussion of how to immobilize a soft tis- 
sue flap in crown lengthening procedures. 

Single Interrupted 

These are the simplest to use, consisting of a 
single penetration of the flap on the buccal 
surface, through the flap on the lingual, and 
then a single tie. They can nicely appose two 
flaps together or a flap to unreflected tissue 
for a full and tight closure. The single inter- 
rupted suture is also the most commonly 
used method to close any vertical releasing 
incision. The sutures may, however, cause 
bunching of the flap if pulled too tightly. 

Vertical Mattress Suturing Technique 

The vertical mattress suturing technique is a 
modification of a technique used in wound 
closure in medicine. In dentistry the pres- 
ence of teeth necessitates modifying a med- 
ical technique that is designed solely for ap- 
position of soft tissue. For most cases of 
crown lengthening, this is an invaluable su- 
turing method because it apposes the mobile 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 131 



flaps toward each other and pulls the flap(s) 
downward toward the bone without bunch- 
ing. This anchors the flap tightly against both 
the tooth and the underlying bone, thus 
minimizing excess tissue at the tissue-tooth 
interface. The vertical mattress suturing tech- 
nique is likely the preferred method in sutur- 
ing the areas immediately adjacent to a tooth. 

It is slightly more difficult to learn than 
the single interrupted method but is well 
worth the learning. The accompanying dia- 
gram shows the basics visually (see Figure 
5.24A and B). 

A teaching dictum that the author has de- 
veloped to go along with the visual diagram 
is stated as, a The suture goes from the out- 
side to the inside' and from the 'inside to the 
outside' of the buccal flap, over the bone 
(which is interproximal if teeth are present), 
then from the outside to the inside' and 
then the 'inside to the outside' of the palatal/ 
lingual flap. It then backtracks over the bone 
to tie at the starting point." If the tie is made 
close to the initial suture penetration point, 
then the flap is compressed to the bone 
without bunching the tissue up the tooth 

Sling Suture 

The sling suturing technique is used by 
many to allow the flap some vertical move- 
ment during normal functional healing. The 
theory is that the flap will assume a natural 
position relative to the muscle pull. 

The flap is manually positioned, and then 
the suture from the outside flap is sutured to 
the inside flap, and a tie is made so that the 
suture itself limits the vertical extent of flap 
movement. This then allows both flaps some 
back-and- forth movement but is restricted 
by the suture. 

A variation to the preceding is to place 
the suture through the flap, around the 
tooth, through the flap, around the tooth 
again, with a tie at the starting point (a true 
sling). In order to hold a flap in position 

Figure 5-24A. Diagram of the author's vertical 
mattress suture technique to apically repostion 
buccal and lingual flaps used for surgical crown 
lengthening. This suture anchors the flaps tightly 
against both the tooth and the underlying bone. 

Figure 5-24B. Diagram of a vertical mattress 
suture that shows a variant of the one illustrated in 
Figure 5-24A. 

with the sling methods, a periodontal dress- 
ing is frequently necessary. 

Suture of Vertical Incisions 

Generally the last areas of a flap to be closed 
are the vertical incisions (if created). Slight 
apical tension is placed in the area of the ver- 
tical incisions by pulling the lip or cheek api- 
cally with the same tension on either side of 
the incision. This then will bring the soft 
tissue lateral to the incision into a proper 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 132 



relation. While holding this position (either 
the doctor or an assistant), single interrupted 
sutures are placed along the length of the in- 
cision. Enough tension is placed on the su- 
ture during knot tying to appose the two 
halves of the flap so that they close tightly 
but without significant overlap or bunching. 
If the knot is tied without apical tension on 
the flap, then the tissues bunch together, 
forming scar tissue at maturity, which is at 
the same time a weakness in healing and an 
esthetic defect. 

After the suturing is complete, the flap 
should be compressed against the tooth and 
underlying bone. Compression can be done 
with sustained digital pressure, gauze com- 
presses, and/or ice packs. The intent of this 
compression is to express out excess blood 
and allow a fibrin clot to form with the 
bone. Failure to adequately compress the 
surgical site may lead to clot formation, de- 
layed healing, and increased postoperative 
pain and infection. 

Postoperative Care 

Most flap surgeries should have antibiotic 
coverage. There is ample research and clini- 
cal evidence of the positive healing effects of 
antibiotics to justify its common usage. 25 

The most commonly used antibiotics that 
are backed by credible research are the peni- 
cillins and the tetracycline compound doxy- 
cycline. Whatever is prescribed is most effec- 
tive when taken from one day to one hour 
prior to the procedure. This allows adequate 
time for the antibiotic to reach needed thera- 
peutic blood levels before the surgical proce- 
dure. The amount prescribed should be suf- 
ficient for a minimum of five days, which 
matches healing studies and normal matura- 
tion of the flap procedure. 26 

Antimicrobial oral rinses can effectively 
control the bacteria on the exposed surface 
areas of the surgical site and should be con- 
sidered postoperatively. Chlorhexidine 
(CHX) in all its formulations is considered 

as the most effective of oral rinses. At this 
writing it is considered the standard against 
which other rinses are compared. 27 

Calculus formation on hard surfaces and 
tooth staining are two worrying negative side 
effects of chlorhexidine (CHX) use. 
The author has long advocated the use of 
chlorhexidine postoperatively not as a full 
mouth rinse but as a topical application to 
the immediate surgical site only. CHX is 
topically applied with a cotton swab to 
the surgical area only twice daily. This puts 
the solution where it is needed and mini- 
mizes staining and calculus formation 

Periodontal dressings are used much less 
frequently now than in the past. Developed 
primarily to cover the large denuded surface 
areas of gingivectomies, periodontal dressings 
initially became a common part of the flap 
procedures. The bulk of the dressing, es- 
thetic concerns, the clinical observation that 
the dressings attract bacterial plaque, and an 
overall feeling that they are not necessary 
have greatly reduced usage. 28 Most practi- 
tioners rely on suture stabilization to hold 
the flap in place and prefer to have the surgi- 
cal area cleansed by oral rinses than to cover 
them with a surgical dressing. 

Ice packs can be applied to the surgical 
site to reduce overall swelling and also lessen 
postoperative pain. The ice packs should be 
applied as much as possible in a sustained 
manner for the first 24 to 48 hours. The 
cold from the pack not only reduces edema 
as indicated previously but also allows the 
patient to apply sustained positive pressure 
over the surgical area. 

Food intake should be altered as the sur- 
gery dictates. For localized crown lengthen- 
ings the patient may not have to change 
much in the dietary intake; simply be careful 
during chewing. For more extensive surger- 
ies, a softer diet and counseling about diet 
may be appropriate. It is well established 
that an increase in fluid intake is a necessity 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 133 



Suture Removal 

Sutures are removed in one or two weeks, de- 
pendant upon the overall healing and the 
technique performed. The most common 
time is at one week. After suture removal, 
CXH can be continued for one additional 
week, and then normal oral hygiene methods 
are initiated, or if healing is advanced, nor- 
mal brushing and flossing immediately 
follows. The important point is to control the 
bacteria postsurgically for optimum healing. 

Postsurgical Complications 

The well-known adage "the best cure is pre- 
vention" applies particularly well to surgical 
procedures of all types in the oral cavity. It is 
well documented that the more experienced 
one is surgically, the fewer are the complica- 
tions. Nevertheless, a small percentage of the 
cases do have some complications. Some of 
the most common are presented in this sec- 
tion with preventive methods listed and 
management for when they do occur. 


A small amount of bleeding occurs in most 
flap procedures. It is best prevented by pre- 
cise surgical incisions and suture techniques 
designed to tightly close the vertical releasing 
incisions (perhaps the most common site of 
prolonged hemorrhage) and sustained posi- 
tive pressure immediately after the surgery. 
Gauze compresses can be placed in the 
surgical area and the patient instructed to 
compress the site with ice packs for the first 
few hours. 

If there is a recurrence of bleeding in spite 
of the preceding, then the patient should be 
seen, and blood clots that may have formed 
under the flap removed with gentle suction 
and positive pressure reapplied. Infrequently 
the area may need to be resutured. 


As a prevention, antibiotics should be initi- 
ated before the surgical procedure. When in- 
fections do occur in spite of the above, the 
dentist should ascertain as much as possible 
the underlying cause (s) and initiate correc- 
tive procedures. Surgical debris left under the 
flap, prolonged hemorrhage with clot forma- 
tion and infection, and reduced patient sys- 
temic healing capacities are the most fre- 
quent issues. 

Most of these can be managed by gentle 
irrigation of the surgical site and either con- 
tinued antibiotic usage or changing to an an- 
tibiotic better suited to controlling the bacte- 
ria. The goal should be not only to correct 
the problem but also to prevent cellulitis, 
which is an infection that enters normal 
body cavities and spaces and that may re- 
quire a regimen of intravenous antibiotics. 


Several studies in medicine and dentistry 
have demonstrated the effectiveness of anal- 
gesics taken prior to the surgery, usually one 
hour prior. The modus operandi is that it is 
easier to prevent pain than to play catch up. 
This subject requires an intimate under- 
standing of the various analgesics and how to 
use them. Each patient is likely to be dis- 
tinctly different in their reaction to pain. 
Some insight into this can be learned by 
questioning the patient before the surgery 
about what they have used for other 

Healing Time before Restorative 

How long one should wait after a flap sur- 
gery before initiating restorative procedures 
is an oft-debated topic. There are several 
considerations, all dependent on actual clini- 
cal healing and on research studies. Most 
histologic studies have noted the presence of 

2879_Koerner_Chap 05 4/17/06 1:27 PM Page 134 



a mature epithelial surface and a well-defined 
biologic width at four weeks postsurgery 
(assuming normal healing). 19 Bone remodel- 
ing after osseous contouring or resection in 
crown lengthening can continue for up to 
six months postoperatively. 

The most frequent time table for healing 
after flap surgery and before restorative pro- 
cedures is six weeks or greater. 26 However, 
Kois indicated that it may take nearly three 
years in some patients for a stable gingival 
environment to form. 27 

The realities for the restorative dentist are 
the formation and maturation of a stable sul- 
cus. Unless there is adequate sulcus depth, 
impression techniques and tooth preparation 
may once again impinge on the biologic 
width, thus negating the effect of the crown 
lengthening. Restorative procedures begin- 
ning before the gingival site is healthy and 
mature may lead to gingival recession in thin 
tissue or inflammatory pocketing in thick 
tissue. A mature surgical site after flap proce- 
dures can take additional time beyond that 
described previously and is very case depen- 
dant. The best guide is to wait as long be- 
yond six weeks (mandatory minimum) as 
the situation will allow. The considerations 
listed previously are for a flap procedure 
only, the gingivectomy having a generally 
shorter healing time frame. 

Surgical Crown Lengthening 

This chapter has dealt with both diagnostic 
and treatment fundamentals of surgical 
crown lengthening. The intent has been to 
provide a clinically practical background that 
will allow the practitioner to use the funda- 
mentals and modify them for the individual 
cases. The assumption has been that the 
more complex things are, the more impor- 
tant are the basics. An almost infinite variety 
of treatment methods is available to the den- 
tal practitioner who understands the under- 
lining principles. 

As one explores the relationship between 
the tooth and the biologic width, one dis- 
covers many individual variations. These 
variations then require the dentist to modify 
the surgical approach. 28 

Surgical crown lengthening is still one of 
the underutilized procedures in dentistry. 
Granted that new dental materials and tech- 
niques have reduced the number of teeth re- 
quiring crown lengthening before restorative 
procedures, there are still many teeth that are 
compromised for lack of crown lengthening. 
By indicating the relative simplicity and pre- 
dictability of crown lengthening, this is a call 
to use the procedures more frequently where 

Finally, a more conservative crown length- 
ening procedure has been presented. This is 
one that uses the body's natural resorption of 
bone in most cases to provide the needed 
vertical height for the attachment fibers. This 
then allows a bone conservative/preservative 
approach to crown lengthening surgeries. 


1. H. Sicher. Changing concepts of the supporting 
dental structures. Oral Surgery Oral Medicine Oral 
Pathology 12: 31-35. 1959. 

2. A. Gargiulo, E Wentz, B. Orban. Dimensions 
and relations of the dentogingival junction in hu- 
mans. Journal of Periodontology 32: 26 1 . 1961. 

3. J. S. Vacek, M. E. Gher, D. A. Assad, et al. The 
dimensions of the human dentogingival junction. 
International Journal of Periodontology and 
Restorative Dentistry 14(2): 155. 1994. 

4. B. D. Wagenberg. Surgical tooth lengthening: 
Biologic variables and esthetic concerns. Journal of 
Esthetic Dentistry 10(1): 30-36. 1998. 

5. A. B. Wade. The relation between the pocket 
base, the epithelial attachment and the alveolar 
process. Les Parodontopathies. 16th ARPA 
Congress, Vienna, 1960. 

6. G. C. Armitage. Periodontal diseases: Diagnosis. 
Annual of Periodontology 1: 37. 1996. 

7. J. M. Goodson, A. D. Haffajee, S. S. Socransky. 
The relationship between attachment level loss 
and alveolar bone loss. Journal of Clinical 
Periodontology 11: 348. 1984. 

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8. M. K. Jeffcoat, I. C. Wang, M. S. Reddy. 
Radiographic diagnosis in periodontics. 
Periodontology 7: 54. 2000, 1995. 

9. G. Dahlen, J. Lindhe, K. Sato, H. Hanamura, H. 
Okamoto. The effect of supragingival plaque con- 
trol on the subgingival microbiota in subjects with 
periodontal disease. Journal of Clinical 
Periodontology 19: 802-809. 1992. 

10. T. Katsanoulas, I. Renee, R. Allstrom. The effect 
of supragingival plaque control on the composi- 
tion of the subgingival flora in periodontal pock- 
ets. Journal of Clinical Periodontology 19: 760. 

11. E. F. Corbet, W. I. Davies. The role of supragingi- 
val plaque in the control of progressive periodon- 
tal disease: A review. Journal of Clinical 
Periodontology 20: 307. 1993 

12. N. P. Lang, B. R. Cumming, H. Low. 
Toothbrushing frequency as it relates to plaque 
development and gingival health. Journal of 
Periodontology 44: 396^05. 1973. 

13. H. Loe, E. Theilade, S. B. Jensen. Experimental 
gingivitis in man. Journal of Periodontology 177. 

14. H. C. Sullivan, J. H. Atkins. Autogenous gingival 
grafts. Periodontics 6: 5-13. 1968. 

15. A. Diamanti-Kipioti, F. Gusberti, N. Lang. 
Clinical and microbiological effects of fixed ortho- 
dontic appliances. Journal of Clinical 
Periodontology 14: 326. 1987. 

16. M. Paolantonio, G. Girolamo, V. Pedrazzoli, et al. 
Occurrence of actinobaccillus actinomycetem 
comitans in patients wearing orthodontic appli- 
ances: A cross-sectional study. Journal of Clinical 
Periodontology 23: 112. 1996 

17. I. Glickman, M. Lewitus. Hyperplasia of the gin- 
giva associated with Dilantin (sodium dipheryl 
hydantoinate) therapy. Journal of the American 
Dental Association 28. 1941, 1991 

18. T.D. Daley, G. P. Wysocki, C. Day. Clinical and 
pharmacologic correlations in cyclosporine- 

induced gingival hyperplasia. Oral Surgery 62: 
417. 1986 

19. D. Lederman, H. Lummerman, S. Reuben, et al. 
Gingival hyperplasia associated with nifedipine 
therapy. Oral Surgery 57: 620. 1984. 

20. B. J. Russel, L. M. Bay. Oral use of chlorhexidine 
gluconate toothpaste in epileptic children. 
Scandinavian Journal of Dental Research 86: 52. 

21. F. A. Carranza, E. L. Hogan. Gingival enlarge- 
ment. M. G. Newman (ed.). Clinical Periodon- 
tology, ed. 9. Philadelphia, PA: Saunders. 2002. 

22. G. Stanton, M. Levy, S. S. Stahl. Collagen restora- 
tion in healing human gingiva. Journal of Dental 
Restorations 48: 27. 1969. 

23. T N. Sims, W. Ammons. Resective osseous sur- 
gery. M. G. Newman MG (ed.). Clinical 
Periodontology, ed. 9. Philadelphia, PA: Saunders. 

24. R. G. Caffesse, S. P. Ramfjord, C. E. Nasjleti. 
Reverse bevel periodontal flaps in monkeys. 
Journal of Periodontology 39: 219. 1968. 

25. J. Kois. Altering gingival levels: The restorative 
connection. Part 1 : Biologic variables. Journal of 
Esthetic Dentistry 6: 3. 1994. 

26. J. M. Goodson, A. D. Haffajee, S. S. Socransky 
The relationship between attachment level loss 
and alveolar bone loss. Journal of Clinical 
Periodontology 11: 348. 1984 

27. W. Becker, C. Ochsenbein, E. Becker. Crown 
lengthening: The periodontal-restorative connec- 
tion. Complete Continuing Education in Dentistry 
19: 239-254. 1998. 

28. A. B. Wade. The relation between the pocket 
base, the epithelial attachment and the alveolar 
process. Les Parodontopathies, 16th ARPA 
Congress, Vienna, 1960. 

2879_Koerner_Chap 06 4/17/06 1:32 PM Page 137 

Chapter 6 

Endodontic Periradicular 


Dr. Louay Abrass 


In the past decade the field of endodontics 
has seen numerous advances, the scope of 
which have reached all facets of endodontic 
treatment in both conventional and surgical 
aspects. These technological advances have 
introduced new instruments and materials 
that did not exist before and revolutionized 
the way endodontic treatment is performed. 
This change could not be more evident than 
in the field of surgical endodontics, where 
both theoretical and practical aspects have 
completely transformed. The purpose of this 
chapter is to present to the surgical-minded 
general dentist the current standards and 
techniques in performing apical surgery with 
evidence-based rationales. 

Problems with Traditional 
Endodontic Surgery 

Traditional apical surgery is viewed as an in- 
vasive, difficult, and less successful procedure 
than conventional endodontic treatment. 
Many reasons contribute to this, examples of 
which include working on a conscious pa- 

tient in an area with restricted access, limita- 
tions in visibility, and operating on minus- 
cule microstructures that are often obscured 
by bleeding. To manage these challenges, op- 
erators had to prepare large osteotomies to 
gain sufficient access that would accommo- 
date the large surgical instruments that were 
traditionally utilized. This unnecessary re- 
moval of healthy buccal bone structure 
sometimes resulted in incomplete healing. 
The root apex was routinely resected with a 
4 5 -degree bevel angle with no biological or 
clinical imperative. Such a practice was per- 
formed merely to allow visualization of root 
canal anatomy and to facilitate retroprepara- 
tion and retrofilling. This steep-bevel angle 
root resection created more problems than 
solutions. It exposed more dentinal tubules, 
which translated into an increase in apical 
leakage. 1 ' 2 In addition, this method sacri- 
ficed more periodontal support of the buccal 
root surface, shortening the distance between 
the base of the gingival sulcus and the os- 
teotomy site. This further predisposed the 
tooth for an endodontic-periodontal com- 
munication. This resection technique also 


2879_Koerner_Chap 06 4/17/06 1:32 PM Page 138 



frequently resulted in an incomplete root re- 
section in which the root apex was merely 
beveled rather than excised and in which the 
lingual aspect of the root was never resected. 
Surgeons thus neglected to eliminate apical 
ramifications and lateral canals and failed to 
identify more lingually situated additional 
canals. 3 ' Finally, it produced a distorted 
and elongated view of the internal root canal 
anatomy that makes it harder to clearly and 
accurately identify and treat the apical 
anatomy. Figure 6.1 illustrates most of the 
common problems associated with conven- 
tional apical surgery and how microsurgical 
techniques can address and correct these de- 

Comparison of Traditional 
Surgery to Microsurgery 

Introduction of the surgical operating micro- 
scope and ultrasonics paved the way in 
changing how endodontic surgery is per- 

Figure 6-1 A. Radiograph of tooth #21 with con- 
ventional apicoectomy and amalgam retrograde 
filling that appears to be well centered within the 
root parameter. (All figures in 6-1 are of tooth #21). 

Figure 6-1 B. Due to failure of previous treat- 
ment and restorability issues extraction was rec- 

Figure 6-1 C. Socket after extraction. 

formed (see Figures 6.2 and 6.3). The micro- 
scope provides illumination and magnifica- 
tion of the surgical site where it is most 
needed. The ultrasonic tips allow a coaxial 
preparation of the root canal system to a 
depth of 3 mm that provides an optimum 
apical seal. 1 These two advances led to the 
miniaturization of surgical instruments. The 
net result of all the previously mentioned de- 
velopments revolutionalized the traditional 
technique into a more precise method — an 
apical surgery with minimal healthy bone re- 
moval and a conservative shallow-bevel angle 
root resection. This transformation allows 
periradicular surgery to be performed on a 
solid biological and clinical basis. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 139 



Figure 6-1 D. Buccal view of extracted tooth. 
Amalgam retrograde is visible. 

Missed apical 


45 degree bevel 


Figure 6-1 E. Proximal view that shows the 45- 
degree bevel with incomplete root resection and 
failure to eliminate apical ramifications. 

Figure 6-1 F. Shows 0-degree bevel root resec- 
tion that eliminates the apical 3mm of the root. 

Figure 6-1 G. Microscopic inspection of the re- 
sected root surface reveals the buccally situated 
amalgam, the untreated lingual canal, and the 
missed isthmus. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 140 



Figure 6-1 H. Ultrasonic retropreparation of 
3 mm depth that includes buccal and lingual 
canals and the connecting isthmus. 

The Need for Endodontic 

The success rate of endodontic treatment 
varies and has been reported to be as high as 
94.8 percent or as low as 53 percent (see 
Figure 6.4). This variability stems from 
many factors, such as the type of study sam- 
ple size, pulpal and periapical status, follow- 
up period, and number of treatment visits. 
Conventional retreatment has a lower success 
rate that ranges between 48 percent and 84 

Figure 6-11. Super EBA retrograde filling. 

percent (see Figure 6.5). One important fact 
remains — a certain percentage of failures will 
be encountered even when the root canal 
treatment has been carried out to the highest 
quality. The following etiological factors ex- 
plain why some conventional endodontic 
treatments fail and eventually necessitate sur- 
gical intervention. 

Anatomical Factors 

Careful examination of the root canal system 
reveals enormous complexities such as acces- 
sory canals, C-shaped canals, fins, and isth- 

Figure 6-2. The surgical operating microscope. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 141 



Figure 6-3A. The ultrasonic unit by Spartan. 




^V ^H 


Figure 6-3B. An ideal case of periradicualr microsurgery; note the 0-degree bevel angle root resection 
and the coaxial retropreparation. 

muses (see Figure 6.6). These microstruc- 
tures are more abundant in the apical one- 
third of the root 5, and are farthest away 
from the operator's control. By providing a 
safe haven for bacteria from biomechanical 
instrumentation, these anatomical complexi- 
ties can impair the treatment outcome in 
cases in which the pulp space is infected. 
This contributes to the lower success rate of 
endodontic treatment in infected cases. 

Bacteriological Factors 

Posttreatment apical periodontitis is caused 
by microbial infection that persists either in 
the intraradicular space or in the extraradicu- 
lar area. Certain bacteria, such as E. faecalis, 
can withstand antibacterial measures, survive 
a restricted nutritional environment, and 
exist in the root canal as a single type of bac- 
teria/ Although extraradicular infection has 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 142 



Conventional Endodontic 

Success Rate 

| Author/Year 

# of cases 

Follow-up (yr) 

Success % | 

1 Strindberg 1956 



S7 1 

1 Seltzer et al 1963 



SO 1 

1 Bender etal 1964 



82 1 

I Grossman etal 
1 1964 




■ Ingle 1965 



91.5 I 

1 Jokinen et al 1978 




1 Pekrubn 1986 



94 .8 1 

| Ray et al 1995 


1 and up 

61.1 1 

Figure 6-4. This table presents a summary and a comparison of multiple studies of conventional en- 
dodontic success rates. It clearly demonstrates that a 1 00 percent success rate is not achievable. 

a lower prevalence than that of root canal in- 
fection, it could, nonetheless, be the etiologi- 
cal factor behind therapy-resistant apical pe- 
riodontitis. 8 Additional studies have shown 
that bacteria such as actinomyces israelii 9 ' 10 
and arachnia propionica 1 1 can survive in the 
periapical tissue. Some can even invade peri- 
apical cementum. 12 

Histological Factors 

A nonmicrobial source of endodontic failure 
is the presence of periapical cysts, which rep- 
resent up to 15 percent of all periupical le- 
sions. 13. Periapical cysts exist in two struc- 
turally distinct classes: periapical true cysts 
and pocket cysts. 15 Pocket cysts contain ep- 
ithelium-lined cavities that are open to the 
root canals. These can heal following non- 
surgical root canal therapy. On the other 
hand, true cysts are less likely to heal with- 
out surgical intervention. 

Case Selection 

When an endodontic treatment fails, clini- 
cians ought to carefully investigate to reveal 
the true etiology behind the failure. It is of 
great importance to reach a sound diagnosis, 
leading to a treatment plan that would ad- 
dress the disease rather than just the symp- 
toms (see Figure 6.7). 

In assessing a previously root canal- 
treated tooth, the following three factors 
should be evaluated: 1) quality of previous 
endodontic treatment, 2) quality of coronal 
restoration, and 3) accessibility to the canals. 
Conventional retreatment should always be 
considered first. Surgical retreatment should 
be considered when access to canals is im- 
possible or when the current endodontic 
treatment and coronal restoration seem to be 
of an adequate quality (see Figure 6.8). 

Failures associated with silver points pose 
another challenging situation. Failing silver 
points usually present with gross leakage and 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 143 

Conventional Retreatment 

Success Rate 


Follow-up (yr) 

Success rate(%) 

Strindbeig (1956) 





Molvai& Hal s e (1988) 



Bergenholtz €t al (1979) 



Allen et at (1989) 



Sjogren et al (1990) 






Figure 6-5. This table summarizes the results of different studies in regard to conventional endodontic 
retreatment success rates. It clearly demonstrates the lower success rate associated with endodontic 
retreatment cases. 

Figure 6-6. Cross sections of some teeth that reveal their complex and variable anatomy. 


2879_Koerner_Chap 06 4/17/06 1:33 PM Page 144 



Figure 6-7A. A radiograph of a rare two-rooted 
maxillary lateral incisor with previous endodontic 
treatment. Patient presented with severe sponta- 
neous pain and tenderness to percussion. 

corrosion byproducts. Surgical treatment can 
only marginally address these problems. 
Since it is extremely difficult to adequately 
retroprepare and retrofill the canals to pro- 
vide a good apical seal, every effort should be 
made to re-treat these cases and to avoid sur- 
gery at any cost (see Figure 6.9). 


There are several reasons why this surgery 
should be performed. The operator should 
consider these indications and then either 
perform the surgery or refer the patient to 
someone who will perform the procedure 
according to current accepted standards. 

Figure 6-7B. Clinical examination reveals local- 
ized palatal swelling. 

Figure 6-7C. Periodontal examination shows a 
12-mm probing on the palatal surface associated 
with a purulent discharge; the diagnosis is peri- 
odontal abscess associated with a palatal devel- 
opmental groove. 

Failure of Previous Endodontic 

When previous endodontic treatment seems 
to be of an adequate quality and/or retreat- 
ment has already been attempted without 
further success, periradicular surgery be- 
comes rightly indicated (see Figure 6.10). 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 145 

Figure 6-8A. A preoperative radiograph of tooth 
#14 that has a failing inadequate endodontic treat- 
ment. Close examination reveals the untreated 
second mesiobuccal (MB) root and an ill-fitting 

Figure 6-8B. Crown removal and conventional 
retreatment are performed; the second mesiobuc- 
cal and second distiobuccal canals are localized 
and treated. 

Figure 6-9A. Tooth #3 that has a previous en- 
dodontic treatment with silver points and has a 
new crown of good quality. A symptomatic peri- 
apical lesion is limited to the MB root only. 

Figure 6-9B. Localized conventional retreat- 
ment of the MB root is performed to address the 
pathology without compromising the crown. 

Figure 6-9C. An angulated radiograph showing 
the two treated mesiobuccal canals. 

Figure 6-9D. The microscopic access needed 
to perform the retreatment. 


2879_Koerner_Chap 06 4/17/06 1:33 PM Page 146 



Figure 6-1 OA. Failing inadequate root canal 

Figure 6-1 OB. Conventional retreatment per- 

Figure 6-1 OC. Retreatment failed again after 
two years. 

Failure of Previous Apical Surgery 

Clinicians should not hesitate to perform 
apical microsurgery on previously failed api- 
coectomies. This is especially true when it is 

Figure 6-1 OD. Apical surgery performed. 

Figure 6-1 OE. Two-year recall demonstrates 
complete healing. 

evident that the previous surgery was inade- 
quate or not performed according to the cur- 
rent standards of care (see Figure 6.11). In 
these cases, it is common to discover an in- 
completely resected apex with malpositioned 
retrofilling material that is mostly placed 
outside the root canal parameter. Thorough 
presentation of such deficiencies was covered 
in a previous section of this chapter. 

Iatrogenic Factors 

Procedural mishaps can occur during the 
course of endodontic treatment. Examples 
include canal transportation, perforation, 
ledge formation, blockage, or separated in- 
struments (see Figure 6.12). These compli- 
cations are likely to result in incomplete 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 147 



Figure 6-1 1 A. Failed previous surgery where 
both mesiolingual (ML) and distolingual (DL) roots 
were not resected nor retroprepared. 

Figure 6-1 1 B. Complete root resection with 
minimum bevel angle and 3 mm retrofilling. 

biomechanical debridement and a compro- 
mised apical seal. Cases involving mishaps in 
the apical one-third of the canal are good 
candidates for apical surgery. However, if 
the error is located in the middle to coronal 
one-third of the root canal, then alternative 
approaches should be considered. 

Anatomical Deviations 

Teeth can present with challenging root 
anatomy that complicates endodontic ther- 
apy and compromises complete debride- 
ment. Common examples include canal 
calcifications, blunderbuss apices, S- and 
C-shaped canals, and severe root curvatures. 

Figure 6-1 2A. Separated file in the MB root of 
tooth 12. 

Figure 6-1 2B. Instrument removed and canal 

The case illustrated in Figure 6.13 shows a 
maxillary lateral incisor that presents with 
dens-in-dente, canal calcification, and a 
blunderbuss apex. Conventional endodontic 
therapy was initially performed. Despite the 
fact that the canal was localized and treated, 
it was still difficult to establish an apical seal 
due to the large, divergent, and irregular api- 
cal foramen. Microsurgery was performed to 
remove the gross overfill and to establish a 
precise apical seal. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 148 



Figure 6-1 3A. Tooth #7 presented with dens- 
in-dente, canal calcification, and a blunderbuss 


Of the few contraindications to endodontic 
surgery, only some are absolute. The major- 
ity of these conditions are only temporary 
and can either be corrected or managed by a 
knowledgeable surgeon. These contraindica- 
tions can be categorized as dental, anatomi- 
cal, and medical. The following sections will 
present each category in detail. 

Tooth-Specific Factors 

The restorability and the periodontal health 
of a tooth are important factors in planning 
treatment and determining a prognosis. 
Probing depth and mobility should be care- 
fully assessed before surgery. Another con- 
cern is the clinical crown-root ratio the tooth 
exhibits. Apical surgery on a short-rooted 

Figure 6-1 3B. A gross overfill of gutta-percha 
was difficult to avoid due to the large, irregular, 
and divergent walls of this blunderbuss apex. 

tooth with significant attachment loss will 
further compromise the crown-root ratio 
(see Figure 6.14). Moreover, such a course of 
treatment could result in an endodontic/ 
periodontic communication, compromising 
the overall outcome of the surgery and lead- 
ing to eventual tooth loss. In these situa- 
tions, conventional retreatment should be 
considered if it is feasible. Otherwise, extrac- 
tion may be the best solution. 

Anatomical Factors 

The Inferior Alveolar Nerve 

The location of the mandibular canal and 
the mental foramen should be carefully as- 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 149 



Figure 6-1 3C. Surgical correction of the overfill 
and the establishment of a precise apical seal 
using microsurgical techniques. The canal was 
retroprepared using surgical ultrasonic tip and 
then retrofilled with super EBA. 

sessed prior to surgery in the posterior 
mandible. The use of a microscope facilitates 
easy identification of the neurovascular bun- 
dle. The added magnification also assists in 
the preparation of the groove technique (a 
shallow horizontal groove in bone), a meas- 
ure that prevents unintentional instrument 
slippage and avoids permanent nerve dam- 
age. However, in certain cases the extreme 
proximity of the neurovascular bundle could 
render the procedure risky and, therefore, 
contraindicated (see Figure 6.15). 

The Maxillary Sinus 

The apices of maxillary molar and premolar 
teeth can be in close proximity to the floor 
of the sinus (see Figure 6.16). In some in- 

Figure 6-14. A radiograph of tooth #4 that has a 
poor crown-root ratio and a moderate attachment 
loss. Apical surgery is contraindicated. 

Figure 6-15. A radiograph that reveals the close 
proximity of the mandibular nerve and the mental 
foramen to the apices of teeth #29, 30, and 31 . 
Apical surgery can be risky, and therefore, it might 
be contraindicated in certain cases to avoid per- 
manent paresthesia. 

Figure 6-16. This radiograph demonstrates the 
close proximity of the maxillary sinus to the apices 
of the teeth in that quadrant. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 150 



stances, the apices are located inside the 
sinus. A watchful examination of preopera- 
tive radiographs, coupled with careful surgi- 
cal dissection under magnification, will min- 
imize the chances of sinus membrane 

When sinus membrane is inadvertently 
perforated, if meticulous surgical techniques 
and proper postoperative care were em- 
ployed, the outcome of apical surgery will 
not be compromised and complications are 
usually minimal. 

Barrier placement is recommended to 
block the perforation area during the surgery 
and to ensure that foreign material or even a 
resected apex does not enter the sinus. 17 
Telfa pads (Kendall Company, Mansfield, 
MA) are excellent materials to use as a sinus 
barrier (see Figure 6.17). They can be cut to 
fit the perforation size, and they contain no 
cotton fibers that could contaminate the sur- 
gical field. To prevent the Telfa pad from get- 
ting dislodged into the sinus cavity, a suture 
is tied through its center, which will keep the 
barrier in place throughout the surgery and 
will allow the operator to easily pull the bar- 
rier out at the end of the surgery. In addi- 
tion, patients should be prescribed an antibi- 
otic (1 g amoxicillin immediately following 
the perforation, continued with 500 mg tid 
for 24 hours) and a nasal decongestant for 
five days. 

The Second Mandibular Molar Area 

The mandibular second molar presents 
many difficult obstacles for apical surgery. 
Due to a thick buccal cortex of bone, lin- 
gually inclined roots, and close proximity of 
the apices to the mandibular canal, these 
teeth are usually poor candidates for surgery. 
In addition, as the far distal location in the 
dental arch impedes easy access, surgery be- 
comes nearly impossible. For mandibular 
second molars, an alternative approach to 
surgery should be considered, such as retreat- 
ment or replantation. 

Figure 6-1 7A. Sinus perforation. 

Figure 6-1 7B. Barrier placement with suture. 

Medical Factors 

A thorough review of a patient's medical his- 
tory is of paramount importance. All med- 
ical concerns and questions should be an- 
swered prior to surgery. There are a few 
medical conditions that contraindicate en- 
dodontic surgery, such as clotting deficien- 
cies, brittle diabetes, dialysis, and compro- 
mised immune system. With certain other 
medical conditions, endodontic surgery 
should be postponed until the condition is 
treated or stabilized and no longer presents 
any risk to the patient. Good examples in- 
clude recent myocardial infarction, radiation 
therapy, anticoagulant medications, and first 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 151 



and third trimesters of pregnancy. The deci- 
sion for surgery should be evaluated on a 
case-by-case basis and in consultation with 
the patient's physician. 

The Surgeons Skill and Ability 

One very important factor in case selection 
is the surgeon's level of knowledge and ex- 
perience. Clinicians should carefully assess 
the difficulty of each case and decide who is 
best suited to perform the procedure. 
Challenging cases should be referred to 

endodontists or oral surgeons with microsur- 
gical expertise. 


A basic endodontic surgery kit should con- 
tain the most commonly used instruments 
to perform periradicular surgical procedures. 
Key instruments and materials with their 
general use are listed in Table 6.1. The surgi- 
cal kit should be supplemented with the fol- 
lowing instruments and devices to perform 
apical microsurgery. 

Table 6-1. Surgical Kit 

Examination Instruments 

Mirror, endodontic explorer, and periodontal probe 

Soft Tissue Incision, Elevation, and Reflection 

1 5C blade 


Periosteal elevators (Howard, #9 Molt, and #149) 

Kim/Pecora retractors 1 through 4 (Hartzell & 

Sons, Inc.) 
Tissue forceps 

Osteotomy and Root Resection Instruments 

Impact Air 45 handpiece 

H 1 61 Lindemann bone cutting bur (Brasseler, 

Surgical-length round burs 

Curettage Instruments 

Small endodontic spoon curette 
Periodontal curette (Columbia 1 3/1 4) 
34/35 Jaquette and Mini-Jaquette scalers 
#2/4 Molt curette 

Inspection Instruments 

Micromirrors (5 mm round and modified rectangular) 

Root-end Filling/Finishing Instruments 

Retrofilling carrier (West carrier) 
MTA pellet forming block with KM-3/Km-4 place- 
ment instruments (Hartzell & Son, Inc.) 
Micropluggers and ball burnishers 
Polishing burs 

Suturing and Soft Tissue Closure 

Castroviejo needle holder 

Surgical scissors 

Various suture types and sizes (5-0 and 6-0) 

Sterile gauze for soft tissue compression 

Miscellaneous Instruments and Materials 

Surgical aspirator 

Irrigation syringes and needles 

Stropko irrigator/drier with disposable micortip 

(Ultradent, Inc.) Cut-Trol (50% ferric sulfate) 
Super EBA (Bosworthjnc.) 
MTA (ProRoot by Dentsply/Tulsa, Inc.) 
Racellet #3 epinephrine cotton pellet (Pascal 

Company, Inc.) 
Methylene blue stain (Fisher Scientific, Inc.) 
Microapplicator tips (Quick Tips by Worldwide 

Dental, Inc.) 

Root-end Preparation Instruments 

Ultrasonic unit (Spartan or Miniendo) 
Surgical ultrasonic tips (KiS 1 through 6, BK3-R 
and BK3-L, or CT tips) 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 152 



Surgical Operating Microscope 

The microscope is defined as an instrument 
that gives an enlarged image of an object or 
substance that is minute or not visible with 
the naked eye. The incorporation of the op- 
erating microscope into apical surgery carries 
great benefits simply by providing illumina- 
tion and magnification to a small surgical 
field. This will translate clinically into a more 
precise and conservative surgical procedure 
with minimal guesswork. It will also allow 
accurate assessment and excision of all 
pathological changes with very conservative 
removal of healthy structures. For the first 
time, the resected root surface can be clearly 
inspected for any anatomical complexities or 

Every microscope contains the following 
components: eyepieces, binoculars, objective 
lens, and the magnification changer (see 
Figure 6.18). Magnification is determined by 
the power of the eyepieces {M ), the focal 

length of the binoculars (/p, the magnifica- 
tion changer factor (M ), and the focal 
length of the objective length (f ). Total 
magnification can be calculated using the 
following equation: 

Total Magnification M = fjf + M Q + M c 

Recommended settings for surgical oper- 
ating microscope in endodontics are XI 2. 5 
eyepieces, five-step magnification changer, 
200-250 mm objective length, and 60 de- 
grees or more inclinable binoculars. 

Incorporating the microscope into general 
dentistry practice is costly and initially will 
slow the operator's speed due to the nature 
of the learning curve. However, it is the sin- 
gle most important element in performing 
apical surgery up to the current standards. 
The use of magnifying loupes with an added 
fiber optic headlamp is helpful, but it is only 
the minimum requirement in performing 
apical surgery. Loupes can only provide a 2 X 

Figure 6-18. Components of the surgical operating microscope. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 153 



to 6 X range of magnification, which is mar- 
ginally useful in anterior surgery. In surgeries 
involving posterior teeth, the microscope is 
absolutely essential due to restricted access, 
limited visibility, and far more complicated 
root anatomy 

The surgical microscope, in contrast to 
loupes, provides a wide range of magni- 
fication from X3 to X30. The lower range 
of magnification (X3 to X8) provides a 
wider field of view and a high focal depth, 
which is practical for orientation. The mid- 
dle range of magnification (X 10 to X 16) is 
the working range, which provides adequate 
enlargement of the surgical field to perform 
most of the surgical steps. The highest range 
of magnification (X20 to X30) is only used 
for fine inspection of the resected root sur- 
face. It has a shallow focal depth, and the 
focus can easily be affected by the slightest 
movement, such as the breathing of the 

Microsurgical Instruments 

Many microsurgical instruments are minia- 
turized versions of traditional surgical instru- 
ments. Other instruments are specifically in- 
vented and designed to perform apical 

The following is a list of microsurgical in- 
struments and their general uses: 

Microblades. A 15C blade is the blade of 
choice in most surgical procedures. How- 
ever, when the interproximal spaces are tight, 
such as the anterior mandibular area, a 
microblade becomes more useful and will 
precisely incise the flap without any tissue 

Micromirrors. A large variety of mi- 
cromirrors are available on the market in dif- 
ferent materials, shapes, and sizes. Only two 
micromirrors are needed, a round shape 
(5 mm in diameter), and a modified rectan- 
gular (see Figure 6.19). Both can be pur- 
chased in stainless steel, sapphire, or dia- 
mond mirror surfaces. The sapphire and 

Figure 6-19. Modified rectangular and round 

diamond micromirrors have scratch-free sur- 
faces and are brighter than stainless ones. 
They are also more costly. 

Ultrasonic units and tips. The intro- 
duction of the ultrasonic units and tips has 
replaced the traditional use of microhand- 
pieces. The two most widely used ultrasonic 
units are the Miniendo II (Analytic/ 
SybronEndo) and the Spartan (Spartan/ 
Obtura) (see Figure 6.3). 

There are many different ultrasonic tips 
available on the market, but the three most 
popular are the KiS, CT, and BIO (see 
Figures 6.20—6.22). All three types are very 
effective and precise; however, they vary in 
material, tip angulation, and design. The 
size of these tips is 1/10 the size of a con- 
ventional microhead handpiece. CT and 
BK3 tips are made of stainless steel, and 
they are also available with a diamond 
coating that improves their cutting 

The BK3 tips come in a set of two 
(BK3-R right, BK3-L left), and each tip has 
three bends that facilitate easy access to any 
preparation. BK3 right is designed for use in 
the upper right and lower left, and BIO left 
is designed for use in the upper left and 
lower right. 

The KiS ultrasonic tips come in a set of 
six different tips, all of which are coated with 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 154 

Figure 6-20. KiS ultrasonic tips. 

Figure 6-21. CT ultrasonic tips. 


2879_Koerner_Chap 06 4/17/06 1:33 PM Page 155 



Figure 6-22. BK3tips. 

zirconium nitride for smoother and more 
efficient cutting. The irrigation port is lo- 
cated close to the 3-mm cutting tip. The 
KiS 1 tip has an 80-degree angled tip and is 
0.24 mm in diameter. This thin-diameter tip 
is ideal for apical preparation on mandibular 

anteriors and premolars. The KiS 2 tip has a 
wider diameter and is ideal for wider prepa- 
ration such as with maxillary anteriors. The 
KiS 3 tip has a double bend and a 70-degree 
angled tip. It is helpful in reaching the max- 
illary left and mandibular right posteriors. 
The KiS 4 tip is similar to the KiS 3 tip ex- 
cept that the tip angle is 1 10 degrees, which 
is designed to reach the lingual apex of 
molar. The KiS 5 tip is the counterpart of 
the KiS 3 tip. The Kis 6 tip is the counter- 
part of the KiS 4 tip. 

Stropko irrigator/drier. This device fits 
on a standard air/water syringe and uses a 
microtip needle (Ultradent, Inc.) to effec- 
tively irrigate and dry retropreparations. 
However, it should be used cautiously and 
only inside the retropreparation to reduce 
the chance of emphysema. It is recom- 
mended to change the pre-existing obtuse 
angle bend on the microtip needle to a 
90-degree bend that is 3 mm in length (see 
Figure 6.23). This manipulation will facili- 
tate direct insertion of the tip into the retro- 
preparation for a thorough drying with min- 



Figure 6-23. Stropko irrigator/drier. Note the microtip needle with the correct 90-degree bend that is 
3 mm in length. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 156 



Figure 6-24. The 90-degree bend of the mi- 
crotip needle will facilitate direct insertion of the 
needle tip into the retropreparation for a thorough 
drying with minimal disturbance of the delicate 
hemostasis of the crypt. 

imal disturbance of the delicate hemostasis 
of the crypt (see Figure 6.24). 

Retrofilling instruments. Micropluggers, 
retrofilling carriers, and ball burnishers (see 
Figure 6.25) are retrofilling instruments. 
Micropluggers come in ball ends ranging 
from 0.25 to 0.75 mm. They can be either 
straight-handled or double-angled. The 
straight-handled micropluggers come in two 
different angles: a 90-degree tip for universal 
use and a 65 -degree tip helpful for the lin- 
gual apex (see Figure 6.26). The double-an- 
gled microplugger tips are offset by 65 de- 
grees — one left and one right for left and 
right molar surgeries. 

The Super EBA retrofilling carrier has a 
flat surface that is designed to carry the 
retrofilling material into the retroprepara- 
tion. Figure 6.27 shows the West carriers 
with straight and offset angles. 

Burnishers are ball shaped and are available 
in different sizes. They are used immediately 
following retrofilling material placement to 

Figure 6-25. The retrofilling instruments. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 157 



Figure 6-26. The straight-handled micropluggers come in two different angles: a 90-degree tip that is 
for universal use and a 65-degree tip that is helpful for the lingual apex. 

Figure 6-27. The West carriers. 

adapt the retrofilling material into the retro- 
preparation and to seal all the margins. 

If mineral trioxide aggregate (MTA) will 
be used as retrofilling material, then a carrier 
system is needed to transport this delicate 
material into the retropreparation. A variety 
of Messing gun systems are available and can 

be used for this purpose. More recently, a 
MTA pellet-forming block has become avail- 
able (Hartzell & Son, Concord, CA) and has 
proven to be more effective and less compli- 
cated than other systems. Directions for 
using this block will be provided later in the 
retrofilling section of this chapter. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 158 



Preoperative Assessment 

The prognosis following surgery is depend- 
ent on thorough preoperative medical, 
intra-oral, periodontic, and radiographic 
evaluations — along with good surgical tech- 
nique and proper postoperative instruction. 

Medical Evaluation 

A routine review of the patient's medical his- 
tory and current medications should be per- 
formed, and when necessary, additional 
medical consultations should be requested. 
As a general rule, no special precautions need 
to be taken when surgery is planned other 
than those that normally apply to routine 
dental procedures. 

A special emphasis should be placed, 
however, on noting any blood-thinning 
medications, especially aspirin. They are so 
commonly prescribed that patients often for- 
get to include it in their medical history. 
Aspirin should be discontinued at least 10 
days prior to surgery. 

Another consideration is the need to pre- 
scribe prophylactic premedication. The 
American Heart Association recommends 
prophylactic premedication for patients with 
a history of rheumatic heart fever, endocardi- 
tis, abnormal or damaged heart valves, organ 
transplantation, and placement of an im- 
plant prosthesis such as hip joint or knee re- 
placement within the past two years. 19 Table 
6.2 represents the currently recommended 

Intra-Oral Evaluation 

A thorough oral examination should com- 
prise all of the following: 

• Patient's chief complaint 

• Chronological history of the problem 

• Presence of swelling 

• Tracing of existing sinus tract with a gutta- 
percha point (see Figure 6.28) 

Table 6-2. Recommended Prophylaxis Regimen 
for Dental Procedures in High-risk Patients 

Standard Regimen 


• Adults: 2 g orally (PO) 

• Children: 50 mg/kg (PO) 1 hour before procedure 
If the patient cannot take oral medications, the 
regimen is: 


• Adults: 2 g intramuscularly (IM) or intraven- 
ously (IV) 

• Children: 50 mg/kg I M or IV within 30 minutes 
before procedure 

Regimen for Patients Allergic to Penicillin 


• Adults: 600 mg PO 

• Children: 20 mg/kg PO 1 hour before procedure 

Cephalexin or Cefadroxil 

• Adults: 2 g PO 

• Children: 50 mg/kg PO 1 hour before procedure 

Azithromycin or Clarithromycin 

• Adults: 500 mg PO 

• Children: 15 mg/kg PO 1 hour before procedure 

Regimen for Patients Allergic to Penicillin and 
Unable to Take Oral Medications 


• Adults: 600 mg 

• Children: 20 mg/kg IV within 30 minutes before 


• Adults: 1 g 

• Children: 20 mg/kg I M or IV within 30 minutes 
before procedure 

Periodontal Evaluation 

The periodontal examination should include 
mobility, probing depth, and requests for 
preoperative scaling and/or root planning if 
needed. Probing depth measurements are an 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 159 



Figure 6-28A. Sinus tract opening buccal to 
tooth #31 . 

essential part of the consultation that aides 
in the diagnosis of vertical root fracture or 
combined perio-endo lesions. Detections of 
such periodontal involvements could drasti- 
cally alter the treatment plan and save pa- 
tients from undergoing unnecessary surgical 
procedures. If patient sensitivity prevents ac- 
curate probing, administration of a local 
anesthetic is recommended. 

Radiographic Evaluation 

A radiological examination is essential and 
should include prior radiographs if available. 
Two radiographs taken from two different 
angles (straight on and mesially angulated) 
can uncover concealed anatomical structures 

Figure 6-28B. Radiograph of gutta-percha (GP) 
point traced to apex of tooth #30. 

by adding a third dimension to an otherwise 
two-dimensional image. 

Preoperative radiographs should be as- 
sessed in a systemic manner for the follow- 

• Approximate root length 

• Number of roots and their configuration 

• Degree of root curvature (see Figure 6.30) 

• Proximity of adjacent root tips, especially 
in anterior teeth (see Figure 6.31) 

• Proximity of anatomical structures includ- 
ing mandibular canal, mental foramen, 
external oblique ridge, zygomatic process, 
and the maxillary sinus 

• Approximate size, location, and type of 

Figure 6-29A-B. Bilateral deep pockets on buccal and palatal — suggestive of a vertical root fracture. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 160 



Figure 6-29C. J-shaped radiolucency com- 
monly associated with root fracture. 

Figure 6-29D. Radiograph taken at slightly dif- 
ferent angulation clearly shows the fracture. 

• Vertical root fracture or radiographic signs 
most commonly associated with it such as 
thickening of the periodontal ligament 
(PDL) surrounding lateral root surfaces, 
J-shaped lesions, or possible endodontic/ 
periodontal lesions 

Preoperative Medications 

The following preoperative regimens are rec- 

• 0.12 percent chlorhexidine mouth rinse 
starting the day before surgery and contin- 
uing for up to a week after surgery to re- 
duce the oral microflora. 

• Ibuprofen 800 mg one hour before sur- 
gery, which is effective in reducing the in- 
flammatory response and postoperative 



• Tranquilizers for anxious patients such as 
Valium (5 mg) one hour before the sur- 
gery. If a tranquilizer is used, another 
persn must accompany the patient on the 
trip to the office and then back home after 
the procedure. 

• Patients should be advised to refrain from 

Figure 6-29E. Radiographic and clinical views of a vertical root fracture case. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 161 



Figure 6-30. Preoperative radiographs provide 
valuable information such as the approximate root 
length, the number of roots and their configura- 
tion, and the degree of root curvature. The ap- 
proximate size, location, and type of lesion can 
also be assessed. 

• As discussed previously, antibiotic prophy- 
laxis premedication should be prescribed 
when indicated. 

Surgical Technique 

Anesthesia and Hemostasis 

The ability to achieve profound anesthesia 
and hemostasis in the surgical site is crucial 
in microsurgery. Profound anesthesia will 
eliminate patient discomfort and anxiety 
during, and for a significant time following, 
the procedure. Excellent hemostasis will 
improve visibility of the surgical site, allow 
microscopic inspection of the resected root 
surface, and minimize the surgery time. 

Hemostatic control can be divided into 
preoperative, intraoperative, and postopera- 
tive phases. These phases are interrelated and 
dependent on each other. 

Preoperative Phase 

An anesthetic solution containing a vasocon- 
strictor is indicated to achieve anesthesia and 
hemostasis. 21 While 2 percent lidocaine with 
1:100,000 concentrations of epinephrine is 

Figure 6-31 . Note the close proximity of the 
apices of these two mandibular incisors. Patient 
should be made aware of the possible loss of 
vitality of the adjacent tooth after apical surgery. 

recognized as an excellent anesthetic agent, 
clinical evidence suggests that 1:50,000 
concentration offers better hemostasis. 22 ' 23 
The amount of the anesthetic solution con- 
taining 1:50,000 epinephrine that is neces- 
sary to achieve anesthesia and hemostasis is 
dependent on the size of the surgical site; 
however, 2.0 to 4.0 ml is usually sufficient. 
This amount of local anesthetic should be 
slowly infiltrated using multiple injections. 
Solution should be deposited throughout the 
entire submucosa superficial to the perios- 
teum at the level of the root apices in the 
surgical site. It is worth mentioning that 
there is a narrow margin of error in deliver- 
ing local infiltration. Skeletal muscles re- 
spond to epinephrine with vasodilation 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 162 



Figure 6-32. Local infiltration for surgery on 
tooth #8 should extend from tooth #6 to #10 at 
the level of the root apices. 

instead of vasoconstriction as they contain 
blood vessels that are mostly innervated 
with (3-2 adrenergic receptors. Thus, great 
care should be taken to avoid infiltrating 
into deeper skeletal tissue beyond the root 
apices and over basal bone instead of alveolar 

In the maxilla, anesthesia and hemostasis 
are usually accomplished simultaneously by 
local infiltration in the mucobuccal fold over 
the apices of the tooth in question and two 
adjacent teeth both mesial and distal to that 
tooth (5 teeth total). This should be supple- 
mented with a nerve block near the incisive 
foramen to block the nasopalatine nerve for 
surgery on maxillary anterior teeth, or near 
the greater palatine foramen to block the 
greater palatine nerve for surgery on the 
maxillary posterior teeth (see Figures 6.32 
and 6.33). 

In the mandible, anesthesia and hemosta- 
sis are usually achieved separately. Anesthesia 
is established by a regional nerve block of the 
inferior alveolar nerve, using 1.5 cartridges of 
2 percent lidocaine with 1:100,000 epineph- 
rine. Hemostasis is established with two car- 
tridges of 2 percent lidocaine with 1:50,000 
epinephrine at the surgical site via multiple 
supraperiosteal injections into the mucobuc- 
cal fold. An additional supplement of 0.5 

Figure 6-33. Incisive foramen block injection. 

cartridge is also injected into the lingual as- 
pect of the tooth. 

The rate of injection will relate to the de- 
gree of hemostasis and anesthesia obtained. 
A rate of 1—2 ml/min is recommended. 
Injecting at a faster rate results in localized 
pooling of the solution, delayed and limited 
diffusion, and less than optimal anesthesia 
and hemostasis. It is essential to allow the 
deposited solution sufficient time to diffuse 
and reach the targeted area to produce the 
desired effects before any incision is made. 
The recommended wait time is usually 
10—15 minutes, until the soft tissue through- 
out the surgical site has blanched (see Figure 

Intraoperative Phase 

The most important measure in achieving 
hemostasis is effective local vasoconstriction. 
Following osteotomy, curettage, and root re- 
section, hemostasis needs to be established 
again as newly ruptured blood vessels emerse 
the bone crypt and the buccal plate with 
blood. The use of a topical hemostatic agent 
is frequently needed at this point of surgery 
to control bleeding. Such an agent maintains 
a dry surgical field that will allow micro- 
scopic inspection of the resected root surface, 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 163 



Figure 6-34. In the mandible, anesthesia is established by a regional nerve block of the inferior alveo- 
lar nerve, using 1.5 cartridges of 2% lidocaine with 1:100,000 epinephrine. Hemostasis is established 
with 2 cartridges of 2% lidocaine with 1 :50,000 epinephrine at the surgical site via multiple suprape- 
riosteal injections into the mucobuccal fold. An additional supplement of 0.5 cartridge (also mainly for 
hemostasis) can be injected at the lingual aspect of the root. 

Figure 6-35A. Before anesthesia. 

adequate visibility during ultrasonic retro- 
preparation, and good isolation during retro- 
filling material placement. 

Many topical hemostatic agents are avail- 
able. The two most widely used by en- 
dodontists are epinephrine cotton pellets and 
ferric sulfate solution. The following is a 
presentation of the properties of these two 

Figure 6-35B. 10 minutes following local 

chemical agents and their mechanisms of 

Epinephrine pellets. Racellets are cotton 
pellets containing racemic epinephrine HC1 
(Pascal Company, Inc., Bellvue, WA). The 
amount of epinephrine in each varies de- 
pending on the number on the label (see 
Figure 6.36). Racellet #3 pellet contains an 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 164 



Figure 6-36. Epinephrine pellets. 

average of 0.55 mg of racemic epinephrine 
and is usually recommended for apical sur- 
gery. The racellet pellets are inexpensive and 
highly effective in achieving hemostasis in 
the bone crypt via the vasoconstriction ef- 
fects of epinephrine coupled with the pres- 
sure applied on these pellets. 25 It has been 
shown that one to seven pellets of Racellets 
#3 can be applied directly to the bone crypt 
and left for two to four minutes with no evi- 
dent cardiovascular changes. 2 

Ferric sulfate. This is another chemical 
hemostatic agent that has been used for a 
long time in restorative dentistry. Its mecha- 
nism of action is not completely clear, but it 
is believed to be due to agglutination of 
blood proteins when in contact with this 

very acidic solution (pH 0.21). The aggluti- 
nated proteins form plugs that occlude the 
capillary orifices to achieve hemostasis. 

Ferric sulfate is commercially available in 
different solutions with different concentra- 
tions. The recommended solution for en- 
dodontic surgery is Cutrol, which contains 
50 percent ferric sulfate (see Figure 6.37). 
Cutrol is an excellent surface hemostatic 
agent on the buccal plate of bone and inside 
the bone crypt. It should be applied directly 
to the bleeding point with a microapplicator 
tip or a cotton pellet (see Figure 6. 3 8 A). 
Upon contact with blood, this yellowish so- 
lution immediately turns dark brown. This 
color change is helpful in identifying any re- 
maining bleeders that need to be addressed 
in the same manner (see Figure 6.38B). 

Ferric sulfate is a very effective hemostatic 
agent that works instantly, but it is also cyto- 

Figure 6-37. Cutrol (50 percent ferric sulfate). 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 165 



Figure 6-38A. Cutrol application to bone. 

Figure 6-38B. Bone color change. 

toxic and causes tissue necrosis. For this rea- 
son, it should not come in contact with the 
flap tissue. The use of this agent should be 
limited as an adjunct to other hemostatic 
measures. For example, if bleeding persists 

after using the epinephrine cotton pellet 
technique. When used correctly as described 
in the previous paragraph, systemic absorp- 
tion is unlikely since the coagulum stops the 
solution from reaching the blood stream. 

Ferric sulfate also has been proved to 
damage bone and delay healing when used 
in large amounts and left in situ after surgery 
(Lemon 1993). It should therefore only be 
used in small amounts and should be imme- 
diately and gently irrigated with saline after 
application. If the coagulum is thoroughly 
removed and irrigated before closure, there is 
no adverse reaction. 27 

The following steps outline the most ef- 
fective method to achieve local hemostasis 
quickly during apical surgery: 

1 . Complete all the cutting necessary (os- 
teotomy and root resection) and then 
thoroughly remove all granulation tissue 
from the bone crypt. 

2. Place a small Racellet #3 cotton pellet in 
the bone crypt and firmly pack it against 
the lingual wall (see Figure 6.39A). 

Figure 6-39A. Initial Racellet pellet placed in- 
side the crypt. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 166 



Figure 6-39B. Bone crypt filled with pellets. 

3. In quick succession, additional Racellet 
pellets are packed in against the first pel- 
let, until the entire crypt is filled with 
pellets (see Figure 6.39B). Depending on 
the size of the crypt, this can take a 
variable number of pellets. A study by 
Vickers has shown that up to seven 
Racellets #3 pellets can be safely used to 
fill the crypt. If more are needed due to 
the large size of the crypt, then some ster- 
ile cotton pellets should be added until 
the crypt is completely filled. 

4. Pressure is applied on these pellets with a 
blunt instrument (for example, back of a 
micromirror handle) for 2—4 minutes 
until no further bleeding is observed (see 
Fig 6.39C). 

5. All pellets are removed one by one, except 
the last epinephrine pellet, which is left 
inside the crypt to avoid reopening of the 
ruptured vessels (see Figure 6.39D). This 
pellet should only be removed at the end 
of the surgical procedure before final irri- 
gation and flap closure. 

6. If small bleeders are still present on the 
buccal plate or inside the crypt, then 

Figure 6-39C. Pressure application on top of 
the pellets. 

Figure 6-39D. Racellet pellets removed until re- 
sected root is exposed leaving at least one pellet 
against the crypt wall. 

Cutrol should be applied directly to the 
bleeding areas. Without disrupting the 
coagulum, the solution is quickly rinsed 
with saline to remove any excess. The co- 
agulum formed should be left intact dur- 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 167 



ing the surgical procedure but must be 
thoroughly curetted and the correspon- 
ding area rinsed before closure. 

Postoperative Phase 

Periradicular surgery should be performed 
within a reasonable amount of time so that 
complicated and hemostasis-dependent steps 
are completed before reactive hyperemia oc- 
curs. As restricted blood flow returns to nor- 
mal, it rapidly increases to a rate well beyond 
normal to compensate for localized tissue hy- 
poxia and acidosis. Reactive hyperemia is 
clinically variable and unpredictable. It can 
be prevented or reduced by compressing the 
flap tissue for three minutes and applying 
firm finger pressure with saline-soaked gauze 
pads placed over the surgical site. This is 
done to induce hemostasis, prevent 
hematoma formation, and enhance good tis- 
sue reapproximation. Flap compressions 
should be followed immediately with 
postsurgical cold compressions to the cheek. 

Flap Designs 

The semilunar flap used to be the flap of 
choice for apical surgery (see Figure 6.40). It 
is not advocated today for a number of rea- 
sons. The semilunar flap provides a restricted 
surgical access and has limited potential for 
further extension if deemed necessary. It also 
carries the danger of postsurgical defects by 
incising through tissues that are not sup- 
ported by underlying bone. 29 Further- 
more, this type of incision results in maxi- 
mum severage of periosteal blood vessels. 
This compromises the blood supply, which 
could lead to shrinkage, gapping, and sec- 
ondary healing. Another disadvantage to 
the semilunar flap is the close proximity 
of the incision to the osteotomy site, 
which makes hemostatic control more 

The following are flap designs recom- 
mended for periradicular surgery. 

Figure 6-40. Semilunar flap design. 

Full Muc op erio steal Tissue Flap 

There are strong biological reasons to use 
this kind of flap whenever possible. 18 ' 30 It 
maintains intact vertical blood supply and 
minimizes hemorrhage while providing ade- 
quate access. It allows a survey of bone and 
root structures, which facilitates excellent 
surgical orientation. However, since this flap 
involves the gingival papilla and exposes the 
crestal bone, it can carry a few potential risks 
including loss of tissue attachment, loss of 
crestal bone height, and possible loss of in- 
terdental papilla integrity. 

The two recommended designs of full 
mucoperiosteal tissue flaps for periradicular 
surgery are the triangular and rectangular 
(trapezoidal) designs. 

The triangular flap design is the most 
widely used flap design in periradicular sur- 
gery, and it is indicated in the anterior and 
posterior regions of both the mandible and 
the maxilla. It requires a horizontal intrasul- 
cular incision and a single vertical releasing 
incision (see Figure 6.41). 

The horizontal incision is made with the 
scalpel held near a vertical position, extend- 
ing through the gingival sulcus and the gin- 
gival fibers down to the level of the crestal 
bone. When passing through the interdental 
region, care should be taken to ensure that 
the incision is separating the buccal and lin- 
gual papillae in the midcol area. A micro- 
blade will ease this separation if the embra- 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 168 



Figure 6-41 A. Anterior triangular flap design. 

Figure 6-41 B. Posterior triangular flap design. 

sure space is narrow (for example, mandibu- 
lar anterior area). A clean incision located ex- 
actly midcol is vital to prevent sloughing of 
the papillae due to a compromised blood 
supply and to prevent the unaesthetic look 
of double papillae. 1 

The vertical releasing incision is prepared 
between the root eminences parallel to the 
long access of the roots. In anterior surgery, 
the vertical incision is prepared in the flap 
perimeter closest to the surgeon. In posterior 
surgery, it always constitutes the mesial 
perimeter of the flap. It is important to keep 
the base of the flap as wide as the top so that 
the vertical incision is kept parallel to the 
vertically positioned supraperiosteal mi- 
crovasculature and tissue-supportive collagen 
fibers. 1 In this manner, the least number of 
vessels and fibers are severed, which will 
translate into faster healing without scarring 
(see Figure 6.42). Vertical incisions should 

Figure 6-42. Vertical releasing incision is parallel 
to microvasculature. 

Figure 6-43. Vertical releasing incision terminat- 
ing at the tooth line angle. It is perpendicular to 
the free gingival margin. 

terminate at the mesial or distal line angles 
of teeth and never in the papillae or the mid- 
root area. It also should meet the tooth at 
the free gingival margin with a 90-degree 
angle (see Figures 6.41 and 6.43). 

The advantages of the triangular flap de- 
sign are simplicity, rapid wound healing, ease 
of flap reapproximation, and ease of sutur- 
ing. A disadvantage, on the other hand, is 
the limited surgical access. In situations 
where more access is warranted, either the 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 169 



horizontal or the vertical incisions can be ex- 
tended to allow some additional mobiliza- 
tion of the flap. 

Alternatively, a rectangular flap design 
should be considered if maximum access is 

The rectangular flap design is very simi- 
lar to the triangular design except for the ad- 
dition of a second vertical releasing incision 
(see Figure 6 .44). The rectangular flap design 
is indicated for anterior surgery when more 
access is needed. It is also used when multi- 
ple teeth will be operated on or when the 
roots are long (for example, cuspid). 
Potential disadvantages associated with this 
flap design include technique sensitive 
wound closure and a higher chance for flap 

Limited Muc op erio steal Tissue Flap 
(Scalloped Flap) 

This limited tissue flap does not include the 
marginal and interdental gingival within its 
perimeter. It is indicated in teeth with exist- 
ing fixed restorations and in cases where aes- 
thetics are a major concern. The limited tis- 
sue flap can be used in both the maxillary 
anterior or posterior regions but only when 
sufficient width of attached gingiva is avail- 
able. It is usually contraindicated in the 
mandible since the attached gingiva is nar- 
row in that region and aesthetics are not a 
major concern. 

An absolute minimum of 2 mm of at- 
tached gingiva from the depth of the gingival 
sulcus must be present before this flap design 
is selected 32 (see Figure 6.45). This submar- 
ginal flap design is formed by a scalloped 
horizontal incision and one or two vertical 
releasing incisions depending on the surgical 
access needed (see Figure 6.46). The scal- 
loped incision reflects the contours of the 
marginal gingiva and provides an adequate 
distance from the depth of the gingival 
sulci. 18 It also serves as a guide for correctly 
repositioning the elevated flap for suturing. 25 

Figure 6-44. Rectangular flap design. 

Figure 6-45. Rectangular submarginal flap 

Figure 6-46. Triangular submarginal flap design. 

All the flap corners, either at the scalloping 
or at the junction of horizontal and vertical 
incisions, should be rounded to promote 
smoother healing and minimize scar for- 
mation. The angle of the incision in relation 
to the cortical plate is 45 degrees to allow 
the widest cut surface as well as better adap- 
tation when the flap is repositioned (see 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 170 



Figure 6-47. 45-degree bevel incision angle. 

Figure 6.47). This 45-degree bevel at the 
scalloped horizontal incision is made with 
the tip of the scalpel pointing away from the 
gingival sulcus. This adds an additional 
safety measure to protect the minimum 
2 mm of attached gingiva. 

The submarginal flap has the advantage 
of leaving the marginal and interdental gin- 
giva intact in addition to leaving the crestal 

bone unexposed. The major disadvantage is 
the severance of supraperiosteal vessels, 
which could leave the unreflected tissue 
without blood supply. This can be prevented 
by preserving an adequate width of unre- 
flected gingival tissue, which will derive sec- 
ondary blood supplies from the PDL and in- 
traosseous blood vessels. The healing of this 
flap seems to be quite similar to the full mu- 
coperiosteal flap. 

Elevation and Retraction 

Tissue elevation always starts in the attached 
gingiva of the vertical incision (see Figure 
6.48A and 6.48B). This allows the periosteal 
elevator to apply reflective forces against the 
cortical bone and not the root surface while 
elevating the tougher fibrous tissue of the 
gingiva. Special attention should be directed 
to ensure that the periosteum is entirely 
lifted from the cortical plate with the ele- 
vated flap (see Figure 6.49). The elevator 
should then be moved more coronally to ele- 
vate the marginal and interdental papilla 
atraumatically using the undermining eleva- 
tion technique. 18 In this technique, all reflec- 
tive forces should be applied to the bone and 
periosteum, with minimal forces on the gin- 
gival tissue (see Figures 6.50A and 6. 5 OB). 
Subsequently, the elevation continues in a 
more apical direction into the submucosa to 
expose the root tip area and to render the 
flap more flexible and movable. 

Figure 6-48A-B. Elevation starts at the middle portion of the vertical incision. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 111 



Figure 6-49. Visual inspection to ensure that the 
periosteum is included within the flap elevation 
and is completely lifted off the cortical plate. 

Figure 6-50A-B. The undermining elevation 

At this point a retractor should be used to 
provide access to the periradicular tissue. The 
retractor tip should rest on bone with light 
but firm pressure and without any trauma to 
the flap soft tissue. The surgeon must ensure 

Figure 6-51 A. The Kim/Pecora (KP) retractors 
1 through 4 (Hartzell & Sons Co.). 

Figure 6-51 B. A closer view of the different 
shapes of the KP retractor tips. 

that minimal tension exists at all perimeters 
of the flap before the osteotomy. If tension 
exists, then one or both of the releasing inci- 
sions should be extended or the reflected tis- 
sue should be elevated further. It is impor- 
tant to evaluate the cortical plate bone 
topography (flat, convex, or concave) to 
choose the right retractor tip — a shape that 
will fit the anatomy to maximize stable an- 
chorage (see Figure 6.5 1A and 6.5 IB). For 
example, if the cortical bone anatomy is con- 
vex such as the area of the canine eminence 
or the zygoma, then a retractor with a con- 
cave or V-shaped tip will best fit this 
anatomy (see Figure 6.52). An appropriate 
retractor tip will allow maximum surface 
contact between the retractor and bone to 
prevent unintentional retractor slippage and 
possible flap impingement. 

For posterior mandibular surgery, the 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 172 



Figure 6-52. KP 2 retractor with a v-shape tip 
perfectly fits against the zygoma and provide 
maximum retention. 

groove technique should be used to provide 
a stable anchor for the retractor. In this tech- 
nique, a 1 5 mm shallow horizontal groove is 
prepared using the Lindemann bur. This 
groove is prepared beyond the apex for 
molar surgery and above the mental foramen 
for premolar surgery. 

The use of a plastic cheek retractor under- 
neath the surgical retractor provides better 
access and visibility to the surgical site while 
protecting the patient's lips at the same time 
(see Figure 6.53). 

The amount of time that the tissue is re- 
tracted is an essential factor in the speed of 
healing. Although related literature does not 
give a specific answer, it seems logical to 
keep this time to a minimum. On the other 
hand, operators should take sufficient time 
to solve the clinical goals of the surgical pro- 
cedure. 29 By keeping the surgical site well 
hydrated with sterile saline, there seems to be 
no specific time limit to the procedure. 


The purpose of the osteotomy in endodontic 
surgery is to deliberately and precisely pre- 
pare a small window through the cortical 
plate of bone to gain direct visual and instru- 
mental access to the periapical area. The os- 
teotomy should allow identification of the 

Figure 6-53. The use of the cheek retractor un- 
derneath the surgical retractor improves surgical 
access and provides added safety to patient's soft 

root apex and thorough enucleation of the 
periapical lesion. 

The osteotomy size should be as small as 
possible but as large as necessary 33 However, 
a minimum diameter of 4 mm is absolutely 
essential. This is very important in order to 
allow a 3-mm root resection and to accom- 
modate free manipulation of microsurgical 
instruments inside the bone crypt. An ultra- 
sonic tip can be used to verify if the os- 
teotomy is adequate. Ideally, the ultrasonic 
tip (which is 3 mm long) should fit freely 
inside the crypt without any contact on 
bone (see Figure 6.54). When a larger lesion 
is encountered, the osteotomy might have to 
be further extended to ensure complete 
curettage of the lesion. 

The osteotomy should be accurately pre- 
pared over the root apex to prevent any un- 
necessary overextension. This is an easy task 
when fenestration through the cortical plate 
is present. On the other hand, when the 
buccal cortical plate is intact and the lesion is 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 173 



Figure 6-54. Ideal osteotomy size of 4 mm is 
confirmed with the use of an ultrasonic tip. It 
allows free manipulation of the microsurgical 
instruments inside the bone crypt. 

limited to the medullary bone space, a care- 
ful assessment should precede any osteotomy 

An important clinical clue in finding the 
apex is the estimated root length, which can 
be measured from a preoperative radiograph 
or simply be obtained from working length 
recorded in the patient's chart. The length 
measurement is then transformed to the buc- 
cal plate using a file or periodontal probe (see 
Figure 6.55A and 6.55B). In addition to the 
length, the radiograph should be carefully ex- 
amined for root curvature, position of the 
apex in relation to the cusp tip, and proxim- 
ity of the apex to the adjacent apices or ana- 
tomical structures (mental foramen, mandib- 
ular nerve, and maxillary sinus). In most 
cases, a visual inspection of the buccal bone 
topography will reveal the root location and 
direct the surgeon to the root apex. In other 
cases, osseous palpation using an endodontic 
explorer is recommended in an attempt to 

Figure 6-55A. Transferring the estimated root 
length measurement to the buccal plate using an 
endodontic file (adapted from Practical Lessons in 
Endodontic Surgery by D.E. Arens). 

Figure 6-55B. Measuring with a periodontal 

penetrate through the thinned cortical plate 
into the lesion to confirm the exact location 
of the apex (see Figure 6.56A and 6.56B). 
If the operator is still unsure about the 
exact location of the apex, the following pro- 
cedure can provide better orientation. Using 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 174 










/ / F^iS 

K "r T^^ 

j^^r Tt3^ / 

/|^ I/// 

*j ^ /^\ / 

/ x Wr W 

ffm u V 

T » ^ 



Figure 6-56A. Apical osseous palpation with 
endodontic explorer to locate exact location of the 
lesion (adapted from Practical Lessons in 
Endodontic Surgery by D.E. Arens). 

Figure 6-56B. Endodontic explorer breaking 
through the thin buccal plate and confirming the 
exact location of the lesion and the apex. 

a surgical #1 round bur, an indentation is 
prepared on the cortical plate over the esti- 
mated location of the apex. The indentation 
is then filled with a radio-opaque material 
such as gutta-percha or tin foil. A radiograph 
is taken with the marker in place to ascertain 
the location of the apex in relation to the 
marker (see Figure 6.57A and 6.57B). 

The osteotomy is usually accomplished 
with a Lindemann bone cutter bur mounted 
on a surgical high-speed handpiece such as 
the Impact Air 45. It is used in a brush- 
stroke fashion coupled with copious saline 
irrigation (see Figure 6.58). The Lindemann 
bur has fewer flutes than conventional burs, 
which results in less clogging and more effi- 
cient cutting with minimal frictional heat 

Figure 6-57A. Gutta-percha (arrow) placed into 
the indentation prepared over the estimated loca- 
tion of the apex. 

Figure 6-57B. The marker location is verified 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 175 



Figure 6-58. Lindemann bone cutter bur 
mounted on an Impact Air 45 handpiece. 

produced. The Lindemann bur also pro- 
duces a smoother bone surface with diver- 
gent walls and fewer undercuts in compari- 
son to a round bur. The advantage of the 
Impact Air 45 handpiece is that water is di- 
rected along the bur shaft while air is ejected 
out of the back of the handpiece, thus mini- 
mizing the chance of emphysema. 

During the osteotomy preparation, it is es- 
sential to use the microscope at a lower mag- 
nification (4X to 8X) in order to make the 
distinction between bone and root tip. The 
root structure can be identified apart from 
bone by texture (smooth and hard), color 
(darker yellowish), lack of bleeding upon 
probing, and the presence of an outline 
(PDL). When the root tip cannot be distin- 
guished, the osteotomy site is stained with 
methylene blue dye, which preferentially 
stains the periodontal ligament (see Figure 
6.59) and identifies the root apex. 25 ' 33, 3 

Periradicular Curettage 

It is important to emphasize that periradicu- 
lar curettage alone does not eliminate the 

origin of the lesion but, rather, temporarily 
relieves the symptoms. The purpose of the 
curettage is only to remove the reactive tis- 
sue, whether it is a periapical granuloma or 
cyst. It is usually performed prior to or in 
conjunction with root-end resection. 

Curettage is accomplished with bone 
curettes (#2/4 Molt), with the concave sur- 
face of the instrument facing the bony wall 
first 18 (see Figure 6.59). Pressure is applied 
only against the bony crypt until the tissue is 
freed along the lateral margins (see Figure 
6.60A— E). Then, the bone curette can be 
rotated around and used in a scraping mo- 
tion. Once loosened, tissue forceps are used 
to grasp the tissue and transfer it directly to 
the biopsy bottle. Periodontal curettes 
(Columbia 13/14, Jaquette 34/35, and mini- 
Jaquette) can be used to remove any remain- 
ing lesion tissue or tags, especially in the re- 
gion lingual to the apex. 

Figure 6-59. Apical curettage (adapted from 
Practical Lessons in Endodontic Surgery by D.E. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 176 



Figure 6-60A. Apical curettage using the back 
action of the spoon excavator. 

Apical Root Resection 

This is also referred to as apicoectomy. 
Apical root resection is performed to ensure 
the removal of aberrant root entities and to 
allow microscopic inspection of the resected 
root surface. Similar to the osteotomy, it is 
usually accomplished with the Lindemann 
bur in an Impact Air 45 handpiece using co- 
pious saline spray and under low range of 
magnification (4X to 8X) (see Figure 6.61). 
The smooth resected root surface produced 
by the Lindemann bur facilitates and eases 
microinspection (see Figure 6.62). 

There are two important factors to con- 

Figure 6-60B-D. The spoon is used circumfer- 
entially around the granulation tissue until the le- 
sion is completely separated from the wall of the 
bone crypt. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 111 



Figure 6-60E. Lesion removed in one piece. 

sider with this procedure: the extent of apical 
resection and the bevel angle. 

Extent of Apical Resection 

The amount of root resection depends on 
the incidence of lateral canals and apical 
ramifications. Apical resection of 3 mm at a 
0-degree bevel has been shown to reduce lat- 
eral canals by 93 percent and apical ramifica- 
tions of lateral canals, deltas, and isthmi by 
98 percent 25 (see Figure 6.63). Additional 
resection does not reduce this percentage sig- 

The level of root resection may need to be 
modified due to the presence of the follow- 
ing factors: 

• Presence and position of additional roots 
(for example, a mesiopalatal root of a max- 
illary molar that is shorter than the 
mesiobuccal root). 

• Presence of a lateral canal at the root resec- 
tion level (see Figure 6.64). 

Figure 6-61 . Apical root resection (adapted 
from Practical Lessons in Endodontic Surgery by 
D.E. Arens). 

Figure 6-62A. The smooth and flat resected 
root surface produced with the Lindemann bur as 
viewed with the help of a micromirror following 
methylene blue staining. This picture shows gross 
apical leakage. All pictures in Figure 6-62 (A-D) 
are courtesy of Dr. Syngcuk Kim. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 178 



Figure 6-62B. MB root of a maxillary molar re- 
vealing a missed MB2 canal and an isthmus. 

Figure 6-62C. Untreated canal space (arrow). 

Presence of a long post and the need to 
place a root-end filling (see Figure 6.65A 
and 6.65B). 

Presence and location of a perforation. 
Presence of an apical root fracture. 
Amount of remaining buccal crestal bone 
(a minimum of 2 mm should remain to 
prevent periodontic-endodontic commu- 

Presence of an apical root curvature (see 
Figure 6.65C and 6.65D) 

Bevel Angle 

Apical root resection should be performed 
perpendicular to the long axis of the root 

Figure 6-62D. Apical transportation. Note the 
off-center location of the GP fill in comparison to 
the original canals that are stained in blue (arrow). 

Figure 6-63. Three-millimeter apical root resec- 
tion eliminates 93 percent of lateral canals. 

(see Figure 6.66). This 0-degree bevel will 
ensure equal resection of the root apex on 
both buccal and lingual aspects. 

In some situations, a 0-degree bevel might 
not be possible (for example, severe lingual 
inclination of an anterior tooth, wide roots 
in a buccolingual dimension). In these cases, 
the operator should use a small bevel angle 
(up to 10 degrees). This bevel should be kept 
to the smallest angle possible, since the real 
bevel angle is almost always greater than 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 179 



Figure 6-64A. Radiograph of a maxillary first 
molar revealing an obvious lateral canal. 

Figure 6-64B. Some resection has been ac- 
complished but additional resection is necessary 
to eliminate the lateral canal as a possible avenue 
for leakage. 

Figure 6-64C. Radiograph of completed resec- 
tion, retropreparation, and retrofill. 

Figure 6-65A. 3mm root resection in this case 
will leave limited room for an adequate retroprepa- 
ration and retrofilling. 

Figure 6-65B. Postoperative radiograph with a 
more conservative root resection. 

Figure 6-65C. Presence of apical curvature. 


2879_Koerner_Chap 06 4/17/06 1:33 PM Page 180 



Figure 6-65D. Root resection extended to elimi- 
nate the apical curvature so that retropreparation 
to a depth of 3 mm could be performed. 

Figure 6-66. 0-degree bevel angle. (Adapted 
from Practical Lessons in Endodontic Surgery by 
D.E. Arens). 

what it appears to be depending on the angle 
at which the tooth is proclined in the alveo- 
lus. For example, mandibular and maxillary 
anterior teeth have lingual inclinations. 
Surgeons might resect the root at what seems 
to be a 10-degree bevel, but in reality the 

Figure 6-67. 45-degree bevel angle will expose 
a large number of dentinal tubules and will barely 
resect the lingual aspect of the root. 

root is being resected with a bevel of 20 de- 
grees or more. The surgeon should compen- 
sate for this distortion of perspective by min- 
imizing the angle of the bevel, keeping it as 
close to degrees as possible. 3 ' 35 

An important advantage of the perpen- 
dicular root resection is the minimal expo- 
sure of dentinal tubules, which results in a 
reduction in apical leakage 1 (see Figure 
6.67). In addition, the root canal anatomy 
is no longer elongated in a buccolingual 
direction as it is by traditional wide-angled 
methods (see Figure 6.68A-B), thus facili- 
tating retropreparation and retrofilling 

Figure 6.69 shows apical root resection 
being performed on tooth #4. An adequate 
osteotomy is prepared to expose the apical 
3 mm of the root prior to resection (see 
Figure 6.69A). Root resection is performed 
at a 0— 10-degree bevel angle (see Figure 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 181 



Figure 6-68A. 45-degree bevel will produce a 
distorted elongated view of the canal in a buccol- 
ingual direction. 

6.69B). The root tip is completely separated 
and is removed (see Figure 6.69C and 

Microscopic Inspection of the 
Resected Root Surface 

The smooth surface of a perpendicular root 
resection will best prepare the root to reveal 
its hidden anatomy to microscopic inspec- 
tion. This is usually accomplished under 
high magnification (16X to25X) and after 
staining with methylene blue dye. Without 
the added clarity provided by the dye, mag- 
nification alone is insufficient for an accurate 
inspection. Like adding colors to a black- 
and-white film, the dye adds borders and 
contrasts to an otherwise monochromatic 
surgical field, revealing a surprising degree of 
additional detailed anatomy. 

Figure 6-68B. 0-degree bevel will produce a 
more accurate and centered view of the canal 

Figure 6-69A. An osteotomy has been prepared 
to expose the apical 3 mm of the root of tooth #4 
prior to resection. 

Methylene Blue Staining Technique 

The resected root surface has to be thor- 
oughly dried using the Stropko drier prior to 
the application of the dye with a microappli- 
cator tip (see Figure 6.70A-B). After waiting 
a few seconds, the excess dye is rinsed with 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 182 



Figure 6-69B. Root resection performed at a 
0-1 0-degree bevel angle. 

Figure 6-69C. The root tip has been separated 
from the root. 

saline and the root surface is dried again in 
final preparation for microinspection. At this 
time, the periodontal ligament and leaky 
areas are clearly defined by the blue stain. If 
the entire root tip has been resected, the 
PDL can be identified as a continuous line 

Figure 6-69D. Root tip removed. 

around the root surface (see Figure 6.70B). 
A partial line indicates that only part of the 
root has been resected. 

Microscopic Inspection 

Microinspection of the resected root surface 
is the single most important step in the en- 
tire surgical procedure. This novel method 
was not available during the period when 
traditional surgical techniques were em- 
ployed. Only when it is performed accu- 
rately can a definite diagnosis be made to 
identify the true etiology of the disease. 

The appropriate size and shape micromir- 
ror is used to reflect a clear and direct view 
of the resected root surface (see Figure 6.71). 
Potentially leaky anatomy or suspicious mi- 
crofractures can be confirmed by probing 
with the CX-1 microexplorer. 

At this point, the resected root surface 
should be checked for the following anatom- 
ical and pathological details: 

• Missed canals 

• Isthmuses, fins, C-shaped canals, and 
accessory canals 

• Leaky canals 

• Microfractures 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 183 



Figure 6-70A. Methylene blue dye application. 

Figure 6-70B. Dye generously applied over the 
root surface. 

Figure 6-70C. After rinsing the excess dye with 
saline the PDL and any leakage around the GP 
are clearly stained in blue. 

• Apical canal transportation 

• Separated instruments 

After all of these structures and defects are 
identified, the operator can proceed with 
their treatments and corrections (see Figure 

If an apical microfracture is discovered, 
further root resection and staining is per- 
formed until the fracture line is completely 
eliminated. If the fracture line persists, then 
either root amputation or extraction should 
be considered. 

All anatomical variations (such as isth- 
muses and fins) should be included in the 
retropreparation to eliminate them as av- 
enues for leakage. 

Separated instruments in the apical third 
of the canal can be effectively removed with 
the combination of the 3 mm root resection 
and retropreparation. 

The majority of apical perforations and 
transportations can simply be corrected with 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 184 



Figure 6-71. The micromirror is appropriately 
positioned to reflect a direct view of the resected 
root surface. 

root resection. When resection alone is inad- 
equate in correcting the problem, the trans- 
ported canal will look off-center while the 
original untreated canal space will be more 
centered and stained in blue (as shown in 
Figure 6.62D). If further resection cannot be 
performed, then emphasis should be placed 
on treating the untreated canal rather then 
the deviated gutta-percha fill. 

Ultrasonic Retropreparation 

The objective of retropreparation is to clean 
and shape the apical canal while providing at 
the same time a retentive cavity preparation 
to receive the root end filling material and 
secure an apical seal. 

Figure 6-72A. Resected root viewed at 4x 

Figure 6-72B. 1 0x magnification. 

An ideal retropreparation is best described 
as: "a class one preparation that is at least 
three millimeters into root dentin with walls 
parallel to and coincident with the anatomic 
outline of the pulpal space' (see Figure 

The outline of the preparation depends 
mainly on the anatomy of the exposed canal 
space in cross-section. For example, in the 
maxillary central incisor, the shape of the 
preparation will be round. In premolars and 
molars, the outline of the preparation will be 
more oval and narrow. 

A preparation depth of 3 mm with 0-10 
degrees root resection bevel angle is gen- 
erally recommended 1 (see Figure 6.74). 
This depth has been shown to significantly 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 185 



Figure 6-72C. 16x magnification. 

Figure 6-72D. Micro-inspection of the resected 
root surface at 20 x magnification with the use of 
the micromirror. The missed second canal and 
isthmus are clearly identified. 

reduce apical dentin permeability and apical 

Apical dentin permeability is directly re- 
lated to the number of open dentinal tubules 
at the resected root end. Tidmarsh and 
Arrowsmith suggested that the angle of the 
bevel should be kept to a minimum to re- 
duce the number of exposed dentinal 
tubules. They also recommended the canal 
to be retrofilled at least to the level of the 

Figure 6-73. Ideal retropreparation outline that 
follows and includes the anatomic outline of the 
pulpal space. This is a case of a maxillary molar 
with fused roots and an isthmus that connects the 
buccal roots to the palatal root. 


■ tfSt ■' 



IWf\Q(k 3mm depth 


/ / 1 Q^ 

//&<// j 

/ \l*^\r 

\W / 

/ wU 

y> \ / j 




Figure 6-74. Adapted from Practical Lessons in 
Endodontic Surgery by D.E. Arens. 

coronal end of the beveled root to internally 
seal any exposed tubules (see Figure 6.75). 

Apical microleakage is the leakage along 
the interface between the filling material and 
the canal wall. Microleakage is dictated by 
two interconnected factors: the retrograde 
filling depth and the root resection bevel 

Increasing the depth of the retrograde fill- 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 186 



45 / 

1 1 

I \ 

LI 1 1 

~~ o 

r l 

l mm 

r ™ t 

3.4 / 
mm I 

r T 

1 / L 

/ y 

Figure 6-75. Increasing the depth of the retrograde filling significantly decreases apical leakage. If 
teeth are resected at degrees to the long access, a retrograde filling with a depth of 1 mm is sufficient 
to prevent apical microleakage. A steeper-beveled apex will require a deeper retrofilling. As the bevel 
angle increases to 30 and 45 degrees, the depth of the retrograde filling should be increased to 2.1 and 
2.5 mm, respectively, to achieve a similar apical seal. This is due to the shorter buccal wall of the retro- 
prepared canal space of a beveled resected apex. 

ing significantly decreases apical leakage. 1 If 
teeth are resected at degrees to the long ac- 
cess, a retrograde filling with a depth of 
1 mm is sufficient to prevent apical mi- 
croleakage. But a steeper-beveled apex will 
require a deeper retrofilling. As the bevel 
angle increases to 30 and 45 degrees, the 
depth of the retrograde filling should be in- 
creased to 2.1 and 2.5 mm, respectively, to 
achieve a similar apical seal. This is due to 
the shorter buccal wall of the retroprepared 
canal space of a beveled resected apex (see 
Figure 6.75). 

Because a small bevel angle is sometimes 
necessary for good surgical access as opposed 
to the ideal 0-degree bevel angle, and be- 
cause it is difficult to accurately assess the 
extent of the bevel angle clinically, retro- 
grade filling with a depth of 3 mm is 
recommended to minimize apical micro- 

Using traditional endodontic surgery in- 
struments and techniques, the objectives 
mentioned above are rarely achieved. Most 
traditional preparations are performed with a 

miniature contra-angle handpiece using 
small round or inverted-cone carbide burs. 
These obsolete approaches often fail to exe- 
cute retropreparation with adequate depth 
that is parallel with the long axis of the 
root, and frequently result in unintentional 
lingual perforation. The net result is retrofill- 
ing that fails to achieve a hermatic seal due 
to its large size, shallow depth, and deviated 

The use of ultrasonic tips in apical micro- 
surgery eliminate most of the major inade- 
quacies and complications associated with 
bur-type root-end preparations. The ultra- 
sonic tips are 1/10 the size of a microhand- 
piece and have a diameter that is as small as 
0.25 mm. When performed correctly and 
accurately, the ultrasonic technique provides 
the following advantages: 

• Conservative preparations coaxial with the 
long axis of the root and of an adequate 
depth of 3 mm. 

• Preparations that are confined to internal 
root canal anatomy. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 187 



• Precise isthmus preparations. 

• Better access with unrestricted visibility. 

• Thorough debridement of tissue debris. 

• Smoother and more parallel walls. 

The Ultrasonic Technique 

After completing osteotomy preparation, 
apical root resection, crypt hemostasis, 
methylene blue staining, and microscopic 
root inspection, the ultrasonic retroprepara- 
tion should be methodically performed. The 
technique is performed in the following 

1 . Selection of an ultrasonic tip with the ap- 
propriate tip angulations and/or diameter. 

2. Thorough examination of the stained re- 
sected root surface for all microanatomy 
at high magnification (16X to25X). 

3. Developing a mental image of the neces- 
sary retropreparation outline needed to 
include all anatomy (see Figure 6.76). 

4. The selected ultrasonic tip is positioned at 
the apex parallel with the long axis of the 
root (see Figure 6.77). This can only be 
achieved at a lower magnification (4 X to 

Figure 6-76A. The dotted line represents the 
ideal retropreparation outline for this round canal. 

6X), which has a wider field of view that 
enables the surgeon to observe the crown, 
the cervical root area, the root eminence, 
and the apical area — all at the same time. 

Figure 6-76B. Ideal retropreparation outline of a 
mandibular molar mesial root. The outline includes 
both mesial canals and the connecting isthmus. 

Figure 6-77A. Ultrasonic tip aligned along the 
long access of the root. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 188 



Figure 6-77B. Tip transferred into the canal 
keeping the exact orientation. 

This is important to prevent off-angle 
retropreparation and possible perforation. 

5. While maintaining the same orientation, 
the ultrasonic tip is activated and the api- 
cal canal is retroprepared with copious 
saline coolant to a 3 mm depth. This 
should be an easy task if the tip is parallel 
to the gutta-percha-filled canal (see Figure 
6.78). If resistance is encountered, then 
angulation of the tip should be slightly 

6. A microplugger is used to check the 3- 
mm depth of the preparation (see Figure 

Figure 6-78. Tip is activated, and the canal is 
prepared to a depth of 3 mm (which is the length 
of the ultrasonic tip). 

Figure 6-79. Microplugger is used to verify 
preparation depth and to condense down the GR 

It is important to maneuver the ultrasonic 
tip in a gentle up-and-down brushing move- 
ment in order to cut effectively. Application 
of pressure that is too firm will dampen its 
movement and render it ineffective. 

If an isthmus is present between canals, 
the canals on the ends are prepared first 
without the connecting isthmus. The isth- 
mus is then scored with the tip of a microex- 
plorer (CXI) producing a tracking groove. 
This groove will act as a guide to the ultra- 
sonic tip and will help in keeping it centered 
during isthmus preparation. A narrow ultra- 
sonic tip (such as KiS-1 or CT-1) is needed 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 189 



Figure 6-80A,B. Isthmus retropreparation. A. The resection of the root has been completed. B. The 
two canals on each end of the isthmus are prepared first, followed by scoring of the isthmus with a 
tracking groove. Finally, the isthmus is prepared to the same depth as the two canals. 

in this area since the isthmus is located in 
the thinner portion of the root, which can 
be perforated easily. The isthmus is prepared 
using a light sweeping motion in a forward 
and backward direction connecting the 
two canals. The isthmus also has to be 
prepared to a 3-mm depth (see Figure 

After the retropreparation is completed, 
the cavity is inspected with the micromirror 
at high magnification (16X to25X). The 
surgeon should confirm that the walls are 
smooth and parallel and that the retropre- 
pared cavity outline has included all the mi- 
croanatomy (see Figure 6.81). 

Gutta-percha remaining on the walls 
needs to either be condensed with a mi- 
croplugger or removed with a microexplorer. 
The use of an activated ultrasonic tip in 
chasing small pieces of gutta-percha is not 
only ineffective but possibly results in 
widened preparation and unnecessary weak- 
ening of the walls. 

Retrograde Filling 

The purpose of retrograde filling is to pro- 
vide an adequate apical seal that will prevent 
the leakage of remaining bacteria and their 
by-products from the root canal system into 
the periradicular tissue. 

Ideal properties for retrograde filling ma- 

Figure 6-81. Microinspection of the retropre- 
pared canal. 

terial as proposed by Grossman are summa- 
rized in Table 6.3. 

Amalgam has previously been the most 
widely used root-end filling material. It is 
easily manipulated and readily available 
and seems to provide a good initial seal. 
Amalgam use is no longer recommended 
due to its corrosion, leakage, staining of soft 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 190 



Table 6-3. Ideal Properties for Retrograde Filling 

1 . Readily available and easy to handle. 

2. Wei I -tolerated by periapical tissues. 

3. Adheres to tooth structure. 

4. Dimensionally stable. 

5. Bacteriocidal or bacteriostatic. 

6. Resistant to dissolution. 

7. Promotes cementogenesis. 

8. Noncorrosive. 

9. Does not stain tooth or periradicular tissue. 

1 0. Electrochemical ly inactive. 

1 1 . Allows adequate working time, then sets 

12. Radiopaque. 

tissue, persistent apical inflammation, and 
lack of long-term success. ' 

The two retrograde filling materials cur- 
rently recommended are Super EBA and 

Super EBA 

In 1978, Oynick and Oynick 38 suggested 
the use of Stailine (later marketed as Super 
EBA) as a retrograde filling material. They 
reported that Super EBA is unresorbable and 
radiopaque. Histological evaluation showed a 
chronic inflammatory reaction, which is 
considered normal in the presence of a for- 
eign body, but it also showed the possibility 
of collagen fibers growing over the material. 

Super EBA is a modified zinc oxide 
eugenol cement (see Table 6.4). The eugenol 
is partially substituted with orthoethoxyben- 
zoic acid to shorten the setting time. 
Alumina is added to the zinc oxide powder 
to make the cement stronger. 

Super EBA has a neutral pH, low solubil- 
ity, and high tensile and compressive 
strength. 39 Several in vitro studies demon- 
strated that Super EBA has less leakage than 
amalgam and IRM. 39 

Advantages of Super EBA include fast set- 
ting time, dimensional stability, good adap- 

Table 6-4. Bosworth's Super EBA retrofilling ma- 
terial composition 


Zinc oxide — 60% 

Alumina— 37% 

Natural resin — 3% 

Eugenol— 37.5% 

Orthoethoxybenzoic acid — 62.5% 

tation to canal walls, and the ability to pol- 
ish. However, it is a difficult material to ma- 
nipulate because the setting time is greatly 
affected by temperature and humidity 

Preparation and Placement of Super EBA 

The liquid and powder are mixed in 1 :4 
ratio over a glass slab. Small increments of 
powder are incorporated into the liquid until 
the mixture loses its shine and the tip of 
EBA does not droop when picked up with 
an EBA carrier. 

When the right consistency is reached, 
the EBA mix is shaped into a thin roll over 
the glass slab. A 3-mm-long segment is 
picked up by the carrier and placed directly 
into the dried retroprepared cavity under 
midrange magnification (10X to 16X) (see 
Figure 6.82). Using a microplugger of appro- 
priate tip size and angulation, the EBA is 
gently condensed into the cavity (see Figure 
6.83). Placement and packing are repeated 
until the entire retroprepared cavity is filled. 
At this point, a microball burnisher is used 
to further condense the material and to seal 
the margins while at the same time pushing 
aside any extra filling material (see Figure 
6.84). A periodontal curette can be used to 
carve away excess Super EBA (see Figure 
6.85). A dry field is maintained from the 
start of the retrofilling process until the 
Super EBA is completely set. Once the ma- 
terial sets, it can be polished with a compos- 
ite finishing bur to a smooth finish (see 
Figure 6.86). 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 191 


Figure 6-82. A 3-mm-long segment is picked 
up by the carrier and placed directly into the 
dried retroprepared cavity under midrange 

Figure 6-83. The EBA is condensed into the 

Although polishing the Super EBA will 
remove extra filling material and produce an 
esthetically pleasing image of the retrofilled 
root-end, a recent study suggests that bur- 

Figure 6-84. A microball burnisher is used to 
further condense the material and to seal the mar- 
gins while pushing aside any extra filling material. 

Figure 6-85. A periodontal curette can be used 
to carve away excess Super EBA. 

nishing the EBA without polishing provides 
a better seal. 

Mineral Trioxide Aggregate (MTA) 

This relatively new material was developed 
by Torabinejad and coworkers in 1995 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 192 



Figure 6-86. The material can be polished with a composite finishing bur to a smooth finish. 

and has proven to be superior to other retro- 
filling materials. MTA is mainly composed 
of tricalcium silicate, tricalcium aluminate, 
and tricalcium oxide in addition to small 
amounts of other mineral oxides (see Figure 
6.87). Bismuth oxide is added to render the 
mix radiopaque. 

MTA is biocompatible and hydrophilic 
and seems to provide excellent sealing prop- 
erties that are not affected by contamination 
with blood. 5 MTA has a high pH, simi- 
lar to calcium hydroxide. It is the only mate- 
rial with the ability to promote regeneration 
of the periodontal apparatus where new ce- 
mentum is formed directly over MTA. 

The two disadvantages of MTA are long 
setting time (48 hours) and the difficult han- 
dling of the material. Due to the long setting 
time and solubility the bone crypt area can- 
not be flushed with saline. Otherwise, the 
material would be washed out. The difficulty 
in the handling of MTA is due to its loose 
granular characteristics; it sticks very well 
neither to itself nor to any instrument. 
Fortunately, the handling problem has been 
solved with the introduction of the MTA 
pellet-forming block. 

To use a system of MTA placement utiliz- 


p Rt£MW 

Figure 6-87. ProRoot MTA (by Dentsply/Tulsa 

ing the pellet-forming block, the MTA 
should be mixed to the proper consistency. 
If the MTA mix is too wet, the pellet will 
not form. If it is too dry it will be crumbly 
and unmanageable. A proper mix should 
have a matte finish and not a watery gloss. 
This system is simply composed of a block 
and a placement instrument (see Figure 
6.88). The block has precision grooves into 
which properly mixed MTA can be loaded 
using a spatula ; then any excess material 
outside the groove should be wiped off using 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 193 



Figure 6-88. Pellet forming block and place- 
ment instrument. 

Figure 6-89. The groove filled with MTA. 

a cotton swab (see Figure 6.89). Finally the 
placement instrument, which perfectly fits 
the groove, should be used to gently slide 
out the MTA (see Figure 6.90). This forms a 
small pellet — shaped like the groove — that 
should stick to the tip of the placement in- 
strument (see Figure 6.91). This MTA pellet 
can be precisely inserted into the root end 
preparation and condensed with a mi- 
croplugger and a ball burnisher. The excess 
material can be simply removed using a wet 
cotton pellet (see Figure 6.92A-E). 

Figure 6-90A and B. The MTA pellet is carried 
out of the groove using the placement instrument. 

Figure 6-91. The MTA pellet on the placement 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 194 



Figure 6-92A and B. MTA transferred into the retropreparation. 

Figure 6-92C. Packing MTA with a ball burnisher. 

Wound Closure 

Wound closure after surgical procedure has 
three stages: reapproximation and compres- 
sion, stabilization with sutures, and suture 

Reapproximation and Compression 

After surgery, the surgical site is thoroughly 
rinsed with copious saline to ensure the re- 

Figure 6-92D. A wet cotton pellet is used to 
wipe off excess cement. 

moval of any debris or blood clots. This 
should apply to the entire surgical field, in- 
cluding the surrounding buccal plate of 
bone, the periradicular bone cavity (except 
where MTA has been used), and the under- 
side of the reflected flap. 

If ferric sulfate was used, it should be 
curetted and rinsed until fresh bleeding is 
observed. When epinephrine Racellet cotton 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 195 



Figure 6-92E. Microinspection of MTA filling. 

pellets are used they should be removed be- 
fore final irrigation. Any loose cotton fibers 
should be removed from the bone crypt with 
the aid of microscopic inspection. 
Undetected cotton fibers left in situ will in- 
duce inflammation and retard healing. 35 

Accurate reapproximation of the tissue 
aids in the initiation of healing by primary 
intention. After the flap is repositioned, 
saline-soaked gauze is used to compress the 
wound site, using firm finger pressure for 
three to five minutes. This is essential for the 
creation of a thin fibrin clot between the flap 
and the bone and between the wound 
edges 18, 7 (see Figure 6.93). 

Stabilization with Sutures and Suture 

A variety of suture materials are available, 
each demonstrating advantages and disad- 
vantages. Suture materials are divided into 
absorbable and nonabsorbable. They can 
also be monofilament or multifilament. 
Silk sutures have been used for years. 
They are easy to handle and inexpensive. 
Unfortunately, since silk sutures are braided, 
they exhibit a wicking effect in which they 
attract fluid and bacteria in as early as 24 

Figure 6-93. The flap is nicely reapproximated 
following saline wet gauze compression of three 

hours postoperatively, making them highly 
inflammatory to the wound. ' 9 However, 
with smaller suture sizes (5-0 or 6-0), proper 
suture placement, use of chlorhexidine rinse, 
and timely suture removal in 48—72 hours, 
this problem can be minimized. 18 

Chromic gut sutures are resorbable. The 
treatment of this type of suture with chromic 
acid prolongs its retention in tissues. 
Nevertheless, they are difficult to handle. 

The use of synthetic monofilament su- 
tures such as nylon is desirable. They are 
nonresorbable and available in small sizes 
and cause minimal tissue reaction. They are 
the sutures of choice in areas with higher es- 
thetic demand. The only disadvantage is 
their high cost. 

Of the many suturing techniques avail- 
able, the interrupted and sling suturing tech- 
niques seem to be the ones most commonly 
used because they are simple and effective. 
The interrupted suturing can be used for the 
vertical releasing incision, while the sling su- 
ture technique can be used for the sulcular 

Suture knots should always be placed 
away from the incision line to minimize mi- 
crobial colonization in that area (see Figure 
6.94). The minimal number of sutures that 
provide adequate flap reapproximation 
should be used. All sutures should be re- 
moved in 48—72 hours. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 196 



Figure 6-94. Interrupted suturing of the vertical 
incision; note the placement of the suture knots 
away from incision line. 

Postsurgical Care 

Postoperative patient instructions should in- 
clude the following: 

1 . Intermittent application of ice pack to the 
surgical site (30 minutes on, 30 minutes 
off) starting immediately after the surgery 
and continuing for six to eight hours. 

2. Strenuous activity smoking, and alcohol 
should be avoided. 

3. Normal food is permitted with emphasis 
on the avoidance of hard, sticky, and 
chewy food. 

4. Do not pull the lip or facial tissues. 

5. Continue the use of analgesics given 
presurgically (600 mg ibuprofen every 
6 hours as needed). Slight to moderate 
discomfort is expected for the first 24—48 
hours. Narcotic analgesics are provided 
and used only as an adjunct to ibuprofen 
if needed. 

6. Oozing of blood from the surgical site is 
normal for the first 24 hours. It can be 
managed with application of a wet gauze 
pack to the site, pressed in place with an 
ice pack. 

7. The day following the surgery, chlorhexi- 
dine rinses should be used twice a day, 
continuing for three to four days. Warm 
salt water rinses can be used every two 

8. Brushing of the surgical site is not recom- 
mended until the sutures are removed. 
Cotton swabs can be used to clean the 
surgical site. 

Surgical Sequelae and 

Oral and written postoperative instructions 
will minimize the occurrence and severity of 
surgical sequelae and will reduce patients' 
anxiety when and if problems develop. 

Pain, swelling, and hemorrhage are the 
most common postsurgical complications. 
They can be easily managed with NSAIDs, 
pressure, and ice application. 

After two to three days, if signs of infec- 
tion are present (for example, fever, pain, 
and progressive swelling with pus drainage), 
antibiotics should be considered. If patients 
develop a serious facial space infection, 
they should be immediately referred for 
emergency medical care and intravenous 

Rarely, ecchymosis can develop. It is char- 
acterized by a discoloration of the facial and 
oral soft tissue due to the extravasation and 
subsequent breakdown of blood in the inter- 
stitial subcutaneous tissue. Usually it occurs 
below the surgical site due to gravity. It can 
also develop in a higher site like the infraor- 
bital area (see Figure 6.95). 

Paresthesia can develop when surgery is 
performed near the mental foramen even 
when the surgical site is far from the nerve. 
It is usually transient in nature and is mainly 
caused by the inflammatory swelling of the 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 197 



Figure 6-95. Ecchymosis in the infraorbital area 
following apical surgery in the maxilla. 

surgical site that impinges on the mandibu- 
lar nerve. If the nerve has not been severed, 
normal sensations usually return in few weeks, 
but it can take up to a few months. On rare 
occasions paresthesia can be permanent. 

Microsurgery Success Rate 

Periradicular microsurgery is a predictable 
and successful treatment of endodontic fail- 
ure when the previous root canal treatment 
and coronal restoration are of adequate qual- 
ity. (The reasons for an endodontic failure 
are not obvious.) 

Surgical treatment is, however, not always 
successful. Possible etiological factors for fail- 
ure are as follows: 

Poor case selection 

Incomplete root canal space debridement 

Incomplete debridement of the canal 


Inadequate apical seal 

Missed canals 

Failure to manage the root-end or retrofill- 

ing material properly 

Vertical root fracture 

Endodontic periodontic communication 

Recurrent cystic lesion 

Other uncertain factors can also play a 
role such as infected dentinal tubules, type of 

root canal filling, more coronally located lat- 
eral canals, and failure to use antibiotics. 

When appropriate case selection criteria 
are used, endodontic microsurgery seems to 
have great success. One study showed a suc- 
cess rate of 96.8 percent after a one-year fol- 
low-up. With longer follow-up periods of 
up to 8 years of the same surgical cases, a 
success rate of 91.5 percent was achieved. 51 
Similar results are reported with other long- 
term prospective studies. 52 


Periradicular surgery in the hands of opera- 
tors who can perform the procedure accu- 
rately can be a great service for patients. 
With the presentation of this chapter, the 
author would like to bring a more thorough 
understanding of contemporary endodontic 
surgical techniques to general dentists who 
have an interest in incorporating this proce- 
dure into their practices. Needless to say, 
materials and methods in dentistry are 
changing constantly. It is the author's hope 
that readers will continuously enrich them- 
selves with evidence-based literature relating 
to the study of endodontics in the grand 
scheme of providing better patient care. 


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microleakage associated with root end resection 
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2. B. G. Tidmarsh. Dentinal tubules at the root ends 
of apicected teeth: a scanning electron micro- 
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3. G. B. Carr. Common errors in periradicular sur- 
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4. G. B. Carr. Ultrasonic root-end preparation. Dent 
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5. W. Hess. Formation of root canal in human teeth. 
7 Nat Dent Assoc 3: 704-734. 1921. 

6. W. Hess, E. Zurcher. The anatomy of the root 
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12. T. Kiryu. Bacteria invading periapical cementum. 
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13. P. N. R. Nair. Types and incidence of human peri- 
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14. P. N. R. Nair. Non-microbial etiology: periapical 
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15. J. H. S. Simon. Incidence of periapical cysts in re- 
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16. A. Freedman. Complications after apicoectomy in 
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17. C. E. Jerome. Preventing root tip loss in the max- 
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21:422-424. 1995. 

18. J. L. Gutmann, J. W. Harrison. Surgical 
Endodontics. St Louis, MO: Ishiyaku 
EuroAmeria. 1994. 

19. A. S. Dajani. Prevention of bacterial endocarditis, 
recommendations by the American Heart 
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20. D. Jackson. Preoperative non-steroidal anti- 
inflammatory drugs for the prevention of postop- 
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21. J. T. Jastak. Vasoconstrictors and local anesthesia: 
a review and rationale for use. J Am Dent Assoc 
107: 623-630. 1983. 

22. J. A. Buckley. Efficacy of epinephrine concentra- 
tion in local anesthesia during periodontal surgery. 
J Periodontal 55: 653-657. 1984. 

23. S. G. Ciancio. Clinical pharmacology for dental 
professionals. 3rd edition. Chicago, IL: Year Book 
Medical, pp. 146-148. 1989. 

24. D. H. Roberts. Local analgesia in dentistry. 2nd 
edition. Bristol, UK: Wright, pp. 84-88. 1987. 

25. S. Kim, G. Pecora, R. Rubinstein. Color atlas of 
microsurgery in endodontics. Philadelphia, PA: 
W.B. Saunders. 2001. 

26. F. J. Vickers. Hemostatic efficacy and cardiovascu- 
lar effects of agents used during endodontic sur- 
gery. J Endod 2 8 (4): 322-323. 2003. 

27. B. G. Jeansonne. Ferric sulfate hemostasis: effect 
on osseous wound healing. II. With curettage and 
irrigation. J Endod 19(4): 174-176. 1993. 

28. J. L. Gutmann. Posterior endodontic surgery: 
anatomical considerations and clinical techniques. 
Int Endod J '18: 8-34. 1985. 

29. L. B. Peters. Soft tissue management in endodon- 
tic surgery. Dent Clin North Am 41(30): 513-528. 

30. J. W Harrison. Wound healing in the tissue of 
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I. The incisional wound. J Endod 17(9): 425-435. 

31. D. E. Cutright. Microcirculation of the perioral 
regions in the Macaca rhesus: part 1 . Oral Surg 
29: 77 G. 1970. 

32. N. P. Lang. The relationship between the width of 
keratinized gingiva and gingival health. / 
Periodontal A3: 623-627. 1972. 

33. S. Kim. Hemostasis in endodontic microsurgery. 
Dent Clin North Am 41(3): 499-512. 1997. 

34. J. V. Cambruzzi. Molar endodontic surgery. / 
Canadian Dent Assoc 49: 61-65. 1983. 

35. G. B. Carr. Surgical endodontics. Pathways of the 
Pulp. 7th edition. St Louis, MO: Mosby-Year 
Book, pp. 608-656. 1998. 

36. S. O. Dorn. Retrograde filling materials: a retro- 
spective success-failure study of amalgam, EBA, 
andIRM./£W^16: 391-393. 1990. 

37. A. L. Frank. Long-term evaluation of surgically 
placed amalgam fillings. J Endod 18: 391-398. 

38. J. Oynick. A study for a new material for retro- 
grade fillings. J Endod A: 203-206. 1978. 

39. R. P. O'Connor. Leakage of amalgam and super- 
EBA root-end fillings using two preparation tech- 
niques and surgical microscopy/ Endod 2\: 
74-78. 1995. 

40. D. L. Bondra. Leakage in vitro with IRM, high 
copper amalgam, and EBA cement as retrofilling 
materials. J Endod 15: 157-160. 1989. 

41. J. T. Briggs. Ten year in vitro assessment of the 
surface status of three retrofilling materials. / 
Endod 2\\ 521-525. 1995. 

2879_Koerner_Chap 06 4/17/06 1:33 PM Page 199 



42. S. G. Forte. Microleakage of super-EBA with and 
without finishing as determined by the fluid filtra- 
tion method. J Endod 24(12): 799. 1998. 

43. M. Torabinejad. Physical and chemical properties 
of a new root-end filling material. J Endod 21: 
349-353. 1995. 

44. M. Torabinejad. Dye leakage of four root end fill- 
ing materials: effects of blood contamination. / 
EndodIO: 159-163. 1994. 

45. M. Torabinejad. Histologic assessment of mineral 
trioxide aggregate as a root-end filling in mon- 
keys. J Endod 23: 225-228.1997. 

46. E. S. Lee. A new mineral trioxide aggregate root- 
end filling technique. J Enodod 26(12): 764-765. 

47. H. L. Levine. Repair following periodontal flap 
surgery with the retention of the gingival fibers. / 
Periodontol 43: 99-103. 1972. 

48. G. E. Lilly. Reaction of oral tissues to suture ma- 
terials: Part III. Oral Surg 28: 432-438. 1969. 

49. G.E. Lilly. Reaction of oral tissues to suture mate- 
rials: Part IV. Oral Surg 33: 152-157. 1972. 

50. R. A. Rubinstein. Short-term observation of the 
results of endodontic surgery with the use of the 
surgical operating microscope and Super-EBA as 
root-end filling material./ Endod 25: 43-48. 

51. R. A. Rubinstein. Long-term follow-up of cases 
considered healed one year after apical micro- 
surgery. / Endod 28: 378-383. 2002. 

52. M. L. Zuolo. Prognosis in periradicular surgery: a 
clinical prospective study. Int Endod J 33: 91-98. 

53. D. E. Arens, M. Torabinejad, N. Chivian, R. 
Rubinstein. Practical Lessons in Endodontic Surgery. 
1st edition. Chicago, IL: Quintessence. 1998. 

I would like to express my deep appreciation for Dr. Alice P. Chen for her outstanding effort in editing and rewriting this chap- 
ter. I would also like to thank Dr. Syngcuk Kim for generously sharing some of his microsurgical slides. I am very grateful for 
the help I received from my assistants and staff in documenting and collecting clinical pictures and illustrations. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 201 

Chapter 7 

The Evaluation and Treatment 
of Oral Lesions 

Dr. Joseph D. Christensen and Dr. Karl R. Koerner 


When a general dentist discovers a lesion in 
the mouth of a patient, there are often sev- 
eral choices on how to proceed. This chapter 
will help the clinician properly evaluate, doc- 
ument, and manage a lesion within the oral 
cavity. It will outline and discuss the indica- 
tions for biopsy, the materials and methods 
necessary to improve screening and early de- 
tection of lesions, and when to refer to 
someone with more knowledge and experi- 
ence. Instructions on different types of 
biopsy and how to properly perform each 
will be described. Careful application of 
sound principles, good judgment, and clini- 
cal skill will help improve the dentist's ability 
to identify, evaluate, and treat — or refer — 
lesions found in the patients for whom we 
are responsible. 

Patient Evaluation 

In order to establish a diagnosis, the dentist 
should have a thorough history of the lesion, 
the patient's health history, and information 
from a clinical exam in order to put the 

questionable tissue into proper context. A 
patient's past health history, including 
medications, trauma, diet, previous surgeries, 
and habits all deserve thorough detective 
work on the part of the dentist. Answers to 
proper questions will often reveal the proba- 
ble cause of the lesion and may help direct 
the clinician down an obvious path of treat- 

Health History 

The dentist should be in possession of a 
written health history that is both accurate 
and current. The patient's answers on the 
form should only be used as a starting point, 
however, and should provoke the dentist to 
probe further for a more complete picture 
of the patient's health. This history informs 
the clinician about situations that might 
cause or predispose a lesion. The history can 
also alert the clinician to various systemic 
conditions that could influence a decision re- 
garding a proposed biopsy or other treat- 
ment. In these instances, it may be appro- 
priate to investigate these issues further 


2879_Koerner_Chap 07 4/17/06 1:31 PM Page 202 



through a physician consultation. Still other 
conditions may, at the very least, require spe- 
cial precautions such as with hypertension, 
brittle diabetes, heart defects, coagulapathies, 
and pregnancy 

The clinician must take into account that 
many oral lesions are manifestations of sys- 
temic conditions. Indeed, it is true that the 
oral cavity is a good barometer of overall 
health. Many diseases have an oral presenta- 
tion as part of the disease process. Common 
examples of this include but certainly are not 
limited to Crohn's disease, HIV, Lupus, 
Sjogren's syndrome, diabetes, and many dif- 
ferent viral, bacterial, and fungal infections. 
Being aware of the patient's systemic condi- 
tions and how they may present is part of 
the puzzle in helping the clinician determine 
a differential diagnosis. 

Lesion History 

In order to see an accurate picture, the den- 
tist should retrieve as much information 
about the lesion as possible. Well-directed 
questioning of the patient will usually in- 
clude the following: 

1 . How long has the lesion been present? 

Lesions that have been present for more 
than two weeks should be of the greatest 
concern. The patient should be asked 
whether they know the origin of the le- 
sion and what may have led to its occur- 
rence. The dentist should look for any 
source of trauma within the mouth (such 
as a denture irritation) and relieve it if 

2. Has the lesion changed in size, shape, 
or color? The lesion may appear to the 
patient to be growing larger. Lesions that 
may have once been white in appearance 
but now are reddish or a speckled white- 
red should raise an immediate concern of 
seriousness, even possible malignancy, to 
the clinician. An ulcer may have recently 
been a vesicle or bulla. Has the tissue in 
question changed from one vesicle to 

many vesicles or ulcers? If this is the case, 
the possibility of a viral process should be 

3. Is the lesion causing pain? If this is the 
case, then what stimulus brings on the 
pain? What makes the pain dissipate? 
Without any pain, the patient may not 
even be aware that the lesion is present. It 
should be noted that oral cancer, al- 
though assumed by many to be a painful 
disease, does not usually elicit any pain 

at all. 

4. Is there anesthesia or loss of sensation? 
If no lesion were present, this symptom 
could be attributed to many things such 
as medication, diabetes, pernicious ane- 
mia, or even injury incurred due to dental 
treatment. However, the clinician should 
be aware that this is also a common 
symptom of malignancy. 

5. Is there any lymph node involvement? 
Careful inspection and palpation of the 
lymph nodes may reveal tenderness and 
sensitivity. The patient may even com- 
plain that their lymph nodes seem 
swollen. This usually indicates an inflam- 
matory response to an infection. Lymph 
nodes may also be affected by other con- 
ditions that could be present in the 
mouth, including oral cancer. 

6. Is there a history of trauma? Trauma or 
oral habits are likely reasons that tissue 
may appear unusual. Denture trauma, a 
sharp tooth, cheek biting, use of tobacco 
products, burns associated with hot foods 
or liquid, cuts and abrasions from hard or 
sharp food, and chemical burns from as- 
pirin or other medicines are just a few of 
the possible reasons why tissue may ap- 
pear unusual. 

7. Are there any constitutional symptoms? 
For example, is the patient febrile? Does 
the patient have dysphagia (difficulty 
swallowing), nausea, or general malaise? 
These are all signs that may have taken 
root from a general systemic condition, 
which may or may not be associated with 
the lesion, but that add information to an 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 203 



overall picture. Fever and dysphagia par- 
ticularly may suggest an inflammatory 
process requiring further investigation. 


A proper examination and description of the 
lesion and the surrounding tissue should be 
accurately recorded in the patient's chart. 
Along with the written description, an illus- 
tration demonstrating the exact location and 

size of the lesion and affected lymph nodes 
(if any) should be included in the record as 
well. This information will be helpful if a le- 
sion is to be followed over a short period of 
time for comparison, resolution, or change 
in appearance. If the dentist decides that re- 
ferral to a specialist for further evaluation 
and more definitive treatment is warranted, a 
copy of all written information (see Figure 
7.1), illustrations, radiographs, and a quality 
photograph (if possible) should be sent to 

Diagnostic Laboratory 






Container: Labeled Unlabeled 






X-rays # enclosed 

Photos # enclosed 







Phone ( 



Surgery Date 

/ / 







Pt Phone ( 



f\ f 1 -*■■ ; 

I I' n \u ; ! \ ! I I : ! ■ ■ ; , : ■ ' ■ ■ ■ ■ : ; ■ •.■ 

v^ ;i O)\j\}\l}liJW,\[i^^^ 

CLINICAL DESCRIPTION OF LESION: (Location, clinical appearance, firmness, size, radiographic findings.) 
Please enclose radiographs/photographs when applicable. 

HISTORY OF LESION: {Describe sequence of events & findings leading to the present state of the lesion - 
duration, rapidity of growth, variation in appearance, pain or other symptoms, possible causes, pertinent lab tests.) 



GROSS: (Dept. Use Only) 



(completion of back 
page is required) 

Figure 7-1 . Biopsy diagnostic report form typical of those used by oral pathology laboratories and 
submitting clinicians. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 204 



the oral pathologist and/or the oral and 
maxillofacial surgeon. 

During an examination, it is a common 
mistake to handle a lesion and the surround- 
ing tissue before a written description can be 
made. This manipulation can cause charac- 
teristics of the lesion to change. For example, 
many lesions are friable and epithelium may 
tear, ulcerations may open and hemorrhage, 
and vesicles may rupture. A lesion may also 
change character, color, and size over time, 
so an accurate initial description, before ma- 
nipulation, will help obtain the proper diag- 
nosis and treatment and may serve as a com- 
parison and reference in the future. 1 

There are a number of factors and ques- 
tions that should be answered and recorded 
in order to place the lesion into proper per- 
spective. Just as variability in the clinical 
presentation of a lesion is a factor, so too, 
can microscopic analysis be a challenge with- 
out the proper lesion history, medical his- 
tory, and preoperative description. 

When describing a lesion for the patient's 
clinical record, there is accepted medical ter- 
minology and descriptors that should be 
used to convey an accurate picture in a lan- 
guage common to all who will evaluate the 
tissue. This is especially true if a specimen is 
to be sent to an oral pathologist. This de- 
scription should include many observed 
characteristics, such as location, size, shape, 
color, texture, consistency, overall character, 
single or multiple lesions, ulcerations, mobil- 
ity or fixation to adjacent structures, fluctu- 
ance, inflammation, and associated lym- 
phadenopathy Table 7. 1 gives definitions of 
proper terminology. 

Clinical Judgment 

After the collection and recording of infor- 
mation has been completed and a differential 
diagnosis made, the clinician must then 
make a professional judgment of how to 
proceed. It is important that a definitive di- 
agnosis of all lesions be determined. 2 It is 

Table 7-1. Clinical Descriptions 

Bulla Loculated fluid in or under the epithelium of 
skin or mucosa. A large blister, larger than 

Crusts Dried or clotted serum protein on the sur- 
face of skin or mucosa. 

Cyst A pathologic epithelium-lined cavity often 
filled with liquid or semisolid contents. 

Ecchymosis A nonelevated area of hemorrhage. 
Larger than petechia. 

Erosion Superficial ulceration (excoriation). 

Fissure A narrow, slit-like ulceration or groove. 

Granuloma A focal area of chronic inflammation 
composed of vascularized granulation tissue. 

Macule Circumscribed area of color change with- 
out elevation. 

Multilocular A radiolucent lesion composed of 
multiple compartments. 

Nodule A large palpable mass elevated above 
the epithelial surface. Larger than 5mm in 

Papillary A tumor or growth exhibiting numerous 
surface projections. 

Papule A small palpable mass elevated above 
the epithelial surface. Less than 5mm in 

Pedunculated A tumor or growth whose base is 
narrower than the widest part of the lesion. 

Petechia A round, pinpoint area of hemorrhage. 

Plaque A flat elevated lesion. The confluence of 

Pustule A cloudy or white vesicle — the color of 
which results from the presence of polymor- 
phonuclear leukocytes (pus). 

Scale A macroscopic accumulation of keratin. 

Sessile A tumor or growth whose base is the 
widest part of the lesion. 

Telangiectasia A vascular lesion caused by di- 
latation of a small, superficial blood vessel. 

Ulcer Loss of epithelium 

Unilocular A radiolucent lesion having a single 

Verrucous A tumor or growth exhibiting a rough, 
warty surface. 

Vesicle A small loculation of fluid on or under the 
epithelium. A small blister under 5mm. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 205 



not consistent with the current standards of 
care to simply watch a lesion over an ex- 
tended period of time. When local irritation 
is thought to be the reason for the problem, 
the area in question should be treated non- 
surgically to allow the tissue to heal. 
Examples of nonsurgical treatment would 
include smoothing the sharp cusp of a tooth, 
acrylic relief or clasp adjustment on a den- 
ture, or just observing an area where it is sus- 
pected that sharp or hot food injured the 
tissue without the patient's knowledge or re- 
membrance. In this situation, a watch-and- 
wait period of two weeks would be prudent. 
If in fact the lesion was trauma induced, the 
area should heal within this period of time. 
However, if after the waiting period the le- 
sion still persists, then it must be assumed 
the causation is not traumatic in nature, and 
therefore biopsy would be indicated. 

It should be noted that most oral cancers 
are asymptomatic in the early stages. 3 The 
consequence of this is that most cases are not 
detected and diagnosed until classic signs of 
malignancy appear late in disease progres- 
sion. The classic signs of oral cancer include: 
erythroplakia, induration, ulceration, paras- 
thesia, bleeding, and cervical adenopathy. 
Unfortunately, all of these signs may be asso- 
ciated with advanced disease and increased 
morbidity and mortality. See Table 7.2. 

The problem for the clinician lies in the 
difficulty of distinguishing precancerous and 
early-stage cancerous oral lesions from simi- 
larly appearing benign lesions. 5 Oral cancer 
in its early stages is insidious, difficult to 
identify, and does not always exhibit consis- 
tent characteristics. For example, Sandler 
found that 25 percent of 207 early stage oral 
cancer lesions did not demonstrate any clas- 
sic signs of malignancy. Unrealized to some 
practitioners, it does not always originate 
from the traditional predisposing risk factors 
either. Blot demonstrated this in their study 
that showed approximately 25 percent of oral 
cancers arise in patients who do not consume 
tobacco or heavy amounts of alcohol. 7 

Table 7-2. Possible Signs of Malignancy 

Erythroplakia Although less common than leuko- 
plakia, almost all true erythroplakias show malig- 
nant changes and have a much greater potential 
for dysplasia or invasive malignancy. 

Leukoplakia Although not often malignant, this is 
by far the most common oral precancer, repre- 
senting 85 percent of such lesions in tobacco 
smoking populations. 

Ulceration Ulcerated areas that do not heal after 
1 4 days must receive a prompt biopsy. 

Parasthesia Oral cancer with deep invasion can 
cause loss of sensation when involved near or 
within nerves. 

Loss of mobility Clinically this may present as fix- 
ation of the tongue or inability to fully open the 

Induration This simply indicates firm or hard tis- 
sue, but in the case of malignancy, it is com- 
monly seen with ulcerations, leukoplakia, and 
especially erythroplakia. 

Persistence If after local trauma and irritation are 
removed, a lesion is highly suspicious — remaining 
longer than 2-3 weeks in duration. 

Sciubba showed the difficulty with visual 
inspection and identification of oral cancer 
in a 1999 study 8 That study surprisingly re- 
vealed that even specialists trained in oral 
and maxillofacial pathology oral medicine, 
and oral and maxillofacial surgery had diffi- 
culty differentiating benign lesions from can- 
cerous or precancerous ones. These experts 
identified and categorized 647 lesions out of 
945 in the study as benign in appearance. 
Results from oral brush biopsy were returned 
on all 945 lesions. Of the 647 benign- 
appearing lesions, 29 of them returned with 
a result of atypical or positive by brush 
biopsy, and scalpel biopsy subsequently con- 
firmed the presence of dysplasia or malig- 
nancy. In this multicenter study, the brush 
biopsy system revealed every precancerous 
and cancerous lesion among all patients 
within the trial. 9 This important study high- 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 206 



lights the fact that visual inspection of the 
oral cavity alone is not a good predictor for 
determining whether a patient has early stage 
oral cancer. 

The clinical lesion decision tree shown in 
Table 7.3 illustrates possible treatment sce- 
narios upon discovering an oral abnormality 
Oral cancer risk factors are listed in Table 7.4. 


Biopsy by definition, is the removal of tis- 
sue, cells, or fluids from the living body for 
diagnostic examination in order to confirm 
or establish the diagnosis of disease. The 
mere mention of the word biopsy tradition- 
ally has implied the eminent use of a sharp 
knife. Scalpel biopsy is still the gold standard 

Table 7-3. Decision Tree for Treatment of Oral Lesions 


Detection of a lesion 



Health history, history of the lesion, clinical exam, radiographs, lab exam, oral speculoscopy 



Differential diagnosis 


Observation or nonsurgical 

treatment for 

10-14 days 


Observation or nonsurgical 

treatment unnecessary or 

high degree of suspicion of 




Oral Brush Biopsy 



No improvement 





D c 



Decision to Scalpel Biopsy 

3 C 



Determine difficulty of 
biopsy procedure 



Perform biopsy y 

ourself J 



Refer to specialist 


Lesion needs no further treatment 


Lesion needs further treatment 



Evaluate difficulty 




Treat yourself 




Refer to specialist 





Patient Follow-Up 

Adapted from L.J. Peterson, E. Ellis, J.R. Hupp, and M.R. Tucker. Contemporary Oral and Maxillofacial 
Surgery, 4th edition. St. Louis, MO: Mosby. 2003. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 207 



upon which all clinicians rely for a definitive 
diagnosis. In addition to this technique, the 
advent of the brush biopsy has allowed den- 
tists the opportunity to perform a noninva- 
sive biopsy on lesions they probably would 
have watched in the past. An obvious point 
to be made is that a clinician should not wait 
to biopsy or refer for biopsy any patient with 
tissue that raises the suspicion of malignancy. 
In fact, a highly suspicious lesion exhibiting 
any classic signs of cancer should, with tactful 
communication to the patient, be referred 
immediately to a specialist. If this situation 
arises, it is easier for the specialist to treat the 
patient if an initial biopsy has not been 
done. It is much easier for the specialist to 
evaluate the tissue in an undisturbed state 
rather than a manipulated and/or incised 
state. 2 

Five types of biopsy/diagnostic measures 
that help enhance and visualize suspect tis- 
sues will be discussed. These five procedures 
are 1) oral brush biopsy; 2) aspiration 
biopsy; 3) incisional biopsy; 4) excisional 
biopsy; and 5) oral speculoscopy A descrip- 
tion of each method and how to perform it 
is given in the following sections. 

Oral Brush Biopsy 

A computer-assisted method of analysis 
developed by Oral CDx (OralScan Labo- 
ratories, Suffern, NY) is an important ad- 
junct in the clinical assessment of an oral 
lesion. As stated, the majority of oral cancer 
goes undiagnosed until obvious signs of ma- 
lignancy are exhibited — usually late in the 
disease process. 10 Consequently, the five- 
year survival rate of oral cancer is low — 
approximately 52 percent 11 (see Table 7.5). 
The purpose of the oral brush biopsy is to 
identify lesions that otherwise may appear 
harmless but in fact histologically exhibit 
atypical cells, dysplasia, or frank carcinoma. 

Brush biopsy is a convenient, inexpensive, 
and noninvasive alternative to watching a le- 
sion for an indefinite amount of time. In the 

Table 7-4. Risk Factors for Oral Malignancy 

• Tobacco use responsible for 90 percent of oral 

• Alcohol and tobacco used concurrently increases 
risk exponentially. 

• Smokers and alcohol users older than age 40 at 
the highest risk. 

• 25 percent of oral cancer patients have no risk 

• Sun exposure to the lip. 

• Human Papillomavirus (HPV16, HPV18, HPV31, 
and HPV33). 

• Squamous cell carcinoma is multifactorial in its 

past, many general dentists have been reluc- 
tant to perform a biopsy on a patient who 
has an innocuous-looking lesion, or even 
refer this patient for biopsy. They may have 
felt a scalpel biopsy was overkill for some- 
thing that appeared so harmless. A watch- 
and-wait approach was most likely accepted 
by the patient and became an acceptable al- 
ternative to the knife. In contrast, the oral 
brush biopsy is a breakthrough advance- 
ment, bridging the gap between observation 
and surgery, bringing a reliable and perhaps 
lifesaving tool to the aid of our patients. 
Just as important, this technique can con- 
firm that a harmless-appearing lesion is in 
fact benign. 

Another benefit of brush biopsy is patient 

Table 7-5. Oral Cancer Statistics* 

30,000 Americans diagnosed each year. 

8,000 Die each year. 

52% Die within 5 yrs. of diagnosis. 

70% Diagnosed in late stage. 

90% Curable if caught early. 

60% Increase in tongue cancer with people 

under age 40 over the past three decades. 

*Oral Health in America: A report of the Surgeon 
General. 2000 Reuters Health. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 208 



compliance. It is well documented that 
many patients referred to an oral surgeon for 
biopsy of a lesion delay, cancel, or avoid the 
appointment altogether. 13. The simplicity 
of this noninvasive procedure allows the den- 
tist to perform the biopsy at the same time 
the lesion is found, without the need for 
local anesthetic. Depending on lab results, it 
may also prevent the need for incisional or 
excisional biopsy in the future. 


A brush biopsy kit supplied from the manu- 
facturer contains a brush biopsy instrument 
(round stiff nylon brush), a bar-coded glass 
slide, alcohol-based fixative, and a protective 
plastic case for mailing (see Figures 7.2A and 
7.2B). Written instructions and a video are 
also available. The nylon brush is designed 
to collect cells from all three layers of epithe- 
lium: superficial, intermediate, and basal. 
This method of collection differentiates itself 
from the unreliable and traditional oral cy- 
tology, where only superficial epithelial cells 
were collected and evaluated. With oral 
brush biopsy, cells are taken from perhaps 
the most important and revealing portion of 
the lesion, the basal layer. Therefore, it is 
critical that the brush extract cells from this 
area of the lesion. This is accomplished by 
applying firm pressure on the lesion and ro- 
tating the brush 5-10 times. Pinpoint bleed- 
ing or exposure of pinkish-red mucosa usu- 
ally signals that an adequate sample of cells 
has been taken. 

After cell extraction, the nylon brush is 
rotated thoroughly and evenly across the 
glass slide in order to transfer as many cells 
as possible. The slide is then doused with the 
alcohol fixative included in the kit and al- 
lowed to dry before being transferred to the 
plastic container for mailing. 

Because this test is designed to be effective 
on tissue exhibiting an epithelial abnormal- 
ity, lesions with an intact, normal-looking 
epithelium or lesions originating in submu- 

Figure 7-2A. Clinician approaching an oval le- 
sion with a white border on the right lateral dor- 
sum of the tongue. 

Figure 7-2B. Cells being smeared on a slide 
prior to adding the fixative. The Oral CDx lab re- 
ported that the cellular representation consisted 
of superficial, intermediate, and basal cells. The 
diagnosis was of benign epithelial cells, singly and 
in clusters — negative for premalignant or malig- 
nant epithelial change. 

cosa, should not be tested by oral brush 
biopsy. This would then exclude fibromas, 
pigmented lesions, lipomas, salivary gland le- 
sions (mucoceles), papillomas, and lesions 
found on the vermilion border of the lip. 
Dentists new to this procedure may be 
concerned that their biopsy may have an in- 
sufficient number of cells and, therefore, risk 
a false-negative result. For this reason, safe- 
guards have been put into place by OralScan 
Laboratories to ensure that only quality 
specimens are given an outcome. Each 
specimen is carefully examined to ensure 
that an adequate cellular representation of all 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 209 



epithelial layers is present. If this has not 
been achieved, it usually means the specimen 
is lacking sufficient cells from the basal layer 
and the dentist will be contacted in order to 
perform another biopsy On the rare occa- 
sion that this occurs, the lab will replace 
the biopsy kit at no cost to the patient or 

After the clinician submits the oral brush 
biopsy to the lab, it is analyzed by a sophisti- 
cated network of computers specifically de- 
signed for this type of pathological review. 
Each biopsy is photographed approximately 
200 times and scanned by the computer for 
epithelial abnormalities associated with oral 
precancerous and cancerous cells. 15 After the 
computer analysis, an oral and maxillofacial 
pathologist then evaluates the biopsy. Results 
are subsequently given in one of three cate- 
gories: negative, atypical, or positive. 

A biopsy returned with a result of atypical 
or positive requires an incisional or excional 
biopsy to microscopically review the histo- 
logic architecture of the lesion for definitive 
diagnosis. A report or finding from the 
scalpel biopsy is returned to the referring 
dentist giving the results. If necessary, the le- 
sion is then given a grading and staging spe- 
cific to that tissue. Of course no matter what 
the finding, even a negative finding, all pa- 
tients possessing lesions or abnormalities 
should be scrutinized and be provided with 
proper follow-up in the future. If during 
these visits the lesion persists or changes 
presentation, prudence would require an ad- 
ditional biopsy be performed. 

Aspiration Biopsy 

Aspiration biopsy is removing contents of a 
lesion for the purpose of analysis or quick 
observation. This technique should not be 
confused with fine needle aspiration biopsy 
(FNA), which will be discussed later. 
Aspiration biopsy is typically used to rule 
out the possibility of a vascular lesion. This 
method of discovery is vastly preferable to 

the unforgettable experience of finding a vas- 
cular lesion unexpectedly. Avoidance of suc- 
cumbing to this misadventure requires the 
treating clinician be familiar with and be 
able to perform an aspiration biopsy on all 
suspected soft tissue vascular lesions and ra- 
diolucent osseous lesions before surgical ex- 
ploration is undertaken. This may require 
referral to a specialist. 

Not only is the aspiration biopsy helpful 
in ruling out vascular lesions, this technique 
is also helpful in identifying contents of vari- 
ous other lesions as well. 

For example, if air is extracted into the sy- 
ringe, a traumatic bone cavity has probably 
been accessed. If it is difficult to aspirate air 
or fluid at all from the tissue, the lesion is 
most likely solid, and a different type of 
biopsy may be indicated. If a purulent white 
fluid is obtained, then an infection may be 
present. If a yellow straw-like substance is 
present, then perhaps the fluid of a cyst was 
removed. The presence of blood on aspira- 
tion can indicate the most important lesion, 
which is the previously mentioned vascular 
lesion; however, it may also suggest the pres- 
ence of other types of lesions. If blood is ob- 
served upon aspiration, the general dentist 
should need no further evidence in order to 
refer the patient to a specialist, where a more 
thorough exploration of the tissue can be ac- 
complished in a controlled surgical setting. 

Aspiration Biopsy Procedure 

This technique requires the use of an 18- 
gauge needle and a 5— 10 cc syringe. The 
patient should be anesthetized, after which 
the 18 -gauge needle and syringe are inserted 
into the approximate area of the mass. The 
needle oftentimes may need successive repo- 
sitioning in order to be correctly placed 
within the center of the lesion. Negative 
pressure (pulling back on the plunger) is 
then applied to the syringe in an attempt to 
achieve positive aspiration. If a bony lesion is 
to be accessed, the needle should be placed 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 210 



on the periosteum and twisted, and firm 
pressure applied. If the needle cannot be in- 
troduced through the cortex with the sug- 
gested technique, a flap should be reflected, 
after which a small dental bur can be used to 
penetrate the cortical plate, allowing for nee- 
dle aspiration. 

Once again, clinical judgment of the le- 
sion, the patient, and the dentist's own 
knowledge, skill, and comfort level are essen- 
tial in determining how to proceed and, 
more importantly, who should perform this 

Fine Needle Aspiration Biopsy 

Although not commonly performed by the 
general dentist, the FNA will be discussed in 
order that the practitioner may be aware of 
the technique, its application, and the differ- 
ence between it and the similar aspiration 

This procedure is normally reserved for 
deep soft tissue lesions not easily obtained 
and incised by simple scalpel biopsy. It is 
normally performed by a pathologist on le- 
sions of the oropharynx, lymph nodes in the 
neck and submandibular area, and suspected 
tumors of the salivary glands. Unlike the as- 
piration biopsy, which provides the practi- 
tioner with quick visual analysis of a lesion's 
nature, the FNA removes cells for histolo- 
gic review and tentative diagnosis by a 


The specialist utilizes a special fine needle 
that is directed to a deep part of the lesion. 
The mass is then pierced with the needle at- 
tached to a disposable 1 Occ syringe contain- 
ing 2-3cc of air. FNA requires many quick 
passes within the mass while at the same 
time applying negative pressure. These jab- 
bing passes should be taken in different areas 
of the tissue in order to capture cells repre- 
sentative of the entire lesion. The air intro- 

duced into the syringe before aspiration 
helps dispel the specimen onto the glass slide 
once the biopsy is completed. Normal fixa- 
tive procedures are then implemented and 
the biopsy is examined. 

Oral Speculoscopy 

This technique is a noninvasive adjunct to 
the normal full-mouth soft tissue examina- 
tion. To be clear, this procedure is not a 
biopsy, but a diagnostic method. However, it 
may aid in the visualization and evaluation 
of an oral mucosal abnormality. Originally, 
this technique was adapted from OB-GYN's 
Visual Cervical Screening Test. Its applica- 
tion in dentistry has been appropriate be- 
cause the epithelium located within the oral 
cavity is histologically the same as epithelium 
within the female reproductive tract. Not 
only is the tissue almost identical, oral cancer 
and cervical cancer are essentially the same 
disease process. 

In a gynecological study, the traditional 
Papanicolaou (Pap) smear when used alone 
detected cervical neoplasia in 3 1 percent of 
the women studied. When the combination 
of acetic acid and chemiluminescent light 
(speculoscopy) was used in conjunction with 
the Pap smear, the number jumped to 83 
percent. Since oral cancer is the sixth most 
common type of cancer in the United States, 
ahead of cervical cancer, Hodgkin's disease, 
and malignant melanoma, there is a natural 
need to utilize this and other new methods 
made available to improve early detec- 
tion. 18 ' 19 This procedure was introduced 
and made available to dental practitioners in 
2002 by ViziLite (Zila Pharmaceuticals). 
Essentially, this product uses acetic acid to 
dehydrate the epithelium, making it easier to 
visualize abnormal tissue with short-wave- 
length light. Its recommended application is 
for patients who have risk factors for oral 
cancer and those patients who have a sus- 
pected lesion or questionable area of mucosa. 
See Figures 7.3 and 7.4. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 211 



Figure 7-3. ViziLite vial of acetic acid, light stick, 
and light stick holder. This product helps the 
dentist visualize and evaluate possible oral abnor- 

Figure 7-4A. White areas of tissue extending 
from the pterygomandibular raphe forward onto 
the buccal mucosa found during a routine dental 

According to a study by Huber and asso- 
ciates, 20 oral epithelium that is normal will 
absorb the chemiluminescent light used in 
oral speculoscopy causing it to have a "blue- 
hue" appearance. In contrast, abnormal ep- 
ithelium may reflect the light, making it 
appear acetowhite (see Figure 7.4B). It 
gives this appearance for either of these 
two reasons: 1) The tissue exhibits excessive 
keratinization, hyperparakeratinization, 
and/or significant inflammatory infiltrate; 
or 2) the cells have an altered nuclear- 
cytoplasmic density ratio. This altered 
nuclear-cytoplasmic ratio oftentimes means 
the cell has a large or enlarged nuclei, which 
is one of the characteristics of dysplastic or 
cancerous tissue. 

Figure 7-4B. The same tissue after application 
of acetic acid rinse for 30-60 seconds followed by 
visualization of tissue with chemiluminescent light. 

This procedure should not only help re- 
veal oral lesions but also impress upon the 
patient the need to reduce any risk factors 
they may have in their life. If test results are 
positive and determine that the patient re- 
quires a biopsy, this technique can help the 
patient go forward with the decision more 
confidently. Whether the biopsy is to be per- 
formed by the general dentist or specialist, 
the ViziLite application will help the clini- 
cian decide what specific area of the lesion 
should receive brush biopsy or scalpel biopsy. 


The provided examination kit contains in- 
structions, a bottle of 1 percent acetic acid 
solution, a short-wave chemiluminescent 
light stick, and a two-piece retractor/holder 
for placement of the light stick (see Figure 
7.4B). After the conventional oral examina- 
tion is performed, the patient rinses with 1 
percent acetic acid solution for 30-60 sec- 
onds. Following this, the light stick capsule 
is activated and placed into the holder, and 
the room lights are dimmed or turned off. 
The light stick is placed next to the oral mu- 
cosa in order to visualize any change in tissue 
appearance. If necessary, the process can be 
repeated. Be aware, however, that when re- 
peating the procedure, the light stick will 
only stay activated for approximately 10 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 212 



minutes. As with any procedure, there is a 
learning curve, and determining results from 
what is seen in the mouth can seem some- 
what arbitrary. Because of this, the company 
provides good clinical color photographs for 
help in interpreting what is seen. 21 

Teaching prevention and early detection 
of oral cancer is the best way the dental pro- 
fessional can ward off this elusive threat. 
Early detection is most easily facilitated by 
revealing and uncovering the extent of le- 
sions with the use of the acetic acid and 
chemiluminescent light. It helps not only 
with patients exhibiting obvious risk factors 
such as those who smoke and frequently 
consume alcohol but also with those with 
general questionable areas of tissue as well. 
The use of oral speculoscopy can provide ad- 
ditional information to the overall situation 
when a dentist is trying to determine if 
brush biopsy or scalpel biopsy should be rec- 
ommended to a patient. If it is determined 
that the patient is in need of biopsy, this pro- 
cedure may help the general dentist or spe- 
cialist decide what portion of the lesion 
should be biopsied for histological exam. In 
addition, a full-mouth soft tissue exam used 
in combination with oral speculoscopy im- 
proves the finding and early detection of le- 
sions within the oral cavity. Although this 
procedure could be useful with any patient, 
it is recommended for routine use on those 
patients exhibiting risk factors. 

Excisional Biopsy 

This type of biopsy is described as the re- 
moval of an entire lesion including a repre- 
sentative portion of normal tissue surround- 
ing the lesion. This is the preferred method 
of removal for small minor lesions that ap- 
pear to be benign. This procedure is both di- 
agnostic and definitive in nature in that the 
entire lesion is removed for examination and 
diagnosis. In most instances, these lesions 
will not need further surgical intervention. 
In an ideal world, the excisional biopsy 

would be utilized almost exclusively. How- 
ever, this procedure is not practical for every 
lesion and situation. It is best used by the 
general dentist on lesions that are 1 cm or 
less in diameter, are surgically accessible, and 
do not appear obviously malignant. Patients 
with more extensive or complicated situa- 
tions should be referred. 

Incisional Biopsy 

Incisional biopsy is the removal of a repre- 
sentative portion of a lesion for microscopic 
examination. This type of biopsy is pri- 
marily used on large, diffuse, or malignant- 
appearing lesions. The intent of this proce- 
dure is to remove a portion of the tissue in 
question along with a sample of normal ad- 
jacent tissue for comparison. 

The incisional biopsy, although not com- 
plicated, requires more forethought and 
planning for proper execution than the exci- 
sional biopsy. A pie-shaped wedge incision is 
usually made, starting 2—3 mm within nor- 
mal tissue and extending into an adjacent 
portion of abnormal tissue. It is a common 
mistake for dentists to incise tissue too su- 
perficially in relation to the actual depth of 
the lesion. Cellular changes are most easily 
detected not in the superficial tissue that is 
often necrotic, but in the deeper cells located 
where the lesion originates. In this case, the 
old surgical adage applies, "It is better to in- 
cise tissue narrow and deep, than broad and 

Surgical Principles for Soft 
Tissue Biopsy 

The general practitioner should be familiar 
with and be able to perform a simple soft tis- 
sue biopsy. Every day, general dentists per- 
form many complicated procedures includ- 
ing: extraction of bony impactions, molar 
root canal therapy, and surgical periodontal 
procedures. All of these procedures are more 
complicated, demand more knowledge and 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 213 



skill, and require much more time to per- 
form than a straightforward soft tissue 
biopsy. It is also true that not all scalpel 
biopsies are easily performed. Factors such as 
presentation of the lesion, surgical accessibil- 
ity, and anatomic hazards may all contribute 
to referral of a difficult case. Nevertheless, 
the straightforward soft tissue biopsy can be 
one of the easiest dental procedures to ac- 
complish. This section of the chapter will 
focus on describing the process of soft tissue 
biopsy and instructing the general dentist 
how this is to be performed. 

As stated earlier, before any biopsy can be 
considered, the patient's health history must 
be evaluated for any contraindications or rel- 
ative contraindications. If a scalpel biopsy 
(incisional or excisional) is to be performed, 
local anatomy within and around the area to 
be incised should be considered. Care should 
be taken to plan incisions that, wherever 
possible, will run parallel with and not across 
significant anatomical structures. For exam- 
ple, are the palatal vessels nearby? Are there 
any salivary ducts close to the proposed inci- 
sion? Are the mental or lingual nerves within 
the proposed surgical site? Familiarity with 
and identification of the local anatomy is 
essential before any surgical procedure is 
planned and undertaken. 22 See Table 7.6. 


Regional block anesthesia is the most desired 
method of anesthesia when performing a 
biopsy. Although block anesthesia ensures 
that histologic integrity of the lesion remains 
intact, practicality may require local infiltra- 
tion with a vasoconstrictor such as epineph- 
rine in order to control bleeding. The 
possibility of changing the microscopic 
architecture of a lesion or causing an artifact 
to be present is heightened when infiltrating 
anesthetic within or very close to a lesion; 
therefore, caution must used in its applica- 
tion. If infiltration is needed to assist in anes- 
thetizing the tissue or to reduce hemorrhage 

Table 7-6. Instrumentation/Supply List for 

Scalpel handle #3 

Scalpel blade #1 5 

Minnesota retractor 

Small hemostat (2) 

Dean scissors 

Curved tenotomy scissors 

Needle holder 

3-0 silk suture for traction 

Additional closing sutures 

Adson tissue forceps 

Gauze sponges 

Specimen bottle with 1 percent formalin 

by way of vasoconstrictor, it should be de- 
posited no closer than 1 cm from the 
lesion. 1 This general rule of thumb will help 
preserve an area of undisturbed tissue for the 
oral pathologist to evaluate. 


Whether an incisional or excisional biopsy is 
being made, the same elliptical pie-shaped 
wedge should be taken where possible. 
Although the shape of the wedge is usually 
the same for both types of scalpel biopsy, the 
small lesion requiring an excisional biopsy 
should include at least 2 mm of normal 
tissue around the entire periphery of the le- 
sion (see Figure 7.5A). However, the inci- 
sional biopsy, depending upon the size and 
character of the tissue, is usually taken from 
the area of the lesion that shows the most 
clinical change and may extend partly across 
or fully across the lesion. Regardless of where 
in the mouth the tissue is removed from, it is 
very important that the dentist include a 
band of normal tissue underneath and adja- 
cent to the lesion for comparison. If the tis- 
sue looks suspiciously malignant or fast 
growing or is diffuse, vascular, or pigmented, 
it is best to include 5 mm of normal tissue 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 214 












^— *v N 


r X \ 

/ J 

t f 

\ I 

•• ••:• / / 

\ \ 


^^--i-^ / 











**■■ j^t^ 

~~ ^™ ™ 1 "' 

Figure 7-5A. Elliptical incision lines for an exci- 
sional biopsy that show leaving a margin of nor- 
mal tissue adjacent to the lesion. 

Figure 7-5B. Elliptical incisions (as shown in 
Figure 7-5A) that meet underneath the lesion. 
Traction is placed on the lesion with tissue pick- 
ups or suture to facilitate tissue control and get 
cleanly beneath the lesion. 

surrounding the specimen. Ideally, in a lon- 
gitudinal view, the incision would create a 
'V" that captures normal tissue below the 
basement layer of cells adjacent to the lesion 
(see Figure 7.5B). 

If the lesion is located within unattached 
tissue (buccal mucosa, tongue, floor of 
mouth, and soft palate), then the length of 
the incision should equal about three times 
the width of the lesion. After removal of the 
tissue, the wound should be undermined (if 
necessary) with blunt dissecting scissors 
(tenotomy scissors) to relieve any tension 
from the submucosa layer. 2 These techniques 
assist the tissue to heal by primary intention 
and help reduce stress being placed on the 

Figure 7-6. The incisional biopsy on the left side 
of the lesion shows the ideal removal of cells 
below the basement layer of the lesion. Less 
ideally, the wedge on the right demonstrates an 
incision that does not capture the entire height of 
the lesion. It is better to incise narrow and deep, 
than wide and shallow. 

suture line, thereby minimizing scar forma- 
tion. See Figure 7.6. 

If the lesion is located within attached 
mucosa, such as the palate and the attached 
gingiva, it is not necessary to incise longer 
and wider than what is required for the his- 
tological examination. The main reason for 
this is because the tissue usually cannot be 
brought together for primary closure. 
Although sometimes quite painful, the 
biopsy site located within attached mucosa is 
left to heal by granulation and secondary in- 
tention. The patient with a biopsy in this 
area can have a periodontal dressing placed 
to help alleviate pain postoperatively. If 
the incision was made on the palate, an 
acrylic stent can be fabricated to hold a 
dressing in place on the underside of the 

It should be kept in mind that a biopsy is 
taken in order to determine histologic iden- 
tity or change in a given area. Therefore, if 
the lesion is large, is not uniform in its ap- 
pearance, or has multiple areas of presenta- 
tion, more than one biopsy may be necessary 
in order to properly characterize the tissue. 
Regardless of whether a single site has been 
biopsied or multiple sites have been excised, 
the dentist must be able to identify and illus- 
trate to the pathologist exactly where the le- 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 215 



sion or lesions were taken from and docu- 
ment this on the tissue submission form. 

Suture material, used for purposes of 
identification, can be helpful to the patholo- 
gist in two different ways. If there is suspi- 
cion of malignancy, a suture may be placed 
in a designated area of the lesion, such as the 
superior margin. That suture position is then 
written both in the patient's record and the 
tissue submission form, which is then for- 
warded to the pathologist. This orientation 
of the lesion, or tagging, then helps the den- 
tist communicate to the oral pathologist an 
accurate characterization of the tissue and 
gives the precise location of something of 
particular interest. Identifying the orienta- 
tion of a lesion and each of its margins also 
facilitates the planning of future surgical in- 
tervention if it is needed. 

When incising tissue in a small enclosed 
area like the mouth, management of the tis- 
sue, especially the tongue, is essential. 
Retraction is critical in management of the 
oral tissues during biopsy and helps the clini- 
cian and assistant visualize the task they are 
performing. There are many methods of re- 
traction, and the dentist must use what spe- 
cific method feels comfortable to him or her. 
Different techniques include the following: 
finger stabilization by an assistant with 
gauze, chalazion forceps for lesions of the lip 
and buccal mucosa, placement of traction 
sutures, tongue retractor/probe for use on 
the floor of the mouth, and an atraumatic 
towel clip for manipulation of the tongue it- 
self. The chalazion forcep, in particular, is 
useful in obtaining hemostasis because it acts 
like a tourniquet as well as a forcep, provid- 
ing a bloodless field in which to operate (see 
Figures 7.7A and 7.7B). 

If the lesion is small, tissue may be incised 
more easily if an anchoring suture is placed 
within the specimen itself. This not only 
helps with traction of the lesion, it also mini- 
mizes tissue damage easily made with tissue 
forceps that tend to crush when not used in 
a gentle manner. For larger lesions in the un- 

Figure 7-7A. The Chalazion forcep is commonly 
used to stabilize tissue for the removal of lesions 
in alveolar mucosa, such as mucocels and 

Figure 7-7B. Here, the forcep is applied to a 
mucosal area, allowing a fluid-filled mucocel 
within the soft tissue to be more easily excised. 

attached areas of the oral cavity such as the 
tongue, buccal mucosa, soft palate, and floor 
of the mouth, traction sutures may be placed 
adjacent to the biopsy site and held by hand 
or hemostats for better manipulation. 

2879_Koerner_Chap 07 4/17/06 1:31 PM Page 216 



Hemorrhage control 

A natural consequence of incising tissue is 
hemorrhage. Use of dental suction to control 
bleeding, especially with high- volume evacu- 
ators, should be avoided if possible. This is 
especially true if a small lesion is to be ex- 
cised. Generally a specimen is not best visu- 
alized microscopically after being fished out 
of a filthy debris-ridden suction trap. Most 
oral pathologists, if polled, would probably 
agree. However, if a suction device must be 
used, a low-volume evacuator with overlying 
gauze can be implemented. Gauze com- 
presses and applied pressure to the donor 
site will usually control most bleeding 

In recent years, many dentists have found 
electrosurgical cautery units to be of great 
use in controlling bleeding, especially when 
performing prosthodontic procedures. Soft 
tissue biopsy might initially be seen to some 
as another appropriate place to utilize the 
unique hemorrhage control that this device 
affords. However, just as direct infiltration of 
anesthetic solution and rough handling with 
instrumentation can distort tissue, so too can 
electrocautery alter and cause destruction of 
the specimen. These electrosurgical units 
may appropriately be used, however, for 
hemorrhage control of the donor site after 
the lesion has been removed. See Figures 

Tissue Management 

When performing a biopsy, extreme care 
must be taken in order to preserve the struc- 
tural integrity of the lesion and associated 
normal tissue that will be evaluated micro- 
scopically. Avoiding unnecessary damage to 
the specimen is something more easily talked 
about than accomplished. By its very nature, 
biopsy is an invasive traumatic procedure 
where tissue is cut and removed from the 
human body. Although damage to the in- 
flicted area is the immediate result, the long- 

Figure 7-8A. Small lesion on the dorsum of the 

Figure 7-8B. With traction on the lesion, a 
scalpel is ready to make the first elliptical incision 
on one side. 

Figure 7-8C. After a cut on both sides of the le- 
sion; cuts that meet underneath while traction is 
applied; the lesion is removed. The defect is ready 
to suture. 

term prospect, if done correctly, is diagnostic 
and healing in nature. Fortunately, use of 
modern surgical principles and instrumenta- 
tion can help the clinician remove the lesion 

2879_Koerner_Chap 07 4/17/06 1:32 PM Page 217 



Figure 7-8D. The defect is sutured with four 4-0 
chromic sutures. 



Figure 7-8E. The lesion has been placed in a 
specimen jar, the report form has been filled out, 
and it is ready to be mailed to the oral pathology 
laboratory. The lesion was diagnosed at a dental 
school pathology laboratory as a squamous 

as atraumatically as possible, while still main- 
taining the architecture of the tissue. 

A common mistake made by practitioners 
when performing this procedure is delivering 
excess pressure with tissue forceps, and con- 
sequently damaging the lesion. These forceps 
should ideally only be used to handle normal 
tissue adjacent to the lesion. If not used in 
the correct place and in a careful gentle man- 
ner, these pick-ups will crush and distort the 
tissue, thereby altering the natural structure 
of the specimen. A hemostat or needle- 
holder should not be used to grasp the lesion. 

After the tissue is carefully removed from 
the operative site, it should be placed imme- 
diately in a jar of 10% neutral buffered for- 

malin to avoid tissue autolysis. The clinician 
should acquire this jar complete with fixative 
and an identification sticker, a tissue submis- 
sion form, and written mailing instructions, 
prior to performing the biopsy. It is impor- 
tant that when the lesion is placed within 
the container, it does not adhere to the wall 
of the jar, but is fully immersed, free floating 
within the solution. It should be noted that 
if multiple biopsies are obtained, each speci- 
men should be placed in a separate container 
of fixative and labeled appropriately. The 
volume of the formalin should equal or ex- 
ceed 10 times the volume of the tissue. This 
is important because, with the exception of 
academic clinicians, most dentists do not 
practice within a short distance of an oral 
pathologist and will have to mail their speci- 
mens for evaluation. The volume of formalin 
and other specific packaging requirements by 
the lab ensure that there will be no chance of 
the tissue absorbing all of the solution and 
becoming dehydrated or necrotic while in 

Tissue Submission Form 

It is important that the oral pathologist re- 
ceive as much information as possible in 
order to identify and correctly characterize 
the submitted lesion. Therefore, a copy of all 
necessary information should be included to 
help solve an often difficult puzzle. The pa- 
tient's obvious demographics should be en- 
closed along with the medical history, lesion 
history, differential diagnosis, patient habits, 
and an illustration of the biopsy site and as- 
sociated lymph nodes (if involved). If the le- 
sion is within bone or is located near hard 
tissue, radiographs should also be included. 
If the dentist has possession of a high-quality 
camera capable of taking excellent intraoral 
photographs, a picture could prove useful to 
the pathologist as well (see Figure 7.1). 

On the form there is an area where the re- 
ferring clinician describes the appearance of 
the lesion and any additional comments that 

2879_Koerner_Chap 07 4/17/06 1:32 PM Page 218 



may prove pertinent in helping to find a de- 
finitive diagnosis. This description may in- 
clude size, shape, color, location, texture, 
consistency, induration, and so on. If the le- 
sion was suspicious in nature, orientations of 
tissue margins were hopefully identified with 
suture. The location of tissue margins and 
the corresponding suture should be given to 
the oral pathologist in written word and 
drawn illustration for clear communication. 


It is vital that general dentists grasp the im- 
portance of their role in oral cancer detec- 
tion. In the patient s oral exam and also the 
head and neck exam, an opportunity is pre- 
sented to identify lesions and follow-up until 
they are diagnosed and, if necessary, treated. 
These could present as suspicious lesions in 
the mouth, on the lips, on the face, or on 
the neck. The generalist can make note of 
the abnormality, make the patient aware, 
and treat with diagnostic testing, biopsy, or 
referral — depending on the knowledge and 
comfort level of the dentist and the nature of 
the problem. Referral of a patient to another 
clinician for consultation and/or treatment is 
rarely a poor decision. 

In this chapter, principles of oral lesion 
management and soft tissue biopsy are em- 
phasized in simple terms from a general den- 
tist's perspective. An acute awareness of the 
importance of these principles, combined 
with continual practice, can help make 
many of these techniques and procedures 
part of the general dentist's routine dental 


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than forty years. Otolaryngol Head Neck Surg 116: 
201-8. 1997. 

14. G. L. Frenandez, R. Sankaranarayanan, J. J. Lence 
Anta, S. A. Rodriguez, P. D. Maxwell. An evalua- 
tion of the oral cancer control program in Cuba. 
Epidemiology 6: 428-31. 1995. 

15. J. P Handlers. Diagnosis and management of oral 
soft- tissue lesions: the use of biopsy, toluidine blue 
staining, and brush biopsy. CDAJ 29(8): 602-06. 

16. H. Dym, O. E. Ogle. Atlas of Minor Oral Surgery. 
p. 180. Philadelphia, PA: W.B. Saunders. 2001. 

17. W. Mann, N. Lonky S. Massad, R. Scotti, J. 
Blanco, S. Vasilev. IntJ Gynecol Obstet 43: 
289-96. 1993 

2879_Koerner_Chap 07 4/17/06 1:32 PM Page 219 



18. R. T. Greenlee, M. B. Hill-Harmon, T. Murray, 
M. Thun. Cancer statistics, 2001. CA Cancer J 
Clin 51(1): 15-36.2001. 

19. N. Johnson. Oral cancer: a worldwide problem. 
FDIWorM6(3): 19-21. 1997. 

20. M. A. Huber, S. A. Bsoul, G. T. Terezhalmy. 
Acetic acid wash and chemiluminescent illumina- 
tion as an adjunct to conventional oral soft tissue 
examination for the detection of dysplasia: a pilot 

study. Quintessence International 35(5): 378-84. 

21. Christensen Research Associates. Intraoral precan- 
cerous and cancerous lesion screening. CRA 
Found News I January: 3. 2005. 

22. R. A. Convissar. Soft tissue biopsy techniques for 
the General Practitioner, Part 2. Dentistry Today 
19: 46^9. 2000. 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 221 

Chapter 8 

Anxiolysis for Oral Surgery and 
Other Dental Procedures 

Dr. Fred Quarnstrom 


This chapter discusses the need for sedation, 
the risks of various modalities of sedation, 
techniques to minimize the risks, and two 
safe techniques to control fear and apprehen- 
sion in the dental office. The biggest risk of 
sedation is respiratory depression. Mech- 
anisms of respiratory control will be re- 
viewed, and various forms of monitoring will 
be discussed along with respiratory condi- 
tions that complicate sedations. Nitrous 
oxide/oxygen sedation are covered, as are oral 
sedatives — with emphasis on benzodi- 
azepines and specifically the use of triazolam 
(Halcion) for conscious sedation to control 
fear and apprehensive. 

Oral surgery is somewhat traumatic for all 
patients. Because of this, many oral surgeons 
will suggest deep intravenous (IV) sedation/ 
general anesthesia for even simple surgery 
procedures. Most of the in-office surgery pro- 
cedures can be done with local anesthesia; 
however, many patients prefer some form of 
sedation for their surgery. The surgery is eas- 
ier and faster for the surgeon if the patient is 
comfortable. The use of nitrous oxide/oxygen 

sedation with and without oral triazolam are 
discussed. With these two drugs, almost all 
surgery procedures can be completed on even 
quite fearful patients without the need for the 
more hazardous general anesthesia. 

A second issue is the dental patient who is 
a dental phobic. A USA Today article quoted 
American Dental Association (ADA) figures 
detailing that 12 million Americans are den- 
tal phobics. Another source estimated that 
12 to 24 million suffer dental anxiety 1 Cop- 
ing with the difficult-to-manage fearful pa- 
tient has long plagued the profession, and 
one of the major challenges of dentistry is 
apprehension control. Fear and pain control 
are closely related. Fear of future treatment is 
often the result of lack of pain control in past 
appointments. Pain control is most often 
achieved with local anesthesia. According to 
Weinstein, 2 patients report the incidence of 
failure of the local anesthetic injection to be 
as high as 26.4 percent. It is suggested that 
fear has a high correlation with those who 
have anesthetic-related problems. 3 

About half the U.S. population avoids 
yearly dental care. Between 6 and 14 percent 


2879_Koerner_Chap 08 4/17/06 1:30 PM Page 222 



of patients avoid any treatment whatsoever 
because of fear. This phenomenon is not 
unique to the United States. Others have 

shown similar problems in Sweden and 

t 4-6 

Japan. ° 

Government regulations that dictate who 
can and cannot be hospitalized (Medicare, 
Medicaid) and the threat of litigation have 
caused many dentists to avoid providing 
dental treatment on all but the most cooper- 
ative and easily managed patients. Some 
dentists refuse to see those patients unable to 
receive dental care in the usual manner/ 

In the late 1990s and early 2000s the 
greatest barrier to using sedation has become 
dental politics. The target is primarily oral 
sedation and those practitioners who provide 
this service. The American Dental Associ- 
ations committee H proposed guidelines 
that were passed by the ADA House of 
Delegates in 2004, severely limiting the use 
of oral sedatives. Many states' licensing bod- 
ies have started adopting these guidelines. 
The American Association of Oral and 
Maxillofacial Surgeons has encouraged state 
licensing boards to limit the use of oral seda- 
tion. In one letter sent to state boards, they 
suggested that the use of oral sedation 
should have the same certification required 
of IV sedation. 

In this chapter, considerable space is spent 
referring to the patient who is unconscious, 
asleep, dozing, and napping — and explaining 
why I am not comfortable with such a pa- 
tient. On the other hand, the patient who is 
orally sedated but awake and will respond to 
verbal directions is a safe patient. So long as 
this patient remains conscious, the operator 
can relax and enjoy performing dentistry. 
With a proper preoperative evaluation, care- 
ful use of the right drug and calculation of 
its dose, a dentist should never have a patient 
lose consciousness; that is, "go to sleep." 
Should this occur, all else should cease until 
the patient is again verbally responsive or 
awake. Some states have regulations dictating 
dentist training and equipment for treating 

patients receiving general anesthesia, and 
rightfully so. It is a little late to start buying 
equipment and getting training when a pa- 
tient is unconscious. General dentists admin- 
istering oral conscious sedation need training 
and special equipment. 

As we discuss triazolam, it will become 
obvious that the chance of problems arising 
with this drug, when it is used properly, is 
very slight. But even if complications should 
occur, with the availability of a selective re- 
versal agent, flumazenil (Romazicon), we re- 
verse the effect that is going beyond the lev- 
els we wanted. As you will see later, 
flumazenil is reported to rapidly reverse the 
sedation of benzodiazepine drugs, much as 
naloxone (Narcan) does the opiate drugs. 

Various forms of oral sedation have been 
used by dentists to help apprehensive pa- 
tients. Patient comfort can be achieved by 
the practitioner who uses oral sedation, 
and/or nitrous oxide to allay patient s anxiety 
and apprehension. Anxiolysis (a relief of anx- 
iety) also decreases the likelihood of stress- 
induced medical emergencies. The difficulty 
of using oral agents is the time it takes to get 
an effect. Since these drugs must be swal- 
lowed and absorbed via the small intestine it 
often takes over an hour to get the drugs into 
the circulation and see the maximum effect. 

What Are the Levels of Sedation? 

Sedation needs to be matched to the level of 
apprehension along with the physical and 
mental stimulation the patient will have to 
endure while their dentistry is being pro- 
vided. Apprehension control is a continuum 
of the levels of sedation — from no sedation 
through general anesthesia. A patient with 
minimal apprehension and a short simple 
procedure will need less help than a severely 
phobic patient who will be undergoing a 
painful, lengthy, noisy, stressful procedure. 
The levels have been named anxiolysis, mod- 
erate sedation/analgesia, deep sedation, and 
general anesthesia. 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 223 



Anxiolysis is a drug-induced state during 
which the patient responds normally to ver- 
bal commands. Their cognitive functions 
and coordination may be impaired, but ven- 
tilatory and cardiovascular functions are nor- 
mal. This level could be compared to a glass 
or two of wine. These patients are exposed to 
little, if any, risk. Anxiolysis may be protec- 
tive for patients with mild to moderate med- 
ical conditions that can worsen due to the 
stress of dentistry. This level of sedation is 
achieved with light oral sedation and/or ni- 
trous oxide/oxygen sedation. 

Moderate sedation/analgesia is a bit 
deeper; the patient will respond to verbal 
commands, but you might have to add light 
tactile stimulation to get a response. They 
are able to maintain their airway, and spon- 
taneous ventilation is adequate. Their cardio- 
vascular system is normal. This level of seda- 
tion is most often achieved with an oral 
sedative, but light IV sedation could also 
achieve these levels. 

Deep sedation/analgesia takes a patient 
to a level where they respond only after re- 
peated or painful stimulation. They may not 

be able to maintain their airway and may 
need an assist to maintain adequate ventila- 
tion. This level requires advanced training 
for the practitioner, as protective reflexes are 
now obtunded or absent. Cardiovascular 
function is maintained. 

General anesthesia is a complete loss of 
consciousness. Often patients will need help 
to maintain their airway, and their respira- 
tory function may need assistance. They 
will have lost the protective swallowing, gag, 
and laryngeal reflexes. General anesthesia can 
be achieved by the inhalation of potent 
anesthetics, with IV drugs, with oral 
drugs if high enough doses are given, or a 
combination of these. It is imperative if this 
level is achieved that the practitioner is 
capable of monitoring the patient s vital 
signs, maintaining the airway, assisting 
respiration if necessary, and handling all 
the various life- threatening emergencies 
that can occur. Children are much more dif- 
ficult because they are less forgiving of alter- 
ations from normal. Their respiratory physi- 
ology has a narrower margin of safety (see 
Figure 8.1). 






■*► + 

1. Protective reflexes 


Patient can independently 

and continuously maintain 

an airway. 

Patient can respond 

appropriately to verbal 


2. Partial loss of 
protective reflexes 
Inability to 
maintain an airway. 
May not respond to 
verbal commands. 

> + 

3. Loss ofprotective 


Inability to 

independently maintain 

an airway. 

No pain sensation or 

reflex withdrawal from 


Figure 8-1. This chapter will discuss only area 1 of the spectrum of anesthesia. Areas 2 and 3 require 
advanced training and come with greater risk to the patient. 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 224 



How Safe Is Sedation? 

Dentists with proper training can perform 
oral sedation safely and effectively. Most 
dental therapy can be accomplished on pho- 
bic patients using local anesthesia and seda- 
tion. Therefore, adequate use of local anes- 
thesia must be considered as the first step of 
not only pain control but also anxiety con- 
trol. Many central nervous system (CNS) 
depressants can alter the level of conscious- 
ness. Most of these can produce a hypnotic 
state if given in higher doses, but only a se- 
lect few can actually produce a complete 
state of general anesthesia. 

The potential for complications is not 
limited to the general anesthetic state. It may 
accompany any degree of drug-induced 
CNS depression. Respiratory and cardiovas- 
cular depression are the most feared compli- 
cations. Respiratory depression represents the 
principal negative variable introduced with 
conscious sedation and, left unrecognized 
and untreated, is the cause of most serious 


Further complicating the question, "To 
Sedate or Not To Sedate?" is the fact that 
nearly all dentistry is elective. It is very rare 
to face the situation in which a life will be 
lost if treatment is not initiated. A nerve may 
die; a tooth may be lost; all the teeth may be 
lost; but the patient will still be alive and rea- 
sonably healthy. It is very difficult to accept a 
dental procedure where there is even a slight 
risk of death. This is not to say that there is 
not a very slight risk with even the most sim- 
ple procedures. Even administration of local 
anesthesia has resulted in death. But, what- 
ever we do, safety protocol is of the utmost 
importance (see Figure 8.2). 

Sedation and deep sedation/general anes- 
thesia has a remarkable safety record; how- 
ever, there have been studies showing that 
the deeper the sedation, particularly when 
administered to medically compromised pa- 
tients such as the very young and the elderly, 
the greater the risk. Dionne reported that 
overall mortality in the United States associ- 
ated with general anesthesia, based on self- 


f 1 

n An 







Figure 8-2. The relative risks of various forms of sedation anesthesia. Because of the high levels of 
oxygen, nitrous oxide is protective for almost all patients. Anxiolysis with oral sedation of a benzodi- 
azepine drug is nearly as safe. With help from Dr. Mark Donaldson B.Sc, Pharm.D. 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 225 



report of oral surgeons, has ranged from 
1:740,000 to 1:349,000; however, self- 
reporting is usually given little credence be- 
cause not all cases are acknowledged. A more 
credible study came out of records from the 
United Kingdom, where the overall mortal- 
ity risk was 1:248,000 for general anesthesia 
and 1:1,000,000 for conscious sedation. 
Only very low risk could be determined for 
local anesthesia. 8 

The risk of sedation and anesthesia can be 
dramatically decreased with modern moni- 
toring devices and the use of persons trained 
in monitoring and administrating anesthesia. 
It has been shown that the risk of anesthesia 
is dramatically reduced when a separate prac- 
titioner trained in general anesthesia admin- 
isters and controls the sedation/anesthesia. In 
the case of two-operator administered anes- 
thesia, the risk went from 1:248,000 to 
1:598, 000. 9 This is particularly true when 
treating patients with underlying medical 

Patient Ambulation 

A problem that was unique to dentistry but 
is now affecting our medical colleagues who 
use day surgery is the need for rapid ambula- 
tion. We need to get our patients back to a 
state that allows them to leave the office in a 
timely manner. Their reflexes need to be 
such that they can walk unassisted after a 
short period of time, even though this au- 
thor insists that another adult take their arm 
for additional support. It may be wise to use 
a wheelchair to transport the patient from 
the dental chair to their auto. They should 
not drive, undertake any task that might be 
hazardous, be placed in a position of respon- 
sibility (for example, taking care of children), 
or make important decisions. Even climbing 
stairs should be avoided. They need to be ac- 
companied and supervised by a responsible 
adult for the rest of the day, during which 
time their activities should be very limited. 
Operating the remote control of a television 

is about as complex a cognitive activity as 
they should attempt. It should be stressed to 
the patient that although they might feel 
normal, their reflexes could still be de- 
pressed. They need to take the remainder of 
the day off. 

It should be mentioned that some of the 
benzodiazepine drugs are initially bound to 
plasma proteins. This binding tends to re- 
verse about six hours after administration. 
This phenomenon is known as a "second 
peak effect." 10 When using most benzodi- 
azepines, it is necessary to inform our pa- 
tients that they will experience an increase in 
sedation about 5—8 hours after leaving the 
office. Interestingly, even after this time, 
blood concentrations of active drug have 
been reported to be close to 50 percent of 
what they were during sedation. For this rea- 
son, it is imperative that they not undertake 
any activity requiring cognitive or coordina- 
tion skills the rest of the day. Because of the 
long half-life of diazepam (Valium), some 
practitioners have felt there was reason for 
some concern even the next day. 

Drug Selection 

Our choice of drugs is guided by considera- 
tion of elimination half-lives and side effects. 
When we examine sedative systems, we find 
a continuum of effects from slightly notice- 
able changes through more profound seda- 
tion to general anesthesia, eventually leading 
to death, if enough drug is administered. 
"General anesthesia is less safe than con- 
scious sedation, which is less safe than local 
anesthesia." 11 

It is our goal to choose a sedation system 
with a very wide difference between desired 
effect and death in a very broad range of pa- 
tients. It is ideal if the effects of the drugs 
can be reversed at will if our system seems to 
be getting out of control. 

It is also our goal to create a state of tran- 
quility that will allow the patient to comfort- 
ably undergo the needed procedure. If we 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 226 



can alleviate apprehension without changing 
any of the patient's other parameters, we 
have achieved success. In fact, we always 
cause some change in our patients' physiol- 
ogy; however, with modern drugs these 
changes are much less hazardous than what 
was accepted a few years ago. 

Routes of Drug Administration 

In attempting to create a state of tranquility, 
we must get a certain concentration of agent 
to the appropriate location in the central 
nervous system. When considering routes, 
we should consider patient comfort, time to 
achieve effect, control of the effect, ease of 
administration, the skill needed for adminis- 
tration of the drug, necessary equipment for 
administration, and monitoring of the pa- 
tient. Unfortunately, we must also consider 
medical-legal questions of insurance and reg- 
ulation by governmental organizations. 

In general, the faster the drug reaches the 
CNS and has an effect, the better the control 
we have over the sedation. By titrating for ef- 
fect, we can give just that amount of drug 
that is necessary to control apprehension. 
Both intravenous and inhalation agents can 
be readily controlled in this manner. Other 
routes of administration require administer- 
ing an appropriate dose and waiting up to an 
hour to see the desired effect. These routes 
require very specific dosages, usually associ- 
ated with body size. They require conserva- 
tive dosages, as hypersensitivity to a medica- 
tion will not be obvious until it is much too 
late to adjust the dosage. It is imperative that 
a drug with a very wide range of safety be 
used when these slower routes of uptake are 
utilized. Ideally, we will have reversal agents 
that can deactivate the drug in the case of 
overdose when using these routes. 

We, in dentistry, have used and continue 
to use a variety of agents and combinations 
of agents. Multiple agents often complicate 
the treatment, as each has side effects that 
can be additive. They all are CNS depres- 

sants and some have unwanted depressing 
effects on respiratory and the cardiovascular 
systems. The combination of all these effects 
can lead to problems that are hard to predict 
and even more difficult to control and treat. 
However, if only one agent is used, the side 
effects are often more predictable and more 

It is easier and safer to use a single agent, 
as we then only have one set of side effects. 
This assumes a single agent will provide the 
needed result at a concentration where few 
side effects are present. When Dionne 
looked at drug mixtures used by 264 den- 
tists, he found 82 distinct combinations. 12 
He said, "The scientific basis for the use of 
such a diverse group of agents and combina- 
tions is unclear." 13 

Inhalation Sedation 

The inhalation route of administration offers 
a major advantage when we consider an 
overdose. By removing the source of the 
drug (having the patient breathe room air or 
100 percent oxygen), the patient will excrete 
most inhalation agents via the lungs, thus re- 
versing the overdose. 

Oral Sedation 

Several factors come to light when we con- 
sider oral sedatives. The time from ingestion 
to sedation becomes very important. For any 
effect to take place, the drug must be ab- 
sorbed into the bloodstream and delivered to 
the site of action, usually thought to be in 
the central nervous system, in sufficient 
quantities to be effective. Some drugs can 
be absorbed sublingually; others must be 
swallowed and absorbed from the small in- 
testine. Depending on the time necessary 
for absorption, it might be necessary to have 
the patient take the drug at home before 
coming to the office. This author prefers to 
administer the drug in the office because 
then you know how much was taken, when 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 227 



it was taken, and by whom it was taken. 
You don't have to worry about the patient 
trying to drive to the appointment as the 
drug starts to take effect, and should there 
be a reaction to the drug, the patient is 
in the office where aid can be administered. 
One downside is that because it will take 
45 minutes to one hour to get the desired 
sedation, it is time-consuming to titrate or 
alter the dose if a patient is not adequately 

Intravenous Sedation 

With the regulations that are now in place in 
many states, it is nearly impossible for the 
average general dentist to use intravenous se- 
dation. Many states require a 60-hour course 
with 20 patient sedations in addition to any 
training that was received in dental school. 
Intravenous sedation has several advantages, 
however. When giving a drug IV, one slowly 
titrates the amount to the level of sedation 
desired. For most drugs, these effects began 
to diminish in a short period of time — first, 
due to redistribution to other tissues in the 
body (primarily fat stores), and then more 
slowly as the drug is metabolized into inac- 
tive forms or eliminated in the urine or 

Although this should be the safest route 
of administration, it is possible to go from 
conscious to deep general anesthesia in a 
matter of seconds. Although this should be a 
very safe technique, this is where we are see- 
ing deaths. 

Drug Options 

Historically, many drugs and routes of ad- 
ministration have been used to control ap- 
prehension in dental offices. As stated earlier, 
insurance companies, state regulatory bodies, 
and other entities have all but eliminated 
intravenous sedation from the armamentar- 
ium of general dentists. If we look into 
other methods of sedation, however, we 

will see that all is not lost for the phobic 

Nitrous Oxide 

Nitrous oxide is possibly the safest of all seda- 
tives. It is estimated that close to 40 percent 
of dentists are equipped to administer nitrous 
oxide. It has been used in dentistry for more 
than 150 years. Trace nitrous oxide released 
into the air of the dental office, and its effect 
on the dental staff, however, must be consid- 
ered. It is recommended that there be post- 
operative oxygenation for not only nitrous 
oxide but also other sedatives. If one is look- 
ing for a very safe anxiolytic drug from which 
the patient recovers quickly and with which 
the patient is able to drive to and from the 
office, nitrous oxide is the only choice. 


Alcohol has been used by some patients for 
years to help with their dental treatments. It 
is not unusual for a patient to self-medicate 
with a bit of liquid reinforcement before 
coming to an appointment. It is important 
when considering the use of sedatives for 
apprehension control that patients be 
warned against using any other substance 
that is a central nervous system 
depressant. The combination of benzodi- 
azepines and alcohol has lead to very serious 
respiratory depression and death. 

Chloral Hydrate 

This drug has been a favorite, particularly for 
children. Evidence is emerging, however, that 
indicates it may not be as safe as we believed. 
Chloral hydrate s sedative action comes from 
its metabolite, trichloroethanol. The peak ac- 
tivity occurs in the plasma within 20 to 60 
minutes after oral administration. Its half-life 
is 4-12 hours. It acts primarily on the CNS 
and has little effect on the respiratory and 
cardiovascular systems of healthy patients. 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 228 



In higher doses, chloral hydrate becomes 
a cardiac irritant. There have been several re- 
ported cases of overdose leading to hypoten- 
sion. In one report of two patients, when 
this hypotension was treated with cate- 
cholamines or agents that released cate- 
cholamines, both patients experienced car- 
diac arrest; one survived, the other did not. 
Any other CNS depressant will enhance the 
sedation-depression of chloral hydrate, in- 
cluding nitrous oxide and narcotics. 
Deaths have occurred in combination with 
local anesthetics when used with small chil- 
dren. It is thought that often this is due to 
using a toxic dose of local anesthesia: four 
cartridges — one for each quadrant to be 
treated. Even two cartridges of local anesthe- 
sia can be a toxic dose for small children. 


Barbiturates were the standard antianxiety 
agent for both medical and dental patients 
for many years. Barbiturates make a patient 
drowsy, and sleepy patients tend to be less 
apprehensive. In larger doses, barbiturates 
have the potential to render patients asleep. 
It is in this way that the short- and ultra- 
short-acting barbiturates were used as induc- 
tion agents for general anesthesia and for 
very brief general anesthetics. 

The ratio of the dose necessary for sleep 
and the dose that will end in death — the 
therapeutic index — is usually stated to be a 
factor of two, as compared to diazepam, 
with a ratio of 20. 15 Unfortunately, barbitu- 
rate drugs in higher doses tend to be potent 
cardiac and respiratory depressants. Because 
of their addictive nature, they are not admin- 
istered for long-term anxiety control. 


Benzodiazepine (BZD) drugs come in many 
varieties. They differ in the rapidity that they 
take effect, the time it takes for them to wear 
off, time to peak blood levels, and half-lives. 

While the names are different they are more 
similar than different in their effect (beyond 
uptake and deactivation times). Dentistry 
has several BZDs that are ideal for use with 
apprehensive patients, and the effect can be 
tailored to the time necessary to perform the 
procedures being contemplated. One, triazo- 
lam, is well suited to dentistry. Triazolam 
came to market as a sleep aid and has be- 
come very popular and controversial. 
Triazolam will be discussed in detail. 

The Two Most Useful Sedative 
Drugs for the General Dentist 

Nitrous oxide has an interesting history. 
Originally it was used as an attraction at 
public science shows. It was at such a pro- 
gram that a dentist, Horris Wells, saw a par- 
ticipant in a nitrous frolic receive a serious 
injury causing a dramatic wound . . . with 
no pain. He took this knowledge to his of- 
fice and began offering painless dentistry 
using nitrous oxide as a general anesthetic. 

Its history as a general anesthetic has 
brought dentistry some criticism. Nitrous 
oxide is a weak anesthetic agent. At one at- 
mosphere of pressure, 80 percent nitrous 
oxide is usually considered to be the mini- 
mum concentration that will achieve general 
anesthesia. Even at this concentration, it is 
not possible to render some patients uncon- 
scious. If we go to a higher concentration, 
we begin to encroach on the 2 1 percent oxy- 
gen found in the atmosphere and expose our 
patients to hypoxia. 

The standard of the past was to watch the 
patient's color. When they began to show a 
blue tinge of cyanosis, the procedure was 
started. (I like to state, tongue in cheek, that 
dentists hoped the pain of the extraction 
would restart the heart.) Anesthetics were 
very short. One tooth in the forceps, one in 
the air and one hitting the bucket, simulta- 
neously, was the goal. Actually, many general 
anesthetics were done by this technique with 
an amazing safety record, which may be 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 229 



more testimony to a patient's desire to live 
than to the safety of the procedure. Today, 
this hypoxic anesthesia technique would be 
severely criticized, as it should be. 

Because nitrous oxide is absorbed and re- 
moved from the blood stream via the lungs 
essentially unchanged, nitrous oxide is a very 
safe sedative. But its major disadvantage — its 
relative weakness — is also its major advan- 
tage. Although sedation with nitrous oxide is 
not adequate for our severely phobic patients 
because it is such a weak anesthetic agent, 
there is little risk of sedation rendering the 
patient unconscious — that is, in a state of 
general anesthesia. However, it is not impos- 
sible. I have had two patients in 40 years 
who were under general anesthesia with very 
modest concentrations (less than 40 percent) 
nitrous oxide. Neither had taken any other 
drugs. If the patient is not responding even 
at low concentrations this might be the 
problem. The mask should be removed and 
the patient allowed to breathe room air or 
just oxygen. 

Our primary concern in anesthesia is the 
loss of swallowing and laryngeal reflexes that 
can lead to regurgitation of stomach con- 
tents and aspiration of the low-pH stomach 
contents into the lungs. So long as a 50 per- 
cent concentration of nitrous oxide is not ex- 
ceeded, there is little chance of general anes- 
thesia or other complications. 

The complications that may arise are not 
serious ones. Occasional vomiting may be 
seen, but since our patients are always con- 
scious, this is not serious, as protective laryn- 
geal reflexes are present. The patient is 
definitely uncomfortable, and vomiting cer- 
tainly can be messy, but it is usually not life- 

Patients will occasionally hallucinate with 
nitrous. Again, this can be uncomfortable for 
them. Treatment consists of removing the 
source of nitrous oxide and reassuring the 
patient, typically by telling them they are all 
right and will return to normal in a few 
minutes. It is helpful to repeatedly assure 

the patient until the hallucination is over. 
Use their first name and remind them they 
are in the dental office — that they should 
relax and will be back to normal in a few 

Another potential problem deserves men- 
tion — that of sexual aberrations. A certain 
number of female patients will experience 
sexual feelings while on nitrous oxide. This 
can happen at relatively low concentrations. 
Some patients describe the sensation of a 
sexual orgasm. It is not all that easy to iden- 
tify when this is taking place. However, if it 
looks like a duck, walks like a duck, and 
quacks like a duck, the chances are we are 
observing a duck. This may, in fact, be the 
ultimate distraction to dental treatment. 
Fortunately, it is very rare. For this reason it 
is important that a male dentist, hygienist, or 
assistant always be accompanied by a female 
dental assistant when treating female patients 
with nitrous oxide. This phenomenon has 
never been documented in male patients. 

A potentially more serious problem can 
arise if we treat chronic obstructive pul- 
monary disease (COPD) patients with ni- 
trous oxide. Should a patient be overdosed 
with nitrous oxide, it is a simple matter to 
remove the source of the gas, and provided 
the patient is breathing, they will eliminate 
the excessive concentration of nitrous oxide. 
If they are not breathing, we should be ready 
and able to assist their respiration. This 
would be a very unusual complication and 
probably would suggest the patient had 
other sedatives or was given excessive nitrous 
oxide (greater than 80 percent). It should be 
stressed that nitrous oxide is a very safe seda- 
tive for almost all patients, provided equip- 
ment has been properly installed and main- 

Nitrous Usage 

It is estimated that about 50 percent of den- 
tists have the equipment to administer this 
mix and that more than 424,000 dental per- 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 230 



sonnel are exposed to the trace amounts of 
gas as a result of its administration. 18 

Many dental and dental hygiene schools 
now take a very cautious attitude toward the 
use of nitrous oxide. This has come about 
because of the publication of a number of 
papers concerned with the effect of waste 
gases on office personnel, particularly those 
who are pregnant. 

The first indication that anesthetic gases 
might be a problem for humans was a report 
in 1 967 by Vaisman, who studied Russian 
female anesthesiologists and reported that 1 8 
of 3 1 pregnancies ended in spontaneous 
abortion. 19 Studies have shown similar prob- 
lems in U.S. operating rooms. 20 It was clear 
the operating room had the potential to be a 
hazardous place to work, but it was not clear 
which chemicals were the causative agents. 

Animal Studies 

Potent anesthetic agents have been shown to 
have teratogenic effects in animal studies. 
Because nitrous oxide was part of many 
anesthetic administrations, it needed to be 
evaluated. Many studies showed problems 
for animals exposed to high levels of nitrous 
oxide. 21-31 It was shown that nitrous oxide 
decreases vitamin B 12 , which can impair 
DNA synthesis. 32 These studies hint that if 
the levels are kept low enough the problems 
can be lessened. 

Retroactive Human Studies 

The dental office was an ideal study site as 
there were two types of offices, those that 
used nitrous oxide and those that did not. 
Cowen did two such studies in conjunction 
with the American Dental Association. 
These studies suggested there is a problem 
with higher levels of exposure for pregnant 
staff. 33 ' 3 Although there may be some 
problems with these retrospective studies, 35 
they did point to a concern for females who 
were pregnant and working in dental offices 

where nitrous oxide was used. The studies 
did not suggest at which level exposure be- 
came a problem. 

Occupational Hygiene Agencies 

There are three governmental bodies associ- 
ated with setting appropriate levels of expo- 
sure to chemicals: OSHA, NIOSH, and 
ACGIH. 36 The NIOSH publication, Alert, 
suggests the recommended exposure limit 
(REL) of 25 parts per million (ppm) on a 
time-weighted average (TWA) of 25-ppm. 
These levels were recommended after review- 
ing two studies by Bruce. 37 ' 38 

The Problem Studies 

The TWA level of 25-ppm came from two 
studies done by Bruce, Bach, and Arbit. In 
the first study, a difference was shown when 
subjects were exposed to 50-ppm nitrous 
oxide with 1-ppm halothane but not to 500- 
ppm nitrous oxide, except for a digit span 
test. 39 The second study showed a slight ef- 
fect to subjects exposed to 500-ppm nitrous 
oxide for four hours. Note that Bruce re- 
canted this study as flawed in two letters — 
one in 1983 the other in 1991. He stated, 

"Several years later, we learned that 
most of the subjects we studied were a 
unique population that used no mood 
altering substances and as such, might 
have been abnormally sensitive to depres- 
sant drugs such as nitrous oxide and 
halothane. There is no longer any need 
to refer to our conclusions as controver- 
sial.' They were wrong, derived from data 
subject to inadvertent sampling bias and 
not applicable to the general population. 
The NIOSH standards should be 

j" 41 42 
revised . ' 

Many papers have been published in the 
dental literature that mention the motor skill 
effect, which was not shown for just nitrous 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 231 



oxide in either study. These two studies and 
the publications of NIOSH that arose from 
these studies have been referenced in so 
many dental journals they have become fact, 
ignoring the two retraction letters. After a 
paper is published, it is very nearly impossi- 
ble to retract the paper. 

What Is a Safe Level of Exposure? 

What studies have been done with humans 
that suggest appropriate exposure levels? 
Ahlborg showed Swedish midwives exposed 
to nitrous oxide and shift work had no diffi- 
culty getting pregnant unless they used ni- 
trous oxide 30 or more times a month to as- 
sist with deliveries. In another study of 
midwives, he showed no increase in sponta- 
neous abortions with exposure to nitrous 
oxide, but he saw an increase with night 
shifts, high work loads, and no nitrous. 
Sweeney performed a study on 20 practic- 
ing dentists. The exposures ranged from 
50 ppm to more than 5,000 ppm on a 
time- weigh ted average. The only depression 
seen was in three dentists with exposure of 
more than 1,800 ppm. To set levels that 
would ensure safety, Sweeney suggested 
we should not exceed 450 ppm on an 
8-hour. 45 ' 46 

Rowland looked at the ability of female 
dental assistants to become pregnant (fe- 
cundability). He showed no problems if 
scavenging was used. These two studies 
strongly suggest that if we use scavenging 
and keep levels below 450 ppm, the dental 
office staff is at no risk. 

What Levels of Exposure Can Be 

Early studies showed that the Brown mask, a 
mask within a mask with suction, could 
achieve levels of 50 ppm under ideal settings. 
OSHA reviewed these data and suggested 
that since this was achievable, it should be 
our goal. Donaldson has shown that many 

scavenging devices being used in practicing 
dental offices can achieve levels in the 40 to 
60 ppm range. 

How Can Levels Be Controlled? 

It is clear that offices should have one of the 
available scavenging systems on each nitrous 
oxide/oxygen unit. Todays scavenging sys- 
tems are predominantly systems with suction 
placed on the mask over the pop-off valve. 
Some systems attempt to suck up additional 
air that is around the mask, and they may re- 
move traces of nitrous oxide that the patient 
exhaled through their mouth or that leaked 
from around the mask. 

Every nitrous machine must have a scav- 
enging system with adequate suction. There 
should be a reasonable exchange of air in our 
dental offices. Outside air should be brought 
into the office by our heating and cooling 
systems. It is suggested that the minimum 
air exchange is five changes per hour, al- 
though is it recognized that 1 5 to 20 changes 
per hour is better. Hoses and connectors 
should be checked for leaks. Masks should 
be selected that fit the patient, and the pa- 
tient should be discouraged from speaking 
while receiving nitrous oxide sedation. If all 
these suggestions are followed, it is possible 
to stay in the 50-ppm range 9 — well below 
the 450-ppm exposure level suggested by 
several authors. 

Oxygenation after Nitrous Oxide 

Oxygen is the one drug that should be avail- 
able in all dental offices. Oxygen can be used 
with little regard for side effects or other 
problems and should be available in every 
office as part of the emergency protocol. 
There are exceptions to this generality and 
times when it should not be used. For exam- 
ple, oxygen should be used cautiously for 
COPD patients (severe emphysema). If a 
COPD patient's disease has progressed to its 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 232 



final stages, his or her breathing may be on 
an oxygen drive — not the primary carbon 
dioxide drive. Giving high levels of oxygen 
to one of these patients could cause him or 
her to go into respiratory arrest. These pa- 
tients are normally quite easy to identify be- 
cause of their obvious respiratory difficulty. 

Oxygen is routinely administered after 
general anesthesia when nitrous oxide was 
used in order to avoid diffusion hypoxia. 
This phenomenon was first described by 
Fink to explain a transient hypoxia after 
anesthesia in conjunction with nitrous 
oxide. 50 Nitrous oxide would diffuse out of 
the blood and fill the alveoli of the lungs and 
the rest of the respiratory tree. Nitrous oxide 
crosses from the blood to the alveoli of the 
lung much more quickly than either oxygen 
or nitrogen, and thus, nitrous oxide would 
tend to fill the dead space in the lungs. On 
the first inspiration of room air, the patient 
would have a mixture of nitrous oxide from 
the dead space (150cc of 100 percent nitrous 
oxide) and 350cc of room air. In theory, this 
would result in hypoxia that could be a 
problem for a sick patient, a patient with a 
compromised respiratory system, or a patient 
with respiratory depression due to the anes- 
thesia drugs. In the case of general anesthe- 
sia, this could be a serious issue. 

What is the harm in using some oxygen? 
Nothing, unless the two gas lines have been 
switched. In such a case, although the ma- 
chine reads 1 00 percent oxygen, it is in real- 
ity delivering 100 percent nitrous oxide. 
There are many ways this can happen. One 
case occurred in a surgery practice using gen- 
eral anesthesia and resulted in the death of a 
young, healthy, adult patient. 

You can use a pulse oximeter to investi- 
gate the need for oxygen after nitrous oxide/ 
oxygen administration. One study failed to 
show any drop in oxygen saturation if the 
mask was simply removed at the end of the 
appointment where nitrous oxide had been 
used. 1 The study has now been repeated by 
others with the same results. 52, 53 

An overriding reason for leaving a patient 
on oxygen, however, is to scavenge the gas 
the patient is exhaling. With our present 
knowledge of the risks of trace contaminants 
of nitrous oxide, we believe we should leave 
our patients on 100-percent oxygen for five 
minutes to ensure that the nitrous oxygen 
they exhale is removed from the atmosphere 
we breathe. However, if a patient ever be- 
comes unresponsive while on 100-percent 
oxygen, remove the mask. It may be that the 
gases have been switched. 

Respiratory Effects of Drugs 
Used for Sedation 

Sedation can be performed safely and effec- 
tively by dentists with proper training. 
Respiratory depression is the principal con- 
cern when sedation is administered. If we are 
going to get into trouble, the most likely 
cause will be due to respiratory depression or 
respiratory inadequacy due to airway ob- 

In all cases of dental sedation, patients 
should remain awake. If the patient tends to 
fall asleep, they should be awakened. General 
anesthesia has been described as great 
amounts of boredom occasionally dispersed 
with moments of stark terror. Unless you are 
well equipped, well trained, and certified, 
you do not want patients to be unconscious. 
It is not possible to tell napping, dozing, or 
sleep from general anesthesia without trying 
to wake the person. If the patient awakes, 
keep them awake. If they do not awaken, 
you are not doing conscious sedation. The 
patient is under general anesthesia. If the 
patient is not awake, you need to reverse the 

With some drugs, our concern may be 
that we have depressed the respiration to the 
point that an adequate exchange of gas is not 
taking place. The presence of an open airway 
should be established, evaluation of the level 
of respiration assessed, and vital signs should 
be taken. It should be noted that several 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 233 



studies have shown that watching the chest 
and/or reservoir bag move is not adequate to 
ensure an adequate minute volume. Skin 
color has been relied on in the past as a way 
of ensuring adequate tissue profusion. The 
arterial oxygen level can be dangerously low, 
however, before we see the blue tinge of 
cyanosis. Cyanosis is no longer considered to 
be an adequate monitor of arterial oxygen 
levels. A pulse oximeter and/or capnograph 
are invaluable in assessing the adequacy of 
ventilation (see Figures 8.3 and 8.4). 

Physiologic Basis of Ventilation 

To properly appreciate the importance of 
monitoring respiration along with reviewing 
the respiratory advantages of benzodiazepine 
drugs, we need to review a topic we all stud- 
ied in dental school but most likely have not 
thought about since then — respiratory physi- 
ology. This is not intended to be a complete 

discussion. Yet, it will review a minimal level 
of knowledge that we should have when 
using sedative drugs. 

Our breathing is controlled by several 
mechanisms. When we consciously take a 
breath, we have conscious control. Normally, 
though, our breathing rate and depth are 
stimulated by carbon dioxide (C0 2 ), a by- 
product of our metabolism. C0 2 alters the 
hydrogen ion concentration, or the pH of 
our blood. This pH change is the primary 
stimulus to breathing (see Figure 8.5). 
Breathing is also stimulated, to a lesser ex- 
tent, by low concentrations of oxygen. Many 
drugs affect the C0 2 drive, but nitrous oxide 
depresses the secondary drive because of a 
lower oxygen level (see Figure 8.6). 

The solution to the aforementioned prob- 
lems lies in several areas. We should use 
drugs that minimally depress respiration. 
Avoid combinations of different drugs that 
affect several things at once. Monitor the 

Figure 8-3. Early dental anesthesia with nitrous oxide was monitored by the patient's color. Pink was 
awake. Slight cyanosis was time to do the extractions. Deep cyanosis was time to give oxygen. 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 234 

Wijh'i 30UrD£ 



b\oo r J 

Jj£jhr d^siors 

Figure 8-4. A pulse oximeter shines light through tissue, usually a finger. Receptors read the levels of 
each light. This information is analyzed, and the percentage of oxygen saturation is displayed on the 

CHO + O 


C0 2 + H 2 

C0 2 + H 2 

H 2 C0 3 

H 2 C0 3 

H + HCO- 

Figure 8-5. Food is oxidized in our bodies and becomes C0 2 and water. The C0 2 is absorbed in the 
water of the plasma to become carbonic acid. Carbonic acid disassociates into hydrogen ions and bi- 
carbonate ions. The negative log of the hydrogen ion concentration is known as pH. The hydrogen ion 
is the prime stimulus to respiration. In the COPD patient, bicarbonate ions are absorbed by the kidneys, 
forcing the hydrogen ions back to carbonic acid. In this way, the stimulation of the hydrogen ion is 
blunted, forcing them to breathe on oxygen drive. The oxygen drive is depressed by nitrous oxide. High 
levels of 2 can do the same. 


2879_Koerner_Chap 08 4/17/06 1:30 PM Page 235 



Respiratory control 

Figure 8-6. Stimulus to the inspiratory area of the respiratory center stimulates the diaphram to con- 
tract. This increases the volume of the chest cavity, drawing air into the lungs as they expand. Stretch 
receptors send an inhibitory signal to the respiratory center. The diaphragm relaxes, and the elastic 
fibers of the lungs cause them to collapse, forcing the air out. The mechanism can be stimulated by 
high hydrogen ion concentrations, low pH, high C0 2 concentrations, or low 2 levels. 

patient to ensure that adequate arterial oxy- 
gen levels are maintained and that C0 2 lev- 
els do not increase. Hypoventilation is char- 
acterized by a reduction in arterial oxygen 
tension and an elevation of C0 2 tension. 
With the advent of pulse oximetry it is now 
possible to easily monitor oxygen saturation 
of hemoglobin. 

Pulse oximetry shows the oxygen satura- 
tion of hemoglobin. In addition, most ma- 
chines also display pulse rate. Knowing the 
saturation of hemoglobin, one can approxi- 
mate the arterial oxygen tension, assuming a 
normal pH of the blood. Although 90 per- 
cent saturation provides reasonable assurance 
of adequate arterial oxygen tension, 95 

percent is preferred. Although oximetry is 
not equivalent to capnography it is valuable 
in alerting the dentist that ventilation is 

The importance of monitoring a patient's 
respiration cannot be overemphasized. If a 
patient is awake and responding to verbal 
commands, we can assume the patient is 
safe. If the patient is unconscious (asleep?), 
we must have more concern. Several studies 
of medical and dental anesthesia have shown 
inadequate ventilation to be the most com- 
mon cause of death or brain damage. As 
practitioners, we must be prepared to moni- 
tor and assist respiration should it become 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 236 



The Reservoir Bag 

In the 1960s, watching the reservoir bag was 
used on several popular television programs 
as a means of determining when it was time 
to discontinue surgery and give condolences 
to the next of kin. We have now all been 
taught via television to read electrocardio- 
graphs (ECGs) and to recognize flat line. 
Some feel the movement of the bag can be 
used to monitor respiration. There have 
been several studies that show one should 
not depend on movement of the bag as an 
accurate indication of the adequacy of respi- 
ratory exchange. It will indicate respiratory 

Pulse Oximeter 

The advent of an affordable pulse oximeter 
has made our lives much easier and patients' 
lives more secure. By passing two different 
frequencies of light through various tissues, 
reading the absorption of the two frequen- 
cies, and evaluating these differences, a pulse 
oximeter can determine the percentage of 
oxygen saturation of the arterial blood with 
great accuracy. In addition to 2 saturation, 
most equipment also shows pulse rate, and 
some shows a pletysmograph of the pulse 
wave. The use of such monitoring has made 
general anesthesia much safer and, conse- 
quently, has decreased the frequency of tragic 

However, there is at least one possible 
caveat to their use: If a patient is given sup- 
plemental oxygen, his or her hemoglobin 
saturation will approach 100 percent. In pa- 
tients with severe respiratory complications, 
oxygen saturation could be normal even 
though exchange rates were inadequate to 
cleanse the blood of C0 2 - This could lead 
to high C0 2 levels and result in low pH 
of the blood. This potential problem can 
be circumvented by limiting sedation to 
patients with no significant respiratory 


Capnography is very sensitive to respiratory 
depression or apnea. This equipment meas- 
ures the CO 2 of a patient's expired gas. It 
then gives a reading of the concentration of 
C0 2 in these gases. This information can be 
invaluable when monitoring patients with 
respiratory problems or those undergoing 
general anesthesia, but it is not necessary for 
the sedated patient. 


It was established that barbiturates, mepro- 
bamate, and alcohol all affect the chlorine 
channel in brain neurons. They hyperpolar- 
ize the neuron, increasing its threshold for 
depolarization. Benzodiazepines act at a dif- 
ferent but closely related site. Alcohol, barbi- 
turates, and meprobamate all act at the same 
site, and all put animals to sleep with only 
modestly higher doses than are required for 

It was shown that all these drugs interact 
with the neurotransmitter gamma amino 
butyric acid (GABA). When GABA binds 
with a receptor site on the neurons, it slows 
the neuron's rate of firing. It serves to modu- 
late the nervous system. 

Specific benzodiazepine receptors exist in 
the brain. If either GABA or a benzodi- 
azepine is present, the other's binding ability 
is enhanced. Thus, the effects of the benzo- 
diazepines are explained by the increased 
activity of GABA. 5556 

The receptor sites are concentrated in 
parts of the brain that regulate emotional be- 
havior. The advantage to benzodiazepines is 
their ability to relieve anxiety. They produce 
some drowsiness and, unfortunately, are 
somewhat addicting. Tolerance develops 
with continued use, and withdrawal occurs 
when the drug is stopped. However, the ex- 
tent of tolerance and withdrawal are less 
than what is seen with barbiturates. 

Historically, we have used barbiturates 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 237 



Anxiolytics and Sedatives 






Death J 


o Sedation 






Most CNS 



Figure 8-7. Most central nervous system (CNS) drugs if given in large enough quantities will result in 
death, usually from respiratory depression. When given as a single agent, benzodiazepines can be given 
in very large doses without causing death. They have a wide margin of safety. 

and narcotics, both of which have significant 
effects on respiration and circulation. The 
most clear-cut advantage of the single-agent, 
benzodiazepine sedation is the fact that over- 
doses are rarely lethal. In the case of barbitu- 
rates, the lethal dose is only a few times 
greater than the dose necessary to cause sleep 
(see Figure 8.7). 

To deactivate most oral sedatives, we must 
wait for the drug to be excreted or metabo- 
lized. In the case of diazepam it is metabo- 
lized in liver to another sedative, oxazepam 
(Serax), which is available as a long-term 
sedative on its own. Triazolam, along with 
midazolam (Versed), have the shortest half- 
life of the benzodiazepine drugs; both are in 
the one- to two-hour range. Midazolam is 
normally considered to be an intravenous 
drug, although it is being used orally and as 
a nasal spray. It is available in Europe as a 
tablet. Unfortunately, it has been shown to 

have a noticeable respiratory depressant ef- 
fect in higher doses. 

The Advantages of Oral Triazolam 

Oral sedation with triazolam is simple to 
administer, and because of the nature of 
the drug, it is convenient and safe to use. 
Triazolam is readily available from any phar- 
macy. Reports of adverse drug reactions are 
rare and tend to be relatively mild. A major 
plus for all oral sedatives is that it is not nec- 
essary to administer an injection or start an 
intravenous line. (The last thing most pho- 
bic patients need is a needle puncture before 
they are sedated.) Getting an IV started in a 
phobic patient can be the most difficult part 
of a dental appointment. Patients readily 
accept oral sedation. 

Triazolam is a drug that has been around 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 238 



for some time but has been used primarily as 
a sleep aid. In this context, it has received 
bad press because of side effects that have 
shown up in patients who used it over an ex- 
tended period of time. In the early 1990s, it 
is the most commonly prescribed sleeping 
pill used in the United States; 7.2 million 
prescriptions were written annually 57 It 
should be emphasized that triazolam is not 
approved by the FDA as a sedative for dental 
purposes. This is an "off-label" use. 

Triazolam comes close to being an ideal 
drug for dental sedation. It has the advan- 
tage of being absorbed rapidly, achieving 
peak blood levels in 1.3 hours. Its half-life is 
two to three hours. In addition, it may be up 
to eight times more effective as a hypnotic 
than diazepam. Yet, triazolam has very little 
effect on the circulatory or respiratory sys- 
tems. Several studies have shown no changes 
in blood pressure, pulse, or percentage of 
oxygen saturation, and only a slight change 
in respiratory rate. The high incidence of 
anterograde amnesia on conscious patients 
further endears it to the dental practitioner. 
Patients do not have to be asleep for their 
dental treatments if they can be relaxed 
enough for us to do the required procedures 
and not have any memory of the proce- 
dure. 62 " 65 

Triazolam's relative lack of respiratory and 
cardiovascular sedation is important for 
safety. Safety is dependant on the ratio of the 
L/D 50 dose (that dose usually fatal to 50 
percent of study animals) to the E/D 50 
dose (concentration that provides sedation to 
50 percent of study animals). 

It would be ideal if this ratio were con- 
stant for humans. If this ratio held for hu- 
mans, it would take a tablet about the size of 
a bowling ball to have fatal consequences. 
Unfortunately, this is not true. The greater 
the difference between the E/D 50 and L/D 
50, the safer the drug. Several patients have 
committed suicide with triazolam. From 
postmortem blood samples, it was estimated 
that one person ingested 26 0.25-mg tablets. 

Another individual was found dead in a hot 
tub. It was estimated she had taken 1 
tablets. So it is possible to overdose and die, 
but the amounts necessary are well beyond 
what is necessary for dental sedation. 66 

Ambien (zolpidem) has been used by 
some dentists to replace triazolam. Ambien is 
an agonist of the GABA-benzodiazepine 
omega- 1 receptor site. It has a similar half- 
life to triazolam, but is a nonbenzodiazepine 
hypnotic of the imidazopyridine class. Some 
claim it has a little faster absorption than tri- 
azolam; however, the manufacturer reports 
maximum blood levels occurred at 59 and 
121 minutes for 5- and 10-mg doses. It has a 
half-life of 1.4-4.5 hours 

Yagiela suggested lorazepam (Ativan) 
would be an alternative to multiple doses of 
triazolam. 67 Lorazepam has a 10-20-hour 
half-life and a slower uptake. He suggested it 
should be taken two hours prior to starting 
treatment. Five hours later, less than half of 
the drug has been deactivated. Ten to 20 
hours later half the effect is still present. Be 
concerned about the patient driving the 
day after treatment. It makes more sense to 
use a drug with a shorter half-life and give a 
supplemental dose after one to two half- 
lives have passed. In this way, recovery 
should be faster. Lorazepam makes sense if 
you will give only one dose of a sedative 
drug, and you need sedation for four or 
more hours. 

Pharmacology of Triazolam 

The unique properties of triazolam are at- 
tributed to its chemical configuration. The 
nitrogen atom prevents it from being water- 
soluble. Midazolam has a carbon in this po- 
sition and, thus, is water soluble and suitable 
for IV administration. 

One chlorine atom is responsible for po- 
tency. Without this chlorine, the drug is 
one-fifth as potent. Larger alkyl substitutions 
also decrease potency. The second chlorine is 
necessary for benzodiazepine action. Bromo 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 239 



and nitro substitution are only weakly anxi- 
olytic. The nitro version is also anticonvul- 
sant, as illustrated by clonazepam. The tria- 
zolo ring and attached methyl group are 
responsible for the rapid oxidation by the 
liver enzymes, resulting in a short elimina- 
tion half-life and conversion to metabolites 
that are rapidly excreted. The methyl group 
also makes a drug more potent. ' 9 


Triazolam reaches a rapid peak within 1.3 
hours/ It works faster in the elderly and in 
young women/ 1 It also works more rapidly 
in daytime than at night, due to a longer 
predose fasting period. It is as much as two 
times quicker after a 12-hour fast/ 2 One 
study reported that 85 percent of the drug is 
absorbed into the bloodstream. The study 
also found that it is absorbed 28 percent 
more quickly if given sublingually, where 
some of it is absorbed but most of it is 
swallowed/ 3 


The distribution of triazolam shows no dif- 
ference in obese and normal patients. It is 89 
percent bound to plasma and 49 percent 
bound to serum proteins and crosses readily 
into the central nervous system because of 
high lipid solubility. It also crosses the placen- 
tal barrier and has been found in milk of rats. 

Metabolism and Elimination 

Triazolam is oxidized in the first pass 
through the liver and the lining of the gut by 
the cytochrome P450-mono-oxygenase sys- 
tem. The P450 system is made up of many 
enzymes. Triazolam is metabolized by the 
3A4 enzyme. Tagamet, cimetidine, erythro- 
mycin, isoniazid, possibly some oral contra- 
ceptives, some anti-HIV drugs, delavirdine 
(DLV), efavirenz (EFV), and grapefruit de- 
press the cytochrome P450-mediated oxi- 

datative system, thus reducing the first-pass 
liver clearance by decreased metabolism and 
reduction in hepatic blood flow/ The ab- 
sence of an enzyme in some people can be 
idiosyncratic or associated with certain pa- 
tient subsets. Southeast Asians may have less 
3A4 enzyme (see Figure 8.8). 

Triazolam has no active metabolites. As 
mentioned, its half-life is approximately two 
to three hours but is slower at night. The 
half-life is longer in the elderly because of 
lower liver oxidizing capacity. There is no 
change with kidney dialysis, but the half-life 
is slower with cirrhosis. Ninety-one percent 
is eliminated in urine and 9 percent in feces 
within 72 hours/ 5 7 

Central Nervous System Effect 

All the benzodiazepines have clinically useful 
antianxiety, sedative-hypnotic, anticonvul- 
sant, and skeletal muscle relaxant properties. 
They all depress the CNS to some degree, 
tending to be more antianxiety oriented as 
compared with barbiturates and other 
sedative-hypnotics. They depress the limbic 
system and areas of the brain associated 
with emotion and behavior, particularly 
the hippocampus and the amygdaloid nu- 
cleus. The major effects are attributed to 
an interaction with the GABA receptor com- 

Cardiovascular System Effect 

In normal therapeutic doses, the benzodi- 
azepines cause few alterations in cardiac 
output or blood pressure when administered 
intravenously to healthy persons. Slightly 
greater than normal doses cause slight de- 
creases in blood pressure, cardiac output, 
and stroke volume in normal subjects and 
patients with cardiac disease, but these 
changes are not usually clinically significant. 
Triazolam did not affect cardiovascular 
dynamics in doses four to eight times greater 
than normal/ 7 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 240 




Oral Dose IV Dose 

> Fraction Of i ™> Tar 9 et Organ 

unchanged drug 
the systemic 
circulation after 
administration by 
any route. 







P450 metabolism in 

liver and gut lining 

Figure 8-8. Benzodiazepine drugs are absorbed through the intestinal wall, where metabolic break- 
down is initiated by the cytochrome P450 metabolic enzymes. They travel to the liver via the portal cir- 
culation. When in the liver, further metabolism occurs prior to entering the systemic circulation. When in 
the systemic circulation the drugs can affect the target organ, the brain. 

Respiratory System Effect 

Most benzodiazepines are mild respiratory 
depressants. Given alone to a healthy patient 
they have little effect; however, they can po- 
tentate other CNS depressants. Midazolam 
is one that can cause respiratory depression 
and apnea. Triazolam did not depress respi- 
ratory response to C0 2 in doses four to 
eight times normal. 


In rats, slightly reduced fertility occurred, 
but the drug did not affect their postnatal 


One method of measuring recovery, a visual 
coordination study (following a randomly 

moving dot with their finger), had patients 
back to normal in five hours after ingesting 
0.25mg and in 1 1.5 hours after ingesting 
0.5mg benzodiazepins. Reported side effects 
include 8 percent sleepiness; 4 percent 
headache; and dizziness, neuritis, and dry 

Triazolam Pharmacology 

Before practitioners use any medication, they 
should be knowledgeable of its pharmacology. 
Likewise, every practitioner, but particularly 
those using sedatives, should be able to initi- 
ate resuscitation (including cardiopulmonary 
resuscitation) and ventilation. The equipment 
necessary to provide these emergency treat- 
ments must, of course, be available. 

There are a few absolute contraindications 
to the use of triazolam. Patients who are 
known to be hypersensitive to triazolam or 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 241 



other benzodiazepine drugs should avoid its 
use. Myasthenia gravis patients should not 
be treated, as triazolam has a muscle relax- 
ation effect. Glaucoma patients should avoid 
all benzodiazepines, as these drugs raise in- 
traocular pressure by increasing the outflow 
resistance to aqueous humor/ 8 (This can 
often be reversed by pilocarpine.) All the 
benzodiazepine drugs are teratogenic and 
should not be given to pregnant women. As 
triazolam has been shown to pass through 
the mammary glands of mice into the milk, 
it should not be given to lactating mothers. 
As it is a CNS depressant, it should be given 
cautiously to anyone on other CNS depres- 
sants or drugs that suppress the P450 meta- 
bolic system/ 9 

Relative Contraindications 

There are no detailed studies of triazolam's 
use as a sedative with pediatric and geriatric 
populations, and practitioners should be cau- 
tious when giving triazolam to these groups. 
Some clinicians teach not to use it with pa- 
tients under 18 or over 65 years of age. 
There have been reports of suicide attempts 
by psychiatric patients. Suicidal tendencies 
were unmasked, creating this paradoxical be- 
havior. 80 Several European countries have 
outlawed triazolam. One report showed an 
incidence of psychotic episodes after triazo- 
lam. However, the study was done in a psy- 
chiatric hospital, where many patients have 
psychotic tendencies. The final relative con- 
traindication is the fact that triazolam has 
not been approved by the FDA for dental 
sedation or the sedation of children. 

Adverse Effects 

Adverse effects have been reported in less 
than 4 percent of patients. Most adverse ef- 
fects were with doses greater than 0.5mg or 
when combined with other CNS depres- 
sants. As with all sedatives, patients cannot 
drive, operate machinery, or undertake any 

activity that could be hazardous. This in- 
cludes such activities as walking unaided, 
climbing stairs, and so on. They should not 
undertake positions of responsibility or care 
of children and should not make important 
decisions (legal, monetary, and so on) for the 
rest of the day. They should not have alcohol 
or other sedatives for 24 hours. 81 

The office should have an effective, effi- 
cient emergency protocol. This should in- 
clude a person to be continuously in the 
room with the patient from the time of ad- 
ministration of the drug until the patient is 
judged able to leave the office. The patient 
should not be allowed to sleep at any time. 
Oxygen saturation should be continuously 
monitored and recorded starting before ad- 
ministration of the drug. Vital signs should 
be taken at regular intervals such as every 1 5 
minutes or even more often if there is any 
indication of over-sedation. 

Management of adverse reactions should 
be planned before the drug is used and 
should be reviewed on a periodic basis. It 
should be noted that most adverse effects 
would be prevented by complete history tak- 
ing, physical examination, and appropriate 
adjustment of drug dosage. Recognition of an 
emergency situation must be followed by ini- 
tiation of a stabilization routine. This essen- 
tially entails the A-airway, B-breathing, and 
C-circulation of basic cardiac life support. 
Opening and maintaining a patient s airway is 
of paramount importance, as is monitoring 
vital signs. Calling the Emergency Medical 
Service by dialing 911 should follow if any 
doubt exists as to how to proceed. 

Use in the General Dental Office 

Over 1 5 years, this author has used triazolam 
more than 400 times. The patients come to 
the office one hour before we want to start 
their dental procedure. They are monitored 
by recording blood pressure, pulse rate, and 
pulse oximetry. The drug dose is determined 
by the patient's weight and purposely kept 

2879_Koerner_Chap 08 4/17/06 1:30 PM Page 242 



conservative — less than might be necessary. 
We usually administer a supplemental dose 
sublingually if at the 30-minute mark we see 
no signs of sedation. 

My patient population has ranged from 7 
to 83 years of age and from 60 to 320 lbs. 103 
All patients were ASA 1 or 2 with no history 
of recent illness. All adult patients were den- 
tal phobics who requested IV sedation or 
general anesthesia for their procedures. The 
children had previous attempts at treatment 
with conventional methods, including ni- 
trous oxide, which were unsuccessful. 

Cardiovascular and respiratory parameters 
measured and recorded included blood pres- 
sure (systolic and diastolic), heart rate, and 
oxygen saturation. With uncooperative chil- 
dren, only heart rate and oxygen saturation 
could be measured. Cardiovascular parame- 
ters were recorded every 1 5 minutes. During 
the procedure, oxygen saturation was contin- 
uously monitored with a pulse oximeter. 

After recording initial baseline data, oral 
triazolam was dispensed. Many authors have 
reported on the appropriate dosage for sleep 
enhancement. Suggested dosages range from 
0.125mg to 0.5mg. 82 ' 83 > 84 > 85 > 86 > 87 

After a discussion and completion of an 
informed consent document and recording 
of preoperative vital signs, a dose of triazo- 
lam is administered. An assistant stays in the 
operatory with the patient for the next hour, 
taking vital signs, blood pressure, pulse, and 
respiration every 1 5 minutes with instruc- 
tions to alert me if there is any change. The 
assistant is instructed to talk with the patient 
to ensure that they remain awake. I check to 
see whether there is any sign of sedation at 
30 minutes. If there is no sedation evident, 
we will administer one-half the original dose. 
If even slight sedation is noted at that time, 
we normally will have adequate sedation for 
the procedure. (Many patients will be disap- 
pointed at the end of the 40 minutes by the 
relative lack of sedation. They are assured 
that this is normal, and they will be ade- 
quately sedated by the time we start.) 

As mentioned, we decide to administer 
one-half the initial dose after 30 minutes if 
there is no evidence of sedation. 
Supplemental dosages were necessary for 
about 10 percent of patients. We used the 
following protocol to determine the dosages. 
Dose in mg = 0.25 mg + 0.125 mg for every 
70-pound weight increment over 40 

Patients reported a decrease in apprehen- 
sion that was greatest the first 30 minutes, 
with the second largest drop between 30 and 
60 minutes. About 50 percent had moderate 
to complete forgetfulness of the appoint- 
ment, and most did not remember the ride 
home. There were no significant changes 
in blood pressure, pulse rate, or oxygen 

It should be emphasized that no patients 
slept, snoozed, snored, or napped. All were 
awake and responded to verbal commands 
without painful stimulation. We have had no 
adverse effects on any of my patients. We 
did have three who were not sedated ade- 
quately to treat. 

Protocol in Our Office 

It should be stressed, and I will repeat again, 
that we do not want a patient who is asleep. 
If a patient sleeps, they are oversedated and 
should be kept awake by verbal commands, 
or if this does not work, the drug should be 
reversed. We do not worry whether the pa- 
tient is disappointed by their level of seda- 
tion because the amnesia that is common to 
this technique will allow them to forget 
most, if not all, of the appointment. It 
should be emphasized with children that 
they might still cry during the appointment. 
If they are controlled enough to allow den- 
tistry to be safely done, they are adequately 
relaxed. Crying, although distracting to the 
practitioner, is an indication of adequate 
ventilation. I would suggest not using any 
form of sedation on children under 7 years 
of age, unless you are trained in pediatric 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 243 



anesthesiology and are equipped and trained 
to handle general anesthesia and all the com- 
plications of anesthesia. 

The Procedure 

At a pre-appointment interview, the medical 
history is reviewed to determine that there 
are no contraindications to triazolam, the 
procedures, or from possible risks. Benefits 
and options are discussed with the patient 
or, in the case of children, with their parents. 

Patient Selection 

1 . The patient is over 7 years of age and 70 
lbs of weight. 

2. The patient is ASA 1 or 2. I suggest not 
treating any person who has any medical 
problem, however slight. 

3. Have a signed consent form. 

4. Start with a dose of triazolam appropri- 
ate for the patients size. 

a. 70 to 1 10 lbs gets 0.25 mg 

b. 1 10 to 180 lbs gets 0.375 mg 

c. 180 to 240 lbs get 0.5 mg 

d. 240 plus get 0.625 mg (see Figures 
8.9 and 8.10) 

5. If after 30 minutes you see absolutely no 
effect and if the patient tells you they do 
not feel any different, give half the origi- 
nal dose sublingually. If they show even 
a very slight effect, no second dose is 
necessary (see Figure 8.1 1). 

6. Two hours later you can give half the 
total dose if you have another hour to 
go and the patient is much less sedated 
than they were at 60 minutes. You are 
giving a dose equal to the amount that 
has been metabolized. 

7. If you need a little more sedation toward 
the end of a case, augment with nitrous 

8. Only use one oral drug, triazolam. Have 
the reversal agent and be prepared to in- 
ject it into the floor of the mouth if the 
patient does not respond to verbal com- 
mand without any tactical stimulation. 
A pinch will arouse the patient until you 
can inject the reversal agent. Reverse the 
sedation as they are starting to get 
deeper, not after they are under general 

9. We are not talking SLEEP, DOZE, 
SNORE, or NAP. We are talking awake 
with anxiolysis. 

Dose (mg) = 0.25mg + 0.125mg (for every 701b weight increase > 401bs) 
Therefore mean dose = 0.005mg/lb or 0.5mg for 180-pound man 

> Triazolam (Halcion) oral sedation can be used effectively 
over traditional intravenous or inhalation sedation. 

> 70 lb to 110 lb = 0.25 mg 

> 110 lb to 180 lb = 0.375 mg 

> 180 lb to 250 lb = 0.5 mg 

> 250 lb and greater 0.625 mg 

> Dosing is simple (based on the "Q-factor"). 

> Give half the original dose if no effect at 30min. 

> Give half the original dose every 2 hr. if sedation lightens. 

> Good body of evidence reporting its successful use. 

Figure 8-9. Dosage calculation: Dose in mg = 0.25mg + 0.125mg for every 70 lb weight increase over 
40 lbs. This equals 0.5 mg for a 180-pound man. If no sedation is observed at 30 minutes, a second 
dose is administered that is half the original dose. For long cases additional doses may be necessary as 
the drug is metabolized. 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 244 




& G&^GO 



59 1 00 

tended to %\-mp 

& yood satiation 


200 250 

difficult but po: 

Figure 8-10. Weight vs. dose of triazolam. This was an early graph of our use of triazolam in 1 10 
patients. It was from these data that I developed a dosing scheme relating to the patient's weight. 



« I 






Figure 8-11. Titration of triazolam: Long cases may require a second dose that equals the amount of 
drug that has been metabolized. Based on information from the following two references: (1) Friedman, 
H. et al. 1886. Population study of triazolam pharmacokinetics. Br J Clin Pharm. 22(6):639-42. (2) Deny, 
C.L. et al. 1995. Pharmacokinetics and pharmacodynamics of triazolam after two intermittent doses in 
obese and normal-weight men. J Clin Psychopharmacol. 15(3): 197-205. 


2879_Koerner_Chap 08 4/17/06 1:31 PM Page 245 



10. Never leave the patient alone in the 

1 1 . Never leave a male dentist, hygienist, or 
assistant alone with a female patient. 

12. Monitor BP, pulse, and oxygen satura- 
tion continuously after you give the ini- 
tial dose. 

13. If the patient needs to use the restroom, 
they must be accompanied by a same- 
sex staff person. 

14. The patient must be with a responsible 
adult the rest of the day. 

a. They are to have no alcohol or other 
sedatives for 24 hours before the ap- 

b. There should be no chance that they 
are pregnant. 

c. They should have none of the other 

d. They cannot drive, operate machin- 
ery, or undertake any activity that 
could be hazardous. This includes 
such things as walking unaided, 
climbing stairs, and so on. 

e. They should not undertake positions 
of responsibility, such as care of chil- 
dren, and should not make impor- 
tant decisions — legal, monetary, and 
so on, for the rest of the day 89, 90, 91 

It is stressed that we are not attempting 
nor is it our intent to have the patient sleep, 
although they might experience amnesia for 
some or all of the appointment. I have 
found that about 75 percent of patients have 
amnesia from the time we start the proce- 
dure (60 minutes after administering triazo- 
lam). The amnesia lasts for 2—3 hours. All 
patients have had some amnesia or forgetful- 
ness of the appointment. 

When the appointment is complete, we 
keep the patient in the dental chair until 
they are able to walk out with someone 
holding their arm. The dentist is the one to 
determine whether they are able to safely 
leave the office. You are looking for a notice- 
able decrease in sedation. Postoperative in- 

structions, the same as were given to the pa- 
tient in the pre-appointment, are reviewed 
with the adult who is going to take the pa- 
tient home and watch over them the rest of 
the day. I assess and record the patient's level 
of sedation prior to his or her leaving the of- 
fice. In addition, my home phone is given to 
this accompanying adult, who is encouraged 
to call if they have any questions or prob- 
lems. Finally, an assistant accompanies the 
patient out to the car, supporting the patient 
so there is no chance of a fall. The patient is 
seated in the passenger seat, and the seat belt 
is buckled. 

It should be noted that a second appoint- 
ment will normally be easier than the first. It 
has never been necessary to use a higher dose 
at the second appointment if the dose on the 
first appointment was adequate. Also, as this 
is a class IV drug, it is necessary to keep care- 
ful accounting records of its use. 

Status of Triazolam 


The Upjohn company distributes triazolam 
in the United States. They make no claims 
of its usefulness as a dental sedative, nor has 
it been tested for use with children. The 
Upjohn company made it very clear to me 
in a letter that the use of this drug for dental 
sedation and with children is investigational 
in nature and not supported or encouraged 
by the company. The patent has run out for 
triazolam. Consequently, there is little 
chance that it will ever be certified for dental 


The FDA does not recognize triazolam's use 
for either dental or pediatric sedation. A 
practitioner must recognize that should there 
be a problem, the lack of FDA approval 
would create problems from a medical-legal 
standpoint. Lack of FDA approval does not, 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 246 



however, prevent our using the drug for 

Recordkeeping Requirements 

The Drug Enforcement Administration, a 
division of the U.S. Department of Justice, 
has a booklet that is available from any DEA 
office, entitled, Physicians Manual An 
Informational Outline of the Controlled 
Substances Act of 1970. This manual spells 
out the requirements of recordkeeping, stor- 
age, inventory, security, and so on required 
for prescribing and dispensing a controlled 
substance. Triazolam is a schedule IV sub- 

To administer, prescribe, or dispense any 
controlled substance, a physician (dentist) 
must be registered with the DEA. The DEA 
requires that "The registration must be re- 
newed every three years and the certificate of 
registration must be maintained at the regis- 
tered location." 

"It is necessary for dentists to keep records 
of drugs purchased, distributed and dis- 
pensed. Having this closed system, a con- 
trolled substance can be traced from the time 
it is manufactured, to the time it is dis- 
pensed to the ultimate user." 

"All controlled substance records must be 
filed in a readily retrievable location from all 
other business documents, retained for two 
years, and made available for inspection by 
the DEA. Controlled substance records 
maintained as part of the patient file will re- 
quire that this file be made available for in- 
spection by the DEA." 

"A physician (dentist) who dispenses con- 
trolled substances is required to keep a 
record of each transaction." 

Inventory requirements 

"A physician (dentist) who dispenses or 
regularly engages in administering controlled 
substances is required to keep records and 
must take an inventory every two years of all 
stocks of the substances on hand." 


"A physician (dentist) must keep these 
drugs in a securely locked, substantially con- 
structed cabinet or safe." 

In my office, the triazolam is kept locked 
in a keyed locker, which is permanently at- 
tached to an office wall. Inventory sheets are 
kept in a book with patient record forms. 
This sheet shows date and patient name, age, 
and weight and has space for comments. 
The inventory total is changed with each 
drug administration so as to provide a run- 
ning total of the drug inventory. When re- 
stocking the drug supply, a copy of the 
prescription is attached to the inventory 

Patient Records 

Patient records are kept for all treatments. 
These records would be the same for any 
sedative agent except when nitrous oxide is 
used with no other sedative drugs. These 
records include the consent form, post- 
sedation evaluation, and a sedation record 
that includes blood pressure records, pulse 
rates, and pulse oximeter readings. These 
values are taken and recorded preoperatively 
and at 1 5 -minute increments from the 
drug administration until the case is com- 
pleted. The patient's medical status (ASA 
rating) is recorded along with age, sex, 
weight, amounts of drug administered, 
name, date, and whether this is the first 
administration of this sedative. 

Sedation records are necessary for several 
reasons. First, they establish a baseline and 
would be one of the first indicators of a 
potential problem. If any of the measured 
parameters start to change, we should im- 
mediately be alerted and start corrective ac- 
tion. Second, the stress of an emergency 
makes time sequencing difficult for the 
practitioner. It becomes all but impossible to 
recall vital signs and the times they were 
recorded. Complete records can provide 
clues about the case and possible solutions 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 247 



to our problem as it progresses. (At what 
point did we lose verbal contact? How long 
has the patient been at this level? Did the 
change come on rapidly or have vital signs 
been slowly changing for some time?) 
Lastly, in the event of legal action, complete 
and accurate records are a must for one's 

Flumazenil (Romazicon) Reversal 

It would be a great advantage to have a med- 
ication that would reverse the effects of any 
drug we use. This is particularly true of any 
drug that requires excretion or metabolism 
to be deactivated. When using drugs intra- 
venously, small test doses can be given and 
augmented as necessary to achieve the de- 
sired effect. These test doses go directly to 
the CNS and show their effect. They are 
then redistributed to the rest of the tissues of 
the body, effectively diluting the effect in the 
case of an overdose or sensitivity to an agent. 
Titration with oral drugs is very slow. It 
takes considerable time before it is obvious 
that we have a problem. Redistribution and 
saturation into the body have already taken 
place and are of little aid. In the case of over- 
dose, there is little we can do except treat the 
symptoms of the overdose and support respi- 
ration and circulation. For this reason, a re- 
versal agent for oral drugs is very desirable. 
The reversal agent for benzodiazepines is 


In 1974, Haefely hypothesized and showed 
that benzodiazepines act by increasing the ef- 
fectiveness of the most important inhibitory 
neurotransmitter, GABA. Later, several com- 
pounds were produced that had a greater 
affinity for this site than diazepam. One of 
these, flumazenil, was selected as an antago- 
nist for clinical trials. 92 


Flumazenil was shown to prevent benzodi- 
azepine sedation if given before the benzodi- 
azepine and to reverse the effect if given dur- 
ing or after the sedative drug. To reverse 
sedation or general anesthesia of benzodi- 
azepine drugs, flumazenil is administered in- 
travenously in titrated doses from 0.2-to-1.0 
mg doses. In the case of overdose, 2.0 to 3.0 
mg may be necessary 93 

Toxicity and Safety 

"Flumazenil has a high therapeutic index 
and a wide margin of safety." It showed min- 
imal effect on patients with ischemic heart 
disease. No withdrawal symptoms were seen 
when it was given to patients who had been 
on diazepam or triazolam for up to 14 days. 
Some symptoms were seen in patients who 
had been on lorazepam. It should not be 
given to patients with severe head injuries 
and unstable intracranial pressures. 9 When 
given to patients with panic disorder, 2mg 
of flumazenil intravenously precipitated 
panic attacks. It had no effect on healthy 


Use with Children 

Jones administered flumazenil to 40 healthy 
children aged 3—12 years of age after they 
had received midazolam for the induction of 
anesthesia. The drug was given along with a 
placebo, and the efficacy of antagonism was 
assessed. Those receiving the active drug 
awoke approximately four times faster. There 
were no cases of resedation and minimal 
changes in the cardio-respiratory variables. 9 

Use with Adults 

The half-life of flumazenil at 54 minutes 
(.7 to 1.3 hr) is less than triazolam, midazo- 
lam, and diazepam, so you may see some re- 
bound of effect (see "Resedation" section 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 248 



later in this chapter). Sedation was gone 
within 2 to 5 minutes. I have seen the rever- 
sal drug used sublingually in the floor of the 
mouth. The pain of this injection noticeably 
aroused the patient. Their sedation was obvi- 
ously lessened within two minutes; however, 
maximum reversal took 10 minutes for IV 
administration and 20 minutes for sublin- 
gual. In both cases, most of the effect oc- 
curred in the first five minutes. 

Co n traindicatio ns 

Flumazenil is contraindicated in patients 
with a known hypersensitivity to flumazenil 
or to benzodiazepines, in patients who have 
been given a benzodiazepine for control of a 
potentially life-threatening condition (for 
example, control of intracranial pressure or 
status epilepticus), and in patients who are 

showing signs of serious cyclic antidepressant 
overdose. 97 


Because of the relatively short half-life of 
flumazenil, 54 minutes, it is possible that its 
reversal effect could disappear before the 
sedative effect of triazolam, with its half-life 
of one to two hours (see Figure 8.12). Mida- 
zolam has a similar half-life (one to two 
hours), and several studies have failed to 
show significant resedation if appropriate 
doses of midazolam had been used. 
Resedation has been shown with diaze- 
pam, which has a much longer half-life 
(20—50 hours), and with larger doses of mi- 
dazolam. 102 Until studies have been reported 
showing no resedation with triazolam, a pa- 
tient who requires flumazenil should be ob- 

Flumazenil Reversal of Triazolam 

act] vb 



Theoretical level 
of triazolam as 
reversal agent 
is metabolized. 


Figure 8-12. The figure shows the reversal with Flumazenil. At time 1 the triazolam is completely re- 
versed. At time 2 one hour later, half the Flumazenil has been metabolized, and part of the effect of the 
triazolam has rebounded. This effect increases through hour 3. 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 249 



served for several hours after reversal to be 
positive resedation does not occur. There is a 
risk that with reversal the patients may feel 
normal and attempt activities they are not 
capable of safely performing. 

With the introduction of this reversal 
agent, we are able to use triazolam with the 
comfort of knowing that we can reverse its 
sedation should we achieve an overdose. Of 
course, this in no way should cause us to use 
excessive doses of triazolam, nor does it re- 
lieve us of the responsibility of monitoring a 
patient's physical status and responding ac- 
cordingly in the case of cardiovascular or res- 
piratory depression. 

Politics of Sedation 

Oral conscious sedation has become a con- 
troversial subject for dentistry. The American 
Dental Association, specialty groups, and 
some state boards have attempted to severely 
limit the use of this very necessary and im- 
portant technique. 

In general, benzodiazepine drugs, and 
specifically triazolam, are very safe when used 
conservatively. Triazolam has become a drug 
of choice in dentistry because of its rapid up- 
take, short half-life, and amnesia. Oral seda- 
tion has come a long way toward addressing 
the unmet needs of phobic patients. 

The AD As guidelines state that titration 
or "giving a second dose of an oral sedative" 
is unpredictable and can lead to deeper levels 
of sedation. These guidelines limit the dose 
of an oral sedative to the maximum recom- 
mended dose (MRD). MRD is a FDA term. 
In the case of triazolam, it refers to the dose 
used as a sleep-aid for a patient who may be 
home alone and has nothing to do with den- 
tal sedation. The MRD for triazolam is 0.50 

When you face a sedation/anesthesia 
emergency, you need all the skill and train- 
ing you have acquired, previous experience 
handling such emergencies, and a little luck. 
This is an area where dental patients can and 

do die. Conservative dosing of triazolam for 
oral conscious sedation will never expose the 
practitioner to these moments of terror or 
the patient to theses risks. Always remember 
DO NO HARM! Death is forever. 

Case Reports 

It can be helpful to clinicians to have exam- 
ples of situations in which a medication was 
actually used with a patient. Following are 
two care reports using triazolam in clinical 

Patient No. 1 

A seven-year-old was sedated for dental treat- 
ment by a pediatric dentist. The patient left 
the office able to walk holding the hand of 
her mother. She went home and tended to 
sleep if left alone. The dentist's home phone 
line was out of order that evening. After 
trying to reach the dentist, her mother be- 
came concerned and called a local emer- 
gency room, who told her to watch the pa- 
tient and that triazolam was not approved 
for use with children. The mother then 
called poison control and was again told that 
triazolam should not be used with children. 
The dentist relieved the mother's concerns 
when she reached him in the office the next 

Patient No. 2 

A 40-year-old black male about 6' 1" tall and 
230 pounds had an uneventful sedation. At 
the close of the case, when he was judged to 
be ready to leave, his wife, a rather petite 
woman of 5 '6", was brought in and given 
postoperative instructions. At this time she 
mentioned they would be taking public 
transportation, a bus, home. Because I was 
concerned about her being able to help the 
patient on and off the bus, we kept him an 
extra hour to ensure that his wife would not 
have any problem getting him home. We did 

2879_Koerner_Chap 08 4/17/06 1:31 PM Page 250 



not insist that the patient be transported by 
auto. The patient arrived home safely. 


1. C. Bennett, C. Richard. Dissociative-sedation. 
Compend. Contin. Educ. Dentl, Vol XI, No. 1 
Jan., p. 34-38. 1990 

2. P. Weinstein, P. Milgrom, E. Kaufman, L. Fiset, 
D. Ramsay. Patient perceptionsof failure to 
achieve optimal local anesthesia. General 
Dentistry, May-June, p. 218-220. 1985. 

3. P. Milgrom, P. Weinstein, R. Kleinknecht, T. 
Getz. Treating fearful dental patients. Reston, VA: 
Reston Publishing Co., Inc.. 1985. 

4. P. Domoto, P. Weinstein, S. Melnick, M. 
Ohmura, H. Uchida, K. Ohmachi, M. Hori, Y. 
Okazaki, T. Shimamoto, S. Matsurma, T. 
Shimono. Results of a dental fear survey in 
Japan: implications for dental public health in 
Asia. Community Dental Oral Epidemiol 16: 
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8. R. A. Dionne. Pharmacologic considerations in 
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10. J. W Dundee. Advantages and problems with 
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13. R. A. Dionne. Pharmacologic considerations in 
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14. J. A. Yagiela, E. A. Neidle. Pharmacology and 
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43. G. Ahlborg, G. Axelsson, L. Bodin. Shift work, 
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45. J. F. Nunn et al. Serum methionine and hepatic 
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46. Sweeney et al. British Medical Journal. 1985. 

47. A. S. Rowland, D. D. Baird, C. R. Wienberg, D. 
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48. D. Donaldson, J. Orr. A comparison of the ef- 
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49. D. Donaldson, J. Orr. A comparison of the ef- 
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50. B. R. Fink. Diffusion anoxia. Anes. Jul; 16(4): 
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51. EC. Quarnstrom, P. Milgrom, M. J. Bishop, T 
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21-23. 1991. 

52. J. B. Brodsky, R. E. McKlveen, J. Zelcer, J. J. 
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pulse oximetry. J Clin Monit. Oct; 4(4):244-6. 

53. M. B. Papageorge, L. W Noonan, M. 
Rosenberg. Diffusion hypoxia: another view. 
Anesth Pain Control Dent. Summer; 2(3): 143-9. 

54. D. E. Becker. The respiratory effects of drugs 
used for conscious sedation and general anesthe- 
isia. JADA, vol. 119, p. 153-156. July, 1989. 

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55. S. H. Snyder. Drugs and the Brain. New York, 
NY: Scientific American Library, Scientific 
American Books Inc., p. 151-177. 1986. 

56. D. L. Gottlieb. GABAergic Neurons. Scientific 
America^ no. 2, p. 82-89. February, 1988. 

57. G. Cowley, K. Springen, D. Iarovici, M. Hager. 
Sweet dreams or nightmare? Newsweek. August 
19, p. 48. 1991. 

58. R. P. Juhl, V. M. Daugherty, P. D. Kroboth. 
Incidence of next-day anterograde amnesia 
caused by flurazepam hydrochloride and 
Triazolam. Clin Pharm (Nov-Dec) 3(6): 622 — 5. 

59. R. H. Meyboom. The triazolam affair in 1979, a 
false alarm? Ned Tijdschr Geneeskd. Nov 4; 
133(44): 2185-90. 1989. 

60. L. Lasagna. The triazolam story: trial by media. 
Lancet (Apr 12) 1(8172): 815-6. 1980. 

61. R. Riefkoh, R. Kosanin. Experience with triazo- 
lam as a preoperative sedative for outpatient sur- 
gery under local anesthesia. Aesthetic Plast Surg. 
8(3): 155-7. 1984. 

62. E. D. Burgess, K. R. Burgess, T R. Reroah, W. 
A. Whitelaw Respiratory drive in patients with 
end-stage renal disease at rest and after adminis- 
tration of meperidine and triazolam. Clin Res,35: 
173a. 1987. 

63. R. T Longbottor, B. J. Pleuvry. Respiratory and 
sedative effects of triazolam in volunteers. Br J 
Anaesth, 56: 179-185. 1984. 

64. R. B. Knapp, E. L. Boyd, B. Linsenmeyer, O. I. 
Linet. A comparison of the cardiopulmonary 
safety and effects of triazolam, flurazepam and 
placebo in pre-surgical patients. Excerpta Med Int 
Cong Ser. 542: 246. 1979. 

65. R. B. Knapp, E. L. Boyd, B. Linsenmeyer, O. I. 
Linet. An evaluation of the cardiopulmonary 
safety and efficacy of triazolam, flurazepam and 
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Ther, 21: 107-108. 1977. 

66. B. Joynt. Journal of Analytical Toxicology, vol. 1 7 
p. 171-177. May/June, 1993. 

67. J. Yagiela. Recent Developments in Local 
Anesthesia and Oral Sedation. Compendium. 
Sept. vol.25, no 9, p. 697-707. 2004. 

68. Anonymous. New benzodiazepine sedatives as- 
sessed at recent symposium. Pharm Pract News, 
14(5): 25-27. 1987. 

69. P. D. Garzone, P. D. Kroboth. Pharmacokinetics 
of the newer benzodiazepines. Auckland, New 
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70. G. E. Pakes, R. N. Brogden, R. C. Heel, T M. 
Speight, G. S. Avery. Triazolam: A Review of its 
Pharmacological Properties and Therapeutic 
Efficacy in Patients with Insommia. Auckland, 
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71. P. D. Garzone, P. D. Kroboth. Pharmacokinetics 
of the newer benzodiazepines. Auckland, New 
Zealand: Adis Press, p. 346. 1989. 

72. P. D. Garzone, P. D. Kroboth. Pharmacokinetics 
of the newer benzodiazepines. Auckland, New 
Zealand: Adis Press, p. 347. 1989. 

73. P. D. Garzone, P. D. Kroboth. Pharmacokinetics 
of the newer benzodiazepines. Auckland, New 
Zealand: Adis Press, p. 348. 1989. 

74. P. D. Garzone, P. D. Kroboth. Pharmacokinetics 
of the newer benzodiazepines. Auckland, New 
Zealand: Adis Press, p. 347. 1989. 

75. P. D. Garzone, P. D. Kroboth. Pharmacokinetics 
of the newer benzodiazepines. Auckland, New 
Zealand: Adis Press, p. 348-976. 1989. 

76. G. E. Pakes, R. N. Brogden, R. C. Heel, T M. 
Speight, G. S. Avery, triazolam: A review of its 
pharmacological properties and therapeutic efficacy 
in patients with insommia. Auckland, New 
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77. G. E. Pakes, R. N. Brogden, R. C. Heel, T M. 
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pharmacological properties and therapeutic efficacy 
in patients with insommia. Auckland, New 
Zealand: Adis Press, p. 91. 1981. 

78. J. A. Yagiela, E. A. Meidle. Pharmacology and 
therapeutics for dentistry. St Louis, MO: CV 
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79. W. A. Parker, R. A. MacLachlan. Prolonged 
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bination in an elderly patient. Drug Intell Clin 
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80. J. B. Weilburg, G. Sachs, W. E. Falk. Triazolam- 
induced brief episodes of secondary mania in a 
depressed patient. / Clin Psychiatry (Dec) 48(12): 
492-3. 1987. 

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and oral sedative for the dental practitioner. 
J Canad Dent Assoc, vol. 54, no.7. July, 


82. H. Heinzl, C. Axhausen, U. Bahler, H. Gehrer. 
Comparison of the effectiveness of triazolam 
(Halcion) and flunitrazepam (Rohypnol) in the 
preoperative period. A double-blind crossover 
study, Schweiz Med Wochenschr (Nov 1 5) 
110(46): 1745-8. 1980. 

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83. A. A. Borbely, M. Loepfe, P. Mattmann, I. 
Tobler. Midazolam and triazolam: hypnotic ac- 
tion and residual effects after a single bedtime 
dose. Arzneimittelforschung 33(10): 1 500-2. 

84. P. D. Kroboth, R. P. Juhl. New drug evaluations. 
Triazolam. Drug Intell Clin Pharm (Jul-Aug) 
17(7-8): 495-500. 1983. 

85. T. Roth, T. A. Roehrs, F. J. Zorick. 
Pharmacology and hypnotic efficacy of triazo- 
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87. L. E Fabre, Jr., W. T. Smith. Multi-clinic cross- 
over comparison of triazolam (Triazolam) and 
placebo in the treatment of co-existing insomnia 
and anxiety in anxious out-patients. Dis New 
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88. E Quarnstrom, M. Donaldson. Triazolam use in 
the dental setting: A report of 270 uses over 1 5 
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89. D. E. Boatwright. Triazolam, handwriting, and 
amnestic states: two cases. J Forensic Sci. (Jul) 
32(4): 1118-24. 1987. 

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sia. Transient global amnesia secondary to 
Triazolam. JAMA (Aug 21) 258(7): 945-6. 

91. M. Leibowitz, A. Sunshine. Long-term hypnotic 
efficacy and safety of Triazolam and flurazepam. 
J Clin Pharmacol. (May-Jun) 18(5-6): 302-9. 


92. H. Heinzl, C. Axhausen, U. Bahler, H. Gehrer. 
Comparison of the effectiveness of triazolam 

(Triazolam) and flunitrazepam (Rohypnol) in the 
preoperative period. A double blind crossover 
study. Schweiz MedWochenschr. (Nov 15) 
110(46): 1745-8. 1980. 

93. B. K. Philip. Flumazenil a review of the literature. 
Excerpta Medica, Prinction. p. 8. 1992. 

94. B. K. Philip. Flumazenil a review of the literature. 
Excerpta Medica, Prinction. p. 9-10. 1992. 

95. R. N. Brogden, K. L. Goa. Flumazenil: A reap- 
praisal of its pharmacological properties and 
therapeutic efficacy as a benzodiazepine antago- 
nist. Auckland, New Zealand: Adis International 
Ltd. p. 1063. 

96. R. D. M. Jones, A. D. Lawson, L. J. Andrew, W. 
N. S. Gunawardene, J. Bacon-Shone. 
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in children: A randomized, double-blind study 
of placebo and flumazenil administered after 
Midazolam induced anesthesia. British Journal of 
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Pharmacol Ther. 4: 35^2. 1990. 

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Jewkes. BrJAnaesth. 64: 586-589. 1990. 

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92): 70-74. 1990. 

101. A. M. Holloway, D. A. Logan. The use of 
flumazenil to reverse diazepam sedation after en- 
doscopy. Fur J Anaesthesio I. suppl 2: 191-194. 

102. R. N. Brogden, K. L. Goa. Flumazenil: A reap- 
praisal of its pharmacological properties and 
therapeutic efficacy as a benzodiazepine antago- 
nist. Auckland, New Zealand: Adis International 
Ltd. p. 1074. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 255 

Chapter 9 

Infections and Antibiotic 


Dr. R. Thane Hales 


Infections of the oral cavity and the sur- 
rounding structures of the head and neck 
can be some of the most complex and seri- 
ous to manage. Minor infections, however, 
are usually easily treated when the correct 
antibiotic and debridement regimen is used. 
This regimen must include a comprehensive 
understanding of the infectious organism 
and the action of the antibiotic used, along 
with its corresponding dosage. 

Oral infections are frequently mild or 
low-grade localized infections. However, 
these may spread to become moderate, and 
if left unattended, grow into a more severe 
complex condition. Appropriate treatment in 
the early stages will usually prevent the need 
for more serious fascial space infections that 
can be life threatening. Infections can rapidly 
become severe, especially in a medically 
compromised patient. 

In this chapter, the most common oral in- 
fections and their causative pathogens will be 
discussed — along with current therapies. As 
we know, the science of oral microbiology is 
evolving and requires constant updating and 

study in order to stay proficient at treating 
patients. The material in this chapter is cur- 
rent at the time of writing, but change is on- 
going, and the serious clinician must update 
frequently for the benefit of the patient. 

Bacterial Characteristics 

Bacteria differ from viruses in that they are 
single-celled organisms. Viruses are far sim- 
pler, consisting of one type of biochemical 
(a nucleic acid, such as DNA or RNA) 
wrapped in another (a protein). Most biolo- 
gists do not consider viruses to be living 
things but, instead, infectious particles. 
Antibiotic drugs attack bacteria, not viruses. 
In the drawing shown in Figure 9.1, we 
would need to draw the virus four times 
smaller to make it correct in size relative to 
the size of the bacteria. 

Perhaps the most relevant problem we 
face today is that we are rapidly reaching a 
critical point in the use of effective antibi- 
otics to destroy microorganisms. One of the 
most significant reasons is the lack of under- 
standing and clinical skill of the clinician. 


2879_Koerner_Chap 09 4/17/06 1:30 PM Page 256 





Figure 9-1 . Bacterium and a virus particle. The 
virus would actually be several times smaller than 
illustrated here. Adapted from Ricki Lewis; FDA 
Consumer, Vol. 29, Sept. 1995. 

Many providers prescribe antimicrobial 
drugs to treat viral infections when they are 
absolutely contraindicated. Another reason is 
that clinicians are not giving the right antibi- 
otics in the appropriate dosages. 

When microbes began resisting penicillin 
shortly after its discovery in the 1 940s, med- 
ical researchers fought back with chemical 
cousins, such as methicillin and oxacillin. By 
1953, the antibiotic armamentarium in- 
cluded chloramphenicol, neomycin, ter- 
ramycin, tetracycline, and cephalosporins. 
But today, researchers fear that we may be 
nearing an end to the seemingly endless flow 
of antibiotic drugs. 

The drug of last resort has long been Van- 
comycin. This is a derivative of Lincomycin, 
which was derived from soil bacteria near 
Lincoln Nebraska. Vancomycin, once our 
last line of defense, is now reported to be in- 
effective against certain hospital strains of 
enterococcus and strains of staphylococcus. 

Microorganisms Produce 

Penicillium and Cephalosporium produce 
the beta-lactam antibiotics penicillin and 
cephalosporin. Actinomycetes, mainly the 
Streptomyces species, produce tetracyclines, 
aminoglycosides (streptomycin and its rela- 
tives), macrolides (erythromycin and its 
relatives), chloramphenicol, and most clini- 
cally useful antibiotics that are not beta- 

Bacillus species, such as B. poly my xa and 
B. subtilis, produce polypeptide antibiotics 
(that is, polymyxin and bacitracin), and B. 
cereus produces zwittermicin. These organ- 
isms live in a soil habitat forming a spore 
or resting structure. Antibiotics are second- 
ary metabolites of these microorganisms. 
They are produced at the same time the 
cells begin sporulation (division) processes. 
Because of their complexity, it may require 
30 separate steps to synthesize them. Some 
of the major antibiotics and the organisms 
they are produced from are listed in 
Table 9. 1. 2 

Anatomy of Bacteria 

The review of the anatomy of single-cell 
bacteria is necessary to understand the dis- 
cussion that follows. The components of 
bacteria are basically the cell wall, cyto- 
plasm, DNA nucleus, plasmids, ribosomes, 
and other external structures shown in 
Figure 9.2. 

Table 9-1. Antibiotic Origins and Actions 


Produced From 


Site of Action 






Clavulanic acid 


Penicillium chrysogenum 
Cephalosporium acremonium 
Streptomyces erythres 
Streptomyces nimnosus 
Synthetic antiprotozoal 
Streptomyces clavuligerus 
Penicillium notatum 

Gram pos/neg 
Broad spectrum 
Gram pos 
Broad spectrum 
Gram neg 
Gram neg 
Gram pos/neg 

Cell wall 
Cell wall 

Protein synthesis 
Protein Synthesis 
DNA replication 
Blocks B-lactamases 
Cell wall 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 257 



Nucleoid DNA , 4 . . 
Plasma membrane (proteins; 

Cell wall 


Figure 9-2. Anatomy of a single cell bacterium 


Bacterial Resistance 

There are at least three known ways bacterial 
resistance can occur. 

1 . Spontaneous mutation of the DNA. 

In spontaneous DNA mutation, bacte- 
rial DNA (genetic material) may mutate 
(change) spontaneously. This can occur 
with low levels of antibiotic therapy or 
noncompliance on the patient's part to 
"take as directed." Patients must take the 
medications for two days after symptoms 
disappear (see Figure 9.3). 

2. Microbial sex transformation. 

The passage of genes from cell to cell 
by direct contact through a sex pilus or 
bridge is termed conjugation. This is an 
important way bacteria can change or 
adapt. It happens when one bacterium 
takes up DNA during replication or 
transformation from another bacterium 
that is already resistant (see Figure 9.4). 

Figure 9-3. Spontaneous DNA mutation. 
Adapted from Ricki Lewis, FDA Consumer, Vol. 
29, Sept. 1995. 

3. Plasmid transfer resistance. 

One of the more serious changes of 
bacteria is resistance acquired from a 
small circle of DNA called a plasmid. A 
plasmid can transfer from one type of 
bacterium to another. A single plasmid 
can provide several resistances. In 1968, 
12,500 people in Guatemala died in an 
epidemic of Shigella diarrhea. The mi- 
crobe harbored a plasmid carrying resist- 
ances to four antibiotics! 1 See Figure 9.5. 

Figure 9-4. Microbial sex transformation. 
Adapted from Ricki Lewis, FDA Consumer, Vol. 
29, Sept. 1995. 

Plasmid Transfer 

Figure 9-5. Plasmid transfer. Adapted from Ricki 
Lewis, FDA Consumer, Vol. 29, Sept. 1995. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 258 



Indiscriminate Prescribing 

We have taken antibiotics for granted. It 
seems that every time we get a cough, the 
sniffles, or a slight earache, the plastic bottle 
of magic medicine is the answer. Even sinus 
headache is treated unwarrantedly with an- 
tibiotics. Most sinusitis problems are viral, 
and the useless administration of antibiotics 
is helping the bacterial resistance to escalate. 
The use of antibiotics in the treatment of a 
well-localized and easily drained dentoalveo- 
lar abscess is usually unnecessary because 
drainage and dental therapy usually resolve 
the infection. On the other hand, when 
there are systemic signs and symptoms such 
as trismus, elevated temperature, poorly lo- 
calized or diffuse cellulitis, diabetes, or im- 
munocompromized diseases, antibiotic ther- 
apy is required. 

The careful use of antibiotics is essential if 
we are to do our part in preserving the an- 
tibiotics that we have. Most odontogenic 
infections are caused by a few predictable 
groups of bacteria with which we must be- 
come familiar. A little time and effort in 
studying these microbes will make a practi- 
tioner's ability to diagnose and treat infec- 
tions more predictable. 

Bacteria Associated with 
Odontogenic Infections 

Many different strains of bacteria exist in the 
oral cavity. Oral bacteria in certain infections 
may number from 350 to 500 3 different 
species. However, if we know the predomi- 
nant ones, we will have a greater advantage 
over infectious disease. 

The most common oral infections are 
those arising from pulpal necrosis and the 
subsequent overflow into the surrounding 
tissue, or periodontal infections that result 
from the invasion of bacteria into bone or 
soft tissue. This could be in the third molar 
region, where pericoronitis allows the bacte- 
ria into the underlying and surrounding tis- 

sues. Pericoronitis is not to be taken lightly 
as it can be a precursor to more serious in- 
fections even after the third molar is ex- 
tracted. The extraction site must be irri- 
gated thoroughly with copious amounts of 
sterile water and the patient placed on an 

The abscessed tooth is the most common 
of all infections that dentists treat, and the 
second most common is periodontal infec- 
tion. There are infections that arise due to 
the condition of the host, where defense 
mechanisms are compromised by illness or 
by drug therapy. This creates an imbalance 
that lets certain flora flourish. Currently, lab- 
oratory culture tests are able to cultivate only 
five or six of the major pathogens in an 
odontogenic infection, but these few cultur- 
able bacteria are usually the major cause of 
the infection. Cultures and sensitivity tests 
then are very useful in choosing the right an- 
tibiotic regimen. 

Aerobic and Anaerobic Bacteria 

Infectious bacteria in the mouth are either 
aerobic or anaerobic. They either need oxy- 
gen or they do not. The bacteria that cause 
infections in the mouth are indigenous to 
the host. They all are prevalent in a balanced 
environment. This balanced environment is 
designed to keep each pathogen in check, 
maintaining function while living in a mu- 
tual coexistence. The effect of one bacterium 
upon another was first witnessed when strep- 
tococcus bacteria were noticed affecting 
diphtheria {Corynebacterium diphtheriae) be- 
fore the advent of immunization. Sprays of 
streptococcus viridians were applied to the 
throat of victims of the disease in an effort to 
control the infection. 

Most odontogenic infections that typi- 
cally invade the host patient are a mix of aer- 
obic or anaerobic bacteria. About 60 percent 
of all oral infections are a mix of these two 
types of flora. Infections that are aerobic 
only amount to about 5 percent of oral in- 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 259 



fections. Those that are anerobic only are the 
cause of roughly 35 percent. 3 

Gram Staining 

Gram stain (an empirical staining procedure 
devised by Gram) is a process in which mi- 
croorganisms are stained with crystal violet 
treated with a 1 : 1 5 dilution of Lugol's io- 
dine, decolorized with ethanol or ethanol- 
acetone, and counterstained with a contrast- 
ing dye — usually safranin. Microorganisms 
that retain the crystal violet stain are said to 
be gram-positive, and those that lose the 
crystal violet stain by decolorization but stain 
with the counter stain are said to be gram- 

Bacteria that retain the stain have a 
thicker wall of peptidogylcan layers and, 
consequently, retain the stain (see Figure 
9.5). This layer is very thin and beneath a 
cell wall in gram-negative bacteria, so the 
stain is decolorized. The ability to retain the 
stain or resist decolorization by alcohol in 
Gram's method of staining is a primary char- 
acteristic of gram-positive bacteria. 

Gram-negative bacteria lose the stain and 
are decolorized by alcohol in Grams method 
of staining. This is a primary characteristic of 
gram-negative bacteria — having a cell wall 
composed of a thin layer of peptidoglycan 
covered by an outer membrane of lipopro- 
tein and lipopolysaccharide (see Figure 9.6). 

The cell walls of bacteria are essential for 
their normal growth and development. 
Peptidoglycan is a heteropolymeric compo- 
nent of the cell wall that provides rigid me- 
chanical stability by virtue of its highly cross- 
linked latticework structure. In gram-positive 
microorganisms, the cell wall is 50 to 100 
molecules thick, but in gram-negative bacte- 
ria, it is only one or two molecules thick. 
Peptidoglycan is composed of glycan chains, 
which are linear strands of two alternating 
amino sugars (7V-acetylglucosamine and N- 
acetylmuramic acid) cross-linked by peptide 

Production of Beta Lactamase 

The most recognized cause of bacterial resist- 
ance is the production, by certain gram- 
negative anaerobes, of the enzyme beta lacta- 
mase. This enzyme attaches to the penicillin 
molecule at the beta lactum ring. If the 
(3 -lactam ring is enzymatically cleaved by 
bacterial (^-lactamases, the resulting product, 
penicilloic acid, lacks antibacterial activity. 
The same scenario holds true for ceph- 
losporins as their structure is similar. See 
Figure 9.7. 

Killing Bacteria That Cause 

Antibiotics generally work in one of five 

1 . Inhibition of nucleic acid synthesis (for 
example, Rifampicin) 

2. Inhibition of protein synthesis (for exam- 
ple, tetracyclines, erythromycins) 

3. Action on cell membrane (for example, 
polyenes; Polymyxin) 

4. Interference with enzyme system (for ex- 
ample, Sulphamethoxazole) 

5. Action on cell wall (for example, peni- 
cillins; cephlosporins, Vancomycin) 

Penicillin works by blocking the forma- 
tion of peptide bonds in the bacterial cell 
wall and, thereby, weakening it, leaving the 
bacterium susceptible to osmotic lysis. 
Although there appears to be a wide assort- 
ment of antibiotics and mechanisms of ac- 
tion, there are a very limited number of tar- 
gets through which bacteria are susceptible 
to antibacterial activity. Researchers are 
constantly looking for new ways to combat 

The causative organisms can be treated 
either empirically or by isolating the bacteria 
by culture. The culture is treated with differ- 
ent antibiotic chips to see which one is the 
most effective in destroying the organism. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 260 



Teichoic Acid 

Gram Positive 

Peptidoglycan Layers 

Penicillin Binding Protein 


Specific Channel Protein 

Gram Negative 

tein v 

I \ 

Cell Wall 


Peptidoglycan layer 

B- lactamase 

binding protein 


B- lactamase 

Cell wall 


Porin channel 

Outer membrane 

Periplasmic space 



Figure 9-6A and B. Structure of the cell wall. Comparison of the structure and composition of gram- 
positive and gram-negative cell walls. (Adapted from Tortora et al., 1989.) 

This is a sophisticated methodology using 
pus aspirates placed on a medium inducing 
their growth. The results of these tests can 
provide enough information to give a close 
picture of what is happening at different in- 
tervals during the infection. These intervals 
are usually related to the invasiveness of the 
organism. The more invasive an infection is, 
especially in the early stages of a cellulitis, 
the more an empirical decision can be made 
that this undefined borderless infection is 
due to aerobic bacteria. When aerobic bacte- 
ria reduce the oxygen potential and an infec- 

tion becomes more localized, it takes the 
form of an abscess with more defined board- 
ers. At this point, even without cultures, we 
can assume that the anaerobes have joined 
the process and we have a mixed microbial 
infection. It is postulated that anaerobic bac- 
teria become opportunistic and feed on the 
essential nutrients and by-products of the 
aerobic bacteria as well as thriving in the 
oxygen-depleted environment. 

In the last few years, science has been able 
to improve the aseptic collection of cultures. 
Also, through DNA mapping, they have 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 261 




Beta lactamase attacks here 
Figure 9-7. Penicillin. 



CH Penicillin 
H 6 


Beta Lactam ring 

more clearly defined what microbes we are 
trying to eliminate. Even though the treat- 
ment of infectious disease of the oral envi- 
ronment without culture is not absolute, we 
can be sure that in most cases a large major- 
ity of them follow patterns that are pre- 
dictable. Every dental infection cannot be 
subjected to the cost of these modern tests. 
We can, however, order these tests when we 
are involved in treating severe infections to 
give us a clear picture of the usual causative 

Common oral flora contain the following 
gram-positive bacteria: Streptococcus viridans 
spp. S. viridans has many different species. 
See Table 9.2. These oral bacteria are alpha- 
hemolytic. The definition of alpha-hemolytic 
is alpha hemolysis; a greenish discoloration 
and partial hemolysis of the red blood cells 
immediately surrounding colonies of some 
streptococci on blood agar plates. Compare 
that to beta-hemolytic. Beta hemolysis: A 
sharply defined clear colorless zone of he- 
molysis surrounding colonies of certain 
streptococci on blood agar plates. So the 
properties of each of these two types of oral 
flora react differently when metabolizing 
blood and sugars. 

Streptococcus viridans 

About 85 percent of all oral infections con- 
tain bacteria of the aerobic strep viridans 

Table 9-2. Streptococcus viridans Group 

S. milleri 
S. sanguis 
S. salivaris 
S. mutans 
S. pyogenes 

group. The viridans group is the group of 
bacteria we are treating in the prophylactic 
prevention of subacute bacterial endocarditis. 
They are sticky and have the ability to at- 
tach to epithelium, especially damaged ep- 
itheium. All of the alpha hemolytic strep are 
sensitive to penicillin and other antibiotics 
with a similar spectrum to penicillin. Other 
bacteria seen occasionally are Streptococcus 
Pyogenes and Staphylococci, but they do not 
play a significant role in oral infections. 

Anaerobic Bacteria 

Anaerobic bacteria far outnumber the aero- 
bic bacteria in oral infections. They consist 
of two groups, gram-positive cocci and 
gram-negative rods. The gram-positive cocci 
are the anaerobic streptococcus and pep- 
tostreptococcus. These bacteria are found in 
about 33 percent of oral infections. They, 
like their cousins of the aerobic strep, are 
sensitive to penicillin and other antibiotics 
with a similar spectrum. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 262 



Table 9-3. Bacteriodes 



P. melanogenica 
P. buccae 
P. intermedia 
P. oralis 
P. loeschii 

P. asaccharolyticus 
P. gingivalis 
P. endodontalis 

Anaerobic Gram-negative Rods 

Anaerobic gram-negative rods are account- 
able for about 50 percent of the bacteria in 
oral infections. 5 The two most prevalent 
genre are fusobacterium and bacteriodes. 
The bacteriodes of the oral cavity were 
thought to be related to or the same as the 
gut flora bacteriodes. Gut bacteriodes are of 
the fragilis group and differ from the oral 
bacteriodes group. The two reclassified bac- 
teriodes are prevotella and porphyromonas. 
Each of these genera has different species. 
For the sake of simplicity, we will address 
them as their genera only. Table 9.3 is pro- 
vided to show some of their specific species 
that are currently identified. 

The most common gram-negative rod 
isolated from infections is prevotella. 
Prevotella have a natural resistance to peni- 
cillin, with 40 percent to 80 percent being 
resistant. 3 

Porphyromonas are rarely found in oral 
infections with the exception of P. gingivalis, 
which is found to be one of the most com- 
mon causes of periodontitis. 

Another group of gram-negative rods are 
the fusobacterium genus. They are very 
pathogenic and destroy tissue like prevotella. 
This is done by the production of prote- 
olytic enzymes and endotoxins. They are 
sensitive to penicillin, but 50 percent are not 
responsive to erythromycin. Fusobacteria are 
often associated with the most severe infec- 
tions and often these include the viridians 
type aerobic Streptococcus milleri. This com- 
bination of virulence is common in severe 

infections that invade the lateral and 
retropharyngeal spaces. These can eventually 
progress downward into the mediastinum. 
Mediastinal and retropharyngeal infections 
are among the most serious infections and 
are very difficult to manage. They can lead 
to death of the patient. 

Bactericidal and Bacteriostatic 

In discussing how best to treat the various 
infections, it is imperative that the doctor 
understand each of the antibiotics and the 
type of infection they are treating. This is an 
ever-changing science with the development 
of more and more resistant bacteria and 
hopefully new antibiotics. 

One of the ways antibiotics are classified 
is the manner in which they destroy the 
pathogens. A bactericidal drug like peni- 
cillin actually destroys the bacteria by attack- 
ing the cell wall of the invading microorgan- 
ism. The action of breaking down the cell 
wall is accomplished by interfering with a 
specific step in cell wall synthesis. Penicillin 
actually binds to a specific protein in the cell 

Bacteriostatic antibiotics merely retard 
the growth of the bacteria by attaching to 
the ribosomes and DNA inside the cell. 
They also interfere with cellular metabolism. 
These actions do not allow the bacteria to 
replicate certain essential proteins. Erythro- 
mycins are all primarily bacteriostatic and 
bind to the 50S subunit of the ribosome. 
This inhibits bacterial protein synthesis. It 
then allows the body's defense mechanism to 
work synergistically to eventually overcome 
the bacteria. 5 See Table 9.4. 

Periodontal Infection 

Of all oral infections, periodontal infection is 
probably the least understood in general 
practice. The changing world of infection 
and reclassification of certain organisms is 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 263 



Table 9-4. Bactericidal and Bacteriostatic Drugs 

Bactericidal Antibiotics 

Bacteriostatic Antibiotics 








Clindamycin at 300mg 




Clindamycin at 1 50mg 



partially to blame. Prior to 1970, most inves- 
tigators focused their attention on supragingi- 
val plaque rather than subgingival plaque. 
The subgingival flora is composed mainly of 
anaerobes, most of which could not be cul- 
tured. When grown, they could not be as- 
signed to known species. Consequently, mi- 
crobial specificity in periodontal disease was 
difficult to demonstrate. More recently, ana- 
erobic culturing by the use of quantitative 
procedures has led to the isolation of several 
new species associated with various clinical 
entities. However, mere association is not evi- 
dence of causation, and the etiologic role of 
some of these species remains to be proven. 
The most current information on peri- 
odontal infections tells us that the causative 
bacteria are mostly gram-negative anaerobes 
such as Treponema denticola, Porphyromonas 
gingivalis, Bacteroides forsythus, and Actino- 
bacillus actinomycetemcomitans. They are all 
treatable with antibiotics that are effective 
against gram-negative pathogens. 

Treponema denticola 

The first of the four most common organ- 
isms in subingival plaque to be discussed is 
Treponema denticola. This spirochete is classi- 
fied under the genus but precise identifica- 
tion of species is difficult. This flora is so 
named because of its surface-to-volume 
ratio, which facilitates nutrient uptake. 
Spirochetes are recognized by a helical shape 

and vigorous motility when observed using a 
dark-field or phase-contrast microscope. 
Trepenoma are extremely difficult to grow, 
and they produce an array of proteolytic en- 
zymes that invade the tissue. They comprise 
almost one-half of the flora in subgingival 
plaque. Treponema vincentii and other spiro- 
chetes are one of the primary causes of acute 
necrotizing ulcerative gingivitis (ANUG), 
along with Fusobacterium spp. Prevotella in- 
termedia and other gram-negative rods that 
are also present. 

Bacteriodes (Prevotella, 

Other bacteria cultured from subgingival 
plaque were thought to be of the bacteria 
melanogenisis family, a genus commonly 
found in the gut. However, recent more so- 
phisticated DNA studies have shown that 
these black-pigmented bacteria are in reality 
nine or more species and are distinctly differ- 
ent from intestinal Bacteroides. Two new 
genera have therefore been proposed. The 
new genera are divided into two types: Asac- 
charolytic (non-carbohydrate-fermenting) 
organisms were assigned to the genus 
Porphyromonas, and those species capable of 
fermenting both carbohydrates and peptides 
were assigned to the genus Prevotella. 

Porphyromonas gingivalis 

Porphyromonas gingivalis is a virulent organ- 
ism found in periodontitis. It is extremely 
aggressive and produces collagenase and 
other proteolytic enzymes. It is found in pa- 
tients who do not respond to debridement 
therapy. It survives and thrives on a variety 
of molecules found in inflammation. The 
added dimension of collagenase production 
by macrophages stimulated by bacterial en- 
dotoxin coupled with bone resorption stimu- 
lated by-products of activated mononuclear 
cells indirectly enhances the process of tissue 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 264 



Tannerella forsythensis 

The other bacteroides that has been isolated 
is Tannerella forsythensis (formally B. 
forsythes). It is an anaerobic, gram-negative, 
pleomorphic, nonmotile, long thin rod. 
Since it is extremely difficult to grow in the 
lab, detailed study of this organism, and 
more specifically its virulent mechanisms, 
has been disouraged. It may not even be a 
true member of the bacteroides family Yet it 
is present in all periodontal infections and, 
in fact, is the most prevalent bacteria in this 
type of infection/ 

Actinobacillus actinomycetemcomitans 

A. actinomycetemcomitans is a small, gram- 
negative, microaerophilic coccobacillus. 
There is substantial evidence that it is the 
bacterial agent responsible for localized juve- 
nile periodontitis (LJP). This coccobacillus is 
found in young people that have been ex- 
posed to other members of the family that 
have a history of LJP. 8 A. actinomycetem- 
comitans produces a leukotoxin that inhibits 
neutrophils in vitro, so in theory, it could lo- 
cally disarm neutrophils in the pocket. The 
host's main protective barrier would thereby 
be removed, allowing the organism to pene- 
trate into the connective tissue. This would 
result in destruction of the periodontal at- 

Other organisms found in periodontal 
infections include Fusobacterium nucleatum, 

Prevotella intermedia, Eubacterium, and Tre- 
ponema. Again there are several hundred bac- 
terial species found in plaque and pockets, 9 
but just a few are responsible for inflam- 
matory periodontal disease. See Table 9.5. 

Treatment of Periodontal 

Most early periodontal infections can easily 
be treated with simple prophylaxis or de- 
bridement. This allows the majority of the 
invasive flora to be mechanically removed so 
the host can stabilize its own flora without 
the aid of chemical intervention. However, 
in severe or chronic periodontitis or ab- 
scesses, antibiotic therapy should be initi- 
ated. Scaling to interrupt biofilm and facili- 
tate the efficacy of the antibiotic should be 

We must consider all that is happening in 
a periodontitis infection. There are direct 
and indirect mechanisms that exist as a result 
of the bacteria and their by-products. Direct 
mechanisms are those in which bacterial sub- 
stances directly injure and destroy tissue. 
These are substances like collagenase (a 
histologic enzyme) and luko toxin produced 
by the bacteria A. actinomyctemcomitans. 
Indirect influence gives the added dimension 
of collagenase production by macrophages 
stimulated by bacterial endotoxins. Products 
of activated mononuclear cells like inter- 
leukin and prostaglandin E-2 are examples 
that indirectly stimulate bone resorption. 

Table 9-5. Pathogens Common in Periodontal Disease Listed by Prevalence in Periodontitis 

Very Prevalent 


Moderately Prevalent 

A. actinomycetemcomitans 
P. gingivalis 
T. forsythenis* 
Spirochetes of AN UG 

P. intermedia 
C. rectus 
E. notatum 
Treponema sp. 

Streptococcus intermedius 
Peptostreptococcus micros 
F. neucleatum 
E. corrodens 

Source: Modified from G. Greenstein. Changing Periodontal Concepts Compend. Dent. Ed. 26(2):81-89, 
2005. The list is not all inclusive. Previously Bacteroides forsythus. 
"Previously Bacteroides forsythus: Treatment Considerations. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 265 



Recent studies reveal a complex interplay be- 
tween the bacteria and host responses that 
cause a destructive process in the bone/ 

Which Antibiotics to Use in 

The drugs that have the most effect on the 
gram-negative anaerobes are metronidazol 
and tetracycline (in the forms of Flagyl 
Doxycycline). Penicillin may be used in 
combination with other bactericidal drugs 
like metronidazol for any of the aerobic 
strains because of its effect on at least half of 
the bacteriodes. Affecting aerobic bacteria 
also stops their exudates by eliminating their 
source. In theory, some of the anaerobic bac- 
teria flourish on the exudates of streptococ- 
cus viridans group. However, in recent stud- 
ies, the penicillins have shown little effect on 
the pathogens of periodontitis. 10 

The advancement of the infection can 
happen over time or rapidly, and it is almost 
always treated with antibiotic therapy. The 
use of antibiotics will not manage the infec- 
tion alone. Treatment must include incision, 
drainage, and debridement to prevent recur- 
rence. In many cases the architecture of the 
tissues and bone must be remodeled to a 
more physiologic state to prevent recurrence. 
When choosing chemical means to facilitate 
the cure, a thorough debridement is also 

Culturing and sensitivity testing are not 
feasible for treatment of a periodontal ab- 
scess because obtaining a sample that is not 
going to violate the oxygen-sensitive anaer- 
obes is difficult and not within the ability of 
normal dental office. The use of empirical 
knowledge is used for immediate treatment. 
Penicillin, even though it is commonly used, 
is not a recommended regimen by itself be- 
cause of the many gram-negative organisms 
that are not affected by it. Therefore, the use 
of a more specific antibiotic like Doxycy- 
cline, which has shown its ability to destroy 
many gram-negative anaerobes and collect in 

gingival crevicular fluid, is advocated. One 
tablet of Doxycycline 100 mg can be given 
daily for 7-10 days. The infection is then 
reevaluated, and the antibiotic continued if 
necessary. Tetracycline can also be used, but 
the compliance is compromised since the pa- 
tient needs to take this drug one hour before 
and two hours after eating. It is given as 250 
mg qid. Metronidazol is a very good treat- 
ment of choice in severe periodontal ab- 
scesses because of its effect on gram-negative 
anaerobes. It is given as 250 mg qid for 
7—10 days. Clindamycin can be given, but 
there is the potential of a negative influence 
on the flora of the gut due to its spectrum. 
It is usually given 300 mg tid for eight 

Do not mix penicillin (bactericidal) and 
any tetracycline (bacteriostatic) for treat- 
ment, as they render each other less ef- 
fective. Giving both a bactericidal and a 
bacteriostatic drug together is contrain- 

The effect of antibiotic therapy in peri- 
odontal infections is determined by several 
factors including the total bacterial load in 
relation to the maximum achievable antibi- 
otic concentration. You must take into con- 
sideration the health of the patient and 
whether there are compromising systemic 
diseases, like diabetes. Smoking further 
complicates the process and affects the host 
defenses. Pregnancy also limits the use of an- 
tibiotics as shown in Table 9.5. Use antibi- 
otics only in the more serious infections and 
coordinate with the attending physician. The 
FDA classifies only penicillin, clindamycin, 
and metronidazol as pregnancy category B. 11 
This indicates they are probably safe after 
the first trimester, but if the disease can be 
handled without chemical intervention, this 
would be preferred. 

Oral Rinses 

Mouth rinses are used in many infectious 
diseases. Chlorhexidine, which was first in- 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 266 



troduced in Europe around 1970 and the 
United States in 1986, is quite effective 
against supragingival plaque. It is used after a 
variety of surgical procedures and except for 
staining of the teeth doesn't seem to have 
any serious side effects when used long term. 
Some patients with physical disabilities can 
use chlorhexidine effectively. It is used in 
many postsurgical situations to lower the 
level of bacteria. There have been reports of 
taste disturbance while it is being used. 12 

It should be noted that the delivery of oral 
rinses and systemic antibiotic therapy alone is 
not without problems. First, it is difficult to 
achieve effective drug levels in the fluids of 
the pocket. Only a very small amount of an 
antibiotic enters the gingival tissue, and even- 
tually the pocket. Irrigating pockets after sur- 
gery or after scaling with chlorhexidine or 
other rinses does not place enough medica- 
tion into the pocket to be effective. Irrigation 
after scaling and root planning does have 
positive effects, probably by flushing out 
colonies of subgingival bacteria. Second, it 
exposes nontarget tissue to the drug. 

Local Delivery 

Controlled delivery of chemotherapeutic 
agents (such as Arestin and Atridox) within 
periodontal pockets can alter the pathogenic 
flora and improve clinical signs of periodon- 
titis. The benefit of local antibiotic delivery 
is that the drug can be delivered to the site 
of disease activity in high bactericidal con- 
centrations. This, because of the medium in 
which the drug is carried, facilitates pro- 
longed drug delivery. 

However, using local delivery systems 
alone presents problems. It has been shown 
that the antibiotic is usually incapable of dis- 
rupting a biofilm. The biofilm has an ex- 
opolysaccharide matrix that is resistant to an- 
tibiotic penetration in the absence of 
mechanical disruption. Also, there has been 
little documentation to show that there is re- 
newed attachment without disrupting the 

biofilm and removal of calculus that may be 
present. The overall consensus is to always 
mechanically debride the area with scaling 
and root planning. This removes debris and 
breaks up the biofilm that harbors the 
pathogens. 13 ' 

Oral pathogens are associated with en- 
dogenous flora (normal flora). Normal oral 
flora has now been discovered to have many 
clonal types. Therefore, it is necessary to di- 
rectly supervise their activity instead of try- 
ing to destroy them. To date, 32 clonal types 
of P gingivalis and 10 clonal types of A. 
actinomyctemcomitans have been identified. 
Current literature does not reveal if P ^ni- 
valis and A. acitinomycetemcomitans are en- 
dogenous or exogenous. Some of the clones 
may be either exogenous or endogenous, and 
it is also difficult to assess whether the clonal 
types are virulent or not. Merely culturing 
the bacterial type does not specifically iden- 
tify it as a clone but generally only as a 
species. This difference may explain why in 
some patients a certain bacterial strain is 
pathogenic and not in other patients. In 
order to treat an endogenous pathogen, you 
cannot eradicate it from its normal environ- 
ment. In other words, you manipulate their 
existence into a normal balanced community 
in the mouth. 15 ' 16 

Current Sequencing of Antibiotic 

Antibiotics should only be an adjunct to 
scaling and root planning. Debridement 
must generally accompany antibiotic ther- 
apy, but antibiotics are rarely used alone to 
treat periodontal disease. The following rep- 
resents a practical approach to periodontal 
antibiotic therapy. 

1 . First perform a thorough mechanical root 

2. Prescribe antibiotics based on the need for 
further treatment, results of cultures, and 
the medical condition of the patient. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 267 



3. In two or three months, evaluate the pa- 
tient's response. If there is no improve- 
ment and no resolution of inflammation, 
do a microbiological exam of the subgin- 
gival flora. This will help determine the 
amount and presence of putative 

4. One to three months after antibiotic ther- 
apy, do a clinical exam. Based upon the 
findings, another microbiological test 
might be needed. This will screen for 
super-infecting organisms and verify the 
elimination of target organisms. The find- 
ing of high levels of Streptococcus viridans, 
Actimomyces, and Veillonella species are 
suggestive of periodontal health or mini- 
mal disease. 

5. Place the patient on an individually tai- 
lored maintenance program. Plaque con- 
trol supragingivally will help deter the re- 
colonization of putative periodontal 
pathogens. Any recurrence of progressive 
disease may necessitate repeated testing 
and antibiotic therapy targeted against 
specific microorganisms that are 

In summary, keep in mind that the science 
of periodontal infections is continually chang- 
ing. Periodontal disease greatly affects the sys- 
temic health of many patients. Resistance is 
causing us to curtail the indiscriminate use of 
antibiotics. A good clinician should refer to 
current literature often and stay abreast of this 
dynamically changing situation. 

Periodontal disease is usually plaque- 
oriented — starting with gingivitis. If left un- 
attended, it starts a series of qualitative shifts 
in the subgingival flora. Adult periodontitis 
is composed of 90 percent anaerobes, with 
the gram-negative anaerobes making up 70 
to 75 percent, and motile forms (spirochetes) 
making up about 25 to 30 percent. About 
plus or minus 5 percent are attributed to aer- 
obic bacteria, but these are probably not re- 
sponsible for the destructive aspect of the 
disease. 11 

In summary, because of the complex na- 
ture of periodontitis and the fact that there 
are new forms or clonal types of bacteria 
identified constantly, it is not an exact sci- 
ence. We can, however, follow the regimen 
of teaching proper oral hygiene and nutri- 
tion along with performing scaling, root 
planning, and surgical procedures when war- 
ranted. The use of the correct antibiotic can 
be used in those cases that need the help. 
In all situations, when antibiotics are used 
they are only effective when many of the 
pathogens are mechanically removed or dis- 
turbed by the dental health professional. 
Using antibiotics and leaving impenetrable 
biofilms and colonies of bacteria behind is 
almost always ineffective and is furthering 
bacterial resistance. Studies have shown that 
regular scaling and root planning can be as 
effective as incorporating various surgical 
techniques. Severe pocket depth does have 
to be corrected to benefit from a patient's 
effective hygiene practices. The control of 
supragingival plaque is vital to the preven- 
tion of subgingival pathogenic flora in previ- 
ously treated pockets. 18 ' 19 

Tissue-Invading Pathogens 

Patients that are not responding to scaling 
and root planning may be infected with bac- 
teria that actually invade the cells of the in- 
fected tissue. This harboring of the bacteria 
makes local delivery of the antibiotic ineffec- 
tive. A. actinomycetemcomitans and P. gingi- 
valis have been detected in the cell walls of 
gingival tissues and are responsive to a sys- 
temic therapy of amoxicillin/clavulanate and 

Antibiotics useful in the treatment of 
mostly gram-negative periodontal pathogens 
are metronidazol, tetracycline, clindamycin, 
and to some extent penicillin and amoxi- 
cillin/clavulanic acid. Metronidazol and 
tetracycline (Doxycycline) are the drugs 
of choice in the majority of periodontal 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 268 




Following is a brief discussion of the most 
commonly used systemic antibiotics in den- 
tistry It is necessary for further understanding 
of their action and appropriate application. 

The Penicillins 

When penicillin became widely available 
during the Second World War, it was a med- 
ical miracle, rapidly vanquishing the biggest 
wartime killer — infected wounds. Dis- 
covered initially by a French medical stu- 
dent, Ernest Duchesne, in 1896, and then 
rediscovered by Scottish physician Alexander 
Fleming in 1928, the product of the soil 
mold Penicillium crippled many types of dis- 
ease-causing bacteria. But just four years 
after drug companies began mass-producing 
penicillin in 1943, microbes began appearing 
that could resist it. 

The penicillins constitute one of the 
most important groups of antibiotics. 
Although numerous other antimicrobial 
agents have been produced since the first 
penicillin became available, penicillin is still 
widely used, and new derivatives of the 
basic penicillin nucleus still are being pro- 
duced. Many of these have unique advan- 
tages, such that members of this group 
of antibiotics are presently the drugs of 
choice for a large number of infectious 

Penicillin V and amoxicillin are the most 
commonly used penicillins in dentistry. They 
have a spectrum that is effective with many 
oral infections and in prophylactic adminis- 
tration. Their spectrum is similar, but amoxi- 
cillin is absorbed faster, and blood levels are 
higher at shorter intervals, making it more 
popular than penicillin V. This, however, is 
not without its problems. Amoxicillin has a 
greater effect on the flora of the gut. This 
causes more gastrointestinal upset. Penicillin 
V is often a better choice for long-term an- 
tibiotic administration when immediate 






Figure 9-8. Clavulanic acid. 

blood levels are not necessary. Penicillin V 
will reach an adequate blood saturation level 
quickly enough, especially with a significant 
loading dose. When you combine amoxi- 
cillin with clavulanic acid, the resulting drug 
is Augmentin. This combination binds the 
bacteria's beta lactamase (penicillinase) so the 
(3 -lactamase will not break down (lyse) the 
penicillin. Clavulanic acid is produced by the 
fermentation of Streptomyces clavuligerus. It is 
a (3 -lactam structurally related to the peni- 
cillins and possesses the ability to inactivate a 
wide variety of (3 -lactamases by blocking the 
active sites of these enzymes. 

Odontogenic Infections 

In noncompromised patients, penicillin 
still remains the empirical antibiotic of 
choice for mouth infections. If the infection 
is not localized but is manifest by cellulitis, 
penicillin will attack the Streptococcus viri- 
dans group bacteria that are a significant part 
of the infection. It is still the drug of choice 
in mild to moderate odontogenic infections 
because of its efficacy across the board. For 
more severe or recalcitrant infections, a cul- 
ture and antibiotic sensitivity study may 
become necessary; however, empirically we 
know that gram-negative anaerobes are 
present, and the addition of metronidazol 
can be added to penicillin to increase 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 269 



Abscessed Teeth 

An abscessed tooth accompanied by long- 
term pathology at the apex is one of the 
more common scenarios in dentistry A 
study of 98 isolates by Lewis et al. 21 in Great 
Britain determined that 23 percent of the 
isolates were resistant to penicillin. In this 
study 15/98 isolates (15 percent) were resist- 
ant to penicillin V and 9/98 (9 percent) were 
resistant to amoxicillin. When clindamycin 
was administered, 94/98 (96 percent) of the 
bacteria were eliminated. The effect of amox- 
icillin/clavulanic acid destroyed 98/98 (100 
percent) of the cultured bacterial strains. 
Metronidazol, an antibiotic effective against 
gram-negative anaerobes, killed 44/98 (45 
percent). In combination with penicillin V, 
metronidazol was effective against 91/98 
(93 percent), and in combination with 
amoxicillin it was effective against 97/98 or 
99 percent of the bacteria. 

Because amoxicillin/clavulanic acid 
(Augmentin) is so expensive, many patients 
will not purchase it unless they are covered 
by insurance. The use of penicillin first, then 
with the addition of metronidazol after two 
or three days (if there is no effect from the 
penicillin), is a good medication combina- 
tion for infection in the mouth. The use of 
penicillin V is still a good antibiotic of 
choice over amoxicillin in the treatment of 
long-term polymicrobial mouth infections 

because of its low cost and narrow spectrum. 
It causes less GI upset long term. 

Amoxicillin, clindamycin, and amoxi- 
cillin/clavulanic acid did show a slightly 
greater activity in this study than penicillin 
V but have a wider spectrum against species 
outside the oral cavity. This would make 
them more likely to cause complications by 
killing normal flora and upsetting the bal- 
ance in the gut and elsewhere. Claritho- 
mycin is a good alternative for erythromycin 
for mild infections when a patient is peni- 
cillin allergic. It cannot be used in combina- 
tion with metronidazol because it is bacterio- 
static and metronidazol is bactericidal. 

The antibiotic table that follows (Table 
9.6) is for adult or pediatric patients and is 
used primarily for periodontal infections. It 
may also be used for infections that invade 
periodontal tissues from an abscessed tooth. 
When the table is used for periodontal infec- 
tions, the clinician should be familiar with 
the bacteria responsible for this disease as 
discussed earlier in the chapter. 

Deep Fascial Plane Infections 

Deep fascial plane infections can be one of 
most serious infections to the human body. 
They must be treated aggressively and with- 
out delay. The recognition of this type of se- 
rious infection is imperative, and the patient 
must be referred to an oral and maxillofacial 

Table 9-6. Antibiotics Used in the Treatment of Periodontitis 






Metronidazole + amoxicillin 

Metronidazole and ciprofloxacin 

500 mg tid 8 days 

300 mg tid 8 days 

100-200 mgqd 21 days 

100-200 mgqd 21 days 

500 mg qd 4-7 days 

250 mg tid 8 days each drug 

500 mg bid 8 days each drug 

Source: Table modified from Systemic Antibiotics in Periodontics position paper. J Periodont; 75; 
1553-1565. 2004. 21 Information is suggestive only; comprehensive microbiological studies may be 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 270 



surgeon or physician who may have to man- 
age the patient with incision and drainage in 
a hospital setting. The drainage of the infec- 
tion and administration of large amounts of 
IV antibiotics is the usual treatment. The 
welfare of the patient must be the main con- 
sideration. There are about 21,000 hospital 
admissions and 150 deaths annually from 
dentoalveolar infections. 

Immediate attention with antibiotics 
and/or surgery is indicated in the following 

• Cellulitis of dental origin 

• Pericoronitis with elevated temperature 
and trismus 

• Infections that penetrate into deep fascial 

• Open fractures of the mandible or 

• Deep wounds more that six hours old 

• Dental infection in the medically compro- 
mised patient 

• Prophylaxis for dental surgery in a patient 
with valvular heart disease or prosthetic 

Antibiotic Prophylaxis 

Antibiotic premedication is recommended 
for certain heart defects and some medically 
compromised joint replacement patients. 

The current recommendations from the 
American Dental Association (ADA) and the 
American Academy of Orthopaedic Sur- 
geons (AAOS) for joint replacement patients 
have been revised since 1997. The most re- 
cent statement concludes that antibiotic pro- 
phylaxis regimens are not recommended for 
patients with pins, plates, or screws, nor is it 
routinely indicated for most dental patients 
with total joint replacements. It is, however, 
advisable to consider premedication for a 
limited number of patients. These are pa- 
tients that, for the most part, have experi- 
enced some complication with previous joint 
infection or have certain compromising 
medical comorbidities. These include but are 
not limited to those in Table 9.7. 

The recommended dose of antibiotics for 
medically compromised patients with joint 
replacement is shown in Table 9.8. 22 

Table 9-7. Medical Conditions Requiring 
Antibiotic Prophylaxis for Joint Replacement 

1 . Previous prosthetic joint infections 

2. Immunocompromised/immunosuppresed patients 

3. Malnourishment 

4. Hemophilia 

5. HIV infection 

6. Insulin-dependant (type 1) diabetes 

7. Malignancy 

Table 9-8. Antibiotic Regimens for Joint Replacement Patients 

Patient Type 


Prescribed Dose 

Patients not allergic to penicillin 

Patients not allergic to penicillin 
but unable to take oral 

Patients allergic to penicillin 

Cephalexin, cephradine, or 

Cefazolin or ampicillin 

Cefazolin 1 g or ampicillin 


Patients allergic to penicillin and Clindamycin 
unable to take oral medications 

2 g orally 1 hour prior to 

dental procedure 
2 g IM or IV 1 hour prior to 

the dental procedure 

600 mg orally 1 hour prior to the 

dental procedure 
600 mg IM 1 hour prior to the 

dental procedure 

The regimes in this table are one dose only, as no follow-up doses are recommended. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 271 



Table 9-9. Heart Problems Requiring Pre- 

1 . Artificial (prosthetic) heart valve 

2. History of previous endocarditis 

3. Heart valves damaged (scarred) by conditions 
such as rheumatic fever 

4. Congenital heart or heart valve defects 

5. Hypertrophic cardiomyopathy 

6. Prolapsed mitral valve with regurgitation 

Antibiotic Regimens for Heart 

Patients with certain heart problems have 
need for a prophylaxis of penicillin, amoxi- 
cillin, or clindamycin. 23 This is the standard 
of care for all patients with the defects 
shown in Table 9.9. 

What Is Bacterial Endocarditis? 

Subacute Bacterial Endocarditis (SBE) is an 
infection of the heart's inner lining (endo- 
cardium) or the heart valves. It can damage 
or even destroy heart valves. 

Endocarditis rarely occurs in patients with 
a normal heart. However, in patients with 

certain pre-existing heart conditions, care 
must be taken to prevent a bacterial colo- 
nization of the damaged heart. Table 9.10 is 
a list of possible risk factors that predispose a 
bacterial endocarditis complication. 

There is some controversy regarding the 
patient with a prolapsed mitral valve (MVP). 
Regurgitation or an audible heart sound is 
not always a true determining factor. Some 
experts feel that an audible nonejection 
click, even without a murmur, may identify 
patients with a potential for intermittent re- 
gurgitation, and therefore, there may be a 
risk of developing endocarditis. Although 
there are insufficient data on this issue, an 
isolated click may be an indication for 
more thorough evaluation of valve mor- 
phology and function, including Doppler- 
echocardiographic imaging or auscultation 
during maneuvers that elicit or augment mi- 
tral regurgitation. Men older than 45 years 
with MVP, without a consistent systolic 
murmur, might warrant prophylaxis even in 
the absence of resting regurgitation. Normal 
mitral valves with normal motion often have 
minimal leaks detectable by Doppler exami- 
nation. This does not appear to increase the 
risk of endocarditis. In contrast, the regurgi- 

Table 9-10. Prophylaxis Dosage for Bacterial Endocarditis Prevention 




Standard general prophylaxis 

Allergic to penicillin 

Allergic to penicillin 

Allergic to penicillin and unable 
to take oral medications 


Unable to take oral medications Ampicillin 

Clindamycin or 

Cephalexin or 

Azithromycin or 

Clindamycin or 


Adults: 2.0g; 1 hr before procedure 

children: 50mg/kg orally 1 h before 

Adults: 2.0g IM or IV; children: 50mg/kg 

or IV within 30 min before procedure 
Adults: 600mg; children: 20mg/kg orally 

1 h before procedure 
Adults: 2.0g; children; 50mg/kg orally 1 h 

before procedure 
Adults: 500mg; children: 15mg/kg orally 

1 h before procedure 
Adults: 600mg; children: 20mg/kg IV 

within 30 min before 
Adults: 1 .0g; children: 25mg/kg I M or IV 

within 30 min before procedure 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 272 



tation that occurs with structurally normal 
but prolapsing valves originates from larger 
regurgitant orifices and creates broader areas 
of turbulent flow. Patients with prolapsing 
and leaking mitral valves, evidenced by audi- 
ble clicks and murmurs of mitral regurgita- 
tion or by Doppler-demonstrated mitral in- 
sufficiency, should receive prophylactic 
antibiotics. These guidelines are meant to aid 

practitioners but are not intended as the 
standard of care or as a substitute for clini- 
cal judgment. 23 ' The most common re- 
sponsible pathogen is Streptococcus viridans 
spp. (a-hemolytic streptococci). This is 
the most prevalent bacteria in the oral 
cavity. Antibiotic prophylaxis to prevent 
SBE is recommended as shown in Table 

Table 9-1 1 . Antibiotics for Oral and Fascial Infections 




Adult dosage 

Childs dosage 



250/500mg qid 

25 to 50 mg/kg/day 
in 3 divided doses 



250/500mg tid 

25 to 50 mg/kg/day 
in 3 divided doses 



875 mg bid or 

90 mg/kg/day in 

500mg tid 

2 divided doses 



250 mg tid 

20 to 40 mg/kg/day 
in 3 divided doses 



250-500 mg bid 

20 to 30 mg/kg/day 
in 2 divided doses 



400 mg qid 

20 to 40 mg/kg/day 


in 4 divided doses 



500 mg followed 

1 mg/kg followed by 

by 250-mg single 

5 mg/kg on days 

daily doses on 

2 to 5 

days 2 to 5 



150 to 450 mg 

1 to 30 mg/kg/day in 

q 6 h in adults 

3 to 4 divided doses 



250 to 500 mg tid 

35 to 50 mg/kg/day 
divided tid for children 



200 mg in 2 divided 

Over 8 yr, 4 mg/kg/day 

doses on the first 

divided in 2 doses 

day then 100 

given orally first day 


then 2 mg/kg/day 



200 mg followed 

Over 8 yr, the oral or IV 

by 100 mg q 

dosage is 4 mg/kg 

12 h in adults. 

followed by 2 mg/kg 
q 12 h 



125 mg q 6 h 

40 mg/kg/day in 4 

in adults 

equally divided doses 



250-500 mg 
q 8 to 1 2 hr 

7.5 mg/kg every 12 h 



250-500 mg qid 

Gm + Gm + Gram - 
Aerobes Anaerobes Anaerobes 
































Yes/No No 






Yes/No Yes/No 



2879_Koerner_Chap 09 4/17/06 1:30 PM Page 273 



Occasionally, a patient may already be 
taking an antibiotic before coming to the 
physician or dentist. If the patient is taking 
an antibiotic normally used for endocarditis 
prophylaxis, it is prudent to select a drug 
from a different class rather than to increase 
the dose of the current antibiotic. In particu- 
lar, antibiotic regimens used to prevent the 
recurrence of acute rheumatic fever are inad- 
equate for the prevention of bacterial endo- 
carditis. Individuals who take oral penicillin 
for secondary prevention of rheumatic fever 
or for other purposes may have viridans 
streptococci in their oral cavities that are rel- 
atively resistant to penicillin, amoxicillin, or 
ampicillin. In such cases, the dentist should 
select clindamycin, azithromycin, or clar- 
ithromycin for endocarditis prophylaxis. 
Because of possible cross-resistance with the 
cephalosporins, this class of antibiotics 
should be avoided. If possible, one could 
delay the procedure until at least 9 to 14 
days after completion of the antibiotic. This 
will allow the usual oral flora to be reestab- 
lished. 25 This has to be approved by the pre- 
scribing doctor, if other than the treating 
dentist, and it is assumed that the infection 
being treated is under control. 

Choosing the Right Antibiotic 


Penicillin V or amoxicillin remain the antibi- 
otics of choice in the treatment of dentoalve- 
olar infections in a noncompromised patient. 
Even though many gram-negative organisms 
have developed resistance, the antibiotics are 
still effective against the majority of them. 
Penicillin is the first of the (3-lactams, and 
with the combination of metronidazol, it is 
effective against almost 100 percent of the 
pathogens in oral infections. Amoxicillin 
combined with clavulanate is almost 1 00 
percent effective, but the cost of amoxi- 
cillin/clavulanate is a factor. 

Penicillin has been one of the most over- 

used drugs since it was developed but con- 
tinues to be effective and to be the standard 
for treating millions of people each year. It is 
also safe to give large doses because the ther- 
apeutic index is high. 


Cephalosporins are also (3 -lactams. They at- 
tack the cell wall much like penicillin. They 
have a less-effective spectrum than penicillin, 
and there is a risk of allergic reaction if used 
on a penicillin-allergic patient. The second- 
(Cefuroxime) and third-generation 
(Cefpodoxime) cephalosporins are broader 
spectrum than first-generation Cephalexin. 
It can also be used with clindamycin or 
metronitazol in the compromised host. It 
is not the first drug of choice because as 
many (60 percent) of the gram-negative 
anaerobes are resistant — especially to the 
first-generation drugs. 


Erythromycin is not as effective as penicillin, 
because it is poorly absorbed and does not 
have much effect against anaerobic bacteria. 
Azithromicin is a newer macrolide and is ef- 
fective against more gram-negative anaerobes 
but still lacks the spectrum necessary for it to 
be useful in all but milder cases. 
Erythromycin is effective against the strepto- 
coccus viridans group of bacteria and can be 
substituted for clindamycin with SBE pro- 
phylaxis in penicillin allergic patients. 
Azithromycin generally is less active than 
erythromycin against gram-positive organ- 
isms (Streptococcus spp. and enterococci) and 
is slightly more active than either erythromy- 
cin or clarithromycin against H. influenzae. 
Azithromycin is very active against 
Chlamydia spp., M. pneumoniae, L. pneu- 
mophila, Fusobacterium spp., and N. gonor- 
rhoeae. The mechanism of action is to bind 
to the 5 OS ribosomal sub units disrupting 
protein synthesis and replication. 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 274 




Tetracycline antibiotics were discovered by 
systematic screening of soil specimens col- 
lected from many parts of the world for 
antibiotic-producing microorganisms. The 
first of these compounds, chlortetracycline, 
was introduced in 1948. Tetracyclines are ef- 
fective against a few gram-positive bacteria, 
but in the oral environment they work well 
against the common oral anaerobes. The 
lipophilic drugs doxycycline and minocy- 
cline usually are the most active by weight 
and are taken with more compliance because 
of their once/day regimen. They are ab- 
sorbed much more slowly with half-lives of 
up to 16 hours and stay in the tissues long 
after their administration has stopped. 
Tetracycline has to be taken one hour before 
meals and two hours after, but doxycycline 
and minocycline are not affected by food. 
The tetracyclines are active against many 
anaerobic and facultative micro-organisms, 
and their activity against a-actinomyces, 
bacteriodes, and spirochetes is particularly 
useful in periodontal disease. 

Differences in clinical efficacy are minor 
and attributable largely to features of ab- 
sorption, distribution, and excretion of 
individual drugs. Tetracyclines enter micro- 
organisms in part by passive diffusion and 
in part by an energy-dependent process of 
active transport. This provides an intracellu- 
lar concentration of the drug. Once inside 
the cell, tetracyclines bind reversibly to the 
30 S sub unit of the bacterial ribosome, 
blocking the binding of aminoacyl-tRNA to 
the acceptor site on the mRNA-ribosome 


Clindamycin is active against most anaer- 
obes, including bacteroides, prevotella, 
Clostridium, peptococcus, peptostrepto coccus, 
and fusobacterium organisms. However, 
10-20 percent of bacteroides isolates are re- 

sistant. It is frequently used to treat moder- 
ately severe infection in which anaerobes are 
significant pathogens, often in combination 
with other drugs (aminoglycosides, 
cephalosporins, and fluoroquinolones). 
Common side effects are diarrhea, nausea, 
and skin rashes. Bloody diarrhea with 
pseudo-membranous colitis has been associ- 
ated with the administration of clindamycin 
and other antibiotics. 


Metronidazole is an antiprotozoal drug that 
also has striking antibacterial effects against 
most anaerobic gram-negative bacilli 
{bacteroides, prevotella, and fusobacterium 
and Clostridium species). It has some activity 
against other anaerobic gram-positive and 
microaerophilic organisms. It is well ab- 
sorbed after oral administration and is 
widely distributed in tissues. It penetrates 
well into the cerebrospinal fluid, yielding lev- 
els similar to those in serum. The drug is 
metabolized in the liver, and dosage reduc- 
tion is required in severe hepatic insuffi- 
ciency or biliary dysfunction. Metronidazole 
is less expensive and equally as efficacious as 
oral vancomycin for the therapy of C. diffi- 
cile colitis and is the drug of choice for the 
disease. A dosage of 500 mg orally three 
times daily is recommended. If oral medica- 
tion cannot be tolerated, intravenous 
metronidazole can be tried at the same 
dose; however, this route is unproved and 
usually less effective than the oral one. 
Because of the emergence of vancomycin- 
resistant enterococci as a major pathogen 
and the role of oral vancomycin in selecting 
for these resistant organisms, metronidazole 
is now used as first-line therapy for C. diffi- 
rile disease (colitis). 

Antibiotic-Induced Colitis 

Antibiotic-associated colitis (AAC) is a sig- 
nificant clinical problem almost always 

2879_Koerner_Chap 09 4/17/06 1:30 PM Page 275 



caused by C. difficile. Hospitalized patients 
are most susceptible, especially those who 
are severely ill or malnourished or who are 
receiving chemotherapy This anaerobic 
bacterium colonizes the colon of 5 percent 
of healthy adults. In hospitalized patients, 
however, it is present in more than 20 per- 
cent of patients, most of whom have re- 
ceived antibiotics that disrupt the normal 
bowel flora and, thus, allow the bacterium 
to flourish. Most of these patients are 
asymptomatic. Recently, patients receiving 
enteral tube feedings have been found to 
have a higher risk for acquisition of C. diffi- 
cile and the development of C. difficile— 
associated diarrhea. The organism is spread 
in a fecal-oral fashion. It is found through- 
out hospitals in patient rooms and bath- 
rooms and can be transmitted from patient 
to patient by hospital personnel. Fastidious 
hand washing and use of disposable gloves 
are essential in minimizing transmission. 
Clindamycin is the antibiotic that has been 
tagged as the responsible agent because 
of the normal flora susceptibility to it. 
However, many other antibiotics can cause 
the onset if the Clostridia difficile is present. 
The Clostridia bacterium gives off toxins 
that damage the walls of the intestine in 
severe cases. 


When a clinician is treating infection, each 
of the previously considered factors must be 
evaluated. Then a decision about of the ap- 
propriate antibiotic can be made. In any 
case, where drainage or debridement can be 
performed, it should be done. The infection, 
whenever possible, must be removed in order 
to render the antibiotic more effective. This 
would include debridement, plaque and 
biofilm removal, and the incising and 
drainage of abscesses. Protection of the an- 
tibiotics we have is essential, and as health 
care providers, we must do our part to pre- 
serve their effectiveness. 


1. R. Lewis. The Rise of Antibiotic Resistant 
Infections. US Food and Drug Admin. Consumer 
Magazine. September, 1995. 

2. K. U. Todar. Wisconsin Dept of Bacteriology. 
Bacterial Resistance to Antibiotics lecture. 2002. 

3. G. Greenstein. Changing periodontal concepts. 
Compendium Feb. p. 81. 2005. 

4. Peterson, Ellis, Hupp, Tucker. Contemporary Oral 
and Maxillofacial Surgery, 4th edition, p. 345. 

5. Topazian Goldberg Hupp Oral and Maxillofacial 
Infections 4th edition. 

6. A. S. Dajani, K. A. Taubert, W. Wilson, et al. 
Prevention of bacterial endocarditis. 
Recommendations by The American Heart 

7. J. Slots, C. Chen. The oral microflora and human 
periodontal disease. In G. W Tannock, ed. 
Medical Importance of the Normal Microflora. 
London: Kluwer Academic Publishers, p. 
101-127. 1999. 

8. A. Asujaubeb, C. Cgeb. Oral ecology and person- 
to-person transmission of A actinomycetemcomi- 
tans and Porphyromonas gingivalis. Periodontol. 

9. Peterson, Ellis, Hupp, Tucker. Contemporary 
Oral and Maxillofacial Surgery. 4th edition, p. 
346. 2002. 

10. Systemic Antibiotics in Periodontics position 
paper; Academy of Periodontology. November, 

11. M. H. Goldberg. The changing nature of acute 
dental infection. J Am Dent Assoc. 80: 1048. 1970. 

12. M. K. Jeffcoat, K. S. Bray, S. G. Ciancio, et al. 
Adjunctive use of a subgingival controlled-release 
chlorhexidine chip reduces probing depth and im- 
proves attachmentlevel compared with scaling and 
root planing alone./. Periodontol. 69: 989-997. 

13. J. M. Goodson, M. A. Cugini, R. L. Kent, et al. 
Multicenter evaluation of tetracycline fiber ther- 
apy: II. Clinical response. J Periodont Res. 26: 
371-379. 1991. 

14. G. Greenstein. Changing periodontal concepts. 
Compendium. Feb. p. 82-84. 2005. 

15. J. Slots, M. Ting. Actinobacilus actinomycetem- 
comitans and Porphyromonas gingivalis in human 
periodontal disease: occurrentce and treatment. 
Periodonto 2000. 20: 82-121. 1999. 

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16. G. Greenstein, I. Lanster. Bacterial transmission in 
periodontal diseases: a critical review. / 
Periodontol. 68: 421-431. 1997. 

17. Systemic Antibiotics in Periodontics position 
paper. Academy of Periodontology. November, 

18. J. W. Knowles, F. G. Burgett, R. R. Nissle, et al. 
Results of periodontal treatment related to pocket 
depth and attachment level: eight years. / 
Periodontol. 50: 225. 1979. 

19. K. S. Kornman. The role of supragingival plaque 
in the prevention and treatment of of periodontal 
disease: a review of concepts. J Periodontol Res. 15: 
111. 1980. 

20. G. Greenstein. Changing periodontal concepts. 
Compendium Feb. p. 82. 2005. 

21. J. Baumgartner, T. Xia. Antibiotic susceptibility of 
bacteria associated with endodontic abcesses. / of 
Endodontics. Vol 29, No 1, p. 44-47. Jan., 2003. 

22. Antibiotic Prophylaxis for Dental Patients with 
Total Joint Replacements Advisory statement. 
JADA. July p. 895-897. 2003. 

23. American Heart Association Circulation 
Prevention of Endocarditis. 96: 338. 1997. 

24. B. A. Carabello. Mitral valve disease. Curr Probl 
Cardiol. 7: 423-478. 1993. 

25. A. S. Bayer, R. J. Nelson, T G. Slama. Current 
concepts in prevention of prosthetic valve endo- 
carditis. Chest. 97: 1203-1207. 1990. 

26. L. M. Tierney, Jr., S. J. McPhee, M. A. Papadakis, 
eds. R. Gonzales, R. Zeiger. Current Medical 
Diagnosis & Treatment. 2005. 

Additional References 

J. Slots, D. Moenbo, J. Langback, et al. Microbiota of 
gingivitis I man. Scand J Dent Res. 86: 174. 1978. 

R. B. Devereux, C. J. Frary R. Kramer-Fox, R. B. 
Roberts, H. S. Ruchlin. Cost-effectiveness of infec- 
tive endocarditis prophylaxis for mitral valve pro- 
lapse with or without a mitral regurgitant murmur. 
Am J Cardiol. 74: 1024-1029. 1994. 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 277 

Chapter 1 

Management of Perioperative 


Dr. Karl R. Koerner and Dr. William L. McBee 


Most general dentists extract teeth. However, 
they are usually discriminatory in their case 
selection — choosing teeth that present 
within their ability and comfort zone. Even 
with this precaution, unexpected situations 
can arise. Bleeding is one of the complica- 
tions that frequently occurs, leading to intra- 
operative and even postoperative problems. 
There are several factors that can cause or ex- 
acerbate a troublesome bleeding episode 
from an oral surgery procedure. 1 Tissues of 
the mouth are highly vascular; many wounds 
are left open (as with most extractions); pres- 
sure dressings don't work very well; talking 
and eating can irritate surgery sites; negative 
pressures in the mouth from the tongue and 
eating can dislodge clots; and salivary en- 
zymes may lyse clots before they have a 
chance to organize. 

This chapter identifies and discusses those 
things that the general dentist should con- 
sider in terms of both prevention and man- 
agement options. With an understanding of 
the material that follows, oral surgery can be 
approached with greater confidence and 

skill. It will also help expedite surgery proce- 
dures and make them more routine and pre- 
dictable. Unfortunately, dental school does 
not always provide the graduate with an ade- 
quate understanding of how to control ex- 
cessive bleeding during or after surgery. The 
pages that follow will serve to fill in the gaps 
and help generalists increase competency in 
this extremely important area. 

Primary Reasons for Coagulation 

What are reasons that blood fails to clot nor- 
mally? Some of the most serious ones are 
listed here. 2 


The concentration of platelets in the blood is 
too low. 

Usually blood contains about 150,000 to 
350,000 platelets per mm 3 . However, when 
this count decreases below 50,000, there can 
be abnormal bleeding, with spontaneous 
bleeding occuring if the platelet count falls 


2879_Koerner_Chap 10 4/17/06 1:29 PM Page 278 



below 10,000. Signs may include gingival 
bleeding, frequent epistaxis (bloody nose), 
ecchymosis, blood in the stool or urine, or 
menstrual periods that are unusually heavy 
Oral surgery or trauma may also lead to 
bleeding that is difficult to control. 

There are five main reasons why platelet 
deficiency occurs: 

1 . Bone marrow doesn't produce enough 
platelets (heavy alcohol consumption, 
bone marrow disorders, vitamin deficien- 
cies, aplastic anemia, certain drugs or in- 
fections, and so on). 

2. Platelets become entrapped in an enlarged 
speen (for example, portal hypertension 
with congestive splenomegaly). 

3. Platelets become diluted (major blood or 
fluid replacement, heart bypass surgery, 
and so on). 

4. The use or destruction of platelets in- 
creases. (Viral infections such as Epstein- 
Barr [EB] or human immunodeficiency 
virus [HIV]; drugs such as heparin; oral 
diabetes drugs; sulfa-containing antibiotics, 
quinidine and rifampin; systemic lupus; 
some cancers; septicemia; and so on). 

5. Increased use of platelets. Patients with 
disseminated intravascular coagulation 
(DIC) will have thrombocytopenia, as 
well as other disorders of coagulation. 

von Willebrand's Disease (VWD) 

Platelets don't clump together to adequately 
plug a tear in a vessel wall. 

This is a hereditary deficiency of the von 
Willebrand factor in the blood — a protein 
that affects platelets. It is the most common 
hereditary disorder of platelet function. This 
factor is found in plasma, platelets, and 
blood vessel walls. When missing or abnor- 
mal, the first step in plugging a blood vessel 
injury (platelets adhering to one another at 
the site of vessel wall injury) doesn't happen. 
Consequently, bleeding temporarily contin- 
ues, and coagulation is delayed. 

Generally, a person with this disease has a 
parent or other close relative with a history 
of bleeding problems. It is often manifest 
when a person bruises easily or has excessive 
bleeding after a minor skin laceration, tooth 
extraction, or other surgery. It may be con- 
fusing to the patient, since there are some 
situations that can stimulate the body to 
temporarily increase the production of the 
factor, such as stress, pregnancy, inflamma- 
tion, infection, and hormonal changes. 

The four types of VWD are types I, Ha, 
lib, and III, progressively more rare and 
serious from I through III. The definitive 
diagnosis can be difficult, requiring mul- 
tiple labs, a physical exam, and a thorough 
understanding of the patient's bleeding 

Many people with this disease do not re- 
quire preoperative treatment. Yet, if there is a 
question of excessive bleeding in the patient's 
history or in the family's medical history, a 
consultation from a hematologist should be 

The patient may require preoperative 
Desmopressin (DDAVP) or replacement 
therapy with von Willebrand Factor (VWF) 
concentrate (Humate-P), or the dentist may 
be advised to use just local measures during 
surgery (reviewed later in this chapter). 


This is characterized by decreased amounts 
of coagulation factors VIII or IX. 

Classic hemophilia (A) makes up about 
80 percent of cases and is a deficiency of 
factor VIII. Hemophilia B (Christmas dis- 
ease) is a deficiency in clotting factor IX. 
Both are inherited through the mother but 
almost always affect male children. The 
severity of the symptoms depends on how 
the gene abnormality affects the activity of 
factors VIII and IX. A patient's clotting con- 
dition may involve any of the following 
(according to the amount of the clotting fac- 
tor present): 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 279 



1 % of normal: severe bleeding and/or re- 
currence of spontaneous bleeding. 
1—5% of normal: moderate hemophilia- 

surgery or injury can cause significant or 
uncontrolled bleeding from even minor 

• 5—25% of normal: mild hemophilia — still 

• Greater than 25% of normal: May not be 
diagnosed. Still potentially dangerous. 

Disseminated Intravascular 
Coagulation (DIC) 

Clotting factors are depleted from excessive 

With this condition, small clots form 
throughout the blood stream. They block 
smaller blood vessels and use up the clotting 
factors required to control bleeding. This 
condition usually arises from a toxic sub- 
stance in the blood, such as uterine tissue 
from complicated obstetric surgery or endo- 
toxins from a severe bacterial infection. In 
addition, it can be from certain leukemias or 
cancer of the stomach, pancreas, or prostate. 
Generally, the problem is resolved when the 
cause is properly addressed. 

Systemic Disease Conditions 
That Can Cause Bleeding During 

Most systemic diseases will produce some al- 
teration in the blood. Blood dyscrasia may 
accompany the disease, or it may be the pre- 
senting feature of a general systemic disease. 
Examples include the following. 3 

Disseminated Malignancy 

This finding is commonly accompanied by 
the presence of tumor cells in the bone 
marrow. Some bleeding disorders related to 
cancer appear to be caused by the selective 
impairment of coagulation from pathologi- 
cal inhibitors of different parts of the coa- 

gulation system or from isolated factor defi- 


There are three forms of anemia that can 
contribute to bleeding problems: 

1 . Anemia as a complication of chronic renal 
failure. The management of bleeding in 
these patients is through dialysis and ap- 
propriate replacement therapy. Manage- 
ment has been revolutionized by the avail- 
ability of recombinant erythropoietin. 

2. Less common forms of anemia associated 
with cancer. Autoimmune hemolytic ane- 
mia is sometimes a feature in patients 
with lymphoma and ovarian tumors. 
Autoimmune hemolysis can also occur in 
patients with tumors of the lung, stom- 
ach, breast, kidney, colon, and testis. 

3. Anemia from pituitary deficiency, thyroid 
disease, adrenal disease, or parathyroid 

Acute and Chronic Bacterial 

Most bacterial infections can be associated 
with a hypervascular tissue called granulo- 
matous tissue. The vessels themselves are 
not only dilated, but there is usually a 
greater number of vessels that have pro- 
liferated within the area of the infection. 
Functionally, this allows for a greater re- 
sponse by the body's own defense mecha- 
nisms, while trying to fend off the unwanted 

Toxins produced and released by microor- 
ganisms within the area of infection can 
damage tissues (including the endothelium 
associated with vascular walls) and also cause 
impairment of liver function and hemostasis. 
Therefore, in the presence of damaged hy- 
pervascular tissue and an impaired hemosta- 
tic response, undesired surgical or sponta- 
neous bleeding may occur. 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 280 



Viral Infections 

This includes rubella, cytomegalovirus 
(CMV), and AIDS. 

HIV- Associated Coagulapathies 

Besides the immunological changes related 
to HIV infections, there are also several 
hematological problems. Lymphopenia (an 
abnormally small number of lymphocytes in 
the circulating blood) is common, as is neu- 
tropenia (an abnormal decrease in the num- 
ber of neutrophils in the blood). Neutro- 
penia reportedly varies between and 30 
percent in HIV antibody-positive asympto- 
matic patients and in 20-65 percent of pa- 
tients with AIDS. Thrombocytopenia is 
present in 5—20 percent of asymptomatic 
HIV-infected persons but rises to 25-50 per- 
cent in patients with AIDS. In addition to 
these complications there is also a risk of 
drug-induced marrow hypoplasia related to 
treatment with zidovudine (AZT). 

Rheumatiod Arthritis 

Anemia in these patients is common but 
usually follows the pattern of anemia from 
chronic disorders. It can be exacerbated by 
iron deficiency resulting from poor diet, 
chronic blood loss, or because of the effects 
of treatment with aspirin, other NSAIDS, or 

Systemic Lupus Erythematosus 

In this autoimmune disease, rogue immune 
cells attack body tissues. Antibodies may be 
produced that can react against blood cells, 
organs, and other tissues. It affects nine 
times as many women than men. Blood dis- 
orders occur in up to 85 percent of those 
with the disease. Both arterial and venous 
blood clots can form and may be associated 
with pulmonary embolism, strokes, hemopt- 
ysis (coughing up blood), miscarriages and 

other disorders. Clots and/or bleeding occur 
because of antibodies against lipids that are 
involved in clotting. It is known as antiphos- 
pholipid antibody syndrome (APS). Com- 
monly platelets are decreased thus causing 
bleeding or clotting problems. There can 
also be anemia in the course of Systemic 
Lupus Erythematosus (SLE). 

Parasitic Disease 

This includes malaria, leishmaniasis, hook- 
worm, visceral larva migrans, schistosomiasis, 
and various other trematode infestations. 

Inflammatory Diseases of the Bowel 

These are often made worse by drugs used in 
managing the diseases. 

Liver Disease 

Liver disease causes a reduction of certain 
clotting factors required in the coagulation 
cascade. There is usually anemia in patients 
with chronic liver failure. Especially with al- 
coholics, anemia may be from a deficient 
diet, chronic blood loss, hepatic dysfunction, 
or the direct toxic effects of alcohol on the 
bone marrow. 


Particularly with pneumonia caused by 
Legionella pneumoph ilia, there can be severe 
thrombocytopenia and lymphopenia. Some 
cases have also been reported to be com- 
plicated by disseminated intravascular co- 

Primary Sources of Serious 
Bleeding around the Oral Cavity 

There are four vascular sources that provide 
blood to the oral cavity that can cause seri- 
ous and sometimes life-threatening bleeding 
if disrupted during oral surgery procedures. 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 281 



These are the lingual, facial, inferior alveolar, 
and the greater palatine arteries. 

The lingual artery branches directly from 
the external carotid. Upper airway obstruc- 
tion from bleeding has occurred from punc- 
ture wounds of the tongue, biopsies of the 
tongue or floor of the mouth, and implant 
perforation out the lingual cortex of the 

The facial artery also branches directly 
from the external carotid. It is accompanied 
by the anterior facial vein, and they pass in 
the cheek lateral to the lower molars. A long 
incision for a vertical release into the mu- 
cobuccal fold, buccal to the mandibular pos- 
terior teeth, could cut one of these vessels 
causing profuse bleeding. 

The inferior alveolar artery branches 
from the maxillary artery, which is the larger 
of the two terminal branches of the external 
carotid. As it descends, it splits off the mylo- 
hyoid artery before entering the mandibular 
foramen and mandibular canal. A mental 
branch emerges from the mental foramen to 
supply the chin and lower lip. The mylohy- 
oid artery traverses along the medial surface 
of the mandible in the mylohyoid groove 
and supplies the muscle of the same name. 
Sometimes a small lingual branch can arise 
from the inferior alveolar artery and descend 
with the lingual nerve to supply the mucosa 
of the floor of the mouth. 

The inferior alveolar artery is usually 
above the inferior alveolar nerve in the 
mandibular canal in the molar area. An in- 
advertent cut with the bur into the canal 
would likely injure the artery before injuring 
the nerve. The nerve would continue intact 
after such an injury but could still result in a 
neuropathy from a disruption of the nerve s 
blood supply. 

The greater palatine artery is found 
emerging from a foramen on the palate su- 
perior to the second molar where the hori- 
zontal and vertical aspects of the palate con- 
verge. Unlike the vessels emerging from the 
incisive canal, the greater palatine artery is 

significant in size and will result in difficult- 
to-control spurting if cut. This can occur 
when removing a palatal torus or obtaining 
donor tissue for a free gingival or connective 
tissue graft. It can also happen with peri- 
odontal surgery, especially if there is loss of 
the alveolus from periodontal disease and a 
significant portion of the vertical palatal 
bone is diseased — causing the artery to be 
closer than anticipated. Tears of the posterior 
palatal tissues involving the greater palatine 
artery are common when the gingival tissues 
have not been completely separated from the 
tooth during a maxillary posterior extraction. 

A previous calculation reported that 
these arteries are 1—2 mm in lumen diame- 
ter. If so, with 0.2 mL per beat at 70 beats 
per minute, it would be possible for 14 mL 
of blood to escape in 60 seconds. In 30 min- 
utes, this could represent approximately 420 
mL of blood loss. The authors, however, find 
this to be a significant underestimation. In 
our experience, the previously mentioned 
vessels can produce a significantly greater 
amount of bleeding in a shorter time period 
if not controlled immediately. This being 
said, they are also usually relatively easy to 
temporarily tamponade, preventing excessive 
blood loss until definitive treatment can 


Preventing Bleeding Problems 

Preventing bleeding problems prior to sur- 
gery is preferable to having to treat them 
intra- or postoperatively. The sections that 
follow review considerations and procedures 
that help dentists avoid excessive hemorrhage 
during oral surgery. 

Patient History 

Every new patient fills out a dental/medical 
history, which is reviewed by the dentist in 
the presence of the patient. This history 
should be updated on an annual basis. This 
screening of prospective patients will usually 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 282 



reveal bleeding disorders serious enough to 
be of consequence (see Table 10.1). Depend- 
ing on the severity, consultation with the pa- 
tient's physician or a hematologist may be 
advised. Following is a list of questions that 
can be reviewed with the patient: 

Is there a history of bleeding problems? 

The dentist should ask whether at any 
time in the past with a previous surgery 
or even an accident where bleeding took 
place, has there been persistent bleeding? 
What about previous oral surgery, a ton- 
sillectomy, or any other surgical proce- 
dure? The question should be asked: "Did 
bleeding last more that 24 hours, or did 
you require special attention from a den- 
tist or physician?" 

Do they have a history of nosebleeds? 
Do they bleed easily? Do they have 
heavy menstrual bleeding? Do they bleed 
spontanteously? If the patient answers 
positively to any of these questions, then 
they should probably be referred to an 
oral and maxillofacial surgeon for treat- 
ment or to a hematologist for coagulation 

Does the patient bruise easily? 

If the answer to this question is in the af- 
firmative and if the patient is not taking 
any over-the-counter prescription or 
homeopathic medications that might be 
responsible for it, then it might suggest 
the need for a bleeding time test. This 
problem could be indicative of a disease 
involving decreased platelet formation or 
possibly increased capillary fragility. 

Is there a history of bleeding problems in 
the family? 

Most people will know whether they have 
an inherited bleeding disorder. However, 
with some, prolonged bleeding after an 
oral surgery procedure may be their first 
indication that they have a bleeding prob- 
lem, von Willebrand disease affects 1—2 
percent of the U.S. population. 5 If this 
condition is suspected, the patient should 

Table 10-1. Bleeding Assessment Prior to 
Surgery: Serious Concerns 

Risk Factors 

1 . Bleeding with prior surgical procedures 
a. dental, other 

2. Heavy menstrual bleeding 

3. Liver disease 

a. Hepatitis B or C 

b. Cirrhosis 

c. Chronic alcohol abuse 

4. Renal disease 

5. Congenital diseases 

a. Hemophilia 

b. von Willebrand 's disease 

c. Other inherited coagulopathies 

6. History of abnormal blood count 

a. Leukemia 

b. Throbocyopenia 

(Either decreased production of platelets or 
increased destruction of platelets.) 

c. AIDS 

7. Medications 

a. Aspirin 

b. Other NSAIDs 

c. Anticoagulants 

d. Antibiotics 

e. Chemotherapeutic agents 

Source: Adapted from Figure 5-1 and 5-2, p. 55. 
Dym, H and Ogle, OE. Atlas of Minor Oral Surgery. 
Philadelphia: W.B. Saunders Co. 2001 . 

be referred to a hematologist or a hemo- 
philia treatment center. 

The patient may have signs indicating 
a platelet defect, such as easy bruising. It 
could be quantitative or qualitative, in ei- 
ther case suggesting the possible need for 
a platelet transfusion. Factor replacement 
may be required if they have von 
Willebrand's disease, hemophilia A or B, 
or another clotting factor deficiency. 
Has the patient ever had a history of liver 

How about a history of hepatitis, hepatic 
carcinoma or jaundice? Is there a history 
of excessive alcohol intake that might af- 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 283 



feet hepatic health? All of the blood clot- 
ting factors except Factor XIII are pro- 
duced in the liver. 

What are the patient's baseline vital signs, 
particularly blood pressure? 
A high systolic blood pressure alone (over 
180) can be a cause of excessive bleeding 
during surgery In this event, they should 
be treated by their physician for hyperten- 
sion prior to performing an oral surgery 

What medications are being taken by the 

This question relates to both prescription 
and nonprescription drugs. Drug usage is 
the most common undocumented cause 
of bleeding in the oral surgery patient. 
The patient may not know whether a 
given medication contributes to increased 

Medications That Influence 

We know that there are many medications 
that can interfere with coagulation. With 
some patients, these medications are thera- 
peutically necessary and are part of a treat- 
ment regimen for a medical condition. Prior 
to surgery it is prudent to consult the pa- 
tient's physician regarding the situation (see 
Table 10.2). One way to remember these 
medications is to know that seven of them 
start with the letter A. These are listed here: 

1. Aspirin. One 325-mg aspirin or low-dose 
(81-mg) aspirin can irreversibly inhibit 
platelet function for the life of the 
platelet. If the surgery is significant and 
the patient's physician is in agreement, 
then it should be discontinued 7—10 days 
prior to the procedure (life span of a 
platelet is nine days). If the health risks 
of discontinuing are too high and the 
surgical procedure is relatively minor, 
then usually intraoperative bleeding con- 
cerns may be managed with "local meas- 

ures" (to be discussed further later in the 

2. Anti-inflammatories. Other NSAIDs 
operate in the body by a similar mecha- 
nism as aspirin but are qualitatively less 
serious — only reversibly inhibiting platelet 
function. They should be stopped 2-3 
days prior to oral surgery. 

3. Anticoagulants, such as warfarin 
(Coumadin), heparin, or low molecular 
weight heparin (Ardeparin, Dalteparin, 

These medications are prescribed for 
the treatment of atrial fibrillation, dilated 
cardiomyopathy, systolic congestive heart 
failure, valvular heart disease, valve re- 
placement, deep vein thrombosis and pul- 
monary emboli, post myocardial infarc- 
tion or cerebral vascular accident, or a 
need for extracorporeal blood flow, such 
as hemodialysis. 

Coumadin inhibits the synthesis of 
vitamin K-dependent coagulation factors, 
altering the extrinsic pathway of the coag- 
ulation cascade. It is usually taken orally 
by dental patients. Unless vitamin K is 
administered, it requires several days for 
coagulation to normalize after its continu- 
ous use. Its anticoagulant effects are mon- 
itored every few weeks by hematologic 
laboratory tests. More recently, the most 
commonly used test is the International 
Normalized Ratio (INR), but Prothrom- 
bin Time (PT) is also used. The INR 
considers both the patient's prothrombin 
time (PT) and the control and is more 
standardized than a PT. It is becoming 
the standard test for monitoring the anti- 
coagulant effects of warfarin (or the func- 
tion of the extrinsic pathway), and the 
prothrombin time ratio (PTR) is becom- 
ing more obsolete. 

Heparin, on the other hand, requires 
IV access for administration. It binds to 
antithrombin III, giving assistance in the 
inhibition of thrombin formation and 
prolonging the intrinsic pathway. Its 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 284 



Table 10-2. Managing Therapeutically Anticoagulated Patients and the Laboratory Values Commonly 
Used to Monitor Anticoagulation 


Lab Value 


1 . Consult with physician on safety of stopping the medication for several days. 

2. Defer surgery for at least five days, depending on the type of antiplatelet 
medication they are taking. 

3. Use extra measures during and after surgery to help promote clot formation 
and retention. 

Bleeding time 

Warfarin (Coumadin) 

1 . Consult with physician on: 

a. Treating the patient with no alteration in anticoagulation therapy. 

b. Safety of discontinuing warfarin and allowing INR to fall to 1 .5 for a few 
days prior to performing surgery, or 

c. Having the patient start on IM heparin that would cease for at least a 
12 hour window during which surgery could be performed. 

2. Use extra measures during and after surgery to help promote clot formation 
and retention. 

PT and INR 


1 . Consult the physician on: 

a. Safety of stopping heparin therapy during the perioperative period. 

b. Restarting heparin once a stable clot has formed. 

2. Use extra measures during and after surgery to help promote clot formation 
and retention. 

Low Molecular Weight Heparin (Lovenox) 

No tests 

blood thinning effects can be gone in a 
few hours or sooner if reversed by 
Protamine. Monitoring is with a PTR 

Low molecular weight heparin 
(LMWH or SQ heparin) is typically used 
for deep vein thrombosis (DVT) treat- 
ment or prevention and is administered 
subcutaneously Similar to heparin, it 
binds to antithrombin III. However, it in- 
hibits factor Xa more than thrombin for- 
mation. Its antithrombotic effect is ex- 
tremely predictable, requiring no 
laboratory values for its monitoring. 
4. Antibiotics (broad-spectrum). These 
medications can alter the nature of the 
body's intestional flora, which can de- 

crease the production of vitamin K. Many 
of the clotting factors require vitamin K 
for their synthesis. 

5. Alcoholism. Alcohol can cause enough 
liver dysfunction to decrease production 
of the clotting factors. 

6. Anticancer drugs. Patients may be on 
chemotherapy drugs that reduce the 
number of circulating platelets. 

7. Antiplatelet drugs. Medications such as 
thienopyridines (Ticlid and Plavix) and 
glycoprotein Ilb/IIIa inhibitors (Reopro 
and Integrilin). 

In addition to the previously mentioned 
types of drugs, many herbal medications 
have anticoagulant properties. A significant 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 285 



portion of the population self-medicates 
with these nonregulated formulations. 
Commonly, they inhibit platelet aggregation 
and prolong bleeding times. If a difficult sur- 
gery is planned, it would be wise to ask 
about these things (along with other more 
conventional medications) as the patient 
health history is reviewed. Examples of some 
of the herbal products that affect clotting are 
as follows: 

• Ginko biloba. Taken for depression, mac- 
ular degeneration, vertigo, and increased 
mental acuity. 

• Garlic. For lowering cholesterol and 
triglycerides, to prevent colds, and so on. 

• Feverfew. For treatment of migranes, 
asthma, arthritis, and so on. 

• Ginseng. For increasing energy and libido. 
It is also said to stimulate immune func- 
tion and normalize glucose levels after 
meals in diabetics. 

• Chamomile. For stress and muscle (in- 
cluding menstrual) cramps. It is reported 
to have antiseptic and anti-inflammatory 

If the patient does happen to be taking a 
substance that compromises the body's clot- 
ting ability, then the dentist needs to be pre- 
pared to implement local measures to en- 
hance hemostasis. For example, the patient 
may be on warfarin. Their INR will usually 
be less than three. For most anticoagulated 
patients, their INR will be 2.0 to 3.0 (thera- 
peutic range). It has become acceptable, even 
recommended, to perform oral surgery on 
patients in this range without altering their 
anticoagulation regimen/ The authors rec- 
ommend that the INR be less than 2.5 for 
surgical dental procedures performed by gen- 
eral dentists and that the practitioner have 
local measures (substances) on hand, as they 
will probably be needed. Persistent bleeding 
in a patient on warfarin can be difficult to 
manage. Furthermore, the administration of 
vitamin K to aid hemostasis is not only un- 

predictable but can increase the chance of an 
embolic phenomenon. 

In some cases, to discontinue wafarin, 
even temporarily puts the patient at extreme 
risk. In this scenario, a physician will most 
likely choose to stop the warfarin 2—3 days 
before surgery but start the patient on low 
molecular weight heparin (Enoxaparin/ 
Lovenox) that the patient self-administers. 
Lovenox was the first injectable, low 
molecular weight heparin approved for at- 
home use and has a 12-hour duration. As 
warfarin stops, the heparin begins. It is given 
every 12 hours and then usually discontin- 
ued 12 hours before the oral surgical proce- 
dure. If there are no bleeding problems, then 
another subcutaneous heparin may be ad- 
ministered the night of surgery, followed by 
warfarin beginning again the next morning. 
This treatment method narrows the window 
of risk and vulnerability while allowing the 
surgery to be performed in the safest manner. 

Frequently, a physician will recommend 
discontinuing warfarin 2-3 days prior to the 
oral surgery, allowing the INR to temporar- 
ily drop from 2.5 or 3 to as low as 1.5, and 
then resume warfarin the day following sur- 
gery. There is greater potential risk with this 
method, but it is the physicians call. 

Similarly, the patient may have a known 
or suspected coagulopathy. With a known 
bleeding problem, it is appropriate to confer 
with the patient's physician or enlist the as- 
sistance of a hematologist. If the problem is 
only suspected because of a past history of 
bleeding irregularities, then the dentist may 
want to order coagulation studies prior to 
treatment such as a complete blood count 
(CBC) including platelets, partial throm- 
boplastin time (PTT), INR, and/or bleed- 
ing time. If the patient needs multiple ex- 
tractions or other more extensive oral sur- 
gery, or if the general dentist is not familiar 
with the interpretation of lab values, it may 
be better for him or her to defer treatment 
to someone with more experience treating 
these situations. 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 286 



Preventing Bleeding Problems 
with Careful Surgery 

Quite often, bleeding problems during sur- 
gery are made worse by poor surgical tech- 
nique. Much bleeding can be avoided by 
careful management of the soft tissues. The 
operator needs to make clean incisions and 
not tear flaps. One should be careful not to 
lacerate or abrade soft tissue with a bur, 
crush it with a forcep, or puncture it with 
elevators or other instruments since these are 
some things that increase and prolong bleed- 
ing. Sometimes we get so focused on hard 
tissue that we may tend to not pay attention 
to the handling of soft tissue. In addition, 
areas of sharp bone should be smoothed and 
diseased, and/or cyanotic tissue should be ex- 
cised from the gumline after extractions. 
Periapical granulomatous lesions should also 
be removed from extraction sites. 

One fault of many general dentists is hav- 
ing a flap that is too small. Enlarging the 
flap to give better visibility and access will, at 
the same time, prevent stretching, pulling, 
and tearing of the mucosa. This may involve 
doing something many generalists are reluc- 
tant to do — making a releasing incision. A 
releasing incision is generally made one 
tooth mesial or distal to the tooth being re- 
moved, thus helping to ensure that the inci- 
sion is over bone for better healing. It doesn't 
need to be long. Five to ten millimeters is 
often sufficient, just into the unattached tis- 
sue. The incision is usually angled slightly to 
give a wider base to the flap and provide a 
more adequate blood supply. Making this 
triangular flap also prevents tension on the 
flap or the need to apply excessive retraction 

Sometimes, despite our best effort during 
surgery, troublesome bleeding occurs. In this 
event, we must do our best to control it. 
The first question we need to ask is, "Where 
is it coming from?" Is it from soft tissue or 
bleeding diffusely from a bony socket? Is it 
from a nutrient canal (artery) in the bone 

that was cut by a bur, or could it be from a 
severed vessel in the mandibular canal? The 
treatment modality will depend on the 
bleeding source. Identification requires good 
lighting, suction, and competent retraction 

Soft Tissue Bleeding 

In a patient with normal clotting, any bleed- 
ing from soft tissue incisions or periosteal re- 
flections will generally subside within a few 
minutes. An exception might be if an artery 
or vein within the soft tissue is severed. For 
example, when making a releasing incision 
for a triangular flap in the mandibular sec- 
ond molar area, the incision could inadver- 
tently extend too far apically If it goes be- 
yond the mucobuccal fold into the cheek, 
the facial artery or anterior facial vein could 
be nicked or even severed. This would cause 
major bleeding and would need to be treated 
before proceeding with the surgery. In this 
case, a mosquito hemostat could be used to 
clamp the bleeder, after which suture mate- 
rial could be used to tie off the vessel. Soft 
tissue bleeders (larger blood vessels) can also 
be packed, although hemostasis is more fre- 
quently obtained with careful suturing or 
electro/chemical cauterization. 

The following are local measures that can 
be used to help stop soft tissue bleeding: 

• Electrocautery 

• Hemostatic liquid 

Examples are Hemodent (aluminum chlo- 
ride), Viscostat (20% ferric sulfate coagu- 
lative gel), Astringedent (15.5% aqueous 
ferric sulfate), Astringedent-X (12.7% 
equivalent ferric sulfate and ferric subsul- 
fate). The latter is the most potent of those 

• Local anesthetic with 1:50,000 epineph- 

• Sutures 

• Pressure 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 287 



Socket bleeding 

Occasionally, bleeding from a tooth socket 

following tooth extraction can be persistent 
and annoying. This often occurs when there 
has been drilling in the socket to help re- 
move a root. The operator may have drilled 
with a bur to help create a purchase area ad- 
jacent to a root, or an interradicular bone 
may have been removed to lessen the body's 
hold on a root. If bleeding fails to subside 
prior to the patient leaving the office, then 
the socket should be packed with something 
to help with hemostasis. 

The following are local measures that can 
be used to help stop socket bleeding: 

• Hemostatic gauze (such as ActCel or 
HemoStyp Hemostatic Gauze™) (See 
Figure 10.1) 

• Gelfoam (see Figure 10.2) 

• Collagen (Colla-Plug or Colla-Tape) (see 
Figure 10.3) 

• Surgicel (see Figure 10.4) 

• Gelfoam with bovine thrombin 

• Bone wax (see Figure 10.5) 

Hemostatic gauze looks like a cotton fab- 
ric (originating from cotton) but has been 
chemically treated with a proprietary process 
to dissolve into glucose and saline within 
1—2 weeks. When one or more small (1X1 
inch) pieces are placed in a socket, it en- 
hances hemostasis and serves to stabilize the 



Figure 10-1. Hemostatic gauze. 

clot. This material is the authors' choice for 
obtaining hemostasis within extraction sites. 
Gelfoam works in a similar manner. Both are 
held in place with a figure-eight suture over 
the socket. 

Colla-Plug and Colla-Tape are highly 
cross-linked collagen products that also pro- 
mote hemostasis. They help coagulation by 

Figure 10-2. Gelfoam. 

Figure 10-3. CollaTape. 

Figure 10-4. Surgicel. 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 288 



Figure 10-5. Bone wax. 

enhancing platelet aggregation. Another 
form of collagen that can be placed in a 
socket is the microfibular type (for example, 
Avitene). This material is more fluffy and 

Surgicel is oxidized regenerated cellulose. 
It can be more effective at hemostasis than 
Gelfoam because it has more strength and 
can be packed under pressure; however, it 
commonly causes delayed healing of the 
socket. For this reason, it is usually only used 
for persistent bleeding. 1 

In difficult situations, a liquid preparation 
of bovine thrombin can be applied to 
Gelfoam and placed in a socket. By using 
thrombin, all the steps in the coagulation 
cascade are bypassed, and fibrinogen is con- 
verted to fibrin enzymatically Since this 
product is of animal origin, it might occa- 
sionally lead to allergic reactions. 

Nutrient Canal Bleeding 

When removing bone with a bur for a surgi- 
cal extraction, a nutrient blood vessel 
(branch of the inferior alveolar artery) can 
sometimes be cut in the process, causing 
profuse bleeding. If this happens, several ac- 
tions can help remedy the situation. One is 
to localize the bleeding orifice with suction. 
Second, bone should be crushed into the 
lumen with a periosteal elevator or other 
similar instrument. Third, a small amount of 
bone wax can be burnished into the bleeding 

orifice. It should be noted that the mechani- 
cal effect of bone wax may not be very long- 

With nutrient canal bleeding, if the tooth 
is still present and can quickly be extracted, 
then control the bleeding with suction and 
remove the tooth. If bleeding is too great to 
allow visibility, and it will take more than a 
few minutes to remove the tooth, then the 
extraction should be postponed to another 
time, and all efforts can be expended on he- 
mostasis. In addition to bone burnishing and 
bone wax, one or more of the methods (local 
measures) listed previously may be imple- 
mented, followed by closure of the soft tissue 
with sutures over the socket. The patient can 
then bite on conventional gauze. This type 
of bleeding can, at times, become life- 

In a study with 175 adult patients who 
had extractions averaging 18 teeth, it was re- 
ported that the blood loss varied from 35 to 
912 mL, with a mean of 223 mL. 8 Another 
study 9 using radioactively labeled 1131, found 
that the blood loss during multiple extrac- 
tions ranged from 148 to 912 mL. Sinclair 
found that blood loss during extractions was 
greater when teeth were removed from the 
upper than the lower jaw and that the 
amount was related to tooth type. 10 There 
was a mean loss of 1.9 mL from lower canine 
sockets and a mean of 14.05 mL from upper 
molars. Sinclair suggested that blood loss was 
related to the surface area of the roots. 

Some operators, in the midst of an 
episode of profuse bleeding, count the num- 
ber of 2 X 2 gauze sponges saturated with 
blood to determine the magnitude of blood 
loss. This method has inherent problems un- 
less pre- and postoperative weight measure- 
ments are performed with the brand of 
gauze used in the office. For example, two 
different brands of 2 X 2s were saturated 
with venous blood to determine how many 
milliliters they would hold. Figures 10. 6A 
and 10. 6B show that a Sullivan-Schein 
brand holds 4.5 mL, and a Johnson & 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 289 



QHenry Schein® 



SYNTHETlCTUri i R - Nicht Steri 

2" X 2 (5cmx 5 cm) 

Figure 10-6A. Two-by-two inch, lightly filled 
cotton -filled gauze commonly used in dental 


Figure 10-6B. The same gauze saturated with 
venous blood holds 4.0 mL 

Johnson brand holds 9.0 mL. See Figures 

lOJAand 10.7B. 

There are multiple reports of external 
carotid ligation or selective vessel emboliza- 
tion during oral surgical procedures in order 
to save the patient. If blood loss is estimated 
to approach 500 mL, the emergency medical 
system (EMS) should be activated, or the pa- 
tient quickly transferred to the emergency 
room since there may be signs of shock at 
800-1000 mL of blood loss. 1 

Signs of shock can include the following: 

• systolic BP 70-80 mm Hg 

• rapid but weak pulse 

• increased rate but shallow respirations 

• limited consciousness 

• cyanosis of lips and nail beds 

• cold sweat 





First Aid 



ff l&Absorben 


Sterile Small Pads 

2 in. x 2 in. (5cm X 5cm » 

For Cleansing 
And Covering 


Figure 10-7A. Two-by-two inch, densely filled 
cotton-filled gauze. 

Figure 10-7B. The same gauze saturated with 
venous blood holds 9.5 mL. 

• thirst 

• restlessness 

• subnormal temperature 

An example of a patient with heavy bleed- 
ing is shown in Figures 10.8A-C. The radi- 
ograph (see Figure 10. 8A) shows tooth #32, 
which is a partial bony impaction. As bone 
was being removed with a bur on the disto- 
buccal of the tooth in this 30-year-old man 
(see arrow), a nutrient canal was cut, causing 
immediate spurting of blood into the socket. 
Adjacent bone was burnished into the bleed- 
ing vessel; bone wax was applied; and suc- 
tion used to maintain visibility for the brief 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 290 



Figure 10-8A. Radiograph of tooth #32, which 
is a partial bony impaction in a healthy 30-year-old 

Figure 10-8B. After cutting a nutrient canal (ar- 
tery) adjacent to the tooth during bone removal, 
emergency measures were implemented including 
burnishing of bone into the bleeding orifice and 
the use of bone wax. Additionally, 15 4x4 gauze 
sponges were used one after another to exert 
pressure and control bleeding. 

time it took to remove the tooth. Then con- 
ventional gauze (4X4 inch) was used as 
packing to control bleeding. (Note: Gauze 
should not be used to just soak up the 
blood, but to pack the site, causing a higher 
pressure outside the vessel than inside. This 
is a temporary measure, but the goal is for 
the vessel to clot or at least for the gauze to 
prevent significant blood loss while other 
preparations are being made to stop the 

Despite these measures, heavy bleeding 
continued. Approximately 1 5 gauze sponges 

Figure 10-8C. As the previously mentioned 
measures were not successful, about 10 1x1 inch 
pieces of HemoStype hemostatic gauze were 
placed in the socket, after which hemostasis was 
achieved. The socket was then sutured and the 
patient observed for about 30 minutes before 
being allowed to leave the office. 

were used, one after the other, as pressure 
dressings in the socket (see Figure 10.8B). 
Each one equaled four 2 X 2s. As they be- 
came saturated and ineffective, they were 
removed. Since this was not working, about 
10 1X1 inch pieces of resorbable hemo- 
static gauze (HemoStyp™) were placed in 
the socket with conventional gauze placed 
on top of it to provide pressure. The bleed- 
ing stopped within a few minutes (see 
Figure 10.8C). At the end of the procedure, 
it was estimated that the pieces of 4 X 4 
gauze likely contained roughly 270 mL of 
blood. This does not include blood aspi- 
rated into the high-speed evacuation 

Mandibular Canal Bleeding 

If, in the process of removing roots of a 
mandibular molar, it is suspected that a 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 291 



blood vessel in the mandibular canal has 
been cut, causing serious bleeding from the 
depth of the socket, then treatment cannot 
be as aggressive as with nutrient canal bleed- 
ing. This is because of proximity to the infe- 
rior alveolar nerve (IAN). In this situation, 
either Gelfoam or hemostatic gauze (both re- 
sorbable) should be placed in the depth of 
the socket. Then moistened strung-out gauze 
(as with several 2X2 gauze sponges) can be 
packed on top of the bleeding vessel. Again, 
this is to allow for a fibrin clot to form 
and/or prevent significant hemorrhaging 
while gathering thoughts and necessary ma- 
terials. Typically, this is left in place for 5-10 
minutes. The more superficial gauze is then 
removed and the situation evaluated. If the 
site continues to bleed, a packing of Iodo- 
form or Vaseline-impregnated gauze should 
be inserted over the resorable material for 
10—15 minutes. The packing should be tight 
enough to prevent any bleeding although 
carefully placed to avoid damaging the LAN. 
If persistent bleeding continues, additional 
resorbable hemostatic material can be laid 
over the vessel and the socket packed again 
with moistened gauze. If unable to control 
the hemorrhaging with these methods, tight 
closure of the soft tissues over the gauze 
should be performed, and the patient should 
be immediately transported to an oral and 
maxillofacial surgeon or nearest medical 

Postoperative Bleeding 

At this point, the surgery is over. It was suc- 
cessfully completed and bleeding was con- 
trolled during the procedure. We can assume 
that soft tissue was managed properly and 
sufficient sutures have been placed. Any 
bony bleeders have been controlled. The pa- 
tient is about to leave the office with bleed- 
ing within normal limits and under control. 
Of course, there may be some oozing of 
blood from the area for 24—36 hours after 
the surgery, but it will not be excessive. 

Immediately Postoperatively 

The following instructions verbally or prefer- 
ably in writing can be used to help ensure 
that postoperative bleeding problems do not 

• Bite on a piece of damp gauze for 20-30 

• Keep head elevated and rest so as to not 
raise the blood pressure. 

• Rest for 2—3 hours. 

• Do not rinse for 24 hours. 

• Do not smoke for at least the first 12 
hours. The smoke is an irritant. 
Additionally, suction from smoking causes 
negative pressure and may make bleeding 

• Avoid talking. 

• Don't spit. 

• Avoid strenuous exercise for the first 24 

• Avoid touching the surgery site with the 

• Avoid hot liquids, carbonation, or hydro- 
gen peroxide rinses because they can pro- 
mote clot lysis. 

• Avoid aspirin or other nonsteroidal anti- 
inflammatory medications. 

• Maintain a liquid diet for 24-48 hours. 

• Don't chew near the surgery site for three 

• If bleeding continues or restarts, bite again 
for 20—30 minutes (repacking and resutur- 
ing by the dentist may be required). 

• Use a moist tea bag instead of the gauze 
for a few times. (The tannic acid in tea has 
vasoconstrictor properties.) 

The dentist must be available in case of an 
emergency. Reasons for a return visit by the 
patient would be prolonged bleeding, large 
clots in the cheek or floor of the mouth, or 
profuse bright red bleeding. Over the phone, 
review the list provided previously. If, after a 
reasonable time, it is still actively bleeding, 
the dentist should see the patient. 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 292 



If the dentist does see the patient back in 
the office, make sure there is good light, re- 
traction, and suction. This may mean calling 
in help after hours for the needed assistance. 
For medico-legal and safety reasons, it is not 
advisable to be alone with the patient when 
providing this treatment. 

Try to identify the source. Remove all su- 
tures, gauze, and so on. If the patient is un- 
comfortable, anesthetize the area with a local 
anesthetic without a vasoconstrictor. The 
vasoconstrictor may fool the practitioner 
into thinking that hemostasis is obtained, 
when in fact only temporary vasoconstric- 
tion has occurred. Rebleeding may occur as 
soon as the vasoconstrictor has worn off 
(usually as soon as the patient arrives back 
home). Packing the site may be required to 
differentiate the source (soft tissue versus 
bone, or specific vessel versus diffuse oozing). 
Diffuse oozing is more likely to occur in a 
patient with a systemic disorder (hyperten- 
sion, medically anticoagulated, bleeding dis- 
order, and so on) as opposed to a vessel in- 
jury from surgery. Evaluating the type and 
discovering the site of bleeding can direct 

If bone is the source of the bleeding, then 
follow the preceding steps for packing the 
site with resorbable hemostatic material, 
such as hemostactic gauze or Gel foam, and 
overpacking with Iodoform or Vaseline-im- 
pregnated gauze. A figure-eight suture over 
the socket should always be performed to as- 
sist in stabilizing the clot. 

If generalized oozing (from bone, soft tis- 
sue, adjacent sulci) is difficult to manage, and 
especially if it is felt to be from a systemic 
disorder or anticoagulation, systemic man- 
agement needs to be performed by the pa- 
tient's primary physician or emergency per- 
sonnel. Laboratory values will be obtained 
with ensuing fluid resuscitation, correction 
of abnormalities, and persistent monitoring. 

Especially when treating patients on anti- 
coagulants, the use of tranexamic acid 
mouthwash is an adjunctive hemostatic 

agent to consider for inhibiting the break- 
down of fibrin clots. It is used to irrigate the 
socket before suturing, after which it is used 
as a mouthwash for two minutes, four times 
a day for one week. It is effective but very 
expensive (about $230 for seven days). 
However, when compared to other local he- 
mostatic measures, it may not be that much 
more useful. It is more a tool of the oral and 
maxillofacial surgeon in a hospital environ- 

Secondary Bleeding 

Secondary bleeding is after the fact. Some 
describe it as bleeding that takes place 24 
hours after a surgical procedure. One should 
first consider the least invasive method of 
bleeding control. 

1 . Initially, it is good to have the patient at 
home rinse gently with cold water and 
bite on gauze for 20-30 minutes. If 
bleeding persists, the patient can substi- 
tute a moist tea bag for the gauze — trying 
this several times for 20—30 minutes each 
time. If unsuccessful, then the patient 
should see the dentist. 

2. When in the office, the dentist should 
rinse and clean the mouth of any clots or 
bleeding. With good lighting, examine 
the surgical site to determine the source. 
Again, pressure should be applied by bit- 
ing on gauze or by having the dentist 
press gauze on the area for five minutes or 
so. Many times, the cause of secondary 
bleeding is from the patient sucking, spit- 
ting, chewing, or engaging in some type 
of physical activity that irritates the 
wound and exacerbates the problem. 

3. Finally, if these two measures don't work, 
it is time for a more aggressive approach. 
Anesthetize the area (a block is preferable 
to infiltration because an infiltration may 
provide a false positive of hemostasis) and 
curette the socket to establish fresh heal- 
ing. Identify sources of bleeding and deal 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 293 



with them appropriately according to 
their location (soft tissue or bone). One 
or more of the previously listed hemosta- 
tic agents can be applied. This time, one 
should be more thorough in instructing 
the patient how and where to place the 
gauze pack. Wait a sufficiently long time 
to make sure that bleeding has stopped 
before dismissing the patient. If bleeding 
continues to be a problem, there may be a 
coagulation disorder that should be evalu- 
ated by laboratory tests — generally under 
the direction of a hemoatologist. 

In Figure 10.9, a lower third molar was 
removed and hemostasis achieved prior to 
the patient leaving the office. When the pa- 
tient was called that night, he said there was 
still oozing from this one site. Instructions 
were given on what the patient should do to 
control the situation, and he was asked to 
call back if bleeding didn't subside. The next 
morning the patient called the dentist to say 
that it had been bleeding all night. The pa- 
tient had been up changing gauze and biting 
on gauze continually. The dentist saw the pa- 
tient within a short time. Several pieces of 
resorbable hemostatic agent (in this case 
Gelfoam) were placed, and the patient asked 
to bite firmly on gauze placed directly over 
the socket. After about five minutes, the 
bleeding stopped and did not start up again. 
More invasive methods were not needed. 

Surgical Contraindications from 
Hematologic Conditions 

There are two situations that present ab- 
solute contraindications to extraction of 
teeth. They are arteriovenous or sinusoidal 
aneurysms and central hemangiomas. 
Removal of teeth with root structures that 
are involved with one of these lesions can 
cause death from three different means: the 
patient may exsanguinate, go into shock, or 
aspirate blood. 

Arteriovenous aneurysms or fistulas are 

Figure 10-9. Control of secondary bleeding with 
Gelfoam and pressure from 2x2 inch gauze. 

uncommon vascular abnormalities that may 
either be congenital or traumatic in origin. 
Those due to trauma are generally singular 
fistular channels resulting from injury to an 
artery and adjacent vein. Congenital arterio- 
venous aneurysms are hemangiomas with 
large-bore, high-flow channels. The latter 
have also been described as pulsating, cen- 
tral, and central cavernous hemangiomas. 
They have a tendency to develop in the head 
and neck but seldom affect the mandible or 
maxilla. When in the jaws, however, they are 
more common in the mandible than the 
maxilla by a ratio of 2:1. Also, there is a 
higher incidence in females than males by 
3:1. They are most common in the molar re- 
gion during the second decade of life. In the 
mandible, signs and symptoms include tooth 
mobility, pain, and pulsation or throbbing. 
Other reports include paresthesia, derange- 
ment of normal arch and occlusion, prema- 
ture exfoliation of deciduous teeth, congeni- 
tally missing teeth, root resorption (30 
percent), and referred pain to the ear. 
Radiographically, lesions range from diffuse 
destruction to multiloculation with a soap- 
bubble appearance and well-defined borders. 
Congenital lesions arise most often within 
bone from marrow spaces near the mandibu- 

2879_Koerner_Chap 10 4/17/06 1:29 PM Page 294 



lar canal, where they can resorb and/or ex- 
pand the mandible, demonstrating radi- 
ographically as a lucency. 

This type of vascular lesion should always 
be kept in mind when performing surgery 
Extraction or deep periodontal surgery of an 
involved tooth or a biopsy of this lesion 
could result in life-threatening exsanguina- 
tions. This situation may even resist carotid 
ligation, radiation therapy, injection of scle- 
rosing agents, or other forms of treatment. 
Radiolucencies should be aspirated with a 
20-gauge needle prior to surgical interven- 
tion. If blood is readily withdrawn, surgery 
should not be performed until a vascular le- 
sion has been ruled out. That will usually re- 
quire referring to an oral and maxillofacial 
surgeon to set up the patient with an inter- 
ventional radiologist for angiographic studies 
and then treatment — first limited to obser- 
vation and then possibly with single or mul- 
tiple treatments of selective embolization fol- 
lowed by surgical excision. 


1. L. J. Peterson, Sr. Ed. Contemporary Oral and 
Maxillofac. Surg., 4th ed. St. Louis: Mosby. 2004. 

2. Merck Manual of Medical Information. Mark H. 
Beer, ed. Section 14. Blood disorders. Whitehouse 
Station: NJ: Merck and Co. 1999. 

3. D. J. Weatherall. The blood in systemic disease. 
In: Oxford Textbook of Medicine, 4th ed. Oxford, 
England: Oxford University Press. 1999. 

4. D. Flanagan. Important arterial supply of the 
mandible, control of an arterial hemorrhage, and 
report of a hemorrhagic incident. / Oral Implant. 
29(4): 165-173. 2003. 

5. Centers for Disease Control, National Center on 
Birth Defects and Developmental Disabilities. 
Heriditary Blood disorders. 

http-.llwww. htm. 

6. H. Dym, O. E. Ogle. Atlas of Minor Oral Surgery. 
Philadelphia, PA: W.B. Saunders Co. 2001. 

7. M. J. Wahl. Myths of dental surgery in patients 
receiving anticoagulant therapy. JADA. 131: 

8. R. L. Johnson. Blood loss in oral surgery. / Dent 
Research. 35: 175-184. 1956. 

9. M. Spengos. Determination of blood loss during 
full-mouth extraction and alveoplasty by plasma 
volume studies with 1131 tagged human albu- 
min. Oral Surg, Oral Med, Oral Path. 16: 16-17. 

10. J. H. Sinclair. Loss of blood following the removal 
of teeth in normal and hemophilia patients. Oral 
Surg, Oral Med, Oral Path. 23: 415^20. 1967. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 295 

Chapter 1 1 

Third World Volunteer Dentistry 

Dr. Richard C. Smith 


The majority of people in developing coun- 
tries live with daily pain, and the word den- 
tist is not in their vocabulary The fortunate 
ones may have access to a local medicine 
man or paraprofessional who may be able to 
extract one or all of their teeth under a tree 
or by the kitchen table. Some may even 
travel a great distance to find a trained prac- 
titioner with expertise but very little in the 
way of instruments or equipment. Because 
of deep poverty and little income, few pa- 
tients can afford more than basic palliative 
measures. This kills incentive for people to 
go into dentistry as a profession since the 
income-producing prospects are so meager. 
Even with some government and interna- 
tional aid trying to solve such widespread 
problems, most of these disadvantaged pop- 
ulations will never see a change in their life- 
times. Volunteer dentists, hygienists, and 
other team members that travel to treat and 
teach these people in this "other world" liter- 
ally bring light and hope with them. 

The purpose of this chapter is to encour- 
age more of such altruistic humanitarian 
service. See Figures 11.1—11.3. This chapter 
is divided into four sections: 

• I. Dental Conditions in the Third World 

• II. Levels of Assistance (including pre- 

• III. Planning and Preparing for Volunteer 

• IV. Gaining a New Perspective 

I. Dental Conditions in the Third 

We live in a time when the "Golden Age of 
Dentistry" with its innovations, inventions, 
research, and scientific methods, has given us 
preventive programs in oral hygiene and 
diet, water fluoridation, and topical fluorides 
that have reduced the impact of dental dis- 
ease. Dental manpower has increased, and 
organized dentistry has done a big part by 
elevating the profession and rewarding the 
practitioners. However, a visit to many for- 
eign countries is a step back in time. As far 
as dentistry is concerned the term underde- 
veloped country means no preventive pro- 
grams. Unindustrialized means most of the 
population cannot afford dental treatment. 
Regrettably, we live in a world of the very 
rich and the very poor. See Figures 1 1 .4 
and 11.5. 


2879_Koerner_Chap 11 4/17/06 1:27 PM Page 296 



Figure 11-1. Village in Indonesia. 

Figure 11-2. Children in Mexico. 

For example, the GDP (gross domestic 
product) per capita or the production of 
goods per person in a year, in Norway is 
US$34,310.00, contrasted with US$90.00 
in Ethiopia. Table 11.1 illustrates the differ- 
ences in these nations with regard to the pos- 

sibility of a patient receiving dental care. 
Norway has a ratio of 1 , 1 00 patients per 
dentist, Ethiopia has a ratio of 1,200,000 
people per dentist. 

One country may graduate 5,600 dentists 
each year from 122 dental schools as op- 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 297 



Figure 11-3. Patients in Peru. 

Figure 11-4. Plowing in Indonesia. 

posed to another country that graduates 25 
students from one school to serve their pop- 
ulation of 1 1.5 million. It is statistics like 
these that are causing organizations like the 
Federation Dentaire Internationale (FDI), 
World Dental Federation (WDF), and 
World Health Organization (WHO) to for- 
mulate programs and push for results. In the 
words of Dr. Sam Thorpe from Sierra Leone, 
who is the former Regional Advisor for Oral 
Health of the Regional Office of the World 

Health Organization, "Previous approaches 
to improving oral health in Africa have been 
modeled on those of affluent countries and 
have, therefore, failed to recognize the epi- 
demiological priorities of the region. The 
main problems can be traced to the follow- 
ing: (a) lack of national oral health policies 
and plans; (b) inappropriately trained den- 
tists (c) services that benefit only affluent 
and urban communities; (d) services that are 
almost entirely curative; (e) and lack of 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 298 

Figure 11-5. Produce going to market. 

Table 11-1. Ratio of Dentists to Population 


Number of Dentists 

Population per Dentist 



1 ,200,000 to 1 



225,000 to 1 



220,000 to 1 



138,000 to 1 



1 19,000 to 1 



1 00,000 to 1 



40,000 to 1 



38,850 to 1 



36,538 to 1 



28,500 to 1 



28,000 to 1 



24,852 to 1 

Sri Lanka 


1 4,000 to 1 

United Kingdom 


2,1 00 to 1 



1,700 to 1 



1 ,503 to 1 

United States* 


1,471 to1 



1 ,358 to 1 



1 ,200 to 1 



1,100 to 1 

Statistics from FDI World Dental Federation for Year 2000, *2004. 

Number of Dental Schools 
















2879_Koerner_Chap 11 4/17/06 1:27 PM Page 299 



equipment and materials, supplies and main- 
tenance." 1 

At the annual FDI World Dental Con- 
gress in New Delhi, India, in 2004, 189 del- 
egates from 48 African and other countries 
met. One result of their planning meetings 
was the Nairobi Declaration on Oral Health 
in Africa, which confirmed the commitment 
to increase the number of countries with 
functioning oral health policies in the region. 
They emphasized that the integration of oral 
health into general health activities and pri- 
mary health care is essential. 2 

It is very important for those going to a 
developing country to provide humanitarian 
service to know what problems they are deal- 
ing with as well as the resources that are al- 
ready being used. It behooves those anxious 
to serve in these countries to have a good 
understanding of the overall plan that is al- 
ready in place with its priorities, goals, and 
methods to accomplish them. 

The World Health Organization has a 
very detailed plan called the Basic Package of 
Oral Care (BPOC), which addresses the ur- 
gent need for change among disadvantaged 
populations that are without adequate com- 
munity oriented preventive services. It has 
three components or goals: 1) Oral Urgent 
Treatment (OUT), 2) Affordable Fluoride 
Toothpaste (AFT), and 3) Atraumatic 
Restorative Treatment (ART). Its objectives 
are to address nonestablished market econ- 
omy (non-EME) countries that often have 
little access to basic emergency treatment 
and no organized system for the prevention 
of oral diseases. 

Oral Urgent Treatment 

This is the first step in primary health care 
(PHC) providing basic emergency care to 
meet the needs and conditions of each local 
population. It involves: 

• Extraction of teeth that cannot be saved 

• Treatment of postextraction complications 

• Drainage of abscesses 

• Palliative drug therapy 

• Trauma first aid 

Affordable Fluoride Toothpaste 

It has been demonstrated that it was not 
until the acceptance of mass preventive 
measures using fluorides that the incidence 
of caries started to decline in market econ- 
omy countries. The use of fluoride tooth- 
paste is considered to be the most efficient 
means of controlling dental caries, especially 
in developing countries without the re- 
sources for water or salt fluoridation. The 
following recommendations have been pro- 
posed by WHO planners: 

• Developing effective low-cost fluoride 

• Promotion campaign 

• Supervised daily tooth brushing with 
flouride toothpaste (1,000 ppm F) 

• Oral hygiene education 

Atraumatic Restorative Treatment 

This is the concept of caries removal and 
cavity preparation without a dental hand- 
piece, water or electricity. It uses hand in- 
strumentation with a minimum of instru- 
ments, glassionomer restorative materials, 
and trained dental auxiliaries. It makes 
restorative treatment more affordable, more 
available, and more accessible, meeting the 
requirements for primary health care for 
large, needy populations. Field studies on 
the technique were done in Tanzania, 
Malawi, Syria, Thailand, Zimbabwe, and 
Pakistan. When compared to conventional 
amalgam restorations, no statistically sig- 
nificant differences in survival rates were 
reported. 3 

It will take methods "other than those of 
affluent countries" to have the greatest im- 
pact in taking care of dental problems in 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 300 



countries where up to 90 percent of the pop- 
ulation is indigent. Murray Dickson in his 
book Where There Is No Dentist states, "Two 
things can greatly reduce the cost of ade- 
quate dental care: popular education about 
dental health, and the training of primary 
health workers as 'dental health promoters'. 
In addition numbers of community dental 
technicians' can be trained in 2 to 3 months 
(plus a period of apprenticeship) to care 
for up to 90 percent of the people who 
have problems of pain and infection." A 
university-trained dentist would be the sec- 
ondary line of care. Simpler more common- 
place procedures could be done in villages 
everywhere. Where a program such as this is 
in place already, these technicians have be- 
come quite skilled. 1 

What is also needed is the training of 
more auxiliary personel (local people) in sim- 
ple inexpensive preventive methods. Oral 
health progress will not be made by the un- 
modified transfer of skills, equipment, or per- 
sonnel. It should be adapted in each country, 
not just adopted from another country. 

In Dr. Thorpe's assessment, those out-of- 
country volunteers who come in to serve for 
a short time can combine with the BPOC 
(Basic Package of Oral Care) to increase the 

availability of needed services without im- 
posing concepts "modeled on those of afflu- 
ent countries." In Belize there is a two-year 
training program in a WHO facility for fe- 
male students who will then return to treat 
primary teeth only. This is a two-tier system, 
but one that is very appropriate for the con- 
ditions and needs in that country. This two- 
tier system is accepted by Guatemala, Ecua- 
dor, Papua New Guinea, and Mozambique. 
In these countries dentists train technicians 
that then do cleanings, extractions, fillings, 
work in schools, and help with health educa- 
tion. 5 The third component of the BPOC 
plan, the ART technique, has been in use in 
New Zealand for several years and in Cam- 
bodia, where dental nurses are being trained 
in its use (see Figure 1 1.6). A single dental 
school like theirs cannot train enough people 
to ever treat the large rural population. 

For example, oral health care is virtually 
nonexistent in rural areas in Pakistan, where 
more than 80 percent of the population live. 

Dr. Ayyaz Ali Khan is Coordinator of the 
National Oral Health Programme at the 
Ministry of Health in Pakistan. He has 
stated, "over the last two decades, it has been 
seen that the existing traditional oral health 
systems, focusing on restorative approaches, 

Figure 11-6. Regional training center for dental nurses in Kompong Cham, Cambodia. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 301 



staffed by highly qualified, highly paid per- 
sonnel using sophisticated technology have 
been unsuccessful in controlling the deterio- 
ration of oral health in developing countries. 
It would be unrealistic to assume that ade- 
quate resources will ever be available for the 
dental surgeons to perform traditional high 
tech dentistry In addition there will never be 
enough dentists in any developing country 
to provide these services to the whole popu- 
lation. Furthermore, auxiliaries provide serv- 
ices at locations where the dentist is not will- 
ing to go or live.' 

II. Levels of Assistance 

Without considering the preventative aspect 
of the second goal (Affordable Fluoride 
Toothpastes), there are basically two types of 
care that we (volunteer dentists) can deliver in 
third world countries: 1) relief of pain by ex- 
traction (Oral Urgent Treatment) and 2) fill- 
ing carious teeth and perhaps even teaching 
the Atraumatic Restorative Treatment proce- 
dures. As volunteers step into third-world sit- 
uations, these two types of care will be the 
primary emphasis for their expenditures and 
expertise. The sections that follow will elabo- 
rate on these and other elements of treat- 
ment. In fact, we will break down our treat- 
ment into three levels or approaches — from 
the most simple to the more sophisticated. 

Level One: Bush dentistry. Treatment in 
the wild with forceps to remove diseased 
teeth, thereby alleviating pain and in- 

Level Two: Dental care with the benefit of 
power and water. This may involve mo- 
bile units, multiple dentists, and auxiliary 
personnel. There may even be portable 
suction and/or x-rays along with oral hy- 
giene instruction for patients. The loca- 
tion could be a church or government 
building such as a school. 

Level Three: Permanent and ongoing facili- 
ties in a community set up by volunteers. 

This is obviously more desirable but more 
difficult to establish. When foreign den- 
tists are not there, care can be provided by 
local dentists who rotate in and out of the 
clinic. Hopefully, patient scheduling 
would be done by someone to maximize 
use and efficiency. 

At some point in their lives, many profes- 
sionals consider the skills and experience 
they have attained and want to expand their 
horizon to help others. The act of serving 
others to relieve pain and suffering without 
monetary return fulfills a desire to make the 
world a better place. Dental professionals are 
fortunate in that their dental skills can be 
adapted for use in underserved areas. Even 
dental specialists can be integrated into a 
team that can effectively treat and teach 
populations that otherwise would not be 

When an individual or team of volunteer 
dentists begins to treat patients in a village or 
town, there are certain invisible barriers that 
need to be recognized and overcome. These 
involve cultural differences, local taboos, sta- 
tus issues, and prevailing attitudes about for- 
eign visitors. This is usually accomplished 
quite easily if the volunteers know the lan- 
guage and talk to local leaders — asking ques- 
tions and explaining what their purpose and 
methods will be. Of more importance are 
some general principles that need to be fol- 
lowed. There are certain guidelines that 
apply to all volunteer activities in third- 
world communities. 

Dr. Jamie Robertson, who has vast experi- 
ence working in Vietnam, gives these obser- 

1 . Volunteers are there to augment existing 
programs, to enthuse and perhaps estab- 
lish local workers, to teach, to innovate 
and offer themselves as role models. 

2. Volunteer projects cannot and should not 
be the sole delivery system of some dental 
activity as ends in themselves. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 302 



3. Local ownership is essential for sustain- 

4. Projects should work on the KISS princi- 
ple (Keep It Simple Stupid). It is better to 
teach all health workers how to minimize 
cross-infection than to show one or two 
dentists advance techniques. 

5. One objective of any project is to make it 
redundant. The ideal way to do this is to 
equip local workers with skills and re- 



The American Dental Associations publi- 
cation, International Dental Volunteer 
Organizations: A Guide to Service and a 
Directory of Programs, also offers good in- 
sights for those looking for opportunities to 
serve. It discusses "Why Volunteer?," 'The 
Nature of Volunteer Work," 'Types of 
Projects," and "Organizations" that have for- 
eign projects. The ADA Directory currently 
lists 64 volunteer programs. The Academy of 
Dentistry International is the first organiza- 
tion listed with the stated purpose of elevat- 
ing dental care standards worldwide through 
continuing education. The last one on the 
list is World Medical Relief Inc. Their volun- 
teers collect supplies, equipment, and phar- 
maceuticals in response to requests from 
other organizations giving assistance. A 
group called World Concern is just one of 
many Christian organizations that is well 
known working in Africa, Asia, and Latin 

Operation Smile is an organization pro- 
viding reconstructive surgery and related 
dental treatment. Since Operation Smile's 
first mission to Bolivia in 1999, 789 children 
have been treated. In 2004 they were again 
in Bolivia for 10 days. Thirty- four volunteer 
team members including plastic surgeons, 
anesthesiologists, pediatricians, nurses, a den- 
tist, and speech therapists worked with a 
Bolivian team that screened 258 patients and 
treated HO. 8 

Many other organizations, not on the 
ADA list, have programs using volunteers for 

projects with agriculture, home building, 
water development, health, and so on. By 
using local project directors, populations 
with the greatest needs are recognized, and 
then volunteeer groups with resources and 
volunteers are invited to help. Many times 
they will organize missions to their projects 
with just dental personal. They plan all de- 
tails, arrange for patients, and provide other 
needed support. This type of dental treat- 
ment, especially in schools and churches 
where there is permanent water and power 
resources, allows more sophisticated dental 
procedures to be done. Also, it increases the 
possibility of return visits to that area to treat 
even more patients. 

When dental groups and individual den- 
tists partner with endowed humanitarian or- 
ganizations or foundations, both of them are 
more successful, and their mission state- 
ments are more likely to be accomplished. 
Choice, Chasqui Humanitarian, and Eagle- 
Condor are just a few. Another partner in 
many foreign projects is Rotary Inernational. 
When a local Rotary club unites with a 
foreign one, it brings together the needed 
expertise, the volunteers, and the people 
to make the arrangements on site. This is 
real synergism with the whole accomplish- 
ing more than the individual parts. See 
Figure 11.7. 

Level One 

There are many approaches to the successful 
treatment of third- world patients. Some have 
proven their worth over the years. On the 
most basic level of care, it can be bush den- 
tistry in the jungle with forceps only to alle- 
viate as much pain as possible. This fulfills 
the first goal of WHO's BPOC approach 
(OUT) for urgent care. There is also the op- 
portunity for oral hygiene instruction (OHI) 
and the possibility of training local villagers 
to continue doing some procedures. This 
is a Level One classification of volunteer in- 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 303 



Figure 11-7. Rotary International-sponsored project in Puerto Escondido, Mexico. 

There is an old saying "he that travels 
alone travels faster." Some feel that with 
large groups of people with inexperienced 
volunteers, accompanying baggage, and nec- 
essary dental equipment, problems are intro- 
duced that they would rather do without. In 
contrast, for those who want to travel light 
and do extractions in remote wilderness en- 
vironments, there are plenty of countries 
where this can be done. See Figure 1 1.8. 

There are also many opportunities for the 
"do it alone" dentist to tag along with hu- 
manitarian foundations, mentioned previ- 
ously, where other volunteers are working on 
their own nondental projects. In this situa- 
tion, a dentist and maybe a companion have 
the advantage of a location that not only 
needs their services but a support team to 
take care of travel arrangements and living 
accommodations without worry or responsi- 
bility for others. Many times, dental expedi- 
tion leaders with large teams feel like travel 

agents with the extra duties, taking away 
from their enjoyment of doing dentistry. 

One oral surgeon, Dr. Dan Bluth, exem- 
plifies this spirit of individual service. Since 
1993 he has serviced the poor in the north- 
ern section of the state of Chihuahua, 
Mexico. Once a month he is on a plane to El 
Paso, Texas. Picking up his car at the airport, 
he crosses the border and heads south to his 
first stop in Ascension at the DIF (Desarrollo 
Integral De La Familia.) This is an all-pur- 
pose facility set up and run by the wife of the 
state s President for Relief of the Poor. It pro- 
vides food, education, and counseling by a 
small staff and, once a month, a visit by a 
dentist. The word is sent out over the local 
radio station that the doctor will be there on 
a certain morning. People are ready and wait- 
ing when he arrives. Patients pay a small 
amount (based on their ability to pay), which 
helps out with the maintenance and the run- 
ning of other programs in the facility. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 304 



Figure 11-8. Dr. Harris Done treating a patient in Belize. 

At the first stop, 15 to 30 patients may be 
seen for extractions on a given day. While 
waiting for the anesthetic to work, a discus- 
sion on oral hygiene may take place. 
Obviously, it helps if the dentist and/or his 
assistant speak the language. In this case, the 
dentist speaks fluent Spanish. After a while 
and with goodbyes all around, he is off to 
the next little community of Janos. It is not 
as well suited to delivering dental care, and 
sometimes the word has not been spread 
that he will be there. Not to worry, though, 
he will be back next month. If this is the 

case, then he will just spend more time in 
the next city of Buenaventura. This time it is 
a Red Cross building with two ambulances 
in the driveway, but the treatment protocol 
is the same as in the other locations. The 
radio has been announcing his arrival, and 
patients are there ready to be seen by the 
Spanish-speaking gringo doctor from the 
United States. Many have been in before, 
and friendships have been previously estab- 
lished. The patients are calm knowing that 
the treatment will be almost painless. The 
doctor knows his job well. With ease and 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 305 



speed, the tooth or teeth are slipped out. 
Some comforting words are offered by the 
doctor, and gratitude is expressed by his pa- 
tients. Soon, it is time for the next town in 
line where similar procedures are done on 
many more patients. The last day on the cir- 
cuit would be Florez Margon. This town is 
situated near a river, and it is not uncom- 
mon for the local treatment facility to have 
been flooded. If so, the doctor would not be 
able to see patients that trip. 

When one looks at this schedule — once a 
month for 11 years: 12 X 11 = 144 trips 
with an average of 75 to 85 patients per trip. 
This equals approximately 11,520 people 
seen and treated with not only great skill but 
a lot of love and kindness. This dentist truly 
is someone who is showing compassion to 
less-fortunate fellow beings. 

Rendering one-on-one basic care is often 
the best environment for teaching a local 
person the skills necessary to treat their own 
people at a future time when a need arises 
but no one more qualified is there. Teofilo 
Cafiero, a Nivacle Indian in Abundancia, 
Paraguay, is a good example. He had some 
experience working in Asuncion in a hospi- 

tal. When visiting dentists came to treat tribe 
members in his village, he showed a lot of 
interest in what they were doing. He already 
was the village medic helping with pregnan- 
cies, calling for the ambulance, and dispens- 
ing some medications. In the course of the 
week-long clinic, he was trained in some 
basic fundamentals by a Spanish-speaking 
dentist (see Figure 11.9). (Teofilo was the 
only one that spoke Spanish, the native 
tongue being Nivacle.) In time and hope- 
fully with some more training, he will be 
able to adequately treat dental emergencies 
for his people. 

An approach that has proven successful 
for including native people in the oral health 
care of their villages includes several impor- 
tant steps: 

1 . Have communication with the govern- 
ment. Many times they will want the 
people to know that they approve and 
even are responsible for the good that is 
being done. 

2. When there is an in-country project man- 
ager of a humanitarian group, volunteers 
can use his or her knowledge to select a 

Figure 11-9. Teofilo Cafiero being coached by California dentist John Moffat. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 306 



local person who would have the interest 
to be trained. This person would likely 
have the trust of the people to possibly 
provide some simple care in the future or 
at least recognize danger signs of a life- 
threatening emergency 
3. In a week-long clinic, the new practi- 
tioner observes the dentist for a couple of 

4. Then he or she does some treating, and 
the dentist observes. 

5. Instruments are left in a kit to be used in 
a level of treatment that they feel they 
can handle (see Figure 11.10). 

6. By observing the use of boiling water and 
rubbing alcohol for instruments infection 
control is learned. 

Mobile Clinic 







Treatment Quad 






Patient sign-in 






Assisting table 

Filling materials 
Curing lights 
Instrument set-ups 


Patient flow 

Patient tables 

□ Mobile units 

Chart 11-1 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 307 



Figure 11-10. Emergency dental kit and manual left with a villager on missions by Dr. Roy Hammond. 

7. Small payments for services are encour- 
aged. This person s standard of living is 
raised as is his status in the community. 

8. Replacement items are sent when possible. 9 

Level Two 

Level Two treatment of the poor involves 
oral hygiene instruction, interceptive restora- 
tive care to prevent the otherwise inevitable 
loss of teeth, and, of course, extractions. 
Treatment is usually provided with the 
benefit of electricity and running water — 
generally using mobile/portable equipment. 
This level of treatment of necessity usually 
involves multiple doctors and auxiliary per- 
sonnel for optimum production. 

An organization that illustrates Level Two 
(giving more comprehensive operative treat- 
ment) is Ayuda Inc. See Figure 11.11. Ayuda 
means help in Spanish. This organization has 
a simple philosophy with the first premise 
being to "See as many patients and save as 
many teeth as possible." This is accom- 

plished with a model of patient care for ef- 
fectively utilizing equipment (see Table 1 1.2) 
and personnel. It is based on using a com- 
pressor and facility that can service modules 
of up to four operating stations. An example 
is the "Treatment Quad" using mobile A-dec 
units. It can be expanded to two modules 
(four units each) for a total of eight operat- 
ing stations. Although mobile chairs can be 
used, a typical setup would utilize school or 
church tables with the patient lying supine 
(see Chart 11-1). 

Ayudas second premise is: "You cant do 
all things for all people." (See Table 1 1.3.) 
Primary teeth are not restored on children. 
By focusing on and treating first and second 
molars in children age 6—12, this age group 
will have fewer carious lesions in permanent 
teeth. More of the "at risk" teeth that are re- 
stored will enable that child to perhaps keep 
a more lasting dentition into adulthood. 
Amalgam is the restorative material of 
choice. Maxillary anterior teeth are almost 
universally decayed in the older age groups. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 308 



Figure 11-11. An Ayuda Inc. clinic in Mexico with eight mobile units set up with two treatment quads. 

Table 11-2. Instruments and Supplies in Kit 

1 . Mouth mirrors (1 5) 

2. Explorers (15) 

3. Syringes, aspirating (3) 

4. Scalers, Ivory c-1 (1) 

5. Gracy curette 11-12(1) 

6. Filling instrument (1) 

7. Cotton pliers (15) 

8. Cement spatula (1) 

9. Elevators, straight #34 (3) 

1 0. Excavator, spoon (3) 

1 1 . Forceps, upper universal #1 50 (3) 

12. Forceps, lower universal #75 (3) 

13. Anesthetic, cement, needles, cotton rolls, and 

In some situations, they can be restored with 
composite restorations. These people, on 
whom anterior composites are done, are gen- 
erally also the same ones who will require 
some extractions in the posterior. 

Using this philosophy and physical setup, 
an ideal team would consist of the following 
personnel: Dentists (4-6), Hygienists (1-2), 
and Auxiliaries (7) for a total of 12-15 

Table 11-3. 


on Four Foreign Mission 






Number of: 


































Note: #1 = Phnom Penh, Cambodia, 2002; #2 = 
Abundancia, Paraguay, 2004; #3 = Chiclayo, Peru, 
2004; #4 = Puerto Escondido, Mexico, 1998. 

members. If an additional treatment quad 
were used, the total would be 26—28. This 
philosophy and equipment setup is very effi- 
cient with many patients screened, treated, 
and instructed daily. See Figure 11.12. 

Level Three 

Progressing to Level Three would add the in- 
corporation of local professionals that ob- 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 309 



Figure 11-12. Dr. Paul Fillmore utilizing a local assistant. 

serve and participate (treat) in clinics in poor 
areas (see Figures 11.13 and 11.14). 

These local people can be instructed in 
preventive, advanced, and newer procedures 
and many times get the vision on their own 
to continue with an out-reach program to 
the poor in their country. With motivated 
individuals like this, there can be more long- 
term benefits for more people. Other proj- 
ects can supplement these efforts as time 
goes on with the installation of new equip- 
ment or updating of existing dental chairs 
and units. There could be remodeling or 
building of new facilities or even establishing 
teaching programs in dental schools and 

Each level, whether one, two, or three, 
contributes in its own way to the general 
goal of decreasing dental disease in these 
countries. Each has its limitations and will 
also have its successes and failures. The chal- 
lenges can be overwhelming, but, at the 
same time, very rewarding for those going to 

developing nations to provide care. Many 
say that their first time was a life-changing 
experience. Their priorities and views of life 
and the world are changed. 

To see some of the components that go 
into Level Three projects, we can start with 
the second organization on the ADA list, the 
Academy of LDS Dentists. This is not a 
church organization but just members of a 
church (The Church of Jesus-Christ of 
Latter-day Saints) who have organized to 
give service. One of their projects will serve 
as a good example of incorporating resources 
and volunteers within the country to be 
visited with resources and volunteers from 
the visiting country. They combine into one 
continuing project that expands much like 
the ripples on the water when a stone is 
dropped. Sometimes viable humanitarian 
programs often begin quite by chance. 
Such is the case with the project described 
in the following case study in Tegucigalpa 
and Choluteca, Honduras. The sequence 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 310 

Figure 11-13. A professor at the University of Indonesia giving instructions during an outreach 

Figure 11-14. Students showing commitment to newfound knowledge of their teeth. 


2879_Koerner_Chap 11 4/17/06 1:27 PM Page 311 



of events in conducting this program were 
as follows: 

August 2003 

Academy members met Dr. Ramon 
Arguelles, Vice Dean of a Dental School, in 
Tegucigalpa Honduras. Need for dental care 
was discussed. It was decided that four goals 
should be set: 

1. Conduct a dental project in Choluteca in 
December for providing patient treat- 

2. Ship dental equipment and supplies to 
the dental school. 

3. Send hospital equipment to the hospital. 

4. Establish and maintain a permanent den- 
tal clinic at the dental school mainly for 
the purpose of treating the indigent but 
also for dentist/auxiliary education. 

November 2003 

A container of dental equipment, instru- 
ments, and supplies was shipped. Some hos- 
pital equipment was also included in the 

December 2003 

Forty-six volunteers including 5 general den- 
tists, 1 oral surgeon, and 1 5 pre-dental stu- 
dents treated patients in the hospital in 
Choluteca. At this time, Academy members 
and Dr. Arguelles were the main people in- 
volved in the project, but it gave these for- 
eign volunteers the opportunity to meet and 
become friends with many local dentists and 
community leaders. 

After the school finished renovating exist- 
ing rooms and installing the donated equip- 
ment, there would be a new dental clinic 
equipped with the following: seven new den- 
tal chairs, x-ray machines, compressors, and 
dental supplies. This new facility was to be 
used for the following: 

1 . A certified sixth-year residency program 
for 12 graduated dental students where 
they would fulfill their one-year govern- 
ment service requirement by treating the 

2. A dental assistant training program. 

3. A center for advanced learning and spe- 
cialty training. 

4. A staging area for future service projects 
for the community with treatment pro- 
vided by either local dentists or volunteers 
from abroad. 

5. Additional opportunities to increase rev- 
enue for the school. 

6. A program of continuing education by 
visiting dental educators (Academy of 
LDS Dentist or others). 

January to April 2004 

The dental equipment was installed. The 
renovations for the new clinic were com- 

May 3, 2004 

Academy members returned again for a 
week-long dental service project for indigent 
patients utilizing the new clinic as well as 
other departments in the school. Thirteen 
dentists, 2 dental assistants, and 12 pre- 
dental students treated 675 patients doing 
787 procedures. The visiting dentists pre- 
sented three lectures on basic oral surgery, 
endodontics, and periodontal surgery. That 
same week inauguration ceremonies were 
held and the new clinic was officially 

Planning and Preparing for 
Volunteer Service 

Many circumstances dictate the where, 
when, why, how, who, and what of a foreign 
dental mission. This applies to a single prac- 
titioner or a large group of volunteers. The 
project illustrating Level III from the preced- 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 312 



ing section can accomplish a considerable 
amount over time, but this may not always 
be possible or desired. 

Regardless of the Level (I, II, or III), if the 
kind of dentistry to be performed is not 
clearly understood by all team members with 
the proper preparation of equipment, instru- 
ments, and materials, the trip may not be as 
successful as anticipated. This being said, 
there should be contingent plans for not 
only emergencies but also for ample materi- 
als and supplies so that shortages don't arise. 
It should be made very clear what each team 
member should bring on the trip and what 
their duties will be. 

'Where" is determined by the particular 
needs of a country and you finding out 
about those needs. Projects have been started 
because of a chance encounter with someone 
on vacation or by hearing about another hu- 
manitarian trip. Many times local officials 
asking through friends request that a certain 
non-government organization (NGO) or 
other humanitarian group help them. The 
question always becomes one of logistics and 
viability. Is this place right for the effort to 
be expended? Are the recipients truly in 

'When," of course, is easy. A scheduled 
date needs to consider weather (not mon- 
soon season), availability of locals (not a hol- 
iday), and so on. 

'Why" is an easy and simple one, too. 
The underserved population of that country 
will not have dental treatment unless you 
and your colleagues provide it. 

'Who" has already been answered. "Who" 
is probably a population of indigenous peo- 
ple that needs help in all too many countries. 

"How" is the hardest one. How can vol- 
unteers from a foreign country best help 
them with the treatment of dental disease? 
This is where humanitarian partnering or- 
ganizations, usually with a native project 
leader in-country can be come into play. For 
example, there is one project in remote areas 
of the Dominican Republic that provides ex- 

odontia, operative (amalgam and light-cured 
composites), prosthetic (transitional partial 
dentures to replace maxillary anterior teeth), 
and preventive (toothbrushes and sealants) 
services to approximately 2,700 people each 
summer. These services are provided using 
totally portable equipment. The dental 
teams travel to a different rural village each 
day establishing their clinic in a school, 
church, or other suitable building. 
Dominican Republic dentists have begun 
providing similar services to the poor during 
the rest of the year, which is the ultimate so- 
lution to these problems. 8 

Conditions, of course, in foreign clinics 
will be far less than ideal and many times 
difficult. The importance of correct diagno- 
sis, correct cavity preparation, and proper 
surgical technique should be stressed. 
Infection control is important and needs to 
be emphasized. Certain things may have to 
be modified, however, and adapted to 
changing conditions. The most obvious 
deterrents for the best dentistry are as 

• Lighting. Head lamps are by far the most 
useful and dependable. 

• Communications between doctor and 
patient. At the very least one member of 
the team needs to speak the language. 
Even then, dental-related facts or post-op 
instructions may not be understood by the 
patient, depending on local dialects. 

• Lack of medication. Medications are 
usually brought by volunteers. 

• Equipment failure. Repair kits for units 
and other tools need to be included when 

• In addition, some other potentially trou- 
blesome areas are as follows: 

1 . Problem with dryness of field. 

2. Longer time needed to perform proce- 

3. Less than ideal patient positioning. 

4. Less help from chairside assistant. 

5. Long work hours. 

2879_Koerner_Chap 11 4/17/06 1:27 PM Page 313 



Table 11-4. Ayuda Foreign Clinic Armamentarium' 


Dental units 


Sterilization unit 


Curing light 



Operative setup 

Nine Instruments 


Amalgam carrier 



Cotton pliers 

Plastic instrument 





Operative, surgery 

# Instruments exam/anesthetic 


Aspirating syringe 
Mirror (exam) 
Explorer (exam) 

# Surgery setup 

Team Members/Assignments 




Patient education 

Patient education 

Note: #, number of each item needed. 
* Based on 4 mobile units, 4-5 dentists. 






Forceps lower-universals 









Elevator- large, and small straight, Potts 



Root-tip pick 






Periosteal elevator 



Scalpel and blades 


Needle holder 


Bone file 


Bite block 


Tissue scissors 




The equipment, instrument, and material 
list (see Tables 1 1.4 and 1 1.5.) will suffice as 
a checklist for anyone finding himself in 
charge of a foreign clinic. 

Another important step is to check the 
web page of the Centers for Disease Control 
for the immunizations required for the 
country to be visited (see Table 1 1.6). 

IV, Gaining a New Perspective 

There is an almost universal consensus from 
people returning from third world volun- 
teer missions that good things were accom- 
plished. Comments like "I learned so 
much," "I want to go back," "I wish I could 
have done more," "I love those people." It 
is a wonderful learning experience. It is too 

2879_Koerner_Chap 11 4/17/06 1:28 PM Page 314 



Table 11-5. Ayuda Foreign Clinic Material List 4 



Alloy (double spill) 

1 ,000 capsules 

Composite kit (anterior) 

1 00 applications 

Sealant kit 

1 00 patients 

Anesthetic (with epi.) 

1 ,000 cartridges 

(without epi.) 

200 cartridges 

Anesthetic (topical) 

2 jars 

Needles (27 ga L) 


(30 ga S) 


Burs (557, #2, #4, #8 rd.#1 2 fluted) 


50 each 

Gauze 2x2 


Cotton rolls 


Gloves (SML) 




Prophy angles/paste 


Evacuator tips 


Cold sterilizing solution 

1 gal 

Distilled water (sterilizer) 

5 gal 

Surface disinfectants (wipes) 

2 bottles 


1 bottle 

Wedges, matrix strips-bands 

Mixing pads, finishing strips 

Temporary cement, cotton pellets 

Base material, articulating paper 

Glass ionomer build-up mat 

1 box each 

* Quantities based on 4-5 days, 4 mobile units, 
4-5 dentists (40 patients/Dr./day = 800 patients). 

bad that more people can't have the oppor- 

It is also a time of personal growth and 
perhaps a changing of attitudes. The first 
trip leaves a sense of satisfaction and appreci- 
ation for the people and culture. With a sub- 
sequent visit there is usually a desire to not 
only treat and teach as before but to get to 
know the people better. After a few trips one 
really looks forward to returning to see good 
friends again. 

To share one of the author s surprising 
memories: A young girl was probably 1 1 or 
12 years old and looked pretty much the 
same as the others waiting to be examined 

Table 11-6. Centers for Disease Control 
Immunization Guidelines for Traveling to South 
America 2004 (subject to change*) 

• Hepatitis A or immune globulin (IG). 

• Hepatitis B if you might be exposed to blood (for 
example, health care workers), stay > 6 months in 
the region. 

• Rabies if you might be exposed to wild or do- 
mestic animals. 

• Typhoid, particularly if you are visiting developing 
countries in this region. 

• Yellow fever vaccination, if you will be traveling 
outside urban areas. 

• As needed booster doses for tetanus-diphtheria 
and measles. 

* See Centers for Disease Control Web site for 
vaccines required for the specific country to be 

and receive dental treatment by a visiting 
dental team. It was very hot and would be a 
very long day before all the people were 

The people who had traveled some dis- 
tance to be seen were wonderful, friendly, 
cooperative, and appreciated everything that 
was done for them. The village and country- 
side with their customs and way of life was a 
source of awe and admiration for the visi- 
tors. These foreigners appreciated the simple 
oneness with nature that they saw. 

Typically, the adults would have few teeth 
left. Many had been extracted; others had 
roots that were slowly being avulsed due to 
infection. Some patients had acute pain; oth- 
ers did not. The children were the main 
focus. How many of their teeth could be 
saved and how many would need extraction? 

At her age this girl would likely be the 
same as most of the others — never having 
seen a dentist, never having had any oral hy- 
giene instruction, and with lower first molars 
decayed probably too deep to be saved. 

"Abre la boca, por favor." (please open 
your mouth). "Grande" (wide) so that I can 
see." What a surprise. Her mouth wasn't typ- 

2879_Koerner_Chap 11 4/17/06 1:28 PM Page 315 



Figure 11-15. Children just arrived from the mountains for their first visit ever to the dentist. 

ical. There had been some home care, and all 
four first molars stood out because of large 
silver fillings in each one. These restorations 
had saved those teeth until now and hope- 
fully long into the future. Any dentist would 
be proud to have placed them under the cir- 
cumstances. "<;Que es esta, de donde 
vinieron esos tapitas, cuando?" (What is this, 
where did these fillings come from, and 
when?) Her proud answer, "Una dentista, 
como tu de America" (A dentist like you 
from America). "Hace dos anos." (It has 
been two years.) 10 

Here is another example: We can read the 
remarks of Fredrick Meyers from his 2000 
trip to Ollantaytambo in the Sacred Valley, 
Peru. This gives the reader not only an orga- 
nizational and procedural overview of a 
working foreign clinic, but also the insights 
and feelings of a compassionate dentist. 

'The clinic was set up in a church, and 
the children were transported in open trucks 
from the surrounding mountains (see Figure 


The first group of children would then ei- 

ther go into the diagnosis room or into a 
room to be taught dental and personal hy- 
giene. In dental hygiene there were instruc- 
tional pictures on the wall. Each person was 
taught about the causes of dental decay and 
prevention through brushing and flossing. 
Each patient was given a bag containing a 
toothbrush, toothpaste, and other useful 
items depending on their age group. 

From there they went into another room 
for diagnosis where a doctor examined their 
teeth and an assistant held a flashlight and 
recorded a list of teeth needing treatment. I 
was touched to see many of them (children) 
try to calm the fears of others. As I started 
working in diagnosis, I was heartbroken to 
see the condition of their little mouths. Most 
had rampant decay, and many had teeth 
with abscesses. A feeling of complete hope- 
lessness started to overcome my emotions, 
and I was at a loss on the best way to treat 
each patient with only minimal time allotted 
to each one. I was very unprepared for this. 

The patient would then go into another 
room to receive injections of local anesthetic. 

2879_Koerner_Chap 11 4/17/06 1:28 PM Page 316 



The patient would be placed into the next 
available spot and receive either fillings in 
permanent teeth or extractions of abscessed 
or painful teeth that were nonrestorable. 
Lastly, the younger patients without serious 
problems would go to an area to receive flu- 
oride treatments and then be ushered outside 
to wait for the ride home. 

In the center of the treatment room was a 
table set up with an amalgamator, curing 
light, and a variety of cements, liners, and 
materials for immediate use by the doctors. 
This helped because things they needed 
could be mixed and ready in an instant so 
the doctors and assistants didn't have to leave 
their workstations. Sterilization was set up in 
the kitchen area and was a marvel of effi- 
ciency. Like I said, the enthusiasm was in- 
credible, and work proceeded at a rapid 

The first day we were able to see 208 pa- 
tients, mostly children. By the end of the 
day volunteers had endured long hours and 
strenuous work. Our bodies cried out for 
rest and a good night s sleep, which came 
easily for most. 

The conversation at the dinner table was 
filled with great stories and experiences of 
how all of us had been touched that day. I 
never saw a decline of enthusiasm for the 
work nor had I ever seen a happier group of 

The next day was a repeat of the first in 
intensity only this time we received a real 
treat. A whole village of pure Inca native 
people was brought down by Jamie and 
Terry Figueroa. Many of these villages sur- 
vived the great conquest of the Spaniards 
and had preserved their cultures by living 
deep within the mountains at altitudes of 
13—14,000 feet. They all showed up dressed 
in their beautiful native dress causing great 
excitement in all of us. It was incredible to 
treat these people. Most didn't understand 
Spanish and spoke only Quechua, the native 
Inca language. 

The work was difficult for two reasons. 

First, the language barrier made it hard to 
build their confidence. Second, we all felt in- 
tense sadness due to their poor health condi- 
tion. One small child when asked how she 
felt and whether there was anything that 
bothered her answered, "At times my stom- 
ach hurts, and sometimes worms come out 
of my body." 

I was excited to observe the behavior and 
actions of children as they came in and 
climbed onto the table. From the way they 
walked and carried themselves to the way 
they interacted with us showed vast cultural 
differences. All had severely chapped cheeks 
and dry skin due to windburn. On their 
feet, they wore sandals. Their feet looked like 
dried leather caked with dirt and dried clay, 
and by the appearance, you would think 
they had never been washed. Everything 
they wore was made by hand — nothing hav- 
ing been purchased in a store. Their world 
was completely different from mine; still, 
they put their total trust in us. 

I don't remember a time in my life when 
I felt such an intense love and admiration for 
a people, all of whom were complete 
strangers. I was willing to do anything for 
them if given the chance. I was humbled to 
see the aura of contentment each had in 
spite of what appeared to us as poverty. 
These were happy people who suffered from 
physical hardships but loved life and their 
community and had a deep belief in their re- 
ligion and moral codes. I am sure that we 
have more to learn from them than they do 
from us. 

When we finished, we were honored with 
a presentation of native songs and dances 
prepared by the children. Once again, the 
emotion was intense, and I again marveled 
at the rich culture and pure joy emanating 
from these beautiful people. Experiences like 
this just don't exist in the Untied States. 

It was hard leaving Cuzco because I was 
leaving a series of experiences that would 
change my life forever (see Figure 1 1.6). This 
place will always be a spot in the world 

2879_Koerner_Chap 11 4/17/06 1:28 PM Page 317 



Figure 11-16. Craig Smith saying good-bye to grateful patients in the outpost of Samburg, Siberia. 

where many of my deepest feelings of love 
for my fellowman were cultivated. For a 
long time, I will remember and relive in 
my thoughts the joy that comes from true 
acts of charity performed by these dental 





Globalization has many facets — not the least 
of which should be recognition of the dis- 
parity that exists among nations. The world 
that has been described in this chapter waits 
for those who are willing to accept not only 
the challenges but also the innumerable re- 
wards that come from sharing needed skills 
and talents with others. 


1. S. Thope. Oral health in Africa. Developing 
Dentistry 5(1): 1.2004. 

2. C. Nackstad. Ferney Communique. March p. 3. 

3. J. E. Frencken, C. J. Holmgren, W. Helderman, 
H. van Palenstein. Basic package of oral care. 
WHO Collaborating Centre for Oral Health Care 
Planning and Future Scenarios. 

4. W Mautsch. The Berlin Oral Health 
Declaration — 10 Years Later: Where Are We 
Now? Developing Dentistry. 1/03 p. 2. 2003. 

5. M. Dickson. Where There Is No Dentist, 8th ed. 
Berkeley, California: The Hesperian Foundation. 
Introduction by D. Werner, p. 169. 1983. 

6. A. A. Khan. Oral Health Services in Developing 
Countries: A case for the Primary Health Care 
Approach. Developing Dentistry 5 (2). 2004. 
J. A. Robertson. McL. Unpublished paper. 
Volunteer Dental Projects, pp. 1-4. 
F. G. Serio., H. M. Cherrett. International Dental 
Volunteer Organizations: A Guide to Service and a 
Directory Of Programs. 2nd ed. Chicago, Illinois: 
American Dental Association, pp. 7, 18, 22, 44, 
52. 1993. 

9. R. A. Hammond. Author Interview. 2005. 

10. R. C. Smith. Ayuda-Inc. Newsletter. 2002. 

11. F. Meyers. Diary Peru 2000. 2004 Honduras 
Project Report to the IDS Academy. 2000. 



2879_Koerner_Index 4/17/06 1:28 PM Page 319 


Academy of LDS Dentists, 309 

Affordable Fluoride Toothpaste (AFT), 299 

Alveoplasty, 85 

Aneurysm, 293 

Anxiety, 9, 10, 222, 224, 228, 236, 239 

Antibiotics, 255, 268, 273 

Bactericidal, 262 

Bacteriostatic, 262 

Cephalosporin, 273 

Clindamycin, 274 

Erythromycin, 273 

Local delivery, 266 

Metronidazole, 274 

Penicillin, 268, 273 

Prophylaxis , 270 

Tetracycline, 274 

Inferior alveolar, 28 1 

Facial, 281 

Greater palatine, 28 1 

Lingual, 281 
Atraumatic Restorative Treatment (ART), 299 
Ayuda Organization, 307 


Aerobic, 258 

Anatomy, 256 

Anaerobic , 258, 261 

Characteristics, 255 

Gram negative, 259, 260, 262 

Gram positive, 259, 260 

Resistance, 257 

Spontaneous mutation, 257 

Plasmid transfer resistance, 257 
Basic Life Support (BLS), 13, 15 
Benzodiazepines, 228, 236 

Halcion (triazolam), 237, 238, 240, 245 

Valium (diazepam), 225 

Versed (midazolam), 237 

Ativan (lorazepam), 238 
Biologic width, 99, 121 

Aspiration, 209 

Brush, 207 

Excisional, 212 

Form for submission, 217 

Incisional, 212 

Needle, 210 

Instrument list for, 213 

Oral CDx, 207 
Bleeding, 12, 77, 133, 277 

History of, 282, 

Medications influencing, 283 

Nutrient canal, 288 

Post-operative, 291 

Prevention of, 281, 286 

Primary sources in oral cavity, 280 

Secondary, 292, 

Socket, 287 

Soft tissue, 286 

Disseminated Intravascular Coagulation (DIC), 

Hemophilia, 278 

Hypertension, 278 

Thrombocytopenia, 277 

von Willebrand s Disease, 278 
Bone removal, 19, 64, 73, 129, 

Cardiovascular disease, 10 
Chalazion forcep, 215 
Chemiluminescent diagnosis, 210 
Complications, 75, 133, 196 
Consent forms, 7, 57, 108, 109 

Dentist to population ratio, 298 

Dentures, 84 

Diabetes, 12 

Dry socket (alveolar osteitis), 76 

Emergency kit, 1 6 
Epilepsy, 12 
Epinephrine, 17, 163 
Epulis fissuratum, 90 

Indications, 20 


2879_Koerner_Index 4/17/06 1:28 PM Page 320 



Exodontia (continued) 
Multiple teeth, 42, 
Technique, 32, 33, 42, 46 

Federation Dentaire Internationale (FDI), 296 

Design, 26, 62, 71, 124, 167 

Envelope, 43, 63 

Scalloped, 169 

Trapezoidal (rectangular), 169 

Triangular (3-cornered) , 45, 64, 167, 168 
Force (controlled), 31 
Fractures (mandible, maxilla), 54, 79 
Frenectomy, 93, 96 

Gelfoam, 77 
Grafting, 96 
Gingivectomy, 114 
Gram staining, 259 

Health history, 201 

Hemangioma, 293 

Hemostatic gauze, 287 

HIPPA, 18 

Human Immunodeficiency Virus (HIV) , 280 

Incisions, 26, 62, 85, 115, 126, 167, 213 
Infection, 50, 76, 133, 255, 258, 259, 262, 264, 268, 

Lesions, 201 

History, 202 

Decision tree, 206 
Levels of Assistance (for 3rd world volunteers), 301 
Liver dysfunction, 11, 282 


Risk factors, 207 

Signs, 205 
Maxillary sinus, 23, 149 
Maxillary tuberosity, 86 
Medical history form, 4, 5, 150, 158, 281 
Microscope (surgical operating), 152 
Microsurgical instruments, 153 
Mineral Trioxide Aggregate (MTA), 191 
Mucocele, 208 

Nerve injury, 52, 55, 78, 
Nitrous oxide, 227, 229, 231 

Oral Urgent Treatment (OUT), 299 

Pain, 54, 76, 133 
Papillary hyperplasia, 92 
Planning for volunteer service, 311 
Patient Evaluation, 3, 5, 9, 81, 201 
Pericoronitis, 50 
Periotomes, 46 
Pregnancy, 13 
Pulse oximeter, 236 

Retrograde filling, 189 
Retropreparation, 184 
Ridge augmentation, 90 
Romazicon (flumazenil), 247 
Root resection, 176 
Root resorption, 5 1 
Root tips, 36, 39, 159 

SBE prophylaxis, 271 

Drugs ,225, 227 

Intravenous, 227 

Levels, 222 

Oral, 226 

Safety, 224 
Sounding bone, 115, 124, 
Speculoscopy, 210 
Super EBA cement, 1 90 
Surgical crown lengthening, 99, 
Surgicel, 44, 77, 287 
Suturing, 43, 46, 71, 130, 131, 133, 195 

Third molar impactions, 49, 58, 71 
Third world dental conditions, 295 
Tori, 90 
Treatment planning, 26, 83, 101 

Ultrasonic instruments, 138, 153 

ViziLite, 210 
Vestibuloplasty, 92 

World Dental Federation (WDF), 297 
World Health Organization (WHO), 297