Principles of

Complicated
Exodontia

Larry J. Peterson CHAPTER

CHAPTER OUTLINE
PRINCIPLES OF FLAP DESIGN, DEVELOPMENT, Technique for Open Extraction of Single-Rooted
AND MANAGEMENT Tooth
Design Parameters for Soft Tissue Flaps Types of Technique for Surgical Removal of Multirooted
Mucoperiosteal Flaps Technique for Developing a Teeth Removal of Small Root Fragments and Root
Mucoperiosteal Flap Principles of Suturing Tips Policy for Leaving Root Fragments
PRINCIPLES AND TECHNIQUES FOR SURGICAL MULTIPLE EXTRACTIONS
EXTRACTION Treatment Planning
Indications for Surgical Extraction Extraction Sequencing
Technique for Multiple Extractions

PRINCIPLES OF FLAP DESIGN, DEVELOPMENT,

he removal of most erupted teeth can be AND MANAGEMENT:
achieved by closed or forceps delivery, but
occasionally this technique does not suffice. The term local flap indicates a section of soft tissue that
The surgical, or open, extraction technique is the (1) is outlined by a surgical incision, (2) carries its own]
method used for recovering roots that were fractured blood supply, (3) allows surgical access to underlying tis-
during routine extraction or teeth and cannot be sues, (4) can be replaced in the original position, and (5]
extracted by the routine closed methods for a variety of can be maintained with sutures and is expected to heal,
reasons. In addition, removal of multiple teeth during Soft tissue flaps are frequently used in oral surgical,
one surgical session requires more than the routine periodontic, and endodontic procedures to gain access to
removal of teeth as described in Chapter 7. Small flaps underlying tooth and bone structures. To perform a tooth
are usually required for recontouring and smoothing extraction properly the dentist must have a clear under-
bone. standing of the principles of design, development, and
This chapter discusses techniques for surgical tooth management of soft tissue flaps.
extraction. The principles of flap design, development,
management, and suturing are explained, as are the Design Parameters for Soft Tissue Flaps
principles of surgical extraction of single-rooted and
multirooted teeth. Also discussed are the principles To provide adequate exposure and promote rapid healing,
involved in multiple extractions and concomitant the flap must be correctly designed. The surgeon must re-
alveoloplasty.

156
 FIG. 8-1 A, Flap must have base that is broader than free gingival margin. B, If flap is too narrow at
base, blood supply may be inadequate, which may lead to flap necrosis.

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

member that several parameters exist when designing a incision should extend one tooth anterior and one
flap for a specific situation. tooth posterior to the area of surgery (Fig. 8-2, 6).
When the flap is outlined, the base of the flap must usually The flap should be a full-thickness
be broader than the free margin to preserve an adequate blood mucoperiosteal flap. This means that the flap
supply. This means that all areas of the flap must have a includes the surface mucosa, submucosa, and
source of uninterrupted vasculature to prevent ischemic periosteum. Because the goal of the surgery is to
necrosis of the entire flap or portions of it (Fig. 8-1). remove or reshape the bone, all overlying tissue must
The flap must be of adequate size for several reasons. be reflected from it. In addition, full-thickness flaps
Sufficient soft tissue reflection is required to provide nec- are necessary because the periosteum is the primary
essary visualization of the area. Adequate access also must tissue responsible for bone healing, and replacement
exist for the insertion of instruments required to perform of the periosteum in its original position hastens that
the surgery. In addition, the flap must be held out of the healing process. In addition, torn, split, and macerated
operative field by a retractor that must rest on intact bone. tissue heals more slowly than a cleanly reflected, full-
There must be enough flap reflection to permit the retractor thickness flap.
to hold the flap without tension. Furthermore, soft tissue The incisions that outline the flap must be made
heals across the incision, not along the length of the over intact bone that will be present after the surgical
incision, and sharp incisions heal more rapidly than torn procedure is complete. If the pathologic condition has
tissue. Therefore a long, straight incision with adequate eroded the buccocortical plate, the incision must be at
flap reflection heals more rapidly than a short, torn inci- least 6 or 8 mm away from it. In addition, if bone is to
sion, which heals slowly by secondary intention. For an be removed over a particular tooth, the incision must
envelope flap to be of adequate size, the length of the flap be sufficiently distant from it so that after the bone is
the anteroposterior dimension usually extends two teeth removed, the incision is 6 to 8 mm away from the bony
anterior and one tooth posterior to the area of surgery defect created by surgery. If the incision line is
(Fig. 8-2, A). If a relaxing incision is to be made, the unsupported by sound bone,
 FIG. 8-3 A, When designing flap, it is necessary to anticipate how much bone will be removed so
that after surgery is complete, incision rests over sound bone. In this situation, vertical release was one
tooth anterior to bone removal and left an adequate margin of sound bone. B, When releasing inci-
sion is made too close to bone removal, delayed healing results.

It tends to collapse into the bony defect, which results Releasing incisions are used only when necessary and
in wound dehiscence and delayed healing (Fig. 8-3). not routinely. Envelope incisions usually provide the
The flap should be designed to avoid injury to local adequate visualization required for tooth extraction in
vital structures in the area of the surgery. The two most areas. When vertical-releasing incisions are
most important structures that can be damaged are necessary, only a single vertical incision is used, which
both located in the mandible; these are the lingual is usually at the anterior end of the envelope component.
nerve and the mental nerve. When making incisions in The vertical-releasing incision is not a straight vertical
the posterior mandible, especially in the region of the incision but is oblique, to allow the base of the flap to be
third molar, incisions should be well away from the broader than the free gingival margin. A vertical-releasing
lingual aspect of the mandible. In this area the lingual incision is made so that it does not cross bony
nerve may be closely adherent to the lingual aspect of prominences, such as the canine eminence. To do so would
the mandible, and incisions in this area may result in increase the likelihood of tension in the suture line, which
the severing of that nerve, with consequent prolonged would result in wound dehiscence.
temporary or permanent anesthesia of the tongue. In Vertical-releasing incisions should cross the free
the same way, surgery in the apical area of the gingival margin at the line angle of a tooth and should not
mandibular premolar teeth should be carefully be directly on the facial aspect of the tooth nor directly in
planned and executed to avoid injury to the mental the papilla (Fig. 8-4). Incisions that cross the free margin
nerve. Envelope incisions should be used if at all of the gin-giva directly over the facial aspect of the tooth
possible, and releasing incisions should be well do not heal properly because of tension; the result is a
anterior or posterior to the area of the mental nerve. defect in the attached gingiva. Because the facial bone is
Flaps in the maxilla rarely endanger any vital frequently quite thin, such incisions will also result in
structures. On the facial aspect of the maxillary vertical clefting of the bone. Incisions that cross the
alveolar process, no nerves or arteries exist that are gingival papilla damage the papilla unnecessarily and
likely to be damaged. When reflecting a palatal flap, increase the chances for localized periodontal problems;
the dentist must remember that the major blood such incisions should be avoided.
supply to the palatal soft tissue comes through the
greater palatine artery, which emerges from the
Types of Mucoperiosteal Flaps
greater palatine foramen at the posterior lateral aspect
of the hard palate. This artery courses forward and A variety of intraoral tissue flaps can be used. The most
has an anastomosis with the nasopalatine artery. The common incision is the envelope, or sulcular, incision,
nasopalatine nerves and arteries exit the incisive which produces the envelope flap. In the dentulous
foramen to supply the anterior palatal gingiva. If the patient the incision is made in the gingival sulcus to the
anterior palatal tissue must be reflected, both the crestal bone, through the periosteum, and the full-
artery and the nerve can be incised at the level of the thickness mucoperiosteal flap is apically reflected (see Fig.
foramen without much risk. The likelihood of 8-2, A). This usually provides sufficient access to perform
bothersome bleeding is small, and the nerve the necessary surgery.
regenerates quickly. The temporary numbness usually If the patient is edentulous, the envelope incision is
does not bother the patient. However, vertical- made along the scar at the crest of the ridge. No vital
releasing incisions in the posterior aspect of the structures are found in this area, and the envelope inci-
palate should be avoided, because they usually sever sion can be as long as is required to provide adequate
the greater palatine artery within the tissue, which access. The tissue can be reflected buccally or lingually as
results in bleeding that may be difficult to control. necessary for the removal of a mandibular torus.
 FIG. 8-4 A, Correct position for end of vertical-releasing incision is at line angle (mesiobuccal angle in
this figure) of tooth. Likewise, incision does not cross canine eminence. Crossing such bony promi-
nences results in increased chance for wound dehiscence. B, These two incisions are made incorrectly:
(1) incision crosses prominence over canine tooth, which increases risk of delayed healing; incision
through papilla results in unnecessary damage; (2) incision crosses attached gingiva directly over facial
aspect of tooth, which is likely to result in soft tissue defect and periodontal deformity.

If the envelope incision has a vertical-releasing inci-

sion, it is a three-cornered flap, with corners at the poste-
rior end of the envelope incision, at the inferior aspect of
the vertical incision, and at the superior aspect of the
vertical-releasing incision (Fig. 8-5). This incision pro-
vides for greater access with a shorter envelope incision.
When greater access is necessary in an apical direction,
especially in the posterior aspect of the mouth, this inci-
sion is frequently necessary. The vertical component is
more difficult to close and may cause some mildly pro-
longed healing, but if care is taken when suturing, the
healing period is not noticeably lengthened. FIG. 8-5 Vertical-releasing incision converts envelope incision
The four-cornered flap is an envelope incision with into three-cornered flap.
two releasing incisions. Two corners are at the superior
aspect of the releasing incision, and two corners are at
either end of the envelope component of the incision
(Fig. 8-6). Although this flap provides substantial access
in areas that have limited anteroposterior dimension, it is
rarely indicated. When releasing incisions are necessary, a
three-cornered flap usually suffices.
An incision that is used occasionally to approach the
root apex is a semilunar incision (Fig. 8-7). This incision
avoids trauma to the papillae and gingival margin but
provides limited access, because the entire root of the
tooth is not visible. This incision is most useful for peri-
apical surgery of a limited extent. The horizontal compo-
nent of the semilunar incision should not cross major
prominences, such as the canine eminence.
Two incisions are useful on the palate: The first is the FIG. 8-6 Vertical-releasing incisions at either end of envelope
Y incision, which is named for its shape. This incision is incision convert envelope incision into four-cornered flap.
useful for surgical access to the bony palate for removal
of a maxillary palatal torus. The tissue overlying the
torus is usually quite thin and must be reflected then rotates to fill a soft tissue defect in another area.
carefully. The anterolateral extensions of the midline The pedicled palatal flap is used primarily for closure
incision are anterior to the region of the canine tooth. of oroantral communications (see Chapter 19).
They are anterior enough in this position that they do
not sever major branches of the greater palatine artery; Technique for Developing a Mucoperiosteal Flap
therefore bleeding is not usually a problem (Fig. 8-8).
Another flap that is used occasionally on the palate is Several specific considerations are involved in
the pedicle flap. This flap mobilizes from one area and developing flaps for surgical tooth extraction. The
first step is to incise the soft tissue to allow
reflection of the flap. The
FIG. 8-7 Semilunar incision, designed to avoid marginal
attached gingiva when working on root apex. It is most useful
when only small amount of access is necessary.

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

The scalpel blade is an extremely sharp instrument,

but it dulls rapidly when it is pressed against bone, such
as when making a mucoperiosteal incision. If more than
one flap is to be reflected, the surgeon should change
blades between incisions.
If a vertical-releasing incision is made, the tissue is api-
cally reflected, with the opposite hand tensing the
alveolar mucosa so that the incision can be made
cleanly through it. If the alveolar mucosa is not tensed,
FIG. 8-8 Y incision is useful on palate for adequate access to the knife will not incise cleanly through the mucosa and
remove palatal torus. Two anterior limbs serve as releasing a jagged incision will result.
incisions to provide for greater access. Reflection of the flap begins at the papilla. The sharp
end of the Woodson elevator or the no. 9 periosteal ele-
vator begins a reflection (Fig. 8-12). The sharp end is
slipped underneath the papilla in the area of the
incision and turned laterally to pry the papilla away
from the underlying bone. This technique is used along
the entire extent of the free gingival incision. If it is
difficult to elevate the tissue at any one spot, the
incision is probably incomplete, and that area should be
reincised. Once the entire free edge of the flap has been
reflected with the sharp end of the elevator, the broad
end is used to reflect the mucoperiosteal flap to the
extent desired.
If a three-cornered flap is used, the initial reflection is
accomplished with the sharp end of the Woodson eleva-
tor on the first papilla only. Once the flap reflection is
started, the broad end of the periosteal elevator is insert-
ed at the middle corner of the flap, and the dissection is
FIG. 8-9 Scalpel handle is held in pen grasp for maximal carried out with a pushing stroke, posteriorly and apical-
control and tactile sensitivity. ly. This facilitates the rapid and atraumatic reflection of
no. 15 blade is used on a no. 3 scalpel handle, and it the soft tissue flap (Fig. 8-13).
is held in the pen grasp (Fig. 8-9). The blade is held Once the flap has been reflected the desired amount,
at a slight angle to the teeth, and the incision is made the periosteal elevator is used as a retractor to hold the
posteriorly to anteriorly in the gingival sulcus by flap in its proper reflected position. To accomplish this
drawing the knife toward the operator. One smooth effectively the retractor is held perpendicular to the bone
continuous stroke is used while keeping the knife tissue while resting on sound bone and not trapping soft
blade in contact with bone throughout the entire tissue between the retractor and bone. The periosteal
incision (Figs. 8-10 and 8-11). ele-
FIG. 8-11 A, Knife is angled slightly away from tooth and incises soft tissue, including periosteum, at crestal bone. B,
Incision is started posteriorly and is carried anteriorly, with care taken to incise completely through interdental papilla.

vator therefore is maintained in its proper position, and

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

Principles of Suturing
Once the surgical procedure is completed and the
wound properly irrigated and debrided, the surgeon
must return the flap to its original position or, if
necessary, arrange it in a new position; the flap should
be held in place with sutures. Sutures perform multiple FIG. 8-12 Reflection of flap is begun by using sharp end
functions. The most obvious and important function of periosteal elevator to pry away interdental papilla.
that sutures perform is to coapt wound margins; that is,
to hold the flap in position and approximate the two
wound edges. The sharper the incision and the less a generally oozing area, such as a tooth socket.
trauma inflicted on the wound margin, the more Overlying tissue should never be sutured tightly in an
probable is healing by primary intention. If the space attempt to gain hemostasis in a bleeding tooth socket.
between the two wound edges is minimal, wound Sutures help hold a soft tissue flap over bone. This
healing will be rapid and complete. If tears or is an extremely important function, because bone
excessive trauma to the wound edges occur, wound that is not covered with soft tissue becomes
healing will be by secondary intention. nonvital and requires an excessively long time to
Sutures also aid in hemostasis. If the underlying heal. When muco-periosteal flaps are reflected from
tissue is bleeding, the surface mucosa or skin should alveolar bone, it is important that the extent of the
not be closed, because the bleeding in the underlying bone be recovered with the soft tissue flaps. Unless
tissues may continue and result in the formation of a appropriate suture techniques are used, the flap may
hematoma. Sur-face sutures aid in hemostasis but only retract away from the bone, which exposes it and
as a tamponade in results in delayed healing.
 FIG. 8-13 When three-cornered flap is used, only anterior papilla FIG. 8-15 A, Figure-eight stitch, occasionally placed over top of
is reflected with sharp end of elevator. Broad end is then used with socket to aid in hemostasis. B, This stitch is usually performed to
push stroke to elevate posterosuperiorly. help maintain piece of oxidized cellulose in tooth socket.

Sutures are made of a wide variety of materials and

come in several sizes, each designed for a particular
purpose. The two basic types of suture material are (1)
resorbable (i.e., the body is capable of easily breaking the
material down) and (2) nonresorbable. In general,
resorbable sutures do not require removal, whereas
nonresorbable sutures do.
Three types of resorbable sutures are commonly used
for oral and maxillofacial surgery: (1) gut, (2) polyglycol-
ic acid, and (3) polyglactin. Gut is fabricated from the
submucosa of sheep intestines or the serosa of beef intes-
tines. Plain gut is susceptible to rapid digestions by pro-
teolytic enzymes produced by inflammatory cells. Treat-
ing the gut suture with basic chromium salts produces
chromic catgut, which is more resistant to proteolytic
enzymes. Plain gut sutures retain their strength for
approximately 5 days, whereas chromic gut sutures
maintain their strength for 7 to 9 days. Polyglycolic acid
and polyglactin sutures do not enzymatically break
FIG. 8-14 Periosteal elevator (Seldin elevator) is used to reflect down. Rather, they undergo slow hydrolysis, eventually
mucoperiosteal flap. Elevator placed perpendicular to bone and being resorbed by macrophages. Polyglycolic and
held in place by pushing firmly against bone, not by pushing it polyglactin sutures have the advantage of being less
apically against soft tissue. stiff than gut sutures and are more likely to remain tied.
However, they may last too long and are more costly
than gut sutures.
Sutures may aid in maintaining a blood clot in the
Resorbable sutures are highly reactive compared with
alveolar socket. A special stitch, such as a figure-eight
nonresorbable sutures; that is, resorbable sutures evoke
stitch, can provide a barrier to clot displacement (Fig.
an intensive inflammatory reaction that may impede
8-15). However, it should be emphasized that suturing
wound healing, occasionally to a clinically significant
across an open wound socket plays a minor role in
extent. This is the reason that neither plain nor chromic
maintaining the blood clot in the tooth socket.
gut is used for suturing the surface of a skin wound.
The armamentarium includes a needle holder, a
The most commonly used nonresorbable sutures in
suture needle, and suture material. The needle holder
oral and maxillofacial surgery are silk, nylon, polyester,
of choice is 15 cm in length and has a locking handle.
and polypropylene. Nonresorbable sutures are either
It is held with the thumb and ring finger through the
monofilament or multifilament. The multifilament form
rings and with the index finger along the length of the
increases the strength of the suture, but also increases
needle holder to provide stability and control (Fig. 8-
suture abrasiveness and is more likely to allow bacteria to
16).
"wick" into the wound. Silk and polyester sutures are
The suture needle usually used in the mouth is a
available only in multifilament form. Polypropylene is
small three-eighths to one-half circle with a reverse
produced only as a monofilament, whereas nylon comes
cutting edge. The cutting edge helps the needle pass
as both a monofilament and a multifilament form.
through the relatively tough mucoperiosteal flap.
Needle sizes and shapes have been assigned numbers. All nonresorbable sutures have some reactivity. Of the
The most common needle shapes used for oral surgery commonly used nonresorbable sutures, silk revokes the
are the FS-2 and X-l (Fig. 8-17). most intensive inflammatory reaction and nylon is
the least reactive. In situations in which it is important to
 FIG. 8-16 Needle holder is held with thumb and ring finger. Index finger extends along instrument for stability and
control.

minimize wound inflammation, such as any facial lacer- are difficult to learn. The following discussion
ation, nylon is usually the cutaneous suture of choice. presents the technique used in suturing; practice is
Sutures are available in various sizes that range from the necessary before suturing can be performed with skill
largest diameter, 7, down to the smallest extremely fine and finesse.
suture size, 11-0. The increasing number of 0's correlates When the envelope flap is repositioned into its
with decreasing suture diameter and strength. For exam- correct location, it is held in place with sutures that
ple, size 1-0 suture is larger in diameter than size 2-0, size are placed through the papillae only. Sutures are not
3-0 is larger than 7-0, etc. Because suture material is foreign placed across the empty tooth socket, because the
to the human body, the smallest diameter of suture suffi- edges of the wound would not be supported over
cient to keeping a wound closed properly should be used. sound bone (Fig. 8-18). When reapproximating the
Generally the size of the suture is chosen to correlate with flap, the suture is passed first through the mobile
the tensile strength of the tissue being sutured. Most oral (usually facial) tissue; the needle is regrasped with the
and maxillofadal surgeons use 3-0 or 4-0 suture. needle holder and passed through the attached tissue
The technique used for suturing is deceptively diffi- of the lingual papilla. If the two margins of the wound
cult. The use of the needle holder and the technique that are close together, the experienced surgeon may be
is necessary to pass the curved needle through the tissue able to insert the needle through both sides of the
wound in a single pass. However, it is best to use two
passes in most situations (Fig. 8-19).
FIG. 8-17 Needle used in oral surgery is 3/8-circle cutting needle. FIG. 8-18 A, Flap held in place with sutures in papillae. B, Cross-
Middle needle is FS-2, and tower needle is X-1. sectional view of suture.

When passing the needle through the tissue, the nee- If a three-cornered flap is used, the vertical end of the
dle should enter the surface of the mucosa at a right incision must be closed separately. Two sutures usually
angle, to make the smallest possible hole in the mucosal are required to close the vertical end properly. Before the
flap (Fig. 8-20). If the needle passes through the tissue sutures are inserted, the Woodson periosteal elevator
obliquely, the suture will tear through the surface layers should be used to elevate slightly the nonflap side of the
of the flap when the suture knot is tied, which results in incision, freeing the margin to facilitate passage of the
greater injury to the soft tissue. needle through the tissue (Fig. 8-22). The first suture is
When passing the needle through the flap, the sur- placed across the papilla, where the vertical release inci-
geon must ensure that an adequate bite of tissue is taken, sion was made. This is a known, easily identifiable land-
to prevent the suture from pulling through the soft tissue mark that is most important when repositioning a three-
flap. Because the flap that is being sutured is a muco- cornered flap. The remainder of the envelope portion of
periosteal flap and should not be tied tightly, a relatively the incision is then closed, after which the vertical com-
small amount of tissue is necessary. The minimal amount ponent is closed. The slight reflection of the nonflap side
of tissue between the suture and the edge of the flap of the incision greatly eases the placing of sutures.
should be 3 mm. Once the sutures are passed through The sutures are left in place for approximately 5 to 7
both the mobile flap and the immobile lingual tissue, days. After this time they play no useful role and, in fact,
they are tied with an instrument tie (Fig. 8-21). probably increase the contamination of the underlying sub-
The surgeon must remember that the purpose of the mucosa. When sutures are removed, the surface debris that
stitch is merely to reapproximate the tissue, and therefore has collected on them should be cleaned off with a cotton-
the suture should not be tied too tightly. Sutures that are tipped applicator stick soaked in peroxide, chlorhexidine,
too tight cause ischemia of the flap margin and result in iodophor, or other antiseptic solution. The suture is cut
tissue necrosis, with tearing of the suture through the tis- with sharp, pointed suture scissors and removed by pulling
sue. Thus sutures that are too tightly tied result in wound it toward the incision line (not away from the suture line).
dehiscence more frequently than sutures that are loosely Sutures may be configured in several different ways.
tied. As a clinical guideline, there should be no blanching The simple interrupted suture is the one most commonly
or obvious ischemia of the wound edges. If this occurs the used in the oral cavity. This suture simply goes through
suture should be removed and replaced. The knot should one side of the wound, comes up through the other side
be positioned so that it does not fall over the incision of the wound, and is tied in a knot at the top. These
line, because this causes additional pressure on the inci- sutures can be placed relatively quickly, and the tension
sion. Therefore the knot should be positioned to the side on each suture can be adjusted individually. If one suture
of the incision. is lost, the remaining sutures stay in position.
FIG. 8-19 When mucosal flap is back in position, suture is passed through two sides of socket in separate passes
of needle. A, Needle is held by needle holder and passed through papilla, usually of mobile tissue first. B, Needle
holder is then released from needle; it regrasps needle on underside of tissue and is turned through flap. C,
Needle is then passed through opposite side of soft tissue papilla in similar fashion. D, Finally, needle holder
graspsneedle on opposite side to complete passing of suture through both sides of mucosa.

FIG. 8-20 A, When passing through soft tissue of mucosa, needle should enter surface of
tissue at right angle. B, Needle holder should be turned so that needle passes easily through
tissue at right angles. C, If needle enters soft tissue at acute angle and is pushed (rather than
turned) through tissue, tearing of mucosa with needle or with suture is likely to occur (D).
FIG. 8-21 Most intraoral sutures are tied with instrument tie. A, Suture is pulled through tissue
until short tail of suture (approximately 1 1/2 to 2 inches long) remains. Needle holder is held
horizontally by right hand in preparation for knot-tying procedure. B, Left hand then wraps
long end of suture around needle holder twice in clockwise direction to make two loops of
suture around needle holder. C, Surgeon then opens needle holder and grasps short end of
suture near its end. D, Ends of suture are then pulled to tighten knot. Needle holder should
not pull at all until knot is nearly tied, to avoid lengthening that portion of suture. E, End of first
step of surgeon's knot. The double wrap has resulted in double overhand knot. This increases
friction in knot and will keep wound edges together until second portion of knot is tied. F,
Needle holder is then released from short end of suture and held in same position as when
knot-tying procedure began. Left hand then makes single wrap in counter-clockwise direction.
Continued
FIG. 8-21—cont'd G, Needle holder then grasps short end of suture at its end. H, This portion of knot is completed by
pulling this loop firmly down against previous portion of knot. I, This completes surgeon's knot. Double loop of first pass
holds tissue together until second portion of square knot can be tied. J, Most surgeons add third throw to their instrument
tie. Needle holder is repositioned in original position, and one wrap is placed around needle holder in original clockwise
direction. Short end of suture is grasped and tightened down firmly to form second square knot. Final throw of three
knots is tightened firmly.

A suture technique that is useful for suturing two closed extraction. Forceps extraction techniques that
papillae with a single stitch is the horizontal mattress require great force may result not only in removal of
suture (Fig. 8-23). A slight variation of that suture is the the tooth but also of large amounts of associated bone
figure-eight suture, which holds the two papilla in posi- and occasionally the floor of the maxillary sinus (Fig.
tion and puts a cross over the top of the socket so that 8-25). The bone loss may be less if a soft tissue flap is
may help hold the blood clot in position (see Fig. 8- reflected and a proper amount of bone removed; it may
15). also be less if the tooth is sectioned- The morbidity of
If the incision is long, continuous sutures can be fragments of bone that are literally torn from the jaw
used efficiently. When using this technique, a knot by the conservative closed technique exceeds by far
does not have to be made for each stitch, which makes it the morbidity of controlled surgical extraction.
quicker to suture a long-span incision. The continuous
simple suture can be either locking or nonlocking (Fig. 8-
24). The horizontal mattress suture also can be used in a Indications for Surgical Extraction
running fashion. A disadvantage of the continuous It is prudent for the surgeon to evaluate carefully
suture is that if one suture pulls through, the entire each patient and each tooth to be removed for the
suture line becomes loose. possibility of an open extraction. Although the vast
majority of decisions will be to perform a closed
PRINCIPLES AND TECHNIQUES extraction, the surgeon must be aware continually that
FOR SURGICAL EXTRACTION open extraction may be the less morbid of the two.
Surgical extraction of an erupted tooth is a technique As a general guideline, surgeons should consider
that should not be reserved for the extreme situation. A performing an elective surgical extraction when they
prudently used open extraction technique may be more perceive a possible need for excessive force to extract a
conservative and cause less operative morbidity than a tooth.
 FIG. 8-23 A, Horizontal mattress suture is sometimes used to close
soft tissue wounds. Use of this suture decreases number of individ-
ual sutures that have to be placed; however, more importantly, it
FIG. 8-22 A, To make the suturing of three-cornered flap easier, compresses wound together slightly and everts wound
Woodson elevator is used to elevate small amount of fixed tissue edges. B, Single horizontal mattress suture can be placed across
so that suture can be passed through entire thickness of both papillae of tooth socket and serves as two individual sutures.
mucoperios-teum. B, When three-cornered flap is repositioned,
first suture is placed at occlusal end of vertical-releasing incision.
Papillae are then sutured sequentially, and finally, if necessary, it is likely that the teeth are surrounded by dense, heavy
superior aspect of releasing incision is sutured.
bone with strong periodontal ligament attachment (Fig.
8-26). The surgeon should exercise extreme caution if
The term excessive means that the force will probably removal of such teeth is attempted with a closed tech-
result in a fracture of bone, a tooth root, or both. In nique. An open technique usually results in a quicker,
any case the excessive bone loss, the need for easier extraction.
additional surgery to retrieve the root, or both can Careful review of the preoperative radiographs may
cause undue morbidity. The following are examples of reveal tooth roots that are likely to cause difficulty if the
situations in which closed extraction may require tooth is extracted by the standard forceps technique.
excessive force.
The dentist should strongly consider performing an One condition commonly seen among older patients is
open extraction after initial attempts at forceps hyper-cementosis. In this situation, cementum has
extraction have failed. Instead of applying continued to be deposited on the tooth and has formed a
unnecessarily great amounts of force that may not be large bulbous root that is difficult to remove through the
controlled, the surgeon should simply reflect a soft available tooth socket opening. Great force used to
tissue flap, section the tooth, remove some bone, and expand the bone may result in fracture of the root or
extract the tooth in sections. In these situations the buccocortical bone and in a more difficult extraction
philosophy of "divide and conquer" results in the procedure (Fig. 8-27).
most efficient extraction. Roots that are widely divergent, especially the
If the preoperative assessment reveals that the maxillary first molar roots (Fig. 8-28) or roots that have
patient has heavy or especially dense bone, severe dilaceration or hooks, also are difficult to remove
particularly on the buccocortical plate, surgical without fracturing one or more of the roots (Fig. 8-29).
extraction should be considered. The extraction of By reflecting a soft tissue flap and dividing the roots
most teeth depends on the expansion of the prospectively with a bur, a more controlled and planned
buccocortical plate. If this bone is especially heavy, extraction can be performed and will result in less
then adequate expansion is less likely to occur and morbidity overall.
fracture of the root is more likely. Dense bone in the If the maxillary sinus has expanded to include the
older patient warrants even more caution. roots of the maxillary molars, extraction may result in
removal of a portion of the sinus floor along with the
Whereas young patients have bone that is more
tooth. If the roots are divergent, then such a situation is
elastic and more likely to expand with controlled
even more likely to occur (Fig. 8-30).
force, older patients usually have denser, more highly
Teeth that have crowns with extensive caries,
calcified bone that is less likely to provide adequate
especially root caries, or that have large amalgam
expansion during luxation of the tooth.
restorations are candidates for open extraction (Fig. 8-
Occasionally, the dentist treats a patient who has
31). Although the root primarily grasps the tooth, a
very short clinical crowns with evidence of severe
portion of the force is applied to the crown. Such
attrition. If such attrition is the result of bruxism (a
pressures can crush and shat-
grinding habit),
 FIG. 8-24 When multiple sutures are to be placed, incision can be closed with running or continuous
suture. A, First papilla is closed and knot tied in usual way. Long end of suture is held, and adjacent
papilla is sutured, without knot being tied but just with suture being pulled firmly through tissue. B,
Succeeding papillae are then sutured until final one is sutured and final knot is tied. Final appearance is
with suture going across each empty socket. C, Continuous locking stitch can be made by passing long
end of suture underneath loop before it is pulled through tissue. D, This puts suture on both deep
periosteal and mucosal surfaces directly across papilla and may aid in more direct apposition of tissues.

ter the crowns of teeth with extensive caries or large

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

Technique for Open Extraction of

Single-Rooted Tooth
The technique for open extraction of a single-rooted
tooth is relatively straightforward but requires
attention to detail, because several decisions must be
made during the operation. Single-rooted teeth are
those that have resisted attempts at closed extraction or
that have fractured at the cervical line and therefore
exist only as a root. The technique is essentially the
same for both. FIG. 8-25 Forceps extraction of these teeth resulted in removal
The first step is to provide adequate visualization and of bone and tooth, instead of just tooth.
access by reflecting a sufficiently large mucoperiosteal
flap. In most situations an envelope flap that is extended reseat the extraction forceps under direct
two teeth anterior and one tooth posterior to the tooth visualization and therefore achieve a better
to be removed is sufficient. If a releasing incision is mechanical advantage and remove the tooth with no
necessary, it should be placed at least one tooth anterior bone removal at all (Fig. 8-32). The second option is
to the extraction site (see Fig. 8-2). to grasp a bit of buccal bone under the buccal beak
Once an adequate flap has been reflected and is of the forceps to obtain a better mechanical advantage
held in its proper position by a periosteal elevator, the and grasp of the tooth root. This may allow the
surgeon must determine the need for bone removal. surgeon to luxate the tooth sufficiently to remove it
Several options are available: First, the surgeon may without any additional bone removal (Fig.
attempt to
 FIG. 8-26 Teeth that exhibit evidence of bruxism may have denser
bone and stronger periodontal ligament attachment, which make
them more difficult to extract.

FIG. 8-29 Severe dilaceration of roots may result in fracture of root

unless surgical extraction is performed.

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

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

8-33). A small amount of buccal bone is pinched off and

removed with the tooth.
The third option is to use the straight elevator as a
shoehorn elevator by forcing it down the periodontal lig-
ament space of the tooth (Fig. 8-34). The index finger of
the surgeon's hand must support the force of the elevator
so that the total movement is controlled and no slippage
of the elevator occurs. A small wiggling motion should be
used to help expand the periodontal ligament space,
which allows the small straight elevator to enter the
space and act as a wedge to displace the root occlusally.
The fourth and final option is to proceed with bone
removal over the area of the tooth. The surgeon who
FIG. 8-28 Widely divergent roots increase likelihood of fracture makes the decision to remove some buccal bone from the
of bone, tooth root, or both.
 FIG. 8-32 Small envelope flap can be reflected to expose
fractured root. Under direct visualization, forceps can be seated
more apically into periodontal ligament space, which eliminates
need for bone removal.

FIG. 8-31 Large caries or large restorations may lead to fracture

of crown of tooth and therefore to more difficult extraction.

tooth may use either the bur or the chisel. If the bone is
thin, a chisel is convenient and frequently requires
hand pressure only. However, most surgeons currently
prefer a bur to remove the bone. The width of buccal
bone that is removed is essentially the same width as
the tooth in a mesiodistal direction (Fig. 8-35). In a
vertical dimension, bone should be removed
approximately one-half to two-thirds the length of the
tooth root (Fig. 8-36). This amount of bone removal
sufficiently reduces the amount of force necessary to
displace the tooth and makes removal relatively easy.
Either a small straight elevator (Fig. 8-37) or a forceps
can be used to remove the tooth (Fig. 8-38).
If the tooth is still difficult to extract after removal of
bone, a purchase point can be made in the root with the
bur at the most apical portion of the area of bone
removal (Fig. 8-39). This hole should be about 3 mm in
diameter and depth to allow the insertion of an
instrument. A heavy elevator, such as a Crane pick, can
be used to elevate or lever the tooth from its socket (Fig.
8-40, A). The soft tissue is repositioned and sutured (Fig.
8-40, B).
The bone edges should be checked; if sharp, they
should be smoothed with a bone file. By replacing the FIG. 8-33 If root is fractured at level of bone, buccal beak of
forceps can be used to remove small portion of bone at same
soft tissue flap and gently palpating it with a finger, the
time that it grasps root.
clinician can check edge sharpness. Removal of
bone
 FIG. 8-34 Small straight elevator can be used as shoehorn to lux- FIG. 8-37 Once appropriate amount of buccal bone has been
ate broken root. When straight elevator is used in this position, hand removed, shoehorn elevator can be used down palatal aspect of
must be securely supported on adjacent teeth to prevent inadver- tooth to displace tooth root in buccal direction. It is important to
tent slippage of instrument from tooth and subsequent injury to remember that when elevator is used in this direction, surgeon's
adjacent tissue. hand must be firmly supported on adjacent teeth to prevent slip-
page of instrument and injury to adjacent soft tissues.

FIG. 8-35 When removing bone from buccal surface of tooth or

tooth root to facilitate removal of that root, mesiodistal width
of bone removal should be approximately same as mesiodistal
dimension of tooth root itself. This allows unimpeded path for
removal of root in buccal direction.

FIG. 8-36 Bone is removed with bone-cutting bur after

reflection of standard envelope flap. Bone should be removed FIG. 8-38 After bone has been removed and tooth root luxated
approximately one half to two thirds length of tooth root. with straight elevator, forceps can be used to remove root.
FIG. 8-39 If tooth root is quite solid in bone, buccal bone can
be removed and purchase point made for insertion of elevator.

with a rongeur is rarely indicated, because it tends to

remove too much bone.
Once the tooth is delivered, the entire surgical field
should be thoroughly irrigated with copious amounts of
saline. Special attention should be directed toward the
most inferior portion of the flap (where it joins the
bone), because this is a common place for debris to set-
tle, especially in mandibular extractions. If the debris is
not removed carefully by curettage or irrigation, it can
cause delayed healing or even a small subperiosteal
abscess in the ensuing 3 to 4 weeks. The flap is then
FIG. 8-40 A, Stout elevator, such as Crane pick, is then
set in its original position and sutured into place with
inserted into purchase point, and tooth is elevated from its
3-0 black silk sutures. If the incision were properly socket. B, The flap is repositioned and sutured over intact bone.
planned and executed, the suture line will be
supported on sound, intact bone.
ment for access and personal preference dictate.
Technique for Surgical Removal of Multirooted Teeth Evaluation of the need for sectioning roots and
removing bone is made at this stage, as it was with
If the decision is made to perform an open extraction the single-rooted tooth. Occasionally, forceps,
of a multirooted tooth, such as a mandibular or elevators, or both are positioned with direct
maxillary molar, the same surgical technique used for visualization to achieve better mechanical advantage
the single-rooted tooth is generally used. The major and to remove the tooth without removing the bone.
difference is that the tooth may be divided with a bur However, in most situations a small amount of
to convert a multirooted tooth into several single- crestal bone should be removed, and the tooth should
rooted teeth. If the crown of the tooth remains intact, be divided. Tooth sectioning is usually
the crown portion is sectioned in such a way as to accomplished with a straight hand piece with a
facilitate removal of roots. However, if the crown straight bur, such as the no. 8 round bur, or with a
portion of the tooth is missing and only the roots fissure bur, such as the no. 557 or no. 703 bur (Fig. 8-
remain, the goal is to separate the roots to make them 42, C).
easier to remove with elevators. Once the tooth is sectioned, the small straight
Removal of the lower first molar with an intact elevator is used to luxate and mobilize the sectioned
crown is usually done by sectioning the tooth roots (Fig. 8-42, D). The straight elevator may be used
buccolingually and thereby dividing the tooth into a to deliver the mobilized sectioned tooth (Fig. 8-42, E).
mesial half (with mesial root and half of the crown) and If the crown of the tooth is sectioned, upper or lower
a distal half. An envelope incision is also made, and a universal forceps is used to remove the individual
small amount of crestal bone is removed. Once the portions of the sectioned tooth (Fig. 8-42, F). If the
tooth is sectioned, it is luxated with straight elevators to crown is missing, then straight and triangular
begin the mobilization process. The sectioned tooth is elevators are used to elevate the tooth roots from the
treated as a lower premo-lar tooth and is removed with sockets.
a lower universal forceps (Fig. 8-41). The flap is Sometimes, a remaining root may be difficult to
repositioned and sutured. remove, and additional bone removal (as is described for
The surgical technique begins with the reflection of a single-rooted tooth) may be necessary. Occasionally, it
an adequate flap (Fig. 8-42, A and B). The surgeon is necessary to prepare a purchase point with the bur and
selects either an envelope or three-cornered flap as the to use an elevator, such as the Crane pick, to elevate the
require- remaining root.
FIG. 8-41 If lower molar is difficult to extract, it can be sectioned into single-rooted teeth. A, Envelope incision is reflected, and
small amount of crestal bone is removed to expose bifurcation. Drill is then used to section the tooth into mesial and distal
halves. B, Lower universal forceps is used to remove two crown and root portions separately.

After the tooth and all the root fragments have been prudently by dividing the root into several sections.
removed, the flap is repositioned and the surgical area This three-rooted tooth must be divided in a pattern
palpated for sharp bony edges. If any are present, they different from that of the two-rooted mandibular
are smoothed with a bone file. The wound is molar. If the crown of the tooth is intact, the two buccal
thoroughly irrigated and debrided of loose fragments of roots are sectioned from the tooth and the crown is
tooth, bone, calculus, and other debris. The flap is removed along with the palatal root.
repositioned again and sutured in the usual fashion The standard envelope flap is reflected, and a small
(Fig. 8-42, G). portion of crestal bone is removed to expose the trifurca-
An alternative method for removing the lower first tion area. The bur is used to section off the mesiobuccal
molar is to reflect the soft tissue flap and remove and distobuccal roots (Fig. 8-45, A). With gentle but firm
sufficient buccal bone to expose the bifurcation. Then bucco-occlusal pressure, the upper molar forceps delivers
the bur is used to section the mesial root from the tooth the crown and palatal root along the long axis of the
and convert the molar into a single-rooted tooth (Fig. root (Fig. 8-45, B). No palatal force should be delivered
8-43). The crown with the mesial root intact is with the forceps to the crown portion, because this
extracted with no. 17 lower molar forceps. The results in fracture of the palatal root. The entire
remaining mesial root is elevated from the socket with a delivery force should be in the buccal direction. A
Cryer elevator. The elevator is inserted into the empty small straight elevator is then used to luxate the buccal
tooth socket and rotated, using the wheel-and-axle roots (Fig. 8-45, C), which can then be delivered either
principle. The sharp tip of the elevator engages the with a Cryer elevator used in the usual fashion (Fig. 8-
cementum of the remaining root, which is elevated 45, D) or with a straight elevator. If straight elevators are
occlusally from the socket. If the interradicular bone is used, the surgeon should remember that the maxillary
heavy, the first rotation or two of the Cryer elevator sinus might be very close to these roots, so apically
removes the bone, which allows the elevator to engage directed forces must be kept to a minimum and
the cementum of the tooth on the second or third carefully controlled. The entire force of the straight
rotation. elevator should be in a mesiodistal direction, and slight
If the crown of the mandibular molar has been pressure should be applied apically.
lost, the procedure again begins with the reflection of If the crown of the maxillary molar is missing or frac-
an envelope flap and removal of a small amount of tured, the roots should be divided into two buccal roots
crestal bone. The bur is used to section the two roots and a palatal root. The same general approach as before is
into mesial and distal components (Fig. 8-44, A). The used. An envelope flap is reflected and retracted with a
small straight elevator is used to mobilize and luxate periosteal elevator. A moderate amount of buccal bone
the mesial root, which is delivered from its socket by is removed to expose the tooth for sectioning (Fig. 8-46,
insertion of the Cryer elevator into the slot prepared A). The roots are sectioned into the two buccal roots
by the dental bur (Fig. 8-44, B). The Cryer elevator is and a single palatal root. Next the roots are luxated
rotated in the wheel-and-axle manner, and the mesial with a straight elevator and delivered with Cryer
root is delivered occlusally from the tooth socket. The elevators, according to the preference of the surgeon
opposite member of the paired Cryer instruments is (Fig. 8-46, B and C). Occasionally, enough access to the
inserted into the empty root socket and rotated roots exists so that a maxillary root forceps or upper
through the interradicular bone to engage and deliver universal forceps can be used to deliver the roots
the remaining root (Fig. 8-44, C). independently (Fig. 8-46, D). Finally, the palatal root is
Extraction of maxillary molars with widely delivered after the two buc-cal roots have been
divergent buccal and palatal roots that require removed. Often much of the inter-
excessive force to extract can be removed more
 FIG. 8-42 A, This primary second molar cannot be removed by
closed technique because of tipping of adjacent teeth into
occlusal path of withdrawal and of high likelihood of ankylosis. B,
Envelope incision is made, extending two teeth anteriorly and one
tooth posteriorly. C, Small amount of crestal bone is removed, and
tooth is sectioned into two portions with bur. D, Small straight
elevator is used to luxate and deliver mesial portion of crown and
mesial root. E, Distal portion is luxated with small straight
elevator. F, No. 1 51 forceps is used to deliver remaining portion of
tooth. G, Wound is irrigated and flap approximated with gut
sutures in papillae.

radicular bone is lost by this time; therefore the small Removal of Small Root Fragments and Root Tips
straight elevator can be used efficiently. The elevator is If fracture of the apical one third (3 to 4 mm) of the
forced down the periodontal ligament space on the root occurs during a closed extraction, an orderly
palatal aspect with gentle, controlled wiggling motions, procedure should be used to remove the root tip from
which causes displacement of the tooth in the buccooc- the socket. Initial attempts should be made to extract
clusal direction (Fig. 8-46, E). the root fragment by a closed technique, but the
surgeon should
 FIG. 8-43 A, Alternative method of sectioning is to use bur to remove mesial root from first molar.
B, No. 178 forceps is then used to grasp crown of tooth and remove the crown and distal root.
C, Cryer elevator is then used to remove mesial root. Its point is inserted into empty socket of distal
root and turned in wheel-and-axle fashion, with sharp point engaging interseptal
bone and root and elevating mesial root from its socket.

FIG. 8-44 A, When crown of lower molar is lost because of fracture or caries, small envelope flap is reflected and small amount of
crestal bone is removed. Bur is then used to section tooth into two individual roots. B, After small straight elevator has been used to
mobilize roots, Cryer elevator is used to elevate distal root. Tip of elevator is placed into slot prepared by bur, and elevator is turned to
deliver the root. C, Opposite member of paired Cryer elevators is then used to deliver remaining tooth root with same type of
rotational movement.
 FIG. 8-45 A, When intact maxillary molar must be divided for judicious removal (as when extreme
divergence of roots is found), small envelope incision is made and small amount of crestal bone is
removed. This allows bur to be used to section buccal roots from crown portion of tooth. B, Upper
molar forceps is then used to remove crown portion of tooth along with palatal root. Tooth is deliv-
ered in buccoocclusal direction, and no palatal pressure is used, because it would probably cause frac-
ture of palatal root from crown portion. C, Straight elevator is then used to mobilize buccal roots and
can occasionally be used to deliver these roots. D, Cryer elevator can be used in usual fashion by plac-
ing tip of elevator into empty socket and rotating it to deliver remaining root.

begin a surgical technique if the closed technique is not the root tip fractured. If sufficient luxation occurred
immediately successful. Whichever technique is chosen, before the fracture, the root tip often is mobile and
two requirements for extraction are critically important: can be removed with the closed technique. However,
excellent light and excellent suction, preferably with a if the tooth was not well mobilized before the
suction tip of small diameter. It is impossible to remove a fracture, the closed technique is less likely to be
small root tip fragment unless the surgeon can clearly successful. The closed technique is also less likely to be
visualize it. It is also important that an irrigation syringe successful if the clinician finds a bulbous
be available to irrigate blood and debris from around the hypercementosed root with bony interferences that
root tip so that it can be clearly seen. prevent extraction of the root tip fragment. In addition,
The closed technique for root tip retrieval is defined as severe dilaceration of the root end may prevent the use
any technique that does not require reflection of soft of the closed technique.
tissue flaps and removal of bone. Closed techniques are Once the fracture has occurred, the patient should
most useful when the tooth was well luxated and be repositioned so that adequate visualization (with
mobile before proper lighting), irrigation, and suction are achieved.
The tooth
 FIG. 8-46 A, If crown of upper molar has been lost to caries or has been fractured from roots, small
envelope incision is reflected and small amount of crestal bone is removed. Bur is then used to section
three roots into independent portions. B, After roots have been luxated with small straight elevator,
mesiobuccal root is delivered with Cryer elevator placed into slot prepared by bur. C, Once mesiobuc-
cal root has been removed, Cryer elevator is again used to deliver distal buccal root. Tip of Cryer ele-
vator is placed into empty socket of mesiobuccal root and turned in usual fashion to deliver tooth root.
D, Maxillary root forceps can be occasionally used to grasp and deliver remaining root. Palatal root can
then be delivered either with straight elevator or with Cryer elevator. If straight elevator is used, it is
placed between root and palatal bone and gently wiggled in effort to displace palatal root in buc-
coocclusal direction. E, Small straight elevator can be used to elevate and displace remaining root of
maxillary third molar in buccoocclusal direction with gentle wiggling pressures.

socket should be irrigated vigorously and suctioned as the maxillary sinus. Excessive lateral force could result
with a small suction tip, because the loose tooth in the bending or fracture of the end of the root tip pick.
fragment occasionally can be irrigated from the socket. The root tip also can be removed with the small straight
Once irrigation and suction are completed, the elevator used as a shoehorn. This technique is indicated
surgeon should inspect the tooth socket carefully to more often for the removal of larger root fragments than
assess whether the root has been removed from the for small root tips. The technique is similar to that of the
socket. root tip pick, because the small straight elevator is forced
If the irrigation-suction technique is unsuccessful, into the periodontal ligament space, where it acts like a
the next step is to tease the loose root apex from the wedge to deliver the tooth fragment toward the occlusal
socket with a root tip pick. A root tip pick is a delicate plane (Fig. 8-48). Strong apical pressure should be avoided,
instrument and cannot be used as the Cryer elevator because it may force the root into the underlying tissues.
can to remove bone and elevate entire roots. The root This is more likely to occur in the maxillary premolar
tip pick is inserted into the periodontal ligament and molar areas, where tooth roots can be displaced into
space, and the root is teased out of the socket {Fig. 8- the maxillary sinus. When the straight elevator is used in
47). Neither excessive apical or lateral force should be this fashion, the surgeon's hand must always be supported
applied to the root tip pick. Excessive apical force on an adjacent tooth or a solid bony prominence. This
could result in displacement of the root tip into other
anatomic locations, such
FIG. 8-47 A, When small (2 to 4 mm) portion of root apex is frac-
tured from tooth, root tip pick can be used to retrieve it. B, Root tip
pick is teased into periodontal ligament space and used to luxate
root tip gently from its socket.

support allows the surgeon to deliver carefully controlled

force and to decrease the possibility of displacing tooth
fragments or the instrument. The surgeon must be able to
visualize clearly the top of the fractured root to see the
periodontal ligament space. The straight elevator must be
inserted into this space and not merely pushed down into
the socket.
If the closed technique is unsuccessful, the surgeon
should switch without delay to the open technique. It is
important for the surgeon to recognize that a smooth,
FIG. 8-48 A, When larger portion of tooth root is left behind after
efficient, properly performed open retrieval of a root extraction of tooth, small straight elevator can sometimes be used
fragment is less traumatic than a prolonged, time-con- as wedge, or shoehorn, to displace tooth in occlusal direction, it is
suming, frustrating attempt at closed retrieval. important to remember that pressure applied in such fashion should
Two main open techniques are used to remove root be in gentle wiggling motions; excessive pressure should not be
tips. The first is simply an extension of the technique applied, B, Excessive pressure in apical direction results in displace-
described for surgical removal of single-rooted teeth. A ment of tooth root into undesirable places, such as maxillary sinus.
soft tissue flap is reflected and retracted with a periosteal
elevator. Bone is removed with a chisel or bur to expose
the buccal surface of the tooth root. The root is buccally Policy for Leaving Root Fragments
delivered with a small straight elevator. The flap is repo-
When a root tip has fractured, when closed approaches of
sitioned and sutured (Fig. 8-49).
removal have been unsuccessful, and when the open
A modification of the open technique just described
approach may be excessively traumatic, the surgeon may
can be performed to deliver the root fragment without
consider leaving the root in place. As with any surgical
removal of the entire buccal plate overlying the tooth.
approach, the surgeon must balance the benefits of surgery
This technique is known as the open-window technique. A
against the risks of surgery. In some situations the risks of
soft tissue flap is reflected in the usual fashion, and the
removing a small root tip may outweigh the benefits.
apex area of the tooth fragment is located. A dental bur is
Three conditions must exist for a tooth root to be left
used to remove the bone overlying the apex of the tooth
in the alveolar process. First, the root fragment must be
and expose the root fragment. An instrument is then
small, usually no more than 4 to 5 mm in length. Second,
inserted into the window, and the tooth is displaced out
the root must be deeply embedded in bone and not
of the socket (Fig. 8-50).
superficial, to prevent subsequent bone resorption from
The preferred flap technique is the three-cornered flap
exposing the tooth root and interfering with the prosthe-
because of a need for more extensive exposure of the api-
sis that will be constructed over the edentulous area.
cal areas. This approach is especially indicated when the
Third, the tooth involved must not be infected, and there
buccocrestal bone must be left intact. An important and
must be no radiolucency around the root apex. This
common example is the removal of maxillary premolars
lessens the likelihood that subsequent infections will
for orthodontic purposes, especially in adults.
result from leaving the root in position. If these three
 Finally, the risks outweigh the benefits if attempts at
recovering the root tip can displace the root into tissue
spaces or into the maxillary sinus. The roots most often dis-
placed into the maxillary sinus are those of the maxillary
molars. If the preoperative radiograph shows that the bone
is thin over the roots of the teeth and that the separation
between the teeth and maxillary sinus is small, the prudent
surgeon will choose to leave a small root fragment rather
than risk displacing it into the maxillary sinus. Likewise,
roots of the mandibular second and third molars can be dis-
placed into the submandibular space during attempts to
remove them. During retrieval of any root tip, apical pres-
sure may displace teeth into tissue spaces or into the sinus.
If the surgeon elects to leave a root tip in place, a strict
protocol must be observed. The patient must be informed
that, in the surgeon's judgment, leaving the root in its posi-
tion will do less harm than surgery. In addition, radi-
ographic documentation of the root tip's presence and posi-
tion must be obtained and retained in the patient's record.
The fact that the patient was informed of the decision to
leave the root tip in position must be recorded in the
patient's chart. In addition, the patient must be recalled for
several routine periodic follow-ups over the ensuing year to
track the fate of this root. The patient should be instructed to
contact the surgeon immediately should any problems
develop in the area of the retained root.

MULTIPLE EXTRACTIONS

If multiple adjacent teeth are to be extracted at a single

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

FIG. 8-49 A, If root cannot be retrieved by closed techniques, Treatment Planning

soft tissue flap is reflected and bone overlying root is removed In most situations where multiple teeth are to be
with bur. B, Small straight elevator is then used to luxate root removed, preextraction planning regarding replacement
buccally by wedging straight elevator into palatal periodontal
of the teeth to be removed is necessary. This may be a full
ligament space.
or removable partial denture or perhaps placement of a
single or multiple implants. Before the teeth are extracted,
the surgeon should communicate with the restorative
conditions exist, then consideration can be given to
dentist and make a determination of the need for such
leaving the root.
items as interim partial immediate dentures. The discus-
For the surgeon to leave a small, deeply embedded,
sion should also include mention of needs for any other
noninfected root tip in place, the risk of surgery must
type of soft tissue surgery, such as tuberosity reduction,
be greater than the benefit. This risk is considered to
and hard tissue surgery, such as removal of undercuts in
be greater if one of the following three conditions
critical areas. If dental implants are to be placed at some
exists: First, the risk is too great if removal of the root
later time, it may also be desirable to graft the extraction
will cause excessive destruction of surrounding tissue;
socket so that healing will be more complete and rapid. In
that is, if excessive amounts of bony tissue must be
some situations, dental implants may be placed at the same
removed to retrieve the root. For example, reaching a
time as the teeth are removed, which would require the
small palatal root tip of a maxillary first molar may
preparation of a surgical guide stent to assist the surgeon
require the removal of large amounts of bone.
in aligning the implants appropriately.
Second, the risk is too great if removal of the root
endangers vital structures, most commonly the inferior
alveolar nerve, either at the mental foramen area or Extraction Sequencing
along the course of the canal. If surgical retrieval of a The order in which multiple teeth are extracted deserves
root may result in a permanent or even a prolonged some discussion. Maxillary teeth should usually be re-
temporary anesthesia of the inferior alveolar nerve,
the surgeon should seriously consider leaving the root
tip in place.
 FIG. 8-50 A, Open-window approach for retrieving root is indicated when buccocrestal bone must
be maintained. Three-cornered flap is reflected to expose area overlying apex of root fragment being
recovered. B, Bur is used to uncover apex of root and allow sufficient access for insertion of straight
elevator. C, Small straight elevator is then used to displace tooth out of tooth socket.

moved first for several reasons. First of all, an infiltration interfere with visualization during mandibular surgery.
anesthetic has a more rapid onset and also disappears Hemorrhage is usually not a major problem, because
more rapidly. This means that the surgeon can begin the hemostasis should be achieved in one area before the sur-
surgical procedure sooner after the injections have been geon turns his or their attention to another area of sur-
given; in addition, surgery should not be delayed because gery, and the surgical assistant should be able to keep the
profound anesthesia is lost more quickly in the maxilla. surgical field free from blood with adequate suction.
In addition, maxillary teeth should be removed first, Extraction usually begins with extraction of the most
because during the extraction process debris such as por- posterior teeth first. This allows for the more effective use
tions of amalgams, fractured crowns, and bone chips may of dental elevators to luxate and mobilize teeth before the
fall into the empty sockets of the lower teeth if the lower forceps is used to extract the tooth. The two teeth that are
surgery is performed first. In addition, maxillary teeth are the most difficult to remove, the molar and canine,
removed with a major component of buccal force. Little should be extracted last. Removal of the teeth on either
or no vertical traction force is used in removal of these side weakens the bony socket on the mesial and distal
teeth, as is commonly required with mandibular teeth. side of these teeth, and their subsequent extraction is
Therefore mandibular extractions that follow maxillary made easier.
extractions are usually easier to perform. A single minor In summary, if a maxillary and mandibular left quad-
disadvantage for extracting maxillary teeth first is that if rant is to be extracted, the following order is recom-
hemorrhage is not controlled in the maxilla before mended: (1) maxillary posterior teeth, leaving the first
mandibular teeth are extracted, the hemorrhage may molar; (2) maxillary anterior teeth, leaving the canine;
 FIG. 8-51 A, This patient's remaining teeth are to be extracted.
The broad zone of attached gingiva is demonstrated in adequate
vestibular depth. B, After adequate anesthesia is achieved, soft tis-
sue attachment to teeth is incised with no. 15 blade. Incision is car-
ried around necks of teeth and through interdental papilla. C,
Woodson elevator is used to reflect labial soft tissue just to crest of
labioalveolar bone. D, Small straight elevator is used to luxate
teeth before forceps is used. Surgeon's opposite hand is reflecting
soft tissue and stabilizing mandible. E, Teeth adjacent to mandibu-
lar canine are extracted first, which makes extraction of remaining
canine tooth easier to accomplish.
Continued

(3) maxillary molar; (4) maxillary canine; (5) mandibular the straight elevator (Fig. 8-51, D) and delivered with forceps
posterior teeth, leaving the first molar; (6) mandibular in the usual fashion (Fig. 8-51, E). If removing any of the
anterior teeth, leaving the canine; (7) mandibular molar; teeth is likely to require excessive force, the surgeon should
and (8) mandibular canine. remove a small amount of buccal bone to prevent fracture
and bone loss.
Technique for Multiple Extractions After the extractions are completed, the buccolingual
plates are pressed into their preexisting position with
The surgical procedure for removing multiple adjacent firm pressure (Fig. 8-51, F). The soft tissue is repositioned,
teeth is modified slightly. The first step in removing a and the surgeon palpates the ridge to determine if any
single tooth is to loosen the soft tissue attachment areas of sharp bony spicules or obvious undercuts can be
from around the tooth (Fig. 8-51, A and B). When found. If any exist, the bone rongeur is used to remove the
performing multiple extractions, the soft tissue larger areas of interference, and the bone file is used to
reflection is extended slightly to form a small envelope smooth any sharp spicules (Fig. 8-51, G). The area is
flap to expose the cre-stal bone only (Fig. 8-51, C). irrigated thoroughly with sterile saline. The soft tissue is
The teeth are luxated with
FIG. 8-51—cont'd F, Alveolar plates are compressed firmly
together to reestablish presurgical buccolingual width of alveolar
process. Because of mild periodontal disease, excess soft tissue is
found, which will be trimmed to prevent excess flabby tissue on
crest of ridge. G, Rongeur forceps is used to remove only bone that
is sharp and protrudes above reapproximated soft tissue. H, After
soft tissue has been trimmed and sharp bony projections removed,
tissue is checked one final time for completeness of soft tissue sur-
gery. I, Tissue is closed with interrupted black silk sutures across
papilla. This approximates soft tissue at papilla but leaves tooth sock-
et open. Soft tissue is not mobilized to achieve primary closure,
because this would tend to reduce vestibular height. J, Patient
returns for suture removal 1 week later. Normal healing has
occurred, and sutures are ready for removal. The broad band of
attached tissue remains on ridge, similar to what existed in preoper-
ative situation (see A).

inspected for the presence of excess granulation tissue. If and J). Interrupted or continuous sutures are used,
any is present it should be removed, because it may pro- depending on the preference of the surgeon.
long postoperative hemorrhage. The soft tissue is then In some patients a more extensive alveoloplasty after
reapproximated and inspected for excess gingiva. If the multiple extractions is necessary. Chapter 13 has an in-
teeth are being removed because of severe periodontitis depth discussion of this technique.
with bone loss, it is not uncommon for the soft tissue
flaps to overlap and cause redundant tissue. If this is the BIBLIOGRAPHY
situation, the gingiva should be trimmed so that no over-
lap occurs when the soft tissue is apposed (Fig. 8-51, H). Berman SA: Basic principles of dentoalveolar surgery. In LJ
Peterson, editor: Principles of oral and maxiltofacial surgery,
However, if no redundant tissue exists, the surgeon must Philadelphia, 1992, JB Lippincott.
not try to gain primary closure over the extraction sock- Brown RP: Knotting technique and suture materials, Br J Surg
ets. If this is done the depth of the vestibule decreases, 79:399, 1992.
which may interfere with denture construction and wear. Cerny R: Removing broken roots: a simple method, Aust Dent)
Finally, the papillae are sutured into position (Fig. 8-51,I 23:351, 1978.