Surgical Removal of Teeth & Roots

SURGICAL REMOVAL OF TEETH & ROOTS
BY DR. ALSHAIMAA AHMED LECTURER OF ORAL AND MAXILLOFACIAL SURGERY
SURGICAL REMOVAL OF TEETH & ROOTS
Tooth fracture is the commonest complication in tooth extraction The open or surgical extraction technique is the method used for removing roots
that were fractured during routine extraction and cannot be extracted by the routine closed methods for a variety of reasons
Is this the only indication ?????
INDICATION FOR SURGICAL EXTRACTION

Any tooth that resists forceps extraction after using reasonable amount of force. Teeth of patients who have had attempted a difficult extractions with frequent tooth
breakage.
Teeth with insufficient crown structure for grip (e.g. severe attrition and reduced
teeth).
Brittle teeth such as: I. II.
Teeth with bulky dental fillings. Teeth with root canal fillings.
III. Teeth with internal (hidden) decay.
Teeth with insufficient crown
structure for grip (e.g. severe attrition and reduced teeth).
Geminated teeth. Impacted teeth.
Malposed or misplaced teeth

Supernumerary teeth with
malposition.

Teeth having complicated root pattern as shown by x-rays, such as: I. II. III.
Teeth with widely divergent roots. Teeth with stout roots.
Teeth with reverse tapering roots

Teeth with dilacerated roots
IV. Teeth with hooked or curving roots. V. VI. Teeth with hypercementosed roots. VII. Teeth with ankylosed roots.
Retained roots which cannot be grasped with
the forceps, especially when these roots are in relation to the maxillary sinus or the mandibular canal.
Teeth involved in pathological conditions such as
tumors or cysts.
Teeth involved in fracture lines of the jaws and
interfering with reduction of the fractured bones.
Isolated maxillary posterior teeth (molars
and premolars):
o The alveolar bone of the maxilla is
weakened by extensions of the maxillary sinus in place of the adjacent missing teeth. condition might lead to the fracture of large segments of the maxillary alveolus or bone of the antral floor with subsequent perforation of the antrum
o Normal forceps extraction in this

In old age when the teeth are usually brittle and the alveolar bony support is devoid
of elasticity
Multiple tooth extractions with immediate alveoloplasty Teeth fractured during forceps extraction whose remnants cannot be removed by
the forceps.
Teeth extraction in Certain systemic diseases such as:
I.
II.
Osteitis deformans (Paget's disease): generalized hypercementosis of the roots.

Cleido-cranial dysplasia: multiple impacted teeth and the teeth frequently possess hooked roots.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION

Radiographic Evaluation Access to the field Reduction of resistance Tooth removal Debridement Closure & suturing
PRINCIPLES OF TRANSALVEOLAR EXTRACTION RADIOGRAPHIC EVALUATION

Aim:
I.
To reveal the number and the pattern of the roots.
II.
To reveal root relation to important adjacent structures e.g. the maxillary sinus, tuberosity of the maxilla, inferior dental and mental nerves, etc.
III. To examine the surrounding bone for pathological changes.

The operator designs proper treatment plan and prepares proper instruments.
Less amount of trauma to the tissues.
Shorter operating time.

Lessens postoperative complications as necrosis and sloughing of tissues
Minimizes after pain Promotes healing

Types of radiographs: I.
Intraoral radiographs: Most commonly used (periapical and occlusal films).
II. Extraoral radiographs: Panorama, lateral oblique, and CT.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION ACCESS TO THE FIELD OF OPERATION
This is performed by designing and reflecting mucoperiosteal flaps.

What is a flap ?

The term Flap used to indicates a section of soft tissue that:
I. II.
Is outlined by a surgical incision. Carries its own blood supply.
III. Allows surgical access to underlying tissues. IV. Can be replaced in the original position. V.
Can be maintained with sutures and is expected to heal.
Vertical releasing Incision
Gingival Incision
PRINCIPLES OF TRANSALVEOLAR EXTRACTION REQUISITES OF MUCOPERIOSTEAL FLAPS

To provide
Adequate exposure Promote proper healing
Several parameters should be considered

The flap should have a broader base than its free margin. The broader base of the flap
maintains adequate blood supply to the tissues of the flap for proper healing.

The flap should be a full-thickness mucoperiosteal flap. This means that the flap includes the surface mucosa, submucosa, and periosteum.
I. II. III.
All overlying tissue must be reflected from it. The periosteum is the primary tissue responsible for bone healing, and replacement of the periosteum in its original position hastens that healing process. Torn, split, and macerated tissue heals more slowly than a cleanly reflected, full-thickness flap.
IV. All tissue between bone and periosteum is relatively avascular so less bleeding is produced
The incision line should not injury nerves and blood vessels in the
region.
I.
Mandible ( Lingual nerve & Mental nerve )
II.
Maxilla ( Greater palatine nerve & Nasopalatine nerve)
PRINCIPLES OF TRANSALVEOLAR EXTRACTION REQUISITES OF MUCOPERIOSTEAL FLAPS Mandible ( Lingual nerve)

Mandible (Mental nerve)

Maxilla ( Greater Palatine & Nasopalatine )

The flap must be of adequate size for:
To expose all the area of operation. To be retracted without excessive tension on the tissues to avoid laceration and
retarded healing of the tissues

After the surgery the incision line should be resting on sound bone at the adjacent
borders ( promote healing & prevent infection)

What is the adequate size?
For an envelope flap to be of adequate size, the length of the flap the anteroposterior
dimension usually extends two teeth anterior and one tooth posterior to the area of surgery.
If a relaxing incision is to be made, the incision should extend one tooth anterior and
one tooth posterior to the area of surgery

If the pathologic condition has eroded the buccocortical plate, the incision must be at
least 6 or 8 mm away from it. In addition, if bone is to be removed over a particular tooth, the incision must be sufficiently distant from it so that after the bone is removed, the incision is 6 to 8 mm away from the bony defect created by surgery.
The gingival margin of standing teeth in the flap should be incised vertically so
that the flap could be detached from the bone without laceration.

Vertical-releasing incisions should cross the free gingival margin at the line
angle of a tooth and should not be directly on the facial aspect of the tooth nor directly in the papilla (localized periodontal problem & facial cleft )
A vertical-releasing incision is made so that it does not cross bony prominences, such
as the canine eminence.

The flap should be repositioned to cover the field of surgery and sutured without
much tension to avoid strangulation of blood vessels which retards healing.

Flaps performed in edentulous ridges in the process alveolectomy must be trimmed
of their excess to cover the alveolus without overlapping at their edges in order to avoid formation of soft flabby ridges which will interfere with prosthetic appliances e.g. dentures.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TYPES OF MUCOPERIOSTEAL FLAPS

Pyramidal flap: these flaps are of two types:
Two incision Line Flap: the flap is made by the cutting one oblique incision together with the gingival incision used in : Adequate for removal of small teeth , teeth fragments or small root
fragment
Three incision line flap:
the flap is made by the cutting two oblique incision together with the gingival incision Used for exposure of a large area

Requests of the oblique incisions: Oblique cuts made to the mucoperiosteum 45 angle. Starting mesial or distal to the gingival papillae. Extending obliquely to 2-3 mm away of the mucobuccal fold. Allows resting of the edges of the flap on sound bone during closure of the field of
surgery.
Advantages: Adequate exposure of the field. Affords discovery of destroyed or necrotic alveolar bone up to the gingival margins.

Disadvantages: Disturbance of the gingival tissue attachment by cutting the gingival incision which
may retard healing.
This disadvantage could be overcome by: I. II.
Performing sharp clean cuts to the gingival tissue. Smooth retraction avoiding laceration.
III. adequate re-adaptation of the tissue after surgery. The vertical component is more difficult to close and may cause some mildly pro-
longed healing.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TYPES OF MUCOPERIOSTEAL FLAPS Semilunar Flaps:

Indications:
This flap is indicated where it is not necessary to expose the alveolar bone up to the gingival margin in:
Removal of small root fragments imbedded in the alveolus far away from
the gingival margin.

In the procedure of apicectomy to amputate the apical portions of
diseased teeth.

Requisites of Semilunar Flaps
To be fulfilled in cutting these flaps, namely:
The semilunar (curved) incision must be cut so that the convex side of the flap is
towards the gingival margin: - This is to allow adequate blood supply to the flap. - The flap cut in this manner possesses a base broader than its free margin.
The incision should be made at least 0.5 cm away from the gingival margin:
- In order to avoid laceration of the gingival attachment.

Advantages:
This type of flap avoids disturbance to the gingival attachment.
Disadvantages:
Inadequate exposure of the field of surgery Areas of destructed alveolar bone that might exist under the mucoperiosteum
beyond the incision line of the flap are not discovered and removed leading to unnecessary complications of necrosis and recurrent infection.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TYPES OF MUCOPERIOSTEAL FLAPS Gingival Flaps:

Indication: When it is required to expose shallow portions of the alveolar bony plates such as:
For gaining access to the necks of teeth Removal of small sharp edges or undercuts from the alveolar bone which are close
to the gingival margin or the crest of the alveolus.
Requisites:
The gingival tissues around the cervical margins of the teeth in the field
of operation must be sharply incised before retracting the mucoperiosteum with periosteal elevator.
The gingival incision must extend for adequate distance mesio-distally in
order to allow retracting the mucoperiosteum without too much tension
Advantages:
Avoiding oblique or curved incisions prevents retarded healing and minimizes
bleeding.
Avoiding disturbance of large areas of the mucoperiosteum minimizes the
postoperative complications of pain, edema and retarded healing.
Y-shape incision:
named for its shape. This incision is useful for surgical access to the bony palate for removal of a maxillary palatal
torus.
The tissue overlying the torus is usually quite thin and must be reflected carefully. The anterolateral extensions of the midline incision are anterior to the region of the canine
tooth.
They are anterior enough in this position that they do not sever major branches of the
greater palatine artery; therefore bleeding is not usually a problem
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TECHNIQUE FOR DEVELOPING A MUCOPERIOSTEAL FLAP
Incising tissue Elevating Mucoperiostium Retracting soft tissue

Incising Tissue:
The primary instrument for making incision is the
scalpel which is composed of a reusable handle and a disposable , sterile sharp blade.
The most commonly used handle for oral surgery is the
Bard parker No. 3 handle.

A variety of differently shaped scalpel blades to be
inserted into the slotted portion of the handle
The most commonly used
scalpel blade for intraoral surgery is the no. 15 blade

No. 10 blade used for large
skin incisions.

The no. 11 blade is a sharp-
pointed blade that is used primarily for making small stab incisions, such as for incising an abscess.
useful for mucogingival procedures in which incisions must be made on the posterior aspect of teeth or in the maxillary tuberosity area.
The hooked no. 12 blade is
The scalpel blade
is loaded onto the handle with a needle holder

Scalpel handle is held in pen grasp
for maximal control and tactile sensitivity

The blade is dull easily when they
come into contact with hard tissue such as bone and teeth.
If several incisions through
mucoperiosteum to bone are required, it may be necessary to use a second blade

After an incision through mucoperiosteum has been made, the mucosa
and periosteum should be reflected from the underlying bone in a single layer with a periosteal elevator.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TECHNIQUE FOR DEVELOPING A MUCOPERIOSTEAL FLAP The periosteal elevator can be used to reflect soft tissue by three methods:
Prying motion to elevate soft tissue: This is most commonly used when
elevating a dental papilla from between teeth.

Push stroke: in this motion the broad end of the instrument is slid
underneath the flap, separating the periosteum from the underlying bone.
Pull, or scrape, stroke: This is tends to shred or tear the periosteum
unless it is done carefully.
Reflecting soft tissue

For small flaps, use the periosteal elevator for retraction For large flaps use Minnesota or Austin retractor Place retractor beneath the flap resting on sound bone Avoid trapping of flap between retractor and bone Retract passively: no attempt is made to pull the flap out of the field
Minnesota Retractor
Austin retractor
PRINCIPLES OF TRANSALVEOLAR EXTRACTION REDUCTION OF RESISTANCE

The resistance around the tooth structure should to be decreased in
order to allow its removal by means of forceps or elevators using least amount of manipulating force
Reduction of resistance is performed by : Removal of a segment from the surrounding alveolar bone
Tooth sectioning or division
PRINCIPLES OF TRANSALVEOLAR EXTRACTION REDUCTION OF RESISTANCE (BONE REMOVAL)

Purpose of bone removal:
1. Gaining access to the tooth structure 2. Reduction of the resistance around the tooth structure 3. Provide a point for application of forceps or elevator 4. Provide a space in which a tooth structure may be displaced by
manipulation
Methods of bone removal: 1.
Chisel technique
2. Surgical burs 3. Bone cutting forceps
Chisel Technique 1. Mallet driven chisel 2. Hand chisel 3. Electric automated chisel

Mallet driven chisel: Monobevel chisel Bibeveled chisel Grooved chisel The chisel is driven by blows of a
metal mallet.
Hand chisel : Works by hand pressure of the operator It is indicated in the areas of soft bone Heavy pressure may cause slippage of the
instrument

Electric automated chisel:
Consists of a variable number of shapes and
sizes of chisel blades
The suitable blade is mounted on aspecial The chisel blade cuts automatically by
hand piece which is deriven by dental engine

applying pressure against the bone. stop cutting
When the pressure is released the chisel
Advantages: 1. Clean and smooth cutting 2. Automated chisel: variable patterns & easy to control

Disadvantages: 1. Need great skills and training 2. Frightening to the patients (used under general anaesthesia )
3. Sometimes its is not practical for removal of extremely dense and hard alveolar
areas of the alveolar bone
4. Contraindicated to be used in maxilla 5. Electrically driven automated chisels is contraindicated with general anesthesia for
the danger of spark generation

Surgical burs : Precautions: 1. The surgical burs generate large amount of heat. Their use should be accompanied by a continus spray of water in order to minimize the heat 2. Sharp new burs should always be used Methods of using surgical burs: Guttering technique The hand piece should have relatively high speed and torque. Most high-speed turbine drills used for routine restorative dentistry must not be used
as the high- speed turbine is air driven and the air exhausted into the wound may be
forced into deeper tissue planes and produce tissue emphysema, a potentially dangerous occurrence.
Advantages 1. Easy control and use 2. Practical in remove of areas of heavy dense bone especially in the mandible 3. Safer and indicated to remove bone in maxilla 4. Not alarming to the patient
Disadvantages: 1. Generation of excessive amount of heat 2. Contraindicated to be used with some general anesthetic gases

Bone rongeurs: This instrument has sharp blades that are squeezed together by the handles, cutting
or pinching through the bone.

Rongeur forceps have a leaf spring between the handle so that when hand pressure is
released, the instrument will open.

This allows the surgeon to make repeated cuts of bone without manually reopening
the instrument

Types of bone Rongeur: 1. Side cutting rongeurs: the Rongeur is designed with blades having sharp cutting sides
it is suitable for trimming sharp edges of the alveolar plates. This type is called a bone shear
2. End cutting Rongeur: designed with end blades which cut bone at their tips . This
type is suitable for cutting projecting bony septum in the socket of extracted teeth
3. End and side cutting Rongeur: the blades are designed to cut at their sides and tip
which makes this type of rongeur more practical

Bone file:
Final smoothing of bone before suturing the mucoperiosteal flap back into position is
usually performed with a small bone file

The bone file is usually a double-ended instrument with a small and large end. The teeth of the bone file are arranged in such a fashion that they remove bone only
on a pull stroke
Pushing the bone file results only in burnishing and crushing the bone and should be
avoided.

Conservative bone removal of teeth:
Operator should only remove the necessary amount of bone that is needed to
facilitate the removal of the tooth, root or tooth fragments

Too much removal leads to: Postoperative complication of edema, pain and retarded healing Scarifies the amount of alveolar bone which will be needed later for a prosthetic
restoration
PRINCIPLES OF TRANSALVEOLAR EXTRACTION REDUCTION OF RESISTANCE Tooth Division (sectioning):

This is performed alone or together with bone removal in order to
remove the tooth in fragment.

Surgical burs, and/or chisels are used for tooth sectioning The tooth is divided along its vertical axis or at its neck
Advantages: 1. Minimize the amount of bone removal, promotes healing and saves the maximum
amount of alveolar bone

2. Minimize the trauma of bone removal and decreases the operating time.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TOOTH REMOVAL
Elevator:
Instrument used in extraction of teeth or tooth fragments
which cannot be grasped by blades of forceps eg. Impacted teeth, malposed roots
Parts of the elevators

Indication to use of elevators: 1. To luxate or remove teeth that cannot be grasped easily or properly by forceps 2. When initial application of the forceps is difficult or liable to cause trauma to the
soft tissue
3. Removal of broken roots 4. Removal of the remaining roots

Dangers in the use of elevators:
1. 2.
Loosening or extraction of the adjacent teeth Fracturing the alveolar process or fracturing maxilla or mandible
3.
4. 5.
Penetrating the maxillary antrum or forcing a root into antrum

Forcing a root of the mandibular third molar in the mandibular canal or into a sublingual space Damaging of soft tissue

Rules in the use of elevators: 1. Never use the adjacent tooth as a fulcrum 2. Never use buccal plate at the gingival line ad a fulcrum except when using the lower
third molar
3. NEVER use lingual plate as fulcrum
4. ALWAYS use finger guards to protect patient if elevator slips. 5. The movement of the elevator should be controlled to avoid the slipping of its tip
and damage to the soft and hard tissue

Classification of elevator according to use:
Elevators designed to remove entire tooth. Elevators designed to remove roots broken off at the gingival line. Elevators designed to remove roots broken off halfway to apex. Elevators designed to remove the apical third of the root. Elevators designed to reflect mucoperiosteum before forceps or extracting elevators
are used. (periosteal elevators)

Classification according to shape: 1. Straight elevator: straight elevator- straight apexo
Curved elevator: curved apexoCryer elevator Miller elevator
Crossbar elevator: buccal applicator socket applicator
Mechanical principles involved in extraction:
Lever principle of first order:

1. 3 basic components: fulcrum - effort- load 2. Fulcrum is b/n effort and load 3. Maximum advantage is when effort arm is longer than load arm
WEDGE PRINCIPLE:
Here 2 movable inclined planes with a base on one end and blade on other end Effort is applied to the base of the plane and resistance has its effect on slant side Used to split, expand or displace the portion that receives it Elevators to luxate tooth when applied b/n bone and tooth
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TOOTH REMOVAL WHEEL AND AXLE PRINCIPLE:

Effort is applied to circumference of wheel which turns the axle so as to
raise the weight

Greater the diameter of wheel more is the mechanical advantage Used in crossbar elevators for removal of mandibular root
Straight elevator:
Uses: Mesial application of force to
the lower last molar with distally curved roots

Mesial application of force
Straight Apexo
Use
Wedging principle & Mesial application of
force
Curved Apexo
Use: removal of single rooted teeth
removal of apical fragment

Mode of action
Miller Elevator
Use : Used to luxate the upper third molars
by mesial application of force

Mode of action
Cryer Elevator
Use Mode of action
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TOOTH REMOVAL Buccal applicator

Use: the tip of the elevator blade
inserted in the root bifurcation and the tooth is removed by elevation using the buccal cortical plate as fulcrum
Mode of action: wheel and axel
PRINCIPLES OF TRANSALVEOLAR EXTRACTION TOOTH REMOVAL Socket applicator

Use: the tip of the elevator is
introduced in the socket facing the root until the tip engaged the root then removed by elevating force.
Mode of action: wheel and axel
PRINCIPLES OF TRANSALVEOLAR EXTRACTION SOFT TISSUE SURGERY
Periapical curette is an angled, double-ended instrument used to remove
soft tissue from bony defects
PRINCIPLES OF TRANSALVEOLAR EXTRACTION SOFT TISSUE SURGERY Allis tissue forceps :

Removing larger amounts of fibrous tissue, such as in an epulis fissuratum
with locking handles and teeth that will grip the tissue firmly
never be used on tissue that is to be left in the mouth, because they
cause a relatively large amount of tissue destruction as a result of crushing injury
PRINCIPLES OF TRANSALVEOLAR EXTRACTION SOFT TISSUE SURGERY Tissue Forceps:

Delicate forceps with small teeth, which can be used to gently hold tissue
and thereby stabilize it.

When this instrument is used, care should be taken not to grasp the
tissue too tightly, thereby crushing it.

Tissue forceps are also available without teeth.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION DEBRIDEMENT OF THE FIELD OF SURGERY

Remove any loose fragments from the socket and the area of surgery Trim any sharp bony edges or bony projections
Smoothen the edges with bone file

Irrigate the field by means of warm saline or antiseptic solutions
PRINCIPLES OF TRANSALVEOLAR EXTRACTION CLOSURE
Once the surgical procedure is completed and the wound properly
irrigated and debrided, the surgeon must return the flap to its original position
The flap should be held in place with sutures. What is the function of the suture ?????
Sutures perform multiple functions: 1. Reapproximating the wound edges together until the healing process is
complete.
2. Protecting underlying tissues from infection or other irritating factors. 3. Preventing postoperative hemorrhage.

Suturing armamentarium includes: 1. Needle holder
2. Suture needle
3. Suture material 4. Tissue forceps
5. Suture scissor

Needle holder
PRINCIPLES OF TRANSALVEOLAR EXTRACTION CLOSURE Suture needle:

sharp, pointed instruments
used for puncturing the tissue and guiding the thread to suture or pass a ligature around vessels
Needles differ in:

Shape (straight, curved) Diameter Cross-sectional view Length

Shape:
1. Straight suture needle: used
in the skin suture

2. Curved suture needle: for
intraoral suture and deep suture

Radius of the needle: 1. One-fourth circle
2. Three-eight circle
3. Half circle 4. Five-eight circle

According to the cross section:
Rounded or Oval Cross Section (non-cutting):
These are considered atraumatic and are mainly used for suturing thin mucosa. Pressure is required when passing through the tissues.
Triangular Cross Section (cutting):
They have sharp cutting edges and are preferred for suturing thicker tissues. If used for thin mucosa, tearing may occur.
Two types: Conventional cutting: cutting edge (apex of the triangle) on the inside of the semicircle. Reverse cutting: cutting edge outside of the semicircle.

According to the presence of the
eye:
1. Eyeless: suture material is
attached to the swage of the needle during manufacture

2. Needles with eye : Traumatic
needles- pulling a double thread thr the tissues

Suture material:
Requisites for suture materials: 1. Tensile strength: Strong enough to hold tissues during first week.
2. Chemically inert / biocompatible /low tissue irritation: Not hamper healing process
3. Low capillarity: which means that sutures must not allow fluids from outside to
penetrate the body through them, which could easily cause infections
4. Good handling & knotting properties 5. Sterilization without deterioration of the properties. Dry heat & ethylene oxide gas 6. Smoothness: Smooth material -Easy passage - Least trauma
PRINCIPLES OF TRANSALVEOLAR EXTRACTION CLOSURE Classifications:

According to their:
1- Diameter.
2- Resorbability.
3- Whether they are monofilament or polyfilament.

According to the Diameter:
The size of the suture related to its diameter and is designed by series of zero like 2-
0, 3-0 etc
The more 0s in the number, the smaller the suture Microsurgery: 9/0 or 10/0
suture
The size most commonly used in oral surgery is 3/0 (000), since it is
1- Large enough to withstand the tension.
2- Strong enough for easy knot making.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION CLOSURE According to Resorbability:

According to Resorbability: 1- Resorbable Sutures:
Made of materials which are broken down in tissue after a given period of time
(coincide with wound healing).

Many types: 1- Plain catgut: It is derived from the serosal surface of the sheep intestine, resorbs quickly (3-5 days) 2- Chromic catgut: It is catgut treated by chromic acid, lasts longer (7-10 days).
3- Synthetic type:
Like polyglycolic acid (Dexon), polyglactin (vicryl), slowly resorbed (around 30days).
These types of sutures are used for :

Internal tissues of the body Children, mentally handicapped or patients who cannot
return to the clinic to have the sutures removed.

Non-resorbable suture:

Nonresorbable Sutures:
They are made from materials which are not metabolized by the body. Various materials available, mainly silk , nylon and stainless steel. The most commonly used one in the oral cavity is silk since:
1- It is easy to use. 2- Economic.
3- Have a good ability to hold a knot .

Polyfilament versus Monofilament sutures:
Polyfilament suture:
It is made of several filaments braided or twisted together, such as silk (nonresorbable) and
polyglycolic acid (resorbable).
Advantages:
1- Easy to tie. 2- The cut ends are soft and nonirritating to the tongue and surrounding soft tissues.
Disadvantage:
Since multiple filaments ,they tend to wick oral fluid along the suture to the underlying tissues, and this may carry bacteria along with the saliva to the underlying tissue.

Monofilament sutures:
It is made of only one thread, such as plain & chromic catgut, nylon and stainless
steel.
Advantage: Do not cause wicking. Disadvantages: 1. Difficult to tie 2. Tend to come untied 3. The cut ends are stiffer, therefore more irritating to the tongue and soft tissues
Principles of suturing :
grasp the needle at approximately 3/4th the distance from the point enter the tissue perpendicular to the surface should follow the curvature of the needle
from free to the fixed tissue

tissues should not close under tension knot should not be placed on incision line
sutures placed 4mm apart sutures should be tied so that edges are everted dog ear should be eliminated
suture should be placed at an equal distance
from the incision on both the sides & at an equal depth

Key suture:

Suturing techniques: 1.
simple Interrupted suture
2. Continuous suture
3. Matterss suture ( vertical & horizontal) 4. Figure of eight suture

Simple Interrupted Suture:
used type in all surgical procedures of the mouth. The needle enters 5 mm away from the margin of the flap (mobile tissue) and
exits at the same distance on the opposite side.

knot.
The two ends of the suture are then tied in a knot and are cut 5mm above the C- The advantage of the interrupted suture is that when sutures are placed in
a row, loosening of one or even losing one stitch will not influence the rest.
PRINCIPLES OF TRANSALVEOLAR EXTRACTION CLOSURE Continuous Suture:

This is usually used for suturing long incision e.g., incision for reshaping
of the alveolar ridge in the maxilla and mandible.

In this technique a knot is not made for each stitch, making the
technique quick, with few knots to collect debris.

Disadvantage of this technique, is that if one stitch get cut or loose, the
entire suture line becomes loose.
Mattress suture :
Vertical - Horizontal
Used in tension areas
PRINCIPLES OF TRANSALVEOLAR EXTRACTION CLOSURE Horizontal:

In cases where strong and secure
reapproximation of wound margins is required

Distance of needle penetration from
incision line & depth of penetration is same.
Vertical
Depth of penetration varies For closing deep wounds
Advantage: run parallel to the blood
supply of the flap not interfere with healing

Figure of eight suturing:
This is a special technique that used
to maintain the blood clot in the alveolar socket after tooth extraction ( aid in hemostasis by providing a barrier to clot displacement) as well as could be used to maintain the hemostatic materials over tooth socket after extraction
PRINCIPLES OF TRANSALVEOLAR EXTRACTION POLICY FOR LEAVING ROOT FRAGMENTS
the root fragment must be small, usually no more than 4 to 5 mm in
length.
The root must be deeply embedded in bone and not superficial The tooth involved must not be infected, and there must be no
radiolucency around the root apex
PRINCIPLES OF TRANSALVEOLAR EXTRACTION EXTRACTION SEQUENCING
Maxillary or mandibular???
Posterior or anterior ????

Surgical Removal of Teeth &amp; Roots

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SURGICAL REMOVAL OF TEETH & ROOTS

BY DR. ALSHAIMAA AHMED LECTURER OF ORAL AND MAXILLOFACIAL SURGERY