Principles of Exodontia










82
PART II
Principles of Exodontia
For most laypersons the term oral surgery usually brings to mind the removal of a tooth. e
atraumatic extraction of a tooth is a procedure that requires nesse, knowledge, and skill on
the part of the surgeon. e purpose of this section is to present the principles of exodontia as
well as the instrumentation, techniques, and management of patients who are undergoing
extraction surgery.
Chapter 7 presents the armamentarium commonly used for exodontia. e basic instrumentation
and the fundamental applications of instruments to their surgical purposes are illustrated and
discussed.
Chapter 8 presents the basic aspects of how to remove an erupted tooth atraumatically. e
preoperative assessment and preparation of the patient are briey discussed. e position of the
patient in the chair and the position of the surgeon and the surgeons hands for the removal of
teeth in various parts of the mouth are detailed. e armamentarium and movements necessary
to extract each type of tooth are presented in illustrations and descriptions.
Chapter 9 presents the basic aspects of managing complicated extractions (commonly termed
surgical extractions). Surgical extractions primarily involve retrieving tooth roots and teeth that
are likely to fracture, have fractured, or, for some other reason, pose an obstacle to extraction.
In these situations, surgical removal of bone or surgical sectioning of the tooth is commonly
required.
Chapter 10 presents the fundamental aspects of the management of impacted teeth. e
rationale for timely removal of impacted teeth is presented in the initial portion of the chapter.
Classication and determination of the degree of diculty of the impaction follows. Finally, a
brief description of the basic surgical techniques required to remove impacted third molars is
provided.
Chapter 11 presents the techniques for managing the patient during the postoperative period.
is chapter discusses postoperative instructions that should be given to the patient as well as
typical postoperative medications. e chapter goes on to cover common surgical sequelae and
complications that are encountered in the removal of teeth. Emphasis is placed on anticipating
sequelae and complications and taking measures to prevent or minimize them.
Chapter 12 discusses the medical and legal considerations involved in basic exodontia. An
important portion of this chapter discusses the concept of informed consent for the patient as
it relates to exodontia. Patient privacy rights are also covered.

83
7
Instrumentation for Basic Oral Surgery
JAMES R. HUPP
CHAPTER OUTLINE
Incising Tissue, 83
Elevating the Mucoperiosteum, 85
Retracting Soft Tissue, 85
Grasping Soft Tissue, 87
Controlling Hemorrhage, 87
Removing Bone, 88
Rongeurs, 88
Burr and Handpiece, 88
Mallet and Chisel, 89
Bone File, 89
Removing Soft Tissue From Bony Cavities, 89
Suturing Soft Tissue, 89
Needle Holder, 89
Suture Needle, 89
Suture Material, 90
Scissors, 90
Holding the Mouth Open, 91
Removing Fluids, 91
Holding Towels and Drapes in Position, 92
Irrigating, 93
Extracting Teeth, 93
Dental Elevators, 94
Types of Elevators, 94
Periotomes, 95
Extraction Forceps, 96
Forceps Components, 96
Maxillary Forceps, 98
Mandibular Forceps, 99
Instrument Tray Systems, 101
T
his chapter is designed to introduce the instrumentation
commonly used to perform routine dental extractions and
other basic oral surgical operations. The instruments
illustrated and described are used for a wide variety of purposes,
including soft and hard tissue procedures. is chapter primarily
provides a description of instruments; their use is discussed in
subsequent chapters.
Incising Tissue
Many surgical procedures begin with an incision. e primary
instrument for making incisions is the scalpel, which is composed
of a handle and a sterile, very sharp blade (Fig. 7.1). Scalpels are
available as single-use instruments with plastic handles and xed
blades; scalpel handles to which disposable blades can be attached
are also available. e most commonly used handle for oral surgery
is the No. 3 handle. e tip of a scalpel handle is congured to
receive a variety of dierently shaped scalpel blades that are inserted
onto the slotted portion of the handle.
e most frequently used scalpel blade for intraoral surgery is
the No. 15 blade (Fig. 7.2). e blade is small and is used to make
incisions around teeth and through soft tissue. e blade is similar
in shape to the larger No. 10 blade, which is used for large skin
incisions in other parts of the body. Other commonly used blades
for intraoral surgery include the No. 11 and No. 12 blades. e
No. 11 blade is a sharp-pointed blade that is used primarily for
making small stab incisions as for incising an abscess to establish
drainage. e hooked No. 12 blade is useful for mucogingival
procedures in which incisions are made on the posterior aspects
of teeth or in the maxillary tuberosity area.
e scalpel blade must be carefully loaded onto the handle,
ideally holding the blade with a needle holder. is lessens the
chance of injuring ones ngers. e blade is held along the
unsharpened edge, where it is reinforced with a small rib, and
the handle is held so that the male portion of the tting is pointing
upward (Fig. 7.3A). e scalpel blade is then slowly slid onto the
handle along the grooves in the male portion until it clicks into
position (see Fig. 7.3B).
e scalpel is unloaded in a similar manner. e needle holder
grasps the end away from the blade (see Fig. 7.3C) and lifts it to
disengage it from the male tting. e scalpel is then slid o the
handle, always away from the body and anyone nearby (see Fig.
7.3D). e used blade is immediately discarded into a specically
designed rigid-sided sharps container (see Fig. 5.6C).
When using the scalpel to make an incision, the surgeon typically
holds the handle in the pen grasp (Fig. 7.4) to allow maximal
control of the blade as the incision is made. For maximum cutting
eciency, mobile tissue should be held rmly in place under some
tension so that as the incision is made, the blade will incise and
not just push away the mucosa. When incising depressible soft
tissue, an instrument such as a retractor should be used to hold
the tissue taut while incising. When a full-thickness mucoperiosteal
incision is desired, the blade should be pressed down rmly so
that the incision penetrates the mucosa and periosteum with the
same stroke.

84 Part II Principles of Exodontia
Fig. 7.1 A scalpel is composed of a handle and a sharp blade. Top, Reus-
able scalpel No. 3 handle with single-use blade (a No. 15 blade is most
commonly used for oral surgery). Bottom, Single-use handle-blade unit
with No. 15 blade.
Fig. 7.2 Scalpel blades used in oral surgery include No. 10, No. 11, No.
12, and No. 15 (left to right).
AB
C
D
Fig. 7.3 (A) When loading a scalpel blade, the surgeon holds the noncutting portion of the blade in the
needle holder and handle, with the male portion of the tting pointing upward. (B) The surgeon then slides
the blade into the handle until it clicks into place. (C) To remove the blade, the surgeon uses the needle
holder to grasp the end of the blade next to the handle and lifts it to disengage it from the tting. (D) The
surgeon then gently slides the blade off the handle away from the body and anyone nearby.

CHAPTER 7 Instrumentation for Basic Oral Surgery 85
Retracting Soft Tissue
Good access and vision are critical to performing excellent surgery.
A variety of retractors have been specically designed to retract
the cheek, tongue, and mucoperiosteal aps to provide access and
visibility during surgery. Retractors are also used to help protect
soft tissue from sharp cutting instruments.
e two most popular cheek retractors are (1) the right-angle
Austin retractor (Fig. 7.6) and (2) the broad oset Minnesota
retractor (Fig. 7.7). ese retractors can also be used to retract the
cheek and a mucoperiosteal ap simultaneously. Before the ap
is created, the retractor is held loosely in the cheek. Once the ap
is reected, the retractor edge is placed on bone and is then used
to retract the ap.
e Henahan and Seldin retractors are other types of instruments
used to retract oral soft tissue (Fig. 7.8). Although these retractors
may look similar to a periosteal elevator, the leading edge is not
sharp but, instead, smooth; these instruments are not typically
used to elevate the mucoperiosteum. e No. 9 Molt periosteal
elevator can also be used as a retractor for small aps. Once the
periosteum has been elevated, the broad blade of the periosteal
elevator is held rmly against bone, with the mucoperiosteal ap
elevated into a reected position.
e instrument most commonly used to retract the tongue
during routine exodontia is the mouth mirror. is is usually part
of every basic setup because it is useful for examining the mouth
and for indirect visualization during dental procedures. e Weider
tongue retractor is a broad, heart-shaped retractor that is serrated
on one side so that it can more rmly engage the tongue and
retract it medially and anteriorly (Fig. 7.9A). When this retractor
is used, care must be taken not to position it so far posteriorly as
to cause gagging or to push the tongue into the oropharynx (see
Fig. 7.9B).
A towel clip (see Fig. 7.28) can also be used to hold the tongue
in certain circumstances. When a biopsy procedure is to be
Scalpel blades are designed for single-patient use. Blades dull
easily when they come into contact with hard tissue such as bone
or teeth and even after repeated strokes through keratinized tissue.
If several incisions through the mucoperiosteum to bone are
required, it may be necessary to use additional blades during a
single operation. Dull blades do not make clean, sharp incisions
in soft tissue and therefore should be replaced before they become
overly dull.
Elevating the Mucoperiosteum
e tissue plane between periosteum and bone is relatively bloodless
and well dened. When an incision is made through the periosteum,
ideally the periosteum should be reected from the underlying
cortical bone in a single subperiosteal layer with a periosteal elevator.
e instrument that is most commonly used in oral surgery is the
No. 9 Molt periosteal elevator (Fig. 7.5). is instrument has a
sharp, pointed end and a broader, rounded end. e pointed end
is used to begin the periosteal reection and to reect dental papillae
from between teeth, whereas the broad, rounded end is used to
continue the elevation of the periosteum from bone.
e No. 9 Molt periosteal elevator is typically used to reect
tissue by two methods. In the rst method, the pointed end is
used in a twisting, prying motion to elevate soft tissue, most
commonly when elevating a dental papilla from between teeth or
the attached gingiva around a tooth to be extracted or when
beginning to elevate a full thickness mucoperiosteal ap. e second
method involves the push stroke in which the side of the pointed
end or the broad end of the instrument is slid underneath the
periosteum, separating it from the underlying bone. is is the
most ecient stroke that results in the cleanest reection of
periosteum.
ere are other types of periosteal elevators for use by perio-
dontists, orthopedic surgeons, and other surgeons involved in work
on bones.
Fig. 7.4 The scalpel handle is held in the pen grasp to allow maximal
control.
Fig. 7.5 The No. 9 Molt periosteal elevator is most commonly used in oral surgery.
Fig. 7.6 The Austin retractor is a right-angle retractor that can be used to
retract the cheek, tongue, or aps.

86 Part II Principles of Exodontia
A
B
Fig. 7.7 The Minnesota retractor is an offset retractor used to retract the
cheek and aps. (A) Front. (B) Back.
Fig. 7.8 The Henahan (top) and Seldin (bottom) retractors are broader
instruments that provide broader retraction and increased visualization.
A
B
Fig. 7.9 (A) The Weider retractor is a large retractor designed to retract the tongue. The serrated surface
helps engage the tongue so that it can be held securely. (B) The Weider retractor is used to hold the
tongue away from the surgical eld. The Austin retractor is used to retract the cheek.

CHAPTER 7 Instrumentation for Basic Oral Surgery 87
performed on the posterior aspect of the tongue, the most positive
way to control the tongue is by holding the anterior tongue with
a towel clip. Local anesthesia must be profound where the clip is
placed, and, if anticipated, it is wise to mention to the patient
that this method of retraction may be used.
Grasping Soft Tissue
Various oral surgical procedures require the surgeon to grasp soft
tissue to incise it, to stop bleeding, or to pass a suture needle. e
instrument most commonly used for this purpose is the Adson
forceps (or pickup; Fig. 7.10A). ese are delicate forceps, with
or without small teeth at the tips, that can be used to hold tissue
gently while stabilizing it. When this instrument is used, care
should be taken not to grasp the tissue too tightly to avoid crushing
it. Toothed forceps allow tissue to be securely held with a more
delicate grip than untoothed forceps.
When working in the posterior part of the mouth, the Adson
forceps may be too short. Longer forceps that have a similar shape
are the Stillies forceps. ese forceps are usually 7 to 9 inches long
and can easily grasp tissue in the posterior part of the mouth, still
leaving enough of the instrument protruding beyond the lips for
the surgeon to hold and control it (see Fig. 7.10B).
Occasionally it is more convenient to have an angled forceps.
ese include the college, or cotton, forceps (they are also called
cotton pliers) (see Fig. 7.10B). Although these forceps are not
especially useful for handling tissue, they are an excellent instrument
for picking up loose fragments of tooth, amalgam, or other foreign
material and for placing or removing gauze packs.
In some types of surgery, especially when removing larger
amounts of tissue or doing biopsies, such as in an epulis ssurata,
forceps with locking handles and teeth that will rmly grip the
tissue are necessary. In this situation, the Allis tissue forceps are
used (Fig. 7.11A–B). e locking handle allows the forceps to be
placed in the proper position and then to be held by an assistant
to provide the necessary tension for proper dissection of the tissue.
e Allis forceps should never be used on tissue that is to be left
A
B
Fig. 7.10 (A) Small, delicate Adson tissue forceps are used to gently
stabilize soft tissue for suturing or dissection. (B) The Stillies pickup (top)
is longer than the Adson pickup and is used to handle tissue in the more
posterior aspect of the mouth. The college pliers (bottom) are angled
forceps that are used for picking up small objects in the mouth or from
the tray stand. The college pliers shown here represent the locking version.
A
B
C
Fig. 7.11 (A) Allis tissue forceps are useful for grasping and holding tissue
that will be excised. (B) Allis forceps are held in the same fashion as the
needle holder. (C) Comparison of Adson beaks (right) with Allis beaks (left)
shows the differences in their designs and uses.
in the mouth because they cause a relatively large amount of tissue
crushing (see Fig. 7.11C). However, the forceps can be used to
grasp the tongue in a manner similar to a towel clamp.
Controlling Hemorrhage
When incisions are made through tissue, small arteries and veins
are incised, causing bleeding. For most dentoalveolar surgery,
pressure on the wound is usually sucient to control bleeding.
Occasionally pressure does not stop the bleeding from a larger
artery or vein. When this occurs, an instrument called a hemostat
is useful (Fig. 7.12A). Hemostats come in a variety of shapes; they
may be small and delicate or larger and are either straight or
curved. e hemostat most commonly used in surgery is the curved
hemostat (see Fig. 7.12B).
A hemostat has long, delicate beaks that are used to grasp tissue
and a locking handle. e locking mechanism allows the surgeon
to clamp the hemostat onto a vessel and then let go of the instrument
or let an assistant hold it. e tip of the hemostat will remain
clamped onto the tissue. is is useful when the surgeon plans to

88 Part II Principles of Exodontia
Burr and Handpiece
Another method for removing bone is with a burr in a handpiece.
is is the technique that most surgeons use when removing bone
for the surgical removal of teeth. Moderate-speed, high-torque
handpieces with sharp carbide burrs remove cortical bone eciently
(Fig. 7.14). Burrs such as No. 557 or No. 703 ssure burr and
No. 8 round burr are used. When large amounts of bone must be
removed, as in torus reduction, a large-bone burr that resembles
an acrylic burr is typically used.
Any handpiece that is used for oral surgery must be completely
sterilizable. When a handpiece is purchased, the manufacturer’s
specications must be checked carefully to ensure that they can
be met. e handpiece should have high speed and torque. is
allows rapid bone removal and ecient sectioning of teeth. e
handpiece must not exhaust air into the operative eld, which
would make it improper to use the typical high-speed air-turbine
drills employed in routine restorative dentistry. e reason is that
the air exhausted into the wound may be forced into deeper tissue
planes and produce tissue emphysema, a dangerous occurrence.
A
B
Fig. 7.12 (A) Superior view of the hemostat used for oral surgery.
(B) Oblique view of the curved hemostat. Straight hemostats are also
available.
A
B
Fig. 7.13 (A) Rongeurs are bone-cutting forceps that have spring-loaded
handles. (B) Blumenthal rongeurs comprise both end- and side-cutting
blades. They are preferred for oral surgery procedures.
place a suture around the vessel or to cauterize it (i.e., use heat to
sear the vessel closed).
In addition to its use as an instrument for controlling bleeding,
the hemostat is especially useful in oral surgery to remove granulation
tissue from tooth sockets and to pick up small root tips, pieces of
calculus, amalgam, fragments, and any other small particles that
have dropped into the wound or adjacent areas. However, it should
never be used to suture.
Removing Bone
Rongeurs
The instrument most commonly used for removing bone in
dentoalveolar surgery is the rongeur forceps. is instrument has
sharp blades that are squeezed together by the handles, cutting
or pinching through bone. Rongeur forceps have a rebound
mechanism incorporated so that when hand pressure is released,
the instrument reopens. is allows the surgeon to make repeated
bone-trimming actions without manually reopening the instrument
(Fig. 7.13A). e two major designs for rongeur forceps are (1)
a side-cutting forceps and (2) the side- and end-cutting forceps
(see Fig. 7.13B).
e side-cutting and end-cutting rongeurs are more practical
for most dentoalveolar surgical procedures that require bone removal.
e end-cutting forceps can be inserted into sockets for the removal
of interradicular bone and can also be used to remove sharp edges
of bone. Rongeurs can be used to remove large amounts of bone
eciently and quickly. Because a rongeur is a delicate instrument,
the surgeon should not use it to remove large amounts of bone
in single bites. Rather, smaller amounts of bone should be removed
in multiple bites. Likewise, the rongeur should never be used to
remove teeth because this practice will quickly dull and destroy
the instrument and risks losing a tooth in the patient’s throat
because a rongeur is not designed to hold an extracted tooth rmly.
Rongeurs are expensive, so care should be taken to keep them
sharp and in working order.
Fig. 7.14 Typical moderate-speed high-torque sterilizable handpiece with
No. 703 burr.

CHAPTER 7 Instrumentation for Basic Oral Surgery 89
larger bony cavities such as cysts. Note that the periapical curette
is distinctly dierent in design and function from the periodontal
curette.
Suturing Soft Tissue
Once a surgical procedure has been completed, the mucoperiosteal
ap is returned to its original position and held in place by sutures.
e needle holder is the instrument used to place the sutures.
Needle Holder
e needle holder is an instrument with a locking handle and a
short, blunt beak. For intraoral placement of sutures, a 7-inch
(15-cm) needle holder is usually recommended (Fig. 7.18). e
beaks of a needle holder are shorter and stronger than the beaks
of a hemostat (Fig. 7.19). e face of the shorter beak of the
needle holder is cross-hatched to permit a positive grasp of the
suture needle. e hemostat has parallel grooves on the face of
the beaks, thereby decreasing the control over needle and suture.
erefore the hemostat is not an instrument used for suturing.
To control the locking handles properly and to direct the long
needle holder, the surgeon must hold the instrument in the proper
fashion (Fig. 7.20). e thumb and ring nger are inserted through
the rings. e index nger is held along the length of the needle
holder to steady and direct it. e second nger aids in controlling
the locking mechanism. e index nger should not be put through
the nger ring because this will result in a dramatic decrease in
control.
Suture Needle
e needle used in closing oral mucosal incisions is usually a small
half-circle or three-eighths–circle suture needle. e needle is curved
to allow it to pass through a limited space where a straight needle
cannot reach, and passage can be done with a twist of the wrist.
Suture needles come in a large variety of shapes, from very
small to very large (Fig. 7.21A). e tips of suture needles either
A
B
Fig. 7.16 (A) The double-ended bone le is used for smoothing small,
sharp edges or spicules of bone. (B) The teeth of this bone le are effective
only in the pull stroke.
Fig. 7.17 The periapical curette is a double-ended, spoon-shaped instru-
ment used to remove soft tissue from bony cavities.
Fig. 7.18 A needle holder has a locking handle and a short, blunt beak.
Fig. 7.15 The surgical mallet and chisel can be used for removing bone.
Mallet and Chisel
Occasionally bone removal is performed using a mallet and chisel
(Fig. 7.15), although the availability of high-speed handpieces for
removing bone and sectioning teeth has greatly limited the need
for mallets and chisels. e mallet and chisel are sometimes used
in removing lingual tori. e edge of the chisel must be kept sharp
if it is to function eectively (see Chapter 13).
Bone File
Final smoothing of bone before the completion of surgery is usually
performed with a small bone le (Fig. 7.16A). e bone le is
usually a double-ended instrument with small and larger ends.
e bone le cannot be used eciently for removal of large amounts
of bone; therefore it is used only for nal smoothing. e teeth
of most bone les are arranged in such a fashion that they properly
remove bone only on a pull stroke (see Fig. 7.16B). Pushing this
type of bone le against bone results only in burnishing and crushing
the bone and should be avoided.
Removing Soft Tissue From Bony Cavities
e curette commonly used for oral surgery is an angled, double-
ended instrument used to remove soft tissue from bony defects
(Fig. 7.17). Its principal use is to remove granulomas or small
cysts from periapical lesions, but the curette may also be used to
remove small amounts of granulation tissue debris from a tooth
socket. Larger currettes are available for removing soft tissue from

90 Part II Principles of Exodontia
conspicuous places on the skin—for example, the face—because
properly placed smaller sutures usually cause less scarring. Sutures
of size 3-0 are large enough to withstand the tension placed on
them intraorally and strong enough for easier knot tying with a
needle holder compared with smaller-diameter sutures.
Sutures may be resorbable or nonresorbable. Nonresorbable
suture materials include such types as silk, nylon, vinyl, and stainless
steel. e most commonly used nonresorbable suture in the oral
cavity is silk. Nylon, vinyl, and stainless steel are rarely used in
the mouth. Resorbable sutures are primarily made of gut. Although
the term catgut is often used to designate this type of suture, gut
actually is derived from the serosal surface of sheep intestines.
Plain catgut resorbs quickly in the oral cavity, rarely lasting longer
than 3 to 5 days. Gut that has been treated with a tanning solution
(chromic acid) is called chromic gut and lasts longer than plain gut
by up to 7 to 10 days. Several synthetic resorbable sutures are also
available. ese materials consist of long chains of polymers braided
into suture material. Examples are polyglycolic acid and polylactic
acid. ese materials are slowly resorbed, taking up to 4 weeks to
do so. Such long-lasting resorbable sutures are rarely indicated for
basic oral surgery.
Finally, sutures are classied on the basis of their being monola-
ment or polylament. Monolament sutures are sutures such as plain
and chromic gut, nylon, and stainless steel. Polylament sutures are
braided sutures such as silk, polyglycolic acid, and polylactic acid.
Sutures that are made of braided material are easier to handle and
tie than monolament sutures and rarely come untied. e cut ends
are usually soft and nonirritating to the tongue and surrounding
soft tissues. However, because of the multiple laments, they tend
to “wick” oral uids along the suture to the underlying tissues. is
wicking action may carry bacteria along with saliva. Monolament
sutures do not cause this wicking action but may be more dicult
to tie and tend to come untied. Also the cut ends are stier, being
more irritating to the tongue and soft tissue.
One of the most commonly used sutures for the oral cavity is
3-0 black silk. e size 3-0 has the appropriate amount of strength;
the polylament nature of the silk makes it straightforward to tie
and well tolerated by the patients soft tissues. e color makes
the suture easy to see when the patient returns for suture removal.
Sutures that are holding mucosa together usually stay no longer
than 5 to 7 days, so the wicking action is of little clinical importance.
Many surgeons prefer 3-0 chromic suture to avoid the need to
later remove it. (Techniques for suturing and knot tying are pre-
sented in Chapter 8.)
Scissors
e nal instruments necessary for placing sutures are suture scissors
(Fig. 7.23). Suture scissors usually have short cutting edges because
their sole purpose is to cut sutures. e most commonly used
suture scissors for oral surgery are Dean scissors. ese have slightly
curved handles and serrated blades that make cutting sutures easier.
Suture scissors usually have long handles and thumb and nger
rings. Scissors are held in the same manner as needle holders.
Other types of scissors are designed for cutting soft tissue. e
two major types of tissue scissors are iris scissors and Metzenbaum
scissors (Fig. 7.24). ese scissors can have straight or curved
blades. Iris scissors are small, sharp-pointed, delicate tools used
for ne work. Metzenbaum scissors are used for undermining soft
tissue and for cutting. ey can have either sharp or blunt (rounded)
tips. Tissue scissors such as iris or Metzenbaum scissors should
not be used to cut sutures because the suture material will dull
A
B
Fig. 7.19 (A) The hemostat (top) has a longer, thinner beak compared with
the needle holder (bottom) and therefore should not be used for suturing.
(B) The face of the shorter beak of the needle holder is cross-hatched to
ensure a positive grip on the needle (left). The face of the hemostat has
parallel grooves that do not allow a rm grip on the needle (right).
are tapered like sewing needles or have triangular tips that allow
them to be cutting needles. A cutting needle will pass through the
mucoperiosteum more readily than a tapered needle (see Fig. 7.21B).
e cutting portion of the needle extends about one-third the
length of the needle, and the remaining portion of the needle is
rounded. Tapered needles are used for more delicate tissues, as in
ocular or vascular surgery. Care must be taken with cutting needles
because, if not used correctly, they can cut through tissue lateral
to the track of the needle. e suture material used for oral surgery
is usually purchased already swaged on (by fusing the end of a
suture onto a needle) by the manufacturer.
e curved needle is held approximately two-thirds of the distance
between the tip and the base of the needle (Fig. 7.22). is allows
enough of the needle to be exposed to pass through the tissue while
allowing the needle holder to grasp the needle in its strong portion
to prevent bending of the needle or dulling of the tip. Techniques
for placing sutures are further discussed in Chapter 8.
Suture Material
Many types of suture materials are available. e materials are
classied by diameter, resorbability, and whether they are monola-
ment or polylament.
e size of suture relates to its diameter and is designated by
a series of zeros. e diameter most commonly used in the suturing
of oral mucosa is 3-0 (000). A larger-sized suture is 2-0, or 0.
Smaller sizes are designated with more zeros, for example 4-0, 5-0,
and 7-0. Sutures of very ne size, such as 7-0, are usually used in

CHAPTER 7 Instrumentation for Basic Oral Surgery 91
teeth and the TMJ and injury may occur with injudicious use.
is type of mouth prop is useful in patients who are deeply
sedated or have mild forms of trismus.
Whenever a bite block or side-action mouth prop is used, the
surgeon should take care to avoid opening the patients mouth
too much because it may cause stress on the TMJ. Occasionally
this may result in stretch injury to the joint, necessitating additional
treatment. When long procedures are being performed, it is a good
idea to remove the prop periodically and allow the patient to move
the jaw and rest the muscles for a short time.
Removing Fluids
To provide adequate visualization, blood, saliva, and irrigating
solutions must be removed from the operative site. Surgical suction
has a smaller orice than the type used in general dentistry to
more rapidly evacuate uids from the surgical site to maintain
adequate visualization. Many of these suction tips are designed
with several orices so that the soft tissue will not become aspirated
into the suction hole and cause tissue injury (Fig. 7.27A).
e Fraser suction has a hole in the handle portion that can
be covered with a ngertip as needed. When hard tissue is being
cut under copious irrigation, the hole is covered so that the solution
is removed rapidly. When soft tissue is being suctioned, the hole
the edges of the blades and make them less eective and more
traumatic when cutting tissue.
Holding the Mouth Open
In performing extractions of mandibular teeth, it is necessary to support
the mandible to prevent stress on the temporomandibular joint (TMJ).
Supporting the patients jaw on a bite block will help protect the
joint. e bite block is just what the name implies (Fig. 7.25). It
is a soft, rubber-like block on which the patient can rest his or her
teeth. e patient opens the mouth to a comfortably wide position,
the rubber bite block is inserted, and the block holds the mouth in
the desired position without eort on the patient’s part. Bite blocks
come in several sizes to t variously sized patients and produce varying
degrees of opening. Should the surgeon need the mouth to be opened
wider using any size of bite block, the patient must open his or her
mouth more widely and the bite block must be positioned more to
the posterior of the mouth. For most adult patients, a pediatric-sized
bite block is adequate when placed over the molar teeth.
e side-action mouth prop or Molt mouth prop (Fig. 7.26)
can be used by the operator to open the mouth wider if necessary.
is mouth prop has a ratchet-type action, opening the mouth
wider as the handle is closed. is type of mouth prop should be
used with caution because great pressure can be applied to the
A
B
Fig. 7.20 The needle holder is held by using the thumb and ring nger in rings (A) and the rst and second
ngers to control the instrument (B).

92 Part II Principles of Exodontia
A
B
Fig. 7.21 (A) Comparison of needles used in oral surgery. To p, C-17
needle, which usually holds a size 4-0 suture. Middle, PS-2 needle.
Bottom, SH. All are cutting needles, and the suture material is swaged
onto the needle. (B) The tip of the needle used to suture mucoperiosteum
is triangular in cross section to make it a cutting needle.
Fig. 7.22 The needle holder grasps the curved needle two-thirds of the
distance from the tip of the needle.
A
B
Fig. 7.23 Suture scissors should be held in the same fashion as the needle
holder.
Fig. 7.24 Soft tissue scissors are of two designs: Iris scissors (top) are
small, sharp-pointed scissors. Metzenbaum scissors (bottom) are longer,
more delicate scissors. Metzenbaum scissors are available as either sharp
tipped (shown here) or blunt tipped.
can be left uncovered to prevent tissue injury or soft tissue obstruc-
tion of the suction tip (see Fig. 7.27B).
Holding Towels and Drapes in Position
When drapes are placed around a patient, they can be held together
with a towel clip (Fig. 7.28). is instrument has a locking handle
and nger and thumb rings. e action ends of the towel clip can
be sharp or blunt. ose with curved points penetrate the towels
and drapes. When this instrument is used, the operator must exercise
extreme caution so as not to pinch the patients underlying skin.

CHAPTER 7 Instrumentation for Basic Oral Surgery 93
A
C
B
Fig. 7.25 (A) The bite block is used to hold the patient’s mouth open in the position chosen by the patient.
(B) The sides of the bite block are corrugated to provide a surface for teeth to engage. (C) The blocks
come in a variety of sizes.
Fig. 7.26 The side-action, or Molt, mouth prop can be used to open the
patient’s mouth when the patient is unable to cooperate, such as during
sedation or in the presence of some degree of trismus.
Irrigating
When a handpiece and burr are used to remove bone, it is essential
that the area be irrigated with a steady stream of irrigation solution,
usually sterile saline or sterile water. e irrigation cools the burr
and prevents bone-damaging heat buildup. e irrigation also
increases the eciency of the burr by washing away bone chips
from the utes of the burr and providing a certain amount of
lubrication. In addition, once a surgical procedure is completed
and before the mucoperiosteal ap is sutured back into position,
the surgical eld should be thoroughly irrigated. A large plastic
syringe with a blunt 18-gauge needle is commonly used for irriga-
tion. Although the syringe is disposable, it can be sterilized multiple
times before it is discarded. e needle should be blunt and smooth
so that it does not damage soft tissue, and it should be angled for
more ecient direction of the irrigating stream (Fig. 7.29).
Extracting Teeth
One of the most important instruments used in the extraction
procedure is the dental elevator. ese instruments are used to
luxate (loosen) teeth from surrounding bone. Loosening teeth
before the application of the dental forceps makes extractions more
straightforward. By elevating teeth before the application of the
forceps, the clinician can minimize the incidence of broken crowns,
roots, and bone. Finally, luxation of teeth before forceps application
facilitates the removal of a broken root, should it occur, because
prior elevator use is likely to have loosened the root in the dental

94 Part II Principles of Exodontia
socket. In addition to their role in loosening teeth from surrounding
bone, dental elevators are also used to expand alveolar bone. By
expanding the buccocervical plate of bone, the surgeon facilitates
the removal of a tooth that has a limited and obstructed path for
removal. Finally, elevators are used to remove broken or surgically
sectioned roots from their sockets.
Dental Elevators
e three major components of the elevator are the handle, shank,
and blade (Fig. 7.30). e handle of the elevator is usually of
generous size, so it can be held comfortably in the hand to apply
substantial but controlled force. e application of specically
applied force is critical in the proper use of dental elevators. In
some situations, crossbar or T-bar handles are used. ese instru-
ments must be used with great caution because they can generate
an excessive amount of force that can fracture both teeth and
bones (Fig. 7.31).
e shank of the elevator simply connects the handle to the
working end, or blade, of the elevator. e shank is generally of
substantial size and is strong enough to transmit the force from
the handle to the blade. e blade of the elevator is the working
tip of the elevator and is used to transmit the force to the tooth,
bone, or both.
Types of Elevators
e biggest variation in the type of elevator is in the shape and
size of the blade. e three basic types of elevators are (1) the
straight type, (2) the triangle or pennant-shaped type, and (3) the
pick type. e straight elevator is the most commonly used elevator
to luxate teeth (Fig. 7.32A). e blade of the straight elevator has
A
B
Fig. 7.27 (A) The typical surgical suction has a small-diameter tip. Suction
tips usually have a hole to prevent tissue injury caused by excessive
suction pressure. Top, Unassembled for cleaning. Bottom, Assembled for
use. (B) The Fraser suction tip has a blade in the handle to allow the
operator more control over the amount of suction power. Holding the
thumb over the hole increases suction at the tip. A wire stylet is used to
clean the tip when bone or tooth particles plug the suction.
Fig. 7.28 The towel clip is used to hold the drape in position. The tips
clasp the towels, and the locking handles maintain the drape in position.
The clip shown has nonpenetrating blunt tips. Towel clamps with sharp
penetrating tips are also available.
Fig. 7.29 Large plastic syringes with an angled blunt tip may be used to
deliver the irrigation solution to the operative site.
Blade Shank Handle
Fig. 7.30 The major components of an elevator are the handle, shank,
and blade.
Fig. 7.31 A crossbar handle is used on certain elevators. This type of
handle can generate large amounts of force and therefore must be used
with great caution.

CHAPTER 7 Instrumentation for Basic Oral Surgery 95
a concave surface on one side that is placed toward the tooth to
be elevated (see Fig. 7.32B). e small straight elevator, No. 301,
is frequently used for beginning the luxation of an erupted tooth
before application of the forceps (Fig. 7.33). Larger straight elevators
are used to displace roots from their sockets and to luxate teeth
that are more widely spaced, or they are used once a smaller-sized
straight elevator becomes less eective. e most commonly used
large straight elevator is the No. 34S, but the No. 46 and the No.
77R elevators are also used occasionally.
e shape of the blade of the straight elevator can be angled
from the shank, allowing this instrument to be used in the more
posterior aspects of the mouth. Two examples of the angled-shank
elevator with a blade similar to that of the straight elevator are the
Miller elevator and the Potts elevator.
e second most commonly used type of elevator is the triangular
elevator (Fig. 7.34). ese elevators are provided in pairs: a left
and a right. e triangular elevator is most useful when a broken
root remains in the tooth socket and the adjacent socket is empty.
A typical example would be when a mandibular rst molar is
fractured, leaving the distal root in the socket but the mesial root
A
B
C
Fig. 7.32 (A) Straight elevators are the most commonly used type. (B–C)
The blade of the straight elevator is concave on its working side.
Fig. 7.33 Straight elevators vary in size depending on the width of the
blade.
Fig. 7.34 Triangular elevators (Cryer) are pairs of instruments and are
therefore used for mesial or distal roots.
Fig. 7.35 The Crane pick is a heavy instrument used to elevate whole
roots or even teeth after the purchase point has been prepared with a
burr.
removed with the crown. e tip of the triangular elevator is placed
into the socket with the shank of the elevator resting on the buccal
plate of bone. e elevator is then turned in a wheel-and-axle
rotation, with the sharp tip of the elevator engaging the cementum
of the remaining distal root; the elevator is then turned and the
root is delivered. Triangular elevators come in a variety of types
and angulations, but the Cryer elevator is the most common type.
(Pairs of these elevators are also commonly referred to as east-west
elevators.)
e third type of elevator used with some frequency is the
pick-type elevator. is type of elevator is used to remove roots.
e heavy version of the pick is the Crane pick (Fig. 7.35). is
instrument is used as a lever to elevate a broken root from the
tooth socket. Usually it is necessary to drill a hole with a burr
(purchase point) approximately 3 mm deep into the root just at
the bony crest. e tip of the pick is then inserted into the hole,
and, with the buccal plate of bone as a fulcrum, the root is elevated
from the tooth socket. Occasionally the sharp point can be used
without preparing a purchase point by engaging the cementum
or the furcation of the tooth.
e second type of pick is the root-tip pick or the apex elevator
(Fig. 7.36). e root-tip pick is a delicate instrument that is used
to tease small root tips from their sockets. It must be emphasized
that this is a thin instrument and should not be used as a wheel-
and-axle or lever type of elevator such as the Cryer elevator or the
Crane pick. e root-tip pick is used to tease the very small root
end of a tooth by inserting the tip into the periodontal ligament
space between the root tip and the socket wall. is instrument
works best on roots left after a tooth has been well elevated.
Periotomes
Periotomes are instruments used to extract teeth while preserving
the anatomy of the tooths socket. e general principle behind
their use is to sever some of the periodontal ligaments of the tooth

96 Part II Principles of Exodontia
size to be used comfortably and to deliver sucient pressure and
leverage to remove the required tooth. e handles have a serrated
surface to allow a positive grip and to prevent slippage.
e handles of the forceps are held dierently depending on
the position of the tooth to be removed. Maxillary forceps are
held with the palm to the side or underneath the forceps so that
the beak is directed in a superior direction (Fig. 7.39). e forceps
used for removal of mandibular teeth are held with the palm on
top of the forceps so that the beak is pointed down toward teeth
(Fig. 7.40). e handles of the forceps are usually straight, but
some may be curved to provide the operator with a better t (Fig.
7.41).
e hinge of the forceps, like the shank of the elevator, is merely
a mechanism for connecting the handles to the beak. e hinge
transfers and concentrates the force applied to the handles to the
beak. One distinct dierence in styles does exist: e usual American
type of forceps has a hinge in a horizontal direction and is used
as has been described (see Fig. 7.38). e English preference is
for a vertical hinge and a corresponding vertically positioned handle
(Fig. 7.42A). us the English-style handle and hinge are used
with the hand held in a vertical direction as opposed to a horizontal
direction (see Fig. 7.42B).
e beaks of the extraction forceps are the source of the great-
est variation among forceps. e beaks are designed to adapt to
the tooth root near the junction of the crown and root. It must
be remembered that the beaks of the forceps are designed to be
adapted to the root structure of the tooth and not to the crown
of the tooth. In a sense, then, dierent beaks are designed for
to facilitate its removal. ere are varying types of periotomes with
dierent blade shapes (Fig. 7.37).
e tip of the periotome blade is inserted into the periodontal
ligament space and advanced using pressure in the apical direction
along the long axis of the tooth. It is advanced about 2 to 3 mm
and then removed and reinserted into an adjacent accessible site.
e process is continued around the tooth, gradually advancing
the depth of the periotome tip while progressing apically. Once
sucient severance of periodontal ligaments has been accomplished,
the tooth is removed by using a dental elevator, extraction forceps,
or both, taking care to avoid excessive expansion or fracture of bone.
Extraction Forceps
e extraction forceps are instruments used for removing the tooth
from alveolar bone. Ideally, forceps are used to lift elevator-luxated
teeth from their sockets rather than to pull teeth from their sockets.
When properly used, they can also help to expand bone during
extractions.
Forceps are designed in many styles and congurations to adapt
to the variety of teeth for which they are used. Each basic design
oers a multiplicity of variations to coincide with individual operator
preferences. is section deals with the basic fundamental designs
and briey discusses several of the variations.
Forceps Components
e basic components of dental extraction forceps are the handles,
hinge, and beak (Fig. 7.38). e handles are usually of adequate
Fig. 7.36 The delicate root-tip pick is used to tease root tip fragments from the socket. The ne tip can
be broken off or bent if the instrument is used improperly.
Fig. 7.37 A periotome with a handle and exchangeable blades. Other types of periotomes have xed
blades or are connected to a motor.

CHAPTER 7 Instrumentation for Basic Oral Surgery 97
Fig. 7.39 Forceps used to remove maxillary teeth are held with the palm
under the handle.
A
B
Fig. 7.40 (A) Forceps used to remove mandibular teeth are held with the
palm on top of forceps. (B) A rmer grip for delivering greater amounts of
rotational force can be achieved by moving the thumb around and under
the handle.
Fig. 7.41 Straight handles are usually preferred, but curved handles are
favored by some surgeons.
A
B
Fig. 7.42 (A) English style of forceps have the hinge in the vertical direc-
tion. (B) English style of forceps are held in the vertical direction.
Beak Hinge Handle
Fig. 7.38 Basic components of extraction forceps.

98 Part II Principles of Exodontia
curve of the No. 150 forceps allows the operator to comfort-
ably reach not only incisors but also premolars. e beak of the
No. 150 forceps comes in a style that has been modied slightly
to form the No. 150A forceps (Fig. 7.44). No. 150A forceps are
useful for extracting maxillary premolar teeth and should not be
used for extracting incisors because of its poor adaptation to the
roots of incisors.
In addition to the No. 150 forceps, straight forceps are also
available. No. 1 forceps (Fig. 7.45), which can be used for maxillary
incisors and canines, are easier to use compared with the No. 150
forceps for upper incisors.
Maxillary molar teeth are three-rooted teeth, with a single
palatal root and a buccal bifurcation. erefore forceps that are
specically adapted to t maxillary molars must have a smooth,
concave surface for the palatal root and a beak with a pointed
design that will t into the buccal bifurcation. is requires that
the molar forceps come in pairs: a left and a right. In addition, the
maxillary molar forceps should be oset so that the surgeon can
reach the posterior aspect of the mouth and remain in the correct
position. e most commonly used molar forceps are the No. 53
right and left forceps (Fig. 7.46). ese forceps are designed to
t anatomically around the palatal beak, and the pointed buccal
beak ts into the buccal bifurcation. e beak is oset to allow
for good surgeon positioning.
A design variation is shown in the No. 88 right and left forceps,
which have a longer, more accentuated pointed beak formation
(Fig. 7.47). ey are particularly useful for maxillary molars with
crowns that are severely carious. e sharply pointed beaks may
reach deeper into the trifurcation to sound dentin. e major
disadvantage is that they crush crestal alveolar bone, and when
used on intact teeth without due caution and proper elevation,
they can fracture large amounts of buccal alveolar bone.
On occasion maxillary second molars and erupted third molars
have a single conical root. In this situation, forceps with broad,
smooth beaks that are oset from the handle can be useful. e
No. 210S forceps exemplies this design (Fig. 7.48). Another design
variation is shown in the oset molar forceps with a very narrow
beak. ese forceps are used primarily to remove broken maxillary
molar roots but can be used for the removal of narrow premolars
and for lower incisors. ese forceps, the No. 65 forceps, are also
known as root-tip forceps (Fig. 7.49).
single-rooted teeth, two-rooted teeth, and three-rooted teeth. e
design variation is such that the tips of the beaks will adapt closely
to the various root formations, improving the surgeons control of
forces on the root and decreasing the chances of a root fracture.
e more closely the beaks of the forceps adapt to the tooth roots,
the more ecient is the extraction and the lower is the chance for
undesired outcomes.
A nal design variation is in the width of the beak. Some forceps
beaks are narrow because their primary use is to remove narrow
teeth such as incisor teeth. Other forceps beaks are broader because
the teeth they are designed to remove are substantially wider, for
example, lower molar teeth. Forceps designed to remove a lower
incisor can theoretically be used to remove a lower molar, but the
beaks are so narrow that they will be inecient for that application.
Similarly, the broader molar forceps will not adapt to the narrow
space occupied by the lower incisor; therefore it cannot be used
in that situation without damage to adjacent teeth.
e beaks of forceps are angled such that they can be placed
parallel to the long axis of the tooth, with the handle in a comfort-
able position. erefore the beaks of maxillary forceps are usually
parallel to the handles. Maxillary molar forceps are oset in a
bayonet fashion to allow the operator to reach the posterior aspect
of the mouth comfortably and yet keep the beak parallel to the
long axis of the tooth. e beaks of mandibular forceps are usually
set perpendicular to the handles, which allows the surgeon to
reach lower teeth and maintain a comfortable controlled position.
Maxillary Forceps
e removal of maxillary teeth requires the use of instruments
designed for single-rooted teeth and for teeth with three roots.
Maxillary incisors, canine teeth, and premolar teeth are considered
single-rooted teeth. e maxillary rst premolar frequently has a
bifurcated root, but because this occurs in the apical third, it has
no inuence on the design of the forceps. e maxillary molars
have trifurcated roots, so there are extraction forceps that will
adapt to that conguration.
After proper elevation, single-rooted maxillary teeth are usually
removed with maxillary universal forceps, usually No. 150 (Fig.
7.43). e No. 150 forceps are slightly S-shaped when viewed
from the side and are essentially straight when viewed from above.
e beaks of the forceps curve to meet only at the tip. e slight
A
C
B
D
Fig. 7.43 (A) Superior view of No. 150 forceps. (B) Side view of No. 150 forceps. (C–D) No. 150 forceps
adapted to the maxillary central incisor.

CHAPTER 7 Instrumentation for Basic Oral Surgery 99
A
B
C
Fig. 7.44 (A) Superior view of No. 150A forceps. (B) No. 150A forceps have parallel beaks that do not
touch, in contrast to the No. 150 forceps. (C) Adaptation of No. 150A forceps to the maxillary premolar.
A
B
C
Fig. 7.45 (A) Superior view of No. 1 forceps. (B–C) No. 1 forceps adapted to the incisor.
A smaller version of the No. 150 forceps, the No. 150S forceps,
is useful for removing primary teeth (Fig. 7.50). ese forceps
adapt well to all maxillary primary teeth and can be used as universal
primary tooth forceps.
Mandibular Forceps
Extraction of mandibular teeth requires forceps that can be used
for single-rooted teeth for the incisors, canines, and premolars as
well as for two-rooted teeth for the molars. e forceps most
commonly used for the single-rooted teeth are the lower universal
forceps, or the No. 151 forceps (Fig. 7.51). ese forceps have
handles similar in shape to the No. 150 forceps, but the beaks are
pointed inferiorly for lower teeth. e beaks are smooth and narrow
and meet only at the tip. is allows the beak to t near the cervical
line of the tooth to grasp the root.
e No. 151A forceps have been modied slightly for mandibular
premolar teeth (Fig. 7.52). ese forceps should not be used for
other lower teeth because their form prevents adaptation to the
roots of teeth.
e English style of vertical-hinge forceps can be used for the
single-rooted teeth in the mandible (Fig. 7.53). Great force can
be generated with these forceps. Unless great care is exercised, the
incidence of root fracture is higher with this instrument.
Mandibular molars are bifurcated, two-rooted teeth that allow
the use of forceps that anatomically adapt to the tooth. Because
the bifurcation is on the buccal and the lingual sides, only

100 Part II Principles of Exodontia
A
B
C
DE
Fig. 7.46 (A) Superior view of No. 53L forceps. (B) Oblique view of No. 53L forceps. (C) Right, No. 53L;
left, No. 53R. (D–E) No. 53L forceps adapted to the maxillary molar.
A
B
C
Fig. 7.47 (A) Superior view of No. 88L forceps. (B) Side view of No. 88L forceps. (C) No. 88R forceps
adapted to the maxillary molar.

CHAPTER 7 Instrumentation for Basic Oral Surgery 101
A
C
B
Fig. 7.48 (A) Superior view of No. 210S forceps. (B) Side view of No. 210S forceps. (C) No. 210S forceps
adapted to the maxillary molar.
A
B
C
Fig. 7.49 (A) Superior view of No. 65 forceps. (B) Side view of No. 65
forceps. (C) No. 65 forceps adapted to a broken root.
Fig. 7.50 The No. 150S forceps (bottom) are a smaller version of the No.
150 forceps (top) and are used for primary teeth.
single-molar forceps are necessary for the both sides, in contradistinc-
tion to the maxilla, for which a right- and left-paired molar forceps
set is required.
Useful lower molar forceps are the No. 17 forceps (Fig. 7.54).
ese forceps are usually straight-handled, and the beaks are set
obliquely downward. e beaks have pointed tips in the center to
be set into the bifurcation of lower molar teeth. e remainder
of the beak adapts well to the sides of the furcation. Because of
the pointed tips, the No. 17 forceps cannot be used for molar
teeth, which have fused, conical roots. For this purpose, the No.
151 forceps are used.
A major design variation in lower molar forceps is the No. 87,
the so-called cowhorn forceps (Fig. 7.55). ese instruments are
designed with two pointed, heavy beaks that enter the bifurcation
of lower molars. After the forceps are seated in the correct position,
usually while gently pumping the handles up and down, the tooth
is actually elevated by squeezing the handles of the forceps together
tightly. As the beaks are squeezed into the bifurcation, they use
the buccal and lingual cortical plates as fulcrums and the tooth
can be literally squeezed out of the socket. As with the English
style of forceps, improper use of the cowhorn forceps can result
in an increase in the incidence of untoward eects such as fractures
of alveolar bone or damage to maxillary teeth if the forceps are
not properly controlled by the surgeon as the molar exits the
socket. e beginning surgeon should therefore use the cowhorn
forceps with caution.
e No. 151 forceps are also adapted for primary teeth. No.
151S forceps are the same general design as the No. 151 forceps
but are scaled down to adapt to primary teeth. ese forceps are
adequate for the removal of all primary mandibular teeth (Fig. 7.56).
Instrument Tray Systems
Many dentists nd it practical to use the tray method to assemble
instruments that will be used for specic types of procedures.
Standard sets of instruments are packaged together, sterilized, and
then unwrapped at surgery. e typical basic extraction pack includes
a local anesthesia syringe, a needle, a local anesthesia cartridge, a
No. 9 periosteal elevator, a periapical curette, small and large straight
elevators, a pair of college pliers, a curved hemostat, a towel clip,
an Austin or Minnesota retractor, a suction tip, and 2 × 2 inch
or 4 × 4 inch gauze (Fig. 7.57). e required forceps would be
added to this tray after it was opened.
A tray used for surgical extractions would include the items
from the basic extraction tray plus needle holder and suture, suture
scissors, blade handle and blade, Adson tissue forceps, bone le,
tongue retractor, Cryer elevators, rongeur, and handpiece and burr
(Fig. 7.58). ese instruments permit incision and reection of
soft tissue, removal of bone, sectioning of teeth, retrieval of roots,
debridement of the wound, and suturing of the soft tissue.

102 Part II Principles of Exodontia
A
B
C
Fig. 7.51 (A) Superior view of No. 151 forceps. (B) Side view of No. 151 forceps. (C) No. 151 forceps
adapted to the mandibular incisor.
AB
Fig. 7.52 (A) The No. 151A forceps have beaks that are parallel and do not adapt well to the roots of
most teeth, in contrast to the beaks of the No. 151 forceps. (B) No. 151A forceps adapted to a lower
premolar tooth. The lack of close adaptation of the tips of the beaks to the root of the tooth is shown.
A
B
Fig. 7.53 (A) Side view of the English style of forceps. (B) Forceps adapted to the lower premolar.

CHAPTER 7 Instrumentation for Basic Oral Surgery 103
C
A
B
D
Fig. 7.54 (A) Superior view of No. 17 molar forceps. (B) Side view of No. 17 molar forceps. (C–D) No. 17
forceps adapted to the lower molar.
C
A
B
D
Fig. 7.55 (A) Superior view of cowhorn No. 87 forceps. (B) Side view of cowhorn forceps. (C–D) Cowhorn
forceps adapted to the lower molar tooth.

104 Part II Principles of Exodontia
Fig. 7.56 The No. 151S forceps (bottom) are a smaller version of the No. 151 forceps (top) and are used
to extract primary teeth.
Fig. 7.57 Basic extraction tray.
Fig. 7.58 The surgical extraction tray includes the necessary instrumentation to reect soft tissue aps,
remove bone, section teeth, retrieve roots, and suture aps back into position.

CHAPTER 7 Instrumentation for Basic Oral Surgery 105
Fig. 7.59 The biopsy tray includes equipment necessary to remove a soft tissue specimen and suture
wounds closed.
Fig. 7.60 The postoperative tray includes instruments necessary to remove sutures and irrigate the mouth.
e biopsy tray includes the basic tray (minus elevators), blade
handle and blade, needle holder and suture, suture scissors, tissue
scissors, Allis tissue forceps, Adson tissue forceps, and a curved hemo-
stat (Fig. 7.59). ese instruments permit incision and dissection
of a soft tissue specimen and closure of the wound with sutures.
e postoperative tray has the necessary instruments to irrigate
the surgical site and remove sutures (Fig. 7.60). e tray usually
includes scissors, college pliers, irrigation syringe, cotton applicator
sticks, gauze, and suction tip.
e instruments may be placed on a at tray, wrapped with
sterilization paper, and sterilized. When ready for use, the tray
is taken to the operatory and opened in such a manner as to
preserve instrument sterility, and the instruments are used from
the tray. is system requires a large autoclave to accommodate
the tray.
Alternatively, metal cassettes can be used instead of a tray.
Cassettes are more compact but must also be wrapped in sterilization
paper.

106
8
Principles of Routine Exodontia
JAMES R. HUPP
CHAPTER OUTLINE
Presurgical Medical Assessment, 106
Indications for Removal of Teeth, 107
Caries, 107
Pulpal Necrosis, 107
Periodontal Disease, 107
Orthodontic Reasons, 107
Malpositioned Teeth, 107
Cracked Teeth, 107
Impacted Teeth, 107
Supernumerary Teeth, 107
Teeth Associated With Pathologic Lesions, 107
Radiation Therapy, 107
Teeth Involved in Jaw Fractures, 107
Financial Issues, 108
Contraindications for Removal of Teeth, 108
Local Contraindications, 108
Clinical Evaluation of Teeth for Removal, 108
Access to the Tooth, 108
Mobility of the Tooth, 108
Condition of the Crown, 108
Radiographic Examination of the Tooth for Removal, 109
Relationship to Vital Structures, 110
Conguration of Roots, 110
Condition of Surrounding Bone, 112
Patient and Surgeon Preparation, 112
Chair Position for Extractions, 113
Mechanical Principles Involved in Tooth Extraction, 116
Principles of Elevator and Forceps Use, 119
Procedure for Closed Extraction, 121
Role of the Opposite Hand, 123
Role of the Assistant During Extraction, 124
Specic Techniques for the Removal of Each Tooth, 124
Maxillary Teeth, 124
Incisors, 124
Canines, 125
First Premolar, 126
Second Premolar, 127
Molars, 127
Mandibular Teeth, 128
Anterior Teeth, 128
Premolars, 130
Molars, 130
Modications for Extraction of Primary Teeth, 131
Postextraction Tooth Socket Care, 132
lifted from its socket. During preextraction planning, the degree
of diculty anticipated for removing a particular tooth is assessed.
If that assessment leads the surgeon to believe that the degree of
diculty will be high or if initial attempts at tooth removal conrm
this, a deliberate surgical approach—not an application of excessive
force—should be taken. Excessive force may injure local soft tissue
and damage the surrounding bone and teeth. Such force may
fracture the crown, usually making the extraction substantially
more dicult than it would have been otherwise. Moreover, excessive
force and haste during an extraction heightens intraoperative and
postoperative patient discomfort and anxiety.
Presurgical Medical Assessment
When conducting the preoperative patient evaluation, it is critical
that the surgeon examine the patient’s medical status. Patients can
have a variety of health problems that require treatment modication
or medical management before the surgery can be safely performed.
E
xtraction of a tooth combines the principles of surgery and
elementary physical mechanics. When these principles are
applied correctly, a tooth can usually be removed from the
alveolar process, even by someone without great strength and
without untoward force or sequelae. is chapter presents the
principles of surgery and mechanics related to uncomplicated tooth
extraction. In addition, there is a detailed description of techniques
for removal of specic teeth with specic instruments. Because
the crown is already “removed” from the bone in fully erupted
teeth, a dental extraction focuses on root extraction. Following
this concept prevents the surgeon from untoward focus on using
force on the crowns to remove teeth. Ignoring this concept com-
monly leads to fracturing the crowns or roots of teeth or fracturing
the bone around the roots.
Proper tooth removal does not require a large amount of strength;
instead, when done properly, it is accomplished with nesse.
Removal of an erupted tooth involves the use of controlled force
so that the tooth is not pulled from bone, but instead is gently

CHAPTER 8 Principles of Routine Exodontia 107
be extracted. A common example of this is the maxillary third
molar, which erupts in severe buccal version and causes ulcer-
ation and soft tissue trauma of the cheek. Another example is
malpositioned teeth that are hypererupted because of the loss of
teeth in the opposing arch. If prosthetic rehabilitation is to be
carried out in the opposing arch, the hypererupted tooth may
interfere with construction of an adequate prosthesis. In this
situation, the malpositioned tooth should be considered for
extraction.
Cracked Teeth
An uncommon indication for extraction of teeth is a tooth with
a cracked crown or a fractured root. e cracked tooth can be
painful and be unmanageable by a more conservative technique.
Cracked teeth have often already undergone endodontic therapy
at some point in the past, which tends to make the crown and
root more brittle and dicult to remove.
Impacted Teeth
Impacted teeth should be considered for removal. If it is clear that
a partially impacted tooth is unable to erupt into a functional
occlusion because of inadequate space, interference from adjacent
teeth, or some other reason, it should be considered for surgical
removal. See Chapter 10 for a more thorough discussion of this
topic.
Supernumerary Teeth
Supernumerary teeth are usually impacted and should be removed.
A supernumerary tooth may interfere with the eruption of suc-
cedaneous teeth and has the potential for causing their resorption
and displacement.
Teeth Associated With Pathologic Lesions
Teeth involved in pathologic lesions may require removal. is is
often seen with odontogenic cysts. In some situations, the tooth
or teeth can be retained and endodontic therapy performed.
However, if maintaining the tooth compromises the complete
surgical removal of the lesion when complete removal is critical,
the tooth should be removed.
Radiation Therapy
Patients who are to receive radiation therapy for oral, head, or
neck cancer should consider removal of teeth that are in the beam
of radiation therapy, particularly if the teeth are compromised in
some manner. However, many of these teeth can be retained with
proper care. See Chapter 19 for a more thorough discussion of
the eects of radiation therapy on teeth and jaws.
Teeth Involved in Jaw Fractures
Patients who sustain fractures of the mandible or the alveolar
process sometimes must have teeth removed. In some situa-
tions, the tooth involved in the line of fracture can be main-
tained, but if the tooth is injured, infected, or severely luxated
from the surrounding bony tissue or interferes with proper
reduction and fixation of the fracture, its removal is usually
indicated.
Special measures may be needed to control bleeding, lessen the
chance of infection, or prevent a medical emergency. is informa-
tion is discussed in detail in Chapter 1, which includes information
regarding the specics of altering surgical treatment for medical
management reasons.
Indications for Removal of Teeth
Teeth are extracted for a variety of reasons. is section discusses
a variety of general indications for removing teeth. ese indications
are only guidelines, not absolute rules.
Caries
Perhaps the most common and widely accepted reason to remove
a tooth is that it is so severely carious that it cannot be restored.
e extent to which the tooth is carious and is considered nonrestor-
able is a judgment call to be made between the dentist and the
patient. Sometimes the complexity and cost required to salvage a
severely carious tooth also makes extraction a reasonable choice.
is is particularly true with the availability and success of reliable
implant-supported prostheses.
Pulpal Necrosis
A second, closely aligned rationale for removing a tooth is the
presence of pulpal necrosis or irreversible pulpitis that is not
amenable to endodontics. is may be the result of a patient
declining endodontic treatment or when a tooth has a root canal
that is tortuous, calcied, and untreatable by standard endodontic
techniques. Also included in this category of general indications
is the case in which endodontic treatment has been done but has
failed to relieve pain or provide drainage, and the patient does not
desire retreatment.
Periodontal Disease
A common reason for tooth removal is severe and extensive peri-
odontal disease. If severe adult periodontitis has existed for some
time, excessive bone loss and irreversible tooth mobility will be
found. In these situations, the hypermobile teeth should be extracted.
Also, ongoing periodontal bone loss may jeopardize the chance for
straightforward implant placement, making extraction a sensible
step even before a tooth becomes moderately or severely mobile.
Orthodontic Reasons
Patients who are about to undergo orthodontic correction of
crowded dentition with insucient arch length frequently require
the extraction of teeth to provide space for tooth alignment. e
most commonly extracted teeth are the maxillary and mandibular
premolars, but a mandibular incisor may occasionally need to be
extracted for this same reason. Great care should be taken to
double-check that extraction is indeed necessary and that the correct
tooth or teeth are removed if someone other than the surgeon
doing the extraction has planned the extractions.
Malpositioned Teeth
Teeth that are malposed or malpositioned may be indicated for
removal in several situations. If they traumatize soft tissue and
cannot be repositioned by orthodontic treatment, they should

108 Part II Principles of Exodontia
A variety of factors must be specically examined to make the
appropriate assessment and treatment plan.
Access to the Tooth
e rst factor to be examined in preoperative assessment is the
extent to which the patient can open the mouth. Any limitation
of opening may compromise the ability of the surgeon to give
local anesthesia or perform a routine extraction. If the patient’s
opening is substantially compromised, the surgeon should consider
a surgical approach to the tooth instead of a routine elevator and
forceps extraction. is requires placing the patient under deep
sedation or general anesthesia. In addition, the surgeon should
look for the cause of the reduction of opening. e most likely
causes are trismus associated with infection around the muscles
of mastication, temporomandibular joint (TMJ) dysfunction, and
muscle brosis.
e location and position of the tooth to be extracted within
a dental arch should be examined. A properly aligned tooth has
a normal access for placement of elevators and forceps. However,
crowded or otherwise malposed teeth may present diculty in
positioning the usually used forceps onto the tooth for extraction.
When access is a problem, a dierent forceps may be needed or
a surgical approach may be indicated.
Mobility of the Tooth
e mobility of the tooth to be extracted should be assessed
preoperatively. Greater-than-normal mobility is frequently seen
with severe periodontal disease. If the teeth are excessively mobile,
uncomplicated tooth removal should be expected, but soft tissue
management after the extraction may be more involved (Fig. 8.1A).
Teeth that have less-than-normal mobility should be carefully
assessed for the presence of hypercementosis or ankylosis of the
roots. Ankylosis is often seen with primary molars that are retained
and have become submerged (see Fig. 8.1B). In addition, ankylosis
is seen occasionally in nonvital teeth that have had endodontic
therapy many years before the extraction. If the clinician believes
that the tooth is ankylosed, it is wise to plan for a surgical removal
of the tooth as opposed to a forceps extraction. Hypercementosis
can create bulbous roots that are more challenging to remove.
Condition of the Crown
e assessment of the crown of the tooth before the extraction
should be related to the presence of large caries or restorations in
the crown. If large portions of the crown have been destroyed by
caries, the likelihood of crushing the crown during the extraction
is increased, thus causing more diculty in removing the tooth
(Fig. 8.2). Similarly, the presence of large amalgam restorations
produces weakness in the crown, and the restoration will probably
fracture during the extraction process (Fig. 8.3). In addition, an
endodontically treated tooth becomes desiccated and typically
becomes brittle and crumbles easily when force is applied. In these
three situations, it is critical that the tooth be elevated as much
as possible and that the forceps then be applied as far apically as
possible in order to grasp an intact root portion of the tooth
instead of the crown.
If the tooth to be extracted has a large accumulation of calculus,
the gross accumulation should be removed with a scaler or ultrasonic
cleaner before extraction. e reasons for this are that calculus
interferes with the placement of the forceps in the appropriate
Financial Issues
A nal indication for removal of a tooth relates to the nancial
status of the patient. All of the indications for extraction already
mentioned may become stronger if the patient is unwilling or
unable to nancially support the decision to maintain the tooth.
e inability of the patient to pay for the procedure may require
that the tooth be removed. Also, implant dentistry is often more
cost eective for a patient than maintaining a compromised tooth.
Contraindications for Removal of Teeth
Even if a given tooth meets one of the requirements for removal,
in some situations, the tooth should not be removed because of
other factors or contraindications to extraction. ese factors, like
the indications, are relative in their strength. In some situations,
the contraindication can be modied by the use of additional care
or treatment, and the indicated extraction can be performed. In
other situations, however, the contraindication may be so signicant
that the tooth should not be removed without taking special precau-
tions. In general, the contraindications are divided into two groups:
systemic and local. Systemic contraindications to routine oral
surgery are discussed in Chapter 1.
Local Contraindications
Several local contraindications to the extraction of teeth also exist.
e most important and most critical is a history of therapeutic
radiation for cancer. Extractions performed in an area of radiation
may result in osteoradionecrosis, and therefore the extraction must
be done with extreme caution. Chapter 19 discusses this in detail.
Teeth that are located within an area of tumor, especially a
malignant tumor, should not be extracted. e surgical procedure
for extraction could disseminate malignant cells, thereby seeding
local metastases.
Patients who have severe pericoronitis around an impacted
mandibular third molar should not have the tooth extracted until
the pericoronitis has been treated. Nonsurgical treatment should
include irrigations and removal of the maxillary third molar, if
necessary, to relieve impingement on the edematous soft tissue
overlying the mandibular impaction. Some clinicians will also
administer antibiotics. If the mandibular third molar is removed
in the face of severe pericoronitis, the incidence of complications
increases. However, if the pericoronitis is mild and the tooth can
be removed in a straightforward manner, then immediate extraction
may be performed.
Finally, the acute dentoalveolar abscess must be mentioned.
Many prospective studies have made it abundantly clear that the
most rapid resolution of an infection resulting from pulpal necrosis
is obtained when the tooth is removed as early as possible. erefore
acute infection is not a contraindication to extraction. However,
it may be dicult to extract such a tooth because the patient may
not be able to open the mouth suciently wide due to trismus,
or it may be dicult to reach a state of profound local anesthesia.
If access and anesthesia considerations can be met, the tooth should
be removed as soon as possible. Otherwise, antibiotic therapy
should be started and extraction planned as soon as possible.
Clinical Evaluation of Teeth for Removal
In the preoperative assessment period, the tooth to be extracted
should be examined carefully to assess the diculty of the extraction.

CHAPTER 8 Principles of Routine Exodontia 109
BA
Fig. 8.1 (A) Tooth with severe periodontal disease with bone loss and wide periodontal ligament space.
This kind of tooth is straightforward to remove. (B) Retained mandibular second primary molar with an
absent succedaneous tooth. The molar is partially submerged, and the likelihood for ankylosed roots is
high.
Fig. 8.2 Teeth with large carious lesions are likely to fracture during
extraction, making extraction more difcult.
Fig. 8.3 Teeth with large amalgam restorations are likely to be fragile and
to fracture when extraction forces are applied.
Fig. 8.4 Mandibular rst molar. If the molar is to be removed, the surgeon
must take care not to fracture amalgam in the second premolar with eleva-
tors or forceps.
fashion, and fractured calculus may contaminate the empty tooth
socket once the tooth is extracted.
e surgeon should also assess the condition of adjacent teeth.
If adjacent teeth have large amalgams or crowns, or have undergone
endodontic therapy, it is important to keep this in mind when
elevators and forceps are used to mobilize and remove the indicated
tooth. If adjacent teeth have large restorations, the surgeon should
use elevators with extreme caution because fracture or displacement
of the restorations may occur (Fig. 8.4). e patient should be
informed before the surgical procedure about possible damage to
these restorations during the process of obtaining informed consent.
Radiographic Examination of the Tooth
for Removal
It is essential that proper radiographs be taken of any tooth to be
removed. In general, periapical radiographs provide the most
accurate and detailed information concerning the tooth, its roots,
and the surrounding tissue. Panoramic radiographs are used

110 Part II Principles of Exodontia
with division of maxillary molar roots into individual roots before
the extraction proceeds (Fig. 8.6).
The inferior alveolar canal may approximate the roots of
mandibular molars. Although the removal of an erupted tooth
rarely impinges on the inferior alveolar canal, if an impacted tooth
is to be removed, it is important that the relationship between
molar roots and the canal be assessed. Such an extraction may lead
to injury of the canal and cause consequent damage to the inferior
alveolar nerve (Fig. 8.7). Cone-beam computed tomography
(CBCT) images are often useful in these circumstances.
Radiographs taken before the removal of mandibular premolar
teeth should include the mental foramen. Should a surgical ap
be required to retrieve a premolar root, it is essential that the
surgeon know where the mental foramen is to avoid injuring the
mental nerve during ap development (Fig. 8.8, see also Fig. 8.3).
Conguration of Roots
Radiographic assessment of the tooth to be extracted probably
contributes the most to the determination of diculty of the
extraction. e rst factor to evaluate is the number of roots on
the tooth to be extracted. Most teeth have the typical number of
roots, in which case the surgical plan can be carried out in the
Fig. 8.5 Properly exposed radiograph for extraction of mandibular rst
molar.
Fig. 8.6 Maxillary molar teeth immediately adjacent to the sinus present
increased danger of sinus exposure.
Fig. 8.7 Mandibular molar teeth that are close to the inferior alveolar
canal. Third molar removal is a procedure most likely to result in injury to
the nerve.
frequently, but their greatest usefulness is for impacted teeth as
opposed to erupted teeth.
For radiographs to have their maximal value, they must meet
certain criteria. Most importantly, radiographs must be properly
exposed, with adequate penetration and good contrast. The
radiographic lm or sensor should have been properly positioned
so that it shows all portions of the crown and roots of the tooth
under consideration without distortion (Fig. 8.5). If digital imaging
is not used, the radiograph must be properly processed, with good
xation, drying, and mounting. e mounting should be labeled
with the patient’s name and the date on which the lm was exposed.
The radiograph should be mounted in the American Dental
Association (ADA) standardized method, which is to view the
radiograph as if looking at the patient; the raised dot on the lm
faces the observer. e radiograph should be reasonably current
in order to depict the presently existing situation. Radiographs
older than 1 year should probably be retaken before surgery. Finally,
nondigital radiographs must be mounted on a view box that is
visible to the surgeon during the operation, and digital images
should be displayed so the surgeon can look at them during
extractions without stopping surgery or degloving. Radiographs
that are taken, but not available during surgery, are of limited
value.
e relationship of the tooth to be extracted to adjacent erupted
and unerupted teeth should be noted. If the tooth is a primary
tooth, the relationship of its roots to the underlying succedaneous
tooth should be carefully considered. e extraction of a primary
tooth can possibly injure or dislodge the underlying tooth. If surgical
removal of a root or part of a root is necessary, the relationship of
the root structures of adjacent teeth must be known. Bone removal
should be performed judiciously whenever necessary, but it is
particularly important to be careful if adjacent roots are close to
the root being removed.
Relationship to Vital Structures
When performing extractions of the maxillary molars, it is essential
to be aware of the proximity of the roots of the molars to the oor
of the maxillary sinus. If only a thin layer of bone exists between
the sinus and the roots of molar teeth, the potential for perforation
of the maxillary sinus during the extraction increases. us the
surgical treatment plan may be altered to an open surgical technique,

CHAPTER 8 Principles of Routine Exodontia 111
e shape of the individual root must be taken into consider-
ation. Roots may have short, conic shapes that make them easy
to remove. However, long roots with severe and abrupt curves or
hooks at their apical end are more dicult to remove. e surgeon
must have knowledge of the shapes of the roots before surgery to
adequately plan the surgery (Fig. 8.11).
e size of the root must be assessed. Teeth with short roots
are easier to remove compared with teeth with long roots. A long
root that is bulbous as a result of hypercementosis is even more
dicult to remove. e periapical radiographs of older patients
should be examined carefully for evidence of hypercementosis
because this process seems to be a result of aging (Fig. 8.12).
e surgeon should look for evidence of caries extending into
the roots. Root caries may substantially weaken the root and make
it more liable to fracture when the force of the forceps is applied
(Fig. 8.13).
Root resorption, internal or external, should be assessed on
examination of the radiograph. Like root caries, root resorption
weakens the root structure and renders it more likely to be fractured.
Surgical extraction may be considered in situations of extensive
root resorption (Fig. 8.14).
e tooth should be evaluated for previous endodontic therapy.
If there was endodontic therapy many years before the extraction
usual fashion; but many teeth have an abnormal number of roots.
If the number of roots is known before the tooth is extracted, an
alteration in the plan can be made to prevent fracture of any
additional roots (Fig. 8.9).
e surgeon must know the curvature of the roots and the
degree of root divergence to properly plan the extraction procedure.
Roots of the usual number and of average size may still diverge
substantially and thus make the total root width so wide that it
precludes extraction with forceps. In situations of excess curvature
with wide divergence, surgical extraction may be required with
planned division of the crown (Fig. 8.10).
Fig. 8.8 Before premolar extractions that require a surgical ap are
performed, it is essential to know the relationship of the mental foramen
to root apices. Note the radiolucent area at the apex of the second pre-
molar, which represents the mental foramen.
Fig. 8.9 Mandibular canine tooth with two roots. Knowledge of this fact
preoperatively may result in a less traumatic extraction.
Fig. 8.10 The widely divergent roots of this maxillary rst molar make
extraction more difcult.
Fig. 8.11 The curvature of the roots of this tooth is unexpected. Preop-
erative radiographs help the surgeon plan the extraction more carefully.

112 Part II Principles of Exodontia
may have periapical radiolucencies that represent granulomas or
cysts. Awareness of the presence of such lesions is important because
these lesions should be removed at the time of surgery (Fig. 8.16).
Patient and Surgeon Preparation
Surgeons must prevent inadvertent injury or transmission of
infection to their patients or to themselves. e principle of universal
precautions states that all patients must be viewed as having
bloodborne diseases that can be transmitted to the surgical team
and other patients. To prevent this transmission, surgical gloves,
surgical mask, and eyewear with side-shields are required. (See
Chapter 5 for a detailed discussion of this topic.) In addition,
most authorities recommend that the surgical team wear long-sleeved
process, there may be ankylosis and the tooth root will be more
brittle. In both situations, surgical extraction may be indicated
(Fig. 8.15).
Condition of Surrounding Bone
Careful examination of the periapical radiograph indicates the
density of bone surrounding the tooth to be extracted. Bone that
is more radiolucent is likely to be less dense, which makes the
extraction easier. However, if bone appears to be radiographically
opaque (indicating increased density), with evidence of condensing
osteitis or other sclerosis-like processes, it will be more dicult
to extract.
e surrounding bone should also be examined carefully for
evidence of any apical pathology. Teeth that have nonvital pulps
Fig. 8.12 Hypercementosis increases the difculty of these extractions
because roots are larger at the apical end than at the cervical end. Surgical
extraction will probably be required.
Fig. 8.13 Root caries in rst premolar tooth make extraction more difcult
because fracture of the tooth is likely. Note hypercementosis of the second
premolar.
Fig. 8.14 Internal resorption of the root makes closed extraction almost
impossible because fracture of the root will almost surely occur.
Fig. 8.15 Tooth made brittle by previous endodontic therapy. The tooth
is thus more difcult to remove.

CHAPTER 8 Principles of Routine Exodontia 113
patient’s mouth to some degree. It is unclear what eect this may
have on postoperative problems.
To prevent teeth or fragments of teeth from falling into the
patient’s mouth and potentially being swallowed or aspirated into
the lungs, many surgeons prefer to place a partially unfolded 4 ×
4 inch gauze loosely into the back of the mouth. is oral partition
serves as a barrier so that should a tooth slip from the forceps or
shatter under the pressure of the forceps, it will be caught in the
gauze rather than be swallowed or aspirated. e surgeon must
take care that the gauze is not positioned so far posteriorly that it
triggers the gag reex. e surgeon should explain the purpose of
the partition to gain the patient’s acceptance and cooperation for
allowing the gauze to be in place.
Chair Position for Extractions
e positions of the patient, the chair, and the operator are critical
for the successful completion of an extraction. e best position
is one that is comfortable for both the patient and surgeon and
allows the surgeon to have maximal control of the force that is
being delivered to the patients tooth through the elevators and
forceps. e correct position allows the surgeon to keep the arms
close to the body and provides stability and support; it also allows
the surgeon to keep the wrists straight enough to deliver the force
with the arm and shoulder, and not with the ngers or hand. e
force delivered can thus be controlled in the face of sudden loss
of resistance from a root or fracture of the bone.
Dentists usually stand during extractions, so the positions for
a standing surgeon will be described rst. Modications that are
necessary to operate in a seated position will be presented later.
Also, descriptions of techniques are for the right-handed operator.
Left-handed surgeons should reverse the instructions when working
on various quadrants.
e most common error dentists make in positioning the dental
chair for extractions is to have the chair too high. is forces the
surgeons to operate with their shoulders raised, thereby making
it dicult to deliver the correct amount of force to the tooth being
extracted in the proper manner. It is also tiring to the surgeon.
Another frequent positioning problem is for the dentist to lean
over the patient and put his or her face close to the patients mouth.
gowns, which should be changed when they become visibly soiled
(Fig. 8.17).
If the surgeon has long hair, it is essential that the hair be held
in position with barrettes or other holding devices and be covered
with a surgical cap. A major breach in aseptic technique is to allow
the surgeons hair to hang over the patients face.
Before the patient undergoes the surgical procedure, a minimal
amount of draping is necessary. A sterile drape should be put
across the patient’s chest to decrease the risk of contamination (see
Fig. 8.17).
Before the extraction, some surgeons advise patients to rinse
their mouths vigorously with an antiseptic mouth rinse such as
chlorhexidine. is reduces the bacterial contamination in the
BA
Fig. 8.16 (A) Periapical radiolucency. The surgeon must be aware of this before extraction for proper
management. (B) Periapical radiolucency around the mandibular premolar represents the mental foramen.
The surgeon must be aware that this is not a pathologic condition. An intact lamina dura is noted in B
but not in A.
Fig. 8.17 The surgeon is prepared for surgery by wearing protective
eyeglasses, mask, and gloves. Surgeons should have short or pinned-
back hair and should wear long-sleeved smocks that are changed daily,
or sooner if they become soiled. The patient benets from a waterproof
drape.

114 Part II Principles of Exodontia
is interferes with surgical lighting, is hard on the dentists back
and neck, and also interferes with proper positioning of the rest
of the dentist’s body.
For a maxillary extraction, the chair should be tipped backward
so that the maxillary occlusal plane is at an angle of about 60
degrees to the oor. Raising the patient’s legs at the same time
helps improve the patient’s comfort. e height of the chair should
be such that the patient’s mouth is at or slightly below the operator’s
elbow level (Fig. 8.18). As mentioned previously, novices tend to
position the chair too high. During an operation on the maxillary
right quadrant, the patient’s head should be turned substantially
toward the operator so that adequate access and visualization can
be achieved (Fig. 8.19). For extraction of teeth in the maxillary
anterior portion of the arch, the patient should be looking straight
ahead (Fig. 8.20). e position for the maxillary left portion of
the arch is similar, except that the patients head is turned slightly
toward the operator (Fig. 8.21).
For the extraction of mandibular teeth, the patient should be
positioned in a more upright position so that when the mouth is
opened wide, the occlusal plane is parallel to the oor (Fig. 8.22).
A properly sized bite block should be used to stabilize the mandible
A
B
Fig. 8.18 Patient positioned for maxillary extraction. The chair is tilted
back so that the maxillary occlusal plane is at about a 60-degree angle
to the oor. The height of the chair should ensure that the level of the
patient’s mouth is slightly below the surgeon’s elbow.
Fig. 8.19 Extraction of teeth in the maxillary right quadrant. Note that
patient’s head is turned toward the surgeon.
Fig. 8.20 Extraction of anterior maxillary teeth. The patient looks straight
ahead.
Fig. 8.21 Extraction of maxillary left posterior teeth. The patient’s head
is turned slightly toward the surgeon.

CHAPTER 8 Principles of Routine Exodontia 115
Fig. 8.22 For mandibular extractions, the patient is more upright so that
the mandibular occlusal plane of the opened mouth is parallel to the oor.
The height of the chair is also lower to allow the operator’s arm to be
straighter.
Fig. 8.23 Extraction of mandibular right posterior teeth. The patient’s
head is turned toward the surgeon.
Fig. 8.24 Extraction of mandibular anterior teeth. The surgeon stands at
the side of the patient, who looks straight ahead.
A
B
Fig. 8.25 When English-style forceps are used for extraction of anterior
mandibular teeth, the patient’s head is positioned straight ahead.
when extraction forceps are used. Even though the surgeon will
support the jaw, the additional support provided by the bite block
will result in less stress being transmitted to the jaws and allows
the patient to rest their muscles of mastication. Care should be
taken to avoid using too large a bite block because large ones can
overstretch the TMJ ligaments and cause patient discomfort.
Typically pediatric bite blocks are the best to use, even
in adults.
During removal of mandibular right posterior teeth, the patient’s
head should be turned acutely toward the surgeon to allow adequate
access to the jaw, and the surgeon should maintain the proper arm
and hand positions (Fig. 8.23). When removing teeth in the anterior
region of the mandible, the surgeon should be to the side of the
patient (Figs. 8.24 and 8.25). When operating on the left posterior
mandibular region, the surgeon should move to the side of the
patient, but the patient’s head should not turn so acutely toward
the surgeon (Fig. 8.26).
Some surgeons prefer to approach maxillary and mandibular
teeth from a posterior position. is allows the left hand of the
surgeon to support the mandible better, but it requires that the
forceps be held in an underhand grip and that the surgeon view
the eld with an upside-down perspective. e left hand of the
surgeon goes around the patient’s head and supports the mandible.

116 Part II Principles of Exodontia
8.33 and 8.34). When the English-style forceps are used, the
surgeons position is usually behind the patient (Fig. 8.35). It
should be noted that the surgeon and the assistant have hand and
arm positions similar to those used when the surgeon is in the
standing position.
Mechanical Principles Involved in
Tooth Extraction
e removal of teeth from the alveolar process requires the use
of the following mechanical principles and simple machines: the
lever, the wedge, and the wheel and axle.
Elevators are used primarily as levers. A lever is a mechanism
for transmitting a modest force—with the mechanical advantages
e usual behind-the-patient approach is seen in Figs. 8.27 and
8.28. Note the surgeons right arm is held closely to their body,
increasing the arms strength.
If the surgeon chooses to sit while performing extractions, several
modications must be made. For maxillary extractions, the patient
is positioned in a semireclining position similar to that used when
the surgeon is standing. However, the patient is not reclined as
much; therefore the maxillary occlusal plane is not perpendicular
to the oor as it is when the surgeon is standing. e patient
should be lowered as far as possible so that the level of the patient’s
mouth is as near as possible to the surgeons elbow (Fig. 8.29).
e arm and hand positions for extraction of maxillary anterior
and posterior teeth are similar to the positions used for the same
extractions performed while standing (Fig. 8.30).
As when the surgeon is standing, for extraction of teeth in the
lower arch, the patient is slightly more upright than for extraction
of maxillary teeth. e surgeon can work from the front of the
patient (Figs. 8.31 and 8.32) or from behind the patient (Figs.
Fig. 8.26 Extraction of mandibular posterior teeth. The patient turns
slightly toward the surgeon.
Fig. 8.27 Behind-the-patient approach for extraction of posterior right
mandibular teeth. This allows the surgeon to be in a comfortable, stable
position.
Fig. 8.28 Behind-the-patient approach for extraction of posterior left
mandibular teeth. The surgeon’s hand is positioned under the forceps.
Fig. 8.29 In the surgeon-seated position, the patient is positioned as low
as possible so that the mouth is at or below the level of the surgeon’s
elbow.

CHAPTER 8 Principles of Routine Exodontia 117
Fig. 8.30 For extraction of maxillary teeth, the patient is reclined approxi-
mately 60 degrees. Hand and forceps positions are the same as for the
standing position.
Fig. 8.31 For extraction of maxillary teeth, the operator can hold the
forceps in an underhand position.
Fig. 8.32 For extraction of mandibular anterior teeth, the operator can
hold the forceps in an overhand manner.
Fig. 8.33 For removal of anterior teeth, the surgeon moves to a position
behind the patient so that the patient’s mandible and alveolar process can
be supported by the surgeon’s other hand.
Fig. 8.34 The behind-the-patient position can be used for removal of
mandibular posterior teeth. The surgeon’s hand is positioned under the
forceps for maximum control.
Fig. 8.35 When English-style forceps are used, a behind-the-patient
position is preferred.

118 Part II Principles of Exodontia
Fig. 8.36 The rst-class lever transforms small force and large movement
to small movement and large force.
BA
Fig. 8.37 In removal of a mandibular premolar tooth, the purchase point
is placed in the tooth, which creates a rst-class lever situation. When the
Crane pick is inserted into the purchase point and the handle is depressed
apically (A), the tooth is elevated occlusally out of the socket with buc-
coalveolar bone used as the fulcrum (B).
Fig. 8.38 A wedge can be used to expand, split, and displace portions
of the substance that receives it.
Fig. 8.39 Beaks of the forceps act as wedges to expand alveolar bone
and displace the tooth in the occlusal direction.
Fig. 8.40 Small, straight elevator used as wedge to displace the tooth
root from its socket by driving the elevator apically in the periodontal liga-
ment space.
of a long lever arm and a short eector arm—into a small move-
ment against great resistance (Fig. 8.36). An example of the
use of a lever is when a Crane pick is inserted into a purchase
point placed in a tooth and then is used to elevate the tooth
(Fig. 8.37).
e second simple machine that is useful is the wedge (Fig.
8.38). e wedge is useful in several dierent ways for the extraction
of teeth. First, the beaks of extraction forceps are usually narrow
at their tips; they broaden as they go superiorly. When forceps are
used, there should be a conscious eort made to force the tips of
the forceps into the periodontal ligament space at the bony crest.
is uses the tooth root as a wedge to expand the bone; as the
beaks of the forceps are pressed apically on the root, they will help
force the tooth out of the socket (Fig. 8.39). e wedge principle
is also useful when a straight elevator is used to luxate a tooth
from its socket. A small elevator is wedged into the periodontal
ligament space, which displaces the root toward the occlusion and
thus out of the socket (Fig. 8.40).
e third machine used in tooth extraction is the wheel and
axle, which is most closely identied with the triangular, or pennant-
shaped, elevator. When one root of a multiple-rooted tooth is left
in the alveolar process, the pennant-shaped elevator, such as a
Cryer, is positioned into the socket and turned. e handle then
serves as the axle, and the tip of the triangular elevator acts as a
wheel and engages and elevates the tooth root from the socket
(Fig. 8.41).

CHAPTER 8 Principles of Routine Exodontia 119
e second major pressure or movement applied by forceps is
the buccal force. Buccal pressures result in expansion of the buccal
plate, particularly at the crest of the ridge (Fig. 8.45). Although
buccal pressure causes expansion forces at the crest of the ridge,
it is important to remember that it also causes lingual apical pressure.
us excessive force can fracture buccal bone or cause fracturing
of the apical portion of the root.
ird, lingual or palatal pressure is similar to the concept of
buccal pressure but is aimed at expanding the linguocrestal bone
and, at the same time, avoiding excessive pressures on the buccal
apical bone (Fig. 8.46). Because lingual bone tends to be thicker
than buccal bone in posterior areas of the mouth, limited bone
expansion occurs.
Fourth, rotational pressure, as the name implies, rotates the
tooth, which causes some internal expansion of the tooth socket
Principles of Elevator and Forceps Use
e primary instruments used to remove a tooth from the alveolar
process are the elevator and extraction forceps. Elevators help in
the luxation of a tooth, and forceps continue that process through
bone expansion and disruption of periodontal attachments. e
goal of forceps use is threefold: (1) expansion of the bony socket
by use of the wedge-shaped beaks of the forceps and the movements
of the tooth itself with the forceps, (2) twisting of conical roots
to disrupt periodontal ligaments, and (3) removal of the tooth
from the socket.
e dental elevator consists of a handle, a shank, and a blade.
e handle of the elevator is usually in line with the shank and is
enlarged to allow it to be grasped in the palm of the hand. e
elevator may also have attened areas for ngers to grasp to help
guide the elevator. e handle can also be set perpendicular to the
shank (cross bar–type elevators). e shank connects the handle
to the blade. Blades can be straight, triangular (Cryer), curved
(Potts), or pointed (Crane pick).
Forceps can apply ve major motions to luxate teeth. e rst
is apical pressure, which accomplishes two goals. (1) Although the
tooth moves in an apical direction minimally, the tooth socket is
expanded by the insertion of the beaks down into the periodontal
ligament space (Fig. 8.42). us the apical pressure of the forceps
on the tooth causes bony expansion. (2) A second accomplishment
of apical pressure is that the center of rotation of the tooth is
displaced apically. Because the tooth is moving in response to the
force placed on it by the forceps, the forceps become the instrument
of expansion. If the fulcrum is high (Fig. 8.43), a larger amount
of force is placed on the apical region of the tooth, which increases
the chance of fracturing the root end. If the beaks of the forceps
are forced into the periodontal ligament space, the center of rotation
is moved apically, which results in greater movement of the expan-
sion forces at the crest of the ridge and less force moving the apex
of the tooth lingually (Fig. 8.44). is process decreases the chance
for apical root fracture.
Fig. 8.41 Triangular elevator in the role of a wheel-and-axle machine
used to retrieve the root from the socket.
Fig. 8.42 Extraction forceps should be seated with strong apical pres-
sure to expand crestal bone and to displace the center of rotation as far
apically as possible.
AB
Fig. 8.43 (A) If the center of rotation (asterisk) is not far enough apically,
it is too far occlusally, which results in excess movement of tooth apex.
(B) Excess motion of the root apex caused by a high center of rotation
results in fracture of the root apex.

120 Part II Principles of Exodontia
In summary, a variety of forces can be used to remove teeth.
A strong apical force is always useful and should be applied whenever
forceps are adapted to the tooth. Most teeth are removed by a
combination of buccal and lingual (palatal) forces. Because maxillary
buccal bone is usually thinner and palatal bone is a thicker cortical
bone, maxillary teeth are usually removed by stronger buccal forces
and less vigorous palatal forces. In the mandible, buccal bone is
thinner from the midline posteriorly to the area of molars. erefore
incisors, canines, and premolars are removed primarily as a result
of strong sustained buccal force and less vigorous lingual pressures.
As mentioned before, rotational forces are useful for single-rooted
teeth that have conic roots and no severe curvatures at the root
end. e maxillary incisors, particularly the central incisor and
mandibular premolars, are most amenable to rotational forces.
and tearing of periodontal ligaments. Teeth with single, conical
roots (such as incisors, canines, and mandibular premolars)
and those with roots that are not curved are most amenable to
luxation by this technique (Fig. 8.47). Teeth that have other than
conical roots or that have multiple roots—especially if those
roots are curved—are more likely to fracture under this type of
pressure.
Finally, tractional forces are useful for delivering the tooth
from the socket once adequate bony expansion is achieved. As
mentioned previously, teeth should not be pulled from their sockets.
Tractional forces should be limited to the nal portion of the
extraction process and should be gentle (Fig. 8.48). If excessive force
is needed, other maneuvers should be performed to improve root
luxation.
BA
Fig. 8.44 (A) If the forceps are apically seated, the center of rotation
(asterisk) is displaced apically, and smaller apical pressures are generated.
(B) This results in greater expansion of the buccal cortex, less movement
of the apex of the tooth, and therefore less chance of fracture of the root.
Fig. 8.45 Buccal pressure applied to the tooth will expand the bucco-
cortical plate toward crestal bone, with some lingual expansion at the
apical end of the root. Asterisk notes the center of rotation.
Fig. 8.46 Lingual pressure will expand the linguocortical plate at the
crestal area and slightly expand buccal bone at the apical area. Asterisk
notes the center of rotation.
Fig. 8.47 Rotational forces are useful for teeth with conical roots, such
as maxillary incisors and mandibular premolars.

CHAPTER 8 Principles of Routine Exodontia 121
A small amount of pressure is felt at this step, but there should
be no sensation of sharpness or discomfort if profound local
anesthesia is in place. e surgeon then begins the soft tissue
loosening procedure, gently at rst and then with increasing force.
(2) e second reason that soft tissue is loosened is to allow the
elevator and tooth extraction forceps to be positioned more apically,
without interference from or impingement on the gingiva. As the
soft tissue is loosened away from the tooth, it is slightly reected,
which thereby increases the width of the gingival sulcus and allows
easy entrance of the beveled tip of the forceps beaks. e adjacent
gingival papilla of the tooth should also be reected to avoid
damage by the insertion of the straight elevator.
Step 2 involves luxation of the tooth with a dental elevator. e
luxation of the tooth begins with a dental elevator, usually the
straight elevator. In most situations, elevation from the lingual or
palatal aspects of roots is limited due to poor access and is of
limited ecacy. Elevation should occur at the mesial and distal
buccal aspects of the root. No elevation should be attempted along
buccal bone because it can be easily fractured or the surgeon can
lose control and cause soft tissue injury.
Expansion and dilation of the alveolar bone and tearing of the
periodontal ligament require that the tooth be luxated in several
ways. e straight elevator is inserted perpendicular to the tooth
into the interdental space, after reection of the interdental papilla
(Figs. 8.50 to 8.52). e elevator is then moved to direct the
blade in an apical direction. e elevator is then rotated in small
motions back and forth, while apical pressure is placed to advance
the blade into the periodontal ligament space. A straight elevator
with a small blade should be used initially. Once some tooth
movement is noted, a larger straight elevator is inserted and used
in a similar manner. If the tooth is intact and in contact with
stable teeth anterior and posterior to it, the amount of movement
achieved with the straight elevator will be minimal. e useful-
ness of this step is greater if the patient does not have a tooth
posterior to the tooth being extracted or it is broken down to an
extent that the crowns do not inhibit movement of the tooth, or
if the adjacent tooth is also planned for extraction at the same
appointment.
Luxation of teeth with a straight elevator should be performed
with caution. Excessive forces can damage and even displace the
Procedure for Closed Extraction
An erupted root can be extracted using one of two major techniques:
closed or open. e closed technique is also known as the routine
technique. e open technique is also known as the surgical tech-
nique, or ap technique. is section discusses the closed extraction
technique; the open (surgical) technique is discussed in Chapter 9.
e closed technique is the most frequently used technique and
is given primary consideration for almost every extraction. e
open technique is used when the clinician believes that excessive
force would be necessary to remove the tooth, when a substantial
amount of the crown is missing or covered by tissue, or when
access to the root of a tooth is dicult, such as when a fragile
crown is present.
e correct technique for any situation should lead to an
atraumatic extraction; the wrong technique commonly results in
an excessively traumatic and lengthy extraction.
Whatever technique is chosen, the three fundamental require-
ments for a good extraction remain the same: (1) adequate access
and visualization of the eld of surgery, (2) an unimpeded pathway
for the removal of the tooth, and (3) the use of controlled force
to luxate and remove the tooth.
For the tooth to be removed from the bony socket, it is usually
necessary to expand the alveolar bony walls to allow the tooth
root an unimpeded pathway, and it is necessary to tear the peri-
odontal ligament bers that hold the tooth in the bony socket.
e use of elevators and forceps as levers and wedges with steadily
increasing force can accomplish these two objectives.
Five general steps make up the closed extraction procedure.
Step 1 involves loosening of the soft tissue attachment from the
cervical portion of the tooth. e rst step in removing a tooth
by the closed extraction technique is to loosen the soft tissue from
around the tooth with a sharp instrument such as a scalpel blade
or the sharp end of the No. 9 periosteal elevator (Fig. 8.49). e
purpose of loosening the soft tissue from the tooth is twofold: (1)
First, it allows the surgeon to ensure that profound anesthesia has
been achieved. When this step has been performed, the dentist
informs the patient that the surgery is about to begin and that
the rst step will be to push the soft tissue away from the tooth.
Fig. 8.48 Tractional forces are useful for the nal removal of the tooth
from the socket. These should always be small forces because teeth are
not pulled.
Fig. 8.49 Periosteal elevator used to loosen the gingival attachment from
the tooth and the interdental papilla. (Courtesy Dr. Edward Ellis III.)

122 Part II Principles of Exodontia
are then seated onto the tooth so that the tips of the forceps beaks
grasp the root underneath loosened soft tissue (Fig. 8.53). e
lingual beak is usually seated rst and then the buccal beak. Care
must be taken to conrm that the tips of the forceps beaks are
beneath the soft tissue and not engaging an adjacent tooth. Once
the forceps have been positioned on the tooth, the surgeon grasps
the handles of the forceps at the ends to maximize mechanical
advantage and control (Fig. 8.54). If the tooth is malposed in such
a fashion that the usual forceps cannot grasp the tooth without
injury to adjacent teeth, another forceps with narrower beaks should
be used. Maxillary root forceps can often be useful for crowded
lower anterior teeth.
e beaks of the forceps must be held parallel to the long
axis of the tooth so that the forces generated by the application
of pressure to the forceps handle can be delivered along the
Fig. 8.50 Small, straight elevator, inserted perpendicular to the tooth
after the papilla has been reected. (Courtesy Dr. Edward Ellis III.)
Fig. 8.51 The handle of the small, straight elevator is turned such that
the occlusal side of the elevator blade is turned toward the tooth. The
handle is also moved apically to help elevate the tooth.
Fig. 8.52 The handle of the elevator may be turned in the opposite
direction to displace the tooth further from the socket. This can be accom-
plished only if no tooth is adjacent posteriorly.
Fig. 8.53 Tips of forceps beak, forced apically under soft tissue. (Cour-
tesy Dr. Edward Ellis III.)
teeth adjacent to those being extracted. is is especially true
if the adjacent tooth has a large restoration or carious lesion.
is is only the initial step in the elevation process. Next, the
small, straight elevator is inserted into the periodontal ligament
space at the mesial–buccal line angle. e elevator is advanced
apically while being rotated back and forth, helping luxate the
tooth with its wedge action as it is advanced apically. A similar
action with the elevator can then be done at the distal-buccal line
angle. When a small, straight elevator becomes too easy to twist,
a larger-sized elevator is used to do the same apical advancement.
Often the tooth will loosen suciently to be removed easily
with forceps.
Step 3 involves adaptation of the forceps to the tooth. e
proper forceps are now chosen for the tooth to be extracted. e
beaks of the forceps should be shaped to adapt anatomically to
the tooth, apical to the cervical line, that is, to the root surface.
(A few exceptions to this include the cowhorn forceps.) e forceps

CHAPTER 8 Principles of Routine Exodontia 123
expand the alveolar socket. For some teeth, small rotational
motions are then used to help expand the tooth socket and tear
the periodontal ligament attachments. Beginning surgeons have
a tendency to apply inadequate pressure for insucient amounts
of time.
e following three factors must be reemphasized: (1) e
forceps must be apically seated as far as possible and reseated
periodically during the extraction; (2) the forces applied in the
buccal and lingual directions should be slow, deliberate pres-
sures and not jerky wiggles; and (3) the force should be held
for several seconds to allow the bone time to expand. It must be
remembered that teeth are not pulled; rather, they are gently lifted
from the socket once the alveolar process has been suciently
expanded.
Step 5 involves removal of the tooth from the socket. Once
alveolar bone has expanded suciently and the tooth has been
luxated, a slight tractional force, usually directed buccally, can
be used. Tractional forces should be minimized because this
is the last motion that is used once the alveolar process is suf-
ciently expanded and the periodontal ligament is completely
severed.
It should be remembered that luxation of the tooth with forceps
and removal of the tooth from bone are separate steps in the
extraction. Luxation is directed toward expansion of bone and
disruption of the periodontal ligament. e tooth is not removed
from bone until these two goals are accomplished. e novice
surgeon should realize that the major role of forceps is not to
remove the tooth, but rather to expand the bone so that the root(s)
can be removed.
For teeth that are malposed or have unusual positions in the
alveolar process, luxation with forceps and removal from the
alveolar process will be in unusual directions. e surgeon must
develop a sense for the direction the tooth wants to move and
then be able to move it in that direction. Careful preoperative
assessment and planning help guide this determination during the
extraction.
Role of the Opposite Hand
While using forceps and elevators to luxate and remove teeth, it is
important that the surgeons opposite hand play an active role in the
procedure. For the right-handed operator, the left hand has a variety
of functions. e left hand is responsible for reecting the soft tissues
of the cheeks, lips, and tongue to provide adequate visualization of
the area of surgery. e left hand helps protect other teeth from the
forceps, should it release suddenly from the tooth socket. e left
hand, and sometimes arm, helps stabilize the patient’s head during
the extraction process. In some situations, greater amounts of force
are required to expand heavy alveolar bone; therefore the patients
head requires active assistance to be held steady. e opposite hand
plays an important role in supporting and stabilizing the jaw when
mandibular teeth are being extracted. e opposite hand is often
necessary to apply considerable pressure to expand heavy mandibular
bone, and such forces can cause discomfort and even injury to the
TMJ unless a steady hand counteracts them. A bite block placed
on the contralateral side is also used to help open the jaw in this
situation. Finally, the opposite hand supports the alveolar process
and provides tactile information to the operator concerning the
expansion of the alveolar process during the luxation period. In
some situations, it is impossible for the opposite hand to perform
all of these functions at the same time, so the surgeon requires an
assistant to help with some of the functions.
long axis of the tooth for maximal eectiveness in dilating and
expanding alveolar bone. If the beaks are not parallel to the long
axis of the tooth, it is increasingly likely that the tooth root will
fracture.
e forceps are then forced apically as far as possible to grasp
the root of the tooth as apically as possible. is accomplishes two
things: (1) e beaks of the forceps act as wedges to dilate the
crestal bone on the buccal and lingual aspects, and (2) by forcing
the beaks apically, the center of rotation (or fulcrum) of the forces
applied to the tooth is displaced toward the apex of the tooth,
which results in greater eectiveness of bone expansion and less
likelihood of fracturing the apical end of the tooth.
At this point, the surgeons hand should be grasping the forceps
rmly, with the wrist locked and the arm held against the body;
the surgeon should be prepared to apply force with the shoulder
and upper arm without any wrist pressure. e surgeon should
be standing upright, with feet comfortably apart.
Step 4 involves luxation of the tooth with forceps. e surgeon
begins to luxate the tooth by using the motions discussed earlier.
e major portion of the force is directed toward the thinnest
and therefore weakest bone. us, with all teeth in the maxilla
and all but molar teeth in the mandible, the major movement
is labial and buccal (i.e., toward the thinner layer of bone). e
surgeon uses slow, sustained, steady force to displace the tooth
buccally, rather than a series of rapid, small movements that do
little to expand bone. e motion is deliberate and slow, and
it gradually increases in force. e tooth is then moved again
toward the opposite direction with slow, deliberate, strong pressure.
As the alveolar bone begins to expand, the forceps are reseated
apically with a strong, deliberate motion, which causes additional
expansion of alveolar bone and further displaces the center of
the rotation apically. Buccal and lingual pressures continue to
B
A
Fig. 8.54 Forceps handles, held at the ends to maximize mechanical
advantage and control. (A) Maxillary universal forceps. (B) Mandibular
universal forceps.

124 Part II Principles of Exodontia
Specic Techniques for the Removal
of Each Tooth
is section describes specic techniques for the removal of each
tooth in the mouth after being elevated. In some situations, several
teeth are grouped together (e.g., the maxillary anterior teeth) because
the technique for their removal is essentially the same. e reader
should take note of the role of the left hand in each instance.
Maxillary Teeth
In the correct position for the extraction of maxillary left or anterior
teeth, the left index nger of the surgeon should reect the lip
and cheek tissues, while the thumb rests on the palatal alveolar
process (Fig. 8.56). In this way, the left hand is able to reect the
soft tissue of the cheek, stabilize the patient’s head, support the
alveolar process, and provide tactile information to the surgeon
regarding the progress of the extraction. When such a position is
used during the extraction of a maxillary molar, the surgeon can
frequently feel with the left hand the palatal root of the molar
becoming free in the alveolar process before feeling it with the
forceps or the extracting hand. For the right side, the index nger
is positioned on the palate, with the thumb on the buccal aspect.
Incisors
e maxillary incisor teeth are extracted with the upper universal
forceps (No. 150), although other forceps can be used such as the
straight forceps (No. 1). Maxillary incisors generally have conic
roots, with the lateral ones being slightly longer and more slender.
e lateral incisor is more likely also to have a distal curvature on
the apical one third of the root, so this must be checked radiographi-
cally before the tooth is extracted. Alveolar bone is thin on the
labial side and heavier on the palatal side, which indicates that
the major expansion of the alveolar process will be in the labial
direction. e initial movement is slow, steady, and rm in the
labial direction, which expands the crestal buccal bone. A less
vigorous palatal force is then used, followed by a slow, rm,
rotational force. Rotational movement should be minimized for
the lateral incisor, especially if a curvature exists on the tooth. e
Role of the Assistant During Extraction
To achieve a successful outcome in any surgical procedure, it is
useful to have a skilled assistant. During extraction, the assistant
plays a variety of important roles that contribute to making the
surgical experience atraumatic for the patient. e assistant helps
the surgeon visualize and gain access to the operative area by
retracting the soft tissue of the cheeks and tongue so that the
surgeon can have an unobstructed view of the surgical eld. Even
during a closed extraction, the assistant can retract the soft tissue
so that the surgeon can apply the instruments to loosen the soft
tissue attachment and adapt the forceps to the tooth in the most
eective manner.
Another major activity of the assistant is to suction away blood,
saliva, and the irrigating solutions used during the surgical proce-
dure. is prevents uids from accumulating and makes proper
visualization of the surgical field possible. Suctioning is also
important for patient comfort because most patients are unable
to tolerate any accumulation of blood or other uids in their
throats (Fig. 8.55).
During extraction, the assistant should also help with protecting
the teeth of the opposite arch, which is especially important when
removing lower posterior teeth. If traction forces are necessary to
remove a lower tooth, occasionally the tooth releases suddenly and
the forceps strike maxillary teeth and may fracture a tooth cusp.
e assistant should hold a suction tip or a nger against maxillary
teeth to protect them from an unexpected blow.
During the extraction of mandibular teeth, the assistant may
play an important role by supporting the mandible during the
application of the extraction forces. A surgeon who uses the hand
to reect soft tissue may not be able to support the mandible. If
this is the case, the assistant plays an important role in stabilizing
the mandible to prevent TMJ discomfort. Most often the surgeon
stabilizes the mandible, which makes this role less important for
the assistant.
e assistant also provides psychological and emotional support
for the patient by helping alleviate patient anxiety during anesthesia
administration and surgery. e assistant is important in gaining
the patient’s condence and cooperation by using positive language
and physical contact with the patient during the preparation and
performance of the surgery. e assistant should avoid making
casual, ohand comments that may increase the patients’ anxiety
and lessen their cooperation.
Fig. 8.55 While the surgeon holds the surgical hand piece and Minne-
sota retractor, the assistant provides cooling irrigation and suction. (Cour-
tesy Dr. Edward Ellis III.)
Fig. 8.56 Extraction of maxillary left posterior teeth. The left index nger
retracts the lip and cheek and supports the alveolar process on the buccal
aspect. The thumb is positioned on the palatal aspect of the alveolar
process and supports the alveolar process. The head is steadied by this
grip, and tactile information about the tooth and bone movement is
gained.

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82PART IIPrinciples of ExodontiaFor most laypersons the term oral surgery usually brings to mind the removal of a tooth. e atraumatic extraction of a tooth is a procedure that requires nesse, knowledge, and skill on the part of the surgeon. e purpose of this section is to present the principles of exodontia as well as the instrumentation, techniques, and management of patients who are undergoing extraction surgery.Chapter 7 presents the armamentarium commonly used for exodontia. e basic instrumentation and the fundamental applications of instruments to their surgical purposes are illustrated and discussed.Chapter 8 presents the basic aspects of how to remove an erupted tooth atraumatically. e preoperative assessment and preparation of the patient are briey discussed. e position of the patient in the chair and the position of the surgeon and the surgeon’s hands for the removal of teeth in various parts of the mouth are detailed. e armamentarium and movements necessary to extract each type of tooth are presented in illustrations and descriptions.Chapter 9 presents the basic aspects of managing complicated extractions (commonly termed surgical extractions). Surgical extractions primarily involve retrieving tooth roots and teeth that are likely to fracture, have fractured, or, for some other reason, pose an obstacle to extraction. In these situations, surgical removal of bone or surgical sectioning of the tooth is commonly required.Chapter 10 presents the fundamental aspects of the management of impacted teeth. e rationale for timely removal of impacted teeth is presented in the initial portion of the chapter. Classication and determination of the degree of diculty of the impaction follows. Finally, a brief description of the basic surgical techniques required to remove impacted third molars is provided.Chapter 11 presents the techniques for managing the patient during the postoperative period. is chapter discusses postoperative instructions that should be given to the patient as well as typical postoperative medications. e chapter goes on to cover common surgical sequelae and complications that are encountered in the removal of teeth. Emphasis is placed on anticipating sequelae and complications and taking measures to prevent or minimize them.Chapter 12 discusses the medical and legal considerations involved in basic exodontia. An important portion of this chapter discusses the concept of informed consent for the patient as it relates to exodontia. Patient privacy rights are also covered. 837 Instrumentation for Basic Oral SurgeryJAMES R. HUPPCHAPTER OUTLINEIncising Tissue, 83Elevating the Mucoperiosteum, 85Retracting Soft Tissue, 85Grasping Soft Tissue, 87Controlling Hemorrhage, 87Removing Bone, 88Rongeurs, 88Burr and Handpiece, 88Mallet and Chisel, 89Bone File, 89Removing Soft Tissue From Bony Cavities, 89Suturing Soft Tissue, 89Needle Holder, 89Suture Needle, 89Suture Material, 90Scissors, 90Holding the Mouth Open, 91Removing Fluids, 91Holding Towels and Drapes in Position, 92Irrigating, 93Extracting Teeth, 93Dental Elevators, 94Types of Elevators, 94Periotomes, 95Extraction Forceps, 96Forceps Components, 96Maxillary Forceps, 98Mandibular Forceps, 99Instrument Tray Systems, 101This chapter is designed to introduce the instrumentation commonly used to perform routine dental extractions and other basic oral surgical operations. The instruments illustrated and described are used for a wide variety of purposes, including soft and hard tissue procedures. is chapter primarily provides a description of instruments; their use is discussed in subsequent chapters.Incising TissueMany surgical procedures begin with an incision. e primary instrument for making incisions is the scalpel, which is composed of a handle and a sterile, very sharp blade (Fig. 7.1). Scalpels are available as single-use instruments with plastic handles and xed blades; scalpel handles to which disposable blades can be attached are also available. e most commonly used handle for oral surgery is the No. 3 handle. e tip of a scalpel handle is congured to receive a variety of dierently shaped scalpel blades that are inserted onto the slotted portion of the handle.e most frequently used scalpel blade for intraoral surgery is the No. 15 blade (Fig. 7.2). e blade is small and is used to make incisions around teeth and through soft tissue. e blade is similar in shape to the larger No. 10 blade, which is used for large skin incisions in other parts of the body. Other commonly used blades for intraoral surgery include the No. 11 and No. 12 blades. e No. 11 blade is a sharp-pointed blade that is used primarily for making small stab incisions as for incising an abscess to establish drainage. e hooked No. 12 blade is useful for mucogingival procedures in which incisions are made on the posterior aspects of teeth or in the maxillary tuberosity area.e scalpel blade must be carefully loaded onto the handle, ideally holding the blade with a needle holder. is lessens the chance of injuring one’s ngers. e blade is held along the unsharpened edge, where it is reinforced with a small rib, and the handle is held so that the male portion of the tting is pointing upward (Fig. 7.3A). e scalpel blade is then slowly slid onto the handle along the grooves in the male portion until it clicks into position (see Fig. 7.3B).e scalpel is unloaded in a similar manner. e needle holder grasps the end away from the blade (see Fig. 7.3C) and lifts it to disengage it from the male tting. e scalpel is then slid o the handle, always away from the body and anyone nearby (see Fig. 7.3D). e used blade is immediately discarded into a specically designed rigid-sided sharps container (see Fig. 5.6C).When using the scalpel to make an incision, the surgeon typically holds the handle in the pen grasp (Fig. 7.4) to allow maximal control of the blade as the incision is made. For maximum cutting eciency, mobile tissue should be held rmly in place under some tension so that as the incision is made, the blade will incise and not just push away the mucosa. When incising depressible soft tissue, an instrument such as a retractor should be used to hold the tissue taut while incising. When a full-thickness mucoperiosteal incision is desired, the blade should be pressed down rmly so that the incision penetrates the mucosa and periosteum with the same stroke. 84 Part II Principles of ExodontiaFig. 7.1 A scalpel is composed of a handle and a sharp blade. Top, Reus-able scalpel No. 3 handle with single-use blade (a No. 15 blade is most commonly used for oral surgery). Bottom, Single-use handle-blade unit with No. 15 blade. Fig. 7.2 Scalpel blades used in oral surgery include No. 10, No. 11, No. 12, and No. 15 (left to right). ABCDFig. 7.3 (A) When loading a scalpel blade, the surgeon holds the noncutting portion of the blade in the needle holder and handle, with the male portion of the tting pointing upward. (B) The surgeon then slides the blade into the handle until it clicks into place. (C) To remove the blade, the surgeon uses the needle holder to grasp the end of the blade next to the handle and lifts it to disengage it from the tting. (D) The surgeon then gently slides the blade off the handle away from the body and anyone nearby. CHAPTER 7 Instrumentation for Basic Oral Surgery 85 Retracting Soft TissueGood access and vision are critical to performing excellent surgery. A variety of retractors have been specically designed to retract the cheek, tongue, and mucoperiosteal aps to provide access and visibility during surgery. Retractors are also used to help protect soft tissue from sharp cutting instruments.e two most popular cheek retractors are (1) the right-angle Austin retractor (Fig. 7.6) and (2) the broad oset Minnesota retractor (Fig. 7.7). ese retractors can also be used to retract the cheek and a mucoperiosteal ap simultaneously. Before the ap is created, the retractor is held loosely in the cheek. Once the ap is reected, the retractor edge is placed on bone and is then used to retract the ap.e Henahan and Seldin retractors are other types of instruments used to retract oral soft tissue (Fig. 7.8). Although these retractors may look similar to a periosteal elevator, the leading edge is not sharp but, instead, smooth; these instruments are not typically used to elevate the mucoperiosteum. e No. 9 Molt periosteal elevator can also be used as a retractor for small aps. Once the periosteum has been elevated, the broad blade of the periosteal elevator is held rmly against bone, with the mucoperiosteal ap elevated into a reected position.e instrument most commonly used to retract the tongue during routine exodontia is the mouth mirror. is is usually part of every basic setup because it is useful for examining the mouth and for indirect visualization during dental procedures. e Weider tongue retractor is a broad, heart-shaped retractor that is serrated on one side so that it can more rmly engage the tongue and retract it medially and anteriorly (Fig. 7.9A). When this retractor is used, care must be taken not to position it so far posteriorly as to cause gagging or to push the tongue into the oropharynx (see Fig. 7.9B).A towel clip (see Fig. 7.28) can also be used to hold the tongue in certain circumstances. When a biopsy procedure is to be Scalpel blades are designed for single-patient use. Blades dull easily when they come into contact with hard tissue such as bone or teeth and even after repeated strokes through keratinized tissue. If several incisions through the mucoperiosteum to bone are required, it may be necessary to use additional blades during a single operation. Dull blades do not make clean, sharp incisions in soft tissue and therefore should be replaced before they become overly dull.Elevating the Mucoperiosteume tissue plane between periosteum and bone is relatively bloodless and well dened. When an incision is made through the periosteum, ideally the periosteum should be reected from the underlying cortical bone in a single subperiosteal layer with a periosteal elevator. e instrument that is most commonly used in oral surgery is the No. 9 Molt periosteal elevator (Fig. 7.5). is instrument has a sharp, pointed end and a broader, rounded end. e pointed end is used to begin the periosteal reection and to reect dental papillae from between teeth, whereas the broad, rounded end is used to continue the elevation of the periosteum from bone.e No. 9 Molt periosteal elevator is typically used to reect tissue by two methods. In the rst method, the pointed end is used in a twisting, prying motion to elevate soft tissue, most commonly when elevating a dental papilla from between teeth or the attached gingiva around a tooth to be extracted or when beginning to elevate a full thickness mucoperiosteal ap. e second method involves the push stroke in which the side of the pointed end or the broad end of the instrument is slid underneath the periosteum, separating it from the underlying bone. is is the most ecient stroke that results in the cleanest reection of periosteum.ere are other types of periosteal elevators for use by perio-dontists, orthopedic surgeons, and other surgeons involved in work on bones.Fig. 7.4 The scalpel handle is held in the pen grasp to allow maximal control. Fig. 7.5 The No. 9 Molt periosteal elevator is most commonly used in oral surgery. Fig. 7.6 The Austin retractor is a right-angle retractor that can be used to retract the cheek, tongue, or aps. 86 Part II Principles of ExodontiaABFig. 7.7 The Minnesota retractor is an offset retractor used to retract the cheek and aps. (A) Front. (B) Back. Fig. 7.8 The Henahan (top) and Seldin (bottom) retractors are broader instruments that provide broader retraction and increased visualization. ABFig. 7.9 (A) The Weider retractor is a large retractor designed to retract the tongue. The serrated surface helps engage the tongue so that it can be held securely. (B) The Weider retractor is used to hold the tongue away from the surgical eld. The Austin retractor is used to retract the cheek. CHAPTER 7 Instrumentation for Basic Oral Surgery 87 performed on the posterior aspect of the tongue, the most positive way to control the tongue is by holding the anterior tongue with a towel clip. Local anesthesia must be profound where the clip is placed, and, if anticipated, it is wise to mention to the patient that this method of retraction may be used.Grasping Soft TissueVarious oral surgical procedures require the surgeon to grasp soft tissue to incise it, to stop bleeding, or to pass a suture needle. e instrument most commonly used for this purpose is the Adson forceps (or pickup; Fig. 7.10A). ese are delicate forceps, with or without small teeth at the tips, that can be used to hold tissue gently while stabilizing it. When this instrument is used, care should be taken not to grasp the tissue too tightly to avoid crushing it. Toothed forceps allow tissue to be securely held with a more delicate grip than untoothed forceps.When working in the posterior part of the mouth, the Adson forceps may be too short. Longer forceps that have a similar shape are the Stillies forceps. ese forceps are usually 7 to 9 inches long and can easily grasp tissue in the posterior part of the mouth, still leaving enough of the instrument protruding beyond the lips for the surgeon to hold and control it (see Fig. 7.10B).Occasionally it is more convenient to have an angled forceps. ese include the college, or cotton, forceps (they are also called cotton pliers) (see Fig. 7.10B). Although these forceps are not especially useful for handling tissue, they are an excellent instrument for picking up loose fragments of tooth, amalgam, or other foreign material and for placing or removing gauze packs.In some types of surgery, especially when removing larger amounts of tissue or doing biopsies, such as in an epulis ssurata, forceps with locking handles and teeth that will rmly grip the tissue are necessary. In this situation, the Allis tissue forceps are used (Fig. 7.11A–B). e locking handle allows the forceps to be placed in the proper position and then to be held by an assistant to provide the necessary tension for proper dissection of the tissue. e Allis forceps should never be used on tissue that is to be left ABFig. 7.10 (A) Small, delicate Adson tissue forceps are used to gently stabilize soft tissue for suturing or dissection. (B) The Stillies pickup (top) is longer than the Adson pickup and is used to handle tissue in the more posterior aspect of the mouth. The college pliers (bottom) are angled forceps that are used for picking up small objects in the mouth or from the tray stand. The college pliers shown here represent the locking version. ABCFig. 7.11 (A) Allis tissue forceps are useful for grasping and holding tissue that will be excised. (B) Allis forceps are held in the same fashion as the needle holder. (C) Comparison of Adson beaks (right) with Allis beaks (left) shows the differences in their designs and uses. in the mouth because they cause a relatively large amount of tissue crushing (see Fig. 7.11C). However, the forceps can be used to grasp the tongue in a manner similar to a towel clamp.Controlling HemorrhageWhen incisions are made through tissue, small arteries and veins are incised, causing bleeding. For most dentoalveolar surgery, pressure on the wound is usually sucient to control bleeding. Occasionally pressure does not stop the bleeding from a larger artery or vein. When this occurs, an instrument called a hemostat is useful (Fig. 7.12A). Hemostats come in a variety of shapes; they may be small and delicate or larger and are either straight or curved. e hemostat most commonly used in surgery is the curved hemostat (see Fig. 7.12B).A hemostat has long, delicate beaks that are used to grasp tissue and a locking handle. e locking mechanism allows the surgeon to clamp the hemostat onto a vessel and then let go of the instrument or let an assistant hold it. e tip of the hemostat will remain clamped onto the tissue. is is useful when the surgeon plans to 88 Part II Principles of ExodontiaBurr and HandpieceAnother method for removing bone is with a burr in a handpiece. is is the technique that most surgeons use when removing bone for the surgical removal of teeth. Moderate-speed, high-torque handpieces with sharp carbide burrs remove cortical bone eciently (Fig. 7.14). Burrs such as No. 557 or No. 703 ssure burr and No. 8 round burr are used. When large amounts of bone must be removed, as in torus reduction, a large-bone burr that resembles an acrylic burr is typically used.Any handpiece that is used for oral surgery must be completely sterilizable. When a handpiece is purchased, the manufacturer’s specications must be checked carefully to ensure that they can be met. e handpiece should have high speed and torque. is allows rapid bone removal and ecient sectioning of teeth. e handpiece must not exhaust air into the operative eld, which would make it improper to use the typical high-speed air-turbine drills employed in routine restorative dentistry. e reason is that the air exhausted into the wound may be forced into deeper tissue planes and produce tissue emphysema, a dangerous occurrence.ABFig. 7.12 (A) Superior view of the hemostat used for oral surgery. (B) Oblique view of the curved hemostat. Straight hemostats are also available. ABFig. 7.13 (A) Rongeurs are bone-cutting forceps that have spring-loaded handles. (B) Blumenthal rongeurs comprise both end- and side-cutting blades. They are preferred for oral surgery procedures. place a suture around the vessel or to cauterize it (i.e., use heat to sear the vessel closed).In addition to its use as an instrument for controlling bleeding, the hemostat is especially useful in oral surgery to remove granulation tissue from tooth sockets and to pick up small root tips, pieces of calculus, amalgam, fragments, and any other small particles that have dropped into the wound or adjacent areas. However, it should never be used to suture.Removing BoneRongeursThe instrument most commonly used for removing bone in dentoalveolar surgery is the rongeur forceps. is instrument has sharp blades that are squeezed together by the handles, cutting or pinching through bone. Rongeur forceps have a rebound mechanism incorporated so that when hand pressure is released, the instrument reopens. is allows the surgeon to make repeated bone-trimming actions without manually reopening the instrument (Fig. 7.13A). e two major designs for rongeur forceps are (1) a side-cutting forceps and (2) the side- and end-cutting forceps (see Fig. 7.13B).e side-cutting and end-cutting rongeurs are more practical for most dentoalveolar surgical procedures that require bone removal. e end-cutting forceps can be inserted into sockets for the removal of interradicular bone and can also be used to remove sharp edges of bone. Rongeurs can be used to remove large amounts of bone eciently and quickly. Because a rongeur is a delicate instrument, the surgeon should not use it to remove large amounts of bone in single bites. Rather, smaller amounts of bone should be removed in multiple bites. Likewise, the rongeur should never be used to remove teeth because this practice will quickly dull and destroy the instrument and risks losing a tooth in the patient’s throat because a rongeur is not designed to hold an extracted tooth rmly. Rongeurs are expensive, so care should be taken to keep them sharp and in working order.Fig. 7.14 Typical moderate-speed high-torque sterilizable handpiece with No. 703 burr. CHAPTER 7 Instrumentation for Basic Oral Surgery 89 larger bony cavities such as cysts. Note that the periapical curette is distinctly dierent in design and function from the periodontal curette.Suturing Soft TissueOnce a surgical procedure has been completed, the mucoperiosteal ap is returned to its original position and held in place by sutures. e needle holder is the instrument used to place the sutures.Needle Holdere needle holder is an instrument with a locking handle and a short, blunt beak. For intraoral placement of sutures, a 7-inch (15-cm) needle holder is usually recommended (Fig. 7.18). e beaks of a needle holder are shorter and stronger than the beaks of a hemostat (Fig. 7.19). e face of the shorter beak of the needle holder is cross-hatched to permit a positive grasp of the suture needle. e hemostat has parallel grooves on the face of the beaks, thereby decreasing the control over needle and suture. erefore the hemostat is not an instrument used for suturing.To control the locking handles properly and to direct the long needle holder, the surgeon must hold the instrument in the proper fashion (Fig. 7.20). e thumb and ring nger are inserted through the rings. e index nger is held along the length of the needle holder to steady and direct it. e second nger aids in controlling the locking mechanism. e index nger should not be put through the nger ring because this will result in a dramatic decrease in control.Suture Needlee needle used in closing oral mucosal incisions is usually a small half-circle or three-eighths–circle suture needle. e needle is curved to allow it to pass through a limited space where a straight needle cannot reach, and passage can be done with a twist of the wrist.Suture needles come in a large variety of shapes, from very small to very large (Fig. 7.21A). e tips of suture needles either ABFig. 7.16 (A) The double-ended bone le is used for smoothing small, sharp edges or spicules of bone. (B) The teeth of this bone le are effective only in the pull stroke. Fig. 7.17 The periapical curette is a double-ended, spoon-shaped instru-ment used to remove soft tissue from bony cavities. Fig. 7.18 A needle holder has a locking handle and a short, blunt beak. Fig. 7.15 The surgical mallet and chisel can be used for removing bone. Mallet and ChiselOccasionally bone removal is performed using a mallet and chisel (Fig. 7.15), although the availability of high-speed handpieces for removing bone and sectioning teeth has greatly limited the need for mallets and chisels. e mallet and chisel are sometimes used in removing lingual tori. e edge of the chisel must be kept sharp if it is to function eectively (see Chapter 13).Bone FileFinal smoothing of bone before the completion of surgery is usually performed with a small bone le (Fig. 7.16A). e bone le is usually a double-ended instrument with small and larger ends. e bone le cannot be used eciently for removal of large amounts of bone; therefore it is used only for nal smoothing. e teeth of most bone les are arranged in such a fashion that they properly remove bone only on a pull stroke (see Fig. 7.16B). Pushing this type of bone le against bone results only in burnishing and crushing the bone and should be avoided.Removing Soft Tissue From Bony Cavitiese curette commonly used for oral surgery is an angled, double-ended instrument used to remove soft tissue from bony defects (Fig. 7.17). Its principal use is to remove granulomas or small cysts from periapical lesions, but the curette may also be used to remove small amounts of granulation tissue debris from a tooth socket. Larger currettes are available for removing soft tissue from 90 Part II Principles of Exodontiaconspicuous places on the skin—for example, the face—because properly placed smaller sutures usually cause less scarring. Sutures of size 3-0 are large enough to withstand the tension placed on them intraorally and strong enough for easier knot tying with a needle holder compared with smaller-diameter sutures.Sutures may be resorbable or nonresorbable. Nonresorbable suture materials include such types as silk, nylon, vinyl, and stainless steel. e most commonly used nonresorbable suture in the oral cavity is silk. Nylon, vinyl, and stainless steel are rarely used in the mouth. Resorbable sutures are primarily made of gut. Although the term catgut is often used to designate this type of suture, gut actually is derived from the serosal surface of sheep intestines. Plain catgut resorbs quickly in the oral cavity, rarely lasting longer than 3 to 5 days. Gut that has been treated with a tanning solution (chromic acid) is called chromic gut and lasts longer than plain gut by up to 7 to 10 days. Several synthetic resorbable sutures are also available. ese materials consist of long chains of polymers braided into suture material. Examples are polyglycolic acid and polylactic acid. ese materials are slowly resorbed, taking up to 4 weeks to do so. Such long-lasting resorbable sutures are rarely indicated for basic oral surgery.Finally, sutures are classied on the basis of their being monola-ment or polylament. Monolament sutures are sutures such as plain and chromic gut, nylon, and stainless steel. Polylament sutures are braided sutures such as silk, polyglycolic acid, and polylactic acid. Sutures that are made of braided material are easier to handle and tie than monolament sutures and rarely come untied. e cut ends are usually soft and nonirritating to the tongue and surrounding soft tissues. However, because of the multiple laments, they tend to “wick” oral uids along the suture to the underlying tissues. is wicking action may carry bacteria along with saliva. Monolament sutures do not cause this wicking action but may be more dicult to tie and tend to come untied. Also the cut ends are stier, being more irritating to the tongue and soft tissue.One of the most commonly used sutures for the oral cavity is 3-0 black silk. e size 3-0 has the appropriate amount of strength; the polylament nature of the silk makes it straightforward to tie and well tolerated by the patient’s soft tissues. e color makes the suture easy to see when the patient returns for suture removal. Sutures that are holding mucosa together usually stay no longer than 5 to 7 days, so the wicking action is of little clinical importance. Many surgeons prefer 3-0 chromic suture to avoid the need to later remove it. (Techniques for suturing and knot tying are pre-sented in Chapter 8.)Scissorse nal instruments necessary for placing sutures are suture scissors (Fig. 7.23). Suture scissors usually have short cutting edges because their sole purpose is to cut sutures. e most commonly used suture scissors for oral surgery are Dean scissors. ese have slightly curved handles and serrated blades that make cutting sutures easier. Suture scissors usually have long handles and thumb and nger rings. Scissors are held in the same manner as needle holders.Other types of scissors are designed for cutting soft tissue. e two major types of tissue scissors are iris scissors and Metzenbaum scissors (Fig. 7.24). ese scissors can have straight or curved blades. Iris scissors are small, sharp-pointed, delicate tools used for ne work. Metzenbaum scissors are used for undermining soft tissue and for cutting. ey can have either sharp or blunt (rounded) tips. Tissue scissors such as iris or Metzenbaum scissors should not be used to cut sutures because the suture material will dull ABFig. 7.19 (A) The hemostat (top) has a longer, thinner beak compared with the needle holder (bottom) and therefore should not be used for suturing. (B) The face of the shorter beak of the needle holder is cross-hatched to ensure a positive grip on the needle (left). The face of the hemostat has parallel grooves that do not allow a rm grip on the needle (right). are tapered like sewing needles or have triangular tips that allow them to be cutting needles. A cutting needle will pass through the mucoperiosteum more readily than a tapered needle (see Fig. 7.21B). e cutting portion of the needle extends about one-third the length of the needle, and the remaining portion of the needle is rounded. Tapered needles are used for more delicate tissues, as in ocular or vascular surgery. Care must be taken with cutting needles because, if not used correctly, they can cut through tissue lateral to the track of the needle. e suture material used for oral surgery is usually purchased already swaged on (by fusing the end of a suture onto a needle) by the manufacturer.e curved needle is held approximately two-thirds of the distance between the tip and the base of the needle (Fig. 7.22). is allows enough of the needle to be exposed to pass through the tissue while allowing the needle holder to grasp the needle in its strong portion to prevent bending of the needle or dulling of the tip. Techniques for placing sutures are further discussed in Chapter 8.Suture MaterialMany types of suture materials are available. e materials are classied by diameter, resorbability, and whether they are monola-ment or polylament.e size of suture relates to its diameter and is designated by a series of zeros. e diameter most commonly used in the suturing of oral mucosa is 3-0 (000). A larger-sized suture is 2-0, or 0. Smaller sizes are designated with more zeros, for example 4-0, 5-0, and 7-0. Sutures of very ne size, such as 7-0, are usually used in CHAPTER 7 Instrumentation for Basic Oral Surgery 91 teeth and the TMJ and injury may occur with injudicious use. is type of mouth prop is useful in patients who are deeply sedated or have mild forms of trismus.Whenever a bite block or side-action mouth prop is used, the surgeon should take care to avoid opening the patient’s mouth too much because it may cause stress on the TMJ. Occasionally this may result in stretch injury to the joint, necessitating additional treatment. When long procedures are being performed, it is a good idea to remove the prop periodically and allow the patient to move the jaw and rest the muscles for a short time.Removing FluidsTo provide adequate visualization, blood, saliva, and irrigating solutions must be removed from the operative site. Surgical suction has a smaller orice than the type used in general dentistry to more rapidly evacuate uids from the surgical site to maintain adequate visualization. Many of these suction tips are designed with several orices so that the soft tissue will not become aspirated into the suction hole and cause tissue injury (Fig. 7.27A).e Fraser suction has a hole in the handle portion that can be covered with a ngertip as needed. When hard tissue is being cut under copious irrigation, the hole is covered so that the solution is removed rapidly. When soft tissue is being suctioned, the hole the edges of the blades and make them less eective and more traumatic when cutting tissue.Holding the Mouth OpenIn performing extractions of mandibular teeth, it is necessary to support the mandible to prevent stress on the temporomandibular joint (TMJ). Supporting the patient’s jaw on a bite block will help protect the joint. e bite block is just what the name implies (Fig. 7.25). It is a soft, rubber-like block on which the patient can rest his or her teeth. e patient opens the mouth to a comfortably wide position, the rubber bite block is inserted, and the block holds the mouth in the desired position without eort on the patient’s part. Bite blocks come in several sizes to t variously sized patients and produce varying degrees of opening. Should the surgeon need the mouth to be opened wider using any size of bite block, the patient must open his or her mouth more widely and the bite block must be positioned more to the posterior of the mouth. For most adult patients, a pediatric-sized bite block is adequate when placed over the molar teeth.e side-action mouth prop or Molt mouth prop (Fig. 7.26) can be used by the operator to open the mouth wider if necessary. is mouth prop has a ratchet-type action, opening the mouth wider as the handle is closed. is type of mouth prop should be used with caution because great pressure can be applied to the ABFig. 7.20 The needle holder is held by using the thumb and ring nger in rings (A) and the rst and second ngers to control the instrument (B). 92 Part II Principles of ExodontiaABFig. 7.21 (A) Comparison of needles used in oral surgery. To p, C-17 needle, which usually holds a size 4-0 suture. Middle, PS-2 needle. Bottom, SH. All are cutting needles, and the suture material is swaged onto the needle. (B) The tip of the needle used to suture mucoperiosteum is triangular in cross section to make it a cutting needle. Fig. 7.22 The needle holder grasps the curved needle two-thirds of the distance from the tip of the needle. ABFig. 7.23 Suture scissors should be held in the same fashion as the needle holder. Fig. 7.24 Soft tissue scissors are of two designs: Iris scissors (top) are small, sharp-pointed scissors. Metzenbaum scissors (bottom) are longer, more delicate scissors. Metzenbaum scissors are available as either sharp tipped (shown here) or blunt tipped. can be left uncovered to prevent tissue injury or soft tissue obstruc-tion of the suction tip (see Fig. 7.27B).Holding Towels and Drapes in PositionWhen drapes are placed around a patient, they can be held together with a towel clip (Fig. 7.28). is instrument has a locking handle and nger and thumb rings. e action ends of the towel clip can be sharp or blunt. ose with curved points penetrate the towels and drapes. When this instrument is used, the operator must exercise extreme caution so as not to pinch the patient’s underlying skin. CHAPTER 7 Instrumentation for Basic Oral Surgery 93 ACBFig. 7.25 (A) The bite block is used to hold the patient’s mouth open in the position chosen by the patient. (B) The sides of the bite block are corrugated to provide a surface for teeth to engage. (C) The blocks come in a variety of sizes. Fig. 7.26 The side-action, or Molt, mouth prop can be used to open the patient’s mouth when the patient is unable to cooperate, such as during sedation or in the presence of some degree of trismus. IrrigatingWhen a handpiece and burr are used to remove bone, it is essential that the area be irrigated with a steady stream of irrigation solution, usually sterile saline or sterile water. e irrigation cools the burr and prevents bone-damaging heat buildup. e irrigation also increases the eciency of the burr by washing away bone chips from the utes of the burr and providing a certain amount of lubrication. In addition, once a surgical procedure is completed and before the mucoperiosteal ap is sutured back into position, the surgical eld should be thoroughly irrigated. A large plastic syringe with a blunt 18-gauge needle is commonly used for irriga-tion. Although the syringe is disposable, it can be sterilized multiple times before it is discarded. e needle should be blunt and smooth so that it does not damage soft tissue, and it should be angled for more ecient direction of the irrigating stream (Fig. 7.29).Extracting TeethOne of the most important instruments used in the extraction procedure is the dental elevator. ese instruments are used to luxate (loosen) teeth from surrounding bone. Loosening teeth before the application of the dental forceps makes extractions more straightforward. By elevating teeth before the application of the forceps, the clinician can minimize the incidence of broken crowns, roots, and bone. Finally, luxation of teeth before forceps application facilitates the removal of a broken root, should it occur, because prior elevator use is likely to have loosened the root in the dental 94 Part II Principles of Exodontiasocket. In addition to their role in loosening teeth from surrounding bone, dental elevators are also used to expand alveolar bone. By expanding the buccocervical plate of bone, the surgeon facilitates the removal of a tooth that has a limited and obstructed path for removal. Finally, elevators are used to remove broken or surgically sectioned roots from their sockets.Dental Elevatorse three major components of the elevator are the handle, shank, and blade (Fig. 7.30). e handle of the elevator is usually of generous size, so it can be held comfortably in the hand to apply substantial but controlled force. e application of specically applied force is critical in the proper use of dental elevators. In some situations, crossbar or T-bar handles are used. ese instru-ments must be used with great caution because they can generate an excessive amount of force that can fracture both teeth and bones (Fig. 7.31).e shank of the elevator simply connects the handle to the working end, or blade, of the elevator. e shank is generally of substantial size and is strong enough to transmit the force from the handle to the blade. e blade of the elevator is the working tip of the elevator and is used to transmit the force to the tooth, bone, or both.Types of Elevatorse biggest variation in the type of elevator is in the shape and size of the blade. e three basic types of elevators are (1) the straight type, (2) the triangle or pennant-shaped type, and (3) the pick type. e straight elevator is the most commonly used elevator to luxate teeth (Fig. 7.32A). e blade of the straight elevator has ABFig. 7.27 (A) The typical surgical suction has a small-diameter tip. Suction tips usually have a hole to prevent tissue injury caused by excessive suction pressure. Top, Unassembled for cleaning. Bottom, Assembled for use. (B) The Fraser suction tip has a blade in the handle to allow the operator more control over the amount of suction power. Holding the thumb over the hole increases suction at the tip. A wire stylet is used to clean the tip when bone or tooth particles plug the suction. Fig. 7.28 The towel clip is used to hold the drape in position. The tips clasp the towels, and the locking handles maintain the drape in position. The clip shown has nonpenetrating blunt tips. Towel clamps with sharp penetrating tips are also available. Fig. 7.29 Large plastic syringes with an angled blunt tip may be used to deliver the irrigation solution to the operative site. Blade Shank HandleFig. 7.30 The major components of an elevator are the handle, shank, and blade. Fig. 7.31 A crossbar handle is used on certain elevators. This type of handle can generate large amounts of force and therefore must be used with great caution. CHAPTER 7 Instrumentation for Basic Oral Surgery 95 a concave surface on one side that is placed toward the tooth to be elevated (see Fig. 7.32B). e small straight elevator, No. 301, is frequently used for beginning the luxation of an erupted tooth before application of the forceps (Fig. 7.33). Larger straight elevators are used to displace roots from their sockets and to luxate teeth that are more widely spaced, or they are used once a smaller-sized straight elevator becomes less eective. e most commonly used large straight elevator is the No. 34S, but the No. 46 and the No. 77R elevators are also used occasionally.e shape of the blade of the straight elevator can be angled from the shank, allowing this instrument to be used in the more posterior aspects of the mouth. Two examples of the angled-shank elevator with a blade similar to that of the straight elevator are the Miller elevator and the Potts elevator.e second most commonly used type of elevator is the triangular elevator (Fig. 7.34). ese elevators are provided in pairs: a left and a right. e triangular elevator is most useful when a broken root remains in the tooth socket and the adjacent socket is empty. A typical example would be when a mandibular rst molar is fractured, leaving the distal root in the socket but the mesial root ABCFig. 7.32 (A) Straight elevators are the most commonly used type. (B–C) The blade of the straight elevator is concave on its working side. Fig. 7.33 Straight elevators vary in size depending on the width of the blade. Fig. 7.34 Triangular elevators (Cryer) are pairs of instruments and are therefore used for mesial or distal roots. Fig. 7.35 The Crane pick is a heavy instrument used to elevate whole roots or even teeth after the purchase point has been prepared with a burr. removed with the crown. e tip of the triangular elevator is placed into the socket with the shank of the elevator resting on the buccal plate of bone. e elevator is then turned in a wheel-and-axle rotation, with the sharp tip of the elevator engaging the cementum of the remaining distal root; the elevator is then turned and the root is delivered. Triangular elevators come in a variety of types and angulations, but the Cryer elevator is the most common type. (Pairs of these elevators are also commonly referred to as east-west elevators.)e third type of elevator used with some frequency is the pick-type elevator. is type of elevator is used to remove roots. e heavy version of the pick is the Crane pick (Fig. 7.35). is instrument is used as a lever to elevate a broken root from the tooth socket. Usually it is necessary to drill a hole with a burr (purchase point) approximately 3 mm deep into the root just at the bony crest. e tip of the pick is then inserted into the hole, and, with the buccal plate of bone as a fulcrum, the root is elevated from the tooth socket. Occasionally the sharp point can be used without preparing a purchase point by engaging the cementum or the furcation of the tooth.e second type of pick is the root-tip pick or the apex elevator (Fig. 7.36). e root-tip pick is a delicate instrument that is used to tease small root tips from their sockets. It must be emphasized that this is a thin instrument and should not be used as a wheel-and-axle or lever type of elevator such as the Cryer elevator or the Crane pick. e root-tip pick is used to tease the very small root end of a tooth by inserting the tip into the periodontal ligament space between the root tip and the socket wall. is instrument works best on roots left after a tooth has been well elevated.PeriotomesPeriotomes are instruments used to extract teeth while preserving the anatomy of the tooth’s socket. e general principle behind their use is to sever some of the periodontal ligaments of the tooth 96 Part II Principles of Exodontiasize to be used comfortably and to deliver sucient pressure and leverage to remove the required tooth. e handles have a serrated surface to allow a positive grip and to prevent slippage.e handles of the forceps are held dierently depending on the position of the tooth to be removed. Maxillary forceps are held with the palm to the side or underneath the forceps so that the beak is directed in a superior direction (Fig. 7.39). e forceps used for removal of mandibular teeth are held with the palm on top of the forceps so that the beak is pointed down toward teeth (Fig. 7.40). e handles of the forceps are usually straight, but some may be curved to provide the operator with a better t (Fig. 7.41).e hinge of the forceps, like the shank of the elevator, is merely a mechanism for connecting the handles to the beak. e hinge transfers and concentrates the force applied to the handles to the beak. One distinct dierence in styles does exist: e usual American type of forceps has a hinge in a horizontal direction and is used as has been described (see Fig. 7.38). e English preference is for a vertical hinge and a corresponding vertically positioned handle (Fig. 7.42A). us the English-style handle and hinge are used with the hand held in a vertical direction as opposed to a horizontal direction (see Fig. 7.42B).e beaks of the extraction forceps are the source of the great-est variation among forceps. e beaks are designed to adapt to the tooth root near the junction of the crown and root. It must be remembered that the beaks of the forceps are designed to be adapted to the root structure of the tooth and not to the crown of the tooth. In a sense, then, dierent beaks are designed for to facilitate its removal. ere are varying types of periotomes with dierent blade shapes (Fig. 7.37).e tip of the periotome blade is inserted into the periodontal ligament space and advanced using pressure in the apical direction along the long axis of the tooth. It is advanced about 2 to 3 mm and then removed and reinserted into an adjacent accessible site. e process is continued around the tooth, gradually advancing the depth of the periotome tip while progressing apically. Once sucient severance of periodontal ligaments has been accomplished, the tooth is removed by using a dental elevator, extraction forceps, or both, taking care to avoid excessive expansion or fracture of bone.Extraction Forcepse extraction forceps are instruments used for removing the tooth from alveolar bone. Ideally, forceps are used to lift elevator-luxated teeth from their sockets rather than to pull teeth from their sockets. When properly used, they can also help to expand bone during extractions.Forceps are designed in many styles and congurations to adapt to the variety of teeth for which they are used. Each basic design oers a multiplicity of variations to coincide with individual operator preferences. is section deals with the basic fundamental designs and briey discusses several of the variations.Forceps Componentse basic components of dental extraction forceps are the handles, hinge, and beak (Fig. 7.38). e handles are usually of adequate Fig. 7.36 The delicate root-tip pick is used to tease root tip fragments from the socket. The ne tip can be broken off or bent if the instrument is used improperly. Fig. 7.37 A periotome with a handle and exchangeable blades. Other types of periotomes have xed blades or are connected to a motor. CHAPTER 7 Instrumentation for Basic Oral Surgery 97 Fig. 7.39 Forceps used to remove maxillary teeth are held with the palm under the handle. ABFig. 7.40 (A) Forceps used to remove mandibular teeth are held with the palm on top of forceps. (B) A rmer grip for delivering greater amounts of rotational force can be achieved by moving the thumb around and under the handle. Fig. 7.41 Straight handles are usually preferred, but curved handles are favored by some surgeons. ABFig. 7.42 (A) English style of forceps have the hinge in the vertical direc-tion. (B) English style of forceps are held in the vertical direction. Beak Hinge HandleFig. 7.38 Basic components of extraction forceps. 98 Part II Principles of Exodontiacurve of the No. 150 forceps allows the operator to comfort-ably reach not only incisors but also premolars. e beak of the No. 150 forceps comes in a style that has been modied slightly to form the No. 150A forceps (Fig. 7.44). No. 150A forceps are useful for extracting maxillary premolar teeth and should not be used for extracting incisors because of its poor adaptation to the roots of incisors.In addition to the No. 150 forceps, straight forceps are also available. No. 1 forceps (Fig. 7.45), which can be used for maxillary incisors and canines, are easier to use compared with the No. 150 forceps for upper incisors.Maxillary molar teeth are three-rooted teeth, with a single palatal root and a buccal bifurcation. erefore forceps that are specically adapted to t maxillary molars must have a smooth, concave surface for the palatal root and a beak with a pointed design that will t into the buccal bifurcation. is requires that the molar forceps come in pairs: a left and a right. In addition, the maxillary molar forceps should be oset so that the surgeon can reach the posterior aspect of the mouth and remain in the correct position. e most commonly used molar forceps are the No. 53 right and left forceps (Fig. 7.46). ese forceps are designed to t anatomically around the palatal beak, and the pointed buccal beak ts into the buccal bifurcation. e beak is oset to allow for good surgeon positioning.A design variation is shown in the No. 88 right and left forceps, which have a longer, more accentuated pointed beak formation (Fig. 7.47). ey are particularly useful for maxillary molars with crowns that are severely carious. e sharply pointed beaks may reach deeper into the trifurcation to sound dentin. e major disadvantage is that they crush crestal alveolar bone, and when used on intact teeth without due caution and proper elevation, they can fracture large amounts of buccal alveolar bone.On occasion maxillary second molars and erupted third molars have a single conical root. In this situation, forceps with broad, smooth beaks that are oset from the handle can be useful. e No. 210S forceps exemplies this design (Fig. 7.48). Another design variation is shown in the oset molar forceps with a very narrow beak. ese forceps are used primarily to remove broken maxillary molar roots but can be used for the removal of narrow premolars and for lower incisors. ese forceps, the No. 65 forceps, are also known as root-tip forceps (Fig. 7.49).single-rooted teeth, two-rooted teeth, and three-rooted teeth. e design variation is such that the tips of the beaks will adapt closely to the various root formations, improving the surgeon’s control of forces on the root and decreasing the chances of a root fracture. e more closely the beaks of the forceps adapt to the tooth roots, the more ecient is the extraction and the lower is the chance for undesired outcomes.A nal design variation is in the width of the beak. Some forceps beaks are narrow because their primary use is to remove narrow teeth such as incisor teeth. Other forceps beaks are broader because the teeth they are designed to remove are substantially wider, for example, lower molar teeth. Forceps designed to remove a lower incisor can theoretically be used to remove a lower molar, but the beaks are so narrow that they will be inecient for that application. Similarly, the broader molar forceps will not adapt to the narrow space occupied by the lower incisor; therefore it cannot be used in that situation without damage to adjacent teeth.e beaks of forceps are angled such that they can be placed parallel to the long axis of the tooth, with the handle in a comfort-able position. erefore the beaks of maxillary forceps are usually parallel to the handles. Maxillary molar forceps are oset in a bayonet fashion to allow the operator to reach the posterior aspect of the mouth comfortably and yet keep the beak parallel to the long axis of the tooth. e beaks of mandibular forceps are usually set perpendicular to the handles, which allows the surgeon to reach lower teeth and maintain a comfortable controlled position.Maxillary Forcepse removal of maxillary teeth requires the use of instruments designed for single-rooted teeth and for teeth with three roots. Maxillary incisors, canine teeth, and premolar teeth are considered single-rooted teeth. e maxillary rst premolar frequently has a bifurcated root, but because this occurs in the apical third, it has no inuence on the design of the forceps. e maxillary molars have trifurcated roots, so there are extraction forceps that will adapt to that conguration.After proper elevation, single-rooted maxillary teeth are usually removed with maxillary universal forceps, usually No. 150 (Fig. 7.43). e No. 150 forceps are slightly S-shaped when viewed from the side and are essentially straight when viewed from above. e beaks of the forceps curve to meet only at the tip. e slight ACBDFig. 7.43 (A) Superior view of No. 150 forceps. (B) Side view of No. 150 forceps. (C–D) No. 150 forceps adapted to the maxillary central incisor. CHAPTER 7 Instrumentation for Basic Oral Surgery 99 ABCFig. 7.44 (A) Superior view of No. 150A forceps. (B) No. 150A forceps have parallel beaks that do not touch, in contrast to the No. 150 forceps. (C) Adaptation of No. 150A forceps to the maxillary premolar. ABCFig. 7.45 (A) Superior view of No. 1 forceps. (B–C) No. 1 forceps adapted to the incisor. A smaller version of the No. 150 forceps, the No. 150S forceps, is useful for removing primary teeth (Fig. 7.50). ese forceps adapt well to all maxillary primary teeth and can be used as universal primary tooth forceps.Mandibular ForcepsExtraction of mandibular teeth requires forceps that can be used for single-rooted teeth for the incisors, canines, and premolars as well as for two-rooted teeth for the molars. e forceps most commonly used for the single-rooted teeth are the lower universal forceps, or the No. 151 forceps (Fig. 7.51). ese forceps have handles similar in shape to the No. 150 forceps, but the beaks are pointed inferiorly for lower teeth. e beaks are smooth and narrow and meet only at the tip. is allows the beak to t near the cervical line of the tooth to grasp the root.e No. 151A forceps have been modied slightly for mandibular premolar teeth (Fig. 7.52). ese forceps should not be used for other lower teeth because their form prevents adaptation to the roots of teeth.e English style of vertical-hinge forceps can be used for the single-rooted teeth in the mandible (Fig. 7.53). Great force can be generated with these forceps. Unless great care is exercised, the incidence of root fracture is higher with this instrument.Mandibular molars are bifurcated, two-rooted teeth that allow the use of forceps that anatomically adapt to the tooth. Because the bifurcation is on the buccal and the lingual sides, only 100 Part II Principles of ExodontiaABCDEFig. 7.46 (A) Superior view of No. 53L forceps. (B) Oblique view of No. 53L forceps. (C) Right, No. 53L; left, No. 53R. (D–E) No. 53L forceps adapted to the maxillary molar. ABCFig. 7.47 (A) Superior view of No. 88L forceps. (B) Side view of No. 88L forceps. (C) No. 88R forceps adapted to the maxillary molar. CHAPTER 7 Instrumentation for Basic Oral Surgery 101 ACBFig. 7.48 (A) Superior view of No. 210S forceps. (B) Side view of No. 210S forceps. (C) No. 210S forceps adapted to the maxillary molar. ABCFig. 7.49 (A) Superior view of No. 65 forceps. (B) Side view of No. 65 forceps. (C) No. 65 forceps adapted to a broken root. Fig. 7.50 The No. 150S forceps (bottom) are a smaller version of the No. 150 forceps (top) and are used for primary teeth. single-molar forceps are necessary for the both sides, in contradistinc-tion to the maxilla, for which a right- and left-paired molar forceps set is required.Useful lower molar forceps are the No. 17 forceps (Fig. 7.54). ese forceps are usually straight-handled, and the beaks are set obliquely downward. e beaks have pointed tips in the center to be set into the bifurcation of lower molar teeth. e remainder of the beak adapts well to the sides of the furcation. Because of the pointed tips, the No. 17 forceps cannot be used for molar teeth, which have fused, conical roots. For this purpose, the No. 151 forceps are used.A major design variation in lower molar forceps is the No. 87, the so-called cowhorn forceps (Fig. 7.55). ese instruments are designed with two pointed, heavy beaks that enter the bifurcation of lower molars. After the forceps are seated in the correct position, usually while gently pumping the handles up and down, the tooth is actually elevated by squeezing the handles of the forceps together tightly. As the beaks are squeezed into the bifurcation, they use the buccal and lingual cortical plates as fulcrums and the tooth can be literally squeezed out of the socket. As with the English style of forceps, improper use of the cowhorn forceps can result in an increase in the incidence of untoward eects such as fractures of alveolar bone or damage to maxillary teeth if the forceps are not properly controlled by the surgeon as the molar exits the socket. e beginning surgeon should therefore use the cowhorn forceps with caution.e No. 151 forceps are also adapted for primary teeth. No. 151S forceps are the same general design as the No. 151 forceps but are scaled down to adapt to primary teeth. ese forceps are adequate for the removal of all primary mandibular teeth (Fig. 7.56).Instrument Tray SystemsMany dentists nd it practical to use the tray method to assemble instruments that will be used for specic types of procedures. Standard sets of instruments are packaged together, sterilized, and then unwrapped at surgery. e typical basic extraction pack includes a local anesthesia syringe, a needle, a local anesthesia cartridge, a No. 9 periosteal elevator, a periapical curette, small and large straight elevators, a pair of college pliers, a curved hemostat, a towel clip, an Austin or Minnesota retractor, a suction tip, and 2 × 2 inch or 4 × 4 inch gauze (Fig. 7.57). e required forceps would be added to this tray after it was opened.A tray used for surgical extractions would include the items from the basic extraction tray plus needle holder and suture, suture scissors, blade handle and blade, Adson tissue forceps, bone le, tongue retractor, Cryer elevators, rongeur, and handpiece and burr (Fig. 7.58). ese instruments permit incision and reection of soft tissue, removal of bone, sectioning of teeth, retrieval of roots, debridement of the wound, and suturing of the soft tissue. 102 Part II Principles of ExodontiaABCFig. 7.51 (A) Superior view of No. 151 forceps. (B) Side view of No. 151 forceps. (C) No. 151 forceps adapted to the mandibular incisor. ABFig. 7.52 (A) The No. 151A forceps have beaks that are parallel and do not adapt well to the roots of most teeth, in contrast to the beaks of the No. 151 forceps. (B) No. 151A forceps adapted to a lower premolar tooth. The lack of close adaptation of the tips of the beaks to the root of the tooth is shown. ABFig. 7.53 (A) Side view of the English style of forceps. (B) Forceps adapted to the lower premolar. CHAPTER 7 Instrumentation for Basic Oral Surgery 103 CABDFig. 7.54 (A) Superior view of No. 17 molar forceps. (B) Side view of No. 17 molar forceps. (C–D) No. 17 forceps adapted to the lower molar. CABDFig. 7.55 (A) Superior view of cowhorn No. 87 forceps. (B) Side view of cowhorn forceps. (C–D) Cowhorn forceps adapted to the lower molar tooth. 104 Part II Principles of ExodontiaFig. 7.56 The No. 151S forceps (bottom) are a smaller version of the No. 151 forceps (top) and are used to extract primary teeth. Fig. 7.57 Basic extraction tray. Fig. 7.58 The surgical extraction tray includes the necessary instrumentation to reect soft tissue aps, remove bone, section teeth, retrieve roots, and suture aps back into position. CHAPTER 7 Instrumentation for Basic Oral Surgery 105 Fig. 7.59 The biopsy tray includes equipment necessary to remove a soft tissue specimen and suture wounds closed. Fig. 7.60 The postoperative tray includes instruments necessary to remove sutures and irrigate the mouth. e biopsy tray includes the basic tray (minus elevators), blade handle and blade, needle holder and suture, suture scissors, tissue scissors, Allis tissue forceps, Adson tissue forceps, and a curved hemo-stat (Fig. 7.59). ese instruments permit incision and dissection of a soft tissue specimen and closure of the wound with sutures.e postoperative tray has the necessary instruments to irrigate the surgical site and remove sutures (Fig. 7.60). e tray usually includes scissors, college pliers, irrigation syringe, cotton applicator sticks, gauze, and suction tip.e instruments may be placed on a at tray, wrapped with sterilization paper, and sterilized. When ready for use, the tray is taken to the operatory and opened in such a manner as to preserve instrument sterility, and the instruments are used from the tray. is system requires a large autoclave to accommodate the tray.Alternatively, metal cassettes can be used instead of a tray. Cassettes are more compact but must also be wrapped in sterilization paper. 1068 Principles of Routine ExodontiaJAMES R. HUPPCHAPTER OUTLINEPresurgical Medical Assessment, 106Indications for Removal of Teeth, 107Caries, 107Pulpal Necrosis, 107Periodontal Disease, 107Orthodontic Reasons, 107Malpositioned Teeth, 107Cracked Teeth, 107Impacted Teeth, 107Supernumerary Teeth, 107Teeth Associated With Pathologic Lesions, 107Radiation Therapy, 107Teeth Involved in Jaw Fractures, 107Financial Issues, 108Contraindications for Removal of Teeth, 108Local Contraindications, 108Clinical Evaluation of Teeth for Removal, 108Access to the Tooth, 108Mobility of the Tooth, 108Condition of the Crown, 108Radiographic Examination of the Tooth for Removal, 109Relationship to Vital Structures, 110Conguration of Roots, 110Condition of Surrounding Bone, 112Patient and Surgeon Preparation, 112Chair Position for Extractions, 113Mechanical Principles Involved in Tooth Extraction, 116Principles of Elevator and Forceps Use, 119Procedure for Closed Extraction, 121Role of the Opposite Hand, 123Role of the Assistant During Extraction, 124Specic Techniques for the Removal of Each Tooth, 124Maxillary Teeth, 124Incisors, 124Canines, 125First Premolar, 126Second Premolar, 127Molars, 127Mandibular Teeth, 128Anterior Teeth, 128Premolars, 130Molars, 130Modications for Extraction of Primary Teeth, 131Postextraction Tooth Socket Care, 132lifted from its socket. During preextraction planning, the degree of diculty anticipated for removing a particular tooth is assessed. If that assessment leads the surgeon to believe that the degree of diculty will be high or if initial attempts at tooth removal conrm this, a deliberate surgical approach—not an application of excessive force—should be taken. Excessive force may injure local soft tissue and damage the surrounding bone and teeth. Such force may fracture the crown, usually making the extraction substantially more dicult than it would have been otherwise. Moreover, excessive force and haste during an extraction heightens intraoperative and postoperative patient discomfort and anxiety.Presurgical Medical AssessmentWhen conducting the preoperative patient evaluation, it is critical that the surgeon examine the patient’s medical status. Patients can have a variety of health problems that require treatment modication or medical management before the surgery can be safely performed. Extraction of a tooth combines the principles of surgery and elementary physical mechanics. When these principles are applied correctly, a tooth can usually be removed from the alveolar process, even by someone without great strength and without untoward force or sequelae. is chapter presents the principles of surgery and mechanics related to uncomplicated tooth extraction. In addition, there is a detailed description of techniques for removal of specic teeth with specic instruments. Because the crown is already “removed” from the bone in fully erupted teeth, a dental extraction focuses on root extraction. Following this concept prevents the surgeon from untoward focus on using force on the crowns to remove teeth. Ignoring this concept com-monly leads to fracturing the crowns or roots of teeth or fracturing the bone around the roots.Proper tooth removal does not require a large amount of strength; instead, when done properly, it is accomplished with nesse. Removal of an erupted tooth involves the use of controlled force so that the tooth is not pulled from bone, but instead is gently CHAPTER 8 Principles of Routine Exodontia 107 be extracted. A common example of this is the maxillary third molar, which erupts in severe buccal version and causes ulcer-ation and soft tissue trauma of the cheek. Another example is malpositioned teeth that are hypererupted because of the loss of teeth in the opposing arch. If prosthetic rehabilitation is to be carried out in the opposing arch, the hypererupted tooth may interfere with construction of an adequate prosthesis. In this situation, the malpositioned tooth should be considered for extraction.Cracked TeethAn uncommon indication for extraction of teeth is a tooth with a cracked crown or a fractured root. e cracked tooth can be painful and be unmanageable by a more conservative technique. Cracked teeth have often already undergone endodontic therapy at some point in the past, which tends to make the crown and root more brittle and dicult to remove.Impacted TeethImpacted teeth should be considered for removal. If it is clear that a partially impacted tooth is unable to erupt into a functional occlusion because of inadequate space, interference from adjacent teeth, or some other reason, it should be considered for surgical removal. See Chapter 10 for a more thorough discussion of this topic.Supernumerary TeethSupernumerary teeth are usually impacted and should be removed. A supernumerary tooth may interfere with the eruption of suc-cedaneous teeth and has the potential for causing their resorption and displacement.Teeth Associated With Pathologic LesionsTeeth involved in pathologic lesions may require removal. is is often seen with odontogenic cysts. In some situations, the tooth or teeth can be retained and endodontic therapy performed. However, if maintaining the tooth compromises the complete surgical removal of the lesion when complete removal is critical, the tooth should be removed.Radiation TherapyPatients who are to receive radiation therapy for oral, head, or neck cancer should consider removal of teeth that are in the beam of radiation therapy, particularly if the teeth are compromised in some manner. However, many of these teeth can be retained with proper care. See Chapter 19 for a more thorough discussion of the eects of radiation therapy on teeth and jaws.Teeth Involved in Jaw FracturesPatients who sustain fractures of the mandible or the alveolar process sometimes must have teeth removed. In some situa-tions, the tooth involved in the line of fracture can be main-tained, but if the tooth is injured, infected, or severely luxated from the surrounding bony tissue or interferes with proper reduction and fixation of the fracture, its removal is usually indicated.Special measures may be needed to control bleeding, lessen the chance of infection, or prevent a medical emergency. is informa-tion is discussed in detail in Chapter 1, which includes information regarding the specics of altering surgical treatment for medical management reasons.Indications for Removal of TeethTeeth are extracted for a variety of reasons. is section discusses a variety of general indications for removing teeth. ese indications are only guidelines, not absolute rules.CariesPerhaps the most common and widely accepted reason to remove a tooth is that it is so severely carious that it cannot be restored. e extent to which the tooth is carious and is considered nonrestor-able is a judgment call to be made between the dentist and the patient. Sometimes the complexity and cost required to salvage a severely carious tooth also makes extraction a reasonable choice. is is particularly true with the availability and success of reliable implant-supported prostheses.Pulpal NecrosisA second, closely aligned rationale for removing a tooth is the presence of pulpal necrosis or irreversible pulpitis that is not amenable to endodontics. is may be the result of a patient declining endodontic treatment or when a tooth has a root canal that is tortuous, calcied, and untreatable by standard endodontic techniques. Also included in this category of general indications is the case in which endodontic treatment has been done but has failed to relieve pain or provide drainage, and the patient does not desire retreatment.Periodontal DiseaseA common reason for tooth removal is severe and extensive peri-odontal disease. If severe adult periodontitis has existed for some time, excessive bone loss and irreversible tooth mobility will be found. In these situations, the hypermobile teeth should be extracted. Also, ongoing periodontal bone loss may jeopardize the chance for straightforward implant placement, making extraction a sensible step even before a tooth becomes moderately or severely mobile.Orthodontic ReasonsPatients who are about to undergo orthodontic correction of crowded dentition with insucient arch length frequently require the extraction of teeth to provide space for tooth alignment. e most commonly extracted teeth are the maxillary and mandibular premolars, but a mandibular incisor may occasionally need to be extracted for this same reason. Great care should be taken to double-check that extraction is indeed necessary and that the correct tooth or teeth are removed if someone other than the surgeon doing the extraction has planned the extractions.Malpositioned TeethTeeth that are malposed or malpositioned may be indicated for removal in several situations. If they traumatize soft tissue and cannot be repositioned by orthodontic treatment, they should 108 Part II Principles of ExodontiaA variety of factors must be specically examined to make the appropriate assessment and treatment plan.Access to the Toothe rst factor to be examined in preoperative assessment is the extent to which the patient can open the mouth. Any limitation of opening may compromise the ability of the surgeon to give local anesthesia or perform a routine extraction. If the patient’s opening is substantially compromised, the surgeon should consider a surgical approach to the tooth instead of a routine elevator and forceps extraction. is requires placing the patient under deep sedation or general anesthesia. In addition, the surgeon should look for the cause of the reduction of opening. e most likely causes are trismus associated with infection around the muscles of mastication, temporomandibular joint (TMJ) dysfunction, and muscle brosis.e location and position of the tooth to be extracted within a dental arch should be examined. A properly aligned tooth has a normal access for placement of elevators and forceps. However, crowded or otherwise malposed teeth may present diculty in positioning the usually used forceps onto the tooth for extraction. When access is a problem, a dierent forceps may be needed or a surgical approach may be indicated.Mobility of the Toothe mobility of the tooth to be extracted should be assessed preoperatively. Greater-than-normal mobility is frequently seen with severe periodontal disease. If the teeth are excessively mobile, uncomplicated tooth removal should be expected, but soft tissue management after the extraction may be more involved (Fig. 8.1A).Teeth that have less-than-normal mobility should be carefully assessed for the presence of hypercementosis or ankylosis of the roots. Ankylosis is often seen with primary molars that are retained and have become submerged (see Fig. 8.1B). In addition, ankylosis is seen occasionally in nonvital teeth that have had endodontic therapy many years before the extraction. If the clinician believes that the tooth is ankylosed, it is wise to plan for a surgical removal of the tooth as opposed to a forceps extraction. Hypercementosis can create bulbous roots that are more challenging to remove.Condition of the Crowne assessment of the crown of the tooth before the extraction should be related to the presence of large caries or restorations in the crown. If large portions of the crown have been destroyed by caries, the likelihood of crushing the crown during the extraction is increased, thus causing more diculty in removing the tooth (Fig. 8.2). Similarly, the presence of large amalgam restorations produces weakness in the crown, and the restoration will probably fracture during the extraction process (Fig. 8.3). In addition, an endodontically treated tooth becomes desiccated and typically becomes brittle and crumbles easily when force is applied. In these three situations, it is critical that the tooth be elevated as much as possible and that the forceps then be applied as far apically as possible in order to grasp an intact root portion of the tooth instead of the crown.If the tooth to be extracted has a large accumulation of calculus, the gross accumulation should be removed with a scaler or ultrasonic cleaner before extraction. e reasons for this are that calculus interferes with the placement of the forceps in the appropriate Financial IssuesA nal indication for removal of a tooth relates to the nancial status of the patient. All of the indications for extraction already mentioned may become stronger if the patient is unwilling or unable to nancially support the decision to maintain the tooth. e inability of the patient to pay for the procedure may require that the tooth be removed. Also, implant dentistry is often more cost eective for a patient than maintaining a compromised tooth.Contraindications for Removal of TeethEven if a given tooth meets one of the requirements for removal, in some situations, the tooth should not be removed because of other factors or contraindications to extraction. ese factors, like the indications, are relative in their strength. In some situations, the contraindication can be modied by the use of additional care or treatment, and the indicated extraction can be performed. In other situations, however, the contraindication may be so signicant that the tooth should not be removed without taking special precau-tions. In general, the contraindications are divided into two groups: systemic and local. Systemic contraindications to routine oral surgery are discussed in Chapter 1.Local ContraindicationsSeveral local contraindications to the extraction of teeth also exist. e most important and most critical is a history of therapeutic radiation for cancer. Extractions performed in an area of radiation may result in osteoradionecrosis, and therefore the extraction must be done with extreme caution. Chapter 19 discusses this in detail.Teeth that are located within an area of tumor, especially a malignant tumor, should not be extracted. e surgical procedure for extraction could disseminate malignant cells, thereby seeding local metastases.Patients who have severe pericoronitis around an impacted mandibular third molar should not have the tooth extracted until the pericoronitis has been treated. Nonsurgical treatment should include irrigations and removal of the maxillary third molar, if necessary, to relieve impingement on the edematous soft tissue overlying the mandibular impaction. Some clinicians will also administer antibiotics. If the mandibular third molar is removed in the face of severe pericoronitis, the incidence of complications increases. However, if the pericoronitis is mild and the tooth can be removed in a straightforward manner, then immediate extraction may be performed.Finally, the acute dentoalveolar abscess must be mentioned. Many prospective studies have made it abundantly clear that the most rapid resolution of an infection resulting from pulpal necrosis is obtained when the tooth is removed as early as possible. erefore acute infection is not a contraindication to extraction. However, it may be dicult to extract such a tooth because the patient may not be able to open the mouth suciently wide due to trismus, or it may be dicult to reach a state of profound local anesthesia. If access and anesthesia considerations can be met, the tooth should be removed as soon as possible. Otherwise, antibiotic therapy should be started and extraction planned as soon as possible.Clinical Evaluation of Teeth for RemovalIn the preoperative assessment period, the tooth to be extracted should be examined carefully to assess the diculty of the extraction. CHAPTER 8 Principles of Routine Exodontia 109 BA• Fig. 8.1 (A) Tooth with severe periodontal disease with bone loss and wide periodontal ligament space. This kind of tooth is straightforward to remove. (B) Retained mandibular second primary molar with an absent succedaneous tooth. The molar is partially submerged, and the likelihood for ankylosed roots is high. • Fig. 8.2 Teeth with large carious lesions are likely to fracture during extraction, making extraction more difcult. • Fig. 8.3 Teeth with large amalgam restorations are likely to be fragile and to fracture when extraction forces are applied. • Fig. 8.4 Mandibular rst molar. If the molar is to be removed, the surgeon must take care not to fracture amalgam in the second premolar with eleva-tors or forceps. fashion, and fractured calculus may contaminate the empty tooth socket once the tooth is extracted.e surgeon should also assess the condition of adjacent teeth. If adjacent teeth have large amalgams or crowns, or have undergone endodontic therapy, it is important to keep this in mind when elevators and forceps are used to mobilize and remove the indicated tooth. If adjacent teeth have large restorations, the surgeon should use elevators with extreme caution because fracture or displacement of the restorations may occur (Fig. 8.4). e patient should be informed before the surgical procedure about possible damage to these restorations during the process of obtaining informed consent.Radiographic Examination of the Tooth for RemovalIt is essential that proper radiographs be taken of any tooth to be removed. In general, periapical radiographs provide the most accurate and detailed information concerning the tooth, its roots, and the surrounding tissue. Panoramic radiographs are used 110 Part II Principles of Exodontiawith division of maxillary molar roots into individual roots before the extraction proceeds (Fig. 8.6).The inferior alveolar canal may approximate the roots of mandibular molars. Although the removal of an erupted tooth rarely impinges on the inferior alveolar canal, if an impacted tooth is to be removed, it is important that the relationship between molar roots and the canal be assessed. Such an extraction may lead to injury of the canal and cause consequent damage to the inferior alveolar nerve (Fig. 8.7). Cone-beam computed tomography (CBCT) images are often useful in these circumstances.Radiographs taken before the removal of mandibular premolar teeth should include the mental foramen. Should a surgical ap be required to retrieve a premolar root, it is essential that the surgeon know where the mental foramen is to avoid injuring the mental nerve during ap development (Fig. 8.8, see also Fig. 8.3).Conguration of RootsRadiographic assessment of the tooth to be extracted probably contributes the most to the determination of diculty of the extraction. e rst factor to evaluate is the number of roots on the tooth to be extracted. Most teeth have the typical number of roots, in which case the surgical plan can be carried out in the • Fig. 8.5 Properly exposed radiograph for extraction of mandibular rst molar. • Fig. 8.6 Maxillary molar teeth immediately adjacent to the sinus present increased danger of sinus exposure. • Fig. 8.7 Mandibular molar teeth that are close to the inferior alveolar canal. Third molar removal is a procedure most likely to result in injury to the nerve. frequently, but their greatest usefulness is for impacted teeth as opposed to erupted teeth.For radiographs to have their maximal value, they must meet certain criteria. Most importantly, radiographs must be properly exposed, with adequate penetration and good contrast. The radiographic lm or sensor should have been properly positioned so that it shows all portions of the crown and roots of the tooth under consideration without distortion (Fig. 8.5). If digital imaging is not used, the radiograph must be properly processed, with good xation, drying, and mounting. e mounting should be labeled with the patient’s name and the date on which the lm was exposed. The radiograph should be mounted in the American Dental Association (ADA) standardized method, which is to view the radiograph as if looking at the patient; the raised dot on the lm faces the observer. e radiograph should be reasonably current in order to depict the presently existing situation. Radiographs older than 1 year should probably be retaken before surgery. Finally, nondigital radiographs must be mounted on a view box that is visible to the surgeon during the operation, and digital images should be displayed so the surgeon can look at them during extractions without stopping surgery or degloving. Radiographs that are taken, but not available during surgery, are of limited value.e relationship of the tooth to be extracted to adjacent erupted and unerupted teeth should be noted. If the tooth is a primary tooth, the relationship of its roots to the underlying succedaneous tooth should be carefully considered. e extraction of a primary tooth can possibly injure or dislodge the underlying tooth. If surgical removal of a root or part of a root is necessary, the relationship of the root structures of adjacent teeth must be known. Bone removal should be performed judiciously whenever necessary, but it is particularly important to be careful if adjacent roots are close to the root being removed.Relationship to Vital StructuresWhen performing extractions of the maxillary molars, it is essential to be aware of the proximity of the roots of the molars to the oor of the maxillary sinus. If only a thin layer of bone exists between the sinus and the roots of molar teeth, the potential for perforation of the maxillary sinus during the extraction increases. us the surgical treatment plan may be altered to an open surgical technique, CHAPTER 8 Principles of Routine Exodontia 111 e shape of the individual root must be taken into consider-ation. Roots may have short, conic shapes that make them easy to remove. However, long roots with severe and abrupt curves or hooks at their apical end are more dicult to remove. e surgeon must have knowledge of the shapes of the roots before surgery to adequately plan the surgery (Fig. 8.11).e size of the root must be assessed. Teeth with short roots are easier to remove compared with teeth with long roots. A long root that is bulbous as a result of hypercementosis is even more dicult to remove. e periapical radiographs of older patients should be examined carefully for evidence of hypercementosis because this process seems to be a result of aging (Fig. 8.12).e surgeon should look for evidence of caries extending into the roots. Root caries may substantially weaken the root and make it more liable to fracture when the force of the forceps is applied (Fig. 8.13).Root resorption, internal or external, should be assessed on examination of the radiograph. Like root caries, root resorption weakens the root structure and renders it more likely to be fractured. Surgical extraction may be considered in situations of extensive root resorption (Fig. 8.14).e tooth should be evaluated for previous endodontic therapy. If there was endodontic therapy many years before the extraction usual fashion; but many teeth have an abnormal number of roots. If the number of roots is known before the tooth is extracted, an alteration in the plan can be made to prevent fracture of any additional roots (Fig. 8.9).e surgeon must know the curvature of the roots and the degree of root divergence to properly plan the extraction procedure. Roots of the usual number and of average size may still diverge substantially and thus make the total root width so wide that it precludes extraction with forceps. In situations of excess curvature with wide divergence, surgical extraction may be required with planned division of the crown (Fig. 8.10).• Fig. 8.8 Before premolar extractions that require a surgical ap are performed, it is essential to know the relationship of the mental foramen to root apices. Note the radiolucent area at the apex of the second pre-molar, which represents the mental foramen. • Fig. 8.9 Mandibular canine tooth with two roots. Knowledge of this fact preoperatively may result in a less traumatic extraction. • Fig. 8.10 The widely divergent roots of this maxillary rst molar make extraction more difcult. • Fig. 8.11 The curvature of the roots of this tooth is unexpected. Preop-erative radiographs help the surgeon plan the extraction more carefully. 112 Part II Principles of Exodontiamay have periapical radiolucencies that represent granulomas or cysts. Awareness of the presence of such lesions is important because these lesions should be removed at the time of surgery (Fig. 8.16).Patient and Surgeon PreparationSurgeons must prevent inadvertent injury or transmission of infection to their patients or to themselves. e principle of universal precautions states that all patients must be viewed as having bloodborne diseases that can be transmitted to the surgical team and other patients. To prevent this transmission, surgical gloves, surgical mask, and eyewear with side-shields are required. (See Chapter 5 for a detailed discussion of this topic.) In addition, most authorities recommend that the surgical team wear long-sleeved process, there may be ankylosis and the tooth root will be more brittle. In both situations, surgical extraction may be indicated (Fig. 8.15).Condition of Surrounding BoneCareful examination of the periapical radiograph indicates the density of bone surrounding the tooth to be extracted. Bone that is more radiolucent is likely to be less dense, which makes the extraction easier. However, if bone appears to be radiographically opaque (indicating increased density), with evidence of condensing osteitis or other sclerosis-like processes, it will be more dicult to extract.e surrounding bone should also be examined carefully for evidence of any apical pathology. Teeth that have nonvital pulps • Fig. 8.12 Hypercementosis increases the difculty of these extractions because roots are larger at the apical end than at the cervical end. Surgical extraction will probably be required. • Fig. 8.13 Root caries in rst premolar tooth make extraction more difcult because fracture of the tooth is likely. Note hypercementosis of the second premolar. • Fig. 8.14 Internal resorption of the root makes closed extraction almost impossible because fracture of the root will almost surely occur. • Fig. 8.15 Tooth made brittle by previous endodontic therapy. The tooth is thus more difcult to remove. CHAPTER 8 Principles of Routine Exodontia 113 patient’s mouth to some degree. It is unclear what eect this may have on postoperative problems.To prevent teeth or fragments of teeth from falling into the patient’s mouth and potentially being swallowed or aspirated into the lungs, many surgeons prefer to place a partially unfolded 4 × 4 inch gauze loosely into the back of the mouth. is oral partition serves as a barrier so that should a tooth slip from the forceps or shatter under the pressure of the forceps, it will be caught in the gauze rather than be swallowed or aspirated. e surgeon must take care that the gauze is not positioned so far posteriorly that it triggers the gag reex. e surgeon should explain the purpose of the partition to gain the patient’s acceptance and cooperation for allowing the gauze to be in place.Chair Position for Extractionse positions of the patient, the chair, and the operator are critical for the successful completion of an extraction. e best position is one that is comfortable for both the patient and surgeon and allows the surgeon to have maximal control of the force that is being delivered to the patient’s tooth through the elevators and forceps. e correct position allows the surgeon to keep the arms close to the body and provides stability and support; it also allows the surgeon to keep the wrists straight enough to deliver the force with the arm and shoulder, and not with the ngers or hand. e force delivered can thus be controlled in the face of sudden loss of resistance from a root or fracture of the bone.Dentists usually stand during extractions, so the positions for a standing surgeon will be described rst. Modications that are necessary to operate in a seated position will be presented later. Also, descriptions of techniques are for the right-handed operator. Left-handed surgeons should reverse the instructions when working on various quadrants.e most common error dentists make in positioning the dental chair for extractions is to have the chair too high. is forces the surgeons to operate with their shoulders raised, thereby making it dicult to deliver the correct amount of force to the tooth being extracted in the proper manner. It is also tiring to the surgeon. Another frequent positioning problem is for the dentist to lean over the patient and put his or her face close to the patient’s mouth. gowns, which should be changed when they become visibly soiled (Fig. 8.17).If the surgeon has long hair, it is essential that the hair be held in position with barrettes or other holding devices and be covered with a surgical cap. A major breach in aseptic technique is to allow the surgeon’s hair to hang over the patient’s face.Before the patient undergoes the surgical procedure, a minimal amount of draping is necessary. A sterile drape should be put across the patient’s chest to decrease the risk of contamination (see Fig. 8.17).Before the extraction, some surgeons advise patients to rinse their mouths vigorously with an antiseptic mouth rinse such as chlorhexidine. is reduces the bacterial contamination in the BA• Fig. 8.16 (A) Periapical radiolucency. The surgeon must be aware of this before extraction for proper management. (B) Periapical radiolucency around the mandibular premolar represents the mental foramen. The surgeon must be aware that this is not a pathologic condition. An intact lamina dura is noted in B but not in A. • Fig. 8.17 The surgeon is prepared for surgery by wearing protective eyeglasses, mask, and gloves. Surgeons should have short or pinned-back hair and should wear long-sleeved smocks that are changed daily, or sooner if they become soiled. The patient benets from a waterproof drape. 114 Part II Principles of Exodontiais interferes with surgical lighting, is hard on the dentist’s back and neck, and also interferes with proper positioning of the rest of the dentist’s body.For a maxillary extraction, the chair should be tipped backward so that the maxillary occlusal plane is at an angle of about 60 degrees to the oor. Raising the patient’s legs at the same time helps improve the patient’s comfort. e height of the chair should be such that the patient’s mouth is at or slightly below the operator’s elbow level (Fig. 8.18). As mentioned previously, novices tend to position the chair too high. During an operation on the maxillary right quadrant, the patient’s head should be turned substantially toward the operator so that adequate access and visualization can be achieved (Fig. 8.19). For extraction of teeth in the maxillary anterior portion of the arch, the patient should be looking straight ahead (Fig. 8.20). e position for the maxillary left portion of the arch is similar, except that the patient’s head is turned slightly toward the operator (Fig. 8.21).For the extraction of mandibular teeth, the patient should be positioned in a more upright position so that when the mouth is opened wide, the occlusal plane is parallel to the oor (Fig. 8.22). A properly sized bite block should be used to stabilize the mandible AB• Fig. 8.18 Patient positioned for maxillary extraction. The chair is tilted back so that the maxillary occlusal plane is at about a 60-degree angle to the oor. The height of the chair should ensure that the level of the patient’s mouth is slightly below the surgeon’s elbow. • Fig. 8.19 Extraction of teeth in the maxillary right quadrant. Note that patient’s head is turned toward the surgeon. • Fig. 8.20 Extraction of anterior maxillary teeth. The patient looks straight ahead. • Fig. 8.21 Extraction of maxillary left posterior teeth. The patient’s head is turned slightly toward the surgeon. CHAPTER 8 Principles of Routine Exodontia 115 • Fig. 8.22 For mandibular extractions, the patient is more upright so that the mandibular occlusal plane of the opened mouth is parallel to the oor. The height of the chair is also lower to allow the operator’s arm to be straighter. • Fig. 8.23 Extraction of mandibular right posterior teeth. The patient’s head is turned toward the surgeon. • Fig. 8.24 Extraction of mandibular anterior teeth. The surgeon stands at the side of the patient, who looks straight ahead. AB• Fig. 8.25 When English-style forceps are used for extraction of anterior mandibular teeth, the patient’s head is positioned straight ahead. when extraction forceps are used. Even though the surgeon will support the jaw, the additional support provided by the bite block will result in less stress being transmitted to the jaws and allows the patient to rest their muscles of mastication. Care should be taken to avoid using too large a bite block because large ones can overstretch the TMJ ligaments and cause patient discomfort. Typically pediatric bite blocks are the best to use, even in adults.During removal of mandibular right posterior teeth, the patient’s head should be turned acutely toward the surgeon to allow adequate access to the jaw, and the surgeon should maintain the proper arm and hand positions (Fig. 8.23). When removing teeth in the anterior region of the mandible, the surgeon should be to the side of the patient (Figs. 8.24 and 8.25). When operating on the left posterior mandibular region, the surgeon should move to the side of the patient, but the patient’s head should not turn so acutely toward the surgeon (Fig. 8.26).Some surgeons prefer to approach maxillary and mandibular teeth from a posterior position. is allows the left hand of the surgeon to support the mandible better, but it requires that the forceps be held in an underhand grip and that the surgeon view the eld with an upside-down perspective. e left hand of the surgeon goes around the patient’s head and supports the mandible. 116 Part II Principles of Exodontia8.33 and 8.34). When the English-style forceps are used, the surgeon’s position is usually behind the patient (Fig. 8.35). It should be noted that the surgeon and the assistant have hand and arm positions similar to those used when the surgeon is in the standing position.Mechanical Principles Involved in Tooth Extractione removal of teeth from the alveolar process requires the use of the following mechanical principles and simple machines: the lever, the wedge, and the wheel and axle.Elevators are used primarily as levers. A lever is a mechanism for transmitting a modest force—with the mechanical advantages e usual behind-the-patient approach is seen in Figs. 8.27 and 8.28. Note the surgeon’s right arm is held closely to their body, increasing the arm’s strength.If the surgeon chooses to sit while performing extractions, several modications must be made. For maxillary extractions, the patient is positioned in a semireclining position similar to that used when the surgeon is standing. However, the patient is not reclined as much; therefore the maxillary occlusal plane is not perpendicular to the oor as it is when the surgeon is standing. e patient should be lowered as far as possible so that the level of the patient’s mouth is as near as possible to the surgeon’s elbow (Fig. 8.29). e arm and hand positions for extraction of maxillary anterior and posterior teeth are similar to the positions used for the same extractions performed while standing (Fig. 8.30).As when the surgeon is standing, for extraction of teeth in the lower arch, the patient is slightly more upright than for extraction of maxillary teeth. e surgeon can work from the front of the patient (Figs. 8.31 and 8.32) or from behind the patient (Figs. • Fig. 8.26 Extraction of mandibular posterior teeth. The patient turns slightly toward the surgeon. • Fig. 8.27 Behind-the-patient approach for extraction of posterior right mandibular teeth. This allows the surgeon to be in a comfortable, stable position. • Fig. 8.28 Behind-the-patient approach for extraction of posterior left mandibular teeth. The surgeon’s hand is positioned under the forceps. • Fig. 8.29 In the surgeon-seated position, the patient is positioned as low as possible so that the mouth is at or below the level of the surgeon’s elbow. CHAPTER 8 Principles of Routine Exodontia 117 • Fig. 8.30 For extraction of maxillary teeth, the patient is reclined approxi-mately 60 degrees. Hand and forceps positions are the same as for the standing position. • Fig. 8.31 For extraction of maxillary teeth, the operator can hold the forceps in an underhand position. • Fig. 8.32 For extraction of mandibular anterior teeth, the operator can hold the forceps in an overhand manner. • Fig. 8.33 For removal of anterior teeth, the surgeon moves to a position behind the patient so that the patient’s mandible and alveolar process can be supported by the surgeon’s other hand. • Fig. 8.34 The behind-the-patient position can be used for removal of mandibular posterior teeth. The surgeon’s hand is positioned under the forceps for maximum control. • Fig. 8.35 When English-style forceps are used, a behind-the-patient position is preferred. 118 Part II Principles of Exodontia• Fig. 8.36 The rst-class lever transforms small force and large movement to small movement and large force. BA• Fig. 8.37 In removal of a mandibular premolar tooth, the purchase point is placed in the tooth, which creates a rst-class lever situation. When the Crane pick is inserted into the purchase point and the handle is depressed apically (A), the tooth is elevated occlusally out of the socket with buc-coalveolar bone used as the fulcrum (B). • Fig. 8.38 A wedge can be used to expand, split, and displace portions of the substance that receives it. • Fig. 8.39 Beaks of the forceps act as wedges to expand alveolar bone and displace the tooth in the occlusal direction. • Fig. 8.40 Small, straight elevator used as wedge to displace the tooth root from its socket by driving the elevator apically in the periodontal liga-ment space. of a long lever arm and a short eector arm—into a small move-ment against great resistance (Fig. 8.36). An example of the use of a lever is when a Crane pick is inserted into a purchase point placed in a tooth and then is used to elevate the tooth (Fig. 8.37).e second simple machine that is useful is the wedge (Fig. 8.38). e wedge is useful in several dierent ways for the extraction of teeth. First, the beaks of extraction forceps are usually narrow at their tips; they broaden as they go superiorly. When forceps are used, there should be a conscious eort made to force the tips of the forceps into the periodontal ligament space at the bony crest. is uses the tooth root as a wedge to expand the bone; as the beaks of the forceps are pressed apically on the root, they will help force the tooth out of the socket (Fig. 8.39). e wedge principle is also useful when a straight elevator is used to luxate a tooth from its socket. A small elevator is wedged into the periodontal ligament space, which displaces the root toward the occlusion and thus out of the socket (Fig. 8.40).e third machine used in tooth extraction is the wheel and axle, which is most closely identied with the triangular, or pennant-shaped, elevator. When one root of a multiple-rooted tooth is left in the alveolar process, the pennant-shaped elevator, such as a Cryer, is positioned into the socket and turned. e handle then serves as the axle, and the tip of the triangular elevator acts as a wheel and engages and elevates the tooth root from the socket (Fig. 8.41). CHAPTER 8 Principles of Routine Exodontia 119 e second major pressure or movement applied by forceps is the buccal force. Buccal pressures result in expansion of the buccal plate, particularly at the crest of the ridge (Fig. 8.45). Although buccal pressure causes expansion forces at the crest of the ridge, it is important to remember that it also causes lingual apical pressure. us excessive force can fracture buccal bone or cause fracturing of the apical portion of the root.ird, lingual or palatal pressure is similar to the concept of buccal pressure but is aimed at expanding the linguocrestal bone and, at the same time, avoiding excessive pressures on the buccal apical bone (Fig. 8.46). Because lingual bone tends to be thicker than buccal bone in posterior areas of the mouth, limited bone expansion occurs.Fourth, rotational pressure, as the name implies, rotates the tooth, which causes some internal expansion of the tooth socket Principles of Elevator and Forceps Usee primary instruments used to remove a tooth from the alveolar process are the elevator and extraction forceps. Elevators help in the luxation of a tooth, and forceps continue that process through bone expansion and disruption of periodontal attachments. e goal of forceps use is threefold: (1) expansion of the bony socket by use of the wedge-shaped beaks of the forceps and the movements of the tooth itself with the forceps, (2) twisting of conical roots to disrupt periodontal ligaments, and (3) removal of the tooth from the socket.e dental elevator consists of a handle, a shank, and a blade. e handle of the elevator is usually in line with the shank and is enlarged to allow it to be grasped in the palm of the hand. e elevator may also have attened areas for ngers to grasp to help guide the elevator. e handle can also be set perpendicular to the shank (cross bar–type elevators). e shank connects the handle to the blade. Blades can be straight, triangular (Cryer), curved (Potts), or pointed (Crane pick).Forceps can apply ve major motions to luxate teeth. e rst is apical pressure, which accomplishes two goals. (1) Although the tooth moves in an apical direction minimally, the tooth socket is expanded by the insertion of the beaks down into the periodontal ligament space (Fig. 8.42). us the apical pressure of the forceps on the tooth causes bony expansion. (2) A second accomplishment of apical pressure is that the center of rotation of the tooth is displaced apically. Because the tooth is moving in response to the force placed on it by the forceps, the forceps become the instrument of expansion. If the fulcrum is high (Fig. 8.43), a larger amount of force is placed on the apical region of the tooth, which increases the chance of fracturing the root end. If the beaks of the forceps are forced into the periodontal ligament space, the center of rotation is moved apically, which results in greater movement of the expan-sion forces at the crest of the ridge and less force moving the apex of the tooth lingually (Fig. 8.44). is process decreases the chance for apical root fracture.• Fig. 8.41 Triangular elevator in the role of a wheel-and-axle machine used to retrieve the root from the socket. • Fig. 8.42 Extraction forceps should be seated with strong apical pres-sure to expand crestal bone and to displace the center of rotation as far apically as possible. AB• Fig. 8.43 (A) If the center of rotation (asterisk) is not far enough apically, it is too far occlusally, which results in excess movement of tooth apex. (B) Excess motion of the root apex caused by a high center of rotation results in fracture of the root apex. 120 Part II Principles of ExodontiaIn summary, a variety of forces can be used to remove teeth. A strong apical force is always useful and should be applied whenever forceps are adapted to the tooth. Most teeth are removed by a combination of buccal and lingual (palatal) forces. Because maxillary buccal bone is usually thinner and palatal bone is a thicker cortical bone, maxillary teeth are usually removed by stronger buccal forces and less vigorous palatal forces. In the mandible, buccal bone is thinner from the midline posteriorly to the area of molars. erefore incisors, canines, and premolars are removed primarily as a result of strong sustained buccal force and less vigorous lingual pressures. As mentioned before, rotational forces are useful for single-rooted teeth that have conic roots and no severe curvatures at the root end. e maxillary incisors, particularly the central incisor and mandibular premolars, are most amenable to rotational forces.and tearing of periodontal ligaments. Teeth with single, conical roots (such as incisors, canines, and mandibular premolars) and those with roots that are not curved are most amenable to luxation by this technique (Fig. 8.47). Teeth that have other than conical roots or that have multiple roots—especially if those roots are curved—are more likely to fracture under this type of pressure.Finally, tractional forces are useful for delivering the tooth from the socket once adequate bony expansion is achieved. As mentioned previously, teeth should not be pulled from their sockets. Tractional forces should be limited to the nal portion of the extraction process and should be gentle (Fig. 8.48). If excessive force is needed, other maneuvers should be performed to improve root luxation.BA• Fig. 8.44 (A) If the forceps are apically seated, the center of rotation (asterisk) is displaced apically, and smaller apical pressures are generated. (B) This results in greater expansion of the buccal cortex, less movement of the apex of the tooth, and therefore less chance of fracture of the root. • Fig. 8.45 Buccal pressure applied to the tooth will expand the bucco-cortical plate toward crestal bone, with some lingual expansion at the apical end of the root. Asterisk notes the center of rotation. • Fig. 8.46 Lingual pressure will expand the linguocortical plate at the crestal area and slightly expand buccal bone at the apical area. Asterisk notes the center of rotation. • Fig. 8.47 Rotational forces are useful for teeth with conical roots, such as maxillary incisors and mandibular premolars. CHAPTER 8 Principles of Routine Exodontia 121 A small amount of pressure is felt at this step, but there should be no sensation of sharpness or discomfort if profound local anesthesia is in place. e surgeon then begins the soft tissue loosening procedure, gently at rst and then with increasing force. (2) e second reason that soft tissue is loosened is to allow the elevator and tooth extraction forceps to be positioned more apically, without interference from or impingement on the gingiva. As the soft tissue is loosened away from the tooth, it is slightly reected, which thereby increases the width of the gingival sulcus and allows easy entrance of the beveled tip of the forceps beaks. e adjacent gingival papilla of the tooth should also be reected to avoid damage by the insertion of the straight elevator.Step 2 involves luxation of the tooth with a dental elevator. e luxation of the tooth begins with a dental elevator, usually the straight elevator. In most situations, elevation from the lingual or palatal aspects of roots is limited due to poor access and is of limited ecacy. Elevation should occur at the mesial and distal buccal aspects of the root. No elevation should be attempted along buccal bone because it can be easily fractured or the surgeon can lose control and cause soft tissue injury.Expansion and dilation of the alveolar bone and tearing of the periodontal ligament require that the tooth be luxated in several ways. e straight elevator is inserted perpendicular to the tooth into the interdental space, after reection of the interdental papilla (Figs. 8.50 to 8.52). e elevator is then moved to direct the blade in an apical direction. e elevator is then rotated in small motions back and forth, while apical pressure is placed to advance the blade into the periodontal ligament space. A straight elevator with a small blade should be used initially. Once some tooth movement is noted, a larger straight elevator is inserted and used in a similar manner. If the tooth is intact and in contact with stable teeth anterior and posterior to it, the amount of movement achieved with the straight elevator will be minimal. e useful-ness of this step is greater if the patient does not have a tooth posterior to the tooth being extracted or it is broken down to an extent that the crowns do not inhibit movement of the tooth, or if the adjacent tooth is also planned for extraction at the same appointment.Luxation of teeth with a straight elevator should be performed with caution. Excessive forces can damage and even displace the Procedure for Closed ExtractionAn erupted root can be extracted using one of two major techniques: closed or open. e closed technique is also known as the routine technique. e open technique is also known as the surgical tech-nique, or ap technique. is section discusses the closed extraction technique; the open (surgical) technique is discussed in Chapter 9.e closed technique is the most frequently used technique and is given primary consideration for almost every extraction. e open technique is used when the clinician believes that excessive force would be necessary to remove the tooth, when a substantial amount of the crown is missing or covered by tissue, or when access to the root of a tooth is dicult, such as when a fragile crown is present.e correct technique for any situation should lead to an atraumatic extraction; the wrong technique commonly results in an excessively traumatic and lengthy extraction.Whatever technique is chosen, the three fundamental require-ments for a good extraction remain the same: (1) adequate access and visualization of the eld of surgery, (2) an unimpeded pathway for the removal of the tooth, and (3) the use of controlled force to luxate and remove the tooth.For the tooth to be removed from the bony socket, it is usually necessary to expand the alveolar bony walls to allow the tooth root an unimpeded pathway, and it is necessary to tear the peri-odontal ligament bers that hold the tooth in the bony socket. e use of elevators and forceps as levers and wedges with steadily increasing force can accomplish these two objectives.Five general steps make up the closed extraction procedure. Step 1 involves loosening of the soft tissue attachment from the cervical portion of the tooth. e rst step in removing a tooth by the closed extraction technique is to loosen the soft tissue from around the tooth with a sharp instrument such as a scalpel blade or the sharp end of the No. 9 periosteal elevator (Fig. 8.49). e purpose of loosening the soft tissue from the tooth is twofold: (1) First, it allows the surgeon to ensure that profound anesthesia has been achieved. When this step has been performed, the dentist informs the patient that the surgery is about to begin and that the rst step will be to push the soft tissue away from the tooth. • Fig. 8.48 Tractional forces are useful for the nal removal of the tooth from the socket. These should always be small forces because teeth are not pulled. • Fig. 8.49 Periosteal elevator used to loosen the gingival attachment from the tooth and the interdental papilla. (Courtesy Dr. Edward Ellis III.) 122 Part II Principles of Exodontiaare then seated onto the tooth so that the tips of the forceps beaks grasp the root underneath loosened soft tissue (Fig. 8.53). e lingual beak is usually seated rst and then the buccal beak. Care must be taken to conrm that the tips of the forceps beaks are beneath the soft tissue and not engaging an adjacent tooth. Once the forceps have been positioned on the tooth, the surgeon grasps the handles of the forceps at the ends to maximize mechanical advantage and control (Fig. 8.54). If the tooth is malposed in such a fashion that the usual forceps cannot grasp the tooth without injury to adjacent teeth, another forceps with narrower beaks should be used. Maxillary root forceps can often be useful for crowded lower anterior teeth.e beaks of the forceps must be held parallel to the long axis of the tooth so that the forces generated by the application of pressure to the forceps handle can be delivered along the • Fig. 8.50 Small, straight elevator, inserted perpendicular to the tooth after the papilla has been reected. (Courtesy Dr. Edward Ellis III.)• Fig. 8.51 The handle of the small, straight elevator is turned such that the occlusal side of the elevator blade is turned toward the tooth. The handle is also moved apically to help elevate the tooth. • Fig. 8.52 The handle of the elevator may be turned in the opposite direction to displace the tooth further from the socket. This can be accom-plished only if no tooth is adjacent posteriorly. • Fig. 8.53 Tips of forceps beak, forced apically under soft tissue. (Cour-tesy Dr. Edward Ellis III.)teeth adjacent to those being extracted. is is especially true if the adjacent tooth has a large restoration or carious lesion. is is only the initial step in the elevation process. Next, the small, straight elevator is inserted into the periodontal ligament space at the mesial–buccal line angle. e elevator is advanced apically while being rotated back and forth, helping luxate the tooth with its wedge action as it is advanced apically. A similar action with the elevator can then be done at the distal-buccal line angle. When a small, straight elevator becomes too easy to twist, a larger-sized elevator is used to do the same apical advancement. Often the tooth will loosen suciently to be removed easily with forceps.Step 3 involves adaptation of the forceps to the tooth. e proper forceps are now chosen for the tooth to be extracted. e beaks of the forceps should be shaped to adapt anatomically to the tooth, apical to the cervical line, that is, to the root surface. (A few exceptions to this include the cowhorn forceps.) e forceps CHAPTER 8 Principles of Routine Exodontia 123 expand the alveolar socket. For some teeth, small rotational motions are then used to help expand the tooth socket and tear the periodontal ligament attachments. Beginning surgeons have a tendency to apply inadequate pressure for insucient amounts of time.e following three factors must be reemphasized: (1) e forceps must be apically seated as far as possible and reseated periodically during the extraction; (2) the forces applied in the buccal and lingual directions should be slow, deliberate pres-sures and not jerky wiggles; and (3) the force should be held for several seconds to allow the bone time to expand. It must be remembered that teeth are not pulled; rather, they are gently lifted from the socket once the alveolar process has been suciently expanded.Step 5 involves removal of the tooth from the socket. Once alveolar bone has expanded suciently and the tooth has been luxated, a slight tractional force, usually directed buccally, can be used. Tractional forces should be minimized because this is the last motion that is used once the alveolar process is suf-ciently expanded and the periodontal ligament is completely severed.It should be remembered that luxation of the tooth with forceps and removal of the tooth from bone are separate steps in the extraction. Luxation is directed toward expansion of bone and disruption of the periodontal ligament. e tooth is not removed from bone until these two goals are accomplished. e novice surgeon should realize that the major role of forceps is not to remove the tooth, but rather to expand the bone so that the root(s) can be removed.For teeth that are malposed or have unusual positions in the alveolar process, luxation with forceps and removal from the alveolar process will be in unusual directions. e surgeon must develop a sense for the direction the tooth wants to move and then be able to move it in that direction. Careful preoperative assessment and planning help guide this determination during the extraction.Role of the Opposite HandWhile using forceps and elevators to luxate and remove teeth, it is important that the surgeon’s opposite hand play an active role in the procedure. For the right-handed operator, the left hand has a variety of functions. e left hand is responsible for reecting the soft tissues of the cheeks, lips, and tongue to provide adequate visualization of the area of surgery. e left hand helps protect other teeth from the forceps, should it release suddenly from the tooth socket. e left hand, and sometimes arm, helps stabilize the patient’s head during the extraction process. In some situations, greater amounts of force are required to expand heavy alveolar bone; therefore the patient’s head requires active assistance to be held steady. e opposite hand plays an important role in supporting and stabilizing the jaw when mandibular teeth are being extracted. e opposite hand is often necessary to apply considerable pressure to expand heavy mandibular bone, and such forces can cause discomfort and even injury to the TMJ unless a steady hand counteracts them. A bite block placed on the contralateral side is also used to help open the jaw in this situation. Finally, the opposite hand supports the alveolar process and provides tactile information to the operator concerning the expansion of the alveolar process during the luxation period. In some situations, it is impossible for the opposite hand to perform all of these functions at the same time, so the surgeon requires an assistant to help with some of the functions.long axis of the tooth for maximal eectiveness in dilating and expanding alveolar bone. If the beaks are not parallel to the long axis of the tooth, it is increasingly likely that the tooth root will fracture.e forceps are then forced apically as far as possible to grasp the root of the tooth as apically as possible. is accomplishes two things: (1) e beaks of the forceps act as wedges to dilate the crestal bone on the buccal and lingual aspects, and (2) by forcing the beaks apically, the center of rotation (or fulcrum) of the forces applied to the tooth is displaced toward the apex of the tooth, which results in greater eectiveness of bone expansion and less likelihood of fracturing the apical end of the tooth.At this point, the surgeon’s hand should be grasping the forceps rmly, with the wrist locked and the arm held against the body; the surgeon should be prepared to apply force with the shoulder and upper arm without any wrist pressure. e surgeon should be standing upright, with feet comfortably apart.Step 4 involves luxation of the tooth with forceps. e surgeon begins to luxate the tooth by using the motions discussed earlier. e major portion of the force is directed toward the thinnest and therefore weakest bone. us, with all teeth in the maxilla and all but molar teeth in the mandible, the major movement is labial and buccal (i.e., toward the thinner layer of bone). e surgeon uses slow, sustained, steady force to displace the tooth buccally, rather than a series of rapid, small movements that do little to expand bone. e motion is deliberate and slow, and it gradually increases in force. e tooth is then moved again toward the opposite direction with slow, deliberate, strong pressure. As the alveolar bone begins to expand, the forceps are reseated apically with a strong, deliberate motion, which causes additional expansion of alveolar bone and further displaces the center of the rotation apically. Buccal and lingual pressures continue to BA• Fig. 8.54 Forceps handles, held at the ends to maximize mechanical advantage and control. (A) Maxillary universal forceps. (B) Mandibular universal forceps. 124 Part II Principles of ExodontiaSpecic Techniques for the Removal of Each Toothis section describes specic techniques for the removal of each tooth in the mouth after being elevated. In some situations, several teeth are grouped together (e.g., the maxillary anterior teeth) because the technique for their removal is essentially the same. e reader should take note of the role of the left hand in each instance.Maxillary TeethIn the correct position for the extraction of maxillary left or anterior teeth, the left index nger of the surgeon should reect the lip and cheek tissues, while the thumb rests on the palatal alveolar process (Fig. 8.56). In this way, the left hand is able to reect the soft tissue of the cheek, stabilize the patient’s head, support the alveolar process, and provide tactile information to the surgeon regarding the progress of the extraction. When such a position is used during the extraction of a maxillary molar, the surgeon can frequently feel with the left hand the palatal root of the molar becoming free in the alveolar process before feeling it with the forceps or the extracting hand. For the right side, the index nger is positioned on the palate, with the thumb on the buccal aspect.Incisorse maxillary incisor teeth are extracted with the upper universal forceps (No. 150), although other forceps can be used such as the straight forceps (No. 1). Maxillary incisors generally have conic roots, with the lateral ones being slightly longer and more slender. e lateral incisor is more likely also to have a distal curvature on the apical one third of the root, so this must be checked radiographi-cally before the tooth is extracted. Alveolar bone is thin on the labial side and heavier on the palatal side, which indicates that the major expansion of the alveolar process will be in the labial direction. e initial movement is slow, steady, and rm in the labial direction, which expands the crestal buccal bone. A less vigorous palatal force is then used, followed by a slow, rm, rotational force. Rotational movement should be minimized for the lateral incisor, especially if a curvature exists on the tooth. e Role of the Assistant During ExtractionTo achieve a successful outcome in any surgical procedure, it is useful to have a skilled assistant. During extraction, the assistant plays a variety of important roles that contribute to making the surgical experience atraumatic for the patient. e assistant helps the surgeon visualize and gain access to the operative area by retracting the soft tissue of the cheeks and tongue so that the surgeon can have an unobstructed view of the surgical eld. Even during a closed extraction, the assistant can retract the soft tissue so that the surgeon can apply the instruments to loosen the soft tissue attachment and adapt the forceps to the tooth in the most eective manner.Another major activity of the assistant is to suction away blood, saliva, and the irrigating solutions used during the surgical proce-dure. is prevents uids from accumulating and makes proper visualization of the surgical field possible. Suctioning is also important for patient comfort because most patients are unable to tolerate any accumulation of blood or other uids in their throats (Fig. 8.55).During extraction, the assistant should also help with protecting the teeth of the opposite arch, which is especially important when removing lower posterior teeth. If traction forces are necessary to remove a lower tooth, occasionally the tooth releases suddenly and the forceps strike maxillary teeth and may fracture a tooth cusp. e assistant should hold a suction tip or a nger against maxillary teeth to protect them from an unexpected blow.During the extraction of mandibular teeth, the assistant may play an important role by supporting the mandible during the application of the extraction forces. A surgeon who uses the hand to reect soft tissue may not be able to support the mandible. If this is the case, the assistant plays an important role in stabilizing the mandible to prevent TMJ discomfort. Most often the surgeon stabilizes the mandible, which makes this role less important for the assistant.e assistant also provides psychological and emotional support for the patient by helping alleviate patient anxiety during anesthesia administration and surgery. e assistant is important in gaining the patient’s condence and cooperation by using positive language and physical contact with the patient during the preparation and performance of the surgery. e assistant should avoid making casual, ohand comments that may increase the patients’ anxiety and lessen their cooperation.• Fig. 8.55 While the surgeon holds the surgical hand piece and Minne-sota retractor, the assistant provides cooling irrigation and suction. (Cour-tesy Dr. Edward Ellis III.)• Fig. 8.56 Extraction of maxillary left posterior teeth. The left index nger retracts the lip and cheek and supports the alveolar process on the buccal aspect. The thumb is positioned on the palatal aspect of the alveolar process and supports the alveolar process. The head is steadied by this grip, and tactile information about the tooth and bone movement is gained. CHAPTER 8 Principles of Routine Exodontia 125 canine is usually thin. In spite of the thin labial bone, this tooth can be dicult to extract simply because of its long root and large surface area available for periodontal ligament attachments. In addition, it is not uncommon for a segment of labial alveolar bone to fracture from the labial plate and be removed with the tooth.e upper universal (No. 150) forceps are the preferred instru-ment for removing the maxillary canine, after elevation. As with tooth is delivered in the labial-incisal direction with a small amount of tractional force (Fig. 8.57).Caninese maxillary canine is usually the longest tooth in the mouth. e root is oblong in cross section and usually produces a bulge called the canine eminence on the anterior surface of the maxilla. e result is that the bone over the labial aspect of the maxillary ACDEB• Fig. 8.57 (A) Maxillary incisors are extracted with No. 150 forceps. The left hand grasps the alveolar process. (B) The forceps are seated as far apically as possible. (C) Luxation is begun with labial force. (D) Slight lingual force is used. (E) The tooth is delivered to the labial incisor with a rotational, tractional move-ment. Asterisk notes the center of rotation. 126 Part II Principles of ExodontiaDuring the luxation process with the forceps, if the surgeon feels a portion of the labial bone fracturing, the surgeon must make a decision concerning the next step. If the palpating nger indicates that a small amount of bone has fractured free and is attached to the canine tooth, the extraction should continue in the usual manner, with caution taken not to tear the soft tissue. However, if the palpating nger indicates that a large portion of labial alveolar plate has fractured, the surgeon should stop the surgical procedure. Usually the fractured portion of bone is still attached to periosteum and therefore is viable. e surgeon should use a thin periosteal elevator to raise a small amount of mucosa from around the tooth, down to the level of the fractured bone. e canine tooth should then be stabilized with the extraction forceps, and the surgeon should attempt to free the fractured bone from the tooth, with the periosteal elevator as a lever to separate the bone from the tooth root. If this can be accomplished, the tooth can be removed and the bone left in place attached to the periosteum. Normal healing should occur. If bone becomes detached from the periosteum during these attempts, it should be removed because it is probably nonvital and may actually prolong wound healing. is same procedure can be used whenever alveolar bone is fractured during extraction.Prevention of labial plate fracture is important. After elevation and during the luxation process with the forceps, if a normal amount of pressure has not resulted in any movement of the tooth, the surgeon should seriously consider doing an open extraction. By reecting a soft tissue ap and removing a small amount of bone, the surgeon may be able to remove the stubborn canine tooth without fracturing a large amount of labial bone. By using the open technique, there will be an overall reduction in bone loss and in postoperative healing time.First Premolare maxillary rst premolar is a single-rooted tooth in its rst two thirds, with a bifurcation into a buccolingual root usually occurring in the apical one third to one half. ese roots may be extremely thin and are subject to fracture, especially in older patients in whom bone density is great and bone elasticity is diminished. Perhaps the most common root fracture when extracting teeth in adults occurs with this tooth. As with other maxillary teeth, buccal bone is thin compared with palatal bone.e upper universal (No. 150) forceps are the instrument of choice. Alternatively, the No. 150A forceps can be used for removal of the maxillary rst premolar. Because of the high likelihood of root fracture, the tooth should be luxated as much as possible with the straight elevator. If root fracture does occur, a mobile root tip can be removed more easily than one that has not been well luxated via elevation.Because of the bifurcation of the tooth into two thin root tips, extraction forces should be carefully controlled during removal of the maxillary first premolar. Initial movements should be buccal. Palatal movements are made with small amounts of force to prevent fracture of the palatal root tip, which is harder to retrieve. When the tooth is luxated buccally, the most likely tooth root to break is the labial root. When the tooth is luxated in the palatal direction, the most likely root to break is the palatal root. Of the two root tips, the labial is easier to retrieve because of the thin, overlying bone. erefore, as for other maxillary teeth, buccal pressures should be greater than palatal pressures. Any rotational force should be avoided. Final delivery of the tooth from the tooth socket is with tractional force in the occlusal direction and slightly buccal (Fig. 8.59).all extractions, the initial placement of the beaks of the forceps on the canine tooth should be as far apically as possible. e initial movement is apical and then to the buccal aspect, with return pressure to the palatal. As the bone is expanded and the tooth mobilized, the forceps should be repositioned apically. A small amount of rotational force may be useful in expanding the tooth socket, especially if adjacent teeth are missing or have just been extracted. After the tooth has been well luxated, it is delivered from the socket in a labial-incisal direction with labial tractional forces (Fig. 8.58).ACBD• Fig. 8.58 (A) Hand and forceps positions for removal of the maxillary canine are similar to those for removal of incisors. The forceps are seated as far apically as possible. (B) The initial movement is in the buccal direc-tion. (C) Small amounts of lingual force are applied. (D) The tooth is delivered in the labial-incisal direction with a slight rotational force. CHAPTER 8 Principles of Routine Exodontia 127 movements to the buccal back to the palate, and then in the bucco-occlusal direction with a rotational, tractional force (Fig. 8.60).Molarse maxillary rst molar has three large and strong roots. Buccal roots are usually close together, and the palatal root diverges widely toward the palate. If the two buccal roots are also widely divergent, it becomes dicult to remove this tooth by closed extraction. Once again, the overlying alveolar bone is similar to that of other teeth in the maxilla; the buccal plate is thin and the palatal–cortical plate is thick and heavy. When evaluating this tooth radiographically, the dentist should note the size, curvature, and apparent divergence Second Premolare maxillary second premolar is a single-rooted tooth for the entire length of the root. e root is thick and has a blunt end. Consequently, the root of the second premolar rarely fractures. e overlying alveolar bone is similar to that of other maxillary teeth in that it is thin toward the buccal aspect, with a heavy palatal-alveolar palate.e recommended forceps are the maxillary universal forceps, or the No. 150 forceps; some surgeons prefer the No. 150A forceps. e forceps are forced as far apically as possible so as to gain maximal mechanical advantage in removing this tooth. Because the tooth root is strong and blunt, the extraction requires strong ABECD• Fig. 8.59 (A) Maxillary premolars are removed with the No. 150 forceps. The hand position is similar to that used for anterior teeth. (B) Firm apical pressure is applied rst to the lower center of rotation as far as possible and to expand crestal bone. (C) Buccal pressure is applied initially to expand the buccocortical plate. The apices of roots are pushed lingually and are therefore subject to fracture. (D) Palatal pressure is applied, but less vigorously than buccal pressure. (E) The tooth is delivered in the bucco-occlusal direc-tion with a combination of buccal and tractional forces. 128 Part II Principles of Exodontiatwo forceps are especially useful if the crown of the molar tooth has serious caries or large restorations.e upper molar forceps are adapted to the tooth and are seated apically as far as possible in the usual fashion (Fig. 8.61). e basic extraction movement is to use strong buccal and palatal pressures, with stronger forces toward the buccal than toward the palate. Rotational forces are not useful for extraction of this tooth because of its three roots. As mentioned in the discussion of the extraction of the maxillary rst premolar, it is preferable to fracture a buccal root rather than a palatal root (because it is easier to retrieve the buccal roots). erefore, if the tooth has widely divergent roots and the dentist suspects that one root may be fractured, the tooth should be luxated in such a way as to prevent fracturing of the palatal root. e dentist must minimize palatal force because this is the force that fractures the palatal root. Strong, slow, steady buccal pressure expands the buccocortical plate and tears the periodontal ligament bers that hold the palatal root in its position. Palatal forces should be used but kept to a minimum.e anatomy of the maxillary second molar is similar to that of the maxillary rst molar except that the roots tend to be shorter and less divergent, with the buccal roots more commonly fused into a single root. is means that the tooth is more easily extracted by the same technique described for the rst molar.e erupted maxillary third molar frequently has conic roots and is usually extracted with the No. 210S forceps, which are universal forceps used for the left and right sides. e tooth is usually readily removed because buccal bone is thin and the roots are usually fused and conical. e erupted third molar is also frequently extracted by the use of elevators alone. Clear visualization of the maxillary third molar on the preoperative radiograph is important because the root anatomy of this tooth is variable, and often small, dilacerated, hooked roots exist in this area. Retrieval of fractured roots in this area is dicult due to more limited access.Mandibular TeethWhen removing lower molar teeth, the index nger of the left hand is in the buccal vestibule, and the second nger is in the lingual vestibule, reecting the lip, cheek, and tongue (Fig. 8.62). e thumb of the left hand is placed below the chin so that the mandible is held between the ngers and the thumb, which support the mandible and minimize TMJ pressures. is technique provides less tactile information, but during extraction of mandibular teeth, the need to support the mandible supersedes the need to support the alveolar process. A useful alternative is to place a bite block between the teeth on the contralateral side (Fig. 8.63). e bite block allows the patient to help provide stabilizing forces to limit the pressure on the TMJs. e surgeon’s or assistant’s hand should continue to provide additional support to the inferior portion of the mandible.Anterior TeethMandibular incisors and canines are similar in shape, with the incisors being shorter and slightly thinner, and the canine roots being longer and heavier. e incisor roots are more likely to be fractured because they are thin, and therefore they should be removed only after adequate preextraction luxation. Alveolar bone that overlies incisors and canines is thin on the labial and lingual sides. Bone over the canine may be thicker, especially on the lingual aspect.e lower universal (No. 151) forceps are usually used to remove these teeth. Other choices include the No. 151A or the English-style of the three roots. In addition, the dentist should look carefully at the relationship of the tooth roots to the maxillary sinus. If the sinus is in proximity to the roots and the roots are widely divergent, sinus perforation caused by removal of a portion of the sinus oor during tooth removal is increasingly likely. If this appears to be likely after preoperative evaluation, the surgeon should strongly consider a surgical extraction.e paired forceps No. 53R and No. 53L are usually used for extraction of the maxillary molars. ese two forceps have tip projections on the buccal beaks to t into the buccal bifurcation. Some surgeons prefer to use the No. 89 and No. 90 forceps. ese ACBD• Fig. 8.60 (A) When extracting the maxillary second premolar, the forceps are seated as far apically as possible. (B) Luxation is begun with buccal pressure. (C) Very slight lingual pressure is used. (D) The tooth is delivered in the bucco-occlusal direction. Asterisk notes the center of rotation. CHAPTER 8 Principles of Routine Exodontia 129 ABCDE• Fig. 8.61 (A) Extraction of maxillary molars. Soft tissues of the lips and cheek are retracted, and the alveolar process is grasped with the opposite hand. (B) Forceps beaks are seated apically as far as pos-sible. (C) Luxation is begun with strong buccal force. (D) Lingual pressures are used only moderately. (E) The tooth is delivered in the bucco-occlusal direction. Asterisk notes the center of rotation. • Fig. 8.62 Extraction of mandibular left posterior teeth. The surgeon’s left index nger is positioned in the buccal vestibule, retracting the cheek, and the second nger is positioned in the lingual vestibule, retracting the tongue. The thumb is positioned under the chin. The mandible is grasped between the ngers and the thumb to provide support during extraction. • Fig. 8.63 A rubber bite block can be placed between the patient’s teeth on the contralateral side to provide support for the mandible and prevent excessive temporomandibular joint pressures. 130 Part II Principles of Exodontiamore when extracting these teeth than for any others, except perhaps the maxillary central incisor. e tooth is then delivered in the occlusobuccal direction (Fig. 8.65). Careful preoperative radio-graphic assessment must be performed to conrm that no root curvature exists in the apical third of the tooth. If such a curvature does exist, the rotational movements should be reduced or eliminated from the extraction procedure (Fig. 8.66).MolarsMandibular molars usually have two roots, with the roots of the rst molar more widely divergent than those of the second molar. In addition, the roots may converge at the apical one.e No. 17 forceps are usually used for extraction of mandibular molars; these forceps have small tip projections on both beaks to t into the bifurcation of the tooth roots. e forceps are adapted to the root of the tooth in the usual fashion, and strong apical pressure is applied to set the beaks of the forceps apically as far as possible. Strong buccolingual motion is then used to expand the tooth socket and allow the tooth to be delivered in the bucco-occlusal direction. Linguoalveolar bone around the second molar Ashe forceps. e forceps beaks are positioned on teeth and seated apically with strong force. e extraction movements are generally in the labial and lingual directions, with equal pressures both ways. Once the tooth has become luxated and mobile, rotational move-ment may be used to expand alveolar bone further. e tooth is removed from the socket with tractional forces in a labial-incisal direction (Fig. 8.64).PremolarsMandibular premolars are among the most straightforward teeth to extract. e roots tend to be straight and conic, albeit sometimes slender. e overlying alveolar bone is thin on the buccal aspect and heavier on the lingual side.e lower universal (No. 151) forceps are usually chosen for the extraction of the mandibular premolars. e No. 151A forceps and the English-style forceps are popular alternatives for extraction of these teeth.e forceps are apically forced as far as possible, with the basic movements directed toward the buccal aspect, returning to the lingual aspect, and nally rotating. Rotational movement is used ABCDE• Fig. 8.64 (A) When extracting mandibular anterior teeth, No. 151 forceps are used. The assistant retracts the patient’s cheek and provides suction. (B) The forceps are seated apically as far as possible. (C) Moderate labial pressure is used to initiate the luxation process. (D) Lingual force is used to continue the expansion of bone. (E) The tooth is delivered in the labial-incisal direction. Asterisk notes the center of rotation. CHAPTER 8 Principles of Routine Exodontia 131 DEFGCBA• Fig. 8.65 (A) Extraction of the mandibular premolar. The mandible is stabilized, soft tissue is retracted, and No. 151 forceps are positioned. (B) The hand position is modied slightly for the behind-the-patient technique. (C) English-style forceps can also be used. (D) The forceps are seated apically as far as pos-sible to displace the center of rotation and to begin the expansion of crestal bone. (E) Buccal forceps are applied to begin the luxation process. (F) Slight lingual pressure is used. (G) The tooth is delivered with a rotational, tractional force. Asterisk notes the center of rotation. Erupted mandibular third molars usually have fused conic roots. Because a bifurcation is not likely, the No. 222 forceps—a short-beaked, right-angled forceps—are used to extract this tooth. e lingual plate of bone is denitely thinner than the buccocortical plate, so most of the extraction forces should be delivered to the lingual aspect. e third molar is delivered in the linguo-occlusal direction. e erupted mandibular third molar that is in function can be a deceptively dicult tooth to extract. e dentist should give serious consideration to using the straight elevator and achieve a moderate degree of luxation before applying the forceps. Pressure should be gradually increased, and attempts to mobilize the tooth should be made before the nal strong pressures are delivered.Modications for Extraction of Primary TeethRarely is it necessary to remove primary teeth before substantial root resorption has occurred. However, when removal is required, is thinner than the buccal plate, so the second molar can be removed more easily with stronger lingual pressure than buccal pressure (Fig. 8.67). An English-style lower molar forceps is also available.If the tooth roots are clearly bifurcated, the No. 23 forceps, or cowhorn forceps, can be used. is instrument is designed to be closed forcefully with the handles, thereby squeezing the beaks of the forceps into the bifurcation. is creates force against the crest of the alveolar ridge on the buccolingual aspects and literally forces the tooth superiorly directly out of the tooth socket (Fig. 8.68). If this is not successful initially, the forceps are given buccolingual movements to expand alveolar bone, and the forceps handles are moved up and down to seat the beaks more fully into the furcation. More squeezing of the handles is performed. Care must be taken with these forceps to prevent damaging maxillary teeth because the lower molar may actually pop out of the socket and thus release the forceps to strike upper teeth. 132 Part II Principles of Exodontia• Fig. 8.66 If any curvature of the premolar root exists, rotational extraction forces will result in fracture of the curved portion of the root; therefore such forces should be minimized. ABCDE• Fig. 8.67 (A) Mandibular molars are extracted with No. 17 or No. 23 forceps. The hand positions of the surgeon and the assistant are the same for both forceps. (B) No. 17 forceps are seated as far apically as possible. (C) Luxation of the molar is begun with a strong buccal movement. (D) Strong lingual pres-sure is used to continue the luxation. (E) The tooth is delivered in the bucco-occlusal direction. Asterisk notes the center of rotation. it must be done with a great deal of care because the roots of the primary teeth are long and delicate and are subject to fracture. is is especially true because the succedaneous tooth causes resorption of coronal portions of the root structure and thereby weakens it. e forceps usually used are an adaptation of the upper and lower universal forceps, the No. 150S and the No. 151S. ey are adapted and forced apically in the usual fashion, with slow, steady pressures toward the buccal aspect and return movements toward the lingual aspect.Rotational motions may be used but should be minimal and should be used judiciously with multirooted teeth. e dentist should pay careful attention to the direction of least resistance and deliver the tooth into that path. If the roots of the primary molar tooth embrace the crown of the permanent premolar, the surgeon should consider sectioning the tooth. Rarely, the roots hold the crown of the permanent premolar rmly enough in their grasp to cause it to be loosened or extracted.Once a primary tooth with substantial root resorption is removed, the extraction site should be carefully inspected to help ensure no small pieces of tooth remain.Postextraction Tooth Socket CareOnce the tooth has been removed, the socket requires proper care. e socket should be debrided only if necessary. If a periapical lesion is visible on the preoperative radiograph and there was no granuloma attached to the tooth when it was removed, the periapical region should be carefully curetted with a periapical curette to remove the granuloma or cyst. If any debris is obvious, such as calculus, amalgam, or tooth fragment remaining in the socket, it should be gently removed with a curette or suction CHAPTER 8 Principles of Routine Exodontia 133 ABCDE• Fig. 8.68 (A) No. 23 forceps are carefully positioned to engage the bifurcation area of the lower molar. (B) The handles of the forceps are squeezed forcibly together, which causes the beaks of the forceps to be forced into the bifurcation and exerts tractional forces on tooth. (C) Strong buccal forces are then used to expand the socket. (D) Strong lingual forces are used to luxate the tooth further. (E) The tooth is deliv-ered in the bucco-occlusal direction with buccal and tractional forces. tip (Fig. 8.69). However, if neither a periapical lesion nor debris is present, the socket should not be curetted. e remnants of the periodontal ligament and the bleeding bony walls are in the best condition to provide for rapid healing. Vigorous curettage of the socket wall merely produces additional injury and may delay healing.e expanded buccolingual plates should be compressed back to their original conguration. Finger pressure should be applied to the buccolingual cortical plate to compress the plates gently, but rmly, to their original position. is helps prevent bony undercuts that may have been caused by excessive expansion of the buccocortical plate, especially after extraction of the rst molar. Care should be taken to not overreduce the socket if implant placement is planned or possible in the future. In some cases, no reduction should be done if implants are planned.If teeth were removed because of periodontal disease, there may be an accumulation of excess granulation tissue around the gingival cu. If this is the case, special attention should be given to removing this granulation tissue with a curette, tissue scissors, or a hemostat. e arterioles of granulation tissue have little or no capacity to retract and constrict, which leads to bothersome bleeding if excessive granulation tissue is left in place.Finally, the bone should be palpated through the overlying mucosa to check for any sharp, bony projections. If any exist, the mucosa should be reected and the sharp edges smoothed judiciously with a bone le or trimmed with a rongeur. 134 Part II Principles of Exodontia• Fig. 8.69 An amalgam fragment has been left in this tooth socket after extraction because the surgeon failed to inspect and debride the surgical eld. ACB• Fig. 8.70 (A) After extraction of a single tooth, a small space exists where the crown of the tooth was located. (B) A gauze pad (2 × 2 inch) is folded in half twice and placed into the space. When the patient bites on the gauze, pressure is transmitted directly to the gingiva and the socket. (C) If a large piece of gauze is used, the pressure goes on teeth, not on the gingiva or the socket. Initial control of hemorrhage is achieved by use of a moistened 2 × 2 inch gauze placed over the extraction socket. e gauze should be positioned such that when the patient closes his or her teeth together, it ts into the space previously occupied by the crown of the tooth. Biting of teeth together places pressure on the gauze, and the pressure is then transmitted to the socket. is pressure results in hemostasis. If the gauze is simply placed on the occlusal table, the pressure applied to the bleeding socket is insuf-cient to achieve adequate hemostasis (Fig. 8.70). A larger gauze sponge (4 × 4 inches) may be required if multiple teeth have been extracted or if the opposing arch is edentulous.e extraction of multiple teeth at one sitting is a more involved and complex procedure and is discussed in Chapter 9. 1359 Principles of More Complex ExodontiaJAMES R. HUPPCHAPTER OUTLINEPrinciples of Flap Design, Development, and Management, 135Design Parameters for Soft Tissue Flaps, 135Types of Mucoperiosteal Flaps, 137Developing a Mucoperiosteal Flap, 137Principles of Suturing, 139Principles and Techniques for Open Extractions, 144Indications for Open Extraction, 145Technique for Open Extraction of a Single-Rooted Tooth, 147Technique for Open Extraction of Multirooted Teeth, 149Removal of Root Fragments and Tips, 153Justication for Leaving Root Fragments, 156Multiple Extractions, 157Treatment Planning, 157Extraction Sequencing, 157Technique for Multiple Extractions, 157The removal of most erupted teeth can be achieved by closed delivery, but occasionally these techniques do not provide adequate surgical access. e open or surgical extraction technique is the method used when greater access is necessary to safely remove a tooth or its remaining roots. In addition, removal of multiple teeth during one surgical session requires more than the routine techniques of tooth removal described in Chapter 8. In addition, the surgical approach for extractions is commonly required for recontouring and smoothing bone after multiple extractions.is chapter discusses techniques for surgical tooth extraction. e principles of ap design, development, management, and suturing are explained, as are the principles of open extraction of single-rooted and multirooted teeth. e principles involved in multiple extractions and concomitant alveoloplasty are also discussed.Principles of Flap Design, Development, and Managemente word ap, when used to describe a surgical procedure, indicates an area of tissue that will be surgically moved from one site in the body to another or temporarily moved to improve surgical access. Flapped tissue can be comprised of soft tissue only or can include bone and/or other tissues to be relocated. Oral-maxillofacial surgeons often create aps that contain bone and adjacent soft tissues to reconstruct the jaws (see Chapter 29).Flap, as used in this chapter, indicates a section of soft tissue that (1) is outlined by a surgical incision, (2) carries its own blood supply, (3) allows surgical access to underlying tissues, (4) can be replaced in the original position, and (5) is maintained with sutures. Soft tissue aps are frequently used in oral surgical, periodontal, and endodontic procedures to gain access to underlying tooth and bone structures. e dental surgeon routinely extracting teeth must have a clear understanding of the principles of design, development, and management of soft tissue aps.Design Parameters for Soft Tissue FlapsTo provide adequate exposure and promote proper healing, the ap must be correctly designed. e surgeon must remember that several parameters exist when designing a ap that vary based on the clinical situation.When the ap is outlined, the base of the ap must usually be broader than the free margin to preserve an adequate blood supply. is means that all areas of the ap must have a source of uninter-rupted vasculature to prevent ischemic necrosis of the entire ap or portions of it (Fig. 9.1).When aps are used to gain surgical access, they must be of adequate size for several reasons. Sucient soft tissue reection is required to provide excellent visualization of the surgical site. Adequate access also must exist for the insertion of instruments required to perform the surgery. In addition, the ap must be held out of the surgeon’s line of sight by a retractor that should rest on intact bone. ere must be enough ap reection to permit the retractor to hold the ap without tension. Furthermore, soft tissue heals across the incision, not along the length of the incision, and sharp incisions heal more rapidly than torn tissue. erefore a long, straight incision with adequate ap reection heals more rapidly than a short, torn incision, which heals slowly by secondary intention. For an envelope ap to be of adequate size, the length of the ap in the anteroposterior dimension usually extends two teeth anterior and one tooth posterior to the area of surgery (Fig. 9.2A). Alternatively, if an anterior releasing incision is planned, the ap only needs to extend one tooth anterior and one tooth posterior to the tooth or teeth planned to be removed (Fig. 9.2B).Flaps for tooth removal should be full-thickness mucoperiosteal aps. is means that the ap includes the surface mucosa, the submucosa, and the periosteum. Because the goal of the surgery is to remove or reshape bone, all overlying tissue must be reected from it. In addition, full-thickness aps are necessary because the periosteum is the primary tissue responsible for bone healing, and 136 Part II Principles of Exodontiamay result in damaging or even severing that nerve, with consequent prolonged temporary or permanent anesthesia of part of the tongue. In the same way, surgery in the apical area of mandibular premolar teeth should be carefully planned and executed to avoid injury to the mental nerve. Envelope incisions should be used, if at all possible, and releasing incisions should be well anterior or posterior from where the mental nerve exits the mandible.Flaps in the maxilla rarely endanger any vital structures. On the facial aspect of the maxillary alveolar process there are no nerves or arteries that are likely to be damaged. When reecting a palatal ap, the surgeon must remember that the major blood supply to the palatal soft tissue comes through the greater palatine artery, which emerges from the greater palatine foramen at the posterior lateral aspect of the hard palate. is artery courses forward and overlaps, to some degree, with the nasopalatine artery. e nasopalatine nerves and arteries exit the incisive foramen to supply the anterior palatal gingiva. If the anterior palatal tissue must be reected, the artery and the nerve can be incised at the level of the foramen without serious consequences. In the area of the incisive neurovascular bundle, the likelihood of bothersome bleeding is small, and the nerve typically regenerates. e temporary numbness usually does not bother the patient. However, vertical-releasing incisions in the posterior aspect of the palate should be avoided because they usually sever the greater palatine artery within the tissue, which results in pulsatile bleeding that may be dicult to control.replacement of the periosteum in its original position hastens that healing process. Also, torn, split, or macerated tissue heals more slowly compared with a cleanly reflected, full-thickness flap. Furthermore, the tissue plane between bone and periosteum is relatively avascular, so less bleeding is produced when a full-thickness ap is elevated.e incisions that outline the ap must be made over bone that will remain intact after the surgical procedure is complete. If the pathologic condition has eroded the buccocortical plate, the incision should be at least 6 to 8 mm away from it in an area of intact bone. In addition, if bone is to be removed over a particular tooth, the incision must be suciently distant from it so that after bone is removed, the incision is 6 to 8 mm away from the bony defect created by surgery. If the incision line is unsupported by intact bone, it tends to collapse into the bony defect, which results in wound dehiscence and delayed healing (Fig. 9.3).e ap should be designed to avoid injury to local vital structures in the area of the surgery. e two most important structures that can be damaged are located in the mandible; these are the lingual nerve and the mental nerve. When making incisions in the posterior mandible, especially in the region of the third molar, incisions should be well away from the lingual aspect of the mandible. In the lower third molar area, the lingual nerve may closely adhere to the lingual aspect of the mandible or even run on the superior aspect of the retromolar area. Incisions in this area AB• Fig. 9.1 (A) The ap must have a base that is broader than the free gingival margin. (B) If the ap is too narrow at its base, blood supply may be inadequate, which can lead to ap necrosis. AB• Fig. 9.2 (A) To have sufcient access to root of second pre-molar, the envelope ap should extend anteriorly, mesial to the canine, and posteriorly, distal to the rst molar. (B) If a releasing incision (i.e., three-cornered ap) is used, the ap extends mesial to the rst premolar. AB• Fig. 9.3 (A) When designing a ap, it is necessary to anticipate how much bone will be removed so that after surgery is completed, the incision rests over sound bone. In this situation, the vertical release was one tooth anterior to bone removal, and left an ade-quate margin of sound bone. (B) When a releasing incision is made too close to bone removal, delayed healing results. CHAPTER 9 Principles of More Complex Exodontia 137 and may cause some mildly prolonged healing, but if care is taken when suturing, the healing period is not noticeably lengthened. Placing the rst suture at corner number 2 will properly align other parts of the incision, making the placement of the other sutures more straightforward.e four-cornered ap is an envelope incision with two releasing incisions. Two corners are at the superior aspect of the releasing incision, and two corners are at either end of the envelope com-ponent of the incision (Fig. 9.6). Although this ap provides substantial access in areas that have limited anteroposterior dimen-sion, it is rarely indicated. When releasing incisions are necessary, a three-cornered ap usually suces.An incision that is used occasionally to approach the root apex is a semilunar incision (Fig. 9.7). is incision avoids trauma to the papillae and gingival margin but provides limited access because the entire root of the tooth is not visible. is incision is most useful for periapical surgery of a limited extent.An incision useful on the palate is the Y-incision, which is named for its shape. is incision is useful for surgical access to the bony palate for removal of a palatal torus. e tissue overlying a torus is usually thin and must be carefully reected. e antero-lateral extensions of the midline incision are anterior to the region of the canine teeth. e extensions are anterior enough in this position that they do not sever major branches of the greater palatine artery; therefore bleeding is usually not a problem (Fig. 9.8).Developing a Mucoperiosteal FlapSeveral specic considerations are involved in developing aps for surgical extractions. e rst step is to incise soft tissue to allow reection of the ap. e No. 15 blade is used on a No. 3 scalpel handle, and it is held in the pen grasp (Fig. 9.9). e blade is held at a slight angle to the tooth, and the incision is made posteriorly to anteriorly in the gingival sulcus by drawing the knife toward the operator. One smooth continuous stroke is used while keeping the knife blade in contact with bone throughout the entire incision (Figs. 9.10 and 9.11).Releasing incisions are used only when necessary and not routinely. Envelope incisions usually provide the adequate visualiza-tion required for tooth extraction in most areas. When vertical-releasing incisions are necessary, only a single vertical incision is usually required, which is usually at the anterior end of the envelope component. e vertical-releasing incision is not a straight vertical incision but an oblique incision, allowing the base of the ap to be broader than the free gingival margin. A vertical-releasing incision is made so that it does not cross bony prominences such as the canine eminence; to do so would increase the likelihood of tension in the suture line, which could result in wound dehiscence.Vertical-releasing incisions should cross the free gingival margin at the line angle of a tooth and should not be directly on the facial aspect of the tooth, nor should it be directly in the papilla (Fig. 9.4). Incisions that cross the free margin of the gingiva directly over the facial aspect of the tooth do not heal properly because of tension; the result is a defect in the attached gingiva. Because facial bone around teeth is frequently thin, such incisions also result in vertical clefting of the bone. Incisions that cross the gingival papilla damage the papilla unnecessarily and increase the chances for localized periodontal problems; such incisions should be avoided.Types of Mucoperiosteal FlapsA variety of intraoral tissue aps exists. e most common incision is the sulcular incision, which, when not combined with a releasing incision, produces the envelope ap. In the dentulous patient, the incision is made in the gingival sulcus down to crestal bone, through the periosteum, and the full-thickness mucoperiosteal ap is reected apically (see Fig. 9.2A). is ap usually provides sucient access to perform the necessary surgery.If the patient is edentulous, the envelope incision is usually made along the scar at the crest of the ridge. No vital structures are found in this area, and the envelope incision can be as long as is required to provide adequate access. e only exception occurs in extremely atrophic mandibles where the inferior alveolar nerve may rest on top of the residual alveolar ridge. Once the incision is made, tissue can be reected buccally or lingually, as necessary, for recontouring of the ridge or the removal of a mandibular torus. Note that aps created through a crestal scar require extra care during elevation due to the presence of brous tissue in the scar that interferes with elevation.If the sulcular incision has a vertical-releasing incision, it is a three-cornered ap with corners at the posterior end of the envelope incision, at the inferior aspect of the vertical incision, and at the superior aspect of the vertical-releasing incision (Fig. 9.5). is incision provides greater access with a shorter sulcular incision. When greater access is necessary in an apical direction, especially in the posterior aspect of the mouth, this incision is frequently necessary. e vertical component can be more dicult to close 12AB• Fig. 9.4 (A) The correct position for the end of the vertical-releas-ing incision is at the line angle (mesiobuccal angle in this gure) of the tooth. Likewise, the incision does not cross the canine emi-nence. Crossing such bony prominences results in increased chance for wound dehiscence. (B) These two incisions are made incorrectly. (1) The incision crosses the prominence over the canine tooth, which increases the risk of delayed healing; the incision through the papilla results in unnecessary damage. (2) The incision crosses the attached gingiva directly over the facial aspect of the tooth, which is likely to result in soft tissue defect as well as peri-odontal and aesthetic deformities. 123• Fig. 9.5 The vertical-releasing incision converts the envelope incision into a three-cornered ap (corners numbered). 138 Part II Principles of Exodontia1234• Fig. 9.6 Vertical-releasing incisions at the other end of the envelope incision convert the envelope incision into a four-cornered ap (corners numbered). • Fig. 9.7 Semilunar incision, designed to avoid marginal attached gingiva when working on a root apex. The incision is most useful when only a limited amount of access is necessary. • Fig. 9.8 The Y-incision is useful on the palate for adequate access to remove a palatal torus. Two anterior limbs serve as releasing incisions to provide for greater access. • Fig. 9.9 The scalpel handle is held in a pen grasp for maximal control and tactile sensitivity. • Fig. 9.10 A No. 15 blade is used to incise the gingival sulcus. e 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 ap is to be reected, the surgeon should consider changing blades between incisions.If a vertical-releasing incision is made, the tissue is apically reected, with the opposite hand tensing the alveolar mucosa so that the incision can be made cleanly through it. If the alveolar mucosa is not tensed, the knife will not incise cleanly through the mucosa, and a jagged incision will result.Reection of the ap begins at a papilla. e sharp end of the No. 9 periosteal elevator begins a reection (Fig. 9.12). e sharp end is slipped underneath the papilla in the area of the incision and is turned laterally to pry the papilla away from underlying bone. is technique is used along the entire extent of the gingival incision. If it is dicult 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 ap has been reected with the sharp end of the elevator, the broad end is used to reflect the mucoperiosteal ap to the extent desired, taking care to keep the edge of the elevator on bone and under the periosteum.If a three-cornered ap is used, the initial reection is accom-plished with the sharp end of the No. 9 elevator on the rst papilla only. Once the ap reection is started, the broad end of the periosteal elevator is inserted at the middle corner of the ap, and the dissection is carried out with a pushing stroke, posteriorly and apically. is facilitates the rapid and atraumatic reection of the soft tissue ap (Fig. 9.13).Once the ap has been reected as desired, the periosteal elevator can be used as a retractor to hold the ap in its proper reected position. To accomplish this eectively, the elevator is held perpendicular to the bone tissue while resting on sound bone and not trapping soft tissue between the retractor and bone. e periosteal elevator is therefore maintained in its proper position, and the soft tissue ap is held without tension (Fig. 9.14). e Seldin elevator, or the Minnesota or Austin retractors, can be used in a similar manner when broader exposure is necessary. e retractor should not be forced against soft tissue in an attempt to pull tissue out of the eld. Instead, the retractor is positioned in the proper place and held rmly against bone. By retracting in this fashion, the surgeon primarily focuses on the surgical eld rather CHAPTER 9 Principles of More Complex Exodontia 139 than on the retractor; thus the chance of inadvertently tearing the ap is lessened.Principles of SuturingOnce the surgical procedure is completed and the wound is properly irrigated and debrided, the surgeon must return the ap to its original position or, if necessary, place it in a new position; the ap should be held in place with sutures. Sutures perform multiple functions. e most obvious and important function that sutures perform is to coapt wound margins; that is, to hold the ap in position and approximate the opposing wound edges. e sharper the incision and the less trauma inicted on the wound margin, the more probable healing occurs by primary intention. If the space between the two wound edges is minimal, wound healing will be rapid and complete. If tears or excessive trauma to the wound edges occur, wound healing will need to occur by secondary intention.AB• Fig. 9.11 (A) The knife is angled slightly away from the tooth and incises soft tissue, including the periosteum, at crestal bone. (B) The incision is started posteriorly and is carried anteriorly, with care taken to incise completely through the interdental papilla. • Fig. 9.12 The reection of the ap is begun by using the sharp end of the periosteal elevator to pry away the interdental papilla. • Fig. 9.13 When a three-cornered ap is used, only the anterior papilla is reected with the sharp end of the elevator. The broad end is then used with a push stroke to elevate posterosuperiorly. • Fig. 9.14 A periosteal elevator is used to retract the mucoperiosteal ap. The elevator is placed perpendicular to the bone and held in place by pressing rmly against the bone, not by pushing it apically against soft tissue. Notice the vertical releasing incision located at the distal line angle of tooth #9. 140 Part II Principles of ExodontiaAB• Fig. 9.15 (A) Figure-of-eight suture occasionally placed over the top of the socket to aid in hemostasis. (B) This suture is usually performed to help maintain a piece of oxidized cellulose in the tooth socket. AB• Fig. 9.16 (A) The needle holder is held with the thumb and ring nger. (B) The index nger extends along the instrument for stability and control. • Fig. 9.17 The shapes and types of needles most commonly used in oral surgery are the three-eighths circle and half-circle cutting needles shown here. Top, PS-2. Middle, FS-2. Bottom, X-1. Sutures also aid in hemostasis. If underlying tissue is bleeding, the surface mucosa or skin should not be closed because continued bleeding may result in the formation of a hematoma. Surface sutures aid in hemostasis but only as a tamponade in a generally oozing area, such as a tooth socket. Overlying tissue should never be sutured tightly in an attempt to gain hemostasis in a bleeding tooth socket.Sutures help hold a soft tissue ap over bone. is is an important function because bone that is not covered with soft tissue becomes nonvital and requires an excessively long time to heal. When mucoperiosteal aps are reected from alveolar bone, it is important that the extent of the bone be recovered with soft tissue aps. Unless appropriate suture techniques are used, the ap may retract away from bone, exposing it and resulting in delayed healing.Sutures may aid in maintaining a blood clot in the alveolar socket. A special suture, such as a gure-of-eight, can provide a barrier to clot displacement (Fig. 9.15). However, it should be emphasized that suturing across an open wound socket plays a minor role in maintaining a blood clot in the tooth socket.e armamentarium for suturing includes a needle holder, a suture needle, and suture material. e needle holder of choice is 15 cm (about 6 inches) in length and has a locking handle. e needle holder is held with the thumb and ring nger through the rings and with the index nger along the length of the needle holder to provide stability and control (Fig. 9.16).e suture needle usually used in the mouth is a small three-eighths to one-half circle with a reverse cutting edge. e cutting edge helps the needle readily pass through the tough mucoperiosteal ap tissue. Needle sizes and shapes have been assigned numbers. e most common needle shapes used for oral surgery are the three-eighths and half-circle cutting needles (Fig. 9.17).e technique used for suturing is deceptively dicult. e use of the needle holder and the technique that is necessary to pass the curved needle through tissue are dicult to learn. e following discussion presents the technique used in suturing; practice is necessary before suturing can be performed with skill and nesse.When an envelope ap is repositioned into its correct location, it is held in place with sutures that are placed through the papillae only. Sutures are not placed across the empty tooth socket because the edges of the wound would not be supported over sound bone (Fig. 9.18). When reapproximating the ap, the suture is passed rst through mobile (usually facial) tissue; the needle is regrasped with the needle holder and is passed through the attached tissue of the lingual papilla. Note that the tip of the needle should never be grasped by the needle holders. If the two margins of the wound are close together, the experienced surgeon may be able to insert the needle through both sides of the wound in a single pass. However, for better precision, it is best to use two passes in most situations (Fig. 9.19).When passing the needle through tissue, the needle should enter the surface of the mucosa at the right angle, to make the smallest possible hole in the mucosal ap (Fig. 9.20). If the needle passes through tissue obliquely, the suture will tear through the surface layers of the ap when the suture knot is tied, which results in greater injury to soft tissue. In addition, if the needle does not CHAPTER 9 Principles of More Complex Exodontia 141 AB• Fig. 9.18 (A) The ap held in place with sutures in papillae. (B) Cross-sectional view of suture. BACED• Fig. 9.19 When the mucosal ap is back in position, the suture is passed through two sides of the socket in separate passes of the needle. (A) The needle is held by the needle holder and passed through the papilla, usually that of mobile elevated tissue rst. (B) The needle holder is then released from the needle; it regrasps the needle on the underside of tissue and is turned through the ap with care taken to never grasp the needle’s tip. (C) The needle is then passed through the opposite side of soft tissue papilla in similar fashion. (D) Finally, the needle holder grasps the needle on the opposite side to complete the passing of the suture through both sides of the mucosa. enter and exit a similar amount of tissue along both sides of the incision, the wound edges will not properly align.When passing the needle through the ap, the surgeon must ensure that an adequate amount of tissue is taken to prevent the needle or suture from pulling through the soft tissue ap. Because the ap being sutured is a mucoperiosteal ap, it should not be tied too tightly. e minimal amount of tissue between the suture and the edge of the ap should be 3 mm. Once the sutures are passed through the mobile ap and the immobile lingual tissue, they are tied with an instrument tie (Fig. 9.21).e surgeon must remember that the purpose of the suture is merely to reapproximate the tissue; therefore the suture should not be tied too tightly. Sutures that are too tight cause ischemia of the ap margin and result in tissue necrosis, with eventual tearing of the suture through tissue. us sutures that are too tightly tied result in wound dehiscence more frequently compared with sutures that are loosely tied. As a clinical guideline, there should be no blanching or obvious ischemia of the wound edges after a suture is tied. If this occurs, the suture should be removed and replaced. e knot should be positioned so that it does not fall directly over the incision line because this causes additional pressure on the incision. erefore the knot should be positioned to the side of the incision, usually toward the facial or buccal aspect of the incision. 142 Part II Principles of ExodontiaABCD• Fig. 9.20 (A) When passing through the soft tissue of mucosa, the needle should enter the surface of tissue at a right angle. (B) The needle holder should be turned so the needle passes easily through tissue at a right angle. (C) If the needle enters soft tissue at an acute angle and is pushed (rather than turned) through tissue, tearing of the mucosa with the needle or with the suture is likely to occur (D). ABCD• Fig. 9.21 Most intraoral sutures are tied with an instrument tie. (A) The suture is pulled through tissue until the short tail of the suture (approximately 1 to 2 cm long) remains. The needle holder is held hori-zontally by the right hand in preparation for the knot-tying procedure. (B) The left hand then wraps the long end of the suture around the needle holder twice in the clockwise direction to make two loops of suture around the needle holder. (C) The surgeon then opens the needle holder and grasps the short end of the suture very near its end. (D) The ends of the suture are then pulled to tighten the knot. The needle holder should not pull the suture it is holding at all until the knot is nearly tied to avoid lengthening that portion of the suture. Most intraoral sutures are tied with an instrument tie. CHAPTER 9 Principles of More Complex Exodontia 143 GHJIEFK(E) End of the rst step of the surgeon’s knot. The double wrap has resulted in a double overhand knot. This increases the friction in the knot and will keep the wound edges together until the second portion of the knot is tied. (F) The needle holder is then released from the short end of the suture and held in the same position as when the knot-tying procedure began. The left hand then makes a single wrap in the counterclockwise direction. (G) The needle holder then grasps the short end of the suture at its end. (H) This portion of the knot is completed by pulling this loop rmly down against the previous portion of the knot. (I) This completes the surgeon’s knot. The double loop of the rst pass holds tissue together until the second portion of the square knot can be tied. (J) Most surgeons add a third throw to their instrument tie when using a resorbable suture material. The needle holder is repositioned in the original position, and one wrap is placed around the needle holder in the original clockwise direction. The short end of the suture is grasped and tightened down rmly to form the second square knot. (K) The nal throw of three knots is tightened rmly. (Note: For demonstration purposes, the rst knot is left loose here, but in actual knot tying, the rst knot is tightened before creating the second knot.) Both ends of the suture are then cut, leaving about 1 cm or less of the suture end with the knot. • Fig. 9.21, cont’d 144 Part II Principles of Exodontia1234AB1432• Fig. 9.22 (A) To make the suturing of the three-cornered ap easier, a periosteal elevator is used to elevate a small amount of xed tissue so that the suture can be passed through the entire thickness of the muco-periosteum. (B) When the three-cornered ap is repositioned, the rst suture is placed at the occlusal end of the vertical-releasing incision (1). The papillae are then sutured sequentially (2, 3), and nally, if necessary, the superior aspect of the releasing incision is sutured (4). AB• Fig. 9.23 (A) A horizontal mattress suture is sometimes used to close soft tissue wounds. The use of this suture decreases the number of indi-vidual sutures that have to be placed; however, more importantly, this suture compresses the wound together slightly and everts the wound edges. (B) A single horizontal mattress suture can be placed across both papillae of the tooth socket and serves in a similar way as do two individual sutures. Once the knot securing a suture is tied, the surgeon or assistant should use suture scissors to cut the ends of the suture. e person cutting the suture should use the tips of the scissors to do the cutting so that the person can see that nothing beyond the suture is being cut. e length of the ends to leave varies, depending on the circumstances. In most situations in which the oral mucosa is being sutured, the ends of the suture should be left no longer than 1 cm.If a three-cornered ap is used, the vertical end of the incision must be closed separately. Two sutures usually are required to close the vertical end properly. Before the sutures are inserted, the No. 9 periosteal elevator should be used to slightly elevate the nonap side of the incision, freeing the margin to facilitate passage of the needle through the tissue (Fig. 9.22). e rst suture is placed across the papilla, where the vertical release incision was made. is is an easily identiable landmark that is most important when repositioning a three-cornered ap. e remainder of the envelope portion of the incision is then closed, after which the vertical component is closed. e slight reection of the nonap side of the incision greatly eases the placing of sutures.Sutures may be congured in several dierent ways. e routine interrupted suture is the one most commonly used in the oral cavity. is suture goes through one side of the wound, comes up through the other side of the wound, and is tied in a knot at the top. ese sutures can be placed quickly, and the tension on each suture can be adjusted individually. If one suture is lost, the remaining sutures stay in position.A suture technique that is useful for suturing two adjacent papillae with a single suture is the horizontal mattress suture (Fig. 9.23). A slight variation of that suture is the gure-of-eight suture, which holds the two papilla in position and puts a cross over the top of the socket that may help hold the blood clot or procoagulant materials in position (see Fig. 9.15).If the incision is long, continuous sutures can be used to e-ciently accomplish the closure. When using this technique, a knot does not have to be made for each suture, which makes it quicker to suture a long-span incision and leaves fewer knots to collect debris and to bother the patient’s tongue. e continuous simple suture can be locking or nonlocking (Fig. 9.24). e horizontal mattress suture also can be used in a running fashion. A disadvantage of the continuous suture is that if one suture pulls through, the entire suture line becomes loose.Nonresorbable sutures are left in place for approximately 5 to 7 days. After this time, sutures play no useful role and increase the contamination of the underlying submucosa. e suture is cut with the tips of a sharp, pointed pair of suture scissors and is removed by being pulled toward the incision line (not away from the suture line).Principles and Techniques for Open Extractionse surgical or open extraction of an erupted tooth using a ap is a technique that should not be reserved for the extreme situation. A prudently used open extraction technique may be more conserva-tive, cause less operative morbidity, and be quicker to perform compared with a closed extraction. Forceps extraction techniques, which require great force, may result in removal not only of the tooth but also of large amounts of adjacent bone and occasionally the oor of the maxillary sinus (Fig. 9.25). e bone loss may be less if a soft tissue ap is reected and a proper amount of bone is removed; it may also be less if the tooth is sectioned (cut into smaller sections). e morbidity of fragments of bone that may be literally torn from the jaw by the “conservative” closed technique CHAPTER 9 Principles of More Complex Exodontia 145 ABCD• Fig. 9.24 When multiple sutures are to be placed, the incision can be closed with running or continuous sutures. (A) The rst papilla is closed and the knot tied the usual way. The long end of the suture is held, and the adjacent papilla is sutured without the knot being tied, but just with the suture being pulled rmly through tissue. (B) Succeeding papillae are then sutured until the nal one is sutured and the nal knot is tied. The nal appearance is with the suture going across each empty socket. (C) A continuous locking suture can be made by passing the long end of the suture underneath the loop before it is pulled through tissue. (D) This puts the suture on the deep periosteal and mucosal surfaces directly across the papilla and may aid in more direct apposition of tissues. • Fig. 9.25 Forceps extraction of these teeth resulted in removal of bone and the tooth instead of just the tooth. controlled, the surgeon should instead reect a soft tissue ap, section the tooth, remove some bone, if needed, and extract the tooth in sections. In these situations, the philosophy of “divide and conquer” results in the most ecient and least traumatic extraction.If the preoperative assessment reveals that the patient has thick or especially dense bone, particularly of the buccocortical plate, surgical extraction should be considered. e extraction of most teeth depends on the expansion of the buccocortical plate. If this bone is especially thick, then adequate expansion is less likely to occur and fracture of the root is more likely. Young patients have bone that is more elastic and more likely to expand with controlled force, whereas older patients usually have denser, more highly calcied bone that is less likely to provide adequate expansion during luxation of the tooth. Dense bone in the older patient warrants even more caution.Occasionally, the dentist treats a patient who has very short clinical crowns with evidence of severe attrition. If such attrition is the result of bruxism, it is likely that teeth are surrounded by dense, thick bone with strong periodontal ligament attachments (Fig. 9.26). e surgeon should exercise extreme caution if removal of such teeth is attempted with a closed technique. An open technique usually results in a quicker, more straightforward extraction.Careful review of the preoperative radiographs may reveal tooth roots that are likely to cause diculty if the tooth is extracted by the standard forceps technique. One condition commonly seen among older patients is hypercementosis. In this situation, cemen-tum has continued to be deposited on the tooth and has formed a large bulbous root that is dicult to remove through the available tooth socket opening. Great force used to expand the bone may result in fracture of the root or the buccocortical bone (Fig. 9.27).Roots that are widely divergent, especially maxillary rst molar roots (Fig. 9.28) or roots that have severe dilaceration or hooks, are also dicult to remove without fracturing one or more of the can greatly exceed the morbidity of a properly done surgical extraction.Indications for Open ExtractionIt is prudent for the surgeon to carefully evaluate each patient and each tooth to be removed for the possibility of an open extraction. Although the decision is to perform a closed extraction in the vast majority of cases, the surgeon must be continually aware that open extraction may be the less traumatic of the two in some situations.As a general guideline, surgeons should consider performing an elective surgical extraction when they anticipate the possible need for excessive force to extract a tooth. e term excessive means that the force will probably result in a fracture of bone, a tooth root, or both. In any case, excessive bone loss, the need for additional surgery to retrieve the root, or both can cause undue tissue damage. e following are examples of situations in which closed extraction may require excessive force.e surgeon should seriously consider performing an open extraction after initial attempts at forceps extraction have failed. Instead of applying greater amounts of force that may be less 146 Part II Principles of Exodontia• Fig. 9.28 Widely divergent roots increase the likelihood of fracture of bone, tooth root, or both. • Fig. 9.29 Severe dilaceration of roots may result in fracture of the root unless surgical extraction is performed. • Fig. 9.30 Maxillary molar teeth “in” the oor of the maxillary sinus increase the chances of fracture of the sinus oor with resulting sinus perforation. • Fig. 9.26 Teeth that exhibit evidence of bruxism may have denser bone and stronger periodontal ligament attachment, which make them more difcult to extract. • Fig. 9.27 Hypercementosis of the root makes forceps delivery difcult. roots (Fig. 9.29). By reecting a soft tissue ap and dividing the roots prospectively with a burr, a more controlled and planned extraction can be performed with less damage overall.If the maxillary sinus has pneumatized to include the roots of the maxillary molars, extraction may result in removal of a portion of the sinus oor along with the tooth. If the roots are divergent, then such a situation is even more likely to occur (Fig. 9.30). Surgical extraction is again indicated.Teeth that have crowns with extensive caries, especially root caries that have large amalgam restorations, or endodontically treated molars are good candidates for open extraction (Fig. 9.31). Although forceps should primarily grasp the tooth root, a portion of the force is applied to the crown. Such pressures can crush and shatter the crowns of teeth with extensive caries, large restorations, or prior endodontic treatment. Open extraction can circumvent the need for extensive force and result in a quicker, less traumatic extraction. Teeth with crowns that have already been lost to caries and that present as retained roots should also be considered for CHAPTER 9 Principles of More Complex Exodontia 147 open extraction. If extensive periodontal disease is found around such teeth, it may be possible to deliver them easily with straight elevators or Cryer elevators. However, if bone around the tooth is rm and no periodontal disease exists, the surgeon should consider an open extraction.Technique for Open Extraction of a Single-Rooted Toothe technique for open extraction of a single-rooted tooth is straightforward but requires attention to detail because several decisions must be made during the operation. e technique is essentially the same for single-rooted teeth that have resisted attempts at closed extraction or that have fractured and, therefore, exist only as a root.e rst step is to provide adequate visualization and access by reecting a suciently large mucoperiosteal ap. In most situations, an envelope ap that is extended two teeth anterior and one tooth posterior to the tooth to be removed is sucient. If a releasing incision is necessary, it should be placed at least one tooth anterior to the extraction site (see Fig. 9.2).Once an adequate ap has been reected and is held in its proper position by a periosteal elevator, the surgeon must determine the need for bone removal. Several options are available. First, the surgeon may attempt to reseat the extraction forceps under direct visualization and thus achieve a better mechanical advantage and remove the tooth with no surgical bone removal at all (Fig. 9.32).e second option is to grasp a bit of buccal bone under the buccal beak of the forceps to obtain a better mechanical advantage • Fig. 9.31 Large caries or large restorations may lead to fracture of the crown of the tooth and thus to a more difcult extraction. • Fig. 9.32 A small envelope ap can be reected to expose the fractured root. Under direct visualization, the forceps can be seated more apically into the periodontal ligament space, which eliminates the need for bone removal. and grasp of the tooth root. is may allow the surgeon to luxate the tooth suciently to remove it without any additional bone removal (Fig. 9.33). A small amount of buccal bone is pinched o and removed with the tooth.e third option is to use the straight elevator, pushing it toward the apex in the periodontal ligament space of the tooth (Fig. 9.34). e index nger 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 to-and-fro motion should be used to help expand the periodontal ligament space, which allows the small straight elevator to enter and proceed apically into the space and act as a wedge to displace the root occlusally. is approach continues with the use of larger straight elevators until the tooth is successfully luxated.e fourth and nal option is to proceed with surgical bone removal over the area of the tooth. Most surgeons prefer to use a burr to remove the bone, along with ample irrigation. e width of buccal bone that is removed is essentially the same width as the tooth in a mesiodistal direction (Fig. 9.35). In a vertical dimension, bone should be removed approximately one-half to two-thirds the length of the tooth root (Fig. 9.36). is amount of bone removal suciently reduces the amount of force necessary to displace the tooth and makes removal relatively straightforward. A small straight elevator (Fig. 9.37) or forceps can be used to remove the tooth (Fig. 9.38).If the tooth is still dicult to extract after the removal of bone, a purchase point (indentation into a tooth into which a pointed elevator can be inserted) can be made in the root with the burr at the most apical portion of the area of bone removal (Fig. 9.39). Care should be taken to limit bone removal to only that needed to remove the root to preserve bone for possible implant placement. e purchase point hole should be about 3 mm in diameter and 148 Part II Principles of Exodontia• Fig. 9.33 If the root is fractured at the level of bone, the buccal beak of the forceps can be used to remove a small portion of bone at the same time that the root is grasped. • Fig. 9.34 The small straight elevator can be used like a shoehorn to luxate the broken root. When the straight elevator is used in this position, the hand must be securely supported on adjacent teeth to prevent inad-vertent slippage of the instrument from the tooth and subsequent injury to adjacent tissue. • Fig. 9.35 When removing bone from the buccal surface of the tooth or tooth root to facilitate removal of that root, the mesiodistal width of bone removal should be approximately the same as the mesiodistal dimension of the tooth root itself. This allows an unimpeded path for removal of the root in the buccal direction. • Fig. 9.36 Bone is removed with a bone-cutting burr after reection of the standard envelope ap. Bone should be removed approximately one-half to two-thirds the length of the tooth root. • Fig. 9.37 Once the appropriate amount of buccal bone has been removed, the straight elevator can be used down the palatal aspect of the tooth to displace the tooth root in the buccal direction. It must be remembered that when the elevator is used in this direction, the surgeon’s hand must be rmly supported on adjacent teeth to prevent slippage of the instrument and injury to the adjacent soft tissue. CHAPTER 9 Principles of More Complex Exodontia 149 the incision was properly planned and executed, the suture line will be supported by healthy, intact bone.Technique for Open Extraction of Multirooted TeethOnce the decision is made to perform an open extraction of a multirooted tooth, such as a mandibular or maxillary molar, the same surgical technique used for the single-rooted tooth is generally used. e major dierence is that the tooth may be divided with a burr to convert a multirooted tooth into two or three single-rooted teeth. If the crown of the tooth remains intact, the crown portion is sectioned in such a way as to facilitate removal of roots. However, if the crown portion of the tooth is missing and only the roots remain, the goal is to separate the roots to make them easier to elevate.Removal of the lower rst molar with an intact crown is usually done by sectioning the tooth buccolingually, thereby dividing the tooth into a mesial half (with mesial root and half of the crown) and a distal half. An envelope incision is also made to gain access to the site and protect the soft tissue from the burr. A small amount of crestal bone may be removed. Once the tooth is sectioned, it is luxated with straight elevators to begin the mobilization process. e sectioned tooth is treated as a lower premolar tooth and is removed with a lower universal forceps (Fig. 9.41). e ap is repositioned and sutured.e surgical technique begins with the reection of an adequately long envelope ap (Fig. 9.42A–B). Evaluation of the need for sectioning roots and removing bone is made at this stage, as it was with the single-rooted tooth. Occasionally forceps, elevators, or both are positioned with direct visualization to achieve better deep enough 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. 9.40A). Soft tissue is repositioned and sutured (Fig. 9.40B).e bone edges should be checked; if they are sharp, they should be smoothed with a bone le. By replacing the soft tissue ap and gently palpating it with a nger, the clinician can check edge sharpness. Removal of bone with a rongeur is rarely indicated because a rongeur tends to remove too much bone in such circumstances.Once the tooth is delivered, the entire surgical eld should be thoroughly irrigated with copious amounts of sterile saline. Special attention should be directed toward the most inferior portion of the ap (where it joins the bone) because this is a common place for debris to settle, 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. e ap is then set in its original position and sutured into place with 3-0 black silk or chromic sutures. If • Fig. 9.38 After bone has been removed and the tooth root luxated with the straight elevator, the forceps can be used to remove the root. • Fig. 9.39 If the tooth root is solid in bone, buccal bone can be removed, and a purchase point can be made for the insertion of the elevator. AB• Fig. 9.40 (A) A triangular elevator, such as the Crane pick, is inserted into the purchase point, and the tooth is elevated from its socket. (B) The ap is repositioned and sutured over intact bone. 150 Part II Principles of Exodontiaelevated from the socket with a Cryer elevator. e elevator is inserted into the empty tooth socket and rotated, using the wheel-and-axle principle. e sharp tip of the elevator engages the cementum of the remaining root, which is elevated occlusally from the socket. If the interradicular bone is heavy, the rst rotation or two of the Cryer elevator removes bone, which allows the elevator to engage the cementum of the tooth on the second or third rotation.If the crown of the mandibular molar has been lost, the procedure again begins with the reection of an envelope ap and removal of a small amount of crestal bone. e burr is used to section the two roots into mesial and distal components (Fig. 9.44A). e small straight elevator is used to mobilize and luxate the mesial root, which is delivered from its socket by insertion of the Cryer elevator into the slot prepared by the dental burr (Fig. 9.44B). e Cryer elevator is rotated in the wheel-and-axle manner, and the mesial root is delivered occlusally from the tooth socket. e opposite member of the paired Cryer instruments is inserted into the empty root socket and rotated through the interradicular bone to engage and deliver the remaining root (Fig. 9.44C).Extraction of maxillary molars with widely divergent buccal and palatal roots that require excessive force to extract can be done more prudently by dividing the root into several sections. is three-rooted tooth must be divided in a pattern dierent from that of the two-rooted mandibular molar. If the crown of the tooth is intact, the two buccal roots are sectioned from the tooth and the crown is removed along with the palatal root.e standard envelope ap is reected, and a small portion of crestal bone is removed to expose the trifurcation area. e burr is used to section o the mesiobuccal and distobuccal roots (Fig. 9.45A). With gentle but rm bucco-occlusal pressure, the upper molar forceps deliver the crown and palatal root along the long axis of the root (Fig. 9.45B). No palatal force should be delivered mechanical advantage and to remove the tooth without removing bone.However, in most situations a small amount of crestal bone should be removed and the tooth should be divided. Tooth sectioning is usually accomplished with a straight handpiece with a straight burr such as the No. 8 round burr or with a ssure burr such as the No. 557 or No. 703 burr (Fig. 9.42C) under copious irrigation.Once the tooth is sectioned, the small straight elevator is used to luxate and mobilize the sectioned roots (Fig. 9.42D). e straight elevator may be used to deliver the mobilized sectioned tooth (Fig. 9.42E). If the crown of the tooth is sectioned, upper or lower universal forceps are used to remove the individual portions of the sectioned tooth (Fig. 9.42F). If the crown is missing, then straight and triangular elevators are used to elevate the tooth roots from the sockets.Sometimes a remaining root may be dicult to remove and additional bone removal (as is described for a single-rooted tooth) may be necessary. Occasionally it is necessary to prepare a purchase point with the burr and to use an elevator, such as the Crane pick, to elevate the remaining root.After the tooth and all the root fragments have been removed, the ap is repositioned and the surgical area is palpated for sharp bony edges. If any sharp edges are present, they are smoothed with a bone le. e wound is thoroughly irrigated and debrided of loose fragments of tooth, bone, calculus, and other debris. e ap is repositioned and sutured in the usual fashion.An alternative method for removing the lower rst molar is to reect the soft tissue ap and remove sucient buccal bone to expose the bifurcation. en the burr is used to section the mesial root from the tooth and convert the molar into two single-rooted teeth (Fig. 9.43). e crown with the mesial root intact is extracted with No. 17 lower molar forceps. e remaining mesial root is AB• Fig. 9.41 If the lower molar is difcult to extract, it can be sectioned into single-rooted teeth. (A) The envelope incision is reected, and a small amount of crestal bone is removed to expose the bifurcation. A drill is then used to section the tooth into mesial and distal halves. (B) Lower universal forceps are used to remove the two crown and root portions separately. CHAPTER 9 Principles of More Complex Exodontia 151 If the crown of the maxillary molar is missing or fractured, the roots should be divided into two buccal roots and a palatal root. e same general approach as before is used. An envelope ap is reected and retracted with a periosteal elevator. A moderate amount of buccal bone is removed to expose the tooth for sectioning (Fig. 9.46A). e roots are sectioned into two buccal roots and a single palatal root. Next, the roots are luxated with a straight elevator and delivered with Cryer elevators, according to the preference of the surgeon (Fig. 9.46B–C). Occasionally, enough access to the roots exists so that a maxillary root forceps or upper universal with the forceps to the crown portion because this results in fracture of the palatal root. e entire delivery force should be in the buccal direction. A small straight elevator is then used to luxate the buccal roots (Fig. 9.45C), which can then be delivered with a Cryer elevator used in the usual fashion (Fig. 9.45D) or with a straight elevator. If straight elevators are used, the surgeon should remember that the maxillary sinus might be close to these roots, so apically directed forces must be carefully controlled. e force of the straight elevator should be toward the palate, with more limited pressure applied apically.ABCDEF• Fig. 9.42 (A) This lower molar has roots that make it necessary to section the tooth. (B) The ap is raised to expose bone and allow sectioning. Note the small releasing incisions on the mesial and distal sides of the tooth. (C) The surgical handpiece with ssure burr used to section tooth into mesial and distal parts, allowing each root to independently be removed. (D) The straight elevator is inserted into the burr cut to complete division of the crown. (E) Each root can now be elevated and removed. (F) The completed procedure with chromic suture closing distal release. 152 Part II Principles of ExodontiaABC• Fig. 9.43 (A) An alternative method of sectioning is to use the burr to remove the mesial root from the rst molar. (B) The No. 178 forceps are then used to grasp the crown of the tooth and remove the crown and the distal root. (C) The Cryer elevator is then used to remove the mesial root. The point of the Cryer elevator is inserted into the empty socket of the distal root and turned in a wheel-and-axle fashion with the sharp point engaging interseptal bone and root, elevating the mesial root from its socket. A BC• Fig. 9.44 (A) When the crown of the lower molar is lost because of fracture or caries, the envelope ap is reected, and a small amount of crestal bone is removed. A burr is then used to section the tooth into two individual roots. (B) After the small straight elevator has been used to mobilize the roots, the Cryer elevator is used to elevate the distal root. The tip of the elevator is placed into the slot prepared by the burr, and the elevator is turned to deliver the root. (C) The opposite member of the paired Cryer elevators is then used to deliver the remaining tooth root with the same type of rotational movement. CHAPTER 9 Principles of More Complex Exodontia 153 requirements for extraction are critically important: (1) excellent light and (2) excellent suction—preferably with a suction tip of small diameter. Removal of a small root tip fragment is dicult unless the surgeon can clearly visualize it. It is also important that an irrigation syringe be available to ush blood and debris from around the root tip so that it can be clearly seen.e closed technique for root tip retrieval is dened as any technique that does not require reection of soft tissue aps and removal of bone. Closed techniques are most useful when the tooth was well luxated and mobile before the root tip fractured. If sucient luxation occurred before the fracture, the root tip often is mobile and can be removed with the closed technique. However, if the tooth was not well mobilized before the fracture, the closed technique is less likely to be successful. e closed technique is also less likely to be successful if the clinician nds a bulbous hypercementosed root with bony interferences that prevent extraction of the root tip fragment. In addition, severe forceps can be used to deliver the roots independently (see Fig. 9.46D). Finally, the palatal root is delivered after the two buccal roots have been removed. Often, much of the interradicular bone is lost by this time; therefore the small straight elevator can be used eciently. e elevator is directed down the periodontal ligament space on the palatal aspect with gentle, controlled wiggling motions, which causes displacement of the tooth in the bucco-occlusal direction (Fig. 9.46E).Removal of Root Fragments and TipsIf fracture of the apical one third (3 to 4 mm) of the root occurs during a closed extraction, an orderly procedure should be used to remove the root tip from the socket. Initial attempts should be made to extract the root fragment by a closed technique, but the surgeon should begin a surgical technique if the closed technique is not immediately successful. Whichever technique is chosen, two ABCD• Fig. 9.45 (A) When an intact maxillary molar must be divided for judicious removal (as when extreme divergence of roots is found), a small envelope incision is made, and a small amount of crestal bone is removed. This allows the burr to be used to section the buccal roots from the crown portion of the tooth. (B) Upper molar forceps are then used to remove the crown portion of the tooth along with the palatal root. The tooth is delivered in the bucco-occlusal direction, and no palatal pressure is used because it would probably cause a fracture of the palatal root from the crown portion. (C) The straight elevator is then used to mobilize the buccal roots and can occasionally be used to deliver these roots. (D) The Cryer elevator can be used in the usual fashion by placing the tip of the elevator into the empty socket and rotating it to deliver the remaining root. 154 Part II Principles of Exodontiainto other anatomic locations such as the maxillary sinus. Excessive lateral force could result in the bending or fracture of the delicate end of the root tip pick.e root tip also can be removed with the small straight elevator. is technique is indicated more often for the removal of larger root fragments. e technique is similar to that of the root tip pick because the small straight elevator is wedged into the peri-odontal ligament space, where it acts like a wedge to deliver the tooth fragment toward the occlusal plane (Fig. 9.48). Excessive apical pressure should be avoided because it may force the root into underlying tissues.Displacement of root tips into the maxillary sinus can occur in the maxillary premolar and molar areas. When the straight elevator is used to remove small root tips in this fashion, the surgeon’s hand must always be supported on an adjacent tooth or a solid bony prominence. is support allows the surgeon to deliver carefully controlled force and to decrease the possibility of displacing tooth fragments or the instrument tip into an unwanted place. e surgeon must be able to visualize the top of the fractured dilaceration of the root end may prevent the use of the closed technique.Once the fracture has occurred, the patient should be reposi-tioned so that adequate visualization (with proper lighting), irriga-tion, and suction are achieved. e tooth socket should be irrigated vigorously and suctioned with a small suction tip because the loose tooth fragment occasionally can be irrigated from the socket. Once irrigation and suction are completed, the surgeon should inspect the tooth socket carefully to assess whether the root has been removed from the socket. e extracted tooth should also be examined to see whether and how much of a root remains.If the irrigation-suction technique is unsuccessful, the next step is to tease the root apex from the socket with a root tip pick. A root tip pick is a delicate instrument and should not be used in the same manner as the Cryer elevator. e root tip pick is inserted into the periodontal ligament space, and the root is teased out of the socket (Fig. 9.47). Neither excessive apical force nor excessive lateral force should be applied to the root tip pick. Excessive apical force could result in displacement of the root tip ABCDE• Fig. 9.46 (A) If the crown of the upper molar has been lost to caries or has been fractured from the roots, a small envelope incision is reected, and a small amount of crestal bone is removed. The burr is then used to section the three roots into independent portions. (B) After the roots have been luxated with the small straight elevator, the mesiobuccal root is delivered with the Cryer elevator placed into the slot prepared by the burr. (C) Once the mesiobuccal root has been removed, the Cryer elevator is again used to deliver the distal buccal root. The tip of the Cryer elevator is placed into the empty socket of the mesiobuccal root and turned in the usual fashion to deliver the tooth root. (D) Maxillary root forceps occasionally can be used to grasp and deliver the remaining root. The palatal root can then be delivered with the straight or Cryer elevator. If the straight elevator is used, it is placed between the root and the palatal bone and gently rotated to and fro in an effort to displace the palatal root in the bucco-occlusal direction. (E) The small straight elevator can be used to elevate and displace the remaining root of the maxillary third molar in the bucco-occlusal direction with gentle to-and-fro motions. CHAPTER 9 Principles of More Complex Exodontia 155 root clearly to see the periodontal ligament space. e straight elevator must be inserted into this space and not blindly 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, ecient, properly performed open retrieval of a root fragment is less traumatic than a prolonged, time-consuming, frustrating attempt at closed retrieval.Two main open techniques are used to remove root tips. e rst is simply an extension of the technique described for surgical removal of single-rooted teeth. A soft tissue ap with a releasing incision is reected and retracted with a periosteal elevator. Bone is removed with a burr to expose the buccal surface of the tooth root. e root is buccally delivered through the opening with a small straight elevator. e wound is irrigated, and the ap is repositioned and sutured (Fig. 9.49).A modication of the open technique, which has just been described, can be performed to deliver the root fragment without excessive removal of the buccal plate overlying the tooth. is technique is known as the open-window technique. A soft tissue ap AB• Fig. 9.47 (A) When a small (2 to 4 mm) portion of the root apex is frac-tured from the tooth, the root tip pick can be used to retrieve it. (B) The root tip pick is teased into the periodontal ligament space and is used to gently luxate the root tip from its socket. AB• Fig. 9.48 (A) When a larger portion of the tooth root is left behind after extraction of the tooth, the small straight elevator can sometimes be used as a wedge to displace the tooth in the occlusal direction. It must be remembered that the pressure applied in such a fashion should be in gentle to-and-fro motions; excessive pressure should not be applied. (B) Excessive pressure in the apical direction results in displacement of the tooth root into undesirable places such as the maxillary sinus. AB• Fig. 9.49 (A) If the root cannot be retrieved by closed techniques, the soft tissue ap is reected, and bone overlying the root is removed with a burr. (B) The small straight elevator is then used to luxate the root buc-cally by wedging the straight elevator into the palatal periodontal ligament space. 156 Part II Principles of Exodontiasubsequent bone resorption from exposing the tooth root and interfering with any prosthesis that will be constructed over the edentulous area. ird, the tooth involved must not be infected, and there must be no radiolucency around the root apex. is lessens the likelihood that subsequent infections will result from leaving the root in position. If these three conditions exist, then consideration can be given to leaving the root.For the surgeon to leave a small, deeply embedded, noninfected root tip in place, the risk of surgery must be greater than the benet. is risk is considered to be greater if one of the following three conditions exists: First, the risk is too great if removal of the root will cause excessive destruction of surrounding tissue; that is, if excessive amounts of bone must be removed to retrieve the root. For example, reaching a small palatal root tip of a maxillary rst molar may require the removal of large amounts of bone.Second, the risk is too great if removal of the root endangers important structures, most commonly the inferior alveolar nerve at the mental foramen or along the course of the inferior alveolar canal. If surgical retrieval of a root runs a high risk of permanent or even prolonged temporary anesthesia of the inferior alveolar nerve, the surgeon should seriously consider leaving the root tip in place.Finally, the risks outweigh the benets if attempts at recovering the root tip highly risk displacing the root tip into tissue spaces or is reected in the same fashion as for the approach just discussed, and the apical area of the tooth fragment is located. A dental burr is used to remove the bone overlying the apex of the tooth, exposing the root fragment. A root tip pick or small elevator is then inserted into the window, and the tooth is guided out of the socket (Fig. 9.50).e preferred ap technique is the three-cornered ap because of a need for more extensive exposure of the apical areas. e open-window approach is especially indicated when the buccocrestal bone must be left intact, such as in the removal of maxillary premolars for orthodontic purposes, especially in adults.Justication for Leaving Root FragmentsWhen a root tip has fractured and closed approaches of removal have been unsuccessful and when the open approach may be excessively traumatic, the surgeon may consider leaving a root tip in place. As with any surgical approach, the surgeon must balance the benets of surgery against the risks of surgery. In some situations, the risks of removing a small root tip may outweigh the benets.ree conditions should exist for a tooth root to be left in the alveolar process. First, the root fragment should be small, usually no more than 4 to 5 mm in length. Second, the root must be deeply embedded in bone and not be superficial to prevent ABC• Fig. 9.50 (A) The open-window approach for retrieving the root is indicated when buccocrestal bone must be maintained. The three-cornered ap is reected to expose the area overlying the apex of the root fragment being recovered. (B) A burr is used to uncover the apex of the root and to allow sufcient access for the insertion of the straight elevator. (C) The small straight elevator is then used to displace the tooth out of the tooth socket. CHAPTER 9 Principles of More Complex Exodontia 157 mandibular surgery is performed rst. Furthermore, maxillary teeth are removed with a major component of buccal force. Little or no vertical traction force is used in the removal of these teeth, as is commonly required with mandibular teeth. A single minor dis-advantage for extracting maxillary teeth rst is that if hemorrhage is not controlled in the maxilla before mandibular teeth are undergoing extraction, the hemorrhage may interfere with visualiza-tion during mandibular surgery. Hemorrhage is usually not a major problem because hemostasis should be achieved in one area before the surgeon turns his or her attention to another area of surgery, and the surgical assistant should be able to keep the surgical eld free of blood with adequate suction.Tooth removal usually begins with extraction of the most posterior teeth rst. is allows for the more eective use of dental elevators to luxate and mobilize teeth before forceps are used to extract the tooth. e tooth that is the most dicult to remove—the canine—should be extracted last. Removal of the teeth on either side weakens the bony socket on the mesial and distal sides of these teeth, and their subsequent extraction is made more straightforward.For example, if teeth in the maxillary and mandibular left quadrants are to be extracted, the following order is recommended: (1) maxillary posterior teeth; (2) maxillary anterior teeth, leaving the canine; (3) maxillary canine; (4) mandibular posterior teeth; (5) mandibular anterior teeth, leaving the canine; and (6) man-dibular canine.Technique for Multiple Extractionse surgical procedure for removing multiple adjacent teeth is a slight modication of techniques used to remove individual teeth. e rst step in removing a single tooth is to loosen the soft tissue attachment from around the tooth. When performing multiple extractions, the soft tissue reection is extended slightly to form a small envelope ap to expose the crestal bone only around all the teeth in a quadrant (Fig. 9.51A–C). e teeth in the quadrant are luxated with the straight elevator (see Fig. 9.51D) and then delivered with forceps in the usual fashion. If removing any of the teeth is likely to require excessive force, the surgeon should remove a small amount of buccal bone to prevent fracture and excessive bone loss. It is benecial to do as much luxation of all teeth in an area to be removed before extracting any of them because the adjacent tooth can be used to anchor against while luxating without worry (since the anchoring tooth is planned for extraction as well).After the extractions are completed, the buccolingual plates are pressed into their preexisting position with rm pressure unless implants are planned. e soft tissue is repositioned, and the surgeon palpates the ridge to determine whether any areas of sharp bony spicules can be found. If a removable partial or complete denture is planned, undercuts should be identied. If any sharp spicules or undercuts exist, the bone rongeur is used to remove the larger areas of interference, and a bone le is used to smooth any sharp spicules (Fig. 9.51E–F). e area is irrigated thoroughly with sterile saline or sterile water. e soft tissue is inspected for the presence of granulation tissue. If any granulation tissue is present, it should be removed because it may prolong postoperative hemorrhage. Soft tissue is then reapproximated and inspected for now redundant gingiva. If teeth are being removed because of severe periodontitis with bone loss, it is common for the soft tissue aps to overlap and cause redundant tissue. If this is the situation, the gingiva should be trimmed so that little or no overlap occurs when the into the maxillary sinus. e roots most often displaced into the maxillary sinus are those of the maxillary molars. If the preopera-tive 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 may 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 displaced into the submandibular space during attempts to remove them. During retrieval of any root tip, apical pres-sure by an elevator may displace teeth into tissue spaces or into the sinus.If the surgeon elects to leave a root tip in place, a strict protocol should be observed. e patient must be informed that, in the surgeon’s judgment, leaving the root in its position will do less harm than the surgery needed to remove it. In addition, radiographic documentation of the presence and position of the root tip must be obtained and retained in the patient’s record. e 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 should be recalled for several routine periodic follow-up visits over the ensuing year to track the condition of this root. e patient should be instructed to contact the surgeon immediately if any problems develop in the area of the retained root.Multiple ExtractionsIf multiple adjacent teeth are to be extracted at a single sitting, slight modications 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 xed or removable prosthesis. is section discusses those modications.Treatment PlanningIn most situations where multiple teeth are to be removed, preextrac-tion planning with regard to the replacement of the teeth to be removed is necessary. is may be a full or removable partial denture or placement of a single or multiple implants. Before teeth are extracted, the surgeon and the restorative dentist should com-municate and make a determination of the need for such items as an interim partial or immediate full dentures. e discussion should also include a consideration of the need for any other type of soft tissue surgery, such as tuberosity reduction or the removal of undercuts or exostoses in critical areas. If dental implants are to be placed at a later time, it may be desirable also to limit bone trimming and socket compression. In some situations, dental implants may be placed when the teeth are removed, which would require the preparation of a surgical guide stent to assist in appro-priately aligning the implants.Extraction Sequencinge order in which multiple teeth are extracted deserves some discussion. Maxillary teeth should usually be removed rst for several reasons. First, an inltration anesthetic has a more rapid onset and disappears more rapidly. is means that the surgeon can begin the surgical procedure sooner after the injections have been given and that surgery should not be delayed because profound anesthesia is lost more quickly in the maxilla. In addition, maxillary teeth should be removed rst because during the extraction process, debris, such as portions of amalgams, fractured crowns, and bone chips may fall into the empty sockets of the lower teeth if the 158 Part II Principles of ExodontiaA BCD• Fig. 9.51 (A) This patient’s remaining mandibular teeth are to be extracted. The broad zone of attached gingiva is demonstrated in adequate vestibular depth. (B) After adequate anesthesia is achieved, the soft tissue attach-ment to teeth is incised with the No. 15 blade. The incision is carried around the necks of the teeth and through the interdental papilla. (C) The periosteal elevator is used to reect labial soft tissue just to the crest of labioalveolar bone. (D) The small straight elevator is used to luxate teeth before forceps are used. The surgeon’s opposite hand is reecting soft tissue and stabilizing the mandible. Teeth adjacent to the mandibular canine are extracted rst, which makes extraction of the remaining canine tooth easier to accomplish. CHAPTER 9 Principles of More Complex Exodontia 159 FEGHI(E) Rongeur forceps are used to remove only bone that is sharp and protrudes above reapproximated soft tissue. (F) The alveolar plates are compressed rmly together to reestablish the presurgical buccolingual width of the alveolar process. Because an implant may be placed in the future, care should be taken to not overly reduce the alveolar width with compression. Because of mild peri-odontal disease, excess soft tissue is found, which will be trimmed to prevent redundant tissue on the crest of the ridge. (G) After soft tissue has been trimmed and sharp bony projections removed, tissue is checked one nal time for completeness of soft tissue surgery. Tissue is closed with interrupted black silk sutures across the papilla. This approximates soft tissue at the papilla but leaves the tooth socket open. Soft tissue is not mobilized to achieve primary closure because this would tend to reduce the vestibular height. (H–I) The 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 the ridge, similar to that which existed in the preoperative situation (see A). • Fig. 9.51, cont’dsoft tissue is apposed. However, if no redundant tissue exists, the surgeon must not try to gain primary closure over the extraction sockets. If this is done, the depth of the vestibule decreases, which may interfere with denture construction and wear. is also puts the wound closure under tension, violating a cardinal rule of wound repair. Finally, the papillae are sutured into position (see Fig. 9.51G). Interrupted or continuous sutures are used, depending on the preference of the surgeon, with removal planned in about a week (Fig. 9.51H–I) if nonresorbable sutures have been used.In some patients, a more extensive alveoloplasty after multiple extractions is necessary. Chapter 13 has an in-depth discussion of this technique. 16010 Principles of Management of Impacted TeethJAMES R. HUPPCHAPTER OUTLINEIndications for Removal of Impacted Teeth, 161Prevention of Periodontal Disease, 161Prevention of Dental Caries, 162Prevention of Pericoronitis, 162Prevention of Root Resorption, 163Impacted Teeth Under a Dental Prosthesis, 164Prevention of Odontogenic Cysts and Tumors, 164Treatment of Pain of Unexplained Origin, 164Prevention of Jaw Fractures, 164Facilitation of Orthodontic Treatment, 166Optimal Periodontal Healing, 166Contraindications for Removal of Impacted Teeth, 166Extremes of Age, 166Compromised Medical Status, 167Probable Excessive Damage to Adjacent Structures, 167Treatment Planning, 167Classication Systems for Mandibular Third Molar Impactions, 167Angulation, 168Relationship to Anterior Border of Ramus, 169Relationship to the Occlusal Plane, 170Root Morphology, 171Size of the Follicular Sac, 173Density of Surrounding Bone, 173Contact With Mandibular Second Molar, 173Relationship to Inferior Alveolar Nerve, 173Nature of Overlying Tissue, 173Classication Systems for Maxillary Third Molar Impactions, 175Removal of Other Impacted Teeth, 176Surgical Procedure, 177Step 1: Reecting Adequate Flaps for Accessibility, 178Step 2: Removal of Overlying Bone, 178Step 3: Sectioning the Tooth, 180Step 4: Delivery of the Sectioned Tooth With Elevator, 182Step 5: Preparing for Wound Closure, 182Perioperative Patient Management, 183An impacted tooth is one that fails to fully erupt into the dental arch within the usual range of expected time. e tooth becomes impacted because abnormal tooth orientation, adjacent teeth, dense overlying bone, excessive soft tissue, or a genetic abnormality prevents eruption. Because impacted teeth do not erupt, they are retained for the patient’s lifetime unless surgically removed or exposed because of resorption of overlying tissues. e term unerupted teeth includes impacted teeth and teeth that are in the process of developing and erupting.Teeth most often become impacted because of inadequate dental arch length and space in which to erupt; that is, the total length of the alveolar bone arch is smaller than the total length of the tooth arch. e most common impacted teeth are maxillary and mandibular third molars, followed by maxillary canines and mandibular premolars. e third molars are the most frequently impacted because they are the last teeth to erupt; therefore they are the most likely to have inadequate space for complete eruption.In the anterior maxilla, the canine is also commonly prevented from erupting by dental crowding. e canine usually erupts after the maxillary lateral incisor and maxillary rst premolar. If space is inadequate to allow eruption, the canine becomes impacted or erupts labial to the dental arch. In the mandible, a similar situation aects the mandibular premolars because they erupt after the mandibular rst molar and canine. erefore, if room for eruption is inadequate, one of the premolars, usually the second premolar, remains unerupted and becomes impacted or erupts into a buccal or lingual position in relation to the dental arch.As a general rule, all impacted teeth should be removed unless removal is contraindicated. Removal of impacted teeth becomes more dicult with advancing age of the patient. e dentist should typically not recommend that impacted teeth be left in place until they cause diculty. If the impacted teeth are left in place until problems arise, the patient may experience an increased incidence of local tissue morbidity, loss of, or damage to, adjacent teeth and bone, and potential injury to adjacent vital structures. In addition, if the removal of impacted teeth is deferred until problems arise later in life, surgery is more likely to be complicated and hazardous because the patient may have compromising systemic diseases, the surrounding bone becomes denser, and more fully formed roots may grow near structures such as the inferior alveolar nerve or the maxillary sinus.is chapter discusses the management of impacted teeth. is is not a thorough or in-depth discussion of the technical aspects CHAPTER 10 Principles of Management of Impacted Teeth 161 recovering more quickly and with less interference to their daily lives. Periodontal healing is better in younger patients because of better and more complete regeneration of the periodontal tissues on the distal aspect of the second molar. Also, recovery is better in these patients if the nerve is injured. e procedure is more straightforward to perform in younger patients because bone is less dense and root formation is incomplete. e ideal time for removal of impacted third molars is when the roots of teeth are one-third formed and before they are two-thirds formed. is usually occurs during the mid-to-late teenage years, between the ages of 16 and 20.If impacted teeth are left in the alveolar process, it is highly probable that one or more of several problems will result, as discussed below.Prevention of Periodontal DiseaseErupted teeth adjacent to impacted teeth are predisposed to periodontal disease (Figs. 10.1 and 10.2). e mere presence of an impacted mandibular third molar decreases the amount of bone on the distal aspect of an adjacent second molar. Because the most dicult tooth surface to keep clean is the distal aspect of the last of surgical impaction removal. Instead, the goal is to provide the information necessary for proper treatment planning and manage-ment and a basis for predicting the diculty of surgery.Indications for Removal of Impacted Teethe average age for completion of normal eruption of the third molar is 20 years, although eruption may continue in some patients until age 25 years. During normal development, the lower third molar begins in a horizontal angulation, and as the tooth develops and the jaw grows, the angulation changes from horizontal to mesioangular to vertical. Failure of rotation from the mesioangular to the vertical direction is the most common cause of lower third molars becoming impacted. e second major factor is that the mesiodistal dimension of teeth versus the length of the jaw is such that inadequate room exists in the alveolar process anterior to the anterior border of the mandibular ramus to allow the tooth to erupt into position.As noted before, some third molars continue to erupt after age 20 years, particularly in males, coming into nal position by age 25 years. Multiple factors are associated with continued eruption. When late eruption occurs, the unerupted tooth is usually covered with only soft tissue or slightly with bone. ese teeth are almost always in a vertical position and are relatively supercially positioned with respect to the occlusal plane of the adjacent second molar, and the completion of root development is late.Finally, and perhaps most importantly, sucient space needs to exist between the anterior border of the ramus and the second molar to allow eruption. is causative factor of lower third molar impaction is shown most graphically by the nding that many of these teeth do erupt, although typically tipped mesially, if the adjacent second molar is lost while the third molar is developing. Likewise, if the lower third molar does not erupt after age 20 years, it is most likely covered with bone. In addition, the tooth is likely a mesioangular impaction and is located lower in the alveolar process near the cervical level of the adjacent second molar. erefore the dentist can use these parameters to predict whether a tooth will erupt into the arch or remain impacted.Early removal reduces postoperative morbidity and allows for the best healing. Younger patients tolerate the procedure better, • Fig. 10.1 Radiograph of a mandibular third molar impacted against a second molar with bone loss resulting from the presence of a third molar. • Fig. 10.2 Radiographs showing variations of a mandibular third molar impacted against a second molar with severe bone loss resulting from periodontal disease and a third molar. 162 Part II Principles of Exodontiaif the patient experiences even a mild, transient decrease in host defenses, pericoronitis commonly results even if the patient does not have any immunologic problems.Pericoronitis can also arise following repeated trauma from a maxillary third molar. e soft tissue that covers the occlusal surface of the partially erupted mandibular third molar (known as the operculum) can be traumatized and become swollen. Often the maxillary third molar further traumatizes the already swollen operculum, which causes a further increase in swelling that is now traumatized more easily. is spiraling cycle of trauma and swelling is often interrupted only by removal of the maxillary third molar.Another common cause of pericoronitis is entrapment of food under the operculum. During eating, food debris may become lodged into the pocket between the operculum and the impacted tooth. Because this pocket cannot be cleaned, bacteria colonize it, which results in pericoronitis.Streptococci and a large variety of anaerobic bacteria (the usual bacteria that inhabit the gingival sulcus) are the usual cause of pericoronitis. Pericoronitis can be treated initially by mechanically debriding the large periodontal pocket that exists under the operculum by using hydrogen peroxide as an irrigating solution. tooth in the arch, patients commonly have gingival inammation with apical migration of the gingival attachment on the distal aspect of the second molar. With even minor gingivitis, the causative bacteria gain access to a large portion of the root surface, which results in the early formation of periodontitis. Patients with impacted mandibular third molars often have deep periodontal pockets on the distal aspect of the second molars, even though they have normal sulcular depth in the remainder of the mouth.e accelerated periodontal problems resulting from an impacted third molar are especially serious in the maxilla. As a periodontal pocket expands apically, it comes to involve the distal furcation of the maxillary second molar. is occurs relatively early, which makes advancement of the periodontal disease more rapid and severe. In addition, treatment of the localized periodontal disease around the maxillary second molar is more dicult because of the distal furcation involvement.By removing the impacted third molars early, periodontal disease can be prevented, and the likelihood of bony healing and optimal bone ll into the area previously occupied by the crown of the third molar is increased.Prevention of Dental CariesWhen a third molar is impacted or partially impacted, the bacteria and other factors that cause dental caries are commonly exposed to the distal aspect of the second molar as well as to the crown of the impacted third molar. Even in situations in which no obvious communication between the mouth and the impacted third molar is visible, there may be enough communication to allow for caries initiation (Figs. 10.3 to 10.5).Prevention of PericoronitisWhen a tooth is partially impacted with a large amount of soft tissue over the axial and occlusal surfaces, the patient frequently has one or more episodes of pericoronitis. Pericoronitis is an infection of the soft tissue around the crown of a partially impacted tooth and is usually caused by normal oral ora. In most patients, bacteria and host defenses maintain a delicate balance, but even normal host defenses cannot eliminate the bacteria (Fig. 10.6).If host defenses are compromised (e.g., during minor illnesses such as inuenza or an upper respiratory infection or because of immune-compromising drugs), infection can occur. us, although the impacted tooth has been present for some time without infection, • Fig. 10.3 Radiograph of caries in a mandibular second molar resulting from the presence of an impacted third molar. • Fig. 10.4 Radiograph of caries in a mandibular impacted molar. • Fig. 10.5 Radiograph of caries in an impacted third molar and a second molar. CHAPTER 10 Principles of Management of Impacted Teeth 163 Patients who have had one episode of pericoronitis, although managed successfully by these methods, are highly likely to continue to have episodes of pericoronitis unless the oending mandibular third molar is removed. e patient should be informed that the tooth should be removed at the earliest possible time to prevent recurrent infections. However, the mandibular third molar should not be removed until the signs and symptoms of pericoronitis have completely resolved. e incidence of postoperative complica-tions, specically dry socket and postoperative infection, increases if the tooth is removed during the time of active soft tissue infection. More bleeding and slower healing also occur when a tooth is removed in the presence of pericoronitis.Prevention of pericoronitis can be achieved by removing the impacted third molars before they penetrate the oral mucosa and are visible. Although excision of surrounding soft tissue, or operculectomy, has been advocated as a method for preventing pericoronitis without removal of the impacted tooth, it is painful and usually ineffective. The soft tissue excess tends to recur because it drapes over the impacted tooth and causes regrowth of the operculum. e gingival pocket on the distal aspect also remains deep after operculectomy. e overwhelming majority of cases of pericoronitis can be prevented only by extraction of the tooth.Prevention of Root ResorptionOccasionally an impacted tooth causes sucient pressure on the root of an adjacent tooth to cause external root resorption (Fig. 10.7). Although the process by which root resorption occurs is not well understood, it appears to be similar to the resorption process primary teeth undergo during the eruptive process of the succedaneous teeth. Removal of the impacted tooth may result in salvage of the adjacent tooth by cemental repair. Endodontic therapy may be required to save these teeth.Hydrogen peroxide not only mechanically removes bacteria with its foaming action, it also reduces the number of anaerobic bacteria by releasing oxygen into the usually anaerobic environment of the pocket. Other irrigants, such as chlorhexidine or iodophors, can also reduce the bacterial counts of the pocket. Even saline solutions, if delivered regularly with pressure via a syringe, can reduce bacterial numbers and ush away food debris.Pericoronitis can present as a mild infection or as a severe infection that requires hospitalization of the patient. Just as the severity of the infection varies, the treatment and management of this problem vary from mild to aggressive.In its mildest form, pericoronitis presents with localized tissue swelling and soreness. For patients with a mild infection, irrigation and curettage by the dentist and home irrigations by the patient usually suce.If the infection is slightly more severe with a large amount of local soft tissue swelling being traumatized by a maxillary third molar, the dentist should consider immediately extracting the maxillary third molar in addition to local irrigation.For patients who have (in addition to local swelling and pain) mild facial swelling, mild trismus resulting from inammation extending into the muscles of mastication, or a low-grade fever, the dentist should consider administering a systemic antibiotic along with irrigation delivered under pressure and extraction. e antibiotic of choice is penicillin or, in the case of penicillin allergy, clindamycin.Pericoronitis can lead to serious fascial space infections. Because the infection begins in the posterior mouth, it can spread rapidly into the fascial spaces of the mandibular ramus and the lateral neck. If a patient has trismus (with an inability to open the mouth >20 mm), a temperature of greater than 101°F, facial swelling, pain, and malaise, the patient should be referred to an oral-maxillofacial surgeon, who is likely to admit the patient to the hospital for parenteral antibiotic administration, careful monitoring, and surgical extraction.• Fig. 10.6 Pericoronitis in the area of impacted tooth #32 exhibiting classic signs of inammation with erythema and swelling. If opposing tooth #1 is erupted, it commonly impinges on this area of swelling when teeth are brought into occlusion, causing even more pain and swelling. 164 Part II Principles of Exodontiadenture may compress the soft tissue onto the impacted tooth, which is no longer covered with bone; the result is ulceration of the overlying soft tissue and the initiation of an odontogenic infection (Fig. 10.8).Impacted teeth should be removed before a prosthesis is con-structed because if the impacted teeth must be removed after construction, the alveolar ridge may be so altered by the extraction that the prosthesis becomes less functional (Fig. 10.9). In addition, if removal of impacted teeth in edentulous areas is achieved before the prosthesis is made, the patient is probably in good physical condition. If ulceration with infection occurs while waiting until the overlying bone has resorbed, it does not produce a favorable situation for extraction. If extraction is postponed, the patient will be older and more likely to be in poorer health.Furthermore, the mandible may have become atrophic, which increases the likelihood of fracture during tooth removal (Fig. 10.10). Also, if implants are planned near the position of impacted teeth, removal is warranted to eliminate the risk of interference with the implantation procedure.Prevention of Odontogenic Cysts and TumorsWhen impacted teeth are completely within the alveolar process, the associated follicular sac is also frequently retained. Although the dental follicle maintains its original size in most patients, it may undergo cystic degeneration and become a dentigerous cyst. If the patient is closely monitored, the dentist can diagnose the cyst before it reaches large proportions (Fig. 10.11). However, unmonitored cysts can reach enormous sizes (Fig. 10.12). As a general guideline, if the follicular space around the crown of the tooth is greater than 3 mm, the preoperative diagnosis of a dentiger-ous cyst is reasonable.In the same way that odontogenic cysts can occur around impacted teeth, odontogenic tumors can arise from the epithelium contained within the dental follicle. e most common odontogenic tumor to occur in this region is the ameloblastoma. Usually, ameloblastomas in this area must be treated aggressively by excision of the overlying soft tissue and of at least a portion of the mandible. Occasionally, other odontogenic tumors may occur in conjunction with impacted teeth (Fig. 10.13).Although the overall incidence of odontogenic cysts and tumors around impacted teeth is not high, the overwhelming majority of pathologic conditions of the mandibular third molar are associated with unerupted teeth.Treatment of Pain of Unexplained OriginOccasionally, patients come to the dentist complaining of pain in the retromolar region of the mandible, but the reason for the pain may not be obvious. If conditions such as myofascial pain dysfunc-tion syndrome and other facial pain disorders are excluded, and if the patient has an unerupted tooth, removal of the tooth sometimes results in resolution of the pain. In addition, delaying third molar removal to a later age may increase the chances of temporomandibular disorders.Prevention of Jaw FracturesAn impacted third molar in the mandible occupies space that is usually lled with bone. is weakens the mandible and renders the jaw more susceptible to fracture at the site of the impacted tooth (Fig. 10.14). If the jaw fractures through the area of an Impacted Teeth Under a Dental ProsthesisWhen a patient has an edentulous area restored, there are several reasons for removing impacted teeth in the area before the prosthetic appliance is constructed. After teeth are extracted, the alveolar process slowly undergoes resorption. is is particularly true with tissue-borne prostheses. us the impacted tooth becomes closer to the surface of the bone, giving the appearance of erupting. e BA• Fig. 10.7 (A) Root resorption of a second molar as result of an impacted third molar. (B) Root resorption of maxillary lateral incisors as a result of an impacted canine. CHAPTER 10 Principles of Management of Impacted Teeth 165 • Fig. 10.8 Impacted canine retained under a denture. The tooth is now at the surface and is causing infection. • Fig. 10.9 Impacted tooth under a xed bridge. The tooth must be removed and therefore may jeopardize the bridge. • Fig. 10.10 Impaction in an atrophic mandible, which may result in jaw fracture during extraction. • Fig. 10.11 Small dentigerous cyst arising around an impacted tooth. • Fig. 10.12 Large dentigerous cyst that extends from the coronoid process to the mental foramen. The cyst has displaced the impacted third molar to the inferior border of the mandible. 166 Part II Principles of Exodontiato the two primary parameters of periodontal health after third molar surgery: (1) bone height and (2) periodontal attachment level on the distal aspect of the second molar.Recent studies have provided information on which to base the likelihood of optimal periodontal tissue healing. Two most important factors that have been shown are (1) the extent of the preoperative infrabony defect on the distal aspect of the second molar and (2) the patient’s age at the time of surgery. If a large amount of distal bone is missing because of the presence of the impacted tooth and its associated follicle, it is less likely that the infrabony pocket can be decreased. Likewise, if the patient is older, the likelihood of optimal bony healing is decreased. Patients whose third molars are removed before age 25 years are more likely to have better bone healing than those whose impacted teeth are removed after age 25 years. In the younger patient, not only is the initial periodontal healing better, but also the long-term continued regeneration of the periodontium is clearly better.As mentioned previously, unerupted teeth may continue to erupt until age 25 years. Because the terminal portion of the eruption process occurs slowly, the chance of developing pericoronitis increases and so does the amount of contact between the third molar and the second molar. Both of these factors decrease the possibility for optimal periodontal healing. However, it should be noted that the asymptomatic completely bony impacted third molar in a patient older than age 30 years should probably be left in place unless some specic pathologic condition develops. Removal of such asymptomatic completely impacted third molars in older patients clearly results in pocket depths and alveolar bone loss, which are greater than if the tooth were left in place.Contraindications for Removal of Impacted TeethAll impacted teeth should be removed unless specic contraindica-tions justify leaving them in position. When the potential benets outweigh the potential complications and risks, the procedure should be performed. Similarly, when the risks are greater than the potential benets, the procedure should be deferred.Contraindications for the removal of impacted teeth primarily involve the patient’s physical status.Extremes of Agee third molar tooth bud can be radiographically visualized by age 6 years. Some surgeons think that removal of the tooth bud at age 7 to 9 years can be accomplished with minimal surgical morbidity and therefore should be performed at this age. However, most surgeons believe that it is not possible to accurately predict if the forming third molar will be impacted. e consensus is that very early removal of third molars should be deferred until an accurate diagnosis of impaction can be made.e most common contraindication for the removal of impacted teeth is advanced age. As a patient ages, the bone becomes highly calcied and, therefore, less exible and less likely to bend under the forces of tooth extraction. e result is that more bone must be surgically removed to elevate the tooth from its socket.Similarly, as patients age, they respond less favorably and with more postoperative sequelae. An 18-year-old patient may have 1 or 2 days of discomfort and swelling after the removal of an impacted tooth, whereas a similar procedure may result in a 4- or 5-day recovery period for a 50-year-old patient.• Fig. 10.13 Ameloblastoma associated with the crown of an impacted third molar. (Courtesy Dr. Frances Gordy.)• Fig. 10.14 Fracture of a mandible, which occurred through the location of an impacted third molar. impacted third molar, the impacted third molar is frequently removed before the fracture is reduced, and xation is applied (see Chapter 24).Facilitation of Orthodontic TreatmentWhen patients require retraction of rst and second molars by orthodontic techniques, the presence of impacted third molars may interfere with the treatment. erefore it is recommended that impacted third molars be removed before orthodontic therapy is begun.Some orthodontic approaches to a malocclusion might benet from the placement of retromolar implants to provide distal anchorage. When this is planned, removal of impacted lower third molars is necessary.Optimal Periodontal HealingAs noted before, one of the most important indications for removal of impacted third molars is to preserve the periodontal health of the adjacent second molar. A great deal of attention has been given CHAPTER 10 Principles of Management of Impacted Teeth 167 Treatment Planninge preceding discussion of indications and contraindications for the removal of impacted third molars has been designed to point out that there are various risks and benets in removing impacted teeth in patients. Patients who have one or more pathologic symptoms or problems should have their impacted teeth removed. Most of the symptomatic, pathologic problems that result from impacted third molars occur because of partially erupted teeth and occur less commonly with complete bony impaction.However, what should be done with impacted teeth before they cause symptoms or problems is less clear. In making a decision as to whether an impacted third molar should be removed, one must consider a variety of factors. First, the available room in the arch into which the tooth can erupt must be considered. If adequate room exists, the clinician may choose to defer removal of the tooth until eruption is complete. Second, the status of the impacted tooth and the age of the patient should be considered. It is critical to remember that the average age of complete eruption is 20 years but that eruption may continue to occur up to age 25 years. Occasionally, a tooth that appears to be a mesioangular impaction at age 17 years may eventually become more vertical and erupt into the mouth. Also, if the patient’s second molar is seriously diseased and is likely to require removal, it may be wise to leave the third molar in place; if the second molar is removed, the stair molar can often be guided into good occlusion. If insucient room exists to accommodate the tooth and a soft tissue operculum exists over the posterior aspect, then pathologic sequelae are likely to occur.Although there have been some attempts at making very early predictions of whether a tooth is going to be impacted, these eorts have not yet resulted in a reliable predictive model. However, by the time the patient reaches age 18 years, the dentist can reason-ably predict whether there will be adequate room for tooth eruption with sucient clearance of the anterior ramus to prevent soft tissue operculum formation. At this time, if surgical removal is chosen, soft tissue and bone tissue healing will occur at its maximal level. At age 18 or 19 years, if the diagnosis for inadequate room for functional eruption can be made, then the asymptomatic third molar can be removed, and the long-term periodontal health of the second molar will be optimized.Classication Systems for Mandibular Third Molar ImpactionsRemoval of impacted teeth can be relatively straightforward or extremely dicult, even for the experienced surgeon. To determine the degree of diculty preoperatively, the surgeon should methodi-cally examine the clinical circumstances. The primary factor determining the diculty of the removal is accessibility. Accessibility is determined by adjacent teeth or other structures impairing access or the extraction delivery pathway. is includes assessing the ease of exposing the tooth, preparing a pathway for its delivery, and preparing a purchase point. With careful classication of the impacted teeth using a variety of systems, the surgeon can approach the proposed surgery in a methodical fashion and predict whether any extraordinary surgical approaches will be necessary or if the patient will encounter certain postoperative problems.e majority of classication schemes are based on an analysis of a radiograph. e panoramic radiograph is the imaging of choice for planning removal of impacted third molars. In some Finally, if a tooth has been retained in the alveolar process for many years without periodontal disease, caries, or cystic degenera-tion, it is unlikely that these unfavorable sequelae will occur. erefore, in an older patient (usually >35 years) with an impacted tooth that shows no signs of disease and that has a radiographically detectable layer of overlying bone, the tooth should not be removed (Fig. 10.15). e dentist caring for the patient should check the impacted tooth radiographically every 1 or 2 years to ensure that no adverse sequelae have occurred.If the impacted tooth shows signs of cystic formation or periodontal disease involving the adjacent tooth or the impacted tooth, if it is a single impacted tooth underneath a prosthesis with thin overlying bone, or if it becomes symptomatic as the result of infection, the tooth should be removed.Compromised Medical StatusA compromised medical status may contraindicate the removal of an impacted tooth. Frequently, compromised medical status and advancing age go hand in hand. If the impacted tooth is asymp-tomatic, its surgical removal must be viewed as elective. If the patient’s cardiovascular or respiratory function or host defenses for combating infection are seriously compromised, or if the patient has a serious acquired or congenital coagulopathy, the surgeon should consider leaving the tooth in the alveolar process. However, if the tooth becomes symptomatic, the surgeon should consider working with the patient’s physician to plan removal of the tooth with minimal operative and postoperative medical sequelae.Probable Excessive Damage to Adjacent StructuresIf the impacted tooth lies in an area in which its removal may seriously jeopardize adjacent nerves, teeth, or previously constructed bridges, it may be prudent to leave the tooth in place. When the dentist makes the decision not to remove a tooth, the reasons must be weighed against potential future complications. In the case of younger patients who may suer the sequelae of impacted teeth, it may be wise to remove the tooth while taking special measures to prevent damage to adjacent structures. However, in the case of the older patient with no signs of impending complications and for whom the probability of such complications is low, the impacted tooth should not be removed. A classic example of such a case is the older patient with a potentially severe periodontal defect on the distal aspect of the second molar but in whom removal of the third molar would almost surely result in the loss of the second molar. In this situation the impacted tooth should not be removed.• Fig. 10.15 Impacted maxillary right third molar in a 63-year-old patient. This molar should not be extracted because it is deeply embedded and no signs of disease are present. 168 Part II Principles of Exodontiaof the adjacent second molar. Teeth at certain inclinations have ready-made pathways for removal, whereas pathways for teeth of other inclinations require the removal of substantial amounts of bone and/or tooth division. is classication system provides an initial useful evaluation of the diculty of extractions but is not sucient by itself to fully dene the diculty of molar removal.e impaction generally acknowledged as the least dicult impaction to remove is the mesioangular impaction, particularly when only partially impacted (Fig. 10.16). e crown of the mesioangular-impacted tooth is tilted toward the second molar in a mesial direction. is type of impaction is the most commonly seen, making up approximately 43% of all impacted lower third molars.When the long axis of the third molar is perpendicular to the second molar, the impacted tooth is considered horizontal (Fig. 10.17). is type of impaction is usually considered more dicult to remove compared with mesioangular impaction. Horizontal impactions occur less frequently, being seen in approximately 3% of all mandibular impactions.In vertical impaction, the long axis of the impacted tooth runs parallel to the long axis of the second molar. is impaction occurs circumstances, a well-positioned periapical radiograph is adequate as long as all parts of the impacted tooth are visible along with important adjacent anatomy. When the roots of a lower third molar appear very close to, or superimpose over, the inferior alveolar canal on a panoramic radiograph, a cone-beam computed tomog-raphy (CT) scan may be useful. is imaging technique can accurately show the relationship of the roots to the canal.For each patient, the surgeon should carefully analyze the factors discussed in this section. By considering all of these factors, the dentist can assess the diculty of the surgery and elect to extract the impacted teeth that are within his or her skill level. However, for the patient’s well-being and the dentist’s peace of mind, the patient should be referred to a specialist if a tooth presents a dicult surgical situation or if the dentist cannot oer optimal intraoperative pain and anxiety control.Angulatione most commonly used classication system with respect to treatment planning uses a determination of the angulation of the long axis of the impacted third molar with respect to the long axis AB• Fig. 10.16 (A) Mesioangular impaction—the most common and easiest impaction to remove. (B) Mesio-angular impaction is usually in proximity to the second molar. AB• Fig. 10.17 (A) Horizontal impaction—an uncommon and more difcult to remove impaction than a mesioangular impaction. (B) The occlusal surface of the horizontal impacted third molar is usually imme-diately adjacent to the root of the second molar, which often produces early severe periodontal disease. CHAPTER 10 Principles of Management of Impacted Teeth 169 still makes a buccal approach appropriate, even when the tooth is inclined toward the lingual aspect.Rarely, a transverse impaction occurs; that is, the tooth erupting in an absolutely horizontal position in the buccolingual direction. e occlusal surface of the tooth can face the buccal or lingual direction. To determine buccal or lingual version accurately, the dentist must take a perpendicular occlusal radiograph or obtain a cone-beam CT scan. However, this determination is usually not necessary because the surgeon can make this identication early in the operation, and the buccal or lingual position of the tooth does not greatly inuence the approach to the surgery.Relationship to Anterior Border of RamusAnother method for classifying impacted mandibular third molars is based on the amount of impacted tooth that is covered with the bone of the mandibular ascending ramus. is classication is known as the Pell and Gregory classication, also referred to as Pell and Gregory classes 1, 2, and 3. For this classication, it is important that the surgeon carefully examine the relationship with the second greatest frequency, accounting for approximately 38% of all lower third molar impactions, and is considered third in ease of removal (Fig. 10.18).Finally, distoangular impaction involves the tooth with the most dicult angulation for removal (Fig. 10.19). In distoangular impaction the long axis of the third molar is distally or posteriorly angled away from the second molar. is impaction is the most dicult to remove because the tooth has a withdrawal pathway that runs into the mandibular ramus, and its removal requires signicant surgical intervention. Distoangular impactions occur uncommonly and account for only approximately 6% of all impacted third molars. Erupted third molars may also be in a distoangular position. When this occurs, these teeth are much more dicult to remove compared with other erupted teeth. e reason is that the third molar’s mesial root is very close to the root of the second molar.In addition to the relationship between the angulation of the long axes of the second and third molars, teeth also can be angled in buccal, lingual, or palatal directions. When approaching lower third molars, the possible presence of a high-riding lingual nerve AB• Fig. 10.18 (A) Vertical impaction—the second most common impaction and the second most difcult to remove. (B) Vertical impaction is frequently covered on its posterior aspect with bone of the anterior ramus of the mandible. AB• Fig. 10.19 (A) Distoangular impaction—an uncommon and the most difcult of the four types of impac-tions to remove. (B) The occlusal surface of distoangular impaction is usually embedded in the ramus of the mandible and requires signicant bone removal for extraction. 170 Part II Principles of Exodontiadetermining the diculty of impaction removal. is classication system was also suggested by Pell and Gregory and is called the Pell and Gregory A, B, and C classication. In this classication the degree of diculty is measured by the thickness of overlying bone; that is, the degree of diculty increases as the depth of the impacted tooth increases. As the tooth becomes less accessible and it becomes more dicult to section the tooth and to prepare purchase points, the overall diculty of the operation substantially increases.A class A impaction is one in which the occlusal surface of the impacted tooth is level or nearly level with the occlusal plane of the second molar (Fig. 10.23). A class B impaction involves an impacted tooth with an occlusal surface between the occlusal plane and the cervical line of the second molar (Fig. 10.24). Finally, the class C impaction is one in which the occlusal surface of the impacted tooth is below the cervical line of the second molar (Fig. 10.25).e three classication systems discussed above can be used together to determine the diculty of an extraction. For example, a mesioangular impaction with a class 1 ramus and a class A depth is usually straightforward to remove (Fig. 10.26). However, as the ramus relationship changes to a class 2 and the depth of the impaction increases to a class B, the degree of diculty becomes • Fig. 10.20 Pell and Gregory class 1 impaction. The mandibular third molar has sufcient anteroposterior room (i.e., anterior-to-anterior border of ramus) to erupt. • Fig. 10.21 Pell and Gregory class 2 impaction. Approximately half is covered by the anterior portion of the ramus of the mandible. • Fig. 10.22 Pell and Gregory class 3 impaction. The impacted third molar is completely embedded in the bone of the ramus of the mandible. • Fig. 10.23 Pell and Gregory class A impaction. The occlusal plane of the impacted tooth is at the same level as the occlusal plane of the second molar. between the tooth and the anterior part of the ramus. If the mesiodistal diameter of the crown is completely anterior to the anterior border of the mandibular ramus, it is in a class 1 relation-ship. If the tooth is angled in a vertical direction, the chances for the tooth to erupt into a normal position are good, provided the root formation is incomplete (Fig. 10.20).If the tooth is positioned posteriorly so that approximately one half is covered by the ramus, the relationship of the tooth with the ramus is class 2. In the class 2 situation, the tooth cannot erupt completely free from bone over the crown and the distal aspect because a small shelf of bone overlies the distal portion of the tooth (Fig. 10.21). A class 3 relationship between the tooth and ramus occurs when the tooth is located completely within the mandibular ramus (Fig. 10.22). Obviously the class 1 relationship provides the greatest accessibility to the impacted tooth; therefore such a tooth is the most straightforward to remove. e class 3 relationship provides the least accessibility and thus presents the greatest diculty.Relationship to the Occlusal Planee depth of the impacted tooth compared with the height of the adjacent second molar provides the next classication system for CHAPTER 10 Principles of Management of Impacted Teeth 171 much greater. A horizontal impaction with a class 2 ramus relation-ship and a class B depth is a moderately dicult extraction and one that most experienced general practitioners do not want to attempt (Fig. 10.27). Finally, the most dicult of all impactions is a distoangular impaction with a class 3 ramus relationship at a class C depth. Even specialists view removing this tooth as a surgical challenge (Fig. 10.28).Root MorphologyJust as the root morphology of the erupted tooth has a strong inuence on the degree of diculty of a closed extraction, root morphology plays a major role in determining the degree of diculty of the removal of an impacted tooth. Several factors must be considered when assessing the morphologic array of the root.e rst consideration is the length of the root. As previously discussed, the optimal time for the removal of an impacted tooth is when the root is one-third to two-thirds formed. When this is the case, the ends of the roots are blunt (Fig. 10.29). If the tooth is not removed during the formative stage and the entire length • Fig. 10.24 Pell and Gregory class B impaction. The occlusal plane of the impacted tooth is between the occlusal plane and the cervical line of the second molar. • Fig. 10.25 Pell and Gregory class C impaction. The impacted tooth is below the cervical line of the second molar. • Fig. 10.26 Mesioangular impaction with class 1 ramus relationship and class A depth. All three classications make this the easiest type of impac-tion to remove. • Fig. 10.27 Horizontal impaction with class 2 ramus relationship and class B depth makes it moderately difcult to extract. • Fig. 10.28 Impaction with a distoangular class 3 ramus relationship and class C depth makes the tooth extremely difcult to remove safely. 172 Part II Principles of Exodontiae direction of the tooth root curvature is also important to examine preoperatively. During removal of a mesioangular impac-tion, roots that are curved gently in the distal direction (following along the pathway of extraction) can be removed without the force that can fracture them. However, if the roots of a mesioangular impaction are straight or curved mesially, the roots commonly fracture if the tooth is not sectioned before being delivered.e total width of the roots in the mesiodistal direction should be compared with the width of the tooth at the cervical line. If the tooth root width is greater, the extraction will be more dicult. More bone must be removed, or the tooth should be sectioned before extraction.Finally, the surgeon should assess the periodontal ligament space. Although the periodontal ligament space is of normal dimensions in most patients, sometimes it is wider or narrower. e wider the periodontal ligament space, typically the more straightforward the tooth is to remove (Fig. 10.33). However, older patients, especially those older than 40 years, tend to have a much narrower periodontal ligament space that increases the diculty of the extraction.• Fig. 10.29 Roots that are two-thirds formed, which are less difcult to remove than if fully formed. • Fig. 10.30 Lack of root development. If extraction is attempted, the crown will often roll around in the socket, making it difcult to remove. • Fig. 10.31 Fused roots with a conical shape. • Fig. 10.32 Divergent roots with severe curvature. Such roots are more difcult to remove. of the root develops, the possibility increases for distorted root morphology, leading to fracture of the root tips during extraction or to the root tips impeding root delivery. If the root development is limited (i.e., less than one-third complete), the tooth is often more dicult to remove because it tends to roll in its socket like a marble, which prevents routine elevation (Fig. 10.30). e next factor to be assessed is whether the roots are fused into a single, conical root (Fig. 10.31) or whether they are separate and distinct roots. e fused, conical roots are more straightforward to remove than are widely separated roots (Fig. 10.32).e curvature of the tooth roots also plays a role in the diculty of the extraction. Severely curved or dilacerated roots are more dicult to remove than are straight or slightly curved roots (see Fig. 10.32). e surgeon should carefully examine the apical area of impacted teeth on the radiograph to assess the presence of small, abnormal, and sharply hooked roots that will probably fracture if the surgeon does not give them special consideration. Even with extra focus during surgery, hooked roots are a challenge to remove. CHAPTER 10 Principles of Management of Impacted Teeth 173 to be pliable, and expands and bends somewhat, which allows the socket to be expanded by elevators or by luxation forces applied to the tooth itself. In addition, the less dense bone is more straightforward to cut with a dental burr and can be removed more rapidly compared with denser bone.Conversely, patients who are older than 25 years have much denser bone with decreased exibility and ability to expand. In these patients the surgeon must remove all interfering bone because it is not possible to expand the bony socket. In addition, as the bone increases in density, it becomes more dicult to remove with a dental burr, and the bone removal process takes longer. Also, excessive force is more likely to fracture very dense bone compared with less dense bone of a similar cross-section.Gender also plays a role in bone density; males, particularly larger ones, in general have greater bone density than females.Contact With Mandibular Second MolarIf space exists between the second molar and the impacted third molar, the extraction will be more straightforward to approach because damage to the second molar is less likely. However, if the tooth is a distoangular or horizontal impaction, it is frequently in direct contact with the adjacent second molar. To remove the third molar safely without injuring the second molar, the surgeon must be cautious with pressure from elevators and with the burr when removing bone. If the second molar has caries or a large restoration or has been endodontically treated, the surgeon must take special care not to fracture the restoration or a portion of the carious crown. e patient should be forewarned of this possibility (see Fig. 10.17B).Relationship to Inferior Alveolar NerveImpacted mandibular third molars frequently have roots that are superimposed on the inferior alveolar canal on radiographs. Although the canal is usually on the buccal aspect of the tooth, it is still in proximity to the roots. erefore one of the potential sequelae of impacted third molar removal is damage to the inferior alveolar nerve. is commonly results in some altered sensation (paresthesia or anesthesia) of the lower lip and chin on the injured side. Although this altered sensation is usually brief (lasting only a few days), it may extend for weeks or months; on rare occa-sions it can be permanent. e duration depends on the extent of nerve damage. If the root ends of the tooth appear to be close to the inferior alveolar canal on a radiograph, the surgeon must take special care to avoid injuring the nerve (Fig. 10.35), which greatly increases the diculty of the procedure. e availability of cone-beam CT scans makes preoperative assessment of the root and canal relationship much easier to view, which helps guide surgical decisions.Nature of Overlying Tissuee preceding systems classify factors that make third molar extraction more straightforward or more dicult. e classication system discussed below does not t into these categories. However, this classication is the system used by most dental insurance companies and is the one by which the surgeon charges for the services.e dental insurance companies separate types of third molar impactions into three categories: (1) soft tissue, (2) partial bony, and (3) full bony. An impaction is dened as soft tissue impaction Size of the Follicular Sace size of the follicle around the impacted tooth can help determine the diculty of the extraction. If the follicular sac is wide (almost cystic in size), much less bone must be removed, which makes the tooth more straightforward to extract (Fig. 10.34). (Young patients are more likely to have large follicles, which is another factor that makes extractions less complex in younger patients.) However, if the follicular space around the crown of the tooth is narrow or nonexistent, the surgeon must create space around the crown, increasing the diculty of the procedure and the time required to remove the tooth.Density of Surrounding Bonee density of bone surrounding the tooth plays a role in determin-ing the diculty of the extraction. Although some clues can be seen on the radiographs, variations in radiographic density and angulation render bone density interpretations based on radiographs unreliable. Bone density is best determined by the patient’s age. Patients who are 25 years old or younger have bone densities favorable for tooth removal. e bone is less dense, is more likely • Fig. 10.33 Wide periodontal ligament space. The widened space makes the extraction process less difcult. • Fig. 10.34 Large follicular sac. When the space of the sac is large, the amount of bone removal required is decreased. 174 Part II Principles of Exodontiawhen the height of the contour of the tooth is above the level of alveolar bone and the supercial portion of the tooth is covered only by soft tissue (Fig. 10.36). To remove soft tissue impaction, the surgeon must incise the soft tissue and reect a soft tissue ap to obtain access to the tooth to elevate it from its socket. e soft tissue impaction is usually the most straightforward of the three extractions but can be complex, depending on factors discussed in the preceding sections.e partial bony impaction occurs when the supercial portion of the tooth is covered by soft tissue, but at least a portion of the height of the contour of the tooth is below the level of the sur-rounding alveolar bone (Fig. 10.37). To remove the tooth, the surgeon must incise the soft tissue, reect a soft tissue ap, and remove the bone above the height of the contour. e surgeon may need to divide the tooth in addition to removing bone. A partial bony impacted tooth is commonly more dicult to remove than a full bony impacted third molar.e complete bony impaction is an impacted tooth that is completely encased in bone, so the tooth is not visible when the surgeon reects the soft tissue ap (Fig. 10.38). To remove the tooth, extensive amounts of bone must be removed, and the tooth almost always requires sectioning.AB• Fig. 10.35 (A) Radiographic view of the mandibular third molar that sug-gests proximity to the inferior alveolar nerve. (B) Hole through the root of the third molar seen in the radiograph after removal. During removal, the inferior alveolar neurovascular bundle was severed. (Courtesy Dr. Edward Ellis III.)• Fig. 10.36 Soft tissue impaction in which the crown of the tooth is covered by soft tissue only and can be removed without bone removal. • Fig. 10.37 Partial bony impaction in which part of the tooth—usually a posterior aspect—is covered with bone and requires bone removal or tooth sectioning for extraction. CHAPTER 10 Principles of Management of Impacted Teeth 175 information available to determine the diculty of the proposed surgery.Classication Systems for Maxillary Third Molar Impactionse classication systems for the maxillary impacted third molar are essentially the same as for the impacted mandibular third molar. However, several distinctions and additions must be made to more accurately assess the diculty of removal during the treatment planning phase of the procedure.Concerning angulation, the three types of maxillary third molars are (1) vertical impaction (Fig. 10.39A), (2) distoangular impaction (Fig. 10.39B), and (3) mesioangular impaction (Fig. 10.39C). Vertical impaction occurs approximately 63% of the time, dis-toangular impaction approximately 25% of the time, and mesio-angular impaction approximately 12% of the time. Rarely, other positions such as a transverse, inverted, or horizontal are encountered; these unusual positions account for less than 1% of impacted maxillary third molars.e same angulations in mandibular third molar extractions cause opposite degrees of diculty for maxillary third molar extractions. Vertical and distoangular impactions are the less complex to remove, whereas mesioangular impactions are the most dicult (exactly the opposite of impacted mandibular third molars). Mesioangular impactions are more dicult to remove because the bone that overlies the impaction and requires removal or expansion is on the posterior aspect of the tooth and is much thicker than in vertical or distoangular impaction. In addition, access to the mesioangularly positioned tooth is more dicult if an erupted second molar is in place.e position of the maxillary third molar in a buccopalatal direction is also important for determining the diculty of the removal. Most maxillary third molars are angled toward the buccal aspect of the alveolar process; this makes the overlying bone in that area thin and therefore straightforward to remove or expand. Occasionally the impacted maxillary third molar is positioned toward the palatal aspect of the alveolar process. is makes the tooth much more dicult to extract because greater amounts of bone must be removed to gain access to the underlying tooth, and an approach from the palatal aspect risks injury to nerves and vessels of the palatine foramina. A combination of radiographic assessment and clinical digital palpation of the tuberosity area can usually help determine whether the maxillary third molar is in the buccopalatal position. If the tooth is positioned toward the buccal aspect, a palpable bulge is found in the area; if the tooth is palatally positioned, a bony decit is found in that region. If a more palatal position is determined by clinical examination, the surgeon must anticipate a longer, more involved procedure.e most common factor that causes diculty with maxillary third molar removal is a thin, nonfused root with erratic curvature (Fig. 10.40). e majority of maxillary third molars have fused roots that are conical. However, the surgeon should carefully examine the preoperative radiograph to ensure that an unusual root pattern is not present. e surgeon should also check the periodontal ligament because the wider the ligament space, the less dicult the tooth is to remove. In addition, similar to mandibular third molars, the periodontal ligament space tends to narrow as the patient ages.e follicle surrounding the crown of the impacted tooth also has an inuence on the diculty of the extraction. If the follicular Although this classication is extensively used, it frequently has no relationship to the diculty of the extraction or to the likelihood of complications (Boxes 10.1 and 10.2). e parameters of angulation, ramus relationship, root morphology, and patient age are more relevant to treatment planning than the system used by third-party dental insurers. e surgeon must use all of the • Fig. 10.38 Complete bony impaction in which the tooth is completely covered with bone and requires extensive removal of bone for extraction. 1. Mesioangular position2. Pell and Gregory class 1 ramus3. Pell and Gregory class A depth4. Roots one-third to two-thirds formeda5. Fused conical roots6. Wide periodontal ligamenta7. Large folliclea8. Elastic bonea9. Separated from second molar10. Separated from inferior alveolar nervea11. Soft tissue impactionFactors That Make Impaction Surgery Less Dicult• BOX 10.1 aPresent in the young patient.1. Distoangular position2. Pell and Gregory class 2 or 3 ramus3. Pell and Gregory class B or C depth4. Long, thin rootsa5. Divergent, curved roots6. Narrow periodontal ligament7. Thin folliclea8. Dense, inelastic bonea9. Contact with second molar10. Close to inferior alveolar canal11. Complete bony impactionaFactors That Make Impaction Surgery More Dicult• BOX 10.2 aPresent in older patients. 176 Part II Principles of ExodontiaTwo additional factors inuence the diculty of maxillary third molar removal but do not exist for mandibular third molars. Both factors are related to the structure and position of the maxillary sinus. First, the maxillary sinus is commonly in intimate contact with the roots of molars; and, frequently, the maxillary third molar actually forms a portion of the posterior sinus wall. If this is the case, removal of the maxillary third molar may result in maxillary sinus complications such as sinusitis or an oroantral stula. e presence of the maxillary sinus does not necessarily make the removal of the impacted tooth more dicult, but it increases the likelihood of postoperative complications.Second, in maxillary third molar removal, the tuberosity of the posterior maxilla can be fractured. is is true even when the third molar is erupted or if an erupted second molar is the most distal remaining tooth. Such fractures are possible, especially when dense and nonelastic bone exists, as in older patients. In addition, a large maxillary sinus makes the surrounding alveolar bone thin and more susceptible to fracture when excessive force is applied. A root morphology that has divergent roots requires greater force to remove and increases the likelihood of bone fracture. In addi-tion, mesioangular impactions increase the possibility of fractures (see Fig. 10.39C). In these situations, the overlying tuberosity is heavier, but the surrounding bone is usually thinner. When the surgeon prepares a purchase point at the mesiocervical line, fracture of the tuberosity becomes a greater risk if (1) the bone is nonelastic (as in older patients), (2) the tooth is multirooted with large bulbous roots (as in older patients), (3) the maxillary sinus is large and greatly pneumatized to include the roots of the impacted third molar, or (4) the surgeon uses excessive force to elevate the tooth. Management of the fractured tuberosity is discussed in Chapter 25.Removal of Other Impacted TeethAfter mandibular and maxillary third molars, the next most com-monly impacted tooth is the maxillary canine.If the dentist decides that the tooth needs to be removed rather than orthodontically repositioned, it must be determined whether the tooth is positioned labially, toward the palate, or in the middle of the alveolar process. If the tooth is on the labial aspect, a soft tissue ap can be reected to allow removal of the overlying bone and the tooth. However, if the tooth is on the palatal aspect or in the intermediate buccolingual position, it is much more dicult to remove. erefore, when assessing the impacted maxillary canine for removal, the surgeon’s most important assessment is of the space is broad, the tooth will be more readily removed than if the follicular space is thin or nonexistent.Bone density is also an important factor in maxillary impaction removal and is closely related to the age of the patient. e younger the patient, the more elastic and expandable the bone is surrounding the impacted third molar.e relationship to the adjacent second molar tooth also inu-ences the diculty of the extraction. Extraction may require that additional bone be removed to displace the tooth tucked under the height of the contour of the closely adjacent second molar. In addition, because the use of elevators is common in the removal of maxillary third molars, the surgeon must be aware of the existence of large restorations or caries in the adjacent second molar. Injudi-cious use of elevators can result in the fracture of restorations or brittle crowns of teeth.e type of impaction, with respect to overlying tissue, also must be considered for maxillary third molars. e insurance industry classication system used for maxillary teeth is the same as the system that is used for mandibular teeth: soft tissue impaction, partial bony impaction, and complete bony impaction. e deni-tions of these types of impactions are precisely the same as those used for mandibular third molars.ABC• Fig. 10.39 (A) Vertical impaction of a maxillary third molar. This angle accounts for 63% of impactions. (B) Distoangular impaction of a maxillary third molar. This angle accounts for 25% of impactions. (C) Mesioangular impaction of a maxillary third molar. This angle accounts for 12% of impactions. • Fig. 10.40 The maxillary third molar has the most erratic and variable root formation of all teeth. CHAPTER 10 Principles of Management of Impacted Teeth 177 tissue with keratinized tissue. As the tooth is pulled into place with orthodontic appliances, soft tissue surrounding the newly positioned tooth should have adequate keratinized tissue, and the tooth should be in an ideal position.If the tooth is positioned toward the palatal aspect, it may be repositioned or removed. If the tooth is repositioned, it is surgically exposed and guided into position orthodontically. In this procedure the overlying soft tissue is excised; aps are not needed to gain attached tissue. Because the bone in the palate is thicker, a burr is usually necessary to remove the overlying bone. e exposed tooth then is managed in the same manner as is the labially positioned tooth (Fig. 10.41).Surgical Proceduree principles and steps for removing impacted teeth are the same as for other surgical extractions. Five basic steps make up the technique. (1) e rst step is to have adequate exposure of the area of the impacted tooth. is means that the reected soft tissue ap must have adequate dimensions to allow retraction of the soft tissue to safely perform the necessary surgery without seriously damaging the ap. (2) e second step is to assess the need for buccolingual position of the tooth. A cone-beam CT is the best way to make this assessment.Similar considerations are necessary for other impactions such as those of mandibular premolars and supernumerary teeth. e supernumerary tooth in the midline of the maxilla, called a mesiodens, is almost always found on the palate and should be approached from the palatal direction for removal.When a buried canine is positioned in such a way that ortho-dontic manipulation can assist the proper positioning, the tooth can be exposed and bracketed. A ap is created to allow the soft tissue to be repositioned apically should this be required for maximum keratinized tissue management. e overlying bone tissue is then removed with burrs as is necessary. Once the area is debrided, the surface of the tooth is prepared by the usual standard procedures of etching and application of primer. e bracket is then luted onto the surface of the tooth. A wire can be used to connect the bracket to the orthodontic appliance or, more com-monly, a gold chain is attached from the orthodontic bracket to the orthodontic arch wire. e gold chain provides a greater degree of exibility, and the incidence of breakage of the chain is much less likely than breakage of a wire. Soft tissue is then sutured in such a way as to provide the maximum coverage of the exposed ACBD• Fig. 10.41 (A) Labially positioned impacted maxillary canine. The tooth should be uncovered with an apically positioned ap procedure to preserve the attached gingiva. (B) The mucoperiosteal ap is outlined, allowing for repositioning of the keratinized mucosa over the exposed tooth. When the ap is reected, the thin overlying bone is removed. (C) The tissue is retracted and bracket bonded to the tooth with an attached gold chain. The ap is apically sutured to the tooth. (D) After 6 months the exposed tooth is in the desired position with the broad zone of the attached gingiva. (Courtesy Dr. Myron Tucker.) 178 Part II Principles of Exodontiapapilla of the mandibular rst molar, around the necks of the teeth, to the distobuccal line angle of the second molar, and then posteriorly to and laterally up the anterior border of the mandibular ramus (Fig. 10.42A).e incision must not continue posteriorly in a straight line because the mandible diverges laterally in the third molar area. An incision that extends straight posteriorly falls o the bone and into the sublingual space and may damage the lingual nerve, which is close to the mandible in the area of the third molar. If this nerve is traumatized, the patient will probably have lingual nerve anesthesia, which is extremely disturbing to patients. e incision must always be kept over bone; therefore the surgeon should carefully palpate the retromolar area before beginning the incision.e ap is reected laterally to expose the external oblique ridge with a periosteal elevator (Fig. 10.42B). e surgeon should not reect more than a few millimeters beyond the external oblique ridge because this results in increased morbidity and an increased number of complications after surgery. e retractor is placed on the buccal shelf, just lateral to the external oblique ridge, and it is stabilized by applying pressure toward the bone. is results in a retractor that is stable and does not continually traumatize soft tissue. e Austin and the Minnesota retractors are the most commonly used for ap retraction when removing mandibular third molars.If the impacted third molar is deeply embedded in bone and requires more extensive bone removal, an oblique, vertical releasing incision may be useful (Fig. 10.42C–D). e ap created by this incision can be reected farther apically without risk of tearing the tissue.e recommended incision for the maxillary third molar is also an envelope incision. e incision extends posteriorly over the tuberosity from the distal aspect of the second molar and anteriorly to the mesial aspect of the rst molar (Fig. 10.43A–B). In situations in which greater access is required (e.g., in a deeply embedded impaction), a release incision extending from the mesial aspect of the second molar can be used (Fig. 10.43C–D).In the removal of third molars, it is vital that the ap be large enough for adequate access and visibility of the surgical site. e ap must have a broad base if a releasing incision is used. e incision must be made with a smooth stroke of the scalpel, which is kept in contact with bone throughout the entire incision so that the mucosa and periosteum are completely incised. is allows a full-thickness mucoperiosteal ap to be reected. e incision should be designed so it can be closed over solid bone (rather than over a bony defect). is is achieved by extending the incision at least one tooth anterior to the surgical site when a vertical-releasing incision is used. e incision should avoid vital anatomic structures. Only a single releasing incision should be used.Step 2: Removal of Overlying BoneOnce the soft tissue is elevated and retracted so that the surgical eld can be visualized, the surgeon must make a judgment concern-ing the amount of bone to be removed. In some situations the tooth can be sectioned with a burr and delivered without bone removal. However, in most cases, some bone removal is required.e bone on the occlusal aspect and on the buccal and distal aspects, down to the cervical line of the impacted tooth, should be removed initially. e amount of bone that must be removed varies with the depth of the impaction, the morphology of the roots, and the angulation of the tooth. Bone should not be removed bone removal and to remove a sucient amount of bone to expose the tooth for any needed sectioning and delivery. (3) e third step, if needed, is to divide the tooth with a burr to allow the tooth to be extracted without removing unnecessarily large amounts of bone. Purchase points may also be placed at this step. (4) In the fourth step, the sectioned or unsectioned tooth is delivered from the alveolar process with the appropriate elevators. (5) Finally, in the fth step, bone in areas of elevation is smoothed with a bone le, the wound is thoroughly irrigated with a sterile solution, and the ap is reapproximated with sutures. e following discussion elaborates on these steps for the removal of impacted third molars.Although the surgical approach to the removal of impacted teeth is similar to other surgical tooth extractions, it is important to keep in mind several distinct dierences. For instance, the typical surgical extraction of a tooth or tooth root requires the removal of a relatively small amount of bone. However, when an impacted tooth (especially a mandibular third molar) is extracted, the amount of bone that must be removed to deliver the tooth can be sub-stantially greater. is bone is also much denser than it is for typical surgical extractions, and its removal requires better instru-mentation and a higher degree of surgical precision.Impacted teeth frequently require sectioning, whereas other types of tooth extractions do not. Although erupted maxillary and mandibular molars are occasionally divided for removal, it is not a routine step in the extraction of these teeth. However, in a substantial majority of patients with impacted mandibular third molars, the surgeon is required to divide the tooth. erefore the surgeon must have the necessary equipment for such sectioning and the necessary skills and experience for dividing the tooth along the proper planes.Unlike most other types of surgical tooth extractions, for an impacted tooth removal, the surgeon must be able to balance the degree of bone removal and sectioning. Essentially, all impacted teeth can be removed without sectioning if a large amount of bone is removed. However, the removal of excessive amounts of bone unnecessarily prolongs the healing period and may result in a weakened jaw. erefore the surgeon should remove most bony impacted mandibular third molars only after sectioning them. However, removal of a small amount of bone with multiple divisions of the tooth may cause the tooth sectioning process to take an excessively long time, thus unnecessarily prolonging the operation. e surgeon must remove an adequate amount of bone and section the tooth into a reasonable number of pieces, both to hasten healing and to minimize the time of the surgical procedure.Step 1: Reecting Adequate Flaps for Accessibilitye ease of removing an impacted tooth depends on its accessibility. To gain access to the area and to visualize the overlying bone that must be removed, the surgeon must reect an adequate mucoperi-osteal ap. e reection must be of a dimension adequate to allow the placement and stabilization of retractors and instruments for the removal of bone.In most situations, the envelope ap is the preferred technique. e envelope ap is quicker to suture and heals better than the three-cornered flap (envelope flap with a releasing incision). However, if the surgeon requires greater access to the more apical areas of the tooth, which might stretch and tear the envelope ap, the surgeon should consider using a three-cornered ap.e preferred incision for the removal of an impacted mandibular third molar is an envelope incision that extends from the mesial CHAPTER 10 Principles of Management of Impacted Teeth 179 ACBD• Fig. 10.42 (A) The envelope incision is most commonly used to reect soft tissue for removal of the impacted third molar. Posterior extension of the incision should laterally diverge to avoid injury to the lingual nerve. (B) The envelope incision is laterally reected to expose bone overlying the impacted tooth. (C) When a three-cornered ap is made, a releasing incision is made at the mesial aspect of the second molar. (D) When the soft tissue ap is reected by means of a releasing incision, greater visibility is pos-sible, especially at the apical aspect of the surgical eld. ABCD• Fig. 10.43 (A) The envelope ap is the most commonly used ap for the removal of maxillary impacted teeth. (B) When soft tissue is reected, the bone overlying the third molar is easily visualized. (C) If the tooth is deeply impacted, a releasing incision into the vestibule can be used to gain greater access. (D) When the three-cornered ap is reected, the more apical portions become more visible. 180 Part II Principles of Exodontiae direction in which the impacted tooth should be divided depends primarily on the angulation of the impacted tooth and any root curvature. Although minor modications are necessary for teeth with divergent roots or for teeth that are more or less deeply impacted, the most important determinant is the angulation of the tooth.Tooth sectioning is performed with a burr, and the tooth is sectioned three fourths of the way toward the lingual aspect. e burr should not be used to section the tooth completely through in the lingual direction because this is more likely to injure the lingual nerve. A straight elevator is inserted into the slot made by the burr and is rotated to split the tooth.e mesioangular mandibular impaction is usually the least dicult impaction to remove of the four basic angulation types. After sucient bone has been removed, the distal half of the crown is sectioned o at the buccal groove to just below the cervical line on the distal aspect. is portion is removed. e remainder of the tooth is removed with a No. 301 elevator placed at the mesial aspect of the cervical line. A mesioangular impaction also can be removed by preparing a purchase point in the tooth with the drill and by using a Crane pick elevator to elevate the tooth from the socket (Fig. 10.45).e next impaction with respect to diculty to remove is the horizontal impaction. After sucient bone has been removed down to the cervical line to expose the superior aspect of the distal root and the majority of the buccal surface of the crown, the tooth is sectioned by dividing the crown of the tooth from the roots at the cervical line. e crown of the tooth is removed, and the roots are displaced with a Cryer elevator into the space previously occupied by the crown. If the roots of an impacted third molar are divergent, they may require sectioning into two separate portions to be delivered individually (Fig. 10.46).e vertical impaction is one of the two most dicult impactions to remove. e procedure of bone removal and sectioning is similar to the mesioangular impaction; that is, the occlusal buccal and distal bone is removed. e distal half of the crown is sectioned and removed, and the tooth is elevated by applying an elevator at the mesial aspect of the cervical line of the tooth. is is more dicult than a mesioangular removal because access around the mandibular second molar is dicult to obtain and requires the removal of substantially more bone on the buccal and distal sides (Fig. 10.47).e most dicult tooth to remove is the distoangular impaction. After sucient bone is removed from the bucco-occlusal and the distal sides of the tooth, the crown is sectioned from the roots just above the cervical line. e entire crown is usually removed because it interferes with visibility and access to the root structure of the tooth. If the roots are fused, a Cryer or a straight elevator can be used to elevate the tooth into the space previously occupied by the crown. If the roots are divergent, they are usually sectioned into two pieces and individually delivered. Extracting this impaction is dicult because so much distal bone must be removed and the tooth tends to rotate distally when elevated, running into the ramus portion of the mandible (Fig. 10.48).Impacted maxillary teeth are rarely sectioned because the overlying bone is usually thin and relatively elastic. In situations in which the bone is thicker or the patient is older (and therefore the bone not so elastic), tooth extraction is usually accomplished by bone removal rather than by tooth sectioning.In general, impacted teeth elsewhere in the mouth are usually sectioned only at the cervical line. is permits removal of the crown portion of the tooth, displacement of the root portion into from the lingual aspect of the mandible because of the likelihood of damaging the lingual nerve and because it is unnecessary.e burrs that are used to remove the bone overlying the impacted tooth vary with surgeons’ preferences. A large round burr, such as a No. 8, is desirable because it is an end-cutting burr and can be used eectively for drilling with a pushing motion. e tip of a ssure burr, such as a No. 703, does not cut well, but the edge rapidly removes bone and quickly sections teeth when used in a lateral direction. Note that a dental handpiece such as that used for restorative dentistry should never be used to remove bone around third molars or to section them.e typical bone removal for the extraction of an impacted mandibular tooth is illustrated in Fig. 10.44. Bone on the occlusal aspect of the tooth is removed rst to expose the crown of the tooth. en, cortical bone on the buccal aspect of the tooth is removed down to the cervical line. Next, the burr can be used to remove bone between the tooth and cortical bone in the cancellous area of bone with a maneuver called ditching. is provides access for elevators to gain purchase points and a pathway for delivery of the tooth. No bone is removed from the lingual aspect so as to protect the lingual nerve from injury.For maxillary teeth, bone removal is usually unnecessary, but when it is, bone is removed primarily on the buccal aspect of the tooth, down to the cervical line to expose the entire clinical crown. Usually, bone removal can be accomplished with a periosteal elevator, rather than a burr. Additional bone usually must be removed on the mesial aspect of the tooth to allow an elevator an adequate purchase area to deliver the tooth.Step 3: Sectioning the ToothOnce sucient amounts of bone have been removed from around the impacted tooth, the surgeon should assess the need to section the tooth. Sectioning allows portions of the tooth to be removed separately with elevators through the opening provided by bone removal.AB• Fig. 10.44 (A) After soft tissue has been reected, bone overlying the occlusal surface of the tooth is removed with a ssure burr. (B) The bone on the buccodistal aspect of the impacted tooth is then removed with a burr. CHAPTER 10 Principles of Management of Impacted Teeth 181 CAB• Fig. 10.45 (A) When removing a mesioangular impaction, buccodistal bone is removed to expose the crown of the tooth to the cervical line. (B) The distal aspect of the crown is then sectioned from the tooth. Occasionally, it is necessary to section the entire tooth into two portions rather than to section the distal portion of the crown only. (C) After the distal portion of the crown has been delivered, a small straight elevator can be inserted into the surgically exposed mesial aspect of the crown to deliver the remainder of the tooth as shown. Alternatively, a purchase point can be placed near the base of the crown near the mesial aspect of the tooth and a Crane pick used to elevate the tooth (not shown). ABC D• Fig. 10.46 (A) During the removal of a horizontal impaction, bone overlying the tooth (i.e., bone on the distal and buccal aspects of the tooth) is removed with a burr. (B) The crown is then sectioned from the roots of the tooth and delivered from the socket. (C) Roots are then delivered together or independently by the Cryer elevator used with a rotational motion. Roots may require separation into two parts; occa-sionally, a purchase point is made in the root to allow the Cryer elevator to engage it. (D) The mesial root of the tooth is elevated in a similar fashion. 182 Part II Principles of ExodontiaDelivery of maxillary third molars is accomplished with small straight elevators, which distobuccally luxate the tooth. Some surgeons prefer angled elevators such as Potts, Miller, or Warwick elevators, which aid in gaining access to the impacted tooth. e elevator tip is inserted into the area at the mesial cervical line, and pressure is applied to displace the tooth in the distobuccal direction (Fig. 10.49). e surgeon should be cautious about applying excessive pressure anteriorly to avoid damage to the root of the maxillary second molar. In addition, as pressure is applied to displace the tooth posteriorly, the surgeon should have a nger on the tuberosity of the maxilla (especially if the impaction is mesioangular) so that if a fracture does occur, steps can be taken to salvage the tuberosity of the maxilla by maintaining the soft tissue attachments. Palpation during elevation also helps the surgeon determine if the tooth is being delivered through the open wound or is, instead, being misdirected into the infratemporal space.Step 5: Preparing for Wound ClosureA bone le is used to smooth any sharp, rough edges of bone, particularly where an elevator was in bony contact. e surgeon should next direct attention to removing all particulate bone chips and debris from the wound. is is done with vigorous irrigation with sterile saline. Special care should be taken to irrigate thoroughly under the reected soft tissue ap. A small hemostat can be used to remove any remnants of the dental follicle, if present. Once the follicle is grasped, it is lifted with a slow, steady pressure, and it the space previously occupied by the crown, and removal of the root portion.Step 4: Delivery of the Sectioned Tooth With ElevatorOnce adequate bone has been removed to expose the tooth and the tooth has been sectioned in the appropriate fashion, the tooth is delivered from the alveolar process with dental elevators. In the mandible the most frequently used elevators are the straight elevator, the paired Cryer elevator, or the Crane pick.An important dierence between the removal of an impacted mandibular third molar and of a tooth elsewhere in the mouth is that almost no luxation of the tooth occurs for the purpose of expansion of the buccal or linguocortical plate. Instead, bone is removed, and teeth are sectioned to prepare an unimpeded pathway for delivery of the tooth.Application of excessive force may result in unfavorable fracturing of the tooth, of excessive buccal bone, of the adjacent second molar, or possibly of the entire mandible.Elevators are designed not to deliver excessive force but to engage the tooth or tooth root and to apply force in the proper direction. Some surgeons use a root tip pick to remove sectioned roots from their sockets. Because the impacted tooth has never sustained occlusal forces, the periodontal ligaments are weak and permit displacement of the tooth root if appropriate bone is removed and force is delivered in the proper direction.BAC• Fig. 10.47 (A) When removing vertical impaction, the bone on the occlusal, buccal, and distal aspects of the crown is removed and the tooth is sectioned into mesial and distal sections. If the tooth has a single-fused root, the distal portion of the crown is sectioned off in a manner similar to that depicted for mesio-angular impaction. (B) The posterior aspect of the crown is elevated rst with the Cryer elevator inserted into a small purchase point in the distal portion of the tooth. (C) A small straight No. 301 elevator is then used to elevate the mesial aspect of the tooth by a rotary-and-lever type of motion. CHAPTER 10 Principles of Management of Impacted Teeth 183 CAB• Fig. 10.48 (A) For distoangular impaction, occlusal, buccal, and distal bone is removed with a burr. It is important to remember that more distal bone must be taken off than for vertical or mesioangular impac-tion. (B) The crown of the tooth is sectioned off with a burr, and the crown is delivered with a straight elevator. (C) The purchase point is put into the remaining root portion of the tooth, and the roots are delivered with the Cryer elevator with a wheel-and-axle type of motion. If the roots diverge, it may be necessary, in some cases, to split them into independent portions. will pull free from the surrounding hard and soft tissues. A nal irrigation and a thorough inspection should be performed before the wound is closed.e surgeon should check for adequate hemostasis. Bleeding can occur from a vessel in the ap from the bone marrow that has been cut with a burr or from the inferior alveolar vessels. Specic bleeding points should be controlled if they exist. If brisk generalized ooze is seen after the sutures are placed, the surgeon should apply rm pressure with a small, moistened gauze pack. Postoperative bleeding to some degree occurs relatively frequently after third molar extraction but is usually self-limited if adequate hemostasis is achieved at the time of the operation.At this point, many surgeons deliver an antibiotic such as tetracycline into the sockets of lower third molars to help prevent osteitis sicca (dry socket).e closure of the incision made for an impacted third molar is usually a primary closure. If the ap was well designed and not traumatized during the surgical procedure, it will t into its original position. e initial suture should be placed through the attached tissue on the posterior aspect of the second molar. Additional sutures are placed posteriorly from that position and anteriorly through the papilla on the mesial side of the second molar. Usually, only two or three sutures are necessary to close an envelope incision. If a releasing incision was used, attention must be directed to closing that portion of the incision as well. If the ap for a maxillary third molar rests passively in place postoperatively, suturing may not be necessary.Perioperative Patient Managemente removal of impacted third molars is a surgical procedure that is usually associated with a great deal of patient anxiety. In addition, this surgical procedure can involve unpleasant noises and sensations. As a result, surgeons who routinely remove impacted third molars commonly recommend to their patients some type of profound anxiety control such as intravenous deep sedation or ambulatory general anesthesia.e choice of technique is based on the surgeon’s preference. However, the goals are to achieve a level of patient consciousness that allows the surgeon to work eciently and that reduces the likelihood of an unpleasant experience for the patient.In addition to the increased need for anxiety control, a variety of medications are used to control the sequelae of third molar extraction surgery. Combinations of codeine or codeine congeners with aspirin or acetaminophen are commonly used; however, recognize that codeine may be ineective in many patients. e use of long-acting local anesthetics should be considered in the mandible. ese anesthetics provide the patient with a pain-free period of 6 to 8 hours, during which prescriptions can be lled and analgesics taken. Analgesics are best begun at the point when 184 Part II Principles of Exodontiamust be carefully followed before the decision is made to give any drugs routinely.Some surgeons recommend the use of ice packs or packages of frozen peas on the face to help prevent postoperative swelling, even though studies show that it is unlikely that the ice has much eect on preventing or limiting swelling. However, patients frequently report that the coldness makes them feel more comfortable.Another medication that is sometimes used is an antibiotic. If a patient has a preexisting pericoronitis or periapical abscess, it is common to prescribe antibiotics for a few days after surgery. However, if the patient is healthy and the clinician nds no systemic indication for antibiotics or a preexisting local infection, systemic antibiotics are usually not indicated. e use of a topical antibiotic, such as minocycline, has been scientically shown to greatly lower the incidence of osteitis sicca (dry socket) in mandibular molar extraction sites.e normal postoperative experience of a patient after surgical removal of an impacted third molar is more involved than after a routine extraction. e patient can expect a modest amount of edema in the area of the surgery for 3 to 4 days, with the swelling completely dissipating by about 5 to 7 days. e amount of swelling depends on the degree of tissue trauma and the variability among patients with the potential for swelling.A modest amount of discomfort usually follows the procedure, the degree of which depends on the amount of surgical trauma necessary to remove impacted teeth. This discomfort can be eectively controlled with oral analgesics. Patients usually require analgesics for 2 or 3 days routinely and intermittently (particularly at bedtime) for several more days. e patient may have some mild soreness in the region for up to 2 to 3 weeks after the surgery.Patients who have had mandibular third molars surgically removed frequently have mild to moderate trismus. is inability to open the mouth interferes with the patient’s normal oral hygiene and eating habits. Patients should be warned that they will be unable to open their mouths normally after surgery. e trismus gradually resolves, and the ability to open the mouth should return to normal by 7 to 10 days after surgery.If pain, edema, and trismus have not greatly improved by 7 days after surgery, the surgeon should investigate the cause.All of the sequelae of the surgical removal of impacted teeth are of less intensity in the young, healthy patient and of far greater intensity in the older, more debilitated patient. Even healthy adult patients between the ages of 35 and 40 years have a signicantly more dicult time after extraction of impacted third molars than do most healthy teenaged patients.See Chapter 11 for a more detailed description of postoperative care.BibliographyAmerican Association of Oral and Maxillofacial Surgeons. White Paper on ird Molar Data. www.aaoms.org/docs/third_molar_white_paper.pdf. 2007.Bean LR, King DR. Pericoronitis: Its nature and etiology. J Am Dent Assoc. 1971;83:1074.Pell GJ, Gregory GT. Report on a ten-year study of a tooth division technique for the removal of impacted teeth. Am J Orthod. 1942;28:660.Perciaccante VJ. Management of impacted teeth. Oral Maxillofac Surg Clin North Am. 2007;19:1–140.Proceedings from the ird Molar Multidisciplinary Conference. J Oral Maxillofac Surg. 2012;70(suppl 1):S1–S70.the patient rst begins to recognize the return of sensation. Some surgeons even have patients begin analgesics before any return of sensation. e surgeon should consider writing a prescription for a potent oral analgesic for every patient who undergoes surgical removal of an impacted third molar, and, if the surgeon does separate consultation appointments, he or she should prescribe postoperative medications at that time so the patient and the patient’s escort do not need to stop on the way home from the procedure. Enough doses should be prescribed to last for at least 3 or 4 days. Combinations of codeine or codeine congeners with aspirin or acetaminophen are commonly used. Nonsteroidal antiinammatory drugs such as ibuprofen also may be of value for patients to use when the discomfort is less signicant.To minimize the swelling that is common after the surgical removal of impacted third molars, some surgeons give parenteral corticosteroids. Intravenous administration of a glucocorticoid steroid provides sucient antiinammatory activity to greatly limit edema. Although many different regimens and protocols for intravenous steroid administration exist, a relatively common one is the single administration of 8 mg dexamethasone before surgery. Dexamethasone is a long-acting steroid, and its ecacy in controlling third molar postsurgical edema is documented. is drug can then be continued in an oral dose of 0.75 to 1.25 mg twice a day for 2 to 3 days to continue edema control. Although steroids given in this manner have few side eects or contraindications, the general philosophy of weighing the risks and benets of drug administration AB• Fig. 10.49 Delivery of an impacted maxillary third molar. (A) Once soft tissue has been reected, a small amount of buccal bone is removed with a burr or the pointed end of a periosteal elevator. (B) The tooth is then delivered with a small straight elevator, with a rotary-and-lever type of motion. The tooth is delivered in the distobuccal and occlusal directions. Note that in most circumstances, bone removal using a burr is not required when removing impacted maxillary third molars. 18511 Postextraction Patient ManagementJAMES R. HUPPCHAPTER OUTLINEControl of Postoperative Sequelae, 185Hemorrhage, 185Pain and Discomfort, 186Diet, 188Oral Hygiene, 188Edema, 188Trismus, 189Ecchymosis, 189Postoperative Follow-up, 189Operative Note, 189Prevention and Management of Complications, 190Soft Tissue Injuries, 190Tear of a Mucosal Flap, 190Puncture Wound, 191Abrasion or Burn, 191Problems With a Tooth Being Extracted, 192Root Fracture, 192Root Displacement, 192Tooth Lost Into the Pharynx, 193Extraction of the Wrong Tooth, 193Injuries to Adjacent Teeth, 194Fracture or Dislodgment of an Adjacent Restoration, 194Luxation of an Adjacent Tooth, 195Injuries to Osseous Structures, 195Fracture of the Alveolar Process, 195Fracture of the Maxillary Tuberosity, 197Fracture of the Mandible, 197Injuries to Adjacent Structures, 197Injury to Regional Nerves, 197Injury to the Temporomandibular Joint, 198Oroantral Communications, 198Postoperative Bleeding, 199Delayed Healing and Infection, 201Wound Dehiscence, 201Dry Socket, 202Infection, 203Many patients have more preoperative concerns about the sequelae of surgery—such as pain, swelling, and complications—than about the procedure itself. is is particularly true if they have condence in the surgeon and planned anesthesia. e surgeon can do many things to mitigate the common problems patients face after surgery. is chapter discusses those strategies. is chapter also discusses the most common complications, some minor and some more serious, that occur during and after oral surgical procedures. ese are surgical complications, as opposed to medical complications, which are discussed in Chapter 2.Once the surgical procedure has been completed, the patient and anyone accompanying him or her should be given proper instructions on how to care for common postsurgical sequelae that may occur on the day of surgery and that often last for a few days. Postoperative instructions should explain what the patient is likely to experience, why these phenomena occur, and how to manage and control typical postoperative situations. e instructions should be given to the patient verbally and in written or printed form on paper, in easily understood layperson terms. ese postoperative instructions should describe the most common complications and how to identify them so that problems such as infection can be caught at an early stage. e instructions should also include a telephone number at which the surgeon or covering on-call doctor can be reached in case of an emergency.Control of Postoperative SequelaeHemorrhageOnce an extraction has been completed, the initial maneuver to control postoperative bleeding is the placement of a folded gauze directly over the socket. Large packs that cover the occlusal surfaces of teeth adjacent to the extraction site do not apply pressure to the bleeding socket and are therefore ineective (Fig. 11.1). e gauze may be moistened so that the oozing blood does not coagulate in the gauze and then dislodge the clot when the gauze is removed. e patient should be instructed to bite rmly on this gauze for at least 30 minutes and not to chew on the gauze. e patient should hold the gauze in place without opening the mouth.Patients should be informed that it is normal for a fresh extraction site to ooze slightly for up to 24 hours after the extraction procedure. Patients should be warned that a small amount of blood mixed with a large amount of saliva might appear to be a large amount of blood. If the bleeding is more than a slight ooze, the patient should be told how to reapply a folded piece of gauze directly over the area of the extraction. e patient should be instructed to hold this second 186 Part II Principles of ExodontiaPain and DiscomfortAll patients expect a certain amount of discomfort after any surgical procedure, so it is useful for the dentist to discuss this issue carefully with each patient before the procedure begins. e surgeon should help the patient have a realistic expectation of what type of pain may occur and correct any misconceptions of how much pain is likely to occur.Patients who make a point of informing the surgeon that they expect a great deal of pain after surgery should not be ignored or automatically told to take an over-the-counter analgesic because these patients are most likely to experience pain postoperatively. It is important for the surgeon to assure patients that their postopera-tive discomfort can and will be eectively managed.e pain a patient may experience after a surgical procedure such as tooth extraction is highly variable and to a great extent depends on the patient’s preoperative expectations. e surgeon who spends some time discussing these issues with the patient before surgery will be able to design the most appropriate analgesic regimen.All patients should be given instruction concerning analgesics before they are discharged. Even when the surgeon believes that no prescription analgesics are necessary, the patient should be told to take ibuprofen or acetaminophen postoperatively to prevent initial discomfort before the eects of the local anesthetic disappear. Patients who are expected to have a higher level of pain should be given a prescription analgesic to help control the pain. e surgeon should also take care to advise the patient that the goal of analgesic medication is management of pain and not elimination of all discomfort.It is useful for the surgeon to understand the three characteristics of the pain that occurs after routine tooth extraction: (1) e pain gauze pack in place for as long as 1 hour to gain control of bleeding. Further control can be attained, if necessary, by the patient placing a tea bag in the socket and biting on it for 30 minutes. e tannic acid in regular tea serves as a local vasoconstrictor.Patients should be cautioned to avoid things that may aggravate the bleeding. Talking should be kept to a minimum for an hour. Tobacco smoke and nicotine interfere with wound healing, so patients should be encouraged to stop or limit smoking. e patient should also be told not to suck thick uids through a straw when drinking because this creates negative intraoral pressure. e patient should not spit during the rst 12 hours after surgery. e process of spitting involves negative pressure and mechanical agitation of the extraction site, which may trigger fresh bleeding. Patients who strongly dislike having blood in the mouth should be encouraged to bite rmly on a piece of gauze to control the hemorrhage and to swallow their saliva instead of spitting it out. Finally, no strenuous exercise should be performed for the rst 12 to 24 hours after extraction because the increased blood pressure may result in greater bleeding.Patients should be warned that there may be some oozing and staining of their saliva while they are asleep and that they will probably have some blood stains on their pillowcases in the morning. Forewarning them of this probability will prevent many frantic telephone calls to the surgeon in the middle of the night. Patients should also be instructed that if they are worried about their bleeding, they should call to get additional advice. Prolonged oozing, bright red bleeding, or large clots in the patient’s mouth are indica-tions for a return visit. e dentist should then examine the area closely and apply appropriate measures to control the hemorrhage and consider having a surgical specialist assist with patient management.A BC• Fig. 11.1 (A) A fresh extraction site will bleed excessively unless a gauze pack is properly positioned. (B) A large or malpositioned gauze pack is not effective in controlling bleeding because the pressure of biting is not precisely directed onto the socket. (C) A small gauze pack is placed to t only into the area of extraction; this permits pressure to be applied directly on the bleeding socket. CHAPTER 11 Postextraction Patient Management 187 analgesics are frequently used to control pain after tooth extraction. e most commonly used drugs are codeine, the codeine congeners oxycodone and hydrocodone, and tramadol. ese narcotics are well absorbed from the gut but may produce drowsiness and gastrointestinal upset. Opioid analgesics are rarely used alone in dental prescriptions; instead, they are formulated with other analgesics, primarily aspirin or acetaminophen. Codeine can be a useful postextraction analgesic because it carries little narcotic abuse potential. However, it is important to note that a large percentage of the population lacks the enzyme necessary to make codeine eective. When codeine is used, the amount of codeine is frequently designated by a numbering system. Compounds labeled No. 1 have 7.5 mg codeine; No. 2, 15 mg; No. 3, 30 mg; and No. 4, 60 mg. When a combination of analgesic drugs is used, the dentist must keep in mind that it is necessary to provide 500 to 1000 mg aspirin or acetaminophen every 4 hours to achieve maximal eectiveness from the nonnarcotic. Many of the compound drugs have only 300 mg aspirin or acetaminophen added to the narcotic. An example of a rational approach would be to prescribe a compound containing 300 mg of acetaminophen and either 30 mg codeine (No. 3) or 5 mg hydrocodone. e usual adult dose would be 2 tablets of the compound every 4 hours. Should the patient require stronger analgesic action, 2 tablets of acetaminophen and codeine may be taken for increased eectiveness. Doses that supply 30 to 60 mg of codeine or 5 mg of hydrocodone but only 300 mg of acetaminophen fail to provide full advantage of the analgesic eect of acetaminophen (Table 11.2).The Drug Enforcement Administration controls narcotic analgesics. To write prescriptions for these drugs, the dentist must is usually not severe and can be managed in most patients with over-the-counter analgesics, (2) the peak pain experience occurs about 12 hours after the extraction and diminishes rapidly after that, and (3) signicant pain from extraction rarely persists longer than 2 days after surgery. With these three factors in mind, patients can be appropriately advised regarding the effective use of analgesics.e rst dose of analgesic medication should be taken before the eects of the local anesthetic subside. If this is done, the patient is less likely to experience the intense, sharp pain after the eects of local anesthesia subside. Postoperative pain is much more dicult to manage if administration of analgesic medication is delayed until the pain is severe. It may take 60 to 90 minutes for the analgesic to become fully eetive. If the patient waits to take the rst dose of analgesic until the eects of local anesthesia have subsided, the patient may become impatient, waiting for the eect, and may take additional medication thus increasing the likelihood of nausea and vomiting.e strength of the analgesic is also important. Potent analgesics are not required in most routine postextraction situations; instead, analgesics with a lower potency per unit dose are typically sucient. e patient can then be told to take one or two unit doses as necessary to control pain. More precise pain control is achieved when the patient takes an active role in determining the amount of medication to take.Patients should be warned that taking narcotic medications often results in drowsiness and an increased chance of gastric upset. In most situations, patients should avoid taking narcotic pain medications on an empty stomach. Prescriptions should be written with instructions to the patient to have a snack or a meal before taking a narcotic analgesic.Ibuprofen has been demonstrated to be an eective medication to control discomfort from a tooth extraction. Ibuprofen has the disadvantage of causing a decrease in platelet aggregation and bleeding time, but this does not appear to have a clinically important eect on postoperative bleeding in most patients. Acetaminophen does not interfere with platelet function and may be useful in certain situations in which the patient has a platelet defect and is likely to bleed. If the surgeon prescribes a combination drug containing acetaminophen and narcotic, it should be a combination that delivers 500 to 650 mg of acetaminophen per dose.Drugs that are useful in situations in which patients have varying degrees of pain are listed in Table 11.1. Centrally acting opioid Analgesics for Postextraction PainTABLE 11.1 Oral Narcotic Usual DoseMild Pain SituationsIbuprofen 400–800 mg q4hAcetaminophen 325–500 mg q4hModerate Pain SituationsCodeine 15–60 mgHydrocodone 5–10 mgSevere Pain SituationsOxycodone 2.5–10 mgTramadol 50–100 mgq4h, Every 4 hours.Commonly Used Combination AnalgesicsTABLE 11.2 Brand Name Amount (mg) Amount (mg)Codeine–Acetaminophen Codeine AcetaminophenTylenol No. 2 15.0 300Tylenol No. 3 30.0 300Tylenol No. 4 60.0 300Oxycodone–Aspirin Oxycodone AspirinPercodan 5.0 325Percodan-demi 2.5 325Oxycodone–AcetaminophenOxycodone AcetaminophenPercocet 2.5 3255.0 325Tylox 5.0 325Hydrocodone–Aspirin Hydrocodone AspirinLortab ASA 5.0 325Hydrocodone–AcetaminophenHydrocodone AcetaminophenVicodin 5.0 325Vicodin ES 7.5 325Lorcet HD 5.0 325Lortab Elixir2.5 mg/5 mL 170 mg/5 mLASA, Acetylsalicylic acid. 188 Part II Principles of Exodontiae the rst postoperative day, patients should begin gentle rinses with dilute salt water. e water should be warm but not hot enough to burn the tissue. Most patients can resume their preoperative oral hygiene measures by the third or fourth day after surgery. Dental oss should be used in the usual fashion on teeth anterior and posterior to the extraction sites as soon as the patient is suciently comfortable doing so.If oral hygiene is likely to be dicult after extractions in multiple areas of the mouth, mouth rinses with agents such as dilute hydrogen peroxide may be used. Rinsing three to four times a day for approximately 1 week after surgery may result in more reliable healing.EdemaSome oral surgical procedures result in a certain amount of edema or swelling after surgery. Routine extraction of a single tooth will probably not result in swelling that the patient can see, whereas the extraction of multiple impacted teeth with reection of soft tissue and removal of bone may result in moderately large amounts of swelling (Fig. 11.2). Swelling usually reaches its maximum 36 to 48 hours after the surgical procedure. Swelling begins to subside on the third or fourth day and is usually resolved by the end of the rst week. Increased swelling after the third day may be an indication of infection rather than renewed postsurgical edema.Once the surgery is completed and the patient is ready to be discharged, some dentists use ice packs or bags of frozen peas to help minimize the swelling and make the patient feel more comfort-able; however, there is no evidence that the cooling actually controls this type of edema. Ice should not be placed directly on the skin; preferably a layer of dry cloth should be placed between the ice container and the tissue to prevent supercial tissue damage. e ice pack or small bags of frozen peas should be kept on the local area for 20 minutes and then kept o for 20 minutes over a period of 12 to 24 hours. e bags of peas should be refrozen after they warm.• Fig. 11.2 Extraction of impacted left maxillary and mandibular third molars was performed 2 days before this photograph was taken. The patient exhibits a moderate amount of facial edema, which resolved within 1 week of surgery. have a Drug Enforcement Administration permit and number. e drugs are categorized into four basic schedules based on their potential for abuse. Several important dierences exist between schedule II and schedule III drugs concerning writing prescriptions (see Appendix 2). Unfortunately, prescription narcotics are sus-ceptible to misuse. Oxycodone- and hydrocodone-containing drugs are particularly sought after and abused. Narcotics tend to be addictive, leading to problems such as patients seeking drugs even when not in pain or nonpatients stealing drugs for their own use or to sell to others. e dental profession and others have developed guidelines for dentists to help limit the overprescription of narcotics and to manage any unused doses that might otherwise fall into the hands of a patient’s family members or others with access to the patient’s medications. Dentists should take advantage of profes-sional educational oerings related to managing patient pain and the use of analgesic medications. Dentists should also have frank discussions with patients about the problem of opioid abuse and how they can help avoid its impact in their own lives.It is important to emphasize that the most eective method of controlling pain is the establishment of a close relationship between the surgeon and the patient. A specic amount of time must be spent discussing the issue of postoperative discomfort, with the surgeon clearly demonstrating his or her concern for patient comfort. A prescription should be given with clear instructions about when to begin the medication and at what intervals it should be taken. If these procedures are followed, mild analgesics given for a short time (usually no longer than 2 to 3 days) are usually all that is required.DietPatients who have had extractions may avoid eating because of local pain or fear of pain occurring when eating. In addition, the physical and emotional stress of undergoing surgery frequently lessens the appetite. erefore they should be given specic instruc-tions regarding their postoperative diet. A high-calorie, high-volume liquid or soft diet is best for the rst 12 to 24 hours.e patient must have an adequate intake of uids, usually at least 2 L, during the rst 24 hours. e uids can be juices, milk, water, or any other nonalcoholic beverage that appeals to the patient.Food in the rst 12 hours should be soft and cool. Cool and cold foods help keep the local area comfortable. Ice cream and milkshakes, unlike harder solid foods, have less tendency to cause local trauma or initiate rebleeding episodes.If the patient had multiple extractions in all areas of the mouth, a soft diet is recommended for several days after the surgical procedure. However, the patient should be advised to return to a normal diet as soon as possible.Patients who have diabetes should be encouraged to return to their normal insulin and caloric intake as soon as possible. For such patients, the surgeon may plan surgery on only one side of the mouth at each surgical appointment, thus not overly interfering with normal caloric intake.Oral HygienePatients should be advised that keeping the teeth and the whole mouth reasonably clean results in a more reliable healing of surgical wounds. Postoperatively, on the day of surgery, patients may gently brush the teeth that are away from the area of surgery in the usual fashion. ey should avoid brushing the teeth immediately adjacent to the extraction site to prevent a new bleeding episode and to avoid disturbing sutures and inducing more pain. CHAPTER 11 Postextraction Patient Management 189 are prolonged bleeding, pain that is not responsive to the prescribed medication, and suspected infection.If a patient who has had surgery begins to develop swelling with surface redness, fever, pain, or all of these symptoms on the third postoperative day or later, it can be assumed that the patient has developed an infection until proven otherwise. e patient should be instructed to call the dentist’s oce immediately. e surgeon should then inspect the patient carefully to conrm or rule out the presence of an infection. If an infection is diagnosed, appropriate therapeutic measures should be taken (see Chapter 16).Postsurgical pain that decreases at rst but begins to increase on the third or fourth day, although not accompanied by swelling or other signs of infection, is probably a symptom of dry socket. is problem is usually conned to lower molar sockets and does not represent an infection. is annoying problem is straightforward to manage but may require that the patient return to the oce several times (see Chapter 10).Operative Notee surgeon must enter into the records a note of what transpired during each visit. Whenever surgery is performed, some critical factors should be entered into the record. e rst is the date of the operation and a brief identication of the patient; then the surgeon states the diagnosis and reason for the extraction (e.g., nonrestorable teeth due to caries or severe periodontal disease).Comments regarding the patient’s pertinent medical history, medications, and vital signs should be noted in the chart. e oral examination done at the time of surgery should be documented briey in the record.e surgeon should record the type and amount of anesthetic used. For example, if the drug prescribed was lidocaine with a On the second postoperative day, neither ice nor heat should be applied to the face. On the third and subsequent postoperative days, application of heat may help to resolve the swelling more quickly. Heat sources such as hot water bottles and heating pads are recommended. Patients should be warned to avoid high-level heat for long periods to prevent injuring the skin.It is important to inform patients that some amount of swelling is to be expected. ey should also be warned that the swelling may tend to wax and wane, occurring more in the morning and less in the evening because of postural variation. Sleeping in a more upright position by using extra pillows will help reduce facial edema. Patients should be informed that a moderate amount of swelling is a normal and healthy reaction of tissue to the trauma of surgery. Patients should not be concerned or frightened by swelling because it will resolve within a few days.TrismusExtraction of teeth, administration of a mandibular block, or both may result in trismus (limitation in mouth opening). Trismus results from trauma and the resulting inflammation involving the muscles of mastication. Trismus may also result from multiple injections of the local anesthetic, especially if the injections have penetrated muscles. e muscle most likely to be involved is the medial pterygoid muscle, which may be penetrated by the local anesthetic needle during the inferior alveolar nerve block.Surgical extraction of impacted mandibular third molars usually results in some degree of trismus because the inammatory response to the surgical procedure is suciently widespread to involve several muscles of mastication. Trismus is usually not severe and does not hamper the patient’s normal activities. However, to prevent alarm, patients should be warned that this phenomenon might occur and that it will likely resolve within a week.EcchymosisIn some patients, blood oozes submucosally and subcutaneously; this appears as a bruise in the oral tissues, the face, or both (Fig. 11.3). Blood in the submucosal or subcutaneous tissues is known as ecchymosis. Ecchymosis is usually seen in older patients because of their decreased tissue tone, increased capillary fragility, and weaker intercellular attachments. Ecchymosis is not dangerous and does not increase pain or infection. Patients should, however, be warned that ecchymosis may occur because if they awaken on the second postoperative day and see bruising in the cheek, subman-dibular area, or anterior neck, they may become apprehensive. is anxiety is easily prevented by postoperative instructions. Typically the onset of ecchymosis is 2 to 4 days after surgery and it usually resolves fully within 7 to 10 days.Postoperative Follow-upAll patients seen by novice surgeons should be given a return appointment so that the surgeon can check the patient’s progress after the surgery and learn about the appearance of a normally healing socket. In routine, uncomplicated procedures, a follow-up visit at 1 week is usually adequate. Sutures should be removed, as needed, at the 1-week postoperative appointment.Patients should be informed that if any question or problem arises, they should call the dentist and, if necessary, request an earlier follow-up visit. e most likely reasons for an earlier visit • Fig. 11.3 Moderate widespread ecchymosis of right side of face and neck is exhibited in an older patient after extraction of several mandibular teeth. 190 Part II Principles of Exodontiato a specialist is an option that should always be exercised if the planned surgery is beyond the dentist’s own skill level. In some situations, this is not only a moral obligation but also wise medi-colegal risk management and provides peace of mind.In planning a surgical procedure, the rst step is always a thorough review of the patient’s medical history. Several of the complications discussed in this chapter can be caused by inadequate attention to medical histories that would have revealed the presence of a factor that would increase surgical risk.One of the primary ways to prevent complications is by obtaining adequate images and carefully reviewing them (see Chapter 8). Radiographs must include the entire area of surgery, including the apices of the roots of the teeth to be extracted as well as local and regional anatomic structures such as the adjacent parts of the maxillary sinus or the inferior alveolar canal. e surgeon should look for the presence of abnormal tooth root morphology or signs that the tooth may be ankylosed. After careful examination of the radiographs, the surgeon may need to alter the treatment plan to prevent or limit the magnitude of the complications that might be anticipated with a closed extraction. Instead, the surgeon should consider surgical approaches to removing teeth in such cases.After an adequate medical history has been taken and the radiographs have been analyzed, the surgeon goes on to preoperative planning. is is not simply a preparation of a detailed surgical plan and needed instrumentation but also a plan for managing patient pain and anxiety and postoperative recovery (instructions and modications of normal activity for the patient). orough preoperative instructions and explanations for the patient are essential in preventing or limiting the impact of the majority of complications that occur in the postoperative period. If the instruc-tions are not carefully explained and the importance of compliance made clear, the patient is less likely to comply with them.To keep complications at a minimum, the surgeon must always follow basic surgical principles. ere should be clear visualization and access to the operative eld, which requires adequate light, adequate soft tissue retraction and reection (including lips, cheeks, tongue, and soft tissue aps), and adequate suction. e teeth to be removed must have an unimpeded pathway for removal. Occasionally bone must be removed and teeth sectioned to achieve this goal. Controlled force is of paramount importance; this means nesse, not force. e surgeon must follow the principles of asepsis, atraumatic handling of tissues, hemostasis, and thorough debride-ment of the wound after the surgical procedure. Violation of these principles can lead to an increased incidence and severity of surgical complications.Prevention of complications should be a major goal. When complications do occur, skillful management is the most essential requirement of the competent surgeon.Soft Tissue InjuriesInjuries to the soft tissue of the oral cavity are almost always the result of the surgeon’s lack of adequate attention to the delicate nature of the mucosa, attempts to do surgery with inadequate access, rushing during surgery, or the use of excessive and uncontrolled force. e surgeon must continue to pay careful attention to soft tissue while operating on bone and tooth structures (Box 11.2).Tear of a Mucosal Flape most common soft tissue injury during oral surgery is tearing of the mucosal ap during surgical extraction of a tooth. is vasoconstrictor, the dentist would write down the dosages of lidocaine and epinephrine in milligrams.e surgeon should then write a brief note about the procedure performed and any problems that occurred intraoperatively.A comment concerning discharge instructions, including postoperative instructions that were given to the patient, should be recorded. e prescribed medications are listed, including the name of the drug, its dose, and the total number of doses. Alter-natively, copies of the prescriptions can be added to the record. Finally, the need for a return appointment is recorded if indicated (Box 11.1; see Appendix 1).With electronic record keeping, built-in elds are often present to document certain aspects of patient visits. e requirements for patient documentation described previously still apply, but these details may be recorded in various ways, depending on the software program used.Prevention and Management of ComplicationsAs in the case of medical emergencies, the best way to manage surgical complications is to prevent them from happening. Preven-tion of surgical complications is ideally accomplished by a thorough preoperative assessment and comprehensive treatment plan followed by careful execution of the surgical procedure. Only when these are routinely performed can the surgeon expect to have few complications. However, even with such planning and the use of excellent surgical techniques, complications still occasionally occur. In situations where the dentist has planned carefully, the complica-tion is often predictable and can be managed routinely. For example, in extracting a maxillary rst premolar that has long thin roots, it is far easier to remove the buccal root than the palatal root. erefore the surgeon will use more force toward the buccal root than toward the palatal root so that if a root does fracture, it will more likely involve the buccal root rather than the palatal root. In most cases buccal root retrieval is more straightforward.Dentists must perform surgery that is within the limits of their capabilities. ey must therefore carefully evaluate their training and abilities before deciding to perform a specic surgical task. us, for example, it is inappropriate for a dentist with limited experience in the management of impacted third molars to undertake the surgical extraction of an embedded tooth. e incidence of operative and postoperative complications is unacceptably high in this situation. Surgeons must be cautious of unwarranted optimism, which can cloud their judgment and prevent them from delivering the best possible care. e dentist must keep in mind that referral • Date• Patientnameandidentication• Diagnosisofproblemtobemanagedsurgically• Reviewofmedicalhistory,medications,andvitalsigns• Oralexamination• Anesthesia(amountused)• Procedure(includingdescriptionofsurgeryandcomplications)• Dischargeinstructions• Medicationsprescribedandtheiramounts(orattachcopyofprescription)• Needforfollow-upappointment• Signature(legibleorprintedunderneath)Elements of an Operative Note• BOX 11.1 CHAPTER 11 Postextraction Patient Management 191 preventing infection and allowing healing to occur, usually by secondary intention. If the wound bleeds excessively, the hemorrhage should be controlled by direct pressure applied to the wound. Once hemostasis is achieved, the wound is usually left open unsutured; thus even if a small infection were to occur, there would be an adequate pathway for drainage.Abrasion or BurnAbrasions or burns to lips, corners of the mouth, or aps usually result from the rotating shank of the burr rubbing on soft tissue or from a metal retractor coming in contact with soft tissue (Fig. 11.6). When the surgeon is focused on the cutting end of the burr, the assistant should be aware of the location of the shank of the burr in relation to the patient’s cheeks and lips. However, the surgeon should also remain aware of the shaft’s location. Soft tissue burns can occur if instruments freshly out of the autoclave or dry heat sterilizer are not allowed to cool before coming in contact with the patient’s skin or mucosa.If an area of oral mucosa is abraded or burned, little treatment is possible other than keeping the area clean with regular oral rinsing. Usually such wounds heal in 4 to 7 days (depending on the depth of damage) without scarring. If such an abrasion or burn does develop on the skin, the dentist should advise the patient to keep it covered with an antibiotic ointment. e patient must apply the ointment only on the abraded area and not spread it onto intact skin because the ointment may cause ulceration or a rash. ese abrasions usually take 5 to 10 days to heal. e patient should keep the area moist with small amounts of ointment during the entire healing period to prevent eschar formation and delayed healing and to keep the area reasonably comfortable. Scarring or permanent discoloration of the aected skin may occur but is usually prevented with proper wound care.usually results from an initially inadequately sized envelope ap that, as the surgeon tries to gain needed surgical access, is then forcibly retracted beyond the ability of the tissue to stretch (Fig. 11.4). is results in tearing, usually at one end of the incision. Prevention of this complication is threefold: (1) creating adequately sized aps to prevent excess tension on the ap, (2) using controlled amounts of retraction force on the ap, and (3) creating releasing incisions when indicated. If a tear does occur in the ap, the ap should be carefully repositioned once the surgery is completed. If the surgeon or assistant sees a ap beginning to tear, the hard tissue surgery should be stopped while the incision is lengthened or while a releasing incision is created to gain better access. In most patients, careful suturing of the tear results in adequate but somewhat delayed healing. If the tear is especially jagged, the surgeon may consider excising the edges of the torn ap to create a smooth ap margin before closure. is step should be performed with caution because excision of excessive amounts of tissue leads to closure of the wound under tension and probable wound dehiscence, or it might compromise the amount of attached gingiva adjacent to a tooth.Puncture Wounde second soft tissue injury that occurs with some frequency is inadvertent puncturing of soft tissue. An instrument such as a straight elevator or a periosteal elevator may slip from the surgical eld and puncture or tear adjacent soft tissue.Once again, this injury is the result of using uncontrolled force and is best prevented by the use of controlled force, with special attention given to using nger rests or support from the opposite hand if slippage is anticipated. If the instrument slips from the tooth or bone, the surgeon’s ngers can catch the operating hand before injury occurs (Fig. 11.5). If a puncture wound does occur in the mucosa, the ensuing treatment is primarily aimed at • Paystrictattentiontosofttissueinjuries.• Developadequate-sizedaps.• Useminimalforceforretractionofsofttissue.Prevention of Soft Tissue Injuries• BOX 11.2 • Fig. 11.4 Mucoperiosteal ap badly torn due to inadequate care during its reection. • Fig. 11.5 The small straight elevator can be used to luxate a fractured root. When a straight elevator is used in this position, the surgeon’s hand must be securely supported on adjacent teeth to prevent inadvertent slip-page of the instrument from the tooth and subsequent injury to adjacent tissue. 192 Part II Principles of ExodontiaIf the displaced tooth fragment is a small 2- or 3-mm root tip and the tooth and sinus have no preexisting infection, the surgeon should make a brief attempt at removing the root. First, a radiograph of the fractured tooth root should be taken to document its position and size. Once that has been accomplished, the surgeon should irrigate through the small opening in the socket apex and then suction the irrigating solution from the sinus via the socket. is occasionally ushes the root apex from the sinus through the socket. The surgeon should check the suction solution and confirm radiographically that the root has been removed. If this technique is not successful, no additional surgical procedure should be performed through the socket, and the root tip should be left in the sinus. A small, noninfected root tip can be left in place because it is unlikely to cause any troublesome sequelae. Additional surgery in this situation causes more patient morbidity than leaving the root tip in the sinus. If the root tip is left in the sinus, the surgeon should take measures similar to those taken in leaving any root tip in place. e patient must be informed of the decision and given proper follow-up instructions for regular monitoring of the root and the sinus.e oroantral communication should be managed as discussed later, with a gure-of-eight suture over the socket, sinus precautions, antibiotics, and a nasal spray to lessen the chance of infection by keeping the ostium open. e most likely occurrence is that the root apex will brose onto the sinus membrane with no subsequent problems. If the tooth root is infected or the patient has chronic sinusitis, the patient should be referred to an oral-maxillofacial surgeon for removal of the root tip via a Caldwell-Luc or endoscopic approach.If a large root fragment or the entire tooth is displaced into the maxillary sinus, it should be removed (Fig. 11.7). e usual method is a Caldwell-Luc approach into the maxillary sinus in the canine fossa region followed by removal of the tooth. is procedure should be performed by an oral-maxillofacial surgeon (see Chapter 20).Impacted maxillary third molars are occasionally displaced into the maxillary sinus (from which they are removed via a Caldwell-Luc approach). However, if displacement occurs, it more commonly does so into the infratemporal space. During elevation of the tooth, the elevator may force the tooth posteriorly through the periosteum into the infratemporal fossa. e tooth is usually lateral to the lateral pterygoid plate and inferior to the lateral pterygoid muscle. If good access and light are available, the surgeon should make a single cautious eort to retrieve the tooth with a hemostat. However, the tooth is usually not visible, and blind probing results in further displacement. If the tooth is not retrieved after a single eort, the incision should be closed and the operation stopped. e patient should be informed that the tooth has been displaced and will be removed later. Antibiotics should be given to help decrease the possibility of an infection, and routine postoperative care should be provided. During the initial healing time, brosis occurs and stabilizes the tooth in a rm position. e tooth is removed later by an oral-maxillofacial surgeon after radiographic localization.Lingual cortical bone over the roots of the molars becomes thinner as it progresses posteriorly. Mandibular third molars, for example, frequently have dehiscence in overlying lingual bone and may actually be sitting in the submandibular space preoperatively. Fractured mandibular molar roots that are being removed with apical pressures may be displaced through the lingual cortical plate and into the submandibular space. Even small amounts of apical pressure can result in displacement of the root into that space. Prevention of displacement into the submandibular space is primarily Problems With a Tooth Being ExtractedRoot FractureThe most common problem associated with the tooth being extracted is fracture of its roots. Long, curved, divergent roots that lie in dense bone are the most likely to be fractured. e main methods of preventing the fracture of roots is to perform surgery in the manner described in previous chapters or to use an open extraction technique and remove bone to decrease the amount of force necessary to remove the tooth (Box 11.3). Recovery of a fractured root with a surgical approach is discussed in Chapter 9.Root Displacemente tooth root that is most commonly displaced into unfavorable anatomic spaces is the maxillary molar root when it is forced or lost into the maxillary sinus. If a fractured root of a maxillary molar is being removed with a straight elevator that is being used with excessive apical pressure, the root can be displaced into the maxillary sinus. Other teeth or roots can be displaced into the maxillary sinus in a similar manner. If a root or tooth is pushed into the maxillary sinus, the surgeon must make several assessments to determine the appropriate treatment. First, the surgeon must identify the size of the root lost into the sinus. It may be a root tip of several millimeters or an entire tooth or root. e surgeon must next assess whether there has been any infection of the tooth or periapical tissues. If the tooth was not infected, management is more straightforward than if the tooth has been acutely infected. Finally, the surgeon must assess the preoperative condition of the maxillary sinus. For the patient who has a healthy maxillary sinus, it is more straightforward to manage a displaced root than if the sinus is or has been chronically infected.• Fig. 11.6 Abrasion of lower lip as a result of shank of burr rotating on soft tissue. The abrasion represents a combination of friction and heat damage. The wound should be kept covered with antibiotic ointment until an eschar forms, taking care to keep the ointment off uninjured skin as much as possible. (Courtesy Dr. Myron Tucker.)• Alwaysconsiderthepossibilityofrootfracture.• Usesurgical(i.e.,open)extractionifhighprobabilityoffractureexists.• Donotusestrongapicalforceonabrokenroot.Prevention of Root Fracture and Displacement• BOX 11.3 CHAPTER 11 Postextraction Patient Management 193 abandon the procedure and refer the patient to an oral-maxillofacial surgeon. e usual denitive procedure for removing such a root tip is to reect a soft tissue ap on the lingual aspect of the mandible and gently dissect the overlying mucoperiosteum until the root tip can be found. As with teeth that are displaced into the maxillary sinus, if the root fragment is small and was not infected preopera-tively, the oral-maxillofacial surgeon may elect to leave the root in its position because surgical retrieval of the root may be an extensive procedure or may risk serious injury to the lingual nerve.Tooth Lost Into the PharynxOccasionally the crown of a tooth, a prosthetic crown, or an entire tooth may be lost in the oropharynx. If this occurs, the patient should be turned toward the surgeon and placed in a position with the mouth facing the oor as much as possible. e patient should be encouraged to cough and spit the tooth out onto the oor.In spite of these eorts, the tooth may be swallowed or aspirated. If the patient has no coughing or respiratory distress, it is most likely that the tooth was swallowed and has traveled down the esophagus into the stomach. However, if the patient has a violent episode of coughing or shortness of breath, the tooth may have been aspirated through the vocal cords into the trachea and from there into a mainstem bronchus.In either case, the patient should be transported to an emergency department, and chest and abdominal radiographs should be taken to determine the specic location of the tooth. If the tooth has been aspirated, consultation with regard to the possibility of removing the tooth with a bronchoscope should be requested. e urgent management of aspiration is to maintain the patient’s airway and breathing. Supplemental oxygen may be appropriate if signs of respiratory distress are observed.If the tooth has been swallowed, it is highly probable that it will pass through the gastrointestinal tract within 2 to 4 days. Because teeth are not usually jagged or sharp, unimpeded passage occurs in almost all situations. However, it may be prudent to have the patient go to an emergency room and have a radiograph of the abdomen taken to conrm that the tooth is indeed in the gastrointestinal tract and not in the respiratory tract. Follow-up radiographs are probably not necessary because swallowed teeth are ultimately passed out along with feces.Extraction of the Wrong ToothA complication that every dentist believes can never happen—but happens surprisingly often—is extraction of the wrong tooth. is is usually the most common cause of malpractice lawsuits against dentists. Extraction of the wrong tooth should never occur if appropriate attention is given to the planning and execution of the surgical procedure.is problem may be the result of inadequate attention to preoperative assessment. If the tooth to be extracted is grossly carious, it is less likely that the wrong tooth will be removed. A common reason for removing the wrong tooth is that a dentist removes a tooth for another dentist. e use of diering tooth numbering systems or dierences in the mounting of radiographs can easily lead the treating dentist to misunderstand the instructions from the referring dentist. us the wrong tooth is sometimes extracted when the dentist is asked to remove teeth for orthodontic purposes, especially in patients who are in mixed dentition stages and whose orthodontists have asked for unusual extractions. Careful achieved by avoiding all apical pressures when removing mandibular roots.Triangular elevators such as the Cryer elevator are usually used to elevate broken tooth roots of mandibular molars. If the root disappears during root removal, the dentist should make a single eort to remove it. e index nger of the left hand is inserted onto the lingual aspect of the oor of the mouth in an attempt to place pressure against the lingual aspect of the mandible and force the root back into the socket. If this works, the surgeon may be able to tease the root out of the socket with a root-tip pick. If this eort is not successful at the initial attempt, the dentist should AB• Fig. 11.7 (A) Large root fragment displaced into the maxillary sinus. The fragment should be removed by the Caldwell-Luc approach or sinus endoscopy. (B) The tooth in the maxillary sinus is the maxillary third molar that was displaced into the sinus during elevation of the tooth. This tooth must be removed from the sinus, potentially by the Caldwell-Luc approach. 194 Part II Principles of Exodontiaapplication of instrumentation and force on the restoration (Box 11.5). is means that the straight elevator should be used with great caution, being inserted entirely into the periodontal ligament space or not used at all to luxate the tooth before extraction when the adjacent tooth has a large restoration. If a restoration is dislodged or fractured, the surgeon should make sure that the displaced restoration is removed from the mouth and does not fall into the empty tooth socket. Once the surgical procedure has been com-pleted, the injured tooth should be treated by replacement of the displaced crown or placement of a temporary restoration. e patient should be informed if a fracture of a tooth or restoration has occurred and that a replacement restoration is needed (see Chapter 12).Teeth in the opposite arch may also be injured as a result of uncontrolled forces. is usually occurs when buccolingual forces inadequately mobilize a tooth, excessive tractional forces are used, or both. e tooth is suddenly released from the socket, and the forceps strikes the teeth of the opposite arch, chipping or fracturing a cusp. is is more likely to occur with extraction of lower teeth because these teeth may require more vertical tractional forces for their delivery, especially when using the No. 23 (cowhorn) forceps. Prevention of this type of injury can be accomplished by several methods. e rst and most important method is to avoid the use of excessive tractional forces. e tooth should be adequately luxated with apical, buccolingual, and rotational forces to minimize the need for tractional forces.Even when this is done, however, occasionally a tooth will be released unexpectedly. e surgeon or assistant should protect the teeth of the opposite arch by holding a nger or suction tip against them to absorb the blow should the forceps be released in that direction. If such an injury occurs, the tooth should be smoothed preoperative planning, clear communication with the referring dentist, and attentive clinical assessment of the tooth to be removed before the elevator and forceps are applied are the main methods of preventing this complication (Box 11.4).If the wrong tooth is extracted and the surgeon realizes this error immediately, the tooth should be replaced quickly into the tooth socket. If the extraction is for orthodontic purposes, the surgeon should contact the orthodontist immediately and discuss whether the tooth that was removed can substitute for the tooth that should have been removed. If the orthodontist believes the original tooth must be removed, the correct extraction should be deferred for 4 or 5 weeks until the fate of the replanted tooth can be assessed. If the wrongfully extracted tooth has regained its attachment to the alveolar process, then the originally planned extraction may proceed. In addition, the surgeon should not extract the contralateral tooth until a denite alternative treatment plan has been made.If the surgeon does not recognize that the wrong tooth was extracted until the patient returns for a postoperative visit, little can be done to correct the problem. Replantation of the extracted tooth after it has dried cannot be successfully accomplished.When the wrong tooth is extracted, it is important to inform the patient or the patient’s parents or caregivers (if the patient is a minor) and any other dentist involved with the patient’s care, such as the orthodontist. In some situations, the orthodontist may be able to adjust the treatment plan so that extraction of the wrong tooth necessitates only a minor alteration of the plan. Also, if the case did not involve orthodontic care, a dental implant–supported restoration may totally restore the patient’s dental status as it was before the inadvertent extraction.Injuries to Adjacent TeethWhen the dentist extracts a tooth, the focus of attention is on that particular tooth and the application of forces to luxate and deliver it. When the surgeon’s total attention is completely focused on just this tooth, the likelihood of injury to the adjacent teeth is increased. Injury is often caused by the use of a burr to remove bone or to divide a tooth for removal. e surgeon should take care to avoid getting too close to adjacent teeth when surgically removing a tooth. is usually requires the surgeon to keep some of the focus on structures adjacent to the site of the surgery.Fracture or Dislodgment of an Adjacent Restoratione most common injury to adjacent teeth is the inadvertent fracture or dislodgment of a restoration or damage to a severely carious tooth while the surgeon is attempting to elevate the tooth to be removed (Fig. 11.8). If a large restoration exists, the surgeon should warn the patient preoperatively about the possibility of fracturing or displacing it during the extraction. Prevention of such a fracture or displacement is primarily achieved by avoiding • Focusattentionontheprocedure.• Checkwiththepatientandtheassistanttoensurethatthecorrecttoothisbeingremoved.• Check,thenrecheck,imagesandrecordstoconrmthecorrecttooth.Prevention of Extraction of Wrong Teeth• BOX 11.4 • Fig. 11.8 Mandibular rst molar. If the rst molar is to be removed, the surgeon must take care not to fracture amalgam in the second premolar with elevators or forceps. • Recognizethepotentialtofracturealargerestoration.• Warnthepatientpreoperatively.• Useelevatorsjudiciously.• Theassistantshouldwarnthesurgeonofpressureonadjacentteeth.Prevention of Injury to Adjacent Teeth• BOX 11.5 CHAPTER 11 Postextraction Patient Management 195 removed so that the tooth can be delivered or, in the case of multirooted teeth, the tooth should be sectioned. If this principle is not adhered to and the surgeon continues to use excessive or uncontrolled force, bone fractures commonly occur.e most likely places for bone fractures are the buccal cortical plate over the maxillary canine, the buccal cortical plate over maxillary molars (especially the rst molar), the portions of the oor of the maxillary sinus that are associated with maxillary molars, the maxillary tuberosity, and labial bone over mandibular incisors (Fig. 11.10). All of these bone injuries are caused by excessive force from the forceps.e primary method of preventing these fractures is to perform a careful preoperative examination of the alveolar process both clinically and radiographically (Box 11.6). e surgeon should inspect the root form of the tooth to be removed and assess the proximity of the roots to the maxillary sinus (Fig. 11.11). e surgeon should also consider the thickness of the buccal cortical plate overlying the tooth to be extracted (Fig. 11.12). If the roots diverge widely, if they lie close to the sinus, or if the patient has a heavy buccal cortical bone, the surgeon should take special measures to prevent fracturing excessive portions of bone. Age is a factor to be considered because the bones of older or larger patients are likely to be less elastic and therefore are more likely to fracture than to expand.With preoperative determination of a high probability for bone fracture, the surgeon should consider performing the extraction by the open surgical technique. Utilizing this method, the surgeon can remove a smaller, more controlled amount of bone, resulting in more rapid healing and a more favorable ridge form for prosthetic reconstruction.When the maxillary molar lies close to the maxillary sinus, surgical exposure of the tooth, with sectioning of the tooth roots or restored, as necessary, to keep the patient comfortable until a permanent restoration can be constructed.Luxation of an Adjacent ToothInappropriate use of the extraction instruments may luxate an adjacent tooth. Luxation is prevented by judicious use of force with elevators and forceps. If the tooth to be extracted is crowded and has overlapping adjacent teeth, as is commonly seen in the mandibular incisor region, a thin, narrow forceps such as the No. 286 forceps may be useful for the extraction (Fig. 11.9). Forceps with broader beaks should be avoided because they will cause injury and luxation of adjacent teeth.A small amount of luxation of an adjacent tooth frequently occurs and generally causes no damage. However, if an adjacent tooth is signicantly luxated or partially avulsed, the treatment goal is to reposition the tooth into its appropriate position and stabilize it so that adequate healing can occur. is usually requires that the tooth simply be repositioned in the tooth socket and left alone. e occlusion should be checked to ensure that the tooth has not been displaced into a hyperocclusion and traumatic occlu-sion. Occasionally the luxated tooth is mobile. If this is the case, the tooth should be stabilized with semirigid xation to maintain it in its position. A silk suture that crosses the occlusal table and is sutured to the adjacent gingiva is usually sucient. Rigid xation with circumdental wires and arch bars results in increased chances for external root resorption and ankylosis of the tooth and therefore should be avoided (see Chapter 25).Injuries to Osseous StructuresFracture of the Alveolar Processe extraction of a tooth usually requires that the surrounding alveolar bone be expanded to allow an unimpeded pathway for tooth removal. However, in some situations, instead of expanding, the bone fractures and is removed still attached to the tooth. e most likely cause of fracture of the alveolar process is the use of excessive force with the forceps, which fractures the cortical plate. If excessive force is necessary to remove a tooth, a soft tissue ap should be elevated and controlled amounts of bone should be AB• Fig. 11.9 (A) No. 151 forceps, which are too wide to grasp the premolar to extract it without luxating adjacent teeth. (B) Maxillary root forceps, which can be adapted readily to the tooth for extraction. • Conductthoroughpreoperativeclinicalandradiographicexaminations.• Donotuseexcessiveforce.• Usesurgical(i.e.,open)extractiontechniquetoreducetheforcerequired.Prevention of Fracture of Alveolar Process• BOX 11.6 196 Part II Principles of Exodontiamultirooted teeth. During a forceps extraction, if the appropriate amount of tooth mobilization does not occur early, then the wise and prudent surgeon will alter the treatment plan to the surgical technique instead of pursuing the closed method.Management of fractures of the alveolar bone takes several dierent forms, depending on the type and severity of the fracture. If the bone has been completely removed from the tooth socket along with the tooth, it should not be replaced. e surgeon should simply make sure that the soft tissue has been repositioned to the best extent possible over the remaining bone to prevent delayed healing. e surgeon must also smooth any sharp edges that may have been caused by the fracture. If such sharp edges of bone exist, the surgeon should reect a small amount of soft tissue and use a bone le to round o the sharp edges or use a rongeur to remove the sharp edges.e surgeon who has been supporting the alveolar process with the ngers during the extraction usually feels the fracture of the buccal cortical plate when it occurs. At this time, the bone remains attached to the periosteum and usually heals if it can be separated from the tooth and is left attached to the overlying soft tissue. e surgeon must carefully dissect the bone with its attached associated soft tissue away from the tooth. For this procedure the tooth must be stabilized with the forceps and a small sharp instru-ment such as a No. 9 periosteal elevator should be used to elevate the buccal bone from the tooth root. Once the bone and soft tissue have been elevated from the tooth, the tooth is removed and the bone and the soft tissue ap are reapproximated and • Fig. 11.10 Forceps extraction of these teeth resulted in removal of bone and tooth instead of just tooth. AB• Fig. 11.11 (A) Floor of sinus associated with roots of teeth. If extraction is required, the tooth should be removed surgically. (B) Maxillary molar teeth immediately adjacent to the sinus present increased danger of sinus exposure. • Fig. 11.12 Patient with a heavy buccal cortical plate, requiring open extraction. (From Neville BW, Damm DD, Allen CM, et al. Oral and Maxil-lofacial Pathology. 2nd ed. St. Louis: Elsevier; 2002.)into two or three portions, usually prevents the removal of a portion of the maxillary sinus oor. is helps prevent the formation of an oroantral stula, which commonly requires secondary procedures to be closed.In summary, prevention of fractures of large portions of the cortical plate depends on preoperative radiographic and clinical assessments, avoidance of the use of excessive amounts of uncon-trolled force, and the early decision to perform an open extraction with removal of controlled amounts of bone and sectioning of CHAPTER 11 Postextraction Patient Management 197 A fracture of the maxillary tuberosity should be viewed as a signicant complication. e major therapeutic goal of management is to maintain the fractured bone in place and provide the best possible environment for healing. is may be a situation that can best be handled by an oral-maxillofacial surgeon.Fracture of the MandibleFracture of the mandible during extraction is a rare complication; it is associated almost exclusively with the surgical removal of impacted third molars. A mandibular fracture is usually the result of the application of a force exceeding that needed to remove a tooth and often occurs during the forceful use of dental elevators. However, when lower third molars are deeply impacted, even small amounts of force may cause a fracture. Fractures may also occur during removal of impacted teeth from a severely atrophic mandible. Should such a fracture occur, it must be treated by methods usually applied for treating jaw fractures. e fracture must be adequately reduced and stabilized; thus the patient should be referred to an oral-maxillofacial surgeon for denitive care.Injuries to Adjacent StructuresInjury to Regional Nervese branches of the fth cranial nerve, which provide innervation to the mucosa and skin, are the adjacent neural structures most likely to be injured during extraction. e most frequently involved specic branches are the mental, lingual, buccal, and nasopalatine nerves. e nasopalatine and buccal nerves are frequently sectioned during the creation of aps for the removal of impacted teeth. e area of sensory innervation of these two nerves is relatively small, and reinnervation of the aected area usually occurs rapidly. erefore the nasopalatine and long buccal nerves can be surgically sectioned without long-lasting sequelae or much bother to the patient.Surgical removal of mandibular premolar roots or impacted mandibular premolars or periapical surgery in the area of the mental nerve and mental foramen must be performed with great care. If the mental nerve is injured, the patient will experience paresthesia or anesthesia of the lip and chin. If the injury is the result of ap reection or manipulation, normal sensation usually returns in a few days to a few weeks. If the mental nerve is sectioned at its exit from the mental foramen or torn along its course, it is likely that mental nerve function will not return, and the patient will have a permanent state of anesthesia. If surgery is to be performed in the area of the mental nerve or the mental foramen, it is imperative that the surgeon be aware of the potential morbidity from injury to this nerve (Box 11.7). If a surgeon has any doubt about his or her ability to perform the indicated surgical procedure, the patient should be referred to an oral-maxillofacial surgeon. If a three-corner ap is to be used in the area of the mental nerve, the vertical releasing incision must be placed far enough anteriorly to avoid severing any portion of the mental nerve. On rare occasion it is advisable to make the vertical releasing incision at the interdental papilla between the canine and the rst premolar.secured with sutures. When treated in this fashion, it is highly probable that the bone will heal in a more favorable ridge form for prosthetic reconstruction than if the bone had been removed along with the tooth. erefore it is worth the special eort to dissect the bone from the tooth.Fracture of the Maxillary TuberosityFracture of a large section of bone in the maxillary tuberosity area is a situation of special concern. The maxillary tuberosity is important for the construction of a stable retentive maxillary denture. If a large portion of this tuberosity is removed along with the maxillary tooth, denture stability is likely to be compromised. An opening into the maxillary sinus may also be created. Fractures of the maxillary tuberosity most commonly result from extraction of an erupted maxillary third molar or from extraction of the second molar if it is the last tooth in the arch (Fig. 11.13).If a tuberosity fracture occurs during an extraction, the treatment is similar to that just discussed for other bone fractures. e surgeon, using nger support for the alveolar process during the fracture (if the bone remains attached to the periosteum), should take measures to ensure the survival of the fractured bone.However, if the tuberosity is excessively mobile and cannot be dissected from the tooth, the surgeon has several options. e rst is to splint the tooth being extracted to adjacent teeth and defer the extraction by 6 to 8 weeks, allowing time for bone to heal. e tooth is then extracted with an open surgical technique. e second option is to section the crown of the tooth from the roots and allow the tuberosity and tooth root section to heal. After 6 to 8 weeks the surgeon can remove the tooth roots in the usual fashion. If the maxillary molar tooth was infected before surgery, these two techniques should be used with caution.If the maxillary tuberosity is completely separated from soft tissue, the usual steps are to smooth the sharp edges of the remaining bone and reposition and suture the remaining soft tissue. e surgeon must carefully check for an oroantral communication and provide the necessary treatment.AB• Fig. 11.13 Tuberosity removed with the maxillary second molar, which eliminates the important prosthetic retention area and exposes the maxil-lary sinus. (A) Buccal view of bone removed with the tooth. (B) Superior view, looking onto the sinus oor, which was removed with the tooth. If possible, the bony segment should be dissected away from the tooth and the tooth should be removed in the usual fashion. The tuberosity is then stabilized with mucosal sutures as previously indicated. (Courtesy Dr. Edward Ellis III, University of Texas Health Science Center, San Antonio.)• Beawareofthenerveanatomyinthesurgicalarea.• Avoidmakingincisionsorstretchingtheperiosteuminthenervearea.Prevention of Nerve Injury• BOX 11.7 198 Part II Principles of Exodontiaif the roots of the tooth are widely divergent, it is common for a portion of the bony oor of the sinus to be removed with the tooth or a communication to be created even if no bone comes out with the tooth. If this problem occurs, appropriate measures are necessary to prevent a variety of sequelae. e two sequelae of most concern are (1) postoperative maxillary sinusitis and (2) formation of a chronic oroantral stula. e probability that either of these two sequelae will occur is related to the size of the oroantral communication and the management of the sinus exposure.As with all complications, prevention is the easiest and most ecient method of managing the situation. Preoperative radiographs must be carefully evaluated for the tooth-sinus relationship whenever maxillary molars are to be extracted. If the sinus oor appears close to the tooth roots and the tooth roots are widely divergent, the surgeon should avoid a closed extraction and perform a surgical removal with sectioning of tooth roots (see Fig. 11.11). Excessive force should be avoided in the removal of such maxillary molars (Box 11.9).e diagnosis of an oroantral communication can be made in several ways. e rst is to examine the tooth once it has been removed. If a section of bone is adherent to the root ends of the tooth, the surgeon should assume that a communication between the sinus and mouth exists. If little or no bone adheres to the molars, a communication may exist anyway. Some advocate using the nose-blowing test to conrm the presence of a communication. is test involves pinching the nostrils together to occlude the patient’s nose and asking the patient to blow gently through the nose while the surgeon observes the area of the tooth extraction. If a communication exists, there will be passage of air through the tooth socket and bubbling of blood in the socket area. However, if there is no communication, forceful blowing like this poses the risk of creating a communication. is is why many surgeons do not feel the nose-blowing maneuver should be used in these circumstances.After the diagnosis of oroantral communication has been established or a strong suspicion exists, the surgeon should guess the approximate size of the communication because the treatment depends on the size of the opening. Probing a small opening may enlarge it, so if no bone comes out with the tooth, the communica-tion is likely to be 2 mm or less in diameter. However, if a sizable piece of bone comes out with the tooth, the opening is of a consider-able size. If the communication is small (≤2 mm in diameter), no additional surgical treatment is necessary. e surgeon should take measures to ensure the formation of a high-quality blood clot in the socket and then advise the patient to take sinus precautions to prevent dislodgment of the blood clot.Sinus precautions are aimed at preventing increases or decreases in the maxillary sinus air pressure that would dislodge the clot. Patients should be advised to avoid blowing the nose, sneezing violently, sucking on straws, and smoking.e surgeon must not probe through the socket into the sinus with a dental curette or a root-tip pick. e bone of the sinus may possibly have been removed without perforation of the sinus mucosa. To probe the socket with an instrument might unnecessarily lacerate The lingual nerve is usually anatomically located directly against the lingual aspect of the mandible in the retromolar pad region. Occasionally the path of the lingual nerve takes it into the retromolar pad area itself. e lingual nerve rarely regenerates if it is severely traumatized. Incisions made in the retromolar pad region of the mandible should be placed so as to avoid coming close to this nerve. erefore incisions made for surgical exposure of impacted third molars or of bony areas in the posterior molar region should be made well to the buccal aspect of the mandible. Similarly, if dissecting a ap involving the retromolar pad, care must be taken to avoid excessive dissection or stretching of the tissues on the lingual aspect of the retromolar pad. Prevention of injury to the lingual nerve is of paramount importance to avoid this problematic complication.Finally, the inferior alveolar nerve may be traumatized along the course of its intrabony canal. e most common place of injury is the area of the mandibular third molar. Removal of impacted third molars may bruise, crush, or sharply injure the nerve in its canal. is complication is common enough during extraction of third molars that it is important routinely to inform patients preoperatively that it is a possibility. e surgeon must then take every precaution possible to avoid injuring the nerve during the extraction.If the lingual or inferior alveolar nerves have been damaged, the surgeon should refer the patient to an oral-maxillofacial surgeon for a consultation. is should be done promptly because, if nerve repair is indicated, the sooner the repair is made, the better the chances of full recovery of nerve function.Injury to the Temporomandibular JointAnother major structure that can be traumatized during an extraction procedure in the mandible is the temporomandibular joint. Removal of mandibular molar teeth frequently requires the application of a substantial amount of force. If the jaw is inadequately supported during the extraction to help counteract the forces, the patient may experience pain in this region. Controlled force and adequate support of the jaw prevent this (Box 11.8). e use of a bite block on the contralateral side may provide an adequate balance of forces so that injury does not occur. e surgeon or assistant should also support the jaw by holding the lower border of the mandible. If the patient complains of pain in the temporomandibular joint area immediately after the extraction procedure, the surgeon should recommend the use of heat, resting the jaw, a soft diet, and 600 to 800 mg of ibuprofen every 4 hours for several days. Patients who cannot tolerate nonsteroidal antiinammatory drugs may take 500 to 1000 mg of acetaminophen.Oroantral CommunicationsRemoval of maxillary premolars or molars occasionally results in communication between the oral cavity and the maxillary sinus. If the maxillary sinus is greatly pneumatized, if little or no bone exists between the roots of the teeth and the maxillary sinus, and • Supportthemandibleduringextraction.• Donotforcethemouthtoopentoowidely.Prevention of Injury to the Temporomandibular Joint• BOX 11.8 • Conductathoroughpreoperativeradiographicexamination.• Usesurgicalextractionearly,andsectionroots.• Avoidexcessiveapicalpressureonmaxillaryposteriorteeth.Prevention of Oroantral Communications• BOX 11.9 CHAPTER 11 Postextraction Patient Management 199 bacteria go from the oral cavity into the sinus, usually causing a chronic sinusitis. In addition, if the patient is wearing a full maxillary denture, the suction seal is broken and retention of the denture is therefore compromised.Postoperative BleedingExtraction of teeth is a surgical procedure that presents a severe challenge to the hemostatic mechanism of the body. Several reasons exist for this challenge: (1) the tissues of the mouth and jaws are highly vascular; (2) the extraction of a tooth leaves an open wound, with soft tissue and bone remaining open, which allows additional oozing and bleeding; (3) it is almost impossible to apply dressing material with enough pressure and sealing to prevent additional bleeding during surgery; (4) patients tend to explore the area of surgery with their tongues and occasionally dislodge blood clots, which initiates secondary bleeding, or the tongue may cause second-ary bleeding by creating small negative pressures that suction the blood clot from the socket; and (5) salivary enzymes may lyse the blood clot before it has organized and before the ingrowth of granulation tissue.As with all complications, prevention of bleeding is the best way to manage this problem (Box 11.10). One of the prime factors in preventing bleeding is taking a thorough patient history with regard to any existing problems with coagulation. e patient must be questioned thoroughly about any history of bleeding, particularly after injury or surgery, because armative answers to these questions should trigger special eorts to control the bleeding (see Chapter 1).e rst question that a patient should be asked is whether he or she has ever had a problem with bleeding in the past. e surgeon should inquire about bleeding after previous tooth extrac-tions or other previous surgery or persistent bleeding after accidental lacerations. e surgeon must listen carefully to the patient’s answers to these questions because what the patient considers “persistent” may actually be normal. For example, it is normal for a socket to ooze small amounts of blood for the rst 12 to 24 hours after extraction. However, if a patient relates a history of bleeding that persisted for more than 1 day or that required special attention from the surgeon, the degree of suspicion should be substantially elevated.e surgeon should inquire about any family history of bleeding. If anyone in the patient’s family has or had a history of prolonged bleeding, further inquiry about its cause should be pursued. Most congenital bleeding disorders are familial, inherited characteristics. ese congenital disorders range from mild to profound, and the latter require substantial eorts to control.e patient should next be asked about any medications currently being taken that might interfere with coagulation. Drugs such as anticoagulants may cause prolonged bleeding after extraction. Patients receiving anticancer chemotherapy or aspirin, those with alcoholism, or patients with severe liver disease for any reason also tend to bleed excessively.the membrane. Probing of the communication may also introduce foreign material, including bacteria, into the sinus, thereby further complicating the situation. Probing of the communication is therefore contraindicated.If the opening between the mouth and sinus is of moderate size (2 to 6 mm), additional measures should be taken. To help ensure the maintenance of the blood clot in the area, a gure-of-eight suture should be placed over the tooth socket (Fig. 11.14). Some surgeons also place some clot-promoting substances such as a gelatin sponge into the socket before suturing. e patient should also be told to follow sinus precautions. Finally, the patient should be prescribed several medications to reduce the risk of maxillary sinusitis. Antibiotics—usually amoxicillin, cephalexin, or clindamycin—should be prescribed for 5 days. In addition, a decongestant nasal spray should be prescribed to shrink the nasal mucosa to maintain patency of the ostium. As long as the ostium is patent and normal sinus drainage can occur, sinusitis and sinus infection will be less likely. Sometimes an oral decongestant is also recommended.If the sinus opening is large (≥7 mm), the surgeon should consider having the sinus communication repaired with a ap procedure. is usually requires that the patient be referred to an oral-maxillofacial surgeon because ap development and closure of a sinus opening are complex procedures that require special training and experience.e most commonly used ap for small openings is the buccal ap. is technique mobilizes buccal soft tissue to cover the opening and provide for a primary closure. is technique should be performed as soon as possible, preferably the same day the opening occurred. e same sinus precautions and medications are usually required (see Chapter 20).e recommendations just described hold true for patients who have no preexisting sinus disease. If a communication does occur, it is important that the dentist inquire specically about a history of sinusitis and sinus infections. If the patient has a history of chronic sinus disease, even small oroantral communications may heal poorly and may result in a chronic oroantral communication and eventual stula. erefore creation of an oroantral communica-tion in a patient with chronic sinusitis is cause for referral to an oral-maxillofacial surgeon for denitive care (see Chapter 20).e majority of oroantral communications treated by using the methods just recommended heal uneventfully. Patients should be followed carefully for several weeks to ensure that healing has occurred. Even patients who return within a few days with a small communication usually heal spontaneously if no maxillary sinusitis exists. ese patients should be monitored closely and referred to an oral-maxillofacial surgeon if the communication persists for longer than 2 weeks. e usual patient complaint in such situations is the leakage of uids from the mouth into the nose. e closure of an oroantral stula is important because air, water, food, and • Fig. 11.14 A gure-of-eight stitch is usually used to help maintain the piece of oxidized cellulose in the tooth socket. • Obtainahistoryofbleeding.• Usetheatraumaticsurgicaltechnique.• Obtaingoodhemostasisatsurgery.• Provideexcellentpatientinstructions.Prevention of Postoperative Bleeding• BOX 11.10 200 Part II Principles of Exodontiasocket about 30 minutes after the completion of surgery. e patient should open the mouth widely, the gauze should be removed, and the area should be inspected carefully for any persistent oozing. Initial control should have been achieved by then. New gauze is then dampened, folded, and placed into position, and the patient is instructed to leave it in place for an additional 30 minutes.If bleeding persists but careful inspection of the socket reveals that it is not of an arterial origin, the surgeon should take additional measures to achieve hemostasis. Several dierent materials can be placed in the socket to help gain hemostasis (Fig. 11.16). e most commonly used and the least expensive is the absorbable gelatin sponge (e.g., Gelfoam). is material is placed in the extraction socket and is held in place with a gure-of-eight suture placed over the socket. e absorbable gelatin sponge forms a scaold for the formation of a blood clot, and the suture helps maintain the sponge in position during the coagulation process. A gauze pack is then placed over the top of the socket and is held with pressure.A second material that can be used to control bleeding is oxidized regenerated cellulose (e.g., Surgicel). This material promotes coagulation better than the absorbable gelatin sponge because it can be packed into the socket under pressure. e gelatin sponge becomes friable when wet and cannot be packed into a bleeding socket. When the cellulose is packed into the socket, it almost always causes some delayed healing of the socket. erefore packing the socket with cellulose is reserved for more persistent bleeding.If the surgeon has special concerns about the coagulability of the patient’s blood, a liquid preparation of topical thrombin (prepared from human recombinant thrombin) can be saturated onto a gelatin sponge and inserted into the tooth socket. e thrombin bypasses steps in the coagulation cascade and helps convert brinogen to brin enzymatically, which forms a clot. e sponge with the topical thrombin is secured in place with a gure-of-eight suture. A gauze pack is placed over the extraction site in the usual fashion.A nal material that can be used to help control a bleeding socket is collagen. Collagen promotes platelet aggregation and thus helps accelerate blood coagulation. Collagen is currently available in several dierent forms. Microbular collagen (e.g., Avitene Davol) is available as a bular material that is loose and uy but can be packed into a tooth socket and held in by suturing and use of gauze packs and other materials. A more highly cross-linked collagen is supplied as a plug (e.g., Collaplug) or as a tape (e.g., Collatape). ese materials are more readily packed into a socket (Fig. 11.17) and are easier to use, but they are expensive.Even after primary hemostasis has been achieved, patients occasionally call the dentist with bleeding from the extraction site, referred to as secondary bleeding. e patient should be told to rinse the mouth gently with chilled water and then to place appropriate-sized damp gauze over the area and bite rmly on it. e patient should sit quietly for 30 minutes, continuing to bite rmly on the gauze. If the bleeding persists, the patient should repeat the cold rinse and bite down on a damp tea bag. e tannin in the tea frequently helps stop the bleeding. Alert the patient that herbal teas do not contain tannin and will not be eective. If neither of these techniques is successful, the patient should return to the dentist.e surgeon must have an orderly, planned regimen to control this secondary bleeding. Ideally, a trained dental assistant will be present to help with treatment. e patient should be positioned in the dental chair and all blood, saliva, and uids should be e patient who has a known or suspected coagulopathy should be evaluated by laboratory testing before surgery is performed to determine the severity of the disorder. It is usually advisable to enlist the aid of a physician if the patient has a hereditary coagulation disorder.e status of therapeutic anticoagulation is measured by using the international normalized ratio (INR). is value takes into account the patient’s prothrombin time and the standardized control. Normal anticoagulated status for most medical indications has an INR of 2.0 to 3.0. It is reasonable to perform extractions on patients who have an INR of 2.5 or less without reducing the anticoagulant dose. With special precautions, it is reasonably safe to do minor amounts of surgery in patients with an INR of up to 3.0 if special local hemostatic measures are taken. If the INR is higher than 3.0, the patient’s physician should be contacted to determine whether the physician would lower the anticoagulant dosage to allow the INR to fall.Primary control of bleeding during routine surgery depends on gaining control of all factors that may prolong bleeding. Surgery should be as atraumatic as possible, with clean incisions and gentle management of soft tissue. Care should be taken not to crush soft tissue because crushed tissue tends to ooze for longer periods. Sharp bony spicules should be smoothed or removed. Granulation tissue should be curetted from the periapical region of the socket and from around the necks of adjacent teeth and soft tissue aps; however, this should be deferred when anatomic restrictions such as the sinus or inferior alveolar canal are nearby (Fig. 11.15). e wound should be carefully inspected for the presence of any specic bleeding arteries. If such arteries exist in soft tissue, they should be controlled with direct pressure or, if pressure fails, by clamping the artery with a hemostat and ligating it with a nonresorbable suture.e surgeon should also check for bleeding from the bone. Occasionally a small, isolated vessel bleeds from a bony foramen. If this occurs, the foramen can be crushed with the closed end of a hemostat, occluding the bleeding vessel. Once these measures have been accomplished, the bleeding socket is covered with a damp gauze sponge that has been folded to t directly into the area from which the tooth was extracted. e patient bites down rmly on this gauze for at least 30 minutes. e surgeon should not dismiss the patient from the oce until hemostasis has been achieved. is requires that the surgeon check the patient’s extraction • Fig. 11.15 Granuloma of second premolar. The surgeon should not curette periapically around this second premolar to remove granuloma because the risk for sinus perforation is high. CHAPTER 11 Postextraction Patient Management 201 patient should be given specic instructions on how to apply the gauze packs directly to the bleeding site should additional bleeding occur. Before the patient with secondary bleeding is discharged from the oce, the surgeon should monitor the patient for at least 30 minutes to ensure that adequate hemostasis has been achieved.If hemostasis is not achieved by any of the local measures just discussed, the surgeon should consider performing additional laboratory screening tests to determine whether the patient has a profound hemostatic defect. In such a case the surgeon usually requests a consultation from a hematologist, who will order typical screening tests. Abnormal test results will prompt the hematologist to investigate the patient’s hemostatic system further.A nal hemostatic complication relates to intraoperative and postoperative bleeding into adjacent soft tissues. Blood that escapes into tissue spaces, especially subcutaneous tissue spaces, appears as bruising of overlying soft tissue 2 to 5 days after the surgery. is bruising is termed ecchymosis and is discussed earlier in this chapter.Delayed Healing and InfectionWound DehiscenceAnother problem of delayed healing is wound dehiscence (separation of the wound edges; Box 11.11). If a soft tissue ap is replaced and sutured without an adequate bony foundation, the unsupported soft tissue ap often sags and separates along the line of incision. A second cause of dehiscence is suturing the wound under tension. is occurs when the surgeon tries to aggressively pull the edges of a wound together with sutures. e closure is under tension if the suture is the only force keeping the edges approximated. If the edges spring apart when the suture is removed just after being placed, the wound closure is under tension. If the soft tissue ap is sutured under tension, the sutures cause ischemia of the ap margin with subsequent tissue necrosis, which allows the suture suctioned from the mouth. Such patients frequently have large “liver clots” (clotted blood that resembles fresh liver), which must be removed from the mouth. e surgeon should observe the bleeding site carefully under eective lighting to determine the precise source of the bleeding. If it is clearly seen to be a generalized oozing, the bleeding site is covered with a folded, damp gauze sponge held in place with rm pressure by the surgeon’s nger for at least 5 minutes.is measure is sucient to control most bleeding. e reason for the bleeding is usually some secondary trauma that is potentiated when the patient continues to suck on the area or spits out the blood instead of continuing to apply pressure with a gauze sponge.If 5 minutes of this treatment does not control the bleeding, the surgeon must administer a local anesthetic so that the socket can be treated more aggressively. Block techniques are to be encour-aged instead of local inltration techniques. Inltration with solutions containing epinephrine causes vasoconstriction and may control the bleeding temporarily. However, when the eects of the epinephrine dissipate, rebound hemorrhage with recurrent bothersome bleeding may occur.Once regional local anesthesia has been achieved, the surgeon should gently curette out the tooth extraction socket and suction all areas of the old blood clot. e specic area of bleeding should be identied as clearly as possible. As with primary bleeding, soft tissue should be checked for diuse oozing versus specic arterial bleeding. Bone tissue should be checked for small nutrient artery bleeding or general oozing. e same measures described for control of primary bleeding should be applied. e surgeon must then decide whether a hemostatic agent should be inserted into the bony socket. e use of an absorbable gelatin sponge with topical thrombin held in position with a gure-of-eight stitch and reinforced with application of rm pressure from a small damp gauze pack is standard for local control of secondary bleeding. is technique works well in almost every bleeding socket. In many situations, an absorbable gelatin sponge and gauze pressure are adequate. e • Fig. 11.16 Examples of materials used to help control bleeding from an extraction socket. Surgicel (left) is oxidized regenerated cellulose and comes in a silky fabric-like form, whereas Gelfoam (right) is absorb-able gelatin that comes as latticework that is easily crushed with pressure. Both promote coagulation. 202 Part II Principles of Exodontiae two major treatment options are (1) to leave the projection alone or (2) to smooth it with bone le. If the area is left to heal untreated, the exposed bone will slough o in 2 to 4 weeks. If the sharp bone does not cause much irritation, this is the preferred method. If a bone le is used, no ap should be elevated because this will result in an increased amount of exposed bone. e le is used only to smooth o the sharp projections of bone. is procedure usually requires local anesthesia.Dry SocketDry socket or alveolar osteitis is delayed healing but is not associated with an infection. is postoperative complication causes signicant pain but is without the usual signs and symptoms of infection, such as fever, swelling, and erythema. e term dry socket describes the appearance of the tooth extraction socket when the pain begins. In the usual clinical course, pain develops on the third or fourth day after removal of the tooth. Almost all dry sockets occur after to pull through the ap margin and results in wound dehiscence. erefore sutures should always be placed in tissue without tension and tied loosely enough to prevent blanching of the tissue.A common area of exposed bone after tooth extraction is the internal oblique ridge. After extraction of the rst and second molars, during initial healing, the lingual ap becomes stretched over the internal oblique (mylohyoid) ridge. Occasionally bone perforates through the thin mucosa, causing a sharp projection of bone in the area.A BCD• Fig. 11.17 (A) Bicon resorbable collagen plug. (B) Collagen being placed into extraction socket. (C) Collagen in extraction socket. (D) Suture used to help retain collagen plug. (B–D, Courtesy Dr. Edward Ellis III, University of Texas Health Science Center, San Antonio.)• Useaseptictechnique.• Performatraumaticsurgery.• Closetheincisionoverintactbone.• Suturewithouttension.Prevention of Wound Dehiscence• BOX 11.11 CHAPTER 11 Postextraction Patient Management 203 medication contains the following principal ingredients: eugenol, which obtunds the pain from the bone tissue; a topical anesthetic such as benzocaine; and a carrying vehicle such as balsam of Peru. e medication can be made by the surgeon’s pharmacist or can be obtained as a commercial preparation from a dental supply house.e medicated gauze is gently inserted into the socket, and the patient usually experiences profound relief from pain within 5 minutes. e dressing is changed every other day for the next 3 to 5 days, depending on the severity of pain. e socket is gently irrigated with saline at each dressing change. Once the patient’s pain has decreased, the dressing should not be replaced because it acts as a foreign body and further prolongs wound healing.Infectione most common cause of delayed wound healing is infection. Infections are a rare complication after routine dental extraction and are primarily seen after oral surgery that involves the reection of soft tissue aps and bone removal. e most important measure to prevent infection following routine extractions is for the surgeon to adhere carefully to the basic principles of surgery. ese principles are to minimize tissue damage, remove sources of infection, and cleanse the wound. No other special measures need be taken with the average patient. Careful asepsis and thorough wound debride-ment after surgery can best prevent infection after surgical ap procedures. is means that the area of bone removal under the ap must be copiously irrigated with saline under pressure and that all visible foreign debris must be removed with a curette.Some patients, especially those with depressed immune host-defense responses, may require antibiotics to prevent infection. Antibiotics in these patients should be administered before the surgical procedure is begun (see Chapter 16). Additional antibiotics after the surgery are usually not necessary for routine extractions in healthy patients.Infections after routine extractions exhibit the typical signs of a fever, increased swelling, reddening of skin, a foul taste in the mouth, or worsening pain 3 to 4 days after surgery. Infected oral wounds look inamed, and some purulence is usually present. e management of such infections is discussed in Chapter 16.the removal of lower molars. On examination, the tooth socket appears to be empty, with a partially or completely lost blood clot, and some bony surfaces of the socket are exposed. e exposed bone is sensitive and is the source of the pain. e dull, aching pain is moderate to severe, usually throbbing in nature and fre-quently radiating to the patient’s ear. e area of the socket has a bad odor, and the patient frequently complains of a foul taste.e cause of alveolar osteitis is not fully clear, but it appears to result from high levels of brinolytic activity in and around the tooth extraction socket. is brinolytic activity results in lysis of the blood clot and subsequent exposure of bone. e brinolytic activity may result from subclinical infections, inammation of the marrow space of the bone, or other factors. e occurrence of a dry socket after a routine tooth extraction is rare (2% of extrac-tions), but it is frequent after the removal of impacted mandibular third molars and other lower molars (20% of extractions in some series).Prevention of the dry socket syndrome requires that the surgeon minimize trauma and bacterial contamination in the area of surgery. e surgeon should perform atraumatic surgery with clean incisions and soft tissue reection. After the surgical procedure, the wound should be irrigated thoroughly with large quantities of saline delivered under pressure, as from a plastic syringe. Small amounts of antibiotics (e.g., a tetracycline) placed in the socket alone or on a gelatin sponge have been shown to substantially decrease the incidence of dry socket in mandibular third molars and other lower molar sockets.e treatment of alveolar osteitis is dictated by the single therapeutic goal of relieving the patient’s pain during the period of healing. If the patient receives no treatment, no sequela other than continued pain will exist (treatment does not hasten healing). Treatment is straightforward and consists of irrigation and the insertion of a medicated dressing. First, the tooth socket is gently irrigated with sterile saline. e socket should not be curetted down to bare bone because this increases the amount of exposed bone and pain. Usually the entire blood clot is not lysed, and the part that is intact should be retained. e socket is gently suctioned of all excess saline, and a small strip of iodoform gauze soaked in or coated with the medication is inserted into the socket with a small tag of gauze left trailing out of the wound. e 20412 Medicolegal ConsiderationsMYRON R. TUCKER AND JAMES R. HUPPCHAPTER OUTLINELegal Concepts Inuencing Liability, 204Duty, 205Breach of Duty, 205Damages, 205Causation, 205Risk Reduction, 205Patient Information and Oce Communication, 205Informed Consent, 206Records and Documentation, 207Electronic Records, 207Referral to Another General Dentist or Specialist, 208Complications, 208Patient Management Problems, 208Noncompliant Patient, 208Patient Abandonment, 208Common Areas of Dental Litigation, 209When a Patient Threatens to Sue, 210Managed Care Issues, 211Telemedicine and the Internet, 211Rules and Regulations Aecting Practice, 212Health Insurance Portability and Accountability Act Privacy and Security, 212Health Information Technology for Economic and Clinical Health Act Regulations, 212Risk Analysis Management, 212Title VI, Limited English Prociency, 213Americans With Disabilities Act, 213Emergency Medical Treatment and Active Labor Act, 214Summary, 214Dentistry is a discipline in which most practitioners regularly perform invasive procedures. us, similar to physicians, particularly those who commonly do procedures, dentists are subject to claims of dental malpractice. Some of the most common lawsuits against dentists relate to the extraction of the wrong tooth, failure to diagnose a problem, and lack of proper informed consent, which are all problems that may occur when a patient requires oral surgery. Malpractice claims arise when a patient believes that his or her dentist, or an employee of the dentist, was negligent in some manner. Whether or not this is true, malpractice cases move forward through the legal system. Such cases take a toll on dental professionals, both nancially and emotionally. To avoid the nancial costs of paying for one’s legal defense and, in some cases, the costs if a case is lost or settled, dentists practice risk management and purchase malpractice (liability) insurance. In addition, many dentists feel pressured into practicing “defensive dentistry,” second-guessing sound clinical decisions because of concerns about potential litigation.e inuence of litigation on dentistry has resulted in an eort by the profession to reduce the risk of legal liability by more closely examining treatment decisions, improving documentation of care, and strengthening dentist-patient relationships. Although no substitute exists for sound clinical practice, nontreatment issues prompt many lawsuits. ese issues often include miscommunication and misunderstanding between the dentist and the patient and poor record keeping, which, in turn, create opportunities for patients’ lawyers to establish grounds for lawsuits.is chapter reviews concepts of liability, risk management, methods of risk reduction, and actions that should be taken if a malpractice suit is led against the dentist or the dentist’s employee.Legal Concepts Inuencing LiabilityTo understand the value of and responsibility of the dentist in risk management, it is important to review several legal concepts pertain-ing to dental practice.Malpractice is dened by the legal system as professional neg-ligence. is occurs when treatment provided by the dentist fails to comply with the standard of care exercised by other similarly trained dentists in similar situations. In other words, professional negligence occurs when professionals fail to have or exercise the degree of judgment and skill ordinarily possessed and demonstrated by members of their profession practicing under similar circumstances.In most states, standard of care is dened as that which an ordinarily skilled, educated, and experienced dentist would do (or not do) under similar circumstances. Most states adhere to a national standard for dental specialists but may follow a more regional standard for general dentists. e dentist is considered to have practiced negligently when a patient and his or her dental expert(s) convince a judge or jury that the dentist failed to comply with this minimal level of care and that such failure caused an injury.In most malpractice cases, the patient must prove all of the following four elements of a malpractice claim: (1) existence of a duty—usually implied by the doctor-patient relationship; (2) breach of the duty—in malpractice, not practicing up to the standard of CHAPTER 12 Medicolegal Considerations 205 suit can be successful if the doctor did not inform the patient of the signicant risks of the planned procedure and obtain written consent to perform the surgery. Further discussion of this concept appears in the section on risk management.Marketing pressures can sometimes lead to written advertisements or promotions that can be interpreted as guaranteeing results. Patients who have diculty chewing after receiving new dentures, if originally promised that they would be able to eat any type of food without diculty, might consider such promises breach of contract or breach of warranty. Dissatisfaction with esthetics or function is often linked to unreasonable expectations, sometimes fueled by ineective communication or excessive salesmanship. Similar problems can occur if a dentist’s promotional materials claim the ability to perform painless or bloodless surgery.e statute of limitations generally provides a certain period for ling a malpractice suit against an individual or a corporation and thereby can limit how long a person may wait to le a lawsuit. is limit, however, varies widely from state to state. In some states the statute of limitations begins when an incident occurs. In other states, the statute of limitations is extended for a short period after the alleged malpractice is discovered (or when a “reason-able” person would have discovered it). Several other factors can extend the statute of limitations in many states. ese factors include patients who are children or younger than 18 years or the age of majority, fraudulent concealment of negligent treatment by the dentist, and leaving a nontherapeutic foreign object in the body (e.g., broken burr or le). As previously mentioned, the more recent development of trade practices and breach of contract claims can be traced in part to a longer statute of limitations period for contract actions and the common triple damages provisions of the deceptive trade practices acts.Risk Reductione foundation for all dental practice should be sound clinical procedures, but even when practitioners try to do all that they can to make sure that a procedure goes well, problems can still occur. To manage this possibility, risk reduction strategies should be adopted to properly address various aspects of patient care and oce policy and to reduce potential legal liability. ese aspects include ensuring eective dentist-patient and sta-patient communication, patient information, informed consent, proper documentation, and appropriate management of complica-tions. Additionally, clinicians should note that patients with reasonable expectations and a favorable relationship with their dentist are much less likely to sue and more likely to tolerate complications.Patient Information and Oce CommunicationA solid dentist-patient relationship is the cornerstone of any risk management program. Well-informed patients generally have a much better understanding of potential complications and more realistic expectations about treatment outcomes. e education of patients can be accomplished by providing them with as much information as possible about the proposed treatment, alternatives to and risks of the planned surgery, and benets and limitations of each reasonable clinical option. Patients are given this information to help them better understand their care so that they can make informed decisions. e information should be communicated in a positive manner and not in a defensive way. If done properly, the informed consent process can improve dentist-patient rapport.care; (3) damages—in nonlegal terms, an injury; and (4) causation—a causal connection between the failure to meet the standard of care and the injury. e initial burden of proving malpractice lies with the plainti (patient). e patient must prove by a preponderance (more than 50%) of the evidence that all four elements of the claim were met.1DutyA professional relationship must exist between the dentist and the patient before a legal duty or obligation is owed to exercise appropri-ate care. is relationship can be established if the dentist accepts the patient or otherwise begins treatment. Accepting a patient can occur automatically, as when a dentist is on call for emergencies and a patient presents for care. But normally a dentist does not legally establish a duty to a patient until the dentist agrees (verbally or in writing) to treat the patient. A new patient simply turning up in a dentist’s oce does not establish a dentist-patient relationship or legal duty.Breach of DutyA dentist has a duty to provide care to a patient that at least meets the standard of good dental care. Such standards are not written down anywhere but are typically determined in individual cases by dental experts hired during dental malpractice cases to give the judge or jury their opinion of what is the standard of care required by the dentist in the circumstances surrounding the case. is standard of care does not obligate the dentist to provide the highest level of treatment exercised by the most skilled dentist or that which is taught in dental school. e standard of care is intended to be a common denominator dened by what average practitioners would ordinarily do under similar circumstances.DamagesSome form of actual damage must be demonstrated. Damages may be physical, mental, or both. However, a patient suing out of simple revenge or a payment dispute cannot successfully win a malpractice case if he or she cannot show any actual damages.CausationIt must be shown that the failure to provide standard care was the cause of the patient’s injury. If something occurred between the time that the dentist provided treatment and when the damages occurred, there may not be a connection between the dentist’s care and the patient’s injury.Dentists are not liable for inherent risks of treatment that occur in the absence of negligence. For example, a dentist is not liable if a patient experiences numbness of lips after a properly performed third molar extraction. is is a complication recognized in the scientic literature. A dentist can be legally liable for numbness of lips if the patient proves it was caused by negligence (e.g., the numbness was caused by a careless incision or by careless use of a burr or other instrument) or if the patient was not told before the surgery that lip numbness was a risk of the procedure.Malpractice suits may arise even when a practitioner has done everything correctly but a complication occurs that is a known risk of the procedure and damages the patient. is is an aberrancy in malpractice law that normally requires some form of negligence to occur for a lawsuit to be successful. In this case, the patient’s 206 Part II Principles of Exodontiaappears in a legal denition and if a lawsuit occurs over the matter, the jury will decide what it means. e implications of this are discussed later in this chapter.In most states dentists have a duty to obtain the patient’s consent; they cannot delegate the entire responsibility. Although sta members in the dental oce can present the consent form and the patient may be shown a video that provides information as part of the informed consent process, the dentist should meet with the patient to review treatment recommendations, options, and the risks and benets of each option; the dentist must also be available to answer questions. Although not required by the standard of care in many states, it is advisable to get the patient’s written consent for invasive dental procedures. Parents or legal guardians must sign for minors. Legal guardians must sign for individuals with mental incapacities. In certain regions of the United States, it is helpful to have consent forms written in other languages or have multilingual staff members available to assist with communication.Informed consent consists of three phases: (1) informing, (2) written consent, and (3) documentation in the patient’s chart. In obtaining informed consent, the clinician should conduct a frank discussion and provide information about seven areas: (1) the specic problem, (2) the proposed treatment, (3) anticipated or common side eects, (4) possible complications and approximate frequency of occurrence, (5) planned anesthesia and any material risks of the anesthesia, (6) treatment alternatives, and (7) uncertain-ties about nal outcome, including a statement that the planned treatment has no absolute guarantees of success.is information must be presented in such a manner that the patient has no diculty understanding it. In the event of a lawsuit, the jury will determine whether the information was provided in an understandable manner. Thus the dentist should provide information such that the average juror would be able to understand descriptions of treatment plans and risks. Video presentations, including Internet-based interactive education, describing dental and surgical procedures and the associated risks and benets are available. ese can be used as part of the informed consent process but should not replace direct discussions between the dentist and the patient. At the conclusion of the presentation, the patient should be given an opportunity to ask any additional questions.After these presentations or discussions, the patient should sign a written informed consent. e written consent should summarize, in easily understandable terms, the items presented. Some states presume that if the information is not on the form, it was not discussed. Whether the patient can read and speak English should also be documented; if the patient does not read or speak English, the presentation and written consent should be given in the patient’s spoken language. To ensure that the patient understands each specic paragraph of the consent form, the dentist should consider having the patient initial each paragraph on the form.An example of an informed consent document appears in Appendix 4. At the conclusion of the discussion, the patient, the dentist, and at least one witness should sign the informed consent document. In the case of a totally electronic record system, signature pads should be used to obtain the patient’s consent. In the case of a minor, the patient and the parent or legal guardian should sign the informed consent. In most states, the age of majority (when the patient is no longer a minor) is 18 years. ere are a few exceptions, including Mississippi (21 years); Alabama, Delaware, and Nebraska (19 years); Nevada, Ohio, Utah, and Wisconsin (18 years or graduation from high school, whichever is earlier); and Arkansas, Tennessee, and Virginia (18 years or graduation from Patients value and expect a discussion with their dentist about their care. Brochures and other types of informational packages help provide patients with general and specic information about general dental and oral surgical care. Patients requiring oral surgical procedures will benet from information on the nature of the problem, recommended treatment and alternatives, expectations, and possible complications. is information should be presented in a well-organized, easy-to-understand format and in layperson language. Informed consent is discussed in detail in the following section.When a dentist has a specic discussion with a patient or gives the patient an informational package, it should be documented in the patient’s chart. Information about complications discussed earlier can be reviewed if complications do occur later. In general, patients with reasonable expectations create fewer problems (a theme repeated throughout this chapter).Informed ConsentIn addition to providing quality care, eective communication should be a standard practice in the dentist’s oce. Dentists can be sued not only for negligent treatment but also for failing to inform patients properly about the diagnosis; the treatment to be provided; reasonable treatment alternatives; and the reasonable benets, risks, and complications of each treatment option. Treat-ment without proper informed consent can be considered battery—that is, intentionally touching a person without his or her consent.e concept of informed consent is that the patient has a right to consider known risks and complications inherent in a treatment. is enables the patient to make a knowledgeable, voluntary decision whether to proceed with the recommended treatment or choose another option. If a patient is properly advised of inherent risks, even if a complication occurs, the dentist is not legally liable in the absence of negligence. However, a dentist can be held liable when an inherent risk occurs after the dentist fails to obtain the patient’s informed consent. e rationale for liability is that the patient was denied the opportunity to refuse treatment after being properly advised of risks associated with the treatment and reasonable options.Current concepts of informed consent are based as much on providing the patient with the necessary information as on actually obtaining a consent or signature for a procedure. In addition to fullling the legal obligations, obtaining the proper informed consent from patients benets the clinician in several ways. First, obtaining an informed consent oers the dentist the opportunity to develop better rapport with the patient by demonstrating a greater personal interest in the patient’s well-being. Second, well-informed patients who understand the nature of the problem and have realistic expectations are less likely to sue. Finally, a properly presented and documented informed consent often prevents frivolous claims based on misunderstanding or unrealistic expectations.e requirements of an informed consent vary from state to state. Initially the informed consent process involved informing patients that bodily harm or death may result from a procedure. Discussions regarding minor, unlikely complications that seldom occur and infrequently result in signicant ill eects are not required. However, some states have adopted the concept of material risk, which requires dentists to discuss all aspects material to the patient’s decision to undergo treatment, even if it is not customary in the profession to provide such information. A risk is material when a reasonable person is likely to attach signicance to it in assessing whether to have the proposed therapy. When the word “reasonable” CHAPTER 12 Medicolegal Considerations 207 5. Allergies6. Clinical and radiographic ndings and interpretations7. Recommended treatment and other alternatives8. Informed consent9. erapy actually instituted10. Recommended follow-up treatment11. Referrals to other general dentists, specialists, or other medical practitionersTen frequently overlooked pieces of information should be recorded in the chart:1. Prescriptions and rells dispensed to the patient2. Messages or other discussions related specically to patient care (including telephone calls)3. Consultations obtained4. Results of laboratory tests5. Clinical observations of progress or outcome of treatment6. Recommended follow-up care7. Appointments made or recommended8. Postoperative instructions and orders given9. Warnings to the patient, including issues related to lack of compliance, failure to appear for appointments, failure to obtain or take medication, instructions to see other dentists or physicians, or instructions on participation in any activity that might jeopardize the patient’s health or success of a procedure10. Missed appointmentsCorrections should be made by drawing a single line through any information to be deleted. Correct information can be inserted above or added below, along with the correct date. Any crossed-out deletion should be initialed and dated. No portion of the chart should ever be discarded, obliterated, erased, or altered in any fashion. In some states, altering records with the intent to deceive is a felony.e period for maintaining records varies from 3 to 10 years and can generally be found in each state’s Dental Practice Act. Records should be kept long enough to be available should a patient decide to sue; this depends on the state’s statute of limita-tions. In the case of minors, the statute of limitations does not begin until the patient reaches the age of majority, as described in the section on informed consent.Electronic Recordse conversion to electronic record keeping from paper record keeping is increasing in practice; it has many potential applications for a modern dental practice. e increasing use of electronic records has raised several issues about the validity of oce notes, other written documents, and radiographs. As with any medical record, it is important that records not be altered in any way after they are initially created and placed in a chart or digital le. Although alterations can be made on electronically generated documents, most software packages have tracking mechanisms in place that can detect whether documents, radiographs, or other images have been altered and when this occurred. If a change to an oce note or other document is required, this should always be done as an addendum and entered into the record separately rather than by changing the original document. Today, forensic computer science can track any attempts to change records; therefore the same caveats about corrections to paper and lm documentation also apply to electronic documentation.Because many oces are completely “paperless,” many documents are signed electronically. Electronic signatures are as valid as the high school, whichever is later). In some states, minors may sign the informed consent for their own treatment if they are married or pregnant. Before assuming this to be the case, the dentist should verify local regulations.e third and nal phase of the informed consent process is to document in the patient’s chart that an informed consent was obtained after the dentist discussed treatment options, risks, and benets with the patient. e dentist should record the fact that consent discussions took place and should also record other events such as showing videos and providing educational brochures. e written consent form should be included.In three special situations, the informed consent process may deviate from these guidelines: (1) A patient may specically ask not to be informed of all aspects of the treatment and complications; if so, this must be specically documented in the chart and signed by the patient. (2) It may be harmful in some cases to provide all of the appropriate information to the patient. is is termed therapeutic privilege for not obtaining a complete informed consent. erapeutic privilege is controversial and would rarely apply to routine oral surgical and dental procedures. (3) A complete informed consent may not be necessary in an emergency, when the need to proceed with treatment is so urgent that the time taken to obtain an informed consent may result in further harm to the patient. is also applies to management of complications during a surgical procedure. It is assumed that if failure to manage a condition immediately would result in further harm to the patient, then treatment should proceed without obtaining specic informed consent.Patients have the right to know whether any risks are associated with their decision to reject certain forms of treatment. is informed refusal and attempts to inform the patient of the risks and consequences of refusing treatment should be clearly docu-mented in the chart. Patients who do not appear for needed treatment should be sent a letter warning them of potential problems that may arise if they do not seek treatment. Copies of these letters should be kept in the patient’s chart.Records and DocumentationPoor record keeping is one of the most common problems encoun-tered in the defense of a malpractice suit. When the quality of patient care is questioned, the records supposedly reect what was done and why. Poor records provide plainti attorneys with an opportunity to claim that patient care must also have been sub-standard. Poor documentation also makes it dicult for the dentist to recall what happened during a particular patient encounter, thus harming the dentist’s defense. Even though a perfect record is neither possible nor required, records should reasonably reect the diagnosis, treatment, consent, complications, and other key events.Adequate documentation of the diagnosis and treatment is one of the most important aspects of patient care. A well-documented chart is the cornerstone of any risk management program. If dentists do not document fundamental clinical ndings supporting the diagnosis and treatment, attorneys may question the need for treatment in the rst place. Some will argue that if something was not charted, it did not happen. e following 11 items are helpful in recording in the chart:1. Chief complaint2. Dental history3. Medical history4. Current medication 208 Part II Principles of Exodontiasecond premolar extracted. Before removing any other teeth or alarming the patient and parents, the dentist should call the orthodontist to discuss the eect on treatment outcome and available treatment modications. e patient and parents should be notied that the wrong tooth was extracted but that the orthodontist indicated that the treatment can proceed without signicantly compromising the result.Another common complication is altered sensation following third molar removal or posterior implant placement. e chart should reect the existence and the extent of the problem. It may be useful to use a diagram to document the area involved. If possible, the density and severity of the sensory decit should be noted after testing. e chart should reect the progress of the condition each time the patient returns for follow-up. Early referral to an oral-maxillofacial surgeon with experience in diagnosing and treating nerve injuries is wise, since, when indicated, the earlier the attempt to repair the nerve, the better the prognosis. In most cases, the referral should occur no later than 3 months after the injury if no signicant improvement is seen. Excessive delays may limit the eectiveness of future treatment. Documentation of the patient’s progress will help to justify any decision to delay the referral.Patient Management ProblemsNoncompliant PatientDentists and sta should routinely chart lack of compliance, including missed appointments, cancelations, and failure to follow advice to take medications, seek consultations, wear appliances, or return for routine visits. Eorts to advise patients of risks associated with failing to follow instructions should also be recorded.When the patient’s health may be jeopardized by continued noncompliance, the clinician should consider writing a letter to the patient, identifying the potential harm and advising the patient that the oce will not be responsible if these and other problems develop as a result of the patient’s noncompliance. If the patient’s care is eventually terminated, the accumulation of detailed chart entries documenting the noncompliance should justify the dentist’s unwillingness to continue the patient’s care.Patient AbandonmentA legal duty is owed to the patient once a dentist-patient relationship is established. Generally duty is established when a patient has been seen in the oce, the initial evaluation has been completed, and the dentist has agreed to treat the patient. e dentist is usually obligated to provide care until the treatment is completed. ere may be instances, however, when it is impossible or unreasonable for a dentist to complete a treatment plan because of several problems. Such problems include the patient’s failure to return for necessary appointments, follow explicit instructions, take medications, seek recommended consultations, or stop activities that may interfere with the treatment plan or otherwise jeopardize the dentist’s ability to achieve acceptable results. is may include a total breakdown of communication between the dentist and the patient.In these cases it is usually necessary for the dentist to follow certain steps before discontinuing treatment to avoid being accused of patient abandonment. First, the chart must document the activities leading to the patient’s termination. e patient should be adequately warned (if possible) that termination will result if system in place used to protect from fraud, not unlike paper records where a signature can be forged. Most systems have some type of security measure imbedded within the software to protect the integrity of the system. As with many computer security issues, this requires the use of user identication and passwords that protect access to the documents by unauthorized individuals. When generated, stored, and protected in the appropriate manner, electronic records are as valid as any other type of medical record. Special issues related to access to patient information and the Health Information Technology for Economic and Clinical Health (HITECH) Act are discussed later in this chapter.Referral to Another General Dentist or SpecialistIn many cases, dentists may decide that the recommended treatment is beyond their scope of training or experience and may choose to refer a patient to another general dentist or specialist. A referral slip or letter should clearly indicate the basis for referral and what the specialist is being asked to do. e referral should be recorded in the chart. A written referral to a specialist should ask the specialist to provide a written report detailing the diagnosis and treatment recommendations.A patient’s refusal to pursue a referral should be clearly noted in the chart. If a patient refuses to seek treatment from a specialist, the dentist must decide whether the recommended treatment is within his or her own expertise. If not, the dentist should not provide this particular treatment, even if the patient insists. A patient’s refusal to seek care from a specialist does not relieve the dentist of liability for injuries or complications resulting from care beyond his or her scope of training and expertise.Dental specialists should carefully evaluate all referred patients. For example, extracting or treating the wrong tooth is a common allegation in court. When in doubt, the specialist should contact the referring dentist and discuss the case. Any change in the treat-ment plan provided by the specialist should be documented in both the referring dentist’s chart and the specialist’s chart. To avoid informed consent problems, the patient must approve any revised plan or recommendation.ComplicationsLess than desirable results can occur despite the dentist’s best eorts in diagnosis, treatment planning, and surgical technique. A poor result does not necessarily suggest that a practitioner is guilty of negligence or other wrongdoing. However, when complications occur, it is mandatory that the dentist immediately begin to address the problem in an appropriate fashion.In most instances the dentist should advise the patient of the complication. Examples of such situations are losing or failing to recover a root tip, breaking a dental instrument such as an end-odontic le in a tooth, perforating the maxillary sinus, damaging adjacent teeth, removing the wrong tooth, or inadvertently fracturing surrounding bone. In these instances the dentist should clearly outline a proposed management of the problem, including specic instructions to the patient, further treatment that may be necessary, and referral to an oral-maxillofacial surgeon, when appropriate.It is advisable to consider and discuss alternative treatment options that may still produce reasonable results. For example, when teeth are extracted for orthodontic purposes, the rst premolar may accidentally be extracted when the orthodontist wanted the CHAPTER 12 Medicolegal Considerations 209 advice if experiencing a complication. e oce may elect to complete treatment in such cases. If treatment continues, the chart should carefully reect all warnings to the patient about potential harm and the increased chance that acceptable results may not be achieved.In certain cases, the patient may be asked to sign a revised consent form that includes three important points:1. e patient realizes that he or she has been noncompliant or has otherwise not followed advice.2. e previously mentioned activities jeopardized the patient’s health or the dentist’s ability to achieve acceptable results or unreasonably increased the chances of complications.3. e dentist will continue treatment but makes no assurances that the results will be acceptable. Complications may occur, requiring additional care, and the patient (or the patient’s legal guardian) will accept full responsibility if any of the foregoing events occur.Common Areas of Dental LitigationLitigation has involved all aspects of dental practice and nearly every specic type of treatment. A few types of dental treatment have a higher incidence of legal action.Removal of the wrong tooth usually results from a communica-tion breakdown between the general dentist and the oral surgeon or between the patient and the dentist. When in doubt, the dentist asked to extract a tooth by another dentist must conrm the identity of the tooth or teeth to be extracted with radiographic and clinical examinations as well as written instructions from, or a discussion with, the referring dentist. If opinions dier regarding the proposed treatment, the patient and the referring dentist should be notied and the outcome of any subsequent conversation documented. A short follow-up letter conrming the nal decision may also be helpful in documenting this decision. If the wrong tooth is extracted, this should be handled administratively in the manner described previously in this chapter. Clinically, some experts recommend that if the removal of the wrong tooth is noticed just after its extraction, the tooth should be put back into the fresh socket and treated like a recently avulsed tooth, as discussed in Chapter 24.Nerve injuries are often grounds for suits, with attorneys claiming that the nerve injuries resulted from extractions, implants, end-odontic treatment, or other procedures. ese allegations are usually coupled with allegations of insufficient informed consent or negligent performance of the procedure.Because nerve injuries are a known complication of some mandibular extractions or mandibular implants posterior to the mental foramen, patient advocates claim that patients have the right to accept these risks as part of treatment. If the dentist can visualize conditions that increase this risk, the patient should be advised and the condition documented. An example would be to note specically the relationship of the inferior alveolar nerve to the third molar tooth to be extracted when these appear to be in proximity on radiographs.Failure to diagnose can be related to several areas of dentistry: One of the most common problems is a lesion that is seen on examination but is not adequately documented and no treatment or follow-up is instituted. If the lesion causes further problems or a subsequent biopsy documents a long-standing pathologic condition or a malignancy, this may be viewed as negligence. is is particularly problematic if the lesion is later diagnosed as a malignancy or other serious condition. is problem can be avoided by following the undesired activity does not stop. e patient should be warned of the potential harm that may result if such activity continues and the reason why the harm may occur. After being told why the oce is no longer willing to provide treatment, the patient should be given a reasonable opportunity to nd a new dentist (usually 30 to 45 days). e oce should continue treatment during this period if the patient is in need of emergency care or if care is required to avoid harm to the patient’s health or to treatment progress.When it has been decided that the dentist-patient relationship cannot continue, the dentist must take the following steps to terminate the relationship.A letter should be sent to the patient, indicating the intent to withdraw from the case and the unwillingness to provide further treatment. e letter should include ve important pieces of information:1. The reasons supporting the decision to discontinue treatment.2. If applicable, the potential harm caused by the patient (or parent’s) undesired activity.3. Past warnings by the oce that did not alter the patient’s actions and continued to put the patient at risk (or jeopardized the dentist’s ability to achieve an acceptable result).4. A warning that the patient’s treatment has not been completed and that therefore the patient should immediately seek another dentist in the area for immediate examination or consultation. (e clinician should include a warning that, if the patient fails to follow this advice, the patient’s dental health may continue to be jeopardized and any treatment progress may be lost or may worsen.)5. An oer to continue treating the patient for a specied reasonable period and for emergencies until the patient nds another dentist.is letter should be sent by certied mail, with conrmation of delivery, to ensure and document that the patient did, in fact, receive it. If a new dentist is treating the patient, he or she should consider advising the former dentist of this decision. e clinician should consult an attorney if he or she has any concerns of condentiality or if a particularly sensitive reason exists behind this decision.e dentist must continue to remain available for treatment of emergency problems until the patient has had adequate time to seek treatment from another dentist. is must be communicated in the letter mentioned above. e dentist must oer to forward copies of all pertinent records that aect patient care. Nothing must be done to deter subsequent treatment to complete patient care.e dentist-patient relationship with those who have tested positive for the human immunodeciency virus or other infectious conditions or those who have handicaps may not be terminated or treatment refused because of their conditions, as this action may violate the Americans with Disabilities Act (ADA) and other federal or state laws. Patients who have tested positive for human immunodeciency virus or who have acquired immunodeciency syndrome are considered to have a handicap under these laws.2 Legal counsel should be consulted if the clinician has another valid reason for terminating his or her professional relationship with such a patient.Exceptions do exist to these suggested guidelines. e dentist must evaluate each situation carefully. On certain occasions the dentist may not wish to lose contact with a patient or lose the opportunity to observe and monitor a complication. Terminating treatment will often anger a patient, who may, in turn, seek legal 210 Part II Principles of Exodontialegible copy, and dental oces are entitled to a reasonable reimburse-ment for making copies. Patients do not own the records merely because they paid for care and treatment.Second, the dentist and sta should not discuss the case with the patient (or a representative of the patient) once a lawsuit is threatened or made. All requests for information or other contact should be forwarded to the insurance carrier or attorney representing the dentist. Any arguments with the patient or representative should be avoided. e dentist should not admit liability or fault or agree to waive fees. Any such statement or admission made to the patient or patient’s representative may be used against the dentist later as an admission of negligence.ird, it is imperative that no additions, deletions, or changes of any sort be made in the patient’s dental record. Records must not be misplaced or destroyed. In fact, extra eorts should be taken to make sure that the records are not lost or altered. e clinician should seek legal advice before making any attempt to clarify an entry.During the process of malpractice litigation, the dentist may be called to give a deposition. is may be as the defendant in a case, as a subsequent person treating the patient, or as an expert witness. Although this is common for attorneys, the procedure is often unnerving and emotionally traumatic for dentists, particularly when testifying in their own defense.e following are six suggestions that should be considered when giving a deposition related to a malpractice case:1. e clinician should be prepared and have complete knowledge of the records. All chart entries, test results, and any other relevant information should be reviewed. In complex cases, the clinician should consider reviewing textbook knowledge of the subject; however, an attorney should be consulted before anything other than the clinician’s own record is reviewed.2. e clinician should never answer a question unless the clinician completely understands it. e clinician should listen carefully to the question, provide a succinct answer to it, and stop talking after the answer is given. A lawsuit cannot be won at a deposition, but it can be lost.3. e clinician should not speculate. If a review of the records, radiographs, or other information is necessary, the clinician should do so before answering a question, and never guess. If the dentist cannot recall certain details, he or she should state as much if asked.4. e clinician should be careful when agreeing that any particular expert author or text is “authoritative.” It is usually best to never agree that a text is authoritative on any given topic. Once such a statement is made, the clinician may be placed in a situ-ation where he or she may have done something or disagreed with something the “expert” has written. In most states, a clini-cian can be impeached by anything an author states once the clinician agrees that the author is “authoritative.”5. e clinician should not argue unnecessarily with the other attorney. e clinician should avoid any display of anger (this will only alert the clinician’s adversary as to what will upset the clinician in front of a jury, who will expect the dentist to act in a professional manner).6. e advice of the clinician’s lawyer should be followed. (Even if retained by the insurance company, the attorney is required to represent the clinician’s interests, not that of the insurance company or anyone else.)Most anxiety related to litigation comes from fear of the unknown. Most dental practitioners have limited or no exposure to litigation. It must be kept in mind that dentists prevail in most up on any potentially abnormal nding. e clinician should chart an initial diagnosis or seek a consultation from a specialist. If the lesion has resolved by the next visit, the clinician should record that fact so that the issue is closed. If the patient is referred to another doctor, the referring clinician should follow up to document the patient’s progress, including whether the patient’s condition was successfully treated.Implant complications and failure are other common areas of litigation. As with any procedure, the patient should be informed of the associated reconstruction and long-term outcome of the complication. e need for careful long-term hygiene and follow-up should be explained. e potential detrimental eect of patient habits such as smoking should be explained and documented. Dentists placing implants being restored by another dentist should consider using a customized consent form, summarizing common complications and stressing the importance of receiving prosthetic care from an appropriately trained and experienced dentist.Failure to provide appropriate referral to another dentist or specialist can be a source of legal problems. Dentists usually determine the appropriate time to refer a patient to a specialist for initial care or management of a complication. Failure to refer patients for complicated treatments not routinely performed by the dentist or delayed referral for management of a complication frequently becomes the basis for litigation. Referrals to specialists can greatly reduce liability risks. Specialists are accustomed to treating more dicult cases and complications. Specialists with whom the dentist has a good relationship can also diuse patient management problems by being objective and caring and by reassuring angry patients. e general dentist and the specialist may discuss ways of relieving the expense of addressing a complica-tion and completing treatment.Temporomandibular joint disorders sometimes become more apparent after dental procedures requiring prolonged opening or manipulation, such as tooth extraction. Documentation of any preexisting condition in the pretreatment assessment is important. e risk of temporomandibular joint pain or other dysfunction as a result of a procedure should be included in the informed consent when indicated. If the patient is in dire need of care that may aggravate or cause a temporomandibular joint condition, a customized consent form should be drafted and signed. e form should clearly dene the problem, giving the patient options and conrming the patient’s authorization to proceed.When a Patient Threatens to SueWhenever a patient, the patient’s attorney or family member, or any other representative of the patient informs the dentist that a malpractice suit is being considered, several precautions should be taken.First, all such threats should be documented and reported immediately to the malpractice insurance carrier. e dentist should follow the advice of the malpractice carrier, institutional risk management team, or the attorney assigned to the case. ese individuals will usually create and send a written response to the threat. Because the rst indication of a potential claim is usually a request for records, the oce should comply with state law regarding what must be provided (usually copies of care and treatment records—never the originals).Patients sometimes request the original chart and radiographs for a variety of reasons. Laws in most states indicate that the dental oce owns the records and has a legal obligation to maintain original records for a specied period. Patients are entitled to a CHAPTER 12 Medicolegal Considerations 211 4. A statement that the dentist believes that the previous denial of authorization by plan administrators is inappropriate. It may be helpful to use key language from the court decision stating, “It is essential that cost limitation programs not be permitted to interfere with decisions based on medical/dental judgment.”Two other documents are needed to close the loop on the communications aspect of a managed care denial: (1) a form for patients to sign that advises them of their diagnosis, recommended treatment, and risks of not undergoing the treatment and indicates acknowledgment that alternative forms of treatment may create less desirable results than those of the recommended treatment and that they understand that they can pay for the recommended treatment from their own funds; (2) a letter to the patient who refuses recommended treatment that has been denied payment under the patient’s insurance plan, asking the patient to reconsider the decision, expressing the dentist’s concern for the consequences, and urging the patient to appeal the decision directly to the insur-ance plan administrators.e Aordable Care Act (or “Obamacare”) requires that all Americans obtain medical insurance coverage.6 Initially there was a requirement that all Aordable Care Act plans include dental coverage for pediatric patients. However, this requirement has been relaxed or eliminated in most states. Adults have no requirement to obtain dental insurance; but if this is available, the same decision-making situations as described in other managed care plans will be applicable.Telemedicine and the InternetTechnologic developments have induced signicant changes in medical and dental practices. Computers and the Internet created new potential duties and liability concerns. Digital imaging—combined with the Internet capabilities for communication and even videoconferencing—has created situations in which patients may receive advice without the traditional doctor-patient interaction.e Internet access to health care information has changed the dynamics of traditional dentist-patient interaction. A dentist’s legal duty to a patient is currently linked to the existence of a doctor-patient relationship. Determining whether this relationship exists, however, is no longer a simple task. e advent of Internet market-ing, telemedicine, and other modes of providing information or advice through electronic media—without direct examination, diagnosis, and recommendation for treatment—has clouded the issue of whether a doctor-patient relationship (and a legal duty owed to a particular patient) exists. Courts make decisions that may provide some guidance related to these evolving issues, although disagreement among jurisdictions still exists. One court decision has determined that a physician who consults with a treating physician over the telephone owes no legal duty to the treating physician’s patient when treatment options were relayed through a telephone call.7 However, another court ruled that a doctor-patient relationship could be implied when an on-call physician is consulted by telephone by an emergency department physician who relied on the consulting physician’s advice.7Dening clear rules that can be relied on by practicing dentists who provide direct or indirect advice over the telephone, Internet, or through websites will not be an easy task. Many questions remain unanswered. Do the laws of the state in which the patient lives or those in which the dentist practices actually apply in this issue? Is the dentist practicing dentistry in another state without cases. Only about 10% of cases go to trial, and dentists win more than 80% of these cases.Unfortunately, a malpractice trial requires a tremendous invest-ment of time, energy, and emotion, all of which detracts from patient care. Most dentists have no choice; they must defend themselves. Dentists who are prepared and who possess reasonable expectations of each step of the litigation process usually experience less anxiety.Managed Care Issuese inuence of managed health care has greatly changed many aspects of dentistry. is includes the dentist-patient relationship and the way decisions are made regarding which treatment alterna-tives are most appropriate. Dentists are often placed in the middle of a conict between a desire to provide optimal treatment and the willingness of a health care plan to approve payment for appropriate or needed care.Traditionally the patient chooses between an ideal comprehensive treatment plan, a compromised treatment plan, or no treatment. Under managed care, however, some patients are being forced to accept compromised treatment or no treatment, based on admin-istrative decisions that may be driven more by cost containment pressures than by sound judgment based on dental science.e American Dental Association Council on Ethics, Bylaws, and Judicial Aairs issued the following statement underscoring dentists’ obligation to provide appropriate care:Dentists who enter into managed care agreements may be called upon to reconcile the demands placed on them to contain costs with the needs of their patients. Dentists must not allow these demands to interfere with the patient’s right to select a treatment option based on informed consent. Nor should dentists allow anything to interfere with the free exercise of their professional judgment or their duty to make appropriate referrals, if indicated. Dentists are reminded that contract obligations do not excuse them from their ethical duty to put the patient’s welfare rst.3Dentists have a responsibility to advise patients that a “com-promised” treatment plan has been approved by the managed care organization. e dentist should seek the patient’s consent to provide such treatment after the pertinent risks, complications, and limita-tions have been reviewed, along with an explanation of more optimal treatment options. Dentists should communicate in writing, to both patients and third-party payers, the outcomes that may reason-ably be expected when the appropriate treatment is not available because of improper decisions by third-party providers.e law has evolved in the area of managed care, and recent court decisions create some additional responsibilities for the dentist in advocating for appropriate patient care.4,5 Ultimately each dentist has a duty to treat the patient and not base treatment decisions on the patient’s insurance plan coverage. is often entails chal-lenging, in writing, the denial of payment by the plan administrators for the recommended course of treatment by appealing on behalf of the patient for medically appropriate dental care. A letter addressing this situation should include the following elements:1. A statement that the patient has been under the dentist’s care for a specic condition (diagnosis) and the dentist’s recommended course of treatment.2. e clinical indications for the recommended treatment.3. e risks and complications involved in failing to undergo the recommended treatment. 212 Part II Principles of Exodontiaentity protect the condentiality, integrity, and availability of electronic protected health information (e-PHI) that it creates, stores, maintains, or transmits. By “condentiality,” the regulations mean ensuring the privacy of the information; by “integrity,” ensuring that the information is not improperly altered or destroyed; and by “availability,” ensuring that the information is accessible and usable to authorized persons.Health Information Technology for Economic and Clinical Health Act Regulationse HITECH Act of 20099 is intended to advance health informa-tion technology by creating incentives for increased use of electronic health records (EHRs). is legislation also increased the protection of electronically transmitted health information by strengthening HIPAA protection.10 e HITECH Act applies to all covered entities (as dened in the HIPAA) that transmit health information electronically.e Aordable Care Act includes requirements and incentives for practices to convert to exclusive use of EHRs.6 e initial deadline for implementation of the EHR was set at 2015. However, due to the inability of many practices and medical institutions to comply by the deadline, this requirement has not been fully implemented, and multiple extensions of the deadline have been required, with a nal date still unknown at the time of this writing.e major provisions of the HITECH Act are aimed at preven-tion and management of breaches in transmitted electronic health information with increased penalties for violation. HIPAA has strict requirements related to the electronic transmission of any portion of the EHR or any other protected health information. ese requirements are contained in the HIPAA Security Rule and are designed to maintain reasonable and appropriate administra-tive, technical, and physical safeguards for protection of the e-PHI and include the following11:1. Ensuring the condentiality, integrity, and availability of all e-PHI created, received, maintained, or transmitted2. Identifying and protecting against reasonably anticipated threats to the security or integrity of the information3. Protecting against reasonably anticipated, impermissible uses or disclosures4. Ensuring compliance by their workforce.Risk Analysis and Managemente Administrative Safeguards provisions in the Security Rule require all covered entities to perform risk analysis as part of their security management processes. Risk analysis aects the implementa-tion of all of the safeguards contained in the Security Rule.A risk analysis should include the following activities12:1. Implement appropriate security measures to address the risks identied in the risk analysis.2. Document the chosen security measures and, where required, the rationale for adopting those measures.3. Maintain continuous, reasonable, and appropriate security protections.Risk analysis should be an ongoing process in which a covered entity regularly reviews its records to track access to e-PHI and detect security incidents, periodically evaluates the eectiveness of security measures put in place, and regularly reevaluates potential risks to e-PHI. e important aspects of ongoing risk assessment should incorporate designating a security ocial who is responsible for developing and implementing its security policies and procedures; a license? In general, courts have found that practitioners must be licensed in the state from which the patient initiates the consultation and that the laws of that jurisdiction apply. Other questions remain. Is the advice oered by electronic means intended for general information and not intended to be relied upon by patients or the treating dentist for specic care? If so, then a prominent disclaimer should be posted and acknowledged before proceeding with the interaction. Will the electronic transfer of the information such as the patient’s chart or billing information violate state or federal privacy laws? Under the Health Insurance Portability and Accountability Act (HIPAA) Security and Privacy regulations, duties are clearly dened, as described later. Can the dentist protect the information sent electronically from manipulation or misuse? In the coming years, it will be important for practitioners to monitor trends in dental care as the Internet, information storage and transfer, and doctor-patient relationships are all aected by advancing technology.Rules and Regulations Aecting PracticeHealth Insurance Portability and Accountability Act Privacy and Securitye HIPAA of 1996 has made major impacts on how patient health information is handled by health care organizations and professionals.8 In recent years the public has grown increasingly concerned about disclosures of condential health information by virtually all parts of the health care industry, including hospitals, pharmacies, managed care organizations, laboratories, and health care providers.e HIPAA was enacted to protect such information. Although originally intended to codify an employee’s right to continue to receive health insurance should he or she change jobs, resign, or be terminated, Congress used this legislation as a springboard to address several additional health care issues such as health care fraud and abuse and the security and condentiality of electronically stored or transmitted health information.e privacy regulations apply to “covered entities,” which include health plans, health care clearinghouses, and health care providers who transmit health information in writing or electronically. is also includes practices that employ third parties to process and transmit electronic claims on their behalf. e regulations require covered entities to protect “individually identiable health informa-tion.” It is important to state that practices are permitted by the privacy laws to use or disclose a patient’s health information for purposes of treatment, payment, and health care operations. In other words, a consent form completed by the patient will allow the practice to use protected patient information in its regular business. Additional uses and disclosures of protected information require separate consent. Compliance with these regulations includes the following:1. Each practice must maintain a condentiality statement, known as a “notice of privacy practices,” posted in a prominent place in the oce and on the website of the practice, if applicable.2. Each patient must sign a consent form that allows the release of his or her health information, as necessary, to conduct the business of the practice.3. All sta must be educated and periodically updated about the privacy and condentiality rules and regulations.e HIPAA security regulations cover protected health informa-tion as well as information that is maintained or transmitted in electronic form. e security regulations require that a covered CHAPTER 12 Medicolegal Considerations 213 this law. Dentists who treat such patients are required to take necessary steps to ensure that LEP persons can meaningfully access programs and services. e key to meaningful access for LEP persons is eective communication. ese requirements apply to practices that treat patients who receive nancial assistance. Medicaid and Medicare patients are those most commonly assisted by the Department of Health and Human Services. ere are varying levels of requirements based on the number of LEP persons served by a practice:1. For practices in which the LEP language group consists of fewer than 100 persons, all such persons must be provided with written notice in the primary language of the LEP language group of the right to receive competent oral translation of written materials.2. For practices in which an eligible LEP language group constitutes 5% of the practice or 1000 persons, whichever is less, the practice must provide translations for vital documents for patient interactions.3. For practices in which an eligible LEP language group constitutes 10% of the practice or 3000 persons, whichever is less, the practice must provide translated written materials, which includes vital documents for patient interactions in the primary language of the LEP language group.If a practice falls under these boundaries, certain rules apply to serve LEP persons. To ensure compliance with these rules, a provider should develop and implement a comprehensive written language assistance program. is program should include the following:• Anassessmentofthelanguageneedsofthepatientpopulationby identifying the non-English languages likely to be encoun-tered, estimating the number of LEP persons eligible for services and their language needs, and identifying the resources needed to provide eective language assistance.• edevelopmentofapolicyonlanguageaccessforprovidingoral language interpretation such as bilingual sta, sta interpret-ers, or outside interpreters, as well as translation of written materials (e.g., health history forms, consent forms, and privacy notices). e practice should post signs in regularly encountered languages about the available services and right to free language assistance services.• EnsuringthatthestaistrainedinLEPpoliciesandproceduresand in how to work eectively with in-person and telephone interpreters and including such training in orientation for new employees.It is illegal for a practice to encourage patients from language minority groups to provide their own interpreters as an alternative to maintaining bilingual employees or interpreters. Condentiality issues aside, patients may naturally be reluctant to disclose or discuss intimate details of their personal and family lives in front of family members or complete strangers who have no formal training or obligation to observe condentiality.Americans With Disabilities Acte ADA, enacted in 1990, is one of the nation’s most compre-hensive civil rights statutes.2 Many doctors have heard of the act but do not realize the signicant implications the ADA can have for the provision of dental care by even the smallest office practice.e basic requirements of the law mandate that private prac-titioners accept patients with disabilities for treatment, provide “auxiliary aids” when necessary for eective communication with patients with disabilities, and make health care facilities physically providing for appropriate authorization and supervision of workforce members who work with e-PHI; limiting physical access to its facilities while ensuring that authorized access is allowed; putting in place policies and procedures regarding the transfer, removal, disposal, and reuse of electronic media to ensure appropriate protection of e-PHI; and implementing technical security measures that guard against unauthorized access to e-PHI that is being transmitted over an electronic network.When health information is transmitted electronically, the information should be secured through encryption, a mechanism for destruction after use, or both. e security or privacy of health information is considered compromised if a breach poses potential harm to the aected individual or there is reputational or nancial compromise. In cases where access to health information has been breached, the covered entity is required to notify the aected individual of the breach.HIPAA violations are expensive.13 e penalties for noncompli-ance are based on the level of negligence and can range from $100 to $50,000 per violation (or per record), with a maximum penalty of $1.5 million per year for violations of an identical provision. Violations can also carry criminal charges that can result in jail time.Fines increase with the number of patients involved and the amount of neglect. e lowest level of penalty involves a situation where a doctor or other practice personnel did not know and, with reasonable diligence, would not have known that he or she had violated a provision. Penalty at the other end of the spectrum occurs when a breach is due to negligence and is not corrected in 30 days.e nes and charges are broken down into several categories ranging from $10,000 to $50,000 for each incident and can result in criminal charges. HIPAA violation categories and their respective penalty amounts are shown in Table 12.1.Almost half of all data breaches are the result of theft. When laptops, smartphones, and other electronic devices are unencrypted, the risk of a breach increases considerably. For this reason it is recommended that all data be safely stored o premises so that a stolen laptop, smartphone, or similar device has no e-PHI stored on the device that can result in possible compromise.Title VI, Limited English ProciencyTitle VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color, or national origin by any entity that receives federal nancial assistance.14 Individuals with limited English prociency (LEP) have also been determined to be protected under HIPAA Violation Categories and PenaltiesTABLE 12.1 Amount Per ViolationViolations of an Identical Provision in a Calendar YearDid not know $100–$50,000 $1,500,000Reasonable cause $1000–$50,000 $1,500,000Willful neglect corrected$10,000–$50,000 $1,500,000Willful neglect not corrected$50,000 $1,500,000HIPAA, Health Insurance Portability and Accountability Act. 214 Part II Principles of Exodontia1. To provide a medical screening to any patient who presents to a hospital emergency department2. To determine whether an emergency medical condition exists3. To stabilize the condition so that transfer or discharge does not threaten a deterioration of the patient’s condition4. To transfer the patient to another facility if warranted, but only if the benets outweigh the risks of the transfere courts have been clear that the EMTALA is intended only to prevent hospitals from purposefully withholding treatment from nonpaying patients in an emergency condition or from dumping patients onto other health care providers or facilities. Dentists become involved with EMTALA issues when patients are referred to the practice by the hospital emergency room and the hospital administrators tell the practitioner that the dentist will be in viola-tion of the antidumping statute, the EMTALA, unless he or she treats the nonpaying patient. is kind of threat is unfounded and should be challenged by asking for the statutory authority of the hospital in making such statements.Liability under the EMTALA may extend to practitioners in two situations: (1) If the dentist is on call with the hospital and the hospital sends a patient to the dentist’s oce (for the convenience of using an appropriately equipped facility), then the dentist most likely has an obligation to examine and stabilize the patient. If the dentist decides that he or she cannot treat the patient, another practitioner who will treat the patient must be found. (2) If the dentist has agreed to be bound by EMTALA duties through a specic contract or under the bylaws of the hospital where he or she holds privileges, these regulations will apply.SummaryIn addition to providing sound technical care, the dentist must address several other aspects of patient care to minimize unnecessary legal liability. e dentist should develop the best possible rapport with patients through excellent communication and by providing any information that may enhance patients’ understanding of their treatments. Adequate documentation of all aspects of patient care is also necessary. Clinicians face a constant struggle to document quality care and their advice to patients. e law requires only that such eorts be reasonable—not perfect.is chapter is intended to provide suggestions to be considered by individual dentists and is not intended to establish, inuence, or modify the standard of care. Medical and dental malpractice laws vary from state to state. When confronted by medicolegal issues, all health care providers should consult local counsel familiar with the laws and regulations that apply in their jurisdictions.References1. Oja v. Kin, 229 Mich. App. 184, 1998.2. Americans with Disabilities Act of 1990, 42 USC, § 12101, 1990.3. ADA Counsel on Ethics, Bylaws, and Judicial Aairs. How to reconcile participation in managed care plans with their ethical obligations. ADA News February 6, 1995.4. Wickline v. State of California 192 Cal. App. 3d 1630 [239 Cal.Rptr. 810], 1986.5. Fox v. HealthNet of California, No. 219692, 1993 WL 794305 (Riverside County Superior Court/Central Cal. Dec. 23, 1993).6. Patient Protection and Aordable Care Act, 42 USC, § 18001 et. seq., 2010.7. Hill v. Koksky, 186 Mich. App. 300, 1993.8. Health Insurance Portability and Accountability Act, 42 USC, § 1395 et. seq., 1996.accessible and usable by patients with disabilities if this is “readily achievable.”e ADA provisions apply to “places of public accommodation.” “e professional oce of a health care professional” is specically included in this category. e law applies to health care oces irrespective of their size.Under Title III of the ADA, a health care provider may not discriminate in providing services to individuals with disabilities. A dentist may not refuse to treat a patient or refuse to accept a new patient because of the patient’s disability. e ADA also imposes obligations on health care providers to provide “auxiliary aids and services” to enable a patient with a disability to benet from the services of the oce. e obligation can be as uncomplicated as the provision of additional assistance to a patient who has diculty getting into an examination chair and as extensive as the provision of qualied signers for patients with hearing impairment.In selecting an auxiliary aid, a doctor must take into account the specic abilities or limitations of the patient. For instance, the National Center for Law and Deafness points out a number of misconceptions regarding the abilities of patients with hearing impairment; these may lead to ineective communication. As an example, lip-reading is eective for only a few of these patients. e vast majority of adults with hearing impairment rate themselves as having poor ability or complete inability to lip-read. e center also notes that the average hearing-impaired high school graduate reads and writes on a third-grade level; therefore the exchange of written communication may also not be eective for many such patients. Some patients may ask the doctor to provide a signer for them. Under the ADA laws, hearing-impaired patients have the right to ask for a signer. If asked, a dental oce must provide a signer for the patient. If the oce refuses to provide a signer, the oce may be subject to a claim for discrimination. e cost of the signer must be borne by the oce and may not be passed on to the patient.In some situations, such as obtaining informed consent before surgery, it may be necessary to use a qualied interpreter. A qualied interpreter is dened by the ADA as someone “who is able to interpret eectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary.” Interpreters need not be specially accredited or aliated with a particular group. In some instances, a family member or friend may be qualied to interpret. It is wise to have the interpreter complete a Translator’s Statement form before performing interpreta-tion services.Dentists and oce sta members must be aware that there may be some instances when a family member may not be able to render the necessary interpretation because of emotional or personal involvement or the family member’s age. Condentiality consid-erations may also adversely aect the ability to interpret “eectively, accurately, and impartially.” If there are concerns that a family member or friend may not be able to interpret for the reasons cited, it is best to obtain an impartial interpreter.Emergency Medical Treatment and Active Labor Acte Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent hospitals from refusing to treat patients who were unable to pay or from transferring such patients to other health care facilities before the emergency condition was identied and stabilized.15 e EMTALA imposes four main duties on hospitals: CHAPTER 12 Medicolegal Considerations 215 14. Title VI of the Civil Rights Act of 1964, 42 USC, § 2000d et. seq., 1964.15. Emergency Medical Treatment and Active Labor Act, 42 USC, § 1395dd et. seq.BibliographyGolder D. Practicing dentistry in the age of telemedicine. J Am Dent Assoc. 2000;131:734–744.Nora RL. Dental malpractice: its causes and cures. Quintessence Int. 1986;17:121.Skas PM. Teledentistry: legal and regulatory issues explored. J Am Dent Assoc. 1997;128:1716–1718.Small RL. How to avoid being sued for malpractice. J Mich Dent Assoc. 1993;75:45.9. Modications to the HIPAA Privacy, Security, and Enforcement Rules under the Health Information Technology for Economic and Clinical Health Act, 75 Fed. Reg. 40867 (July 14, 2010) (to be codied at 45 C.F.R. pts. 160, 164).10. McGowan JJ, Cusack CM, Bloomrosen M. e future of health IT innovation and informatics: a report from AMIA’s 2010 policy meeting. J Am Med Inform Assoc. 2011;epub Oct 28.11. Summary of the HIPAA Security Rule. https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html.12. Blanke SJ, McGrady E. When it comes to securing patient health information from breaches, your best medicine is a dose of prevention: a cybersecurity risk assessment checklist. J Healthc Risk Manag. 2016;36(1):14–24.13. Brown M. What is the penalty for a HIPAA violation? https://www.truevault.com/blog/what-is-the-penalty-for-a-hipaa-violation .html.

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