10

Principles of Oral and Maxillofacial Surgery

Minor Oral
Surgical Procedures

I. Minor Oral Surgery

The first dictum of medicine and surgery is—‘Primum • Decontamination and debridement

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Non Curarum—first do no harm’. Minor oral surgery • Suturing
comprises of those surgical procedures, which can be • Oedema control
comfortably completed by a dentist in not more than • Postoperative infection control
30 minutes. Minor surgical procedures will include • Patient’s general health and nutrition
carrying out complicated surgical extractions • Follow-up.
(combination of tooth sectioning, mucoperiosteal flap
reflection, bone removal prior to the use of a forceps or Developing a Surgical Diagnosis
elevators), elimination of small lesions in the oral cavity, The decision to perform a surgery depends upon the
which are in the hard or soft tissues. several diagnostic steps. Before undertaking the
surgery, the clinician should perform following steps:
Basic Purpose of Surgery • First identify the clinical problem
The basic purpose of any surgery is as follows: • Carry out thorough logical reasoning and use the
• Elimination of disease available data
• Prevention of disease • Establish the relationship between the individual
• Removal of damaged or redundant tissue problems
• Improvement of function and esthetics. • Obtain the presurgical evaluation data
a. Patient’s physical, laboratory and imaging
examination data
Principles of Oral Surgery
b. Possible aetiological factors for the lesion
• Developing a surgical diagnosis development
• Basic necessities for surgery c. The thorough history of lesion.
• Aseptic technique
• Incision planning Clinical Characteristics of the Lesion
• Flap design • Location
• Tissue handling • Shape
• Haemostasis • Sharpness of boundaries
116 • Dead space management • Colour
• Consistency i. Oral opening of the patient – adequate
• Texture ii. Restricted—due to trismus, TMJ disorders,
• Mobility or fixation muscle fibrosis, etc.
• Local induration or inflammation • Hypomobility of the tooth—hypercementosis, anky-
• Erosion or ulceration losis
• Pulsation • Condition of the crown:
• Fluctuation i. Marked attrition—usually with calcified pulp
• Regional lymphadenopathy chamber, brittle tooth

Minor Oral Surgical Procedures

• Radiological changes. ii. Presence of extensive caries, large restorations
The oral cavity is an excellent barometer of general iii. Previous history of endodontic treatment
systemic health. Oral abnormalities can be extensions • Tooth alignment in the arch
or manifestations of underlying systemic disease. • Age of the patient—old age—sclerosis
Therefore the surgical decision should be undertaken • Embedded roots.
after ruling out systemic problems.
Indications for the preoperative radiographs
History of the Lesion • History of difficult or attempted, failed extraction
• A tooth which is abnormally resistant to elevation
• Chief complaint—pain, oedema, swelling, regional
or forceps extraction (hypercementosis, ankylosis,
lymphadenopathy, decreased sensation (hypoesthe-
dilacerated roots, extra-long roots, curved roots)
sia) and altered sensation (paraesthesia)
• Any teeth or roots in close relationship to either the
• Duration of the lesion
maxillary sinus or inferior dental canal or mental
• Change in any senses—taste, smell, hearing, vision
nerve
• Change in size, degree of fluctuation, erythema,
• Any teeth with history of trauma (fractured crown
erosion, etc.
or roots or alveolar bone)
Transalveolar Extraction (Open or Surgical Extraction) • Any partially erupted, unerupted tooth, missing
tooth, supernumerary tooth, retained root, lingually
Transalveolar extraction is the method used for recover-
placed tooth, impacted tooth

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ing the roots, that are fractured during routine
• Heavily restored tooth or pulpless tooth—brittle,
extraction of teeth (routine closed extraction method)
possible presence of periapical pathology
for a variety of reasons. It consists of removal of some
• Any condition, which predisposes to dental or
amount of the bone investing the roots, if required, and
alveolar abnormalities like: osteitis deformans
using the forceps or elevators to deliver a tooth/root.
(hypercementosis of the roots), osteoradionecrosis,
Indications for transalveolar surgical extraction osteopetrosis, etc.
• Any tooth, which offers a lot of resistance for
elevation technique Pre-extraction Radiological Evaluation (Fig. 10.1A)
• Retained roots, which cannot be grasped by the
forceps or delivered with an elevation technique Relationship with associated vital structures
• Previous history of difficult or attempted and failed • Maxillary sinus
extraction technique • Inferior alveolar canal
• Any large restoration with root canal therapy— • Mental nerve
brittle teeth • Adjacent teeth roots.
• Hypercementosis/ankylosis of a tooth Configuration of roots
• Germinated/dilacerated tooth • Number of roots
• Radiographic evidence of complicated/difficult root • Width—greater below CE junction than at the CE
pattern or roots with unfavorable or conflicting lines junction. Size of roots
of withdrawal • Curvature of roots, divergence of roots
• Sclerosis of the bone • Length—thin, tapered roots
• Teeth associated with pathology—periapical granu- • Resorption of roots
loma, cyst, tumour, etc. • Shape of the individual root
• Impacted teeth, embedded teeth. • Hypercementosis, ankylosis, root caries
Pre-extraction clinical assessment • Previous endodontic therapy
• Presence of infection Condition of surrounding bone
• Access to the tooth: • Density of bone surrounding the tooth 117
 Fig. 10.1A: Preoperative radiograph is helpful to detect these conditions: (1) Hypercementosis, (2) Extra-roots,
(3) Dilacerated roots, (4) Curved, long root, (5) Roots in the maxillary sinus, (6) Approximity to the inferior alveolar nerve
Principles of Oral and Maxillofacial Surgery

• Dense bone—condensing osteitis, sclerosis will • Properly planned surgical extraction is always less
increase the difficulty. traumatic (people attack the tooth- the hardest
structure in the body, but hesitate, when it comes
Multiple Extractions to soft tissue incision)
• Do not shy away from complicated extraction
Single sitting procedure for multiple adjacent teeth with
slight modification of routine extraction pattern • Proceed as predicted with fewer surprises.
facilitates a smooth transition from a dentulous to an
Postage Stamp Technique for Transalveolar
edentulous state.
Extraction (Fig. 10.1B)
• Soft tissue reflection is extended slightly to form a
small envelop flap, exposing a crestal bone prior to • Helps in controlled removal of bone, preventing
extractions uncontrolled fracture of the alveolar process
• After extractions, the ridge is checked for any sharp • Allows judicious use of elevators and forceps
bony spicules or undercuts • Allows tooth sectioning in a controlled manner,
• Alveolectomy/plasty—suturing facilitating predictable result instead of an apical
root fracture.
Order of Multiple Teeth Extractions

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• Maxillary posterior teeth except first molar Three Basic Principles
• Maxillary anterior teeth except the canines
• Obtain adequate access which makes difference
• Maxillary first molar between success and failure
• Maxillary canine
• Create an unimpeded path of removal
• Mandibular posterior teeth except the first molar
• Use controlled force.
• Mandibular anterior teeth except the canines
• Mandibular first molar
• Mandibular canine.

Difficult Extraction/Breakage of the Root

• Reposition the patient
• Visualize the root directly or with the help of a
mouth mirror
• Irrigate the socket forcibly
• Suction the area
• Probe with an explorer, endofile or an apexo
elevator
• Sometimes it is prudent to leave very small root tip
behind, but the risk/benefit ratio should be in
patient’s favour.

Surgical Extractions: (Complicated Extractions)

Fig. 10.1B: Postage stamp technique of transalveolar
• Unplanned extractions—an event that can convert extraction: (1) Reflection of mucoperiosteal flap and bur holes
an uncomplicated extraction into a complicated one are made, (2) Connected bur holes to create a window, (3)
• Proper pre-extraction assessment of a difficult case Exposing the roots, (4) Sectioning the crown and roots for
• Any premonition or suspicion that the tooth/bone easy removal, (5) Transalveolar extraction of a root piece by
will break—think and plan planning small envelop flap
118
Basic Necessities for Surgery for surgical access. Thorough anatomical knowledge
is essential. Incision is placed parallel to the structures
The main requirements for any surgery are adequate
without causing damage to the vital structures.
visibility and assistance. Adequate visibility will
Extraoral incisions should be planned along the
depend on the following:
‘Langer’s lines’ of the normal skin tension or creases,
• Adequate access
so that minimum scar formation will be seen. Intraoral
• Adequate light source
incision should be planned to prevent subsequent scar
• A clean surgical field (free from excessive bleeding).
contraction or fibrosis, which will prevent normal

Minor Oral Surgical Procedures

Adequate Access functioning of the oral soft tissues.
The sharp blade of a proper size and shape should
Adequate access will require: be selected. Essential for clean, single stroke incision
• Comfortable patient without much tissue damage.
• Adequate oral opening • Incision should be placed on the sound bone, or
• Proper retraction of the tissues by assistant away from the surgical area to ensure the prevention
• High volume suction, haemostasis of the operating of wound dehiscence
field. • Either pen (intraoral incision) (Fig. 10.1C) or table
knife (extraoral incision) grasp is used with proper
Patient support and pressure to produce uniform atrau-
• Comfortable, mentally and physically matic clean incision, with predictable depth
• Alleviation of fear, assurance • The skin or the mucosa to be incised, should be stabi-
• Informed consent lized with finger pressure to guide the passage of
• Minimum amount of draping the blade
• Rinsing with antiseptic mouth wash. • A firm continuous stroke should be used. Repeated
strokes increase both the amount of tissue damage
Equipment and the bleeding, thereby impairing the wound
healing. Long continuous strokes are preferable to

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• The instrument kit should be prepared and
short interrupted ones
sterilized
• No sharp angles, the change in direction is accom-
• Effective light source and suction. plished by a gradual curve. Sharp angles tend to
produce slough due to poor circulation and may
Assistant
lead to extensive scarring.
Four-handed surgery with the help of a skilled assistant.
The assistant should be familiar with the procedure Incisions in the Oral Cavity
being performed to anticipate the surgeon’s needs.
• It is desirable to incise through attached gingiva and
over a healthy bone. The suture line should have
Surgeon’s and Assistant’s Preparation
adequate bone support underneath for uneventful
• Wearing of protective eye glasses healing
• Wearing mask • Incisions placed near the teeth for extractions should
• Wearing surgical cap be made in the gingival sulcus
• Wearing gloves. • Incisions involving the reflection of the mucoperio-
steal flap are direct, straight line or curvilinear
Aseptic Technique
Aseptic technique has been explained in detail in
Chapter 7 on Asepsis and Sterilization.

Planning of an Incision
Planning of an incision is a basic step in any surgery.
The incision is defined as ‘a cut or a wound deliberately
made by an operator in the skin or mucosa using a sharp
instrument such as a surgical blade, cautery, etc. so that
Fig. 10.1C: Pen grasp for intraoral incisions
the underlying structures can be exposed adequately
119
 taking the shortest distance vertically through the intact around the teeth and for endodontic surgery. The
tissues. horizontal component of this flap rests on the alveolar
• Indirect incisions are used to access the areas like bone. The gap of 5 mm must be present from the base
soft palate, tongue, cheeks, lips, floor of the mouth, of the gingival sulcus to the incision.
etc.
• Integrity of the interdental papillae should be main- Flap Design
tained as far as possible. The preparation of adequate mucoperiosteal flaps is of
• Blood supply to the incision should be adequate
Principles of Oral and Maxillofacial Surgery

paramount importance. Standard surgical protocols

• Incisions should be at right angles to mucosa to should be followed while designing a flap or reflecting
prevent shelfing edges, that might cause necrosis it to preserve the integrity and function of the soft
of the undermined part. tissues. The properly designed flap may bring about
minimum morbidity like pain, swelling, etc. postopera-
Contraindications for Placement of Incision Lines tively, but it will definitely prevent the potential
Avoid placing incisions morbidity (including complications) associated with
• Over the canine prominence—soft tissue defect will damage due to inadequate exposure.
be created due to bony fenestration While taking intraoral incision for flap designing,
• Vertical incision in the mental nerve region convenience, access, avoidance of injury to the vital
• On the palate—near the greater palatine vessels structures, maintaining the integrity of the interdental
• Through incisive papillae papilla, etc. should be thought about.
• Over bony lesions—dehiscence
• Over freni Main Complications of Flap Surgery
• Vertical incisions on the lingual side of the • Flap tearing
mandibular arch. • Flap necrosis
• Flap dehiscence
Types of Incisions
Flap tearing The incision should be clean, sharp and

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Horizontal It is seldom used because of natural contour should penetrate the entire mucoperiosteum, if the flap
of maxilla and mandible. These types of incisions are is being reflected over the bone. The flap should be
directed along the gingival margin either mesially or reflected as one unit. The flap should be large enough
distally. to prevent tearing or for avoiding the need to modify
• Internal bevel incision—starts at distal area from during surgery. Adequate size of the flap is a must for
the margin and is aimed at bony crest. This is also proper instrumentation and visual access. The length
known as first incision. of the flap should be no more than twice the width of
• Crevicular incision—starts at the bottom of the the base.
pocket and is directed to the bony margin. This is
known as second incision. These incisions are Flap necrosis Ideally, the base of the flap should be
mainly used in periodontal flap surgeries. wider than the reflected free margins to allow for the
adequate blood supply to the reflected tissues. Flap
Vertical Vertical or oblique incisions are most desirable should have margins that either run parallel to each
and are also called as releasing incisions, on one or both other or preferably converge from the base to the apex
the sides of the flap. It may be single resulting in of the flap. Whenever possible, the axial blood supply
triangular type of flap. should be included in the base of the flap. For example,
• Double vertical incisions on both sides of the flap palatal flap can be based on greater palatine artery
will result in trapezoidal flap (pedicled flap).
• The incisions should extend beyond mucogingival
Flap dehiscence This is seen in the immediate post-
line reaching the alveolar mucosa to allow the
operative phase after suturing is done. This means
release of a flap for reflection
separation of the flap margins or gaping of a wound.
• Vertical incisions should be placed at obtuse angle
This is prevented by designing a flap in such a way
to the horizontal incision and should leave
that the sutures will be placed over the solid healthy
interdental papillae intact.
bone. Poor tissue handling, too tight suturing, haema-
Semilunar (curved, elliptical) This type of incision is used, toma formation, infection, suturing under tension may
when it is desirable to maintain the attached gingiva lead to dehiscence.
120
 Minor Oral Surgical Procedures
Fig. 10.1E: Incision and reflection of the mucoperiosteal
flap with periosteal elevator

Two-sided triangular flap In addition to the envelope

Fig. 10.1D: Types of flaps. (1) Gingival margin crevicular flap, a vertical releasing incision is used in order to have
incision, (2) Two-sided triangular flap, (3) Three-sided better access to the area. This vertical releasing incision
rhomboid flap. Note that the base should be wider than height,
is made on one side of the envelope flap (at the proximal
(4) Semilunar flap
or distal end) going divergent towards the buccal
vestibule forming an obtuse angle at the free gingival
Principles of Flap Designing margin. The vertical incision should be made in the
interproximal area, as the tissues here are thick. To
Intraoral surgical flaps are made to gain surgical access
avoid periodontal defect, the incision should never lie
to the area to be operated or to move tissues from one
directly on the facial aspect of the tooth. Once the
place to another.
incision is taken, then the two sided triangular flap is
reflected towards the base of the flap by using periosteal
Indications
elevator.

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For basic oral surgical procedures to allow complete
Three-sided rhomboid flap This is the modification of the
visualization of the operative field and to access osseous
earlier flap to improve the visibility and access. An
tissues, whenever required.
additional vertical incision is added in the opposite
Types of Flaps (Fig. 10.1D) direction from the earlier release. Here care should be
taken that the base of the flap must be wider than the
A. • Full thickness—mucoperiosteal flap apex to ensure good blood supply.
• Partial thickness
B. • Envelope flap Semilunar flap Whenever the periapical area is required
• Two-sided triangular flap to be exposed to carry out periapical surgery, this flap
• Three-sided rhomboid flap is designed. Again the base of the flap should be
• Semilunar flap. broader than the apex and the suture line should not
C. • Labial, buccal flaps lie on the bony defect.
• Palatal, lingual flaps The incision is taken at least 5 mm away from the
free gingival margin. This flap is useful to avoid damage
Envelope Flap (Fig. 10.1E) to interdental papilla and to prevent periodontal post-
surgical defects. In case of crowding of the teeth, the
• The most common type of flap. suturing is not a problem with this flap. The only dis-
• The incision is made to any length (depending on advantage of this flap is that it often lies on the bony
the amount of exposure needed) intraorally around defect.
the necks of the teeth along the free gingival margin
on the buccal or lingual aspect including the inter-
Tissue Handling
dental papillae
• The entire mucoperiosteal flap is raised by using Respect the tissue and the tissue will respect you (Remember
periosteal elevator to a point to the apical one-third this adage).
of the tooth Gentle handling, no excessive pulling or crushing,
• This is mainly used for the surgical extraction of a proper retraction with judicious force, avoidance of
tooth or roots. extreme temperature, minimum use of electrocautery, 121
 avoidance of the use of chemical agents are the key Use of vasoconstrictor agents Such as epinephrine,
factors for satisfactory wound healing. During cutting commercial thrombin or collagen gelfoam, etc.
of the bone by using electrical engine and hand piece
and bur, continuous saline irrigation should be done Dead Space Elimination
to avoid generation of heat. Selection of the proper
Dead space is the area that remains devoid of tissue
instruments is also important to minimize the tissue after closure of the wound. It is created as a result of
trauma.
removal of tissue in the depths of a wound or by not
Principles of Oral and Maxillofacial Surgery

suturing in multiple layers (Single layer approxima-

Haemostasis
tion). This dead space is usually filled with haematoma.
Haemostasis should be achieved during surgery for the
following reasons: How To Avoid a Dead Space
• to minimize the intraoperative total blood loss
• Multiple layer suturing from the depth to the surface
• increase visibility • Use of pressure dressing over the wound in the
• to increase the speed of the surgery and to cut down
postoperative period for 12 to 18 hours
the total operating time
• Use of surgical packing of the defect. Whenever
• to minimize the postsurgical haematoma proper approximation of the margins is not possible
(Haematoma decreases the vascularity, increases the
the strip or the ribbon gauze impregnated with an
wound tension, acts as a culture media and makes it
antibacterial medication can be used
susceptible for the development of postoperative • Use of drains alone or along with the pressure
wound infection).
dressings
• Nonsuction drains or suction drains can be used.
Haemostasis can be Achieved by
Intermittant pressure With cotton/gauze sponges or with Decontamination and Debridement
haemostat clamping. Pressure is usually applied for 20
• Irrigation during surgery
to 30 seconds for smaller tiny vessels, while large vessels
• Irrigation at the end of surgery

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require about 5 to 10 minutes of continuous pressure. • Careful debridement of necrotic tissue, foreign
Use of electrocautery For this judicious thermal coagu- bodies, severely injured tissues
lation, the area around the vessel should be dried • Antibiotic prophylaxis
thoroughly. Avoid unnecessary burning the tissue. In intraoral wounds, patients should be instructed
to use frequent medicated mouthwashes after every
Suture ligation Whenever large vessel is severed, the
food intake.
ends are grasped with a haemostat. Nonabsorbable
In extensive oral surgical wounds, the patient
suture (linen) is used to ligate the ends of the vessels.
should be fed through Ryle’s tube till the wound heals
Placement of compression dressing over the wound Many to avoid oral contamination.
times there is oozing over a large area and haemostasis
is difficult. A cotton pad or folded ribbon gauze is Suturing
stabilized over the wound and secured with tie over
Suturing has been described in detail in Chapter 6 on
sutures and left in place for 2 to 3 days.
Suturing Materials and Techniques.

II. Surgical Management of Impacted Teeth

• An unerupted tooth—is a tooth that is in the process • An embedded or impacted tooth—is the tooth that has
of eruption and is likely to erupt based on clinical failed to erupt completely or partially to its correct
and radiographic findings. position in the dental arch and its eruption potential
• Malposed tooth—A tooth unerupted or erupted has been lost.
which is in an abnormal position in the maxilla or The word impaction is from Latin origin—impactus.
in the mandible Impaction is cessation of eruption of a tooth caused by
122
a physical barrier or ectopic positioning of a tooth. An Indications for Removal of Impacted Teeth
impacted tooth is one that is erupted, partially erupted
• Recurrent pericoronitis/pain/infection/caries—
or unerupted and will not eventually assume a normal
pericoronitis is the inflammation of the gingiva
arch relationship with the other teeth and tissues.
surrounding a crown of a partially erupted tooth
• Deep periodontal pocket associated with partially
Impacted Teeth erupted tooth
Impacted teeth seen in the following order of frequency: • Prior to orthodontic treatment—to control the tooth

Minor Oral Surgical Procedures

1. Mandibular third molars crowding in the mandible
2. Maxillary third molars • Prevention of root resorption and caries—caries of
3. Maxillary canine the impacted tooth crown and the adjacent tooth
4. Mandibular premolar can be seen due to an inability to access and clean
5. Maxillary premolar the area. Root resorption of the distal root of the
6. Mandibular canine adjacent second molar is seen in the 21 to 30 years
7. Maxillary central incisors of age group. Root resorption of lateral incisor may
8. Maxillary lateral incisors. be seen associated with an impacted maxillary or
mandibular canine
Causes of Impaction of Teeth • Management of cysts and tumours, abscess of
odontogenic origin (Associated lesions).
Inadequate Space in the Dental Arch for Eruption • Prevention of pathological fractures
The phylogenic theory Due to evolution, the human jaw • Preparation of orthognathic surgery—prior to
size is becoming smaller and since the third molar tooth sagittal split osteotomy of ramus in order to avoid
is last to erupt, there may not be room for it to emerge bad split—inadvertent fracture of the mandible,
in the oral cavity. lower third molars are extracted. Maxillary third
molars are removed during Le Fort I osteotomy
Mendelian theory Here genetic variations play a major procedure
role. If the individual genetically receives a small jaw • Management of preprosthetic concerns—before the

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from one of the parents and/or large teeth from the fabrication of the prosthesis, impacted teeth should
other parent, then impacted teeth can be seen, because be removed
of ‘lack of space’. • Impacted teeth in the line of fracture
Causes of impaction of a tooth can be divided into • Prophylactic removal.
local and systemic causes (Table 10.1).

Table 10.1. Local and systemic causes of impaction of tooth

Local causes Systemic causes

• Obstruction for eruption • Prenatal causes—heredity

— irregularity in position and presence of an adjacent tooth.
— density of the overlying and surrounding bone
• Lack of space in the dental arch—crowding, supernumerary • Postnatal—ricketts, anaemia, tuberculosis, congenital syphilis,
teeth. malnutrition
• Ankylosis of primary or permanent teeth • Endocrinal disorders of thyroid, parathyroid, pituitary glands like
hypothyroidism, achondroplasia, etc. Here the primary retention
of teeth is seen due to lack of osteoclastic activity, which does not
provide resorption of the bone overlying the developing tooth
• Nonabsorbing, over-retained deciduous teeth • Hereditary-linked disorders—Down syndrome, Hurler’s syndrome,
osteopetrosis. Cleidocranial dysostosis, cleft palate, etc.
Here failure of the overlying bone to resorb and develop an eruption
pathway is absent
• Nonabsorbing alveolar bone
• Ectopic position of tooth bud
• Dilaceration of roots (trauma)
• Associated soft tissue or bony lesions
• Habits involving tongue, finger, thumb, cheek,
pencil, etc.
(Secondary retention—ankylosis of teeth. Infra-occlusion of the
tooth is seen due to arrested eruption, after initial emergence
without any obvious barrier such as a tooth, tissue or habit to
block eruption) 123
 Risk of Nonintervention Table 10.2. Difficulty index for removal of impacted lower
third molars
• Crowding of dentition based on growth prediction
Classification Difficulty index value
• Resorption of adjacent tooth and periodontal status
Angulation
• Development of pathological conditions such as
infection, cyst, tumour. Mesioangular 1 easiest to remove
Horizontal/transverse 2
Vertical 3
Risk of Intervention Distoangular 4
Principles of Oral and Maxillofacial Surgery

Minor transient Sensory nerve alteration, alveolitis, Depth

trismus and infection. Haemorrhage, dentoalveolar Level A 1
fracture and displacement of tooth. Level B 2
Level C 3
Minor permanent Periodontal injury, Adjacent tooth
Ramus relationship/space available
injury, Temporomandibular joint injury.
Class I 1
Major Altered sensation, Vital organ infection, Fracture Class II 2
of the mandible, maxillary tuberosity. Injury and Class III 3
litigation.

Benefits of Nonintervention
Winter’s Classification (Fig. 10.2A)
• Avoidance of risk.
• Preservation of functional teeth. Angulation According to the position of the impacted
• Preservation of residual ridge. third molar to the long axis of the second molar. The
Winter’s classification is suggested:
Benefits of Intervention 1. Mesioangular These may occur
2. Horizontal/transverse/ simultaneously in:
• In relation to age—in young patients, less morbidity.
inverted i. buccal version

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• In relation to different therapeutic measures. Local
3. Vertical ii. lingual version
measures against alveolitis, pain, swelling and
4. Distoangular iii. Torsoversion
trismus, etc.
5. Buccoangular
6. Linguoangular
Classification of Impacted Teeth
• Mesioangular impaction is the most common
Maxillary and mandibular third molars are classified finding.
radiographically by angulation, depth and arch length • Forty-three per cent of mandibular impacted
or relationship to the anterior aspect of the ascending third molars are mesioangular
mandibular ramus. • Sixty-three per cent of maxillary impacted third
Classification is helpful for the following- molars are mesioangular.
• Describes the general position of the impacted third Depth (Fig.10.2B) As per the relationship to the occlusal
molar. surface of the adjoining second molar of the impacted
• Aids in estimating the difficulty in removing the maxillary or mandibular third molar, the depth can be
tooth. judged.
1. Position A: The highest position of the tooth is on a
Difficulty Index
level with or above the occlusal line.
• Very difficult : 7 to 10 2. Position B: Highest position is below the occlusal
• Moderately difficult : 5 to 7 plane, but above the cervical level of the second
• Minimally difficult : 3 to 4 molar.
From Table 10.2 difficulty index can be arrived at 3. Position C: Highest position of the tooth is below
as follows: the cervical level of the second molar.
Distoangular impaction 4 The deeper the impacted tooth, the more overlying
Level B 2 bone is present and the more the angulation of
Class II 2 impaction deviates from parallel to the long axis of the
Eight is the total difficulty score. Very difficult adjacent tooth, the more difficult it is to remove the
extraction. impacted tooth.
124
 Minor Oral Surgical Procedures
Fig. 10.2A: Winter’s classification of impacted mandibular third molars: (a) mesioangular (b) distoangular, (c) vertical, (d) horizontal,
(e) buccoangular, (f) linguoangular, (g) inverted

of the third molar. It denotes that the distal portion

of the third molar crown is covered by the bone from
the ascending ramus

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• Class III: The third molar is totally embedded in the
bone from the ascending ramus because of absolute
lack of space.
Fig. 10.2B: Classification of impacted mandibular third molars
according to the depth of impaction
Maxillary Third Molars’ Classification (Fig. 10.2D)
1. Angulation and Depth classification is same as
mandibular third molars.
2. Classification of the maxillary third molar in relation
to the floor of maxillary sinus.
a. Sinus approximation (SA)—no bone or a thin
bony partition present between impacted
maxillary third molar and the floor of the
Fig. 10.2C: Pell and Gregory’s classification
maxillary sinus.
b. No sinus approximation (NSA)—2 mm or more
bone is present between the sinus floor and the
Pell and Gregory’s Classification (Fig. 10.2C) impacted maxillary third molar.
Relationship of the impacted lower third molar to the
Classification of Impacted Maxillary Canines
ramus of the mandible and the second molar (Based
(Fig. 10.2E)
on the space available distal to the second molar).
• Class I: Sufficient space available between the • Labial or palatal placement of impacted maxillary
anterior border of the ascending ramus and the canine
distal side of the second molar for the eruption of • Intermediate position
the third molar. a. Crown between the lateral incisors and
• Class II: The space available between the anterior premolar.
border of the ramus and the distal side of the second b. Crown above the root tip with labial/palatal
molar is less than the mesiodistal width of the crown orientation of the lateral incisor or premolar. 125
 Principles of Oral and Maxillofacial Surgery

Fig. 10.2D: Classification of impacted maxillary third molars: (1) Mesioangular, (2) Distoangular, (3) Vertical, (4)
Horizontal, (5) Buccoversion, (6) Linguoversion, (7) Inverted

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Fig. 10.2E: Impacted maxillary canine position; (1) Palatally placed, (2) Labially placed, (3) Partly on the labial side
and partly on palatal side, (4) Canine locked between the roots of adjacent teeth, (5) Canine in the edentulous maxilla

• Aberrant position Classification for Impacted Mandibular Canine

Impacted maxillary canines lie in the maxillary (Table 10.3)
sinus or nasal cavity.
• Class I: Palatally placed maxillary canine Table 10.3. Classification for impacted mandibular canine
a. Horizontal Labial Aberrant
b. Vertical
• Vertical • At inferior border
c. Semivertical • Oblique • On the opposite side
• Class II: Labially or buccally placed maxillary canine • Horizontal
a. Horizontal
b. Vertical
c. Semivertical Factors Responsible for Increasing the Difficulty
• Class III: Involving both buccal and palatal bone, e.g. Score for Removal of Impacted Teeth
crown is placed on the palatal aspect and the root is • As per the angulation
toward the buccal alveolar process • As per the depth
• Class IV: Impacted in the alveolar process between • As per the space available for the eruption
the incisors and first premolar. • Crown size—large bulbous crown increases the
• Class V: Impacted in the edentulous maxilla. difficulty
126
• Configuration of the roots of the impacted tooth—
the point of application of the elevator and the path
of delivery of the impacted tooth depends mainly
on the configuration of the roots.
a. Length of the roots—longer the roots—more
difficult the extraction.
b. Root development—if the root development is (less
than one-third) insufficient, then the tooth is

Minor Oral Surgical Procedures

more difficult to remove. It moves like a ball in
the socket and difficult to elevate.
c. Curvature of the roots—dilacerated, curved, diver-
gent roots are difficult to remove. Fused conical
roots are easy.
d. Root size— thin, slender roots are difficult to Fig. 10.2F: Winter’s lines: W-White line, A-Amber line, R-Red
remove. Stout, bulbous, hypercementosed roots line
also increase the difficulty.
• Bone texture and density—depends on the age, sex
and systemic problems. Younger patients have • Possible if oral opening is adequate
spongy, elastic pliable bone, while older group of • If there is no gagging
patients may exhibit sclerosed bone. • Useful to study the relation with adjoining tooth
• Size of the follicular sac—presence of large follicular • Useful to study the configuration of the roots and
sac makes the extraction easier, as the amount of status of the crown (caries, size, etc.)
bone removal is less. Nonexistent or narrow • Useful to record the relationship with inferior
follicular sac around the crown will require bone alveolar canal
cutting around the crown – Difficult extraction. • For bucco or linguoversion ‘tube shift’ method
• Space or contact in relation to mandibular second should be used or occlusal film is taken.

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molar—If the impacted tooth is locked against the The position and depth of the tooth can be assessed
crown of the second molar and there is no space for by taking intraoral X-ray or even lateral extraoral
elevation, then sectioning of the tooth should be X-ray and tracing can be done, which was originally
planned. advocated by George Winter.
• Relationship to the inferior alveolar neurovascular Three imaginary lines are drawn which are known as
bundle—proximity of the roots to the neurovascular Winter’s lines (Fig. 10.2F).
bundle increases the possibility of the damage/ • White line—corresponds to the occlusal plane. The
injury to the nerve during extraction. Temporary line is drawn touching the occlusal surfaces of first
altered sensation of the lower lip can be experienced and second molar and is extended posteriorly over
by the patient (paraesthesia/anaesthesia) which can the third molar region. It indicates the difference in
last for few days/few months. Radiological occlusal level of second and third molars.
assessment is important. Dentascan can show exact • Amber line—represents the bone level. The line is
location of the nerve. drawn from the crest of the interdental septum bet-
• Nature of covering tissue: ween the molars and extended posteriorly distal to
a. Soft tissue impaction third molar or to the ascending ramus. This line
b. Partial bony impaction—covered by soft tissue, denotes the alveolar bone covering the impacted
as well as partially by the bone. tooth and the portion of tooth not covered by the
c. Fully bony impaction bone.
• Access to the operative field, inability to open the • Red line—is drawn perpendicular from the amber
mouth wide, a large uncontrollable tongue, small line to an imaginary point of application of the
orbicularis oris muscle (oral sphincter). elevator. It indicates the amount of bone that will
have to be removed before elevation, i.e. the depth
Radiological Examination of the tooth in bone and the difficulty encountered
in removing the tooth.
Intraoral X-ray
If the length of the red line is more than 5 mm then
• Intraoral X-rays are possible, if tooth is in the the extraction is difficult. Every additional mm renders
alveolus and not in the ramus the removal of the impacted tooth three times more 127
 Principles of Oral and Maxillofacial Surgery

Fig. 10.2G(1): Extraoral X-rays for detection of impacted

teeth (1) OPG-lower right and upper left third molars are
impacted Fig. 10.2G(2): Multiple impacted teeth

• Impacted tooth in an aberrant position

• For ruling out associated pathology
• To study the relationship of the tooth to inferior
alveolar nerve (Fig. 10.2H) and (Figs 10.2-I: 1, 2, 3)/
inferior border. For maxillary teeth—relationship to
the maxillary sinus.

Surgical Removal of Impacted Teeth

1. Asepsis and isolation
2. Local anaesthesia/sedation + LA/ general anaes-
thesia
3. Incision—flap design

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4. Reflection of mucoperiosteal flap
5. Bone removal
6. Sectioning (division) of tooth
Fig. 10.2G(3): Lateral view-impacted lower third molar in the
edentulous jaw
7. Elevation
8. Extraction
difficult (more than 9 mm—below the level of the apices 9. Debridement and smoothening of bone
of the second molar). 10. Control of bleeding
11. Closure—suturing
Extraoral X-rays (Figs 10.2G 1, 2, 3) 12. Medications – antibiotics, analgesics, etc.
For mandibular teeth For maxillary teeth 13. Follow-up
• OPG • OPG
Isolation of Surgical Site
• Lateral oblique view • PA view Water’s position
mandible • Scrubbing + painting of skin and oral mucosa.
Scrubbing solutions used first on skin only.
Indicated in
— Cetrimide + absolute alcohol or cetrimide +
• Patients with restricted oral opening/trismus/
povidone + iodine
excessive gagging
— Cetrimide + absolute alcohol + chlorhexidine

Fig. 10.2H: Radiological prediction for inferior alveolar nerve proximity: (1) Darkening of root, (2) Deflection of root, (3) Narrowing
of root, (4) Dark and bifid apex, (5) Interruption of white line of the canal, (6) Diversion of canal, (7) Narrowing of canal
128
 • Cleaning solutions—used on skin only to remove
residual soap solution
— Normal saline
— Alcohol—spirit
• Painting solution—act topically to inhibit further
growth of microbes
— Povidone-iodine 5 per cent for skin, 1 per cent
for oral mucosa

Minor Oral Surgical Procedures

— Chlorhexidine gluconate—7.5 per cent for skin,
0.2 per cent for rinsing oral cavity.
Drape the patient with sterile drapes to cover upper
Fig. 10.2-I(1): Narrowing of canal
part of the face to isolate the oral cavity.

Fig. 10.2-I(2 and 3): (2) Interruption of the white line of the canal (3) Darkening of root

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Table 10.4. Radiological prediction of injury to the inferior alveolar nerve: Depends on the relationship
of the root to the canal (Figs 10.2H and I)
Related, but not involving Related to changes in canal Related with changes in canal
the canal
Close proximity of the i. Darkening of the root (radioluscent) i. Interruption (loss of lines) The
root to the canal, but ii. Dark and bifid root dense roof and floor of the
intervening bone iii. Narrowing of the root canal is seen as two white radio-
separates the both iv. Deflected root paque lines (Tram lines).
(i) separated (ii) adjacent, a. Density of the root is altered, Either of these two lines or both
(iii) super imposed. when the root impinges on may be disrupted to indicate
Trace the outline of the canal deep grooving of the roots
the root as well as b. When the canal crosses the root ii. Converging (narrowing) canal—
the canal, which will apex, it can be identified by the when canal crosses root apex,
show no disturbance double periodontal membrane there is reduction in its dia-
shadow of the bifid root apex meter. Hour glass appearance
c. If sudden narrowing of the root indicates partial encirclement
is noted where the canal crosses, of the canal
it indicates the deep grooving or iii. Diverted canal The canal
perforation of the root or involve- appears diverted, when it
ment of the root with the canal. changes its direction. This is
d. The root may be seen deflected due to an upward displace-
buccally, lingually or mesially, ment of the canal passing
distally, when it reaches the canal through the root

Local Anaesthesia • For maxillary canines—infraorbital nerve block +

• For mandibular molars and canines—pterygo- palatal infiltration of incisive canal and bilateral
mandibular nerve block. palatine nerve blocks.
• For maxillary molars—posterior superior alveolar Good infiltration is a must to provide haemostasis
nerve block and palatine nerve block or infiltration. and to define the tissue planes. 129
 Principles of Oral and Maxillofacial Surgery

Fig. 10.2J: (1) Vertical mucoperiosteal flap design, (2) An envelope flap design

• Saline adrenaline in concentration of 1:400000 i. Intraoperative brisk bleeding from the buccal
• Plain saline (in case of hypertensive patients) vessels and anastomosing branches from lingual
• LA solution with adrenaline. and facial arteries.
ii. Postoperative trismus due to cutting through the
Incision (Flap Design) fibers of temporalis muscle.
iii. Herniation of buccal pad of fat into the surgical
The mucoperiosteal flap for removal of impacted tooth
field.
is required to be designed well for adequate access and
The sharp point of periosteal elevator is used to
for elimination of obstruction to the pathway of
carefully elevate a mucoperiosteal flap beginning at the
removal. The incision for this mucoperiosteal flap will
point of the incision behind the second molar. The
have an anterior limb and a posterior limb connected

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elevator is brought forward to elevate the periosteum
with or without an intermediate limb. around the second molar and down the releasing
incision. The other flatter end of the periosteal elevator
For Mandibular Molars (Fig. 10.2J)
is then used to elevate the periosteum posteriorly to
Anterior releasing incision should begin from the the ascending ramus of the mandible.
vestibule upwards towards midway of the CEJ of
second molar at an angle. If third molar is deep and For Maxillary Molars (Fig. 10.2K)
surgery requires more removal of bone, this incision The anterior releasing incision is started anterior to
should be placed anterior to the second molar. The second molar from the vestibule and till the mesial
incision is then continued in the gingival sulcus (over interdental papilla of the second molar. The incision
the alveolar crest, if tooth is fully embedded) up to the should follow the gingival sulcus of second molar and
distal aspect of third molar. Distal releasing incision is continue over the tuberosity area from the distal most
started from the distal most point of third molar across point of second molar.
external oblique ridge into the buccal mucosa. This
incision should not be taken on the lingual aspect of For Maxillary Canines
the ridge, as the lingual nerve can be found at or above If the canine is buccally placed:
the crest of the alveolar ridge, in approximately 17 per • Flap with anterior releasing incision
cent of the population. However, the normal position • Trapezoidal flap
of the lingual nerve is 2 mm inferior to the crest and • Semilunar flap.
0.5 mm lingual to the lingual cortex of the mandible in If the canine is palatally placed—the incision is taken
the third molar region. The length of this mucoperio- in the gingival sulcus on the palatal side from the mesial
steal flap and the number of teeth included will be aspect of the first molar of the same side. Releasing
determined by the amount of exposure necessary to incision is given obliquely across the palate and should
gain the visibility of the region and the experience of be deflected away from the palatine foramen. If
the clinician. unilateral—an incision is restricted to the canine region
The incision should not be extended too far upward of the opposite side. If bilateral—an incision is extended
distally to avoid: to the first molar of the opposite side.
130
 Minor Oral Surgical Procedures
Fig. 10.2K: Mucoperiosteal flap design for the removal of impacted maxillary third molar. Dotted line indicates possible extension
of the incision for additional access

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Fig. 10.2L: (1) Removal of impacted lower third molar by chisel and mallet, (2) Removal of impacted
lower third molar with bur and handpiece

For Mandibular Canines Two Ways of Bone Removal (Fig. 10.2L)

If buccally placed then crevicular incision from the a. High speed, high torque handpiece and bur
midline is taken upto first molar. Anterior releasing technique
incision is given close to the midline. Care should be b. Chisel and mallet technique.
taken to protect the mental nerve. If the canine is placed
Bur technique Either no. 7/8 round bur or a straight no.
on the lingual side, then lingual envelop flap is taken.
703 fissure bur is used. Either of these burs can be used
for bone removal or for sectioning of a tooth. Burs
Bone Removal
should be always used along with copious saline
Aim irrigation to avoid thermal trauma to the bone.

i. To expose the crown by removing the bone First step: The bur is used in a sweeping motion around
overlying it. the occlusal, buccal and distal aspect of the mandibular
ii. To remove the bone obstructing the pathway for third molar crown to expose it and to have its
removal of a tooth. orientation.
Second step: Once the crown has been located, the buccal
How much Bone is to be removed? surface of the tooth is exposed with the bur to the
Adequate amount of bone should be removed to enable cervical level of the crown contour and a buccal trough
for elevation. But the extensive bone removal can be or gutter is created. The buccal trough should be made
minimized by sectioning the tooth. in the cancellous bone. It is important that the adequate 131
 Principles of Oral and Maxillofacial Surgery

Fig. 10.2M: Lingual split bone technique

amount of trough is created to remove any bony facing upwards or occlusally, and oblique cut is made
obstruction for exposure and the delivery of the tooth, till the distal most point of third molar. This will result
especially around the distal aspect of the crown. The in the removal of a triangular piece of buccal plate distal
distolingual portion of the tooth should be exposed to second molar. Additional triangular piece of bone is
without cutting through the lingual bony plate to removed at the junction of vertical and oblique bone
prevent damage to the lingual nerve. cut to gain the entry of the elevator tip. Finally the distal
For the canine removal, the gutter/trough is created bone must be removed, so that when the tooth is

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around the surface of the crown free from the contact elevated, there should be no obstruction at the
with the neighbouring/overlying teeth. The bone distobuccal aspect.
removal around the crown is done till CE junction and In case of canine removal, bone is cut till the level
to expose the crown beyond the greatest width. of CEJ and to expose the entire crown.
Important precautions while drilling the bone:
Lingual Split Bone Technique (Fig. 10.2M)
• Protect overlying soft tissues by retraction with
either periosteal elevator or Langenbeck retractor • It is described originally by Sir William Kelsey Fry
• Continuous irrigation either with 1 per cent • Later popularized by T. Ward
povidone-iodine or with normal saline to reduce the • Quick and clean technique
thermal necrosis of bone. • Creates a saucerization of the socket, thereby
reduces the size of the residual blood clot
Chisel and mallet technique • Used for mandibular third molar removal,
• Historical importance especially those which are placed lingually
• Very rarely used • Support the mandible at the inferior border.
• Less bone necrosis than bur technique
Steps
• Can cause inadvertent fracture of the bone
1. Vertical stop cut is made by placing the chisel with
• The jaw bone should be supported, while using this
the bevel facing posteriorly, distal to the second
technique.
molar.
First step: For mandibular/maxillary molars,the first 2. With the chisel bevel downward, a horizontal cut
step is the placement of vertical stop cut, which is made is made backward from the lower end of the vertical
by placing a 3 mm or 5 mm chisel vertically at the distal limiting stop cut.
aspect of the second molar with bevel facing posteriorly 3. The buccal bone plate is removed above the
(5 to 6 mm height). The aim is to prevent the force horizontal cut.
transmission anterior to the direction of the bone 4. The distolingual bone is then fractured inward by
removal. placing the cutting edge of the chisel along the
Second step: At the base of the vertical stop (limiting) dotted line A. Bevel side of the chisel is facing
132 cut, the chisel is placed at an angle of 45° with the bevel upward and cutting edge is parallel to the external
 oblique ridge. The chisel is held at 45° to the bone Horizontal Impaction (Fig. 10.2N-1)
surface.
Same as that for distobuccal impaction.
5. Finally small wedge of bone, which then remaining
distal to the tooth and between the buccal and
Mesioangular Impaction (Fig. 10.2N-2)
lingual cut, is excised and removed.
6. A sharp straight elevator is then applied and Distal half of the crown is sectioned off from the buccal
minimum force is used to elevate the tooth. As the groove till the CEJ; from buccal to lingual and extended
tooth moves upward and backward, the lingual into the furcation. A straight elevator is placed in the

Minor Oral Surgical Procedures

plate gets fractured and facilitates the delivery of cut and rotated to fracture the distal portion of the
the tooth. crown which is removed. Then a straight elevator is
7. After the tooth is removed, the lingual plate is placed on the mesial aspect of the third molar below
grasped with the haemostat and freed from the soft the cervical area. A purchase point can be prepared into
tissue and removed. the crown at the mesiobuccal line angle with a small
8. Smoothening of the edges is done with bone file. round bur, if the access to the elevator is not possible.
Wound irrigated and sutured. Then a cryer or crane pick elevator can be used to
elevate the tooth, engaging the purchase point.
Tooth Sectioning, Elevation and Extraction
Vertical Impaction (Fig. 10.2N-3)
• Reduces the amount of bone removal (conserves the
Sectioning is similar to mesioangular disimpaction
bone) required prior to elevation of the tooth
procedure.
• Reduces the risk of damage to the neighbouring
teeth Distoangular Impaction (Fig. 10.2N-4)
• Planned sectioning permits the parts of the tooth to
Most difficult to remove, because of its pathway of
be removed separately in an atraumatic manner by
delivery into the ascending ramus. Large amount of
creating space into which it is displaced and the
distal bone removal is required. The crown is sectioned
remaining crown or root segments removed.
from the roots just above the cervical line after sufficient
• The direction in which the impacted tooth should

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bone is removed from the occlusal and distobuccal
be sectioned is dependent on the angulation of the
aspect. The entire crown is removed to improve the
impacted tooth, based on the line of draw of the
visibility and access to the roots. If the roots are
segments
divergent, they are further sectioned into two pieces
• Can be performed either with a bur or chisel. Bur
and delivered individually. If the roots are convergent
use is preferable. Mallet blows may give psycholo-
the simple use of straight elevator is sufficient.
gical discomfort to the patient
• The bur is used in a controlled fashion to avoid Elevation
damage to the vital structures and surrounding
a. Coupland elevator—placed at the base of the crown.
teeth and soft tissues
b. Winter cryers’—may be used in wedging action/
• The tooth is usually sectioned one-half to three-
buccal elevation. Buccal elevation may be done in
fourths with the bur and then it is completely
molar and canines by drilling a purchase point in
sectioned with the elevator.
the roots just below CEJunction.

Fig. 10.2N: Sectioning method during removal of impacted lower third molar: (1) Sectioning of the
horizontally placed lower third molar, (2) Sectioning of the mesioangularly placed lower third molar,
(3) Sectioning of the vertically placed lower third molar, (4) Sectioning of the distoangularly placed
lower third molar
133
 • Wedging action is useful, when molar crown is Closure
split vertically down to bifurcation of roots.
3-0 black silk is used. Interrupted sutures given and
Important precautions Support the inferior border and maintained for 7 days. Complete surgical procedure
lingual cortex of the bone in the mandibular impaction. for the removal of lower impacted third molar is shown
Support to the palatal bone in the maxillary third molar in (Fig. 10.2O).
or canine impactions during elevation should be given. In case of molars, suture distal to second molar
Support the neighbouring tooth to prevent luxation of should be placed first and should be water tight to
Principles of Oral and Maxillofacial Surgery

the same. prevent pocket formation.

In case of palatally impacted canines, incisive
Debridement and Smoothening of Bone Margins papilla should be sutured carefully to reduce
• Irrigation of the socket postoperative bleeding.
• Curetting to remove any remaining dental follicle
and epithelium Complications
• Look for pieces of coronal portion (especially in
carious teeth/sectioned teeth), check for remnants Intraoperative Complications
of bone/granulation tissue, bleeding points
During Incision
• Check for caries (root/crown)/erosion/damage to
the adjacent teeth For molars, facial vessel or buccal vessel may be cut.
• Round off the margins of the socket with large For lower canines – mental vessels and for upper
vulcanite round bur or bone file canines—incisive canal or greater palatine vessels may
• Irrigate the socket again be damaged.
• Control bleeding before suturing.

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Fig. 10.2O: Surgical procedure for removal of lower right impacted third molar: (1) OPG of mesioangularly impacted lower right
third molar, (2) Intraoral clinical picture, (3) Incision and mucoperiosteal flap reflection, (4) Sectioning of a tooth, (5) Surgical
extraction done, (6) Suturing, (7) Extracted tooth
134
During Bone Removal • Damage to nasal wall/overlying teeth/ lingual,
Damage to the second molar, damage to the roots of inferior alveolar or mental nerve.
overlying teeth, slipping of the bur into the soft tissues,
fracture of the mandible when using chisel and mallet. During Debridement
Damage to inferior alveolar nerve/lingual nerve.
During Elevation Damage to maxillary sinus.
• Luxation of neighbouring/overlying tooth

Minor Oral Surgical Procedures

• Fracture of the adjoining bone Postoperative Complications
• Fracture of the tuberosity
Pain, swelling, trismus, hypoesthesia, sensitivity, loss
• Slipping of the tooth into pterygomandibular/
of vitality of neighbouring teeth. Pocket formation.
temporal spaces , sublingual pouch and / maxillary
Sinus tract formation, oroantral fistula, oronasal fistula.
sinus.

III. Surgical Endodontics

Apicoectomy, apical surgery, endodontic surgery, root

resection, root amputation are the terms which are used
for surgery involving the root apex to treat the apical
infection. It is the cutting off of the apical portion of
the root and curettage of periapical necrotic, granulo-
matous, inflammatory or cystic lesions. In spite of good
endodontic treatment, if periapical lesions are not

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resolved, then apical surgery is undertaken.

Indications
• Apical anomaly of root tip—dilacerations, intra-
canal calcification, open apex
• Presence of lateral/accessory canal/apical region
perforations
• Roots with broken instruments/overfillings
• Fracture of apical third of the root
• Formation of periapical granuloma/cyst
• Draining sinus tract/nonresponsive to RCT
• Extension of root canal sealant cement/filling Fig. 10.3A: Apicoectomy and curettage-Surgical procedure:
(1) Semilunar incision, (2) Reflection of mucoperiosteal flap,
beyond the apex (3) Creating a bony window with bur, (4) Bony window
• Teeth with ceramic crowns complete to expose the root apex area, (5) Sectioning of the
• When patient with chronic periapical infection, will root tip horizontally, (6) Removal of sectioned root tip and
not be available for follow-up. periapical curettage, (7) Preparation of the retrograde filling,
(8) Suturing
Contraindications
• Presence of systemic diseases—leukaemia, uncont-
• Root tips close to the nerves, e.g. mental nerve,
rolled diabetes, anaemia, thyrotoxicosis, etc.
inferior alveolar nerve or in maxilla close to the
• Teeth damaged beyond restoration
maxillary sinus.
• Teeth with deep periodontal pockets and grade III
mobility (Pre-existing bone loss)
Procedure (Figs 10.3A to E)
• When traumatic occlusion cannot be corrected
• Short root length Three accepted procedures can be used:
• Acute infection which is nonresponsive to the 1. Root canal filling and immediate apicoectomy and
treatment curettage. 135
 Principles of Oral and Maxillofacial Surgery

Fig. 10.3B: Leubke-Ochsenbein submarginal envelop flap for

apicoectomy

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Fig. 10.3C (3,4,5): (3) Bony window widened and cystic lesion
Fig. 10.3C (1, 2): Surgical procedure for apicoectomy (1) enucleation is being carried out. (4) All the apices of three
Persistant sinus tract after root canal filling (2) Mucoperiosteal anterior teeth involved in the lesion are exposed for
flap reflected to expose the periapical lesion. Note the apicoectomy procedure. (Root canal filling is done prior to
perforation of the buccal cortex surgery). (5) Suturing
136
 Minor Oral Surgical Procedures
Fig. 10.3E: (1) Preoperative periapical X-ray of a periapical
lesion involving (R) central and lateral incisors. (2) Follow up
X-ray after two years

Fig. 10.3D: (1) Overfilled root canal beyond the root apex. (2)
After burnishing of the filling at the root apex, apicoectomy
was done. (3 and 4) Retrograde filling with amalgam

2. Root canal filling is done several days/weeks/

months earlier followed by apicoectomy and Fig. 10.3F: (a) Apicoectomy of one-third of the length of the

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curettage. root, (b) Overfilled Gutta percha point and preparation of bevel
3. Increase in the periapical lesion even after root canal between 0 and 10 degrees, (c) Cutting off of excess gutta
percha point, (d) Preparation for retrograde filling using
filling and draining sinus. May be due to faulty
amalgam, (e) Final retrograde filling
filling which is redone and then followed by root
amputation and curettage.

Steps (make bur holes with round bur and then join them
with tapered fissure bur). Locate the apex.
• Asepsis and isolation
• Section the root tip horizontally (not more than one-
• Local anaesthesia with infiltration technique
third the length of the entire root). No bevel angle
• Incision design
is advocated for sectioning (0 to 10 degrees)
• Mucoperiosteal flap—either semilunar or
• Remove all periapical granulation tissue with
submarginal envelope flap with extension of at least
angulated curettes
one tooth on either side
• Use hot burnisher to seal the root tip
• Submarginal envelope flap is known as Leubke-
• Close flap and suture it.
Ochsenbein flap design. It is indicated when the
esthetics of the gingival margin cannot be compro-
Retropreparation (Fig. 10.3F)
mised (maxillary teeth with crowns). A scalloped
incision is made below the attached gingiva with The ultrasonic tip is used for retropreparation. The tip
one or two releasing incisions. Contraindication for is placed at the apical opening of the canal and guided
this flap—periodontal breakdown, large periapical gently deeper into the canal as it cuts. Once the retro-
lesion, a short root. preparation is completed the prepared cavity is
• Raise the mucoperiosteal flap with periosteal inspected. The gutta-percha at the base is recondensed
elevator with small 0.5 mm microplugger.
• Retract the flap away with Langenbeck retractor The aim of placing root end filling material is to
• Identify the apex in the intact buccal plate—create establish an apical seal that inhibits the leakage of
a bony window with surgical bur over the root apex residual irritants from the root canal into the
area. Care is taken not to damage the adjoining roots surrounding tissues. 137
 A wide variety of retrograde filling materials have 3. Dunbeck WE. The Impacted Lower Third Molar. New
been used—gutta-percha, amalgam, gold foil, titanium York, Dental Items Int Publishing Co. 1945.
4. Field HJ. The Impacted Upper Cuspid. Dent Cosmos
screws, glass ionomer, zinc oxide-eugenol, cavit,
1935;77:378.
composite resin, polycarboxalate cement, silver points, 5. Gorlin R, Goldman HM. Thoma’s Oral Pathology. 7th
etc. Edition, [Link], The CV Mosby Co. 1970.
In the defect in the periapical region hydroxylapatite 6. Hitchin AD. The Impacted Maxillary Canine. BDJ
can be packed to enhance the bony healing. 1956;100:1.
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