oral surgery II

1. Surgical Removal of teethSurgical Removal of teeth
ByBy
Dr. Essam M. AshourDr. Essam M. Ashour
BDS 1992, Ms 2000, Alexandria UniversityBDS 1992, Ms 2000, Alexandria University
PHD 2007, Cairo UniversityPHD 2007, Cairo University
Lecturer of Oral & Maxillofacial Surgery,Lecturer of Oral & Maxillofacial Surgery,
Oct. 6 UniversityOct. 6 University
Head of Oral & Maxillofacial Surgery Unit,Head of Oral & Maxillofacial Surgery Unit,
Oct. 6 University HospitalOct. 6 University Hospital
Surgical ExodontiaSurgical Exodontia

2. Surgical extraction is the method
by which a tooth is removed from its
socket, after creating a flap and
removing part of the bone that
surrounds the tooth.
Indications:

3. 1. Teeth of the maxilla or mandible that
present unusual root morphology.

4. 2.2. Teeth with hypercementosis of root and
root tips, presenting large bulbous roots

5. 3.3. Teeth with dilaceration of root
tips

6. 4.4. Teeth with ankylosed roots or with
abnormalities, e.g., dens in dente

7. 5.5. Impacted and semi-impacted
teeth

8. 6.6. Teeth fused with an adjacent
tooth

9. 7.7. Maxillary posterior teeth, whose roots
are included in the maxillary sinus

10. 88.. Roots with periapical lesions, whose
entire removal through the tooth socket
would not be possible with curettage alone

11. 9.9. Roots of teeth found below the gum line,
when their removal is impossible by any
other way

12. 10.10. Deciduous molars whose roots embrace
the crown of the subjacent premolar.

13. Basic Principles ofBasic Principles of
Dentoalveolar SurgeryDentoalveolar Surgery
 Radiographic examinationRadiographic examination
 Access to the field of operationAccess to the field of operation
 Reduction of resistanceReduction of resistance
 Removal of tooth structureRemoval of tooth structure
 Debridement of the fieldDebridement of the field
 ClosureClosure
 Post-operative carePost-operative care

14. I.Radiographic examinationI.Radiographic examination
 Root patternRoot pattern
 Relation toRelation to
importantimportant
structuresstructures
• Max sinusMax sinus
• TuberiosityTuberiosity
• IANIAN
• Mental N.Mental N.

15. II. Access to the field ofII. Access to the field of
operationoperation
 Adequate visibilityAdequate visibility
during surgery isduring surgery is
very important.very important.
1.1. Adequate Light.Adequate Light.
Continually reposition theContinually reposition the
source of light, modify yoursource of light, modify your
position to avoid obstructingposition to avoid obstructing
the light, or use a headlight.the light, or use a headlight.

16. 2. Adequate access2. Adequate access::
a)a) Ability to open the mouth widely.Ability to open the mouth widely.
b)b) A surgical field free of excess bloodA surgical field free of excess blood
& other fluids.& other fluids.
c)c) Surgically created exposure.Surgically created exposure.
d)d) Retraction of tissues away from theRetraction of tissues away from the
surgical field.surgical field.

17. Adequate accessAdequate access
Ability to open the mouth widelyAbility to open the mouth widely
1.1. Mouth props:Mouth props:
Rubber bite blocksRubber bite blocks
used to hold theused to hold the
mouth open.mouth open.
2.2.Mouth Gag:Mouth Gag:
Used to open theUsed to open the
mouth withmouth with
uncooperativeuncooperative
patients.patients.

18. Adequate accessAdequate access
A surgical field free of excess blood & other fluidsA surgical field free of excess blood & other fluids
The typical suction is one thatThe typical suction is one that
has a small orifice so thathas a small orifice so that
the tooth socket or surgicalthe tooth socket or surgical
cavity can be suctioned.cavity can be suctioned.
Fergusson suctionFergusson suction: Has a: Has a
hole in the handle portionhole in the handle portion
that can be covered tothat can be covered to
remove solutions rapidlyremove solutions rapidly
as during cutting boneas during cutting bone
under copious irrigation,under copious irrigation,
and when soft tissue isand when soft tissue is
being suctioned the hole isbeing suctioned the hole is
uncovered to preventuncovered to prevent
tissue injury.tissue injury.

19. Soft tissue flap:Soft tissue flap:
The flap is a section of soft tissue that isThe flap is a section of soft tissue that is
outlined by a surgical incision, carries itsoutlined by a surgical incision, carries its
own blood supply, allows surgical accessown blood supply, allows surgical access
to underlying tissues, can be replaced intoto underlying tissues, can be replaced into
its original position to cover & protect theits original position to cover & protect the
site of surgery and can be maintained withsite of surgery and can be maintained with
sutures & expected to heal & promotesutures & expected to heal & promote
good healing to underlying tissues.good healing to underlying tissues.
II. Access to the field of operationII. Access to the field of operation
Surgically created exposureSurgically created exposure

20. Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps
1.1. The incision must be carried out with a
firm, continuous stroke, not interrupted
strokes.
. During the incision, the scalpel should be
in constant contact With bone.
Repeated strokes at the same place, many
times, impair wound healing.

21. 2.2. Flap design and incision should be carried
out in such a way that injury of anatomic
structures is avoided, such as:
The mental neurovascular bundle, palatal
vessels emerging from the greater
palatine foramen and incisive foramen,
infraorbital nerve, lingual nerve,
submandibular duct & parotid duct.
Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps

22. Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps
3.3. The width of the flap must
be adequate, so that the
operative field is easily
accessible, allowing easy
instrumentation without
creating tension and
trauma during
manipulation.
4. The base of the flap must
be broader than the free
gingival margin, to ensure
adequate blood supply and
to promote healing.
Compromised blood supply
can cause ischemic
necrosis of the flap.

23. 5.5. The flap itself must be larger than
the bone defect so that the flap
margins, when sutured, are resting
on intact, healthy bone and not over
missing or unhealthy bone, thus
preventing flap dehiscence and
tearing.
Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps

24. 6.6. The flap should be a full-thickness
mucoperiosteal flap including the
surface mucosa, submucosa and
periosteum which must be reflected
together. This is achieved (after a
deep incision) when the
mucoperiosteal elevator is
continuously kept and pressed firmly
against the bone.
Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps

25. 7.7. Vertical releasing incisions should
begin approximately at the buccal
vestibule and end either mesial or
distal to the interdental papillae of
the gingiva in order not to damage
the papilla or alter its contour.
Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps

26. Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps
8. Flaps performed in edentulous8. Flaps performed in edentulous
ridges in the process of alveoloplastyridges in the process of alveoloplasty
must be trimmed of their excess tomust be trimmed of their excess to
cover the alveolus without overlapingcover the alveolus without overlaping
at their edges. To avoid theat their edges. To avoid the
formation of flappy ridges.formation of flappy ridges.

27. Ideal requirements ofIdeal requirements of
mucoperiosteal flapsmucoperiosteal flaps
9.9. During the surgical procedure,
excessive pulling and crushing or
folding of the flap must be avoided,
because the blood supply is
compromised and healing is delayed.

28. Types of FlapsTypes of Flaps
Flaps may be described by:Flaps may be described by:
-Shape (pyramidal, semilunar)-Shape (pyramidal, semilunar)
-Location (buccal, palatal)-Location (buccal, palatal)
-Tissue included (skin, mucosal,-Tissue included (skin, mucosal,
mucoperiosteal)mucoperiosteal)
-Number of incision lines (2 or 3 lines)-Number of incision lines (2 or 3 lines)
-Number of corners (3 or 4 corners)-Number of corners (3 or 4 corners)
-Microvascular.-Microvascular.

29. A. Triangular Flap (2 incision lines)
This flap is the result of an L-shaped
incision with a horizontal incision made
along the gingival sulcus and a vertical or
oblique incision.
The vertical incision begins approximately
at the vestibular fold and extends to the
interdental papilla of the gingiva
. The triangular flap is performed labially or
buccally on both jaws and is indicated in
the surgical removal of root tips, small
cysts, and apicectomies.
1. Pyramidal flaps1. Pyramidal flaps

31. B. Trapezoidal Flap (3 incision lines)B. Trapezoidal Flap (3 incision lines)
The trapezoidal flap is created by a
horizontal incision along the gingival
sulcus, and two oblique vertical releasing
incisions extending to the buccal vestibule.
The vertical releasing incisions always
extend to the interdental papilla and never
to the center of the labial or buccal surface
of the tooth.
1. Pyramidal flaps1. Pyramidal flaps

33. 1. Pyramidal flaps1. Pyramidal flaps
(Triangular & Trapezoidal)(Triangular & Trapezoidal)
 AdvantagesAdvantages
• Adequate exposure & excellent access.Adequate exposure & excellent access.
• Allow discovery of local pathosis.Allow discovery of local pathosis.
• Allows resting on sound bone.Allows resting on sound bone.
• Allows surgery to be performed on more than
one or two teeth.
 DisadvantagesDisadvantages
• Disturb gingival attachmentDisturb gingival attachment (recession of
gingiva).

34. 2. Semilunar flaps2. Semilunar flaps
 This flap is the result of a curved incision, which
begins just beneath the vestibular fold and has a
bow-shaped course with the convex part towards
the attached gingiva.
 The lowest point of the Incision must be at least
0.5 cm from the gingival margin, so that the
blood supply is not compromised.
 The horizontal component should not cross major
prominences such as the canine eminence.
.

36. • AdvantagesAdvantages
 Avoids disturbance to the gingivaAvoids disturbance to the gingiva
attachmentattachment
• DisadvantagesDisadvantages
 Limited exposureLimited exposure
• RequisitesRequisites
 0.5 mm away from the gingival margin0.5 mm away from the gingival margin
2. Semilunar flaps2. Semilunar flaps

37. 3. Gingival (Envelope) flaps3. Gingival (Envelope) flaps
 Normally this flap is made by incising theNormally this flap is made by incising the
tissues in the gingival sulcus around thetissues in the gingival sulcus around the
necks of several teeth and spreading thenecks of several teeth and spreading the
flap away from the bone.flap away from the bone.
 The envelope flap is used for surgery of
incisors, premolars and molars, on the
labial or buccal and palatal or lingual
surface and is usually indicated when the
surgical procedure involves the cervical
lines of the teeth

39. • AdvantagesAdvantages
 Avoids oblique incisions.Avoids oblique incisions.
 Avoids large area of periosteal detachment.Avoids large area of periosteal detachment.
 Minimize postoperative pain and edema.Minimize postoperative pain and edema.
• DisadvantagesDisadvantages
 Limited & shallow exposure.Limited & shallow exposure.
 Increased incidence of flap lacerations.Increased incidence of flap lacerations.
• RequirementsRequirements
 Adequate extensionAdequate extension..
3. Gingival (Envelope) flaps3. Gingival (Envelope) flaps

40. 4. Palatal flaps4. Palatal flaps
 Y-shaped Palatal FlapY-shaped Palatal Flap
 An incision is made along the midline of the
palate, as well as two anterolateral incisions,
which are anterior to the canines to avoid
severing of the nasopalatine artery to prevent
bleeding.
 This type of flap is indicated in surgical
procedures involving the removal of small
exostoses & small palatal tori.
.

41.  Double Y-shaped Palatal FlapsDouble Y-shaped Palatal Flaps
This type of flap is used in larger palatal tori &
bony exostoses, and is basically an extension of
the Y-shaped incision. The difference is that two
more posterolateral incisions are made, which are
necessary for adequate access to the surgical
field.
This flap is designed such that major branches
of the greater palatine artery are not severed.
4. Palatal flaps4. Palatal flaps

43. 5. Pedicle Flaps5. Pedicle Flaps
 The Pedicle flap isThe Pedicle flap is
designed to bedesigned to be
mobilized from onemobilized from one
area and rotated toarea and rotated to
fill a soft tissuefill a soft tissue
defect in anotherdefect in another
area like in closurearea like in closure
of oro-antralof oro-antral
communications.communications.

44. The IncisionThe Incision
 Incisions are madeIncisions are made
by means of sterileby means of sterile
disposabledisposable BardBard
ParkerParker bladesblades
mounted on sterilemounted on sterile
Bard ParkerBard Parker
blade handles.blade handles.

47.  Scalpel (Handle and Blade)
 Handle: The most commonly used
handle in oral surgery is the Bard
Parker blade handle no. 3.
 Its tip may receive different types of
blades.
The IncisionThe Incision

48.  Blade
 Blades are disposable and are of three different types
(nos. 11, 12, and 15).
 Blade is no. 15 The most common type used for
flaps and incisions on edentulous alveolar ridges.
 Blade no. 12 is indicated for incisions in
inaccessible areas such as the maxillary
tuberosity & retromolar areas.

Blade no. 11 is used for small incisions, such as
those used for incising abscesses (stap incision)
.
The IncisionThe Incision

50. Basic principles of tissueBasic principles of tissue
incisionincision
1.1. A sharp blade of proper size shouldA sharp blade of proper size should
be used.be used.
2. One firm, smooth, continuous2. One firm, smooth, continuous
stroke should be used keeping thestroke should be used keeping the
blade in contact with bone throughblade in contact with bone through
out the entire incision.out the entire incision.

51. Basic principles of tissueBasic principles of tissue
incisionincision
3. The incisions through tissues should be3. The incisions through tissues should be
made with the blade held perpendicular tomade with the blade held perpendicular to
the epithelial surface in order to producethe epithelial surface in order to produce
wound edges that can be easily reorientedwound edges that can be easily reoriented
& re-approximated properly during& re-approximated properly during
suturing, thus preventing necrosis ofsuturing, thus preventing necrosis of
wound edges.wound edges.
For gingival incisions, the blade is held atFor gingival incisions, the blade is held at
a slight angle to the teeth.a slight angle to the teeth.

52. Basic principles of tissueBasic principles of tissue
incisionincision
4.Avoid cutting through vital4.Avoid cutting through vital
structures as the mental, lingual,structures as the mental, lingual,
nasopalatine & greater palatinenasopalatine & greater palatine
neurovascular bundles.neurovascular bundles.
5.Incisions should be properly placed5.Incisions should be properly placed
through attached gingiva & overthrough attached gingiva & over
healthy bone to provide support tohealthy bone to provide support to
the healing wound.the healing wound.

53. Mucoperiosteal elevators usedMucoperiosteal elevators used
for reflection of the intra-oralfor reflection of the intra-oral
mucoperiosteal flapsmucoperiosteal flaps

54. RetractorsRetractors
Minnesota retractors for
retraction of the cheek and
tongue

55. RetractorsRetractors

56. RetractorsRetractors

57. III Reduction of ResistanceIII Reduction of Resistance
 AimAim
• Allow removal of teeth with the leastAllow removal of teeth with the least
amount of force.amount of force.
 MethodsMethods
• Bone removalBone removal
• Tooth sectioningTooth sectioning

58. III Reduction of ResistanceIII Reduction of Resistance
 Bone removalBone removal
 PurposePurpose
• Gaining access to the tooth structure.Gaining access to the tooth structure.
• Reduction of resistance around the tooth.Reduction of resistance around the tooth.
• Provides point of application.Provides point of application.
• Provides space into which the tooth may beProvides space into which the tooth may be
displayed.displayed.
 MethodsMethods
• Chisels.Chisels.
• Rotary (surgical burs)Rotary (surgical burs)
• Bone Rongeur.Bone Rongeur.

59. III Reduction of ResistanceIII Reduction of Resistance
1.1. Bone removal using chiselsBone removal using chisels
Chisels shapeChisels shape
1.1. Unibeveled.Unibeveled.
2.2. Bibeveled (Osteotome).Bibeveled (Osteotome).
3.3. Grooved.Grooved.

61. Bone removal using chiselsBone removal using chisels
Methods of applicationMethods of application
1.1. Hand driven (copland chisel)Hand driven (copland chisel)
2.2. Mallet drivenMallet driven
3.3. Electric Pneumatic drivenElectric Pneumatic driven

62. Bone removal using chiselsBone removal using chisels
• AdvantagesAdvantages
 Clean and smooth cutClean and smooth cut
 Rapid bone removalRapid bone removal
 No heat generationNo heat generation
• DisadvantagesDisadvantages
 Needs skill and trainingNeeds skill and training
 Not comfortable for the patientNot comfortable for the patient
 Not practical in extremely dense boneNot practical in extremely dense bone
 Not indicated in the maxilla to avoid fractureNot indicated in the maxilla to avoid fracture
of max. sinus bone, max. tuberosity or largeof max. sinus bone, max. tuberosity or large
segment of alv. Bone.segment of alv. Bone.

63. 2. Bone removal using surgical burs2. Bone removal using surgical burs
 Different sizes & shapes are available.Different sizes & shapes are available.
 They work on straight hand piece orThey work on straight hand piece or
contra-angles.contra-angles.
 Round burs are used to drill holes in theRound burs are used to drill holes in the
bones which are then connected by thebones which are then connected by the
Fissure bur.Fissure bur.

65. 2. Bone removal using surgical burs2. Bone removal using surgical burs
 PrecautionsPrecautions
• Needs copious irrigationNeeds copious irrigation
• Needs frequent replacement and cleaningNeeds frequent replacement and cleaning
• Sharp burs should be used to avoid using extra pressureSharp burs should be used to avoid using extra pressure
and time during cutting bone & to prevent postop. Painand time during cutting bone & to prevent postop. Pain
& necrosis.& necrosis.
 AdvantagesAdvantages
• ControllableControllable
• Practical especially in dense bonePractical especially in dense bone
• Safe & accurate in maxillaSafe & accurate in maxilla
• Comfortable to the patientComfortable to the patient
 DisadvantagesDisadvantages
• Heat generation which can cause bone necrosis.Heat generation which can cause bone necrosis.

66. 3. Bone removal using Rongeurs3. Bone removal using Rongeurs
Types:Types:
1.1. Side-cuttingSide-cutting; suitable for trimming; suitable for trimming
sharp edges of the alv. Plates.sharp edges of the alv. Plates.
2.2. End-cuttingEnd-cutting; suitable for cutting; suitable for cutting
bone septum projecting in thebone septum projecting in the
socket of extracted teeth.socket of extracted teeth.
3.3. Side and end cuttingSide and end cutting..

68. 4. Bone removal using Bone files4. Bone removal using Bone files
 Bone files are usually double-endedBone files are usually double-ended
instruments with a small & large ends.instruments with a small & large ends.
 They cannot remove large amounts of bone.They cannot remove large amounts of bone.
 They are used only for final smoothening ofThey are used only for final smoothening of
sharp bone edges or spicules of bone beforesharp bone edges or spicules of bone before
closure of the flap.closure of the flap.
 The teeth of the bone file are arranged soThe teeth of the bone file are arranged so
that they remove bone on pull stroke only.that they remove bone on pull stroke only.

70. Tooth Sectioning or divisionTooth Sectioning or division
 Alone or together with bone removalAlone or together with bone removal
 2 or more segments2 or more segments
 MethodMethod
• Surgical bursSurgical burs
• ChiselsChisels
 AdvantagesAdvantages
• Minimizes amount of bone removalMinimizes amount of bone removal
• Decrease operating timeDecrease operating time
• Minimizes trauma to bone, thus less postop.Minimizes trauma to bone, thus less postop.
pain & edema.pain & edema.
• Saves more alv. Bone for better prostheticSaves more alv. Bone for better prosthetic
options.options.

72. IV. Removal of tooth structureIV. Removal of tooth structure
 ForcepsForceps
 ElevatorsElevators

73. Dental ElevatorsDental Elevators
 Instruments used in extraction of teethInstruments used in extraction of teeth
which cannot be grasped by forceps.which cannot be grasped by forceps.
 Indications:Indications:
1.1. To luxate teeth before application ofTo luxate teeth before application of
forceps specially in difficult extractionsforceps specially in difficult extractions
(impacted, malposed, fragile & endo-(impacted, malposed, fragile & endo-
treated teeth).treated teeth).
2. To remove broken or surgically sectioned2. To remove broken or surgically sectioned
roots from their sockets.roots from their sockets.

74. Dental ElevatorsDental Elevators
 ComponentsComponents
• HandleHandle
• ShankShank
• BladeBlade

75. Dental ElevatorsDental Elevators
Classification of elevatorsClassification of elevators
 According to shapeAccording to shape
• StraightStraight
• Cross barCross bar
• CurvedCurved
 According to useAccording to use
• Luxation of teeth & roots.Luxation of teeth & roots.
• Complete extraction (Miller for extraction ofComplete extraction (Miller for extraction of
upper wisdom)upper wisdom)
• Apical root fragmentsApical root fragments
• Reflection of flaps (Periosteal elevators)Reflection of flaps (Periosteal elevators)

76. Dental ElevatorsDental Elevators

77. Dental ElevatorsDental Elevators

78. Dental ElevatorsDental Elevators

79. Dental ElevatorsDental Elevators

80. Dental ElevatorsDental Elevators

81. Dental ElevatorsDental Elevators
 Rules of elevator useRules of elevator use
 Never use adjacent teeth as fulcrum.Never use adjacent teeth as fulcrum.
 Never use the buccal plate as a fulcrumNever use the buccal plate as a fulcrum
except in the area of ext. oblique ridgeexcept in the area of ext. oblique ridge
 Controled movement with the left handControled movement with the left hand
used as a guard to avoid slippage of theused as a guard to avoid slippage of the
elevator with possible injury to hard orelevator with possible injury to hard or
soft tissues.soft tissues.

82. Dangers in elevator useDangers in elevator use
 Loosening or extraction of adjacent teethLoosening or extraction of adjacent teeth
 Fracturing alveolar process, tuberiosity,Fracturing alveolar process, tuberiosity,
maxilla or mandiblemaxilla or mandible
 Forcing teeth or roots into nearby vitalForcing teeth or roots into nearby vital
structuresstructures
• Maxillary sinusMaxillary sinus
• IACIAC
• Tissue spacesTissue spaces
 Slippage leading to tissue injurySlippage leading to tissue injury
• Lingual nerveLingual nerve
• Soft palateSoft palate
• Oral mucosaOral mucosa
• TongueTongue
• Floor of the mouthFloor of the mouth
• Pharynx and tonsilsPharynx and tonsils

83. Straight elevatorsStraight elevators
 Straight elevatorStraight elevator
• Luxation of mandibular 3rd molars withLuxation of mandibular 3rd molars with
distally curved roots.distally curved roots.
• Mesial application of force.Mesial application of force.
• Principal of actionPrincipal of action
 Simple lever actionSimple lever action
 Rotational movementRotational movement
 Straight apexo.Straight apexo.

84. Straight elevatorsStraight elevators
STRAIGHT APEXO

85. Straight elevatorsStraight elevators
COUPLAND CHISEL

86. Straight elevatorsStraight elevators
Straight Hospital elevatorStraight Hospital elevator

87. Curved elevatorsCurved elevators
 Curved ApexoCurved Apexo
• Removal of singleRemoval of single
rootsroots
• Removal of apicalRemoval of apical
fragmentsfragments
 Principal ofPrincipal of
actionaction
• wedgingwedging

88. Cryer elevatorCryer elevator

89. Curved Hospital patternCurved Hospital pattern

90. CROSS BAR ElevatorsCROSS BAR Elevators
 SOCKET APPLICATORSOCKET APPLICATOR

91. CROSS BARCROSS BAR
 BUCCAL APPLICATORBUCCAL APPLICATOR

92. V. Debridement of the fieldV. Debridement of the field
 Removing of any loose fragments orRemoving of any loose fragments or
pathological tissues from the socketpathological tissues from the socket
using bone curettes.using bone curettes.
 Trimming of sharp bony edges.Trimming of sharp bony edges.
 Smoothening of the edges by boneSmoothening of the edges by bone
file.file.
 Irrigation of the surgical field toIrrigation of the surgical field to
remove any fine debris.remove any fine debris.

93. V. Debridement of the fieldV. Debridement of the field

94. V. Debridement of the fieldV. Debridement of the field

95. VI. Closure (Suturing)VI. Closure (Suturing)
 Approximation of the soft tissueApproximation of the soft tissue
edges to cover the surgical fieldedges to cover the surgical field
 Advantages of suturing:Advantages of suturing:
• Promotes healingPromotes healing
• Prevents complicationsPrevents complications
 InfectionInfection
 HaemorrhageHaemorrhage
 Tissue necrosisTissue necrosis
• Restores the normal contour and shapeRestores the normal contour and shape
of tissuesof tissues

96. VI. Closure (Suturing)VI. Closure (Suturing)
 Sutures can be classified accordingSutures can be classified according
to:to:
 A. size: 3/8 to ½ circle cutting edge.A. size: 3/8 to ½ circle cutting edge.
 B. Performance:B. Performance:
Resorbable or Non-resorbable.Resorbable or Non-resorbable.
C. Physical configuration:C. Physical configuration:
Monofilament or multifilament.Monofilament or multifilament.

97. VI. Closure (Suturing)VI. Closure (Suturing)
 Suturing armamentariumSuturing armamentarium
1.1. Suture needles.Suture needles.
2.2. Suture materials.Suture materials.
3.3. Needle holders.Needle holders.
4.4. Toothed tissue forceps.Toothed tissue forceps.
5.5. Suture scissors.Suture scissors.

98. Suture NeedlesSuture Needles
 Patterns of thePatterns of the
suture needlesuture needle
according toaccording to
accessibility:accessibility:
• Straight suture needlesStraight suture needles
 For skin closureFor skin closure
• Curved suture needlesCurved suture needles
 For intraoral suturingFor intraoral suturing
 For deep suturingFor deep suturing
• Half circle sutureHalf circle suture
needlesneedles
 For intraoral suturingFor intraoral suturing
 For deep suturingFor deep suturing

99. Suture NeedlesSuture Needles
 Patterns of suture needles accordingPatterns of suture needles according
to cross section:to cross section:
• Round suture needlesRound suture needles
 Round cross sectionRound cross section
 May be straight, curved or half circleMay be straight, curved or half circle
 Suturing of fragile and delicate tissues e.g. oralSuturing of fragile and delicate tissues e.g. oral
mucosa and mucous membranesmucosa and mucous membranes
• Cutting (Atraumatic) suture needlesCutting (Atraumatic) suture needles
 Triangular cross sectionTriangular cross section
 May be straight, curved or half circleMay be straight, curved or half circle
 Suturing of dense tissues e.g. oral mucoperiosteumSuturing of dense tissues e.g. oral mucoperiosteum

100. Suture NeedlesSuture Needles
 Patterns of suture needlesPatterns of suture needles
according to attachment:according to attachment:
 Frech eyed.Frech eyed.
 Swaged (eyeless).Swaged (eyeless).

101. Suture NeedlesSuture Needles

102. Suture MaterialsSuture Materials
 Types of suture materialTypes of suture material
• Non-Absorbable suture materialsNon-Absorbable suture materials
 Skin closureSkin closure
 Routine intraoral closureRoutine intraoral closure
 Blood vessels ligationBlood vessels ligation
• Absorbable suture materialAbsorbable suture material
 Deep tissuesDeep tissues
 Fascial layersFascial layers
 Intraoral closure in cases of:Intraoral closure in cases of:
• Inability of the patient to return to remove theInability of the patient to return to remove the
suturessutures
• Mentally retarded patientsMentally retarded patients
• Epileptic patientsEpileptic patients
• Sutures under surgical stentsSutures under surgical stents

103. Suture MaterialsSuture Materials
 Non-Absorbable suture materialsNon-Absorbable suture materials
• SilkSilk
 Black or whiteBlack or white
 Tough suture materialTough suture material
 Intraoral suturingIntraoral suturing
• CottonCotton
 Weak suture materialWeak suture material
• NylonNylon
• PolypropylenePolypropylene
 Very hard suture materialVery hard suture material
 Used for skin closureUsed for skin closure
 Cause mucosal irritation if used intraorallyCause mucosal irritation if used intraorally

104. Suture MaterialsSuture Materials
 Absorbable suture materialsAbsorbable suture materials
• Plain catgutPlain catgut
 Resorbed 5-10 daysResorbed 5-10 days
 Used for suturing of deep fascia and musclesUsed for suturing of deep fascia and muscles
 Occasionally tissue irritantOccasionally tissue irritant
• Chromic catgutChromic catgut
 Resorbed completely after 10-15 daysResorbed completely after 10-15 days
 Non irritant to the tissuesNon irritant to the tissues
 Sutures of ligaments, tendons and severed bloodSutures of ligaments, tendons and severed blood
vesselsvessels
• Collagen suturesCollagen sutures
• Polyglycolic acids sutures (Dexon)Polyglycolic acids sutures (Dexon)
• Polyglactin-910 (Vicryl) suturesPolyglactin-910 (Vicryl) sutures

105. Suture MaterialsSuture Materials
• Collagen suturesCollagen sutures
 More uniform physical propertiesMore uniform physical properties
 Prepared from tendons of cattlePrepared from tendons of cattle
• Polyglycolic acids sutures (Dexon)Polyglycolic acids sutures (Dexon)
 Synthetic polymerSynthetic polymer
 Resorped by hydrolysis within 15-30 daysResorped by hydrolysis within 15-30 days
• Polyglactin-910 (Vicryl) suturesPolyglactin-910 (Vicryl) sutures
 Synthetic inert copolymerSynthetic inert copolymer
 The strongest absorbable suture materialThe strongest absorbable suture material
 Resorped 60 – 90 daysResorped 60 – 90 days

106. Suture MaterialsSuture Materials

107. Suture MaterialsSuture Materials

108. Needle holderNeedle holder

109. Needle holderNeedle holder

110. Tissue forcepsTissue forceps
 Used to hold softUsed to hold soft
tissue & stabilize ittissue & stabilize it
for suturing orfor suturing or
dissection.dissection.

111. Suture scissorsSuture scissors
 They have longThey have long
handles & shorthandles & short
cutting edges.cutting edges.

112. Suturing techniquesSuturing techniques
 Simple interrupted sutures.Simple interrupted sutures.
 Continuous sutures.Continuous sutures.
 Continuous with lock (blanket)sutuesContinuous with lock (blanket)sutues
 Horizontal mattres sutures.Horizontal mattres sutures.
 Vertical mattress sutures.Vertical mattress sutures.
 Figure-of- 8 sutures.Figure-of- 8 sutures.

114. Simple Interrupted SuturesSimple Interrupted Sutures

115. Continuous SuturesContinuous Sutures

116. Continuous with Lock SuturesContinuous with Lock Sutures

117. Horizontal Mattress SuturesHorizontal Mattress Sutures

118. Vertical Mattress SuturesVertical Mattress Sutures

119. Principles of suturingPrinciples of suturing
 Use suture needle of suitable shape andUse suture needle of suitable shape and
size.size.
 Use suture material that is of suitable typeUse suture material that is of suitable type
and size for the tissues being sutured.and size for the tissues being sutured.
 Good bite (2:3 mm from the free edge ofGood bite (2:3 mm from the free edge of
the soft tissue).the soft tissue).
 Sutures should not be placed underSutures should not be placed under
tension to avoid strangulation of bloodtension to avoid strangulation of blood
vessels leading to ischemia & tissuevessels leading to ischemia & tissue
necrosis.necrosis.

120. Principles of suturingPrinciples of suturing
 Knots should be tied 2-3mm awayKnots should be tied 2-3mm away
from the incision line.from the incision line.
 Suture material is cut 4-5 mm awaySuture material is cut 4-5 mm away
from the knot.from the knot.
 Superficial sutures must be removedSuperficial sutures must be removed
5 days after surgery to prevent5 days after surgery to prevent
infection / forigen body reaction.infection / forigen body reaction.

121. TONGUE HOLDERTONGUE HOLDER

122. ARTERY FORCEPSARTERY FORCEPS

123. ARTERY FORCEPSARTERY FORCEPS

124. ALLIS FORCEPSALLIS FORCEPS

125. KOCHERKOCHER

126. Extraction of Multi-Rooted Teeth
with Destroyed Crown

130. Root Extraction After Removal of
Part
of the Buccal Bone

143. THANK YouTHANK You
for your attentionfor your attention