This document discusses surgical removal of teeth and roots. It provides indications for surgical removal such as teeth that resist forceps extraction, brittle teeth, impacted teeth, and teeth requiring extensive bone removal. The principles of transalveolar extraction are outlined, including radiographic examination, accessing the field through a mucoperiosteal flap, reducing resistance through bone removal and/or tooth sectioning, removing tooth structure using elevators, debridement, and closure. Specific techniques are described for creating flaps, reducing bone, sectioning teeth, and using various elevators, burs, chisels, and rongeurs to carefully and safely remove impacted or embedded teeth and roots.

1. SURGICAL REMOVAL OF
TEETH AND ROOTS
Dr. Saleh Bakry
Assistant Professor of Oral and Maxillofacial Surgery

2. INDICATIONS
• Any tooth that resist forceps extraction after using reasonable
amount of force.
• Patients who had frequent teeth breakage.
• Brittle teeth such as:
– Teeth with bulky fillings.
– Teeth with root canal fillings.
• Teeth with insufficient crown structure.

3. INDICATIONS
• Teeth having complicated root pattern.
– Widely divergent roots.
– Tapering root.
– Hooked or curved roots.
– Dilacerated roots.
– Hypercementosed roots.
– Ankylosed roots.

4. INDICATIONS
• Impacted teeth.
• Geminated teeth (two crowns with one root).
• Isolated maxillary posterior teeth (molars and premolars).

5. INDICATIONS
• Multiple teeth extraction with alveolectomy.
• Teeth extraction in certain systemic diseases e.g.: Paget's
disease and Cleidocranial dysostosis.
• In old age in which teeth are brittle and the alveolar bone is
dense and devoid of elasticity.
• Retained roots which cannot be grasped by the forceps.

6. PRINCIPLES OF TRANSALVEOLAR
EXTRACTION
1. Radiographic examination.
2. Access to the field of surgery or exposure of the area of
surgery by performing mucoperiosteal flap.
3. Reduction of resistance:
• Bone Removal.
• Tooth sectioning or division.
• Both.
4. Removal of tooth Structure or root (Elevators).
5. Debridement of the field of surgery.
6. Closure or suturing of the wound.
7. Post-operative care.

7. 1) RADIOGRAPHIC
EXAMINATION

8. 1) RADIOGRAPHIC EXAMINATION
A. INTRAORAL FILMS
1. Periapical view
Reveals:
• Number & shape of Roots.
• Curvature of Roots.
• Root width & length.
• Root fracture or resorption.
• Relationship to maxillary sinus.
• Alveolar bone loss.
• Bone density.
2. Occlusal view
Reveals:
• Buccolingual deflection of the tooth.

9. 1) RADIOGRAPHIC EXAMINATION
B. EXTRA ORAL FILMS
•Lateral oblique.
•Posteroanterior.
•Water's view.
•Panorama.
Indications
•When the introduction of
intraoral film is difficult or
impossible as in case of trismus or
in gagging sensation.
•When intraoral film is not
sufficient.
•Impactions in remote areas.
•Tooth is associated with large
pathologic lesions.

10. 1) RADIOGRAPHIC EXAMINATION
Radiographic examination gives
•Proper planning of operation.
•Preparing proper instruments required to
perform surgery.

11. 2) ACCESS TO THE
FIELD OF SURGERY
BY PERFORMING A
MUCOPERIOSTEAL
FLAP

12. 2) ACCESS TO THE FIELD OF SURGERY BY
PERFORMING A MUCOPERIOSTEAL FLAP
DEFINITION:
• It is the exposure of the area of operation by reflection of
the mucoperiosteal tissues overlying the field which makes
the operative site visible and accessible for surgery.
•This is performed by designing and reflecting the
mucoperiosteal flaps.
TYPES OF FLAP DESIGN:
1)Pyramidal flap.
2)Semilunar flap.
3) Gingival flap (envelope).
4) Palatal flap (Specific for torus palatinus).

13. REQUISITES OF
MUCOPERIOSTEAL FLAP
1. DESIGN:
•Should avoid injury to important (large) blood vessels & nerves
(Mental N. and Infraorbital N.).
•Should have wider base than free margins.
Wide base → maximum blood supply.
Narrow base → little blood supply + slow healing.

14. REQUISITES OF
MUCOPERIOSTEAL FLAP
1. DESIGN:
•Size of the Flap: Should be slightly larger than the expected
operative field.
Smaller → Excessive reflection + laceration of flap + Sutures
rest on defective bone.
Larger → No need for excessive reflection + Sutures rest on
sound bone.

15. REQUISITES OF
MUCOPERIOSTEAL FLAP
2. INCISION:
•Generally, should be sharp clean cut through mucous
membrane & periosteum in one step.
•Scalpel blade rests on bone during incision.
•Gingival incision: The gingival tissues of teeth standing in
operative field should be incised vertically.

16. REQUISITES OF
MUCOPERIOSTEAL FLAP
2. INCISION:
•Oblique (semivertical= vertical) Incision: Should be 450
with
base (mucobuccal fold).
•Oblique (semivertical= vertical) Incision: Does not alter the
shape of interdental papillae either mesial or distal to it.
•Oblique incision should stop at a point approximately 0.5 cm
from muco-buccal fold to allow good blood supply for flap and
prevent retarded healing.

17. REQUISITES OF
MUCOPERIOSTEAL FLAP
3. REPOSITIONING OF THE FLAP
•In edentulous patients or in areas which have no teeth (palate)
trim excess soft tissue before suturing to avoid Flabby tissues.
•Should avoid suturing under tension
•Tension → Strangulation of blood vessels → little or no blood
supplies.

18. INSTRUMENTS USED IN
FLAP CREATION
1. Bard-parker handle No. 3.
2. Blades:
• 10 Extra oral skin incision.
• 11 Stab incision of an abscess.
• 12 Inaccessible area Õ as maxillary tuberosity.
• 15 Conventional intra oral incisions.

19. INSTRUMENTS USED IN
FLAP CREATION

20. INSTRUMENTS USED IN
FLAP CREATION

21. TYPES OF FLAPS

22. 1. PYRAMIDAL FLAP
3 incision lines 2 incision lines
Gingival incision 1 1
Vertical incision 2 1
Exposure Greater exposure Little exposure
For teeth
(Indication)
Large teeth as molars Small teeth as
premolar and
anterior
Operation
(Indication)
Large operation
(cyst, impactions)
Small operation
(removal of roots)

23. 1. PYRAMIDAL FLAP
3 incision lines 2 incision lines
Gingival incision 1 1
Vertical incision 2 1

24. 1. PYRAMIDAL FLAP
Advantages of Pyramidal F:
•Wide base, no laceration & Suture rest on sound bone.
•Bone exposed up to gingival level.
•No necrotic bone is overlooked.
Disadvantages:
•Disturbance of the gingival tissue (papillae) attachment.

25. 2. SEMILUNAR FLAP
REQUISITES
•Convexity of the incision should be
towards the gingival margin.
•Wide base with adequate blood
supply.
•Wide apical exposure.
•At least 5mm between the incision
& gingival margin 2mm below the
gingival sulcus.
•To avoid gingival laceration during
reflection.
•To avoid gingival laceration during
suturing.

26. 2. SEMILUNAR FLAP
REQUISITES

27. 2. SEMILUNAR FLAP
ADVANTAGES
•Avoid disturbance of the gingival tissues.
DISADVANTAGES
•Narrow and inadequate exposure of the surgical field.
•Bone removal close to flap margin Õ delayed healing.
INDICATION
•All apical procedures (Apical 1/3 of the root).
•Apicectomy.
•Periapical (granuloma, cyst, abscess).

28. 3. GINGIVAL FLAP
(ENVELOPE):
REQUISITES
•Gingival tissues around cervical margin of the teeth must be
sharply incised and retracted.
•Must be extended for adequate number of teeth mesio-distally
for good exposure.
•Envelop flaps are usually extended one tooth distal and two
teeth mesial to the tooth being removed.

29. 3. GINGIVAL FLAP
(ENVELOPE):
INDICATIONS
•To expose margin of the bone for removal of undercut or sharp
bony edge.
•In case of implant placement to decrease amount of bone
exposure.
•Other procedures in which oblique incision is dangerous:
Lingual flap → Torus mandibularis.
Palatal flap → Torus palatinus (palatally impacted canine).
ADVANTAGE
•Limited reflection.
•Rapid healing.
•Avoid injury to lingual or palatine blood vessel.
DISADVANTAGE:
•Minimal exposure.

30. FLAP REFLECTION
• Full thickness flaps are: reflected with a Mucoperiosteal
elevator (Molt Mucoperiosteal elevator or No.9 elevator).
• The concave side of the elevator must be toward the bone
during reflection of the flap.

31. FLAP REFLECTION
• The sharp pointed end of the elevator, first prying the
interdental papilla free from the underlying bone as well as
the attached crestal gingiva.
• The broad end of the elevator continues to reflect the
attached gingiva & alveolar mucosa to the desired depth.

32. FLAP RETRACTION
• Retractors are instruments designed to hold the flap away
from the surgical area.
• The type of the retractor should be appropriate for the size of
the flap
• Small flaps → Periosteal elevator as retractor.
• Large flaps → Use a Minnesota.

33. ANATOMICAL STRUCTURES TO
BE AVOIDED IN THE
MANDIBULAR ARCH
• Avoid the use of a scalpel or bur in
the lingual soft tissue immediately
adjacent to the third molar region
because the lingual nerve may be
damaged → permanent
anaesthesia of the anterior 2/3 of
the tongue.

34. ANATOMICAL STRUCTURES TO
BE AVOIDED IN THE
MANDIBULAR ARCH
• Avoid placing vertical relaxing
incision in the premolar
region as you may sever the
mental nerve & vessels →
permanent loss of labial
sensation.
• If the scalpel slips while
making an incision into the
buccal vestibule opposite the
second molar, the facial artery
or vein may be severed.

35. CONTRAINDICATIONS FOR
PLACEMENT OF INCISION
LINES
• Avoid placing incisions
over canine prominences.
• Avoid placing vertical
incisions in the region of
the mental foramen
• Avoid placing incisions on
the palate because of the
danger of severing the
greater palatine nerve
artery and vein.

36. CONTRAINDICATIONS FOR
PLACEMENT OF INCISION
LINES
• Avoid placing unnecessary
incisions through the
incisive papillae.
• Avoid placing incisions
over bony lesions since a
dehiscence would result
with subsequent delayed
healing.
• Avoid placing vertical
incisions on the lingual
side of the mandibular
arch.

37. 3) REDUCTION
OF RESISTANCE

38. 3) REDUCTION OF
RESISTANCEREDUCTION OF RESISTANCE IS PERFORMED BY:
I- Removal of bone segments of surrounding alveolar bone.
II- Tooth sectioning or division.
III- Both.

39. I- BONE REMOVAL
PURPOSE OF BONE REMOVAL:
• Gaining access to the tooth structure.
• Reduce resistance around the tooth structure.
• Provides point of application of forceps or elevator.
• Provides a space into which the tooth may be displaced by
manipulation.

40. I- BONE REMOVAL
METHODS OF BONE REMOVAL
•Bone Removal.
•Tooth Sectioning:
Chisels:
Mallet Driven Chisel.
Hand Driven Chisel.
Electric Driven Chisel (automatic).
Burs.
Rongeurs.

41. A) CHISEL TECHNIQUE
1) MALLET DRIVEN CHISEL
•Acts by mallet blows (2-3 blows in every time).
•Apply at 45 o
to the bone surface → Chisel becomes // to bone
surface → bone into flakes.
•Types:
Unibevelled chisel: For bone removal.
Bibevelled chisel: used for:
Tooth sectioning.
Re-fracturing of mal-united fracture.
Grooved chisel: for removal of soft bone and bone biopsy.

42. A) CHISEL TECHNIQUE
1) MALLET DRIVEN CHISEL

43. A) CHISEL TECHNIQUE
Advantages of chisel technique:
•Clean and smooth cutting which prevents complications and
aids in proper healing.
Disadvantages of chisels:
• Needs great skill by the operator.
• Causes great fright to the patient.
• Not practical for removal of dense bone.
• Contraindicated for bone removal in the maxilla because
maxillary bone is thin and weak which may lead to fracture
of bones.

44. A) CHISEL TECHNIQUE
2. HAND CHISEL: work by hand pressure of the operator. It is
indicated in area of soft bone.
3. ELECTRIC (AUTOMATED) CHISEL: Consist of variable
number of shapes and sizes of chisel blade
Advantages of Electric Chisel
•It needs little skill i.e. more safe with both experienced & non-
experienced operators.
•Precise cutting.
•Different blades →Different uses & sites.
•Local anesthesia → apprehension i.e. cooperative.
Disadvantage of Electric Chisel
•Heat generation.

45. B) SURGICAL BURS IN
BONE REMOVAL
• Large size burs (fissure, cone,
round).
• Used with straight low speed hand
piece and motor (40.000 RPM).
PRECAUTIONS DURING USE
• Continuous cooling (H20 spray, H2O &
air spray) to avoid overheating of
bone this might cause →
osteomyelitis.
• Regular clearance of the blades of
surgical bur to clean out bone chips
→ Bone chips → clogging →
overheating & less efficiency.

46. B) SURGICAL BURS IN
BONE REMOVAL
METHODS OF BONE REMOVAL WITH BUR
•Holes (round bur) to surround the segment.
•Connect holes by fissure bur.
•Elevation with Chisel or Rongeur or any Elevator.
ADVANTAGES:
•Easy to control and use.
•Used in areas of heavy dense bone.
•Not alarming or freighting to the patient.
•No need for skillful operator.
DISADVANTAGES:
•Rough irregular bony cut → slower healing.
•Heat generation.

47. C) RONGEURS (BONE
CUTTING FORCEPS)
These are bones cutting forceps made
in special designs for bone removal in
different areas.
TYPES:
1. SIDE CUTTING RONGEURS:
•It is designed with blades having
sharp cutting sides.
•It is suitable for trimming sharp edges
of the alveolar plates and bony
undercuts of alveolar process.
•This type of rongeurs sometimes
called bone shear.

48. C) RONGEURS (BONE
CUTTING FORCEPS)
2. END CUTTING RONGEURS:
•Designed with cutting end
blades which cut at their tips.
•It is suitable for cutting
projecting bony septum in the
sockets of extracted teeth.
3. END AND SIDE CUTTING
RONGEURS:
•The blades are designed to cut
at their sides and tips. It is more
practical.

49. II) TOOTH DIVISION
(SECTIONING)
DEFINITION:
•Division of the tooth into smaller parts which can be removed
without need for excessive bone removal that would be needed
if tooth was removed in one piece.
INDICATIONS OF TOOTH SECTIONING
•Reduction of resistance in cases which are in need for excessive
bone removal as in Deep impactions or in case of Horizontal
impaction.
•Severe Root Curvature.
•Part of the tooth is locked under adjacent tooth or bone.
•To create space in which the tooth will be displaced.

50. II) TOOTH DIVISION
(SECTIONING)
CONTRAINDICATIONS
•Loose teeth.
•Teeth of old age (brittle).
ADVANTAGES
•Reduce amount of bone removal.
•Reduce size of operative field.
•Reduce time of operation.
•Reduce postoperative complications, edema and pain.
•Rapid healing.
•Avoid use of Excessive Force.
•Avoid injury to hard & soft tissue.

51. II) TOOTH DIVISION
(SECTIONING)
DISADVANTAGES
•Under local anesthesia (patient, uncooperative).
•Not used with Brittle & loose teeth or Teeth in Maxilla.

52. II) TOOTH DIVISION
(SECTIONING)
TECHNIQUE OF TOOTH
SECTIONING
•Bibevel Chisel + Mallet.
•Surgical bur.
TYPES OF TOOTH
DIVISION:
•Longitudinal tooth division.
•Horizontal tooth division.
•Oblique tooth division.

53. 4) REMOVAL OF
TOOTH STRUCTURE:
(USE OF
ELEVATORS IN
ORAL SURGERY)

54. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
INDICATIONS FOR USE OF ELEVATORS:
•To reflect mucoperiosteal membranes (done by mucoperiosteal
elevators).
•To luxate and remove teeth which cannot be engaged by the
forceps such as impacted and malposed teeth.
•To loosen teeth prior to the application of forceps, e.g. wisdom
teeth.
•To remove roots whether fractured or carious.

55. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
RULES WHEN USING ELEVATORS:
•Never use the adjacent tooth as a fulcrum.
•Never use the buccal plate at the gingival line as a fulcrum
except for removal of lower third molar.
•Never use the lingual plate at the gingival line as a fulcrum.
•Always use finger guards to protect the patient in case the
elevator slips.
•Be certain that the forces applied by the elevator are under
control.

56. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
CLASSIFICATION OF ELEVATORS
1. According to use:
•Elevators designed to remove the entire tooth.
•Elevators designed to remove roots broken off at the gingival
line.
•Elevators designed to remove roots broken off halfway to the
apex.
•Elevators designed to remove the apical third of the root (apical
fragment ejector or apical root pick).
•Elevators designed to reflect the mucoperiosteum.

57. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
CLASSIFICATION OF ELEVATORS
2. According to forms (shape):
•Straight elevators.
•Angular (curved) Rt, Left:
Curved Apexo.
Miler.
Cryer elevator.
•Cross-Bar (handle at right angle to shank):
Buccal applicators.
Socket applicator.

58. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
PART OF THE ELEVATOR

59. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
PRINCIPLES OF USE OF ELEVATOR
•Wedge principle: Curved Apexo elevator.
•Lever principle: straight elevator, Miller elevator.
•Wheel and Axel principle: Cryer’s elevator and cross bar
elevator.

60. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevator Use Point of application action
Single
or pair
Periosteal
Elevators
reflecting the
mucoperiosteum away
from bone
At the incision line with
the concave surface
facing the bone
single

61. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevator Use
Point of
application
action
Single
or pair
Straight
elevator
• Extraction and luxation of
lower wisdom tooth with
distally curved roots
Mesial
application
Leverage single

62. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevator Use Point of application action
Single
or pair
Curved
apexo
Removal of single roots
broken at the gingival line.
Mesio- and disto-
buccal line angles
Wedging Pair

63. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevato
r
Use Point of application action
Single
or pair
Miller’s
or potts
elevator
Luxation and/or extraction
of upper wisdom tooth.
Mesial application leverage pair

64. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevator Use Point of application action
Single
or pair
Cryer’s
elevator
Used as socket applicator
but with less force
generated.
Into the empty socket
to remove the
remaining adjacent
root
Wheel
and
axel
pair

65. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevator Use Point of application action
Single
or pair
Socket
(Winter)
applicator
Removal of lower molar
roots fractured at or below
the gingival line where
there are an empty socket.
Into the empty socket
to remove the
remaining adjacent
root
Wheel
and
axel
pair

66. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
Elevator Use Point of application action
Single
or pair
Buccal
applicator
Luxation and/or removal of
lower wisdom tooth with
straight roots after flap
refraction.
Buccal application
resting on buccal
plateau of bone
Wheel
and
axel
pair

67. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
DANGER IN THE USE OF ELEVATORS
•Loosening or extracting the adjacent teeth.
•Fracture the alveolar process or fracturing the mandible.
•Penetrating the maxillary antrum or forcing the root into the
antrum.
•Forcing a root a root of a mandibular molar through lingual
plate of the mandible.
•Damage of soft tissues by slipping of the tip of the elevator.

68. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)

69. 4) REMOVAL OF TOOTH
STRUCTURE: (USE OF
ELEVATORS IN ORAL
SURGERY)
POLICY FOR LEAVING ROOT FRAGMENTS
•Small size less than 4 mm in length.
•Very deeply seated root tips in the bone need excessive bone
removal.
•Root tips are adjacent vital structures and its removal might
force them into those structures so benefit of root removal is
riskier.
•Patient free from any bone diseases.
•Not infected root tips Õ No pathosis and radiolucency.

70. 5) DEBRIDEMENT
OF THE FIELD OF
SURGERY

71. 5) DEBRIDEMENT OF THE
FIELD OF SURGERY
1. Bone curettes are used to remove any loose fragments
from the socket and the area of surgery

72. 5) DEBRIDEMENT OF THE
FIELD OF SURGERY
2. Trim any sharp bony edges or bony projections by rongeurs
or bone cutting forceps.
3. Smoothing of edges with bone files: Filling should be done in
one direction to avoid clogging of bone file and re-
sharpening of edge of bone.
4. Irrigate the field by saline or antiseptic solutions to remove
any particles or debris.

73. 6) CLOSURE OR
SUTURING

74. 6) CLOSURE OR SUTURING
DEFINITION:
•Suturing means approximation of soft tissue edges to cover the
surgical field.

75. 6) CLOSURE OR SUTURING
ADVANTAGES OF SUTURING:
•During operation:
Retraction of soft tissue flap.
Ligation of severed blood vessels.
•Immediate after operation:
Cover the surgical field.
Prevent saliva, food debris & bacteria from gaining access to
the field.
•After operation:
Promote healing.
Preserve shape of the tissues.
Prevent the postoperative hemorrhage.
Prosthetic construction.

76. PRINCIPLES OF SUTURING:
• Needle holder should grasp the needle at approximately 3/4
of the distance from the points to avoid bent or broken
needle.

77. PRINCIPLES OF SUTURING:
• The needle should enter the tissue perpendicular to the
surface. If pierces obliquely Õ tearing may develop.

78. PRINCIPLES OF SUTURING:
• If one tissue side is free (as with flap) and the other is fixed,
the needle should pass from the free to the fixed side.
• The insertion of needle should be about 2-3 mm away from
the free edges of the soft tissue to be sutured in order to
avoid weakening and laceration of those edges.

79. PRINCIPLES OF SUTURING:
• The suture material should not be denser than the sutured
tissues in order to:
 Prevent necrosis of tissues caused by too thick suture
material.
 Prevent scarring of tissues.
• Sutures should not be placed under tension:
• Too tight suturing causes Õ strangulation of B.V. which
decrease Blood supply to the area Õ retards healing.

80. PRINCIPLES OF SUTURING:
• The knots should be tied 2-3 mm far from the incision line
i.e. on one side of the incision line:
• Knots placed on top of the incision line cause strangulation
of B.V. (Ischemia) which interferes with proper healing.

81. PRINCIPLES OF SUTURING:
• After ligation of the knots the suture end is cut at 4-5 mm
far from the knot (to be easily handled and removed after)
except in deep suturing.
• Subsequent stitch: at least 5mm apart to avoid over
suturing & to allow drainage of exudate & blood.

82. PRINCIPLES OF SUTURING:
• Superficial sutures should be removed 5 -7 days after
surgery and may be absorbable or non-absorbable
materials.
• Deep sutures (B.V., muscles, and deep fascia) should be
made with absorbable materials.

83. PRINCIPLES OF SUTURING:

84. PRINCIPLES OF SUTURING:
• The needle holder is placed parallel with the incision being
tied.
• The long end of the suture is wrapped around the tip of the
needle holder in a clockwise direction forming a loop.
• The short end of the suture is grasped with the needle holder
and pulled through the loop.
• This creates the first hitch of a square knot.
• The second hitch is formed by wrapping the long end of the
suture around the instrument in a counterclockwise direction.
• The short end of the suture is then grasped and pulled
through the loop.
• Pull the needle holder away from you, squaring the knot.

85. ARMAMENTARIUM FOR
SUTURING
NEEDLE HOLDER: Used for holding suturing needle and knotting
the thread during flap suturing.

86. ARMAMENTARIUM FOR
SUTURING
• Suture needle.
• Suture material.
• Tissues Pickup (forceps): Used to grasp and handling the soft
tissues during suturing or during any surgical procedures.

87. ARMAMENTARIUM FOR
SUTURING
Suture Scissor: Used for cutting the suture material

88. SUTURE NEEDLES
ANATOMY
Three basic components
•The Eye
•The Body
•The Point

89. SUTURE NEEDLES
CLASSIFICATION
1. According to its Shape
•Straight
Superficial suturing.
Skin suturing.
•Curved or ½ or ¾ or ¼ circle
needles
Deepsuturing.
Intraoral suturing.

90. SUTURE NEEDLES
CLASSIFICATION
2. According to Cross- section
•Round Needles (non-cutting needle)
Delicate tissues (mucus membrane
alone).
Mainly in cleft palate patient, we
use Round ½ needle to suturing the
nasal lining.
•Triangular Needle (cutting needle)
Dense tissues.
Mucoperiosteum.
Muscles.

91. SUTURE NEEDLES
Threaded Needle:
Used many times.
Problem of sterilization &
infection.
Blunt.
Double layer of suture
material.
More scar.
Ordinary surgery.
Fused Needle:
Disposable.
No problem of sterilization &
infection.
Sharp.
Single layer of suture
material.
Fewer scars.
Plastic surgery.
3. According to connection with suture material

92. SUTURE NEEDLES
Threaded Needle (B) Fused Needle (A)
3. According to connection with suture material

93. SUTURE MATERIALS
REQUIREMENTS OF IDEAL SUTURE MATERIALS:
•Should have adequate strength.
•Sterilizable.
•Knot tying characteristics.
•Minimal tissue reaction
•Ease of handling - Minimum memory.
•Cost effectiveness.

94. SUTURE MATERIALS
SUTURE MATERIALS ARE CATEGORIZED INTO TWO
GROUPS:
•Non-absorbable suture materials.
•Absorbable suture materials.

95. SUTURE MATERIALS
SUTURE MATERIALS COULD BE CLASSIFIED ACCORDING TO
FILAMENT COMPOSITION:
BRAIDED (MULTIFILAMENT) MONOFILAMENT
Made of several strands of fibers. Made of single strand.
Increased infection risk Less infection risk
Less smooth passage Smooth tissue passage
Less tensile strength Higher tensile strength
Better handling Has memory
Better knot security Lesser in knot security

96. SUTURE MATERIALS
SUTURE MATERIALS COULD BE CLASSIFIED ACCORDING TO SIZE
•Size: Refers to the diameter of the suture.
•The more “0’s” in the number, the smaller the suture.
SUTURE MATERIALS COULD BE CLASSIFIED ACCORDING TO
INDICATIONS
•Microsurgery/repair: 9-0 or 10-0 suture.
•Facial skin closure: 5-0 or 6-0 suture.
•Floor of the mouth: 4-0 or 5-0 suture.
•Muscle, deep skin, intraoral mucosa: 3-0 or 4-0 suture.

97. NON-ABSORBABLE
NATURAL SYNTHETIC
SILK COTTON NYLON PROLENE
Supplied as 03
black silk.
Advantages:
•Well tolerated by
oral tissues.
•Multifilament Õ
stable knot.
•Produce less
tissues reaction.
•Cheap.
Disadvantages:
•Weak material.
•Early dislodged or
broken in the
tissues.
•Not widely used.
• Used intraorally
• Too hard, may
cause irritation
to oral tissues.
• May be used
for skin
suturing.
• Monofilament
suture
material.
• Not widely
used.
E.g. Polypropylene
Advantages:
•cause less tissue
reaction than any
Non-absorbable
material.
•Used mainly in skin
suturing.

98. ABSORBABLE
NATURAL SYNTHETIC
Cat gut Polyglycolic acid
(Dexon)
Polyglactin-910
(Vicryl)
• Derived from sheep intestinal
mucosa.
• Two types:
1. Plain:
 Completely absorbed in a period
of 5-7 days.
 Used for intra-oral suturing
when pt is travelling or when
applying splints in oral cavity.
2. Chromic:
 Completely absorbed in a period
of 10-15 days
 Used for deep suturing of
ligaments, tendons, & B.V.
• Synthetic polymer
with minimal tissue
reaction.
• Absorption occurs
between 14-30 days
(2-4 w).
• If used intraorally Õ
must be removed as
non-absorbable
suture materials.
• Strongest suture
material.
• Synthetic polymer
with minimal
tissue reaction.
• Absorption occurs
between 60-90
days (3 months).
• If used intraorally
Õ must be
removed as non-
absorbable suture
materials.

99. TYPES OF SUTURING
1. INTERRUPTED SUTURING
Advantage:
•Looseness of one stitch does not affect the entire suture.
Disadvantage:
•Time consuming.

100. TYPES OF SUTURING
2. CONTINUOUS SUTURING
Advantage:
•Time saving.
Disadvantage:
•One loop is loosened affects the
entire suture.

101. TYPES OF SUTURING
3. CONTINUOUS LOCK (BLANKET) SUTURING
•Same advantage & disadvantage of continuous suture
•Horizontal lock // incision line.

102. TYPES OF SUTURING
4. MATTRESS SUTURING
•It provides more tissue eversion than interrupted sutures.
Indications:
•In areas where tissue eversion required (oroantral closure).
•In areas where wound contraction could cause dehiscence or
road scar formation.

103. TYPES OF SUTURING
A. Horizontal mattress
Advantages:
•Reinforces the subcutaneous tissue.
•Can be applied quickly.
Disadvantages:
•Apposition of wound edges better with the vertical mattress.

104. TYPES OF SUTURING
B. Vertical mattress
Advantages:
•Provide eversion of wound edges.
Disadvantages:
•Takes time to apply.
•Produces more cross-marks.

105. TYPES OF SUTURING
5. FIGURE 8 STITCH
•To approximate dilated socket.
•Temporary method to arrest hemorrhage from inaccessible
blood vessel.

106. THANK YOU