Practical Oral Surgery

for the General Dentist

Star of the South
March 28, 2008
Hands-On

Jay B. Reznick, D.M.D., M.D.
Diplomate, American Board of Oral and Maxillofacial Surgery
Tarzana, California

Outline
•Review surgical tray/ instruments
•Flap reflection 
•Single rooted teeth extraction:
–Proximators/ apical retention
forceps
•Multi‐rooted teeth: premolars
–Sectioning with handpiece
–Elevators/ Cryer elevators

Outline- continued
•Root tip retrieval
– Root tip pick
– 701 bur/ troughing
•Impacted teeth
– Flap
– Bony exposure
– Sectioning
•Socket Preservation grafting
– BioHorizons (bone/ membrane)
– Premolar sites

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 Outline- continued
•Alveoloplasty
•Suturing
–Closure of 3rd molar flap
–Transposed papilla closure over
alveoloplasty area
•Biopsy
–Excision with margin
–Primary closure w/ undermining
flaps

Strategy
• Mentally visualize the 
procedure from start to 
finish
• Anticipate what 
instruments will be 
needed, and have them 
ready/ readily available
• Anticipate complications
• Headlight, loupes
• “Measure twice, cut 
once”

Exodontia Surgical Setup

• Local •Curette
• Retractor(s) •Hemostat(s)
• Mouth prop •Suction tip(s)
• Scalpel •Needle holder/ 
• Periosteal elevator suture
• Tooth elevator(s) •Scissors
• Universal forcep •Gauze

2
 Exodontia Surgical Setup

Extraction Instruments

•Elevators
•Periotomes/ Proximators
•Forceps

Elevators
•Used to 
–Luxate teeth
• Try to luxate
against bone
• Avoid
excessive
pressure on
adjacent
crowns
–Elevate roots

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 Forceps Extraction

TOOTH LUXATION 
• Max. Anterior MOVEMENT
• Max. Premolar ¾B‐L, Rotation
• Max. Molar ¾B‐L
• Mand. Incisor ¾B
• Mand. Canine/PM ¾B‐L
• Mand Molar ¾B‐L, Rotation
¾B‐L

Surgical Handpiece

•Allow sectioning of tooth and 
removal of bone
•Does not allow air to vent into the 
surgical field
•Subcutaneous emphysema

Angled Surgical Handpiece

• Air exhausted
to rear
• 400-500K RPM
• Sabra OMS 105
– 105 degree head
• Sabra OMS 45
– 45 degree head

4
 Pig Jaw Anatomy
Incisors: 3
Canine: 1

Premolars: 4
Molars: 3

Surgical Flap Design

•Purpose of flap is to gain access to 
surgical site, to obtain adequate 
visualization of field and avoid 
trauma to soft tissues.
• Should be based on anatomy, blood 
supply
• Base broader than apex

Surgical Flap Design

•Size of flap depends
on purpose • Flap should be 
broader at base

•Releasing incision

5
Flap Reflection

•Sulcular incision‐ premolar 

region
•Flap for impacted teeth‐ distal 
release
•Instruments:
–#15 blade
–Periosteal elevator

Surgical Extractions

•Single‐Rooted Teeth
•Multi‐Rooted Teeth

Single-Rooted Teeth
Maxillary/ Mandibular Anteriors

•Atraumatic extraction
desireable
•Want to minimize flap
reflection and bone removal
•Proximators are ideally suited
for this task

6
 Atraumatic Flapless Extraction

Multi-Rooted Teeth
• Bicuspid/ 
Premolar
• Molars

Root Retrieval- Molars

•Cryer/ East‐West
•Cogswell‐B

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 Root Retrieval

•Root tip 
elevators
–Trough with 701

Impactions
• Visualize 
procedure from 
start to finish
• Have instruments 
available
• Adequate flap to 
visualize target 
and minimize soft 
tissue trauma

Lower 3rd Molar Incisions

8
 Bony Exposure
• Sweep away bone
• The tooth crown is 
harder than bone
• Light pressure
• Let the bur “drive”
itself
• Fully expose 
furcation to facilitate 
sectioning

Impacted Teeth

• Expose crown
• Bisect crown/
roots
• Deliver
sections

Alveoloplasty
•Multiple adjacent teeth
•Removal of interdental bone, and 
contouring of ridge
•Eliminate sharp edges, sore spots

9
Alveoloplasty
Premolar Sites
•Rongeur
•Bone File
•Rotary instruments

Rongeur

Rotary Instrument

10
 Suturing
• To reapproximate
surgical flaps
• To hold packing in 
place
• A suture alone does 
not hold the blood 
clot in place.

Suture

• Size
ƒ 3-0: basic
ƒ 4-0: finer
• Type
ƒ Silk
ƒ Gut
ƒ Plain
ƒ Chromic
ƒ Vicryl (PGA)

Closure of Multiple Adjacent

Extraction Sites

Transposed
Papillae
Closure

11
 Transposed Papillae Closure

Ridge Preservation Grafting

• Optimizes the 
amount of bone 
present at 
extraction site
• Reduces early (1st 6 
months) ridge 
resorbtion by about 
75%

Ridge Preservation Grafting

•After extraction socket is 
debrided and irrigated, graft 
material is packed into socket
•Barrier membrane is placed over 
graft
•Sutured in place

12
 Biopsy Technique
• Excise down to 
connective tissue 
layer
• If ulcerative, biopsy 
near edge
• If suspect 
malignancy, biopsy 
“worst” area
• If excising, excise 
completely, 
consider closure

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