Dentoalveolar Surgery PDF

Dentoalveolar Surgery
Editor
MICHAEL A. KLEIMAN
ORAL AND MAXILLOFACIAL SURGERY

CLINICS OF NORTH AMERICA
www.oralmaxsurgery.theclinics.com
Consulting Editor
RICHARD H. HAUG
August 2015 • Volume 27 • Number 3

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ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA Volume 27, Number 3
August 2015 ISSN 1042-3699, ISBN-13: 978-0-323-39348-5
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Contributors
CONSULTING EDITOR
RICHARD H. HAUG, DDS

Professor and Chief, Oral Maxillofacial Surgery,
Carolinas Medical Center, Charlotte, North
Carolina
EDITOR
MICHAEL A. KLEIMAN, DMD

Private Practice, Oral and Maxillofacial
Surgery, Edison-Clark Oral Surgery
Associates, Edison, New Jersey
AUTHORS
SHELLY ABRAMOWICZ, DMD, MPH Dentistry, Virginia Commonwealth University,

Assistant Professor, Division of Oral and Richmond, Virginia
Maxillofacial Surgery, Department of Surgery,
Emory University School of Medicine, Atlanta, STEPHANIE J. DREW, DMD
Georgia Assistant Clinical Professor, Hofstra Medical
School, Hofstra University, Hempstead, New
ADRIAN BECKER, BDS, LDS, DDO York; Assistant Clinical Professor, University
Clinical Associate Professor Emeritus, Hospital Stony Brook, Stony Brook,
Department of Orthodontics, Hebrew New York; The New York Center for
University-Hadassah School of Dental Orthognathic and Maxillofacial Surgery, West
Medicine, Jerusalem, Israel Islip, New York
MICHAEL S. BLOCK, DMD HILLEL EPHROS, DMD, MD

Private Practice, Metairie, Louisiana Program Director, Oral and Maxillofacial
Surgery; Chairman, Department of Dentistry,
STELLA CHAUSHU, DMD, MSc, PhD Medical Director of the Regional Craniofacial
Associate Professor and Chair, Department Center, St. Joseph’s Regional Medical Center,
of Orthodontics, Hebrew University-Hadassah Paterson, New Jersey
School of Dental Medicine, Jerusalem,
Israel
JAMES R. HUPP, DMD, MD, JD, MBA
GEORGE R. DEEB, DDS, MD Founding Dean and Professor of Oral-
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dental
Maxillofacial Surgery, School of Dentistry, Medicine, East Carolina University, Greenville,
Virginia Commonwealth University, Richmond, North Carolina
Virginia
ROBERT KLEIN, DDS
JANINA GOLOB DEEB, DDS, MS Chief Resident, Oral and Maxillofacial Surgery,
Assistant Professor, Departments of St. Joseph’s Regional Medical Center,
Periodontics and General Practice, School of Paterson, New Jersey
iv Contributors
STUART E. LIEBLICH, DMD Maxillofacial Surgery and Hospital Dentistry,

Clinical Professor, Oral and Maxillofacial Christiana Care Health System, Wilmington,
Surgery, University of Connecticut Health Delaware
Center, Farmington, Connecticut; Private
Practice, Avon Oral and Maxillofacial Surgery, STEVEN M. ROSER, DMD, MD
Avon, Connecticut DeLos Hill Professor of Oral Surgery;
Chief, Division of Oral and Maxillofacial
SAMI A. NIZAM II, DMD, MD Surgery, Department of Surgery, Emory
Resident, Department of Oral and Maxillofacial University School of Medicine, Atlanta,
Surgery, Rutgers University School of Dental Georgia
Medicine, Newark, New Jersey
M. ANTHONY POGREL, DDS, MD, FRCS, ANTHONY SALLUSTIO, DDS

FACS Chief, Prosthodontics and Maxillofacial
Professor of Oral and Maxillofacial Surgery, Prosthetics, St. Joseph’s Regional Medical
Department of Oral and Maxillofacial Surgery, Center, Paterson, New Jersey
University of California San Francisco, San
Francisco, California VINCENT B. ZICCARDI, DDS, MD, FACS
Professor, Chair and Residency Director,
LOUIS K. RAFETTO, DMD Department of Oral and Maxillofacial Surgery,
Director of Surgical Implantology and Alveolar Rutgers University School of Dental Medicine,
Reconstruction, Department of Oral and Newark, New Jersey
Contents
Preface: Achieving and Maintaining Excellence in Dentoalveolar Surgery ix
Michael A. Kleiman
Medical Management of Patients Undergoing Dentoalveolar Surgery 345
Shelly Abramowicz and Steven M. Roser

The oral and maxillofacial surgeon (OMS) should have an understanding of common
medical comorbidities. This understanding allows for risk stratification and thus preven-
tion of potential problems. Remaining knowledgeable regarding diseases, diagnosis,
treatment strategies, and pharmacology ultimately improves patient care. This article
provides an update on some of the most common medical diseases for the patient under-
going dentoalveolar surgery.
Dental Extractions and Preservation of Space for Implant Placement in Molar Sites 353
Michael S. Block
The clinician is often asked to remove a tooth and place an implant into the site. The
implant must be placed with appropriate stability to allow for integration to occur, which
requires bone presence. Bone is also necessary to allow for ideal implant positioning
within the alveolus for functional and esthetic concerns. The purpose of this article is
to discuss the changes in socket dimensions over time and how to promote space main-
tenance, with an algorithm for treatment based on evidence.
Managing Impacted Third Molars 363
Louis K. Rafetto
Oral and maxillofacial surgeons can be reasonably certain of the behavior of wisdom
teeth and the outcomes of different management strategies. An organized approach
based on symptom and disease status simplifies management recommendations. The
patients who provide the greatest challenge to certainty are those whose wisdom teeth
are asymptomatic and disease free. Patients who elect to retain a third molar should
be advised about this risk of removal over time. Given the increased complication rate
when third molars are removed with increasing age, it may be prudent to extract them
by the middle of the third decade.
Coronectomy: Partial Odontectomy or Intentional Root Retention 373
M. Anthony Pogrel
Coronectomy is considered in patients older than 25, where there is an intimate relation-
ship between the roots of a retained lower third molar (occasionally second or first molars)
and the inferior alveolar nerve, in noncontraindicated circumstances. It may be used on
younger patients with a medium to high risk of inferior alveolar nerve damage. The deci-
sion to use this technique is made with the aid of cone-beam computed tomography
scans. Short- to medium-term success rate is excellent, but long-term studies are not
yet available. The technique is gaining wider acceptance, although there are differences
in the indications and actual technique used within and between countries.
vi Contents
Current Concepts of Periapical Surgery 383
Stuart E. Lieblich
Preoperative decision-making is vital to determine potential success of periapical
surgery. Adequate exposure of the root apical region is best approached via a
sulcular-type incision. Surgical procedures include resection of 2 to 3 mm of the apical
portion along with root end preparation and seal. The surgeon must decide if submission
of periapical tissues to pathology is indicated.
Best Practices for Management of Pain, Swelling, Nausea, and Vomiting in

Dentoalveolar Surgery 393
Stephanie J. Drew
Pain, swelling, nausea, and vomiting associated with outpatient oral and maxillofacial
surgical procedures are common occurrences in daily practice. The need to minimize
these often unavoidable consequences of surgical intervention is of utmost importance
in delivering a good experience for our patient population, thus improving outcomes of
our surgery as well as anesthesia. A review of current therapies available to manage these
experiences is presented to enable the practitioner to develop multimodal protocols and
custom tailor treatment based on procedure and patient risk factors for these unfortunate
consequences of surgery.
Developing and Implementing a Culture of Safety in the Dentoalveolar

Surgical Practice 405
James R. Hupp
The health care industry and delivery systems are placing greater emphasis on making
their organizations safe. They do this by cultivating a culture of safety to help anticipate
and prevent injuries and documenting and investigating injuries to develop prevention
protocols. Many of the strategies used in the hospital industry can be applied to the
dentoalveolar surgery practice of oral-maxillofacial surgeons and other dentists. This
article discusses the development of a culture of safety in the dentoalveolar practice
and gives ideas of how threats of injuries to patients, guests, and the surgical care
team can be reduced or eliminated.
Trigeminal Nerve Injuries: Avoidance and Management of Iatrogenic Injury 411
Sami A. Nizam II and Vincent B. Ziccardi

Iatrogenic injury to the trigeminal nerve can remain a source of concern and litigation even
for the most experienced oral and maxillofacial surgeons. This article provides the most
up-to-date evidence-based recommendations for identification, prevention, and man-
agement of these injuries to help clinicians provide the highest level of patient care.
Soft Tissue Grafting Around Teeth and Implants 425
George R. Deeb and Janina Golob Deeb

The presence of healthy attached tissue at the tooth and implant soft tissue interface
correlates with long-term success and stability in function and esthetics. There are
several soft tissue grafting procedures that increase the volume and quality of soft tissue
and provide coverage on both teeth and implants. Many of these techniques can be used
in conjunction with implant placement, or after placement as a means of salvage. This
article describes the techniques for augmentation of keratinized and soft tissue around
Contents vii
teeth and implants. These tools should be in the armamentarium of oral and maxillofacial
surgeons providing implant services.
Surgical Treatment of Impacted Canines: What the Orthodontist Would Like the
Surgeon to Know 449
Adrian Becker and Stella Chaushu

Videos of two very high impacted canines using cone beam computed tomography
accompany this article. One is located high on the palatal side of the incisor root
apices and the second in the line of the arch, high above the premolar with
interference from abnormal premolar roots
When an impacted permanent maxillary canine has been diagnosed, the referring general
practitioner or pediatric dentist thinks in terms of surgery and orthodontics, usually in that
order. If there is an existing malocclusion that also requires to be resolved, the orthodon-
tist must undertake a full orthodontic appraisal to plan the overall treatment including a
decision on whether to extract or align the impacted tooth. The orthodontist is ultimately
responsible to the patient for the success of the treatment plan.
Preprosthetic Surgery 459
Hillel Ephros, Robert Klein, and Anthony Sallustio

Preprosthetic oral and maxillofacial surgery has changed dramatically over the last 3
decades. Surgical preparation for dentures has been displaced by site development
for implants. Nonetheless, there is still a role to play for several preprosthetic procedures.
In this article, historical context is provided, enduring concepts are reviewed, and proce-
dures that remain relevant are described and discussed.
Index 473
viii Dentoalveolar Surgery
ORAL AND MAXILLOFACIAL SURGERY

CLINICS OF NORTH AMERICA
FORTHCOMING ISSUES RECENT ISSUES
November 2015 May 2015
Management of Medication-related Dental Implants: An Evolving Discipline
Osteonecrosis of the Jaw Alex M. Greenberg, Editor
Salvatore L. Ruggiero, Editor
February 2015
February 2016 Contemporary Management of
Pediatric Oral and Maxillofacial Pathology Temporomandibular Joint Disorders
Antonia Kolokythas and Michael Miloro, Editors Daniel E. Perez and Larry M. Wolford, Editors
May 2016 November 2014
Management of the Cleft Patient Orthognathic Surgery
Kevin S. Smith, Editor Daniel B. Spagnoli, Brian B. Farrell, and
Myron R. Tucker, Editors
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P re f a c e
A c h i e v i n g an d M a i n t a i n i n g
E x c e l l e n c e in D e n t o a l v e o l a r
Surgery
Michael A. Kleiman, DMD

Editor
Oral and maxillofacial surgery (OMS) is a specialty scopes. They are trying to become expert in areas
that has significantly expanded in scope far that were once solely the province of the specialty
beyond the limits of the oral cavity. However, den- of Oral and Maxillofacial Surgery.
toalveolar surgery is where it began as a specialty To keep dentoalveolar surgery within the inter-
and where it began for many individuals as practi- section of our specialty’s “three circles,” we as
tioners. As a general topic, dentoalveolar surgery practitioners must be sure to continue to be the
is not the most glamorous or impressive of the “best in the world” at what we do. The “mission”
things we do. In fact, it may not even be listed by of this issue of Oral and Maxillofacial Surgery
some of our surgical residents when they are Clinics of North America is to help us as oral and
asked to explain what the specialty of OMS is. maxillofacial surgeons achieve and maintain that
Despite that, it is the thing that most oral and goal. We as oral and maxillofacial surgeons can-
maxillofacial surgeons do the most of and what not take our ability in dentoalveolar surgery for
many, if not most of us, have a passion for. granted. It must be approached in the same way
Jim Collins, in his book Good to Great, teaches as all of the other “sexy” things that we do!
that an organization should determine where to At the outset, I tried not to cross the line into
direct its energy by examining the intersection of other topics that may be covered in other issues
three circles. They are: of Oral and Maxillofacial Surgery Clinics of North
America. However, it soon became clear that this
1. What you have a passion for is not possible or appropriate. One cannot talk
2. What drives your economic engine about extraction techniques, hard and soft tissue
3. What you can be the best in the world at grafting, or preprosthetic surgery without also
considering the world of dental implants. Nor can
Clearly, for the specialty of Oral and Maxillofa- one expose an impacted canine with a high level
oralmaxsurgery.theclinics.com
cial Surgery, the area of dentoalveolar surgery falls of “excellence” without appreciating what the
solidly within the intersection of these three circles. orthodontist’s perspective is in the treatment of
As basic as it is in some respects, dentoalveolar the patient. As an overall umbrella, we must oper-
surgery has evolved and changed significantly. ate within a “Culture of Safety,” to protect our
The advent of modern dental implants and readily patients, coworkers, and ourselves.
available 3-dimensional imaging techniques have I greatly appreciate the tremendous contri-
altered our objectives and changed the ways butions of each and every one of our authors. I
that we sometimes measure “excellence.” In addi- am sure that any oral and maxillofacial surgeon
tion, we have seen other specialties expand their looking at the table of contents will be struck
Oral Maxillofacial Surg Clin N Am 27 (2015) ix–x

http://dx.doi.org/10.1016/j.coms.2015.05.001
1042-3699/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
x Preface
by the collection of experts and leaders in their she said, “You have to do this!” She was right,
fields who have worked hard to contribute to and I guess I did!
this effort. I am grateful to Dr. Richard Haug for
asking me to edit this issue and recognizing the Michael A. Kleiman, DMD
importance of the topic. I would also like to Oral and Maxillofacial Surgery
recognize the excellence of the publishing staff Edison-Clark Oral Surgery Associates
at Elsevier. 1857 Oak Tree Road
Last, I must recognize and thank my wife, Edison, NJ 08820, USA
Frayda, for convincing me to take on this project.
I initially told Rich Haug that I didn’t think I would E-mail address:
have the time to take on this additional work, but [email protected]
M e d i c a l M a n a g e m e n t of
Pa tie nts Undergo ing
Dentoalveolar Su r g er y
Shelly Abramowicz, DMD, MPH*, Steven M. Roser, DMD, MD
KEYWORDS
Medical management Dentoalveolar surgery Anticoagulation
Medication-related osteonecrosis
KEY POINTS
Presurgical evaluation should include risk stratification for prevention of potential problems.
There are new guidelines regarding management of patients taking oral anticoagulants.
There is a recent update regarding management of patients with medication-related osteonecrosis
of the jaw (MRONJ).
INTRODUCTION anesthesia. The patient’s risk of having a compli-

cation is then stratified according to the Surgical
The oral and maxillofacial surgeon (OMS) should Classification System (Table 2).
have an understanding of common medical co-
morbidities. This understanding allows for risk
stratification and thus prevention of potential prob- CARDIOVASCULAR
lems. Remaining current with updated literature
regarding diseases, diagnosis, treatment strate- When meeting a patient, the OMS should begin
gies, and pharmacology ultimately improves pa- with a cardiac-focused physical examination.
tient care. This article provides an update on This examination consists of obtaining blood
some of the most common medical diseases for pressure in both arms, assessing for carotid/
the patient undergoing dentoalveolar surgery. jugular pulsations/bruits/murmurs, examining the
abdomen for distension and hepatosplenomegaly,
PRESURGICAL EVALUATION and assessing the extremities for peripheral
edema. One or more of these findings may alert
Preoperative evaluation begins with a complete the surgeon that decompensated cardiac disease
history and physical examination. First, the patient is present. Next, the surgeon should consider clin-
completes a screening questionnaire, which in- ical predictors of increased perioperative cardio-
cludes medical and surgical histories, allergies, vascular risk. The American Heart Association
and a list of current medications. The patient is and American College of Cardiology determined
then classified according to the American Society that a patient who has specific cardiac clinical
of Anesthesiologists (ASA) Physical Status Classi- risks should be further evaluated by a cardiologist
fication System (Table 1). The ASA classification for additional cardiac risk stratification (Table 3).
system provides an overall impression of a surgi- Next, the OMS should evaluate the patient’s func-
cal patient who is to undergo a procedure under tional status using activities of daily living and
Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University, School of Medicine, 1365
Clifton Road, Northeast, Building B, Suite 2300, Atlanta, GA, USA
* Corresponding author. Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University,
School of Medicine, 1365 Clifton Road, Northeast, Building B, Suite 2300, Atlanta, GA 30306.
E-mail address: [email protected]
Oral Maxillofacial Surg Clin N Am 27 (2015) 345–352

1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
346 Abramowicz & Roser
Table 1
American Society of Anesthesiologists patient classification
ASA Preoperative Health

PS Status Comments and Examples
1 Normal healthy patient No organic, physiologic, or psychiatric disturbance; healthy with
good exercise tolerance
2 Mild systemic disease No functional limitations; has a well-controlled disease of 1 body
system
Examples: controlled hypertension without systemic effects,
cigarette smoking without COPD, mild obesity, pregnancy
3 Severe systemic disease Some functional limitation; has a controlled disease of more than 1
body system or 1 major system with no immediate danger of
death
Examples: controlled CHF, stable angina, poorly controlled
hypertension, morbid obesity, chronic renal failure
4 Severe systemic disease Has at least 1 severe disease that is poorly controlled or at end
that is a constant threat stage; possible risk of death
to life Examples: unstable angina, symptomatic COPD, symptomatic CHF,
hepatorenal failure
5 Moribund, not expected Not expected to survive more than 24 h without surgery; imminent
to survive without the risk of death
operation Examples: multiorgan failure, sepsis syndrome with hemodynamic
instability, poorly controlled coagulopathy
6 Declared brain dead, —
organ donor
Note: if a surgical procedure is performed emergently, ‘‘E’’ is added to the previously defined ASA classification.
Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.
Adapted from ASA Physical Status Classification System. American Society of Anesthesiologists. Available at: https://
www.asahq.org/resources/clinical-information/asa-physical-status-classification-system; with permission.
Table 2
metabolic equivalents (METs). One MET is the ox-
Surgical classification system ygen consumption of a 70-kg, 40-year-old at rest.
A patient who is able to perform activities of
Category 1 Minimal risk to patients greater than 4 METs without symptoms is consid-
independent of anesthesia ered to have a good functional capacity (Table 4).1
Minimally invasive procedures Finally, the Goldman criteria relies on multivariate
with little or no blood loss analysis and assigns points to certain physical
Operation done in an office characteristics, helping to assess a patient’s car-
setting diac risk (Table 5). The points are then tallied
Category 2 Minimal to moderately and correlated with the cardiac risk.2 Patients
invasive procedures range from having 0 points and thus a 0.9% risk
Blood loss<500 mL of serious cardiac event or death to greater than
Mild risk to patients
26 points and a 63.6% risk of serious cardiac
independent of anesthesia
event or death.2
Category 3 Moderately to significantly
invasive procedure
Blood loss 500–1000 mL Hypertension
Moderate risk to patients
independent of anesthesia Hypertension is defined as blood pressure higher
Category 4 Highly invasive procedure than 140/90 mm Hg measured on 2 different oc-
Blood loss>1500 mL casions over a 1- to 2-week span. The Joint Na-
Major risk to patients tional Committee on Prevention, Detection,
independent of anesthesia Evaluation, and Treatment of High Blood Pressure
From Fattahi T. Perioperative laboratory and diagnostic
(JNC) classified patients according to blood pres-
testing–what is needed and when? Oral Maxillofac Surg sure (Table 6).3 Accordingly, when a patient’s
Clin North Am 2006;18(1):3, v; with permission. systolic blood pressure is greater than 140 or
stated specific targeted systolic and diastolic

Table 3
Clinical predictors of increased perioperative blood pressures and drugs based on gender,
cardiovascular risk race, cardiac history, and other ongoing medical
comorbidities.4 Perioperatively, patients who
Major Unstable coronary syndromes have severe hypertension (>210/110 mm Hg)
Acute or recent MI have an exaggerated hypotensive response to
Unstable or severe angina anesthesia and labile responses. Therefore, elec-
Decompensated heart failure tive office surgery should be deferred if systolic
Significant dysrhythmias blood pressure is greater than 180 and diastolic
High-grade atrioventricular
blood pressure is greater than 110 when other
block
Symptomatic ventricular
systemic comorbidities are present and if systolic
dysrhythmias blood pressure is greater than 210 and diastolic
Supraventricular dysrhythmias blood pressure is greater than 120 if no other co-
with uncontrolled ventricular morbidities are present.3
rate
Severe valvular disease Pacemaker/Defibrillator
Intermediate Mild angina pectoris Symptomatic bradycardia is treated with an
Previous MI based on history or
implantable pacemaker.5 A demand pacemaker
Q waves on ECG
Compensated or previous heart discharges with missed beat or when heart rate
failure is below a predetermined bradycardia threshold.
Diabetes mellitus A pacemaker can be single or dual chamber or
Renal insufficiency biventricular where each ventricle is wired sepa-
Minor Advanced age (>70 y) rately.6 Recurrent ventricular tachycardia or
Abnormal result of ECG ventricular fibrillation is treated with an implant-
Rhythm other than sinus able cardioverter-defibrillator (ICD). ICD is pro-
Low functional capacity grammed to treat different dysrhythmias by
History of stroke defibrillating, cardioverting, or pacing. ICD pro-
Uncontrolled systemic vides a shock within 15 seconds of sensing a
hypertension dysrhythmia.7 When a patient has ICD and elec-
Abbreviations: ECG, electrocardiogram; MI, myocardial trocautery will be used during an operation, the
infarction. surgeon must communicate preoperatively with
Data from Fleischer LA, Beckman JA, Brown LA, et al. cardiology so that it is suspended intraopera-
American College of Cardiology/American Heart Associa- tively and reprogrammed postoperatively. Alter-
tion (ACC/AHA) 2007 Guidelines on perioperative cardio-
vascular evaluation and care for noncardiac surgery: a natively, a magnet can be placed externally
report of the American College of Cardiology/American over the pacemaker to convert it to asynchro-
Heart Association Task Force on Practice Guidelines. Circu- nous mode.8
lation 2007;116:418–99.
Coronary Artery Disease
diastolic blood pressure is greater than 90, phar- Coronary artery disease (CAD) or atherosclerotic
macologic treatment should be initiated.4 disease is defined as chronic inflammation of
Recently, the JNC released updates that arterial endothelium by low-density lipoprotein,
described no change in classification, but rather and lipid macrophage accumulation causes
Table 4
METs based on activities of daily living
Excellent (>7 METs) Moderate (4–7 METs) Poor (<4 METs)

Recreational sports (swimming, Cycling Vacuuming
tennis, etc)
Jogging (10-min mile) Walking 4 mph Walking 2 mph
Household work (lifting Light household work Personal care (dressing,
furniture) (dusting, dishes) eating, bathing)
Data from Fleischer LA, Beckman JA, Brown LA, et al. American College of Cardiology/American Heart Association (ACC/
AHA) 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the Amer-
ican College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2007;116:418–99.
Table 5
Goldman criteria for cardiac index
Criteria Points
History
Age>70 y 5
Myocardial infarction<6 mo 10
Physical examination
S3 gallop 11
Jugular venous distention 11
Aortic valve stenosis 3
Electrocardiogram
Rhythm other than sinus or premature atrial contraction 7
>5 premature ventricular contractions per minute 7
General status
PO2<60 or PCO2>50 3
K levels<3 mEq/L or HCO3 levels<20 mEq/L 3
SUN>50 or creatinine>3 mg/dL 3
Abnormal AST or chronic liver disease 3
Bedridden 3
Operation
Intraperitoneal, intrathoracic, aortic 3
Emergency 4
Abbreviations: AST, aspartate aminotransferase; SUN, serum urea nitrogen.
From Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures.
N Engl J Med 1977;297:26.
atheromas and calcification of tunica medica, CAD are male gender, increasing age, dyslipide-
which leads to a narrowed artery with acute to mia, hypertension, diabetes, obesity, sedentary
chronic endothelial inflammation with an lifestyle, and family history.9 Treatment consists
atheroma rupture or vasospasm. Risk factors for of lifestyle modifications, pharmacologic therapy,
and coronary revascularization.
Table 6 Atrial fibrillation occurs when there is no
JNC classification coordinated electrical atrial conduction. The
atrioventricular node sporadically reacts with no
Category SBP DBP cardiac contraction, which reduces ventricular
filling and cardiac output and places the patient
Normal <120 >80
at an increased risk for thromboembolic events.
Prehypertension 120–139 80–89
New atrial fibrillation is treated by electrical or
Stage I 140–159 90–99 pharmacologic cardioversion to obtain rate con-
Stage II 160–180 100–110 trol. Patients are often placed on long-term anti-
Urgent/ >180 >110 coagulants such as Coumadin. The goal of
emergent With signs/ Examples: rales, Coumadin therapy is to maintain a balance
symptoms papilledema, between preventing clots and causing excessive
of end- headache, bleeding. However, Coumadin has many drug
organ chest pain interactions and a narrow therapeutic window
damage
and requires frequent monitoring. International
Abbreviations: DBP, diastolic blood pressure; SBP, systolic normalized ratio (INR) provides information to
blood pressure. prescribing physicians to ensure that Coumadin
Adapted from James PA, Oparil S, Carter BL, et al. 2014 is producing the desired effect; it helps to ensure
Evidence-based guideline for the management of high
blood pressure in adults: report from the panel members
that the person’s clotting time is at a therapeutic
appointed to the Eighth Joint National Committee (JNC level without causing excessive bleeding or
8). JAMA 2013;311(5):507–20. bruising.
ANTICOAGULATION dabigatran (Pradaxa), with renal insufficiency and

creatinine clearance between 30 and 50 mL/min,
Newer oral anticoagulants were developed as al- should discontinue the medication 2 to 4 days
ternatives to warfarin in the treatment of arterial before the procedure.15 Because of the rapid
and venous thromboembolism and in stroke pre- onset of action of these newer anticoagulant med-
vention in patients with nonvalvular atrial fibrilla- ications, bridging is reserved for patients with a
tion. These anticoagulants include dabigatran high risk for thromboembolism and the inability
(Pradaxa), a direct thrombin inhibitor, as well as ri- to take oral medications for 2 or 3 days
varoxaban (Xarelto) and apixaban (Eliquis), factor postprocedure.
Xa inhibitors. These drugs do not require
monitoring, and therefore patient compliance is
essential. However, in emergency situations
ENDOCARDITIS PROPHYLAXIS
such as life-threatening bleeding or nonelective Valvular heart disease is a significant risk factor
major surgery, they cannot be reversed because for perioperative complications. Valves can have
there are no antidotes currently available. Phase stenosis or regurgitation. Mitral and aortic valve
1 and 2 research studies are ongoing.10 For dabi- disorders are more common.16 Conditions which
gatran, a specific antidote has been tested in a rat require prophylaxis for endocarditis to include
model of anticoagulation and a study in healthy prosthetic heart valves, history of infective endo-
male volunteers has been recently reported. For carditis, unrepaired cyanotic congenital heart dis-
rivaroxaban, prothrombin complex concentrates ease, and repaired congenital heart defect with
(PCCs) have been found to completely reverse prosthetic material or device during the first
the prolongation of the prothrombin time induced 6 months following the procedure.17 The antibi-
by this new oral anticoagulant. For apixaban, re- otic regimen remains the same and is given in
combinant factor VII was found in an experimental Table 7.
study using human blood to be superior to acti-
vated PCC and PCC. MEDICATION-RELATED OSTEONECROSIS OF
The decision to discontinue anticoagulants THE JAW
should be based on the risk of surgical bleeding
and discussion with the treating physician. For a Management of patients with or at risk for MRONJ
simple procedure such as a single tooth extrac- was discussed in the American Association of Oral
tion, there is typically no need to change these and Maxillofacial Surgeons (AAOMS) position pa-
medications.11 Local hemostatic measures suffice pers in 200718 and 2009.19 Since then, the knowl-
to control possible bleeding problems resulting edge base and experience in addressing MRONJ
from minor dental treatment. If multiple extractions has expanded, necessitating modifications and re-
are scheduled, after consultation with the pre- finements to the previous guidelines.20 A patient is
scribing physician, ideally, a patient should stop considered to have MRONJ if all of the following
taking this medication 5 to 7 days before the criteria are met: current or previous treatment
scheduled procedure. If use of anticoagulants with antiresorptive or antiangiogenic agents,
cannot be stopped because of the risk of thrombo- exposed bone or bone that can be probed through
embolism, the patient’s INR should be carefully an intraoral or extraoral fistula in the maxillofacial
monitored during the week before operation and region that has persisted for longer than 8 weeks,
obtained on the morning of the procedure. The and no history of radiation therapy to the jaws or
desired range is 2 to 3, which often corresponds obvious metastatic disease to the jaws.20 This
with the therapeutic range. There is no need to dis- new term was adopted to accommodate the
continue aspirin.12 During surgical procedures growing number of osteonecrosis cases involving
involving high bleeding risk (multiple extractions, the maxilla and mandible associated with antire-
operations lasting>45 minutes, head and neck sorptive and antiangiogenic therapies. There are
cancer surgery), the recommendation is to sus- multiple hypotheses concerning the potential
pend the medication 2 to 3 days before the opera- mechanisms leading to MRONJ, including altered
tion and consider bridging or switching to bone remodeling, oversuppression of bone
subcutaneous heparin or Lovenox.13 Medication resorption, angiogenesis inhibition, constant mi-
should be reintroduced after 24 hours, provided crotrauma, suppression of innate or acquired im-
good hemostasis has been achieved.14 The cur- munity, vitamin D deficiency, soft tissue toxicity,
rent idea for patients taking rivaroxaban (Xarelto), inflammation, and/or infection.20 Intravenous
and apixaban (Eliquis) is to discontinue these med- administration of medication increases the risk
ications, in the case of high surgical bleeding risk, for MRONJ. The prevalence of osteonecrosis of
2 to 3 days before the procedure. Patients taking the jaw increases over time. The risk of MRONJ
Table 7
Antibiotic prophylaxis for prevention of endocarditis
Medication Adults Children

Oral Amoxicillin 2g 50 mg/kg
Allergic to penicillin Clindamycin 600 mg 20 mg/kg
Azithromycin 500 mg 15 mg/kg
Unable to take oral medicines Ampicillin 2 g IM or IV 50 mg/kg IM or IV
Allergic to penicillin Ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
Abbreviations: IM, intramuscularly; IV, intravenously.

Adapted from Wilson W, Taubert KA, Gewtiz M, et al. Prevention of infective endocarditis: guidelines from the Amer-
ican Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Dis-
ease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.
Circulation 2007;116:1736–54.
in patients exposed to oral bisphosphonates (BPs) endodontic or periodontal procedures is un-

after tooth extraction is 0.5%.21 The risk of known.20 Therefore, according to the special com-
MRONJ in patients exposed to intravenous BPs mittee appointed by AAOMS, the risk of MRONJ
ranges from 1.6% to 14.8%.20 The risk of devel- after the above-mentioned procedures is compa-
oping MRONJ in patients who have been exposed rable to the risk associated with tooth extraction.20
to antiresorptive medications for dentoalveolar op- Staging and treatment strategies are given in
erations such as dental implant placement or Table 8.
Table 8
Staging and treatment strategies for patients with MRONJ
Stage Description Treatment Strategies

At risk No apparent necrotic bone in a patient who No treatment
was treated with oral or intravenous BP Patient education
Stage 0 No clinical evidence of necrotic bone but Systemic management (pain medication,
nonspecific clinical findings, radiographic antibiotics)
changes, and/or symptoms
Stage 1 Exposed and necrotic bone or fistulas that Antibacterial mouth rinse, clinical follow-up
probe to bone in patients who are on quarterly basis, patient education,
asymptomatic and have no evidence of review of indications for continued BP
infection therapy
Stage 2 Exposed and necrotic bone or fistulas that Symptomatic treatment with oral antibiotics,
probe to bone associated with infection as antibacterial mouth rinse, pain control,
evidenced by pain and erythema in the debridement to relieve soft tissue
region of exposed bone with or without irritation, and infection control
purulent drainage
Stage 3 Exposed and necrotic bone or a fistula that Antibacterial mouth rinse, oral antibiotics,
probe to bone in patients with pain, pain control, debridement or resection for
infection, and 1 or more of the following: longer-term palliation of infection and
Exposed and necrotic bone extending pain
beyond the region of alveolar bone re-
sulting in pathologic fracture
Extraoral fistula
Oroantral or oronasal communication
Osteolysis extending to inferior border of
mandible or sinus floor
Adapted from Ruggiero SL, Dodson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons position
paper on medication-related osteonecrosis of the jaw-2014 update. J Oral Maxillofac Surg 2014;72(10):1938–56; with
permission.
SUMMARY American Heart Association Task Force on Practice

Guidelines). Circulation 2007;116:418–99.
Patients who undergo oral and maxillofacial sur- 2. Goldman L, Caldera DL, Nussbaum SR, et al. Multi-
gery are often relatively healthy, and complications factorial index of cardiac risk in noncardiac surgical
related to medical conditions are not common. procedures. N Engl J Med 1977;297:26.
However, medical conditions may be present in 3. Matei V, Sami Haddadin A. Systemic and pulmonary
any patient and may lead to increased morbidity arterial hypertension. In: Hines RL, Marschall KE,
and mortality unless these conditions are uncov- editors. Stoelting’s anesthesia and co-existing dis-
ered in those without such a history and recog- ease. 6th edition. Philadelphia: Elsevier Saunders;
nized in those with a history of disease. A 2012. p. 104–19.
thorough medical and social history will elicit med- 4. James PA, Oparil S, Carter BL, et al. 2014 Evidence-
ical comorbidities when known. A thorough phys- based guideline for the management of high blood
ical examination will often confirm the presence of pressure in adults: report from the panel members
systemic disease or identify it in those without a appointed to the Eighth Joint National Committee
prior history. (JNC 8). JAMA 2013;311(5):507–20.
Obtaining a thorough history and physical ex- 5. Yew KL. Electrocution induced symptomatic brady-
amination requires a systematic approach to a cardia necessitating pacemaker implantation. Heart
patient interview, consisting of: chief complaint, Views 2014;15:49–50.
history of the chief complaint; a medical history 6. Barol SS, Delnoy PP, Kucher A. Interventricular
with review of all systems, allergies, and medica- pacemaker-mediated tachycardia during biventricu-
tions, a social history, a family history, surgical lar pacing. Pacing Clin Electrophysiol 2014. [Epub
history, and assessment of functional status. The ahead of print].
sensitivity of a thorough history to identify a previ- 7. Joshi GP. Perioperative management of outpatients
ously unrecognized medical condition should not with implantable cardioverter defibrillators. Curr
be underestimated. The physical examination Opin Anaesthesiol 2009;22:701–4.
should also be standardized to include all relevant 8. American society of anesthesiologist task force on
systems. The history and physical examination will perioperative management of patients with cardiac
then enable the surgeon to request additional in- rhythm management devices. Practice advisory for
vestigations and medical referrals that allow risk the perioperative management of patients with car-
stratification. diac implantable electronic devices: pacemakers
The risk assessment for each patient undergo- and implantable cardioverter-defibrillators. An up-
ing surgery requires an understanding of the surgi- dated report by the American Society of Anesthesi-
cal stress and the patient’s medical condition. ologists Task Force on Perioperative Management of
Major oral and maxillofacial surgery is considered Patients with Cardiac Implantable Electronic De-
to be intermediate in surgical operative risk. Oral vices. Anesthesiology 2005;103:186–98.
and maxillofacial procedures performed in an 9. Akshar S. Ischemic heart disease. In: Hines RL,
ambulatory setting would be considered low risk. Marschall KE, editors. Stoelting’s anesthesia and
Preoperative patient assessment is best co-existing disease. 6th edition. Philadelphia:
completed by the surgeon who has a vested Elsevier Saunders; 2012. p. 1–30.
interest in the patient’s well-being. When medical 10. Lévy S. Newer clinically available antithrombotics
conditions and comorbidities are recognized pre- and their antidotes. J Interv Card Electrophysiol
operatively, appropriate workup or referral is easily 2014;40:269–75.
organized. The involvement of other medical and 11. van Diermen DE, Aartman IH, Baart JA, et al. Dental
surgical subspecialties should be readily sought management of patients using antithrombotic drugs:
when indicated. The ultimate goal of the preoper- critical appraisal of existing guidelines. Oral Surg Oral
ative evaluation is to identify medical concerns Med Oral Pathol Oral Radiol Endod 2009;107:616–24.
and provide the perioperative treatment algo- 12. Servin FS. Is it time to re-evaluate the routines about
rithms that minimize patient morbidity. stopping/keeping platelet inhibitors in conjunction to
ambulatory surgery? Curr Opin Anaesthesiol 2010;
23:691–6.
REFERENCES 13. Mingarro-de-Leon A, Chaveli-Lopez B, Gavalda-
Esteve C. Dental management of patients receiving
1. Fleischer LA, Beckman JA, Brown LA, et al. American anticoagulant and/or antiplatelet treatment. J Clin
College of Cardiology/American Heart Association Exp Dent 2014;6:e155–61.
(ACC/AHA) 2007 Guidelines on perioperative cardio- 14. Spyropoulos AC, Douketis JD. How I treat anticoa-
vascular evaluation and care for noncardiac surgery: gulated patients undergoing an elective procedure
a report of the American College of Cardiology/ or surgery. Blood 2012;120:2954–62.
15. Hankey GJ, Eikelboon JW. Dabigatran etexilate: Osteonecrosis of the Jaws. Advisory Task Force on
a new oral thrombin inhibiter. Circulation 2011; Bisphosphonate-Related Osteonecrosis of the
123:1436. Jaws, American Association of Oral and Maxillofacial
16. Herrera A. Valvular hear disease. In: Hines RL, Surgeons. J Oral Maxillofac Surg 2007;65:369–76.
Marschall KE, editors. Stoelting’s anesthesia and 19. Ruggiero SL, Dodson TB, Assael LA, et al. American
co-existing diseases. 6th edition. Philadelphia: Association of Oral and Maxillofacial Surgeons posi-
Elsevier Saunders; 2012. p. 31–47. tion paper on bisphosphonate-related osteonecrosis
17. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/ of the jaws—2009 Update. J Oral Maxillofac Surg
AHA 2008 Guideline Update on Valvular Heart Dis- 2009;67(5 Suppl):2–12.
ease: focused Update on Infective Endocarditis: a 20. Ruggiero SL, Dodson TB, Fantasia J, et al. American
Report of the American College of Cardiology/Amer- Association of Oral and Maxillofacial Surgeons posi-
ican Heart Association Task Force on Practice tion paper on medication-related osteonecrosis of
Guidelines Endorsed by the Society of Cardiovascu- the jaw-2014 update. J Oral Maxillofac Surg 2014;
lar Anesthesiologists, Society for Cardiovascular 72:1938–56.
Angiography and Interventions, and Society of 21. Kunchur R, Need A, Hughes T, et al. Clinical investi-
Thoracic Surgeons. J Am Coll Cardiol 2008;52: gation of C-terminal cross-linking telopeptide test in
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18. American Association of Oral and Maxillofacial Sur- associated osteonecrosis of the jaws. J Oral Maxillo-
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Denta l Extract ion s and
P re s e r v a t i o n of Sp a c e f o r
Implant Placement in Molar
Sites
Michael S. Block, DMD
KEYWORDS
Dental implants Extraction sites Mandibular molars
KEY POINTS
The algorithm for implant placement, either immediately after tooth removal or delayed, works well
with excellent long-term crestal bone width maintenance.
Clinicians can use tissue health as 1 factor to form their treatment strategy for the timing of implant
placement into molar sites.
Bone resorption is common after tooth extraction; the use of graft material may be necessary to
provide ideal bone for implant placement and reconstruction of the patient with an esthetic and
functional restoration.
INTRODUCTION implant placement and reconstruction of the pa-

tient with an esthetic and functional restoration.
The clinician is often asked to remove a tooth and Bone resorption usually is greater in the horizon-
place an implant into the site. The implant must tal plane than in the vertical plane.3,4 Horizontal
be placed with appropriate stability to allow for inte- bone loss may be enhanced by thin facial cortical
gration to occur, which requires bone presence. bone over the roots or bone loss from extension of
Bone is also necessary to allow for ideal implant local infection, such as caries or periodontal dis-
positioning within the alveolus for functional and ease. Ideal placement of a dental implant centers
esthetic concerns. The purpose of this article is to the implant over the crest in a line connecting the
discuss the changes in socket dimensions over fossae of the adjacent posterior teeth, or for ante-
time and how to promote space maintenance, rior teeth, palatal to the emergence profile of the
with an algorithm for treatment based on evidence. planned restoration. Unless the horizontal bone
dimension is reconstructed or preserved after
SOCKET HEALING tooth extraction, implant placement is compro-
mised, and in the esthetic zone, flattening of the
Socket healing approximates 40 days, beginning ridge will occur, which results in a compromised
with clot formation and culminating in a bone- restoration appearance. In the posterior mandible,
filled socket with a connective and epithelial tissue these changes may be less dramatic, presumably
covering.1,2 An extraction site may heal with bone because of the thickness of the buccal bone. The
formation to preserve the original dimensions of thin bundle bone, which was/is adjacent to the
the bone. Unfortunately, bone resorption is com- tooth roots, lies within the corpus of thick buccal
mon after tooth extraction. The use of graft mate- cortical bone, and thus its remodeling may not
rial may be necessary to provide ideal bone for result in rapid loss of ridge width.
Private Practice, 110 Veterans Memorial Boulevard, #112, Metairie, LA 70005, USA
Oral Maxillofacial Surg Clin N Am - (2015) -–-

2 Block
With regard to the esthetic zone of the maxilla, 1. The tooth is nonrestorable but has intact sur-
which includes the premolars, canines, and inci- rounding bone and relatively healthy gingiva,
sors, patients often present with teeth in need of with minimal pain (Fig. 1).
extraction. Reasons for extraction of a single- 2. The tooth is nonrestorable and has intact sur-
rooted maxillary tooth in an adult include internal rounding bone. However, the tooth is acutely
or external resorption after trauma, a breakdown painful and may have purulent exudate and
of post and cores that were placed because of nonhealthy gingiva.
trauma, caries, root canal failure, and periodontal 3. The tooth is nonrestorable but has lost a portion
disease. Traditional protocols for restoring these of the buccal bone (Fig. 2).
sites rely on bone deposition to fill the extraction
site before the implant is placed.5,6 Hard and soft Preoperative imaging can determine the pres-
tissue grafting often is necessary to provide an ence of the surrounding bone, the presence of in-
ideal functional and esthetic restoration. Grafts terceptal bone, and the location of the inferior
compensate for the bone resorption that accom- alveolar nerve canal in relation to the tooth. Suffi-
panies the natural healing process in an extraction cient space is necessary for placement of an
socket.7–10 When implants are placed 8–16 weeks implant of sufficient length to maintain a single
after tooth extraction, the clinician must compen- molar implant tooth.
sate for the loss of labial bone that occurs during The molar tooth has roots that diverge and are
the early phase of extraction site healing.3,11,12 separated by an isthmus of bone. The thickness
To prevent the need for hard or soft tissue grafting of the bone between the roots may not be sufficient
when implant placement is delayed, it is recom- by itself for immediate implant placement. The
mended to place an osteoconductive graft mate- labial and lingual cortical bone plates narrow in
rial within the extraction site to promote bone fill, the apical regions and can be engaged to stabilize
to limit labial bone collapse, and to maintain an implant in the molar site. The bone surrounding
bone for optimal implant placement.13 the molar tooth may be completely intact, or
chronic infection may have caused large areas of
TREATMENT PLANNING bone loss, which if not grafted, result in inadequate
bone available for implant placement. If the treat-
When a patient presents with a molar tooth in need ment plan includes placement of an implant into
of removal, 3 situations are common: a posterior tooth site, cone-beam cross-sections
Fig. 1. (A) This patient required removal of a lower right first molar. The tooth was in cross bite. (B) A sulcular
incision was made with vertical release sparing the papilla and a flap developed. The tooth was removed. (C)
The implant was placed on the lingual aspect of the extraction site to correct the cross bite. The initial drill
was placed without regard to interceptal bone, since the implant position needed to be different than the tooth’s
position due to the cross bite tendency. Allograft was placed into the defects from the root sockets. (D) A post-
operative radiograph shows good implant positioning.
Dental Extractions and Preservation of Space 3
Fig. 2. (A) This patient’s mandibular first molar requires extraction. The patient had been using antibiotics and
chlorhexidine rinses preoperatively to reduce the bacterial flora around this tooth as much as possible. (B) An
incision is made around the labial surface of the tooth and linked with 2 vertical extensions. The vertical releasing
incisions are made within the site of the first molar, with care taken to avoid raising the attached tissues on the
adjacent teeth. A full-thickness exposure is performed, exposing the lateral aspect of the tooth and the extensive
bone loss. (C) The tooth is removed along with a small amount of granulation tissue. The area is irrigated thor-
oughly. Note the intact lingual plate of bone and the loss of the labial plate to the root apices. This defect has
intact mesial and distal walls, as well as the lingual plate; therefore, this can be characterized as a 3-wall defect.
(D) A graft of human mineralized bone is placed into the defect to reconstruct both the height and the width of
the socket. After compaction of the graft material, the area is closed primarily. Primary closure was achieved with
advancement of the keratinized gingiva, previously on the labial aspect of the tooth, and was sutured to the
lingual aspect of the ridge. Chromic sutures are used in the vertical releasing incisions. To advance the flap,
the periosteum was scored to provide mobilization of the flap, allowing tension-free closure. (E) 4 months later,
the ridge has healed and is ready for implant placement. (F) This is the final crown 2 years after implant place-
ment showing an excellent tissue response. (G) The 2 year radiograph showing excellent bone healing around the
implant.
4 Block
can be used to determine the amount of bone pathology associated with the tooth, the preferred
available or determine that there has been signifi- treatment is to graft the socket and place the
cant bone loss that prevents primary stability of implant 4 months after grafting.
the implant at time of tooth removal.14 The tech-
nique described next has proved useful for grafting Loss of Less Than 3 mm of Facial Bone at the
of the posterior molar site. Crest
After reviewing the image from a cone beam This is a common situation when a tooth has exten-
scanner, and the physical examination of the pa- sive caries or a fracture. Crestal resorption may be
tient, a decision can be made for treatment. limited to 3 mm from the planned gingival margin or
the cemento-enamel junction (cej) of the adjacent
ANATOMIC CONFIGURATIONS AFTER TOOTH tooth. In this situation, the implant can be placed
EXTRACTION at the level of the bone. This places the implant
After a tooth has been extracted, the resultant 3 mm from the gingival margin, which is the
defect in the bone may have several anatomic preferred location. There is usually no need to graft
configurations that directly influence implant the buccal bone in this situation unless it is very thin.
placement. This section discusses 10 findings
Lack of Bone Inferior to the Apex of the
that may be seen after tooth extraction. Each
Socket, with Extreme Proximity of Adjacent
finding may be isolated or may be among several
Vital Structures, Such as the Inferior Alveolar
morphologic observations (Box 1).
Canal or Mental Foramen
Loss of All Facial Bone to the Apex of the These extraction sites may need grafting prior to
Tooth implant placement to ensure implant stability is
If the bone on the facial aspect of the socket is not achieved only.
present, the clinician should graft the socket and
Lack of Lingual Bone
delay implant placement. Primary implant stability
at the time of placement is compromised by the This is an uncommon finding, because lingual
loss of bone. A mobile implant at the time of place- bone is the last to resorb after tooth loss. If the
ment does not reliably integrate. These sites need lingual bone is not present, a graft is necessary
to be reconstructed with bone before implant before placement of an implant.
placement.
Concavity Within the Extraction Site When
Loss of a Portion (3–6 mm) of the Facial Bone Removing an Ankylosed Deciduous Molar
In this situation, a graft is necessary to restore the This finding is seen in younger individuals and is
facial portion of the missing bone. If the surgeon is associated with congenitally missing teeth and
unsure of the result in these cases and 50% of the retention of the deciduous teeth. The buccal
facial bone has been lost as a result of the bone may be normal in shape, with a concavity
Box 1
Anatomic configurations after tooth extraction
1. Loss of all labial bone to the apex of the tooth

2. Loss of a portion (3–6 mm) of the labial bone
3. Loss of <3 mm of labial bone at the crest
4. Lack of bone superior to the apex of the socket, with extreme proximity of adjacent vital structures
(eg, inferior alveolar canal, mental foramen, floor of the nose, floor of the sinus)
5. Lack of palatal or lingual bone
6. Concavity along the palatal or labial contours of the extraction site
7. Socket that is larger than the proposed diameter of the implant in all dimensions
8. Socket that is oval in shape, with the long dimension palatal to facial and the short dimension
mesial to distal
9. Very thin surrounding bone
10. Bone adjacent to the neighboring tooth (or teeth) absent and root surface of adjacent tooth
exposed
within the confines of the buccal and lingual TREATMENT INDICATIONS IN 3 COMMON
cortical bone. These patients may have vertical SITUATIONS
deficiency and may need shorter implants with The Tooth is Nonrestorable but has Intact
attention to avoid the inferior alveolar nerve. Surrounding Bone and Relatively Healthy
Gingiva, with Minimal Pain
A Socket That is Larger Than the Proposed
The tooth can be removed and an implant immedi-
Diameter of the Implant in all Dimensions
ately placed. The indications for placement of an
When an implant is placed into an extraction site, implant into a tooth site at the time of extraction
the normal drill sequence is used to prepare the include the following
implant site. Bone is removed until the implant
can be placed and stabilized. When the diameter 1. Absence of purulent drainage
of the root of the tooth is larger than the implant 2. Healthy gingiva without gingival hyperplasia or
in all dimensions, stabilizing the implant is most erythema
difficult unless bone is present beyond the apex 3. Lack of active apical infection
of the socket or the cortical walls converge in the 4. Adequate bone present to allow ideal implant
apical regions. In these cases, grafting of the large placement and stability
extraction socket provides the surgeon with an Reports indicate a high incidence of success in
ideal site for placement of an implant after the graft integration and function with implants placed
has healed with bone formation in the socket. immediately into extraction sites as long as the
site has no purulent exudate, a healthy collar of
Socket That is Oval in Shape, With the Long gingival tissue is present around the tooth, and
Dimension Palatal to Facial and the Short minimal lucency is seen at the apex of the tooth
Dimension Mesial to Distal to be extracted.15 The placement of implants into
The oval, or figure-eight–shaped, socket typically the extraction site immediately after tooth removal
is found in canine or premolar sites, or within molar has been anecdotally recommended to eliminate
root sockets. The implant site is prepared in the an additional surgical procedure, prevent labial
ideal location to place the axis of emergence in bone loss, and preserve the labial root form of
the fossa or under the working cusp. After the the esthetic site.16–23 Exposure of the implant
implant has been placed, the gap between the into the oral cavity does not seem to result in a
implant and labial cortex can be grafted to prevent decrease in crestal bone levels.
epithelial migration. The choice to graft or not to
graft depends on the clinician; this author grafts Surgical procedure
the spaces in an attempt to promote bone forma- After a conservative elevation of the gingiva to
tion and avoid epithelia migration. visualize the junction of bone to the tooth, the
tooth is elevated gently and removed with minimal
Very Thin Surrounding Bone lateral subluxation. Every effort should be made to
preserve the lateral cortical bone. As necessary,
After extraction of the tooth, the remaining facial
the tooth can be sectioned to facilitate bone pres-
bone may be exceptionally thin even when careful
ervation. Another option is to create a trough
methods were used to preserve bone. In this situ-
around the roots using the periotome insert for
ation, as long as the implant can be placed and
the Piezosurgery unit. The roots are easily
secured in the surrounding bone, the implant can
removed after the Piezosurgery unit has been
be placed, and the space between the implant
used. If present, granulation tissue is curetted.
and thin facial bone is grafted. If insufficient bone
The site is irrigated gently with sterile saline, and
is present to stabilize the implants, a graft is indi-
the flap is tested to ensure passive rotation to
cated, and a delayed placement is planned. The
the lingual tissues only to cover the root sockets
thicker the labial plate, the greater the chance to
on the mesial and distal aspect of the implant after
maintain labial thickness.
implant placement.
A small round bur or bur of choice is used to
Bone Adjacent to the Neighboring Tooth (or
locate a definitive hole in the bone exactly in the
Teeth) Absent, and Root Surface of Adjacent
middle of the extraction site. This results in ideal
Tooth Exposed
restorative management. Placement of the implant
In this situation, the socket can be grafted, with the asymmetrically in the extraction site leads to
understanding that the final crestal bone level in restorative problems. The sequencing drills are
the interdental area will be apical to the ideal used to prepare the implant site as recommended
position. for the specific implant used. This author finds that
6 Block
implants 5.0 mm or less in diameter may be diffi- advancement of the papilla and fixed gingiva on
cult to achieve primary stability. Implants 5.4 to the adjacent teeth. The incision is made in the sul-
6 mm in diameter are found to engage the cortical cus to within 2 mm of the interdental papilla. Verti-
bone approximately 5 mm subcrestal and allow for cal release incisions are made for full-thickness
excellent primary stability. Larger diameter im- flap elevation to expose the lateral aspect of the
plants may result in buccal bone thinning. alveolus and advance the flap to cover the site after
The implant is placed taking into consideration graft material has been placed. When resorption of
the level of the buccal and lingual bone and to the labial or facial cortical bone has been exten-
avoid excessive countersinking. A healing abut- sive, elevation of the flap is performed with sharp
ment is placed. Allograft is usually used to graft dissection, with care taken to prevent perforation
the defects where the tooth roots had been. The of the labial gingiva. After the flap has been raised,
gingiva is closed mesially and distally, leaving the the periosteum is scored and relieved to allow pas-
healing abutment exposed. A large diameter heal- sive advancement of the flap for primary closure.
ing abutment is recommended to allow for ease of Particulate graft material is placed into a small
abutment placement during the restorative phase dish and dampened with sterile saline. A 1 mL
after 4 months is allowed for integration. plastic syringe can be used to deliver the graft.
The tip of the syringe is removed with a scalpel
The Tooth is Nonrestorable and has Intact and Rongeur forceps. The particulate graft is
Surrounding Bone; however, the Tooth is packed into the syringe and then placed into the
Acutely Painful and May Have Purulent extraction site. The graft material is compacted
Exudate and Non-healthy Gingiva with a blunt instrument, and gauze is used to re-
move excess fluids. After the socket and bone de-
At the time of tooth extraction, the clinician may
fects have been restored to original form by the
find purulent discharge, active periapical pathol-
graft, the flap is advanced over the site.
ogy, unhealthy gingiva with gingivitis and active
A 4-0 chromic resorbable suture is used by the
periodontal disease in the mouth, a patient history
author to approximate the edge of the labial KG
of poor wound healing (eg, uncontrolled diabetes,
across the socket to the lingual gingiva. After the
chronic steroid use, immune compromise, alco-
sutures have been placed, the vertical incisions
holism, drug dependence), or a lack of bone to sta-
are closed. Using this design, the labial KG is
bilize an implant. In these cases, the tooth should
banked toward the lingual aspect of the ridge. It
be extracted and the implant placed after the
will be transposed to the labial surface of the abut-
infection and other local problems have resolved.
ment when the implant is placed. Occasionally,
In these situations, the implant can be easily
advancing the gingiva across the broad base of a
placed 4 to 8 weeks after tooth removal into a
maxillary molar is difficult. In this situation, a
noninfected and nonpainful site.
collagen material is placed over the palatal root
The surgical procedure is identical to the proce-
site, and the buccal sockets are primarily closed
dure described for immediate implant placement.
with the KG, with sutures holding the collagen ma-
terial in position similar to anterior sites (Box 2).
The Tooth is Nonrestorable but has Lost a
Portion of the Buccal Bone
If there is loss of buccal bone, it is recommended GRAFTING MATERIAL
to graft the site and proceed with implant place- The clinician should consider several points when
ment after the bone has consolidated, typically 4 choosing materials to graft the extraction socket:
to 6 months after grafting. When the defect and
socket are grafted with particulate material, the 1. Space should be maintained with a material
bone volume created and preserved depends on that promotes bone incorporation and does
the density and retention of the graft within the not inhibit or adversely alter the normal
socket. In contrast to single-rooted or premolar sequence of extraction site healing.
sites, which can be treated with a collagen plug 2. The bone formed should be dense enough to
over the socket, leaving the molar site open may allow stable placement of the implant. The ma-
result in loss of a portion of the graft. Therefore, terial placed should have osteoconductive fea-
primary closure is performed to retain the graft in tures to enhance bone formation.
molar sites. The incision design is critical for 3. The material should resorb within a selected
achieving primary closure of the site after place- period of time with replacement by bone that
ment of the graft. is normal to the site.
The incision design allows advancement of 4. The resorption rate of the material over time
the labial keratinized gingiva (KG) without should be taken into consideration to plan the
Box 2
Algorithm for implant placement after tooth removal
1. Buccal and lingual bone is intact. No purulent exudate; gingiva is healthy—remove tooth and imme-
diately place implant if sufficient bone is available to stabilize the implant.
2. Buccal and lingual bone is intact. There is purulent exudate or the gingiva is not healthy—remove
tooth and wait 4–6 weeks for resolution of the infection and then place the implant.
3. Buccal bone or intramedullary bone is not intact—remove tooth and place a graft. Close primarily.
After 4 months place an implant.
sequencing of therapies such as implant place- a specific indication. The freeze-dried mineralized
ment, additional contour grafting, and pontic bone allograft usually is irradiated to sterilize it
and site development. even though the entire process for harvesting to
5. The material should be relatively inexpensive, packaging is performed under strict sterile condi-
readily available, and should not transfer path- tions. Comparative reports and clinical results
ologic conditions. involving different methods of processing mineral-
ized bone are limited. The choice of allograft
BOVINE OR EQUINE SINTERED XENOGRAFT should be based on the ease of delivery, cost, con-
sistency in the appearance of the graft material,
Bovine or equine derived bone is a xenograft. It is a and quality of the bone bank.
carbonate-containing apatite with crystalline ar- When placed in an extraction site, mineralized
chitecture and a calcium/phosphate ratio similar bone graft material is still present at 4 months.30
to that of natural human bone.24 With time, the sin- However, the bone forming around the mineralized
tered xenograft becomes integrated with bone. It bone particles usually is sufficiently mineralized to
may be slowly replaced by newly formed bone, allow immediate provisionalization, with adequate
but because the sintering process increases the primary stability after placement of the implant in
crystallinity of the bone particles, it may not clini- the extraction site grafted with a mineralized
cally appear to significantly resorb and will often allograft.
be present years after placement.24–27 When sin- One goal of grafting of the extraction site is
tered xenograft material is used to graft an extrac- retention and preservation of the original ridge
tion site, 6 to –9 months may need to be allowed form and maintenance of the crestal bone after
before placement of the implant. The relatively the implants have been restored. In 1 study in
inert nature of this material delays revasculariza- which no membrane was used at the time of
tion and subsequent bone formation compared extraction site grafting, the grafted sites felt
with more natural materials such as autogenous bone hard at 4 months and appeared to be filled
bone.28,29 with bone.10 The average mesial crestal bone
level was 0.66 plus or minus 0.67 mm (range,
MINERALIZED BONE ALLOGRAFT 0 to 1.27 mm) at implant placement and 0.51
Human mineralized bone in particulate form can plus or minus 0.41 mm (range, 0– 1.91 mm) at
result in short-term preservation of an extraction final restoration. The average distal crestal bone
site’s bone bulk and volume in preparation for level was 0.48 plus or minus 0.68 mm (range,
the placement of implants. The advantages of an 0.64– 1.91 mm) at implant placement and 0.48
allograft are (1) the graft material is readily avail- plus or minus 0.53 mm (range, 0–1.27 mm) at final
able without the need for a second surgical harvest restoration. A measurement of 1.27 mm from the
site, and (2) the material is osteoconductive. Over top of the shoulder of the implants correlated to
time, the allograft resorbs, and, it is hoped, re- the level of the first thread of the implant.30
placed with bone. Bone heights were maintained with mineralized
Human mineralized bone is available as particu- bone graft material.
late cortical or cancellous bone. The recommen-
ded particle size ranges from is 250 mm to AUTOGENOUS BONE
1.0 mm. Allografts are prepared by bone banks.
Sterile procedures are used to harvest the bone, Clinicians believe that the ideal bone replacement
which is washed with a series of delipidizing graft material has always been autogenous
agents such as ethers and alcohol, lyophilized, bone.31–34 Few clinicians use a separate harvest
and then sieved to the particle size necessary for site to obtain autogenous bone to graft extraction
8 Block
sites. The past use of bone harvested from the can be scraped from adjacent sites, collected in
symphysis, ramus, or maxillary tuberosity is not a a sieve after the bone has been shaved with a
common, current procedure. Bone removed dur- bur and collected with Rongeur forceps from adja-
ing alveoloplasty can be used as a graft. Bone cent sites or the alveolar ridge.35
Fig. 3. (A) This patient had the first molar removed and the site grafted secondary to a large abscess form a frac-
tured tooth. He recently fractured the lingual cusp to the level of the alveolar bone and is planned for tooth
removal and immediate implant placement. (B) The tooth was removed and the implant placed in the middle
of the socket, through the interceptal bone. The radiofrequency index was 82, indicating excellent primary sta-
bility. (C) Allograft was placed into the sockets. (D) The healing abutment was placed, and the mesial and distal
gingiva were gently approximated to the lingual. (E) This is the immediate postplacement cross section radio-
graph. (F) 5-year follow-up cross section of the grafted first molar site, showing excellent maintenance of the
crestal width. (G) 5-year follow-up cross section of the immediate placement second M site, showing excellent
maintenance of the crestal width, compared with Fig. 3E.
POSTOPERATIVE CARE From this preliminary set of data, there appears

to be excellent maintenance of crestal width at the
The patient is given antibiotics and pain medica- implant shoulder region, regardless of the timing of
tion. Antibacterial rinses are not used after graft implant placement.
placement because of toxicity to fibroblasts and
other cells involved with epithelialization. The pa-
tient is given instructions for a soft diet to avoid SUMMARY
trauma from chewing textured food on the surgical The algorithm for implant placement, immediately
site. after tooth removal or delayed, works well, with
The sutures are removed 7 to 10 days after graft excellent long-term crestal bone width mainte-
placement. A cone beam collimated 6 cm scan is nance. Clinicians can use tissue health as 1 factor
taken 3 months after graft placement for evalua- to form their treatment strategy for the timing of
tion of the bone height for implant placement. Im- implant placement into molar sites.
plants are usually placed 4 months after graft
placement.
REFERENCES
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OF BONE histochemical investigation of human alveolar
The following are preliminary data form an Institu- socket healing in undisturbed extraction wounds.
J Am Dent Assoc 1960;61:32–44.
tional Review Board (IRB)-approved retrospective
evaluation with 4- to 5-year follow-up on crestal 2. Amler MH. The time sequence of tissue regeneration
width changes after tooth removal and implant in human extraction wounds. Oral Surg Oral Med
Oral Pathol 1969;27:309–18.
placement (Block and Scogin, unpublished data,
2014). Three groups were evaluated with 4- to 5- 3. Lekovic V, Kenney EB, Weinlaender M, et al. A bone
year follow-up cone beam scans after implant regenerative approach to alveolar ridge mainte-
nance following tooth extraction: report of 10 cases.
placement and restoration. Patients with mandib-
ular molars to be removed with implant placement J Periodontol 1997;68:563–70.
were included. Three groups were measured. One 4. Lekovic V, Camargo PM, Klokkevold PR, et al. Pres-
group had the tooth removed and an implant ervation of alveolar bone in extraction sockets using
bioabsorbable membranes. J Periodontol 1998;69:
immediately placed. A second group had the
molar tooth removed and the implant placement 1044–9.
4 to 10 weeks after tooth removal. The third group 5. Nir-Hadar O, Palmer M, Soskolne WA. Delayed imme-
diate implants: alveolar bone changes during the
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removal. 6. Palmer RM, Smith BJ, Palmer PJ, et al.
A prospective study of astra single tooth implants.
The width of the crestal bone from facial to
lingual was measured. Intraexaminer error on mul- Clin Oral Implants Res 1997;8:173–9.
tiple measures was determined to be 0.3 mm. The 7. Block MS. Hard and soft tissue grafting for esthetic
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inferior to the crest was measured prior to tooth implants: the art and science. Philadelphia: Saun-
removal, at the time of implant placement, and at ders; 2000. p. 217–28.
long-term follow-up (Fig. 3). 8. Block MS, Salinas TS, Finger IM, et al. Incidence of
The results showed hard and soft tissue grafts in esthetic maxillary
implant restorations. J Oral Maxillofac Surg 2000;
1. No changes in width measurements 5 and 58(8 suppl 1):77.
10 mm inferior to the crest for any time period 9. Gher ME, Quintero G, Assad D, et al. Bone grafting
for any group. and guided bone regeneration for immediate dental
2. The width of the ridge at the crest decreased implants in humans. J Periodontol 1994;65:881–91.
from 1 to 1.5 mm over the 4- to 5-year period 10. Tritten CB, Bragger U, Fourmousis I, et al. Guided
of time. bone regeneration around an immediate transmu-
3. These changed were statistically significant cosal implant for single tooth replacement: a case
compared with pre-extraction and implant report. Pract Periodontics Aesthet Dent 1995;7:29–38.
placement time periods. 11. Gruber H, Solar P, Ulm C. Maxillomandibular anat-
4. There were not significant width changes in the omy and patterns of resorption during atrophy. In:
early time periods from extraction to the Watzek G, editor. Endosseous implants: scientific
implant placement time period, only the long- and clinical aspects. Chicago: Quintessence;
term time period. 1996. p. 29–60.
10 Block
12. Lang N, Becker W, Karring T. Alveolar bone forma- root form implant: a clinical report. J Oral Implantol
tion. In: Lindhe J, editor. Textbook of clinical peri- 1998;24:159–66.
odontology and implant dentistry. 3rd edition. 24. Berglundh T, Lindhe J. Healing around implants
Copenhagen (Denmark): Munksgard; 1998. placed in bone defects treated with Bio-Oss: an
13. Block MS. Soft tissue esthetic procedures for teeth experimental study in the dog. Clin Oral Implants
and implants. In: Block MS, Sclar T, editors. Atlas Res 1997;8:117–24.
of the oral and maxillofacial surgery clinics. Philadel- 25. Artzi Z, Tal H, Dayan D. Porous bovine bone mineral
phia: Saunders; 1999. p. 61–78. in healing of human extraction sockets. Part 1. Histo-
14. Nedir R, Bischof M, Szmukler-Moncler S, et al. Pre- morphometric evaluations at 9 months. J Periodontol
dicting osseointegration by means of implant 2000;71:1015–23.
primary stability. Clin Oral Implants Res 2004;15: 26. Wetzel AC, Stich H, Caffesse RG. Bone apposition
520–8. onto oral implants in the sinus area filled with
15. Arlin ML. Immediate placement of osseointegrated different grafting materials: a histologic study in
dental implants into extraction sockets: advantages beagle dogs. Clin Oral Implants Res 1995;6:155–63.
and case reports. Oral Health 1992;82(19–20):23– 27. van Steenberghe D, Callens A, Geers L, et al. The
4, 26. clinical use of deproteinized bovine bone mineral
16. Mazor Z, Peleg M, Redlich M. Immediate placement on bone regeneration in conjunction with immediate
of implants in extraction sites of maxillary impacted implant installation. Clin Oral Implants Res 2000;11:
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28. Block MS, Kent JN. A comparison of particulate and
17. Rosenquist B, Grenthe B. Immediate placement of
solid root forms of hydroxylapatite in dog extraction
implants into extraction sockets: implant survival.
sites. J Oral Maxillofac Surg 1986;44:89–93.
Int J Oral Maxillofac Implants 1996;11:205–9.
29. Block MS, Kent JN. Healing of mandibular ridge
18. Schwartz-Arad D, Chaushu G. Placement of im-
augmentations using hydroxylapatite with and
plants into fresh extraction sites: 4 to 7 years retro-
without autogenous bone in dogs. J Oral Maxillofac
spective evaluation of 95 immediate implants.
Surg 1985;43(1):3–7.
J Periodontol 1997;68:1110–6.
30. Block MS, Finger I, Lytle R. Human mineralized bone
19. Werbitt MJ, Goldberg PV. The immediate implant:
in extraction sites before implant placement: prelim-
bone reservation and bone regeneration. Int J Peri-
inary results. J Am Dent Assoc 2002;133:1631–8.
odontics Restorative Dent 1992;12:206–17.
31. Becker W, Urist M, Becker BE, et al. Clinical and his-
20. Grunder U, Polizzi G, Goené R, et al. A 3-year pro- tologic observations of sites implanted with intraoral
spective multicenter follow-up report on the immedi- autologous bone grafts or allografts: 15 human case
ate and delayed immediate placement of implants. reports. J Periodontol 1996;67:1025–33.
Int J Oral Maxillofac Implants 1999;14:210–6. 32. Robinson E. Osseous coagulum for bone induction.
21. Schwartz-Arad D, Grossman Y, Chaushu G. The J Periodontol 1969;40:503–10.
clinical effectiveness of implants placed immedi- 33. Schallhorn RG, Hiatt WH, Boyce W. Iliac trans-
ately into fresh extraction sites of molar teeth. plants in periodontal therapy. J Periodontol 1970;
J Periodontol 2000;71:839–44. 41:566–80.
22. Wohrle PS. Single-tooth replacement in the aesthetic 34. Froum SJ, Thaler R, Scopp IW, et al. Osseous auto-
zone with immediate provisionalization: fourteen grafts: I. Clinical responses to bone blend or hip
consecutive case reports. Pract Periodontics Aes- marrow grafts. J Periodontol 1975;46:515–21.
thet Dent 1998;10:1107–14. 35. Gunther KP, Scharf H-P, Pesch H-J, et al. Osteointe-
23. Gomes A, Lozada JL, Caplanis N, et al. Immediate gration of solvent preserved bone transplants in an
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M a n a g i n g I m p a c t e d T h i rd
Molars
Louis K. Rafetto, DMD
KEYWORDS
Third molars Asymptomatic Disease free Retention Management strategies
KEY POINTS
Clinicians can be reasonably certain about some, but not all, things related to the behavior of third
molars.
There is a tangible, measurable, but not totally predictable risk for future extraction among patients
with retained third molars that were asymptomatic and disease free at the time of baseline
examination.
Based on an analysis of relevant historical, clinical, and imaging information, findings can be orga-
nized based on the presence or absence of symptoms and disease, which helps simplify decision
making.
Oral and maxillofacial surgeons should educate their patients and the community about the benefits
and consequences (short and long term) of different third molar management strategies, including
active surveillance.
One of the most common decisions made by oral and imaging examination. As a result, recommen-
and maxillofacial surgeons is how best to dations can be made to the patient.
manage third molars. Most of these decisions This article reviews what is known about third
are straightforward owing to the presence of molar behavior and advocates an organized
symptoms and/or disease. Recently these deci- approach to the clinical problem. Such an
sions have come under increased scrutiny. approach begins with the collection of relevant
Commonly cited areas of concern include when clinically generated data followed by review of
surgical management is indicated (particularly in this information in light of what is known about
the case of asymptomatic teeth), the optimal the behavior of third molars. The last part of the
timing for treatment, the cost of treatment, and process is formulation of a management strategy
what should be done when a decision is made with implementation after an informed discussion.
to retain a third molar.
There are differences of opinion when it comes to OBSTACLES TO CONSENSUS
what constitutes best practice in the area of third
As is the case in many areas of clinical practice,
molar management. In an effort to develop co-
some clinicians may disagree with any proposed
nsensus on best-practice approaches to any clin-
management strategy.
ical dilemma, attention should be given to
evidence-based clinical practice and its role in the
DESIRES AND PERSPECTIVES OF PARTIES OF
decision-making process. This process is charac-

INTEREST
terized by merging the best available evidence
(ideally from practice-based research) with the Patients and families focus their attention on
results of a comprehensive and focused clinical risks, convenience, and limiting out-of-pocket
Department of Oral & Maxillofacial Surgery & Hospital Dentistry, Christiana Care Health System, 3512 Silverside
Road, Suite 12, Wilmington, DE 19810, USA

2 Rafetto
expenses and red tape. Clinicians value the American Association of Oral and
freedom to provide what they think is the best Maxillofacial Surgeons
treatment and to be fairly compensated. Third
The American Association of Oral and Maxillofa-
parties and government agencies focus on cost
cial Surgeons1 (AAOMS) “Parameters of Care
management and quality measures. Consumer
2012: Clinical Practice Guidelines for Oral and
groups and media outlets focus on risks of oper-
Maxillofacial Surgery (ParCare 2012)” lists more
ative treatment and the potential for overtreat-
than 20 specific indications for removal of cate-
ment. This lack of unanimity in part represents
gories of third molars along with goals for ther-
honest disagreement but also reflects the bias
apy. It recognizes the benefit of removal to
of self-interest (Fig. 1).
prevent disease and the role of the treating sur-
geon as the person best qualified to determine
Uncertain Terminology care for an individual patient. Therapeutic goals
“Asymptomatic” does not indicate the absence of listed include “prevention of pathology,” “preser-
disease, but merely the absence of symptoms. It is vation of periodontal health of adjacent teeth,”
well understood that disease precedes symptoms and “optimization of prosthetic rehabilitation.”
and that disease often progresses in the absence Along with specific indications are the following
of symptoms. Effective management strategies statements: “Given the following and the desire
should take into account the likelihood of the to achieve therapeutic goals, obtain positive out-
development of disease. comes, and avoid known risks and complica-
tions, a decision should be made before the
middle of the third decade to remove or continue
Misconceptions to observe third molars knowing that future
In the eyes of many clinicians, third molar decision treatment may be necessary based on the clinical
making consists of either tooth removal or reten- situation. There is a growing body of knowledge
tion. Management may also include partial suggesting that retention of third molars that
removal (coronectomy), retention with active clin- are erupted or partially erupted contribute to a hi-
ical and radiographic surveillance, surgical expo- gher incidence of periodontal disease. This per-
sure, tooth repositioning, transplantation, surgical sistent periodontal disease has both dental and
periodontics, and marsupialization of associated medical consequences for the host and there-
soft tissue disorder with observation and possible fore, may be an indication for prophylactic
secondary treatment. removal.”1
Unlike medicine, the dental profession in the The AAOMS also offers so-called anchor
United States is made up of about 80% general statements, best represented by the following:
practitioners, with most of the remaining 20% “Predicated on the best evidence-based data,
practicing in disciplines other than surgery. Most impacted teeth that demonstrate pathology, or
patients seeking consultation have been referred are at high risk of developing pathology, should
from other different dental professionals who be surgically managed. In the absence of pathol-
have nothing at stake other than the well-being ogy or significant risk of pathology, active clinical
of the patient. and radiographic surveillance is indicated.”
The American Dental Association

RELATED ORGANIZATIONAL POLICY
The American Dental Association offers state-
STATEMENTS
ments that are less detailed but support in prin-
Several professional organizations have developed ciple the guidelines contained in the AAOMS
policy statements on third molar management. ParCare document. Comments include that,
“Your dentist or specialist may also recommend
removal of teeth to prevent problems or for
others reasons, such as.” “In addition, the con-
dition of your mouth changes over time. Wisdom
teeth that are not removed should continue to be
monitored, because the potential for developing
problems later on still exists. As with many other
health conditions, as people age, they are at
greater risk for health problems and that
Fig. 1. Agenda bias and self-interest are obstacles to includes potential problems with their wisdom
arriving at the best care. teeth.”
Academy of Pediatric Dentistry development of disease. Further, their methodol-

ogy allows many patients with retained third
The Academy of Pediatric Dentistry advocates for
molars to have associated disease even if overtly
the removal of asymptomatic third molars if there
asymptomatic.6
is a likelihood of future disease. In addition,
“When a decision is made to retain impacted third
United States Military
molars, they should be monitored for change in
position and/or development of pathology, which The US Military supports removal of third molars
may necessitate later removal.”2 based on the findings/recommendation of the
treating surgeon. Appointees to the military acad-
Cochrane Systematic Review emies are required to have their third molars
removed before entrance in recognition of the
“General agreement exists that removal is appro-
benefits of prophylactic treatment.
priate in case of symptoms of pain or pathological
conditions. Controversial statements exist with re-
American Public Health Association
gard to the prophylactic removal of asymptomatic
or disease-free impacted third molars. This review In 2008, the American Public Health Association
found no evidence to support or refute routine pro- (APHA) issued a policy statement opposing the
phylactic removal of asymptomatic impacted wis- prophylactic removal of wisdom teeth.7 This policy
dom teeth in adults; no studies of adults met the was not based on an evidence-based analysis or
criteria for inclusion.”3 formulated with the benefit of input from experts
in wisdom tooth management. It was formulated
United Kingdom’s National Health Service by a long-time critic well known for his bias against
The UK National Health Service (NHS) restricts the removal of third molars. This policy treats all third
removal of third molars based on recommenda- molar extractions as unnecessary and extrapo-
tions issued by the National Institute of Clinical lates isolated cost and complication data to imply
Evidence (NICE) in an effort to restrain short-term great financial impact. It lacks consideration of
costs. “The routine practice of prophylactic active surveillance as well as the costs associated
removal of pathology-free impacted third molars with ignoring the long-term effects on local (and
should be discontinued in the NHS” and “Surgical possibly systemic) health and quality of life.
removal of impacted third molars should be limited Approaches like those of the APHA and NICE
to patients with evidence of pathology. Such emphasize the outcomes of third molar removal
pathology includes unrestorable caries, non- but overlook the costs and outcomes associated
treatable pulpal and/or periapical pathology, cellu- with retention, because that is where most of the
litis, abscess and osteomyelitis, internal/external available data are.
resorption of the tooth or adjacent teeth, fracture
of tooth, disease of follicle including cyst/tumour, THIRD MOLARS ARE DIFFERENT
tooth/teeth impeding surgery or reconstructive
Third molars are different from other teeth in
jaw surgery, and when a tooth is involved in or
important ways, highlighted by their greater fre-
within the field of tumour resection.”4
quency and severity of disease and because they
In a recent article, McArdle and Renton5
are typically nonfunctional. Important differences
reviewed the effects of the NICE guidelines and
are, to a large degree, secondary to their location
concluded that third molar removal is now as com-
as the most distal teeth in the dental arch, and
mon as it was before their institution. The investi-
they are the last to erupt into the oral cavity, leav-
gators state that the dynamics of removal have
ing less physiologic space for eruption and main-
altered with the changing mean age of patients,
tenance. The resulting poor-quality soft tissue
and that the reason for extraction is now pre-
support often leads to percolation of bacteria
dominantly caries, periodontal disease, and peri-
beneath the gingival tissues surrounding the third
coronitis rather than impaction.5
molar, contributing to subclinical inflammation
that often progresses to pericoronitis and infection
National Health Service of Finland
(Fig. 2). Periodontal pocketing is frequently found
The National Health Service of Finland has a policy around third molars, as well as dental caries, which
similar to the NICE guidelines, despite a highly re- are difficult to restore. In addition, the roots of
garded Finnish researcher having published data these teeth, particularly with increasing age, are
from a long-term retention study documenting more likely to approximate important anatomic
that most patients who retain their third molars structures such as the maxillary sinus, adjacent
eventually have 1 or more removed based on the teeth, and the neurovascular canal, as well as
4 Rafetto
Fig. 2. Despite #17 near occlusal

plane, it lacks physiologic space for
eruption and maintenance.
being positioned in places where associated infec- States, Canada, Finland, and the United Kingdom
tions may become more of an issue because of the presented and reviewed the latest research find-
position of the mylohyoid muscle and thin area of ings on third molar extraction, retention, patient
the lingual cortical plate, which can predispose surveillance, potential risks, and attendant costs.
to bacterial migration to adjacent facial spaces, Many other articles have been published since
leading to deep facial space infections. Removal these efforts and have helped to give better clarity
may therefore be the most cost-effective path to what is known and what needs further study.
and allow a healthier oral environment. As a result, there is general agreement on impor-
tant aspects of third molars and their behavior.
CLINICALLY RELEVANT SCIENCE

KNOWN ASSOCIATED DISEASE
Considerable evidence published over the last
There are well documented disorders associated
decade has moved clinicians closer to answering
with retained third molars. These include but are
important questions about third molars. As in all
not limited to:
matters of decision making, relevant evidence
should be fairly interpreted by those who are 1. Caries
expert, experienced, and active in the manage- 2. Pericoronitis
ment of patients with third molars, using an orga- 3. Root resorption
nized approach to evaluate the validity and 4. Periodontitis
clinical relevance of evidence (Fig. 3). 5. Infections (local and fascial space)
Highlights include a series of prospective, longi- 6. Cysts (Fig. 4)
tudinal studies conducted by investigators from a 7. Tumors
variety of disciplines at multiple sites known as 8. Mandible fractures
the Third Molar Clinical Trials. This effort resulted
in more than 125 articles and abstracts published
in peer-reviewed journals. Also important was the
2010 AAOMS Multidisciplinary Conference on
Third Molar Science.8 Experts from the United
Fig. 4. Second molar unable to erupt (contralateral

molar erupted) because of odontogenic cyst at un-
Fig. 3. Hierarchy of clinically relevant evidence. formed third molar site.
POTENTIAL ADVERSE OUTCOMES Note that clinicians who support retention as a

ASSOCIATED WITH THIRD MOLAR REMOVAL lower cost option fail to consider these lifetime
risks associated with third molar retention and
As with any form of treatment, complications may should factor in the current and future costs of
occur secondary to any management approach, active surveillance and risks of incurring the costs
including retention. Complications from third of treatment, which can range from the full scope
molar removal are generally minor and resolve of restorative options to extraction on either a
within a few days. Problems that may be associ- planned or unplanned basis.
ated with the removal of third molars include It is clear that, despite most patients eventually
inflammatory complications, such as infection or requiring removal of their third molars, some are
osteitis; hemorrhage; injury to adjacent anatomic able to maintain them for a lifetime (although
structures, teeth, or nerves; periodontal defects; some are nonfunctional). However, at this time, it
fractures of maxillary tuberosity or mandible; cannot be determined with confidence what the
persistent oral-antral communication; retained future will be for all patients with asymptomatic
roots; and the need for additional treatment to disease-free teeth. Accordingly, it comes down to
manage complications. The risks and implications the clinicians’ ability to use experience and exper-
of third molar retention are less well documented, tise to develop a sense of the likelihood of disease
but are equally important. developing and to communicate that in realistic
terms to the patient. In the case of a decision to
CONSEQUENCES OF THIRD MOLAR retain, a reasonable interval between follow-up
RETENTION for patients is every 2 years, and sooner if symp-
toms or obvious signs become evident (Fig. 5).
Recently the AAOMS established a committee of
experts to address an important clinical question: THINGS CONSIDERED CERTAIN ABOUT THIRD
among young adults who elect to retain their MOLAR BEHAVIOR AND MANAGEMENT
asymptomatic third molars, what is the risk of hav-
ing 1 or more third molars extracted in the future?9 1. Third molars are different from other teeth in
They conducted a systematic review of the litera- significant ways.
ture. During the initial search, 65 articles were 2. An absence of symptoms associated with
identified that reported on patients who required third molars does not equate to the absence
extraction of previously asymptomatic third mo- of disease.
lars. Seven articles met inclusion criteria for the 3. Retained wisdom teeth frequently and unpre-
final analysis. Studies included were prospective, dictably change position, eruption, and peri-
had sample sizes greater than or equal to 50 sub- odontal status.
jects with at least 1 asymptomatic third molar, and 4. The microbial biofilm associated with partially
at least 12 months of follow-up. The annual and erupted third molars and pericoronitis is
cumulative incidence rates of third removal were conducive to the development of periodontal
estimated. disease.
The mean incidence rate for the extraction of 5. Periodontal disease in the third molar area
previously asymptomatic third molars was 3.0% begins with their eruption.
per year with the cumulative incidence rates for 6. Pocketing around wisdom teeth is an impor-
removal ranging from 5% at 1 year to 64% at tant indicator of periodontal disease, espe-
18 years. The reasons for extraction were pre- cially when bleeding occurs on probing.
dominantly caries, periodontal disease, and other
inflammatory conditions. The group concluded
that the cumulative risk of third molar extraction
for young adults with asymptomatic third molars
is sufficiently high to warrant discussion when re-
viewing the risks and benefits of third molar reten-
tion as a management strategy.
In light of the findings discussed earlier, and
given that the absence of symptoms does not
equal the absence of disease, it is clear that pa-
tients who elect to retain their third molars should Fig. 5. Keratocyst identified on image of 34-year-old
be followed with active surveillance, including rec- patient with unexplained tingling in his lower lip.
ommendations for the frequency of regular follow- He returned to his dentist as a part of active surveil-
up visits. lance of his retained third molars.
6 Rafetto
7. Third molars with probing depths greater than

4 mm increase the risk for developing in-
creased pocketing anteriorly.
8. Extraction of a third molar reduces the risk for
periodontal disease in young adults.
9. There are identifiable risk factors for delayed
healing and for surgical complications associ-
ated with third molar surgery.
10. There are identifiable ways to improve post-
operative healing and recovery.
11. Most patients with retained, asymptomatic, Fig. 6. A 28-year-old patient who previously elected
disease-free wisdom teeth eventually require retention of asymptomatic third molars. Roots
surgical management. approach inferior alveolar nerve and clinical findings
12. When patients elect to retain their third include increased periodontal pockets at distal side
molars, the frequency of future disease is suf- of second molars. Removal is now more likely to be
associated with prolonged recovery, possible compli-
ficiently high that active surveillance is a supe-
cations, and increased cost associated with advanced
rior management strategy compared with
imaging to assess position of root tips in relation to
symptomatic (as needed) follow-up. nerve.
STATEMENTS LIKELY TO BE VALID BUT

REQUIRING MORE STUDY BEFORE BEING choosing to monitor them are committed to a
CONSIDERED CERTAIN lifetime of follow-up. The known variables of
active surveillance include the cost of regular
1. Although it is likely that most third molars will imaging and follow-up visits, the uncertainty
develop disease over time, clinicians are not regarding the future behavior of the teeth, the
certain how to identify those that can be risk for developing inflammatory dental dis-
maintained. ease, and a statistically significant increased
2. Active surveillance of retained wisdom teeth risk with age for operative or postoperative
may be more expensive than extraction in the complications if extraction or other treatment
long term. becomes unavoidable.
3. Some clinicians suggest that systemic dis- 5. Third molars that are completely erupted and
eases are linked to the oral inflammation asso- functional, symptom free, free of caries, in
ciated with third molars. Although this may be hygienic position with a healthy periodontium,
true, and although it does make biological and and without other associated pathologic condi-
clinical sense, current evidence for a cause- tions do not require extraction, but do require
and-effect link is suggestive rather than routine maintenance and periodic clinical and
definitive. radiographic surveillance.
6. An impacted tooth with completed root forma-
RECOMMENDATIONS SUPPORTED BY tion that is totally covered by bone in a patient
CLINICALLY RELEVANT EVIDENCE beyond the third decade that is not associated
with disease should be monitored for change in
1. Surgical management of third molars is appro- position and/or development of disease, which
priate when there is evidence of disease. may then indicate its removal.
2. Surgical intervention or removal of third molars
before the development of disease should be
considered in patients who have insufficient SIMPLIFIED APPROACH TO CLINICAL
physiologic space for eruption and maintenance DECISION MAKING
at a time when the postsurgical healing is optimal
and the risk of complications low (Fig. 6). Although the recommendations discussed earlier
3. To limit the known risks and complications provide guidelines in the best management of
associated with surgery, it is medically appro- patients with third molars, there is no formula
priate and surgically prudent to remove third that can be applied successfully to answer every
molars in patients with demonstrated disease clinical question about the best management of
before the middle of the third decade and wisdom teeth.
before complete root development. Where there is evidence of disease, manage-
4. Given that third molars have been shown to be ment is generally straightforward. When symp-
dynamic in their behavior and position, patients toms are present, it is important to identify the
source with subsequent management focused on

removal or control of the cause.
Uncertainty is more prominent in the case of pa-
tients who have asymptomatic disease-free third
molars. Common sense dictates that the optimum
strategy should be somewhere between removal
of all versus retention of all. Given that clinicians
cannot confidently predict what the future holds
for all patients with asymptomatic disease-free
teeth, they must rely on the clinician’s ability to Fig. 7. Patient who is S1/D1.
use experience and expertise in developing a sense
of the likelihood that disease will develop and
communicate this in realistic terms to the patient. addressing the presence of disease, with removal
A helpful way to take what is known about third of the offending third molar as the preferred treat-
molar behavior and apply it to the clinical setting ment strategy. In some cases, dental restoration,
has been advocated by Dodson.10 This strategy periodontal therapy, and/or enhanced hygiene
involves categorizing teeth based on the presence may be considered based on the patient’s ability
of symptoms (S1) or absence of symptoms (S ) to maintain adequate hygiene, the restorative sta-
as well as the presence of disease (D1) or tus of the tooth, its functional usefulness, and the
absence of disease (D ). desires of the patient. If damage has occurred sec-
This approach begins with a thorough medical ondary to the disease process, attention should
and dental history with attention paid to any symp- also be directed to repair any defect.
toms that may be associated with the wisdom
teeth. Often patients do not report overt symptoms, SYMPTOMS PRESENT/DISEASE FREE
whereas others may have vague complaints. The
clinician should ascertain whether they are related Patients in the S1/D group are seen less
to their third molars or whether they are from frequently than those in other groups. If symptoms
another source. In part, this is done through clinical are secondary to impending tooth eruption, the
and radiographic examinations. surgeon must decide whether it is likely to erupt
Physical examination should include eruption into a useful position. Other times the symptoms
status and position of the tooth in the jaws/oral cav- are not related to the third molars and may repre-
ity, functionality, and periodontal and caries status. sent myofascial disorders or odontogenic disease
Imaging allows determination of the presence or of nearby teeth (Fig. 8). Management is based on
absence of the tooth, presence or absence of dis- the likelihood of developing associated disease
ease, anatomy of the tooth and its root system, as and the functionality of the third molars, particu-
well as its relationship to important structures larly if the surgeon is unable to identify the source
such as the inferior alveolar nerve, adjacent second
molar, and maxillary sinus. In addition, imaging can
detect significant associated (and nonassociated)
disorders, such as cysts or tumors.
Teeth are then categorized into (1) symptomatic
and disease present (S1/D1), (2) symptomatic
and disease absent (S1/D ), (3) asymptomatic
and disease present (S /D1), and (4) asymptom-
atic and disease absent (S /D ). In general, the
largest category of patients presenting to oral
and maxillofacial surgery offices is S /D1 (about
half), followed by S /D (about a third), with the
smallest category being S1/D (less than 1%).
SYMPTOMS AND DISEASE PRESENT

Fig. 8. Patient from S1/D group. Symptoms are
Patients in the first group (S1/D1) generally pre- caused by an unresolved disorder from #18. Treatment
sent with pain, swelling, and/or trismus. Common options may include retreatment of #18 with removal
findings include acute pericoronitis, dental caries, of #17 (inadequate physiologic space/interference
bone loss, localized or fascial space infection, or with restoration of #18), or removal of #18 to allow
a combination (Fig. 7). Treatment should focus on possible eruption and repositioning of #17.
8 Rafetto
removal for orthodontic removal is justified (such

as when the tooth is preventing the eruption of
the second molar), and in the case of planned or-
thognathic surgery. Patients should also be
informed of the greater difficulty and increased
rate of complications with removal of wisdom
teeth as they age. When appropriate, patients
should be told that, if they retain their disease-
free wisdom teeth, it is possible that they will live
Fig. 9. S /D1 patient.
their entire lives without problems.
of symptoms. The patient and family should be SUMMARY

informed of the uncertainty of resolving symptoms
if they cannot be directly linked to the third molars. Based on extensive evidence, oral and maxillofa-
cial surgeons can be certain, or reasonably
SYMPTOM FREE/DISEASE PRESENT certain, about important aspects of the behavior
of wisdom teeth and the outcomes of different
Patients in the this group, S /D1, typically pre- management strategies.
sent with periodontitis, dental caries, or a cyst or A recent article documents a tangible, measur-
tumor associated with the tooth. Treatment fo- able, but not totally predictable risk for future
cuses on removal of disease and its cause, with extraction among patients with retained third mo-
options favoring removal. Other possible options lars that were asymptomatic and disease free at
include restoration, periodontal therapy, and the time of baseline examination. Although the
enhanced hygiene (Fig. 9). Here again, if damage annual risk is low, the cumulative lifetime risk is
has occurred secondary to the disease process, considerably higher, with most teeth requiring
attention should be directed to repair if possible. operative management over time. When patients
elect to retain a third molar, they should be advised
SYMPTOM FREE/DISEASE FREE about this risk of removal over time. Given the
increased complication rate when third molars
This group, the least straightforward and most are removed with increasing age, it may be more
controversial, consists of patients with no current prudent to extract them by the middle of the third
symptoms or disease (S /D ) (Fig. 10). In the decade.
absence of evidence to support routinely retaining In the pursuit of a model for best practice, this
or removing third molars in this group, the surgeon knowledge should be applied to the clinical setting
should review the likelihood of disease developing by surgeons who are expert, experienced, and
in the future, functionality, risks of removal, risks of active in providing care for patients with third mo-
retention, and protocol for active surveillance. lars. Where there is an absence of conclusive evi-
Removal should be favored when the third molar dence, the available evidence should be
is or is likely to be nonfunctional, when there is interpreted in a manner that is most likely to benefit
an overlying removable prosthesis, when the the patients, considering both short-term and
long-term consequences of removal and retention
strategies. An organized approach based on the
patient’s symptom and disease status is useful in
simplifying management recommendations.
ACKNOWLEDGMENTS
The author acknowledges Alexandra C. Rafetto
for her contributions to this article.
Fig. 10. A 16-year-old girl with unerupted and asymp- REFERENCES

tomatic third molars. Clinical examination is necessary
to help ascertain physiologic space for eruption and 1. American Association of Oral and Maxillofacial Sur-
maintenance. Informed discussion should include po- geons. Parameters of care: clinical practice guide-
tential consequences of surgical management as lines for oral and maxillofacial surgery (AAOMS
well as consequences of retention and the impact of ParCare 2012), dentoalveolar surgery version 5.0,
age on risks. DEN 1. J Oral Maxillofac Surg 2012.
2. American Academy on Pediatric Dentistry Council 7. Opposition to prophylactic removal of third molars
on Clinical Affairs. Guidelines on pediatric oral sur- (wisdom teeth). Policy date: 10/28/2008, policy num-
gery. Pediatr Dent 2014;30(7 Suppl):205–11. ber: 20085. 2008. Available at: apha.org.
3. Mettes TG, Nienhuijs ME, van der Sanden WJ, et al. 8. Dodson TB, Rafetto LK, Nelson WJ. Introduction.
Interventions for treating asymptomatic impacted Proceedings of the Third Molar Multidisciplinary
wisdom teeth in adolescents and adults. Cochrane Conference. Washington, DC, October 19, 2010.
Database Syst Rev 2005;(2):CD003879. J Oral Maxillofac Surg 2012;70(9):S2–3.
4. National Institute of Clinical Excellence (N.I.C.E.) on
the indications for the removal of third molars. 2000. 9. Bouloux GF, Busaidy KF, Beirne OR, et al. What is
Available at: nice.org.uk. the risk of future extraction of asymptomatic third
5. McArdle L, Renton T. The effects of NICE guidelines molars? A systematic review. J Oral Maxillofac
on the management of third molar teeth. Br Dent J Surg 2014. [Epub ahead of print].
2012;213:E8. 10. Dodson TB. The management of the asymptomatic,
6. Ventä I, Ylipaavalniemi P, Turtola L. Long-term eval- disease-free wisdom tooth: removal versus reten-
uation of estimates of need for third molar removal. tion. Atlas Oral Maxillofac Surg Clin North Am
J Oral Maxillofac Surg 2000;58:288. 2012;20:169–76.
C o ron e c t o m y
Partial Odontectomy or Intentional
Root Retention
M. Anthony Pogrel, DDS, MD, FRCS
KEYWORDS
Coronectomy Intentional root retention Partial odontectomy Third molars Wisdom teeth
Inferior alveolar nerve
KEY POINTS
Coronectomy protects the inferior alveolar nerve from damage when lower third molars need
removing.
Cone-beam computed tomography (CBCT) has become the standard of care in deciding whether
to offer coronectomy to a patient where there is a close relationship between the tooth and the
nerve.
There are reported variations in technique, but they do not seem to affect the results.
Root migration seems to be the most frequent complication.
My personal interest in coronectomy started when Dental Association approved a procedure code
I heard Brian O’Riordan (a London-based oral and (D7251) for coronectomy, effective January
maxillofacial surgeon) give his retirement talk to 2011. However, just because the American Dental
the annual meeting of the British Association of Association recognized the technique and gave it
Oral and Maxillofacial Surgeons in Buxton, En- a code number does not make it universally
gland in 1997. The title of his talk was “Uneasy accepted and even more does not ensure that
Lies the Head that Wears a Crown.”1 In this he dental insurance companies will reimburse for
presented a fascinating story of his 30-year love the technique, and even now several of them do
affair with coronectomies and showed much of not reimburse for this technique. Nevertheless,
the rationale and also his long-term results. I re- the technique does seem to be gaining wider
turned to California energized and determined to acceptance, although there are some differences
try this technique. At that time, it was not widely in the indications and actual technique used
practiced in the United States and nobody was within and between countries.
lecturing or publishing on the topic. As we began In this article I discuss these differences in the
to develop the technique and look at our early re- light of personal experience. The degree of accep-
sults (our first publication was in 2004),2 the tance of the technique in some ways can be judged
technique began to gain some popularity locally on the number of articles in peer-reviewed journals
and nationally, and although it still remains on the topic. From 1965 to 2004, there were only
controversial in the United States, it did assume seven articles on coronectomy in the English lan-
a degree of respectability when the American guage literature over a 38-year period,1,3–8 and all
Department of Oral and Maxillofacial Surgery, University of California San Francisco, Box 0440, Room C522,
521 Parnassus Avenue, San Francisco, CA 94143-0440, USA

2 Pogrel
of these were after 1988. Since then, the numbers 1. Low risk: This occurs when the panoral radio-
each year are as follows: graphic appearance turns out on the CBCT
scan to be superimposition only. There is sepa-
2004 3 ration of the nerve and the root with a covering
of bone in between (Fig. 1).
2005 3
2. Medium risk: This occurs when the nerve is
2006 2
directly adjacent to the roots of the tooth or is
2007 1 mildly grooving the root of the tooth (Fig. 2).
2008 1 3. High risk: This occurs when there is deep
2009 5 grooving of the tooth by the nerve or even
2010 5 perforation of the tooth root by the nerve with
2011 6 the roots growing around the nerve (Fig. 3).
2012 8 We prefer not to use numbers, or percentages,
2013 11 because patients often want to apply overall
2014 6 numbers to their own personal situation.
It is important to realize the differences in image
acquisition with fan-beam (medical grade) CT and
CBCT scanning. In principle, fan-beam or medical-
CONTROVERSIAL ISSUES CONCERNING grade CT uses slices that are now usually less than
CORONECTOMY 1 mm apart, to build up a composite image. In
contrast, CBCT scanning uses volumetric image
Most authorities agree that the technique is indi-
acquisition and visualization. Because of this, the
cated when there is high probability of damage
resolution of CBCT scanning cannot match that of
to the inferior alveolar nerve if the whole tooth is
fan-beam CT scanning and so it is not always
removed. Previously evaluations were made on
possible to visualize the exact relationship at some
Panorex radiographs using several criteria
including overlapping of the nerve shadow on the
roots of the teeth, narrowing of the nerve shadow,
or deviation of the nerve shadow.9–12
Although medical-grade (also called fan beam
or multislice) computed tomography (CT) scan-
ning has been available since the mid-1970s to
determine the relationship in three dimensions, it
was not widely used because it was relatively
expensive, the radiation dosage was compara-
tively high, the availability was limited, insurance
would not reimburse for it, and the software did
not allow easy visualization of the relationship
between the inferior alveolar nerve and the roots
of the third molar. The increasing availability of
cone-beam CT (CBCT) scanning from 2002 on-
ward eased these problems in that the radiation
dose is much lower than with fan-beam CT, the
cost is much lower (around $300 in the United
States), and the software makes easy visualiza-
tion of the relationship between the inferior alve-
olar nerve and the tooth in three dimensions.
CBCT scanning is now the preferred imaging
technique to determine in three dimensions what
appears to be a close relationship between the
inferior alveolar nerve and the third molar
roots.13–19
Classifications of the relationship of the nerve to Fig. 1. A coronal slice from a cone-beam CT scan
the tooth vary on CBCT, but in general there are showing the inferior alveolar nerve (arrow) as sepa-
three groups, based on the risk of permanent infe- rate from the root of the tooth. This represents a
rior alveolar nerve damage following removal of low risk of permanent nerve involvement following
the whole tooth. removal of the tooth.
Coronectomy 3
Fig. 3. A coronal slice of a cone-beam CT scan showing

the inferior alveolar nerve (arrow) passing between
the roots of the lower third molar. This represents a
high risk of permanent nerve involvement should
this tooth be removed in one piece.
Fig. 2. An axial slice of a cone-beam CT scan where the

inferior alveolar nerve (arrow) is directly adjacent to the instrument players). The patient’s age is important
root of the tooth and is lightly grooving it. There is no in treatment planning, in that conceptually coro-
indication of cortical bone separating the nerve from nectomy is believed to be more appropriate for
the tooth. This represents a medium risk of permanent older patients, who in general do not tolerate nerve
nerve involvement following removal of the tooth. damage as well as young patients. It was not
precise points. The images shown in Fig. 4 are of a initially designed for teenagers (the commonest
case where the nerve actually passed through a group having third molars removed in the United
hole in the roots, and although a CBCT scan was States) for the following reasons:
taken preoperatively, the resolution did not allow 1. It is often important to remove the tooth
direct visualization of the root perforation. Therefore, completely in teenagers in conjunction with or-
this tooth was subsequently removed complete and thodontic treatment.
the perforation was seen clinically. If this had been 2. Teenagers are less likely to get nerve involve-
accurately visualized preoperatively, it is likely that ment because the nerve is more resilient.
a coronectomy would have been performed. 3. If they do get nerve involvement, it is more likely
to recover and less likely to result in permanent
INDICATIONS FOR CORONECTOMY dysesthesia.
4. Even if it does turn out to be permanent in a
The technique is generally performed on lower teenager, they often get used to it and are
third molars but occasionally on deeply impacted hardly aware of it, whereas older patients are
second molars and even very occasionally first much less adaptable and much more likely to
molars.20 The technique is offered to any patient be inconvenienced by the discomfort of perma-
when there is a moderate or high risk of damage nent nerve involvement.
to the inferior alveolar nerve if the tooth is re-
moved completely as assessed by Panorex-type In our particular program, we do not routinely
radiograph supplemented by CBCT scanning. offer coronectomy to younger patients having third
The technique may be offered in low-risk cases molars removed unless it is believed that they are
on patients older than 25 or where nerve involve- at medium or high risk. For older patients, it is
ment might present special problems (eg, wind offered even when there is a low risk.
4 Pogrel
Fig. 4. (A) Panoramic reconstruction. (B) Axial slices. (C) Actual tooth after removal. These represent an attempt
to visualize the relationship between the inferior alveolar nerve and the lower third molar before tooth removal.
The cone-beam CT, because of its more limited power of resolution, cannot visualize objects in the detail that can
be obtained with fan-beam CT. In this case, the cone-beam CT scan was unable to show that the nerve went right
between the roots of the tooth. The tooth was consequently removed without coronectomy, but fortunately the
mesial root fractured and so it was possible to remove the tooth without causing permanent nerve damage. If
this had been visualized preoperatively, coronectomy would probably have been performed. (From Pogrel MA.
Coronectomy to prevent damage to the inferior alveolar nerve. Alpha Omegan 2009;102:61–7; with permission.)
CONTRAINDICATIONS FOR CORONECTOMY technique have increased. As originally conceived,

the technique involved total sectioning of the
The following situations are contraindications for crown of the tooth, removal of all enamel, and
coronectomy: removal of enough of the coronal portion of the
When the tooth is lying horizontally along the tooth such that the portion to be retained was at
path of the inferior alveolar nerve. In these cir- least 2 to 3 mm below the alveolar crest of bone.
cumstances, sectioning of the crown could This was believed to be important for new bone
present as high (if not higher) risk of nerve to grow over the retained roots and for them not
involvement than just taking out the whole to become exposed. As described by our unit,
tooth (Fig. 5). the technique involves raising buccal and lingual
Where it is not believed that all the enamel of flaps, the placement of a lingual retractor to pro-
the tooth can be removed. Retention of tect the lingual nerve and lingual soft tissues so
enamel seems to be associated with a much that the crown of the tooth could be sectioned
higher failure rate (Fig. 6). with a 702-type fissure bur through the whole
Infection involving the roots of the teeth. crown of the tooth.2 This is the technique that is
Caries involving the roots of the teeth. still used in our unit (Fig. 7). However, two other
If the roots are mobilized during the proce- techniques have been described.
dure, they should be removed.
When the second molars are to be distalized
orthodontically.
SURGICAL TECHNIQUE
As the procedure has gained wider acceptance
the numbers of variations on the basic surgical
Fig. 5. Lower third molars lying horizontally along the Fig. 6. A postcoronectomy radiograph showing re-
inferior alveolar nerve making it impossible to carry tained enamel on the mesial aspect of the lower left
out coronectomy. third molar.
Coronectomy 5
Fig. 7. (A) The conventional third

molar incision extending down the
external oblique ridge to the disto-
buccal line angle of the lower second
molar with a buccal releasing incision
going no further forward than the
midpoint of the first molar to avoid
a frequent arteriole located in this
area. (B) Diagramatic representation
of coronectomy technique. A lingual
retractor has been placed to protect
the lingual soft tissues, including the
lingual nerve, and a 702 fissure bur
is used at approximately a 45-degree
angle to section the crown
completely before removal. The gray
area represents the portion of the
tooth root that is then removed to
place them 3 to 4 mm below the alve-
olar crest. (From [A] Pogrel MA. Partial odontectomy. Oral Maxillofac Surg Clin North Am 2007;19:85–9, with
permission; and [B] Pogrel MA, Lee JS, Muff DF, et al. Coronectomy: a technique to protect the inferior alveolar
nerve. J Oral Maxillofac Surg 2004;62:1447–52, with permission.)
The first is a similar technique except that a The most frequent instance of this is in the case of
lingual flap is not raised and a lingual retractor is the dentigerous cyst (Fig. 8). Although a fairly large
not placed, but rather the crown of the tooth is defect may be left, this does not seem to require
removed from above with either a fissure bur or a any type of grafting in most cases.22 No authors
high-speed round bur such that the crown is either currently recommend any type of endodontic treat-
split vertically from above into small sections or it ment of the retained roots,23 and articles have
is just ground away until one ends up 2 to 3 mm shown that the retained roots do remain vital.24
below the alveolar crest. Other areas showing differences in techniques
The second is a technique whereby no lingual are discussed next.
flap is raised and no lingual retractor is used,
but the crown is still sectioned horizontally in Antibiotics
the same manner as one would use for routine
Many authors have always believed that the use
third molar removal. In this, the fissure bur is
of antibiotics is important for the success of this
taken approximately two-thirds of the way across
technique. It is believed that antibiotics should
the tooth and then the crown is fractured off in the
be given prophylactically so that they are in the
normal way with a straight elevator. The crown is
pulp chamber of the tooth to be sectioned at
then removed and the roots smoothed if neces-
the time of removal. This means giving them peri-
sary to the correct level.21 In this technique there
operatively if given intravenously, or an hour pre-
is a reasonable possibility of mobilizing the re-
operatively if given orally. However, several
tained roots, which must then be removed. How-
authors have published on carrying out the tech-
ever, the proponents of this particular technique
nique without using any antibiotics, and the suc-
state if the roots are mobilized or loosened, it nor-
cess rates and infection rates seem similar.21,25–27
mally means that the nerve could not be too inti-
mately involved with the roots and therefore they Suturing
can be removed without undue risk. If the roots
are firm, they are retained in the usual way. In our technique we raise a buccal flap, and un-
Studies using this technique always show a dermine and release the periosteum if necessary,
higher incidence of failed coronectomies in that to obtain a tension-free, water tight, primary
the roots are removed at the initial surgery. How- closure of the socket.28 This was believed to be
ever, proponents of this technique do not report important for primary healing and for new bone
any higher incidence of inferior alveolar nerve to grow over the socket. However, some authors
involvement. suture without raising a buccal flap and without
Coronectomy can also be used in conjunction periosteal release, so that the socket is not
with removal of pathology in the third molar region. completely closed.21 Again, success rates seem
to be similar.
6 Pogrel
Fig. 8. Radiographs demonstrating the technique being used in the presence of pathology. (A) Preoperative im-
age showing an impacted lower right third molar in a close relationship with the inferior alveolar nerve and asso-
ciated with a dentigerous cyst. (B) Postcoronectomy.
The Distance Below the Alveolar Crest to primarily in dogs.29–31 Now that there are adequate
Leave the Roots results obtained from clinical studies on patients, it
does seem that the technique works best if the
As originally described, this technique recommen-
retained roots are left 3 to 4 mm below the alveolar
ded removal of the tooth until it was 2 to 3 mm
crest of bone.15,25,32 By leaving them a little lower
below the alveolar crest of bone (Fig. 9). These
down, the bone grows over the roots more consis-
numbers were derived from animal studies,
tently and they may move somewhat less.
RESULTS
Randomized controlled clinical trials are difficult to
perform but have been attempted33,34 as have
case control studies.15 Other studies are mainly
case series2,25,35–37 or review articles.38,39 Most
published papers describe successful results
with a low complication rate.32 Because the tech-
nique is designed to avoid permanent damage to
the inferior alveolar nerve, most published papers
do show that this aim is achieved.28,35,40,41
Typically the infection rate is noted to be no
higher than with complete third molar removal,
and by definition there can be no dry socket
because there really is no socket. Most cases of
infection seem to result from leaving some enamel
behind, from the tooth being removed. There
seems no doubt that retained enamel can harbor
bacteria and that bone does not attach to enamel,
leaving a potential problem area.
Excessive pocketing behind the second molar
has not been reported, and on average, pocket
depths measure 2 to 4 mm. If this is believed to
be an issue grafting has been suggested.42
The major complication seems to be that many
of these roots subsequently migrate. Migration
Fig. 9. Clinical result postcoronectomy. Note the
exposed pulp chamber and the retained root frag- occurs at different times but can be visible on ra-
ments below the rim of the alveolar crest. (From diographs 3 months after the extraction. It appears
Pogrel MA, Lee JS, Muff DF, et al. Coronectomy: a tech- as a periapical radiolucency and comparison of
nique to protect the inferior alveolar nerve. J Oral serial Panorex radiographs makes the movement
Maxillofac Surg 2004;62:1447–52; with permission.) obvious (Fig. 10). Some practitioners have
Coronectomy 7
Fig. 10. Panorex radiographs showing early migration of retained roots of lower left third molar. (A) Immediately
postcoronectomy. (B) Four months later. Note that beneath the apices of the roots there is a radiolucency that has
been mistaken for periapical infection. Roots have moved despite the appearance of bone growing over the
roots.
mistaken the periapical radiolucency for infection, In our own program, the results are as follows:
but this is not the case. The radiolucency merely
represents the space where the roots were but Total number of cases carried out between
have now migrated. The roots always appear to 1997 and August 2014: 742.
migrate away from nerve, and although sometimes Infections: six (0.8%); two roots subsequently
they do migrate all the way to the surface (Fig. 11), required removal.
they seem to be easy to remove without complica- Number of teeth migrating following coronec-
tion and this may occur in 1% to 5% of cases.21,43 tomy: 230 (31%).
It was believed that if the nerve truly perforated the Number of roots subsequently requiring
roots, or the roots were deeply grooving them, removal: six or 0.8% (two for infection and
they could not in fact migrate. However, cases four because of migration). One of these pa-
have been described where the roots have tients suffered an inferior alveolar nerve injury
migrated apically taking the inferior alveolar nerve (see later).
up with them.3 Obviously, if roots such as these The number of teeth migrating and the num-
had to be removed subsequently, considerable ber of retained roots that are subsequently
care would need to be taken. removed is probably related to the time of
Fig. 11. Radiograph showing coronal migration of the retained roots of a lower third molar over a 2-year period.
(A) Preoperative appearance showing gross decay of the tooth. (B) Six months postcoronectomy showing good
healing with apparent bone over the retained roots. (C) Two years postcoronectomy showing occlusal migration
of the retained root necessitating removal now without risk to the inferior alveolar nerve. (From Pogrel MA. Cor-
onectomy to prevent damage to the inferior alveolar nerve. Alpha Omegan 2009;102:61–7; with permission.)
8 Pogrel
follow-up, and the longer the patients are fol- technique is obviously time consuming (and pre-
lowed, the more likely it is that retained roots sumably costly) but may be indicated in certain
move and need removal. We need to await circumstances.
20- and 30-year follow-up studies to assess
the final outcome. Sequential Removal of Small Portions of the
Number of failed coronectomies (roots were Occlusal Surface of the Impacted Third Molar
mobilized at the time of surgery and were
removed): 12, none causing inferior alveolar The technique of sequential removal of small por-
nerve symptoms. tions of the occlusal surface of the impacted third
molar such that it can erupt further until it moves
In our own series, the infection rate is actually far enough away from the nerve so that it can be
lower for coronectomy than for routine third molar safely removed was advocated by Tolstunov and
removal, and we have speculated on the reason coworkers,47 under the name of pericoronal ostec-
for this. It could simply be that many of our third tomy. Presumably one does need adequate
molars are removed by residents in training, access to the crown of the tooth to remove 1 or
whereas coronectomies are normally performed 2 mm of the occlusal surface and whichever sur-
by attendings, and therefore a lower infection face is causing the impaction at the time, and
rate might be expected. We also had one partic- again if the tooth is actually perforated by the
ularly troublesome case where the patient did get nerve, presumably it will not erupt.
repeated infections after coronectomy, and the
decision was made to surgically remove the re-
tained roots, which were found to be perforated
SUMMARY
by the inferior alveolar nerve. Despite removing Coronectomy (also called intentional root retention
the tooth fragments as atraumatically as possible, or partial odontectomy) should be considered in
this patient did suffer inferior alveolar nerve cases of patients older than 25, where there ap-
involvement, which after 6 months has largely pears to be an intimate relationship (low, medium,
resolved, but not completely. The patient still or high risk) between the roots of a retained lower
has about a 10% nerve involvement, fortunately third molar (or occasionally second or even first
manifest as paresthesia and not dysesthesia. Us- molars) and the inferior alveolar nerve, in circum-
ing our technique of lingual nerve retraction, we stances where it is not contraindicated. It may be
have had a transient lingual paresthesia rate of used on younger patients with a medium to high
slightly above 1% (eight cases), all but one of risk of inferior alveolar nerve damage. The decision
which resolved over 10 days. This last case did to use this technique is currently made with the aid
resolve completely but took 5 months to do so, of CBCT scans. The short- to medium-term suc-
which was concerning. Presumably these injuries cess rate seems to be excellent, but long-term
are stretch injuries of the lingual nerve. We have studies are not yet available and could influence
no other cases of inferior alveolar nerve the conclusions.
involvement.
REFERENCES
ALTERNATIVE TECHNIQUES
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Since publications commenced on coronectomy,
crown. Br J Oral Maxillofac Surg 1997;35:209.
a small number of alternative techniques have
2. Pogrel MA, Lee JS, Muff DF. Coronectomy: a tech-
been advocated to avoid inferior alveolar nerve
nique to protect the inferior alveolar nerve. J Oral
damage when removing lower third molars that
Maxillofac Surg 2004;62:1447.
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3. Drage NA, Renton T. Inferior alveolar nerve injury
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Orthodontic Extrusion of the Third Molars
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Bonetti and others have published on the tech- Pathol Oral Radiol Endod 2002;93:358.
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Coronectomy 9
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vs surgical removal. Dentomaxillofac Radiol 2013; inferior alveolar nerve. Alpha Omegan 2009;102:61.
42:98870341. 29. Johnson DL, Kelly JF, Flinton RJ, et al. Histologic
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J Oral Maxillofac Surg 2011;69:1557. vital submerged roots in dogs. Oral Surg Oral Med
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16. Tantanapornkul W, Okouchi K, Fujiwara Y, et al. tomy practice. Paper 2: complications and
A comparative study of cone-beam computed to- long term management. Br J Oral Maxillofac
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N Y State Dent J 2005;71:32. technique for protecting the inferior alveolar nerve:
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with computed tomography. Dentomaxillofac Radiol 36. O’Riordan BC. Coronectomy (intentional partial
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20. Chalmers E, Goodall C, Gardner A. Coronectomy for Med Oral Pathol Oral Radiol Endod 2004;98:274.
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of two cases. J Orthod 2012;39:117. tomy: a surgical option for impacted third molars in
10 Pogrel
close proximity to the inferior alveolar nerve. J Am 43. Goto S, Kurita K, Kuroiwa Y, et al. Clinical and dental
Dent Assoc 2012;143:363. computed tomographic evaluation 1 year after coro-
38. Geisler S. Coronectomy is an effective strategy for nectomy. J Oral Maxillofac Surg 2012;70:1023.
treating impacted third molars in close proximity to 44. Wang Y, He D, Yang C, et al. An easy way to apply
the inferior alveolar nerve. J Am Dent Assoc 2013; orthodontic extraction for impacted lower third molar
144:1172. compressing to the inferior alveolar nerve.
J Craniomaxillofac Surg 2012;40:234.
39. Long H, Zhou Y, Liao L, et al. Coronectomy vs. total
45. Bonetti GA, Parenti SI, Checchi L. Orthodontic
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41. Leung YY, Cheung LK. Can coronectomy of wis- thodontic extraction: riskless extraction of impacted
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42. Leizerovitz M, Leizerovitz O. Modified and grafted tectomy: an alternative surgical technique for man-
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C u r re n t Co n c e p t s of
P e r i a p i c a l Su r g e r y
Stuart E. Lieblich, DMDa,b,*
KEYWORDS
Periapical surgery Endodontic surgery Mineral trioxide aggregate (MTA) Fractured tooth
KEY POINTS
Preoperative decision-making is vital to determine potential success of periapical surgery.
Adequate exposure of the root apical region is best approached via a sulcular-type incision.
Surgical procedures include resection of 2 to 3 mm of the apical portion along with root end
preparation and seal.
The surgeon must decide if submission of periapical tissues to pathology is indicated.
PREOPERATIVE PLANNING treatment is most commonly due to lack of an

adequate coronal seal with the presence of bacte-
Although endodontic care is typically successful, ria within the root canal system and apical leakage.
in approximately 10% to 15% of the cases1 Continued infection may also result from debris
symptoms can persist or spontaneously reoccur. displaced out the apex during the initial endodon-
It is known that many endodontic failures are due tic treatment. Technical factors alone are a less
to the failure to place an adequate coronal seal. common indication for surgery comprising only
Therefore, there is the competing interest of 3% of the total cases referred for surgery,2 yet it
observing the tooth following endodontic treat- is this author’s opinion that there is a higher suc-
ment to ascertain successful treatment versus cess rate in these cases.
placing a definitive restoration with an adequate Before surgery, discussions with patients are
coronal seal. Many endodontic failures will occur critical in order for the patient to give appropriate
a year or more following the initial root canal treat- informed consent. The particular risks of surgery
ment, often creating a situation wherein a definitive based on the anatomic location (sinus involvement
restoration has already been placed, creating a or proximity to the inferior alveolar nerve) need to
higher “value” for the tooth because it now may be reviewed and documented. It is important to
be supporting a fixed partial denture. A decision stress the exploratory nature of periapical surgery
is then needed to determine if orthograde end- to the patient. Depending on the findings at sur-
odontic retreatment can be accomplished should gery, a limited root resection with retrograde resto-
periapical surgery be recommended or consider- ration may be placed. However, the patient and
ation of extraction of the tooth with loss of the surgeon must also be prepared to treat fractures
overlying prosthesis. of the root or the entire tooth. Plans must be
Causes of endodontic failures can often be made preoperatively on how such situations will
separated into biologic issues, such as a persis- be handled should they be noted intraoperatively.
tent infection, or technical factors, such as a Surgical endodontics success rates have
broken instrument in the root canal system dramatically improved over the years with the de-
(Fig. 1), or transportation of the apex, perforation, velopments of newer retrofilling materials and the
and ledging of the canal. Failure of endodontic
a b
Oral and Maxillofacial Surgery, University of Connecticut Health Center, Farmington, CT, USA; Private
Practice, Avon Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT 06001, USA
* Avon Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT 06001.

2 Lieblich
Fig. 1. Two examples of technical factors requiring apical surgery. Although less frequent in occurrence, the suc-
cess rate is usually high because the canal system is likely well obturated. (A) Overfill of gutta percha causing
symptoms including chronic sinusitis. (B) Broken endodontic instrument in apical third with pain and drainage.
use of the ultrasonic preparation. Previously cited The primary option for the treatment of symp-
success rates of 60% to 70% have now increased tomatic endodontically treated teeth is that of con-
to more than 90% in many studies,3,4 due to the ventional retreatment versus the surgical
routine use of ultrasonic retrograde preparation approach. An algorithm for a decision regarding
and the use of mineral trioxide aggregate (MTA retreatment versus surgery versus extraction is
[ProRoot MTA, Tulsa, Ok]) as a filling material. presented in Fig. 2. In discussions with patients,
This significant improvement makes apical surgery the option of conventional retreatment should be
a much more predictable and valuable adjunct in discussed. Clinical studies though have not shown
the treatment of symptomatic teeth. Most signifi- retreatment to be more successful than surgery
cantly, studies5 show once the periapical bony and in fact one prospective study found surgical
defect is considered “healed” (reformation of the treatment to have a higher success rate.8 Another
lamina dura or the case had healed by scar) the study found a higher success rate with surgery
long-term prognosis is excellent. They reported from 2 to 4 years (77.8% vs 70.9%), but from 4
91.5% of healed cases still successful after a to 6 years it reversed to a success rate of 71.8%
follow-up period of 5 to 7 years. Therefore, with with surgery and 83% with conventional retreat-
adequate radiographic follow-up, the surgeon ment.9 Although endodontic retreatment seems
should be able to predict the long-term viability more “conservative,” the removal of posts, rein-
of the tooth and its usefulness to retain a pros- strumentation of the tooth, and removal of tooth
thetic restoration. structure increase the chance of fracture. Surgical
There is some controversy in the endodontic treatment of failures also provides the opportunity
literature that the use of magnification may to retrieve tissue for histologic examination to rule
improve outcomes in surgical management of out a noninfectious cause of a lesion (Fig. 3).
endodontic failures. In a 2-part article by Setzer The option of extraction with either immediate or
and colleagues,6,7 a meta-analysis was reviewed delayed implant placement must also be dis-
on this subject of endodontic surgery. In part 1, cussed as an alternative to periapical surgery.
they compared outcomes with traditional root There is no debate in dentistry that implants can
end preparation with a rotary burr and amalgam outlast tooth-supported restorations. It is valuable
filling versus more contemporary surgery with ul- therefore to have data to predict the expected suc-
trasonic preparation and improved root end filling cess of the endodontic surgery so the patient can
materials (Super-EBA, MTA). With the more use that in their decision-making process. Factors
contemporary surgery techniques, the outcomes that improve success are noted in Table 1. In
improved from 59% to 94%. They then divided cases of an expected poorer success rate, such
the literature into 2 groups in 2012: those using as the presence of severe periodontal bone loss
no magnification or loupes up to 10 with those (especially the presence of furcation involvement),
cases using the operating microscope or an endo- the decision to extract the tooth and place an
scope with magnification greater than 10. The implant may be a more efficacious and clinically
group without magnification had a cumulative suc- predictable procedure.
cess rate of 88%, whereas the use of magnifica- There is a body of literature that supports the
tion had a pooled success rate of 93%. Of note duration of restorations fabricated on endodonti-
was that no difference in success was noted for cally treated teeth. Blomlof and Jansson10 found
treatment of anterior teeth or premolars with or surgically treated molars with healthy periodontal
without magnification, but some improved suc- status had a 10-year survival rate of 89%, and
cess for molars (98% vs 90%). Basten and colleagues11 reported a 92% 12-year
Fig. 2. Algorithm for apical surgery. (From Lieblich SE. Periapical surgery: clinical decision making. Oral Maxillofac
Clin North Am 2002;14:180; with permission.)
4 Lieblich
Fig. 3. Atypical radiolucency along

the lateral aspect of the root and
not truly involving the apex.
Although correctly treated at the
time of referral due to the nonre-
solving radiolucency with periapical
surgery, the suspicious nature of the
lesion warranted submission of the
tissue for histologic examination.
Confirmation with the original
treating dentist revealed the indica-
tion for the endodontic treatment
was solely the incidental finding of
a radiolucency and vital pulp tissue
was noted. The final pathology
finding was a cystic ameloblastoma.
rate. The factors most associated with failures are Table 1 to help predict the likelihood of the surgi-
long posts in teeth with little remaining coronal cal intervention being successful. If the tooth has
structure. Thus, the condemnation of a tooth multiple factors that indicate the success of the
because it can be replaced with an implant is not surgical intervention would be compromised or
that clear. the tooth has a poor expectation for 10-year sur-
An economic analysis may be indicated to guide vival, then extraction with implant placement is a
the patient’s decision. If the case has a final pros- more efficacious means of care.
thetic restoration already in place, it is usually The surgeon may be called on to treat teeth that
easier to recommend surgical intervention. If the cannot be negotiated for conventional orthograde
symptoms do not resolve, the patient has only ex- endodontics. The treatment of teeth with calcified
pended the additional time, operative risk, and canals may be appropriately managed with apical
expense of the surgical portion of their care surgery alone with a retrograde filling if the tooth is
because they have already have a definitive resto- critical to a restorative treatment plan. Danin and
ration. The surgeon should review the factors in colleagues12 showed at least a 50% rate of
Table 1
Factors associated with success and failures in periapical surgery
Preoperative Factors Postoperative Factors

Success Dense orthograde fill Radiographic evidence of bone fill
Healthy periodontal status following surgery
a. No dehiscence Resolution of pain and symptoms
b. Adequate crown:root ratio Absence of sinus tract
Radiolucent defect isolated to apical 1/3 of tooth Decrease in tooth mobility
Tooth treated
a. Maxillary incisor
b. Mesiobuccal root of maxillary molars
Failure Clinical or radiographic evidence of fracture Lack of bone repair following surgery
Poor or lack of orthograde filling Lack of resolution of pain
Marginal leakage of crown or post Fistula does not resolve or returns
Poor preoperative periodontal condition
(furcation involvement)
Radiographic evidence of postperforation
Tooth treated
a. Mandibular incisor
complete radiographic healing and only one failure situation is not clear at that time (6 months post-
in 10 cases over a 1-year observation period in surgically), a temporary restoration, loaded for at
cases treated surgically only and without end- least 3 months, is often a good “litmus test” of
odontic treatment. Bacteria still remained in the the success of the surgery and predictive as to
canals of the tooth in 90% of these cases, which whether the final restoration will last for some time.
may lead to a later failure.
THE CRACKED OR FRACTURED TOOTH
DETERMINATION OF “SUCCESS”
Preoperative radiographs and a careful clinical ex-
More complicated decisions are involved with amination should be done with a high index of sus-
teeth that have not been definitively restored. In picion of a vertical root fracture (VRF) before
that situation, not only does the surgeon have to undertaking surgery. Mandibular molars and
consider the preoperative potential for the apical maxillary premolars are the most frequent teeth
surgery to be successful but also often must deter- to present with occult VRF. Although surgical
mine when the case is deemed successful and the exploration may be needed to definitively show
case can proceed to the final restoration. Once a the presence of a fracture (Fig. 4), subtle radio-
final restoration is placed, considerably more graphic signs may alert the surgeon that a fracture
time and expense have been invested and subse- is present, and the surgery is unlikely to be suc-
quent failure is more troublesome to the patient. cessful. Tamse and colleagues15 looked at radio-
Rud and colleagues13 retrospectively reviewed graphs of maxillary premolars for comparison
radiographs following apical surgery to determine with the clinical findings at the time of surgery.
radiographic signs of success. Their work showed Very few (1 of 15) teeth with an isolated, well-
that with a retrospective review of cases over at corticated periapical lesion had a VRF. In contrast,
least 4 years after surgery, once radiographic evi- a “halo”-type radiolucency was almost always
dence of bone fill occurs, noted as “successful” associated with a VRF (Fig. 5). This type of radio-
healing in their classification scheme, that tooth lucency is also known as a “J” type, wherein a
was stable throughout the remainder of their study widened periodontal ligament space connects
period (up to 15 years). A waiting period of more with the periapical lesion, creating the “J” pattern.
than 4 years is not acceptable in contemporary It is critical in patient discussions to review the
practice, but their classification scheme has exploratory nature of the surgery; this author
been validated over shorter observation times. routinely uses that as a descriptor of the planned
They found that if radiographic evidence of bone surgery. In cases of root fracture, a decision during
fill of the surgical defect is noted, then the tooth re- surgery may need to be made to either resect a
mained a radiographic success over their observa- root or extract a tooth if a fractured root is found.
tion periods. Many of the partially healing cases, Obtaining the appropriate preoperative consent
noted as “incomplete healing” in their study, as well as determining how the extracted tooth
tended to move into the complete healing group site will be managed (with or without a temporary
during the 2 years following surgery, with very little removable partial denture) must be established
changes throughout the next 4 years of before surgery commences.
observation.
An appropriate follow-up protocol is to obtain a CONCOMITANT PERIODONTAL PROCEDURES
repeat periapical film 3 months after surgery with
critical comparison with the immediate postopera- The use of guided tissue regeneration, alloplastic
tive film. If significant bone fill has occurred, or allogenic bone grafting, and root planing in
mobility has decreased, pain is resolved, and no conjunction with periapical surgery can be consid-
fistula is present, the case can proceed to the final ered. In cases of severe bone dehiscence, the like-
restoration. However, if significant bone fill has not lihood of success is known to be substantially
been noted, the patient should be recalled at compromised and may lead to the intraoperative
3 months for a new film. Rubinstein and Kim14 decision to extract the tooth. Periodontal probing,
found complete healing in 25.3% of cases in before surgery, often will detect the presence of
3 months, and 34% took 6 months, 15.4% took significant bony defects. Sometimes the amount
9 months, and 25.3% took 12 months. Small of bone loss cannot be appreciated until the area
bony defects healed faster than large, which is flapped (Fig. 6). Thus, the exploratory nature of
showed significant differences in their prospective the surgery needs to be stressed preoperatively
study. In contrast, any increase in the size of the with the patient.
radiolucency or no improvement should caution The placement of an additional foreign body,
the dentist about making a final restoration. If the such as a Gore-Tex (W.L. Gore and ASSOC,
6 Lieblich
Fig. 4. VRF that was not diagnosed until explored at the time of surgery. The use of a sulcular flap permitted a
resection of the mesiobuccal root and preservation of the tooth with its existing restoration.
Flagstaff, Ariz) membrane, to an area already in- SURGICAL PROCEDURES

fected is more likely to lead to failure of the sur-
gery. Membrane stabilization and adequate Various steps are involved in the periapical surgi-
mobilization of soft tissues to cover the membrane cal procedure. Initial exposure of the apical region
may increase the complexity of the surgical proce- is needed; this must allow access to the apex for
dure. Nonresorbable membranes also require a the root resection. Approximately 2 to 3 mm of
second procedure for its removal that may not the root apex is resected. The root resection re-
be tolerated by the patient as well as lead to an in- moves the end of the root containing the aberrant
crease in scarring. A recent review by Tsesis and canals. Also, the further from the coronal portion of
colleagues16 seems to show a trend toward higher the tooth, the less dense the endodontic filling is
success with the use of resorbable membranes in likely to be.
cases of large defects and through and through le- Following the root resection, a thorough curet-
sions. However, this author does not advocate tage of the periapical region is accomplished,
grafting or the use of membranes in conjunction being cognizant of local structures such as the
with endodontic surgery. Clinical success defined maxillary sinus or the inferior alveolar nerve.
as reduction in symptoms and spontaneous bone Curettage removes periapical debris that may
fill is routinely demonstrated without the use of have been forced out the apex during the previ-
allogenic bone or other GTR (guided tissue regen- ous preparation of the root canal system. Tissue
eration) procedures (Fig. 7). may be recovered at this time for histologic
Fig. 5. (A) Example of a periapical lesion isolated to the apical one-third of the root. These lesions are rarely asso-
ciated with a VRF. (B) In contrast, this type of radiographic lesion, known as a “halo” or “J” type of radiolucency,
has ill-defined cortical borders and is most likely associated with a VRF.
conservative preparation and often finds unfilled

canals or an isthmus of retained pulpal tissue con-
necting 2 canals, particularly in the mesiobuccal
roots of maxillary first molars (Fig. 8). The ultra-
sonic preparation has been shown to be advanta-
geous to the rotary drills because it will center the
preparation along the long axis of the canal and
significantly reduces the tendency to create root
perforations.17
The retrograde filling is important to hermetically
seal the root canal system, preventing further
leakage of bacteria into the periapical tissues.
Fig. 6. A combination endodontic and periodontal Many filling materials have been used throughout
lesion has a very low likelihood of success. The deci- the years and many do work well. The most
sion was made preoperatively to treat the tooth surgi- contemporary material is MTA, which has been
cally because an adequate final restoration had shown histologically to deposit bone around it.
already been placed. Otherwise, extraction with Its handling characteristics are somewhat different
consideration of local bone grafting is indicated. than other dental materials because it is hydrophil-
ic and does not reach a full firm set for 2 to 4 hours;
examination if indicated (see later discussion). A this is not clinically significant because the region
retrograde filling is then prepared with the use of is not load-bearing, at least for quite some time
the ultrasonic device; this creates a microapical following the apical surgery. MTA has been shown
restoration that is retentive due to the parallel to produce regeneration of cementum, something
walls. The ultrasonic device creates a very not seen with other root end filling materials.
Fig. 7. (A) Large periapical lesion associated with teeth numbers 27 and 28 in proximity with an implant. Apical
surgery was performed (B) with an MTA seal, and no graft or membrane was placed into the defect. (C) Bone fill
after 3 months. (D–F) Similar situation with large defect successfully treated with apical surgery and MTA retro-
grade filling. No graft or membrane was placed in the defect.
8 Lieblich
premolars will involve an opening into the sinus

cavity.18 The incision line with this type of flap
might contribute to a postoperative oral-antral
fistula.
In contrast, a sulcular incision with 1 or 2 vertical
releases keeps the incision primarily within the
attached gingiva, promoting rapid healing with
less pain and scarring. Healing of the incision is
facilitated by curetting the adjacent teeth and
any exposed root surfaces before closure. The
incision permits full observation of the root sur-
face, leading to more accurate apical localization
and treatment of a fractured root should it be
discovered on flap reflection (see Fig. 4). By keep-
ing the incision as far away from the sinus opening
as possible and over healthy bone (vs a semi-lunar
incision), the chance of an oral-antral communica-
tion is significantly reduced.
Concerns about sulcular incisions have
revolved primarily around the concern for an
esthetic defect that may be created with the
Fig. 8. The use of the ultrasonic tips allows a precise
and retentive retrograde preparation. A minimal to shrinkage or loss of the interdental papilla. Jans-
no bevel is needed, which exposes less of the dentinal son and colleauges19 found the greatest predica-
tubules in the apical aspect of the tooth. tor of papilla loss was the presence of a continued
apical infection and no difference in the attach-
SURGICAL ACCESS ment whether a semilunar or trapezoidal flap
was used. A recent publication by Velvart20 has
Surgical access is a compromise between the proposed the use of a “papilla-based incision” in
need for visibility and the risk to adjacent struc- which the triangle of interdental papilla is not
tures. Many surgeons use the semilunar flap to incised and not mobilized during reflection of the
access the periapical region. Although it provides flap. It reports maintenance of the papilla with little
rapid access to the apices of the teeth, it sub- to no recession in contrast to mobilization of the
stantially limits the surgery to only a root resection papilla. Von Arx and colleagues21 (Fig. 9) reviewed
and periapical seal. Proponents of this flap claim the papilla-based incision with the intrasulcular
that it prevents recession around existing crowns, type and found less recession with this type of
which could lead to a metal margin showing flap design.
postoperatively. In selected cases, an Ochsenbein and Luebke
The semilunar flap is placed entirely in the non- flap, also known as a submarginal flap, can be
keratinized or unattached gingiva. By definition, used. The requirements for this flap include at least
this tissue is constantly moving during normal a band of attached gingival tissue 2 mm in length
oral function, leading to dehiscence and increased (not including any periodontal pocketing) along
scarring. Incisions placed in unattached tissues with a periapical lesion that does not extend to
tend to heal slower and with more discomfort. this region.22 Therefore, there are few cases
Once a semilunar incision is made, the surgeon whereby this flap design can be used. There is
has access limited to only the periapical region. If the limitation that if extraction of the tooth or root
the root is noted to be fractured, extraction via resection becomes the intraoperative decision,
this flap may lead to a severe defect. With a multi- there becomes a technical complication. In addi-
rooted tooth, a root resection of one of the frac- tion, scarring is significant and recession can
tured roots may not be possible. In addition, occur from that outcome.
localized root planing or other periodontal proce-
dures cannot be accomplished. The size of the TO BIOPSY OR NOT?
bone defect may be greater than that anticipated
based on the preoperative radiographs and the A clinical controversy has ensued over the consid-
possibility of the suture line being over the defect eration as to whether all periapical lesions treated
might cause the incision to open up and heal surgically should have soft tissue removed and
secondarily. Last, it is known that many cases of submitted for histologic evaluation. An editorial
periapical surgery on maxillary molars and by Walton23 questioning the rationale of submitting
Fig. 9. Papilla-based incision has been shown to have less recession than the intrasulcular incision. (A) Schematic
illustration of papilla based incision. (B) Baseline before apical surgery of the first molar. (C) Closure of incision.
(D) One year follow-up picture. (From von Arx T, Vinzens-Majaniemi T, Bürgin W, et al. Changes of periodontal
parameters following apical surgery: a prospective clinical study of three incision techniques. Int Endod J
2007;40(12):963; with permission.)
all soft tissue recovered for histologic examination An approach more logical than a purely defen-
ignited a series of letters to the editor. Organiza- sive one is to set up guidelines on which it is deter-
tions such as the American Association of End- mined submission of tissue was not indicated.
odontists have stated in their standards that if These guidelines are listed in Box 1. It is recom-
soft tissue can be recovered from the apical sur- mended that the surgeon have documented in
gery that it must be submitted for pathologic the record the rationale for electing not to submit
evaluation. tissue in each specific case. At a recent meeting
On cursory review, it seems that it is easier to of the American Association of Oral and Maxillofa-
make this recommendation than to have the sur- cial Surgeons, only 8% of those attending a sym-
geon determine if there is anything unusual about posium on endodontic surgery “always” submit
the case that warrants histologic examination.
Walton23 makes a convincing argument against
Box 1
the submission of all tissues, because similar- Indications for nonsubmission of periapical
appearing radiolucencies that are not treated sur- soft tissues for histologic review
gically do not have tissue retrieved for pathologic
identification. It also is accepted that the differen- 1. Clear evidence of pre-existing endodontic
tiation between a periapical granuloma or periapi- involvement of a tooth
cal cyst has no direct bearing on clinical outcomes a. Pulpal necrosis was present, not just a
and therefore cannot be used as a rationalization periapical radiolucency
for the submission of tissue.
2. Unilocular radiolucency associated with api-
The dilemma falls back to the surgeon that if a cal one-third of the tooth
rare lesion should present itself in the context of
a periapical lesion, and is not biopsied in a timely 3. Lesion is not in association with an impacted
tooth
manner, the surgeon may have exposure in a
potential malpractice suit. Many surgeons have a 4. No history of malignancy that could repre-
case or two in their careers that have “surprised” sent spread of a metastasis
them based on the final pathologic diagnosis. 5. Patient will return for follow-up examina-
However, careful review of these cases usually de- tions and radiographs
picts a clinical situation inconsistent with a typical 6. No tissue recovered at the time of surgery
periapical infection (see Fig. 3).
10 Lieblich
tissue for histologic examination (Lieblich, study. Int J Periodontics Restorative Dent 1996;16:
personal communication, 2009). 206–9.
12. Danin J, Linder LE, Lundqvist G, et al. Outcomes of
REFERENCES periradicular surgery in cases of apical pathosis and
untreated canals. Oral Surg Oral Med Oral Pathol
1. Kerekes K, Tronstad L. Long-term results of end- Oral Radiol Endod 1999;87(2):227–32.
odontic treatment performed with a standardized
13. Rud J, Andreasen JO, Jensen JE. A follow-up study
technique. J Endod 1979;5:83–90.
of 1,000 cases treated by endodontic surgery. Int J
2. El-Siwah JM, Walker RT. Reasons for apicectomies.
Oral Surg 1972;1:215–28.
A retrospective study. Endod Dent Traumatol 1996;
14. Rubinstein RA, Kim S. Short term observation of the
12:185–91.
results of endodontic surgery with the use of a surgi-
3. Von Arx T, Kurl B. Root-end cavity preparation after
cal operation microscope and Super-EBA as root-
apicoectomy using a new type of sonic and
end filling material. J Endod 1999;25:43–8.
diamond-surfaced retrotip: a 1-year follow-up study.
15. Tamse A, Fuss Z, Lustig J, et al. Radiographic fea-
J Oral Maxillofac Surg 1999;57:656–61.
tures of vertically fractured, endodontically treated
4. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in
maxillary premolars. Oral Surg Oral Med Oral Pathol
periapical surgery: a clinical prospective study. Int
Oral Radiol Endod 1999;88:348–52.
Endod J 2000;33(2):91–8.
16. Tsesis I, Rosen E, Tamse A, et al. Effect of guided tis-
5. Rubinstein RA, Kim S. Long-term follow-up of cases
sue regeneration on the outcome of endodontic
considered healed one year after apical microsur-
treatment: a systematic review and meta-analysis.
gery. J Endod 2002;28:378–83.
J Endod 2011;37(8):1039–45.
6. Setzer FC, Shah S, Kohli M, et al. Outcome of end-
odontic surgery: a meta-analysis of the literature— 17. Wuchenich D, Meadows D, Torabinejad M.
part 1: comparison of traditional root-end surgery A comparison between two root end preparation
and endodontic microsurgery. J Endod 2010;36: techniques in human cadavers. J Endod 1994;20:
1757–65. 279–82.
7. Setzer FC, Shah S, Kohli M, et al. Outcome of end- 18. Feedman A, Horowitz I. Complications after api-
odontic surgery: a meta-analysis of the literature— coectomy in maxillary premolar and molar teeth.
part 2: comparison of endodontic microsurgical Int J Oral Maxillofac Surg 1999;28:192–4.
techniques with and without the use of higher 19. Jansson L, Sandstedt P, Laftman AC, et al. Relation-
magnification. J Endod 2012;38:1–12. ship between apical and marginal healing in perira-
8. Danin J, Stromberg T, Forsgren H, et al. Clinical dicular surgery. Oral Surg Oral Med Oral Pathol Oral
management of nonhealing periradicular pathosis. Radiol Endod 1997;83:596–601.
Surgery versus endodontic retreatment. Oral Surg 20. Velvart P. Papilla base incision: a new approach to
Oral Med Oral Pathol Oral Radiol Endod 1996; recession-free healing of the interdental papilla after
82(2):213–7. endodontic surgery. Int Endod J 2002;35:453–60.
9. Trobinejad M, Corr R, Handysides R, et al. Out- 21. Von Arx T, Vinzens-Majanemi T, Jensen S. Changes
comes of nonsurgical retreatment and endodontic of periodontal parameters following apical surgery.
surgery: a systematic review. J Endod 2009;35(7): Int Endod J 2007;40:959–69.
930–7. 22. Velvert P, Peters CI. Soft tissue management in end-
10. Blomlof L, Jansson L. Prognosis and mortality of odontic surgery. J Endod 2005;31(1):4–16.
root-resected molars. Int J Periodontics Restorative 23. Walton RE. Routine histopathologic examination of
Dent 1997;17:190–201. endodontic periradicular surgical specimens—is it
11. Basten CH, Ammons WF, Persson R. Long-term warranted? Oral Surg Oral Med Oral Pathol Oral Ra-
evaluation of root-resected molars: a retrospective diol Endod 1998;86(5):505.
Best Practices for
Ma na gement of P ain,
Swelling, Nausea, an d
Vom i t i n g i n D e n t o a l v e o l a r
Surgery
Stephanie J. Drew, DMDa,b,c
KEYWORDS
Pain Wisdom teeth Nausea Vomiting Swelling Outpatient
KEY POINTS
Develop techniques to customize the outpatient experience and minimize these potential side
effects.
Review current therapies to minimize swelling, pain, and postoperative nausea and vomiting.
Staying abreast of the current surgical and pharmacologic and even homeopathic methods of treat-
ing our patients’ needs will ensure a safe outcome and good experience for our patients.
BEST PRACTICES FOR CONTROLLING PAIN, level of factors related to mounting an inflamma-
SWELLING, NAUSEA, AND VOMITING FROM tory response.
DENTOALVEOLAR SURGERY The inflammatory response to injury is the key
to the development of pain and eventually
Currently, therapy for the management of patient swelling after any surgery. The inflammatory
comfort after third molar surgery should be chemicals released from injury to tissue include
directed toward procedure-specific pharmaco- prostaglandins, leukotrienes, bradykinin, and
logic techniques that will minimize the inflamma- platelet-activating factors, to name a few. These
tory and noxious stimulus to the soft and hard chemicals, in turn, cause several chain reactions
tissues of patients. The buzzword today is all leading to vascular dilation and increased perme-
about preemptive methods to minimize the unto- ability, causing edema through interstitial fluid
ward effects of the surgery and anesthesia. accumulation and increased tissue pressure.
Although good surgical technique is a given, The emotional response to pain and the actual
all surgery creates injury to the soft and hard tis- surgical event can upregulate the response to
sues when it is related to the removal of the painful stimulus as well as the inflammatory
impacted teeth. Multiple biochemical cascades stimulus that creates nausea, possibly leading to
are activated on the first incision in the mucosa. vomiting via the vagal pathways, our fight-or-
End fibers of afferent neurons send signals flight mechanism.
created by the noxious stimulus to both the cere-
Patient-specific factors to consider are their

bral cortex and limbic system. The clotting general health, including the possibility of a patient
cascade is also activated, bringing in not only in chronic pain already on pain medications, drug
the necessary clotting factors but also the next
a
Hofstra Medical school, 500 Hofstra University, Hempstead, NY 11549, USA; b University Hospital Stony
Brook, 101 Nicolls Rd, Stony Brook, NY 11794, USA; c The New York Center for Orthognathic and Maxillofacial
Surgery, 474 Montauk Highway, West Islip, NY 11795, USA

2 Drew
abusers, immune compromise, and multiple al- primary closure versus a wound dressing was
lergies to medications. These patient issues are also assessed.4 They found the use of a whitehead
often difficult to manage well. Any patient that varnish dressing was more effective than primary
must take daily medication for any condition will closure to reduce swelling and trismus. Pain con-
need to be assessed for possible interactions be- trol was not changed with either method in this
tween medications you would like to use, the sur- study. Logically the conclusion relates back to
gical procedure needing to be done, and the risks the initial issues described of tissue dissection
of taking them off any medications they are using and pain. The more dissection of either soft tissue
for their other health issues if indicated by the na- or bone you do, the more it will create inflamma-
ture of the procedure. tion and, thus, increase pain.
Thus, there are multiple pathways that pharma-
cologic intervention can obtund, block, redirect, PAIN CONTROL
upregulate, or downregulate signals to improve
the patients’ physiologic experience as well as As stated previously, the best method to control
emotional experience postoperatively. Preventive postoperative pain will be to minimize the soft
measures should be considered in this light to and hard tissue trauma from surgery. However,
decrease the pain, nausea, vomiting, and swelling this unfortunately cannot always be avoided in
associated with third molar surgery. the removal of third molars. Pain control, thus, be-
gins with good surgical technique. The rest is up to
SURGICAL TECHNIQUE FROM OPENING TO the medications we choose to use for our patients
CLOSING to interfere with the propagation of pain and the
perception of pain. Of course, during the removal
The more difficult the surgery, the more likely the of third molars the surgeon will use a local anes-
patient will experience pain, swelling and trismus thetic to achieve pain control for the short-term.
after the surgical removal of third molars. Overall Local anesthetics block the afferent neural stimuli
this impacts on the patient experience and quality from the surgery by blocking the low voltage–
of life for several days after the event. The grade gated sodium channels on the cell membranes
of extraction thus correlates positively with the and, thus, interfere with the afferent signal propa-
trauma created to remove a third molar. Parant gation. Blocking of the afferent neural stimuli by
grade I tooth is equivalent to a simple forceps the local anesthesia will reduce the hyperalgesia
removal, whereas grade IV will require bone cutting and allodynia associated with surgery. Block injec-
and flap reflection.1 Understanding this relation- tions or infiltration of local anesthesia, long-acting
ship should guide the practitioner to provide appro- or short-acting drugs, and postoperative use of
priate surgical techniques to minimize trauma as extended-release local aesthetics should be
much as possible. It also allows the surgeon to considered. The block injections will last longer
formulate a pharmacologic action plan for mini- than the infiltration of medications regardless of
mizing pain, swelling, and trismus after surgery. the type of local used. The need for rescue injec-
If a tooth is impacted and requires removal, the tions, which further traumatize soft tissues and
thought of flap design and type of closure will play create more inflammation, should be reduced.
a role in minimizing pain, swelling, and trismus. Many different types of local anesthetics are
Borgonovo and colleagues2 recently evaluated available for use in third molar surgery. Of interest
the use of 3 different types of flaps in third molar is the speed of onset of the medication and how
surgery on postoperative discomfort. They long it will last when it comes to postoperative
described the use of an envelope flap, a triangular pain management. Lidocaine is the standard that
flap, or a trapezoidal flap. An envelope flap was the all other medications are compared. Recent
least traumatic with dissection; the trapezoidal flap studies of local anesthesia comparing the effi-
required the most dissection, periosteal stripping, ciency of lidocaine with articaine and bupivacaine
and perhaps manipulation or injury of the masseter have been published.5–8 In all the onset of action of
muscle. An envelope flap led to the least amount of these drugs is not as much an issue in relation to
pain, trismus, and swelling. postoperative pain as the duration of action. Bupi-
Closure of the flaps created to remove third mo- vacaine should be the local anesthetic of choice
lars has also been evaluated in regard to prevent- when it comes to achieving long-acting postoper-
ing pain, swelling, and trismus.3 Closure either ative anesthesia. Its duration of action has been
primarily or secondarily did not seem to impact reported to be as long as 10 hours. This duration
pain or facial swelling according to the reviews in is important because the initial onset of the
these papers. However, secondary closure has maximum severity of postoperative pain peaks
been found to create less trismus. The use of within the first several hours after surgery. This
Management of Pain, Swelling, Nausea, and Vomiting 3
feature of bupivacaine will allow patients to get narcotic medications for breakthrough pain is bet-
other medications on board that will be necessary ter controlled with the preemptive use of NSAIDs.
to help decrease and control the swelling and pain Gastrointestinal (GI) complications, including
of third molar removal before the onset of pain. upset and hemorrhage, have been known side
Improvement of the patients’ experience over all effects of NSAID medications. Those drugs devel-
and quality of life after third molar surgical inter- oped to be selective COX-2 inhibitors have less risk
vention may be the most important aspect of prac- for damage to the GI mucosa.15 Selective COX-2
tice management. inhibitor drugs, such as loxoprofen sodium and cel-
On the forefront is the development of a delivery ecoxib, have been recently compared and found to
system for the extended release of bupivacaine. be clinically compatible in the management of
The Food and Drug Administration (FDA) has decreasing pain after third molar extraction.16
approved its use in 2011 for patients older than
18 years. The system has biodegradable and NARCOTICS
biocompatible lipid-based particles that contain
the drug and allow diffusion over an extended Hydrocodone, oxycodone, and codeine have
time, which gives sustained local analgesia. The been the go-to narcotics for the control of postop-
pharmaceutical company claims that the formula- erative pain resulting from dentoalveolar surgery.
tion should last up to 72 hours. This medication These drugs have a place in our armamentarium,
has been used in orthopedic surgery and soft tis- but their use must be monitored for abuse poten-
sue incisions of plastic and general surgery. There tial. While they work well in changing the percep-
have been no publications in dentistry thus far, tion of pain and centrally mediating the response,
perhaps because of the cost of a single-dose vial their side effects may overrun the benefits of use.
being approximately $250. The development of Nausea, vomiting, constipation, dizziness, and
pain, trismus, and swelling lasts for several days allergy should be monitored during their use.
after the removal of third molars. Perhaps studies These drugs are usually delivered in combination
on the use of this medication delivery modality with acetaminophen. The potential for toxic levels
with sustained release should be considered.9,10 of the acetaminophen must also be monitored.17
Often these drugs can be used in combination
NONSTEROIDAL ANTIINFLAMMATORY with an antiinflammatory drug, such as ibuprofen,
DRUGS AND POSTOPERATIVE PAIN CONTROL to enhance the response to pain control.
Tramadol is a centrally acting opiate that also has
Prostaglandins are the primary mediator of acute the properties of inhibiting serotonin reuptake.18–20
postsurgical inflammatory changes and, thus, the
development of pain. Inhibition of cyclooxygenase ACETAMINOPHEN
(COX) will prevent the production of prostaglan-
dins. Two forms of COX exist: COX-1 and COX- This drug is a centrally acting analgesic and anti-
2. It is known that COX-2 is primarily responsible pyretic. The analgesic effects of this drug are
for the cause of inflammation, pain, and fever. created by it acting centrally by raising the pain
Nonsteroidal antiinflammatory drugs (NSAIDs) threshold through what is thought to be inhibition
are drugs with antiinflammatory properties that of the nitric oxide pathway mediated by a variety
work by blocking cyclooxygenase via the arachi- of neurotransmitters, including N- methyl-D-aspar-
donic acid pathway. tate and substance P. Although acetaminophen is
When these drugs are given preemptively before one of the oldest and most widely prescribed anal-
the initiation of surgical trauma, they are found to gesic drugs, its analgesic efficiency has been
significantly reduce postoperative swelling, pain, found to be improved by combining it with NSAID
and trismus.11 One study compared the preopera- medications, such as ibuprofen.21–24 These new
tive administration of oral diclofenac potassium, combination medications or just combining them
etodolac, and naproxen sodium on postoperative on your own may obviate or decrease the need
pain, swelling, and trismus.12 The study concluded for narcotic use in many patients.
that diclofenac potassium was best at reducing Toxic levels of acetaminophen, especially
swelling and equal to naproxen sodium and etodo- affecting the liver, can increase quickly if the medi-
lac in reduction of pain and trismus. In another cation is not used appropriately, especially in the pe-
study, dexketoprofen trometamol was used in an diatric population. Recently, the FDA decreased the
intravenous preparation preoperatively and was maximum daily dose of N-Acetyl-p-Aminophenol
found to have an excellent preemptive decrease (APAP) from 4 g/d to 3 g/d because of the preva-
in pain and swelling caused by third molar sur- lence of hepatic injury. The FDA has also stated
gery.13,14 The need for the use of postoperative that single doses greater than 325 mg may cause
4 Drew
liver toxicity (FDA 2014 http://www.fda.gov/drugs/ In other words, steroids decrease swelling and,
drugsafety/safeuseinitiative/ucm230396.htm). thus, pain by decreasing the action of pain
mediators.
PSYCHOLOGY OF PAIN The delivery of steroids to patients can be via
oral, intramuscular injection, or intravenous
Anxiety and fear can upregulate the pain signals methods. One recent study compared the different
received in the limbic system to create a hyper routes of administration of methylprednisolone on
response to a painful stimulus. This center in the edema and trismus after third molar surgery.26
brain is responsible for the emotional component They found that the systemic application of a ste-
to our perception of a painful stimulus. The afferent roid was more effective on increasing range of
fibers cross over from the trigeminal nucleus. As motion. However, the direct injection of the steroid
they do, they send off signals to this area as well into the musculature had the best effect on
as to the sensory cortex. There is neurochemical decreasing postoperative swelling. Another study
stimulation of the pathways that bring about the by Ehsan and colleagues27 looked at the effect
fear and anxiety known to be created from painful of preoperative submucosal administration of
experiences.25 This protective mechanism is a dexamethasone injection on swelling and trismus.
way that the signals are upregulated to enhance They found that this injection was very effective in
the emotional response and, thus, increase the re- reducing the postoperative swelling and trismus
action and response to a painful stimulus, not in associated with third molar removal. An update
proportion with the actual injury. In reality, this is on the use of corticosteroids use in third molar sur-
a signal to get away from the noxious stimulus gery literature review revealed similar results. The
that is threatening our well-being. administration of corticosteroids in the preopera-
tive period via the parenteral route has the greatest
SWELLING impact on reducing postoperative swelling and
Inflammation is the local physiologic response to trismus.28
tissue injury. The early stage of inflammation has Comparing corticosteroid administration versus
fibrin and neutrophil polymorphs accumulation in NSAIDs for the relief of pain, swelling, and trismus
the extracellular space of the damaged tissues. has also been studied. The preemptive intrave-
Three processes occur during this time: The ves- nous administration of tenoxicam (NSAID) was
sels change in diameter; vascular permeability is compared with the intravenous administration of
changed and fluid exudate forms; and the cellular methylprednisolone on pain, swelling, and trismus
exudates of neutrophil polymorphs emigrate into after wisdom teeth extraction.29 Because the
the extravascular space. The chemical mediators mechanism of action of these drugs has its effects
of acute inflammation include histamine, prosta- on different parts of the inflammatory pathways,
glandins, leukotrienes, serotonin, and various comparing the efficacy of them will be important
cytokines. in deciding which one to use. The oxicam group
The prevention of inflammation and, thus, of NSAIDs works on the inhibition of cyclooxyge-
swelling is the goal of reducing postoperative nase and lipoxygenase enzymes. This action will
pain and decreased quality of life after third molar prevent prostaglandin and leukotriene formation.
surgery. Inflammatory mediator’s processes can Thus, it decreases the active oxygen radicals and
last up to 96 hours. Of note are the multiple steps inhibits migration and phagocytosis of leukocytes.
along the biochemical pathways to inflammation This drug also has antipyretic, analgesic effects
and then swelling and pain that can be blocked and also inhibits thrombocyte aggregation. Meth-
with medications to prevent and decrease this ylprednisolone inhibits macrophage development
postsurgical phenomenon. and decreases fibroblast formation and sup-
presses the immune system. It stabilizes cell
STEROIDS membranes and reduces kinin and bradykinin for-
mation and blocks histamine. The preemptive
Corticosteroids have been the most common intravenous dosing of these drugs had both a pos-
medications used to treat and prevent swelling itive and equal impact on postoperative control of
and edema after surgery. They are immunosup- pain and swelling. However, the use of methyl-
pressive agents blocking both the early and late prednisolone had better relief of trismus.
stages of inflammation. By inhibiting phospholi- The comparison of preemptive administration of
pase A2, the release of arachidonic acid will be by-mouth prednisolone (steroid) to celecoxib
reduced at the site of inflammation. This reduction (NSAID) on trismus and pain after third molar
will decrease the synthesis of prostaglandins and extractions was also studied. Once again, these
leukotrienes and the accumulation of neutrophils. drugs have different mechanisms of action. They
found no difference in trismus; however, pain was and neutrophil infiltration and inflammatory cyto-
better controlled with preemptive celecoxib.30 kines and enzymes. The swelling is reduced by
accelerating the regeneration of lymph vessels
PROTEASE INHIBITORS and decreasing vascular permeability.34–37
Complications of steroid use are well known.

These complications include suppression of the OTHER METHODS TO DECREASE SWELLING
immune system, hypertension, hyperglycemia, Topical hyaluronic acid spray was recently intro-
and suppression of adrenal corticosteroid activ- duced as a way to reduce swelling and trismus
ity. Alternative therapies for the use of steroids postoperatively. A recent study was done to
have been studied. Another class of drugs called compare it with the use of benzydamine. They
serine protease inhibitors have been evaluated to were used as a spray: 2 pumps to the extraction
compare their effectiveness in controlling pain sites 3 times a day for 7 days. It was found that
and swelling after third molar surgery against the hyaluronic acid was more effective at reducing
the use of dexamethasone.31 The drug aprotinin swelling and trismus. It had no effect on pain.38
was used in this study delivered by submucosal Further studies are needed.
injections before incision. This drug works by in- Another recent study looked at the impact of
hibiting the action of kallikrein and bradykinin. It warm saline rinses on the development of inflam-
also has a property to reduce bleeding. The dexa- mation or osteitis postoperatively. They concluded
methasone was given intravenously 30 minutes that the rinses helped prevent the osteitis; how-
before surgery. This study proved that aprotinin ever, the normal inflammatory response from sur-
was better than dexamethasone in controlling gical trauma is unavoidable and will not be
postoperative swelling and pain after third molar prevented by the rinses.39
surgery.
THE POWER OF THE PINEAPPLE POSTOPERATIVE NAUSEA AND VOMITING
Bromelain is a proteolytic enzyme obtained from Nausea and vomiting are two of the most undesir-
Ananas comosus, or pineapple plant. It is a potent able causes of patient dissatisfaction after third
antiinflammatory and antiedematous substance. molar removal. Postoperative nausea and vomit-
The natural substance works by blocking bradyki- ing (PONV) after oral surgery can arise from multi-
nin and its modulation of prostaglandin synthesis. ple causes and lead to a myriad of complications,
Ordesi and colleagues32 studied the effect of this including dehydration and wound dehiscence and,
plant enzyme on reducing postoperative pain in the worst case scenario, aspiration during the
and swelling after third molar surgery. Bromelain postoperative period. Controlling the potential
was found to significantly reduce the swelling causes of this complication may benefit patients
and inflammation of third molar surgery. When tak- and improve the overall experience by avoiding
ing bromelain tablets before surgery to 4 days after this issue when possible. Understanding the po-
surgery compared with diclofenac sodium tablets tential causes of PONV enables surgeons to see
started the day before surgery until 4 days after how to possibly modify their patients’ behavior
surgery, it was found to have compatible results and make pharmacologic choices for maximum
on the effect of reducing pain and swelling and benefit.
trismus after third molar removal.33 This natural There are 3 areas to address: the patients’ risk
supplement may be considered as an alternative factors, the anesthetic choices, and the type of
to NSAID therapy for improving the postoperative surgery done. Adequate management of PONV
course. should include an evaluation of the risk factors
associated with developing nausea, creating a
LOW-LEVEL LASER ENERGY IRRADIATION plan for the anesthetic drug choices, and possibly
planning to use prophylactic premedication as well
Low-level laser energy irradiation has been used as a plan for rescue antiemetic medications.
locally at the surgical site in an attempt to decrease There are 2 risk scoring systems available to
pain, swelling, and trismus after third molar help in patient risk assessment for PONV. In the
removal while also increasing tissue healing. The adult patient population, the Apfel risk scoring sys-
laser treatment is typically given both intraorally tem has been used (Box 1).40 In the pediatric pop-
and extraorally. The benefit of trismus reduction ulation, the Eberhart scale is used (Box 2). Risks
has been reported as well as decreasing pain and factors associated with higher incidences of
swelling. The decrease in pain with this technique nausea and vomiting may include the types of
comes from the reduction in edema, hemorrhage, anesthetic agents used, the length of surgery,
6 Drew
Box 1 the site of surgery, patient sex, and postoperative

Apfel score: for adult patients use of opioids. In a recent poster presented at the
American Association of Oral and Maxillofacial
Risk factors get one point each up to a total of 4 Surgeons 2014 annual meeting, Ashrafi and col-
points leagues41 presented their preliminary results on
Risks assessed trying to identify risk factors specific to ambulatory
anesthesia in the third molar surgery patient popu-
Female sex
lation. The incidence of nausea in the oral surgery
Nonsmoker populations was 54.0% and vomiting 11.49%.
History of motion sickness or PONV However, none of the risk factors mentioned in
Use of opioids during surgery or after surgery the research for the general anesthesia population
were found to correlate with our ambulatory oral
Interpretation of risk surgery population. One reason could be their
Score of 0 still have a 9% risk of PONV small sample size. Nonetheless, these factors
Score of 1 low risk has a 20% risk of PONV deserve further evaluation to see if there are any
areas where we can control PONV or postdi-
Score of 2 moderate risk has a 39% risk of scharge nausea and vomiting (PDNV) with good
PONV
anesthesia techniques and postoperative man-
Score of 3 high risk has a 60% risk of PONV agement of issues that are known to induce
Score of 4 high risk has a 78% risk of PONV nausea and perhaps vomiting.
(especially when narcotics are used)
Adapted from Apfel CC, Laara E, Kiovuranta M, et al. FEAR AS A CAUSE OF NAUSEA
A simplified risk score for predicting postoperative
nausea and vomiting: conclusions from cross vali- Fight or flight with release of endogenous cate-
dations between two centers. Anesthesiology cholamines and then with vagal stimulation may
1999;91:693–700. lead to nausea and perhaps syncope as well.
This concept is simple but difficult to control un-
less you can create a relaxed environment in
your offices and among yourself and staff. The pa-
tients’ fears will only be enhanced in a chaotic
setting. It is obvious that the fear factor can be
managed pharmacologically in the beginning of
sedation. However, emergence from anesthesia
is also an important factor for these patients’ over-
Box 2
Eberhart score
all experience. When a patient is extremely
anxious, consideration to using a benzodiazepine
Risk factors get one point up to a total of 4 during emergence may have a calming, although
points sedative effect. If a fearful patient wakes up feeling
Risks assessed nauseated, it may induce fear and, thus, potentiate
this unpleasant experience.
Surgery 30 minutes
Age 3 years old
ANESTHETIC DRUGS AND NAUSEA
Strabismus surgery
Side effects of multiple medications, especially
History of POV or PONV in relatives
narcotics and nitrous oxide, are thought to induce
Interpretation of risk nausea in the postoperative period. Nitrous oxide
Score of 0 has 10% risk of PONV works by releasing endogenous catecholamines.
Ketamine also releases endogenous catechol-
Score of 1 has 10% risk of PONV
amines. Opioid medications create nausea on
Score of 2 has 30% risk of PONV many different levels. They delay gastric emptying,
Score of 3 has 55% risk of PONV directly stimulate the chemoreceptor trigger zone,
Score of 4 has 70% risk of PONV release serotonin, and increase the sensitivity of
the vomiting reflex to signals from the vestibular
Adapted from Eberhart LH, Geldner G, Kranke P, et al. apparatus. In a high-risk patient population,
The development and validation of a risk score to pre-
dict the probability of postoperative vomiting in pedi-
consideration may be given to modify the types
atric patients. Anesth Analg 2004;99(6):1630–7. of drugs used for sedation to avoid PONV. Total
intravenous anesthesia with a combination of a
short-acting narcotic and propofol has been stud- TYPE OF SURGERY

ied and found to have less PONV compared with
the use of volatile anesthesia in the general anes- Hospital health care costs continue to increase. As
thesia patient population. This practice may be a consequence, access to care in the hospital has
translated to the ambulatory setting such that our been limited for many patients. This economic
sedation techniques can also be modified to follow challenge has caused a shift in our choice of loca-
these protocols.42 tion to deliver care. Thus, more oral and maxillofa-
cial procedures may be done in an ambulatory
setting. The delivery of anesthesia, even in the
LOCAL ANESTHESIA TOXICITY AND NAUSEA ambulatory office setting, may need to be via
Of special consideration is the careful monitoring general anesthesia with intubation using volatile
of the amount of local anesthesia one uses in the anesthetics and/or total intravenous general anes-
setting of dental surgery. Toxic doses of local thesia. From wisdom teeth to osteotomies to
anesthetics may not only manifest with cardiac temporomandibular joint (TMJ) arthroscopy, the
electrical changes but also nausea as an early types of surgery are quite varied among the surgi-
sign of toxicity. cal population in the office setting today. The rule
of thumb is the longer the procedure, the higher
the risk of PONV. The longer the procedures, the
INGESTION OF BLOOD AND NAUSEA more anesthesia is needed and the more clear-
The breakdown of blood into its various compo- ance time is needed to get rid of the agents for
nents and byproducts in the stomach may leave anesthesia. All oral surgery procedures come
patients in a negative nitrogen balance situation with some inherent risks of swallowing blood.
and lead to the feeling of nausea. In the outpatient The more postoperative oozing, the higher the
setting, adequate suturing, suctioning during sur- risks of PONV. Different anesthetic techniques in
gery, special oval-shaped sponges that have the ambulatory setting may be modified to mini-
been developed for throat screens during seda- mize the risks of PONV by considering the pa-
tion, and perhaps using microfibrillar collagen tients’ risks and timing of surgery when planning
plugs may be used to help obtain good hemosta- for determining either the anesthetic medications
sis and minimize the amount of blood swallowed as well as the use of antiemetic drugs.
in the outpatient setting.
ANTIEMETIC MEDICATIONS FOR THE
HYPOGLYCEMIA AND DEHYDRATION PREVENTION OF NAUSEA AND VOMITING:
CAUSING NAUSEA PREEMPTIVE VERSUS SYMPTOMATIC
MANAGEMENT
Patients who have not been eating or drinking
before oral surgery either because of dental pain Many different types of drugs may be used as an
or observation of nothing-by-mouth status are all antiemetic (Table 1). These drugs include pheno-
fluid depleted to some degree. Patients may also thiazines, butyrophenones, benzamines, anticho-
have a component of electrolyte imbalance, linergics, antihistamines, and serotonin receptor
including hypoglycemia. These factors in combi- antagonists. Each drug type has a specific target
nation with the potential fear-inducing experience and beneficial effect in preventing or alleviating
may lead to the development of nausea both PONV. Their individual side effects and potential
before and after surgery. Patients must be prop- drug interactions must be weighed against their
erly hydrated and have good postoperative pain benefits when considering their use either alone
control. This point is especially true for the patients or in combination.
who are operated on later in the day with sedation Phenothiazines (promethazine hydrochloride
techniques. They may be observing nothing-by- [Phenergan] and prochlorperazine [Compazine])
mouth status longer than the first patient of the are direct dopamine-2 receptor antagonists. These
day. receptors are located in the chemoreceptor trigger
zone (CRTZ). They also have antihistaminic and
SEX BIAS RELATED TO NAUSEA anticholinergic effects. It is thought that these drugs
can counter the emetic effects of opioids on the
Hormonal influences of the menstrual cycle create CRTZ. Benzamines (metoclopramide hydrochlo-
a propensity to have more nausea and vomiting ride [Reglan] and trimethobenzamide hydrochloride
within the first 8 days of menstruation. Several [Tigan]) are also dopamine-2 antagonists. They
studies have noted this to increase the chances work on both central and peripheral dopamine re-
of vomiting by 4 fold.43 ceptors. These medications also have serotonin or
8 Drew
Table 1
Quick reference guide for use of antiemetic drugs for PONV from oral and maxillofacial surgery
procedures
Antiemetic Agent Site of Action Side Effects Best Practice Uses Trade Names
Phenothiazines Dopamine-2 receptor Extrapyramidal Counter effects of Phenergan
antagonists in Respiratory opioids on CRTZ Compazine
CRTZ depression treating PONV
antihistaminic Sedation Longer acting
Anticholinergic Hypotension Lots of side effects
Shorten local effects Careful with patients
with dystonia
Benzamines Dopamine-2 receptor Serotonin receptor Good for nausea Reglan
antagonist both agonist/antagonist caused by Tigan
central and activity swallowing blood
peripheral caused by increase
gastric emptying
Butyrophenones Dopamine-2 receptor Arrhythmias: QT Use with caution in Droperidol
antagonist in CRTZ interval outpatient setting
and area postrema prolongation for PONV
a-blocker Hypotension
Anticholinergic Tachycardia
Anticholinergics Block acetylcholine Dry mouth Good for motion Dramamine
action on the Additive effects with sickness and Scopolamine
parasympathetic opioids vertigo
nervous system Consider in TMJ
surgery or early
ambulating
patients
See notes on
pretreatment with
scopolamine patch
Antihistamines H-1 receptor inverse Additive Good for nausea Vistaril
agonists with anticholinergic caused by anxiety Atarax
anticholinergic effects with Cyclizine
properties opioids
Serotonin receptor Block the CRTZ and — Fast onset Zofran
antagonists peripheral vagal Most expensive
receptors liked to Has oral dissolving
vomiting center tablet (ODT)
available
Use to prevent or
treat PONV
5-hydroxytryptamine (5HT-3) receptor agonist/ hydrochloride [Zofran]) block in both the central ner-
antagonist properties. The anticholinergics (dimen- vous system at the CRTZ and peripheral receptors
hydrinate [Dramamine] and scopolamine) block the at the vagal terminals, which are linked centrally to
action of acetylcholine on the parasympathetic ner- the vomiting center.
vous system. In the 2015 report by Brookes and The side effects of these drugs may cause any-
colleagues44 on using multimodal therapy to pre- thing from a dry mouth (anticholinergics), cardiac
vent PONV in patients with Le Fort I, they advocate arrhythmia changes (butyrophenones), additive
for the use of preoperative transdermal scopol- anticholinergic effects with opioids (anticholiner-
amine to alleviate the PONV associated with Le gics and antihistamines), more sedation, hypoten-
Fort surgery. Antihistamines (hydroxyzine [Vistaril], sion, respiratory depression, extrapyramidal side
hydroxyzine hydrochloride [Atarax], and cyclizine) effects and shortened desired effects of local anes-
are H-1 receptor inverse agonists that have anticho- thetics caused by increase epinephrine metabolism
linergic properties that work to prevent nausea. Se- (phenothiazines), and headache, constipation, and
rotonin 5HT-3 receptor antagonists (ondansetron dizziness (serotonin receptor antagonists).
Prophylactic use of antiemetic medications, manage, and treat PONV and PDNV. In this
such as ondansetron hydrochloride (Zofran), has comprehensive paper they remind us that a 20%
been suggested as a way to prevent PONV.45–47 to 30% incidence of PONV and PDNV can be
These medications are serotonin receptor antago- expected from sedation or general anesthesia in
nists. One of the most challenging patients to oral and maxillofacial surgery procedures. High-
manage postoperative nausea in is the tympano- risk patients should be identified and treated pro-
plasty patient group. This patient population has phylactically with antiemetic medications. The
been studied comparing the use of ondansetron use of anesthetic medications with antiemetic
versus dexamethasone versus placebo. They properties should be considered if appropriate.
found using either the ondansetron or the dexa- The use of anesthetic medications with antiemetic
methasone was more effective in controlling properties should be considered if appropriate.
PONV when compared with a placebo.48 The drugs one could consider may include Benzo-
However, the evidence to support prophylactic diazepines, propofol, and dexamethasone. The
use of ondansetron on every patient is lacking in addition of the steroid dexamethasone seems to
support in the oral and maxillofacial surgery litera- decrease the likelihood of PONV. Minimize the
ture because of the cost, safety, and adverse reac- use of opioids when appropriate, especially in
tions reported when using these drugs. Several the postoperative period. The same antiemetic
studies have compared the use of these medica- medication should not necessarily be used again
tions against a placebo and have found equivocal as rescue therapy if initial treatment of PONV fails.
results.49–51 Thus, their routine prophylactic use Silva and colleagues55 called for development of
cannot be advocated as an absolute at this time. protocols for preventing PONV in the orthognathic
A more logical approach would be to use the surgery population in 2006, and today Brookes
observation of more than one risk factor on the Ap- and colleagues44 have addressed these needs
fel scale as well as type and predicted length of based on good science and understanding of
surgery and likelihood of swallowing a great deal multimodal approach to managing PONV in the or-
of blood to guide the practitioner to consider using thognathic surgery population. Perhaps these pro-
preemptive medications. Otherwise treat PONV tocols can be studied and modified for our
symptomatically.52,53 outpatient surgical procedures in the future.
Consideration to the use of anesthetic agents
with antiemetic properties should also be consid- SUMMARY
ered (Table 2). The symptomatic treatment of
PONV seems to be a more reasonable approach Best practices refer to the most common and
for these patients. Cruthirds and colleagues54 proven techniques used in medicine and dentistry
have reviewed the pharmacology of the antiemetic that have predictable outcomes for our patients.
drugs and the current therapies to prevent, Best practices are used as a guideline for the
Table 2
Commonly used anesthetic agents in oral and maxillofacial surgery and their effects
Anesthetic Agent Emetic Pain Control Antiinflammatory Anxiolytic

Lidocaine 1 1 — —
Bupivacaine hydrochloride (Marcaine) 1 1 — —
Mepivacaine hydrochloride (Carbocaine) 1 1 — —
Articaine hydrochloride and epinephrine 1 1 — —
(Septocaine)
Midazolam — — — 1
Diazepam (Valium) — — — 1
Methohexital sodium (Brevital) — — — 1
Fentanyl 1 1 — 1
Remifentanil 1 1 — 1
Ketamine — 1 — 1
Propofol — 1 — 1
Nitrous oxide 1 1 — 1
Volatile agents 1 1 — 1
10 Drew
surgeon to help in managing and preventing com- 9. Portillo J, Kamar N, Melibary S, et al. Safety of lipo-
plications of surgery. The caveat is that not all pa- some extended –release bupivacaine for postopera-
tients will respond to our best practices protocols, tive pain control. Front Pharmacol 2014;5:1–6.
but most do. Understanding the complex nature of 10. Saraghi M, Hersh EV. Three newly approved analge-
the inflammatory response to our surgical trauma sics: an update. Anesth Prog 2013;60:178–87.
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helps to also guide us in finding ways to decrease removal of mandibular third molars. Oral Surg Oral
pain, swelling, nausea,and vomiting. Staying Med Oral Pathol Oral Radiol 2014;117(1):27–31.
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ing) and pain following removal of impacted 42. Fujii Y, Uemura A, akano M. Small dose of propofol
mandibular third molars. J Maxillofac Oral Surg for preventing nausea and vomiting after third molar
2013;12(2):184–7. extraction. J Oral Maxillofac Surg 2002;60:1246–9.
31. Akrakeri G, rai KK, Shivakumar HR, et al. 43. Ramsay TM, McDonald PF, Faragher EB. The
A randomized clinical trial to compare the efficacy of menstrual cycle and nausea or vomiting after wis-
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Surg 2013;12(1):73–9. col reduces postoperative nausea and vomiting in
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cacy of bromelain in impacted third molar surgery: illofac Surg 2015;73(2):324–32.
a randomized controlled clinical study. Quintes- 45. Talesh KT, Motamedi MH, Kahnamouii S. Compari-
sence Int 2014;45(8):679–84. son of ondansetron and metoclopramide antiemetic
33. Majid OW, Al-Mashhadani BA. Perioperative brome- prophylaxis in maxillofacial surgery patients. Oral
lain reduces pain and swelling and improves quality Surg Oral Med Oral Pathol Oral Radiol Endod
of life measures after mandibular third molar sur- 2011;111(3):275–7.
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controlled clinical trial. J Oral Maxillofac Surg a 4-mg preoperative intravenous dose of ondanse-
2014;72(6):1043–8. tron in preventing nausea and vomiting after maxillo-
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Developing and
I m p l e m e n t i n g a C u l t u re
o f S a f e t y i n th e D e n t o a l v e o l a r
Surgical Practice
James R. Hupp, DMD, MD, JD, MBA
KEYWORDS
Culture of safety Dentoalveolar practice Risk management
KEY POINTS
A culture of safety is the establishment and maintenance of organizational behavior in which
members of the organization place a high priority on identifying and rectifying safety issues.
Surgeons must take the lead in instituting a culture of safety and in continuing to nurture it over the
long run; discussions of safety matters should be a standard agenda item for office meetings.
The culture of safety in an oral-maxillofacial surgery dentoalveolar practice has several dimensions:
(1) clinical care safety, (2) intraoffice guest and health care team safety, and (3) safety from extra-
office dangers.
INTRODUCTION responsible for overseeing transportation, public

spaces, and facilities, and elected officials
Many industries face the problem of injuries due to creating regulations affecting food, drugs, and
accidents. Employee safety awareness programs other matters, attention to safety in the health
are longstanding in manufacturing firms, where care industry is a relatively new development.1
employees are exposed to dangerous environ- The works of Treadwell and colleagues2 and Ga-
ments. However, more recently, it has been recog- wande,3,4 among others, drew attention to the
nized that patients too may suffer injuries while problem of patient safety in the US hospital indus-
under the care of doctors. This finding has led to try. Their articles discuss how many foreseeable
the culture of safety movement within the health and preventable problems occur when patients
care industry. This article reviews some of the require hospitalization. These injuries are due to
background related to this relatively new focus wrong surgery site, improper drug administration,
on patient safety. The background is followed by and infections caused by unexpected pathogens,
a discussion of some practices hospitals have among a host of other issues.5 These errors were
put in place to reduce the risk of patient injury. not complications of needed care; instead, the
Then, the main thrust of this article focuses on alarm was raised because of not recognizing
how general concepts of a culture of safety can them as safety issues.
be applied to the oral-maxillofacial surgery (OMS) The airline industry has a long history of a focus
office, providing dentoalveolar surgical care. on safety.6 This focus on safety arose because of
the catastrophic results possible when a plane

THE CULTURE OF SAFETY CONCEPT crashes. Once the hospital industry was sensitized
to the common safety problems present in their
Although public safety has long been a focus of organizations, many turned to safety practices
police and fire departments, government officials used in the airline industry to address problems
School of Dental Medicine, East Carolina University, Greenville, NC, USA


406 Hupp
affecting hospital patients. The most important and compatible for the patient. Surgeons use time-
concept adopted by hospitals was the airline in- outs just before making the initial incision to
dustry’s culture of safety. double-check the patient’s identity, operative
A culture of safety is the establishment and site, consent, allergies, preoperative medications
maintenance of organizational behavior in which given, all needed supplies available (implants,
members of the organization place a high priority bone plates, drill bits, and so on), and all needed
on identifying and rectifying safety issues (Box 1). equipment available, among other necessities.
When hospitals work to develop a culture of Hospital safety protocols also relate to issues
safety, they strive to have all clinical staff mem- such as patient falls, giving patients the wrong
bers, including doctors, nurses, and medical tech- dose or wrong medication, and failure to hand
nicians as well as others on the hospital staff who wash between patients during rounds. Hospitals
play a role in patient care, understand and accept also usually have protocols in place to address
the responsibility to identify and help to mitigate nonclinical problems, such as fires, bomb threats,
patient safety risks. Commonly, hospitals appoint intruders, and power outages. It is now common
safety officers to head the culture of safety activ- for safety issues to be part of medical staff meeting
ities. Such activities include establishing the use agendas and various standing committees of the
of checklists and operating room timeouts, blood hospital. Through these efforts, the frequency of
bank storage and delivery protocols, hand- patient injuries has dropped dramatically.
washing routines, and drug administration algo-
rithms. Institutions with an effective culture of CULTURE OF SAFETY IN ORAL-
safety establish safety monitoring and injury re- MAXILLOFACIAL SURGERY
porting protocols.7,8 In addition, policies are de-
signed to mandate root cause analysis of patient OMS practices with a culture of safety see several
injuries, followed by meetings to develop and benefits. The incidence of patient injuries de-
implement preventative practices that are then creases, an obvious positive outcome. Injuries
disseminated throughout the organization. As not only affect the health and satisfaction of the
with any initiative of this magnitude, the institu- patient suffering the harm, but can affect a prac-
tion’s leadership plays a critical role in ensuring tice’s local reputation and be a trigger of legal
its success. action. Thus, patient safety is a winning strategy.
Workplace injuries are also deleterious to a prac-
HOSPITAL SAFETY PRACTICES tice. Doctors and staff injuries on the job often
result in lost workdays, a decrease in practice
Because most oral-maxillofacial surgeons work to income, and lowered morale. Therefore, a practice
some degree in hospitals, they are familiar with that has developed a culture of safety should take
some of the practices hospitals now use to help steps to make patients and new employees of the
protect patients from injuries. In the operating practice aware of the high priority the organization
suite, most hospitals require surgeons to have pa- places on keeping everyone as safe as possible.8,9
tients initial the site of surgery before they begin The culture of safety in an OMS dentoalveolar
the anesthesia process. Initialing the site of sur- practice has several dimensions. These dimen-
gery has helped decrease the incidence of wrong sions are as follows:
site surgery, including the amputation of the wrong
body part. Anesthesiologists often use checklists 1. Clinical care safety
to prepare to give anesthesia, helping make sure 2. Intraoffice guest and health care team safety
the proper equipment and drugs are available, 3. Safety from extraoffice dangers.
any known allergies or previous untoward reac- Each plays an important role when embracing
tions are identified, and the correct patient re- the culture of safety concept.
ceives the correct care. Blood products are
triple-checked to ensure they are appropriate
CLINICAL CARE SAFETY
OMS offices have a strong track record of taking
Box 1 steps to avoid patient harm in the provision of clin-
Culture of safety definition ical care. These steps relate to various aspects of
patient management. Dentoalveolar surgery–
A culture of safety is the establishment of orga-
nizational behavior in which members of the related precautions include ensuring the correct
organization place a high priority on identi- tooth to be removed or surgical site to be operated
fying and rectifying safety issues. on is double-checked by the surgeon and assist-
ing staff. This step is similar to the timeout strategy
Developing and Implementing a Culture of Safety 407
used in hospital operating rooms. This step helps expiration date of drugs, double-checking that the
slow down what is often a hectic schedule at the correct drug and dosage are being administered
moment when haste may lead to critical errors. to the right patient, double-checking that indwelling
Other evidence-based safety measures include lines are indeed in a vein before using them for drug
keeping incisions distal to lower third molars over administration, and double-checking that patient
the lateral cortex of the ascending ramus, avoiding allergies and other history of adverse drug reac-
overelevation (retraction) on the lingual aspect of tions are documented and reviewed before giving
lower third molars, carefully elevating maxillary a patient any drug, including prescriptions. Small
molar teeth before or instead of using extraction patients and those under the age of 12 require
forceps, and carefully measuring the distance adjustment of dosages of anesthetic drugs and
over the inferior alveolar canal before the implant other medications to avoid untoward reactions.
site preparation. Rotary equipment is a common Patients can also suffer nonphysical injuries
threat to patient safety. Such equipment can when receiving health care. Following HIPPA
develop heat in the cutting area and along the (Health Insurance Portability and Accountability)
shaft capable of burning patient tissue. Irrigation regulations will minimize these risks. In addition,
prevents heat accumulation at the surgical site, because patients often use credit cards to pay
but not elsewhere on the drill. Recently autoclaved for services, office computer equipment should
instruments not allowed to properly cool are have software in place that lessens the chances
another source of patient burn injuries. A spinning of identity theft.
burr can easily cut tissue outside of the surgical The final aspect of clinical care safety involves
site if allowed to rotate while inserting or removing being cognizant of and making appropriate care
the drill from the site. Similar unwanted cuts can modifications for patients with medical conditions.
occur if the surgeon is not focused on the scalpel A well-planned and executed protocol for docu-
blade while it moves to and from the planned inci- menting and updating patient health issues is
sion site. Oral and maxillofacial surgeons are important to prevent or be prepared to manage
trained in numerous other means of lowering the medical emergencies affecting ambulatory office
incidence of unplanned surgical injuries. patients. This area is another area where having
Anesthetic injuries are also possible. Their pre- an emergency management case or cart and con-
vention usually revolves around careful prepara- ducting periodic drills are essential.
tion to manage emergencies and precisely
monitoring the patient while anesthetized. Pulse INTRAOFFICE GUEST AND HEALTH CARE
oximeters and end-tidal carbon dioxide monitors TEAM SAFETY
are important means of detecting patient hypoxia
or bradypnea. When these monitors are added to Injuries in the OMS office can occur to nonpatients
the surgeon’s and assistant’s visual monitoring of as well. These injuries can affect individuals
the anesthetized patient, problems potentially accompanying patients, delivery people, cleaning
leading to patient injuries are highly unlikely. Pre- crews, and others that fall into the category of of-
paring for managing anesthetic emergencies is fice guests. Safety concerns affecting guests typi-
also part of a culture of safety. Again, oral and cally relate to problems such as wet floors, loose
maxillofacial surgeons typically ensure the ready rugs, and other tripping hazards and things
availability of airway adjuncts, drug reversal located where they might cause head injuries,
agents, and resuscitation equipment and supplies. such as low hanging objects or heavy objects sus-
Checklists can be useful for this task. Regular sur- ceptible to falling from elevated sites. Because
gical team emergency drills are another compo- many patients may have young children accompa-
nent of emergency preparation. After surgery, nying them, office reception areas should be
clear protocols should be in place for when screened to remove items that may risk harm to
patients may be moved, how they are monitored young guests. Regularly monitoring for all potential
during recovery and by whom, and formal criteria hazards is part of an office culture of safety.
for discharge to the care of their escort. Finally, Clinical care team safety is another facet of pre-
for child patients, long-acting local anesthetics venting injuries. The OSHA (Occupational Safety
should be avoided. and Health Administration) has many regulations
Medication errors are more likely in a hospital in place that mandate certain employee safety
setting simply because of the larger variety and fre- practices. The owners of OMS practices are usu-
quency of administration compared with an OMS ally well aware of those requirements that include
office. However, oral and maxillofacial surgeons the safe use of chemicals, radiation, and power
and their team should take similar steps to protect equipment. In addition, the increase in the use of
patients. These steps include checking the universal precautions during the 1980s made the
408 Hupp
wearing of protective garments, masks, and is usually fully under the control of the surgeon
eyewear become routine. Similarly, the adoption and their staff. Much of this control is lost once
of protocols involving the proper use and disposal patients, guests, and care team members leave
of sharps has also improved workplace safety. the office. An office site controlling its own external
Because back injuries are common in the work- walkways and parking facilities does have some
place, protocols for lifting heavy objects or control over things such as tripping or slipping
patients should be established. The main thrust hazards and should regularly monitor those parts
of an office seeking to grow a culture of safety of the property, including ensuring proper ice
for the patient care team is not just to develop and snow removal when applicable. The owners
safety practices but also to ingrain in team mem- of the practice who identify dangers in public areas
bers an unwavering adherence to established pro- near their property, such as broken sidewalks or
tocols and comfort in reminding those forgetting to nonfunctioning street illumination, can alert public
follow them (Box 2). agencies to the areas in need of repair. The dan-
gers of external office assaults or robberies on
the premises might be mitigated by security
SAFETY FROM EXTRAOFFICE THREATS
fencing, escorts to vehicles, and video monitoring
Although complex and time-consuming to estab- equipment. Other dangers may be totally out of
lish, creating a culture of safety in the OMS office anyone’s control, including electrical outages,
severe weather, fires, floods, and earthquakes. In
these cases, an office with a culture of safety
Box 2 should develop contingency plans of how office
Safety threats in oral-maxillofacial surgery staff should react to protect patients and guests,
practice as well as themselves, in the event of an actual
or threatening emergency. These protocols should
Clinical care examples be in writing and known to members of the staff to
Treatment at wrong site/on wrong tooth help minimize the chances of preventable injuries.
Nerve damage from incisions, retraction, or
power equipment ESTABLISHING A CULTURE OF SAFETY
Tuberosity fracture
Although protecting patients, guests, and em-
Soft tissue burns ployees from injuries makes perfect sense, estab-
Damage outside of surgical field lishing a true culture of safety can be challenging.
Damage to vital structures during implant It is easy to take shortcuts in patient care that
placement bypass safety protocols, because many shortcuts
take less time and less thought and focus than
Hypoxia during advanced forms of anesthesia
ensuring safety practices are followed. Employees
Drug overdose or incorrect drug used may not understand or care why a culture of safety
Premature discharge after anesthesia is important. Having a culture of safety in place
does put the onus on everyone to be vigilant
Care team and guest examples
when at the office to look for hazards and take
Tripping and slipping the steps necessary to remove or reduce the risk.
Electrical shocks Therefore, it is mandatory that an office’s sur-
Chemical burns geons take the lead in instituting a culture of safety
and in continuing to nurture it over the long run.
Radiation overexposure
Discussions of safety matters should be a stan-
Injury from sharps and power equipment dard agenda item for office meetings. Staff mem-
Contraction of infectious diseases bers identifying ways to improve office safety
Back injuries
should receive encouragement, and all staff
should understand that helping foster office safety
External threats is an essential part of their job. Surgeon leaders
Tripping and slipping need to “walk the walk,” closely following safety
protocols and making it clear by word and deed
Assaults and robberies
that safety is an organizational priority.
Severe weather The OMS dentoalveolar office, like a hospital,
Floods, earthquakes, and fires can be the site of injuries to patients, guests, and
Electrical outages employees. By establishing and promoting an
office culture of safety, preventable injuries can
Developing and Implementing a Culture of Safety 409
be minimized. Like other measures used to ma- patients – results of the Harvard Medical Practice
nage risk and potential liability, a culture of safety Study I. N Engl J Med 1991;324:370–6.
can provide valuable peace of mind to those 6. Schamel J. How the checklist came about. Flight Service
responsible for ensuring the success of an OMS Station History. 2012. Available at: http://www.atchistory.
office. org/History/checklst.htm. Accessed April 20, 2015.
7. Does improving safety culture affect patient out-
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Qual Saf 2014;23:299–318. Pages/Changes/DevelopaCultureofSafety.aspx. Ac-
3. Gawande A. Complications: a surgeon’s note on an cessed April 20, 2015.
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4. Gawande A. The checklist manifesto. New York: what do we need to know? Fundamental patient safety,
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adverse events and negligence in hospitalized 189–96.
Tr i g e m i n a l N e r v e I n j u r i e s
Avoidance and Management of
Iatrogenic Injury
Sami A. Nizam II, DMD, MDa, Vincent B. Ziccardi, DDS, MDb,*
KEYWORDS
Trigeminal nerve injuries Iatrogenic injury Dentoalveolar surgery
KEY POINTS
Neurosensory disturbances after dentoalveolar surgery remain a significant concern for patients
and surgeons.
Mechanisms of trigeminal nerve injures resulting from dentoalveolar injury include surgical end-
odontic therapy, removal of impacted teeth, local anesthetic nerve blocks, implant placement,
bone grafting, and management of oral and maxillofacial pathology.
Current literature indicates third molar removal has the highest overall risk for injury to either the
inferior alveolar nerve or lingual nerve, occurring in 0.4% to 22% of cases.
Iatrogenic injury to the trigeminal nerve can remain a source of concern and litigation even for the
most experienced oral and maxillofacial surgeons.
INTRODUCTION anesthetic nerve blocks, implant placement, bone

grafting, and management of oral and maxillofacial
The specialty of oral and maxillofacial surgery has pathology. Libersa and colleagues1 conducted a
continued to broaden its scope; however, the review of insurance claims from 1988 to 1997 in
most significant aspect of many practices remains France. They grouped nerve injury patients into
dentoalveolar surgery. The specialty’s commit- one of four groups: (1) surgical procedure (removal
ment to maintaining excellence and providing the of teeth excluding third molars, cysts, and nerve
highest standard of care is paramount for patients, blocks), (2) third molar removal, (3) endodontic
and is the overall theme of this issue. Neurosen- treatment, and (4) implant placement. It was deter-
sory disturbances after dentoalveolar surgery mined that third molar removal had the highest inci-
remain a significant concern for patients and sur- dence of injury (40.8%), followed by endodontic
geons. This article focuses on identifying mecha- therapy (35.3%), other surgical procedures
nisms of trigeminal nerve injury and their (20.7%), and implant placement (3.2%). This is
prevalence, pertinent preoperative evaluation, consistent with typical clinical practice in which
strategies to minimize risk, identification of injury third molar removal is the most commonly per-
including sensory testing, indications for referral formed surgical procedure in most oral and maxillo-
to microsurgeons, and a discussion of medical facial surgery offices. In 2011, Renton and Yilmaz2
management options. published their study describing causes of 93
Mechanisms of trigeminal nerve injuries resulting lingual nerve injuries and 90 inferior alveolar nerve
from dentoalveolar injury include surgical end- injuries and reported similar findings to the previ-
odontic therapy, removal of impacted teeth, local ously mentioned study. In regards to inferior
a
Oral and Maxillofacial Surgery; b Department of Oral and Maxillofacial Surgery, Rutgers University School of
Dental Medicine, 110 Bergen Street, Room B854, Newark, NJ 07103-2400, USA
* Corresponding author.

2 Nizam II & Ziccardi
alveolar nerve (IAN) injury, third molar surgery was Panoramic radiograph should be considered a
again the most common (60%), followed by local standard of care in the preoperative evaluation of
anesthetic injections (19%), implants (18%), and patients with impacted third molars. In 1990,
endodontic surgery (18%). The higher prevalence Rood and Shehab5 published their landmark
for implant-related injury likely highlights the article correlating panoramic radiographic imaging
increasing prevalence of implant placement by with potential IAN injury. They described three fac-
nonsurgeons. They also reviewed lingual nerve tors that were considered to indicate high potential
injury in their population and found 73% to be for IAN injury because of proximity of the impacted
caused by third molar removal and 17% by local third molar roots with the IAN. These radiographic
anesthesia injections. findings included radiolucency of the IAN canal
shadow across the root of the impacted molar,
PREOPERATIVE EVALUATION deviation or deflection of the IAN canal, and inter-
ruption of the white line delineating the superior
As with any surgical procedure, patient evaluation and inferior margins of the IAN canal. Two of these
begins with review of chief complaint, medical his- signs are present in the panoramic film depicted in
tory, and physical examination. This should be Fig. 1. Signs that were considered clinically impor-
augmented with appropriate imaging studies. Af- tant were deflection of third molar root by canal
ter data have been collected, a true appreciation and narrowing of third molar root. Many studies
of risks and benefits can be presented to the have confirmed these as reliable indicators of
patient as part of the informed consent process. involvement of the IAN and most practitioners still
Patient selection, indicated procedures, risks, use these criteria in the preoperative evaluation of
and benefits can be discussed with the patient us- patients before third molar surgery.5
ing American Association of Oral and Maxillofacial With the advent and availability of cone-beam
Surgeons Parameters of Care as a guide.3 computed tomography (CBCT), many oral and
Current literature indicates third molar removal maxillofacial surgery practices use this advanced
has the highest overall risk for injury to either the imaging modality in the preoperative risk assess-
inferior alveolar nerve or lingual nerve, occurring ment of patients with complex impacted third
in 0.4% to 22% of cases. This is well appreciated molars. This is not advocated for the routine eval-
by the oral and maxillofacial surgery community uation of every third molar patient because of cost
because there is a significant body of research and radiation exposure; however, it remains a use-
devoted to the issue of trigeminal nerve injury ful supplementary imaging modality in those pa-
including prevention, assessment, and manage- tients identified on panoramic radiographs as
ment. Patients older than age 35 have an increased being high risk for IAN injury because of local pa-
risk of IAN injury presumably from denser cortical thology or the relative position of the impacted
bone, fully developed root structure, concomitant tooth with the IAN canal. Most of the reported
medical conditions, and decreased healing poten-
tial. The type of impaction and operator experience
correlate with increased risk of nerve injury, specif-
ically depth and angulation of the impactions. The
more tissue manipulation and/or bone removal
required correlates with increased risk of injury.
For instance, there is an increased chance of injury
in horizontally impacted teeth when compared with
mesioangular, vertical, or distoangular impactions.
Third molars removed in the operating room under
general anesthesia have also been shown to have
increased chance of injury, presumably from
increased forces and overall more difficult case se-
lection.4 The authors have also hypothesized that
local anesthetic nerve blocks given to patients un-
der general anesthesia could potentially have an
increased incidence of nerve injuries because pa-
tients are unable to respond to injections while un-
der general anesthesia. For this reason, the
authors do not administer nerve blocks to patients Fig. 1. Multiple impacted teeth with root darkening
under general anesthesia, but rather use local infil- at the apex of #18 and diversion at the apex of tooth
tration techniques. #19 evident on panoramic radiograph.
Trigeminal Nerve Injuries 3
research focuses on those patients determined to American Association of Oral and Maxillofacial
be high risk by Rood’s criteria. It is known that Surgeons Parameters of Care states “Indications
exposure or contact of a tooth root with the IAN for cone beam computed tomography for routine
increases the chance of nerve injury 20% to third molar surgery should be documented before
30%.6 Researchers have focused on assessment ordering scans and follow the principles of ALARA
of decortication of the IAN canal by the root of (as low as reasonably achievable),” essentially
the third molar as a risk factor. Nakamori and col- leaving the decision to the surgeon’s discretion.3
leagues7 found that when Rood’s criteria were Lingual nerve injury during third molar removal
present, there was a greater than 50% chance of occurs at a similar rate of 0.4% to 22% of cases.
decortication of the IAN canal. The group MRI studies have elucidated the preoperative po-
cautioned, however, that teeth that were deemed sition of the nerve to be at or above the height of
superimposed and did not meet Rood’s criteria the lingual alveolar crest in 10% of patients and
still had a 32% chance of demonstrating decorti- in contact with the lingual plate in 25% of cases
cation of the canal. Guerrero and colleagues8 in the third molar region.12,13 Fig. 3 demonstrates
examined just this group and determined that an example where a high lingual nerve was
CBCT is more accurate than panoramic radio- damaged during extraction of tooth #32 and sub-
graphs; however, clinically this did not result in a sequently reconstructed. Anatomic factors, such
difference in neurosensory outcome for patients. as lingual angulation of the impacted tooth and
Selvi and colleagues9 recently examined the need for vertical sectioning, increase the risk of
high-risk group of patients and found that in partic- lingual nerve injury.4 Ultrasound has also recently
ular, darkening of the root did correlate with been described as an alternative imaging modality
cortical perforation on CBCT. Furthermore, a for assessing the path of the lingual nerve in this
decortication of the canal greater than 3 mm corre- region. Benninger and coworkers14 using ca-
lated with an increased risk of injury at time of sur- davers described the path of the nerve as traveling
gery.9,10 Fig. 2 presents a sagittal and coronal CT on average 13.2-mm anteriorly from the distolin-
image of the same patient presented in Fig. 1 that gual aspect of the third molar before it turned infe-
was selected for further imaging based on Rood’s rior and medial to innervate the tongue on
criteria. ultrasound studies. They additionally reported the
Proponents of advanced imaging, such as nerve being 7.3-mm inferior to the lingual alveolar
CBCT or traditional CT scanning, state that crest on average, with this number remaining
advanced imaging allows for formulation of surgi- similar between dentate and edentulous patients.
cal plans and therefore avoidance of iatrogenic This 13.2-mm anterior travel along the lingual cor-
injury to the nerve. This is highlighted by Umar tex places it in intimate contact with the second
and colleagues,11 where 200 teeth demonstrating molar site and provides a route for potential iatro-
contact with the IAN on imaging were removed genic injury during third molar surgery.14
with a 12% incidence of temporary hypoesthesia Preoperative evaluation for implant patients also
and no permanent deficits. Opponents argue that begins with thorough physical examination. Bone
there have been no randomized clinical trials stock availability and bone defects can be appre-
demonstrating actual outcome benefit with ciated through bimanual palpation. If a thin ridge
advanced imaging. In light of current controversy is encountered and bone height will be removed
over the role of advanced imaging, the most recent for implant placement, this vertical change needs
Fig. 2. CT scan images of the patient

in Fig. 1. Note the loss of decortica-
tion of the canal on teeth #18 and
#19. The inferior alveolar nerve is
noted to be present in the notched
apex of impacted tooth.
establishing bone heights for better mechanical

stability of implants. CBCT and other implant plan-
ning software could also be used to position
implants buccal or lingual relative to the IAN canal
if indicated.
A similar algorithm can be developed for
implants placed in the mental foramen region,
the only difference being the placement of
implants anterior to the foramen because of a
possible anterior loop of the nerve before exit
from the bony canal. Greenstein and colleagues16
Fig. 3. Example of lingual nerve above the lingual reviewed the literature on this subject and found a
crest (10% incidence), which was subsequently injured wide variance of not only presence of the anterior
during extraction of tooth #32. The nerve has been re- loop but also its distance when it exists. If a
paired after excision of neuroma and covered with planned implant osteotomy encroaches within 2-
Neuragen collagen conduit from Integra Life Sciences
mm superiorly or anterior to the mental foramen,
(Plainsboro, NJ).
they suggest two options: CBCT or surgically
probing the canal with a Nabers 2N probe at
to be factored into the final height of bone avail- time of surgery. The key to probing is to probe
able for implant placement. As with third molar the distal aspect of the foramen. If it is not patent,
removal, panoramic imaging remains clinically this means the nerve enters from an anterior to
useful for the initial evaluation of implant patients posterior region signifying an anterior loop. This
with the understanding that distortion can create same procedure cannot be performed probing
inaccuracy of up to 25%. Standardization can be anterior in the foramen because the incisive
accomplished by placing a known-size metallic portion of the canal will be probed. The authors
object in the area of interest and accounting for advocate maintaining a distance of 5-mm anterior
distortion based on actual measurements of the to the visible mental foramina to avoid injuries to
metallic object. Once the radiograph is taken, a the anterior loop of the IAN.
simple conversion formula can be used to deter- Planning for periradicular endodontic surgery in
mine actual bone height ([radiographic bone the posterior mandible starts as described previ-
height/radiographic marker size] x [N/actual ously with physical examination including neuro-
marker size], where N is actual bone height). A 2- logic examination. Although rare, numerous
mm margin of safety should be minimally main- reports exist of periapical infection and inflamma-
tained above the IAN canal. If this margin is not tion producing temporary neurosensory distur-
available or poor visualization of the nerve is pre- bances. This may occur because of roots of the
sent, then an advanced imaging technique, such premolars and distal root of the second molar hav-
as CBCT, should be considered.15 Fig. 4 shows ing close proximity to the IAN with inflammation or
an instance where a 2-mm safety margin was not pathology at the apex.17 This provides clinical in-
maintained at time of implant placement. Alterna- formation as to the indication of close involvement
tively, bone augmentation of the deficient ridge is of the IAN and the possibility of a more serious
an option to be discussed with patients in re- cause, such as malignancy, to be ruled out with
Fig. 4. (A) Panoramic image of patient with bilateral IAN damage caused by improper planning before placement
of ceramic implants. Also note osteotomy shadows bilaterally, which represent temporary implants removed by
secondary surgeon that also contributed to nerve injury. (B) Same patient demonstrating bilateral compression of
the IAN at the mental foramen and body region.
laboratory assessment of pathologic tissues. Vel- intraoperatively, which can be protected by

vart and coworkers18 examined a series of 78 covering with resorbable gelatin sponge.
patients scheduled for periradicular endodontic For routine extractions, a plan is formulated that
surgery and found definitive identification of the allows the least amount of force, trauma, and
IAN in only half of these patients and evidence of development of postoperative edema to be placed
the periapical lesion in only 61 of the 78 patients. on the neurovascular bundle. Preoperative ste-
They suggested if the mandibular canal cannot roids have been found in small studies to attenuate
be detected in imaging or is in close proximity, sensory disturbances after extraction of third mo-
CT scan should be used to delineate the existing lars.19 Additionally, nonsteroidal anti-inflammatory
anatomy and provide the added benefit of eluci- drugs (NSAIDs), in particular diclofenac, have
dating the three-dimensional anatomy around the been shown by Shanti and coworkers20 2013 to
tooth apex.18 Fig. 5 depicts the postoperative attenuate post–sciatic nerve injury in a rat model.
panoramic radiograph of a patient who underwent The combination of dexamethasone and diclofe-
apicoectomy of tooth #19 with injury to the IAN. nac was studied in 2005 with a preoperative
dose of 8-mg dexamethasone and 50-mg diclofe-
nac and a postoperative dose of 4-mg dexameth-
SURGICAL STRATEGIES FOR AVOIDANCE OF asone and continued 5-mg diclofenac two times a
INJURIES day for 5 days. The combination was found to be
synergistic when compared with either agent
After risk stratification using the previously
alone and provided statistically significant
mentioned methods, discussion with the patient
decrease in short-term pain and swelling.21 Pro-
occurs to decide on the particular surgical proce-
phylactic antibiotics have recently been demon-
dure to be performed. If the patient fits into a
strated in the Cochrane database to prevent
high-risk category for any of the previously
complications after extractions of third molars.22
mentioned reasons and there is no active pathol-
In light of the data, and the added benefits of pa-
ogy associated with impacted teeth, partial inten-
tient comfort, it seems reasonable that a preoper-
tional odontectomy or orthodontic extrusion
ative dose of steroids, NSAID, and antibiotic may
should be considered. Surgeon experience has
be advised before undertaking complex third
also been found linked to lower incidence of post-
molar impaction surgery.
operative neurosensory deficits.4 For the experi-
Complex impacted tooth removal may require
enced surgeon, a traditional extraction may still
the use of releasing incisions. On designing the in-
be attempted with good outcome if the prior stated
cisions, the surgeon must also pay particular atten-
algorithm is used and no absolute contraindica-
tion to the lingual crest because of variability in the
tions to extraction exist.11 The authors often use
position of the lingual nerve necessitating a disto-
this approach after advanced imaging with surgery
buccal release to avoid nerve injury.13 In rare cir-
performed in the operating room under general
cumstances, the nerve may take a path across
anesthesia to allow potential repair of any wit-
the retromolar pad, in which case lingual nerve
nessed nerve injury at the time of surgery. These
injury is almost unavoidable in even the most skilled
cases often demonstrate exposure of the nerve
hands. Once a surgical flap is developed, a subper-
iosteal dissection is undertaken. If the preoperative
plan dictates need for distal bone removal, a lingual
flap may be retracted for better visualization and
protection of the lingual nerve. This technique has
been shown to result in higher temporary neurosen-
sory disturbance but no increase in long-term
disturbance (something that should be disclosed
during the consent process).23 The surgical plan
is then carried out with appropriate troughing of
the bone to the level of the cementoenamel junction
to allow for visualization and performance of
sectioning with caution not to encroach on the
lingual plate. Once the crown is sectioned and
removed, roots can be delivered with minimal force
to allow for copious socket irrigation. A visual
Fig. 5. Apicoectomy was performed on this patient assessment of the socket is then undertaken noting
without the use of advanced imaging despite close any lingual perforation or exposure of the IAN neu-
proximity to the IAN nerve resulting in nerve injury. rovascular bundle, which should also be noted in
the patient record. It may be advised to document Partial intentional odontectomy or coronectomy
pertinent negative findings at this time, such as provides another option (discussed elsewhere in
intact lingual plate, no bone fractures, no active this issue). Contraindications for intentional partial
bleeding from socket, and no visualization of the odontectomy include significant medical comor-
IAN noted. Fig. 6 presents intraoperative photo- bidities, such as immunocompromization, patients
graphs of the same patient in Figs. 1 and 2. Wide planned for or having received radiation therapy,
access was obtained with releasing incisions in patients with poorly controlled diabetes, and the
an operative room setting with the patient under presence of local pathology that contradicts use
general anesthesia. Note the exposure of the IAN of this technique.27 Horizontally impacted teeth
as preoperative CT predicted. The site was recon- have been reported as a relative contraindication,
structed using gelatin sponge as a protective bar- although a recent article by Monaco and col-
rier over the nerve and then grafted with leagues28 reporting on this technique found no
allogeneic bone and finally collagen membrane. complications when treating horizontal impactions.
If control of hemorrhage becomes necessary, Orthodontic extrusion is another potential op-
the appropriate agent must be selected. Alkan tion for extraction of third molars at high risk; how-
and colleagues24 reviewed four commonly used ever, the authors have minimal experience with
hemostatic agents and found oxidized regener- this techniques and it has had limited review in
ated cellulose to cause an increase in compound the literature. Orthodontic anchorage is first ob-
action potentials and decrease in nerve conduc- tained with banding of the first molars and a stain-
tion velocity at 1 hour, with full sensory recovery less steel lingual arch wire welded too it. The
by 4 weeks. They found a gelatin sponge to anchorage is further strengthened with a stainless
demonstrate an increased compound action po- steel sectional wire from second molar to first
tential at 4 weeks, although their sponge was bicuspid. Tooth angulation dictates bracket posi-
coated with silver potentially causing this effect. tion. Vertical or distal angulated teeth require
They cautioned against the use of bone wax bracket placement on the occlusal surface
because of case reports of chronic inflammation centered in an axial position. Mesially or horizon-
and embolization to the lungs. They concluded tally inclined teeth require bracketing on the distal
that bovine collagen was the safest agent in surface of the crown and possibly stripping of a
regards to adverse effects on neural function. portion of the crown. Regardless of impaction
Collagen conduits are a popular choice for nerve type, advanced imaging is necessary to appre-
entubulization techniques clinically. ciate vector of forces required to erupt the roots
Once hemostasis is obtained, a single suture away from the canal. After 1 week of soft tissue
should be placed for partial closure distal to the healing, a cantilever wire is placed off the buccal
second molar. A review of recent literature tube on the first molar to the bracket placed on
revealed this to be the best overall closure method the impacted third molar. This is then adjusted
in regards to edema and ease of application.25 every 4 to 6 weeks until the tooth is extruded. A
One must also be aware of proximity to the lingual panoramic radiograph is then taken once clinical
nerve and not take an excessive bite of lingual tis- extrusion has been confirmed. Standard third
sue to avoid incorporating the lingual nerve with molar impaction techniques can be used once
suturing, which can directly damage the nerve the risk of injury to the IAN is minimized.29
with the needle, and potentially compressing the Intraoperative techniques can be used to mini-
nerve after tie down of the suture.26 mize nerve injuries during placement of dental
Fig. 6. Intraoperative photographs of

the same patient in Figs. 1 and 2. On
the left note the exposure of the IAN
at the apex of #18 as predicted by CT
scan. The image to the right shows
allograft placed over gelatin sponge,
which was used as a protective barrier
of the IAN. The patient underwent a
short period of maxillomandibular
fixation and experienced no neuro-
sensory deficits postoperatively.
implants in the mandible. This starts with local material. In an in vitro model, mineral trioxide aggre-
anesthesia techniques where some have advo- gate was found to be the only root end filling mate-
cated the use of infiltration versus a block, allowing rial that was incapable of inducing neurotoxicity
the patient to respond to pain if there is encroach- even while setting.34 Because of its favorable
ment on the nerve.30 If a flap is being reflected and biocompatibility it provides an excellent material
it is in the second molar region, the practitioner choice when the IAN is in close proximity. If guided
must be cognizant of the potential for proximity bone regeneration is planned and graft material is
to the lingual nerve.14 Careful retraction of the placed at the apex one must ensure it is not com-
flap in the mental nerve region and skeletonization pacted into the canal. Fig. 7 depicts intraoperative
of the nerve as it exits the mandible may also be photographs of the same patient in Fig. 5. The nerve
necessary to avoid traction injuries. During osteot- had presumably been damaged from aggressive
omy preparation, use of periapical radiographs curettage or rotary instrumentation at the time of
with marking pins has been shown to decrease injury. Foreign body was noted within the resultant
the chance of neurovascular encroachment, scar tissue and submitted to pathology.
particular in cases of marginal vertical height.31 Although no preoperative evaluation can avoid
Some also advocate the use of stoppers on os- local anesthetic-related nerve injury, injection
teotomy burs to avoid overpenetration.15 Osteot- technique can play a role. When performing
omy sites should be palpated with blunt probe to mental nerve or inferior alveolar nerve blocks, the
ensure there is no decortication of the nerve canal. surgeon should aspirate before injection. If a pa-
Surgical guides have been demonstrated to in- tient reports an immediate jolt or shock-like sensa-
crease accuracy, although these guides must be tion, the needle should also be withdrawn and
properly positioned to avoid inaccuracy when redirected to avoid intraneural injection. The event
transferring from the virtual plan to the patient. A should be documented in the chart to help differ-
2-mm safety zone should still be followed to allow entiate cause in the event a nerve injury occurs.32
for any potential inaccuracies. Thermal injury can The use of high-concentration local anesthetics
occur even without direct penetration because of should be avoided, and multiple blocks if at all
lack of appropriate irrigation or high-drill speeds. possible. In particular 4% prilocaine and 4% arti-
If graft materials are placed and there is decortica- caine are 7.3% and 3.6% more likely to cause
tion of the canal, this material may be mechanically paresthesia when used for IAN nerve blocks.35
pressed into the canal causing nerve injuries. Additionally, these agents have a higher chance
Finally, at the time of implant insertion, the implant of producing neuropathic pain compared with
must not be placed beyond the apical extent of the other commonly used local anesthetic agents.36
osteotomy by countersinking if the IAN is known to
be close apically.32 WHEN INJURY OCCURS
Apical surgery begins with review of existing
imaging. Landmarks should be identified to help Unfortunately, despite the best preparation and
guide the surgeon intraoperatively and maintain surgical techniques, injuries may still occur. Time
safe distances from the IAN and mental foramen.
Three incision designs can be used: (1) sulcular,
(2) papilla sparing, and (3) a semilunar flap.33 Typi-
cally releasing incisions are used with the first two
and these should be planned at least one tooth
anterior or posterior to the identified mental fora-
men. The dissection for all incisions should then
be subperiosteal and if near the mental nerve this
structure should be identified and protected to
avoid iatrogenic injury during instrumentation. Ac-
cess to the periapical lesion and root should be ob-
tained using anatomic references that were
selected before surgery. Caution must be exer-
cised when instrumenting the cavity being cogni-
zant of anatomic danger zones mentioned
previously. Once the periapical lesion has been Fig. 7. Damaged IAN nerve at apicoectomy site #19
removed, hemostasis is achieved using known he- shown in Fig. 5. The nerve appears to be damaged
mostatic agents.24 If the nerve is exposed, a resorb- from either rotary instrumentation or aggressive
able collagen barrier should be placed over the curettage. A foreign body was also noted within the
nerve to provide a barrier from the root end filling scar tissue and sent for pathologic examination.
from injury dictates actions that can be taken. Wit- with a patient who returns with a postoperative
nessed or open injuries mandate immediate or de- neurosensory deficit.
layed early intervention depending on surgeon skill First and foremost, a baseline complete neuro-
level. If the patient is in the operating room and sensory examination is conducted and docu-
appropriate equipment is available, immediate mented in the chart. This begins with history and
repair may be attempted. If not, the ends of the a description of the sensory deficit or pain. It
nerve can be tagged with nonresorbable suture, must first be classified as painful or unpleasant
such as nylon or polypropylene, and the wound (dysesthesia) or absent, decreased, or altered
closed. Note is made of the site and type of injury (paresthesia, hypoesthesia, or anesthesia). Con-
and prompt referral can be made to a microneuro- stant pain is usually a result of a long-term injury
surgeon.26 Prior research has shown benefit to that has resulted from lack of afferent input from
anti-inflammatory medications following acute the periphery (differentiation) and is seen in
nerve injury, and consideration should be given patients with neuroma formation. If pain is intermit-
to a steroid, NSAIDs, or both.20 tent, one must determine if pain is stimulated or
Most nerve injuries, however, are not witnessed merely spontaneous and the length of each
and are noted at postoperative follow-up. The key episode. A visual analog scale is then used to
to ensuring the best overall patient outcome is quantify the pain on a scale of 1 to 10. The patient
identification of mechanism, appropriate neuro- should be questioned what if any pain medications
sensory testing, and timely surgical intervention if have been attempted and if so what their effects
necessary. An algorithm is provided in Fig. 8 that have been. If the patient’s complaint is caused
may provide guidance to the practitioner faced by decreased sensation it should be quantified
Fig. 8. Trigeminal nerve injury algorithm. NST, neurosensory testing.

on a level of 1 to 10 and compared with the oppo- provide static light touch sensation. These fibers
site side. For either type of injury, interference with are evaluated by lightly touching the skin without
activates of daily living should be documented. Of indentation with the wooden end of a cotton
special note, if a lingual nerve injury has occurred, swab. If the patient cannot feel the contact, the
alteration of taste sensation (paraguesia) should pressure is then increased and the skin is lightly in-
be noted.26 dented. If this can be felt at the higher threshold it
After the chief complaint and symptoms have is recorded as felt, however, at a higher threshold.
been elucidated, attention is next directed at phys- If sensation is still not present even at the higher
ical examination. The patient should be seated threshold then this is recorded and the examiner
comfortably and all tests are administered with moves on to level C testing. Alternatively and
the patient’s eyes closed in a quiet environment. more accurately, Semmes-Weinstein filaments
The contralateral normal side is always tested first may be used. These are a graded set of filaments
to establish baselines. The examination starts with with increasing pressures required to deform each
mapping of the altered region. This can be done by filament. The filaments can be used in stepwise
using the wisp of a cotton-tip applicator in a brush fashion to accurately assess the patient’s
stroke fashion and having the patient raise his or threshold for detection.37,38
her hand when they no longer sense the cotton. Level C testing measures response to noxious
This is then marked and the process is repeated stimulus, which are carried by scantily myelinated
from different directions until the area is marked A delta fibers or nonmyelinated C fibers. Testing is
in its entirety. Photographic documentation can similar to level B in that initially light contact is
also be taken at this time. At this point, neurosen- made with a dental needle. If the patient does
sory testing differs if the patient suffers from anes- not feel this, contact is then made once again,
thesia/paresthesia versus dysesthesia.4 however this time slightly indenting the skin. If
If the patient has reduced or no sensation, levels the patient feels this it is recorded as an abnormal
of function are tested in a stepwise approach. response. If the patient does not feel this it is also
Level A testing evaluates larger-diameter A alpha recorded; however, further pressure need not be
and A beta fibers that are 5 to 12 mm in diameter. applied. Further testing by thermal means is not
This is performed implementing a cotton swab necessary; however, it may provide insight into
with the cotton drawn into a wisp. Testing is car- the exact damaged fibers. Ethyl chloride spray
ried out by applying 10 strokes on the normal provides cold stimulus and heat can be applied
side and the patient is asked to determine the di- with warmed gutta-percha or warm water dipped
rection of stroke for each. This process is then cotton-tip applicators. The results of these tests
repeated on the altered side and results are once are then recorded and the patient is diagnosed
again recorded by documenting how many out of as being normal, mildly impaired, moderately
the 10 attempts were correctly identified. A score impaired, severely impaired, or anesthetic. De-
of 9/10 or greater is considered normal. Two- grees of impairment can be ascertained from per-
point discrimination is then performed using a Bo- formance at each level of testing using Zuniga and
ley gauge or college pliers and a millimeter ruler. Essik’s algorithm seen in Fig. 9.4,37,39
The normal side is again tested first by starting If the patient suffers from dysesthesia, the three
with the calipers at zero and lightly touching the levels are again examined; however, in this context,
area. The patient is asked to identify if this feels all three levels are always examined regardless of
as one or two objects. The distance is then incre- outcome at any specific level. The goal of this ex-
mentally widened until the patient can discriminate amination is to identify the type of dysesthesia.
two separate points. After this the process is Starting with level A, testing is carried out as before
repeated on the side of pathology in similar by stroking the region with a cotton wisp. If the pa-
fashion. Within the inferior alveolar nerve and tient experiences pain that stops on removal of the
lingual nerve distributions the patient should wisp, this is termed allodynia or abnormal pain
have two-point discrimination of 4 mm and response to unpainful stimulus that ceases with
3 mm, respectively. Because there is a large vari- removal of stimulus. Level B is used to reveal if
ation from patient to patient, numbers should be the patient has hyperpathia, which is present if the
correlated to the contralateral nonpathologic patient has delayed-onset pain, increased intensity
side. If the patient has normal responses, the ex- on repeated stimuli, or pain that continues after the
amination need not continue. If abnormal re- stimulus ends. Level C testing tests for hyperalge-
sponses are recorded the examiner moves to sia. As before, a dental needle is used at a normal
level B testing.37 threshold to evoke pain and a slightly higher
Level B testing measures the smaller A beta fi- threshold if no reaction takes place. If the patient
bers of approximately 4- to 8-mm diameter, which has pain out of proportion to the examination on
Fig. 9. Grading algorithm for evaluating trigeminal nerve injury by Zuniga and Essik. (From Lieblich SE. Endodon-
tic surgery. Dent Clin North Am 2012;56(1):121–32, viii–ix; with permission.)
the contralateral nonpathologic side this is consid- sprouting has occurred from adjacent nerves, or
ered hyperalgesia.37 there is a central mechanism to the pain. If, how-
Diagnostic nerve blocks may serve as a useful ever, the pain is relieved by diagnostic nerve
adjunct in localizing the lesion in a patient who is block, microsurgery may be indicated.4
dysesthetic. The blocks can be administered first After confirmation of nerve injury, classification,
more peripherally and then more centrally to help and documentation of injury, one may return to the
locate the lesion. Failure of the local anesthetic beginning of the algorithm in Fig. 8. The next step
block to eradicate symptomatology may indicate is to obtain imaging, which may start with a
that the nerve was not blocked, collateral macro panoramic radiograph to identify if any obvious
pathology is evident. If suspicion exists and a for surgical intervention. If the patient has no return
possible mechanical injury is detected, advanced of sensation, minimal return that is not improving,
imaging, such as CBCT or traditional CT, may be or dysesthesia that is responsive to peripheral
obtained. If this confirms the suspicion and there blockade, a referral to a microneurosurgeon is pru-
is loss of continuity of the canal or encroachment dent at this time. Our own results have shown sta-
by foreign body, a referral should be made to a mi- tistically significant better sensory outcomes if
croneurosurgeon as soon as possible. If an repair is conducted before 6 months and in partic-
implant is encroaching on the canal this should ular for IAN injury. Additionally, it has been shown
be backed out or removed as soon as possible. that after 3 months, a complex array of central and
Fig. 10 shows the same patient with IAN injury peripheral changes that are unlikely to respond to
shown in Fig. 4 at time of surgery. Unfortunately, surgical manipulation may occur.42 This 3-month
the implants were not removed at time of identifi- referral decision point allows for examination, con-
cation of injury, relegating her to surgical explora- sent, and scheduling within 6 months by a micro-
tion and repair of the nerve. At this time no reliable neurosurgeon. If the patient is experiencing
method is available for lingual nerve imaging; how- continued improvement, the patient is then fol-
ever, with the advent of 3-T MRI, new imaging se- lowed on a monthly schedule and reassessed
quences, and advanced ultrasound, this may soon when no further improvement occurs or 12 months
be a possibility. have been reached. Conflicting data exist in re-
If no obvious pathology is noted, the patient gards to late repair of the IAN and lingual nerve.
should start a regimen of serial neurosensory Good outcomes have been noted in some studies
testing along with NSAIDS and possible consider- even after the 12-month mark, whereas others
ation for corticosteroids. An identical examination note drastic decreases in success.43,44 Because
should be performed at each appointment to allow conflicting evidence is present at this time, it
for comparison over time. Follow-up schedule seems prudent to respect wound healing physi-
should include examinations at 1 week, and 1, 2, ology and avoid the irreversible scaring that
and 3 months. Controversy still remains as to affects neural tracts by staging any delayed inter-
optimal time for surgical intervention. What is vention by no later than 1 year. Fig. 11 depicts a
known is that 75% of iatrogenic injuries to the third case of late repair. Large neuroma and scar tissue
division of the trigeminal nerve recover without formation is evident requiring resection of a large
intervention.40 Perhaps one of the best in vitro portion of the lingual nerve and subsequent cadav-
studies to date was performed by Jääskeläinen eric nerve graft (AxoGen, Alachua, FL).
and colleagues41 in 2004. They intraoperatively Dysesthesia that is unresponsive to peripheral
monitored 40 IAN nerves during bilateral sagittal nerve blocks is likely caused in part by central
split osteotomy (BSSO). They found that simple mechanisms, and surgical repair may not be indi-
demyelinating injuries recovered to baseline on cated (see Fig. 8). Benoliel and coworkers45
neurophysiologic testing within 3 months of injury. recently published a review article on this subject
For the reasons described previously, serial detailing terminology, mechanisms, and treat-
neurosensory testing is performed until the ment. They suggested the term painful traumatic
3-month point and a decision is made as to need trigeminal neuropathy to describe painful lesions
Fig. 10. This is the same patient in Fig. 3 who suffered bilateral IAN damage during implant placement. Unfor-
tunately the nerves were not decompressed immediately after identification of injury. (A) Right IAN after resec-
tion of nonviable segment and primary neurorrhaphy and before Axoguard (AxoGen, Alachua, FL)
entubulization. (B) The left IAN suffered less damage and required only external and internal decompression
on exploration.
Fig. 11. (A) A late lingual nerve repair. Note a large neuroma and large amount of perineural scar tissue forma-
tion. (B) Because of the condition of the proximal and distal stump a large amount of nerve tissue was excised to
allow viable tissue neurorrhaphy. A cadaveric nerve graft (AxoGen) was placed. (C) The nerve graft was then sur-
rounded with a Neuragen collagen conduit (Integra Life Sciences) to protect from further perineural scar tissue
ingrowth.
postsurgically. Their evidence-based treatment al- norepinephrine receptor inhibitors (duloxetine)

gorithm is seen in Fig. 12. After someone has been versus gabapentin or pregabalin. Amitriptyline re-
diagnosed with painful traumatic trigeminal neu- mains the drug of choice; however, TCAs have
ropathy, a decision is made to start the patient multiple side effects because of their activity at
on tricyclic antidepressants (TCA) or selective multiple receptors (cholinergic, alpha, histamine,
Painful trauma c trigeminal

neuropathy (PTTN)
Amitriptyline Gabapen n
Nortriptyline/Duloxe ne Pregabalin
Gabapen n 1
Pregabalin
TCA/SNRI with
Gabapen n/Pregabalin 2
Opioids
Fig. 12. Stepped approach for treatment of painful traumatic trigeminal neuropathy. (1) If anticonvulsants fail
strong consideration should be given for combining a selective norepinephrine receptor inhibitor (SNRI). (2) If
this is contraindicated consideration should be given to opioids. TCA, tricyclic antidepressant. (From Zuniga JR,
LaBanc JP. Advances in microsurgical nerve repair. J Oral Maxillofac Surg 1993;51(1 Suppl 1):62–8; with
permission.)
and so forth) and may be contraindicated or poorly panoramic images and computed tomography.
tolerated by patients. Selective norepinephrine re- J Oral Maxillofac Surg 2008;66(11):2308–13.
ceptor inhibitors address one of the TCA mecha- 8. Guerrero ME, Nackaerts O, Beinsberger J, et al.
nisms of action but have been found to be less Inferior alveolar nerve sensory disturbance after
effective. The newer antiepileptic drugs including impacted third molar evaluation using cone beam
gabapentin or pregabalin have a more benign computed tomography and panoramic radiography:
side effect profile and may be started in patients a pilot study. J Oral Maxillofac Surg 2012;70:
who refuse TCAs or have a contraindication. If 2264–70.
either class fails, then the other class is tried. If 9. Selvi F, Dodson TB, Nattestad A, et al. Factors that
this fails, then combination therapy is instituted are associated with injury to the inferior alveolar
with an agent from each class. If this again fails, nerve in high-risk patients after removal of third mo-
opioids may be considered. Unfortunately, even lars. Br J Oral Maxillofac Surg 2013;51(8):868–73.
with this stepped approach only 25% of patients 10. Susarla SM, Sidhu HK, Avery LL, et al. Does
experience 30% or greater improvement in symp- computed tomographic assessment of inferior alve-
toms.46 Of note, these drugs can be used in the olar canal cortical integrity predict nerve exposure
management of patients where surgery is indi- during third molar surgery? J Oral Maxillofac Surg
cated to help reduce further central and peripheral 2010;68(6):1296–303.
sensitization. 11. Umar G, Obisesan O, Bryant C, et al. Elimination of
permanent injuries to the inferior alveolar nerve
following surgical intervention of the “high risk” third
SUMMARY molar. Br J Oral Maxillofac Surg 2013;51(4):353–7.
12. Behnia H, Kheradvar A, Shahrokhi M. An anatomic
Iatrogenic injury to the trigeminal nerve can remain
study of the lingual nerve in the third molar region.
a source of concern and litigation even for the
J Oral Maxillofac Surg 2000;58(6):649–51 [discus-
most experienced oral and maxillofacial surgeons.
sion: 652–3].
This article provides the most up-to-date evi-
13. Miloro M, Halkias LE, Slone HW, et al. Assessment of
dence-based recommendations for identification,
the lingual nerve in the third molar region using mag-
prevention, and management of these injuries to
netic resonance imaging. J Oral Maxillofac Surg
provide the highest level of patient care. Through
1997;55(2):134–7.
this, the specialty can maintain excellence in den-
14. Benninger B, Kloenne J, Horn JL. Clinical anatomy
toalveolar surgery.
of the lingual nerve and identification with ultraso-
nography. Br J Oral Maxillofac Surg 2013;51(6):
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Soft Tissue Grafting
A ro u n d Te e t h a n d
I mplants
George R. Deeb, DDS, MDa,*, Janina Golob Deeb, DDS, MSb
KEYWORDS
Free gingival graft Subepithelial connective tissue graft Recession Soft tissue defect Allograft
Xenograft
KEY POINTS
Esthetic appearance and functional longevity for teeth and implants often requires conversion of
unfavorable soft tissue traits to more favorable ones.
Improvement of tissue quality and quantity can be accomplished with many different techniques
and materials, and largely depends on clinical presentation of the case and the familiarity of the
clinician with the procedures and materials available.
Identification of causal factors, selection of appropriate surgical technique, and evidence-based
material selection lead to predictable success when improving soft tissue characteristics around
teeth or implants.
THE IDEAL CHARACTERISTICS OF THE SOFT optimal soft and hard tissue health.3 However, in
TISSUE TOOTH/IMPLANT INTERFACE patients maintaining proper plaque control, the
absence of attached gingiva around teeth does
The presence of healthy attached tissue at the not result in an increased incidence of soft tissue
tooth and implant soft tissue interface correlates recession.1,4 It has been shown in long-term
with long-term success and stability in function studies that even minimal amounts of keratinized
and esthetics. Not only can a lack of keratinized tissue can provide long-term stability of soft tissue
tissue facilitate plaque aggregation around teeth margin in the presence of good plaque control.1
and implants but it can also lead to recession of Early studies suggested that the recession of
free soft tissue margin in the esthetic zone. The soft tissue margin around implants may be the
thicker periodontium is less prone to recession, result of the remodeling of the periimplant soft tis-
because of the thickness of the cortical bone as sue barrier. Lack of masticatory mucosa and the
well as the thickness of the surrounding gingiva. mobility of periimplant soft tissue were related to
Treatment of mucogingival deficiencies has more pronounced soft tissue recession around im-
become a large part of practices involving teeth plants.5 Plaque-induced inflammation has been
and implants. The ramifications of not having an shown to cause recession when mucosal margins,
adequate keratinized tissue surrounding teeth rather than gingiva, are surrounding implants.6
have been studied extensively for decades,1,2 Thicker keratinized tissue facilitates plaque
and have also extended into implantology. The removal around implants. Plaque has been found
presence of gingiva is strongly correlated with as the causal factor in periodontal diseases7 as
a
Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, 521
North 11th Street, Richmond, VA 23298, USA; b Departments of Periodontics and General Practice, School
of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond, VA 23298, USA

426 Deeb & Deeb
well as periimplant inflammation, and its removal is When considering correction of recession it is
paramount in tooth and implant long-term health. important to identify the presence and the amount
Facilitating plaque removal is not the only indica- of gingiva as well as causal factors contributing to
tion when considering improvement of soft tissue displacement of soft tissue margin. Causal factors
structure surrounding teeth or implants. Esthetic of soft tissue recession around teeth include the
demands for implants have become as high as quantity and quality of surrounding keratinized
those for natural dentition. Exposed metal or any attached tissue, supporting alveolar bone, and
visible discrepancies in soft tissue volume or mar- the level of plaque control of the affected area.
gins suggesting an implant-supported prosthesis Causes of soft tissue defects surrounding implants
in anterior regions have become largely unaccept- include poor implant spatial positioning, incorrect
able by patients. Implant-supported restorations abutment contour, excessive implant diameter,
and teeth restored side by side should be in har- horizontal biologic width formation, and peri-
mony, not only when it comes to prosthetic supra- odontal phenotype.11
structures but also in levels of gingival margins,
thickness, color, and contour of adjacent gingiva. CLASSIFICATION OF RECESSION
Several soft tissue grafting procedures has been
developed to improve both the volume of kerati- Several classification systems have been devel-
nized tissue and the soft tissue contour around im- oped to assess and quantify the amount of sur-
plants. Concepts for these surgical techniques rounding soft tissue and osseous components.
have been drawn from procedures developed to Sullivan and Atkins12 introduced a classification
enhance soft tissue support around teeth. system in 1968 to describe recession around
teeth. This classification system was based on
DEVELOPMENT OF MUCOGINGIVAL the width and length of recession. It was already
DIAGNOSIS AND SURGERY established at that time that those parameters
determined the amount of root coverage obtain-
The term mucogingival surgery was first intro- able with soft tissue grafting procedures.
duced by Friedman8 in 1957 in reference to cor- Miller13 introduced his classification system in
recting relationships between mucosa and 1985 (Box 1). He related the extent of the soft tis-
gingiva around teeth. In the following decades, sue recession to the location of the mucogingival
that term has expanded to include numerous pro- junction as well as the height of interproximal clin-
cedures used to correct and alter defects, ical attachment adjacent to the surface affected by
position, thickness, and the width of keratinized the recession.
tissue surrounding teeth. As implantology has Miller’s13 classification is a helpful diagnostic
expanded and esthetic demand for prosthetic re- tool in treatment planning and setting realistic ex-
placements has grown, periodontal plastic surgery pectations for both patients and clinicians. Root
procedures have been developed around implants coverage can be predictably obtained in class I
and edentulous ridges restored with pontics and and II groups, only partially in class III, and not at
removable prostheses. The term periodontal plas- all in class IV. Properly diagnosing the soft tissue
tic surgery was introduced by Miller9 in 1988 and recession is helpful in choosing a proper soft tis-
presently includes procedures to prevent or cor- sue grafting technique and setting expectations
rect oral soft tissue defects of anatomic, develop- for surgical outcome.
mental, traumatic, and disease-related origin. In 1999, the International Workshop for Classifi-
cation of Periodontal Diseases and Conditions
GINGIVAL RECESSION AROUND TEETH AND formed by the American Academy of Periodontol-
IMPLANTS ogy agreed on a new classification system for peri-
odontal diseases. Category VIII on developmental
The displacement of the soft tissue margin in an or acquired deformities and conditions was added
apical direction from the cementoenamel junction to provide more comprehensive diagnostic tool for
leads to exposure of the root surface of a tooth, soft tissue characteristics around teeth and eden-
and is referred to as a marginal soft tissue reces- tulous ridges (Table 1).14
sion.10 When the soft tissue margin recedes
apically around an implant, it can lead to exposure ESTHETIC CONSIDERATIONS
of the abutment or implant body depending on the
extent of displacement, as well as the design of the Loss of gingival symmetry is most notable on ante-
implant and its suprastructure. In both cases, the rior teeth15 and implants, especially with regard to
term soft tissue margin is inclusive of either mu- the principles of gingival zenith positions and
cosa or gingiva, whichever is present at the site. levels.
Box 1 points should be used as guides to reestablish

Miller classification system of marginal soft the proper intratooth gingival zenith line of the
tissue recession maxillary anterior teeth during root coverage and
reconstructive procedures.16
Class I:
Recession does not extend to mucogingival
junction THICK VERSUS THIN GINGIVAL
ARCHITECTURE
There is no loss of interproximal clinical
attachment Treatment planning for dental implant placement
Class II: should consist of assessment of the periodontal
biotype of both the proposed implant site and
Recession extends to or beyond mucogingival the adjacent dentition. This soft tissue assessment
junction
is particularly important for the immediate implant
There is no loss of interproximal clinical case as well as treatment in the esthetic zone
attachment (Fig. 1).
Class III: The thick, flat periodontal biotype is character-
ized by dense fibrotic gingiva. There is a larger
Recession extends to or beyond mucogingival
junction
zone of attached gingiva, with smaller embrasures
associated with square-shaped teeth. Gingival
Some interproximal clinical attachment loss is scallop on anterior teeth is flat and does not
present or malpositioning of teeth is present
exceed 3 to 4 mm. The contact points are long
Class IV: and are located in the middle third of the teeth.
Recession extends to or beyond mucogingival Soft tissue is supported by thick bone, with the
junction high incidence of exostosis resisting the tendency
for recession to occur.
Severe interproximal clinical attachment loss
The thin periodontal biotype displays a thin,
is present or severe malpositioning of teeth
is present scalloped gingiva with a narrow zone of attach-
ment. The teeth are triangular and have long inter-
From Miller PD. A classification of marginal tissue proximal contacts in the incisal third region.
recession. Int J Periodontics Restorative Dent 1985;5:9.
Gingival scallop on anterior teeth can reach 4 to
6 mm. The thin periodontium often reveals undu-
lating contours of the prominent roots of the teeth
Tarnow showed that the gingival zenith line of alternating with the concave interdental bone. In
the lateral incisors relative to the adjacent central this biotype, bone is thin and has a high incidence
incisor and canine teeth is positioned more coro- of dehiscence and fenestration defects. Brushing
nally by approximately 1 mm. These reference can result in soft tissue recession over the
Table 1
Developmental or acquired deformities and conditions
Mucogingival Deformities and Conditions Around Mucogingival Deformities and Conditions on

Teeth Edentulous Ridges
1. Gingival/soft tissue recession 1. Vertical and/or horizontal ridge deficiency
a. Facial or lingual surfaces
b. Interproximal (papillary)
2. Lack of keratinized gingiva 2. Lack of gingiva/keratinized tissue
3. Decreased vestibular depth 3. Gingival/soft tissue enlargement
4. Aberrant frenum/muscle position 4. Aberrant frenum/muscle position
5. Gingival excess 5. Decreased vestibular depth
a. Pseudopocket
b. Inconsistent gingival margin
c. Excessive gingival display
d. Gingival enlargement
6. Abnormal color 6. Abnormal color
From Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol
1999;4(1):1–6.
428 Deeb & Deeb
Fig. 1. (A) Thick, flat periodontal biotype is characterized by dense fibrotic gingiva, large zone of attached
gingiva, smaller embrasures, and square-shaped teeth. (B) Thin periodontal biotype has a thin, scalloped gingiva
with a narrow zone of attachment. The teeth are triangular, and the thin periodontium often reveals undulating
contours of the prominent roots of the teeth and bone.
dehiscence defects, which continues until the Kan and colleagues17 recommend that the
bone margin is reached. placement be 1 mm palatal in relation to the facial
Kan and colleagues17 evaluated the dimensions emergence profiles of the adjacent teeth, and not
of the periimplant mucosa around 2-stage maxil- less than 1 mm because of the risk of losing the
lary anterior single implants. The investigators facial bone and soft tissue.
concluded that the level of the interproximal
papilla around the implant is independent of the The Implant Should Be Placed with the
proximal bone level next to the implant, but is Platform at the Level of the Gingival Zenith
related to the interproximal bone level next to the and 3 mm Apical to the Soft Tissue Margin
adjacent tooth. Greater periimplant mucosal di-
Gingival zenith position (GZP) does not line up with
mensions were noted in the presence of a thick
the middle of the facial surface of the tooth or ver-
periimplant biotype compared with a thin biotype.
tical bisected midline (VBM) for all anterior tooth
groups. The largest discrepancy between GZP
THE RELATIONSHIP BETWEEN IMPLANT
and VBM was noted in maxillary central incisors
PLACEMENT AND SOFT TISSUE
with GZP located 1 mm distal to the VBM.16 The
The relationship between the bone and soft tissue lateral incisors showed an average of 0.4 mm
ultimately defines the final esthetic result. The discrepancy, whereas the canines showed almost
three-dimensional relationship between the no deviations of the GZP from the VBM.16
implant and surrounding bone determines the
soft tissue contours and interdental papilla. Implants Should Be Placed with a Minimum of
1.5 mm Between the Adjacent Tooth and
Implants Should Be Placed 3 mm Below the Implant
Facial Gingival Margin in an Apicocoronal
Esposito and colleagues19 indicated a strong cor-
Dimension for the Following Reasons
relation between bone loss of adjacent teeth and
To allow for prosthetic abutment placement horizontal distance of the implant fixture to the
and formation of biologic width. tooth. The greatest amount of bone loss was noted
To allow for creation of a natural emergence at the lateral incisor position.
profile.
To allow for restorative margins to be placed Implants Should Be Placed with an
subgingivally. Interimplant Distance of at Least 3 mm in a
To allow for age-related recession without im- 2-Stage Protocol
mediate exposure of the implant abutment Tarnow and colleagues20 in their retrospective
interface.
study of patients with 2 adjacent implants found
that when implants were placed within 3 mm of
Implants Should Be Placed in a Buccolingual
each other they developed 1.04 mm of interprox-
Dimension 1 to 2 mm Palatal from the
imal bone loss compared with implants placed
Anticipated Facial Margin of the Restoration
with greater than 3.0 mm of bone between them,
Schneider and colleagues18 recommend a 2-mm which lost only 0.45 mm of bone. The loss of height
palatal placement in anticipation of a 1.4-mm of interproximal bone has an effect on papilla
lateral bone loss as a guideline. support.
PAPILLA tooth or another implant. Tarnow and colleagues26

observed that, when placing 2 implants adjacent
Maintaining papillae between anterior teeth leads to each other, only an average of 3.4 mm of soft
to optimal gingival contour and appearance. Sur- tissue height can be expected to form over the in-
gical techniques for soft tissue grafting around terimplant crest of bone.
teeth all include papilla preservation in height Schropp and Isidor27 evaluated soft tissue levels
and at least partial thickness. and papilla dimensions for early versus delayed
single implants. Implants placed 10 days following
Papilla Adjacent to Teeth
extraction tended to be superior to delayed im-
Maintenance of interproximal papillae is more pre- plants regarding soft tissue appearance at crown
dictable in periodontally healthy patients because delivery as well as 10 years later. The implant re-
of predictable tissue rebound over time, which gion does not seem to influence the papilla,
can be anticipated by the height of interproximal although patients younger than 50 years received
bone on the adjacent teeth.21 Complete papilla fill significantly better papilla scores. An apically
has been observed when the distance from the located bone level at the tooth neighboring the
contact point to the bone crest was 5 mm or less. implant negatively influenced the papilla dimen-
When the distance exceeds 6 mm, papillae are pre- sion. In contrast, the presence of a bone defect
sent only 56% of time.22 Restorative solutions for buccally to the implant at second-stage surgery
manipulation of contact point location are used to did not have a negative impact on the gingival
reduce the distance from contact point to the crest margin 10 years after implant placement.27
as well as adding the length to the contact surface
and bulk to coronal contours. Surgical techniques Provisional Restoration
intended to increase the volume of papillae include
The selection of the provisional restoration signifi-
case reports of the use of platelet-rich fibrin,23 in-
cantly influences healing of the soft tissues (Fig. 2).
jection of hyaluronic acid–based gel,24 and con-
Placement of an immediate provisional affects the
nective tissue graft with coronally advanced flap
periimplant tissue morphology according to its
(CAF).25 Most case reports on these techniques
emergence profile.28 Papilla preservation as well
represent a small number of cases and short-term
as restoration can be accomplished. Part of the
follow-up, failing to show long-term stability.
anterior esthetic case planning should involve
planning for the provisional restoration. In general,
Papillae Adjacent to Implants
fixed provisionals work better than removable pro-
The projected height of a papilla next to an implant visionals. Screw-retained provisional restorations
largely depends on whether it is adjacent to the are preferred in cases in which soft tissue contours
Fig. 2. (A) Preoperative view of a #9 edentulous ridge planned for a single-tooth implant. (B) Surgical guide in
place during implant placement. Note that the guide pin is palatal in order maintain the buccal plate and prevent
recession of the soft tissue. (C) Intraoperative view with a 3.0-mm healing abutment in place. The 3.0-mm healing
abutment is flush with the gingiva and ensures that proper emergence can be achieved. (D) Screw-retained pro-
visional with the correct gingival contours. (E) The provisional restoration in place along with the veneer showing
acceptable esthetic outcome. (F) Postoperative panoramic film showing the implant and provisional crown in
place.
430 Deeb & Deeb
are critical. Screw-retained restorations avoid When performing the socket preservation proce-
cement-caused periimplant inflammation. Screw- dure, anatomic features of the socket which will
retained restorations also allow retrieval and become a future implant site should be assessed
adjustment of the contours of the restoration, and improved with grafting techniques. Closure af-
which are critical in guiding papilla restoration. ter extraction can be manipulated in ways to create
Contact points on adjacent teeth as well as emer- or move keratinized tissue for future implant place-
gence dictate the final result. ment. Covering bone graft with a membrane or soft
tissue graft results in expansion of gingival tissue.
Obtaining primary closure by advancing the flap
SOFT TISSUE MANAGEMENT BEFORE
often comes at the expense of displacing or losing
IMPLANT PLACEMENT
facial keratinized tissue.
Extraction Sockets
Patient factors that define the success of an
In the absence of keratinized tissue or when implant placement include bone level, buccal
gingiva is present but inflamed and fragile, it is bone thickness, soft and hard tissue relationship,
important to incorporate procedures to preserve and gingival biotype.29
and augment surrounding connective tissue in Bone grafting for socket preservation or ridge
early phases of treatment (Fig. 3A–H). Following augmentation techniques can be implemented to
extraction in an anterior segment with deficient improve osseous characteristics of the site. The
gingiva, the clinician might choose not to proceed bone support will define the soft tissue architec-
with an immediate implant placement but rather ture after healing. Connective tissue grafts or
resort to a staged approach. pedicle grafts can be used to augment deficient
Fig. 3. (A) Preoperative view of a patient with a thin, scalloped periodontium with external resorption of tooth
#9. (B) Extracted tooth with external resorption visible on the buccal aspect of the tooth. (C) Postextraction view
showing buccal wall defect. (D) Rigid collagen membrane bridging the buccal wall dehiscence before placement
of bone graft into the socket. The connective tissue graft for socket coverage has been harvested. (E) Connective
tissue graft sutured into place over the socket preservation procedure. (F) Natural tooth bonded into place post-
operatively and without contacting the ridge. (G) One-week postoperative view showing improved bulk and co-
lor after socket preservation procedure. (H) Four-month postoperative result.
soft tissue components. Autogenous grafts can be of greater prosthesis retention during the healing
allowed to heal in part by secondary intention stage (Fig. 4).
further enhancing the amount of keratinized tissue
available for future implant placement. Treatment Planning for Soft Tissue Grafting
Note that immediate implant placement into Around Teeth and Implants
sockets with deficient facial keratinized tissue
The ultimate goal of soft tissue grafting is to
and thin buccal bone may lead to unpredictable
improve the prognosis of affected teeth or im-
height and contour of soft tissue margin and
plants. Prognosis depends on the ability to
esthetic outcome. Delaying implant placement
practice good plaque control and to maintain
and creating healthy and adequate amounts of
healthy soft tissue margins. In esthetic areas,
gingiva first yields more predictable esthetic
achieving optimal soft tissue contours around
results.
teeth, implants, or prostheses is also of great
importance.
SOFT TISSUE MANAGEMENT AT THE TIME OF Numerous techniques involving soft tissue
IMPLANT PLACEMENT manipulation from adjacent or distant donor sites
have been developed to cover exposed roots and
Sites augmented with subepithelial connective tis-
enhance soft tissue structure in areas with deficient
sue grafts (SCTG) at the time of implant placement
or absent gingiva. Conventional periodontal plastic
have better esthetics and thicker periimplant tis-
surgical techniques are generally separated into
sues.30 When SCTG is used with immediate
pedicle grafts and free soft tissue grafts (Box 2).
implant placement and provisionalization in the
esthetic zone it significantly improves mainte-
nance of facial gingival level.31 FREE SOFT TISSUE GRAFTING
Grunder32 measured the dimension of the labial When treatment planning a soft tissue graft it is
volume before and 6 months after implant place- important to consider the goal. Indications can
ment in the maxillary anterior area with or without be driven by esthetic demands with the purpose
SCTG using a flapless tunnel technique. The non- of establishing a harmony with regard to health,
grafted group had an average 1.063-mm loss of height, volume, color, and contours of gingiva
volume, whereas the grafted group presented with the surrounding dentition.
with a slight gain of 0.34 mm. These results In addition, indications are often related to
confirmed the effectiveness of placing a soft tissue inability to remove plaque efficiently around teeth
graft at the time of immediate implant placement in and implants surrounded by thin mucosa, resulting
the esthetic zone.32 in recession. Longitudinal evaluations conclude
In totally edentulous patient, firm keratinized tis- that minimizing inflammation is sufficient and is
sue surrounding the implants and adequate necessary to maintain attachment levels despite
vestibular depth are among the determining fac- the width of keratinized tissue surrounding teeth.34
tors for long-term implant success. In the staged Therefore it is important to educate patients about
approach of mandibular implant reconstruction, how to properly exercise oral hygiene and to
adequate vestibular depth and gingiva surround- consider soft tissue surgery in appropriate circum-
ing the implants can be readily established at the stances when enhanced soft tissue will result in an
time of implant placement or when the implants improved prognosis of the grafted tooth or
are uncovered. implant.
However, in cases in which extractions and In cases in which the sole goal is to increase the
alveolar ridge reduction are done in the mandible amount of keratinized tissue, the most suitable
immediately before implant placement, surgeons technique remains a free gingival graft. When the
have a challenging task to maintain adequate ker- desired outcome includes coverage of exposed
atinized tissue and vestibular depth on buccal and root, connective tissue grafting provides more pre-
lingual aspects of the implants. Securing both dictable outcomes.35
flaps apically to a fixed and stable bony anchorage
greatly reduces the likelihood of prolapse of the THE FREE GINGIVAL GRAFT
buccal vestibule and elevation of the lingual floor
into prosthetic space as well as beyond the The term free gingival graft was introduced in 1966
implant margins. This fixed anchorage is by Nabers36 and this graft is now referred to as free
especially important in patients who cannot wear epithelialized soft tissue graft. This technique orig-
prosthetic devices during the healing phase.33 inally used tissue removed after gingivectomy, but
Single-stage surgery with the placement of healing was later modified to include palatal or mastica-
abutments allows the patient the additional benefit tory gingiva as a primary donor source.37
432 Deeb & Deeb
Fig. 4. (A) Five lower implants placed for an immediate loaded full-arch provisional restoration. (B) Close-up view of a
fissure burr being used to make an interimplant osteotomy of the lingual cortical bone as a means of stabilizing flaps in
an apical position. In this example the lingual cortex is being perforated because of the wide buccolingual dimension
of the alveolar ridge as well as to avoid inadvertent damage to the implants. (C) Intraoperative view showing the su-
turing sequence. The operator passes from the buccal tissues through the alveolus and through the lingual tissues
before tying the knot over the ridge to secure the tissues. (D) Intraoperative view with 3 transalveolar sutures in place.
The sutures are placed in the interimplant bone and secured. The rest of the final closure is completed in chromic gut
suture. Note the preservation of keratinized tissue and apical position of the flaps. (E) Intraoperative view after implan-
tation showing the needle being passed through the alveolus in order to show the placement of the transalveolar os-
teotomy in a 5-mm apical position. For altering vestibular height the osteotomy should be placed apically, as shown.
For use the buccal flap should be engaged before entering the osteotomy and the lingual flap on exiting, as in Fig. 3. (F)
Immediate postoperative view of the closure using the transalveolar suture (arrow) securing the flaps in an apical po-
sition in order to increase vestibular depth. (G) One week after surgery showing favorable healing and stable tissue
adaptation around the implants. The transalveolar sutures (arrows) are still intact.
The autogenous free gingival graft can be subdi- it is not suited when root coverage is attempted.
vided by thickness of the donor tissue into 3 The thin free gingival graft heals the fastest but
categories: also has the highest percentage of secondary
shrinkage after healing (25%–30%).38,39 The donor
1. Thin (0.5–0.8 mm)
site is shallow and therefore heals mostly
2. Average (0.9–1.4 mm)
uneventfully.
3. Thick (1.5 to >2 mm)
The average-thickness graft is best suited for all
The thin graft is well suited to increasing the types of grafting except root coverage. This graft
amount of keratinized gingiva and provides the provides acceptable appearance and better pro-
best color match. A thin graft has to be placed in tection against future recession than the thin graft.
intimate contact with an intact blood supply of The donor site is deeper, which can cause more
the recipient site with the incision on the recipient complications following surgery. A palatal stent is
site placed submarginally. Placement over an recommended to protect the donor site and
exposed root surface should be avoided because ensure blood clot stabilization.
Box 2 of color and thickness incompatibility with adja-

Conventional periodontal plastic surgical cent gingiva (Fig. 5).
techniques
Indications for Free Gingival Graft
Pedicle graft
Free gingival grafts remain the gold standard for
Flap advancement procedures: augmentation of width and thickness of keratinized
Coronally positioned flaps tissue around teeth and implants. It has remained a
predictable technique when objectives include:
Semilunar coronally positioned flaps
Flap rotation procedures: Augmentation of gingival dimensions
Elimination of the frenum
Laterally sliding flap
Increase of vestibular depth
Partial-thickness double pedicle graft Improvement of local anatomic factors asso-
Rotational flap ciated with facial tooth position
Transpositioned flap Large, prominent roots with dehiscence
Stabilization of progressive gingival recession
Free soft tissue grafts Correction of ridge deformities and undercuts
Free gingival grafts Protection of denture bearing surface42
SCTGs Free gingival grafting can be used as a 2-stage
Free soft tissue grafts can be further divided de- procedure for root coverage with coronal
pending on the source of origin into: advancement once the graft has healed. It has
Autogenous grafts also been found to achieve root coverage as a
1-step surgical procedure in 44%43,44 and up to
Allografts 89.9% of the sites when applied appropriately.40
Xenografts Despite its ability to obtain root coverage, free
gingival graft is not suitable for areas with esthetic
concerns. Previous studies have shown that free
The thick free gingival graft can be used for gingiva grafted onto ectopic oral sites retains
covering exposed root surfaces.40 When root the tissue characteristics of their donor site,
coverage is desired, a 1.25-mm or thicker graft which may affect the esthetics of the grafted
should be used. Recipient bed margins should site.45,46
include epithelial denudation of marginal and
Technique
papillary gingiva.
The thick graft undergoes greater primary The incision is made at the mucogingival junction
contraction, but the secondary contraction is min- along the length of recipient area and extended
imal because of thick lamina propria. Thick grafts to adjacent teeth; however, it should not involve
are more resistant to future recession. There tends the sulci of the nongrafted adjacent teeth. On the
to be an increase in root coverage over a 1-year mesial and distal aspects, the horizontal incision
period following surgery, known as creeping is connected to 2 vertical incisions at 90 or slightly
attachment, which is most often observed with divergent toward mucosa. A split-thickness
thick grafts.41 Once healed, thick grafts result in dissection is performed, leaving in place perios-
less esthetically acceptable appearance because teum and deepening the fornix. Preparation of
Fig. 5. (A) Preoperative view of a patient presenting for a 2-implant overdenture with a thin periodontium and
recession. (B) Intraoperative view after implant placement. The blue lines will be deepithelialized and closed in a
double papilla fashion (arrows) in order to increase the keratinized tissue. (C) The final closure over the connec-
tive tissue grafts. The arrows indicate the double papilla closure. These grafts increase keratinized tissue and
convert the patient to a thicker periodontal biotype.
434 Deeb & Deeb
the recipient bed should extend 3 mm past the SOFT TISSUE GRAFTING ON IMPLANTS
edge of the denuded root surface and include VERSUS TEETH
removal of aberrant frenum.
When root coverage is also the objective of the Free gingival grafting provides a wider zone of ker-
procedure, the initial horizontal incision should atinized tissue and promotes a tight adaptation of
be placed at the level of the desired new gingival denser tissue around implants, which allows better
level. The level of gingiva anticipated following plaque control and gingival health. Only a small
grafting can be either at the cemento-enamel junc- number of studies are available reporting long-
tion for Miller class I and II recession defects or term stability of exposed implant coverage
below it for class III and IV. The larger donor tissue compared with studies performed on teeth. From
is easier to stabilize, therefore rendering root available data, it is suggestive that gained soft tis-
coverage more successful. Thick grafts that cover sue coverage on teeth remains stable in the long
only 1 tooth are harder to suture and stabilize, term compared with implants (Figs. 6 and 7).
making them less predictable for use in root The technique used by Burkhardt and col-
coverage procedures. leagues47 to cover approximately 3 mm of soft tis-
Gingival grafts should be excised from the donor sue recession on buccal aspect of implants
site with recipient site size and shape in mind and resembles in every step techniques used to cover
contoured to the recipient area.36 exposed root surfaces with SCTG on teeth. How-
Suturing the graft to the recipient site should ever, despite achieving immediate recession
completely immobilize the graft to encourage the coverage of more than 100% following surgery,
anastomosing of capillaries by maintaining inti- that gain was not maintained and shrank to 66%
mate contact with the recipient site vascular bed. at the 6-month follow-up. In contrast, similar soft
The thicker grafts should be slightly stretched to tissue defects on implants were treated by Zuc-
keep capillaries open, thus enabling the establish- chelli and colleagues48 also using connective tis-
ment of the blood supply to the graft. Interrupted sue grafts. At 1 year they observed a mean
sutures are used on the edges. Sling sutures coverage of 96% and a significant increase in the
around grafted teeth ensure intimate contact of amount of keratinized tissue. The main difference
the graft interproximally and elimination of the between the two studies was the removal of the
dead space between graft and recipient bed. crown and reshaping and polishing of the implant
At present, free gingival grafts are not used as abutment before surgery, allowing better adapta-
often as in the past because of less than optimal tion between the graft and abutment. Reshaping
esthetics and a more uncomfortable postoperative and polishing the implant abutment closely
course than newer subepithelial techniques. resembles the way grafting is performed over
Fig. 6. (A) Adolescent patient with an inadequate zone of keratinized tissue around the facial aspect of the
mandibular incisors. (B) Split-thickness dissection of the anterior mandible to prepare the recipient bed for
palatal free gingival grafting. Note that the flap has been positioned apically in order to avoid coronal migration.
(C) Free gingival graft harvested from the palate. (D) Palatal donor site with Surgicel and Periacryl dressing over-
sewn with chromic gut suture. (E) Palatal graft sutured into place using chromic gut suture. (F) One week after
surgery showing an increased zone of attached tissue.
Fig. 7. (A) A single-tooth implant showing a lack of keratinized tissue. (B) Supraperiosteal dissection in prepara-
tion for the free gingival graft. (C) A template in place before graft harvest. (D) The free gingival graft secured
into the recipient bed. (E) The final result showing increased keratinized tissue. Coverage of the porcelain at the
apical portion of the restoration was not achieved (and rarely is).
root surfaces with root planning, reshaping, condi- favored a prolonged period of revascularization
tioning, and placement of grafts in close proximity and delayed healing.51
to recipient surfaces. Addition of abutment and
crown modifications provides more space and Technique for Subepithelial Connective Tissue
better adaptation of the graft into the recipient Graft
site. Provisional crowns can be modified to guide Donor site for subepithelial connective tissue
and sculpt soft tissue during healing.49 graft
Masticatory mucosa on the palate between palatal
SUBEPITHELIAL CONNECTIVE TISSUE GRAFT raphae and maxillary posterior teeth is the most
common location for the donor site for SCTG
This technique is currently used in most soft tissue (see Fig. 16). It is composed of connective tissue
grafts performed in periodontal plastic surgery. and loosely organized glandular and adipose tis-
The connective tissue graft, also known as SCTG sue.52 The best-quality connective tissue is found
was introduced in 1980 by Langer and Calagna.50 closest to the teeth; however, harvesting tissue
Its use was described for root coverage and ridge closer than 2 mm to the teeth places those teeth
augmentation procedures. at risk for developing postoperative gingival reces-
The donor site was the patient’s palate, the graft sion caused by inadequate blood supply to the
was 1 to 2 mm thick, and split-thickness recipient apex of the retained flap.
bed preparation was suggested to provide double Surgeons harvesting SCTG from the palate must
blood supply to the newly added tissue graft.50 be familiar with the anatomy and characteristics of
The autogenous SCTG is divided by thickness of this donor site. It is important to avoid the nerves
the donor tissue into 3 categories: and vessels located in the greater palatine groove
1. Thin (0.5–0.8 mm) at the junction of vertical and horizontal palate. The
2. Average (0.9–1.4 mm) palatal vault height varies from 7 mm to 17 mm,
3. Thick (1.5 to >2 mm) with an average distance of 12 mm from the neuro-
vascular line.
The thickness of the graft proved to have an ef- The incision is started 2 mm from the soft tissue
fect on the amount of shrinkage and the rate of margin on the palatal aspect of the teeth and it
healing of the graft that occurred following sur- should end 2 mm above the neurovascular line.
gery. Rapid revascularization can be expected The width of donor tissue can therefore vary from
when uniform thin or intermediate grafts are 3 to 13 mm, with an average width of 8 mm.
placed on a periosteal recipient site. An uneven, The size of SCTG needed depends on the de-
thick graft placed on a site of denuded bone mands of the recipient site; however, for most
436 Deeb & Deeb
sites, 5 to 9 mm is an adequate width. Limitations Partially covered subepithelial connective

that the shallow vault represents as a donor site tissue graft
should be considered before surgery. Alternative Partially covered SCTG was originally described
sources for donor tissue are available and should by Langer and Langer.55 This technique can be
be used in such cases. Encroaching on neurovas- used for class I, II, and III recession defects; how-
cular structures can lead to bleeding and some de- ever, the increase in keratinized tissue obtained
gree of postoperative paresthesia to the palate. with this technique makes it more suitable for class
Donor sites can often be adequately stabilized by II and III recession defects in which keratinized
suturing (Figs. 11C and 16C). gingiva is deficient (Fig. 8).
SCTG can be removed from the palate by Blood supply is not as good for SCTG left
single-line incision (see Fig. 16B) or double parallel partially exposed as it is for the completely
incisions. Single-line incision allows for primary covered SCTG, therefore the donor tissue must
closure after removal of the graft (see Fig. 16C) be thick enough to survive over the avascular
and is used for larger grafts. Double parallel inci- root of the tooth.
sions are used for smaller grafts and provide grafts Partial graft coverage techniques offer several
with very uniform thickness. advantages, such as maintaining the preoperative
vestibular depth and position of mucogingival
Recipient Site for Subepithelial Connective junction, as well as augmentation of keratinized
Tissue Graft tissue as the exposed SCTG keratinizes over
when left exposed.56 Submerged grafts without
Modifications of preparation of the recipient site epithelial collar performed better esthetically,
have followed the introduction of the original tech- whereas exposed epithelial collar grafts resulted
nique. To eliminate vertical incisions, envelope in better gingival augmentation with similar results
flaps were explored for recipient sites with similar in root coverage.57 In spite of attempts to remove
success.53 Connective tissue grafts are used in the epithelium, it remains in 80% of the grafts.58
combination with many different recipient site
pedicle flap designs. SCTG can be either Completely covered subepithelial connective
completely covered or left partially exposed. Har- tissue graft
ris and colleagues54 compared 3 variations of Connective tissue grafts can be completely
recipient site flap design in conjunction with con- covered by the use of CAF. Vertical incisions can
nective tissue graft. Techniques including coro- be used for increased access and to facilitate cor-
nally positioned flap, double pedicle flap, and a onal repositioning; however, they decrease blood
tunneling procedure over an autogenous connec- supply and can cause scarring.
tive tissue graft were all effective in obtaining In the absence of keratinized tissue before graft-
root coverage and improving clinical parameters. ing, the flap to cover the graft consists of only
Fig. 8. (A) Preoperative clinical view showing 2 dental implants with inadequate keratinized tissue on the facial
aspect. (B) Supraperiosteal dissection to prepare a bed for free gingival grafting. The apical flap margin is sutured
to periosteum to prevent coronal migration during healing. (C) Palatal free gingival graft harvest. (D) Palatal
donor sites. These sites can be dressed with Surgicel and Periacryl. (E) Free gingival grafts sutured into place using
3.0 chromic gut. (F) Eight weeks after surgery showing increased keratinized tissue.
mucosa. When covering an SCTG with a flap lack- TECHNIQUE FOR PEDICLE FLAP WITH
ing keratinized tissue, the outer surface over the VERTICAL INCISIONS
graft heals as nonkeratinized mucosa for a soft tis-
sue margin. To alter the surface of a new soft tis- The horizontal incision is made at the desired level
sue margin from mucosa to keratinized tissue of the future gingival margin, usually at the level of
once the graft has established its own blood sup- the CEJ. The incision extends to the interdental
ply, overlying mucosa can be released and apically area adjacent to the terminal grafted tooth. When
positioned leaving SCTG exposed to keratinize the second incision is used parallel to the first inci-
over. sion, it should be spaced as far apically from the
first one as the recession measures on the
PARTIAL-THICKNESS DOUBLE PEDICLE GRAFT exposed root. These incisions are then connected
with mesial and distal vertical incisions that extend
The use of a double pedicle flap should be consid- beyond the mucogingival junction to allow manip-
ered when the objective of grafting includes the in- ulation of the flap in the coronal direction. The
crease of keratinized tissue. The overlying double recipient bed is prepared with split-thickness
pedicle slides laterally interproximal papillary kera- dissection to free the flap from the periosteum.
tinized tissue over the grafted root surface and, SCTG is sutured in place, extending to the
compared with a coronally positioned pedicle edges of the recipient bed (Fig. 10B). The flap is
flap deficient in keratinized tissue, results in a then coronally advanced for as many millimeters
larger increase of keratinized tissue (3.0 mm vs as the recession measured before grafting (see
1.8 mm) (Fig. 9).59 Fig. 10).
Fig. 9. (A) Punch technique used for uncovering at stage 2 surgery. (B) Healing abutment placed at stage 2 sur-
gery. Note the horizontal ridge deficiency and narrow zone of attached tissue. (C) Papilla-sparing incision with
vertical releases is being elevated in preparation for connective tissue grafting to buccally augment the zone
of attachment. (D) Palatal connective tissue graft being sutured in place. (E) One week after surgery showing
buccal and vertical augmentation of the site. (F) The connective tissue donor site 1 week after surgery. (G) Final
restoration at 1 year after surgery showing improved buccal and vertical soft tissue contours.
438 Deeb & Deeb
Fig. 10. Connective tissue graft and pedicle flap (A) Preoperative view of lower left premolar area. Note receding
soft tissue margin with minimal amount of keratinized tissue present on tooth #21 and amalgam restoration ex-
tending onto root surface. (B) Intraoperative view showing recipient site with pedicle flap and SCTG sutured to
obtain desired root coverage apically of amalgam restoration. (C) Four weeks postoperatively, teeth #20 and #21
present with improved soft tissue support and good root coverage apically of margins of preexisting
restorations.
TECHNIQUE FOR ENVELOPE FLAP coronally to the CEJ. Papillary tissue is under-
mined but not reflected. The pouch must extend
This technique can also be called the single-tooth far enough laterally and apically to allow passive
tunnel or pouch technique. The SCTG is sutured placement of the SCTG. Dissection for this tech-
into a recipient tunnel donor site without reflecting nique is more difficult and tactile sensation is the
a traditional flap. The envelope flap maintains only method of negotiating the preparation of the
ample blood supply from the adjacent papillary, recipient site between periosteum and mucosa
overlying mucogingival and underlying mucoper- or gingiva. The suturing technique is also more
iosteal sides. challenging; however, fewer sutures are needed
A small scalpel blade is placed in the sulcus and because of good graft stability under the envelope
a split-thickness pouch is developed under the flap. The suturing technique is designed to pull the
surface of the mucogingival tissue. The recipient donor tissue into the tunnel preparation of the
bed preparation must extend to the papilla slightly recipient site (See Fig. 11).
Fig. 11. Connective tissue graft tunnel. (A) Preoperative clinical view showing root exposure and a thin zone of
keratinized tissue. (B) Subepithelial tunnel being prepared in a split-thickness dissection to receive the connective
tissue. (C) Single-incision technique used to harvest the connective tissue graft. (D) Connective tissue graft placed
into the subepithelial pocket. (E) Connective tissue graft and buccal flap sutured to the level of the CEJ. (F) One-
month postoperative visit showing root coverage as well as an increased zone of keratinized tissue.
SEMILUNAR AND LATERAL SLIDING FLAPS thoroughly root planed and conditioned with either
citric acid,61 tetracycline, or ethylenediaminetetra-
Semilunar coronally positioned flaps and laterally acetic acid (EDTA). The implant surface can be
sliding flaps are mostly used without adding cleaned with air-power abrasive with sodium bi-
SCTG and are suitable for high vestibules with carbonate powder and application of tetracycline
thick and wide adjacent keratinized tissue that (Fig. 13).
can be transpositioned. Because of limitations of Elimination of endotoxins, demineralization, and
flap mobility and the numerous alternatives that removal of the smear layer provide exposure of
are now available, these techniques remain in dentinal tubules, which seems to be essential for
use for single teeth or implants in specific circum- new attachment procedures on the root surface.
stances (Fig. 12). Citric acid causes a greater degree of morpho-
logic alterations than EDTA62 or tetracycline
PINHOLE SURGICAL TECHNIQUE HCl63–65 and is considered to be a better root-
In recent years a novel surgical approach to root conditioning agent.
coverage, called the pinhole surgical technique, Deviating from the protocol can result in dam-
has been gaining exposure. Chao60 introduced it age to the tooth, demineralization, and lack of ce-
for Miller class I, II, and III recession defects and mentogenesis. Chemical conditioning of the
reported favorable predictability for root coverage dentin has been shown to stimulate the attach-
and defect reduction up to 18 months following the ment of fibroblasts65 as well as gingival keratino-
procedure. cytes, which could favor the reformation of a
junctional epithelium.66
ROOT SURFACE AND IMPLANT SURFACE Some clinical studies have failed to observe
TREATMENT improved outcomes of surgical technique when
using citric acid.67
Root or implant surface should be smooth and de-
contaminated before receiving the tissue graft. ALTERNATIVES TO AUTOGENOUS SOFT
Grooves or notches on the root surfaces should TISSUE GRAFTS
be properly contoured because they create dead
spaces between the graft and root surface. De- The concept of avoiding the secondary donor sur-
fects, calculus, and restorative materials should gical site adds great appeal to materials that repre-
be eliminated or reshaped with fine diamond burrs sent an alternative to autogenous donor sites for
or hand instruments. Root surface should be soft tissue grafting. Although these new materials
Fig. 12. Lateral sliding flap. (A) Canine with an inadequate zone of keratinized tissue. (B) Lateral pedicled flap
design just before split-thickness dissection. (C) Flaps mobilized and sutured into place using 4.0 chromic gut.
(D) Final result showing an increase in keratinized tissue.
440 Deeb & Deeb
Fig. 13. Allograft for connective tissue graft tunnel. (A) Preoperative clinical view showing recession and root
exposure. (B) Root preparation with EDTA after scaling and root planning. (C) Alloderm acellular dermal graft
being hydrated and measured. (D) Placement of Alloderm into recipient site tunnel preparation without flap
elevation. (E) Final closure of the coronally advanced flap over the Alloderm. (F) Postoperative clinical result,
showing complete root coverage in the upper left quadrant.
do not surpass the gold standard (SCTG), they do In systematic review evaluating esthetic soft
provide patient satisfaction and esthetics and are tissue management for both teeth and dental
available in abundance. implants, xenogeneic collagen matrix was compa-
rable with SCTG in terms of mean keratinized tis-
Allograft sue gain; however, it did not achieve the same
Allografts such as acellular dermal matrix (ADM) root coverage.73
have been used around teeth and implants to sub- Similarly, in another systematic review of the
stitute the autogenous connective tissue grafts, most effective techniques for soft tissue manage-
especially for larger recipient sites or when obtain- ment around dental implants, the technique using
ing autogenous tissue is not feasible and would an animal-derived collagen matrix was able to
lead to much higher postoperative discomfort. Al- achieve its goal, but at the cost of a worsened
lografts and autografts yield similar predictability esthetic outcome.30
for root coverage techniques; however, connec-
tive tissue autografts result in superior defect Guided Tissue Regeneration
coverage, higher keratinized tissue and attach-
Guided tissue regeneration (GTR) has been used
ment gain, and lower residual probing depths
for treatment of recession defects around teeth
(see Fig. 13).68–72
and implants using resorbable and nonresorbable
Allografts also provide an alternative to replace
barriers in combination with various bone grafts
an autogenous free gingival graft (Fig. 14).
and biologic agents.
Wei and colleagues73,74 conducted a study
GTR-based root coverage can be used suc-
comparing the effectiveness of ADM and free
cessfully to repair gingival recession defects.
gingival graft for increasing the width of attached
However, most studies that compared GTR and
gingiva. The results suggested that tissue formed
SCTG concluded that SCTG resulted in statisti-
at the ADM-treated site did not parallel any known
cally better root coverage, width of keratinized
mucosa and was more similar to scar tissue.
gingiva, and complete root coverage.76–79 Ten-
Xenograft year follow-up comparing SCTG and GTR for
root coverage found that the long-term stability
Xenografts that include thick collagen matrices of root coverage (ie, the reduction of recession
have been introduced as an alternative to auto- depth) and esthetic results perceived by patients
grafts or allografts for use as free gingival or con- were significantly better using SCTG compared
nective tissue grafts. with GTR surgery using bioabsorbable barriers.80
McGuire and Scheyer75 showed that xenoge-
neic collagen matrix with a CAF represents a viable
Living Cellular Construct
alternative to SCTG in the treatment of recession
defects, without the morbidity of soft tissue graft Living cellular constructs (LCC) are derived from
harvest. autogenous or allogenic sources.
Fig. 14. Allograft for free gingival graft (A) Anterior mandibular preoperative view showing a narrow zone of
keratinized tissue. (B) Subperiosteal dissection in preparation for Alloderm augmentation. Note that the flap
has been sutured inferiorly to the apical periosteum. (C) Operative view showing the Alloderm secured in place
over the periosteal bed with interrupted and sling sutures. (D) Eight-week postoperative view showing an
increased zone of keratinized tissue.
Platelet-rich fibrin (PRF) is of autologous origin addition of PRF to a CAF in treatment of Miller
and has been reported in the literature as being class I and II recession defects resulted in superior
used for enhancing healing of the palatal donor root coverage compared with CAF alone.84
site81 and for papilla reconstruction.23 Search of site-appropriate tissue in the oral cavity
PRF was also used to treat multiple gingival re- has included application of living cellular sheet (LCS)
cessions.82 The natural fibrin architecture of PRF in oral soft tissue therapy as a free gingival graft.85,86
seems responsible for releasing large amounts of LCS is an allogenic graft composed of cultured
growth factors and matrix glycoproteins. These keratinocytes and fibroblasts in bovine collagen
biochemical components of PRF are involved in and has been used for more than 14 years to treat
wound healing and tissue regeneration.83 The patients with cutaneous wounds.87–90 (Fig. 15).
Fig. 15. (A) Preoperative view showing an inadequate zone of keratinized tissue in the anterior mandible. (B) Supra-
periosteal dissection completed in order to receive the graft. Note that the flap is secured inferiorly to the apical
periosteum. (C) The Mucograft is sutured into place using a combination of interrupted and sling sutures in order
to ensure graft immobility. (D) Final 12-week postoperative result showing an increased zone of keratinized tissue.
442 Deeb & Deeb
Based on histologic findings, the authors sug- comparisons of the mean keratinized tissue
gested that LCS-treated sites resembled gingiva gain.69
rather than alveolar mucosa. Compared with sites
treated with autogenous grafts, tissue generated Biologic agents
at LCS-treated sites presented with more site- Biologic agents have been explored in conjunction
appropriate tissue that was deemed superior in with soft tissue grafting to improve migration and
terms of color and texture match to adjacent un- differentiation of cells in grafted sites. The data
treated tissue, absence of scar formation, or ke- from systematic review by Fu and colleagues69
loidlike appearance as well as mucogingival concluded that the adjunctive use of biologic
junction alignment. Besides superior esthetics, agents did not exert a significant effect on mean
LCC also scored better in patient satisfaction; root coverage and mean amount of keratinized tis-
however it was inferior to free gingival graft in sue gain.
Fig. 16. SCTG ridge augmentation. (A) Preoperative view showing an inadequate bucolingual dimension under
pontic #8 in the anterior maxilla. (B) Intraoperative view showing harvesting of SCTG from the palatal donor site
by single-incision approach. (C, D) Donor site sutured (C) and covered with periodontal dressing (D). (E) Split-
thickness dissection for recipient site preparation using single vertical incision and tunnel preparation. Care
was taken to avoid disruption of gingival collars surrounding implants. (F, G) Sutures (arrows) were used to facil-
itate advancement of the graft into the recipient site. (H, I) SCTG sutured to recipient site before (H) and after (I)
the reinsertion of the implant-supported temporary prosthesis. (J) Healing after 8 weeks. Placement of connective
tissue graft augmented soft tissue support on the facial aspect of pontic #8. (K, L) Placement of connective tissue
graft in edentulous area enhanced the esthetics, volume of soft tissue, and papillae under the implant-supported
provisional prosthesis as shown by comparing before (K) and 8 weeks following surgery (L).
Fig. 17. (A) Surgicel is sutured to the donor site. (B) Application of a hemostatic agent made of an oxidized poly-
anhydroglucuronic acid is easy and effective in improving hemostasis.
SOFT TISSUE GRAFTS FOR RIDGE Miller98 described a surgical technique using 1
AUGMENTATION vertical incision creating a tunnel between soft tis-
sue and bone, and inserting into it a connective tis-
Soft tissue grafts can be used for ridge augmenta- sue graft to augment deficient alveolar ridge. This
tion to improve esthetics and enhance pontic technique is useful for management of soft or
adaptation (See Fig. 16). hard tissue defects under existing restorations on
Seibert91,92 presented a classification of ridge teeth or implants as well as improving soft tissue
deformities and described a full-thickness onlay support around new ones.
grafting technique. Other investigators described
the use of connective tissue grafts to restore de-
Donor and Recipient Wound Site Protection
fects in bucolingual dimension.93–96 Allen and col-
leagues97 established that, following surgery, Donor sites often present with more postoperative
shrinkage was complete in 6 weeks and SCTG re- complications than recipient sites. Techniques for
mains volumetrically stable over several years. protection of donor sites include removable
Fig. 18. (A) Free gingival graft sutured to recipient site. (B) The placement of dressing is helpful in maintaining
vestibular depth and protecting the recipient site. (C) No root coverage is attempted for Miller class IV soft tissue
defect. (D) Placement of free gingival graft augmented the amount of keratinized gingiva and improved vestib-
ular depth, as is evident when comparing before (C) and 4 weeks following surgery (D).
444 Deeb & Deeb
devices or application of materials that stabilize attached gingiva. J Clin Periodontol 1985;12(8):
the clot and facilitate wound healing. 667–75.
Removable devices for the palate include stents 2. Wennstrom JL, Lindhe J. Role of attached gingiva
made from polymethyl methacrylate or vacuum- for maintenance of periodontal health. Healing
formed thermoplastic material as well as existing or- following excisional and grafting procedures in
thodontic retainers or dentures. Properly fabricated dogs. J Clin Periodontol 1983;10(2):206–21.
palatal stents should be secure and tightly adhering 3. Block MS, Kent JN. Factors associated with soft- and
to palatal tissue. The stent is important for larger and hard-tissue compromise of endosseous implants.
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ative bleeding and discomfort. Patients with a ten- 4. Wennstrom JL. Lack of association between width
dency for slower healing, including smokers,99 of attached gingiva and development of soft tissue
make good candidates for the use of stents (Fig. 17). recession. A 5-year longitudinal study. J Clin Perio-
Materials used most frequently on palatal donor dontol 1987;14(3):181–4.
sites include oxidized cellulose (Surgicel) and 5. Bangazi F, Wennstrom JL, Lekholm U. Recession of
PRF.81,100 They have been credited as aiding in the soft tissue margin at oral implants. A 2-year lon-
healing and also adding to procedure time and gitudinal prospective study. Clin Oral Implants Res
cost. Periodontal dressing can be applied over 1996;7(4):303–10.
smaller donor sites for SCTGs (Fig. 18). 6. Warren K, Buser D, Lang NP, et al. Plaque-induced
Recipient sites can also be covered by a protec- peri-implantitis in the presence or absence of kera-
tive barrier. Cyanoacrylate tissue adhesive is tinized mucosa. Clin Oral Implants Res 1995;6:131.
applied in a thin layer over the junction of recipient 7. Silness J, Loe H. Periodontal disease in pregnancy.
site and graft once the graft is sutured in place. Re- II. Correlation between oral hygiene and peri-
ports using cyanoacrylate in the oral environment odontal condition. Acta Odontol Scand 1964;22:
have shown favorable healing and improved 121–35.
hemostasis101–103 and it has a safe record for in- 8. Friedman N. Mucogingival surgery. Tex Dent J
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adaptation over grafted areas and can be helpful 9. Miller PD Jr. Regenerative and reconstructive peri-
in maintaining an increased vestibular depth ob- odontal plastic surgery. Dent Clin North Am 1988;
tained with surgery. 32:287–306.
10. Genco RJ, Newman MG. Consensus report-
SUMMARY mucogingival therapy Ann Periodontol 1996;1:
702–6
Esthetic appearance and functional longevity for 11. Chu SJ, Tarnow DP. Managing esthetic challenges
teeth and implants often requires conversion of with anterior implants. Part 1: midfacial recession
unfavorable soft tissue traits to more favorable defects from etiology to resolution. Compend
ones. Improvement of tissue quality and quantity Contin Educ Dent 2013;34(7):26–31.
can be accomplished with many different tech- 12. Sullivan HC, Atkins JH. Free autogenous gingival
niques and materials and largely depends on clin- grafts. III. Utilization of grafts III. Utilization of
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clinician with the procedures and materials avail- 1968;6:153.
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15. Kokich VO, Kokich VG, Kiyak HA. Perceptions of
ACKNOWLEDGMENTS dental professionals and laypersons to altered
The authors thank the following graduate dental esthetics: asymmetric and symmetric situa-
students at Virginia Commonwealth University for tions. Am J Orthod Dentofacial Orthop 2006;
their contributions of photographs for this publica- 130(2):141–51.
tion: Dr Anya Rost, Dr Fadi Hassan, Dr Sarmad Ba- 16. Chu SJ, Tan JH, Stappert CF, Tarnow DP. Gingival
kuri, Dr Diego A. Camacho, and Dr Nicholas Kain. zenith positions and levels of the maxillary anterior
dentition. J Esthet Restor Dent 2009;21(2):113–20.
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S u r g i c a l Tre a t m e n t o f
Impacted Canines
What the Orthodontist Would Like the
Surgeon to Know
Adrian Becker, BDS, LDS, DDO*, Stella Chaushu, DMD, MSc, PhD
KEYWORDS
Impacted canine Surgical exposure Open or closed exposure Attachment bonding
Immediate traction Steel ligature connector
KEY POINTS
If there is an existing malocclusion that requires orthodontic treatment, a full orthodontic appraisal
is needed for planning the overall mechanotherapy.
It is incumbent on the oral and maxillofacial surgeon and the orthodontist to evaluate the 3-dimen-
sional location of the tooth and assess whether the tooth or teeth are salvageable.
Excepting the very simplest and mildest forms of impaction, orthodontics will be necessary to
properly resolve the impaction and align the tooth.
Videos of two very high impacted canines using cone beam computed tomography
accompany this article at http://www.oralmaxsurgery.theclinics.com/. One is located high
on the palatal side of the incisor root apices and the second in the line of the arch, high
above the premolar with interference from abnormal premolar roots
INTRODUCTION encourage autonomous eruption of the

canine.1,2
When an impacted permanent maxillary canine 3. A supernumerary tooth or odontome that has
has been diagnosed, the general practitioner or impeded the normal eruption of the tooth could
pediatric dentist typically thinks in terms of surgery be removed.
and orthodontics and, usually, in that order. Thus, 4. Access to the tooth may be provided for the
the patient is frequently referred to the oral sur- later placement of an attachment and for the
geon in the first instance. application of traction if rehealing of the tissues
In this scenario, a “surgery first” approach can over the crown is prevented using a surgical/
achieve several important goals. periodontal pack over the open wound or by
1. By exposing the tooth to the oral environment, apically repositioning a surgical flap higher up
surgery can provide a way for autonomous nat- on the crown of the exposed tooth.
ural eruption. However, surgery alone is limited when:
2. Surgery could simplify orthodontic treatment

that would then be delayed for several months 1. Space is inadequate in the dental arch to
if, as advocated by the late Vince Kokich, expo- accommodate the impacted tooth, thereby
sure and packing of the exposure wound would impeding its natural eruption.
Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine, 6 Shalom Aleichem

Street, Apartment #3, Jerusalem 92148, Israel

450 Becker & Chaushu
2. To maintain a patent exposure, an excessive which he or she may not be prepared. Perhaps
amount of gingival tissue and bone must be oral hygiene is poor or there is frank caries in
removed, to the detriment of the periodontal other teeth, or simply that the patient is unwilling
outcome.3–5 or financially unprepared to wear braces.
3. Autonomous eruption is unlikely to occur and
the surgeon feels the necessity for a much THE ORTHODONTIST MUST BE THE “MASTER
more radical open exposure and/or the tooth OF CEREMONIES”
is “gently” elevated to “free” it from the sur-
rounding tissues, or if bone channeling is per- If there is an existing malocclusion that requires or-
formed. These procedures are highly suspect thodontic treatment, a full orthodontic appraisal is
for inflicting irreversible damage to the perio- needed for planning the overall mechanotherapy.
dontium4 or the cementum layer of the root.6 The orthodontist will undertake a clinical examina-
4. Immediate application of traction cannot be em- tion, including plaster casts and the routine radio-
ployed because there is no orthodontic appli- graphs needed for any orthodontic case. For a
ance or temporary orthodontic bone anchor patient with an impacted maxillary canine, there
present, from which to apply the traction force. will be the additional requirement of accurately
5. The tooth needs to be moved away from the locating the impacted tooth in 3 planes of space
root of an adjacent tooth, particularly when and in relation to the adjacent teeth. Further radi-
there are signs of resorption of that root.7 ography, together with cone beam CT, will often
6. The tooth is located in a grossly ectopic site.8 be required to diagnose resorption of the roots of
the incisors and to confirm the integrity of the
Surgery without orthodontic coordination may outline and texture of the impacted tooth itself.9,10
occasionally result in: When all the information is collated, a treatment
plan will be formulated to resolve the overall
1. The surgeon exposing an impacted tooth before malocclusion and to decide the future of the
an orthodontic appraisal has been made. This impacted tooth, which may lead to a decision to
may be one of the teeth that the orthodontist extract permanent teeth. In general, the choice of
would wish to sacrifice in the course of subse- tooth for extraction devolves on a premolar in
quent orthodontic treatment, because overall each quadrant. However, no tooth is sacrosanct
and comprehensive considerations may demand and, if the choice is between an erupted healthy
the remedial extraction of 4 permanent teeth. premolar and a deeply buried canine in an ectopic
2. Rehealing of the surrounding tissues over the location, whose periodontal outcome may be
exposed tooth, making it once again compromised in the final analysis, the canine
inaccessible. should be extracted.4
3. The surgeon bonding an attachment to an Excepting the very simplest and mildest forms
aspect of the crown of the tooth in a strategi- of impaction, orthodontics will be necessary to
cally incorrect position during the operation, resolve properly the impaction and align the tooth.
which may make subsequent orthodontic trac- This being so, the dental arches need to be aligned
tion difficult to direct or control. and leveled and adequate space provided in the
4. Poor timing, because active traction may be canine location, to place a heavy archwire in the
impossible to apply for several months or years, bracket slots and, thus, to establish a sound
during which reburial of the tooth may still occur. anchorage base from which to apply traction to
5. A successful treatment from the surgical and or- the tooth. This preparatory step takes time—occa-
thodontic standpoints, but that may become a sionally, as much as a year or more—but ortho-
periodontal disaster if the root apex of an dontists are well-practiced at achieving these
impacted tooth is in a severely displaced initial goals.
location. The orthodontist may consider that, Clearly then, the orthodontist is the person who
although it may be possible to achieve a good or- is ultimately responsible to the patient for the suc-
thodontic resolution of the impaction and align- cess of the treatment plan as a whole. The oral and
ment of the tooth into its place in the dental maxillofacial surgeon is responsible only for the
arch, the periodontal prognosis may be compro- success of the immediate operative procedure,
mised, after the difficult orthodontic root move- in which he or she provides access to the tooth,
ments of the tooth, with the outcome showing previously denied. It is incumbent on both the
insufficient bony support, poor soft tissue cover, oral and maxillofacial surgeon and the orthodontist
and an unsightly and elongated clinical crown. to evaluate the 3-dimensional location of the tooth
6. Committing the patient to orthodontic treatment, and, together, assess whether the tooth or teeth
because this is the “best” line of treatment, but for are salvageable. If the canine position is beyond
Surgical Treatment of Impacted Canines 451
reasonable bounds, extraction will be advised. For the direction he or she will have planned, to reduce
the oral and maxillofacial surgeon, an assessment the impaction and align the tooth.
of the location of the crown of the canine in the 3
planes of space and in relation to the roots of the THE SURGICAL PROCEDURE
adjacent teeth is essential, because the surgeon
is only interested in exposing the crown and pre- There are several appropriate surgical procedures
venting damage to the adjacent teeth. Orientation that need to be contemplated and these are
of the root of the tooth is not relevant to his or her classified into open procedures and closed proce-
ability to achieve success in the exposure dures. Each method must additionally take into ac-
procedure. count the elimination of a supernumerary tooth or
For the orthodontist, the assessment also in- odontome, if appropriate.
volves the 3-dimensional orientation of the long
The Palatal Canine and the Open Exposure
axis of the tooth and an exact positional diagnosis
Technique
of its root apex. If the apex is in the line of the arch in
the buccolingual plane and in the mesiodistal The palatal area is composed of tightly bound
plane, then the crown of the tooth will only need attached mucosa, which means that a palatally
to be tipped into its place in the arch, a relatively impacted canine that is erupted through it, after
simple biomechanical exercise. For as long as the an open exposure procedure, will be invested
tooth is not fully engaged in the main archwire, no with attached epithelium in the final instance. After
root movements are possible and, thus, any devia- this procedure, the canine must be left exposed to
tion of the location of the apex, particularly in the the oral environment and care taken to ensure that
buccolingual plane, will demand complicated up- healing of the adjacent soft tissues will not recover
righting and torqueing mechanotherapy, which is the tooth and again make it inaccessible. This may
technically difficult to perform and reduces the be done by clearing a broad area of soft tissue,
periodontal prognosis of the tooth in the long term.4 including the entire dental follicle, oral mucosa
Accordingly, the orthodontist’s evaluation as to and bone, down to the cementoenamel junction
whether surgical exposure should be undertaken (CEJ) and placing a surgical pack to cover the
at all must be considered of primary importance. area (Fig. 1). This pack would normally be left for
It follows that the surgeon’s essential role is to pro- 2 to 3 weeks in the hope that the tooth remains
vide optimal conditions for the orthodontist to be visible when the pack is removed, and to provide
able to proceed to apply forces to the tooth in access for later bonding of an attachment in the
Fig. 1. (A) Panoramic view showing palatally impacted maxillary canine and other dental anomalies. (B) Occlusal
view to show the palpable bulges indicative of relatively superficial, palatally displaced, canines (arrows). (C)
Open exposure of the 2 canines. (D) A suture-stabilized periodontal pack covers the exposed area, with the
aim of preventing healing over of the palatal soft tissue and maintaining access to the tooth. (Treatment by grad-
uate student Dr O. Yitschaky.)
relative comfort of the orthodontist’s office. A word will still be invested with the same healthy attached
of caution arising from overzealous surgical expo- gingiva, but the clinical crown length, the gingival
sure is at this juncture. To ensure that the tooth level, the alveolar crest height and the periodontal
does not become recovered by the tissues during parameters will be much more favorable.13 This
the healing period, bone and mucosal tissue are method is particularly useful when the impacted
often pared back liberally around the tooth. tooth is situated deeply. An open procedure would
Together with a complete elimination of the dental leave a very wide mucosal deficiency in the palate.
follicle, the entire crown down to the CEJ is Conversely, a superficially palpable canine should
revealed and a surgical pack placed to maintain be left open after the exposure, with or without a
the patency of the open exposure site. Exposure surgical pack as a dressing.
of the tooth down to the CEJ and excessive
removal of bone and soft tissue will have a detri- The Labial Canine and the Window Technique
mental effect on the periodontal outcome of an A labially impacted canine, on the other hand, is
otherwise successfully treated case, because the usually palpable above the level of the attached
junctional epithelium that encircles the cervical gingiva and covered only by a thin and mobile
few millimeters of crown enamel will be severed oral mucosa. To expose the tooth by opening a
irreparably and be pushed apically. The outcome semilunar window in the oral mucosa directly
will be seen many months later when the ortho- over it is very simple, very popular, and often per-
dontic treatment has been completed, in the formed by the orthodontist. However, this will
form of a long clinical crown, with loss of bone result in the tooth being drawn down with no
height, gingival recession, and poor periodontal attached gingiva on its labial side and with only
appearance. On occasion, particularly with the this thin, mobile, and easily traumatized covering
more deeply located teeth, the surgeon will for its long-term protection (Fig. 3). The only time
moderately luxate the tooth, with the intention of that this is acceptable is when there is a broad
“loosening it up” or “to check if it is ankylosed” band of attached gingiva within which the incision
by pushing an elevator beyond the CEJ and into is made, leaving a portion of the thicker tissue
the sensitive cementum covering the root surface. above the cut. This will then become the labial
This has been claimed by many to facilitate spon- gingiva when the tooth is brought into alignment.
taneous eruption and even to positively redirect its There are 2 alternatives to the window tech-
eruption path. However, this common practice, nique, each of which will produce superior results
whose intention is to facilitate the orthodontist’s in terms of the periodontal health and appearance.
later resolution of the impaction, may actually
initiate a cervical root resorption process or an The Labial Canine and the Apically
ankylotic union at that site. The development of Repositioned Flap Technique
these pathologic entities will then prevent eruption
of the tooth, causing the failure of all attempts at The first is the apically repositioned flap, which is only
orthodontic traction.6,11 suitable for the canine which is not displaced mesi-
ally or distally from its normal location in the arch. It
involves raising a flap from the keratinized gingiva
The Palatal Canine and the Closed Exposure at the crest of the ridge or from the gingival margin
Technique of the retained deciduous canine. It is elevated above
Alternatively, the orthodontic attachment may be the height of the labial canine and to reveal the follicle
bonded as an integral part of the surgical proce- of the canine. The follicle is opened over its labial sur-
dure in the office of the oral and maxillofacial surface only and the flap sutured tightly to the cervical
geon. This method demands a less radical surgical half of the crown of the tooth, leaving the coronal
procedure, eliminating the need for exposure half exposed (Fig. 4). Either at the same time or at
down to the CEJ and leaving the deeper part of a subsequent visit to the orthodontist, an attachment
the dental follicle intact.12 This is because contact may be placed on the tooth, although the vertical
with and control of the tooth may be maintained force of the upward-displaced and tightly sutured
through the ligature wire that is tied to the attach- flap creates a mild extrusive force on the canine
ment. This is the thinking involved in the closed that will often improve its position quite markedly in
exposure procedure (Fig. 2, Video 1, available a short time.14,15
online at http://www.oralmaxsurgery.theclinics.
The Labial Canine and the Closed Exposure
com/). In essence, hard and soft tissue preserva-
Technique
tion, particularly in the CEJ area, and full replace-
ment of the surgical flap create an environment The second alternative is appropriate even in
at the completion of treatment, in which the tooth cases where the labial canine is displaced in the
Fig. 2. (A) Panoramic view of impacted maxillary canine high at the level of the incisor root apices. (B) Anterior
section of the lateral cephalogram shows the impacted canine in the same long axis as the incisors. (C) A 3-dimen-
sional screen shot extracted from the cone beam CT. (D) Transaxial slices from the cone beam CT to show the rela-
tionship of the canine with the central and lateral incisors. (E) The orthodontic setup with the preoperative
auxiliary labial archwire in its passive (vertical) state. (F) Minimal exposure of the canine from the palatal aspect.
Note that the labial-facing surface of the crown has not been exposed, to avoid exposing the incisor roots. Metic-
ulous hemostasis and moisture control are necessary at this point and are best achieved by the surgeon to enable
the orthodontist to perform reliable attachment bonding. (G) With the attachment in place, the ligature exit site
must be decided before resuturing. It will be appreciated that the tip of the canine is mesial to the roots of the
central incisor and there is no direct route to the canine’s location in the arch. (H) The deciduous canine has been
extracted and the full flap resutured to its former place. The twisted steel ligature from the bonded attachment
pierces the flap overlying the impacted tooth. (I) The active loop of the auxiliary labial archwire is ensnared hor-
izontally in the steel ligature to produce vertical traction. (J) After many months of vertical traction and addi-
tional posterior movement of the tooth using a miniscrew in the palate, the tooth has erupted and a new
eyelet bonded to its labial surface for its renewed traction in the direction of the main archwire.
Fig. 3. (A) Open surgical exposure through the oral mucosa. (B) Successful alignment of the tooth; however, that
labial aspect of the tooth is invested with thin and easily ulcerated oral epithelium. (Courtesy of Dr G. Engel, Je-
rusalem, Israel.)
mesiodistal plane, making the technique more uni- limiting these complications insofar as it erupts
versally applicable. The same partial thickness flap the canine down through the evacuated socket of
is raised from within the keratinized gingiva of the the extracted deciduous canine, leaving the labial
crest of the ridge, as with the apically repositioned part of the socket wall intact (Fig. 5).17
flap technique. The follicle of the canine is opened
to a very minimal extent over the middle of the
crown, with an aperture only large enough to BONDING THE ATTACHMENT
accommodate a small, preferably, eyelet attach- Some surgeons will not undertake the task of
ment, yet large enough for hemostasis to be bonding the attachment at the time of surgery,
secured, because bonding must be performed preferring to opt for an open procedure to expose
immediately. The remainder of the follicle is left the tooth and then placing a pack to maintain
intact. The attachment is bonded and the gold patency and access to the tooth. The pack will
chain or twisted steel pigtail ligature is drawn be removed 2 to 3 weeks later and the patient re-
downwards and held in place by the sutured turned to the orthodontist to continue orthodontic
edge of the flap.15,16 treatment, including the placement of an attach-
ment on the canine. Inevitably, time elapses and
the wound will partially close over in many cases.
The Midalveolar Canine and the Tunnel
Even when performed promptly, the healing tissue
(Closed Exposure) Technique
surrounding the exposed tooth is hemorrhagic and
Generally considered together with the labial ca- may ooze exudate, particular for those canines
nines because surgical access to it is performed that are located more deeply in the palate. Acid
on the labial side of the alveolar process, the mid- etch bonding under these circumstances will
alveolar impaction is often the result of a mesioan- almost certainly fail and a second surgical expo-
gular canine impacting against the distal aspect of sure to reestablish access may be necessary.
the lateral incisor. In these cases, exposing the Thus, bonding the attachment at the time of sur-
crown of the tooth in the usual manner will require gery is preferable, both to permit a choice of surgi-
the removal of a relatively large area of overlying cal procedures and to ensure a more reliably
labial plate of bone, which will result in the erupted bonded attachment.18
tooth exhibiting a long, unaesthetic, clinical crown, It goes without saying that a surgeon is perfectly
and reduced bone support on the labial side. Cres- capable to bond an attachment to an exposed
cini’s tunnel technique is an excellent method of tooth! But does the oral and maxillofacial surgeon
Fig. 4. (A) The unerupted canine of this 16-year-old girl has been in this situation for 2 years and has not pro-
gressed. (B) A flap has been raised from the crest of the ridge incorporating a thick band of attached gingiva
and sutured apically on the teeth, exposing half of the crown. (Surgery by Prof L. Shapira.) (C) At 9 months post-
operatively, the canine has erupted spontaneously, invested with an optimal periodontal environment.
Fig. 5. (A) A cone beam CT 3-dimensional screen shot of a very high midalveolar canine, whose location is the
result of the mesial curvature on the roots of the first premolar. The deciduous canine has a completely unre-
sorbed root. (B, C) Transaxial cone beam CT cuts in the deciduous canine and first premolar areas, respectively,
show the relationship between the canine and the premolar roots. (D) Orthodontic preparation before surgery
was performed to create space in the arch for the canine and the roots of the premolar were moved distally, to
distance the apices from the canine eruption path. The illustration shows a full flap raised from the cervical mar-
gins of lateral incisor, deciduous canine, and premolar teeth, after extraction of the deciduous canine. The crown
of the canine was exposed minimally in the incisal area. (E) An eyelet attachment has been bonded to the canine
and the twisted stainless steel ligature has been drawn down and through the socket of the extracted deciduous
canine, leaving the entire labial wall intact. (F) The flap has been sutured back to its former place and traction is
applied to the hooked end of the twisted steel ligature by the “swinging gate” offset in the labial archwire. (G)
The case at completion. (H) A panoramic view on the day the orthodontic appliances were removed.
know about the preferred bonding site for the spe- pigtail ligature that is connected to the attachment
cific case in treatment? Is it important for the be made to exit the surgical field? Should this
attachment to be placed in the midlabial aspect connector be drawn directly toward the space
of the canine, just like the brackets on the other that will have been prepared in the arch or in a
teeth, or is it acceptable or even preferable in spe- different direction? (Video 2, available online at
cific cases to locate it on the palatal, mesial, or http://www.oralmaxsurgery.theclinics.com/)
distal aspects? Does it matter if it is sited close Bonding site preference depends entirely on the
to the cusp tip or near the cervical area of the intended direction of the initial traction force that
crown? How should the gold chain or twisted steel will be applied to the tooth.19 For the simpler
impactions, where a palatally impacted canine is orthosurgical modality for the treatment of
adjacent to the line of the arch, the tooth needs impacted teeth.
to be drawn direct to the labial archwire into the
space provided. If the attachment in this case is 1. Choice of surgical technique: This choice re-
bonded mistakenly to the palatal aspect of the lates to the periodontal outcome and depends
tooth, direct ligation to the archwire will cause on the location of the tooth and on the planned
the tooth to rotate adversely and end up 180 direction of traction, where one technique may
rotated when it reaches the wire. On the other be more suited than another.
hand, an attachment sited in the midbuccal posi- 2. Extent of surgical exposure: Exposure of the
tion will generate a favorable rotation as the tooth area around the CEJ, the unnecessary elimina-
moves toward the archwire. tion of the entire dental follicle, when partial
In direct contrast, should the canine lie mesial to removal will suffice, and the aggressive removal
the root of the lateral incisor, which is a frequent of alveolar bone and of the soft tissue is
occurrence, then this tooth will obstruct the direct damaging. The more radical the surgery, the
path of the canine to the labial archwire. In this sit- greater and the more permanent will be the
uation, the canine must first be distanced from the periodontal consequences.
root of the lateral incisor. To achieve this, a pala- 3. Bonding the attachment: The acid-etch
tally placed attachment will be useful to avoid bonding procedure is highly technique sensi-
any rotation, as the tooth is moved in a vertically tive. It is a procedure that an oral surgeon
downward and/or posterior direction.7 Much later, uses quite rarely. To expect the oral and maxil-
when the tooth has cleared the obstruction and lofacial surgeon to bond a small attachment un-
lies erupted in midpalate with an unobscured der the conditions of an open, bleeding surgical
path to the archwire, the orthodontist will substi- field and to know exactly where to position it, is
tute the attachment for another. This will be placed unfair and, for the orthodontist, self-defeating.
in a more strategic location on the crown, for the Accidental detachment of a bonded device at
tooth to be drawn to the archwire. the time of surgery will involve repeat surgery.
An experienced and skilled orthodontist will have It has been shown that when this is performed
planned the location on the orthodontic appliance by the orthodontist and surgeon working as a
from which the traction force will be applied to the team, the procedure is highly reliable.
attachment on the impacted tooth, which therefore 4. Bonding site selection: Bonding on the wrong
presumes that placement of an attachment on one site on the crown of the tooth will introduce a
aspect of the tooth rather than another, will make a rotational component when traction is applied.
considerable difference to the outcome. Both the The degree of rotation will increase markedly
exact bonding site of the attachment and the direc- before the tooth reaches the labial archwire.
tion that the gold chain or twisted steel ligature exits Correcting the rotation toward the end of treat-
the surgical wound should, as far as possible, be ment will unnecessarily extend treatment time
decided in advance to enable the orthodontist to considerably.
exercise full control over the movement of the 5. Directing the connector: Drawing the gold chain
tooth. Directional planning of forces is fully in the or steel pigtail ligature connector in the wrong
realm of the orthodontist, who is answerable for direction means either applying traction in the
both the initial response of the tooth and for its later wrong direction or that a second round of sur-
artistic alignment. gery will be needed to reorient it.
For the orthodontist, the outcome of the surgical 6. Surgical flap closure: In a closed exposure
episode is of crucial importance and is often the procedure, the soft tissue flap needs to be sutured
“make or break” factor of the entire treatment back to its former place. In some cases, the
plan. Because surgical exposure is a critical pro- connector should be drawn down and held in its
cedure where the possibilities for failure are place by the sutures at the cut edge of the flap.
many, it surely behooves the orthodontist to be In others, particularly for a palatal canine that
present even if only in a supervisory capacity. has to avoid the adjacent lateral incisor root, the
connector needs to be drawn through the middle
IT IS ALL A QUESTION OF MAKING THE RIGHT of the flap to permit traction in a path that avoids
CHOICES clashing with this potential obstruction.
7. The application of immediate traction: The
In the light of the many points raised in the forego- value of applying traction immediately after
ing description, we present a list that summarizes the flap is closed, as the last task to be per-
the many aspects where choices need to be made formed in the operating room, should not be
to suit the special circumstances surrounding the underestimated. Immediate force application
using a mechanism that imparts a light force invested in preparing the other teeth to act in con-
over a wide range can be placed with ease cert as a multiple orthodontic anchor base is time
while the patient is anesthetized. In many well spent. However, the presence of a palatally
cases, there is rapid eruption seen at the next impacted maxillary canine associated with marked
visit to the orthodontist. However, the oral and resorption of the root of the adjacent incisor is one
maxillofacial surgeon cannot be expected to of the rare instances that must be considered an
place this mechanism and must opt instead orthodontic emergency. In an earlier study, we
for making sure the connector is exposed and showed that distancing the canine from the imme-
not irritant or sharp, leaving activation to the diate vicinity will effectively arrest the resorption
orthodontist at the next visit. This and subse- process and will later permit the orthodontic
quent adjustments will be much more difficult movement of the affected incisor without its un-
for the orthodontist to achieve and uncomfort- dergoing further resorption. Accordingly, in these
able for the patient to tolerate, and there are cases surgery should be arranged as soon as
many cases for which considerable delay is possible, even before the placement of an ortho-
incurred because of the inability to properly dontic appliance. At the same time the tooth is
activate a traction mechanism. exposed in the palate and an attachment bonded
to the tooth, a miniscrew bone anchor should be
This is a very long list of possible bad choices and placed at a convenient site in the posterior palate.
operational errors of judgment that emanate from Elastic thread or an elastic chain should then be
ignorance on the part of the surgeon for the require- applied under tension between the steel ligature
ments of the orthodontist and vice versa, or simply from the bonded attachment to the head of the
a lack of coordination between the two. Making the miniscrew (Fig. 6). This will need to be reapplied
wrong choices will lead to longer overall treatment 3 or 4 times more until, in favorable circumstances,
and/or poorer periodontal outcome and even to the the palatal tissue bulges as the canine is drawn
difference between success and failure. What can away from the anterior teeth, to erupt in the midpa-
go wrong will go wrong! Thus, any factor that can latal area.20 Once the tooth shows positive signs of
streamline the treatment must be adopted. None eruption, a full maxillary fixed orthodontic appli-
of these prophesies of doom need occur if the ance may be placed. This will need to be reapplied
orthodontist is present at the surgical procedure 3 or 4 times more until, in favorable circumstances,
as an essential and active member of the team. the palatal tissue bulges as the canine is drawn
away from the anterior teeth, to erupt in the midpa-
IS THIS TREATMENT URGENT? latal area. Once the tooth shows positive signs of
movement away from the anterior teeth, a full
For the overriding majority of cases, there is no ur- maxillary fixed orthodontic appliance may be
gency to expose the impacted tooth and time placed, with confidence that further root
Fig. 6. (A) A palatal canine was exposed minimally in an adult patient in whom there was some concern as to
whether the tooth would respond to traction. An attachment was bonded to its palatal aspect. (B) After fully
suturing the flap back to its former place, a miniscrew was inserted in the posterior palate and an elastic chain
stretched between the hooked end of the pigtail ligature and the miniscrew, to apply extrusive traction. The
elastic chain was changed several times until evidence of canine movement could be seen as a bulge in the palate.
Only at that point were orthodontic appliances placed to achieve a successful orthodontic outcome. (From Becker
A. Orthodontic treatment of impacted teeth. 3rd edition. Oxford (United Kingdom): Wiley Blackwell Publishers;
2012; with permission).
resorption will not occur.20 This approach may 9. Chaushu S, Chaushu G, Becker A. The role of digital
also be used when treating an adult in whom there volume tomography in the imaging of impacted
may be concern that the impacted canine is anky- teeth. World J Orthod 2004;5(2):120–32.
losed and may not therefore respond to orthodon- 10. Becker A, Chaushu S, Casap-Caspi N. Cone-beam
tic traction. With the increased risk of noneruption computed tomography and the orthosurgical man-
that exists with advancing age,21 checking if there agement of impacted teeth. J Am Dent Assoc
will be positive movement of the canine before em- 2010;141(Suppl 3):14S–8S.
barking on expensive orthodontics, may save the 11. Becker A, Chaushu G, Chaushu S. Analysis of failure
patient much time, discomfort, and money. in the treatment of impacted maxillary canines. Am J
Orthod Dentofacial Orthop 2010;137(6):743–54.
SUPPLEMENTARY DATA 12. Becker A, Chaushu S. Palatally impacted canines:
the case for closed surgical exposure and immedi-
Supplementary data related to this article can be ate orthodontic traction. Am J Orthod Dentofacial
found online at http://dx.doi.org/10.1016/j.coms. Orthop 2013;143(4):451–9.
2015.04.007. 13. Chaushu S, Dykstein N, Ben-Bassat Y, et al. Peri-
odontal status of impacted maxillary incisors uncov-
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Preprosthetic Surgery
Hillel Ephros, DMD, MDa,*, Robert Klein, DDSb, Anthony Sallustio, DDSc
KEYWORDS
Stability Retention Vestibuloplasty Dental prosthesis Skin graft Tuberosity Torus
KEY POINTS
The need for preprosthetic surgery may be caused by anatomic variations, gradual loss of support-
ing tissues, or a lack of foresight during earlier stages of treatment.
Functional, comfortable, and esthetically pleasing prostheses often require collaboration between
the surgeon and restoring dentist.
All denture bearing hard and soft tissues should be evaluated with great care before denture
construction.
Surgical improvement of existing anatomy should at least be considered in every patient for whom a
conventional prosthesis is planned.
Even the partially implant-borne prosthesis may benefit from preprosthetic surgery.
Preprosthetic surgery comprises a unique and for preprosthetic surgery, focusing on the core
evolving group of soft and hard tissue procedures. concepts and detailing selected procedures that
Although the focus of such procedures has shifted continue to be useful in the successful oral rehabil-
dramatically over the last 30 years, the funda- itation of partially and fully edentulous patients.
mental concepts remain unchanged. Prepros-
thetic surgery exists to serve the needs of GOALS
dentists who provide patients with replacements
for missing teeth and associated tissues. The pur- In the introductory paragraph of his 1972 article
pose is to facilitate the fabrication of prostheses or “Objectives of Preprosthetic Surgery,” Lawson
to improve the outcome of prosthodontic treat- asks: “Why should it be assumed that a full den-
ment. The surgeon’s role is to produce an environ- ture is the one type of dental restoration for which
ment in which esthetics and function may be the mouth is already perfectly designed?”1 In fact,
optimized by manipulating, augmenting, or replac- the quality of dentures and the patients’ experi-
ing soft and/or hard tissues. With the emergence ence can often be enhanced significantly by surgi-
of implants as predictable anchors for a wide vari- cal preparation. Oral and maxillofacial surgeons
ety of dental prostheses, many preprosthetic pro- must understand the criteria for successful pros-
cedures, particularly those that were developed to theses and let the needs of patients and the
prepare the jaws for dentures, have become less dentist/prosthodontist dictate the selection of
relevant and may be headed toward obsoles- applicable preprosthetic procedures. Lawson’s
cence. They have been displaced by a newer set criteria include insertion, comfort, retention, stabil-
of surgical interventions designed to prepare sites ity, adequate occlusion, satisfactory appearance,
for implant placement. Dr Michael Block reviews and no damage to the oral tissues.
these procedures elsewhere in this issue. The dis- The surgical/prosthetic collaboration begins
cussion that follows provides a historical reference with treatment planning based on diagnostics
The authors have nothing to disclose.

a
Oral and Maxillofacial Surgery, Department of Dentistry, St. Joseph’s Regional Medical Center, 703 Main
Street, Paterson, NJ 07503, USA; b Oral and Maxillofacial Surgery, St. Joseph’s Regional Medical Center, 703
Main Street, Paterson, NJ 07503, USA; c Prosthodontics and Maxillofacial Prosthetics, St. Joseph’s Regional
Medical Center, Paterson, NJ 07503, USA

460 Ephros et al
that are adequate to ensure appropriate proce- Surgical procedures that address skeletal dis-
dure selection. These diagnostics should include crepancies, particularly anteroposterior and
a thorough clinical examination, mounted study vertical issues, may be indicated.
models, and a panoramic radiograph supple- Damage to the oral tissues must be minimized
mented by periapical films and other imaging as even with consistent denture use over long pe-
needed. Medical, surgical, anesthetic, and psy- riods of time. Maximal denture-bearing surface
chological risk assessment should all be done as area distributes the compressive load; high-
for any other elective surgery. In the realm of pre- quality, immobile soft tissue in that area handles
prosthetic surgery, communication between the that load most effectively. Removal of bony un-
surgeon and restoring dentist is crucial. For each dercuts may allow the masticatory load to be
of the criteria listed earlier, the team must deter- spread as widely as possible. Skin graft vestibu-
mine whether existing anatomy is satisfactory loplasty provides a larger surface area for den-
and, if not, what intervention might best serve ture contact and replaces moveable alveolar
the needs of the patients and the restoring dentist. mucosa with immobile, tough soft tissue that
Insertion requires adequate interarch space is capable of bearing the masticatory load.
and a clear path free of bony protuberances,
sharp undercuts, and bulbous soft tissue BONY RECONTOURING PROCEDURES
prominences. Applicable procedures may Preoperative Planning
include alveoloplasty, tuberosity reduction,
torus, and exostosis removal. As with any other surgical procedure, planning be-
Comfort is related to the seating of a pros- gins with a thorough history and physical examina-
thesis on good-quality soft tissue overlying tion. An understanding of patients’ surgical and
smooth bone. Examples of procedures that prosthetic expectations must be clear and a deter-
may enhance comfort are alveoloplasty, mination made as to whether these goals can be
lingual balcony reduction, removal of redun- achieved.1 Special emphasis is placed on systemic
dant soft tissue, frenectomy, and skin graft conditions that may directly affect bone healing.
vestibuloplasty. The clinical examination focuses on bony projec-
Retention is resistance to vertical displace- tions and undercuts, large palatal and mandibular
ment and is optimized by an intimate relation- tori, and other gross ridge abnormalities. The inter-
ship between the prosthesis and the arch relationship should be evaluated in 3 dimen-
underlying soft tissue. The surface area of sions. Radiographs are reviewed for bony
contact should be maximized and sealed pathology, impacted teeth, retained root tips, de-
peripherally. Procedures designed to address gree of maxillary sinus pneumatization, and the po-
retention include frenectomies and various sition of the inferior alveolar canal and mental
vestibuloplasties.2 foramina.3 This section focuses on bony reduction
Stability is resistance to lateral displacement and recontouring procedures.
from functional horizontal and rotational
stresses. It depends on adequate ridge height Alveoloplasty
as well as the quantity and quality of soft tis- Alveolar bone irregularities may be found at the
sue in the denture-bearing area. In general, time of tooth extraction or after healing and re-
severely resorbed maxillae and mandibles modeling has occurred. The goal for alveoloplasty
are poor candidates for bony augmentation is to achieve optimal tissue support for the
when implants are not part of the restorative planned prosthesis, while preserving as much
plan. When bone is adequate, procedures bone and soft tissue as possible.4
such as lingual balcony reductions, removal
of redundant soft tissue, and skin graft vesti- 1. An incision along the crest of the alveolus, or a
buloplasty may enhance stability.1,2 sulcular incision before tooth extractions, is
Adequate occlusion requires a reasonable created with adequate extension to allow
skeletal relationship between the jaws. For proper visualization of the area of interest.
patients with severe skeletal class II or III rela- Generally, extension approximately 1 cm
tionships, orthognathic surgery may be indi- mesial and distal to the site is adequate.
cated as a preprosthetic procedure. 2. A full-thickness envelope flap is then elevated.
Satisfactory appearance is at or near the top Vertical releasing incisions may be necessary
of the list of patient expectations and can for exposure; however, this may lead to a
only be achieved when the restoring dentist greater amount of patient discomfort postoper-
is able to set teeth properly in the context of atively. Extensive flap reflection may lead to de-
the facial skeleton and overlying soft tissues. vitalization of bone and should be avoided.
3. The degree of bony abnormality will dictate the Maxillary Tuberosity Reduction
most effective method for alveoloplasty. Smaller
The intermaxillary space necessary for proper
irregularities at an extraction site may only
prosthesis fabrication may be decreased because
require digital compression of the socket walls.
of vertical excess of the maxillary tuberosity.
A rongeur, bone file, handpiece with bur, or a
Generally, the intermaxillary distance should be
mallet and osteotome are all viable options for
at least 1 cm when patients are placed into the
bony recontouring (Fig. 1). Irrigation with normal
correct or planned vertical dimension of occlu-
saline during the procedure is critical to maintain
sion.4 A dental mirror passing freely between the
bony temperature less than 47 C.6
tuberosity and retromolar tissue suggests
4. The site is inspected carefully and irrigated
adequate vertical clearance. The mirror can then
copiously with normal saline. Undetected resid-
be placed on the lateral aspect of the tuberosity,
ual free bony fragments may lead to delayed
and patients are instructed to open and close. If
postoperative healing or possibly infection.
the mirror intrudes on the mandible’s path during
5. The mucoperiosteal flap is reapproximated and
function, horizontal reduction of the tuberosity
the site palpated to ensure removal of all irreg-
may be required. A determination as to the extent
ularities. Excess soft tissue should also be
of soft tissue and bony contribution to the problem
removed at this time. The flap is then closed
is made radiographically. A panoramic view is rec-
with a running resorbable suture, as fewer
ommended to ensure an adequate assessment of
knots may be more comfortable and hygienic
the relationship between the maxillary sinus and
for patients.7
residual alveolus, particularly if bony reduction is
Historically, intraseptal alveoloplasty offers an contemplated.
alternative technique to remove large bony under-
1. Local anesthetic with epinephrine is adminis-
cuts while maintaining vertical ridge height (Fig. 2).
tered, and a crestal linear or elliptical incision is
However, this method should be used judiciously
made from the posterior tuberosity to a point
while maintaining adequate ridge width to accom-
anterior to the site of interest (Fig. 3). When an
modate possible future implant placement.7
Fig. 1. Alveoloplasty techniques using hand and rotary instruments. (A) Flap elevation, alveoloplasty using ron-
geurs. (B) Alveoloplasty using rotary instrumentation. (C) Final contouring and smoothing using a bone file.
(From Peterson LJ, Ellis E, Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillofacial sur-
gery. St Louis (MO): C.V. Mosby; 1988; with permission.)
462 Ephros et al
Fig. 2. Intraseptal bone is removed and digital pressure applied to collapse ridge and eliminate undercuts. (A)
Alveolar bone after extractions. (B) Intraseptal bone removed to depth of socket with rotary instrumentation.
(C) Intraseptal bone removed with a rongeur. (D) Finger pressure applied to in-fracture labial plate of bone
and eliminate undercuts. (E) Cross-sectional view of pre-extraction alveolus. (F) Cross-sectional view after alveo-
loplasty. (From Peterson LJ, Ellis E, Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillo-
facial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
Fig. 3. Incisions for tuberosity reduction: (A) Single crestal incision (red dashed line) used when minimal reduc-
tion is planned. (B) Elliptical incision with anterior release. (From Peterson LJ, Ellis E, Hupp JR, et al, with six con-
tributors, editors. Contemporary oral and maxillofacial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
elliptical design is selected, the width of the el- unlimited keratinized, attached tissue. The site
lipse is estimated by the magnitude of antici- is then closed with a running resorbable suture
pated tissue removal. The buccal side of the (see Fig. 4D).
ellipse is placed first, well within the zone of
attached tissue. When minimal reduction is antic- In the case of solely soft tissue tuberosity reduc-
ipated, a single crestal incision may be used. tion, excess tissue can be removed by simple wedge
2. Before flap elevation, excess fibrous tissue is resection. Tension free closure is then achieved by
removed by undermining the mucosa with a undermining the buccal and palatal flaps subperios-
beveled incision and excising a wedge on the teally. Additional submucosal tissue can be under-
palatal side of the wound and, if indicated, on mined and removed to aid in closure (Fig. 5).
the buccal side as well (Fig. 4A).
3. A buccal release at the anterior end of the inci- Torus Removal
sion provides significantly enhanced access The cause of maxillary and mandibular tori is un-
and visibility, particularly when horizontal as clear.8 In dentate individuals, removal is often un-
well as vertical bony reduction is planned. The necessary unless normal speech, mastication, or
mucoperiosteal flap is then elevated in both general patient comfort is affected. However, after
buccal and palatal directions allowing access teeth are lost, tori may complicate or even pre-
to the bony tuberosity (see Fig. 4B). clude denture fabrication. Large, lobulated tori
4. Depending on the circumstances and operator with undercuts must be treated, whereas the
preference, bone can be removed with hand restoring dentist may deem smaller, smooth,
and/or rotary instruments (see Fig. 4C). The broad-based tori insignificant.
site should be smoothed with a bone file, in-
spected for residual bony fragments, and irri- Maxillary (palatal) torus removal
gated copiously with normal saline. Before surgery, potential complications should be
5. Any excess soft tissue can be excised from the discussed with patients, including wound
palatal aspect as this side of the wound has dehiscence, prolonged pain, and oral-nasal
Fig. 4. (A) Beveled incision to eliminate bulky tissue while preserving mucosa. (B) Elevation of buccal and palatal
mucoperiosteal flaps. (C) Removal of excess bone from the tuberosity. (D) Closure with interlocking continuous
suture technique. (Courtesy of [A] Alan Samit, DDS, West Orange, NJ; and From [B, C] Peterson LJ, Ellis E,
Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillofacial surgery. St Louis (MO): C.V.
Mosby; 1988; with permission.)
464 Ephros et al
Fig. 5. Soft tissue tuberosity reduction. (A) Maxillary tuberosity with excess soft tissue. (B) Removal of tissue be-
tween buccal and palatal arms of the incision. (C) Flap edges after undermining and removing excess tissue. (D)
Primary closure after any necessary mucosal trimming. (From Fonseca RJ, Davis WH. Reconstructive preprosthetic
oral and maxillofacial surgery. St Louis (MO): W.B. Saunders; 1986; with permission.)
communication caused by thin overlying palatal 2. Depending on the size of the torus and the nature
bone following torus removal. A maxillary impres- of its attachment to the underlying bone, removal
sion is taken and study model poured. The torus may be accomplished with rongeurs, a rotary in-
is then removed from the cast until flush with the strument with an acrylic bur, or a mallet and os-
surrounding palate, and a splint is formed with re- teotome. It is recommended that large tori be
lief provided in the area of the torus. The splint may sectioned with a fissure bur and then removed
be made from acrylic or thermoplastic (suck down) with the mallet and osteotome. Final contouring
material. Soft tissue liner may be used when the is done with an egg-shaped bur and/or bone file.
splint is placed postoperatively to aid in patient 3. The site is irrigated copiously with normal sa-
comfort and prevent hematoma formation. line. Excess soft tissue may be trimmed, and
the flaps are reapproximated with interrupted
1. Local anesthesia with epinephrine is adminis- resorbable sutures.
tered, and a midline incision is made with poste- 4. The stent is relined with tissue conditioner and
rior and/or anterior releases (Y shape incision at inserted.
each end [Fig. 6]). Great care is taken to elevate
full-thickness mucoperiosteal flaps without
Removal of Mandibular Tori
tearing the thin overlying mucosa. A modified
palatal flap has been described to avoid incision 1. Local anesthesia is achieved with inferior alve-
lines over possible palatal perforations.9 olar and lingual blocks. Infiltration at the site
Fig. 6. Palatal torus removal. (A) Palatal torus. (B) Incision design. (C) Exposure of the palatal torus with retraction
sutures. (From Peterson LJ, Ellis E, Hupp JR, et al, with six contributors, editors. Contemporary oral and maxillo-
facial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
may aid in hemostasis as well as facilitate for smoothing on the lingual surface of the
dissection. mandible and their use is recommended.
2. Incision over the crest of the ridge, or along the 5. The site is irrigated copiously with normal sa-
lingual sulcus of teeth when present, is made line; the tissue is adapted and palpated for ir-
with extension to ensure adequate visualization regularities, and closure is achieved with a
of the tori to be removed. Vertical incisions may running resorbable suture.
interfere with the blood supply to the thin over- 6. Some sources advise placement of a gauze
lying mucosa covering the tori and should be pack under the tongue in the floor of the mouth
avoided4 (Fig. 7). for approximately 6 to 12 hours to prevent he-
3. Elevation of the delicate lingual mucoperiosteal matoma formation.6
flap requires great care. A periosteal elevator or
Seldin retractor is placed beneath the torus to
SOFT TISSUE PROCEDURES
protect the floor of the mouth during removal.
Frenectomy
4. Depending on the size of the torus and the na-
ture of its attachment to the underlying bone, Many maxillary dentures are fabricated working
removal may be accomplished with rongeurs, around a pronounced labial frenum (Fig. 9A).
a rotary instrument with an acrylic bur, or a The result is a deeply notched prosthesis, irrita-
mallet and osteotome. A trough to guide proper tion of the mucosa, and the loss of surface area
osteotome cleavage can be created initially that might otherwise contribute to retention and
with a bur paralleling the lingual cortex to avoid stability. A variety of frenectomy techniques are
unfavorable fractures. Final contouring is done used; but if the moveable tissue interposed be-
with an egg-shaped bur or bone file. Specially tween mucosa and periosteum is not addressed,
designed bur guards are available that help the frenectomy is incomplete as a preprosthetic
protect the lingual soft tissues by exposing procedure.
only the surface of the bur in contact with the The maxillary labial frenectomy for denture
bone (Fig. 8). S-shaped bone files are designed patients should be a limited submucosal
Fig. 7. Mandibular torus removal. (A) Infiltration of local anesthesia at site to facilitate elevation of thin mucosa
overlying a mandibular torus. (B) Incision placed over the alveolar crest. (C) Flap elevation to ensure adequate access
and allow retractor placement to protect the floor of the mouth. (From Peterson LJ, Ellis E, Hupp JR, et al, with six
contributors, editors. Contemporary oral and maxillofacial surgery. St Louis (MO): C.V. Mosby; 1988; with permission.)
466 Ephros et al
Fig. 8. (A, B) Bur guard designed to protect lingual tissues during mandibular torus removal.
vestibuloplasty. Instrumentation is minimal: a pair the submucosal and supraperiosteal tunnels.

of Dean (or similar) scissors, a needle holder, and The cut is made as inferiorly as possible so
a local anesthetic syringe. One specific require- that all of the submucosal tissue can retract
ment is a 3-0 or 4-0 suture on a taper needle. upward. The scissors may be used to push
the tissue superiorly so that only mucosa
1. After local anesthesia administration, the lip is and periosteum remain in the denture-bearing
retracted upward and the frenal connection to area.
the alveolus is cut with the scissors continuing 4. The height of the vestibule is then established
superiorly until a diamond-shaped wound is by passing a suture through one mucosal
created (see Fig. 9B). edge, engaging periosteum, coming through
2. The scissors are then held parallel to the alve- the mucosal edge on the opposite side of the
olar bone and used to perform submucosal wound, and tying the suture to tack the mucosa
and supraperiosteal dissections for 1 to 2 cm to periosteum. The use of a taper needle is crit-
on both sides of the wound (see Fig. 9C). ical as the periosteum is delicate, tightly bound
This procedure produces 2 tunnels: one sub- to bone, and may be torn if a cutting needle is
mucosal and the other supraperiosteal (see used. At least one additional pass above and
Fig. 9D). below the initial suture is generally indicated.
3. The scissors are then turned so that the cutting Periosteum may be engaged again where
surfaces are perpendicular to the alveolar bone possible, but this is critical only with the first
and used to cut the moveable tissue between tacking suture (see Fig. 9E).
Fig. 9. (A) Hyperplastic maxillary labial frenum. (B) Incision at base of frenum with Dean scissors. (C) Submucosal
and supraperiosteal dissection. (D) Cross-sectional view of submucosal and supraperiosteal tunnels. (E) Completed
frenectomy with the new vestibular height established by periosteal tacking suture. (Courtesy of [D] Alan Samit,
DDS, West Orange, NJ.)
Submucosal vestibuloplasty techniques have with minimal morbidity. Clearly, an implant-borne

been used to address entire maxillary arches prosthesis is superior to one that rests on the tis-
with the dissections described earlier carried as sues. Nonetheless, the skin graft vestibuloplasty
far as possible from the midline incision. When is a versatile procedure that is potentially transfor-
treating an entire arch, a stent has been used to mative for patients who are not candidates for im-
maintain vestibular integrity.4 plants and may be beneficial for those who have
Submucosal vestibuloplasty techniques create implant-supported but partially tissue-borne
a zone of immobile denture-bearing tissue, but prostheses.
they do not change the quality of the tissue. Use The procedure as described by Samit and Po-
of the submucosal vestibuloplasty in the mandible powich13 is based on a careful review of several
puts the mental nerves at risk, and Obwegeser5 cases done using the traditional method. The
recommended that the procedure be limited to modified procedure is highly predictable and
the maxilla.4 successful with few significant complications.14,15
The stent was a frequent source of inaccuracy
Skin Grafting and required additional awl passes. Grafts
inadequately adapted to the recipient bed were
The concept of transplanting skin to cover open
lost as were those under excessive pressure
wounds has a long history. A definitive article on
from the stent. It was noted that graft failure labi-
the Thiersch graft published in 1934 by T.P. Kil-
ally invariably led to significant loss of vestibular
ner,10 a London plastic surgeon, describes indica-
depth, whereas the lingual vestibular extension
tions, techniques, and care of patients. Although
was stable regardless of the status of the graft.
some of this has changed over the last 80 years,
much of Kilner’s work is still relevant. Free skin
grafts survive over the first few days by imbibition Modifications
and then inosculation as vascular connections are Eliminate the stent and place the skin graft on the
established. This phase is followed by neovascu- labial only suturing it directly to periosteum with a
larization and the development of a firm con- taper needle. The number of awl passes is
nection between the graft and recipient bed. reduced to 4:2 anterior and 2 posterior to the
Ultimately, a well-healed intraoral skin graft mental nerves.
becomes part of the denture-bearing area with Hematoma under the graft is possible even
positive characteristics, including immobility, when it is sewn directly to periosteum.
favorable texture, and a good response to load
bearing and irritation. Modification
Using an 18-gauge needle or No. 11 blade, the
Vestibuloplasty graft is fenestrated at the end of the procedure tak-
The skin graft vestibuloplasty with lowering of the ing care not to cut sutures or injure the mental
floor of the mouth offers several advantages over nerves.
other methods of preparing the edentulous Floor-of-mouth swelling has been reported and,
mandible for a complete denture. With good pain some case, interfered with salivary flow. Dexa-
tient selection and surgical technique, this proce- methasone injection into the floor of the mouth
dure can transform a moderately atrophic and cannulation of the submandibular ducts
mandible with unfavorable soft tissue attachments were advocated. Prophylactic antibiotics were
into an excellent bed for a comfortable and func- used to cover the awl passes.
tional prosthesis. The traditional procedure using
a stent was unpopular among surgeons and pa- Modifications
tients as it was a long, laborious operation with Intravenous dexamethasone is effective without
an often unpleasant postoperative course. Com- the risks associated with injection into the floor
plications related to the stent, the awl passes, graft of the mouth. With fewer awl passes and careful
take, and donor site morbidity, made the proce- management of floor-of-mouth tissues, prophy-
dure unattractive despite its ability to produce dra- lactic cannulation of the submandibular ducts is
matic changes.11 Modifications were proposed, not necessary. There is no evidence to support
and the procedure evolved into a more reasonable the use of prophylactic antibiotics. Localized ab-
option for patients and surgeons.12 The modified scesses at the site of awl passes on skin are rare
version described later eliminates the need for a and may be managed with incision, drainage,
stent, reduces the number of awl passes, cuts and antibiotics, if indicated.
operating time to less than 2 hours, and is associ- The donor site was expansive and a source of
ated with a relatively benign postoperative course significant pain in the postoperative period.
468 Ephros et al
Fig. 10. (A) Split-thickness skin graft harvest using a dermatome. (B) Placement of a semiporous membrane over
the donor site.
Modifications junction, which is generally near the crest on

A skin graft capable of successfully treating an these cases. Using a tissue scissors with a
entire labial vestibule can be derived from a donor snip-and-push technique, the mucosa and
site as small as 2 by 5 cm. A semiporous adhesive all loose, moveable supraperiosteal tissues
membrane (Opsite [Smith1Nephew, London, UK], are moved inferiorly (Fig. 11).
Tegaderm [3M Corp., St. Paul, MN]) is used to 4. La Grange scissors or similar instrument is
dress the donor site, and patients report minimal used to remove all remnants of moveable tis-
or no pain and can bathe and dress normally. sue remaining on the periosteum as these
Extensive and highly detailed descriptions of the are gently pulled away from the periosteal
traditional procedure appear in the literature.4 bed using a Frazier-tip surgical suction.
Many of the elements of the modified, stentless 5. The lingual incision should be slightly shorter
technique are similar, with major modifications in length than the labial; the blade is held par-
noted earlier. The steps involved are presented in allel to the alveolus, not facing the bone. A
outline form: sponge stick is used to tense the floor of the
mouth so that the incision can be made as
1. Graft harvest using a dermatome is most often described earlier without jeopardizing the deli-
from a hairless area on the upper lateral thigh. cate lingual periosteum (Fig. 12).
Antibacterial skin preparations are made fol- 6. Dissection on the lingual is easily accom-
lowed by alcohol to remove all stickiness plished with a gloved finger. Four lengths of
from the surface. A liberal application of min- a 2-0 chromic suture are attached to the cut
eral oil to the skin and the dermatome pro- lingual mucosal edge: 2 on each side of the
vides needed lubrication. midline, one placed posteriorly, and the other
2. A marked site measuring between 2.0 and 2.5 more anterior. The needles are removed and
by 5 to 6 cm is harvested and set epithelial the 4 sutures are held in order on snaps in
side up on a hard surface, such as the bottom preparation for awl passes (Fig. 13).
of a kidney basin, and covered with a saline 7. Using a standard technique, 4 submandibular
sponge. If the skin is not marked before har- passes are made with an awl after skin prep
vest, note the direction it curls: always inward and puncture with a No. 11 blade. At each
toward the dermal side (Fig. 10). site, the ends of each of the 4 sutures are
3. The labial dissection begins with a molar-to- picked up lingually and brought around to
molar mucosal incision at the mucogingival the facial side where one end is removed
Fig. 11. (A) Labial incision: note preservation of crestal attached gingiva. (B) Labial dissection: note development
of extensive periosteal bed free of moveable tissue.
engage the periosteum under the nerve with

the needle traveling posterior to anterior.
Instead of tying the ends at this point, which
would damage the nerve, the needle is passed
back through periosteum under the nerve
from anterior to posterior and back through
the mucosa in mattress fashion. Using this
technique, the mucosa is tightly bound to the
periosteum without constructing the nerve.
10. The skin is divided into two by making a semi-
diagonal cut through the rectangular graft
(Fig. 15). With the surgical suction eliminated
from the field to preclude inadvertent loss of
the skin graft, a 3-0 chromic suture on a cut-
ting needle is used to attach one of the sec-
Fig. 12. Use of a sponge stick for traction to facilitate tions of skin to one side of the recipient bed.
the lingual incision. (From Fonseca RJ, Davis WH. The suture is passed through the corner of
Reconstructive preprosthetic oral and maxillofacial the skin graft and attached to residual tissue
surgery. St Louis (MO): W.B. Saunders; 1986; with just superior to the edge of the recipient bed
permission.) in a continuous fashion while stretching the
skin posteriorly with each suture pass. This
procedure is repeated on the opposite side
so that the site is covered with skin widest at
from the eye of the awl at the base of the ves- the midline, with the dermal side of the graft
tibule and the other is passed through the cut facing the periosteum.
edge of the mucosa. The 4 sutures are tied in 11. The process is completed by tacking the two
succession with the assistant’s gloved finger skin sections together at the midline using a
in the lingual vestibule ensuring that the 3-0 chromic on a taper needle. The inferior
mucosal edge is secured inferiorly (Fig. 14). edge is also tacked to the periosteum (not to
8. The labial mucosal edge will require additional the mucosa) using the same material and
attachment to periosteum. This attachment is technique with the skin stretched gently so
accomplished with a 3-0 chromic suture on a that it lies flat on the periosteal bed. Excess
taper needle. The mucosa should be sutured skin may be trimmed as needed.
to the periosteum as low in the vestibule as 12. Finally, a No. 11 blade or needle is used to
possible tacking the loose edges between fenestrate the graft. Multiple small punctures
and behind the awl-passed suture ties. are made through the skin down to bone,
9. Should this require a tacking suture near the carefully avoiding sutures and the mental
mental nerve, the taper needle should be nerves. This, along with a pressure bandage
passed through the mucosal edge, then placed across the chin, makes hematoma
Fig. 13. (A) Lingual dissection accomplished by the gentle use of a gloved finger. (B) Suture placed through the
mucosal edge of the lingual flap. The awl will be introduced through a submandibular cutaneous puncture.
470 Ephros et al
Fig. 14. (A) Both ends of the suture are fed through the eye of the awl. (B) The awl is withdrawn and carefully
brought around the inferior border of the mandible without exiting the skin. (C) The awl is passed into the labio-
buccal vestibule. This technique is done for each of the 4 sutures, right and left, anterior and posterior to the
mental nerve. (D) One end of the suture is removed from the eye of the awl, and the awl is then passed through
the mucosa near the edge of the labio-buccal flap. (E) The suture is now ready to be tied down lowering the floor
of the mouth and securing the labio-buccal mucosa at its new vestibular depth. (From [E] Fonseca RJ, Davis WH.
Reconstructive preprosthetic oral and maxillofacial surgery. St Louis (MO): W.B. Saunders; 1986; with permission.)
formation unlikely and allows the graft to Sloughing of outer layers of the graft is expected
remain well adapted during the critical early at week one; but by week 4 the graft is well adapt-
stages of healing. ed, and impressions may be taken by the restoring
dentist to begin the restorative phase of treatment
Donor site management and oral wound care (Fig. 16).
are performed as have been described for any
type of skin graft. The most critical instruction to
patients is to ensure that no alcohol comes into Other Skin Graft Procedures
contact with the graft for the first 10 to 14 days. Prosthodontic rehabilitation of patients with oral
Mouthwashes as well as alcoholic beverages will cancer is a major challenge. Denture-bearing tis-
interfere with graft healing. sues affected by surgery and/or radiation therapy
are not only changed morphologically but also
may acquire characteristics that impede or even
preclude denture construction. Implants may not
be an option for some who have undergone head
and neck cancer treatment. Although a complete
discussion of functional postablative reconstruc-
tion is well beyond the scope of this publication,
there is one relatively minor procedure used in
this population that may be appropriately included
on the preprosthetic menu. The pig-in-the-blanket
technique for enhancing tongue mobility is a sim-
Fig. 15. The rectangular graft is divided as shown to ple and efficacious method of managing patients
produce 2 segments. Each is placed into the recipient who have undergone wide local excision of lateral
bed, tacking the wider end at the midline and work- tongue/floor-of-the-mouth squamous cell carci-
ing posteriorly, right and left. noma. In these patients, there is often scarring
Fig. 16. (A) Preoperative view demonstrating shallow vestibules with superiorly positioned muscle attachments
and a minimal zone of crestal attached tissue. (B) Postoperative view with well-adapted skin graft, significant
labio-buccal vestibular depth, and floor of mouth lowered. (C) Postoperative view with well-adapted skin graft:
note skin pigmentation maintained at the recipient site. (D) Postoperative view with well-adapted skin graft, sig-
nificant labio-buccal vestibular depth, and floor of mouth lowered. (E) Postoperative view with well-adapted skin
graft, significant labio-buccal vestibular depth, and floor of mouth lowered. (F) Prosthesis demonstrating
maximal extension fabricated after skin graft vestibuloplasty.
that binds the tongue laterally and obliterates the

lingual vestibule. This scarring limits tongue
mobility and makes it very difficult, if not impos-
sible, to fabricate a functional prosthesis. Skin
grafting may be considered 1 year after treatment
of the cancer provided there is no evidence of
recurrence or a new primary at that time.
1. An incision is made into the scarred area where

a lingual vestibule would normally be. This inci-
sion is carried to a depth that provides separa-
tion and some degree of freedom for the tongue
while respecting local anatomy.
2. Skin will have been harvested as described
earlier with the graft size estimated by the antic-
ipated surface area of the defect. The skin is
attached to the periphery of the defect and
stretched gently as it is sutured so that the
defect is lined with skin that is taut and well
adapted.
3. Additional resorbable sutures may be used to
tack the skin to the muscle bed, and a No. 11
blade or needle may be used to fenestrate the
graft to reduce the likelihood of hematoma
formation.
4. A roll of saline-moistened sterile gauze is
Fig. 17. The wound is closed to the original incision
placed in the defect, and the original incision
line after suturing in the skin graft and inserting a
line is closed with silk. The gauze puts gentle roll of saline-moistened gauze to maintain pressure
pressure on the skin, which then adapts well against the recipient bed. (From Leban SG. The use
to both sides of the defect (Fig. 17). of a modified skin grafting technique for alveolar
5. The silk sutures are removed along with the sulcus extension. J Oral Surg 1977;35:553; with
gauze roll in 7 to 10 days. A vestibular fold is permission.)
472 Ephros et al
produced that is lined by skin, and there is 3. Peterson LJ, Ellis E, Hupp JR, Tucker MR, With six
generally a significant improvement in tongue contributors, editors. Contemporary oral and maxil-
mobility. lofacial surgery. St Louis (MO): C. V. Mosby; 1988.
4. Fonseca RJ, Davis WH. Reconstructive prepros-
Care must be taken to ensure that graft healing thetic oral and maxillofacial surgery. St Louis (MO):
continues with appropriate instructions given to W. B. Saunders; 1986.
patients and dietary restrictions imposed for an 5. Obwegeser H. Die submukose vestibulumplastik.
additional 1 to 2 weeks. Dtsch Zahnarztl Z 1959;14:629, 749.
6. Eriksson RA, Albrektsson T. Temperature threshold
SUMMARY levels for heat-induced bone tissue injury. A vital micro-
scopic study in the rabbit. J Prosthet Dent 1983;50:101.
The delivery of a prosthesis that meets the Lawson 7. Miloro M, Ghali GE, Larson PE, et al, editors. Waite:
criteria often requires collaboration between the Peterson’s principles of oral and maxillofacial sur-
surgeon and the restoring dentist. Preprosthetic gery. 3rd edition. Shelton, CT: PMPH USA; 2011.
surgery should always be considered for patients 8. Garcı́a-Garcı́a AS, Martı́nez-González JM, Gómez-
receiving conventional dentures as well as for Font R, et al. Current status of the torus palatinus
those who will have prostheses that are partially and torus mandibularis. Med Oral Patol Oral Cir Bu-
implant borne.16 Preoperatively this involves a cal 2010;15:E353.
careful and critical evaluation of the relevant anat- 9. Chacko JP, Joseph C. Modified palatal flap: a
omy and a shared vision of what is necessary to simpler approach for removal of palatal tori. J Oral
optimize the function and esthetics of the planned Maxillofac Surg 2010;68(4):943–4.
prosthesis. Intraoperatively, each procedure 10. Kilner TP. The Thiersch graft: its preparation and
should be carried out with the intent of maximizing uses. Postgrad Med J 1934;10:176–81.
the contours, quantity, and quality of denture- 11. Steinhauser EW. Vestibuloplasty – skin grafts. J Oral
bearing tissues. Postoperatively, the surgeon en- Surg 1971;29:777–85.
sures that healing is adequate before prosthesis 12. Leban SG. The use of a modified skin grafting tech-
fabrication begins. Once the prosthesis is deliv- nique for alveolar sulcus extension. J Oral Surg
ered, patients are followed as needed by the sur- 1977;35:552–4.
geon; but the restoring dentist must take primary 13. Samit A, Popowich L. Mandibular vestibuloplasty: a
responsibility for periodic evaluation of the denture clinical update. Oral Surg Oral Med Oral Pathol
and its supporting tissues. The fit of the denture 1982;54:141–7.
should maintain adequate adaptation, and the oc- 14. Popowich L, Samit A. Respiratory obstruction
clusion should direct forces appropriately to the following vestibuloplasty and lowering of the floor
supporting tissues. of the mouth. J Oral Maxillofac Surg 1983;41:255–7.
15. Samit A, Kent K. Complications associated with skin
REFERENCES graft vestibuloplasty – experiences with 100 cases.
Oral Surg Oral Med Oral Pathol 1983;56:586–92.
1. Lawson WA. Objectives of pre-prosthetic surgery. Br 16. Cillo JE Jr, Finn R. Reconstruction of the shallow ves-
J Oral Surg 1972;10:175–88. tibule edentulous mandible with simultaneous split
2. Castelberry DJ. The prosthodontist’s perspective of thickness skin graft vestibuloplasty and mandibular
the deficient alveolar ridge. Compend Contin Educ endosseous implants for implant-supported over-
Dent 1982;(suppl 2):S49–51. dentures. J Oral Maxillofac Surg 2009;67:381–6.
Index
Note: Page numbers of article titles are in boldface type.
A surgical procedure, 451–454

labial, apically repositioned flap technique,
Academy of Pediatric Dentistry, policy statements on
452
third molar removal, 364
labial, closed exposure technique, 452–454
Acetaminophen, for postoperative pain in
labial, window technique for, 452
dentoalveolar surgery, 395
midalveolar, tunnel (closed) exposure
Allografts, mineralized bone, for the extraction
technique, 454
socket, 359
palatal, closed exposure technique for, 452
soft tissue grafting around teeth and implants with,
palatal, open exposure technique for,
440
451–452
Alveoloplasty, preprosthetic, 460–461
urgency of treatment, 457–458
American Association of Oral and Maxillofacial
Cardiovascular evaluation, presurgical, of patients
Surgeons, policy statements on third molar
undergoing dentoalveolar surgery, 345–349
removal, 364
anticoagulation, 348
American Dental Association, policy statements on
coronary artery disease, 347–348
endocarditis prophylaxis, 348
American Public Health Association, policy
hypertension, 346–347
statements on third molar removal, 365
pacemaker/defribrillator, 347
Anatomic configurations, after tooth extractions,
Closed exposure technique, in surgical treatment of
354–355
impacted canines, 451–454
Anesthetic drugs, nausea related to, 398–399
Cochrane Systematic Review, policy statements on
Anticoagulation, in pre surgical evaluation for
Coronary artery disease, in presurgical evaluation for
Antiemetic medications, for postoperative nausea
dentoalveolar surgery, 347–348
and vomiting, 399–401
Coronectomy, 373–382
Attachment bonding, in surgical treatment of
alternative techniques, 380
orthodontic extrusion of third molars, 380
Autogenous bone, for allografts for the extraction
sequential removal of small portions of
socket, 359–360
impacted third molar, 380
contraindications, 376
B controversial issues, 374–375
indications, 375
Biologic agents, soft tissue grafting around teeth and results, 378–380
implants with, 442 surgical technique, 376–378
Biopsy, controversy over, in periapical surgery, antibiotics, 377
390–392 distance below alveolar crest to leave roots,
Blood, ingestion of, nausea related to, 399 378
Bovine-derived xenografts, for the extraction socket, suturing, 377
359 Cracked teeth, in periapical surgery, 387
Bromelain, to treat and prevent swelling in Culture of safety, in the dentoalveolar surgical
dentoalveolar surgery, 397 practice, 405–409
clinical care safety, 406–407

concept of, 405–406
C
establishment of, 408–409
Canine teeth, impacted, surgical treatment of, hospital safety practices, 406
449–458 in oral-maxillofacial surgery, 406
bonding the attachment, 454–456 intraoffice guest and health care team safety,
making the right choices, 456–457 407–408
orthodontist’s role in planning, 450–451 safety from extra-office threats, 408

http://dx.doi.org/10.1016/S1042-3699(15)00065-5
474 Index
D symptoms and disease present, 369

symptoms present/disease free, 369–370
Defibrillators, in presurgical evaluation for
medical management of patients undergoing,
345–352
Dehydration, nausea related to, 399
presurgical evaluation, 345–351
Dental implants. See Implants, dental.
cardiovascular, 345–349
Dentoalveolar surgery, 345–472
medication-related osteonecrosis of jaw,
coronectomy, 373–382
349–350
alternative techniques, 380
periapical surgery, 383–392
contraindications, 376
biopsy, 390–392
controversial issues, 374–375
concomitant periodontal procedures,
indications, 375
387–388
results, 378–380
cracked or fractured tooth, 387
surgical technique, 376–378
determination of “success,” 387
culture of safety in, 405–409
preoperative planning, 383–387
clinical care safety, 406–407
surgical access, 390
concept of, 405–406
surgical procedures, 388–390
establishment of, 408–409
postoperative pain, swelling, nausea and vomiting
hospital safety practices, 406
in, 393–404
in oral-maxillofacial surgery, 406
best practices for controlling, 393–394
intraoffice guest and health care team safety,
pain control, 394–396
407–408
postoperative nausea and vomiting,
safety from extra-office threats, 408
397–401
extractions and preservation of space for implant
surgical technique, 394
placement, 353–362
swelling, 396–397
anatomic configurations after tooth extraction,
preprosthetic surgery, 459–472
356–357
bony recontouring procedures, 460-465
autogenous bone, 359–360
alveoloplasty, 460–461
bovine or equine sintered xenograft, 359
maxillary tuberosity reduction, 461–463
evidence of long-term preservation of bone,
preoperative planning, 460
360
torus removal, 463–465
grafting material, 358–359
goals, 459–460
mineralized bone allograft, 359
soft tissue procedures, 465–472
socket healing, 353–354
frenectomy, 465–467
treatment indications in common situations,
other, 470–472
357–358
skin grafting, 467
treatment planning, 354–356
vestibuloplasty, 467–470
soft tissue grafting around teeth and implants,
bonding the attachment, 454–456
425–448
making the right choices, 456–457
alternatives to autogenous, 439–443
orthodontist’s role in planning, 450–451
allograft, 440
surgical procedure, 451–454
biologic agents, 442
urgency of treatment, 457–458
guided tissue regeneration, 440
impacted third molars, management of, 363–371
living cellular construct, 440–442
clinical decision making for, 368–369
xenograft, 440
clinically relevant science, 366
classification of recession, 426
consequences of retention of, 367
development of mucogingival diagnosis and
differences with third molars, 365–366
surgery, 426
known associated disease, 366
donor and recipient wound site protection,
obstacles to consensus, 363
443–444
organizational policy statements, 364–365
envelope flap, 438
perspectives of parties of interest, 363–364
esthetic considerations, 426–427
potential adverse outcomes with removal, 367
for ridge augmentation, 443
recommendations supported by clinical
free gingival graft, 431–434
evidence, 368
free soft tissue grafting, 431
symptom free/disease free, 370
gingival recession around teeth and implants,
symptom free/disease present, 370
426
Index 475
ideal characteristics of interface, 425–426 esthetic considerations, 426–427

on implants versus teeth, 434–435 Grafting materials, for the extraction socket, 358–359
papilla, 429–430 Grafts, soft tissue. See Soft tissue grafts.
partial-thickness double pedicle graft, 437 Guided tissue regeneration, around teeth and
pedicle flap with vertical incisions, 437 implants with, 440
pinhole technique, 439
relationship between implant placement and
soft tissue, 428 H
root surface and implant surface treatment,
Hypertension, in presurgical evaluation for
439
semilunar and sliding flaps, 438
Hypoglycemia, nausea related to, 399
soft tissue management, 430–431
at time of implant placement, 431
before implant placement, 430–431
I
subepithelial connective tissue graft, 435–437
thick versus thin gingival architecture, 427–428 Iatrogenic injuries, of trigeminal nerve, avoidance and
trigeminal nerve injuries, 411–424 management of, 411–424
preoperative evaluation, 412–415 preoperative evaluation, 412–415
surgical strategies for avoidance of injuries, surgical strategies for, 415–417
415–417 when injury occurs, 417–423
when injury occurs, 417–423 Impacted teeth, canine, surgical treatment of,
449–458
E bonding the attachment, 454–456
making the right choices, 456–457
Endocarditis prophylaxis, in presurgical evaluation for orthodontist’s role in planning, 450–451
dentoalveolar surgery, 349 surgical procedure, 451–454
Endodontic surgery. See Periapical surgery. urgency of treatment, 457–458
Envelope flap, 437 third molar, management of, 363–371
Equine-derived xenografts, for the extraction socket, clinical decision making for, 368–369
359 clinically relevant science, 366
Extractions, molar, and preservation of space for consequences of retention of, 367
implant placement, 353–362 differences with third molars, 365–366
anatomic configurations after tooth extraction, known associated disease, 366
356–357 obstacles to consensus, 363
autogenous bone, 359–360 organizational policy statements, 364–365
bovine or equine sintered xenograft, 359 perspectives of parties of interest, 363–364
evidence of long-term preservation of bone, potential adverse outcomes with removal, 367
360 recommendations supported by clinical
grafting material, 358–359 evidence, 368
mineralized bone allograft, 359 symptom free/disease free, 370
socket healing, 353–354 symptom free/disease present, 370
treatment indications in common situations, symptoms and disease present, 369
357–358 symptoms present/disease free, 369–370
treatment planning, 354–356 Implants, dental, extractions and preservation of
space for placement of, 353–362
F anatomic configurations after tooth extraction,
Fear, as cause of nausea, 398 356–357
Fractured teeth, in periapical surgery, 387 autogenous bone, 359–360
Free gingival graft, 431–434 bovine or equine sintered xenograft, 359
indications, 433 evidence of long-term preservation of bone,
technique, 433–434 360
Frenectomy, preprosthetic, 465–467 grafting material, 358–359
mineralized bone allograft, 359
socket healing, 353–354
G
treatment indications in common situations,
Gingival recession, around teeth and implants, 426 357–358
classification of, 426 treatment planning, 354–356
476 Index
Implants (continued ) National Health Service of Finland, policy statements

soft tissue grafting around teeth and, 425–448 on third molar removal, 365
Injuries, iatrogenic. See Iatrogenic injuries. Nausea, postoperative, in dentoalveolar surgery,
Intentional root retention. See Coronectomy. 397–401
anesthetic drugs an nausea, 398–399
antiemetic medications for prevention of,
J 399–401
fear as cause of nausea, 398
Jaw, medication-related osteonecrosis of, and
hypoglycemia causing nausea, 399
ingestion of blood and nausea, 399
local anesthesia toxicity and nausea, 399
sex bias related to nausea, 399
L
type of surgery, 399
Labial canine, impacted, surgery for, apically Neurosensory disturbances, iatrogenic trigeminal
repositioned flap technique, 452 nerve injuries, 411–424
closed exposure technique, 452–454 Nonsteroidal anti-inflammatory drugs (NSAIDs),
window technique, 452 for postoperative pain in dentoalveolar surgery,
Laser energy irradiation, low-level, to treat and 395
prevent swelling in dentoalveolar surgery, 397
Living cellular construct, soft tissue grafting around
teeth and implants with, 440–442 O
Local anesthesia, toxicity and nausea related to,
Odontectomy, partial. See Coronectomy.
399
Open exposure technique, in surgical treatment of
Low-level laser energy irradiation, to treat and
prevent swelling in dentoalveolar surgery, 397
Orthodontics, role in surgical treatment of impacted
canines, 450–451
Osteonecrosis, of jaw, medication-related, and
M
Mandibular molars, extraction of, and preservation of
space for implant placement, 353–362
Maxillary tuberosity reduction, preprosthetic, P
461–463
Pacemakers, in presurgical evaluation for
Medical management, of patients undergoing
Pain, postoperative, control of in dentoalveolar
presurgical evaluation, 345–351
surgery, 394–396
cardiovascular, 345–349
acetaminophen, 395–397
medication-related osteonecrosis of jaw,
narcotics, 395
349–350
NSAIDs, 395
Medication-related osteonecrosis, of jaw, and
psychology of, 397
Palatal canine, impacted, surgery for, closed
Midalveolar canine, impacted, surgery for, tunnel
exposure technique, 452
(closed) exposure technique, 454
open exposure technique, 451–452
Mineral trioxide aggregate, in periapical surgery, 384,
Papilla, preservation of in soft tissue grafting,
389
429–430
Mineralized bone, human, for allografts for the
Pedicle flap, with vertical incisions, 437
extraction socket, 359
Periapical surgery, 383–392
Molars, coronectomy for removal of lower third,
biopsy, 390–392
363–371
concomitant periodontal procedures, 387–388
extraction of, and preservation of space for
cracked or fractured tooth, 387
implant placement, 353–362
determination of “success,” 387
impacted third, management of, 363–371
preoperative planning, 383–387
surgical access, 390
surgical procedures, 388–390
N
Pineapple. See Bromelain.
Narcotics, for postoperative pain in dentoalveolar Postoperative nausea and vomiting, in dentoalveolar
surgery, 395 surgery, 397–401
Index 477
anesthetic drugs an nausea, 398–399 Sex bias, related to nausea, 399

antiemetic medications for prevention of, Socket healing, after dental extractions, 353–354
399–401 Soft tissue grafting, around teeth and implants,
fear as cause of nausea, 398 425–448
hypoglycemia causing nausea, 399 alternatives to autogenous, 439–443
ingestion of blood and nausea, 399 allograft, 440
local anesthesia toxicity and nausea, 399 biologic agents, 442
sex bias related to nausea, 399 guided tissue regeneration, 440
type of surgery, 399 living cellular construct, 440–442
Preprosthetic surgery, 459–472 xenograft, 440
bony recontouring procedures, alveoloplasty, classification of recession, 426
460–461 development of mucogingival diagnosis and
maxillary tuberosity reduction, 461–463 surgery, 426
preoperative planning, 460 donor and recipient wound site protection,
torus removal, 463–465 443–444
goals, 459–460 envelope flap, 438
soft tissue procedures, 465–472 esthetic considerations, 426–427
frenectomy, 465–467 for ridge augmentation, 443
other, 470–472 free gingival graft, 431–434
skin grafting, 467 free soft tissue grafting, 431
vestibuloplasty, 467–470 gingival recession around teeth and implants,
Presurgical evaluation, of patients undergoing 426
dentoalveolar surgery, 345–351 ideal characteristics of interface, 425–426
cardiovascular, 345–349 on implants versus teeth, 434–435
anticoagulation, 348 papilla, 429–430
coronary artery disease, 347–348 partial-thickness double pedicle graft, 437
endocarditis prophylaxis, 348 pedicle flap with vertical incisions, 437
hypertension, 346–347 pinhole technique, 439
pacemaker/defribrillator, 347 relationship between implant placement and
medication-related osteonecrosis of jaw, soft tissue, 428
349–350 root surface and implant surface treatment,
Prostheses, dental. See also Implants. 439
preposthetic surgery, 459–472 semilunar and sliding flaps, 438
Protease inhibitors, to treat and prevent swelling in soft tissue management, 430–431
dentoalveolar surgery, 397 at time of implant placement, 431
Psychology, of pain, 396 before implant placement, 430–431
subepithelial connective tissue graft,
435–437
R thick versus thin gingival architecture,
427–428
Ridge augmentation, soft tissue grafts for, 442
Steroids, to treat and prevent swelling in
Risk management, implementing a culture of safety,
405–409
Subepithelial connective tissue graft, 435–437
Root retention, intentional. See Coronectomy.
donor site, 435–436
recipient site, 436–437
Swelling, postoperative, control of in dentoalveolar
S
surgery, 396–397
Safety, culture of, in the dentoalveolar surgical bromelain, 397
practice, 405–409 low-level laser energy irradiation, 397
clinical care safety, 406–407 other methods, 397
concept of, 405–406 protease inhibitors, 397
establishment of, 408–409 steroids, 396–397
hospital safety practices, 406
in oral-maxillofacial surgery, 406
intraoffice guest and health care team safety,
T
407–408 Third molars, coronectomy, 363–371
safety from extra-office threats, 408 impacted, management of, 363–371
478 Index
Third molars. See Molars. V

Torus removal, preprosthetic, 463–465
Vestibuloplasty, preprosthetic, 467–470
Trigeminal nerve injuries, avoidance and
Vomiting. See Postoperative nausea and vomiting.
management of iatrogenic, 411–424
preoperative evaluation, 412–415
surgical strategies for, 415–417 W
when injury occurs, 417–423
Wisdom teeth. See Third molars.
U X
United Kingdom National Health Service, policy Xenografts, bovine or equine, for the extraction
statements on third molar removal, 365 socket, 359
United States Military, policy statements on third soft tissue grafting around teeth and implants with,
molar removal, 365 440

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Dentoalveolar Surgery

ORAL AND MAXILLOFACIAL SURGERY

August 2015 • Volume 27 • Number 3

1600 John F. Kennedy Boulevard  Suite 1800  Philadelphia, Pennsylvania, 19103-2899

Editor: John Vassallo; [email protected]

ª 2015 Elsevier Inc. All rights reserved.

Electronic Storage or Usage

RICHARD H. HAUG, DDS

MICHAEL A. KLEIMAN, DMD

SHELLY ABRAMOWICZ, DMD, MPH Dentistry, Virginia Commonwealth University,

MICHAEL S. BLOCK, DMD HILLEL EPHROS, DMD, MD

STUART E. LIEBLICH, DMD Maxillofacial Surgery and Hospital Dentistry,

M. ANTHONY POGREL, DDS, MD, FRCS, ANTHONY SALLUSTIO, DDS

Medical Management of Patients Undergoing Dentoalveolar Surgery 345

Shelly Abramowicz and Steven M. Roser

Managing Impacted Third Molars 363

Coronectomy: Partial Odontectomy or Intentional Root Retention 373

Current Concepts of Periapical Surgery 383

Best Practices for Management of Pain, Swelling, Nausea, and Vomiting in

Developing and Implementing a Culture of Safety in the Dentoalveolar

Trigeminal Nerve Injuries: Avoidance and Management of Iatrogenic Injury 411

Sami A. Nizam II and Vincent B. Ziccardi

Soft Tissue Grafting Around Teeth and Implants 425

George R. Deeb and Janina Golob Deeb

Adrian Becker and Stella Chaushu

Preprosthetic Surgery 459

Hillel Ephros, Robert Klein, and Anthony Sallustio

ORAL AND MAXILLOFACIAL SURGERY

THE CLINICS ARE NOW AVAILABLE ONLINE!

Michael A. Kleiman, DMD

Oral Maxillofacial Surg Clin N Am 27 (2015) ix–x

INTRODUCTION anesthesia. The patient’s risk of having a compli-

Oral Maxillofacial Surg Clin N Am 27 (2015) 345–352

ASA Preoperative Health

stated specific targeted systolic and diastolic

Excellent (>7 METs) Moderate (4–7 METs) Poor (<4 METs)

ANTICOAGULATION dabigatran (Pradaxa), with renal insufficiency and

Medication Adults Children

Abbreviations: IM, intramuscularly; IV, intravenously.

in patients exposed to oral bisphosphonates (BPs) endodontic or periodontal procedures is un-

Stage Description Treatment Strategies

SUMMARY American Heart Association Task Force on Practice

INTRODUCTION implant placement and reconstruction of the pa-

Oral Maxillofacial Surg Clin N Am - (2015) -–-

1. Loss of all labial bone to the apex of the tooth

POSTOPERATIVE CARE From this preliminary set of data, there appears

decision-making process. This process is charac-

Oral Maxillofacial Surg Clin N Am - (2015) -–-

The American Dental Association

Academy of Pediatric Dentistry development of disease. Further, their methodol-

Fig. 2. Despite #17 near occlusal

CLINICALLY RELEVANT SCIENCE

Fig. 4. Second molar unable to erupt (contralateral

POTENTIAL ADVERSE OUTCOMES Note that clinicians who support retention as a

7. Third molars with probing depths greater than

1600 John F. Kennedy Boulevard Suite 1800 Philadelphia, Pennsylvania, 19103-2899