**SURGICAL EXTRACTIONS AND** **MINOR ORAL SURGERY** This section covers the principles and techniques associated with surgical extractions and minor oral surgery procedures. # **LEARNING OUTCOMES** * Describe indications for surgical asepsis techniques * Describe a basic overview of wound healing * Perform the basic steps to raise a simulated mucoperiosteal flap * Discuss advantages and rationales for suture selection * Explain common surgical complications and understand principles of management Upon completion of this module, students should be able to: - Describe indications for surgical asepsis techniques - Describe a basic overview of wound healing - Perform the basic steps to raise a simulated mucoperiosteal flap - Discuss advantages and rationales for suture selection - Explain common surgical complications and understand principles of management **RECOMMENDED READING** <img src="book_cover.png" alt="Book cover for Oral Surgery by Fragiskos D. Fragiskos, published by Springer."> Fragiskos, Fragiskos D, *Oral Surgery* (Springer Berlin Heidelberg, 2007) - Available online via UWA  #### Primary Textbook Fragiskos, Fragiskos D, *Oral Surgery* (Springer Berlin Heidelberg, 2007) - Available online via UWA The book cover for "Oral Surgery" by Fragiskos D. Fragiskos, published by Springer, featuring a blue background with an illustration of teeth and dental instruments. # MEDICAL CONSIDERATIONS * Diabetes – medications, control, eaten before? * Cardiac – hypertension, ischaemic heart disease * Drugs - anticoagulants * Neurological – seizures, recent TIA * Immunocompromised by disease or medications * Steroids (long term use and adrenal insufficiency) #### Key Patient History Factors - Diabetes: assess medications, glycemic control, and recent nutritional intake - Cardiac health: evaluate for hypertension and ischaemic heart disease - Pharmacological history: specifically anticoagulants - Neurological status: history of seizures or recent Transient Ischaemic Attack (TIA) - Immune status: immunocompromised state due to disease or medications - Steroid use: long-term use and risk of adrenal insufficiency **MEDICAL CONSIDERATIONS** * If in doubt – speak to patients GP or specialist physician for advice #### Clinical Consultation - If in doubt regarding a patient's medical status, speak to the patient's GP or specialist physician for professional advice. # **PERIOPERATIVE INFECTION CONTROL** * **Enhanced precautions:** * Sterile gloves * Surgical hand hygiene * Sterile drapes * Sterile irrigation solutions (note difference between irrigation and injection) * Surgical cap * **Apply when:** * Elevation of a mucoperiosteal flap * Surgical penetration of bone ADA Infection Prevention and Control 5th Edition, 2025 #### Enhanced Precautions - Sterile gloves - Surgical hand hygiene - Sterile drapes - Sterile irrigation solutions (note the distinction between irrigation and injection solutions) - Surgical cap #### Clinical Indications Enhanced precautions must be applied during: - Elevation of a mucoperiosteal flap - Surgical penetration of bone *Source: ADA Infection Prevention and Control 5th Edition, 2025* # SHARPS MANAGEMENT * Clinician who has used a disposable sharp item is responsible for immediate safe management AND disposal after use. * OHCWA – Dispose of needles as soon as they have been used. * Follow protocol with Ash Jenker #### Clinician Responsibility - The clinician who has used a disposable sharp item is responsible for its immediate safe management and disposal after use. - Per OHCWA guidelines: Dispose of needles as soon as they have been used. - Follow established protocols with Ash Jenker. September 2025 v2 **Safe Assembly & Disassembly of Local Anaesthetic** | Step | Image/Action Description | Instruction | | :--- | :--- | :--- | | **1** | | Choose the correct needle (25 or 27 gauge) and anaesthetic cartridge. | | **2** | | Holding the sheathed needle in your dominant hand, use your other hand to remove the stub cap in the direction AWAY from the needle. | | **3** | | Next, pick up the syringe and screw the sheathed needle on to the syringe in a clockwise direction. | | **4** | | Unlock the syringe handle and insert the correct end of the LA cartridge (i.e. the rubber diaphragm end first with the rubber plunger end furthest away) into the syringe with a firm push to ensure that the needle pierces the rubber diaphragm. | | **5** | | Lock the syringe handle and gently push down on the plunger to confirm that the needle has pierced the cartridge – some LA solution should be seen to be ejected into the needle cap. This also confirms that the needle did not bend when engaging the rubber diaphragm. | | **6** | | Holding the syringe in your dominant hand (with your thumb on the plunger), with your other hand, remove the sheath in the direction AWAY from the needle and place in the Needle Recapping Device. | | **7** | | Administer the local anaesthetic. | | **8** | | WITH ONE HAND, firmly fit the needle into the sheath and you will hear a click when the sheath is fitted. You must never hold the Needle Recapping Device with the other hand whilst fitting the needle into the sheath. Note that the Needle Recapping Device is stable enough and stays upright. | | **9** | | Holding the syringe in your dominant hand, use artery forceps to grab on to the hub of the needle (not the sheath) with the other hand. While holding on to the hub with the artery forceps, unscrew the syringe in an anti-clockwise direction with your dominant hand, and remove syringe in the direction AWAY from the needle. Place the needle straight in the sharps bin. | | **10** | | Pull back the plunger, unlock the syringe handle, remove the empty cartridge and place in the sharps bin. | September 2025 v2   1. Choose the correct needle (25 or 27 gauge) and anaesthetic cartridge. 2. Holding the sheathed needle in your dominant hand, use your other hand to remove the stub cap in the direction AWAY from the needle. 3. Pick up the syringe and screw the sheathed needle onto the syringe in a clockwise direction. 4. Unlock the syringe handle and insert the correct end of the LA cartridge (rubber diaphragm end first) into the syringe with a firm push to ensure the needle pierces the diaphragm. 5. Lock the syringe handle and gently push the plunger to confirm the needle has pierced the cartridge; LA solution should be visible in the needle cap. This also confirms the needle is not bent. 6. Holding the syringe in your dominant hand (thumb on plunger), use the other hand to remove the sheath in the direction AWAY from the needle and place it in the Needle Recapping Device. 7. Administer the local anaesthetic. 8. **Recapping:** WITH ONE HAND, firmly fit the needle into the sheath until it clicks. Never hold the Needle Recapping Device with the other hand during this process. 9. **Disassembly:** Holding the syringe in your dominant hand, use artery forceps to grab the hub of the needle (not the sheath). Unscrew the syringe anti-clockwise and remove it in the direction AWAY from the needle. Place the needle directly in the sharps bin. 10. Pull back the plunger, unlock the syringe handle, remove the empty cartridge, and place it in the sharps bin. A step-by-step instructional table titled "Safe Assembly & Disassembly of Local Anaesthetic" with numbered steps, each accompanied by a photograph and a brief description of the action. The table outlines the process from choosing the correct needle and cartridge to disassembling the syringe and disposing of components safely. A second instructional table with numbered steps (6-10) detailing the disassembly process of a local anaesthetic syringe. Each step includes a photograph and a descriptive caption, focusing on actions like removing the sheath, administering the anaesthetic, and safely disposing of the needle and cartridge. $$\text{SHARPS MANAGEMENT}$$ * Additional sharps will be present with surgical extractions: * Scalpel blade * Must be placed down in a **KNOWN** location if intending to be re-used * In theatre a kidney dish is used * In my practice a disposable tray is used to hold sharps * Consider disposal once you identify it will no longer be used * Disposal will depend on whether disposable handle or disposable blade + reusable holder #### Scalpel Blade Management Additional sharps are present during surgical extractions, specifically scalpel blades: - Blades must be placed in a **KNOWN** location if they are intended for re-use during the procedure. - In theatre settings: Use a kidney dish. - In private practice: Use a disposable tray to hold sharps. - Consider disposal immediately once the item is no longer required. - Disposal method depends on the equipment used (disposable handle vs. disposable blade with reusable holder). Videos of scalpel blade insert/removal and flask #### Instructional Resources - Refer to video demonstrations regarding scalpel blade insertion, removal, and flask usage. # SHARPS MANAGEMENT * Additional sharps will be present with surgical extractions: * Suture **needle** * We have discussed safe mounting and unmounting protocols * Whilst at OHCWA try and minimise holding the needle or putting hands in the way of the sharps * Increased number of sharp injuries in 2025. #### Suture Needle Safety - Suture needles represent additional sharps in surgical extractions. - Adhere to established safe mounting and unmounting protocols. - At OHCWA, minimize direct handling of the needle and avoid placing hands in the path of the sharp. - Note: There has been an increased number of sharp injuries reported in 2025. WOUND HEALING Wound healing is a complex biological process that restores the integrity of tissues following injury or surgical intervention. # SOFT TISSUE WOUND HEALING | | | | |---|---|---| | **Primary intention** | **Secondary intention** | **Tertiary intention** | | Clean incised wound/surgical wound | Highly contaminated wound or tissue loss | Contaminated wound | | Wound closed by suturing, skin grafting or flap closure | Wound is left open to heal | Treated by repeated debridement | | | Closed by reepithelialization | Wound is closed by suturing skin grafting or flap | **Regeneration > fibrosis** **Fibrosis > regeneration** **‘Delayed primary closure’**  #### Classifications of Wound Closure 1. **Primary Intention** - Characteristic of clean incised wounds or surgical wounds. - The wound is closed by suturing, skin grafting, or flap closure. - Biological outcome: Regeneration is greater than fibrosis. 2. **Secondary Intention** - Occurs in wounds with significant tissue loss or high levels of contamination. - The wound is left open to heal. - Closed via the process of re-epithelialization. - Biological outcome: Fibrosis is greater than regeneration. 3. **Tertiary Intention (Delayed Primary Closure)** - Utilized for contaminated wounds. - Treated initially by repeated debridement. - The wound is eventually closed by suturing, skin grafting, or flap closure. A flowchart diagram illustrating the three types of soft tissue wound healing: primary intention, secondary intention, and tertiary intention. The diagram shows that primary intention involves clean incised wounds closed by suturing, skin grafting, or flap closure, leading to regeneration over fibrosis. Secondary intention deals with highly contaminated wounds or tissue loss left open to heal by reepithelialization, resulting in fibrosis over regeneration. Tertiary intention involves contaminated wounds treated by repeated debridement and closed later by suturing, skin grafting, or flap closure, also resulting in fibrosis over regeneration. | Hemostasis and coagulation | Inflammatory stage | Proliferation stage | Modeling and remodeling stage | | :---: | :---: | :---: | :---: | | Tooth Extraction | | | | | | | | | | | **Phase I** **Hemostasis and coagulation** | **Phase II** **Inflammatory stage** | **Phase III** **Proliferation stage** | **Phase IV** **Modeling and remodeling** | | • First 24 hours post- extraction • Red and white blood cells with platelets • Formation of the initial blood clots • Clot organization, maintenance, and retraction are determined factors | • From 24 hours post- extraction • Response of inflammatory cells includes neutrophils, macrophages, and lymphocytes • Blood clots replaced by granulation tissue within the first week | • From 2 weeks post- extraction • Initiated by fibroplasia • Blood circulation re- establishment • Granulation tissue formed the provisional matrix • Provisional matrix replaced by woven bone | • From 4 weeks post- extraction • Modeling causes size and shape changes • Remodeling takes place later with qualitative changes • Woven bone eventually replaced by lamellar bone and bone marrow | | | | | | | | | | :---: | :---: | :---: | :---: | :---: | :---: | :---: | | | Red blood cells | | Macrophages | | Fibroblasts | | Osteoblasts | | | Platelets | | Neutrophils | | Mesenchymal stem cells | | Osteocytes | | | Fibrin | | Lymphocytes | | Osteoprogenitor cells | | Osteoclasts | | | | | | | | | Vessels | | | | | | | | | Collagen | | | | | | | | | Cytokines and Growth factors | Yijia Yin, Fangyuan Shuai, Xian Liu, Yuxi Zhao, Xianglong Han, Hang Zhao. Biomaterials and therapeutic strategies designed for tooth extraction socket healing. Biomaterials. Volume 316. 2025. 122975.ISSN 0142-9612,   #### Phases of Extraction Socket Healing - **Phase I: Hemostasis and Coagulation** - Timeline: First 24 hours post-extraction. - Key Components: Red and white blood cells, platelets, and fibrin. - Process: Formation of the initial blood clots. Clot organization, maintenance, and retraction are determining factors for successful healing. - **Phase II: Inflammatory Stage** - Timeline: From 24 hours post-extraction. - Key Components: Neutrophils, macrophages, and lymphocytes. - Process: Response of inflammatory cells. Blood clots are replaced by granulation tissue within the first week. - **Phase III: Proliferation Stage** - Timeline: From 2 weeks post-extraction. - Key Components: Fibroblasts, mesenchymal stem cells, and osteoprogenitor cells. - Process: Initiated by fibroplasia and the re-establishment of blood circulation. Granulation tissue forms a provisional matrix, which is subsequently replaced by woven bone. - **Phase IV: Modeling and Remodeling** - Timeline: From 4 weeks post-extraction. - Key Components: Osteoblasts, osteocytes, osteoclasts, vessels, collagen, cytokines, and growth factors. - Process: Modeling causes changes in size and shape. Remodeling occurs later with qualitative changes where woven bone is eventually replaced by lamellar bone and bone marrow. A table summarizing the four phases of tooth extraction socket healing: Phase I (Hemostasis and coagulation), Phase II (Inflammatory stage), Phase III (Proliferation stage), and Phase IV (Modeling and remodeling). Each phase includes a description of key events, such as blood clot formation, inflammatory cell response, granulation tissue formation, and bone remodeling. A diagram illustrating the four stages of tooth extraction socket healing: Hemostasis and coagulation, Inflammatory stage, Proliferation stage, and Modeling and remodeling stage. The diagram includes illustrations of cellular components like red blood cells, platelets, macrophages, fibroblasts, and osteoblasts, and shows the progression of tissue repair over time. Average horizontal bone loss of 3.4mm Average vertical bone loss 1.33mm on the buccal and 0.5mm lingual Socket preservation with synthetic materials may help to mitigate effects Barootchi S, Tavelli L, Majzoub J, Stefanini M, Wang H-L, Avila-Ortiz G. Alveolar ridge preservation: Complications and cost-effectiveness. Periodontol 2000. 2023; 92: 235-262. doi: 10.1111/prd.12469  #### Alveolar Ridge Alterations Following tooth extraction, the alveolar ridge undergoes natural resorptive changes: - **Horizontal Bone Loss:** Average of 3.4 mm. - **Vertical Bone Loss:** Average of 1.33 mm on the buccal aspect and 0.5 mm on the lingual aspect. #### Clinical Considerations Socket preservation techniques using synthetic materials may help to mitigate these resorptive effects and maintain ridge dimensions for future restorative procedures. A medical diagram illustrating alveolar ridge preservation, showing two scenarios: (A) without intervention, demonstrating bone loss with a hollow socket, and (B) with socket preservation using synthetic materials, showing maintained bone structure. The diagram includes text indicating average horizontal bone loss of 3.4mm and vertical bone loss of 1.33mm buccally and 0.5mm lingually. **SOCKET HEALING** * Socket healing is influenced by: * Local factors – infection and poor perfusion * Systemic factors – hormones, stress, blood glucose, other deficiencies * Iatrogenic – tissue trauma * Socket healing is a process which results in volumetric changes to the alveolar bone. Socket healing is a physiological process that results in volumetric changes to the alveolar bone. The efficiency and outcome of this process are influenced by several variables: - **Local Factors:** Presence of infection and poor tissue perfusion. - **Systemic Factors:** Hormonal balance, stress levels, blood glucose regulation, and nutritional deficiencies. - **Iatrogenic Factors:** Degree of tissue trauma during the surgical procedure. MORE TO COME IN **PERIODONTOLOGY LECTURES** Further detailed information regarding tissue management and bone response will be covered in subsequent Periodontology lectures. # **INDICATIONS FOR SURGICAL** # **TREATMENT** * Difficult extraction anticipated * Impacted/retained or buried tooth / root * Pathological management eg cyst enucleation / marsupialization * Pre-prosthetic surgery  Surgical intervention is indicated in various clinical scenarios where standard non-surgical approaches are insufficient or inappropriate. Key indications include: - Anticipation of a difficult extraction - Management of impacted, retained, or buried teeth and roots - Pathological management, such as cyst enucleation or marsupialization - Pre-prosthetic surgery to prepare the oral environment for dental appliances A rectangular box containing the title "INDICATIONS FOR SURGICAL TREATMENT" in bold, uppercase letters, which serves as a heading for the list of surgical indications below it. PRE-PROSTHETIC SURGERY Surgery prior to construction of a prosthesis to assist in its function or comfort   #### Definition and Purpose Pre-prosthetic surgery refers to surgical procedures performed prior to the construction of a prosthesis. The primary objectives of these procedures are to: - Assist in the overall function of the prosthesis - Improve patient comfort while wearing the appliance A composite of four intraoperative photographs (labeled a-d) showing various stages of pre-prosthetic surgery on the oral cavity, including tissue manipulation and suturing. A composite of two photographs showing the surgical site of the oral cavity, with the top image showing the tissue after resection and the bottom image showing the tissue after suturing. Note, that this is **NOT** a common surgery due to risks Sorrentino, D., Lombardi, N., Battilana, C., Decani, S., Henin, D., & Rossi, V. (2019). Treatment of Symptomatic Mandibular Tori: A Case Report. Proceedings, 35(1), 75. https://doi.org/10.3390/proceedings2019035075   #### Clinical Considerations and Risks It is important to note that pre-prosthetic surgery is not a common procedure. The infrequency of these operations is primarily due to the associated surgical risks. #### Case Study Reference - Sorrentino, D., Lombardi, N., Battilana, C., Decani, S., Henin, D., & Rossi, V. (2019). Treatment of Symptomatic Mandibular Tori: A Case Report. Proceedings, 35(1), 75. https://doi.org/10.3390/proceedings2019035075 A close-up intraoral photo showing the left side of the mandible with multiple mandibular tori, indicated by white, rounded growths on the lingual surface, with surgical markings and minor bleeding visible. A close-up intraoral photo showing the right side of the mandible post-surgery, with the surgical site sutured, revealing the underlying tissue and the removal of the mandibular tori, with a black suture line visible. **FLAPLESS SECTIONING (ITEM 314)** #### Overview of Item 314 Flapless sectioning is a surgical technique utilized to facilitate the removal of teeth while minimizing trauma to the surrounding tissues. <div style="text-align: center;"> <div style="border: 2px solid black; padding: 10px; display: inline-block;"> **SECTIONING OF TEETH** </div> </div> * Why section? * The tooth dictates it: * Complex anatomy (divergent roots OR higher risk of complications) * Gross caries and lack of purchase points * The long-term plan dictates it: * Minimising trauma and bone loss * Socket preservation * Prosthetic replacements – bridge/implants #### Rationale for Sectioning Teeth - **Anatomical Indications:** - Complex root anatomy, such as divergent roots. - Situations presenting a higher risk of surgical complications. - Presence of gross caries resulting in a lack of adequate purchase points for traditional extraction. - **Long-term Clinical Goals:** - Minimizing surgical trauma and associated bone loss. - Facilitating socket preservation techniques. - Preparing the site for future prosthetic replacements, such as bridges or dental implants. # INSTRUMENTS REQUIRED * Handpiece * If **absolutely sure** no flap raised then can use restorative high speed + course diamond (if taking this approach, must not fully section through – i.e must not touch bone) * If **unsure** about attached gingival tissue – straight handpiece and surgical bur * Round OR flat fissure (clinician dependant) * Will require manual irrigation (saline for irrigation) * Elevator * For propagating the fracture * Forceps * Usually the fine variation for singular root removal * May elect to use cowhorns to section #### Handpiece Selection - **Restorative High-Speed Handpiece:** - May be used with a coarse diamond bur only if it is absolutely certain that no flap will be raised. - Caution: Must not section fully through the tooth; the bur must not contact the bone. - **Straight Surgical Handpiece:** - Used with a surgical bur if there is any uncertainty regarding the status of the attached gingival tissue. - **Bur Types:** - Round or flat fissure burs may be used based on clinician preference. - **Irrigation:** - Manual irrigation using saline is required. #### Extraction Instruments - **Elevators:** - Used for propagating the fracture after initial sectioning. - **Forceps:** - Fine variation forceps are typically used for the removal of individual roots. - Cowhorn forceps may be elected as a tool to assist in the sectioning process. Section 80% through the crown.  #### Initial Sectioning Depth Section approximately 80% of the way through the crown of the tooth to prepare for elevation. A close-up photo of a dental crown section at 80% through the crown, showing a white, tooth-like structure with a visible internal cavity or filling material. The surrounding area appears to be a pink, gum-like material, likely representing the gingival tissue or a model of the oral environment. Elevate off the crown, (in a non plastic tooth) this will expose the pulp chamber **Shaded area in red shows how bur penetrated into the crown and then ‘swept’**   #### Crown Elevation and Pulp Exposure - Elevate the crown segment off the tooth; in a natural (non-plastic) tooth, this action will expose the pulp chamber. - The bur should penetrate into the crown and then be moved in a 'sweeping' motion to create the necessary space for elevation. Close-up photo of a dental model showing a non-plastic tooth with a crown that has been elevated, exposing the pulp chamber. The image highlights the preparation of the tooth for further dental work. Close-up photo of a dental model showing a tooth with a red shaded area indicating where a bur penetrated into the crown and then 'swept' during the procedure, as described in the accompanying text.  Close-up photograph of a dental model showing a section through a tooth with a furcation, highlighted by a red line indicating the cross-section. The surrounding teeth are intact, and the image focuses on the interproximal area between the teeth.  A close-up photo of a dental model showing a section through a tooth with a furcation, highlighted by a red curved line and vertical line. The surrounding teeth are intact, and the central tooth exhibits a split or gap in the furcation area, indicating a treatment approach. The caption below reads "Section through the furcation (alternate approach)." Elevate the roots out one-by-one  #### Root Removal Following the successful sectioning and removal of the crown, elevate and remove the remaining roots individually. A close-up photo of a dental model showing three teeth with the central tooth having its root exposed and elevated, surrounded by pink gum-like material. The text below reads "Elevate the roots out one-by-one," indicating a step in a dental procedure.  A close-up photo of a dental model showing a tooth with a cavity and exposed root structure, surrounded by healthy teeth. The image is labeled 'Elevate the roots out one-by-one,' indicating a step in a dental procedure.  A close-up photo of a dental model showing a tooth with a root canal treatment, where the root is exposed and the surrounding tissue appears to be elevated. The image includes text at the bottom reading "Elevate the roots out one-by-one," indicating a step in the dental procedure. # **WHAT DO WE MEAN WHEN WE SAY SURGICAL EXTRACTION?** * Elevation of a mucoperiosteal flap * May be in isolation, e.g root * Surgical penetration of bone Surgical extraction involves specific clinical procedures to access and remove teeth or fragments that cannot be extracted by conventional means. This typically includes: - Elevation of a full-thickness mucoperiosteal flap - Management of isolated fragments, such as retained roots - Surgical penetration or removal of bone to facilitate access # **PRINCIPLES OF FULL THICKNESS MUCOPERIOSTEAL FLAP DESIGN** * Think clearly about what our surgical field needs to be – this dictates the flap * Be conscious of how the flap will be closed * When considering the flap design, ensure: * Broad base (base wider than the free margin) * Incision made perpendicular to the mucosa * Incision down to bone * Minimise trauma to the papillae #### Clinical Considerations for Flap Design When designing a full-thickness mucoperiosteal flap, the surgical field requirements dictate the flap's dimensions. Practitioners must also plan for how the flap will be closed upon completion of the procedure. #### Essential Design Criteria To ensure adequate healing and visibility, the following principles should be followed: - **Broad Base:** The base of the flap must be wider than the free margin to maintain an adequate blood supply. - **Incision Technique:** Incisions should be made perpendicular to the mucosa and extend through the periosteum down to the bone. - **Tissue Preservation:** Efforts should be made to minimize trauma to the interdental papillae. FLAP DESIGNS This section covers various flap designs utilized in minor oral surgery to provide access to the surgical site. Videos on different types of flap to raise Instructional videos demonstrate the clinical techniques for raising different types of mucoperiosteal flaps. **OTHER FLAP DESIGNS** * **Crestal** * **Retained roots?** * **Implants** <img src="figure_placeholder.jpg" alt="Intraoral photograph showing posterior teeth area with some soft tissue changes."> Beldar, Amol & Bhongade, Manohar & Byakod, Girish & Buregoni, Chandrashekar. (2013). Early Loading of Single-Piece Implant for Partially Edentulous Posterior Arch: A Prospective One-Year Case Report. Case reports in dentistry. 2013. 854062. 10.1155/2013/854062.  #### Specialized Flap Applications Specific flap designs are selected based on the clinical indication: - **Crestal Flaps:** Often utilized for implant placement or accessing the alveolar ridge. - **Retained Roots:** Flap design is modified to locate and retrieve buried root fragments. - **Implants:** Specific considerations for early loading and partially edentulous posterior arches. Intraoral photograph showing the posterior teeth area with visible soft tissue changes, illustrating a case related to flap designs for dental implants. The image is referenced in a study on early loading of single-piece implants for partially edentulous posterior arches. **OTHER FLAP DESIGNS** * Crestal * Semilunar <img src="image.png" alt="Diagram and clinical photograph of Semilunar flap"> Fig. 3.12a, b. Semilunar flap. a Diagrammatic illustration. b Clinical photograph. It is used in apicoectomies and removal of small cysts and root tips   #### Semilunar Flaps The semilunar flap is a specific design used in various minor oral surgical procedures: - **Indications:** - Apicoectomies - Removal of small cysts - Retrieval of root tips - **Characteristics:** A curved incision that avoids the gingival margin, providing localized access to the periapical area. Diagrammatic illustration of a semilunar flap, showing the surgical technique with a pink flap design over teeth and a dotted line indicating the incision path. Clinical photograph of a semilunar flap in use, displaying the surgical site with a flap raised to expose the underlying tissue and teeth, used in apicoectomies and removal of small cysts and root tips. # **OTHER FLAP DESIGNS** * Crestal * Semilunar * Pedicled flaps (see later slides on OAC) #### Additional Flap Types - **Crestal Flaps** - **Semilunar Flaps** - **Pedicled Flaps:** These are specifically utilized for the closure of Oro-Antral Communications (OAC). FLAP AND BONE REMOVAL +/- SECTIONING This section details the methods for bone removal and the potential need for tooth sectioning during surgical extractions. **FLAP AND BONE REMOVAL +/-** **SECTIONING** * The tooth may be grossly carious, or a retained root fragment * It may not be possible to identify key landmarks or create any form of purchase point * Sometimes it is necessary to raise a full thickness mucoperiosteal flap, remove bone: * Mesial/distal * Buccal * Remember the point of this is to make space to help elevate out the tooth and no more. * Any bone removal will worsen the healing outcomes – larger buccal defects or periodontal defects #### Indications for Bone Removal Bone removal may be necessary when a tooth is grossly carious or when dealing with a retained root fragment where key landmarks or purchase points cannot be identified. #### Surgical Approach - **Procedure:** Raise a full-thickness mucoperiosteal flap and remove bone at the mesial, distal, or buccal aspects. - **Objective:** The primary goal is to create sufficient space to elevate the tooth; excessive bone removal should be avoided. - **Healing Considerations:** Bone removal can negatively impact healing outcomes, potentially leading to larger buccal defects or periodontal complications. **FLAP AND BONE REMOVAL +/-** **SECTIONING** * Manual irrigation is required to: * Wash out debris * Keep the bone cool * Necrosis of the bone has been demonstrated if the temperature of the bone exceeds 47 degrees for 1 minute or more$^1$ 1. Kniha K, Heussen N, Weber E, Möhlhenrich SC, Hölzle F, Modabber A. Temperature Threshold Values of Bone Necrosis for Thermo-Explantation of Dental Implants-A Systematic Review on Preclinical In Vivo Research. Materials (Basel). 2020 Aug 6;13(16):3461. doi: 10.3390/ma13163461 #### Irrigation Requirements Manual irrigation is a critical component of bone removal to ensure: - **Debris Clearance:** Washing out surgical fragments and bone dust. - **Thermal Control:** Keeping the bone cool to prevent thermal damage. #### Thermal Thresholds Maintaining low temperatures is vital for bone viability. Research has demonstrated that bone necrosis occurs if the temperature exceeds 47 degrees Celsius for a duration of 1 minute or more. Video on bone removal on model Demonstration video illustrating the technique for bone removal using a surgical model. **FLAP AND BONE REMOVAL +/-** **SECTIONING** * If single rooted: * Enough space is made to elevate or grasp with forceps * If multi-rooted: * A decision made as to whether to elevate/grasp with forceps OR * Section roots * Remembering now a mucoperiosteal flap has been raised, only the straight handpiece can be used #### Management of Different Tooth Morphologies - **Single-Rooted Teeth:** Bone is removed until enough space is created to either elevate the tooth or grasp it with forceps. - **Multi-Rooted Teeth:** Practitioners must decide between: - Direct elevation/grasping with forceps. - Sectioning the roots to facilitate individual removal. #### Equipment Safety Once a mucoperiosteal flap has been raised, only the straight handpiece should be used for bone removal or sectioning to prevent surgical complications such as surgical emphysema. **FLAP AND BONE REMOVAL +/-** **SECTIONING** * Once all fragments removed, as per previous discussion: * Ensure apices intact * Inspect socket walls * Consider curettage and irrigation to remove granulation tissue #### Post-Extraction Protocol After all fragments have been successfully removed, the following steps should be completed: - **Verification:** Ensure that all apices are intact and accounted for. - **Inspection:** Carefully inspect the socket walls for any remaining debris or abnormalities. - **Debridement:** Perform curettage and irrigation to remove granulation tissue and promote healthy healing. ADVANCED SUTURING Advanced suturing techniques and materials for surgical extractions and minor oral surgery. THE SUTURE PACKET | **3-0**<br> (2 Ph. Eur.) | ETHICON®<br>Coated | **REF**W9923| |---|---|---| | **PS-2**<br>19mm 3/8c<br>REVERSE CUTTING | **VICRYL RAPIDE**™<br>Polygactin 910<br>undyed braided absorbable suture<br>incoloro trenzado sutura absorbible<br>incolore tressé suture résorbable<br>sutura absorvível incolor entrançada | | | **PRIME**™<br>**ETHALLOY**™<br>**75cm** | **STERILE R** $\boxplus$ $\triangle$ $\textcircled{C}$ **2797** XZW9923.3 | **LOT** AU8873<br>X 2028-08 |  #### Anatomy of a Suture Packet - **Size:** 3-0 (2 Ph. Eur.) - **Product Name:** VICRYL RAPIDE™ (Polyglactin 910) - **Type:** Undyed braided absorbable suture - **Needle Specifications:** - PS-2 - 19mm 3/8c - Reverse Cutting - **Material Technology:** PRIME™ ETHALLOY™ - **Length:** 75cm - **Reference Number:** W9923 - **Lot Number:** AU8873 - **Expiry:** 2028-08 The image displays a suture packet labeled "THE SUTURE PACKET" with detailed information about the product. The packet contains VICRYL RAPIDE™, an undyed braided absorbable suture made of Polyglactin 910, with specifications including a 3-0 size (2 Ph. Eur.), 19mm 3/8c reverse cutting needle, and a length of 75cm. The packaging also includes sterilization and regulatory markings such as CE 2797 and lot number AU8873. **THREAD SIZE** * Initially suture threads based on large sizes - 0, 1, 2, 3, 4 etc * As technology improved threads could become smaller without breaking. * The system couldn't cope with smaller than 0, so they developed: * 00 (2 zeroes = 2/0) * 000 (3 zeroes = 3/0) * 0000 (4 zeroes = 4/0) * And so on.. #### Evolution of Sizing - Initially, suture threads were based on large sizes: 0, 1, 2, 3, 4, etc. - As technology improved, threads became smaller without losing tensile strength. - To accommodate sizes smaller than 0, a "zero" numbering system was developed: - 00 (2 zeroes = 2/0) - 000 (3 zeroes = 3/0) - 0000 (4 zeroes = 4/0) - And so on. Ph. Eur // **metric** European Pharmacopoeia USP United States Pharmacopoeia Standardised? 2 different standards you may see: <img src="image_of_thread_label.png" alt="Image showing 'THREAD' in a box"> **USP 4/0** **Ph. Eur // metric** **3-0** (2 Ph. Eur.) **3-0** (2.0 **metric**)    #### Measurement Standards There are two primary standards used to classify suture diameter: 1. **USP (United States Pharmacopoeia):** e.g., 4/0 or 3-0. 2. **Ph. Eur. // Metric (European Pharmacopoeia):** e.g., 2 or 3. **Examples of Labeling:** - USP 4/0 - 3-0 (2 Ph. Eur.) - 3-0 (2.0 metric) A close-up photo showing a label with '3-0' and '(2 Ph. Eur.)' printed on it, representing a metric thread standard from the European Pharmacopoeia. A close-up photo of a label displaying '3-0 (2.0 metric)', indicating a metric thread size used in the European Pharmacopoeia standard. A close-up photo of a label showing 'USP 4/0', representing a thread size standard from the United States Pharmacopoeia. # THREAD SIZE <table> <thead> <tr> <td style="background-color: #d0e0f7;">EP / Metric</td> <td style="background-color: #d0e0f7;">USP</td> <td style="background-color: #d0e0f7;">Ø (mm)</td> <td style="background-color: #d0e0f7;">Ø (mm)<br>Absorbable monofilaments</td> </tr> </thead> <tbody> <tr> <td>0,2</td> <td>10-0</td> <td>0,020-0,029</td> <td>-</td> </tr> <tr> <td>0,3</td> <td>9-0</td> <td>0,030-0,039</td> <td>-</td> </tr> <tr> <td>0,4</td> <td>8-0</td> <td>0,040-0,049</td> <td>-</td> </tr> <tr> <td>0,5</td> <td>7-0</td> <td>0,050-0,069</td> <td>0,050-0,094</td> </tr> <tr> <td>0,7</td> <td>6-0</td> <td>0,070-0,099</td> <td>0,095-0,149</td> </tr> <tr> <td>1</td> <td>5-0</td> <td>0,100-0,149</td> <td>0,150-0,199</td> </tr> <tr> <td>1,5</td> <td>4-0</td> <td>0,150-0,199</td> <td>0,200-0,249</td> </tr> <tr> <td style="background-color: #d0e0f7;">2</td> <td style="background-color: #d0e0f7;">3-0</td> <td style="background-color: #d0e0f7;">0,200-0,249</td> <td style="background-color: #d0e0f7;">0,250-0,339</td> </tr> <tr> <td>2,5</td> <td>-</td> <td>0,250-0,299</td> <td>-</td> </tr> <tr> <td>3</td> <td>2-0</td> <td>0,300-0,349</td> <td>0,340-0,399</td> </tr> <tr> <td>3,5</td> <td>0</td> <td>0,350-0,399</td> <td>0,400-0,499</td> </tr> <tr> <td>4</td> <td>1</td> <td>0,400-0,499</td> <td>0,500-0,570</td> </tr> <tr> <td>5</td> <td>2</td> <td>0,500-0,599</td> <td>0,571-0,610</td> </tr> <tr> <td>6</td> <td>3+4</td> <td>0,600-0,699</td> <td>-</td> </tr> <tr> <td>7</td> <td>5</td> <td>0,700-0,799</td> <td>-</td> </tr> <tr> <td>8</td> <td>6</td> <td>0,800-0,899</td> <td>-</td> </tr> </tbody> </table> Table from : https://www.chirmax.ch/en/eur-pharmacopoeia.html  #### Suture Diameter Comparison Table | EP / Metric | USP | Ø (mm) Standard | Ø (mm) Absorbable Monofilaments | | :--- | :--- | :--- | :--- | | 0.2 | 10-0 | 0.020–0.029 | - | | 0.3 | 9-0 | 0.030–0.039 | - | | 0.4 | 8-0 | 0.040–0.049 | - | | 0.5 | 7-0 | 0.050–0.069 | 0.050–0.094 | | 0.7 | 6-0 | 0.070–0.099 | 0.095–0.149 | | 1 | 5-0 | 0.100–0.149 | 0.150–0.199 | | 1.5 | 4-0 | 0.150–0.199 | 0.200–0.249 | | 2 | 3-0 | 0.200–0.249 | 0.250–0.339 | | 2.5 | - | 0.250–0.299 | - | | 3 | 2-0 | 0.300–0.349 | 0.340–0.399 | | 3.5 | 0 | 0.350–0.399 | 0.400–0.499 | | 4 | 1 | 0.400–0.499 | 0.500–0.570 | | 5 | 2 | 0.500–0.599 | 0.571–0.610 | | 6 | 3+4 | 0.600–0.699 | - | | 7 | 5 | 0.700–0.799 | - | | 8 | 6 | 0.800–0.899 | - | Table comparing thread sizes across different systems: EP/Metric, USP, and diameter in millimeters for both standard and absorbable monofilament threads. The table lists sizes from 0.2 to 8, showing corresponding USP designations and diameter ranges, with specific data for absorbable monofilaments where applicable. THE SUTURE PACKET | 3-0 | **ETHICON®** | | :---: | :---: | | (2 Ph. Eur.) | **Coated** | | **PS-2** | **VICRYL RAPIDE™** | | 19mm 3/8c | Polyglactin 910 | | REVERSE CUTTING | undyed braided absorbable suture | | | **incoloro trenzado sutura absorbible** | | | **incolore tressé suture résorbable** | | | **sutura absorvível incolor entrançada** | | PRIMETM | | | ETHALLOY™ | **ETHICON, LLC** | | **75cm** | STERILE **R** **⊗** **△** **CE 2797** XZW9923.3 | | | **REF N9923** | | :---: | :---: | | | | | | **ε26000** | | | **LOT AU8873** | | | **☒ 2028-08** |  #### Suture Packet Reference (Detailed) - **Size:** 3-0 (2 Ph. Eur.) - **Material:** Coated VICRYL RAPIDE™ (Polyglactin 910) - **Structure:** Undyed braided absorbable - **Needle:** PS-2, 19mm 3/8c, Reverse Cutting - **Technology:** PRIME™ / ETHALLOY™ - **Length:** 75cm - **Manufacturer:** ETHICON, LLC - **Reference:** REF W9923 - **Lot:** AU8873 - **Expiry:** 2028-08 The image shows a suture packet labeled "THE SUTURE PACKET" with details about the product. The central label highlights the brand "ETHICON®" and the product name "VICRYL RAPIDE™," which is a polyglactin 910, undyed braided absorbable suture. Key specifications include size 3-0, PS-2 needle, 19mm 3/8c reverse cutting, and a length of 75cm. The packet also indicates sterilization and regulatory compliance with CE 2797. <div style="text-align: center;"> <div style="border: 2px solid black; padding: 20px; display: inline-block;"> SUTURE MATERIALS (DENTAL) </div> </div> <br> <span style="font-size: 1.8em; text-decoration: underline;">**Absorbable**</span> <span style="font-size: 1.5em;">**Synthetic**</span> * Polyglactin 910 (Vicryl/rapide) * Polydioxanone (PDS) <span style="font-size: 1.5em;">**Natural**</span> * (Chromic) Gut  #### Absorbable Dental Suture Materials **Synthetic** - Polyglactin 910 (Vicryl / Vicryl Rapide) - Polydioxanone (PDS) **Natural** - Gut (including Chromic Gut) The image displays a title box with the text "SUTURE MATERIALS (DENTAL)" in bold, centered within a rectangular frame. This figure serves as the main heading for a list of absorbable suture materials categorized into synthetic and natural types, including Polyglactin 910, Polydioxanone (PDS), and (Chromic) Gut. | SUTURE MATERIALS (DENTAL) | | :--- | | **Absorbable** | **Non-absorbable** | | **Synthetic** | **Synthetic** | | • Polyglactin 910 (Vicryl/rapide) | • Polypropylene (Prolene) | | • Polydioxanone (PDS) | • PTFE | | **Natural** | **Natural** | | • (Chromic) Gut | • Silk |  #### Dental Suture Classification **Absorbable** - **Synthetic:** - Polyglactin 910 (Vicryl/rapide) - Polydioxanone (PDS) - **Natural:** - (Chromic) Gut **Non-absorbable** - **Synthetic:** - Polypropylene (Prolene) - PTFE - **Natural:** - Silk A table titled 'SUTURE MATERIALS (DENTAL)' that categorizes suture materials into absorbable and non-absorbable types, further divided into synthetic and natural subcategories. The table lists specific materials such as Polyglactin 910 (Vicryl/rapide), Polydioxanone (PDS), (Chromic) Gut, Polypropylene (Prolene), PTFE, and Silk. ```markdown <div style="text-align: center;"> <div style="border: 2px solid black; display: inline-block; padding: 5px 10px;"> THREAD STRUCTURE </div> </div> <table> <thead> <tr> <th>Monofilament</th> <th>Multifilament</th> </tr> </thead> <tbody> <tr> <td> <ul> <li>Lower tissue drag</li> <li>Lower infection risk</li> <li>More difficult handling</li> </ul> </td> <td> <ul> <li>Higher tissue drag</li> <li>Higher infection risk</li> <li>Easier handling</li> </ul> </td> </tr> </tbody> </table> ```   #### Comparison of Thread Structures | Monofilament | Multifilament | | :--- | :--- | | - Lower tissue drag | - Higher tissue drag | | - Lower infection risk | - Higher infection risk | | - More difficult handling | - Easier handling | A rectangular box with the title 'THREAD STRUCTURE' in bold, black text centered at the top. The box is outlined with a thin black border and has a white background, serving as a header for the content below. A two-column table comparing 'Monofilament' and 'Multifilament' thread types. The left column lists monofilament characteristics: lower tissue drag, lower infection risk, and more difficult handling. The right column lists multifilament characteristics: higher tissue drag, higher infection risk, and easier handling. The table uses bullet points for each characteristic. **THE SUTURE PACKET** | | | | | |---|---|---|---| | 3-0 | ETHICON® | | | | (2 Ph. Eur.) | Coated | **REF** W9923 | 000323 | | **PS-2** | **VICRYL RAPIDE**™ | | | | 19mm 3/8c | Polyglactin 910 | | | | **REVERSE CUTTING** | undyed braided absorbable suture | | | | (Image of a reverse cutting needle) | incoloro trenzado sutura absorbible | | | | | incolore tressé suture résorbable | | | | | sutura absorvível incolor entrançada | | | | **ETHALLOY**™ | | | | | **75cm** | ETHICON, LLC | | | | | **STERILE** R ✇ CE **2797** XZW9923.3 | | | | | | | **LOT** AU8873 | | | | | ✇ 2028-08 |  #### Suture Specifications Summary - **Identification:** 3-0 (2 Ph. Eur.) - **Material:** Coated VICRYL RAPIDE™ (Polyglactin 910) - **Needle:** PS-2, 19mm 3/8c, Reverse Cutting - **Length:** 75cm - **Sterility:** Sterile R (Gamma Irradiation) - **Reference:** W9923 - **Lot:** AU8873 - **Expiry:** 2028-08 The image shows a suture packet labeled "THE SUTURE PACKET" with details about the product. The packet contains a 3-0 ETHICON® VICRYL RAPIDE™ suture, which is a coated, undyed braided absorbable suture made of Polyglactin 910. It includes a reverse cutting needle (PS-2, 19mm 3/8c) and is sterilized, as indicated by the "STERILE" label and CE marking. The package also features a QR code, lot number (AU8873), and expiration date (2028-08). **NEEDLE // ATRAUMATIC** | CODE | MEANING | CODE | MEANING | CODE | MEANING | |---|---|---|---|---|---| | BB | Blue Baby | FSLX | For Skin Extra Large | STB | Straight Blunt | | BF | Intraocular Fixation | G | Greishaber | STC | Straight Cutting | | BN | Bunnell | GS | Greishaber Spatula | STP | Straight Taper Point | | BP | Blunt Point | J | Conjunctive | TE | Three-Eighths | | BV | Blood Vessel | KS | Keith Straight | TF | Tetralogy of Fallot | | BVH | Blood Vessel Half | LH | Large Half | TG | Transverse Ground | | C | Cardiovascular | LR | Larger Reversion | TGW | Transverse Ground Wide | | CC | Calcified Coronary | LS | Large Stermotomy | TN | Trocar Needle | | CCS | Conventional Cutting Stermotomy | M | Muscle | TP | Taper Percostal / Point | | CE | Cutting Edge | MF | Modified Fergusan | TPB | Taper Percostal / Point Blunt | | CFS | Conventional for Skin | MH | Medium Half (circle) | TS | Tendon Straight | | CIF | Cutting Intraocular Fixation | MA | Mayo | TQ | Twisty Q | | CP | Cutting Point | MOB | Mayo Blunt | UCL | 3/8 Circle Collateral Ligament | | CPS | Conventional Plastic Surgery | OPS | Ocular Plastic Surgery | UR | Urology | | CPX | Cutting Point Extra Large | OS | Orthopaedic Surgery | URB | Urology Blunt | | CS | Corneal-Scleral | P | Plastic | V | TAPER CUT Surgical Needle | | CSB | Corneal-Scleral Bi-Curve | **PS** | **Plastic Surgery** | VAS | Vas Deferens | | CSC | Corneal-Scleral Compound Curve | X or P | Esodontal (dental) | | CT | Circle Taper | RD | Retinal Detachment | XLH | Extra Large Half (circle) | | CTB | Circle Taper Blunt | RH | Round Half (circle) | XXLH | Extra Extra Large Half (circle) | | CTX | Circle Taper Extra Large | RV | Retinal-Vitreous | | | | CTXB | Circle Taper Extra Large Blunt | S | Spatula | | | | CV | Cardiovascular | SC | Straight Cutting | | | | DC | Dura Closure | SFS | Spatulated for Skin | | | | DP | Double Point | SH | Small Half (circle) | | | | EN | Endoscopic Needle | SIF | Skin Intraocular Fixation | | | | EST | Eyed Straight Taper | SKS | Stermotomy Keith Straight | | | | FT | For Tonsil | SM | Spatulated Module | | | | FS | For Skin | ST | Straight Taper | | | | FSL | For Skin Large | | | | | Ethicon needle type image from: https://x.com/rbarbosa91/status/1629860890622173191  #### Atraumatic Needle Codes and Meanings | Code | Meaning | Code | Meaning | | :--- | :--- | :--- | :--- | | **PS** | **Plastic Surgery** | **X or P** | **Esodontal (dental)** | | BB | Blue Baby | FSLX | For Skin Extra Large | | BF | Intraocular Fixation | G | Greishaber | | BN | Bunnell | GS | Greishaber Spatula | | BP | Blunt Point | J | Conjunctive | | BV | Blood Vessel | KS | Keith Straight | | C | Cardiovascular | LH | Large Half | | CC | Calcified Coronary | LS | Large Stermotomy | | CE | Cutting Edge | M | Muscle | | CFS | Conventional for Skin | MH | Medium Half (circle) | | CP | Cutting Point | OS | Orthopaedic Surgery | | CS | Corneal-Scleral | P | Plastic | | CT | Circle Taper | RD | Retinal Detachment | | CV | Cardiovascular | S | Spatula | | DC | Dura Closure | SC | Straight Cutting | | FS | For Skin | SH | Small Half (circle) | | FSL | For Skin Large | V | TAPER CUT Surgical Needle | The image contains a table titled "NEEDLE // ATRAUMATIC" that lists various needle codes and their corresponding meanings. The table is organized into three columns, each with a "CODE" and "MEANING" header, detailing abbreviations for different types of surgical needles used in various medical procedures. The table includes codes such as BB (Blue Baby), BF (Intraocular Fixation), and PS (Plastic Surgery), among others, providing a comprehensive guide for identifying needle types based on their specific applications. # **NEEDLE // ATRAUMATIC**      #### Atraumatic Needle Overview This section covers the design and application of atraumatic needles used in surgical procedures. A diagram illustrating the components of a surgical needle, including labels for needle point, needle radius, needle diameter, needle body, needle length, and needle chord length, with a curved needle shown in cross-section. A diagram showing different needle curvature types, labeled as 1/4 circle, 1/2 circle, and 3/8 circle, each represented by a curved line segment. A diagram displaying various needle curvature types, including 3/8 circle, 5/8 circle, 1/2 curve, and straight, each depicted as a curved or straight line segment with corresponding labels. A diagram comparing different needle tip designs, including conventional cutting, reverse cutting, taper, and blunt, with illustrations of the needle body and point shapes. A figure showing a compound circle needle, with a curved needle depicted alongside a crosshair, illustrating the concept of a compound circle needle design. THE SUTURE PACKET | | | | |---|---|---| | **3-0** (2 Ph. Eur.) | ETHICON® Coated | REF **W9923** | | **PS-2** 19mm 3/8c REVERSE CUTTING $\nabla$ | **VICRYL RAPIDE**™ Polyglactin 910 undyed braided absorbable suture incoloro trenzado sutura absorbible incolore tressé suture résorbable sutura absorvível incolor entrançada | **000323** | | **ETHALLOY**™ **75cm** | ETHICON, LLC **STERILE** $\text{R}$ $\text{2}$ $\text{A}$ $\text{CE}$ **2797** $\text{XZW9923.3}$ | **LOT AU8873** $\text{2028-08}$ |  #### Suture Packet Data - **Size:** 3-0 (2 Ph. Eur.) - **Material:** VICRYL RAPIDE™ (Polyglactin 910) - **Needle:** PS-2, 19mm 3/8c Reverse Cutting - **Length:** 75cm - **Reference:** W9923 - **Lot:** AU8873 - **Expiry:** 2028-08 The image displays a suture packet labeled "THE SUTURE PACKET" with detailed product information. It includes specifications such as suture size (3-0, PS-2), material (VICRYL RAPIDE™ Polyglactin 910), and features like reverse cutting needle. The packet also shows the brand ETHICON®, reference number W9923, and additional details like sterile status, lot number AU8873, and expiration date 2028-08. A red box highlights the ETHALLOY™ 75cm label. LENGTH 30” or 75cm 18” or 45cm What are you doing?  #### Standard Suture Lengths Commonly available lengths for surgical procedures include: - 30” or 75cm - 18” or 45cm Selection depends on the specific clinical application and surgical site requirements. A table with the header 'LENGTH' displaying two rows of data: '30” or 75cm' and '18” or 45cm', likely indicating dimensions. # **Common Suture Knots in Dentistry** Simple interrupted  #### Simple Interrupted Suture The simple interrupted suture is a fundamental technique used in dental surgery for wound closure. A close-up photo showing a dental model with teeth and gum tissue, illustrating a simple interrupted suture knot with a black thread passing through the tissue. The image is labeled 'Simple interrupted' and demonstrates a common suture technique in dentistry.  A close-up photo showing a dental model with three teeth embedded in pink gum material, illustrating a suture knot technique with black thread crossing between the teeth. The image is labeled as "Figure of 8" and relates to common suture knots in dentistry. Common Suture Knots in Dentistry Horizontal mattress   #### Horizontal Mattress Suture This technique is utilized for eversion of wound edges and providing significant tension relief across the surgical site. A close-up photo showing a dental model with a horizontal mattress suture technique applied to a tooth, illustrating the placement of sutures through the gingival tissue and around the tooth. Another close-up photo of a dental model demonstrating a horizontal mattress suture, highlighting the suture thread passing through the tissue and securing the flap, with adjacent teeth visible. # Common Suture Knots in Dentistry Vertical mattress   #### Vertical Mattress Suture The vertical mattress suture is effective for deep and superficial closure, ensuring excellent edge adaptation and eversion. A close-up photo of a dental model showing a vertical mattress suture technique, with black sutures passing through the pink gum tissue and around the white artificial teeth. Another close-up photo of a dental model demonstrating a suture technique, with a black suture thread being manipulated around the white artificial teeth and pink gum tissue. # **Common Suture Knots in Dentistry** **Continuous**  #### Continuous Suture A continuous (running) suture technique allows for rapid closure of long incisions using a single strand of suture material. A close-up photo showing a continuous suture knot in dentistry, with black sutures forming a series of loops on a blue surgical drape. The knot is tied at the top, with the suture line extending downward, illustrating a common technique used in dental procedures.  A triptych of images showing a step-by-step process of threading a needle and sewing a material, likely demonstrating a technique for suturing or stitching. The sequence shows the needle being inserted, pulled through, and the thread being tied, all on a blue surface.   Close-up photo showing a black pen-like tool with a stitched pattern on its surface, alongside a black thread being manipulated against a blue background, illustrating a sewing or crafting process. Close-up photo depicting a black thread being threaded through a series of stitches on a blue surface, with a metallic tool visible, demonstrating a step in a sewing or knot-tying technique. # **Common Suture Knots in Dentistry** **Continuous Locking**   #### Continuous Locking Suture This variation of the continuous suture provides additional stability by locking each pass, preventing the "accordion effect" and maintaining tension along the suture line. A close-up photo showing a continuous locking suture pattern on a blue surface, with black thread forming a series of loops and knots along a line, illustrating the technique described in the text. A detailed photo capturing the process of creating a suture knot, with a surgical instrument holding the thread and needle, demonstrating the knot-tying technique in a dental context. # **Troubleshooting - Suturing** * **Blunting of the needle** <img src="image_description.jpg" alt="Two close-up images of a surgical needle tip against a black background, illustrating the concept of needle blunting as a suturing troubleshooting issue.">  #### Needle Integrity Issues - **Blunting of the needle**: Loss of the sharp point, making penetration through tough tissue difficult and increasing trauma. Two close-up photographs of a surgical needle tip against a black background, illustrating the concept of needle blunting as a suturing troubleshooting issue. The images show the needle's tip in detail, highlighting wear and damage. # Troubleshooting - Suturing * Blunting of the needle * Straightening of the needle <img src="image_description"> A slide with the title "Troubleshooting - Suturing" and a bulleted list of two issues: "Blunting of the needle" and "Straightening of the needle." To the right, there are two images showing curved surgical needles against a black background. </img>  #### Needle Deformation and Wear - Blunting of the needle - Straightening of the needle: Occurs when excessive force is applied or when the needle is not appropriate for the tissue density. Two curved surgical needles are shown against a black background, illustrating examples of needle blunting and straightening as discussed in the accompanying text on troubleshooting suturing. # Troubleshooting - Suturing * Blunting of the needle * Straightening of the needle * High friction - thread and needle driver * Usually dried/drying blood #### Mechanical Obstructions - Blunting of the needle - Straightening of the needle - High friction between the thread and needle driver: This is usually caused by dried or drying blood on the instruments or suture material. # **Troubleshooting - Suturing** * Blunting of the needle * Straightening of the needle * High friction - thread and needle driver * Loose knots #### Knot Security and Handling - Blunting of the needle - Straightening of the needle - High friction between the thread and needle driver - Loose knots: Failure to maintain proper tension or incorrect knot-tying technique leading to potential wound dehiscence. # **Troubleshooting - Suturing** * **Pulling through** * Troubleshooting - Suturing * Blunting of the needle * Straightening of the needle * High friction - thread and needle driver * Loose knots * **Pulling through** #### Tissue and Structural Failures - Blunting of the needle - Straightening of the needle - High friction between the thread and needle driver - Loose knots - **Pulling through**: The suture material cuts through the tissue (cheese-wiring) due to excessive tension or fragile tissue quality. **COMPLICATION** **MANAGEMENT** This section covers the identification and management of common surgical complications encountered during and after dental extractions. **BLEEDING** * Keep calm * Assess – flow rate – minor/major * Ensure suctioning – blood is a gastric irritant * Think about cause – extraction socket ooze? minor artery during bone removal? * Pressure – how it is applied is dependant on the cause * If extracted * Can you see where it is coming from? * Consider patient biting on some thick gauze * Consider firm digital pressure or pressure with an instrument * Think packing (haemostatic agent) and suturing * Bone wax? #### Immediate Assessment and Management - Keep calm. - Assess flow rate (minor vs. major). - Ensure suctioning; blood is a gastric irritant. - Identify the cause: extraction socket ooze or minor artery during bone removal? #### Pressure Application Pressure application depends on the specific cause. If the bleeding is from an extraction site: - Visualize the source of bleeding. - Have the patient bite on thick gauze. - Apply firm digital pressure or pressure with an instrument. - Consider packing with a haemostatic agent and suturing. - Consider the use of bone wax. # **HAEMOSTATIC AGENTS** * Spongostan * Off white sponge * Porcine gelatin sponge matrix for scaffolding to structure the clot * Used at OHCWA  #### Spongostan - Off-white sponge. - Porcine gelatin sponge matrix. - Provides scaffolding to structure the clot. - Used at OHCWA. A product photo showing a box of Spongostan Dental, an off-white sponge hemostatic agent. The box contains 24 sponges, each measuring 1cm x 1cm x 1cm, and is labeled as a porcine gelatin sponge matrix used for scaffolding to structure the clot. The product is used at OHCWA. **HAEMOSTATIC AGENTS** * Gelatamp * Several varieties but the version containing colloidal silver is generally most common * Gelatine sponge provides scaffold * Colloidal silver provides broad antibacterial effect  #### Gelatamp - Available in several varieties; the version containing colloidal silver is most common. - Gelatine sponge provides a scaffold. - Colloidal silver provides a broad antibacterial effect. A photo of several brown, porous gelatin sponge cubes, which are described as providing a scaffold for haemostasis. The image is positioned next to text detailing the properties of Gelatamp, a haemostatic agent containing colloidal silver. # **HAEMOSTATIC AGENTS** * **Surgicel** * Oxidised regenerated cellulose * Plant based * Matrix for platelet adhesion and aggregation  #### Surgicel - Oxidised regenerated cellulose. - Plant-based material. - Acts as a matrix for platelet adhesion and aggregation. A product image showing a box of Surgicel, an absorbable hemostat made from oxidised regenerated cellulose. The image includes a close-up of the white, mesh-like material and the packaging, which indicates it is plant-based and used as a matrix for platelet adhesion and aggregation. # HAEMOSTATIC AGENTS * Tranexamic acid * Anti-fibrinolytic * In dental uses: * Tablet is **NOT TAKEN ORALLY** * Tablet is crushed and dispersed into 10mL water (5% solution) * Gauze soaked in solution and pressure applied to wound OR * Gentle rinses 2mins QDS 2-5 days post operatively. Do not spit out, gently dribble out <img src="image_description.png" alt="Box of Tranexamic Acid 500mg Tablets by MANX Healthcare, containing 60 Tablets">  #### Tranexamic Acid - Anti-fibrinolytic agent. - **Dental Administration Guidelines:** - Tablet is **NOT TAKEN ORALLY**. - Tablet is crushed and dispersed into 10mL water (5% solution). - Use: Gauze soaked in solution with pressure applied to the wound OR gentle rinses for 2 minutes QDS for 2-5 days post-operatively. - Instruction: Do not spit out; gently dribble out. A photograph of a box of Tranexamic Acid 500mg Tablets by MANX Healthcare, containing 60 tablets. The box is shown in the context of a presentation slide about haemostatic agents, specifically detailing its use in dental applications. | HAEMOSTATIC AGENTS | |---| | • Tea bag | |      • Steeped in boiling water for 3-5mins | |      • Allowed to cool | |      • Patient bites on the bag, applying pressure to the wound | |      • Natural tannins help vasocontstriction | |      • Can be good verbal advice if patients call for advice | <img src="image.png" alt="Image of a Tetley tea box">  #### Tea Bags (Home Remedy) - Preparation: Steeped in boiling water for 3-5 minutes and allowed to cool. - Application: Patient bites on the bag, applying pressure to the wound. - Mechanism: Natural tannins help vasoconstriction. - Utility: Good verbal advice for patients calling from home. A product image of a Tetley tea box, featuring the brand's blue packaging with the text 'Tetley Since 1837' and 'Original Delicious & Refreshing'. The box also displays an image of a cup of tea and indicates it contains 240 tea bags. This photo is used to illustrate the use of tea bags as a haemostatic agent, as described in the adjacent text. # **SURGICAL EMPHYSEMA** * Caused by the extrusion of air into tissues. * **DO NOT** use front exhausting handpiece if mucoperiosteal flap raised. * **DO NOT** use triple to dry surface if mucoperiosteal flap raised. * Usually self limiting as the air will be reabsorbed by tissues. * Consider whether antibiotics are of benefit Gamble, E and P Chami, ‘Dental Surgical Emphysema Following Bridge Sectioning: Dental Complications’ (2024) 237(11) *British dental journal* 859  - Caused by the extrusion of air into tissues. - **Prevention:** - **DO NOT** use front exhausting handpieces if a mucoperiosteal flap is raised. - **DO NOT** use a triple syringe to dry the surface if a mucoperiosteal flap is raised. - **Management:** - Usually self-limiting as air is reabsorbed by tissues. - Consider the benefit of antibiotics. A close-up photograph of a patient's face showing surgical emphysema, characterized by subcutaneous air accumulation in the facial tissues. The image illustrates the clinical presentation of the condition discussed in the surrounding text, which includes precautions for dental procedures and management considerations. RETAINED ROOT • Consider size and pathology present • Size – generally accepted if under 3mm OK but no definitive evidence\* • Pathology – no periapical lesion pre-operatively • If attempting retrieval: • Consider use of a root pick • Consider proximity of anatomy e.g. maxillary sinus and risk of displacement • Consider bone removal to create space for the instrument Nayyar, J et al, ‘Fractured Root Tips during Dental Extractions and Retained Root Fragments. A Clinical Dilemma?’ (2015) 218(5) British Dental Journal 285 #### Assessment Criteria - Consider size and pathology present. - Size: Generally accepted as okay if under 3mm (though no definitive evidence exists). - Pathology: Ensure no periapical lesion was present pre-operatively. #### Retrieval Considerations - Consider use of a root pick. - Evaluate proximity of anatomy (e.g., maxillary sinus) and risk of displacement. - Consider bone removal to create space for instruments. # LOST ROOT/TOOTH * Stop. Breathe. Think about where this could have gone? * If posterior lower tooth – is this in the lingual? Is this something you can see with gentle pressure? * If upper tooth – has this gone into the sinus - fully/partially? * If easily seen/visible – **GENTLY** attempt retrieval * If not easily seen and conceding retrieval is not possible: * Priority is to the patient – stabilise (e.g suture) and explain * Ask a senior colleague/principal dentist for advice * Call local OMFS rooms for advice or consider calling local OMS department on call registrar for advice #### Immediate Actions - Stop and assess the likely location of the fragment. - **Posterior lower tooth:** Check the lingual aspect; see if it is visible with gentle pressure. - **Upper tooth:** Determine if it has entered the sinus (fully or partially). #### Retrieval and Referral - If easily visible: **GENTLY** attempt retrieval. - If not easily seen or retrieval is not possible: - Stabilise the patient (e.g., suture) and explain the situation. - Seek advice from a senior colleague or principal dentist. - Contact local OMFS rooms or the local OMS department on-call registrar for advice. ## WRONG TOOTH EXTRACTION * **DO NOT DO.** * Correct site surgery checklist * Confirm with nurse * Most likely to occur with orthodontic extractions e.g. healthy teeth with no obvious caries * Explain to patient/parents/guardian * If orthodontic extractions, speak to orthodontist – **DO NOT** remove correct tooth. * *May* be able to modify plan. #### Prevention - **DO NOT DO.** - Utilize a correct site surgery checklist. - Confirm the site with the dental nurse. #### Management of Errors - Most likely to occur with orthodontic extractions (healthy teeth with no obvious caries). - Explain the error to the patient, parents, or guardian. - If orthodontic extractions are involved, speak to the orthodontist immediately. - **DO NOT** remove the correct tooth until the plan is reviewed; the orthodontist may be able to modify the treatment plan. # **ORO ANTRAL COMMUNICATION + FISTULA** * Oro-antral communication is defined as an unnatural communication between the maxillary sinus and the oral cavity. * Think about the layers at the base of the high risk socket: * Bone * Sinus lining (Schneiderian membrane) * Both have to be breached for it to be a communication * It is possible to remove the bony base but not perforate the sinus membrane * Must be over 2mm in size to require formal closure * Oro-antral fistula is a more chronic form where the epithelium infiltrates and lines the communication. #### Definitions - **Oro-antral communication (OAC):** An unnatural communication between the maxillary sinus and the oral cavity. - **Oro-antral fistula (OAF):** A chronic form where epithelium infiltrates and lines the communication. #### Anatomical Considerations - Layers at the base of high-risk sockets include bone and the sinus lining (Schneiderian membrane). - Both must be breached for a communication to exist. - It is possible to remove the bony base without perforating the membrane. - Formal closure is required if the communication is over 2mm. **ORO ANTRAL COMMUNICATION +** **FISTULA** * **Diagnosing:** * Pre-operative assessment * Post extraction assessment of the tooth * Post extraction assessment of the socket * Valsalva? * Bubbling of blood in the socket * If large will be very obvious <img src="image.png"> Parvini, P., Obreja, K., Begic, A. et al. Decision-making in closure of oroantral communication and fistula. Int J Implant Dent 5, 13 (2019)  #### Diagnosis - Pre-operative assessment. - Post-extraction assessment of the tooth and socket. - Valsalva maneuver. - Bubbling of blood in the socket. - Large communications are usually obvious. A clinical photograph showing an oroantral communication, with a visible opening in the alveolar ridge adjacent to a tooth socket, illustrating a case of a fistula. The image is used to demonstrate diagnostic signs such as bubbling of blood in the socket, as mentioned in the surrounding text. # **ORO ANTRAL COMMUNICATION +** # **FISTULA** * **Management:** * If small (<2mm) * Haemostatic agent * Suture over the socket * Sinus precautions (no nose-blowing, no drinking through a straw and no closed-mouth sneezing) for 2 weeks * Rx nasal spray – oxymetazoline (500mcg/mL) intranasally 1 or 2 sprays TDS 5/7 * Review after 2 weeks to ensure closure * If large (>3mm) * Depending on size, maybe haemostatic agent and suture. If very large consider nothing (assuming haemostasis achieved) * Refer to experienced colleague or OMF Surgeon – consider calling rooms and asking what they want you to do. E.g. send immediately, send next day and how to manage the wound  #### Management Protocols **Small Communications (<2mm):** - Use a haemostatic agent. - Suture over the socket. - **Sinus precautions for 2 weeks:** No nose-blowing, no drinking through a straw, and no closed-mouth sneezing. - Prescription: Oxymetazoline nasal spray (500mcg/mL), 1-2 sprays TDS for 5 days. - Review after 2 weeks to ensure closure. **Large Communications (>3mm):** - Depending on size, use haemostatic agent and suture. If very large, consider leaving open once haemostasis is achieved. - Refer to an experienced colleague or OMF Surgeon. - Contact specialist rooms for specific management/referral instructions. The image displays a title section with the text 'ORO ANTRAL COMMUNICATION + FISTULA' in bold, capitalized letters, enclosed within a rectangular border. This appears to be a heading for a medical or dental presentation slide, introducing the topic of oro-antral communication and fistula management. # **ORO ANTRAL COMMUNICATION + FISTULA** * Options to close: * Buccal advancement  #### Surgical Closure Options - Buccal advancement flap. A diagram illustrating an oro-antral communication and fistula, showing a buccal advancement flap procedure. It depicts a bony defect in the maxilla with a transverse releasing incision, highlighting the surgical approach to close the communication. **ORO ANTRAL COMMUNICATION + FISTULA** • Options to close: • **Buccal advancement** • **Palatal rotational** <br> <img src="image_description.png" alt="Diagram showing three steps (A, B, C) of a Palatal rotation flap for closing a fistula. A shows a fistulous opening, B shows a buccal advancement flap being outlined, and C shows a palatal rotation flap covering the defect."> Figure 7. Palatal rotation flap. A. Fistula with  #### Surgical Closure Options (Continued) - **Buccal advancement flap** - **Palatal rotational flap** A three-step diagram illustrating the palatal rotation flap procedure for closing an oro-antral fistula. Panel A shows a fistulous opening in the maxillary arch, Panel B depicts a buccal advancement flap, and Panel C demonstrates the palatal rotation flap covering the defect. The diagram is labeled as Figure 7 and corresponds to the text discussing closure options. **ORO ANTRAL COMMUNICATION + FISTULA** * Options to close: * Buccal advancement * Palatal rotational * **Buccal fat pad** Bravo Cordero, Gustavo, Simona Minzer Ferrer and Lara Fernández, ‘Odontogenic Sinusitis, Oro-Antral Fistula and Surgical Repair by Bichat’s Fat Pad: Literature Review’ (2016) 67(2)  #### Surgical Closure Options (Continued) - Buccal advancement - Palatal rotational - **Buccal fat pad (Bichat’s fat pad)** A six-step diagram illustrating the surgical repair of an oro-antral fistula using the buccal fat pad. The sequence shows the placement of a buccal advancement flap, the preparation of the buccal fat pad, its insertion into the fistula site, and the final closure, highlighting the use of Bichat's fat pad as a graft material. **FRACTURED TUBEROSITY** * **High risk teeth:** * Divergent roots, bulbous roots, ankylosed roots * Lone standing molar * Maxillary 3rd molars * Older patients (but not always) * Excessive forces * Unsupported extraction technique O’Sullivan, Laura, ‘Management of the Fractured Maxillary Tuberosity’ [2024] Journal of the Irish Dental Association   #### High Risk Factors - Divergent, bulbous, or ankylosed roots. - Lone standing molars. - Maxillary 3rd molars. - Older patients. - Excessive forces during extraction. - Unsupported extraction technique. A clinical photograph showing a fractured maxillary tuberosity during a dental procedure, with visible bone fragments and surrounding soft tissue. The image is positioned next to a list of high-risk teeth for this complication. A close-up photograph of a tooth fragment held by dental forceps, illustrating a fractured molar that may have contributed to the tuberosity fracture. This image is located below the main clinical photo. $\text{FRACTURED TUBEROSITY}$ * Signs you have fractured the tuberosity: * Loud cracking noise * Palatal mucosal tear * Mobile alveolar segment * Excessive bleeding O’Sullivan, Laura, ‘Management of the Fractured Maxillary Tuberosity’ [2024] Journal of the Irish Dental Association #### Clinical Signs - Loud cracking noise. - Palatal mucosal tear. - Mobile alveolar segment. - Excessive bleeding. <div style="text-align: center; border: 2px solid black; padding: 10px;"> <h1>FRACTURED TUBEROSITY</h1> </div> <ul> <li>Management of the fractured tuberosity: <ul> <li>If small – may just be considered an incidental finding</li> <li>Dissection of the segment from the mucosa to prevent further soft tissue trauma</li> <li>Tooth is still removed and then the mobile segment stabilised or removed</li> <li>Splinting <ul> <li>Extraction is abandoned and fracture stabilised WITH the tooth</li> <li>Composite wire splint</li> <li>Essix retainer</li> </ul> </li> </ul> </li> </ul> <p style="text-align: center;">O’Sullivan, Laura, ‘Management of the Fractured Maxillary Tuberosity’ [2024] <em>Journal of the Irish Dental Association</em></p> #### Management Strategies - **Small fractures:** May be considered an incidental finding. - **Segment Dissection:** Dissect the segment from the mucosa to prevent further soft tissue trauma. - **Removal:** The tooth is removed, and the mobile segment is either stabilised or removed. - **Splinting:** - Abandon the extraction. - Stabilise the fracture with the tooth in situ. - Methods: Composite wire splint or Essix retainer. <img src="image1.png" alt="Panoramic radiograph of the lower jaw showing restored teeth and an extracted tooth specimen."> <img src="image2.png" alt="Extracted tooth specimen with a pink, possibly restorative or healing material attached to the crown.">   Visual documentation of clinical cases involving fractured segments and extracted specimens. Panoramic radiograph of the lower jaw showing restored teeth and an extracted tooth specimen, with visible dental implants and surrounding bone structure. Extracted tooth specimen with a pink, possibly restorative or healing material attached to the crown, placed on a white surface. MRONJ/ORN - To come next week  #### MRONJ/ORN - Content to follow in subsequent sessions. The image displays a rectangular box with a white background and a black border, containing the text "MRONJ/ORN" in bold, black, uppercase letters centered within the box. The box is positioned against a light gray background, and there are no other visible elements or details within the figure. <div style="text-align: center; border: 1px solid black; padding: 10px;"> **ALVEOLAR OSTEITIS / DRY SOCKET** </div> * Failure or premature loss of the blood clot * Thought to involve increased fibrinolysis and impaired scaffold formation * Increased likelihood of dry socket: * Smoking * Oral contraceptive use * Traumatic extraction (heavy forces) #### Pathophysiology - Failure or premature loss of the blood clot. - Involves increased fibrinolysis and impaired scaffold formation. #### Risk Factors - Smoking. - Oral contraceptive use. - Traumatic extraction (heavy forces).  [Page intentionally left blank or contains no unique text content] The image shows two close-up photographs of dental procedures, likely related to alveolar osteitis. The left photo displays a tooth extraction site with visible bone and surrounding tissue, while the right photo shows a dental implant or restoration in place within the socket, with adjacent teeth and gum tissue. **ALVEOLAR OSTEITIS / DRY SOCKET** <table> <tr> <td><u>**Feature**</u></td> <td><u>**Normal Healing**</u></td> <td><u>**Dry Socket (Alveolar Osteitis)**</u></td> </tr> <tr> <td>**Clot formation**</td> <td>Stable and maintained</td> <td>Lost or disintegrated</td> </tr> <tr> <td>**Pain**</td> <td>Mild early discomfort</td> <td>Severe throbbing pain</td> </tr> <tr> <td>**Tissue appearance**</td> <td>Gradual granulation then bone fill</td> <td>Exposed bone, no clot</td> </tr> <tr> <td>**Healing outcome**</td> <td>Progressive bone maturation</td> <td>Delayed healing</td> </tr> </table>   #### Clinical Comparison | Feature | Normal Healing | Dry Socket (Alveolar Osteitis) | | :--- | :--- | :--- | | **Clot formation** | Stable and maintained | Lost or disintegrated | | **Pain** | Mild early discomfort | Severe throbbing pain | | **Tissue appearance** | Gradual granulation then bone fill | Exposed bone, no clot | | **Healing outcome** | Progressive bone maturation | Delayed healing | The figure is a title box with the text 'ALVEOLAR OSTEITIS / DRY SOCKET' in bold, centered at the top of the page. It serves as the main heading for the content below, which compares normal healing to dry socket conditions. The table compares features of normal healing versus dry socket (alveolar osteitis) across four categories: clot formation, pain, tissue appearance, and healing outcome. It highlights that in normal healing, clot formation is stable, pain is mild, tissue shows gradual granulation then bone fill, and healing results in progressive bone maturation. In contrast, dry socket involves lost or disintegrated clots, severe throbbing pain, exposed bone with no clot, and delayed healing. **ALVEOLAR OSTEITIS / DRY SOCKET** * Irrigation with saline (caution with CHX) * Placement of an obtundent dressing – Alveogyl * Should remain in place for 24-72 hours and then come away. * It is not resorbable – if suturing in place it must be removed prior to soft tissue closure. * Wound care / smoking cessation * Antibiotics not indicated unless underlying spreading infection #### Treatment and Care - **Irrigation:** Use saline (exercise caution with CHX). - **Obtundent Dressing (Alveogyl):** - Should remain in place for 24-72 hours. - Note: It is not resorbable. If suturing, it must be removed prior to soft tissue closure. - **Post-operative Care:** Wound care and smoking cessation. - **Antibiotics:** Not indicated unless there is evidence of underlying spreading infection. **ALVOGYL OR ALVEOGYL?** | **Table 1 Alvogy**l **and Alveogyl Ingredients** | | |---|---| | **Alvogyll** | **Alveogyl** | | Butamben* | Eugenol* | | Iodoform* | Penghawar Djambi | | Eugenol* | Sodium lauryl sulphate | | Penghawar Djambi | Calcium carbonate | | Sodium lauryl sulphate | Mint flavour | | Calcium carbonate | Excipients | | Spearmint oil | | | Olive oil | | | Purified Water | | | **\*active ingredients** | | Kalsi, **HK**, **R Major** and **H Jawad**, ‘**Alvogy**l **or Alveogyl**?’ (**2020**) **229**(4) *British dental journal* **211**  #### Comparison of Alvogyl and Alveogyl Ingredients | Alvogyll | Alveogyl | | :--- | :--- | | Butamben* | Eugenol* | | Iodoform* | Penghawar Djambi | | Eugenol* | Sodium lauryl sulphate | | Penghawar Djambi | Calcium carbonate | | Sodium lauryl sulphate | Mint flavour | | Calcium carbonate | Excipients | | Spearmint oil | | | Olive oil | | | Purified Water | | \*Denotes active ingredients. Table 1 compares the ingredients of Alvogyll and Alveogyl, listing active ingredients such as butamben and eugenol, and other components like iodoform and sodium lauryl sulphate. The table highlights differences in formulation, with Alvogyll containing spearmint oil and olive oil, while Alveogyl includes mint flavour and excipients. ACTIVITY 1 Raising a full thickness mucoperiosteal flap This activity focuses on the surgical technique for raising a full thickness mucoperiosteal flap. # ACTIVITY 1 * In each group: * Student 1 is to raise a **full thickness envelope** flap across 12-22 * Students 2 and 3 are going to place a sulcular incision around the 7 and then move the blade along the crest, distally. * Using the periosteal elevator, retract the tissue back #### Group Procedures and Techniques - **Student 1:** Raise a full thickness envelope flap across the 12-22 region. - **Students 2 and 3:** - Place a sulcular incision around the 7. - Extend the incision by moving the blade along the crest in a distal direction. - Use the periosteal elevator to retract the tissue.   a dental model showing the upper jaw with white teeth and pink gums, with a red line indicating the gingival margin. a dental model of the lower jaw with white teeth and pink gums, showing a missing tooth and a red line outlining the gumline. ACTIVITY 2 Continuous suturing This activity involves practicing the technique of continuous suturing. ## ACTIVITY 2 * Remove all anterior teeth 5-5 * The 3, 4, 5 were extracted last time so should be easily removed * This will create a situation very similar to an anterior clearance * Close the wound using continuous suturing * Each person will place a continuous suture * Simple interrupted * 3 passes with the suture * Lock it off #### Preparation and Extraction - Remove all anterior teeth from 5 to 5. - Note that teeth 3, 4, and 5 were extracted previously and should be easily removed. - This procedure simulates a clinical situation similar to an anterior clearance. #### Suturing Technique Close the wound using continuous suturing. Each participant will perform the following steps: 1. Start with a simple interrupted suture. 2. Perform three passes with the suture material. 3. Lock the suture off to secure the closure.    A series of three sequential photos showing the process of suturing a material with a needle and thread. The first image shows the needle entering the material, the second shows the needle being pulled through, and the third shows the completed stitch with the thread tied off. A close-up photo illustrating the intermediate stage of a surgical suture technique. The image shows the needle and thread passing through a material, with a surgical instrument visible, indicating the process of creating a secure stitch. A photo depicting the final stage of a suturing procedure. The image shows a completed series of stitches with a loop of thread, demonstrating the closure of a wound or material with a secure knot.   Close-up photo showing a black thread being threaded through a blue material with a tool, demonstrating a stitching process. The image captures the thread forming a knot and the completed stitches on the material. Close-up photo of a black cylindrical tool with a thread wrapped around it, positioned above a blue surface with several black stitches. The image shows the thread being pulled through the material, illustrating a sewing technique. [^1]: Original PDF page 1: [[W1 Surgical Extraction Workshop.pdf#page=1|W1 Surgical Extraction Workshop, p.1]] [^2]: Original PDF page 2: [[W1 Surgical Extraction Workshop.pdf#page=2|W1 Surgical Extraction Workshop, p.2]] [^3]: Original PDF page 3: [[W1 Surgical Extraction Workshop.pdf#page=3|W1 Surgical Extraction Workshop, p.3]] [^4]: Original PDF page 4: [[W1 Surgical Extraction Workshop.pdf#page=4|W1 Surgical Extraction Workshop, p.4]] [^5]: Original PDF page 5: [[W1 Surgical Extraction Workshop.pdf#page=5|W1 Surgical Extraction Workshop, p.5]] [^6]: Original PDF page 6: [[W1 Surgical Extraction Workshop.pdf#page=6|W1 Surgical Extraction Workshop, p.6]] [^7]: Original PDF page 7: [[W1 Surgical Extraction Workshop.pdf#page=7|W1 Surgical Extraction Workshop, p.7]] [^8]: Original PDF page 8: [[W1 Surgical Extraction Workshop.pdf#page=8|W1 Surgical Extraction Workshop, p.8]] [^9]: Original PDF page 9: [[W1 Surgical Extraction Workshop.pdf#page=9|W1 Surgical Extraction Workshop, p.9]] [^10]: Original PDF page 10: [[W1 Surgical Extraction Workshop.pdf#page=10|W1 Surgical Extraction Workshop, p.10]] [^11]: Original PDF page 11: [[W1 Surgical Extraction Workshop.pdf#page=11|W1 Surgical Extraction Workshop, p.11]] [^12]: Original PDF page 12: [[W1 Surgical Extraction Workshop.pdf#page=12|W1 Surgical Extraction Workshop, p.12]] [^13]: Original PDF page 13: [[W1 Surgical Extraction Workshop.pdf#page=13|W1 Surgical Extraction Workshop, p.13]] [^14]: Original PDF page 14: [[W1 Surgical Extraction Workshop.pdf#page=14|W1 Surgical Extraction Workshop, p.14]] [^15]: Original PDF page 15: [[W1 Surgical Extraction Workshop.pdf#page=15|W1 Surgical Extraction Workshop, p.15]] [^16]: Original PDF page 16: [[W1 Surgical Extraction Workshop.pdf#page=16|W1 Surgical Extraction Workshop, p.16]] [^17]: Original PDF page 17: [[W1 Surgical Extraction Workshop.pdf#page=17|W1 Surgical Extraction Workshop, p.17]] [^18]: Original PDF page 18: [[W1 Surgical Extraction Workshop.pdf#page=18|W1 Surgical Extraction Workshop, p.18]] [^19]: Original PDF page 19: [[W1 Surgical Extraction Workshop.pdf#page=19|W1 Surgical Extraction Workshop, p.19]] [^20]: Original PDF page 20: [[W1 Surgical Extraction Workshop.pdf#page=20|W1 Surgical Extraction Workshop, p.20]] [^21]: Original PDF page 21: [[W1 Surgical Extraction Workshop.pdf#page=21|W1 Surgical Extraction Workshop, p.21]] [^22]: Original PDF page 22: [[W1 Surgical Extraction Workshop.pdf#page=22|W1 Surgical Extraction Workshop, p.22]] [^23]: Original PDF page 23: [[W1 Surgical Extraction Workshop.pdf#page=23|W1 Surgical Extraction Workshop, p.23]] [^24]: Original PDF page 24: [[W1 Surgical Extraction Workshop.pdf#page=24|W1 Surgical Extraction Workshop, p.24]] [^25]: Original PDF page 25: [[W1 Surgical Extraction Workshop.pdf#page=25|W1 Surgical Extraction Workshop, p.25]] [^26]: Original PDF page 26: [[W1 Surgical Extraction Workshop.pdf#page=26|W1 Surgical Extraction Workshop, p.26]] [^27]: Original PDF page 27: [[W1 Surgical Extraction Workshop.pdf#page=27|W1 Surgical Extraction Workshop, p.27]] [^28]: Original PDF page 28: [[W1 Surgical Extraction Workshop.pdf#page=28|W1 Surgical Extraction Workshop, p.28]] [^29]: Original PDF page 29: [[W1 Surgical Extraction Workshop.pdf#page=29|W1 Surgical Extraction Workshop, p.29]] [^30]: Original PDF page 30: [[W1 Surgical Extraction Workshop.pdf#page=30|W1 Surgical Extraction Workshop, p.30]] [^31]: Original PDF page 31: [[W1 Surgical Extraction Workshop.pdf#page=31|W1 Surgical Extraction Workshop, p.31]] [^32]: Original PDF page 32: [[W1 Surgical Extraction Workshop.pdf#page=32|W1 Surgical Extraction Workshop, p.32]] [^33]: Original PDF page 33: [[W1 Surgical Extraction Workshop.pdf#page=33|W1 Surgical Extraction Workshop, p.33]] [^34]: Original PDF page 34: [[W1 Surgical Extraction Workshop.pdf#page=34|W1 Surgical Extraction Workshop, p.34]] [^35]: Original PDF page 35: [[W1 Surgical Extraction Workshop.pdf#page=35|W1 Surgical Extraction Workshop, p.35]] [^36]: Original PDF page 36: [[W1 Surgical Extraction Workshop.pdf#page=36|W1 Surgical Extraction Workshop, p.36]] [^37]: Original PDF page 37: [[W1 Surgical Extraction Workshop.pdf#page=37|W1 Surgical Extraction Workshop, p.37]] [^38]: Original PDF page 38: [[W1 Surgical Extraction Workshop.pdf#page=38|W1 Surgical Extraction Workshop, p.38]] [^39]: Original PDF page 39: [[W1 Surgical Extraction Workshop.pdf#page=39|W1 Surgical Extraction Workshop, p.39]] [^40]: Original PDF page 40: [[W1 Surgical Extraction Workshop.pdf#page=40|W1 Surgical Extraction Workshop, p.40]] [^41]: Original PDF page 41: [[W1 Surgical Extraction Workshop.pdf#page=41|W1 Surgical Extraction Workshop, p.41]] [^42]: Original PDF page 42: [[W1 Surgical Extraction Workshop.pdf#page=42|W1 Surgical Extraction Workshop, p.42]] [^43]: Original PDF page 43: [[W1 Surgical Extraction Workshop.pdf#page=43|W1 Surgical Extraction Workshop, p.43]] [^44]: Original PDF page 44: [[W1 Surgical Extraction Workshop.pdf#page=44|W1 Surgical Extraction Workshop, p.44]] [^45]: Original PDF page 45: [[W1 Surgical Extraction Workshop.pdf#page=45|W1 Surgical Extraction Workshop, p.45]] [^46]: Original PDF page 46: [[W1 Surgical Extraction Workshop.pdf#page=46|W1 Surgical Extraction Workshop, p.46]] [^47]: Original PDF page 47: [[W1 Surgical Extraction Workshop.pdf#page=47|W1 Surgical Extraction Workshop, p.47]] [^48]: Original PDF page 48: [[W1 Surgical Extraction Workshop.pdf#page=48|W1 Surgical Extraction Workshop, p.48]] [^49]: Original PDF page 49: [[W1 Surgical Extraction Workshop.pdf#page=49|W1 Surgical Extraction Workshop, p.49]] [^50]: Original PDF page 50: [[W1 Surgical Extraction Workshop.pdf#page=50|W1 Surgical Extraction Workshop, p.50]] [^51]: Original PDF page 51: [[W1 Surgical Extraction Workshop.pdf#page=51|W1 Surgical Extraction Workshop, p.51]] [^52]: Original PDF page 52: [[W1 Surgical Extraction Workshop.pdf#page=52|W1 Surgical Extraction Workshop, p.52]] [^53]: Original PDF page 53: [[W1 Surgical Extraction Workshop.pdf#page=53|W1 Surgical Extraction Workshop, p.53]] [^54]: Original PDF page 54: [[W1 Surgical Extraction Workshop.pdf#page=54|W1 Surgical Extraction Workshop, p.54]] [^55]: Original PDF page 55: [[W1 Surgical Extraction Workshop.pdf#page=55|W1 Surgical Extraction Workshop, p.55]] [^56]: Original PDF page 56: [[W1 Surgical Extraction Workshop.pdf#page=56|W1 Surgical Extraction Workshop, p.56]] [^57]: Original PDF page 57: [[W1 Surgical Extraction Workshop.pdf#page=57|W1 Surgical Extraction Workshop, p.57]] [^58]: Original PDF page 58: [[W1 Surgical Extraction Workshop.pdf#page=58|W1 Surgical Extraction Workshop, p.58]] [^59]: Original PDF page 59: [[W1 Surgical Extraction Workshop.pdf#page=59|W1 Surgical Extraction Workshop, p.59]] [^60]: Original PDF page 60: [[W1 Surgical Extraction Workshop.pdf#page=60|W1 Surgical Extraction Workshop, p.60]] [^61]: Original PDF page 61: [[W1 Surgical Extraction Workshop.pdf#page=61|W1 Surgical Extraction Workshop, p.61]] [^62]: Original PDF page 62: [[W1 Surgical Extraction Workshop.pdf#page=62|W1 Surgical Extraction Workshop, p.62]] [^63]: Original PDF page 63: [[W1 Surgical Extraction Workshop.pdf#page=63|W1 Surgical Extraction Workshop, p.63]] [^64]: Original PDF page 64: [[W1 Surgical Extraction Workshop.pdf#page=64|W1 Surgical Extraction Workshop, p.64]] [^65]: Original PDF page 65: [[W1 Surgical Extraction Workshop.pdf#page=65|W1 Surgical Extraction Workshop, p.65]] [^66]: Original PDF page 66: [[W1 Surgical Extraction Workshop.pdf#page=66|W1 Surgical Extraction Workshop, p.66]] [^67]: Original PDF page 67: [[W1 Surgical Extraction Workshop.pdf#page=67|W1 Surgical Extraction Workshop, p.67]] [^68]: Original PDF page 68: [[W1 Surgical Extraction Workshop.pdf#page=68|W1 Surgical Extraction Workshop, p.68]] [^69]: Original PDF page 69: [[W1 Surgical Extraction Workshop.pdf#page=69|W1 Surgical Extraction Workshop, p.69]] [^70]: Original PDF page 70: [[W1 Surgical Extraction Workshop.pdf#page=70|W1 Surgical Extraction Workshop, p.70]] [^71]: Original PDF page 71: [[W1 Surgical Extraction Workshop.pdf#page=71|W1 Surgical Extraction Workshop, p.71]] [^72]: Original PDF page 72: [[W1 Surgical Extraction Workshop.pdf#page=72|W1 Surgical Extraction Workshop, p.72]] [^73]: Original PDF page 73: [[W1 Surgical Extraction Workshop.pdf#page=73|W1 Surgical Extraction Workshop, p.73]] [^74]: Original PDF page 74: [[W1 Surgical Extraction Workshop.pdf#page=74|W1 Surgical Extraction Workshop, p.74]] [^75]: Original PDF page 75: [[W1 Surgical Extraction Workshop.pdf#page=75|W1 Surgical Extraction Workshop, p.75]] [^76]: Original PDF page 76: [[W1 Surgical Extraction Workshop.pdf#page=76|W1 Surgical Extraction Workshop, p.76]] [^77]: Original PDF page 77: [[W1 Surgical Extraction Workshop.pdf#page=77|W1 Surgical Extraction Workshop, p.77]] [^78]: Original PDF page 78: [[W1 Surgical Extraction Workshop.pdf#page=78|W1 Surgical Extraction Workshop, p.78]] [^79]: Original PDF page 79: [[W1 Surgical Extraction Workshop.pdf#page=79|W1 Surgical Extraction Workshop, p.79]] [^80]: Original PDF page 80: [[W1 Surgical Extraction Workshop.pdf#page=80|W1 Surgical Extraction Workshop, p.80]] [^81]: Original PDF page 81: [[W1 Surgical Extraction Workshop.pdf#page=81|W1 Surgical Extraction Workshop, p.81]] [^82]: Original PDF page 82: [[W1 Surgical Extraction Workshop.pdf#page=82|W1 Surgical Extraction Workshop, p.82]] [^83]: Original PDF page 83: [[W1 Surgical Extraction Workshop.pdf#page=83|W1 Surgical Extraction Workshop, p.83]] [^84]: Original PDF page 84: [[W1 Surgical Extraction Workshop.pdf#page=84|W1 Surgical Extraction Workshop, p.84]] [^85]: Original PDF page 85: [[W1 Surgical Extraction Workshop.pdf#page=85|W1 Surgical Extraction Workshop, p.85]] [^86]: Original PDF page 86: [[W1 Surgical Extraction Workshop.pdf#page=86|W1 Surgical Extraction Workshop, p.86]] [^87]: Original PDF page 87: [[W1 Surgical Extraction Workshop.pdf#page=87|W1 Surgical Extraction Workshop, p.87]] [^88]: Original PDF page 88: [[W1 Surgical Extraction Workshop.pdf#page=88|W1 Surgical Extraction Workshop, p.88]] [^89]: Original PDF page 89: [[W1 Surgical Extraction Workshop.pdf#page=89|W1 Surgical Extraction Workshop, p.89]] [^90]: Original PDF page 90: [[W1 Surgical Extraction Workshop.pdf#page=90|W1 Surgical Extraction Workshop, p.90]] [^91]: Original PDF page 91: [[W1 Surgical Extraction Workshop.pdf#page=91|W1 Surgical Extraction Workshop, p.91]] [^92]: Original PDF page 92: [[W1 Surgical Extraction Workshop.pdf#page=92|W1 Surgical Extraction Workshop, p.92]] [^93]: Original PDF page 93: [[W1 Surgical Extraction Workshop.pdf#page=93|W1 Surgical Extraction Workshop, p.93]] [^94]: Original PDF page 94: [[W1 Surgical Extraction Workshop.pdf#page=94|W1 Surgical Extraction Workshop, p.94]] [^95]: Original PDF page 95: [[W1 Surgical Extraction Workshop.pdf#page=95|W1 Surgical Extraction Workshop, p.95]] [^96]: Original PDF page 96: [[W1 Surgical Extraction Workshop.pdf#page=96|W1 Surgical Extraction Workshop, p.96]] [^97]: Original PDF page 97: [[W1 Surgical Extraction Workshop.pdf#page=97|W1 Surgical Extraction Workshop, p.97]] [^98]: Original PDF page 98: [[W1 Surgical Extraction Workshop.pdf#page=98|W1 Surgical Extraction Workshop, p.98]] [^99]: Original PDF page 99: [[W1 Surgical Extraction Workshop.pdf#page=99|W1 Surgical Extraction Workshop, p.99]] [^100]: Original PDF page 100: [[W1 Surgical Extraction Workshop.pdf#page=100|W1 Surgical Extraction Workshop, p.100]] [^101]: Original PDF page 101: [[W1 Surgical Extraction Workshop.pdf#page=101|W1 Surgical Extraction Workshop, p.101]] [^102]: Original PDF page 102: [[W1 Surgical Extraction Workshop.pdf#page=102|W1 Surgical Extraction Workshop, p.102]] [^103]: Original PDF page 103: [[W1 Surgical Extraction Workshop.pdf#page=103|W1 Surgical Extraction Workshop, p.103]] [^104]: Original PDF page 104: [[W1 Surgical Extraction Workshop.pdf#page=104|W1 Surgical Extraction Workshop, p.104]]