Principles of complicated Exodontia I

1. Principles of complicated Exodontia I Dr Ashraf Abu Karaky

2. Surgical extraction. • Open extraction. • Fractured roots. • Remaining roots. • Teeth cannot be extracted by closed extraction. • Multiple extraction and concomitant alveoloplasty.

3. Chapter 8 • Contemporary Oral and Maxillofacial Surgery 6th Edition.

4. Principles of flap design. • Local flap: • Outlined by surgical incision • Carries its blood supply • Surgical access • Replaced to the original position • Oral surgery, peridontic and endodontic procedures.

5. Design parameters for soft tissue flap Adequate exposure Rapid healing. • Parameters: • Base of the flap broader than free margins • Adequate size; visualization, access, retraction without tension, sharp incisions heals better than torn incisions. • Full thickness flap.

7. Incisions must be made over intact bone. • Flap should avoid injury to local vital structures. Mental nerve, palate.

8. Types of flaps • Enveloped flap • Three-cornered flap • Four cornered flap • Semilunar flap • Subgingival flap • Palatal flaps

9. Enveloped flap • Most common flap • Sulcular incision. • Edentulous patients; crest of the ridge, as long as required, reflected buccally or lingually.

11. Three-cornered flap • Vertical releasing incision • Greater access, shorter envelop flap, apical area, posterior area. • Prolonged healing, difficult to close.

13. Four cornered flap • Two releasing incisions • Substantial access. • Rarely needed.

15. Semilunar incision or flap • Root apex • Avoid trauma to the papillae and gingival margin • Limited access

17. Palatal flaps • Y incision • Pedicle flap

19. Technique for developing a Muccoperiosteal flap • Incision; blade 15, scalpel handle no. 3, pen grasp. • Posterior to anterior, in contact with bone. One smooth stroke. • Reflection start at the papilla. • Muccoperiosteal elevator. • Retractor.

24. Principles of suturing

25. Principles of complicated Exodontia II

26. The surgical or open extraction of an erupted tooth is a technique that should not be reserved for the extreme situation. A prudently used open extraction technique may be more conservative and cause less operative morbidity compared with a closed extraction. Forceps extraction techniques, which require great force, may result not only in removal of the tooth but also of large amounts of associated bone and occasionally the floor of the maxillary sinus The bone loss may be less if a soft tissue flap is reflected and a proper amount of bone is removed; it may also be less if the tooth is sectioned. The morbidity of fragments of bone that may be literally torn from the jaw by the “conservative” closed technique can greatly exceed the morbidity of a properly done surgical extraction

28. Indications for Open Extraction • As a general guideline, surgeons should consider performing an elective surgical extraction when they anticipate the possible need for excessive force to extract a tooth. • The surgeon should seriously consider performing an open extraction after initial attempts at forceps extraction have failed

29. If the preoperative assessment reveals that the patient has thick or especially dense bone, particularly of the buccocortical plate, surgical extraction should be considered. • Occasionally, the dentist treats a patient who has very short clinical crowns with evidence of severe attrition. If such attrition is the result of bruxism it is likely that teeth are surrounded by dense, thick bone with strong periodontal ligament attachments

31. Careful review of the preoperative radiographs may reveal tooth roots that are likely to cause difficulty if the tooth is extracted by the standard forceps technique. One condition commonly seen among older patients is hypercementosis

33. Roots that are widely divergent, especially maxillary first molar roots.

35. roots that have severe dilaceration or hooks, are also difficult to remove without fracturing one or more of the roots

37. If the maxillary sinus has expanded to include the roots of the maxillary molars, extraction may result in removal of a portion of the sinus floor along with the tooth. If the roots are divergent, then such a situation is even more likely to occur Surgical extraction is again indicated

39. Teeth that have crowns with extensive caries, especially root caries, or that have large amalgam restorations are candidates for open extraction

41. Technique for Open Extraction ofSingle-Rooted Tooth The first step is to provide adequate visualization and access by reflecting a sufficiently large mucoperiosteal flap. In most situations, an envelope flap that is extended two teeth anterior and one tooth posterior to the tooth to be removed is sufficient. If a releasing incision is necessary, it should be placed at least one tooth anterior to the extraction site

42. surgeon may attempt to reseat the extraction forceps under direct visualization and, thus, achieve a better mechanical advantage and remove the tooth with no surgical bone removal at all

43. The second option is to grasp a bit of buccal bone under the buccal beak of the forceps to obtain a better mechanical advantage and grasp of the tooth root. This may allow the surgeon to luxatethetooth sufficiently to remove it without any additional bone removal. A small amount of buccal bone is pinched off and removed with the tooth

44. The third option is to use the straight elevator, pushing it down the periodontal ligament space of the tooth. The index finger of the surgeon’s hand must support the force of the elevator so that the total movement is controlled and no slippage of the elevator occurs. A small to and fro motion should be used to help expand the periodontal ligament space, which allows the small straight elevator to enter the space and act as a wedge to displace the root occlusally. This approach continues with the use of larger straight elevators until the tooth is successfully luxated.

45. The fourth and final option is to proceed with surgical bone removal over the area of the tooth. Most surgeons prefer to use a bur to remove the bone, along with ample irrigation. The width of buccal bone that is removed is essentially the same width as the tooth in a mesiodistal direction In a vertical dimension, bone should be removed approximately one half to two thirds the length of the tooth root (Figure 8-36). This amount of bone removal sufficiently reduces the amount of force necessary to displace the tooth and makes removal relatively easy. A small straight elevator or forceps can be used to remove the tooth

46. If the tooth is still difficult to extract after the removal of bone, a purchase point can be made in the root with the bur at the most apical portion of the area of bone removal (Figure Care should be taken to limit bone removal to only that needed to remove the root to preserve bone for possible implant placement

47. Soft tissue is repositioned and sutured • The bone edges should be checked; if sharp, they should be smoothed with a bone file. By replacing the soft tissue flap and gently

48. Technique for Open Extraction ofMultirooted Teeth The major difference is that the tooth may be divided with a bur to convert a multirooted tooth into two or three single-rooted teeth. If the crown of the tooth remains intact, the crown portion is sectioned in such a way asportion of the tooth is missing and only the roots remain, the goal to facilitate removal of roots. However, if the crown is to separate the roots to make them easier to elevate .

49. Removal of the lower first molar with an intact crown is usually done by sectioning the tooth buccolingually, thereby dividing the tooth into a mesial half (with mesial root and half of the crown) and a distal half. An envelope incision is also made, and a small amount of crestal bone is removed.