Surgical Exodontia Overview

Surgical Exodontia

• Surgical exodontia is a specialized procedure for removing teeth that are challenging to extract using standard techniques.
• Techniques are categorized into closed and open.
• Excessive force during forceps extraction can damage bone and the tooth itself.
• Atraumatic extraction is essential, avoiding excessive force.
• The open technique is sometimes less traumatic.

Indications for Trans-alveolar Exodontia

• Teeth with severely undermined crowns.
• Fractured teeth.
• Teeth treated endodontically.
• Root fragments.
• Teeth with unfavorable root forms (bulbous or dilacerated roots).
• Teeth with multiple divergent roots.
• Ankylosed teeth.
• Teeth with hypercementosis.
• Teeth with dense bone.
• Impacted teeth.
• Teeth close to vital structures.
• Teeth with grossly carious crowns.

Aim of Surgical Exodontia

• Atraumatic tooth removal.
• Avoid excessive force.
• Consider the open technique if appropriate.

Impacted Teeth

• These types of teeth require surgical procedures for proper extraction.
• X-ray images (radiographs) demonstrate their position relative to the surrounding bone and teeth.

Hypercementosis

• Thickening of the tooth root make forceps removal more difficult.

Severe Dilaceration of Roots

• This can cause the tooth root to fracture, requiring surgical extraction.

Maxillary Molar Teeth

• Teeth close to the sinus floor increase the risk of fracture and sinus perforation.

Bruxism

• Constant grinding or clenching can give teeth denser bone and stronger periodontal ligaments, making extraction more difficult.

Wide Divergent Roots

• The roots of some teeth are spread wide apart.
• Wide roots increase the potential for root or bone fracture.

Large Caries or Resorations

• Large cavities or fillings in teeth can weaken teeth, creating a need for more careful extraction.

Root Fragments

• The presence of root fragments needs to be identified during extraction.

Multiple Extractions

• Sometimes, multiple teeth need extraction.

Preoperative Assessment—Bone Density

• Evaluating bone density, especially the buccal cortical plate, helps determine extraction method.
• Dense or thick bone may require surgical extraction.

Open Extraction Technique

• Carefully choosing open extraction can sometimes reduce complications during procedure.

Correct Technique

• Choosing the correct technique for tooth extraction minimizes trauma.
• Incorrect techniques commonly cause trauma and lengthen the extraction procedure.

Fundamentals of Tooth Extraction

• Three key elements determine the success of extractions: appropriate access to the tooth, a clear access channel for extracting the tooth, and appropriately controlled force for removing the tooth.

Mucoperiosteal Flap Designs

• Properly designed mucoperiosteal flaps protect vital oral structures while facilitating tooth extraction.
• Flaps need to be full thickness, covering mucosa, submucosa, and periosteum.
• Adequate sizing with a broad base on intact bone is essential.

Types of Flaps

• Envelope Flap: A crevicular incision without releasing incision.

• Triangular Flap: Single vertical incision, often used when greater exposure is needed.

• Trapezoidal Flap: Multiple releasing incisions creating four corners, providing significant access.

• Semilunar Flap: To access root apices, the incision avoids the marginal attached gingiva

• The Y-incision is useful in palatal torus removal.

• Pedicle Flap

• This has mobility and can be rotated to fill an area with a soft tissue defect.

Flap Design Considerations

• Avoid crossing canine eminences, as this increase risk of wound dehiscence.
• Appropriate flap design prevents damage to important structures.
• Flaps must not damage lingual or mental nerves when placed on the mandible.
• Maxillary alveolar process procedures do not commonly damage nerves or arteries.
• Surgical procedures require careful consideration of blood supply to the hard and soft palate, nasopalatine nerves and vessels.

Surgical Instruments

• Instruments for incision and flap reflection include scalpels (various blade types).
• Handheld devices used for separating soft tissue and bone, including periosteal elevators, and cheek or tongue retractors to maintain a field of clear visualization.
• Retractors, including Austin, Weider, and Minnesota models, help to hold the cheek or tongue away from the surgical area, providing a view for the procedure.

This quiz covers the essential aspects of surgical exodontia, including techniques for tooth extraction that may be difficult with standard methods. It highlights indications for trans-alveolar exodontia and the aim of performing atraumatic extractions to prevent damage. Test your knowledge on the principles and practices of surgical tooth removal.