Surgical Extraction Indications

• Surgical extraction is defined as extractions not removable via forceps and elevators

Indications for Surgical Extraction

• Unusual root morphology of teeth in the maxilla or mandible
• Hypercementosis of the root and tip in large bulbous roots
• Malposed, impacted, supernumerary or ectopically erupted teeth
• Teeth with ankylosed roots
• Teeth with dens in dente abnormalities
• Roots that are widely divergent, like those of maxillary first molars
• Roots with severe dilaceration or hooks
• Teeth fused with adjacent teeth in the apical area
• Maxillary posterior teeth with roots in the maxillary sinus
• Roots below the gum line and not removable otherwise
• Roots with periapical lesions not treatable by curettage alone
• Deciduous molars with roots embracing the crown of a premolar
• Brittle teeth with extensive carries especially the root
• Teeth which resist intralveolar or closed extraction with moderate force
• Used for multiple extractions

Contraindications for Leaving a Root Fragment

• The root fragment is small, usually no more than 3-4 mm
• The root is deeply embedded, not superficial, to prevent bone resorption
• The tooth involved is not infected, and there is no radiolucency around the apex
• No risk of serious local complications, like dislodging a root tip into the sinus or nerve injury
• Serious health problems present, particularly in older patients

Steps of Surgical Extraction

• Incision to access the area
• Removal of an adequate amount of bone
• Sectioning of the tooth
• Elevating the tooth or root
• Preparing the wound for closure, wound toilet
• Closure of the wound or incision
• Postoperative care

Incision

• Incisions must be made in oral soft tissue/mucoperiosteum
• A mucoperiosteal flap (MPF) must be reflected from the surgical site

Instruments

• Scalpel with handle and blade
• Bard-Parker handle number 3 is the most commonly used in oral surgery
• Blades are disposable and of different types, numbers 10, 11, 12, and 15
• Number 15 is the most common conventional type
• Number 12 is for gingival sulcus incisions posterior to the teeth, especially in the maxillary tuberosity
• Number 11 is for small incisions for incising abscesses
• Number 10 is used for extroaral incisions

Flap Design Principles

• A sharp blade should be used
• Design the flap to avoid injury to local vital structures
• The lingual and mental nerves in the mandible are crucial
• The lingual nerve is 17% at/above the alveolar ridge crest, 83% 2mm inferior to the alveolar crest, 0.5 mm lateral to the lingual cortical bone
• Surgery in the mandibular premolar apical area requires careful planning to protect the mental nerve
• On the facial aspect of the maxillary alveolar process there are no nerves or arteries likely to be damaged
• For Palatal flaps, consider the greater palatine artery
• Incisions should be over intact bone present post surgical operation
• When an incision is 6-8 mm away from the bony defect created by a surgery
• Full-thickness mucoperiosteal flap should be employed
• The periosteum is responsible for bone healing
• Incisions with blade held perpendicular to the epithelial surface
• Squared wound edges easier to re-approximate, and less susceptible to necrosis
• Vertical-releasing incisions cross the free gingival margin at the line angle, not on the facial aspect or papilla directly
• The MPF should be large for visibility, accessibility and instrumentation
• Avoid incisions in thinned mucosa (e.g., over an exostosis)
• Apex of the flap should never be wider than the base, unless a major artery is present in the base
• Flap sides should run parallel or converge from base to apex
• Length of a flap should not extend beyond the width of the base
• The vertical relaxing incision should not extend beyond the depth of the mucobuccal fold

Flap Necrosis Prevention

• Flap apex should not to be wider than its base, major artery presence is an exception
• The flap length should never exceed its width
• when possible, an axial blood supply included at the flap's base
• A flap in the palate should be towards the greater palatine artery
• The base of flaps should not be twisted, excessively stretched, or grasped with anything that might damage blood vessels

Flap Tearing & Dehiscence Prevention

• Flap should be sufficient in size
• Incisions should be avoided in the thinned mucosa and sharp blades should be used
• Flap margin dehiscence/separation is prevented by the following
• Approximating the edges of the flap over healthy bone
• Gently handling the flap edges
• Avoid flap under tension, or not placing the flap under tension
• Dehiscence exposes underlying bone leading to increased scarring, pain, bone loss

Mucoperiosteal Flaps

• Envelope/horizontal
• Triangular
• Rectangular
• Semilunar
• Palatal pedicle flap
• Y-shaped incision
• X -shaped incision

Envelope Flaps

• Advantage: Minimal risk violating major anatomical landmarks
• Advantage: Can be extended as you need, where you need
• Advantage: Easy to operate in incision, reflection, re-approximation, and suturing
• Disadvantage: More advanced access requires more horizontal extension
• Disadvantage: Inadequate access to apical part of tooth, deep impactions

Triangular Flaps

• Advantage: Great access to the area, especially in cases of surgery in the vicinity of the apex of the tooth
• Disadvantage: For surgical exposure of mandibular premolar teeth, vertical relaxing incision may sever the mental nerve with substantial loss of labial sensation
• Disadvantage: Can severe the facial artery or vein
• Disadvantage: Tension when flap held with retractor and having restricted access of long roots
• Disadvantage: Causes defects in the attached gingiva

Rectangular Flaps

• Advantage: Increased amount of access than horizontal and triangular flaps.
• Disadvantage: Possibility of gingival recession
• Disadvantage: More difficult to incise and reflect
• Disadvantage: Injury to local vital structures
• Disadvantage: Re-approximation of the flap itself, post surgical stabilization and closing of a wound is relatively more tough

Semilunar Flaps

• A full-thickness flap is useful for the retrieval of small root tip and the periapical endodontic surgery of a limited extent.
• Can perform an incision up to 2mm apical to the base.
• Periodontal probing should be done up to 5mm apical to the gingival margin for the best results
• Advantages = no trauma to the papilla and gingival margin.
• Provides limited access because the entire root of the tooth is not visible

Palatal Pedicle Flap

• Typically a long and narrow flap that mobilizes a certain area, then rotates the soft tissue in another area.
• Used to close onto Oroantral Communications.
• Is a tough full thickness flap that has a rich blood supply.
• Involves the Greater Palatine Artery (GPA)
• Exposes palatal bone and trauma to the GPA may cause severe bleeding
• Reflection is hard and the palatal mucosa is firmly attached

Flap resulting from Y- Shaped Incision

• An incision is along the middle of the palate as well as 2 anterolateral incisions which are anterior to the canines.
• This type of flap is used for small exostoses' removals

Flap resulting from Double Y-Shaped Incision

• It is used in larger exostoses and is basically an elongated version of the Y Shape.
• Is made in 2 more posterolateral incisions, which are important for adequate access to the surgical field
• Flap made such that major branches of the GPA are not severed

Flap Reflection

• Reflection of the flap begins at the papilla
• The sharp end of the periosteal elevator begins the reflection
• The broad end is used in a pushing stroke to reflect the mucoperiosteal flap
• If triangular/rectangular flap
• Sharp end is MP elevator at 1st papilla only and broad end inserts at the middle corner

Flap Retraction

• Instruments are to do surgery, have good vision, have good access, and avoid soft tissue injury.
• Retractor is made perpendicular bone with firm bone, underneath flap
• Sutures/traction can retract mucoperiosteal flaps

Removal of Adequate Amount of Bone

• Bone belongs to the patient but tooth belongs to the surgeon
• A removal should lead to decreased resistance with roots, give a point for an elevator/forceps and create a space for the tooth/root to be displaced in

Tooth Sectioning

• In order to remove the tooth to minimize bone removal, the crown of a surgical bur will split into pieces
• Pell and Gregory determined several advantages to this process
• Bone removal is decreased
• The operation is small
• Trismus and swelling is less post op
• Operation is shortened
• Fracture risk decreases and no injuries to adjacent areas

Teeth Division Types

• Horizontal: Separate crown and root
• Vertical: Split vertically
• Partial: Remove Locked Cusp

Extracting Root Techniques

• Closed
• Open Window Approach

Preparing the Wound

• After extraction, you must
• Smooth spicules of bone/Sharp Edges.
• Interdental socket that is made in the sockets in mistaken for the tooth fragments by patient
• The residual tissue/fragments in the bone and the gingival margin must be removed
• Any pathological tissue removal that happens, including tooth follicles and apical granulomas
• Finally should irrigate between closing and more irregularities result to the alveolar process