Surgical Exodontia PDF

Surgical Exodontia By: Dr Ahmed Abdelghany Shararah Lecturer of Oral &Maxillofacial Surgery, Faculty of Dentistry, AAST. Oral and maxillofacial Consultant. PhD of Oral &Maxillofacial Surgery, Alexandria University. Fellow...

Surgical Exodontia By: Dr Ahmed Abdelghany Shararah Lecturer of Oral &Maxillofacial Surgery, Faculty of Dentistry, AAST. Oral and maxillofacial Consultant. PhD of Oral &Maxillofacial Surgery, Alexandria University. Fellow of Cosmetic Dentistry, Genoa University –Italy  Closed Exodontia Open Closed Technique Shararah Excessive force during Forceps extraction of these teeth resulted in removal of bone and the tooth instead of just the tooth. Aim Atraumatic extraction. No excessive force. Consider the open technique. The open technique may be the less traumatic of the two techniques in some situations.  Teeth with Severely undermined crown Fractured teeth Endodontically treated teeth Indications of Root pieces Trans alveolar Teeth with unfavorable root form like bulbous or dilacerated roots exodontia Multiple divergent roots Ankylosed teeth Hypercementosis Presence of dense bone Malposed tooth Impacted tooth Tooth in proximity to vital structures Long standing tooth with grossly carious crown Impacted teeth Hypercementosis of the root makes forceps delivery difficult. Severe dilaceration of roots may result in fracture of the root unless surgical extraction is performed. Maxillary molar teeth “in” the floor of the maxillary sinus increase the chances of fracture of the sinus floor with resulting sinus perforation. Teeth that exhibit evidence of bruxism may have denser bone and stronger periodontal ligament attachment, which make them more difficult to extract. Widely divergent roots increase the likelihood of fracture of bone, tooth root, or both. Large caries or large restorations may lead to fracture of the crown of the tooth and thus to a more difficult extraction. Root framents Multiple extractions  If the preoperative assessment reveals that the patient has thick or especially dense bone, particularly of the Bucco cortical plate, surgical extraction should be considered A careful decision of open extraction technique may be more conservative and cause less operative morbidity than a closed extraction. The correct technique for any situation should lead to an atraumatic extraction. The wrong technique commonly results in an excessively traumatic and lengthy extraction. The three fundamental (1) adequate access and visualization of the field of surgery, requirements for a good extraction : (2) an unimpeded pathway for the removal of the tooth, and (3) the use of controlled force to luxate and remove the tooth Mucoperiosteal Flap Designs for Transalveolar Extraction Transalveolar exodontia necessitates incision making and subsequent mucoperiosteal flap reflection for adequate exposure of the underlying alveolar bone. The flap must be an adequately sized full-thickness mucoperiosteal flap with a broader base which is made on intact bone, avoiding injury to the local vital structures The soft tissue flap signifies a piece of soft tissue characterized by the following: 1. It is surrounded by a surgical incision. 2. Holds its own blood supply. 3. Permits surgical access to underlying tissues. 4. Can be restored in the original position. 5. Can be up-holding with sutures and is likely to heal.  (A) The flap must have a base that is broader than the free gingival margin. (B) If the flap is too narrow at its base, blood supply may be inadequate, which can lead to flap necrosis.  1. Envelope Flap: a crevicular incision without any releasing incision is given, it produces an envelope flap. Envelope flap (sulcular flap) To have sufficient access to root of second premolar, the envelope flap should extend anteriorly, mesial to the canine, and posteriorly, distal to the first molar. Extend it 2 teeth mesial and one tooth distal to operative site.  Soft tissue heals across the incision not along the length of the incision. The sharp incisions heal more rapidly than torn tissue. A long straight incision with adequate flap reflection heals more rapidly than torn incision, which heals slowly by secondary intention. 2.Triangular Flap: When a crevicular incision has one vertical releasing incision, it produces a triangular flap. It is also known as a two-sided or three-cornered flap When a greater exposure is required, this flap is preferred.  Releasing incisions are used only when necessary and not routinely. Envelope incisions usually provide the adequate visualization required for tooth extraction in most areas. When vertical releasing incisions are necessary, only a single vertical incision is usually required, which is usually at the anterior end of the envelope component. The vertical-releasing incision is not a straight vertical incision but an oblique incision, allowing the base of the flap to be broader than the free gingival margin.  Triangular flap The vertical-releasing incision converts the envelope incision into a three-cornered flap (corners numbered).  (A) the incision should rest over sound bone. In this situation, the vertical release was one tooth anterior to bone removal and left an adequate margin of sound bone. (B) When a releasing incision is made too close to bone removal, delayed healing results. The incision should not cross the canine eminence. Crossing such bony prominences results in increased chance for wound dehiscence. (1) The incision crosses the prominence over the canine tooth, which increases the risk of delayed healing. The incision through the papilla results in unnecessary damage. (2) The incision crosses the attached gingiva directly over the facial aspect of the tooth, which is likely to result in soft tissue defect as well as periodontal and aesthetic deformities. 3. Trapezoidal Flap: Vertical-releasing incisions at the other end of the envelope incision convert the envelope incision into a four-cornered flap (corners numbered).  It is also known as a three-sided or four cornered flap. Two corners are at the superior aspect of the releasing incisions and the other two corners are at the ends of the crevicular incision. The vertical releasing incisions are not vertically placed but are directed obliquely to allow a broader base  4.Semilunar incision It designed to avoid marginal attached gingiva when working on a root apex. The incision is most useful when only a limited amount of access is necessary. The Y-incision It is useful on the palate for adequate access to remove a palatal torus. Two anterior limbs serve as releasing incisions to provide for greater access  Pedicle flap This flap is designed to be mobilized from one area and then rotated to fill a soft tissue defect in another area.  Shararah Shararah Shararah  The flap should be a full-thickness mucoperiosteal flap. This means that the flap includes the surface mucosa, the submucosa, and the periosteum. Because the goal of the surgery is to remove or reshape the bone, all overlying tissue must be reflected from it.  The flap should be designed to avoid injury to local vital structures in the area of the surgery. The two most important structures that can be damaged are both located in the mandible, the lingual nerve, and the mental nerve.  On the facial aspect of the maxillary alveolar process, no nerves or arteries exist that are likely to be damaged. When reflecting a palatal flap, one must remember that the major blood supply to the palate comes through the greater palatine artery, which emerges from the greater palatine foramen at the posterior lateral aspect of the hard palate. It should be saved within the flap avoiding its injury  The nasopalatine nerves and arteries exit the incisive foramen to supply the anterior palatal gingiva. If the anterior palatal tissue must be reflected, both the artery and the nerve can be incised at the level of the foramen without much risk. Shararah Shararah Instruments for incision and flap reflection  Blade loading The surgeon then slides the blade into the handle until it clicks into place.  Blade removal To remove the blade, the surgeon uses the needle holder to grasp the end of the blade next to the handle and lifts it to disengage it from the fitting Mucoperiosteal elevator Molt periosteal elevator is most commonly used in oral surgery. The Austin retractor is a right-angle retractor that can be used to retract the cheek, tongue, or flaps. The Weider retractor The Weider retractor is a large retractor designed to retract the tongue. The serrated surface helps engage the tongue so that it can be held securely. The Weider retractor is used to hold the tongue away from the surgical field. The Austin retractor is used to retract the cheek. The Minnesota retractor It is s used to retract the cheek and flaps.