Pre-Extraction Preparations Principles of Uncomplicated and Complicated Exodontia

Paul H. Kwon, D.D.S. Oral & Maxillofacial Surgery University of Minnesota Medical history and physical examination Radiographic evaluation Surgical plan Pain and anxiety control Patient and surgeons preparations

READY FOR SURGERY

Chair and Surgeons Position

Comfortable for both the patient and surgeon Stand during extraction Mx: Maxillary occlusal plane 60 to the floor Mn: Mandibular occlusal plane parallel to the floor

> Over garment > Mask > Cap: hair covered > Eye protection

Again note patient and surgeon positions

A mouth prop is used to stabilize the mandible for mandibular procedures

Extraction Technique
A pharyngeal partition is used for the duration of all procedures
Closed technique (simple, forcep) Open technique (surgical, flaps)

Daily Scrub Routine for Aseptic Procedures

Procedure for Closed Extraction

Loosening of soft tissue
Woodson elevator #9 periosteal elevator

Luxation of the tooth with small straight elevator (301)

> >
Only one 2 minute scrub with pre-op sponge needed prior to clinic start Hand wash each timer thereafter

Handle of small straight elevator, turned so that occlusal side of elevator blade is turned toward tooth.

Handle of elevator, which may be turned in opposite direction to displace tooth further from socket. This can be accomplished only if there is no tooth adjacent posteriorly.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

Principle of Forcep Use

Periapical pressure (bony expansion) Buccal movement (except mandibular molars) Lingual movement (mandibular molars) Rotational pressure (conic roots) Tractional force (delivering)

Procedure for Closed Extraction continued

Adaptation of the forceps
Lingual first then buccal (beneath the soft tissue) Grasp end of forcep Parallel to the long axis of the tooth Grasp the root of the tooth as apically as possible Standing straight feet comfortably apart

Procedure for Closed Extraction continued

Luxation of the tooth with the forceps
Force to the thinnest therefore weakest bone Slow, steady force No jerky wiggle motion

Procedure for Closed Extraction continued

Removal of the tooth from the socket
Slight traction force Develop a sense for the direction the tooth wants to move

Beaks of forceps act as wedge to expand alveolar bone and displace tooth in occlusal direction

The forcep is seated as far apically as possble.

Luxation is begun with labial force.

Slight lingual force is used.

The tooth is removed to the labial-incisional.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

Handles of forceps are squeezed forcibly together, which causes beaks of forceps to be forced into bifurcation and exerts tractional forces on tooth.

Strong buccal forces are the used to expand socket.

Strong lingual forces are used to luxate tooth further.

Tooth is delivered in bucco-occlusal direction with buccal and tractional forces.

REMEMBER:
Extraction of tooth does not require a large amount of brute force but rather can be accomplished with finesse and controlled force in such a manner that the tooth is not pulled from the bone but instead is lifted gently from the alveolar process. Larry J. Petersons book

Post-Extraction Care of Tooth Socket

Curetted or not curetted Compressed back Periodontal disease case Bony projections

Principles of Complicated Exodontia Surgical Extractions

Principles of Flap Design Base must be broader than free margin (blood supply) Adequate size (surgical access) Can be maintained with suture (6 8mm away from the bony defect)

Principles of Complicated Exodontia continued

Envelope flap: 2 teeth anterior and 1 tooth posterior / Relaxing incision: 1 tooth anterior and posterior Full thickness mucoperiosteal flap (surface mucosa, submucosa, periosteum) Avoid injury to local vital structure (lingual nerve, mental nerve)

Types of Mucoperiosteal Flap

Envelope flap Envelope flap with vertical releasing incision (1 x 2) Semilunar incision Y flap Pedicle flap

Why anterior release?

Do not release over bony prominences

Types (Flap)
Envelope flap
Advantage Disadvantage

Indications for Surgical Extraction

Failed forcep extraction Heavy and dense bone older patient vs. young patient Severe attrition (bruxism) Hypercementosis
Large bulbous root Widely divergent roots (maxillary 1st molar) Hook, dilaceration

Flap with V.C.

Advantage Disadvantage

Indications for Surgical Extraction continued

Maxillary sinus has expanded to include the roots of the maxillary molars Crown with extensive caries or retained roots

Removal of Small Root Fragments and Root Tips

Fx of apical 1/3 (3 4mm) Closed technique vs. open technique Open window technique

Technique for Open Extraction of Single-Rooted Tooth

Adequate visualization Reflect flap
Forceps Grasp a bit of buccal bone Straight elevator Remove buccal bone (Width: tooth width / Length: root or 2/3) Purchase point: craine pick

Small, straight elevator, used as wedge to displace tooth root from its socket.

Technique for Surgical Removal of Multirooted Teeth

Convert multirooted tooth into single-rooted tooth
Mandibular 1st molar (crown present vs. no crown) Maxillary 1st molar (crown intact vs. no crown)

Careful! Lots of force generated

Purchase Point

Principles of Suturing
Flap to its original position Hemostasis Hold a soft tissue flap over bone No suture across the empty tooth socket Mobile tissue first Passing the tissue: right angle Amount of tissue: 3mm Not to be tightened too much Not fall over incision line

Policy for Leaving Root Fragments

Excessively traumatic (risk / benefit) Smaller than 4 5mm Deeply embedded No infection, no radiolucency on apex

Multiple Extractions
Treatment planning (immediate full denture, partial, implants) Extraction sequencing (maxillary first, advantages, disadvantages) Last teeth to remove (1st molars, canines)

Thank You