ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
SURGICAL TOOTH EXTRACTION
- Removal of most erupted teeth can be
achieved by closed delivery, but
sometimes these techniques do not
provide adequate surgical access
- Open or surgical extraction – used when
greater access is necessary to safely
remove a tooth or its roots.
PRINCIPLES OF FALP DESIGNS,
DEVELOPMENT, AND MANAGEMENT
• FLAP – a section of soft tissue that:
1. Is outlined by a surgical incision
2. Carries its own blood supply
3. Allows surgical access to underlying
tissues
4. Can be replaced in the original
position
5. Maintained with sutures
• DESIGN PARAMETERS
1. The base of the flap must be broader
than the free margin – to preserve an
adequate blood supply.
2. Flap must be of adequate size
o To provide necessary
visualization of the area
o For the insertion of
instruments
o To permit the retractor to hold
the flap without tension
o Long, straight incision with
adequate flap reflection =
heal more rapidly
Envelope Flap – two teeth
anterior and one tooth posterior to
the area of surgery
With anterior releasing incision
– one tooth anterior and one tooth
posterior.
3. Should be full thickness mucoperiosteal
flaps
o Must include surface mucosa,
submucosa, and the
periosteum
o Necessary because the
periosteum is the primary
tissue responsible for bone
healing, replacement of the
periosteum in its original
position hastens the healing
process
o Torn, split and macerated
tissue heals more slowly
o Tissue plan between bone
and periosteum is avascular
= less bleeding
4. Incision that outline the flap must be
made over healthy, intact bone
o If pathologic condition has
eroded the buccocortical
plate, incision should be at
least 6-8mm away from it in
an area of intact bone.
o If the bone is to be removed
over a particular tooth,
incision must be sufficiently
distant from it (after bone is
removed, incision is 6-8mm
away from the bony defect
created by the surgery)
o If incision is unsupported by
sound bone –> collapse into
body defect = wound
dehiscence and delayed
healing
5. Flap should be designed to avoid
injury to local vital structures in the
area of surgery
o Lingual nerve and mental
nerve
o When making incisions in the
posterior mandible, it should
be away from the lingual
aspect of the mandible
o Surgery in the apical area of
the mandibular premolar
teeth should be carefully
planned and executed – to
avoid injury to the mental
nerve
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
▪ Envelope incisions 2. AN ENVELOPE INCISION WITH TWO
are better RELEASING INCISION = FOUR
▪ If a releasing incision CORNERED FLAP
is needed, it should - Two corners are at the superior aspect of
be made anterior or the releasing incision, and two corners are
posterior to the area at either end of the envelope component
of exit of the mental of the incision.
nerve
o Flaps in the maxilla rarel endanger
any vital structures
o Palatal flap – greater palatine artery
o Avoid making vertical releasing
incisions in the posterior aspect of the
palate = might sever the greater
palatine artery = pulsatile bleeding
o Releasing incisions are used only
when necessary and not routinely
o Envelope incisions usually provide the
adequate visualization in most areas 3. SEMI-LUNAR INCISION – used
o When vertical releasing incisions are occasionally to approach the root apex.
necessary, only a single vertical o Avoids trauma to the papilla and
incision is usually needed (made at gingival margin but provides limited
the anterior end of the envelope access
component) o Most useful for periapical surgery a
o Vertical releasing incision in not a limited extent
straight vertical incision but is oblique
o Vertical releasing incisions should
cross the free gingival margin at the
line of a tooth and should not be
directly on the facial aspect of the
tooth, nor directly in the papilla

4. Y INCISION – used on the palate

o Removal of palatal torus
o Anterolateral extensions of the midline
TYPES OF MUCOPERIOSTEAL FLAPS incision are anterior to the region of
the canine
1. SULCULAR INCISION = VERTICAL
RELEASING INCISION = THREE
CORNERDED FLAP
- Corners at the posterior end of the
envelope incision, at the inferior of the
vertical incision, and at the superior aspect
of the vertical releasing incision.
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
DEVELOPING A MUCOPERIOSTEAL FLAP

• First step: incise the soft tisse to allow

reflection of the flap
• No. 15 blade on No. 3 scalpel handle held
in a pen grasp
• Blade is held at a slight angle to the tooth
and is made towards the operator
• One smooth continuous stoke while
keeping the knife blade in contact with
bone

• Consider changing blades between

incision (the blade dulls rapidly when it is
pressed against bone)
• If a vertical releasing incision is made,
tissue is apically reflected, with the
opposite hand tensing the alveolar
mucosa.
• Reflection of the flap begins at a papilla
o Sharp end is slipped underneath
the papilla in the area of incision
and is turned laterally to pry the
papilla away from the underlying
bone
o Broad end is used to reflect the
mucoperiosteal flap to the extent
desired.
• Periosteal elevator can then be used as a
retractor to hold the flap in its proper
reflected position
• Retractor is held perpendicular to the bone
tissue while resting on sound bone and
not trapping soft tissue between the
retractor and bone
• Seldin, Minnesota or Austin retractors
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
PRINCIPLES AND TECHNIQUES FOR OPEN better mechanical advantage and
EXTRACTION grasp the root.
c) Use a straight elevator, pushing it
• A technique that should not be used for down the PDL space of the tooth
extreme situations d) Proceed with surgical bone
• Can be more conservative and causes removal
less operative morbidity compared with a
closed exo.

Technique for Open Extraction of Single-Rooted

Indications for Open extraction Tooth
1. General guidelines: consider performing • Width of the buccal bone that is removed
an elective surgical extraction when you is the same width as the tooth in MD
anticipate the possible need for excessive dimension
force to extract a tooth • In vertical dimension, bine should be
2. After initial attempts at forceps extraction removed approximately ½ or 2/3 the
have failed length of the root
3. Thick and dense bone • A small straight elevator or forceps can be
4. Very short clinical crowns with evidence of used to remove the tooth
severe attrition
5. Hypercementosis
6. Widely divergent roots (especially
maxillary first molar roots
7. Severe dilaceration
8. Teeth “in” the floor of the maxillary sinus
9. Crowns with extensive caries (especially
root caries) or with large amalgam
restorations

Techniques for Open Extraction of Single-Rooted

Tooth

• Provide adequate visualization and

access- reflect a sufficiently large
mucoperiosteal flap
• Determine the need for bone removal
a) Attempt to reseat the forceps
under direct visualization – better
mechanical advante and remove
the toot hwith no surgical bone
removal
b) Grasp a bit of buccal bone under
the buccal beak of the forceps
(alveolar purchase)- obtain a
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
• If the tooth is still difficult to extract even TECHNIQUE FOR OPEN EXTRACTION OF
after removal of bone, a purchase point MULTIROOTED TEETH
(3mm in diameter and deep enough to
allow insertion of an instrument) can be • Generally, the same technique for single-
made in the root with the bur at the most rooted tooth is used
apical portion of the area of the bone • Major difference: tooth may be divided
removal. with a bur -> convert a multirooted tooth
• A heavy elevator can then be used ti into 2 or 3 single-rooted teeth
elevate or level the tooth
• Soft tissue is repositioned and sutured

• Check bone edges: use bone file to

smoothen sharp edges
• Irrigation with copious amounts of sterile
saline
o Special attention should be
directed at the most inferior
portion of the flap
o If debris is not removed, it can
causes delayed healing/
subperiosteal abscess
• Flap is then set in its original position and
sutured
o 3-0 black silk or chromic sutures
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
2. Excellent suction (with suction tip
of small diameter
• Closed technique for root tip removal –
any technique that does not require
reflection of soft tissue flaps and removal
of bone
• Closed techniques are useful when tooth
was well luxated and mobile before the
root tip fractures
• Strong apical pressures should be avoided

• Displacement of root tips into the maxillary

• The surgeon’s hands must always be
• Two main open techniques used for
REMOVAL OF ROOT FRAGMENTS AND TIPS
sinus can occur in the maxillary premolar
and molar areas.
supported on an adjacent tooth or a solid
bony prominence -> allows the surgeon to
deliver carefully controlled force and
decrease the possibility of displacing tooth
fragments or instrument tip into an
unwanted place.
surgical removal of a single-rooted tooth
1. Simply an extension of the
technique used for surgical removal of a
single-rooted tooth.
2. Open-window technique- a soft
tissue flap is reflected; apical area of the
tooth fragment is located. A dental bur is
used to remove bone overlying the apex to
expose the RF. Root tip pick or small
elevator is inserted in the window. Tooth is
guided out of the socket.

• If fracture of the apical 1/3 (3-4mm_ of the

root occurs during a closed extraction, it
must be removed.
• Initial attempts by closed techniques but if
unsuccessful, surgeon should begin a
surgical technique
• Two requirements:
1. Excellent Light
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
JUSTIFICATION FOR LEAVING ROOT
FRAGMENTS
• Risk is considered to be greater if one of
the following conditions exists:
1. Risk is too great if removal of the root will
cause excessive destruction of
surrounding tissue (excessive amounts of
bone must be removed to retrieve the rot)
2. Risk is too great if removal of the root
endangers important structures (IAN at the
mental foramen or along the course if the
inferior alveolar canal)
3. Risks outweigh the benefits if attempts at
recovering the root tip highly risk
displacing the root tip into tissue spaces or
into the maxillary sinus.
MULTIPLE EXTRACTIONS
• If multiple adjacent teeth are to be
extracted at a single setting, slight
modifications of the routine exo procedure
must be made to facilitate a smooth
transition from a dentulous to an
edentulous state that allows for proper
rehabilitation with a fixed or removable
prosthesis.
TREATMENT PLANNING
• Pre-extraction planning
• Include consideration of a need for any
other type of soft tissue surgery (tuberosity
reduction or removal of undercuts or
exostoses in critical areas0
• Dental implants – limit bone trimming and
socket compression
EXTRACTION SEQUENCING
• Maxillary teeth be removed first
- An infiltration anesthetic has more rapid
onset and also disappears more rapidly.
- Debris may fall into empty sockets of
lower teeth if mandibular surgery is
performed first.
- Maxillary teeth are removed wit ha major
component of buccal force
- Single minor advantage for extracting
maxillary teeth first – if hemorrhage is not
controlled in the maxilla, the hemorrhage
may interfere with visualization during
mandibular surgery.
- Tooth removal usually begins with exo of
the most posterior tooth first -> more
effective use of dental elevators to luxate
and mobilize teeth before forceps are
used to extract the tooth
- Tooth that is most difficult to remove –
canine - should be extracted last
- For example, if the teeth in the maxillary
and mandibular left quadrants are to be
extracted the following order is
recommended:
1. Maxillary posterior teeth
2. Maxillary anterior teeth, leaving
the canine
3. Maxillary canine
4. Mandibular posterior teeth
5. Mandibular anterior teeth, leaving
the canine
6. Mandibular canine
TECHNIQUES FOR MULTIPLE EXTRACTIONS
• A slight modification of techniques used to
removed individual teeth
 ORAL SURGERY: SURGICAL TOOTH EXTRACTION AND MULTIPLE
EXTRACTIONS
4TH YEAR 2ND SEM FINALS
• Loosen the soft tissue attachment from the
tooth (soft tissue reflection is extended
slightly to form a small envelope flap to
expose the crestal bone only)
• Luxation using a straight elevator (do as
much luxation of all teeth before extracting
any of them, since the adjacent tooth can
be used to anchor against while luxating
without worry because anchoring tooth if
for exo as well)
• Delivery with forceps
• After extractions are completed,
buccolingual plates are pressed into their
pre-existing position with firm pressure
unless implants are planned.
• Soft tissues is repositioned, palpate the
ridges to check for any sharp bony
spicules
• Undercuts should be identified (for
RPD/CD)
• Bone rongeur is used to remove larger
areas of interference, bone file to smooth
any sharp spicules.
• Irrigation with sterile saline
• Soft tissue reapproximation