Oral Surgery II

Principles of Complex Exodontia

 1. Broader Base than the margin
Design
Parameters 2. Adequate Size

3. Full Thicknes Mucoperiosteal Flap

Goal:
4. Outline is over intact bone
Adequate Expore and 5. Avoid vital structures
Promote Healing
6. Use releasing incision when necessary

7. Releasing incision should not cross the

free gingival margin
Broader Base Than
The Free Marginal
Gingiva

• Preserve Adequate Blood Supply

• Prevent Ischemia
Adequate Size
• Visualization

• Proper Instrumentation

• Avoid applying tension

Full Thickness
Mucoperiosteal Flap
Epithelium or
Surface Mucosa

• Hastens Healing
Connective Tissue
or Submucosa
• Lessens Bleeding

Periosteum
Outline over intact
bone

• Avoid Dehiscence and

Delayed Healing

6 - 8 mm
Avoid Vital Structures

Mandible:
1. Lingual Nerve
2. Mental Nerve

Maxilla:
1. Greater Palatine Artery
 • Delayed wound healing
Use releasing incision only
• Wound Dehiscence
when necessary
• Vertical Clefting of the bone
Do not cross directly at the • Localized Periodontal problems
facial aspect, on bondy
prominences nor the papilla
 Types of Mucoperiosteal Flap
1. Envelope Flap 3. Four Cornered Flap

Note: The audio

continue up to slide
10

2. Three Cornered Flap 4. Semi-lunar Incision

Types of Mucoperiosteal Flap

5. Y Incision
Developing a Mucoperiosteal Flap

note: the audio

Step 1: Create your incision continues up to
slide number 13
Developing a Mucoperiosteal Flap

Step 2: Reflection of the flap.

Developing a Mucoperiosteal Flap

Step 3: Retraction of the reflected flap.

Principles of Suturing
Function
1. Coapt Wound Margins
2. Aid in Hemostasis
3. Holding soft tissue flap over bone
Armamentarium
Principles of Suturing
1. Suture should be passed first through mobile tissue.

2. Needle should enter the surface mucosa at a right angle.

3. Adequate tissue must be taken when the needle is passed through.

- a minimum of 3mm from the wound edge to the suture.

4. Do no tie the suture tigtly

5. When cutting the suture, only use the tip of the scissors

6. In a three cornered flap, start on the papilla of th releasing incision

 Note: This audio extends up to Slide 20

Indications for Open Extraction

1. When a possible use of excessive force is anticipated.

1.1 Initial attempt at forcep extraction

1.2 Pre-operative assessment reveals a thick or dense bone,
especially in the buccalcortical plate
1.3 Patient with evidence of severe attrition secondary to bruxism.
 Indications for Open Extraction
2. Careful review of radiograpgs reveal tooth roots that are likely to difficult.

2.1 Hypercementosis 2.2 Widely Divergent Roots 2.3 Dilacerated Roots

Indications for Open Extraction
2.4 Pneumatization and close approximation of the Maxillary sinus to
the roots fo the maxillary molars
Indications for Open Extraction
2.5 Extensive carious lesions, root carie or large amalgam restoration
 Technique for Open Extraction of Single-Rooted Teeth

Step 1. Provide adequate visualization and access

Reflect a full thickness mucoperiosteal flap

Option 3
Step 2. Option 1 Option 2

Note: This audio extends up to Slide 23

 Technique for Open Extraction of Single-Rooted Teeth

Step 2.

Option 4
Technique for Open Extraction of Single-Rooted Teeth

When it is stilll difficult to extract, creat a purchase point

Techniques for Open Extraction of Multirooted Teeth

Note: This audio extends up to Slide 26

Techniques for Open Extraction of Multirooted Teeth
 Techniques for Open Extraction of Multirooted Teeth

Please excuse the recording when I said “Use a number 17 forcep”For the forcep: When tooth is sectioned
in mesial and distal half, we are treating this as a mono rooted tooth so you can use your #150 or 151 forcep
to finish the extraction.
Techniques for Open Extraction of Multirooted Teeth
Techniques for Open Extraction of Multirooted Teeth
Techniques for Open Extraction of Multirooted Teeth
Techniques for Open Extraction of Multirooted Teeth
Removal of Root Fragment and Tips
• A fractured apical 1/3rd (3 - 4 mm )

• Inital attempts should begin with a Close Technique

• 2 Critical Factors that can affect the sucess of the removal

1. Excellent Lighting
2. Excellent Suction

Note: This audio extends up to Slide 32

 Remova of Root Fragment and Tips

Conditions affecting the success of a Close Technique

1. Tooth was no properly luxated and mobolized before the fracture.

2. A bulbous hypercemented root with bony interference is found

3. Sever dilaceration of the root end

The approach of the removal of the root tip
Step 1. Reposition the patient so that adequate visualization, irrigation
and suction can be achieved.

Step 2. Irrigate the socket vigorously and suction using a small tip

Step 3. Tease the root fragment with a root tip pick.

Note: This audio extends up to Slide 34
Step 3. Tease the root fragment with a root tip pick
Open Technique to Remove Root Tips
Step 1. Reflect a full thickness flap

Stpe 2. Buccal Ostectomy to

expose the tooth root

Step 3. Tooth is buccal delivered

through the opening

Step 4. Wound is irrigated,

reposition and sutured.
Open Technique to Remove Root Tips
Conditions to leave a root tip
1st Root fragment shoudl be small, no more than 4-5 mm in length.

2nd The root must be deeply embedded in bone and not superficial.

3rd The tooth must not be infected and there must be no radiolucency
around the apex.

Note: This audio extends up to Slide 39

Risk of surgery is greater under these
conditions
1. Removal of the root will cause execssive destruction around the
surrounding tissue .

2. When the removal of the root endagers important structures

- Inferior alveolar nerve

3. If the attempt at recovering the root tip highly risk displacing the
roots into tissue spaces or into the maxillary sinus.
Protocol in leaving a root tip
1. Inform the patient, and record the fact that the patient was infromed.

2. Radiographic documentation of the presence, position of the root tip and

recorded in the patient char.

3. Recall for several routine periodic follow-ups over the year to track the
condition of the tooth.

4. Instruct the patient to contact you when problems arise

Multiple Extraction
• Pre-extraction planning
• replacement of the teeth to be removed

• Communicate with the Restorative dentsit

• Interim and Complete Immediate Dentures
• Pre-prosthetic surgery
• Dental Implant
Extraction Sequence
 Maxillary Teeth before Mandibular Teeth
• Fast onset of anesthesia
• Falling debris; Portions of Amalgam, Fractured Crown and Bone Chips
Disadvantage
• Hemorrhage may interfere with the visualization of the mandibular surgery

 Posterior teeth to Anterior

 1) Maxillary Posterior teeth 2) Maxillary Anterior teeth 3) Maxillary Canine, 4)

Mandibular Posterior Teeth 5) Mandibular Anterior Teeth 6) Mandibular Canine
Technique in Multiple Extraction
1. Loosen Soft tissue
• Slightly extend this to form a small envelope flap to expose the crestal bone around the
quadrant
2. Luxate the teeth with straight evlevator

3. Deliver with forcep in the usual fashion.

4. If use of excessive force is anticipated, remove a small amount of

buccal bone
Technique in Multiple Extraction
5. Compress the buccolingual plates into their pre-existing position with
firm pressure .
• unless implants are intended

6. Inspect the ridge, palpate for any sharp bony spicules.

• Rongeur
• Bone File

7. Irrigate with a sterile saline solution

Technique in Multiple Extraction
8. Check for excess granulation tissue
• may prolong hemorrhage

9. Reapproximate the tissue and check for excess gingiva

• Trim to make sure no overlap occurs

10. The papillae is sutured into position

End of Lecture
Exam next meeting.