Chapter 20: Complex Exodontia Flashcards
- complex exodontia is when which tooth extraction technique has to be used?
Open
The open or surgical extension technique is a method used when?
Greater access is necessary to safely remove a tooth or it’s remaining tooth
Surgical steps of complex exodontia?
- Incision
- Flap reflection
- Bone removal/ osteotomy
- Root sectioning
- Smoothing
- Suturing
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The flaps are:
- outlined by?
- carries?
- allows?
- can be ?
- maintained with?
- Outlined by a surgical incision
- Carries its own blood supply
- Allows surgical access to underlying tissues
- Can be replaced in the original position
- Maintained with sutures
Advantages of complex exodontia?
- Wider surgical field
- Gain access: remove crestal bone, section the root
- Less traumatic than a long closed technique
- Better healing and postoperative than closed technique with lacerated or torn soft tissues
Indications of complex exodontia:
- Open extraction may be the less traumatic procedure in certain circumstances
- The surgeon anticipate the possible need for excessive force to extract a tooth
- After initial attempts at forceps extraction have failed
- Preoperative assessments: thick or dense buccacortical plate
- Short clinical crowns with evidence of severe attrition
- Hypercementosis: bulbous roots
- Widely divergent roots
- Roots with hooks
- Roots close or into the maxillary sinus
- Crowns and roots with extensive caries
- Unerupted teeth in abnormal position
- Erupted teeth in abnormal position
- Restored teeth that hinder the adaptation of the forceps
- Fractured roots
- Endodontic teeth
- Excessively restored teeth
- Ankylosis
- Bone sclerosis
- Alveolar bone hyper-condensation
Most common design of the mucoperiosteal flap?
New man incision
Design of the mucoperiosteal flap has to be?
- base should be?
- preserve
- full thickenss?
- over ?
- avoid?
- The base of the flap must be broader than the free margin
- Preserve blood supply: ischemic necrosis
- Full-thickness mucoperiosteal flaps: mucosa, submucosa and periosteum
- Incisions that outline the flap must be made over intact bone
- The flap should be designed to avoid injury to local vital structures
When are releasing incisions used?
When necessary and not routinely
Incisions factors?
- use?
- pressure?
- structures?
- method?
- Sharp scalpel
- Firm pressure
- Mucosa + submucosa+ periosteum
- Sufficient length at once
Bone removal:
- To expose root / tooth
- Facilitated by large flaps
- Provides point of application
- Remove all sharp edges and bone prominence
- Round / rose head provides less clogging, better control
- It doesn’t cut the tooth that easily
- Should not contact soft tissue
- Avoid overheating
Tooth sectioning:
- Different line of removal for different roots
- Divide the root from furcation area
- Make space for application of forceps or elevator
- can do it to preserve the buccal bone if you want to place an implant later for example, divide the tooth into two parts, easier, and then it’s like dealing with 2 single rooted teeth
Single rooted tooth steps:
- reflecting a mucoperiosteal flap
- bone removal
- surgical field
- flap replacement
Reflecting a mucoperiosteal flap can be either?
- envelope flap or releasing incision
Bone removal for single rooted teeth:
• Reseat the forceps under direct visualisation
• Grasp a bit of buccal bone under the buccal beak of the forceps
• Use the straight elevator pushing it down the periodontal ligament space of the tooth
• Surgical bone removal: bur
• Tooth removal
Surgical field of single rooted teeth:
• Bone edges: smoothed with a bone file. Palpate with a finger, Rongeur
• Irrigation with sterile saline
• Curettage and irrigation of the socket: debris
Flap replacement of single rooted teeth:
• Set in its original position
• Sutured into place with 3-0 black silk
• The suture line will be supported on healthy, intact bone
Multi-rooted teeth:
- The same surgical technique used for single-rooted tooth
- The tooth may be divided with a bur to convert a multi-rooted tooth into two or three single-rooted teeth
- Elevators and forceps are positioned with direct visualisation
- Small amount of crestal bone is removed
- Tooth sectioning: straight hand-piece with straight fissure bur
- Straight elevator: luxate and mobilise the sectioned roots
- Sharp bony edges: smoothed with a bone file
- The wound is thoroughly irrigated and debrided of loose fragments, bone calculus
- The flap is repositioned then fractured
Extraction of root fragments and tips:
- Closed extraction: fracture of the apical third of the root
- Initial attempts: closed technique
- Surgical technique: whenever the closed technique is not immediately successful
- Excellent light
- Excellent suction: small diameter
Extraction of fractured roots below the gingival margin?
• Soft tissue flap with a releasing incision is reflected
• Retracted with a periosteal elevator
• Bone is removed with a bur to expose the buccal surface of the root
• The root is buccally delivered through the opening with a small straight elevator
Extraction of root fragments impacted and underneath fixed prosthesis?
• Opening window technique:
Soft tissue flap is reflected
The tooth fragment is located
Bur is used to removed the bone overlying the apex of the tooth
Exposure the root fragment
Small elevator is inserted into the window
Post extraction care:
- Scrape carefully periapical region: debris, calculus, amalgam, tooth fragments
- Irrigation of the socket
- Compress the expanded buccolingual plates: finger pressure
- Palpation of the bone: check for any sharp bony projections
- Control of hemorrhage: moistened gauze over the extraction socket: bitting of teeth together ,Hemostasis
- Medication: anti-inflammatory, painkillers, antibiotics
- Avoid aspiring and corticosteroids
- Post-extraction instruction verbal and written:
• Keep the gauze 30-60 min
• Rest and avoid physical exertion
• Application of local ice 2-3 h
• Avoid rinse and brushing 1d
• Soft and cold diet 1d
• Rinse with saline next day
• No smoking
How to prevent surgical complications:
• Preoperative assessment
• Comprehensive treatment plan
• Careful extraction of the surgical procedure
Surgical procedure planning:
- Step 1 → Review of the patient’s medical history
- Step 2 → Radiographic evaluation:
• Entire area of surgery
• Apices of the roots
• Regional anatomic structures
• Abnormal tooth root morphology
• Ankylosis
• Alter the treatment plan - Step 3 → Preoperative planning
• Detailed surgical planning
• Surgical instruments
• Preoperative instructions and explanations for the patient: pain and anxiety and postoperative
recovery - Step 4 → Always follow basic surgical principles:
• Clear visualisation and access
• Light, retraction and reflection, suction
• Controlled force: finesse
• Asepsis
• Atraumatic handling of tissues
• Haemostasis
Local immediate complications include:
13:
1. Failure to achieve anaesthesia for tooth removal
2. Fracture of tooth
3. Root displacement
4. Tooth lost into the pharynx
5. Fracture or dislodgement of adjacent restoration
6. Luxation of adjacent tooth
7. Extraction of the wrong tooth
8. Soft tissues injuries
9. Injuries to the osseous structures
10. Injury to the regional nerve
11. Oroantral communications
12. Injury to the TMJ
13. Fracture of the surgical instruments
Fracture of the tooth (crown or root) can occur due to? And what method is indicated
• Grossly carious
• Tooth with endodontic treatment (more fragile, easy to break dentin)
• Improper application of forceps (beak should be parallel to the apex of the tooth)
• One point contact
• Slip off forceps
• Excessive force
• Hurry
• Tooth with divergent roots/hypercementosis
- trans alveolar method (open technique)
Root displacement:
- most common location of root displacement of maxillary molar root
Maxillary sinus
• Fractured root removed with a straight elevator that is being used with excessive apical pressure
• Size: several millimetres or entire root
• Root infected/periapical lesions
• Healthy sinus/chronically infected
Root displacement:
- most common location of root displacement of impacted maxillary third molar root ?
Maxillary sinus or infratemporal fossa
• The elevator may force the tooth posteriorly through the periosteum into the infra-temporal
fossa
• Retrieve the tooth with a haemostat
• Avoid further displacement
Root displacement:
- most common location of root displacement of mandibular third molar root ?
Submandibular space
• Mandibular third molars frequently have dehiscence in overlying lingual bone
• Fractured molar roots/apical pressures
• Avoid apical pressures
Other locations where the root might displace to?
- nasal fossa
- floor of the mouth
- mandibular canal
- zygomatic canal
- cheek
Tooth lost into the pharynx:
How should the patient be positioned and what should they do?
Patient positioning: position with the mouth facing the floor as much as possible
The patient should be encouraged to cough and spit the tooth out into the floor
Use the suction device
2 possibilities when the tooth is lost into the pharynx:
Tooth swallowed or aspirated
Tooth swallowed:
• No coughing or respiratory distress
• Tooth travels down the oesophagus into the stomach
• Pass through the gastrointestinal tract within 2 to 4 days
• Radiograph of the abdomen
Tooth aspirated:
• Violent episode of coughing/shortness of breath
• Tooth aspirated through the vocal cords into the trachea/main stem bronchus
• Removing the tooth with a bronchoscope
• Went into the larynx
Luxation of an adjacent tooth usually happens where?
- Mandibular incisor region (because the root is very thin, easy to break when you apply force
with an instrument)
Luxation of an adjacent tooth:
- Avoid forceps with broader beaks
- Detect adjacent teeth significantly luxated
- Reposition in the tooth socket and stabilise it
- Occlusion checked
If the dentist extracts the wrong tooth?
Replace quickly into the tooth socket
Inform the patient
Soft tissue injuries include:
- tear of mucosal flap
- puncture wound
- stretch or abrasion
Which of the 3 examples of soft tissue injuries is the most common?
Tear of the mucosal flap
Tear of the mucosal flap?
• Inadequate sized envelope flap
• Forcibly retracted beyond the ability of the tissue to stretch
• Prevention:
Creating adequately sized flaps to avoid excess tension on the flap
Using controlled amounts of retraction force on the flap
Creating realising incisions when indicated
Stretch or abrasion:
• Inform the patient
• Keep the area clean with regular oral rinsing
• Such wounds heal in 4-7 days
Injuries to osseous structures include?
Fracture of the alveolar process
Fracture of the maxillary tuberosity
Fracture of the wall of the maxillary sinus
Fracture of the mandible
Bone of older patients is less?
Elastic
If a fracture of the alveolar process occurs and the bone is removed from the tooth?
Dont replace, reposition the soft tissue
If a fracture of the alveolar process occurs and the bone remains attached to the periosteum?
Separate from the tooth
Leave attached to the overlying soft tissue
Fracture of the maxillary tuberosity might happen when extracting which tooth?
Maxillary third molar
Fracture of the maxillary tuberosity:
A. Splint the tooth to adjacent teeth and defer the extraction by 6 to 8 weeks, Surgical extraction
B. Section the crown from the roots and allow the tuberosity and tooth root section to heal, Surgical extraction.
Which nerves are frequently sectioned during the creation of flaps?
Nasopalatine and buccal nerves
When is there a change of injuring the mental nerve
Surgical removal of mandibular premolar roots
And if u section the nerve from the exit, sensation wont return
When is there a chance of injuring the lingual nerve or inferior alveolar nerve?
Mandibular third molar surgical extraction
Oroantral communications?
- when?
- sequelae?
- prevention?
- Removal of maxillary molars
- Sequalea: postoperative sinusitis/chronic oroantral fistula
- Prevention: preoperative radiographic examination/ surgical extraction and section roots/avoid excessive apical pressures
Injury to the TMJ ?
- when
- how to prevent
- treat?
- Removal of mandibular molar frequently requires the application of a substantial amount of force
- Adequate support of the jaw (bite block)
- Moist heat, resting the jaw, a soft diet, anti-inflammatories
- TMJ luxation/dislocation/reduction
Fracture of the surgical instrument ?
- due to?
- treatment?
Inadequate technique, excessive force, or surgical instruments in bad condition
Radiographic detection and immediate removal
