Complicated exodontia

Complicated Exodontia
Copyright by Linn Pe Than
Department of Oral & Maxillofacial Surgery
University of Dental Medicine

1. COMPLICATED EXODONTIA Linn Pe Than Department of Oral & Maxillofacial Surgery University of Dental Medicine

2. ASA – American Society of Anesthesiologists established in 1940 , modified in 1961 System of classifying patients according to their physical status and guiding judgement decisions ASA I – Normal healthy patient ASA II – A patient with mild systemic disease that does not interfere with day to day activity or that has a significant health risk factor ASA III- A patient with moderate to severe systemic disease that is not incapacitating but that may alter day-to-day activity; may have significant drug concerns; may require special patient care; would generally require dental management alterations ASA IV- A patient with severe systemic disease that is a constant threat to life; definitely requires dental management alterations; best treated in special facility ASA V – Moribund , not expected to live 24hrs regardless of operation

3. ASA II , III , IV – consultation , specialist opinion Fit to do extraction /surgery - justification

4. PMH – Past Medical history any hospitalization Where? , When? , Why? How ? medical/surgery , GA , LA What ? procedure , complications any medication any illness health status any complication with the previous dental treatment –

5. Check vital sign BP PR RR Temperature

6. Extraction techniques ; Closed Open

7. Techniques Closed type of exodontia ; Simple or forceps technique Open type of exodontia ; Surgical or flap technique , Complicated exodontia

8. Closed type of exodontia ; Simple or forceps technique Primary consideration for almost every extraction. Intra- alveolar extraction which require either forceps or elevator without surgical flap

9. Procedure of closed extraction ; Step 1 : Loosening of soft tissue attachment from the cervical portion of the tooth . Step 2: Luxation of the tooth with a dental elevator . Step 3: Adaptation of the forceps to the tooth . Step 4: Luxation of the tooth with the forceps Step 5: Removal of the tooth from the sochet .

10. Open type of exodontia ; Surgical or flap technique , Complicated exodontia Trans-alveolar extraction is commonly known as surgical extraction or open extraction of tooth The method is employed when forceps extraction is not possible due to various difficulties

11. Generally if a tooth fracture during a regular extraction, surgical approach is necessary to remove the root fragment The reflection of an adequate muco-periosteal flap for adequate access and visualization of the field of surgery The Ostectomy ( removal of bone) or/and Odontectomy ( coronal and root section) is for an unimpeded pathway for removal of the tooth

12. Alveolar purchase is when the crest of the alveolar bone is purchased by the forceps along with the coronal portion of the root

13. Complicated exodontia Surgical / open extraction

14. removal of most erupted teeth can be achieved by closed or forceps delivery surgical or open extraction is the method used for recovering roots that were fractured during routine extraction or tooth/teeth that can not be extracted by the routine closed methods for a variety of reasons

15. to evaluate carefully each patient and each tooth to be removed for the possibility of an open extraction most of them will be perform a closed extraction the surgeon must be aware that, in some situation, open extraction may be less morbid than closed method

16. Indications for surgical extraction as a general guide line, surgeon should consider surgical extraction when they perceive a possible need for excessive force to extract a tooth the term “excessive” means that the force will probably result in a fracture of bone , a tooth root or both excessive bone loss, need for additional surgery to retrieve the root or both, can cause undue morbidity

17. preoperative assessment reveals that the patient has heavy or especially dense bone ( especially dense buccal cortical plate in old age adequate expansion is less likely to occur) a patient who has very short clinical crown with evidence of severe attrition ( may be because of bruxism or a grinding habit, it is likely that the teeth are surrounded by dense heavy bone with strong periodontal ligament attachment )

18. careful review of preoperative radiograph may reveal tooth roots that are likely to be cause difficulty such as hypercementosis, widely diverged root, .. in relation to the surrounding anatomical structure, such as maxillary molar teeth which are too near to the maxillary antrum ( can reveal by radiograph ) crown with extensive caries especially root caries, very large amalgam restoration ( if there is extensive periodontal disease around such tooth, it may possible to deliver easily by means of closed method)

19. Principle of flap design, development, and management What is Flap? is outlined by a surgical incision carries its own blood supply allows surgical access to underlying tissues can be replaced in the original position can be maintained with sutures and is expected to heal

20. Design parameters for soft tissue flap base of the flap must be broader than the free margin to preserve an adequate blood supply adequate access full-thickness muco-periosteal flap incisions must be made over intact bone avoid injury to local vital structures releasing incision should be used only when necessary and not routinely

21. Types of muco-periosteal flap envelope flap (*) three-cornered flap ( envelope incision with one vertical releasing incision ) (*) four-cornered flap ( envelope incision with two vertical releasing incisions ) semi-lunar flap Y incision flap (useful on the palate ) pedicle flap

22. Technique for developing a mucoperiosteal flap to incise a soft tissue to allow reflection of the flap ( no 15 blade is used on the no 3 scalpel handle and in is held in the pen grasp) incision is made posterior to anteriorly by drawing the knife toward the operator one smooth continuous stroke keeping the blade in contact with bone through out the entire incision scalpel blade is extremely sharp, but it dulls rapidly when it is pressed against bone

23. if the vertical releasing incision as made , the tissue is apically reflected , with the opposite hand tensing the alveolar mucosa so the knife will incise cleanly through the mucosa without jagged incision reflection of the flap begins at the interdental papilla with the sharp end of the periosteal elevator the broad end is used to reflect the mucoperiosteal flap to the desired extent with pushing stroke towards posteriorly and apically

24. once the flap has been reflected , the periosteal elevator is used as a retractor to hold the flap in its proper reflected position the retractor is held perpendicular to the bone while resting on the sound bone without trapping soft tissue between retractor and bone the retractor should not be forced against the soft tissue in an attempt to pull the tissue out of the field

25. Principle of suturing once the surgical procedure is completed, the wound should be properly irrigated and debrided the surgeon must return the flap to its original position by means of suturing ( mostly used simple interrupted suture during complicated exodontia - can be placed relatively quickly and suture can be adjusted individually, and , if one suture is lost the remaining sutures stay in position ) the sharper the incision, the less trauma inflicted on the wound margin, the wound will be probably healed by primary intention ( if the space between two wound edges is minimal )

26. sutures also aid in hemostasis if the underlying tissue is bleeding , result in the formation of a haemtoma the suture must be placed on the sound bone (if not, wound dehiscence can be occurred ) overlying tissue should never be sutured tightly in an attempt to gain haemostasis in a bleeding tooth socket

27. a special stitch such as a figure of eight , can provide a barrier to clot displacement ( but it plays a minor role in maintaining the blood clot in the tooth socket

28. Armamentarium needle holder (15 cm in length and has a locking handle ) suture needle ( a small 3/8 to 1/2circle with a reverse cutting edge which helps the needle pass through the relatively tough mucoperiosteal flap or in some occasion, round body )

29. Resorbable sutures gut – plain ( strength can stay for 5 days) and plain gut with basic chromium salt (chromic gut – strength can stay for 7 to 9 days), rapid digestion by proteolysis enzyme, produced by inflammatory cells polyglycolic acid and polyglactin, does not enzymatically breakdown, they under go slow hydrolysis, eventually being resorbed by macrophages polyglycolic and polyglactin are less stiff , much longer in stay and more costly than gut

30. Non-resorbable sutures silk (multi-filaments) polyester (multi-filaments) polypropylene (mono-filaments ) nylon ( both mono and multi-filaments ) multi-filaments form increases the strength of the suture, but also increases suture abrasiveness and more likely to allow bacteria to harbor into the wound

31. suture size varies the inscreasing number of 0’s correlates with decreasing suture diameter and strength most oral and maxillofacial surgeons use 3-0 or 4-0 suture

32. suture are usually not placed across the empty tooth socket when approximating the flap, the suture is passed first through the mobile (usually facial) tissue the experienced surgeon may be able to insert the needle through both sides of the wound in single pass, however, it is best to use two passes in most situation

33. the needle should enter of the surface of the mucosa at a right angle, to make the smallest possible hole in the mucosal flap the minimal amount of tissue between the suture and the edge of the flap should be 3 mm usually , they are tied with an instrument tie in oral and maxillofacial surgery

34. the purpose of the stitch is merely to re-approximate the incised tissue, and therefore the suture should not be tied too tightly (there should be no blanching of the mucosa) sutures that are too tight cause ischemia of the flap margin and result in tissue necrosis with tearing of the suture through the mucosa the knot should be positioned to the side of the incision why fall over the incision causes additional pressure on the incision

35. the sutures are left in placed for approximately 5 to 7 days ( after that no useful role and probably increases the chance of contamination of healing wound ) when sutures are removed the surface debris that collected on them should be cleaned off with peroxide, chlorhexadine, iodophor… the suture is cut with sharp, pointed suture scissors and removed by pulling it towards the incision line (not away from the suture line)

36. Techniques for complicated exodontia Technique for open extraction of single rooted tooth Technique for surgical removal of multi-rooted tooth Technique for removal of small root fragments and root tips Technique for multiple extraction

37. Technique for open extraction of single rooted tooth single rooted teeth that have been resisted attempts at closed extraction have fractured at the cervical line

38. to provide adequate visualization and access by reflecting a sufficiently large mucoperiosteal flap if you choose envelop flap, up to two teeth anterior and one tooth posterior to the extraction side if releasing incision is necessary, should be placed one tooth anterior to extraction side

39. the surgeon must determine the need for bone removal or not once adequate flap has been reflected, we can choose one of the following technique: surgeon may attempt to reseat the extraction forceps under direct visualization, remove the tooth with no bone removal to grasp a bit of buccal bone under the buccal beak of the forceps to obtain a better mechanical advantage and grasp the root ( only small amount of buccal bone is pinched off, without any additional bone removal)

40. to use the straight elevator as a shoehorn elevator with controlled force , down to the periodontal ligament space of the extracted tooth ( with finger rest to prevent slippage of the elevators ) bone removal over the area of tooth by using bur or chisel (approximately 1/2to2/3 of the length of root

41. bone edge should be checked, if sharp, they should be smoothed with bone file ( rongeur is rarely indicated why it tends to remove much more bone ) surgical field should be thoroughly irrigated with copious amount of normal saline

42. Technique for surgical removal of multi-rooted tooth the major difference from the single rooted tooth is that, the tooth may be divided with a bur to convert a multi-rooted tooth into several single rooted tooth once the tooth/root is sectioned, it is luxated with straight elevators to begin the mobilization process however, in most situation, small amount of crestal bone should be removed

43. Removal of small root fragments and root tips initial attempts should be made to extract the root fragment by a closed technique (that does not require reflection of soft tissue flap and removal of bone) begin a surgical technique if the closed technique is not immediately successful whichever technique is chosen, have an excellent light and excellent suction

44. closed technique is more useful when the tooth was well luxated and mobile before the root tip fractured a root tip pick (delicate instrument ), which is inserted into the periodontal ligament space, act like a wedge neither excessive apical or lateral force should be applied to the root tip pick excessive apical force which could result in displacement of the root tip pick into other anatomic location, such as the maxillary sinus excessive lateral force could result in the bending or fracture of the end of the root tip pick

45. endodontic files can be used in certain situation visualization is impotence and appropriate size of an endodontic file must be selected shank of the file is gripped with a needle holder, which is used as a lever to lift the root fragment from the socket the tooth that is used as the fulcrum should be protected with a gauze or cotton wool not useful for removing the root tip with non visible canal, hypercementosed root fragment, bony interference…..

46. also can be removed with small straight elevator used as a shoe horn similar to that of the root tip pick the surgeon’s hand must always be supported on the adjacent tooth or solid bony prominence ( like a finger rest ) always used controlled force

47. if the closed technique is failed, the surgeon should switch without delay to the open technique two main technique after soft tissue flap was reflected, almost always, buccal bone is removed with a chisel or bur to exposed the buccal surface of the tooth root, then, the root is delivered bucally open window technique is, soft tissue flap was reflected, dental bur is used to remove the bone overlying the apex of the tooth, and, an instrument is inserted into widow and the root is displaced out of the socket ( three cornered flap is preferable )

48. Policy for leaving root fragments three conditions must exist for a tooth root to be left in the alveolar process the root fragment must be small, not more than 4 to 5 mm in length the root must be deeply embedded the involved tooth must not be infected, no radiolucency around the root apex

49. must be balanced risk and benefit if removal of the tooth root will cause excessive destruction of surrounding bone if removal of the tooth root endangers vital structure root tip can displaced into tissue spaces or anatomical structure such as maxillary sinus

50. the patient must be informed that, the surgeon’s judgment, leaving the root in its position will do less harm than surgery must be recorded in the patient chart with radiographic documentation must be recalled contact the surgeon immediately , should any problems develop

51. Multiple extraction if multiple adjacent teeth are to be extracted at a single setting, slight modification of routine extraction procedure to facilitate smooth transition from a dentulous to an edentulous state

52. maxillary teeth should be removed first for following reasons an infiltration anaesthetic has a more rapid onset during the extraction process debris may fall into the empty socket of lower teeth, if the lower surgery is performed first minor disadvantage is , that if haemorrhage is not well controlled in the maxilla, the haemorrhage may interfere with visualization during mandibular extraction

53. extraction begins with the most posterior tooth first (not only allow for collection of blood but also allow for more effective use of dental elevators to luxate and mobilize the tooth the two teeth that are most difficult to remove , first permanent molar and canine, should be extracted last

54. soft tissue reflection is extended slightly to form a small envelop flap just to expose the crestal bone only teeth are luxated with straight elevator and delivered with forceps in usual fashion is likely to require excessive force, the surgeon should remove small amount of buccal bone to prevent fracture and bone loss

55. after extraction, the lingual plate and buccal plate are pressed together with firm pressure soft tissue is repositioned palpate the ridge to determine if there are any area of sharp bone spicules or obvious undercut excess granulation should be excised inspect for excess gingiva after extraction, the gingiva should be trimmed, so that no overlap occurs if there is no redundant tissue, not try to gain primary closure, which leading the depth of vestibule is decreases, that may interfere denture construction interrupted or continuous sutures are usually used

56. Thank you for your kind attention