Transalveolar Extraction

A Clinical Presentation

1. TRANS ALVEOLAR EXTRACTION 1 st year PG student Oral and Maxillofacial Surgery Rama Dental college Hospital & Research Centre Kanpur. Dr Rudraprasad Chakraborty

2. INTRODUCTION This method of extraction comprises the dissection of tooth or root from its bony attachment. it often called the open or surgical method.

3. The surgical, or open, extraction technique is the method used for recovering roots that were fractured during routine extraction or teeth and cannot be extracted by the routine closed methods for a variety of reasons ……..Peterson To Define with…..

4. FACTORS THAT COMPLICATE THE EXTRACTION PROCEDURE 1. Crown 2. Roots 3. Bone 4. Diminished access 5. Adjacent/non-adjacent teeth 6. Adjacent vital structures 7. Prosthetic concerns

5. Grossly Decayed Crown

6. Severe crowding in the dental arch can limit access to the application of a forcep .

7. Significant exostoses can limit the amount of buccal bone expansion.

8. Teeth with unusual root morphology.

9. Root Canal Treated Tooth

10. Abnormal root morphology

11. Fusion of two mandibular premolars.

12. Ankylosis

13. Dilacerated root

14. Increased bone density around root

15. Internal resorption of tooth

16. The technical goals to be achieved 1. To improve the access 2. To achieve mechanical advantage 3.To reduce resistance 4.To correct an inadequate path of withdrawal.

17. 1. Improved access: This is done by raising a mucoperiosteal flap and adequate bone removal 2. Improved mechanical advantage: This is achieved by bone removal and preparation of purchase point

18. 3. Reduce resistance: This is achieved by removal of bone support and sectioning of teeth ( Odontectomy ) 4. Correct path of removal: This is achieved by removal of bone and sectioning of teeth.

19. principles involved during surgical removal of teeth: 1. Flap design 2. Bone removal 3. Sectioning teeth 4. Wound closure.

20. PRINCIPLES OF FLAP DESIGN The general indications for flap reflection include the following: • To allow for complete access and visualization of the surgical field. • To allow for bone removal and tooth sectioning. • To prevent unnecessary trauma to soft tissue and bony structures.

21. The term local flap indicates 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, and (5) can be maintained with sutures and is expected to heal.

22. Types of flap A. i . Full Thickness Mucoperiosteal Flap ii. Partial Thickness Flap B. i . Envelope Flap ii. Two Sided Triangular Flap iii. Three Sided Rhomboid Flap iv. Semilunar Flap C. i . Labial or Buccal Flap ii. Palatal or Lingual Flap

23. Types of Incisions Horizontal Internal bevel incision—starts at distal area from the margin and is aimed at bony crest. This is also known as first incision. Crevicular incision—starts at the bottom of the pocket and is directed to the bony margin. This is known as second incision.

24. Vertical --- also called as releasing incisions, on one or both the sides of the flap. • Double vertical incisions on both sides of the flap will result in trapezoidal flap The incisions should extend beyond mucogingival line reaching the alveolar mucosa to allow the release of a flap for reflection • Vertical incisions should be placed at obtuse angle to the horizontal incision and should leave interdental papillae intact.

25. A trapezoidal or four-cornered flap. The base of the flap ( doubleended blue arrow) should be wider than the coronal aspect of the flap

26. The Incision When making an incision, the #15 blade should be carried down to the bone in a full-thickness fashion.

27. Semilunar (curved, elliptical) This type of incision is used, when it is desirable to maintain the attached gingiva intact around the teeth and for endodontic surgery.

28. Avoid releasing incisions in the area of the mental nerve, as depicted here.

29. Avoid making a releasing incision too close to or directly over the area of the extraction.

30. Releasing incisions should be 6–8mm anterior and/or posterior to the extraction site.

31. Envelope flap. Ideally, this type of flap should be extended one tooth posterior and two teeth anterior to the one being extracted in order to provide adequate reflection with minimal tension on the flap.

32. The Extraction Techniques

33. TECHNIQUE FOR SURGICAL EXTRACTION OF A SINGLE-ROOTED TOOTH A forcep is shown being used to remove the root with a small portion of the alveolus.

34. Bone Removal Postage Stamp Technique for Transalveolar Extraction

35. Wedge principle

36. The placement of purchase point should be placed close to the level of the bone. should be deep enough to allow for placement of a Crane pick. Enough tooth structure (3 mm) should be left coronal to the purchase point to prevent tooth fracture during elevation.

37. TECHNIQUE FOR SURGICAL EXTRACTION OF A MULTIROOTED TOOTH A multirooted tooth can be divided with a bur to convert it into multiple single rooted teeth to facilitate its removal.

38. The tooth is sectioned with a fissure bur on a surgical drill. The sectioning should extend into the furcation area and about three quarters of the way through the tooth in a bucco -lingual dimension—avoiding the lingual plate. Note the cut extending into the furcation area (red arrow).

39. The area is irrigated, especially under the flap, and then sutured.

40. Leave enough coronal tooth structure for extraction of the roots.

41. Indications for Leaving a Root Tip 1—Small root tip less than 4 mm in size 2—No evidence of periapical pathology or infection associated with root tip 3—Inability to visualize root tip 4—Removal of root tip will cause destruction to adjacent structures 5—Proximity to the inferior alveolar nerve 6—Proximity to the maxillary sinus 7—Ill-feeling patient 8—Uncontrolled hemorrhage

42. Principles of Flap Closure When the surgical procedure is completed and the surgical site has been irrigated, the flap can be sutured. Suturing the flap holds it in position and reapproximates the wound margins.

43. The Horizontal Mattress suture

44. Closure of a three-corner flap. The releasing incision is closed first to reorient the tissue.

45. Common Mistakes during Surgical Extractions Attempting a simple forcep extraction. Poor flap design, Inadequate reflection of a flap, Use of uncontrolled force, Inadequate seating and adaptation of the forceps, Attempting the removal of root tips without adequate access and visualization, Inadequate irrigation of the surgical site prior to reapproximation of the flap, Poor reapproximation of the flap.

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