Complicated
Exodontia
AGD Las Vegas 2017.
Patient
Evaluation
and
Work-up
Identifies
Risk of Treating
the
Patient
Radiographic Examination■ The radiographic evaluation is an important
part of the extraction or surgical workup
● There is an absolute need for
- Current radiographs
- Diagnostic radiographs
- If you need one…take one
■ The radiographic exam
● Identifies clinically important factors only
observable on the radiograph
● Factors which will have impact on the extraction
of the teeth.
● How the teeth need to be extracted
Overall Planning■When you are performing surgical
procedures………..You have to think
like a surgeon
■There are no double standards
●The General Dentist must perform to
same standard as the Specialist
Overall Planning■ Make your plan to address the worst case
scenario
● Then you will be prepared for that and anything less
● Transitions will be seamless
■ If you don’t have that mindset, transition to
plans B, C, D……may be difficult, time
consuming, and awkward
● Patients who are wide awake can tell
● Often creates scenarios where referrals are needed
Armamentarium■ Surgical sets
● Basic vs. Complicated
● Anesthesia syringe
● Scalpel
● Periosteal elevator
● Tissue retractor
● Elevators
● Appropriate forceps
● Curettes
● Bone files
● Tissue pick ups
● Needle holder (suturing)
● Scissors
■ Additional Instrumentation● Surgical handpiece
Burrs
Irrigation
● Surgical suction tips
● Yankaur suction tips
● Irrigation setup
syringe and tips
● Appropriate sutures
● Hemostats
● Biteblocks
● Guaze
Armamentarium■ Standard Sets are ideal
● A standard basic se
● A standard complex surgery set
● All basic instrumentation will be included
Have other anticipated instruments in the room
● Smoother transitions when “problems: arise
■ Less time spent getting other instrumentation
● Kills the “flow”
● Less delays in the procedure, less chair time
■ Patients catch on quickly when you are not prepared
● Lots of leaving the room, calling for instruments
Dentoalveolar Surgery
To remove any tooth in the
mouth, the surgeon needs
three things:
Good visibility
An unimpeded path of removal
Controlled force.
These factors will be
addressed individually;
Good Visibility
■ Includes all factors which will allow the
operator to see his/her surgical site and be
unimpeded while working.
●Good light whether it is overhead or through
headlight, use of loupe magnification may be
utilized
●Good assistant who is able to anticipate and
move with the operator
Good Visibility
● Good suction to keep the site free from ooze,
hemorrhage, and secretions
Improving visibility and patient comfort,
● The use of flaps when indicated to temporarily
reposition soft tissues
Improving visibility of the teeth and surrounding bone.
● The use of flaps to better expose teeth and fully
expose the underlying bone
The ability to reapproximate flaps and soft tissues are
critical skills that the surgeon must have.
Flap Design ■ Base must be larger than it’s free margins
● All areas of the flap must have an uninterrupted blood supply
■ Flap must be of adequate size● Provide necessary visualization of the area
● Instrument access
■ Flap should be full thickness
■ Flap margins should be made over intact bone which will be present after the procedure● Avoids flap collapse into wound
● Dehiscence
● Delayed healing
■ Flap must avoid injury to local vital structures● Lingual nerve
● IAN
● Greater palatine
Flap Design
■ Flap must be held out of operative field by a retractor resting on bone
■ The flap must be held without tension
● Sharp incisions heal more rapidly than torn tissue
● Flap length should extend 2 teeth anterior and one tooth posterior
■ Releasing incisions should be 1 tooth anterior and 1 tooth posterior to surgical site
● Releasing incisions should not cross prominences
● Releasing incisions should cross free gingiva at line angles
Mucogingival Flaps
■ Types of flaps:
●Envelope/sulcular incision
●Envelope with one releasing incision
- Three corner flap
●Envelope with two releasing incisions
- Four corner flap
●Semilunar flap
●Y-incision flap
●Pedicled flap
Full Thickness Mucoperiosteal Flap
An Unimpeded Path of Removal
■ Refers to actions taken by the operator which will
allow for the tooth or portions thereof to move in the
desired direction as luxating or elevating forces are
applied.
■ Such actions include use of rotary instruments (surgical
handpieces) with burrs to trough the alveolar bone
around the teeth and interproximally
■ Sectioning of multi-rooted teeth to obtain several
single roots
An Unimpeded Path of Removal
■ Placing of “purchase points” in the roots of teeth to
facilitate better engagement of the tooth with the
surgical instrument
■ Also included in this principle are actions which will
provide or restore mechanical advantage and regain
“handles”.
■ When teeth fracture during extraction, the remaining
portion of the tooth is frequently left below the height
of the ridge, where there are no “handles” to engage to
continue the extraction.
Surgical handpiece Unit
Self irrigating
Rear air discharge
• Electric
• Gas
• Air
Straight attachment
Contra-angle
450 Surgical handpiece
Surgical Handpiece and Burrs
703 typical burr size
Removes much bone
Maybe too large for more detailed bone manipulation
702 Burr
Removes less bone
Allows for more detailed removal of bone
701 burr
Consider when working near adjacent roots
Gives most amount of leverage with elevators
Provides most conservative and detailed approach
Surgical Handpiece and Burrs
Acrylic burs
Surgical Handpiece and Burrs
An Unimpeded Path of Removal
■ Using the rotary instrument with burr to remove
facial, buccal, lingual, or palatal bone will re-
expose tooth structure which may then provide
“handles” which can then be engaged with
extraction instruments.
■ Use of troughing and purchase points should
also be considered to regain mechanical
advantage.
Controlled Force
■Fact: Knowing how much force is too
much takes repetitions and experience
●Common sense should prevail to know
when too much force is applied to the
extraction site…and STOP
●Busy elbow syndrome
■Finesse not force
Controlled Force■ Something undesirable will occur most of the
time● Fracture of the buccal plate
● Fracture of the tooth and roots
● Fracture of the tuberosity
● Fracture of the floor of the sinus with violation of the sinus
membrane
● Breaking of surgical instruments
Controlled Force
■ When an appropriate force is applied with no
movement of the tooth with several attempts,
the operator must change plans and move to a
surgical extraction
■ Using principles/techniques described above
● Troughing of bone
● Judicious removal bone
● Sectioning teeth or roots.
● Purchase points
● This will in most cases avoid the complications
mentioned above
Controlled Force
■ In today’s restorative climate the placement of
implants is in the minds of many the standard of
care in restoring form and function
● Maintaining all bone possible during an extraction is
critical.
■ When using uncontrolled force, with subsequent
fracturing of the buccal plate, implant placement
will be compromised.
THE END