PRINCIPLES OF

COMPLICATED EXODONTIA

By
Dr. Tanzila Mushtaq
Demonstrator (OMFS)
 LOCAL FLAP
• A section of soft tissue that
• Out lined by surgical incison
• Carries its own blood supply
• Allows surgical acess to underlying
structure
• Can be placed to original position
• Can be sutured and is expected to heal
 DESIGN PARAMETERS FOR
SOFT TISSUE FLAPS
• Base of flap must broader than free
margin to preserve adequate blood supply
 DESIGN PARAMETERS FOR
SOFT TISSUE FLAPS
• Should be of adequate size for several reasons
– Adequate acess
– Easy flap reflection
– Long straight incision with adequate flap reflection heals rapidly than
short torn incison
– Envelop flap extend 2 teeth anterior & 1 tooth posterior to area of
surgery If releasing incision made than extension will be one tooth
anterior and one posterior to surgical area
 DESIGN PARAMETERS FOR
SOFT TISSUE FLAPS
• Full thickness muoperiosteal flap should
be taken.
• incision must be made over intact bone
that will present after surgical procedure is
complete.
• flap should designed to ovoid injury to
local anatomical vital stuctures.
• releasing incisions are used only when
necessary not routinely.
 DESIGN PARAMETERS FOR
SOFT TISSUE FLAPS
• vertical releasing incision should cross
free gingival margin should not directed on
the facial aspect of tooth nor directly in
papilla
• Incision must be carried out with a firdm
continous stroke nor intrupte stroke
TYPES OF MUCOPERIOSTEAL FLAP
ENVELOP FLAP
• In dentulous pt incision made in gingival sulcus to the
crestal bone through periosteum & full thickness flap
apically reflected
• Indicated when surgical procedure involves cervical line
of tooth
• ADVANTAGES
– Avoidance of vertical incison
– Easy approximation
• DISADVANTAGES
– Risk of end tearing
– Limited visualization
– Limited acess
– Possibility of injury of palatal vessels & nerves
– Defect in attached gingiva
Envelop flap
THREE CORNER FLAP (Triangular
flap)
• Envelop incison with one releasing incison
• Horizontal incison made along gingival sulcus & vertical
incison extending from vestibular fold to interdental
papilla to gingiva
• Indicated in surgical removal of root tips. Small cyst &
apicectomies
• ADVANTAGES
– Adequate blood supply
– Good stability & reproximation
• DISADVANTAGES
– Limited access to long roots
– Tension created while retraction
– Defect in attached gingiva
THREE CORNER FLAP (Triangular
flap)
 FOUR CORNER FLAP
(TRAPEZIODAL FLAP)
• An envelop flap with 2 releasing incison
• Mostly indicated for excessive surgical
procedure
• ADVANTAGES
– Excellent access
– Allows surgery to performed in one or more
teeth
• DISADVANTAGES
– Produce defect in attached gingiva
FOUR CORNER FLAP
(TRAPEZIODAL FLAP)
 SEMILUNAR FLAP
• Curved incision just beneath vestibular fold; convex part
toward attached gingival
• Lowest point of incison must be at least 0.5 cm from
gingival margin
• Indicated for apicectomy ;small cyst & root tip
• ADVANTAGES
– Small incison ;easy reflection
– No intervention at periodontium
– Easy 2 maintain oral hygiene
• DISADVANTAGES
– Limited acess
– Increase tendency to tear
– Possibility of incison performed right over lesion
SEMILUNAR FLAP
 FLAP RESULTING FROM Y
SHAPE INCISON
• Incison made along midline of palate as well as
2 anterolateral incison which are anterior to
canine
• INDICATIONS
– Removal for long exostosis
 PEDICAL FLAP
• Use occasionally on palate
• Mobilize from one area to another & fill
soft tissue defect
• Used to close oral antral fistula
 BUCCAL FLAP
• Result of 2 oblique incison that diverge
upward & extend as far as tooth socket
 PALATAL FLAP
• Used in edentulous
• Flap rotated posteriorly & bucally & place
over the orifice of socket
 PEDICAL BRIDGE FLAP
• Is plato buccal & perpendicular to alveolar ridge
• Flap rotated posteriorly or anteriorly to cover
orifice of OAF
• Used in edentulous part of alveolar ridge
 PRINCIPAL OF SUTURING
• Function of suturing
• Hold the flap in position & approximate two
wound edges
• Aids in hemostasis
• Help hold the soft tissue over bone
• Maintain the blood clot in alveolar socket
 ARMANTERIUM
• A needle holder
• The suture needle (small 3/8th- _ ½ circle)
• Most common needle shape of oral surgery are
fs-2 & x-1
 SUTURE MATERIAL
• RESORBABLE
– Gut
– Polyglycolic acid
– Polyglactan
• NON RESORBABLE
– Silk
– NYLON
– Polyester
– Polypropylene
 THINGS TO REMEMBER
• Needle should enter at right angle to flap to
make small possible hole in flap
• The minimal amount of tissue b/w suture & edge
of flap should be 3mm
• Suture should not tied too tightly
• There should be no blenching of wound edges
• In three corner flap vertical incison must be
closed separately
• Suture should placed for approx 5-7 days
 TECHNIQUES
SIMPLE INTRUPTED SUTURE
• The suture simply goes through one side of
wound comes through other side & is tied in a
knot at top
 CONTINOUS SUTURE
• For suturing wound that are superficial & long
• After passing needle through both flap initial knot made
free end cut; needle bearing suture used
• to create successive continuous suture at wound margin
PRINCIPLE & TECHINQUES FOR
SURGICAL EXTRACTION
INDICATIONS
• When initial attempt at forcep extraction failed
• Pt has dense & heavy cortical bone
• Short clinical crowns
• Hypercementosis of roots
• Widely divergent roots
• Maxilary sinus has expand to include roots of
maxillary molar
• Crown with extensive caries
ROOTMORPHOLOGY
 TECHNIQUES FOR OPEN
EXTRACTION
SINGLE ROOTED TOOTH
• Adequate flap reflection
• Access to need for bone removal
– Reseat extraction forcep
– Grasp a bit of buccal cortical bone in forcep to obtain better
mechanical advantage
– Forcing straight elevator down to PDL space of tooth
– Final option is to remove bone over the area of tooth in vertical
dimension bone removal is one half to two third of length of root
– If tooth is still difficult to out then purchase point made in apical
portion of bone removal crane pick then used for extraction
• Bone edge should inspected
• Wound irrigated
• Sutured
TECHNIQUES FOR OPEN
EXTRACTION
 TECHNIQUES FOR OPEN
EXTRACTION
MULTI ROOTED TOOTH
MANDIBULAR MOLARS
• Reflection of flap
• Evaluation of need for suctioning roots &
removing bone
• A small amount of crestal bone removed
• Tooth should be suctioned
• Small straight elevator then inserted to mobilize
suctioned roots
• Forcep or straight elevator or triangular elevator
used to elevate tooth from socket
TECHNIQUES FOR OPEN
EXTRACTION
 TECHNIQUES FOR OPEN
EXTRACTION
MULTI ROOTED TOOTH
MAXILLARY MOLARS
• Flap reflected
• Crestal bone removed to expose trifurcation
area
• Bur used to suctioned mesio buccal & disto
buccal & a palatal root
• Roots luxated with straight elevator & deliver
with creyer
TECHNIQUES FOR OPEN
EXTRACTION
 REMOVAL OF ROOT
FRAGMENTS & ROOT TIP
• Pt should be repositioned to achieve
adequate visualization & suction achieved
• If irrigation suction technique unsuccessful
then tease the loose root apex with a root
tip pick
• Root tip can be removed by using small
straight elevator
 REMOVAL OF ROOT
FRAGMENTS & ROOT TIP
• OPEN TECHNIQUE
– Flap reflected
– Bone removed to expose buccal surface of root
– Root delivered by straight elevator
• OPEN WINDOW TECHINQUE
– Flap reflected
– Apex area of tooth root located
– Dental bur used to remove bone from apex of root
– Instrument inserted into window & root is pushed out
 REMOVAL OF ROOT
FRAGMENTS & ROOT TIP
 POLICY FOR LEAVING ROOT
FRAGMENT
• Small root tip less than 4mm
• No evidence of periapical pathology or infection
• Inability to visualize root tip
• Removal of root tip will cause destruction to
adjacent structure
• Proximity to IDN
• Proximity to maxillary sinus
• ill fitting pt
• Un controlled hemorrhage
 MULTIPLE EXTRACTION
SEQUENCE
• Maxillary teeth
• Mandibullar teeth
• Posterior to anterior teeth
• From 1 quardent to another
• Reflection of minimal buccal flap will facilitate
extraction & allow alveloplasty
• Irrigation
• Suturing
• Post operative instruction
QUESTIONS?
THANK YOU.