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