Complex Exodontia
Jone Kim, DDS, MS
Diplomate, American Board of Oral & Maxillofacial Surgery
Lecturer, UCLA School of Dentistry, Dept. of Oral & Maxillofacial Surgery
Principle of Complex Exodontia
Principle of soft tissue flaps
flap design
types of flaps
Principle of suturing
rationale for suturing
types of sutures
suturing technique
Principle of open extraction (surgical extraction)
indications for open extraction
technique for open extraction of single rooted tooth
technique for open extraction of multi-rooted tooth
removal of root fragments and tip
Technique for multiple extractions
Adequate reflection for visualization
Adequate access for instruments
Adequate reflection without tension
Adequate reflection for retractor to rest on bone
Sharp incision heals more rapidly
Base needs to be wider than free margin
Presence of bone loss, incision should be at
least 6-8 mm away from intact bone
Principle of Soft Tissue Flap
Flap design
Principle of Soft Tissue Flap
Types of flap
Semi-lunar incision #6 - Surgical exposure for orthodontic tx
When making vertical releasing incision… • Usually a single anterior vertical releasing is needed
• Incision is oblique
• Do not cross bony prominence i.e. canine prominence
• Incision should cross the free gingival margin at the line angle
Principle of Suturing
Coapt wound margin for primary healing
Aid in hemostasis
Help hold a flap over bone
Maintain blood clot
Tension free
No blanching
Principle of Complex Exodontia
Principle of soft tissue flaps
flap design
types of flaps
Principle of suturing
rationale for suturing
types of sutures
suturing technique
Principle of open extraction (surgical extraction)
indications for open extraction
technique for open extraction of single rooted tooth
technique for open extraction of multi-rooted tooth
removal of root fragments and tip
Multiple extractions
Consider open (surgical) extraction ….
After initial attempts at forceps extraction have failed
Anticipate possible need for excessive force
Thick or dense bone
Older patient
RCT
Principles and Techniques for Open (Surgical) Extractions
Large caries and/or restorations
Bruxism
Divergent roots
Hypercementosis/bulbous
Severe dilaceration
Indications for Open (Surgical) Extractions
Maxillary sinus
Technique for Open Extraction of Single-Rooted Tooth
Make a flap
Remove bone
Reseat forcep Use of elevator
Technique for Open Extraction of Multi-Rooted Tooth
Make a flap Minimal bone removal if needed
Section the tooth (convert multi-rooted tooth into 2 or 3 single rooted teeth)
Mandibular molar
703, 702, round burs
Cryer elevator
Technique for Open Extraction of Multi-Rooted Tooth
Make a flap Minimal bone removal if needed
Section the tooth (convert multi-rooted tooth into 2 or 3 single rooted teeth)
After extraction… • Thoroughly irrigate surgical site • Make sure all root tips/debris are removed • Reposition flap and suture
Mandibular molar
Nowadays…..
Increase of implant surgery…..
Good extraction technique is very important
Flapless extraction
No or minimal bone removal
Technique for Removal of Root Fragments & Tips
Root tip pick
Straight elevator
Attempt closed technique
Good lighting, irrigation and suction
Open technique
Surgical & Post-Op Complications
Alveolar Osteitis (dry socket)
Bleeding
Maxillary sinus
Complications are rare
Alveolar Osteitis Most common post-op complication (3-5% of patients)
Symptom: Severe pain going up the side of the face, HA
Cause: Lack of blood clot in the extraction socket
Occurrence: 2-5 days after extraction, almost all in lower posterior
Causes of lack of blood clot: • Spitting • Rinsing too early and too hard • Drinking hot liquid or eating hot food • Smoking • Chewing hard food • Birth control pill • female
Treatment: Irrigate with water to clean out socket Pack Nu-Gauze with LA & eugenol Replace packing every 2-3 days as needed Do not repack if pain is managed with med Do not need antibiotics
Bleeding Place pressure
(3x 3 or 4 x 4)
Large suction ready
Arteriole vs venous
Find out where bleeding is
Soft Tissue Place pressure (direct)
Local anesthetic (with epi) Gelfoam, Surgicel (collagen) Suture (pressure & ligation)
Bone Place pressure (indirect)
Gelfoam, Surgicel (collagen) Bone wax
Gauze packing (need to take out) Suture
If there was significant blood loss, monitor patient prior to discharge
Post-op bleeding can happen at home
Post-op instruction 1) Do not blow nose
2) Do not sneeze with mouth closed
3) Do not smoke
4) Do not chew in same side of mouth
5) Oral rinse with water 6-10 /day
6) No water activity (swimming)
7) Shower is ok
8) Can use nasal decongestant
Oroantral Communication (sinus perforation)
OAC
4-5 mm will usually resolve w/o treatment
Do not recommend placing anything
Primary closure (if flap is made & no sinus infection)
Antibiotic 10 days (Amoxicillin)
Post-op instruction is very important
How to close persistent oroantral communication (OAC)?
Buccal flap advancement
Palatal flap advancement
Buccal & palatal flap advancement
Buccal fat pad advancement (OAC in 2nd molar)
How to retrieve root tip:
Retrieve through OAC
Technique
Use small suction tip or small pick up
Make opening slightly bigger, if needed
Do not pack anything into sinus
Secondary healing
Caldwell Luc procedure
Technique Make lateral window opening
Use suction or small pick up
Do not need barrier (membrane)
Do not pack anything into sinus
Irrigate & suture (primary healing)
Post-op instruction 1) Do not blow nose 2) Do not sneeze with mouth closed 3) Do not smoke 4) Do not chew in same side of mouth 5) Oral rinse with water 6-10 /day 6) No water activity (swimming) 7) Shower is ok 8) Can use nasal decongestant
Coronectomy (Partial odontectomy)
Indications & Procedure Risk to IAN or maxillary sinus if removing the roots
No caries or peri-apical infection/pathology
Pre-existing mobility of tooth
Section 3-4 mm below buccal and lingual cortical bone
Remove follicle
No need for endodontic therapy
No need to bone graft
Try not to mobilize roots
Primary closure if possible
Follow up with radiograph for 1-2 years
What happens to the root after coronectomy?
Bone will form over the root
Resorption
Infection/lesion