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

3/8 – 1/2 circle Reverse cutting

Needle holder

3 mm

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

Technique for Open Extraction of Multi-Rooted Tooth

Maxillary 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

Root Tips Near Maxillary Sinus

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

Buccal flap advancement

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

Case

Purulent discharge from #17 site

What flap design?

Thank You