TRANS ALVEOLAR

EXTRACTION

1st year PG student

Oral and Maxillofacial Surgery

Rama Dental college Hospital & Research Centre

Kanpur.

Dr Rudraprasad Chakraborty

INTRODUCTION

This method of extraction comprises the

dissection of tooth or root from its bony

attachment.

it often called the open or surgical

method.

The surgical, or open, extraction

technique is the method used for

recovering roots that were fractured

during routine extraction or teeth and

cannot be extracted by the routine

closed methods for a variety of reasons

……..Peterson

To Define with…..

FACTORS THAT COMPLICATE

THE

EXTRACTION PROCEDURE

1. Crown

2. Roots

3. Bone

4. Diminished access

5. Adjacent/non-adjacent teeth

6. Adjacent vital structures

7. Prosthetic concerns

Grossly Decayed Crown

Severe crowding in the dental arch

can limit access to the application of a

forcep.

Significant exostoses can limit the

amount of buccal bone expansion.

Teeth with unusual root morphology.

Root Canal Treated Tooth

Abnormal root morphology

Fusion of two mandibular

premolars.

Ankylosis

Dilacerated root

Increased bone density around

root

Internal resorption of tooth

The technical goals to be

achieved

1. To improve the access

2. To achieve mechanical advantage

3.To reduce resistance

4.To correct an inadequate path of withdrawal.

1. Improved access:

This is done by raising a

mucoperiosteal flap and adequate bone removal

2. Improved mechanical advantage:

This is achieved by bone

removal and preparation of purchase point

3. Reduce resistance:

This is achieved by removal of

bone support and sectioning of

teeth (Odontectomy)

4. Correct path of removal:

This is achieved by removal of

bone and sectioning of teeth.

principles involved during

surgical removal of teeth:

1. Flap design

2. Bone removal

3. Sectioning teeth

4. Wound closure.

PRINCIPLES OF FLAP DESIGN

The general indications for flap reflectioninclude the following:

• To allow for complete access and visualization of the surgical field.

• To allow for bone removal and tooth sectioning.

• To prevent unnecessary trauma to soft tissue and bony structures.

The term local flap indicates a section of

soft tissue that

(1) is outlined by a surgical incision,

(2) carries its own] blood supply,

(3) allows surgical access to underlying

tissues,

(4) can be replaced in the original position,

and

(5) can be maintained with sutures and is

expected to heal.

Types of flap

A.

i. Full Thickness Mucoperiosteal Flap

ii. Partial Thickness Flap

B.

i. Envelope Flap

ii. Two Sided Triangular Flap

iii. Three Sided Rhomboid Flap

iv. Semilunar Flap

C.

i. Labial or Buccal Flap

ii. Palatal or Lingual Flap

Types of Incisions

Horizontal

Internal bevel incision—starts at distal

area from the margin and is aimed at

bony crest. This is also known as first

incision.

Crevicular incision—starts at the bottom

of the pocket and is directed to the bony

margin. This is known as second

incision.

Vertical --- also called as releasing

incisions, on one or both the sides of the

flap.

• Double vertical incisions on both sides of the flap

will result in trapezoidal flap The incisions should

extend beyond mucogingival line reaching the alveolar

mucosa to allow the release of a flap for reflection

• Vertical incisions should be placed at obtuse angle

to the horizontal incision and should leave

interdental papillae intact.

A trapezoidal or four-cornered flap. The base of the flap

(doubleended blue arrow) should be wider than the coronal

aspect of the flap

The Incision

When making an incision, the #15 blade

should be carried down to the bone in a

full-thickness fashion.

Semilunar (curved, elliptical)

This type of incision is used, when it is

desirable to maintain the attached

gingiva intact around the teeth and for

endodontic surgery.

Avoid releasing incisions in the area of the

mental nerve, as depicted here.

Avoid making a releasing incision too close

to or directly over the area of the extraction.

Releasing incisions should be 6–8mm

anterior and/or posterior to the extraction

site.

Envelope flap. Ideally, this type of flap should be

extended one tooth posterior and two teeth anterior to

the one being extracted in order to provide adequate

reflection with minimal tension on the flap.

The Extraction

Techniques

TECHNIQUE FOR SURGICAL EXTRACTION

OF A SINGLE-ROOTED TOOTH

A forcep is shown being used to remove the root with a small portion

of the alveolus.

Bone Removal

Postage Stamp Technique for Transalveolar Extraction

Wedge principle

The placement of purchase point

should be placed close to the

level of the bone.

should be deep enough to allow

for placement of a Crane pick.

Enough tooth structure (3 mm)

should be left coronal to the

purchase point to prevent tooth

fracture during elevation.

TECHNIQUE FOR SURGICAL EXTRACTION

OF A MULTIROOTED TOOTH

A multirooted tooth can be divided with a

bur to convert it into multiple single

rooted teeth to facilitate its removal.

The tooth is sectioned with a fissure bur on a surgical drill. The

sectioning should extend into the furcation area and about three

quarters of the way through the tooth in a bucco-lingual

dimension—avoiding the lingual plate. Note the cut extending

into the furcation area (red arrow).

The area is irrigated, especially under the flap,

and then sutured.

Leave enough coronal tooth structure for

extraction of the roots.

Indications for Leaving a Root Tip

1—Small root tip less than 4 mm in size

2—No evidence of periapical pathology or infection

associated with root tip

3—Inability to visualize root tip

4—Removal of root tip will cause destruction to

adjacent structures

5—Proximity to the inferior alveolar nerve

6—Proximity to the maxillary sinus

7—Ill-feeling patient

8—Uncontrolled hemorrhage

Principles of Flap Closure

When the surgical procedure is

completed and the surgical site has

been irrigated, the flap can be sutured.

Suturing the flap holds it in position and

reapproximates the wound margins.

The Horizontal Mattress suture

Closure of a three-corner flap. The releasing

incision is closed first to reorient the tissue.

Common Mistakes during Surgical

Extractions

Attempting a simple forcep extraction. Poor flap design, Inadequate reflection of a flap, Use of uncontrolled force, Inadequate seating and adaptation of the

forceps, Attempting the removal of root tips without

adequate access and visualization, Inadequate irrigation of the surgical site prior

to reapproximation of the flap, Poor reapproximation of the flap.