The document outlines the process and considerations for complicated exodontia in oral and maxillofacial surgery, focusing on patient classification by the ASA system to assess health risks, and extraction techniques for both closed and open procedures. It details surgical principles including flap design, suturing techniques, and specific methods for removing single-rooted and multi-rooted teeth, emphasizing the importance of careful assessment and technique selection based on individual patient needs. Additionally, it highlights the policy for managing root fragments and guidelines for performing multiple extractions efficiently.

1. COMPLICATED EXODONTIA
Linn PeThan
Department of Oral & Maxillofacial Surgery
University of Dental Medicine

2. ASA – American Society of Anesthesiologists
establishedin1940,modifiedin1961
 System of classifying patients according to their physical status and guiding
judgement decisions
 ASA I – Normal healthy patient
 ASA II – A patient with mild systemic disease that does not interfere with day
to day activity or that has a significant health risk factor
 ASA III- A patient with moderate to severe systemic disease that is not
incapacitating but that may alter day-to-day activity; may have significant drug
concerns; may require special patient care; would generally require dental
management alterations
 ASA IV- A patient with severe systemic disease that is a constant threat to life;
definitely requires dental management alterations; best treated in special
facility
 ASA V – Moribund , not expected to live 24hrs regardless of operation

3.  ASA II , III , IV – consultation , specialist opinion
 Fit to do extraction /surgery - justification

4. PMH – Past Medical history
any hospitalization
 Where? , When? , Why?
 How ? medical/surgery , GA , LA
 What ? procedure , complications
any medication
any illness
 health status
any complication with the previous dental treatment –

5. Check vital sign
 BP
 PR
 RR
 Temperature

6. Extraction techniques ;
 Closed
 Open

7. Techniques
 Closed type of exodontia; Simple or forceps
technique
 Open type of exodontia; Surgical or flap
technique , Complicated exodontia

8. Closed type of exodontia;
 Simple or forceps technique
 Primary consideration for almost every
extraction. Intra- alveolar extraction which
require either forceps or elevator without
surgical flap

9. Procedure of closed extraction ;
 Step 1 : Loosening of soft tissue attachment from the
cervical portion of the tooth.
 Step 2: Luxation of the tooth with a dental elevator.
 Step 3: Adaptation of the forceps to the tooth.
 Step 4: Luxation of the tooth with the forceps
 Step 5: Removal of the tooth from the sochet.

10. Open type of exodontia; Surgical
or flap technique , Complicated
exodontia
 Trans-alveolar extraction is commonly known as
surgical extraction or open extraction of tooth
 The method is employed when forceps
extraction is not possible due to various
difficulties

11.  Generally if a tooth fracture during a regular
extraction, surgical approach is necessary to
remove the root fragment
 The reflection of an adequate muco-periosteal
flap for adequate access and visualization of
the field of surgery
 The Ostectomy ( removal of bone) or/and
Odontectomy ( coronal and root section) is for
an unimpeded pathway for removal of the tooth

12.  Alveolar purchase is when the crest of the
alveolar bone is purchased by the forceps along
with the coronal portion of the root

13. Complicated exodontia
Surgical / open extraction

14.  removal of most erupted teeth can be
achieved by closed or forceps delivery
 surgical or open extraction is the method
used for recovering roots that were fractured
during routine extraction or tooth/teeth that
can not be extracted by the routine closed
methods for a variety of reasons

15.  to evaluate carefully each patient and each
tooth to be removed for the possibility of an
open extraction
 most of them will be perform a closed
extraction
 the surgeon must be aware that, in some
situation, open extraction may be less morbid
than closed method

16. Indications for surgical extraction
 as a general guide line, surgeon should
consider surgical extraction when they
perceive a possible need for excessive force
to extract a tooth
 the term “excessive” means that the force
will probably result in a fracture of bone , a
tooth root or both
 excessive bone loss, need for additional
surgery to retrieve the root or both, can cause
undue morbidity

17.  preoperative assessment reveals that the patient
has heavy or especially dense bone ( especially
dense buccal cortical plate in old age adequate
expansion is less likely to occur)
 a patient who has very short clinical crown with
evidence of severe attrition ( may be because of
bruxism or a grinding habit, it is likely that the
teeth are surrounded by dense heavy bone with
strong periodontal ligament attachment )

18.  careful review of preoperative radiograph may
reveal tooth roots that are likely to be cause
difficulty such as hypercementosis, widely diverged
root, ..
 in relation to the surrounding anatomical structure,
such as maxillary molar teeth which are too near to
the maxillary antrum ( can reveal by radiograph )
 crown with extensive caries especially root caries,
very large amalgam restoration ( if there is extensive
periodontal disease around such tooth, it may
possible to deliver easily by means of closed
method)

19. Principle of flap design,
development, and management
What is Flap?
 is outlined by a surgical incision
 carries its own blood supply
 allows surgical access to underlying tissues
 can be replaced in the original position
 can be maintained with sutures and is
expected to heal

20. Design parameters for soft tissue flap
 base of the flap must be broader than the free
margin to preserve an adequate blood supply
 adequate access
 full-thickness muco-periosteal flap
 incisions must be made over intact bone
 avoid injury to local vital structures
 releasing incision should be used only when
necessary and not routinely

21. Types of muco-periosteal flap
 envelope flap (*)
 three-cornered flap ( envelope incision with
one vertical releasing incision ) (*)
 four-cornered flap ( envelope incision with
two vertical releasing incisions )
 semi-lunar flap
 Y incision flap (useful on the palate )
 pedicle flap

22. Technique for developing a mucoperiosteal flap
 to incise a soft tissue to allow reflection of the
flap ( no 15 blade is used on the no 3 scalpel
handle and in is held in the pen grasp)
 incision is made posterior to anteriorly by
drawing the knife toward the operator
 one smooth continuous stroke
 keeping the blade in contact with bone through
out the entire incision
 scalpel blade is extremely sharp, but it dulls
rapidly when it is pressed against bone

23.  if the vertical releasing incision as made , the
tissue is apically reflected , with the opposite
hand tensing the alveolar mucosa
 so the knife will incise cleanly through the
mucosa without jagged incision
 reflection of the flap begins at the interdental
papilla with the sharp end of the periosteal
elevator
 the broad end is used to reflect the
mucoperiosteal flap to the desired extent with
pushing stroke towards posteriorly and apically

24.  once the flap has been reflected , the
periosteal elevator is used as a retractor to
hold the flap in its proper reflected position
 the retractor is held perpendicular to the
bone while resting on the sound bone
without trapping soft tissue between
retractor and bone
 the retractor should not be forced against the
soft tissue in an attempt to pull the tissue out
of the field

31. Principle of suturing
 once the surgical procedure is completed, the wound
should be properly irrigated and debrided
 the surgeon must return the flap to its original
position by means of suturing ( mostly used simple
interrupted suture during complicated exodontia -
can be placed relatively quickly and suture can be
adjusted individually, and , if one suture is lost the
remaining sutures stay in position )
 the sharper the incision, the less trauma inflicted on
the wound margin, the wound will be probably
healed by primary intention ( if the space between
two wound edges is minimal )

32.  sutures also aid in hemostasis
 if the underlying tissue is bleeding , result in
the formation of a haemtoma
 the suture must be placed on the sound bone
(if not, wound dehiscence can be occurred )
 overlying tissue should never be sutured
tightly in an attempt to gain haemostasis in a
bleeding tooth socket

33.  a special stitch such as a figure of eight , can
provide a barrier to clot displacement ( but it
plays a minor role in maintaining the blood
clot in the tooth socket

34. Armamentarium
 needle holder (15 cm in length and has a
locking handle )
 suture needle ( a small 3/8 to 1/2circle with a
reverse cutting edge which helps the needle
pass through the relatively tough
mucoperiosteal flap or in some occasion,
round body )

36. Resorbable sutures
1. gut – plain ( strength can stay for 5 days) and
plain gut with basic chromium salt (chromic gut
– strength can stay for 7 to 9 days), rapid
digestion by proteolysis enzyme, produced by
inflammatory cells
2. polyglycolic acid and polyglactin, does not
enzymatically breakdown, they under go slow
hydrolysis, eventually being resorbed by
macrophages
 polyglycolic and polyglactin are less stiff , much
longer in stay and more costly than gut

37. Non-resorbable sutures
1. silk (multi-filaments)
2. polyester (multi-filaments)
3. polypropylene (mono-filaments )
4. nylon ( both mono and multi-filaments )
 multi-filaments form increases the strength
of the suture, but also increases suture
abrasiveness and more likely to allow
bacteria to harbor into the wound

38.  suture size varies
 the inscreasing number of 0’s correlates with
decreasing suture diameter and strength
 most oral and maxillofacial surgeons use 3-0
or 4-0 suture

39.  suture are usually not placed across the
empty tooth socket
 when approximating the flap, the suture is
passed first through the mobile (usually
facial) tissue
 the experienced surgeon may be able to
insert the needle through both sides of the
wound in single pass, however, it is best to
use two passes in most situation

40.  the needle should enter of the surface of the
mucosa at a right angle, to make the smallest
possible hole in the mucosal flap
 the minimal amount of tissue between the
suture and the edge of the flap should be 3
mm
 usually , they are tied with an instrument tie
in oral and maxillofacial surgery

45.  the purpose of the stitch is merely to re-
approximate the incised tissue, and therefore
the suture should not be tied too tightly (there
should be no blanching of the mucosa)
 sutures that are too tight cause ischemia of the
flap margin and result in tissue necrosis with
tearing of the suture through the mucosa
 the knot should be positioned to the side of the
incision why fall over the incision causes
additional pressure on the incision

46.  the sutures are left in placed for approximately 5
to 7 days ( after that no useful role and probably
increases the chance of contamination of healing
wound )
 when sutures are removed the surface debris
that collected on them should be cleaned off
with peroxide, chlorhexadine, iodophor…
 the suture is cut with sharp, pointed suture
scissors and removed by pulling it towards the
incision line (not away from the suture line)

48. Techniques for complicated exodontia
I. Technique for open extraction of single
rooted tooth
II. Technique for surgical removal of multi-
rooted tooth
III. Technique for removal of small root
fragments and root tips
IV. Technique for multiple extraction

49. Technique for open extraction of single rooted
tooth
 single rooted teeth that have been resisted
attempts at closed extraction
 have fractured at the cervical line

50.  to provide adequate visualization and access
by reflecting a sufficiently large
mucoperiosteal flap
 if you choose envelop flap, up to two teeth
anterior and one tooth posterior to the
extraction side
 if releasing incision is necessary, should be
placed one tooth anterior to extraction side

51.  the surgeon must determine the need for bone
removal or not
 once adequate flap has been reflected, we can
choose one of the following technique:
I. surgeon may attempt to reseat the extraction
forceps under direct visualization, remove the
tooth with no bone removal
II. to grasp a bit of buccal bone under the buccal beak
of the forceps to obtain a better mechanical
advantage and grasp the root ( only small amount
of buccal bone is pinched off, without any
additional bone removal)

52. III. to use the straight elevator as a shoehorn
elevator with controlled force , down to the
periodontal ligament space of the extracted
tooth ( with finger rest to prevent slippage
of the elevators )
IV. bone removal over the area of tooth by
using bur or chisel (approximately 1/2to2/3
of the length of root

53.  bone edge should be checked, if sharp, they
should be smoothed with bone file ( rongeur
is rarely indicated why it tends to remove
much more bone )
 surgical field should be thoroughly irrigated
with copious amount of normal saline

57. Technique for surgical removal of
multi-rooted tooth
 the major difference from the single rooted
tooth is that, the tooth may be divided with a
bur to convert a multi-rooted tooth into
several single rooted tooth
 once the tooth/root is sectioned, it is luxated
with straight elevators to begin the
mobilization process
 however, in most situation, small amount of
crestal bone should be removed

60. Removal of small root fragments
and root tips
 initial attempts should be made to extract the
root fragment by a closed technique (that
does not require reflection of soft tissue flap
and removal of bone)
 begin a surgical technique if the closed
technique is not immediately successful
 whichever technique is chosen, have an
excellent light and excellent suction

61.  closed technique is more useful when the tooth was well
luxated and mobile before the root tip fractured
 a root tip pick (delicate instrument ), which is inserted
into the periodontal ligament space, act like a wedge
 neither excessive apical or lateral force should be
applied to the root tip pick
 excessive apical force which could result in
displacement of the root tip pick into other anatomic
location, such as the maxillary sinus
 excessive lateral force could result in the bending or
fracture of the end of the root tip pick

62.  endodontic files can be used in certain situation
 visualization is impotence and appropriate size
of an endodontic file must be selected
 shank of the file is gripped with a needle holder,
which is used as a lever to lift the root fragment
from the socket
 the tooth that is used as the fulcrum should be
protected with a gauze or cotton wool
 not useful for removing the root tip with non
visible canal, hypercementosed root fragment,
bony interference…..

63.  also can be removed with small straight
elevator used as a shoe horn
 similar to that of the root tip pick
 the surgeon’s hand must always be supported
on the adjacent tooth or solid bony
prominence ( like a finger rest )
 always used controlled force

64.  if the closed technique is failed, the surgeon should
switch without delay to the open technique
 two main technique
1) after soft tissue flap was reflected, almost always,
buccal bone is removed with a chisel or bur to
exposed the buccal surface of the tooth root, then,
the root is delivered bucally
2) open window technique is, soft tissue flap was
reflected, dental bur is used to remove the bone
overlying the apex of the tooth, and, an instrument
is inserted into widow and the root is displaced out
of the socket ( three cornered flap is preferable )

65. Policy for leaving root fragments
 three conditions must exist for a tooth root to
be left in the alveolar process
1) the root fragment must be small, not more
than 4 to 5 mm in length
2) the root must be deeply embedded
3) the involved tooth must not be infected, no
radiolucency around the root apex

66.  must be balanced risk and benefit
1) if removal of the tooth root will cause
excessive destruction of surrounding bone
2) if removal of the tooth root endangers vital
structure
3) root tip can displaced into tissue spaces or
anatomical structure such as maxillary sinus

67.  the patient must be informed that, the
surgeon’s judgment, leaving the root in its
position will do less harm than surgery
 must be recorded in the patient chart with
radiographic documentation
 must be recalled
 contact the surgeon immediately , should any
problems develop

69. Multiple extraction
 if multiple adjacent teeth are to be extracted
at a single setting, slight modification of
routine extraction procedure
 to facilitate smooth transition from a
dentulous to an edentulous state

70.  maxillary teeth should be removed first for
following reasons
1) an infiltration anaesthetic has a more rapid
onset
2) during the extraction process debris may fall
into the empty socket of lower teeth, if the
lower surgery is performed first
 minor disadvantage is , that if haemorrhage is
not well controlled in the maxilla, the
haemorrhage may interfere with visualization
during mandibular extraction

71.  extraction begins with the most posterior
tooth first (not only allow for collection of
blood but also allow for more effective use of
dental elevators to luxate and mobilize the
tooth
 the two teeth that are most difficult to
remove , first permanent molar and canine,
should be extracted last

72.  soft tissue reflection is extended slightly to
form a small envelop flap just to expose the
crestal bone only
 teeth are luxated with straight elevator and
delivered with forceps in usual fashion
 is likely to require excessive force, the
surgeon should remove small amount of
buccal bone to prevent fracture and bone loss

73.  after extraction, the lingual plate and buccal plate are
pressed together with firm pressure
 soft tissue is repositioned
 palpate the ridge to determine if there are any area of
sharp bone spicules or obvious undercut
 excess granulation should be excised
 inspect for excess gingiva after extraction, the gingiva
should be trimmed, so that no overlap occurs
 if there is no redundant tissue, not try to gain primary
closure, which leading the depth of vestibule is decreases,
that may interfere denture construction
 interrupted or continuous sutures are usually used

75. Thankyou
foryour
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