A Clinical Presentation

1. TRANS ALVEOLAR
EXTRACTION
Dr Rudraprasad Chakraborty
1st year PG student
Oral and Maxillofacial Surgery
Rama Dental college Hospital & Research Centre
Kanpur.

2. INTRODUCTION
 This method of extraction comprises the
dissection of tooth or root from its bony
attachment.
 it often called the open or surgical
method.

3.  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…..

4. 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

5. Grossly Decayed Crown

6. Severe crowding in the dental arch
can limit access to the application of a
forcep.

7. Significant exostoses can limit the
amount of buccal bone expansion.

8. Teeth with unusual root morphology.

9. Root Canal Treated Tooth

10. Abnormal root morphology

11. Fusion of two mandibular
premolars.

16. Ankylosis

17. Dilacerated root

18. Increased bone density around
root

19. Internal resorption of tooth

20. 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.

21.  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

22.  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.

23. principles involved during
surgical removal of teeth:
 1. Flap design
 2. Bone removal
 3. Sectioning teeth
 4. Wound closure.

24. PRINCIPLES OF FLAP DESIGN
The general indications for flap reflection
include 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.

25.  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.

26. 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

27. 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.

28.  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.

29. A trapezoidal or four-cornered flap. The base of the flap
(doubleended blue arrow) should be wider than the coronal
aspect of the flap

30. The Incision
 When making an incision, the #15 blade
should be carried down to the bone in a
full-thickness fashion.

31.  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.

32. Avoid releasing incisions in the area of the
mental nerve, as depicted here.

33. Avoid making a releasing incision too close
to or directly over the area of the extraction.

34. Releasing incisions should be 6–8mm
anterior and/or posterior to the extraction
site.

35. 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.

43. The Extraction
Techniques

44. 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.

45. Bone Removal
 Postage Stamp Technique for Transalveolar Extraction

46. Wedge principle

47. 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.

48. 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.

52. 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).

55. The area is irrigated, especially under the flap,
and then sutured.

57. Leave enough coronal tooth structure for
extraction of the roots.

72. 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

73. 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.

76. The Horizontal Mattress suture

77. Closure of a three-corner flap. The releasing
incision is closed first to reorient the tissue.

78. 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.