Dr Rudraprasad Chakraborty
1st year PG student
Oral and Maxillofacial Surgery
Rama Dental college Hospital & Research Centre
This method of extraction comprises the
dissection of tooth or root from its bony
it often called the open or surgical
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
To Define with…..
The technical goals to be
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
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 reflection
include the following:
• To allow for complete access and visualization
of the surgical field.
• To allow for bone removal and tooth
• 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
(4) can be replaced in the original position,
(5) can be maintained with sutures and is
expected to heal.
Types of flap
i. Full Thickness Mucoperiosteal Flap
ii. Partial Thickness Flap
i. Envelope Flap
ii. Two Sided Triangular Flap
iii. Three Sided Rhomboid Flap
iv. Semilunar Flap
i. Labial or Buccal Flap
ii. Palatal or Lingual Flap
Types of Incisions
Internal bevel incision—starts at distal
area from the margin and is aimed at
bony crest. This is also known as first
Crevicular incision—starts at the bottom
of the pocket and is directed to the bony
margin. This is known as second
Vertical --- also called as releasing
incisions, on one or both the sides of the
• 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
When making an incision, the #15 blade
should be carried down to the bone in a
Semilunar (curved, elliptical)
This type of incision is used, when it is
desirable to maintain the attached
gingiva intact around the teeth and for
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
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 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
5—Proximity to the inferior alveolar nerve
6—Proximity to the maxillary sinus
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.
Closure of a three-corner flap. The releasing
incision is closed first to reorient the tissue.
Common Mistakes during Surgical
Attempting a simple forcep extraction.
Poor flap design,
Inadequate reflection of a flap,
Use of uncontrolled force,
Inadequate seating and adaptation of the
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.