SURGICAL REMOVAL OF TEETH AND ROOTS

By

Dr. Mohamed Hassan Ahmed Lecturer of Oral and Maxillofacial Surgery Department Cairo University Lecture I

Indications:
I) The Tooth itself: A) From the start: 1. Brittle teeth such as: a) Teeth with bulky dental fillings. b) Teeth with root canal fillings. c) Teeth with internal (hidden) decay. 2. Teeth with insufficient crown structure for grip (e.g. severe attrition and reduced teeth). 3. Teeth having complicated root pattern as shown by x-rays, such as: a) Teeth with widely divergent roots. b) Teeth with stout roots. c) Teeth with reverse tapering roots d) Teeth with hooked or curving roots. e) Teeth with dilacerated roots f) Teeth with hypercementosed roots. g) Teeth with ankylosed roots. 4. Geminated teeth. 5. Impacted teeth. 6. Malposed or misplaced teeth 7. Supernumerary teeth with malposition. 8. Retained roots which cannot be grasped with the forceps, especially when these roots are in relation to the maxillary sinus or the mandibular canal. B) After attempting simple extraction: 1) Any tooth that resists forceps extraction after a reasonable amount of force. 2) Teeth fractured during forceps extraction whose remnants cannot be removed by the forceps. II) The surrounding tissues: 1. Teeth involved in pathological conditions such as tumors or cysts. 2. Teeth involved in fracture lines of the jaws and interfering with reduction of the fractured bones. 3. Isolated maxillary posterior teeth (molars and premolars): - The alveolar bone of the maxilla is weakened by extensions of the maxillary sinus in place of the adjacent missing teeth. - Normal forceps extraction in this condition might lead to the fracture of large segments of the maxillary alveolus or bone of the antral floor with

subsequent perforation of the antrum. III) General condition of the patient: 1) Patients with history of difficult extractions with frequent tooth breakage. 2) Certain systemic diseases such as: a) Osteitis deformans (Paget's disease): generalized hypercementosis of the roots. b) Cleido-cranial dysplasia: multiple impacted teeth and the teeth frequently possess hooked roots. 3) In old age when the teeth are usually brittle and the alveolar bony support is devoid of elasticity. IV) Procedure: 1) Multiple tooth extractions with immediate alveoloplasty.

Principles of transalveolar extraction:

I. Radiographic examination. II. Access to the field of operation. III. Reduction of resistance. IV. Removal of tooth structure. V. Debridement. VI. Closure.

I. Radiographic examination:
Aim: 1) To reveal the number and the pattern of the roots. 2) To reveal root relation to important adjacent structures e.g. the maxillary sinus, tuberosity of the maxilla, inferior dental and mental nerves, etc. 3) To examine the surrounding bone for pathological changes. So that: The operator designs proper treatment plan and prepares proper instruments. Less amount of trauma to the tissues. Shorter operating time.

Lessens postoperative complications as necrosis and sloughing of tissues Minimizes after pain Promotes healing.

Types of radiographs: a) Intraoral radiographs: Most commonly used (periapical and occlusal films). b) Extraoral radiographs: Panorama, lateral oblique, and CT.

II ACCESS TO THE FIELD OF OPERATION

This is performed by designing and reflecting mucoperiosteal flaps. Definition of local flap: Indicates a section of soft tissue that: 12345Is 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.

Requisites of Mucoperiosteal Flaps: I) Design: 1) The flap should have a broader base than its free margin. The broader base of the flap maintains adequate blood supply to the tissues of the flap for proper healing. 2) The flap should be large enough to fulfill the following: a) To expose all the area of operation. b) To be retracted without excessive tension on the tissues to avoid laceration and retarded healing of the tissues c) To cover all the operative field after surgery: - The edges of the flap should rest on sound bone at the adjacent borders - This prevents the flap from falling into the bony defect created by surgery. - A flap resting on bony defect filled with blood clot is subjected to infection and breakdown - The underlying blood is a perfect culture medium for microorganisms leading to infection, necrosis, and break down of the flap. - Thus, it is advisable to make the flap little larger than the field of surgery so that it could be sutured at its borders to the sound tissues resting on sound bony edges. II) Incision: 1) The incision line should not injury nerves and blood vessels in the region.

2) The incision must include; the mucous membrane and the underlying periosteum in one sharp clean cut until the bone is reached. This will avoid tearing and laceration of the tissues during reflection of the flap. 3) The gingival margin of standing teeth in the flap should be incised vertically so that the flap could be detached from the bone without laceration. 4) The oblique incision should not alter the contour of the gingival papillae i.e. the incision should be cut either mesial or distal to the papillae to prevent necrosis of the soft tissue, and the underlying alveolar bone. III) Closure: 1) Flaps performed in edentulous ridges in the process alveolectomy must be trimmed of their excess to cover the alveolus without overlapping at their edges in order to avoid formation of soft flabby ridges which will interfere with prosthetic appliances e.g. dentures. 2) The flap should be repositioned to cover the field of surgery and sutured without much tension to avoid strangulation of blood vessels which retards healing.

Types of Mucoperiostal Flaps:

A. Pyramidal Flaps: These flaps are of two types
Two incision Lines Flap Consists of - One oblique incision line. - The gingival incision. Removal of: - Small teeth (e.g. front teeth and premolars). - Teeth fragments such as one root - A small root fragment. Three incision Lines Flap - Two oblique incision lines - The gingival incision Exposure of a large area as in: - Surgical removal of molar teeth - Impacted teeth, - Teeth involved with cystic lesions.

Uses

Requests of the oblique incisions: - Oblique cuts made to the mucoperiosteum 45 angle. - Starting mesial or distal to the gingival papillae. - Extending obliquely to 2-3 mm away of the mucobuccal fold. Advantages: - Adequate exposure of the field. - Affords discovery of destroyed or necrotic alveolar bone up to the gingival margins.

- Allows resting of the edges of the flap on sound bone during closure of the field of surgery. Disadvantages: - Disturbance of the gingival tissue attachment by cutting the gingival incision which may retard healing. - This disadvantage could be overcome by: Performing sharp clean cuts to the gingival tissue. Smooth retraction avoiding laceration. adequate re-adaptation of the tissue after surgery.

B. Semilunar Flaps:
Indications: - This flap is indicated where it is not necessary to expose the alveolar bone up to the gingival margin in: 1. Removal of small root fragments imbedded in the alveolus far away from the gingival margin. 2. In the procedure of apicectomy to amputate the apical portions of diseased teeth. Advantages: - This type of flap avoids disturbance to the gingival attachment. Disadvantages: 1. Inadequate exposure of the field of surgery 2. Areas of destructed alveolar bone that might exist under the mucoperiosteum beyond the incision line of the flap are not discovered and removed leading to unnecessary complications of necrosis and recurrent infection. Requisites of Semilunar Flaps To be fulfilled in cutting these flaps, namely: 1- The semilunar (curved) incision must be cut so that the convex side of the flap is towards the gingival margin: - This is to allow adequate blood supply to the flap. - The flap cut in this manner possesses a base broader than its free margin. 2- The incision should be made at least 0.5 cm away from the gingival margin: - In order to avoid laceration of the gingival attachment.

C. Gingival Flaps:
Advantages: 1- Avoiding oblique or curved incisions prevents retarded healing and minimizes bleeding. 2- Avoiding disturbance of large areas of the mucoperiosteum minimizes the postoperative complications of pain, edema and retarded healing. Indication: - When it is required to expose shallow portions of the alveolar bony plates such as: 1- For gaining access to the necks of teeth 2- Removal of small sharp edges or undercuts from the alveolar bone which are close to the gingival margin or the crest of the alveolus. Requisites: - The gingival tissues around the cervical margins of the teeth in the field of operation must be sharply incised before retracting the mucoperiosteum with periosteal elevator. - The gingival incision must extend for adequate distance mesio-distally in order to allow retracting the mucoperiosteum without too much tension.