DEFINATION

The branch of Dentistry which deals with the surgical treatment of tooth and surrounding area or in other words the extraction of teeth is called exodontia.

Exodontia
Uncomplicated

extraction. Complicated --- surgical extraction, flap raising and bone removal or tooth sectioning is required. Modified --- whether simple or complicated extraction, some systemic condition require modification, pre; during or intra operative.

--- simple or forcep tooth

Technique
A

care full technique based on knowledge & Skill. Living tissues should be dealt gently. Other wise damage & necrosis can occur which lead to bacterial growth & retardation of healing, thus causing postoperative complications like pain, swelling & possibly deformity.

Before going for extraction1

You

should know this is the only branch of dentistry where the bleeding is experienced by the patient. Access to the teeth and other oral structures becomes difficult by lips & cheeks & further complicated by the movements of tongue & mandible. Oral cavity communicate with pharynx & larynx & is full of saliva which also makes operation difficult. It also lies close to vital centers.

Pre surgical Medical Assessment

History taking

Biographic Data
Name.

Address.
Gender. Occupation. Mental

status

Chief complaint

Pain onset etc. Fever etc

Medical Hx.

Present Past

Examination
>

Focus on oral cavity. < Focus on Maxillofacial region. << GPE

Fear of pain & Anxiety

Verbal.

LA
GA Sedation.

 Pain

Three main indications Dialometry

Labor 10 dm, rheumatic/ G surgery 4dm dental 2dm Pain up to thalamus non narcotic beyond up to cerebral cortex narcotic Dental pain can be relieved by LA but short duration unless open pulp or extraction Peri coronitis / dentoalveolar abscess

Infection

Functionless

tooth

Malposed Lower 3rd molar ext upper supra occ Solitary maxillary last molar for F/D

INDCATIONS FOR EXTRACTION

1.

2.
3. 4. 5.

Hopelessly carious tooth. Teeth with non vital pulps. Periodontitis or periodontosis where 2/3rd of bone is lost. Acute or chronic pulpitis where endodontic treatment is not indicated. Mal posed teeth which can not be treated by orthodontic treatment.

6. 7. 8. 9. 10.

Any tooth that lies in field of radiations for some oral malignant lesions. Supernumerary teeth. Any tooth which lies in the line of #. Non functional tooth or any tooth lying alone in oral cavity. Broken down roots or fragments.

11.

12.
13. 14. 15.

Teeth traumatizing soft tissues. Retained primary teeth, when permanent teeth are present. Teeth not restorable by operative dentistry. Impacted teeth. Teeth associated with any cyst or tumour.

16. 17. 18. 19. 20. 21.

Teeth which can not be saved by apiceotomy. Teeth mechanically interfering with placement of restorative appliances. Foci of infection. Prosthetic purposes. Obscure pain. Infection --- pericoronitis.

22.

23.

Over erupted teeth. Socioeconomic factors

Contra indications for the extractions of teeth

Local contraindications.

A.

B.

Systemic contraindications.

Local contraindications
1.

Acute inflammation.
1.
2.

Gingivitis e.g. fusospirochetal or streptococcal infection. Stomatitis.

2. 3. 4. 5.

Acute peri coronal infection -- 3rd molars. Acute alveolar abscess.(3 Reasons) Maxillary sinusitis. (OAF) Tooth lying in area of alveolar nerve.

6.

7.

During therapeutic radiations. Tooth lying in the area of malignant tumors and suspected haemangioma of jaw.

Systemic contraindicatio n for tooth extractions

Patients on steroid therapy

Cortisone

is a life saving drug. It acts as a shock absorber. Patients on steroid therapy have a suppression of secretions of their own & resultant adrenal cortical atrophy. The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction.

 If

the patient is under going oral surgery or extraction under GA,

50-100 mg orally 2 Hrs preoperatively. 100mg + 500cc of 5% Dextrose during operation. 50mg 12 Hrs orally or 100mg I/M.

Diabetes Mellitus
Under

production of insulin. A resistance of insulin receptors. Or both.

It is of two types; Insulin dependent. Non-insulin dependent

Diabetes Mellitus
Characterized

by hyperglycemia due absolute or relative deficiency of insulin.

Symptoms:
Polyuria. Increased

thrust. Excessive appetite.

 Loss

of weight. Skin disturbances. Vision disorders. Numbness & tingling. Glucosuria. Pain especially in lower limbs.
Diabetic

patients are more prone to infections because;

Increased

sugar in blood. Arteriosclerosis which decreases peripheral

circulation General resistance of patient is low immunity. Bacterial growth is favorable as increased blood sugar level act as a good medium for their growth.

Precautions for diabetic patients

3 steps Patient at home before surgery:

Put patient on broad spectrum antibiotics 24 Hrs before surgery;

Amoxicillin

500 mg Erythromycin 250/500mg TDS & BD respectively. Doxycyucllin (vibramycin) 200mg stat, 100mg daily. Oxytetracycllin 250mg 6 Hrly.

Put the patients on sedatives;

Diazepam

4-10mg or Phenobarbitone 30 60 mg or .5 G=30mg.or 0.5 1 G.

24 Hrs before operation, which relieve anxiety because anxiety increases adrenaline level which in turn increase blood sugar level.
Patient

in clinic or surgery:

Early morning appointment, break fast + insulin.

Fresh blood sugar level fasting at the day of surgery. Calm & sympathetic attitude from you. Local anaesthesia should be plain i.e. with out adrenaline because;
Increases B. Sugar level. Vasoconstriction gangrene. Not remain there for a longer time.

Short appointment. Recent HBA1C 60 days picture of diabetic pt

Various school of thoughts about LA with or without adrenaline

Adrenaline

should be given, as bleeding is severe in such patients. Should not be given because it increase sugar level. Use it because adrenaline which is given is less than secreted by patients ( endogenous). Broadly speaking Adrenaline should not be given because such patient are very sensitive it & plain LA should be used.

Important points
Anaesthesia

should be complete Ext with out pain. Procedure should not be more than 15 mins. Procedure should be a traumatic. There should be complete sterilization. Ext one tooth at a time. Antiseptic m/wash before ext. After ext pt should remain under observation for at least 30 min& should have adult attendant.

 Patient

at home after extraction:

Antibiotic for 1 week duration.

In

case of emergency at chair:

Pt has taken break fast but no insulin;
Hyperglycemic

Coma

Signs:

Pt is ill looking before extraction. Vomiting & abdominal pain. Tongue & skin dry. Low BP, Low pulse volume but rapid.

Flexer planter response. High glucosuria.

Rx: Inj. Insulin Hypoglycemic coma (More Common);

Pt has not taken his break fast but has taken insulin or has done unnecessary exercise.

Signs:Pt is healthy looking before ext. Not vomiting & abdominal pain. Tongue & skin moist. B.P Normal.

Extensor planter responses. Low glucosuria

Rx.

5% Dextrose ampoule (2-4mm IV), if recovers give sugar.

Pregnancy
Pregnancy

is a physiological phenomenon, but care has to be taken while dealing such pt. One school of thought that care should be extended to prophylaxis and restorations and surgery be deferred till birth of the baby, because;
Abortion. Premature

labor.

Actual physiological damage to the child.

1.

On these basis Rx of a pregnant women is divided in to 3 classes. Emergency Treatment.

1.

Severe pain e.g. pulpitis

2.

Non Emergency treatment but essential Rx.

1.

Chronic periapical abscess. Postpone Rx to

2nd trimester.

2. Elective Rx. e.g. BDRs postpone till delivery. Precautions for a pregnant women. Be very care full because of altered physiology. 1. LA more Safe.

Comfortably seated, to avoid vomiting.

 No

x-ray. If emergency Lead cover. Certain sympathomimetic drugs (vasoconstrictors) can diminish uterine blood flow, so as minimum as possible.
GA

better done in middle trimester

Volatile

anaesthetic like halothane should be avoided as it crosses placenta & death of baby. N2O2 & O2 mixture can be used. Short acting barbiturate like pentothane I/V . Analgesics .

 Consult

obstritician Oxygenation avoid hypoxia. Antibiotics (like tetracycline group should be avoided).

Bleeding Disorders
1.

Platelet Inadequacy Coagulopathies

2.

3.

Therapeutic anticoagulation

Haemophilia
Congenital

bleeding disorder due lack of coagulation factor VIII & IX designated as Haemophilia A & B respectively. CT is increased ( Normal CT= 2-5min) Males are sufferers & females are carriers.

Precautions
LA

is absolutely contra indicated because of continuous bleeding and haemotoma formation. GA is preferred & pt is hospitalized. Fresh blood, Plasma, Fresh frozen plasma or cryoprecipitate (deficient factors). Anti hemophilic globulin (AHG) i.e. fraction I 400 mg in 20cc of normal saline I/V with in hour, the CT is reduced to normal. AHG level should be 20 % above normal or normal level

 Factor

VIII should be build up to 50-70 % Mask anaesthesia to reduced the risk of pricking in OT & avoid endotracheal intubation because of danger of bleeding. A traumatic procedures are carried out & no stitching. After extraction one should pack the socket with gauze or with spongostan cubes 12 Hrs afterwards. If bleeding occurs after 4-5 hours fraction I can be given & when clot is settled no more fraction I or other maintenance is required.

Patient on anticoagulants
Patients

on anticoagulant therapy face two problems;

Profuse bleeding after surgery. Thromboembolic accident.

We

should stop anticoagulant therapy un till PT is in normal limits; Adjust the dose to bring PT OR INR in normal limits.

ASPIRIN & OTHER PLATELET- INHIBITING DRUGS

Consult physician. Defer surgery & stop platelet inhibiting drug for 5 days. Extra measure to control clot formation & retention. Restart drug on the day after surgery.

WARFARIN (Coumadin)
With physician consultation PT should brought to 1.5 INR for few days. If PT is between 1-1.5 INR proceed surgery.

 If

not, stop the drug 2days prior surgery. Check PT daily. When normal do surgery & restart this drug on the day of surgery. If in physician opinion is that it is unsafe for the pt to stop this drug the admit pt with his consent stop warfarin give Heparin during peri operative period.
HEPARIN
Consult

physician. Stop it 6 Hrs prior to surgery or reverse with protamine. Restart drug when a good clot is formed

Epilepsy
Precautions must be taken when treating an epileptic pt, because attack can occur in the dental chair. 1. Pt must have taken medicine early before coming for Rx, i.e. phenbarbitone 30-60mg or carbamezapine 200mm or 1 Hr before surgery. 2. Instruments must be away from the pt.

3. 4.

5.

6.

Before examination one should place mouth gag or prop in the patients mouth & remove when the procedure is completed. If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) I/V can be given to control convulsion. When attack occurs, it must be differentiated from an anaphylactoid shock or syncopy where patient warns you that he or she does not feel well & is pale and sweaty while in case of epileptic shock pt does not warn you. Convulsions in case of epilepsy.

Angina pectoris
This

disease occurs due obstruction of coronary blood supply to the myocardium of heart. This due to narrowing of one or both coronary artery leading to increased demand of oxygen. This further increases in stress. Sign & symptoms are sub sternal pain with dyspnea, radiating to the left arm & lower jaw. Following precautions are required while dealing such pt;

 Sedation.

Nitroglycerin

tablet sublingually when pt sits in the dental chair prophylactically. Anaesthesia should be plain (Controversial). If pt feels uncomfortable during operation, another tab should be given. After extraction pt should stay in the clinic for an hour & then sent with an adult fellow.

Rheumatic Heart Disease

Pt

with a history of rheumatic fever, or rheumatic or congenital valvular heart disease or synthetic vascular graft or prosthesis or a cardiac pacemaker implanted require special care. Colonies of circulating organisms may settle on scared endothelium to form vegetations ,the condition SABE. This disease has high mortality or morbidity. Bacteraemia must be avoided in such pts.

 Management

Oral hygiene brought to normal or near normal e.g. Povidide M/W. Antibiotic cover ORAL

Amoxycillin 3G 1 Hr before ant dental treatment in front of dental surgeon. Post treatment 250 or 500mg 6 Hrly for 72 hours. If sensitive to penicillin then, 1.5G Erythromycin 1 Hr before Rx & 250/500mg tds or bd respectively for 72 hrs.

PARENTERAL

When maximum protection required or If pt can not take orally or under GA

Ampicillin 2G I/V or I/M plus Gentamycin 1.5 mg/kg I/v or I/M ( not exceeding 80mg) followed by 1.5 oral amoxicillin 6Hrly where maximum protection is required. ( prosthetic Valves). Ampicillin 2G I/V or IM 30 min before procedure, 1G Ampicillin IV or IM or 1.5 G orally 6 Hrly after initial dose. Vancomycin 1G I/V administered over one Hr before surgery. No repeat dose.

PEDIATRIC DOSES

Half the adult dose or Ampicillin50mg/kg or erythromycin 20mg/Kg - 1 hr before Rx then 10mg/kg 6 Hrly.

In

running disease pt should be treated while hospitalized.

Thyrotoxicosis
This

is the result of hyperthyroidism due to thyroid disease disease like a multi nodular goiter, a thyroid adenoma or Graves disease. There is excess circulating triiodothyronine (T3) & Thyronine (T4).

 The

only absolute contraindication for extraction. Extraction can cause crises. SYMPTOMS:

Nervousness, tremors, emotional instability. Tachycardia & palpitation. Excessive perspiration. Diffuse enlargement of thyroid gland.

Exopthalmos. Loss of weight. Elevation of BMR. Easy fatigue. Muscle weakness. GIT symptoms like diarrhea & at times nausea & vomiting. Pressure symptoms in some instances such as dyspnea, dysphagia etc.

EFFECTS:

Thyroid crisis can be precipitated by oral surgery. Pt with thyroid crisis is restless, semiconscious, uncontrollable even with heavy sedation Cyanotic & at times delirious & an extremely rapid thready pulse & a high temperature.

So ext is absolutely contraindicated because

The trauma can precipitate thyroid crisis with cardiac embarrassment & heart failure. We can not control them. Refer pt for Rx before under going any surgical procedure.

Nephritis
SYMPTOMS:

Reduced urinary output or dysurea, Hematuria. Fever. Albuminuria Chills. Xerostomia & burning in the mouth. Generalized Stomatitis. Urinous ordour in pts breath.

EFFECTS:
Extraction of chronically infected tooth may precipitate acute nephritis or extraction in a dirty mouth lead to nephritis. These pt must first put on antibiotics.

Jaundice
There

is impaired liver function due to alcohol abuse, infectious disease or billiary obstruction. The production of Vitamin K dependent coagulation factors (II,VII,IX & X) may lead to prolonged bleeding. Check PT & INR or PPT. Prophylactic doses of Vit K & transamine.

 PRECAUTION

& Rx.

Tab anaroxyl or Azeptil is given. Dont describe any drug that is excreted & metabolized by liver such as paracetamol. Antibiotics are given. Such pts are usually virally infected like Hepatitis A,B,C &D. so, self and cross contamination be avoided.

Hypertensive Patient
Essential

hypertension. Mild to moderate hypertension (systolic PB <200 & Diastolic PB < 110 usually not a problem.

Care;
Anxiety

reduction protocol & monitoring of vital signs. LA with epinephrine given carefully. After surgery pt advise to seek medical care.

 Severe

hypertension (systolic PB > 200 or more or diastolic PB > 110 or more.

Should

be postponed until PB is well controlled. Refer pt or emergency dental TT carried out in well controlled environment in a hospital.

Local
99%

teeth are extracted under LA. Infiltration Anaesthesia Inferior dental block

How to minimize pain while giving LA

4%

surface anaesthesia is given Needle must be sharp Solution must be isotonic Deposition should be slow ( inj directly into blood vessel increases the toxicity by 16 times)

Causes of anaesthesia failure

Defect

in operator Defect in patient Defect in LA

Defect in operator
99.9% due to wrong technique. Cartridge is leaked. Needle is not accurately inserted.

Defect in patient

Infection;

There is increased vascularization so immediate absorption occur & there is no time for LA to work Medium is acidic but we require alkaline medium for LA

Addiction Extra

innervation VV rare

Defect in LA
Manufacturer LA

hasnt supplied 2% LA

is expired

How to check block anaesthesia

Numbness Prick

& probe PDL

Other techniques
Peripress Pulpal

Intraosseous
Intra

lesional

Seating of the patient for Lower jaw: extraction

The

occlusion plane of pt should be at elbow joint of operator. When the pt opens the mouth the occlusal plane be parallel to the floor.
The

Upper jaw:
occlusion plane of patient should be above the elbow & at the shoulder level of operator The head, neck & trunk should be in one level When pt opens mouth occ: plane should be b/w 45 0 - 600 .

Detailed Examination of Teeth

Before extraction the tooth to be extracted should be examined thoroughly both clinically & radiographically.

Any filling in the crown Any pathology especially caries Is the tooth abraded Root canal filling Position of roots Position of tooth to surrounding & max sinus Position of tooth ID canal

In detailed examination, we also see what type of technique can be used;

Forcep only Forcep plus elevator Elevator alone What type of forcep & elevator Odontectomy is require or not Possibilities of # of roots

Dental radiographs are very valuable in preventing un wanted accidents like;

Fracture of mandible Tearing of the floor of max sinus

Examination of supporting Hard tissues

See

the thickness of labial, buccal and lingual cortical plates Are there any nodular area of exostosis overlying the roots of the tooth Estimate the density of bone In old age, osseous tissue & tooth structure are brittle & dense. Expansion of cortical plate is impossible.

Principles of tooth extraction

Selection

of forcep Application of forcep Dilate the socket Cut the periodontal ligaments Take the tooth out of the socket to the least resistant way.
( usually the path of eruption is the path of extraction provided there is no change in the roots)

Technique of extraction
Forcep

extraction/ simple extraction/ non surgical extraction Transalveolar extraction/ odontectomy/ surgical extraction

99% teeth are extracted by this method. It is the best easier method without involving soft tissues

Forcep Extraction

Check anaesthesia tooth & surrounding buccal/ lingual mucosa Any loose filling in tooth be removed. Ask the pt to rinse with antiseptic m/wash Take periosteal elevator & detach attached gingivae surrounding crown on buccal & lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth, take forcep, grip tooth & do extraction

Selection of forcep

Upper anterior forcep or straight forcep

Grip

the palatal & labial side Beak should be maximally at root portion Beak must be parallel to the long axis of tooth Apply force apically to hold the deepest part

Upper Premolar or Bayonet forcep

The

difference b/w previous & upper premolar forcep is that it is slightly curved As it is a posterior one there must be some angle to make the grip easy

Upper molar forcep

Rounded

beak on the palatal side Nobed beak on the buccal side This nob should be at bifurcation point, as there are 2 roots on this side (DB & MB)

Lower forceps
Lower anterior forceps

 The

beaks at right angle to the handle. Lower BDR are similar

Difference b/w ant & BDR forceps

In

BDR forceps the beaks should approximate each other when we press the two handles. While in post the beaks don't approximate each other when we press the handle.

Difference b/w premolar & molar forceps

In

case of premolar forceps both beaks are rounded while there are knobs on both the sides in case of molar forceps because there are two roots mesial & distal.

As the grip should be at right angles to the long axis, which is impossible in last lower molars so, we use cow horn forceps.

Application of forcep

1. 2.

3. 4. 5. 6.

Select proper forcep Hold the tooth with the forcep, so that the beak applied to the long axis of the tooth to be extracted Hold the forcep firmly in hand Hold should be away from the beaks Hold the tooth from the cemento enamel junction & never from the enamel portion Beak should not slip

Technique & movements

PRINCIPLES OF FORCEP USE

1.

Expansion of bony socket & movement of Tooth

2.

Removal of Tooth

Major motions of forceps

1.

Apical pressure
1. 2.

Dilatation of bone Displacing centre of rotation apically

2.

Buccal force

3.
4.

Lingual pressure
Rotational pressure

5.

Tractional forces

General procedure of forceps extraction

1.

Loosening of soft tissue around tooth Luxation of tooth Adaptation of forcep Luxation of tooth with forcep Removal of tooth from socket
tractional force

2. 3. 4. 5.

Maxillary teeth
First movement should be apical, parallel to long axis of tooth

11
Labial

movement with Slight palatal pressure Labial pressure Mesial rotation

22
Only

labial movement with Mesial rotation ? No palatal movement because tip is more close to palatal plate & there is a chance of infection over there Tip is slightly curved rotation may be avoided.

33
As

upper one/ icisor Labial movement Palatal movement Labial & mesial rotation

44
Buccal

movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots

55

Buccal

movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal

76 67
Buccal

movement Palatal movement Buccal delivery of tooth

88
No

palatal movement Buccal movement with Distal rotation Buccal delivery of tooth

Mandibular teeth
First

pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth, Resting on cementum & then forces are applied

21 12
Labial

movement Lingual movement Slight mesio distal rotation & Labial delivery of teeth

33
As

upper two/ upper lateral incisor Labial movement Mesial rotation & delivery No lingual movement

54 45
Having

conical roots Rotatory movements Slight buccal movement

76 67

Buccal

movements Lingual movements Slightly rotatory movements Buccal delivery of tooth

88
All

teeth are embedded in spongy alveolar bone except 8 8 which are embedded in external oblique ridge Buccal pressure Lingual or buccal delivery

Primary or deciduous teeth

cba abc cba abc Labial movement Mesial rotation ed de ed de Buccal movement Palatal/lingual movement Teeth delivered on lingual side

Which tooth is most difficult to extract

8

8 is most difficult to extract buccal plate is supported by external oblique ridge Buccal plate may # but usually green stick type Remains there, not seen by operator

Post operative care: Immediate post ext measures:

See the socket & position of alveolar bone. Buccal plate is usually fractured in green stick fashion so;
Press

the socket to reduce the # Approximate the socket for quick healing & clot formation

See the position of inter radicular bone, if its level above the mucoperiosteum or gingival level, it should be trimmed. Also inter dental septum if ext of adjacent tooth. If there is granuloma at the root tip it should be curetted, gently remove or scope the granuloma out b/c,

 It

can cause R cyst Can cause infection

Pack the socket with sterilize gauze. It should press directly on wound and shouldnt make a bridge upon the wound

Instructions to the patient: Bleeding;

Keep the gauze sponge & hold it firmly b/w your jaws & over the socket for a full or half an hour after extraction Dont rinse or use a mouth wash for 6 hrs after extraction. Frequent mouth washing disturbs the clot. After 24 hrs nothing can enter the clot.

If there is some ooze no problem, there will be some oozing for 24-48 hrs. Dont talk 2 hrs. If there is more bleeding, then patient should use tea leaves wrapped in a piece of gauze or cotton soaked. Discoloration some swelling of the soft tissues of face is followed by discoloration. This is a normal post operative event. The purplish black discoloration fades in to greenish yellow & then yellow & black to normal. Heat in any form applied to the face help in dissipation of discoloration. Pain - put pt on analgesics. Antibiotics

Swelling & stiffness may be due to bleeding beneath the oral tissues. To reduce apply ice cap or towel wring out of ice water on 1st day & on 2nd day apply heat to your face.

OPEN SURGICAL EXTRACTIONS

Odontectomy
This is the surgical removal of tooth/teeth by the reflection of an adequate mucoperiosteal flap & the removal of overlying bone.

Advantages:
1. 2.

Reduces the chances of tooth# during extraction Less danger of creating OAF.

3. 4.

1. 2. 3. 4.

5.
6.

Decreases the possibilities of # of maxilla & mandible Reduces the chances of tearing out of alveolar bone Indications: Hypercementosis Widely divergent roots of molars Locked roots Teeth with apices at right angles to the long axis of teeth (curved roots) Teeth with post crowns Extensively decayed tooth

7. 8. 9. 10. 11. 12. 13.

Teeth with root canal fillings When a thick, dense buccal or labial cortical plate or multi nodular exostosis is present in maxilla or mandible Low antral floor dips b/w roots of maxillary molars When the maxillary alveolar tuberosity is hollow b/c the antral cavity extends into it Thin mandible when excessive forces may fracture it Malposed, impacted & supernumary teeth When forcep force (pressure) results

14. 15. 16. 17.

in dislocation of TMJ, despite manual effort to retain it Ankylosed roots When customary force fails to produce luxation Dialaceration BDR

Reasons for removal of roots:

Fractured roots should be removed at the time of extraction. Large roots left will be a localized source of inflammation & soreness as the alveolar ridge resorbs & denture strike this prominence; Roots are removed to eliminate possible residual infection Remaining roots & fragments may act as mechanical irritant May give rise to neuralgia or pain of obscure origin Retaining of root fragment

1. 2. 3.

Oral Surgical Incision & Flaps

Principles of ; 1. Incision 2. raising of flap

Incision

Proper size/sharp blade Firm continuous stroke Avoid cutting vital structures Blade perpendicular to epi.- squared wound edges Incision over attached gingiva &healthy bone Extraction incision gingival sulcus

Oral Surgical flap

Section of soft tissue out lined by incision;

Qualities of proper design;

Carry

Mucosal Sub mucosal Full thickness mucoperiostal

its on blood supply Access to under lying tissues Anatomically re approximated back and retained by sutures Uneventful healing with minimal

Principles of proper design of flap

Basic Objective is to gain surgical ascess in order to Prevent;

Flap necrosis Flap dehiscence Flap tearing

 Mentally

tissues to be included in the flap Design a flap so that maximum area is exposed Base of the flap reflected should be broader than apex so that it may have a good blood supply During reflection of flap the periosteum should be reflected intact & should not be injured, otherwise there will be post OP slough of flap, pain & delayed healing.

review the nerve & blood supply of Principles/design of Flapthe soft

Angle of the flap should not be acute but rounded Always have the flap wider than bone cavity which will be present at the end of operation so that stitches does not come on the bony cavity & stitches get solid bony support which means quick & painless healing, other wise stitches will never stay. Never extend the incision on lingual side.

Types of Incision/Flap
1. 2. 3. 4. 5.

Envelope incision/flap: Three corner flap: Four corner flap: Semi lunar Flap: Elliptical Type:

 Procedure:
Knife

handle & blade -- in pen grip fashion. Start incision with blade No. 12, cut through junction of periodontal membrane & mucoperiosteum around the neck of teeth to be exposed Give incision in one stroke & be deep enough (touching the bone) Next with the blade NO. 15 start incision b/w the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla. Don't cut the inter dental papilla i.e. its morphology should not be disturbed. Make the incision through the mucoperiosteum towards the mucobuccal fold mesially at an angle of 45o to the long axis of tooth. If adequate exposure is not obtained when mucoperiosteum is reflected then make a second incision at the distal side in the same manner & extent

Suturing
principles
Close

technique
Holding

wound margins Aid in hemostasis Hold soft tissues over bone Maintaunance of blood clot

holder Holding of suturing needle Use of tissue holding forceps to hold flap margins surgeons knot Cutting suturing

of needle

 Return

Instruments

of flap. Suturing

Needle holder 15cm Suture needle 3/8th to circle reverse cutting edge Non resorbable 2/0 silk Resorbable
Gut

plain & chromic Vicryl polyglycolic acid / polyglactin

technique

Suture

The word "suture" describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues.

Example Suture Selection

Absorbable Fast Absorbing Gut
NaturalGut Plain
Chromic gut Ethilon* VICRYLRapide*

Non Absorbable Silk

Natural Stainless steel

Synthetic

(nylon) suture

Synthetic

(polyglactin 910) suture

NOROLON*
(nylon) suture

VICRYL*
( polyglacin 910) suture (polyglecaprone 25) suture

MERSILENE*
(polyester) suture

MONOCRYL* PDS II*

(polydioxanone) suture

ETHIBOND*
(polyester) suture

PROLENE*
(polypropylene) suture

Needle anatomy
Swage Body Point

Body of the needle

classification

by the body of the needle:

circle

3/8 circle

circle

5/8 circle

Knots
Half

Hitch or Single knot Granny Knot Reef Knot Triple Knot Surgeons Knot