Complex Exodontia. Jone Kim, DDS, MS

Transcription

1 Complex Exodontia Jone Kim, DDS, MS Diplomate, American Board of Oral & Maxillofacial Surgery Lecturer, UCLA School of Dentistry, Dept. of Oral & Maxillofacial Surgery

2 Principle of Complex Exodontia Principle of soft tissue flaps flap design types of flaps Principle of suturing rationale for suturing types of sutures suturing technique Principle of open extraction (surgical extraction) indications for open extraction technique for open extraction of single rooted tooth technique for open extraction of multi-rooted tooth removal of root fragments and tip Technique for multiple extractions

3 Principle of Soft Tissue Flap Flap design Adequate reflection for visualization Adequate access for instruments Adequate reflection without tension Adequate reflection for retractor to rest on bone Sharp incision heals more rapidly Base needs to be wider than free margin Presence of bone loss, incision should be at least 6-8 mm away from intact bone

4 Principle of Soft Tissue Flap Types of flap Semi-lunar incision #6 - Surgical exposure for orthodontic tx

5 When making vertical releasing incision Usually a single anterior vertical releasing is needed Incision is oblique Do not cross bony prominence i.e. canine prominence Incision should cross the free gingival margin at the line angle

6 Principle of Suturing Coapt wound margin for primary healing Aid in hemostasis Help hold a flap over bone Maintain blood clot Tension free No blanching

7 Needle holder 3/8 1/2 circle Reverse cutting 3 mm

8 Principle of Complex Exodontia Principle of soft tissue flaps flap design types of flaps Principle of suturing rationale for suturing types of sutures suturing technique Principle of open extraction (surgical extraction) indications for open extraction technique for open extraction of single rooted tooth technique for open extraction of multi-rooted tooth removal of root fragments and tip Multiple extractions

9 Consider open (surgical) extraction. After initial attempts at forceps extraction have failed Anticipate possible need for excessive force Thick or dense bone Older patient RCT

10 Principles and Techniques for Open (Surgical) Extractions Indications for Open (Surgical) Extractions Maxillary sinus Bruxism Hypercementosis/bulbous Divergent roots Severe dilaceration Large caries and/or restorations

11 Technique for Open Extraction of Single-Rooted Tooth Make a flap Reseat forcep Use of elevator Remove bone

12 Technique for Open Extraction of Multi-Rooted Tooth Make a flap Minimal bone removal if needed Section the tooth (convert multi-rooted tooth into 2 or 3 single rooted teeth) Mandibular molar Cryer elevator 703, 702, round burs

13 Technique for Open Extraction of Multi-Rooted Tooth Make a flap Minimal bone removal if needed Section the tooth (convert multi-rooted tooth into 2 or 3 single rooted teeth) Mandibular molar After extraction Thoroughly irrigate surgical site Make sure all root tips/debris are removed Reposition flap and suture

14 Technique for Open Extraction of Multi-Rooted Tooth Maxillary molar

15 Nowadays.. Increase of implant surgery.. Good extraction technique is very important Flapless extraction No or minimal bone removal

16 Technique for Removal of Root Fragments & Tips Attempt closed technique Good lighting, irrigation and suction Open technique Root tip pick Straight elevator

17 Root Tips Near Maxillary Sinus

18 Surgical & Post-Op Complications Alveolar Osteitis (dry socket) Bleeding Maxillary sinus Complications are rare

19 Alveolar Osteitis Most common post-op complication (3-5% of patients) Symptom: Severe pain going up the side of the face, HA Cause: Lack of blood clot in the extraction socket Occurrence: 2-5 days after extraction, almost all in lower posterior Causes of lack of blood clot: Spitting Rinsing too early and too hard Drinking hot liquid or eating hot food Smoking Chewing hard food Birth control pill female Treatment: Irrigate with water to clean out socket Pack Nu-Gauze with LA & eugenol Replace packing every 2-3 days as needed Do not repack if pain is managed with med Do not need antibiotics

20 Soft Tissue Place pressure (direct) Local anesthetic (with epi) Gelfoam, Surgicel (collagen) Suture (pressure & ligation) Bleeding Place pressure (3x 3 or 4 x 4) Large suction ready Arteriole vs venous Find out where bleeding is Bone Place pressure (indirect) Gelfoam, Surgicel (collagen) Bone wax Gauze packing (need to take out) Suture If there was significant blood loss, monitor patient prior to discharge Post-op bleeding can happen at home

21 Oroantral Communication (sinus perforation) OAC 4-5 mm will usually resolve w/o treatment Do not recommend placing anything Primary closure (if flap is made & no sinus infection) Antibiotic 10 days (Amoxicillin) Post-op instruction is very important Post-op instruction 1) Do not blow nose 2) Do not sneeze with mouth closed 3) Do not smoke 4) Do not chew in same side of mouth 5) Oral rinse with water 6-10 /day 6) No water activity (swimming) 7) Shower is ok 8) Can use nasal decongestant

22 How to close persistent oroantral communication (OAC)? Buccal flap advancement

23 Buccal flap advancement

24 How to close persistent oroantral communication (OAC)? Buccal flap advancement Palatal flap advancement Buccal & palatal flap advancement Buccal fat pad advancement (OAC in 2 nd molar)

25 How to retrieve root tip: Retrieve through OAC Technique Use small suction tip or small pick up Make opening slightly bigger, if needed Do not pack anything into sinus Secondary healing

26 Caldwell Luc procedure Technique Make lateral window opening Use suction or small pick up Do not need barrier (membrane) Do not pack anything into sinus Irrigate & suture (primary healing) Post-op instruction 1) Do not blow nose 2) Do not sneeze with mouth closed 3) Do not smoke 4) Do not chew in same side of mouth 5) Oral rinse with water 6-10 /day 6) No water activity (swimming) 7) Shower is ok 8) Can use nasal decongestant

27 Coronectomy (Partial odontectomy) Indications & Procedure Risk to IAN or maxillary sinus if removing the roots No caries or peri-apical infection/pathology Pre-existing mobility of tooth Section 3-4 mm below buccal and lingual cortical bone Remove follicle No need for endodontic therapy No need to bone graft Try not to mobilize roots Primary closure if possible Follow up with radiograph for 1-2 years

28 What happens to the root after coronectomy? Bone will form over the root Resorption Infection/lesion

29 Case

30 Purulent discharge from #17 site

31 What flap design?

32 Thank You