TRANSALVEOLAR EXTRACTION

INDICATIONS
1. Any tooth which resists attempts at intra alveolar extraction when moderate force is applied 2. Retained roots which cannot be either grasped with forceps or delivered with an elevator, especially those in relationship to the maxillary antrum

3. h/o attempted or difficult extractions

INDICATIONS
Any heavily restored tooth, especially when root filled or pulpless Hyper cementosis or ankylosed tooth Geminated or dilacerated Radigraphically having complicated root pattern

INDICATIONS

INDICATIONS

1. DIAGNOSIS AND TREATMENT PLANNING

History (past dental and medical) Clinical examination Radiographs Possible complications to be considered ( maxillary molar, mandibular premolar)

2. DECISIONS TO BE TAKEN PRIOR TO SURGERY

a. Outpatient or inpatient procedure which is determined by

i. general medical condition of patient ii. Probable duration of operation iii. Type of anesthesia indicated

2. DECISIONS TO BE TAKEN PRIOR TO SURGERY

b. Any special arrangements required Instruction to the patient driving after procedure, timing of surgery taking meals in diabetic patients, probable length of incapacity, accompanied person

3. AT SURGERY
I. All instruments which may be needed are available and sterilized II. Arrange instrument in a regular order III. Other requirements good light, skilled assistance, pre op radiographs, preparedness for management of complications

4. POSTOPERATIVE
1.Prescription of analgesics selection of drugs 2. Post extraction instructions oral hygiene instructions Post extraction bleeding, pain, swelling Indications for emergency treatment and arrangements available for it 3. Follow up appointment

STEPS OF TRANSALVEOLAR EXTRACTION

1. 2. 3. 4. 5. Reflection of muco periosteal flap Bone removal Tooth division Socket toilet Suturing

TYPES OF MUCO PERIOSTEAL FLAP

Envelope flap Three cornered flap Four cornered flap Semilunar flap

ENVELOPE FLAP

THREE CORNERED FLAP

FOUR CORNERED FLAP

SEMILUNAR FLAP

MUCOPERIOSTEAL FLAP
Soft tissue flap used in oral surgical , periodontal and endodontic surgeries. 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 5.Can be maintained with sutures and is expected to heal

PRINCIPLES OF FLAP DESIGN

Flap should be full thickness muco periosteal flap

1.Base of the flap broader than free margin to preserve adequate blood supply

DESIGN PARAMETERS
Releasing incision used only when necessary not routinely
.

Flap must be of adequate size to provide necessary visualization and adequate access

Releasing incision is to be made, the incision should extend one tooth anterior and one tooth posterior to the area of surgery

Releasing incision not given on bony prominences not straight but oblique

DESIGN PARAMETERS

Incision must be made over intact bone. Pathology - 8mm away from it. Flap designed to avoid vital structures

COMPLICATIONS
1. Overextention of flap Stripping of buccinator muscle results in hematoma and post op swelling Delayed healing fibrosis and loss of vestibular depth 2. damage to nerve and vessels

3. Button hole
Flap elevation is complicated by fibrosis resulting from chronic inflammation or sinuses dur to periapical abcess Holing of flap during its elevation prejudices the blood supply of the tissue distal to the button hole

BUTTON HOLE

BONE REMOVAL
The surface of bone investing the tooth or roots to be extracted is removed to To expose tooth or tooth root To provide point of application of an elevator or engaging the forceps To create space into which the tooth or root may be displaced Alveolar bone must not be sacrificed unnecessarily After tooth removal , sharp bony margins trimmed

REMOVAL OF BONE BY DENTAL BURS

Removal of bone alongside the periodontal membrane - guttering Soft tissue retracted using retractor to prevent soft tissue injury with rotating bur Bur should not be allowed to overheat during bone removal by continuous irrigation Bone removal done continuously or postage stamp method Dislocation of tooth or root using elevators or forceps

BONE REMOVAL
Bone removal done by 1. dental bur 2. Chisel and mallet

BUCCAL GUTTERING

EXPOSURE OF ROOT

ROOT REMOVAL

WINDOW IN ALVEOLAR BONE

POSTAGE STAMP

TOOTH DIVISION
Line of withdrawal of tooth in multi rooted tooth unfavourable tooth division If bone is elastic removed without fracturing the alveolar process if it fails , then root division is done Before division , bone removal up to the level of bifurcation is done Separated root delivered using elevators or forceps If needed Purchase point is made. Round bur directed at an angle of 45 0 to vertical long axis of the root

TOOTH SECTION

UPPER FIRST MOLAR ROOT SECTION

SOCKET TOILET
Bony prominences trimmed Granulation tissue, calculus, bone/ tooth piece currette Irrigation

SUTURING
Placed to hold the incised edges of flap in place Removal of sutures 7 days post op

NEEDLE , NEEDLE HOLDER

SUTURING

SUTURING

SUTURING

POST OP INSTRUCTIONS
Prescription of drugs Post extraction bleeding Patient instructed to avoid vigorous mouth wash , violent exercise, Patient shown how to use gauze in case of bleeding

 Diet very hot food or drink Use of straw - negative pressure

Smoking and alcohol consumption

Effect of Local Aesthesia Numbness of lip, tongue or cheek