Trans-alveolar Extraction

It is essentially a technique that

includes dissection of a tooth or root
from its bony attachments.

It is often referred to as Open method.

Trans-alveolar Extraction - Indications

Any tooth which resists attempts at intra-alveolar
extraction when moderate force is applied.
Retained roots which cannot be either grasped
or delivered with an elevator.
A history of difficult or attempted extractions.
Hypercementosed and ankylosed teeth.
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Trans-alveolar Extraction - Indications

Any heavily restored tooth, especially when
root filled or pulpless.
Impacted and dilacerated teeth.
Teeth shown radiographically to have a
complicated root patterns.
During immediate denture treatment, where
there is a need to trim some alveolar bone.
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A. Determination of the type of anesthesia to be used.

B. Formulation of overall treatment plan.

Important components of such a plan are:

1. Incision to gain access to the area
2. Removal of adequate amount of bone
3. Sectioning of the tooth (tooth division)
4. Elevating the tooth or root from its socket
5. Preparing the wound before closure
6. Closure of the wound or incision
7. Postoperative care

Instruments used in trans-alveolar surgery

Incision to gain access to the area:

Mucoperiosteal flap

 Principles of flap design :

1. Incisions should avoid anatomical structures, such as
major nerves or blood vessels.

Anatomical structures to be avoided in the

mandibular arch include

Lingual nerve,
Mental nerve,
Long buccal nerve,
Facial artery, and
Buccinator artery.

The anatomical structures to be avoided in the

maxillary arch include

Greater palatine nerve, artery, and vein,

Incisive papilla,
Nasopalatine nerve.

2. incisions far enough away from the surgical

area:

The wound margins should rests on

sound bone, so that it won't collapse into
the bony defect, and at the same time
rapid revascularization is preserved.
Radiographically, the lesion may look
smaller than its true size, and so, the
incision should be placed in an area far
enough from the expected periphery of
the lesion.

3. Incisions should be made parallel to major blood

vessels,
4. The base of the flap should be wider than the apex to
ensure adequate blood supply.
5. A firm pressure upon a sharp scalpel should be used
so that both the mucosa and periosteal layers of the
gingiva are incised down to bone
6. Incisions are made in one operation, as extensions
and "second cuts" often leave ragged flap margins
and delay healing. The scalpel should be used as a
pen not as a plough, and the soft tissues cut at right
angles to the surface of underlying bone.

6. The mucoperiosteal flap should be made large enough

to provide for visibility, accessibility and adequate
room for instrumentation. It should be known that a
large flap heals as rapidly as a small flap and that post
surgical pain does not appear to be related to the size
of the flap as much as the amount of bone removed.
7. Incisions should not be made in an area of thinned
mucosa e.g. over an exostosis or bony protuberances
because the blood supply is reduced, suturing is
difficult, and the rate of dehiscence is high.

8. The vertical releasing (relaxing) incision should be

avoided if the horizontal incision will provide
adequate access. This is because the vertical
releasing cut
reduces the blood supply to the flap
and cause added discomfort
9. The vertical releasing incision, if needed, should be
made at a line angle to maintain the integrity of the
interdental papilla, which is not included with the flap
because of the difficulty in precisely re-approximating
them.

Types;

However, the following terminology is commonly

used to describe the various types of MPFs.
1. Envelope Flap :
It is a full-thickness flap.
Incision is made horizontally along the crest
of the ridge or in the buccal gingival crevice.
When incision is made around teeth, it
extends at least one tooth distal and two
teeth mesial to the site of the operation.

Has no vertical incision.

Advantages
.It is the flap of choice for most surgical procedures . 1
Provides the broadest base and fully covers the. 2
. resultant bony cavity
With the envelope flap, there is little danger of violating . 3
.
any major anatomical landmarks
During the procedure, the envelop flap can be. 4
extended as needed; if still greater access is required,
.
a vertical relaxing incision can be placed

2. Triangular (three-cornered) Flap

It is an envelop flap with one vertical relaxing

incision.
The horizontal incision extends from one tooth
distal to the surgical site to one tooth mesial.

Advantages

It is the next most useful flap for exodontia.

It provides greater access; therefore, it is used
primarily for surgery in the vicinity of the apex of
the tooth or in a deeply impacted tooth.

3. Rectangular (four-cornered) Flap :

It is an envelope flap with two vertical
relaxing incisions.
It provides substantial access.
However, it have limited anteroposterior
dimension.

4. Semilunar Flap
Most useful for retrieval of small root tips and
periapical endodontic surgery of a limited
extent.
The horizontal component of this incision
should not cross major prominences, such as
the canine eminence.
The incision should be placed at least 2 mm
apical to the base of the gingival sulcus (4-5mm
from gingival margin).

Advantage and disadvantage

No involvement of the gingival sulcus, thus, avoids
trauma to the papilla and gingival margin.
Provides limited access because the entire root of the
tooth is not visible.

Making the incision

1. The No. 15 scalpel blade on a No . 3 scalpel handle is used and
held in the pen grasp.
2. In the edentulous areas, a crestal incision is made.
3. Incisions placed around teeth are made by placing the scalpel
blade at a slight angle to the teeth and into the periodontal
sulcus. Incision is made to the height of the crestal bone
moving from posterior to anterior by drawing the knife toward
the operator.
4. If making a vertical relaxing incision, tissues are apically
reflected, with the opposite hand tensing the alveolar mucosa
so that the incision is made cleanly through it.
5. Because scalpel blades dull rapidly after being pressed against
bone they should be changed between incisions if more than
one flap is to be reflected.

Instruments used in trans-alveolar surgery

Blade Handle

Handles for the

blades

Instruments used in trans-alveolar surgery

Surgical Blade
#15 is the most commonly
used scalpel blade.
#15 is a smaller version of
#10
#11 is pointed (stab
incisions for Incision and
Drainage).
#12 is hooked

Instruments used in trans-alveolar

surgery Disposable Blade

Reflection of the Flap:

Flaps are reflected with the mucoperiosteal
elevators.
Using the sharp pointed end of the elevator
interdental papilla are freed from the underlying
bone (using the tooth as a fulcrum).
Using the broad end of the elevator in a push
stroke, the attached gingiva and alveolar mucosa
are reflected to the desired extent.
Using the mucoperiosteal elevator in a pull stroke
can sometimes shred the periosteum.

Handling The Instruments

The scalpel is held with
thumb, middle and ring
finger while the index
finger is placed on the
upper edge to help
guide the scalpel.
The scalpel should
never be used in a
"stabbing" motion
especially while raising
a flap.

Retraction of the Flap:

A periosteal elevator is used as a retractor for
small flaps and the Minnesota or Austin
retractors for large flaps.

Austin

periosteal

Kays austin

Minnesota

elevator

 Theretractorshouldbeplacedbeneaththeflapand
heldfirmlyperpendicularonsoundbonewithno
softtissuetrappedbetween.

Inordernottofocusontheretractorratherthanthe
surgicalfield,donotforcetheretractoragainstthe
MPFinanattempttopullthesofttissueoutofthe
fieldbutrathertheretractorisheldincontactwith
thebonesothattheflaprestsonitpassively.

Bone Removal :

Bone is remove some to expose the underlying tooth/root.

Bone, must not be sacrificed unnecessarily and removal
must be limited to what is required to achieve certain
objectives.
Removal of bone is intended to:
Expose either the tooth or roots before their delivery.
Provide a point of application for an elevator or
forceps.
Create a space into which the tooth or root may be
displaced.

Instruments Used for removing bone :

Chisel and mallet
- The chisel is a fine instrument for removing bone.
- Monobeveled or bibeveled.
- Driven by hand, mallet or engine.

Bone Gauge

Unibeveld Chisel

Bibeveld Chisel

Mallet

 Hand driven chisel (bone gouge):

Used for removing thin or weakened bone.
The mallet driven chisel
Used for removing less porous and porous
bone
in the mandible or maxilla, respectively.
bibeveled chisel (osteotome) :
Used for sectioning teeth.
Using mallet is alarming to the conscious patient, and
so, it is preferred to used under GA.
The engine driven chisel (impactor) is mounted on a
handpiece and cuts bone when pressure is applied to
bone and stops cutting when pressure is released.

Bone burs
The most frequently used method for bone removal.
Available in many forms: crosscut fissure burs,
tapered, or round.
Bone can be reduced or removed in 3 ways:
1. Using the round bur, holes in a necklace or postagestamp pattern are created above the area of surgery.
The holes are then connected and the disc or
postage-stamp piece of bone is removed permitting
entry into the surgical area.

2. Using the fissure bur, bone is removed alongside the

periodontal membrane in a "guttering" action.
3. Using a large round bur, bone is grounded down to the
desired amount (sometimes a tooth root may be
ground down with the bur "atomization").
N..B: Round burs are also used to create a purchase
point or point of application by directing the bur at an
angle of 45 to the vertical axis of the root

Rongeur forceps
It is a forceps-like instrument used to remove bone by
shearing on a planning action.
It has sharp blades that are squeezed together by the
handles, cutting or pinching through the bone.
Rongeur forceps have a leaf spring between the handle
so that the instrument will open when the hand
pressure is released. This allows the surgeon to make
repeated cuts without manually reopening the
instrument.

1. The side-cutting rongeur (Cleveland or Blumenthal rongeur):

- ideal for alveolectomy procedures.
- used in a horizontal position with one of the biting
edges of the forceps locked high on the alveolus
while the other blade is brought to it in a planning
action.

2. End-cutting Cleveland bone rongeur:

- used for removal of interradicular bone

3. The side- and end-cutting rongeur (Cleveland or Blumenthal rongeur):

- more practical for most dentoalveolar surgical procedures that
require bone removal.
- As it is end cutting, it can be inserted into sockets for removal
of interradicular bone, but can also be used to remove sharp
edges of bone.

Bone file or rasp

It is a double-ended instrument with a small and
large end.
used only for final smoothing of the bony ridge after
gross removal with the rongeur.
Filing before suturing the MPF back into position
should always follow use of the rongeur.

Bone File

Tooth Sectioning :

Indication:
1. Bone is insufficiently elastic.
2. Multi-rooted teeth in which the lines of
withdrawal of different roots prevents removal
with either the forceps or buccal application of
elevator.
- The roots are separated to be removed along their
individual paths of withdrawal.
- Tooth division may be effected using a bur, an
osteotome or tooth-splitting forceps (tooth shear
forceps).

 Guidelines
During sectioning using a surgical bur, irrigation
is a must. Considerable heat may be generated,
and the tooth structure clogs the bur blades
quickly.
When dividing the root-mass of a lower molar,
expose the bifurcation and separate the roots from
below upwards with the bur. This method allows
you to know when the roots are completely
divided; whereas it is difficult to be certain if you
cut down towards the bifurcation from above.

Elevating the tooth or root from

the socket:

If a firm grip of the root or root-mass can be obtained,

forceps is used, if not, the use of elevators is
necessary.

When applying buccal force it is necessary to engage

the elevator in a notch on the side of the root-mass.
Bifurcation of lower molars.
Created with a round bur.

When using elevators, excessive force is never

necessary if the principles outlined for their use are
followed.

If a tooth or root resists elevation, the elevator should

be discarded and the cause discovered and overcame

Removal of the tooth

segment with a forceps

Removal of the root with an

elevator applicated in a
prepared purchase point

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1.

Preparing the Wound Before

Closure:
Gently
irrigate the wound with sterile warm saline and then
inspect the wound.

2. Any tooth or bone residual fragments should be removed.

3. All pathological tissue should be removed.
4. Any sharp edges should be Smoothed, especially the
interdental septum in molar sockets which is frequently
mistaken for a piece of tooth by the patient.
5. If greater irregularities are present, a regular alveoloplasty may
be done.
6. Compress the alveolar process between the thumb and
forefinger.
7. Finally irrigate the wound before closure.

7 - Closure of the Wound: