4. Teeth has complicated root patterns as shown in radiographs: -Teeth with widely divergent roots. -Tapering roots. -Hooked or curved roots. -Dilacerated roots. -Hypercementosed roots. -Ankylosed teeth.
Dens in Dente (also called Dens Invaginatus) (tooth within a tooth) Dilaceration
Fusion Dens Evaginatus (extra cusp)
5.Geminated teeth. 6. Impacted teeth.
7. Malposed or misplaced or supernumerary.
8. Teeth involved in cysts or tumors.
9. In performing multiple extraction of teeth.
Also dental surgical procedure can be indicated for the removal of: 1. Traumatized teeth. 2. To make room for orthodontic manipulation
10. Teeth in certain systemic diseases: -Paget’s disease. -Cliediocranial dysostosis. 11. Retained roots. 12Teeth fractured during extraction..13. Teeth with root resorption.
1.Outline the extent of mucoperiosteal flap. 2.Bone removal. 3.Sectioning of the teeth. 4.Elevating of tooth from its socket. 5.Debridment of wound before closure. 6.Closure of the incision. 7.Post operative care.
Access to the field of SURGERY Is achieved by performing A mucoperiosteal flaps.→
The term flap indicates a section of soft tissue.
flaps must provide adequate exposure & promote rapid healing. Flaps
The Flap is: 1.Outlined by a surgical incision. 2.Carries its own blood supply. 3.Allows surgical access to the underlying tissues. 4.Can be replaced to its original position. 5.Can be maintained with sutures & is expected to heal.
The Goal in Flap Design A Chance to Cut is a Chance to Cure. * Use a new knife with sharp blade [ for clean undamaged incision]. * Be assertive [ be confident]. * Use firm, continuous strokes. * Repeated soft strokes increase amount of damaged tissues & amount of bleeding. * Watch where you are going. * Consider closure.
Design Parameters for soft tissue flaps Size. Anatomical landmarks.
Requirements of Mucoperiosteal Flap 1. The incision should be designed to avoid injury to nerves & blood vessels in the region. 2.The incision must include the mucosa & periosteum; in one sharp clean cut until the bone is reached, to avoid tearing of the flap. 3. flap should have a base broader than the free margin, to maintain maximum blood supply to the tissues healing
4. The flap should be large enough to fulfill the followings: -To expose all the area of operation. -To be retracted without tension on tissues during reflection. - To avoid laceration & promote healing. -To cover the operative field after surgery, with the edges of the flap resting on sound bone.
5. The flap should be repositioned to cover the field of surgery & suture without tension, to avoid strangulation of vessels. 6. The vertical (oblique) incision should not alter the contour of the gingival papillae to prevent necrosis of the soft tissues & alv. bone. 7. Excess flabby tissues in edentulous ridge must be excised to avoid soft flabby ridge.
Types of flaps A variety of intra-oral soft tissue flaps. Pyramidal flap. Semilunar flap. Gingival flap. Palatal flap.
1. Semilunar flap : A curved, horizontal incision where the convex portion nearest to the gingival crest. The deepest part of the flap should be 5-10 mms from the starting and ending points, and 3mms at least from the depth of the gingival sulcus..
Advantages : 1.Simple to incise and reflect. 2.Close to the apical area of the tooth. 3.Requires minimal anesthesia. 4.No gingival recession. 5.Gingiva around crowns is not disturbed giving good esthetic result. 6.Patient can maintain good oral hygiene.
Disadvantages: 1. It gives minimal access & visibility. 2.Misjudging the size of the lesion may result an incision crossing the lesion or the surgical defect causing dehiscence. 3.Clefting can occur if the incision is made too close to the gingival margin. 4.Incision crosses bony eminences where the tissues are thin ; scar is more prominent.
5. No reference points in the flap; replacing is difficult & may result stretching on one edge & puckering on the other on suturing. 6. Part of the incision is in the alveolar mucosa which is vascular (may cause bleeding during surgery) & highly mobile (soreness & delayed healing are not uncommon).
3. Triangular flap: A horizontal gingival incision made in the gingival sulcus joined by a relaxing vertical incision.
Example of a triangular flap in extraction
Advantages: 1.The possibility of the incision’s crossing the lesion is eliminated. 2. periodontal curettage and alveoloplasty can be done when necessary. 3.It provides good access to lateral root repairs. 4.A good design for treatment of short roots. 5.The flap is easy to reposition. 6.The blood supply to the flap is at maximum.
Disadvantages: 1.Difficult to retract. 2.Pocketing may result duo to stripping of the gingival fibers. 3.Long incisions are needed to gain access to the apices of the long roots. 4.Shorter flaps suffer more tension on the edges during retraction. 5.In long roots, extension of the vertical incision into the mucobuccal or mucolabial fold will soreness & delayed healing.
6.Gingival contour around existing crowns may change resulting in poor esthetic result. 7.Oral hygiene is difficult. 8. Interdental suturing is more difficult.
4. Pyramidal flap: A horizontal gingival incision joining two vertical relaxing incisions.
Advantages: 1.Excellent access & visibility. 2.No tension on the released flap. 3.It has good reference points for repositioning. 4.Access for root repair is increased. 5.periodontal curettage or alveoloplasty can be done simultaneously if needed. 6.Multiple tooth treatment can be done.
Disadvantages: 1. Elevation is difficult to initiate. 2. Diminished blood supply to the flap. 3. Stripping of the gingival fibers may lead to clefting and/or poor esthetic results if the teeth involved in the flap were crowned. 4.Interdental sutures are needed which is more difficult. 5.Oral hygiene is difficult to maintain. 6.Extension of the vertical incisions into the alveolar mucosa causes soreness & delayed healing.
5. Gingival (envelope) flap: A horizontal incision in the gingival sulcus involving many teeth.
Advantages: 1.Gingivictomy can be done in the same visit. 2.Good reference points protect from lateral displacement of the flap. 3.Gingival levels can be changed in either directions.
Disadvantages: 1.Flap is difficult to reflect. 2.Tension on the flap is excessive. 3.No relaxing incisions may lead to tearing of the flap at the ends of the incision. 4.Cannot reach the apex of long roots. 5.The deeper the area of surgery, the longer should be the flap to have access & visibility. 6.Oral hygiene is difficult to maintain.