Technique for Open Extraction of Single Rooted Tooth
The technique for open extraction of a single rooted tooth is relatively straightforward but requires attention to detail, because several decisions must be made during . the operation. Single-rooted teeth are those that have resisted attempts at closed extraction or that have fractured at the cervical line and therefore exist only as a root. The technique is essentially the same for both.
The first step is to provide adequate visualization and access by reflecting a sufficiently large mucoperiosteal flap. In most situations an envelope flap that is extended two teeth anterior and one tooth posterior to the tooth to be removed is sufficient. If a releasing incision is necessary,it should be placed at least one tooth anterior to the extraction site (see Fig. 8-2).
Once an adequate flap has been reflected and is held in its proper position by a periosteal elevator, the surgeon must determine the need for bone removal. Several options are available First, the surgeon may attempt to reseat the extraction forceps under direct visualization and therefore achieve a better mechanical advantage and remove the tooth with no bone removal at all (Fig. 8-32).
The second option is to grasp a bit of buccal bone under the buccal beak of the forceps to obtain a better mechanical advantage and grasp of the tooth root. This may allow the surgeon to luxate the tooth sufficiently to remove it without any additional bone removal (Fig.8-33). A small amount of buccal bone is pinched off and removed with the tooth.
The third option is to use the straight elevator as a shoehorn elevator by forcing it down the periodontal ligament space of the tooth (Fig. 8-3-t). The index finger of the surgeon’s hand must support the force of the elevator so that the total movement is controlled and no slippage of the elevator occurs. A small wiggling motion should be used to help expand the periodontal ligament space, which allows the small straight elevator to enter the space and act as a wedge to displace the root occlusally.
The fourth and final option is to proceed with bone removal over the area of the tooth. The surgeon who makes the decision to remove some buccal bone from till tooth may use either the bur or the chisel. If the bone is thin, a chisel is convenient. and frequently requires hand pressure only. However, most surgeons currently prefer a bur to remove the bone. The width of buccal bone that is removed is essentially the same width as the tooth in a mesiodistal direction (Fig. 8-35). In a vertical dimension,bone should be removed approximately one-half to two thirds the length of the tooth root (Fig. 8-36). This amount of bone removal sufficiently reduces the amount of force necessary to displace the tooth and makes removal relatively easy. Either a small straight elevator (Fig. 8-37) or a forceps can be used to remove the tooth (Fig. 8-38).
If the tooth is still difficult to extract after removal of bone, a purchase point can be made in the root with the bur at the most apical portion of the area of bone removal (Fig. 8-39). This hole should be about 3 mm in diameter and depth to allow the insertion of an instrument. A heavy elevator, such as a Crane pick can be used to elevate or lever the tooth from its socket (Fig. 8-40, A). The soft tissue is repositioned and sutured (Fig. 8-40, B).
The bone edges should be checked; if sharp, they should be smoothed with a bone file. By replacing the soft tissue flap and gently palpating it with a finger, the clinician can check edge sharpness, Removal of bone with a rongeur is rarely indicated, because it tends to remove too much bone.
Once the tooth is delivered, the entire surgical field should be thoroughly irrigated with copious amounts of saline. Special attention should be directed toward the most inferior portion of the flap (where it joins the bone), because this is a common place for debris to settle, especially in mandibular extractions. If the debris is, not removed carefully by curettage or irrigation, it can cause delayed healing or even a small subperiosteal abscess in the ensuing 3 to 4 weeks, The flap is then set in its original position and sutured into place with 3-0 black silk sutures. If the incision were properly planned and executed, the suture line will be supported on sound, intact bone.