6- complex extractions

Why may some extractions be complex due to the patients?

Due to medical conditions

Lack of cooperation

Multiple extractions

Local variation and pathology

What medical conditions may make the extraction complex?

Heart condition/rate disorder

Severe hemostasis disorder

Allergy to LA

How can lack of cooperation make an extraction complex?

Under LA + premedication

Gag reflex

Psychiatric disorders

Dentophobic

Involuntary movement- Parkinson’s…

Why may someone have multiple extractions at one time?

Immediate prosthesis

In quadrants

Start posterior and go anterior

May need alveoloplasty, hemostatic control 

What variations and pathologies may make an extraction complex?

Morphological alterations

Altered position of roots and teeth

Osteoformative and cementiform lesions

Cysts and tumours

Crowded teeth

Inflammation

What factors make an extraction complex during a simple one?

No response to force applied- resistance due to-

Ankylosis-hypercementosis

Osteocondensation (sclerotic bone)

Curved or anomalous roots

Requires very controlled force- if have big restorations or fragile mandible/maxillafy tuberosity

Has difficult exit route

When are surgical extractions indicated?

Impacted or erupted teeth in anomalous position

If fixed prostheses or posts may break under pressure

Retained roots 

Decay affects crown/root

External or internal resorption 

Ankyloses with loss of PDL

Hypercementosis

What are the 3 objectives of surgical extractions?

Widen surgical field for access or point to place elevators/luxators

Remove bone cortex to reduce tooth resistance 

Sepereate karts if tooth (Odontosection) 

What are the types of retained roots?

Visible- extract with forceps and/or elevators

Submerged in alveolar bone- may need surgery 

Indications for extraction using forceps?

Single straight roots 

Indivualised roots in multi rooted teeth 

If roots retained for long time with chronic inflam- need enough tissue to get hold 

What forceps are used for extraction and how?

Maxilla- bayonet

Mandible- right angle with fine active area

Valves applied as apically as possible- intrusion, luxation, rotation, traction

How do you extract with elevators on single straight roots?

With straight elevator

As apically as possible, luxate, rotate, extract following 1st order lever movement

How do you extract with elevators on multi rooted teeth with roofsarealy separated?

Use straight luxator

3 roots- DB, luxate mesial to MB, P with fine root forceps

2 roots- d then m 

What is Odontosection used for and what instruments are used?

Erupted or unerupted teeth

Single or multiple roots

Intact or destroyed crowns

Lindemann or long diamond fissure bur

High-speed handpiece with copious irrigation

Indications for Odontosection?

• Impacted teeth → reduce ostectomy

• Grossly carious molars → weak crown

• Multi-rooted teeth → divergent/abnormal roots

• Single roots → curved roots, hypercementosis

• Primary molars → permanent successor between roots

Technique for Odontosection of single roots

• Flap release & ostectomy – for access and visibility

• Curved section – follow root curvature

• Elevate apical fragment – use elevator to remove separated tip

• If malpositioned:

  • Coronectomy at cementoenamel junction (CEJ)

  • Extract remaining root with forceps

What is the odontosection technique for multiple-rooted teeth (premolars and upper molars)?

• Perform a transverse section through the neck of the tooth to separate the crown from the roots.

• Make a longitudinal T-shaped section to individualize buccal roots from the palatal root.

• Remove each root using root forceps or an elevator

What is the odontosection technique for multiple-rooted teeth (Lower molars)?

Divide M and D root

Extract using lower root forceps or elevator 

What is a Hemisection, and when is it used as a conservative technique for prosthetic purposes?

Surgical division of a lower molar to remove one diseased root and its crown portion while preserving a healthy root.

To maintain part of the tooth for prosthetic restoration

When is hemisection contraindicated and its technique?

Short or narrow roots, endodontic or periodontal disease, poor oral hygiene.

• Make a longitudinal crown section through the furcation.

• Extract the affected root and its crown portion.

• If both roots are preserved → Bicuspidation (conversion of one molar into two premolar-like teeth).

What is Root Amputation, and when is it indicated?

• Surgical removal of one root while preserving the entire crown of a multi-rooted tooth.

• Purpose: To maintain the tooth’s function and structure when only one root is diseased.

• Indicated for:

  • Upper and lower first molars (2- or 3-rooted teeth).

• Contraindicated for:

  • Upper second molars due to frequent root fusion (as seen on radiographs).

What is the technique for Root Amputation?

• Prerequisite: No gingival recession — tooth must be periodontally stable.

• Flap: Raise a small flap to gain access to the furcation area.

• Sectioning:

  • Start the section in the furcation, working from buccal to lingual and extending toward the crown.

• Extraction:

  • Remove the separated root using premolar or bayonet forceps.