Principles Of Complicated Exodontia-Surgical/Open method of tooth extraction

1. Surgical method of tooth extraction is used when there are broken or fractured root tips or when tooth cant be extracted by normal ways of extraction.
2. Principles Of Flap Design,Development & Management:Flap is a local section of soft tissue that follows following points- 

• Outlined by surgical incision from surrounding tissue.
• Carries its own blood supply.
• Allows proper surgical access to the site of interest
• Can be replaced in the original position without much tension in the flap.
• Can be maintained with suture and is expected to heal on its own.

       3. Flaps are used frequently in various surgical procedures in oral surgeries,periodontal surgeries and     endodontic surgeries

       4. Design parameters for soft tissue flaps:

• Base of the flap should be wide,this ensures adequate blood supply to the flap.Otherwise there are chances that flap can undergo necrosis.
• Reflect sufficient amount of soft tissue flap .It should be done because of the following reasons:

1. It provide proper access.
2. It avoid tension in the reflected flap

• Soft tissue heals across the incision,not along the length of incision.
• Sharp incision that are long,straight and provide proper reflection heals faster than torn,short incisions.
• For an envelope flap to be of an adequate size,the length of flap in anteroposterior dimension usually extends two teeth anterior and one tooth posterior to the area of surgery.
• If relaxing incision is to be given it should be extending one tooth anterior and one tooth posterior to the area of surgery.
• Flap raised should be full thickness.That means flap should include mucosa,submucosa and periosteum.This is because it has been found that periosteum is responsible for new bone formation.
• Incision should be made over intact bone,that will be present after the surgical procedure is complete.If the pathological condition has destroyed the buccocotical plate than the incision must be at least 6-8 mm away from the defect.In addition if bone is to be removed over a particular teeth,incision must be sufficient distant from it.If the incision is not supported by sound bone than flap tends to get collapsed in the defect and may lead to dehiscence and delayed healing.
• Flaps should avoid injury to vital structures like nerves and vessels.
• Incisions should be avoided on bony prominence and like that of canine eminences as there are chances of dehisence.
• Vertical releasing incisions should cross the free gingival margin at the line angle of a tooth and should not be directly on the lateral aspect  of tooth nor  directly into the inter dental papilla.
• Types of  mucoperiosteal flaps-

1. Envelope Flap-Most common.In dentulous patient incision is made in gingival sulcus to the crestal bone,periosteum and a full thickness mucoperisoteal envelope flap is reflected apically.In edentulous patients incision is given on the alveolar crest.
2. Three Cornered flap-If envelope incision has vertical releasing incision at one end than its three cornered flap.Its usually given when greater access is required in apical part specially in posterior areas.
3. Four cornered Flap-If releasing incision is given at both the ends of envelope flap than its called as four cornered flap.Rarely used.
4. Semilunar Flap-Occasionally used in the cases where apical surgeries are to be done.It provides access to limited area of root apex.This incison avoids trauma to the papilla and gingival margin.

• Always handle the blade at slight angle to the teeth.And give incision posteriorly to anteriorly in gingival sulcus by drawing the knife toward the operator.One smooth continuous stroke is used while keeping the blade in contact with the bone throughout its course.
• Start reflecting the flap from papilla.