Dental extraction

• Loose teeth.
  Tooth mobility is an unreliable indicator of need to extract.
• Periodontal disease Periodontal disease : if caused by loss of attachment.
• Supernumerary teeth : if affecting occlusion or crowding other teeth.
• Persistent deciduous teeth Teeth: retained deciduous : if likely to interfere with eruption of permanent teeth, or predispose to periodontal disease by crowding.
• Advanced caries Teeth: caries.
• Fractured teeth Dental fracture : if beyond repair, eg long axis root fractures, root fractures in the middle third, teeth with crown fractures when no endodontic treatment is authorized.
• Teeth on fracture line of fractured mandible or maxilla.
• Stomaliths caused by dental plaque.
• Malocclusion causing self-trauma.
• Dental pulp necrosis, eg discolored teeth.

• Endodontic techniques.
• Restorative techniques Teeth: restoration of dental caries.

Criteria for choosing test

• Ensure client understands that general anesthesia General anesthesia: overview is necessary.

Minimum equipment

• Molt P9 periosteal elevator.
• Root tip pick-Schein H1.
• Svenska luxators: 3 mm straight, 3 mm curved, 5 mm straight, 5 mm curved.
• Lindo-Levien elevators: LLL, LLM, LLS.
• MacPhail 6" needle holder or Mayo-Hagar needle holder.
• Fine toothed dissecting forceps.
• Straight scissors 5".
  Must be sharp.
• Extraction forceps: small breed.
• Dental elevator: medium ST-8.
• Cutting burrs: 701, 702, 330, round 2, 3, 4 and 5.
• Bone file.
• Drapes, clips, swabs.

Minimum consumables

• Suture material: vicryl 1.5 metric cutting needle swaged.
• Scalpel blade 11 and handle .

• Opioid analgesia, eg butorphanol Butorphanol tartrate provides good analgesia or NSAID Analgesia: opioid , eg carprofen Carprofen Butorphanol tartrate provides good analgesia or NSAID Analgesia: opioid , eg carprofen Carprofen

• Withhold food from animal for 12 hours before general anesthesia to prevent reflux esophagitis.

• General anesthesia.
• Mouth gag.

Step 1 - Single rooted teeth

• Cut epithelial attachment at bottom of sulcus with 11 blade at 45° to long axis of root.
• Select an elevator or luxator with correct blade.
  Select blade with circumference one third the size of a target root.
• Introduce the luxator in an apical direction between alveolar bone and root surface.
• Rotate luxator blade circumferentially while maintaining apical pressure.
• Stop from time-to-time to allow the hydraulic pressure of hemorrhage from periodontal ligament to assist expulsion of root from alveolus.
• Continue working luxator against all surfaces of root until loose.
• Extract loose root in rotational manner using dental forceps.
• Debride alveolus, filing off bone spikes.
• Suture gum.
• Radiograph to ensure complete removal.

Step 2 - Multi-rooted teeth

• Create one or more single roots for extraction.
• Break down epithelial attachment.
• Incise gingiva at caudal and mesial margins diverging away from root axis.
• Lift full-thickness mucous membrane, and gingiva, from bone using Molt elevator.
• Remove semi-circle of crestal bone, using 701 cross-cut taper fissure burr, to identify furcation angle.
• Split tooth in two halves cutting from furcation coronally.
• Apply wedge elevator into cut channel and gently rotate to push two roots apart.
• Hold pressure for 10 seconds then turn blade around and repeat procedure.
• Keep applying pressure until one or both roots become loose.
• Rotate loose root and remove.
• Apply pressure to healthy root from healthy neighbor if available.
• Debride, filing off bone spikes.
• Suture gum.
• Radiograph to ensure complete removal of roots.

Step 3 - Upper canine

• Sever epithelial attachment.
• Locate end of root by digital palpation following lateral canine eminence.
• Make 'L' shaped incision in mucosa from end of root to interproximal space between canine and upper corner incisor.
  Locate 2 mm rostral to rostral margin of root to avoid post extraction suturing over a void.
• Extend incision forward to caudal margin of corner incisor and caudal to mesial root of lower premolar 2.
• Use Molt elevator to lift full thickness mucoperiosteal flap, from leading margin at mesial angle of canine, backwards to expose lateral canine eminence.
• Cut channel round canine, from caudral crestal margin to mesial crestal margin, to at least mid-root depth. Use a 701 cross-cut fissure burr, or similar high speed water cooled handpiece.
• Insert a luxator blade into the mesial channel down the long axis direction and rotate in a lateral direction.
• Repeat until periodontal ligament begins to loosen.
• Apply the blade to caudal channel in a similar direction and rotate.
• Repeat from side-to-side until root loosens and can be gently rotated from the socket with forceps.
• Gently irrigate the socket with 0.05% chlorhexidine gluconate.
  Blood or fluid from ipsilateral nostril indicates a fistula (see complications).
• Suture flap using interrupted sutures. Start at leading edge of flap nearest caudral margin of upper incisor.
  Sutures must not be under tension; otherwise dehiscence will occur.

Step 4 - Lower canine

• More difficult than extracting upper canine tooth: long axis of tooth is bucco-lingual rather than dorso-ventral; apex lies at caudal end of mandibular symphysis.
• Sever epithelial attachments, as for single rooted teeth.
• Incise oral mucous membranes on lingual aspect along the long axis of tooth from mesial margin.
• Create a full thickness flap rostrally and caudally, with the Molt elevator, to expose lingual bone plate of canine.
• Cut channel round outline of root on lingual aspect to mid root depth, or remove lingual bone plate with bone chisel.
• Apply luxator blade to caudal channel along long axis of root - rotate blade, while applying pressure apically, to rotate root out of alveolus.
• Repeat process in reverse with blade in mesial channel.
• Irrigate and suture.

Step 5 - Deciduous teeth

• Most common are lingually displaced mandibular canines with the tips of the lower canines occluding into the hard palate.
• All deciduous teeth are rostral to their permanent counterparts, with exception of lower canines which are buccal to permanents.
• Extraction follows same principle as permanent teeth, but deciduous teeth more fragile and prone to fracture.
  Excessive luxation may scratch enamel of permanent tooth which is undergoing amelogenesis at this time - important to know location of permanent tooth bud.
• Post-extraction radiography very useful .

Analgesia

• NSAID Analgesia: NSAID pre-operatively or intra-operatively.

Antimicrobial therapy

• Clindamycin Clindamycin : good bone penetration; gram-negative anaerobic spectrum.

Potential complications

• At any location: upper canines and caudally to them, most commonly where bone plates thinnest, ie medial to upper canine and upper premolar 4.

• Requires complex flap surgery; correct attention at the time of extraction can limit the need for complex flap surgery later; debride socket gently with 0.05% chlorhexidine gluconate Chlorhexidine and suture the tissues closed without tension. Treat with suitable antibiotics. Review after 4-6 weeks to identify the need for flap surgery.
• Most commonly caused by chronic osteitis at site, or by tension on sutures.
  Expect 20% contraction of soft tissues during healing
• Can use polylactic acid granules to promote osteogenesis.
• Many oronasal fistulae stay open due to pressure differential between nasal and oral cavity.
• Close oronasal fistula if, after 6 weeks, it is large enough to cause chronic rhinitis and sneezing.

• Most sockets stop bleeding quickly post-extraction with little need for attention beyond gentle pressure.
• Packing socket with polylactic acid granules (expensive) or tetracycline powder (cheap) may help.
• Hemostatic gauze may help but must be removed after a short period.
  Check clotting time etc before extraction to assess suitability; hospitalize overnight if necessary

• Common if poor technique. Carnivore teeth taper towards the apex. Over-robust or impatient elevation will fracture the root.
• A fractured fragment containing necrotic pulp, or in an infected periodontal pocket, will cause bone lysis and must be removed.
• EitherUse a root tip pick or fine blade luxator to loosen and remove root tip.
  OrBurr away part of the bone plate to remove the root tip.
  OrAtomize root tip with high speed round burr with water irrigation.

• Support body of mandible with the palm of the hand during tooth elevation.
  Elderly toy or minature breeds - many have secondary hyperparathyroidism and extensive bone loss due to advanced periodontal disease

• Radiograph to differentiate temporary from permanent tooth - temporary teeth may have a less distinct root morphology.
  Do not extract tooth unless sure it is temporary - seek expert advice if necessary

Refereed papers

• Recent references from PubMed and VetMedResource.
• Smith M M (1996) Lingual approach for surgical extraction of the mandibular canine tooth in dogs and cats. JAAHA 32 (4), 359-364 PubMed.
• Scheels J L, Howard P E (1993) Principles of dental extraction. Semin Vet Med Surg (Small Anim) 8 (3), 146-154 PubMed.

Other sources of information

• Wiggs R B, Lobprise H B & Lippincott-Raven (1997)Veterinary Dentistry, Principles and Practice.