Dental Extraction Techniques Flashcards
Triadan numbering
- Dogs = 44 teeth, cats = 30 teeth
- Ordered numerically from mesial to
distal - Canine is -04
- 1st Molar is -09
- Maxillary carnassial is PM4 (-08)
- Mandibular carnassial is M1 (-09)
- Cats missing PM1 (first cheek tooth = PM2 on upper jaw/maxilla); only have one molar tooth - PM1; only have PM3 + PM4 on mandible)
Gingivitis index
- 0 = no inflam
- 1 = swelling, reddening, no bleeding when probed
- 2 = inflam, reddening + swelling, will bleed when probed
- 3 = sig swelling of gingiva, sometimes w/ ulceration, spontaneous bleeding
Normal periodontal probing depth
- Dog = 1 - 3 mm
- Cat = 0.5 - 1 mm
- Measurements w/o gingival enlargement > indicative of apical migration of gingival attachment
- Measurement of periodontal pocket
Gingival recession
Cemento-enamel junction to free gingival margin - measurement made w/ periodontal probe
Periodontal index
- Adding periodontal probing depth to gingival recession then divide by total length of the tooth root (from x-ray)
- 0 = no attachment loss
- 1 = up to 25% attachment loss
- 2 = between 25 - 50% attachment loss
- 3 = > 50% attachment loss
Furcation exposure
Where roots divide
- 0 = no furcation exposure
- 1 = furcation felt w/ probe, bone loss < 1/3
- 2 = Probe placed > 1/3 of width of furcation
- 3 = Probe placed through furcation from buccal to lingual/palatal side
Tooth mobility
- 0 = no mobility
- 1 = single root: horizontal mobility < 1 mm
- 2 = single root: horizontal mobility > 1 mm; multiple roots: horizontal movement < 1 mm
EXTRACTION: - 3 = single root: horizontal + vertical movement; multiple roots: horizontal movement > 1 mm and /or vertical movement
Luxator
- Flat blade to cut/sever periodontal ligament
Dental elevators
- Lever
- Rotational force to tooth or alveolar bone
Hybrid instrument
- Sharp cutting edges
- Made of robust steel - used for elevation as well
Extraction forceps
- After elevation/luxation
- Grasp loosened tooth + remove from alveolus
Periosteal elevators
- Elevate mucoperiosteal flaps
Rotatory instrument
- Sectioning teeth, removing + smoothing alveolar bone, cutting bone + drilling into bone
- E.g. Sectioning multi-rooted teeth into single-rooted units
Closed extraction
- Without incising the gingiva (other than within gingival sulcus)
- Incisors
Closed extraction - indications
- Small, single-rooted teeth e.g. incisors + 1st premolars
- Maxillary 2nd molars in dog - 2 or 3 partly fused roots
- Sig bone loss -> inc in mobility associated w/ periodontal disease -> uncomplicated tooth extraction
Surgical tooth extraction - indications
- Multi-rooted teeth
- Canine teeth - non-Sx predisposes to oronasal fistula
- Periodontally healthy teeth
- Radio - dilacerations (abnormal bend in tooth)/other abnormalities in root morphology
Adjacent structures to teeth - consider when X
- Infraorbital a., v. + n. exit infraorbital foramen - important for cuts in gingiva, canal sits close - PM3 + PM4
- Major palatine a.
- Parotid salivary duct
- Zygomatic papilla
- Maxillary recess - lateral diverticulum of nasal cavity - opening lies in transverse plane through mesial roots of maxillary fourth premolar
- Orbit in Brachies - lies dorsal to maxillary fourth premolar, first molar + second molar
- Ventral aspect of each mandible = mandibular canal - inferior alveolar a, v, n
- Middle mental foramen - ventral to second premolar tooth - root apices sit v closely to mandibular canal, tooth root v thin
- Eye - superficial eyes in brachies, X can slip + skewer eyeball
Patient + Sx prep
- Lateral recum - allowing drainage of fluids, good visibility of the buccal surfaces of the uppermost teeth
- Pharyngeal gauze pack is recommended regardless of patient positioning to protect the airway
- Removal of calculus prior to extractions will allow more accurate assessment of the tooth structure and provides a cleaner environment for surgery
- Rinsing the oral cavity with a 0.12% chlorhexidine gluconate solution prior to the procedure will reduce bacteraemia and aerosolised bacteria
- Instruments should be sharpened and sterilised prior to use
- To prevent contact with aerosolised bacteria and fluid particles, operator should wear a mask, gloves, and protective eyewear
Types of gingival + mucogingival flaps
- Envelope flap
- Extended envelope flap
- Triangle flap
- Pedicle flap
Envelope flap
- Gingival flap - not extending apical to mucogingival junction
- Sulcular incision made + elevate attached gingiva on lingual + buccal aspects + no vertical releasing incisions
- Common for use in cats - when amputating crown during tooth resorption
Extended envelope flap
- Extraction of several adjacent teeth
- Mucogingival flaps - incisions extend apical to mucogingival junction
- Flaps used for extraction procedures = full-thickness + include periosteum
Triangle flap
- Mucogingival flap
- Sulcular incision
- Vertical releasing incision
Pedicle flap
- Sulcular incision
- Two vertical releasing incisions
- Provides best exposure
1). Flap design + management - local flaps
Section of ST - gingiva/mucosa + periosteum
- Outlined by surgical incision
- Contains own blood supply
- Allows access to underlying tissues
- Can be replaced in its original position
- Expected to heal after sutured in place
- Big enough to allow adequate exposure of Sx area
- Base of flap must be as wide or broader than free margin to preserve blood supply
- Edges of flap must lie over intact bone
- Consider adjacent vital structures
2). Mucogingival flap technique
- 1). Incise through gingival sulcus
- 2). If need mesial vertical releasing incision - place at distobuccal line angle of adjacent tooth through mucogingival junction + extending into alveolar mucosa
- 3). Second distal vertical releasing incision made
- 4). Incisions should extend apical to the mucogingival junction so flap os as long as root
- 5). Periosteal elevator introduced into sulcus + remove gingiva from underlying bone -> distally reflect mucosa + periosteum from bone
3). Bone removal (alveolectomy) technique
- Once exposed bone
- Round diamond bur (or carbide) -
- Buccal alveolar bone removed - begin at alveolar margin to how far apically desired
- Removal of 75% of buccal alveolar bone facilitates X
- Small round bur - cut periodontal ligament + make space for elevator/luxator
Sectioning multi-rooted teeth
- Tapered bur on high-speed
- Begin at furnication + progress coronally
- ‘V’ shape removed
Luxation technique - tooth extraction
- Long-thin PM roots, cats
- Used parallel to the root surface of the tooth
- Blade of the luxator is inserted into the periodontal ligament space and pushed apically, severing the collagen fibres and acting as a wedge
- Then advanced in the periodontal ligament space until the apex is reached
- Repositioned on the opposite root surface and advanced in the periodontal ligament space - will push the tooth root into the space created initially, tearing the periodontal ligament fibres and loosening the root
Elevation technique - robust roots = canines + carnassials
(Once sectioned, from the furnication)
- 1). Elevator = first class lever
- Blade placed into periodontal space, parallel to long axis of tooth
- Rotate + push root away from elevator -> tearing of periodontal ligament + expanding of alveolar bone
- 2). Elevator = wheel + axle lever
- Blade placed at level of alveolar margin, perpendicular to long axis/crown of tooth + rotated w/ concave surface against tooth - move around at 90 degrees to allow periodontal ligament fibres to tear
Bone removal (alveoplasty)
- Sharp bone edges after luxation - elevation delays healing of gingival flap -> post-op discomfort
- Round bur on high-speed/bone rongeurs
- Smooth down - like sandpaper
Management of alveolus post alveoplasty
- Empty alveolus cleared of debris
- Curettage of alveolus performed to remove pocket of epithelium + remnants of subgingival calculus
Suturing
- 5-0/4-0 monocryl for intraoral use (completely absorbed by hydrolysis in 90 d)
- Reverse cutting needle - oromaxillofacial Sx
Suturing the flap
- No tension on the suture line
- If necessary, bluntly dissect the flap submucosally (sub-cutaneously) towards the lip margin in order to gain more tissue
- Free the edge of the palatal/lingual mucosa by gently inserting the periosteal elevator between the bone and soft tissue
- Lowering the margin of remaining alveolar bone using a round diamond bur will also help reduce tension
- Periosteum, may be incised if necessary, to ensure closure without tension
Perioperative management
Analgesia
- Opioids - pre-op + post-op
- NSAIDs
- Local anaesthesia - regional nerve blocks
Homestasis support
- IVFT
- Warmth
- Post-op nutrition
Wound management
- Post-op chlorhexidine oral rinse
Trigeminal nerve CN V branches
- 1). Ophthalmic
- 2). Maxillary -> pterygopalatine nerve (major + minor); infraorbital nerve
- 3). Mandibular -> lingual nerve; inferior alveolar nerve
Regional local anaesthesia - maxilla
- 1). Infraorbital - doesn’t really anaesthetise tissues of interest, too far rostrally
- Insert needle into infraorbital canal + inject LA - de-sensitises tissue into foramen/canal
OR - Deposit local anaesthetic at opening of canal (infraorbital foramen)
- 2). Caudal maxillary - anaethetises whole side of maxilla
- Insert needle into soft tissues caudal to dental arcade + inject LA
- Completely anaesthetises ipsilateral half of maxilla
- > palatine n. -> infraorbital n -> infraorbital foramen, needle goes straight up
Regional local anaesthesia - mandible
- 1). Mental
- Needle into mental foramen + inject LA
OR - Deposit anaesthesia at opening of mental foramen
- 2). Inferior alveolar (caudal mandibular) - needle on lingual aspect of mandible, caudal to dental arcade + deposit LA half way between 3rd molar + angular process
- Halfway between tooth + angular process - anaesthetises whole side of mandible
- Corner of the jaw
Types of LA drugs
- Lidocaine - rapid onset, duration 1 - 2 h, total dose < 4 mg/kg, may contain adrenaline, least cardiotoxic
- Bupivicaine - onset 20 - 30 min, duration 6 - 8/12 h, < 2 mg/kg
- Mepivicaine
- Articaine
Complications of local anaesthesia - systemic
- Local anaesthetic drugs are cardiotoxic if injected intravenously
- Cause unresponsive cardiac arrest
- Cats are especially sensitive to local anaesthetic drugs
- Lidocaine least cardiotoxic
- All regional local anaesthetic techniques require perineural injection of LA, but all are neurovascular bundles therefore
- Must withdraw syringe plunger before injecting to ensure not within
blood vessel.
Perioperative management
- Analgesia - NSAIDs
- Homeostasis support - IVFT, patient warmth post-op nutrition
- Wound management - pos chlorhexidine oral rinse
- AB not used - unless really need to
Complications of X
- H+ - control w/ digital pressure
- Trauma to adjacent teeth - adjacent teeth should not be used as fulcrum for elevation
- Trauma - during primary extraction of teeth, before eruption of their counterparts, damage to enamel will permanent
- Trauma from opposing teeth
- Sublingual oedema + salivary mucocele
- Orbital trauma
- Surgical site dehisces
- Fracture of alveolus/jaw
- Fx of roots
Fx of alveolus/jaw
- Usually as a result of pre-operative bone loss from disease
- Pre-op radiography is essential to demonstrate pathology before surgery is
attempted - Treated by removal of diseased tissue and good repair of soft tissues
- Stabilisation of fracture fragments and/or partial mandibulectomy may be
required
Oronasal communication
- As a result of disease or iatrogenic trauma
- Good tension free closure with single layer buccal mucosal/mucoperiosteal lap
- Two layer closure if required
Fx of roots
- May be part of disease process (trauma/periodontal disease/TR) or may be as a result of ineffective extraction technique
- If inflamed or infected tissue remains then inflammation and pain in the surrounding tissues is likely to persist
- Care must be taken with their extraction
- Pre and post extraction radiography is essential
- Atomisation is never an acceptable way of treating these, will just leave hole in tooth
