Dental Extractions

Question 1

When would you extract teeth?

Answer 1

*Periodontitis
*Pulp necrosis
*Persistent deciduous teeth / malocclusions
*Abnormal response to normal plaque levels
*Dental fractures
*Tooth resorption
*Mobile teeth (luxation)
*Caries (tooth decay)
*Ectopic, unerupted / impacted teeth
*Failed restorative treatment

Question 2

What is the closed extraction technique?
When would you use it?

Answer 2

*Closed extraction is performed without us making an incision through the gingiva other than through the gingival sulcus
*Uses:
ØSmall, single-rooted teeth (incisors)
ØMobile teeth with significant periodontal disease
Ø1st and 2ndPMs

Question 3

What is luxation?

Answer 3

ØApply controlled pushing force to periodontal space with luxator’s sharp blade
ØAim: to cut through the periodontal ligament attachments in direction of root apex

Question 4

What is elevation?

Answer 4

ØApply sustained, rotational force to the tooth, using alveolar bone as fulcrum
ØAim: to fatigue the periodontal ligament and ultimately tear its attachments

Question 5

What is extraction?

Answer 5

ØGripping as close to the root, apply gentle rotation to detach entire tooth from alveolus
ØAim: removal of tooth with no root remnants or fractures

Question 6

What is the surgical extraction technique?
When would you use it?

Answer 6

*Surgical extraction involves vertical releasing incisions through the gingiva, as well as bone removal and/or tooth sectioning
*Uses:
ØMost multi-rooted teeth
ØCanines
ØTooth resorption or retained roots
ØBizarre root morphology (diagnosed via x-ray)

Question 7

What are the 3 different types of gingival flaps to make?

Answer 7

*Envelope flap
*Triangle flap
*Pedicle flap

Question 8

What is the envelope flap?

Answer 8

ØGingival sulcus incision but no ‘releasing incisions’ performed
ØUseful for PM tooth where FP is usually close to gumline
ØGood for crown amps in cats

Question 9

What is the triangle flap?

Answer 9

ØSulcal incision +1 releasing incision
ØCreates a drape-like flap, easy to close
ØPerfect for triangular rooted teeth like the maxillary 4thPM

Question 10

What is the pedicle flap?

Answer 10

ØInvolves 2 releasing incisions
ØGrants extensive access to
alveolar space

Question 11

What is periosteal elevation?

Answer 11

ØElevate the mucoperiosteal flap away from the underlying bone
ØUse pushing/rotating strokes to reveal alveolus

Question 12

What is alveolectomy?

Answer 12

ØRemove alveolar bone from buccal aspect of tooth to then expose the tooth root for elevation/luxation
ØPerform sweeping motions from the crown → root

Question 13

What is a good sectioning technique?

Answer 13

ØMust have knowledge of tooth root morphology in order to section in the correct direction
ØMulti-rooted teeth are divergent (different withdrawal paths for each sectioned root)
*Sectioning Technique
ØLocate the furcation point using a dental probe
ØUse high-speed taper fissure burr with cooled H2O
ØBurr from FP to the crown until all the way through
ØWedge elevator between sectioned roots and rotate

Question 14

What are complications arising from surgical extraction?

Answer 14

*Mandibular jaw fractures
*Surrounding soft tissue trauma
*Oro-nasal fistula (maxillary canine extraction)
*Ankyolosis of roots
*Flap dehiscence
*Retained/fractured roots

Question 15

When would you leave a root tip and what would you do?

Answer 15

*Root tips can be left in place if the risks of surgery to remove the root tip outweigh the benefits of removing the root tip

*If leaving a root tip in-situ:
ØTake dental radiographs to document the remaining root structure
ØInform the owners of the decision, the reasons behind that decision and the possible consequences (infection, abscess, cyst etc.)
ØRadiographs of the retained root should be obtained annually to check for any progressing pathology

Question 16

How would you remove a fractured remnant root tip?

Answer 16

ØMay need to convert from closed → surgical
ØKeep the fractured tooth to view ‘the scene of the crime’
ØDental rads invaluable in assessing remaining root
ØVisualise root tip (via flap + alveolectomy) before removing it
ØCan create ‘moats’ with small bur to allow luxator/elevator access (or needle if very small)
ØMobilise the root, never apply apical pressure as this can cause root tip migration
ØUse root tip extraction forceps once mobilised

Question 17

What dental blocks would you use for dentistry?

Answer 17

*Caudal maxillary
*Inferior alveolar (caudal mandibular)

Question 18

What does the caudal maxillary block do?

Answer 18

Desensitise maxilla
ØDeposit LA to anaesthatise palatine +
infraorbital n. and therefore all sensation to ipsilateral maxilla

Question 19

Where is your landmark for caudal maxillary block?

Answer 19

ØSpongy soft tissue mucosa caudal to position of last upper tooth

Question 20

What syringe would you use and what would you do with it for caudal maxillary block?

Answer 20

ØUse 27G (⇡) needle in 1ml syringe
ØBend needle, draw back to ensure no intra-vascular injection
ØSlowly inject plunger whilst withdrawing needle simultaneously

Question 21

What is your aim when doing a caudal mandibular block?

Answer 21

*Deposit LA at the area of the caudal mandibular foramen, to therefore anaesthatise inferior alveolar n.

Question 22

What is the anatomical reference for caudal mandibular block?

Answer 22

*Angular process of the jaw
*Main cusp of 1stmandibular molar (309/carnassial)

Question 23

How is a caudal mandibular block carried out?

Answer 23

ØPlace finger on angular process (skin)
ØInsert needle on the lingual aspect of the mandible just after the last tooth, angling towards the angular process of the jaw
ØDeposit LA halfway between last tooth and angular process of jaw

Question 24

What local anaesthetic could you use for a block?

Answer 24

*Lidocaine - short duration
*Bupivicaine - long duration

Question 25

What is easier surgical extraction of mandibular or maxillary canine?

Answer 25

Maxillary canine extraction easier

Question 26

What is required for maxillary canine surgical extraction approach?

Answer 26

*Gingival flap approach
*Regional local anaesthesia
*High-speed burr
*Elevator/luxator
*Periosteal elevator
*Patience!

Question 27

How would you extract the maxillary canine?

Answer 27

Pedicle Flap
*Sulcal incision + 2 vertical releasing incisions
ØUse No 11 or 15 blade
ØReleasing incision transects; gingiva, muco-gingival junction and buccal mucosa
*Flap must be big enough to allow adequate access to underlying tissue
*Elevate periosteum
ØPerform firm sweeping motions to separate gingiva and mucosa from underlying bone
ØLike de-icing a car or colouring in

Question 28

How would you perform alveolectomy of maxillary canine?

Answer 28

*Cutting burr on high-speed drill with H20
ØSweeping motions to remove alveolar bone
ØStart at alveolar margin ⟶root apex
ØFollow colour change between root and bone
ØCan remove up to 75% of buccal alveolar bone
*Create gutters or moats to allow instrument access
ØPlace elevator or luxator to break remaining periodontal ligament attachments
*Using extraction forceps, remove the tooth in the direction of the root curvature

Question 29

How would you perform alveoplasty + flap closure of maxillary canine?

Answer 29

Completing extraction
*Smooth edges of extraction site using a round burr to act like sandpaper to the alveolus
ØHelps to aid in flap closure and healing
*If there is significant periapical pathology then remove any dead/diseased tissue prior to closure
*Gingival flap closure: 4-0 Monocryl on a reverse cutting needle with no tension:
Ø3mm from wound edge
Ø3mm between each bite
Ø3mm suture ears

Question 30

With an extraction what are peri / post operative management?

Answer 30

*Peri-operatively
ØRinse mouth with Hexarinse (0.12% Chlorhexidine)
ØLocal anaesthesia

*Post-operatively
ØDentisept oral paste (2mg/g Chlorhexidine) to be applied both sides of gumline SID for 5-10 days
ØPain relief for 5-10 days (Opioids, NSAIDs)
ØSoftened food for 2-3 days

*Post-op checks (ideally)
Ø3 days and 10 days to assess flap healing