Lecture 8: Exodontics

Question 1

When are extractions indicated

Answer 1

Indicated when a tooth cannot be salvaged -ex
Grade 4 periodontal disease
Tooth root abscess
Grade 3 furcation exposure
Very deep periodontal pockets
Complicated fracture that is not amenable to root canal (cost, location or type of fracture)
Tooth resorption affecting the neck or crown of the tooth
When a client is unable or unwilling to perform home care

Question 2

Primary tools for dental extractions

Answer 2

Primary tools are
Dental elevators
Extraction forceps

Question 3

Dental elevators are used for

Answer 3

Used to release the tooth from the root socket

Question 4

Why are different sizes important for dental elevators

Answer 4

A variety of sizes are necessary because of the variation in tooth size
The size of the instrument should conform to the size of the root you are working on
Each manufacturer uses their own system for identifying their instruments

Question 5

Luxating elevator is

Answer 5

Thinner and sharper at the tip
Used in a wrist-rocking motion to cut the periodontal ligament
Do not twist or apply pressure as they can easily break

Question 6

Winged elvators are

Answer 6

Head flares out wider than the shaft

Question 7

What styles are there for dental elevators

Answer 7

Also come in different handle styles and lengths (personal preference)
Several styles- based on personal preference and level of continuing education
Standard elevator
Luxating elevator
Winged elevators
Notched elevators- in the tip of the elevator
Special shapes to accommodate specific teeth

Question 8

Extraction forceps are used for and as

Answer 8

Used to grasp the tooth once it has been released and remove it from its socket when it is very loose
Some techniques use the forceps to loosed the final attachments, but this requires additional training and can lead to broken and retained root tips

Question 9

Why do you sterilize dental instruments

Answer 9

Because extraction is a surgical procedure an the instruments enters tissue, sterile instrument should always be used, to prevent introduction of a different species of bacteria into the area

Question 10

Would you use chemical sterilization for dental instruments

Answer 10

Chemical sterilization not recommended
Requires complete cleaning of the instruments before use to remove chemicals- negating the sterilization procedure
Can dull sharp instruments and weaken some metals

Question 11

Would gas sterilization be used for dental instruments

Answer 11

Potential health hazards to personnel

Question 12

What is the preferred method for sterilizing dental equipment

Answer 12

Steam sterilization (autoclaving)

Question 13

Tooth may be removed from the socket in two ways

Answer 13

Force technique
Stretch and tear technique

Question 14

Force technique down sides

Answer 14

DON’T DO IT!!!
Breaks bone (and tooth root)
Causes more trauma then necessary

Question 15

Stretch and tear technique for teeth removal is

Answer 15

recommended
Uses a rotational motion rather then a see saw motion
Must maintain pressure for at least 10 seconds (and preferably 20 seconds) to stretch the ligament
Tooth should be eased out of socket
Patiens, patience, patience!!!

Question 16

Root removal of teeth should be done when

Answer 16

All of the root should be removed
The exception is when attempts to retrieve the root will cause more damage
Use dental radiography to ensure all the root tissue has been removed

Question 17

When can you leave a root on tooth removal

Answer 17

Ex: tooth resorption in a cat where there is a complete loss of the periodontal ligament. It is acceptable (to many) to remove the crown of the tooth only prior to closing the gingiva. This is called a coronal amputation
Ex: tooth rot that has accidentally been pushed into the mandibular canal. Huge risk of massive haemorrhage with retrieval

Question 18

Exodontic techniques is and goal

Answer 18

A step-by-step approach is important
The object is to remove the tooth with as little trauma as possible
Use of each part of the technique may not be necessary for every extraction, nor is the order of steps followed each time
Combinations of vertical extraction, horizontal extraction and cutting of the periodontal ligament may be used

Question 19

Single roots in dogs

Answer 19

Incisors
Canines
1st premolars’
Mandibular 3rd molars
Sometimes mandibular 2nd premolars and mandibular 2nd molars due to fusion of their two roots into one root!

Question 20

Single roots in cat teeth

Answer 20

Incisors
Canines
Maxillary 2nd premolar
Maxillary 1st molar

Question 21

Why are canine teeth removal most likely done by a vet

Answer 21

Although canine teeth are single rooted, they almost always require creation of a gingival flap to close the extraction site, therefore, extraction of canine teeth usually is performed by the veterinarian

Question 22

Step one of single root tooth extraction

Answer 22

In the healthy mouth, the gingival attachment to the tooth is very fibrous and cannot be stretched or torn as easily as the periodontal ligament
A root tip pick or dental elevator is most commonly used to sever this attachment
Some clinicians cut the attachment with a scalpel blade
Ensure you release the attachment all the way around the tooth
Gentle wedge and slight rotation movement is using elevator
With severe gingivitis and gingival recession, this attachment is lost, and you can skip this step

Question 23

Step two for single root tooth extraction option A

Answer 23

separate the attachment of the tooth to the socket (damage the periodontal ligament)
Option A = stretching the ligament
Need continuous pressure to fatigue the ligament )at least 10 secs, preferably 20 secs)
Be patient !!!
Rapid seesaw movements will not get you anywhere

Question 24

Vertical rotation for separating the tooth from the socket

Answer 24

Elevator is parallel to the root
Work the levator into the space between the root and the alveolus with a wrist rock motion to seat the instrument in the periodontal space
Exert slow steady pressure on the tooth (at least 10 secs) to break down the ligament

Question 25

Horizontal rotation for separating the tooth from the socket

Answer 25

Elevator is placed perpendicular to the crown and tooth root
Pressure is applied to the coronal aspect of the tooth to be extracted
Be careful not to luxate the tooth that you are using a fulcrum!
This method is ONLY when you can almost pull the tooth out with your fingers

Question 26

Option B for separating the attachment of the tooth to the socket

Answer 26

wedge and cute technique
Generally used if you have a VERY sharp instruments (ie: luxating elevators)
These instruments are a wrist rock technique as you insert them into the periodontal space to cut the ligament
You can also wedge them into the space and hold that position to loosen the ligament (DO NOT TWIST OR PRY, the tooth will break!)

Question 27

Step 3 of removal for single root extraction

Answer 27

After the periodontal ligament is completely broken down, you can grasp the tooth with extraction forceps for easy removal
Using the forceps too early results in fracture of the tooth with retention of the root tip

Question 28

Step 4 of single root extraction

Answer 28

clean the socket
In order to speed healing and prevent infection, the socket should be scrapped (curetted) using a special tool
Then the socket should be flushed (usually with a dilute chlorhexidine solution)
After curettage and flushing of the socket, there are optional materials that can be placed in the socket to potentially assist bone healing (depends on veterinarian preference)

Question 29

step 5 of single root extractions is

Answer 29

gingival closure
Generally accepted that all extraction sites in companion animals should be closed with suture unless the defect is very small
Use a rapidly absorbable suture
4-0 and 5-0 monocryl and vicryl common
Usually close in simple interrupted or cruciate pattern
Can use continuous pattern but increased likelihood of dehiscence
MUST be closed without tension on the suture line - if tension is present, a gingival flap is needed

Question 30

Why do we use sutures to close a gingival flap

Answer 30

Prevents food material and bacteria from entering the socket
Speeds healing the gingiva
Also greatly reduces the risk of “dry socket” which is a very painful condition caused by inflammation of the dental nerves

Question 31

Why would you split a multi-rooted tooth

Answer 31

Splitting the tooth before extraction is the easiest method
Must know anatomy of the tooth
After splitting, each section should be removed using the steps for a single rooted tooth
You must wear eye protection and a mask during tooth sectioning

Question 32

How to do a two rooted premolar extraction

Answer 32

Section the tooth from the furcation to the tip of the crown

Question 33

Maxillary 4th premolar extraction

Answer 33

Must be separated between the furcations and the crown of each of the 3 roots
First cut is made between the cusps over the mesial-buccal and distal roots
Second cut is made to separate the mesial-buccal and palatal roots

Question 34

Maxillary 1st and 2nd molars (dogs) extractions

Answer 34

T-shaped cut is made
First split off the mesial and distal roots from the palatal root
Then separate the mesial and distal roots
Once crown has been split, each individual root is treated like a single rooted tooth
Adjoining roots may be used as fulcrums for the extraction before and after the root has been elevated

Question 35

Helpful hints for preforming teeth extractions

Answer 35

Cradle the jaw with the opposite hand
Hold the elevator down the shaft
Keep your index finger near the cutting tip
Select the appropriate sized elevator for the tooth and the job
Give it a rest and have patience!
Advanced hands-on training is required before attempting flap surgery (usually the job of a veterinarian)

Question 36

Extraction complications and how to stop them

Answer 36

Trauma due to instrument slippage
-Hold the instrument as close to the tip as possible
-The finger will act as a stop
Hemorrhage
-Control via pressure, ligation or manufactured products
Removal of Canines
-Maxillary – hold upper lip away from lower teeth– lip biting may occur
-Mandibular – keep the tongue in the mouth – tongue may now hang out the side