Oral surgery: surgical extraction technique Flashcards
1
Q
Discuss raising a ST flap and removing bone?
A
Need in a lot of cases as teeth of cats and dogs are solidly set in bone and tooth roots vary
2
Q
Discuss intra-sulcular releasing incisions?
A
- First step use scalpel blade to cut into sulcus and release attachment to tooth
- Extend that incision on tooth in front and behind
3
Q
Discuss flap creation?
A
- Looking at length of the flap in these photos
- There are a number of teeth which need removing they only look healthy as they have been cleaned prior to removal they do have severe periodontal disease.
- Incision extended right along the majority of pre-molars and molar.
4
Q
Discuss raising the flap using a periosteal elevator?
A
- When we go to raise periosteal flap place periosteal elevator underneath the sulcus easing between the ST and bone.
- The lip of bone there is thin so make sure you go over top of bone not underneath it wear you would use it like an elevator or luxator so we go above to strip off the periosteum to leave bare bone underneath this loosened flap.
- Work in horizontal direction in other words we don’t want to tease away periosteum and overlying gingiva and mucosa from bone in one place and head deeper and deeper to ventral border
- so start off from side to side so whole length of flap becomes loosened in an equal amount as you go along and then when you have loosened the whole length equally can start to go a bit deeper.
5
Q
Discuss the gingivomucoperiosteal flap?
A
- Photo on the left shows how close fingers are and how finger over periosteal elevator is making flat surface on bone and concave surface towards ST other finger of the left hand here is preventing it perforating the flap
- Photo on the right gingival retractor is showing ST flap that is able to be pulled away from bone allowing us to see furcation of number of premolars.
6
Q
Discuss surgical extraction flap creation?
A
- To make our flap we have sulcular incision seen in photo and if we only do that we only have an envelope flap.
- Far better to have a bigger space to look in to so we can make vertical releasing incisions placed in approx 90 degrees to sulcular incision so join line from mucosa to incision and end up with a triangular shaped flap or two incision to create a square shape for even more visualisation.
- We can elongate incision, increase undermining.
- Periosteum is underneath your incisions and will prevent anymore movement of you flap so can incise this carefully to get even more movement and even more visualisation.
7
Q
Discuss cutting the tooth?
A
- Access and retracting flap with ginigiva lretractor
- Then use high speed cutting burr and place that into area with furcation
- Divide tooth into individual its individual (single rooted portions)
8
Q
Discuss making individual root segments?
A
- A whole row or premolars which have periodontitis.
- Double rooted teeth apart from first premolar which have now been sectioned so essentially you have a whole row of singly rooted teeth.
9
Q
Discuss exodontics: bur usage?
A
Burrs and other techniques used for cutting
- Divided into cutting bone and tooth. High speed burr for tooth cutting (be careful as high speed teeth can fly out and blind you if you are not wearing goggles). Cut towards to crown from the root side towards the crown side away from ST to try and protect them.
- Bone removal use low speed round burr hand piece with a coolant such as hartmann’sto cool the heat.
- However in veterinary we still tend to use high speed which is not ideal but rongeurs can be used instead and these create no heat. If you do use high speed on bone use it for short period of time otherwise you’ll get thermal necrosis of bone and remember that is water that is coming through thin bur and it wont be physiological like hartmann’ssolution.
10
Q
Discuss buccal bone removal?
A
- Can see using a high speed on bone and using a bigger burr this time as it will abrade more bone rather than digging in and causing huge clefts.
- Remove it like sand from an archeologically dig.
- On the right can see that by removing some of the alveolar bone can see more tooth root.
- We need to remove enough bone to useful but not so much that causing excess bone loss about 25% of tooth root length of bone appropriate.
11
Q
Discuss tooth root loosening using a luxator?
A
- Using luxator and elevator here to work all the way around.
- The prior bone removal has allowed better visualisation and better access so have less wall attachment to root so should be a lot easier to remove and should just gently slide out of the socket.
12
Q
Look at this diagram of tooth sectioning and periodontal ligament destruction?
A
- Trying to chop out chunks so have straight line access.
- Periodontal ligament fibres are holding our socket in place and we want straight line access so we can then cut them or shear them in case of elevator.
13
Q
Discuss atraumatic extraction?
A
- Atraumatic extraction root slides out intact and we should have nice smooth tip to apex of tooth root.
- Then X-ray after to prove full removal.
14
Q
Discuss post-extraction sites?
A
Extraction sites should appear like this afterwards not loads of blood not mascerated mangled tissue no crush splintered bone should be nice and neat and follow Hallstead principles of tissue handling.
15
Q
Discuss extraction site treatments?
A
- Initially you will find you may have rough areas on edges of alveolus/socket and we don’t want these spikey bits as when we put the flap back they can be sore, restrict the blood supply and cause damage.
- What we do is alveoloplasty which is reshaping of alveolus. Rongeurs can clip this away and check its ok with gloved hand after.
- We may also have bone dust, paste, granulation tissue from long standing disease which we may want to remove too but don’t remove/play around too much in this area as we want a clean/neat blood clot to occur.
16
Q
Discuss flushing the extraction site?
A
- Occasionally need to flush alveolus to remove small debris use hartmann’sor saline
- Use 10ml syringe with blue needle which gives you right hydrostatic pressure for flushing wounds.
- Don’t do to excess to make sure blood clot can still form.
17
Q
Discuss flap placement?
A
- Rules here are there must be not tension and sutures must be supported.
- Tension in the mouth is a lot worse than in skin.
- Supported sutures means when you close you don’t want the sutures to sit over the void you have made by removing the tooth so you have to design the flap with the end product in mind.
- We want the sutures to sit over the bone so they don’t move too much and this is helpful in preventing breakdown.
- Use monocryl 4-0 5-0 with a reverse cutting suaged on needle.
- Approximate your flap first before placing sutures.
18
Q
Discuss flap closure further?
A
- The sutures are being placed here.
- Placing them in a nice bite through reasonable chunk of gingiva so the gingiva is tougher and less likely to break down and will be less sensitive than mucosa.
- We want no tension and blanching once sutured
- it should sit there of it’s own accord and the sutures are simply preventing it from flapping open/tacking it in place.
19
Q
Discuss surgical extractions with regards to specific dentition?
A
Certain teeth are move difficult to remove:
- structural teeth carnassials (maxillary 4 th premolar and mandibular 1 st molar. Maxillary 4 th premolar: 3 roots. Mandibular 1 st molar has 2 roots)
- max and mandibular canines (mandibular canines most diff to remove)
20
Q
Discuss maxillary carnassial extraction?
A
- Our triple roots can cause a bit of a problem
- Use same general technique sulcular incision with scalpel blade.
- Can see on radiograph area of radiolucency on distal root showing pulpitis is going on releasing factors that will start to destroy the bone around the apex and this would be common presentation of an abscess.
21
Q
Discuss maxillary PM4, M1 sectioning?
A
- Can see shape of crown more easily here and where you would need to place your cuts.
- So for the molars it is relatively simple as each of those cusps/raised parts of the crown have a root underneath so can see that we can do a t shaped cut as in the diagram seen bottom right left image and that will section to 3 individual root portions but notice how we run out of hard palate immediately behind our last molar so be very careful as this is where you can slip with an elevator or luxator and slip into an eye or even brain.
22
Q
Discuss maxillary PM4, M1 sectioning?
A
- The carnassial our pre-molar is a slightly different pattern with its 3 roots here (bottom right picture right image) 2 roots at front and one great big root at back.
- Again can chop into 3 but we would normally section in to two pieces before (2 smaller root section and 1 huge root section) as the distal root is less likely to # take out first then the 2 roots together last.
23
Q
Discuss canines and adjacent anatomy?
A
- Make sure you are familiar with anatomy.
- For our canine we have the nasal cavity as we move back along the maxilla we have the infraorbital foramen and within the bone there we have our infraorbital canal and our eye and brain and also the maxillary sinuses which sit close to the molars and 4 th premolar.
- In the mandible can see mental foramen neurovascular bundles run through mandibular canal and out of mental foramen. The tip of the canine root is right under that middle biggest mental foramen.
24
Q
Discuss maxillary canine extraction?
A
- Here is a discoloured maxillary canine being extracted. Designed a square shaped flap seen clearer on bottom left picture being raised from periosteal elevator.
- The right image shows how we are starting to cut into the bone to remove that buccal bone and therefore access the root.
25
Q
Discuss this maxillary canine extraction diagram?
A
- ST flap raised to give access to the bone.
- Our bone is gently removed to show where the root is so again going very gently like an archeologically dig so we can see where the mesial and distal aspect of the tooth root is.
- What we are trying to do is see where our periodontal ligament is either side of the tooth
- By removing around 2/3rds of buccal bone we are removing most of one wall of support for the tooth making out life easier to remove it.
- Would do it with big burr initially and then with a small burr (size 1 -2 round bur) going to cut bone gutters where arrows are point these are deep vertical cuts.
- Those gutters remove a lot of the support of other two walls so by time we’ve finished the wall remaining is the one on the inside between nasal cavity and root of maxillary canine. Watch out for infraorbital foramen especially when making the releasing incisions as may run into them at that stage.
26
Q
Maxillary canine extraction images?
A
- TL image our elevator is placed in the gutter created and other finger holds the flap up.
- In BL picture can see hand has rotated slightly. Do this then hold the pressure against tooth which opens up the gap. Hold for 10-20 secs precisely. Repeat these steps on mesial and distal aspects of tooth NEVER between nasal cavity and the root or we will push our instrument into nasal cavity.
- TR can see the tooth has loosened.
- BR tooth is removed if done correctly tooth should slide out easily after 5-6 goes
- key to this is patience.
27
Q
Discuss maxillary canine extraction flap closure?
A
- This is the end result and have closed the sutures (monocrylso is translucent) and it all looks like healthy happy tissue and has good chance of healing with less pain, quicker healing and less chance of infection.
- Keep area clean with salt water rinse and buster collar if dog liable to rub head and analgesia to go home with.
28
Q
Discuss mandibular canine extractions?
A
- Mandibular canines are a difficult tooth to remove.
- Takes much more time to remove and there are complications including jaw # but the approach is similar to maxilla.
29
Q
Discuss canine mandibular extraction?
A
- So in diagrammatic form it looks similar to maxillary removal but look out for the mental foramen on the mandible.
- One of the big differences here is if you put a twist when you try and extract with your elevator you will probably # the jaw.
- So instead use a luxator something that is so thin and sharp that it will sink down the gap and cut the periodontal ligaments fibres without forcing bone apart in any way. If you do this you can’t get straight line access so instead you can amputate the crown and then work around it.
- It will take time to remove buccal bone and then make more room with gutters.
- If it all goes horribly wrong and you cant get it close flap over the top flush with hartmanns put on Abs and refer.
30
Q
Disccus canine mandibular extraction?
A
- Here it is in live animal.
- Removed buccal bone in top left photo now cutting the gutters.
- Bottom left have used gutters to insert our luxators dissecting the tooth out.
- Right upper pic out comes lower canine.
- Bottom right: Close up.
- Remember the tooth root of canine is 60% of the jaw so initially before it heals will have a weaker jaw another reason why if people are willing and suitable candidate root canal can be less traumatic and quicker.
31
Q
Discuss mandible canine extraction of a juvenile?
A
- Same procedure in a juvenile
- Showing in juvenile pulp is majority of tooth at this point BR pic.
- The pulp looks like a slug and sits inside thin walled tooth, very little dentine if squeeze is like a plastic straw in young animal easier to extract because of inherent weakness of tooth but this may mean it may shatter/split up tooth more easily.
32
Q
Discuss post operative checks and homecare of exodontics?
A
- For a lot of these extractions are more invasive than having wisdom teeth removed so don’t underestimate amount of surgery involved and discomfort.
- ABs may be needed if you have caused severe amount of trauma due to amount of work required and you will have caused a bacteraemia by doing these extractions.
33
Q
Discuss exodontic complications?
A
#s: will happen to everyone at some point. Important thing is to recognise you have done it and then hopefully be able to fix it moving forwards with help from colleague.
Ankylosis: root fuses to the bone makes extraction difficult.
RR: can cause ankylosis
Trauma: to ST or bone
Wound breakdown: seen on cat on right after canine extraction. At time of extraction had caused an oral nasal communication leading to a fistula after wound breakdown which needed further treatment. When you do surgery get it right first time if you think you don’t have the right set up rethink whether appropriate to do it.
Note removal of maxillary canine has meant mandibular canine can now come into contact with lip warn owner this may happen.
34
Q
Summarise exodontics?
A
- We want to get all information ready beforehand probe, chart and radiograph vital.
- Create a treatment plan a, b and c just incase and this means you have pre-empted what could go wrong.
- Visualisation is imperative: good lighting and head torch, good flap size (remember maxim big mistakes happen through little holes)
- Asepsis: halsteads principles
- Let owner know if all root cannot be removed be honest
- Debride and flush to allow good healing
- Bottom line: Patience and practice is key give yourself plenty of time to do these at least an hour. When you do practical get a sense of how long it takes and see how much you get through! Bear this in mind for real cases.
