SA Dental Extractions Flashcards

1
Q

Describe pulp necrosis

A
  • Pulp is the living soft tissue of the tooth; becomes inflamed (pulpitis) or exposed and bacteria enters
  • Then results in periapical pathology; tooth root abscess, sinus tracts, oronasal fistula, osteomyelitis
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2
Q

Name some dental situations where the ‘to extract or not to extract’ question would be asked

A
  • Periodontitis
  • Pulp necrosis
  • Persistent deciduous teeth or malocclusions
  • Abnormal response to normal plaque levels
  • Dental fractures
  • Tooth resorption
  • Mobile teeth
  • Caries
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3
Q

What are the names given to abnormal response to normal plaque levels in cats and dogs

A
  • Chronic gingivostomatitis in cats

- Chronic ulcerative paradontal stomatitis in dogs

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4
Q

What is the main benefit of mobile teeth?

A

Usually, the easiest teeth to remove as periodontal lig. already very weakened

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5
Q

What is a closed extraction technique?

A

Closed extraction is performed without making an incision through the gingiva other than through the gingival sulcus

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6
Q

Which teeth is closed extraction used for?

A
  • Small, single-rooted teeth (incisors)
  • Mobile teeth with significant periodontal disease
  • 1st and 2nd PMs
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7
Q

Which instruments are required for closed extraction

A
  • Correct technique
  • Elevator, luxator, scalpel, extraction forceps
  • Practice and patience
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8
Q

What is the best technique for closed extraction

A

Combination of luxation and elevation

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9
Q

Describe luxating a tooth

A
  • Apply controlled pushing force to periodontal space with luxator’s sharp blade
  • Aim: to cut through the periodontal ligament attachments in direction of root apex
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10
Q

Describe elevation of a tooth

A
  • Apply sustained, rotational force to the tooth, using alveolar bone as fulcrum
  • Aim: to fatigue the periodontal ligament and ultimately tear its attachments
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11
Q

Once luxated and elevated how can the tooth be extracted?

A

Gripping as close to the root, apply gentle rotation to detach the entire tooth from the alveolus
Aim: removal of the tooth with no root remains or fractures

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12
Q

Describe surgical extraction

A

Surgical extraction involves vertical releasing incisions through the gingiva, as well as bone removal and/or tooth sectioning

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13
Q

Which teeth is surgical extraction used for?

A
  • Most multi-rooted teeth
  • Canines
  • Tooth resorption or retained roots
  • Bizarre root morphology (diagnosed via x-ray)
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14
Q

Which instruments are required for surgical extraction?

A
  • Knowledge of tooth root morphology
  • High speed burr (round + cutting heads)
  • Gingival flaps
  • Periosteal elevator, luxator, elevator
  • Dental radiography extremely helpful/necessary
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15
Q

Name the 3 different flaps that can be made for surgical extraction of a tooth

A
  • Envelope flap
  • Triangle flap
  • Pedicle flap
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16
Q

Describe the envelope flap technique

A
  • Gingival sulcus incision but no ‘releasing incisions’ performed
  • Useful for PM tooth where FP is usually close to gumline
  • Good for crown amps in cats
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17
Q

Describe the triangle flap technique

A
  • Sulcal incision +1 releasing incision
  • Creates a drape-like flap, easy to close
  • Perfect for triangular rooted teeth like the maxillary 4th PM
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18
Q

Describe the pedicle flap technique

A
  • Involves 2 releasing incisions

- Grants extensive access to alveolar space

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19
Q

How must dental flaps be closed?

A

By primary intention

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20
Q

Describe the periosteal elevation surgical extraction technique

A
  • Elevate the mucoperiosteal flap away from the underlying bone
  • Use pushing/rotating strokes to reveal alveolus
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21
Q

Describe an alveolectomy

A
  • Remove alveolar bone from buccal aspect of tooth to then expose the tooth root for elevation/luxation
  • Perform sweeping motions from the crown → root
22
Q

How must multi-rooted teeth be extracted?

A

By tooth sectioning them into single rooted teeth

23
Q

What is the technique for sectioning a tooth?

A
  • Locate the furcation point using a dental probe
  • Use high-speed taper fissure burr with cooled H2O
  • Burr from FP to the crown until all the way through
  • Wedge elevator between sectioned roots and rotate
24
Q

Name some examples of complications that arise from surgical extraction

A
  • Mandibular jaw fractures
  • Surrounding soft tissue trauma
  • Oro-nasal fistula
  • Ankylosis of roots (pathological fusion between the alveolar bone and the cementum of teeth)
25
Q

How can fractured or remnant root tips be managed?

A
  • Best chance of removal is via surgical extraction
  • 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
26
Q

What must be done if the root tips are left in-situ?

A
  • Take dental radiographs to document the remaining root structure
  • Inform the owners of the decision, the reasons behind that decision and the possible consequences (infection, abscess, cyst etc.)
  • Radiographs of the retained root should be obtained annually to check for any progressing pathology
27
Q

How can fractured or remnant root tips be removed?

A
  • May need to convert from closed → surgical
  • Keep the f# tooth to view ‘the scene of the crime’
  • Dental rads invaluable in assessing remaining root
  • Visualise root tip (via flap + alveolectomy) before removing it
  • Can create ‘moats’ with small bur to allow luxator/elevator access (or needle if very small)
  • Use root tip extraction forceps once mobilised
28
Q

Why should you not apply apical pressure to the to the root tip being removed?

A

This can cause further migration down into the socket

29
Q

Why use local anaesthesia in dental procedures?

A
  • Tooth extraction involves soft tissue and bone dissection, all extremely painful
  • Reduces requirement for inhalant anaesthetic
  • Reduces potential ‘wind up’ (central sensitisation)
  • Immediate post-op comfort and better recoveries
  • Multimodal analgesia
30
Q

Why are regional nerve blocks more common than dental nerve blocks in veterinary medicine?

A

Regional more common in veterinary dentistry as often remove more than 1 tooth in single sitting

31
Q

Which nerve blocks provides regional anaesthesia of the maxilla?

A

Caudal maxillary block

32
Q

What is the aim when performing a caudal maxillary block?

A

Deposit LA to anaesthetise palatine + infraorbital n. and therefore all sensation to ipsilateral maxilla

33
Q

Where are the anatomical references for a caudal maxillary block?

A

Spongy soft tissue mucosa caudal to position of last upper tooth

34
Q

Describe how to perform the caudal maxillary block procedure

A
  • Use 27G (⇡) needle in 1ml syringe
  • Bend needle, draw back to ensure no intra- vascular injection
  • Slowly inject plunger whilst withdrawing needle simultaneously
35
Q

Which regional nerve block is used for the mandible?

A

Caudal mandibular block (intra-oral approach)

36
Q

What is the aim when performing a caudal mandibular block?

A

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

37
Q

Where are the anatomical references for a caudal mandibular block?

A
  • Angular process of the jaw

- Main cusp of 1st mandibular molar (309/carnassial)

38
Q

Describe how to perform the caudal mandibular nerve block procedure

A
  • Place finger on angular process (skin)
  • Insert needle on the lingual aspect of the mandible just after the last tooth, angling towards the angular process of the jaw
  • Deposit LA halfway between last tooth and angular process of jaw
39
Q

Which 2 nerve blocks, when used together will anaesthetise the entire dental arcade?

A

Caudal maxillary and caudal mandibular regional blocks

40
Q

Name two other regional anaesthetic sites

A

Infra-orbital block

Mental foramen block

41
Q

Which nerve is not blocked by an intra-orbital block?

A

Palatine

42
Q

Which local anaesthetics can be used?

A

Lidocaine

Bupivicaine

43
Q

What are the benefits of using Lidocaine?

A
  • Rapid onset (5 mins)
  • Short duration (1-2 hrs)
  • Dose ≤ 4mg/kg
  • Cost £1.36/2ml vial
44
Q

Compare the properties of Bupivicaine compared to lidocaine

A

Bupivicaine:

  • Delayed onset (20-30mins)
  • Long duration (6-8 hrs)
  • Dose 2mg/kg
  • Cost £5.16/10ml vial
45
Q

What are the main points to consider when using local anaesthetic blocks

A
  • Bleb volumes
  • Administer LA blocks periodically, NOT all at once
  • Local infiltration/splash blocks encouraged
  • Always draw back, IV is cardiotoxic
46
Q

Describe the surgical extraction method and equipment for removal of the maxillary canine

A
  • Gingival flap approach
  • Regional local anaesthesia
  • High-speed burr
  • Elevator/luxator
  • Periosteal elevator
  • Patience!
47
Q

What can be performed to gain best access to the root when removing the maxillary canine?

A

Pedicle flap

- Sulcal incision + 2 vertical releasing incisions

48
Q

How can the gingiva and mucosa be separated from the underlying bone during maxillary canine removal?

A

Elevate periosteum using firm sweeping motions

49
Q

What can be performed to access the naked maxillary canine tooth root?

A

Alveolectomy

  • Sweeping motions to remove alveolar bone
  • Start at alveolar margin ⟶ root apex
  • Follow colour change between root and bone
  • Can remove up to 75% of buccal alveolar bone
50
Q

Describe completing the maxillary canine extraction and flap closure

A
  • Smooth edges of extraction site using a round burr to act like sandpaper to the alveolus
  • 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
51
Q

What is involved in the post-operative management following surgical extraction?

A
  • Dentisept oral paste (2mg/g Chlorhexidine) to be applied both sides of gumline SID for 5-10 days
  • Pain relief for 5-10 days (Opioids, NSAIDs)
  • Softened food for 2-3 days
52
Q

Describe post-op checks following surgical extraction

A
  • 3 days and 10 days to assess flap healing
  • Dehiscence likely due to tension; antibiotics usually warranted (clindamycin, cephalexin) or chlorhexidine washes and cleaning out food from pockets