SA Dental Extractions Flashcards
Describe pulp necrosis
- 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
Name some dental situations where the ‘to extract or not to extract’ question would be asked
- Periodontitis
- Pulp necrosis
- Persistent deciduous teeth or malocclusions
- Abnormal response to normal plaque levels
- Dental fractures
- Tooth resorption
- Mobile teeth
- Caries
What are the names given to abnormal response to normal plaque levels in cats and dogs
- Chronic gingivostomatitis in cats
- Chronic ulcerative paradontal stomatitis in dogs
What is the main benefit of mobile teeth?
Usually, the easiest teeth to remove as periodontal lig. already very weakened
What is a closed extraction technique?
Closed extraction is performed without making an incision through the gingiva other than through the gingival sulcus
Which teeth is closed extraction used for?
- Small, single-rooted teeth (incisors)
- Mobile teeth with significant periodontal disease
- 1st and 2nd PMs
Which instruments are required for closed extraction
- Correct technique
- Elevator, luxator, scalpel, extraction forceps
- Practice and patience
What is the best technique for closed extraction
Combination of luxation and elevation
Describe luxating a tooth
- 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
Describe elevation of a tooth
- Apply sustained, rotational force to the tooth, using alveolar bone as fulcrum
- Aim: to fatigue the periodontal ligament and ultimately tear its attachments
Once luxated and elevated how can the tooth be extracted?
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
Describe surgical extraction
Surgical extraction involves vertical releasing incisions through the gingiva, as well as bone removal and/or tooth sectioning
Which teeth is surgical extraction used for?
- Most multi-rooted teeth
- Canines
- Tooth resorption or retained roots
- Bizarre root morphology (diagnosed via x-ray)
Which instruments are required for surgical extraction?
- Knowledge of tooth root morphology
- High speed burr (round + cutting heads)
- Gingival flaps
- Periosteal elevator, luxator, elevator
- Dental radiography extremely helpful/necessary
Name the 3 different flaps that can be made for surgical extraction of a tooth
- Envelope flap
- Triangle flap
- Pedicle flap
Describe the envelope flap technique
- 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
Describe the triangle flap technique
- Sulcal incision +1 releasing incision
- Creates a drape-like flap, easy to close
- Perfect for triangular rooted teeth like the maxillary 4th PM
Describe the pedicle flap technique
- Involves 2 releasing incisions
- Grants extensive access to alveolar space
How must dental flaps be closed?
By primary intention
Describe the periosteal elevation surgical extraction technique
- Elevate the mucoperiosteal flap away from the underlying bone
- Use pushing/rotating strokes to reveal alveolus
Describe an alveolectomy
- Remove alveolar bone from buccal aspect of tooth to then expose the tooth root for elevation/luxation
- Perform sweeping motions from the crown → root
How must multi-rooted teeth be extracted?
By tooth sectioning them into single rooted teeth
What is the technique for sectioning a tooth?
- 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
Name some examples of complications that arise from surgical extraction
- Mandibular jaw fractures
- Surrounding soft tissue trauma
- Oro-nasal fistula
- Ankylosis of roots (pathological fusion between the alveolar bone and the cementum of teeth)
How can fractured or remnant root tips be managed?
- 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
What must be done if the root tips are left in-situ?
- 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
How can fractured or remnant root tips be removed?
- 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
Why should you not apply apical pressure to the to the root tip being removed?
This can cause further migration down into the socket
Why use local anaesthesia in dental procedures?
- 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
Why are regional nerve blocks more common than dental nerve blocks in veterinary medicine?
Regional more common in veterinary dentistry as often remove more than 1 tooth in single sitting
Which nerve blocks provides regional anaesthesia of the maxilla?
Caudal maxillary block
What is the aim when performing a caudal maxillary block?
Deposit LA to anaesthetise palatine + infraorbital n. and therefore all sensation to ipsilateral maxilla
Where are the anatomical references for a caudal maxillary block?
Spongy soft tissue mucosa caudal to position of last upper tooth
Describe how to perform the caudal maxillary block procedure
- Use 27G (⇡) needle in 1ml syringe
- Bend needle, draw back to ensure no intra- vascular injection
- Slowly inject plunger whilst withdrawing needle simultaneously
Which regional nerve block is used for the mandible?
Caudal mandibular block (intra-oral approach)
What is the aim when performing a caudal mandibular block?
Deposit LA at the area of the caudal mandibular foramen, to therefore anaesthetise inferior alveolar n.
Where are the anatomical references for a caudal mandibular block?
- Angular process of the jaw
- Main cusp of 1st mandibular molar (309/carnassial)
Describe how to perform the caudal mandibular nerve block procedure
- 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
Which 2 nerve blocks, when used together will anaesthetise the entire dental arcade?
Caudal maxillary and caudal mandibular regional blocks
Name two other regional anaesthetic sites
Infra-orbital block
Mental foramen block
Which nerve is not blocked by an intra-orbital block?
Palatine
Which local anaesthetics can be used?
Lidocaine
Bupivicaine
What are the benefits of using Lidocaine?
- Rapid onset (5 mins)
- Short duration (1-2 hrs)
- Dose ≤ 4mg/kg
- Cost £1.36/2ml vial
Compare the properties of Bupivicaine compared to lidocaine
Bupivicaine:
- Delayed onset (20-30mins)
- Long duration (6-8 hrs)
- Dose 2mg/kg
- Cost £5.16/10ml vial
What are the main points to consider when using local anaesthetic blocks
- Bleb volumes
- Administer LA blocks periodically, NOT all at once
- Local infiltration/splash blocks encouraged
- Always draw back, IV is cardiotoxic
Describe the surgical extraction method and equipment for removal of the maxillary canine
- Gingival flap approach
- Regional local anaesthesia
- High-speed burr
- Elevator/luxator
- Periosteal elevator
- Patience!
What can be performed to gain best access to the root when removing the maxillary canine?
Pedicle flap
- Sulcal incision + 2 vertical releasing incisions
How can the gingiva and mucosa be separated from the underlying bone during maxillary canine removal?
Elevate periosteum using firm sweeping motions
What can be performed to access the naked maxillary canine tooth root?
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
Describe completing the maxillary canine extraction and flap closure
- 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
What is involved in the post-operative management following surgical extraction?
- 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
Describe post-op checks following surgical extraction
- 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
