Surgical Extractions And Resorptive Lesions

Question 0

Outline an analgesia protocol for oral surgery

Answer 0

Multimodal pain control perioperatively (opioid and NSAID premed, regional nerve blocks) and post- op pain control

Question 1

List 4 indications for surgical extraction

Answer 1

Big rooted teeth (canine tooth, mandibular first molar tooth), persistent deciduous canine tooth, limitation of the risk of iatrogenic jaw bone fracture, dealing with or preventing extraction complications

Question 2

What is an envelope flap?

Answer 2

No vertical release incision. It is mostly used in cases of feline tooth resorption.

Question 3

Describe a vertical release incision

Answer 3

Small tooth - one release incision can be sufficient
Larger tooth - 2 release incisions and longer incisions permit better exposure. The two incisions should be divergent to provide a broader base.

Question 4

Outline some examples of gentle tissue handling considerations

Answer 4

Elevate slowly and gently with sharp periosteal elevators. Use fine tipped a traumatic tissue forceps and use them cautiously. Use retraction at base of flap more than holding onto and pulling on flap when retracting.

Question 5

What should you be cautious of not cutting into? 2

Answer 5

Infra orbital foramen and mental foramen

Question 6

How should you avoid the infra orbital foramen?

Answer 6

Palpate the bundle and push it up and out of the way before making the caudal oblique release incision for the canine tooth extraction

Question 8

How should you avoid the mental foramen? And when?

Answer 8

Avoid during vertical release incisions for mandibular premolar extractions. You will likely visualise it during the flap-retraction for the mandibular canine tooth extraction.

Question 9

What passes through the infraorbital foramen? 3

Answer 9

infraorbital artery and vein. maxilllary branch of the trigeminal nerve

Question 10

What passes through the mental foramen? 3

Answer 10

mental artery and vein. mandibular branch of the trigeminal nerve (n.b. there are often accessory mental formanina)

Question 11

What should you be careful of when doing surgical extraction of maxillary PM4?

Answer 11

spare the parotid duct and its orifice (the parotid pailla - above the distal root of the maxillary PM4)

Question 12

What is one of the most common dental diseases in cats?

Answer 12

tooth resorption - at least a third of adult cats have one or more lesions, prevalence increases with age.

Question 13

Pathogenesis - tooth resorption

Answer 13

teeth attacked by odontoclasts (these cells are similar to oestoclasts) –> adhere to surface of tooth and form resoprtive lacunae. Vasuclar granulation tissue fills the lesion and may be replaced by bone and cementum-like tissue (looks similar to jaw bone on xray)

Question 14

Why do adult roots get attacked?

Answer 14

degeneration and narrowing of the periodontal ligament and changes to the cementum of roots in the pre-resorption stages. An intact periodontal ligament exerts a protective function, inhibiting root resorption.

Question 15

Name 2 anatomical landmarks of dental radiographs

Answer 15

LAMINA DURA - white line around root is made of alveolar bone which is denser immediately around the root
PERIODONTAL LIGAMENT SPACE = thin black line around root

Question 16

What is type 1 resorption?

Answer 16

focal lesion, periodontal ligament around root is still intact. Requires standard extraction technique

Question 17

What is type 2 resorption?

Answer 17

usually has root replacement resorption or at least partial loss of periodontal ligament. can often be treated by crown amputation with intentional root retention.

Question 18

What is type 3 resorption?

Answer 18

a combination of type 1 and 2 resorption. very common.

Question 19

3 treatment options for tooth resorption

Answer 19

• extraction - currently only accepted option
• restorations - attempted previously but lesions may continue under the filling.
• medical therapy to prevent or stop further progression

Question 20

When is crown amputation for type 2 resorption contra-indicated? 2

Answer 20

in the presence of infection or inflammation at root-level (check radiographs for inflammation). In stomatitis patients and if the can has a systemic condition that compromises the immune system.

Question 21

How to perform a crown amputation.

Answer 21

elevate a muco-gingival flap for exposure and closure of the defect, sutures must be tension free. no drilling without visualisation!!! drill any dental material only to 1-2mm below the alveolar margin. if in doubt consider referral!

Question 22

What might be the signs of infected retained root remnants?

Answer 22

a painful inflammatory swelling and drain-tract, radiography revels root remnant surrounded by a lucency, following extraction of the root remnant, the inflammation and infection resolve.

Question 23

When might you see tooth resorption in dogs?

Answer 23

it is often a coincidental finding during dental radiography.

Question 24

What should you do with tooth resoption in dogs? 2 cases.

Answer 24

• EXTRACT if supra-gingival/communication of the lesion with the oral cavity.
• LEAVE IN if only subgingival and no sign of pain or radiographic sign of inflammation

Question 25

What should you elevate a flap with?

Answer 25

periosteal elevator (requires firm action of pushing down onto bone in a controlled push and twist action). flat surface to bone, curved surface to soft tissue, be especially careful when elevating the corners and at the mucogingival junction

Question 26

How do you push the flap out of the way? 2

Answer 26

using a suitable retractor. some surgeons prefer to use stay sutures to hold back the flap

Question 27

What do you use to remove the alveolar bone plate?

Answer 27

use a roundbur (this action exposes the root)

Question 28

What do you inspect the root apex for?

Answer 28

ensure there is no sign of a root fracture

Question 29

What is alveoloplasty? What do you use for this?

Answer 29

the surgical shaping and smoothing of the tooth socket after extraction. use a large round bur

Question 30

What should you do if the flap for closure doesn’t cover the defect with no tension?

Answer 30

enlarge release incision and/or incisise the periosteum

Question 31

How do you close the flap made by release incisions? Materials? Techniques?

Answer 31

NO TENSION. suture materials (5/0 or 4/0 monocryl - better or vicryl = acceptable; reverse cutting needle curved 13-16mm, take fairly big ‘bites’ about 3-5mm away from flap margin, sutures 3-4mm apart.