Tooth Extractions

What are the indications for extractions?

Fractures, advanced periodontal disease, tooth resorptive lesions, inflammatory diseases, persistent deciduous teeth, un-erupted teeth, nonvital teeth, malocclusions, strategic extractions to prevent dz, carious lesions where restoration is not an option, failed endodontic treatment

Tooth fracture, endodontic dz (pulp is visible)

Advanced periodontal dz

Tooth resorptive lesions

Feline chronic gingivostomatitis

Persistent Deciduous teeth (604 and 704)

Unerupted tooth

Malocclusion

What are the advantages to saving the teeth instead of extracting them?

Preserve function

Prevent occlusal trauma

Aesthetics

What does the client need to understand?

Problem, what you recommend, why you recommend, cost, complications, post op needs, follow ups

Why do you need radiographs before pulling teeth?

See anatomy

Look for complicating factors

What are the blocks used for dental extractions?

Infraorbital

Maxillary

Mental

Inferior alveolar

Describe the infraorbital block

Place in infraorbital foramen to block buccal bone, teeth, and soft tissue

What determines which teeth are numbed with infraorbital blocks?

How far caudally the anesthetic agent diffuses

What animals have a very short infraorbital canal?

Small toy dogs, cats, and brachycephalics

What does the maxillary block?

Blocks maxillary nerve before it enters the infraorbital canal

What anatomical features do you need to be careful of during a maxillary block?

Maxillary artery eye

What does the mental block?

Rostral mandible, lip, and teeth

Why is reliability of the mental block questionable?

Anesthetic depends on diffusion of drug

What animals have a difficult mental block to do?

Small dogs and cats

What does the inferior alveolar block?

Lower arcade

What are the general instruments you need?

Scalpel, handle, scissors, periosteal elevators, tissue forceps, tissue retractor, drill, elevator and luxator, alveolar curette, suture, saline, gauze, cotton tip applicator, suction

What are the types of extractions?

Closed and open

Describe a closed extraction

No gingival flap, sectioning of teeth, or removal of buccal bone

When do you do a closed extraction?

Incisors, single rooted premolars and single rooted molars

What are the steps of a closed extraction

1. Incise attached gingiva with a scalpal

2. Insert elevator or luxator into periodontal ligament space

3. Apply rotational or wedge forces

4. Extraction forceps for tooth removal

5. Close with a simple interrupted or cruciate

When do you do an open/surgical extraction?

Multi-rooted teeth

Single-rooted tooth with large roots (canines)

Teeth with fragile roots

There is a complication in a closed fracture

What is the steps of an open extraction?

1. Mucoperiosteal flap is made for increased exposure of buccal bone

2. Some buccal bone over tooth root is removed

3. Multi rooted teeth are sectioned into single rooth

4. Extraction of entire root

5. Alveoloplasty and curettage

6. Closure of flap

What is an alveolotomy?

Removal of buccal bone to add in extraction of individual roote

How much do you remove with a alveolotomy?

1/3-1/2 of the bone covering length of the root

What burs are used for a alveolotomy?

Round, pear, and tapered

Why do you section the bone into individual roots?

It makes it easier to remove

What is the problem with removing the first molar?

It has variable roots so you sometimes have to section it sometimes dont

Need to use radiographs to identify roots

What do you use to divide the tooth into single root segments?

Cross-cut taper or pear bur

What is a must on a elevator or luxator when removing a tooth?

Using a short finger stop

What should the tooth socket feel like after removing a tooth?

Smooth and round

If you feel a tooth socket after removing a tooth and it is gritty what do you need to do?

Remove your fragment or look for underlying disease

When do you use extraction forceps?

After tooth is mobile

What are some complicating factors of tooth removal?

Diseased teeth may be fragile and break, ankylosis, tooth resorption, dilaceration of roots, fused roots, extra roots, amount of supporting bone present, placement of teeth in mouth, shape of mouth

What is ankylosis?

Fusion of tooth to surrounding alveolar bone

Common in older patients

What do you do after removing a tooth?

Radiograph to make sure that there are fragments left

What is an alveoloplasty?

Contouring the bone so no sharp edges that can damage the flap are present

What do you use to do a alveoloplasty?

Diamond burr, football or taper shape

Why do you use a curette on the alveolus after removing a tooth?

Remove debris like granulation tissue, calculus, or bony fragments

When do you not need to curette the alveolus?

If the alveolus is clean

How do you do a alveolus debridement and flush?

Curette to remove debris

Saline flush after

T/F a tension free closure is a must?

True

How do you prepare the flap for closure?

Fresh margins, shape flap for fit, lengthening incisions may be needed, release periosteum for more mobility

Use gentle tissue handling

What suture do you use to close?

4-0 - 5-0 Monocryl because it is monofilament and glides through tissue easily

How long does monocryl suture take to resorb?

2-4 weeks

What can be helpful when closing a flap?

A small amount of palatal and lingual gingival elevation

What might you have to reduce to close a flap in a cat?

Boney ridge palatally

How do you close a flap?

Simple interrupted 1-3mm apart

2-3 mm from tissue edge

Tag length of 2-3mm

How many throws to close a flap?

4-6 so t the tongue cannot untie

Why do you close a flap?

Keeps blood clot out of alveolus

Improves patient comfort

Faster healing

Prevent food and debris from packing in

What are some complications of extractions?

Fractured roots, root displacement, excessive bleeding, oronasal fistula, fractured alveolus, fractured mandible, damage to surrounding teeth, soft tissue trauma, flap dehiscence, post op infection

Where can roots be displaced while doing an extraction?

Nasal cavity, mandibular canal, retrobulbar area

What is the after care of an extraction?

Soft food

Pain control

Nothing to chew on

E-collar

Rechecks

How long do you give soft food afterwards?

Until follow up

T/F you can give canned or moistened dry food as after care for an extraction?

True

What can you use for pain control after an extraction?

NSAIDs is baseline

Can add in opioids, gabapentin, or tramadol

When should you use antibiotics?

Severe infections of soft tissue or bone

Immunocompromised patients

Sub-aortic stenosis

Recent implants

How long can a patient not have a toy or a chew after an extraction?

Until a recheck

Why can a patient not have toys or chews after an extraction?

Minimize stress on suture line

What do you do at the recheck?

Ensure proper healing

Talk about preventative like tooth brushing, or diet

Behavior modification

What are the approaches for the maxillary block?

intraorally or extraorally

What are the approaches to an inferior alveolar?

intraorally or extraorally

What are mucoperiosteal flaps?

Flaps that allow for access to underlying structures

What do you need to plan ahead for before creating a mucoperiosteal flap?

What type of flap

If and when you need to make a vertical incision

Anatomy that is nearby

How much tissue you have to work with

What are the types of mucoperiosteal flaps?

Envelope

One vertical incision

Two vertical incisions

What flap does not have a vertical incision?

Envelope

What flap is triangle shaped?

One vertical incision

What flap is pedicle shaped?

2 vertical incision

Describe a no vertical incision / envelope flap steps

1. A sulcular incision is made parallel to the attached gingiva

2. Periosteal elevator is used to raise a full thickness flap

3. Buccal bone is exposed

What do you need to avoid with any type of flap?

Mucogingival junction

What does the length of the envelope flap depend on?

Number of teeth that need to be removed

What is the ideal location for a vertical incision of a flap?

Interproximal space between teeth

Where should a vertical incision not be placed?

In the furcational area of adjacent teeth

For a vertical incision flap, where should the suture line be?

Over the bone after closing. You need to plan this while making the vertical incision

What are the steps of a one vertical incision flap?

1. Sulcular incision made into gingiva parallel to the tooth

2. One vertical full thickness incision made traversing apically past mucogingival junction

3. Periosteal elevator used to raise a full thickness flap

4. Buccal bone is exposed

What are the steps of a two vertical incision flap?

1. Sulcular incision made into gingiva parallel to the tooth

2. Two vertical full thickness incision made traversing apically past mucogingival junction

3. Periosteal elevator used to raise a full thickness flap

4. Buccal bone is exposed

What is a downside of a 2 vertical incision flap?

It takes longer to close

What are the different forces used to remove a tooth?

Luxation

Elevation

Wheel-and-axle motion

Leverage

Rotation

Traction

What is a luxation motion used for?

Expand alveolar bone and cut periodontal ligament fibers

What is a elevation motion used for?

Expand alveolar bone and cut and stretch periodontal ligament fibers

What is a wheel and axle motion used for?

Elevator is placed perpendicular to 2 roots and handle is rotated to engage the elevator against a tooth root

Lifts tooth from alveolus

What is a rotation movement used for when removing a tooth?

Fatigue remaining periodontal ligament fibers

What is a traction motion used for when removing a tooth?

Removal of tooth from alveolus