Dental extraction

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• Mobile teeth.
• Periodontal disease .
• Supernumerary teeth: if affecting occlusion or crowding other teeth.
• Persistent deciduous teeth .
• Advanced caries.
• Fractured teeth : if beyond repair, eg long axis root fractures, root fractures in the middle third, teeth with crown fractures when no endodontic treatment is authorized.
• Teeth on fracture line of fractured mandible or maxilla.
   Skull smaller and more fragile in cat than in dog.

• Endodontic techniques .
• Restorative techniques.

• Ensure client understands that general anesthesia is necessary.

• Scalpel blade No. 11 and handle.
• Molt p9 periosteal elevator .
• Root tip pick.
• Svenska luxators : 3 mm straight, 3 mm curved.
• Lindo-Levien elevators: LLL, LLM, LLS.
• Needle holder .
• Fine-toothed dissecting forceps.
• Straight scissors 5 inch .
   Must be sharp.
• Dental elevator: a selection of sizes to match tooth root size and diameter.
• Cutting burrs : 701, 702, 330, round 2, 3, 4 and 5
• Bone file .
• Drapes, clips, swabs.

• Suture material: monocryl 1.5 metric rapidly absorbable suture with swaged on cutting needle.

• Opioid .

• Mouth prop.
   Avoid using sprung mouth gags in cats as can cause serious muscle damage.

• Cut epithelial attachment at bottom of sulcus with No. 11 blade at 25° to long axis of root .
• Select an elevator or luxator with correct blade.
   Select blade with circumference one third the size of a target root.
• Introduce the elevator/luxator in an apical direction between alveolar bone and root surface .
• Rotate luxator blade circumferentially while maintaining apical pressure .
• Stop from time-to-time to allow the hydraulic pressure of hemorrhage from periodontal ligament to assist expulsion of root from alveolus.
• Continue working luxator against all surfaces of root until loose .
• Extract loose root .
• Debride alveolus, removing bone spikes .
• Radiograph to ensure complete removal.
• Suture gingiva.

• Create one or more single roots for extraction.
• Break down epithelial attachment (see single-rooted tooth - earlier).
• Lift full-thickness mucous membrane and gingiva from bone using Molt elevator .
• If necessary incise gingiva at caudal and mesial margins diverging away from root axis .
• Remove semi-circle of crestal bone, using 701 cross-cut taper fissure burr, to identify furcation angle .
• Split tooth in two halves cutting from furcation coronally .
• Apply elevator into cut channel and gently rotate to push two roots apart .
• Hold pressure for 10 seconds then turn blade around and repeat procedure.
• Combine with longitudinal elevation of tooth root.
• Keep applying pressure until one or both roots becomes loose.
• Remove loose root.
• Elevate remaining root normally.
• Debride, filing off bone spikes.
• Suture gingiva.
• Radiograph to ensure complete removal.

• Sever epithelial attachment (see single-rooted teeth).
• Locate end of root by digital palpation following lateral canine eminence .
   Locate 2 mm rostral to rostral margin of root to avoid post-extraction suturing over a void.
• Extend incision forward to caudal margin of corner incisor and caudal to mesial root of lower premolar 2 .
• Use Molt elevator to lift full thickness mucoperiosteal flap from leading margin at mesial angle of canine backwards to expose lateral canine eminence .
• Use a 701 cross-cut fissure burr or similar high speed, water cooled handpiece.
• Insert a luxator blade into the mesial channel down the long axis direction and rotate in a lateral direction.
• Repeat until periodontal ligament begins to loosen.
• Apply the blade to caudal channel in a similar direction and rotate.
• Repeat from side-to-side until root loosens and can be gently lifted from the socket with forceps.
• Gently irrigate the socket with saline 0.05% chlorhexidine gluconate.
   Blood or fluid from ipsilateral nostril indicates a fistula (see complications).
• Suture flap, using interrupted sutures. Start at leading edge of flap nearest caudal margin of upper incisor.
   ESSENTIAL that sutures are not under tension otherwise dehiscence will occur.

• More difficult than extracting upper canine tooth: long axis of tooth is buccolingual rather than dorsoventral; apex lies at caudal end of mandibular symphysis .
• Sever epithelial attachments as for single-rooted teeth .
• Incise oral mucous membranes on lingual aspect along the long axis of tooth from mesial margin .
• Cut channel round outline of root on lingual aspect to mid root depth or remove lingual bone plate with bone chisel .
• Apply luxator blade to caudal channel along long axis of root - rotate blade while applying pressure apically to rotate root out of alveolus .
• Repeat process in reverse with blade in mesial channel .
• Irrigate and suture (see upper canine extraction).

• Indications: crowding. Most common is lingually displaced mandibular canines with the tips of the lower canines occluding into the hard palate.
• All deciduous teeth are rostral to their permanent counterparts with exception of lower canines which are buccal to permanents.
• Extraction follows same principle as permanent teeth, but deciduous teeth more fragile and prone to fracture.
   Excessive luxation may damage permanent tooth if it is undergoing amelogenesis at this time - important to know location of permanent tooth bud.
• Pre- and post-extraction radiography is very useful.

• Opioid administered pre-operatively or intra-operatively.

• Antibiotics: good bone penetration; gram-negative anaerobic spectrum .

• At any location most commonly upper canines and caudally to them, where bone plates thinnest, ie medial to upper canine and upper premolar 4.

Flap dehiscence

• Requires complex flap surgery. Correct attention at the time of extraction can limit the need for complex flap surgery later. Debride socket gently with 0.05% chlorhexidine gluconate and suture the tissues closed without tension. Treat with suitable antibiotics. Review after 4-6 weeks to identify the need for flap surgery.
• Most commonly caused by tension on sutures or active infection at site.
   Expect 20% contraction of soft tissues during healing.
• Many oro-nasal fistulae stay open due to pressure differential between nasal and oral cavity.
• After 6 weeks, if ONF present, closure is indicated otherwise chronic rhinitis will occur (although may not be clinically apparent).

Hemorrhage

• Most sockets stop bleeding quickly post-extraction with little need for attention beyond gentle pressure.
• Packing socket with polylactic acid granules (expensive) or bone graft (cheap) may help.
• Hemostatic gauze may help but has to be removed after a short period.
   Beware of clotting factor defects. Pre-test clotting factors to assess suitability for surgery or bleeding time .
• Hospitalize overnight if necessary.

Root fracture

• Common with poor technique. Carnivore teeth taper towards the apex. Over-robust and impatient elevation will fracture the root.
• A fractured fragment containing necrotic pulp or in an infected periodontal pocket will cause bone lysis and must be removed:
  Either Use a root tip pick or fine blade luxator to loosen and remove root tip.
  Or Burr away part of the bone plate to remove the root tip.

Mandibular body fracture

• Beware of extensive bone loss predisposing to fracture.
   Pre-operative radiography may be helpful in assessing risk.
• Support body of mandible with the palm of the hand during tooth elevation.

Mistaken removal of permanent tooth

• Use radiography to differentiate temporary from permanent tooth - temporary teeth may have a less distinct root morphology.
   Do not extract tooth unless sure it is temporary - seek expert advice if necessary.

• See under Aftercare/Complications.

• See earlier.

• Recent references from PubMed.
• Wiggs R B et al (1998) Oral and periodontal tissue - maintenance, augmentation, rejuvenation and regeneration. Vet Clin North Am Small Anim Pract 2 (5), 1165-1188.
• Smith M M (1996) Lingual approach for surgical extraction of the mandibular canine tooth in dogs and cats. JAAHA 32 (4), 359-364 PubMed.
• DuPont G (1995) Crown amputation with intentional root retention for advanced feline resorptive lesions - a clinical study. J Vet Dent 12 (1), 9-13.
• Scheels J L et al (1993) Principles of dental extraction. Semin Vet Med Surg Small Anim 8 (3), 146-154.

• Wiggs R B, Lobprise H B & Lipincott-Raven (1997) Veterinary Dentistry, Principles and Practice.

• Dr Jan Bellows DVM DipAVetDC, All Pets Dental Clinic, 17100 Arvida Parkway, Weston, FL 33326, USA.
• D A Crossley BVetMed FAVD MRCVS, Animal Medical Centre, 511 Wilbraham Road, Chorlton, Manchester M21 0UB, UK. Tel: +44 (0)161 881 3329; Fax: +44 (0)161 861 8553.
• Dr Mark Thompson DVM DipABVP, 179 Island Ford Road, Brevard, NC 28712, USA.

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