Assisting with Extractions
Sandra Manfra Marretta, DVM, Diplomate
The recent development of veterinary dental techniques has decreased the ultimate need for dental extractions. However, dental extraction remains a commonly performed oral surgical procedure in veterinary practices. It can be a very time-consuming, frustrating, and disappointing endeavor, but with the proper surgical techniques and instrumentation, assisting with dental extractions can be an efficient, rewarding, and extremely profitable part of a veterinary practice.
Indications for Extractions
Indications for dental extractions may include the following: (1) retained deciduous teeth, (2) supernumerary teeth, (3) maloccluded teeth, (4) advanced periodontal disease, (5) fractured teeth, (6) gross decay/erosions, (7) diseased teeth in fracture site of mandible or maxilla, (8) periapical abscesses, (9) impacted teeth, and (10) deformed teeth.
Retained deciduous teeth should be removed as soon as they are recognized. Failure to do so can result in malocclusion of the permanent dentition. Permanently retained deciduous teeth predispose the permanent dentition to premature periodontal disease because of accelerated accumulation of dental plaque and calculus formation.
Supernumerary teeth may cause the same dental problems that are associated with retained deciduous teeth. They should be extracted as necessary.
Maloccluded teeth can occur from overcrowding, overly retained deciduous teeth, supernumerary teeth, or trauma to the developing teeth. Extraction is indicated when these teeth predispose to periodontal disease prematurely. Maloccluded teeth leading to soft tissue trauma can be managed by extraction, crown shortening procedures, or orthodontic therapy.
Severe periodontal disease resulting in extremely mobile teeth should be treated by extraction. Other indications for extraction of teeth affected with periodontal disease include periodontal pockets extending to the apex of the tooth pockets that reach the nasal cavity or maxillary sinus, and periapical abscesses.
Fractured teeth should be differentiated from dental attrition (worn teeth). Dental attrition rarely requires treatment. Occasionally, rapid wear of the tooth results in pulpal exposure. These rare cases should be managed the same as fractured teeth with pulpal exposure. Extraction is indicated in fractured teeth that are not endodonticallly treatable or when the owners decline endodontic therapy.
A periapical abscess is an infection around the apex of a tooth. Extraction is the treatment of choice in animals with periapical abscesses secondary to periodontal disease. Fractured teeth that develop periapical abscesses can be treated with endodontic therapy or extraction.
Dental caries, soft areas of demineralized enamel or cementum, are rare in dogs and cats. Teeth with dental caries should be restored or extracted.
Odontoclastic resorptive lesions in cats are very common. These lesions are often extensive and painful and should be treated by restoration or removal.
Unerupted teeth (impacted teeth) should be extracted if they are causing nasal discharge, orthodontic problems, or pain. Dentigerous cysts can occur wth unerupted or impacted teeth. These cysts cause expansion of bone with subsequent facial asymmetry, extreme displacement of teeth, and root resorption of adjacent teeth. Dentigerous cysts may also give rise to ameloblastomas. Symptomatic impacted teeth should be treated by extraction, or in rare cases, orthodontic therapy.
Pathologic fractures can occur through the alveolus of diseased teeth. These teeth must be extracted prior to fracture fixation because they prevent fracture healing.
Proper Extraction Techniques
There are three basic types of extraction techniques: simple, multirooted, and complicated surgical extrations.
A simple extraction refers to the extraction of small single-rooted teeth, such as incisors. An appropriate-sized dental elevator is placed in the gingival sulcus to sever the attachments of the gingiva around the tooth. The elevator should be advanced apically between the alveolar bone and the root. The periodontal ligament can be torn by rotating and holding the elevator 90 degrees for 15-second intervals. A dental extraction forceps can then be placed on the crown to rotate the tooth and remove it from the alveolus.
Multirooted teeth such as premolars and molars are more difficult to extract. These teeth may have only one root affected with the other roots firmly attached to the alveolar bone. Most roots are embedded in the alveolar bone at divergent angles which further anchors the tooth into the alveolus. Sectioning of a multiroooted tooth into two or three sections converts the procedure into multiple simple extractions. A tapered fissure bur on a high-speed handpiece is an efficient technique for sectioning teeth. A low-speed handpiece with a dental bur can be used with adequate irrigation to prevent osseous necrosis. The furcation should be located prior to sectioning the tooth. This can be done by elevating the gingiva with a periosteal elevator. The bur should be placed at the furcation and directed through the crown. The sections of the tooth can then be independently extracted.
A complicated surgical extraction involves the removal of teeth with large roots such as the canine teeth in dogs or large multirooted teeth. The technique involves: (1) reflection of a mucoperiosteal flap exposing buccal bone overlying the root, (2) removal of buccal alveolar bone overlying the root, (3) sectioning of the tooth if multirooted, (4) extraction of the tooth, (5) alveoloplasty, with flushing and curettage of the alveolus, and (6) replacement and sututing of the mucoperiosteal flap.
<sic> tooth and marginal alveolar bone with a small feline periosteal elevator. The gigiva is retracted and protected with the end of a small flat elevator while the crown of the affected tooth is amputated with a #3 round bur on a high speed handpiece with sterile water flush at or slightly below the level of the alveolar crest. Sharp bony projections are smoothed with the bur and the gingiva is closed with a single simple interrupted 3-0 chromic suture.
<sic> dible during extraction, and a rotational motion with the dental extractor can help prevent pathologic fractures. These fractures should be managed conservatively with tape muzzles or intraoral acrylic splints and a soft gruel diet.
1. Kapatkin AS, Manfra Marretta S, Schloss AJ. Problems associated with basic oral surgical techniques. Prob Vet Med 1990:85-109.