INDICATIONS
- Cause for extraction
- Periodontal disease
- Endodontic disease: open canal; nonvital pulp; poor transillumination; periapical bone loss
- Tooth resorption
- Retained (persistent) deciduous teeth
- Supernumerary, crowded, or maloccluded teeth
- Periodontal disease
- Decision process: criteria
- Tooth: strategic versus nonstrategic; relative importance of tooth compared with extent of therapy necessary to save it
- Patient: underlying systemic considerations may lead to a decision to extract a tooth compared with additional efforts at periodontal therapy with frequent anesthetic episodes, chance of persistent inflammation, and so on
- Client: more advanced therapy will need a commitment for additional cost, home care, and follow-up visits, as compared with extraction resolving the problem
- Tooth: strategic versus nonstrategic; relative importance of tooth compared with extent of therapy necessary to save it
EQUIPMENT
- Instruments for gingival flap (see Chapter 7)
- Means of sectioning teeth and removing alveolar bone (alveoloplasty)
- Power equipment
- High-speed handpiece on air-driven unit
- Contra angle gear on slow-speed handpiece (micromotor unit)—set on highest speed possible
- High-speed handpiece on air-driven unit
- Cutting burs
- Crosscut fissure bur for sectioning teeth (#699, #700, #701)
- Round bur for alveoloplasty (#2, #4, #6)
- Crosscut fissure bur for sectioning teeth (#699, #700, #701)
- Dental elevators (Fig. 8-1, a)
- Various sizes and shapes
- Sharpened edge: elevators must be sharpened on a regular basis to allow the edge to fit in the periodontal ligament space between tooth and alveolar bone (Fig. 8-1, b)
- Various sizes and shapes
- Extraction forceps
- Power equipment
Figure 8-1 (a) Dental extraction forceps, winged dental elevator, and crosscut fissure bur on high-speed handpiece. (b) Dental elevators must be sharpened on a regular basis: a rounded edge on an Arkansas stone to fit the curve of the winged elevator can be used with a simple downstroke of the elevator on the edge.
PROCEDURE
- General steps (for details, see individual descriptions)
- Adequate pain management: preoperative, multimodal, local blocks, and postoperative dispensing
- Appropriate antimicrobial selection
- Appropriate patient monitoring and support during anesthetic procedures
- Access (see Chapter 7)
- Alveolar bone removal to access furcation or expose wide root structure (canines) (Fig. 8-2)
- Section multirooted teeth with crosscut fissure bur, using bur flat on tooth, moving from furcation down through the crown (shortest distance) (Fig. 8-3)
- On slow-speed handpiece, have an assistant drip water onto site to reduce heat buildup
- Elevation
- Position dental elevator
- In periodontal ligament space: advance tip of dental elevator in between tooth root and bone (Fig. 8-4)
- With sharpened tip, take great care and have controlled use of the elevator with the tip just past your finger and advance with caution to avoid slipping
- In between root section crowns, with care (Fig. 8-5)
- Between crown/root section and adjacent tooth: be careful not to loosen adjacent tooth (Fig. 8-6)
- In periodontal ligament space: advance tip of dental elevator in between tooth root and bone (Fig. 8-4)
- Adjustment (rotation or other movement) of instrument to contact and push tooth root to stretch and fatigue periodontal ligament (Fig. 8-7)
- Remove root segments with dental extraction forceps (Fig. 8-8); if not ready to be removed, with gentle rotation of the forceps, determine where further elevation is needed, or remove additional bone
- Debride/curette alveolus of debris with periosteal elevator (Fig. 8-9)
- Smooth rough bony spicules on alveolar margin—round bur: alveoloplasty (Fig. 8-10)
- Place osseopromotive substance in select sites to support osseous healing (optional)
- Suture: nonabsorbable, simple interrupted
- Position dental elevator
- Adequate pain management: preoperative, multimodal, local blocks, and postoperative dispensing
- Uncomplicated elevation
- Access/exposure with envelope flap or simple releasing incisions (see Chapter 7) (Fig. 8-11)
- Section multirooted teeth with crosscut fissure bur (Fig. 8-12)
- Elevate root segments to loosen; remove with extraction forceps
- Debride socket; alveoloplasty
- Suture
- Access/exposure with envelope flap or simple releasing incisions (see Chapter 7) (Fig. 8-11)
- Maxillary canine
- After the gingival flap is elevated, use round bur to make a groove at the mesial (rostral) and distal aspects of the canine for 3–4 mm
- Using round or crosscut fissure bur, remove 2–3 mm of buccal alveolar bone plate (Fig. 8-13), to extend the alveolar opening to a location at the widest part of the root
- Elevate and remove tooth or tooth root segments; debride socket; alveoloplasty; suture
- If tooth does not loosen sufficiently initially, additional buccal bone removal may be necessary
- After the gingival flap is elevated, use round bur to make a groove at the mesial (rostral) and distal aspects of the canine for 3–4 mm
- Maxillary fourth premolar
- After the gingival flap is elevated, use round or crosscut fissure bur to remove crestal alveolar bone to expose furcation, and use crosscut fissure bur to section tooth between the mesiobuccal and distal roots, cutting through to the developmental groove (Fig. 8-14, a); a second cut is made from the furcation mesially to remove a triangular piece of tooth that will facilitate visualization of the furcation between the two mesial roots (Fig. 8-14, b)
- Use the crosscut fissure bur to section the tooth between the two mesial (buccal and palatal) roots; this cut should be made at the furcation between the roots (Fig. 8-15)
- With the crosscut fissure bur, remove the distal aspect of the distal crown to provide space for dental elevator (Fig. 8-16)
- If one root is removed, and the others are still solid, you can remove additional bone in between the roots to better access the remaining roots; preserve as much buccal cortical bone as possible
- Keep the interseptal bone in place initially to help elevate the palatal root out; if the palatal root is retained, use the crosscut fissure bur in the alveolus coronal to the root tip in a funnel-shaped action to allow easier access and elevation (Fig. 8-17)
- If a buccal root is retained, further elevate the soft tissue to expose the jugae over the root, and use the crosscut fissure bur in a “windshield wiper” action to remove the buccal bone over the root to expose it for further elevation
- Elevate and remove tooth segments; debride socket; alveoloplasty; suture (Fig. 8-18)
- Do not use the burs to “pulverize” root tips out; infected debris can be forced into deeper tissues and the root tips may even go into the nasal cavity
- After the gingival flap is elevated, use round or crosscut fissure bur to remove crestal alveolar bone to expose furcation, and use crosscut fissure bur to section tooth between the mesiobuccal and distal roots, cutting through to the developmental groove (Fig. 8-14, a); a second cut is made from the furcation mesially to remove a triangular piece of tooth that will facilitate visualization of the furcation between the two mesial roots (Fig. 8-14, b)
- Mandibular first molar
- After the gingival flap is elevated, use round or crosscut fissure bur to remove crestal alveolar bone to expose furcation, and use crosscut fissure bur to section tooth between the roots, cutting through to distal aspect of the mesial crown (Fig. 8-19)
- With the crosscut fissure bur, remove the distal aspect of the distal crown to provide space for dental elevator as the distal segment is elevated (Fig. 8-20)
- Often the distal root will elevate more easily; use a round bur at this point to remove cancellous bone behind the mesial root to provide better access for the elevator; avoid removing buccal cortical bone when possible, as it provides strength for the mandible (Fig. 8-21)
- The mesial root can be one of the most difficult ones to remove due to its size and a groove on its distal aspect that can discourage rotation and elevation (Fig. 8-22)
- Elevate and remove tooth segments; debride socket; alveoloplasty; consider packing osseopromotive material; suture
- Do not use the burs to “pulverize” root tips out; infected debris can be forced into deeper tissues and the root tips may even go into the mandibular canal
- After the gingival flap is elevated, use round or crosscut fissure bur to remove crestal alveolar bone to expose furcation, and use crosscut fissure bur to section tooth between the roots, cutting through to distal aspect of the mesial crown (Fig. 8-19)
- Mandibular canine
- After the gingival flap is elevated, use round or crosscut fissure bur to remove a crescent-shaped area of bone from the distal-lingual aspect of the tooth (Fig. 8-23), and make a groove at the mesial aspect of the tooth to help elevator placement (Fig. 8-24)
- Before elevating, assess the degree of mandibular symphysis laxity/movement, if any present (not uncommon in small dogs and cats), and record on chart
- Elevate carefully while supporting the mandible with the opposite hand; evaluate integrity of symphysis and adjacent teeth (third incisor, first premolar) on a regular basis. Elevate at the distal aspect of the tooth, following the line of the root lingually (Fig. 8-25, a), and at the mesial aspect of the tooth, following the root (Fig. 8-25, b).
- Remove tooth; debride socket; alveoloplasty; consider placement of osseopromotive substance; suture. With adequate flap release, there should be no tension when the buccal flap is extended over the defect for suturing (Fig. 8-26).
- If the tooth does not loosen sufficiently, additional bone may be removed, but be careful with the mental foramen buccally and subgingival tissues lingually
- After the gingival flap is elevated, use round or crosscut fissure bur to remove a crescent-shaped area of bone from the distal-lingual aspect of the tooth (Fig. 8-23), and make a groove at the mesial aspect of the tooth to help elevator placement (Fig. 8-24)
- Tooth resorption
- If a tooth has been diagnosed as a true odontoclastic tooth resorption with no visible distinction between tooth and bone (periodontal ligament space obliterated, tooth root converting into osseous tissue), then a modified extraction technique may be considered (see Fig. 4-36 in Chapter 4)
- The term “crown amputation” might not be a favorable term to use with clients
- Follow all steps of local analgesia, flap (envelope), and sectioning tooth (if multirooted)
- Begin elevation: the tooth crown will usually snap off (premolars); some canine teeth will not be easily removed; crown amputation may be necessary in those cases to avoid traumatizing the mandible
- Continue removal of remaining crown and smooth any remaining tooth edges or bony spicules
- Suture site closed (cruciate suture)
- Record odontoclastic resorption, modified technique; monitor for any persistent inflammation
- Radiographs are essential! Some externally appearing “resorptive” lesions have intact roots that must be elevated! (see Fig. 4-37 in Chapter 4)
- If a tooth has been diagnosed as a true odontoclastic tooth resorption with no visible distinction between tooth and bone (periodontal ligament space obliterated, tooth root converting into osseous tissue), then a modified extraction technique may be considered (see Fig. 4-36 in Chapter 4)
Figure 8-2 Using a round bur on a high-speed handpiece, alveolar bone may be removed for better access for sectioning at a furcation.
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