SURGICAL EXTRACTION TECHNIQUES
Stephen Juriga DVM, DAVDC
Small Animal Track
2012 ISVMA Annual Conference Proceedings
In the past, extraction therapy was performed only on mobile teeth or teeth with a
significant loss of attachment. Poor extraction techniques, inadequate instrumentation,
the unavailability of intra-oral radiology and inadequate time scheduled for the procedure
have resulted in technicians or veterinarians taking a “wait and see” approach on:
 fractured teeth with pulp exposure
 teeth with tooth resorption(s)
 multirooted teeth with loss of furcational bone
 multirooted teeth with only one diseased root
These extractions were considered very difficult, required a lot of time, may have
resulted in a complication (root fracture, hemorrhage) and generated additional charges
not included in the dental estimate. When performed veterinarians had a tendency to
undercharge for the extractions, clients were not prepared for the additional charges and
clients expressed concern on loss of teeth. Overall veterinarians found extractions to be
time consuming, frustrating and unprofitable.
Fortunately, veterinarians have access to dental C.E/wet laboratories and are now
performing thorough oral examinations. This has led to proper probing and charting of
patients during dental procedures, improved instrumentation, so extractions are now
being performed with a higher degree of success in general practice. Veterinarians have
learned the value of showing clients their pet’s oral pathology and formulate a dental
treatment plan and estimate for each patient. These dental treatment plans/estimates
detail the need for intraoral radiographs, local nerve blocks, possible extraction or oral
surgery and post-operative antibiotics/analgesics.
Simple extraction(s) refer to the extraction of single rooted teeth (incisors, first
premolars, deciduous canine teeth and mandibular 3rd molars) or mobile teeth with
significant loss of attachment. These extractions are not difficult, do not require the use
of mucoperiosteal flaps or bone removal unless a complication (root fracture) occurs.
Surgical extractions are indicated for canine teeth, multi-rooted teeth, teeth with pulp
exposure or root resorption, impacted teeth and removal of fractured roots. This
technique requires a mucoperiosteal flap, tooth sectioning, bone removal, individual
luxation of roots, alveloplasty and closure of the extraction site. If one follows the
principles of proper extraction technique this will minimize the frequence of the
complications, reduce time of the procedure, improving healing and comfort to the
patient.
Common indications for dental extractions:
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Fractured teeth w/ pulp exposure*
Non-vital teeth*
Malpositioned teeth causing trauma*
Mobile teeth > 1mm*
Grade 3 furcation exposure
Grade 4 periodontal disease
Retained deciduous teeth
Tooth resorptions
Retained roots
Retained or impacted teeth
Dentigerous cyst
Rotated or crowded teeth causing problems
Supernumerary teeth causing problems
***Note some can be treated (endodontically, orthodontically or with regenerative
periodontal therapy) rather than simply extracting the teeth
Pre-emptive analgesia
Pre-emptive analgesia refers to the administration of one or more analgesic medications
prior to the painful stimulus (surgical insult). This concept of drug administration prior to
the introduction of a painful stimulus has been shown to be more effective than giving
the same drug after the stimulus is induced. An example of a pre-emptive protocol in
veterinary dentistry would include the use of a premedication such as an opioid, alpha-2,
NSAID and regional nerve block prior to the oral surgical insult. This protocol would
suppress the pain response, reduce the dose of anesthetic agents used for induction
and maintenance (inhalants), provide intraoperative and extend into the postoperative
period. The end result is a smoother recovery from anesthesia, reduced the amounts of
post postoperative analgesics, improved patient comfort, and improved healing.i
Pre-extraction radiograph
A pre-extraction radiograph is indicated prior to performing extraction therapy. A
radiograph will allow the clinician to document the pathology that dictated extraction
therapy and to identify any pre-existing abnormalities such as root resorption, root
ankylosis, root dilacerations (root curvature), supranumery roots (feline patients
commonly have a 3rd root of the maxillary PM3) as well as an assessment of the
relationship of the tooth to vital structures (mandibular canal and floor of the maxillary
sinus or nasal cavity).
Regional analgesia
Regional nerve blocks have become the standard in oral surgery. When combined with
narcotics and non-steroidal anti-inflammatory drugs, local anesthetics reduce post
operative pain and improve healing. Bupivicaine (0.5%) or a mixture of bupivicaine
(0.5%)/lidocaine (2%) are the most commonly used local anesthetics in the oral cavity.
The knowledge of their onset and duration of action must be considered when selecting
an agent. Local anesthetics with epinephrine are used to provide hemostasis to prolong
their duration of action.
Loosen soft tissue attachment
Using a #11 or #15 scalpel blade, the gingival attachment is incised 360 degrees around
the tooth. This will aid in the placement of a periosteal elevator under the attached
gingiva and allows the introduction of a luxator into the periodontal ligament space.
Mucoperiosteal flap
First, take a moment to identify salivary ducts, major blood vessels and nerves in the
region of the proposed flap. Secondly, identify the line angle incision point for the
creation of the flap (draw a box around the tooth to identify the line angles). A
mucoperiosteal flap is created by making two full thickness divergent incisions starting at
the gingival margin on either side of the tooth and extending them apically into the
alveolar mucosa. The divergent incisions should create a wide based flap to insure good
blood supply. Extending the incision into the alveolar mucosa will allow tension free
closure after transecting the periosteum at the base of the flap. A periosteal elevator is
used to raise the mucosa and periosteum as a single layer in an apical direction. This
will expose the buccal cortical bone overlying the root(s) of the tooth.
Removal of buccal bone
The buccal cortical bone is removed from the coronal 1/3-1/2 of the root using a #2 or #4
round bur on a high speed handpiece. This will create a lateral space (window) to
elevate to tooth into, will reduce time and reduce the incidence of root fracture during
extraction. Moreover, removal of a small amount of bone from the mesial and distal root
surfaces will allow for easier placement of the luxator/elevator within the periodontal
ligament space.
Sectioning of multi-rooted tooth
Using the round bur, a small amount of furcational bone is removed to identify the
furcation region of the tooth. The tooth is sectioned using a cross cut taper bur in a
coronal direction starting at the furcation. A dental elevator is placed between the
sectioned roots and gently rotated. The two segments will move in opposite directions
when the sectioning is complete. The goal is to convert multirooted teeth into single
rooted segments to extract.
Root elevation
The individual root must be separated from the alveolar attachment (periodontal
ligament) and this is accomplished by placement of a luxator into the PDL space at the
mesial/distal aspects and within gingival sulcus (palatal/lingual aspect). Gentle apical
pressure is applied to engage the luxator/elevator into the space between the alveolus
and root surface then a slow and deliberate rotational force is applied. This force is
sustained for 15-40 seconds to fatigue or tear the PDL. The elevator is repositioned (¼
of the way) around the root and rotational force is applied. Hemorrhage from the PDL
space will be visible. This hemorrhage will deliver a “hydraulic like force” that will further
weaken the periodontal ligament/attachment. These steps are repeated on several
aspects of the tooth until the tooth has been significantly loosened. Extraction forceps
are placed as apically as possible, reducing the likelihood of fracturing the tooth root.
The tooth maybe gently rocked or rotated.
Alveloplasty
This step is performed to smooth any rough bone edges or to remove any diseased
bone. This is performed with a round bur or cylindrical diamond bur on a water cooled
high speed handpiece. The palatal or lingual alveolar crestal bone should be isolated
and reduced 2-3 mm. This will prevent tearing of this tissue during the suturing of the
flap. Alveloplasty will improve healing and patient comfort.
Alveolar curettage and lavage
The alveolus is examined for fractures, debrided of bone fragments and inflammatory
tissue using a curette. Then the extraction site is lavaged with an air-water syringe or
saline (delivered in a 12-20 cc syringe with a 22 gauge needle). At this point bone
augmenting materials (Consil or Osteoalloplast) may be placed in the alveolus to
encourage new, dense bone. The extraction sites of the mandibular first molars and
mandibular canine teeth benefit from this therapy.
Mobilize the flap & primary wound closure
Tension-free closure is the key to successful oral surgery. This is accomplished by
incising the periosteum and undermining the connective tissue. The periosteum is
incised at the base of the flap with a #15 blade. An iris scissors may be used to
undermine and mobilize the flap. The epithelial edges of the mucoperiosteal flap should
be sharply debrided with a #15 scalpel blade or using iris scissors. Sutures are placed
every 3mm with 3mm of tissue between the suture and the edge of the flap. The suture
should re-approximate the tissues to allow healing and ideally be placed over bone.
Absorbable suture material (Vicryl Rapide, Monocryl) is recommended in a 4-0 to 5-0
size with a reverse cutting needle.
Post-operative analgesia
A multimodal approach to pain control in extraction therapy is accomplished using premedications (opiods, +/- alpha-2 agents, +/- NSAID), intra-operative regional nerve
blocks, and post-operative analgesics (NSAIDs, Buprenorphine, Tramadol…). Patients
with multiple extractions or quadrant extractions will benefit from constant rate infusion of
morphine/lidocaine/ketamine or equivalent. Pet owners are instructed to feed only soft
food for 5-10 days and to limit access to hard chew objects/toys. A post-procedure
phone call within 24 hours of the procedure is essential to assess patient comfort,
patient recovery and answer any questions. A re-examination of the extraction site
should be performed in two weeks to ensure proper healing has occurred.
Avoid these common complications:
 Oronasal fistula
 Fractured roots
 Hemorrhage
 Jaw fracture
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Nerve damage
Roots lost into soft tissue places
Ocular damage
Step by Step: Extraction of the Maxillary 4th Premolar
1.
Identify the parotid salivary duct, major blood vessels and site for regional nerve
block.
2.
Identify the line angle incision points for the creation of the gingival flap needed
to surgically extract the tooth (draw a box around the tooth to identify the line
angles)
3.
Using a #15 scapel blade make an incision from the free gingival margin in a
divergent direction apically at the mesial and distal line angles of the affected
tooth. Then make an incision into the base of the gingival sulcus.
4.
Using a periosteal elevator, gently elevate the attached gingiva apically. Continue
into the alveolar mucosa including the periosteum.
Locate the furcation(s) of the multi-rooted teeth and remove ½ of the alveolar
bone overlying the furcation using a #4 round bur. This is also a good time to
remove a portion of the buccal bone over each exposed root. This allows for
more accurate placement of the luxator/elevator into the periodontal ligament
space.
Section the tooth (distal root from the two mesial roots) into single root segments
with a #701L tapered fissure bur starting at the furcation in a direction towards
the crown. Check to make sure your sectioning is complete by placing the dental
elevator between the segments and rotating the elevator 90 degrees. If the
sectioning is complete the two segments will move in opposite directions.
Luxators cut and elevators flex/torque/fatigue the periodontal ligament to loosen
the tooth within the alveolus. Using a short finger stop place the dental
instrument at about a 35 degree angle to the tooth into the periodontal ligament
space between the root and alveolar bone. Rotate the dental elevator 45-90
degrees and hold for 15-40 seconds, engage the elevator around the tooth at
several points.
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Tip:
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The objective is to transform multi-rooted teeth into single rooted entities to
prevent root fractures and complications.
Make your buccal “windows” over the distal and mesial buccal roots
Transect the tooth from distal to mesial to allow extraction the distal root first.
Also, remove 2 mm of the distal cusp to allow room for the tooth to move distally
when the luxator is placed between the mesial and distal tooth sections.
Then section the mesial roots and extract the mesial buccal root
Make one more largebuccal “window” in the furcational bone found between the
mesial roots
Elevate and extract the mesial palatal root
Once the each root segment is mobile extract with the extraction forceps by
gently pulling and rotating.
Using the same round bur or diamond bur to smooth all sharp bony edges.
Lower the palatal/lingual alveolar crest 2-3 mm to allow trauma free suturing.
Next, use a Miller curette to clean out the alveolus of any granulation
tissue/debris and lavage with saline or water.
Using the scapel blade incise the periosteum at the base of flap to mobilize the
flap allowing tension-free closure of the extraction site with 4-0 absorbable suture
(4-0 Monocryl or Vicryl Rapide). The first two sutures are placed at the corners of
the flap, then sutures are placed every 3 mm until all tissue is apposed.
Extraction of the Maxillary Canine tooth
1. Radiograph the tooth
2. Identify the line angle incision points for the creation of the gingival flap needed
to surgically extract the tooth.
3. Using a #15 scapel blade make an incision from the free gingival margin in a
divergent direction apically at the mesial and distal line angles of the affected
tooth. For the canine tooth the incision should extend at least the width of the
attached gingival into the alveolar mucosa. You may palpate the juga/buccal
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alveolar bone to orient yourself. Then make an incision into the base of the
gingival sulcus.
Using a periosteal elevator, gently elevate the attached gingiva apically. Continue
into the alveolar mucosa including the periosteum.
Remove the approximately ½ of the buccal bone over the root. This allows for
more accurate placement of the luxator/elevator into the periodontal ligament
space and serves as a space to elevate the tooth into.
Luxators cut and elevators flex/torque/fatigue the periodontal ligament to loosen
the tooth within the alveolus. Using a luxator and a short finger stop place the
dental instrument at about a 35 degree angle to the tooth into the periodontal
ligament space between the root and alveolar bone. Rotate the dental elevator
45-90 degrees and hold for 15-40 seconds, engage the elevator around the tooth
at several points.
Once the tooth is mobile extract with the extraction forceps by gently pulling and
rotating.
Using the same round bur or diamond bur to smooth all sharp bony edges.
Lower the palatal/lingual alveolar crest 2-3 mm to allow trauma free suturing.
Next, use a Miller curette to clean out the alveolus of any granulation
tissue/debris and lavage with saline or water.
Using the scapel blade incise the periosteum at the base of flap to mobilize the
flap allowing tension free closure of the extraction site with 4-0 absorbable suture
(4-0Monocryl or Vicryl Rapide). The first two sutures are placed at the corners of
the flap, then sutures are placed every 3 mm until all tissue is apposed.
Step-by-step: Feline patient
Extraction therapy in the feline patient:
1.
Based on the radiographic findings determine whether extraction therapy or
crown amputation therapy will be performed.
2.
Complete root resorption visible on radiographs= crown amputation:
**note the patient can not have endodontic disease (periapical lucency),
periodontal disease (deep pockets) or lymphoplasmacytic stomatitis.
Crown amputation:
Make two short divergent incisions and using a periosteal elevator elevate the
attached gingiva to the level of the crest of the alveolar bone. Using a #2
round bur remove the crown of the tooth below the alveolar crest. Place 1 or
2 interrupted sutures to appose the tissues for healing.
3.
Intact root structure on radiographs
Surgical extraction:
Using steps 1-9 in the canine step-by-step to extract the intended tooth or
teeth. In the feline patient a #2 round bur is suggested as well as a # 2
luxator. A feline patient’s gingiva is more delicate and roots more fragile than
canine patients-Be Patient!
 Using a scapel blade incise the periosteum at the base of flap to free the flap
allowing tension free closure of the extraction site with 5-0 absorbable suture.
(5-0 Monocryl or Vicryl Rapide –reverse cutting needle)
Tip
 In feline patients, it is helpful to elevate the lingual or palatal gingiva to
expose the alveolar crestal bone. Using a bur, lower or reduce the bone
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height by 2-3 mm. This will prevent tearing of this tissue during the suturing of
the flap.
I also recommend that the suture needle is placed through one tissue,
grasped and then gently placed through the next tissue to prevent inadvertent
tearing of the delicate gingiva. The first two sutures are placed at the corners
of the flap, then sutures are placed every 3 mm until all tissue is apposed.