BASIC ORAL SURGERY

Heidi B. Lobprise, DVM, Dipl AVDC
Main Street Veterinary Dental Clinic
Flower Mound, Texas, USA

Introduction
Performing various types of oral surgery is part of daily dental practice. With the right knowledge and equipment, optimal patient care can be provided. Efforts can be maximized by starting to know what tools to use and how to maintain them. 

Extraction Decisions

	Sometimes it is easy to decide when to keep a tooth and when to extract, but at others time, the choice is not as obvious. Of the three criteria to evaluate, examining the tooth in question is the first step. If periodontal attachment loss is greater than 50% or the pulp is compromised or there is extensive tooth resorption, then it is typically best to remove. If periodontal disease is moderate, then you consider the relative importance of the tooth and if the disease around it can impact a more strategic tooth. For instance, if either the fourth premolar or second molar adjacent to the large mandibular first molar can compromise the health of that important tooth, it may benefit the patient to extract the smaller tooth, thus giving better access to treat the adjacent surface of the first molar. The same would apply to the mandibular third incisor or even the maxillary third premolar. If the decision is still up in the air, the health of the patient is to be considered: any patient with an ongoing systemic issue (heart murmur, diabetes, renal disease) would likely benefit more from an extraction that will remove the source of infection in one visit, as compared to extended anesthetic times and more frequent procedures. And third, consider the owner: if an advanced periodontal procedure or root canal is to be done, are they willing to consider the additional expense, and be committed to thorough home care and regular re-treatments? If not, then again, extraction may be optimal

Requirements
Equipment
•	Periosteal elevator – Molt #2 and Molt #4 – for elevating flaps
•	Means of sectioning – 
o	High speed handpiece/unit is preferable, but sectioning teeth can be done with a lowspeed unit, just have someone dripping water on the site for cooling
•	Set up regular maintenance schedule, including daily oiling
o	Sectioning burs – replace regularly, they get dull quickly
•	700L – dog teeth
•	699 – cat teeth
•	#2 or #4 – round burs for alveoloplasty
•	Dental elevators
o	Winged, not too thick – to fit in the PDL space
o	SHARPEN  on a regular basis, even during the procedure
•	If used and sharpened regularly, they will wear down and will need to be replaced
•	Dental luxators – thinner, more delicate – be careful not to bend
•	Extraction forceps – small breed
•	Blade – 15C
•	Suture – 4-0 to 5-0 poliglecaprone
o	Reverse cutting for dogs
o	Tapered for cats
•	Magnification – better posture

Pain Management
	Apply general principles of surgical pain management to every dental patient, even if not performing extractions. Pre-operative analgesia with opioids, alpha 2 agents,and NSAIDs when appropriate, with  post-operative dispensing of NSAIDS, opioids. Peri-operative regional, local and splash blocks can minimize the amount of general anesthesia used, help keep the patient more stable, and provide better post-operative analgesia for a smoother recovery. While lidocaine and bupivacaine can be mixed, if surgery sites are identified early in the procedure, use bupivacaine alone if it can be administered 20 minutes prior to extraction.  Bupivacaine with 1:200,000 epinephrine premixed will provide longer analgesic effect and reduce bleeding.  Watch total dose, not to exceed 1 mg/kg for cats and 2mg/kg for dogs. 
	Regional blocks can be very effective when placed accurately and not causing damage. Adequate training should proceed any attempts on patients, as nerve damage can result.  If a regional block cannot be placed (infraorbital on brachycephalic, inflamed purulent tissue, etc), then at least place a linear local block in the alveolar mucosa above/below the tooth, and you can place additional material directly at the site when open (splash block).

Radiographs
	Extractions are one of the major reasons to use intraoral radiographs, particularly when challenging procedures are encountered. Pre-operative radiographs should be closely evaluated to determine the presence and condition of the periodontal ligament (PDL), as this is the structure that elevation attempts to impact. If there is no periodontal ligament space, indication of ankylosis or even tooth/root resorption, then elevation will not go as planned. Radiographs will also alert you to abnormal root structure (or number), and if there is any compromise to the jaw strength. Radiographs will not always be decisive in evaluation teeth with compromised pulps, so use transillumination and examination to assess those teeth. 	Post-operative radiographs are a good medical and legal record, to show the correct tooth was extracted completely, without any complications (root tip, fractured jaw).

Steps of Extractions
Flaps
	With few exceptions (very loose incisors, premolars where envelope flaps are sufficient), most extraction sites benefit from full thickness mucoperiosteal flaps with releasing incison(s). 
•	Flap design – broad base, not directly over bone defect if possible
o	Extend releasing incision just past mucogingival junction, into alveolar mucosa
o	Maxillary canine – two releasing incision
o	Maxillary fourth premolar – one releasing incision mesially (rostral)
o	Mandibular canine – T- or Y- shaped distal incision, mesial incision
•	Follow the ‘path’ of the root – angled lingually
•	Elevate buccal flap completely
•	Elevate lingually to expose distal aspect of root
o	Maxillary first molar – if extracted on its own, a flap will not be reasonable
•	Flap elevation and release
o	Debride gingival margin before elevating – cut 1-2mm away
o	Periosteal elevation to lift full thickness flap off of bone – past MGJ
•	Only elevate as far as you need for adequate access
o	Use blade or iris scissors to snip the fibers of the periosteum on the under side of the flap
Alveoloplasty/Sectioning
•	Maxillary Canine
o	Make a groove at mesial and distal aspects of the root – place for elevator – to the widest part of the root, then connect across
•	Mand Canine
o	Remove bone from buccal, distal and lingual surfaces, as well as a groove at the buccal-mesial aspect
•	Multi-rooted teeth
o	Shave away buccal bone until furcation is visualized
o	Using crosscut fissure bur – section from furcation through the crown
•	Max fourth premolar – one cut from furcation into developmental groove; second cut from furcation mesially to remove ‘diamond’ shaped piece of crown
•	Access to furcation between two mesial roots now visible, section those two apart
•	Mand first molar – section from furcation to just past mesial crown, but not at too much of an angle
•	Max molars – section palatal root away from two buccal roots, then separate the two buccal roots
Elevation – the goal is to fatigue the periodontal ligament to the extent that the tooth can be elevated from the socket
•	Advancing the sharpened tip of the dental elevator down the root, in the periodontal ligament space, with rotational hold, is the best force to use
•	Elevating in between crown portions with the fulcrum of force below the alveolar ridge – teeth may break
•	Elevate tooth/section against adjacent tooth – make sure that tooth is very stable
•	Gently grasping the tooth/segment with the extraction forceps and putting rotational force can help fatigue the ligament and/or tell you where you need further elevation
•	If there is no movement and Radiographically the PDL was healthy, remove more buccal or interseptal bone.
o	In the maxilla, additional buccal bone removal is reasonable (window washer movement of the bur on the bone surface)
o	In the mandible, particularly of small dogs, preserve as much buccal bone as possible (cortical bone)
•	To access adjacent roots, remove one first, then remove the cancellous bone that was in between the roots to get better access for elevation without having to remove buccal bone
•	Once fully elevated, radiograph to confirm
Finishing
•	Elevate the lingual/palatal mucosa once the tooth is gone for better exposure for alveoloplasty and to facilitate suturing
•	Smooth any rough edges of the alveolar bone (alveoloplasty)
•	Curette any debris or infected tissue from the alveoli
•	Determine if any bone graft material is needed
•	Small breed dog – mandibular canines and first molars, incisor?
•	Osseconductive or promotive?
•	Scarify any epithelial edges
•	Simple interrupted, bite through palatal, lingual mucosa first, then buccal flap

Complications
	One of the most important resources in performing extractions is a load of patience. As soon as you lose focus or are distracted, that’s when you hear the ‘crack’. If that sound is a root tip breaking off, go through these steps to manage the situation:
•	On radiographs – was the PDL intact and healthy
o	Elevation should continue – more bone may have to been removed
•	Buccal bone removal at maxillary teeth – ‘shave’ the cortical bone away to expose the root further
•	Mandibular teeth – try to preserve buccal bone, but remove the cancellous bone that was in between the teeth for better access
•	Palatal root – dig a trench around the root and make sure there are no overhangs
o	If there is any periapical bone loss (and the pulp is dead or infected), the root HAS to come out
•	Avoid aggressive elevation toward the apex – the root could punch through into the nasal cavity or mandibular canal
•	Work the root tip from side to side – use a root tip pick
•	If the root tip goes into the nasal cavity or mandibular canal, every effort should be made to remove it THEN! – this is your best chance to remove it while it is still loose and not encased in scar or fibrous tissue
o	Take radiographs at several angles to localize where the tip is
o	Open the hole it pushed through even more (watch for important vessels)
o	If you can gently grasp it without damaging other structures, attempt to do so – but it will usually move further away
o	Once the hole is wider than the root tip without overhangs, uses copious water to flush the area, and adjust the head to allow ventral drainage
o	Many times you won’t even see the tip flush out – so re-radiograph often.

If you hear the big ‘crack’ – the jaw breaking – hopefully you had pre-operative radiographs and have told the owner that the jaw could be fragile. If this is a pathological fracture due to extensive periodontal disease, it will be a difficult area to stabilize, as the affected teeth usually have to be extracted anyway. Sometimes a partial rostral mandibulectomy is the best option for the patient.

Tooth Resorption
	The term Tooth Resorption (TR) is now used to describe any level of root and/or crown erosion or loss due to a variety of processes. While this is most commonly seen in cats, dogs can also exhibit signs of TR. The ‘typical’ tooth resorptive lesions that are diagnosed are those in cats, frequently in the premolars (mandibular third premolar) where radiographically it appears as if the root is being turned into bone. This odontoclastic lesion is a Type 2 TR and should be distinguished from the less common Type 1 inflammatory lesion. The inflammatory lesions may appear similar to odontoclastic lesions in the physical appearance of the crowns (some crown loss with gingival tissue growing into the defect), but radiographs will show roots with intact periodontal ligament space(s) and intact roots, other than where the resorption is taking place. If this type is diagnosed, careful extraction of the entire root(s) is necessary.
	If the radiograph shows root structure that is not distinct, with no clear periodontal ligament (PDL) space (as the root is being converted into bone, the PDL space is obliterated), and if there is no indication of apical bone loss or infection, then a modified extraction technique may be appropriate. While some of these roots can still be gently elevated, if the PDL is damaged, elevation will not be able to fatigue the ligament for extraction. If this is the case, after radiographic evaluation and initial attempts at elevation result in the crown breaking off, the modified technique may be done: remove the remainder of the crown and coronal aspects of the root (if possible), and smooth the alveolar bone before suturing the gingival closed. These areas should be radiographed post-operatively, the client should be informed that there was intentional root retention of the resorbing roots, and that the patient should be monitored for any persistent inflammation in the area.

Post-Operative
	Most patients benefit from appropriate pain medications, and some may require antibiotics after the oral surgery. Depending on the extent of surgery, a softened diet may be needed, and in rare instances, supplemental feeding may be needed. Active tooth brushing may be delayed for two weeks, until the oral recheck, but oral rinses and gels may be used immediately post-operatively to help with tissue healing and antimicrobial needs.

Summary
	With the right equipment, training and patience, extractions in practices can be successful surgical procedures with minimal complications. Often these patients will clinically be much healthier once the infection in their oral cavities have been managed with extractions.