Dental Corner: How to perform a surgical extraction
Step 1: Provide analgesia, obtain pretreatment radiographs, and clean the oral cavity
Before surgical tooth extraction, administer analgesics and perform regional anesthetic nerve blocks to provide preemptive analgesia. Obtain pretreatment radiographs to reveal any hidden pathology, such as root fracture or dilacerations. Perform a dental prophylaxis, and thoroughly rinse the oral cavity with a dilute chlorhexidine solution to prepare the mouth for oral surgery. Try to avoid using a mouth gag because its prolonged use can leave the patient uncomfortable after the procedure.
Step 2: Create a mucoperiosteal flap
Create a mucoperiosteal flap by making two full-thickness incisions (through the mucosa and periosteum) with a scalpel blade starting at the gingival margin on one or both sides of the tooth to be extracted and then extending the incisions apically. The incisions should diverge so that the base of the flap is slightly wider than the gingival margin. Then, use the scalpel blade to incise the epithelial attachment of the flap at the gingival margin. Next, raise the flap with a periosteal elevator (Figure 2).
Step 3: Remove the buccal cortical bone
Once the buccal cortical bone overlying the root is exposed, remove it with a round bur operating on a high-speed, water-cooled dental drill (Figure 3). A water-cooled dental drill is essential to prevent heat necrosis of the surrounding bone. The jugum is the bony prominence overlying the root. Palpating and visualizing the jugum give you landmarks for removing the bone. The root can be identified by its different color. Use the bur with a gentle touch, and keep it moving. For multirooted teeth, it is also helpful to use the bur to expose the root furcation (the area where the root splits). For most surgical extractions, you should remove two-thirds to three-fourths of the buccal bone overlying the tooth root.
Step 4: Section roots (for multirooted teeth)
To aid in extraction, section all multirooted teeth into individual root components by using a round or taper fissure crosscutting bur operating on a high-speed, water-cooled dental drill (Figure 4). To ascertain if the sectioning is complete, place a dental elevator between the sectioned roots and gently rotate it. If the sectioning is complete, the individual roots will move. A working knowledge of tooth root anatomy (or a skull beside the dental workstation) of all multirooted teeth, especially the three-rooted teeth, is essential for making the proper sectioning cuts.3,4
Step 5: Sever the periodontal ligament, and elevate the roots
The individual roots must now be separated from their alveolar attachment. The teeth are attached to the alveolus by the periodontal ligament, so the remaining periodontal ligament must be severed (a portion of the periodontal ligament was removed when the buccal cortical bone was removed).
Repeat this procedure several times to stretch the periodontal fibers to the point of fatigue, at which time the tooth will loosen. Then use appropriately sized dental extraction forceps to grasp the crown near the gingival margin. Gently rotate the tooth along its long axis until it can be removed from the alveolus.
This step is where most root fracture complications occur. Go slowly—taking a few extra minutes to be careful avoids many extra minutes digging out broken root tips. Evaluate each root to be sure extraction is complete.
Step 6: Perform alveoloplasty
Perform alveoloplasty to remove any rough or sharp bony projections in the extraction site, which can negatively affect flap adaptation and the healing and comfort of a mucoperiosteal flap. Alveoloplasty is best accomplished with a No. 4 round bur operating on a high-speed, water-cooled dental drill (Figure 6).
Alveoloplasty is complete when digital palpation of the extraction site reveals no sharp projections. Débride any necrotic debris or other infected tissue from the alveolus, and flush the alveolus with saline or dilute chlorhexidine solution.
Step 7: Suture the extraction site
Another rule that applies is to suture fresh-cut epithelium to fresh-cut epithelium. Freshen the epithelial edges to be sutured with a scalpel blade or scissors. For oral surgery, the suture material of choice should be absorbable and not bulky. Good choices are 4-0 chromic gut and 4-0 Monocryl (Ethicon) sutures (Figure 8).
Postoperative radiography is unnecessary unless complications occur. Complications can include root tip, alveolar bone, or mandibular fracture; excessive hemorrhage; iatrogenic trauma to adjacent tissues caused by a misdirected dental elevator; oronasal fistula formation; and alveolitis.
Step 8: Provide aftercare
If antibiotics are indicated because of infection, administer them for five to 10 days after surgery. Analgesics are essential and based on the anticipated amount of pain. Instruct owners to provide patients with only soft food and to avoid giving patients hard chew toys for several weeks. A recheck examination of the extraction site in two or three weeks is recommended to ensure that proper healing has occurred.
1. Bellows J. Small animal dental equipment, materials and techniques. In: Oral surgical equipment, material, and techniques. Ames, Iowa: Blackwell, 2004;297-321.
2. Colmery BH. Oral surgery: dental extractions. In: Carmichael DT, ed. Recent advances in small animal dentistry. Ithaca, NY: International Veterinary Information Service ( http://www.ivis.org/), 2001.
3. Holmstrom SE, Frost P, Eisner ER. Exodontics. In: Veterinary dental techniques for the small animal practitioner. 2nd ed. Philadelphia, Pa: WB Saunders, 1998;215-254.
4. Carmichael DT. Surgical extraction of the maxillary fourth premolar tooth in the dog. J Vet Dent 2002:19;231-233.
The information and photographs for "Dental Corner" were provided by Daniel T. Carmichael, DVM, DAVDC, The Center For Specialized Veterinary Care, 609-5 Cantiague Rock Road, Westbury, NY 11590.