Step 2: Incise the gingival epithelial attachment
The next step is incising the gingival attachment. This can be performed with a No. 15 scalpel blade. Incise the gingival
attachment 360 degrees around the tooth, using the gingival sulcus as a landmark (Figure 2).
Step 3: Insert a dental elevator
Next, insert a dental elevator into the gingival sulcus to engage the tooth. Insert the tip, or blade, of the elevator between
the tooth and the alveolar crest, slightly angling it toward the tooth. By applying gentle pressure apically as you also rotate
the elevator a few degrees in a side-to-side rocking motion, you establish a purchase on the tooth so levering forces can
be applied (Figure 3). From this point, rotate the elevator in a motion similar to turning a door handle (Figure 4). Hold the elevator in this rotated position for 10 to 15 seconds to allow the periodontal ligament fibers to stretch, fatigue,
and separate, creating micromovement of the tooth. Next, find another purchase point and repeat the procedure, holding the
tooth in the distracted position for 10 to 15 seconds. Repeat this procedure several times to stretch the periodontal fibers
to the point of fatigue, at which time the tooth will loosen. Do not use the extraction forceps until the elevator has produced
marked tooth mobility.
When you perform an extraction, patience cannot be overemphasized. The extra seconds spent holding the tooth in the slightly
distracted position will prevent the many minutes needed to retrieve retained roots, not to mention the added trauma to the
patient associated with additional bone removal and surgical intervention.
Step 4: Extract the tooth
When the tooth is markedly loose, 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 (Figure 5). Do not use excessive force with the extraction forceps when removing a tooth that has not been appropriately loosened with
the elevator. Complications could include root fracture or even fracture of the alveolus, mandible, or maxilla. Digitally
palpate the apex of the root after extraction (Figure 6). It should be round and smooth. If it is not, a root fracture has probably occurred, and radiography is indicated to plan
for root tip retrieval.
Once the tooth has been removed from the alveolus, flush out any calculus or foreign debris. If periodontal disease has left
parts of the alveolus necrotic, curet these areas. Finally, apply digital pressure (squeeze the alveolus) to return the alveolar
bone plates to their normal anatomical position. The alveolar squeeze will aid in clot retention, which is important for healing.
All extraction sites larger than 2 mm should be sutured without tension. If such a wound is left open to heal by second intention,
food and debris can enter it, causing delayed healing and increased patient discomfort. Suturing can also ameliorate postoperative
hemorrhage. In some cases, a gingival flap may need to be created to close the defect without tension.1 Suture material should be fine and rapidly absorbable; 3-0 and 4-0 chromic gut are good choices.
Step 5: Provide aftercare
In addition to providing perioperative analgesics and nerve blocks, you should discharge patients with an appropriate course
of analgesic therapy. Nonsteroidal anti-inflammatory drugs, alone or in combination with narcotics, are appropriate choices
if not contraindicated by the patient's medical history. Instruct the owners to offer the patients only soft food and to avoid
giving the patient hard chew toys and treats for five to seven days after the extraction.
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.
REFERENCE
1. Bellows J. Small animal dental equipment, materials and techniques. In: Oral surgical equipment, material, and techniques. Ames, Iowa: Blackwell, 2004;297–321.
SUGGESTED READING
1. Colmery B. 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.
2. Holmstrom SE, Frost P, Eisner ER. Exodontics. In: Veterinary dental techniques for the small animal practitioner. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1998;215–254.
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