OK, as, as Anthony said, I'm still in practise. I research and develop new veterinary products as well. We started working on this one several years back, and it's to try and find a solution to the problem of blunt instrumentation for dental surgery.

Which we all have, dental surgery, at least in my experience, is the most common procedure that's not neutering that we ever do. And certainly from my point of view, it's the most frustrating one as well. So, safe dental surgery, whether you're a referral surgeon or a general practise surgeon, it's about decent quality instruments.

The reason for that, sharp instruments, it's like a sharp scalpel blade. If the instrument is of decent standard and is in decent condition, you don't have to push so hard because you're not pushing so hard, you won't slip. You're actually trying to surgically cut the periodontal ligaments to remove these teeth.

Blunt instruments won't do that. The key point with maintaining the instruments is do it frequently, but don't do it very much. So you only need 1 or 2 strokes from a sharpening stone after the instrument has been cleaned to maintain it in a really good surgical condition.

If you leave it for months or several months and then try and get the edge back, it's too late, the instrument is damaged beyond repair. Blunt instruments, which I'm sure we've all seen, you don't have the edge that you need to work with. You have to put more force in, you're levering rather than cutting, and you're much, much, much more likely to do damage to yourself and damage to the patient.

So it's best avoided. So what we came up with was a system where you could take a blade off and change it, very much like a scalpel blade, and this is a little video to show you what we've come up with. So, you can take the blade out of the handle.

You can replace it, you can have one handle with multiple blades, you can take the blades off whenever you want to. There's a small bolt that runs through the middle. And once these blades are in place, and you can see you're not screwing them in hard, once they're in place, they will not rotate, they will not move.

They're as solid as a normal dental instrument. And there's a series of shapes on that blade that keep it locked in place. You can see that we've designed them so they fit nicely in the palm, and your finger is coming down to the end of the blade, that will give you a stop point and that means that if you slip, your finger stops you from going in too deep and causing damage.

These things are distributed in the UK through N2 UK and they are a well-known instrument manufacturer. So the instruments themselves, the Dentonomic instruments, they've been designed by myself and a group of very, very good engineers. They are completely made in the UK.

None of this is from abroad. And we've chosen the best quality metals to make them out of. When they are made We turn them out of high quality metal.

We then harden them and electric polish them, and that's a chemical polishing method that gets a very, very good edge on them. You can get a very nice cutting edge on these instruments, much better than you'll be used to, because the quality of the steel is much higher. You can remove the blades very easily for sharpening or disposal, and you can replace them very quickly.

Some people will have one handle for each blade, that's what I do. Some people just get one handle and have a range of different blades of different sizes. But the point is that it's easy.

This was designed for practise. So Anthony has all the details, you can get hold of these very easily. This is contact details for N2, contact details for myself.

I've been using these instruments in practise for several years while they were under development, and they've been on sale for the last 6 months. The handles are 80 pounds excluding VAT. The colours are just there for fun, frankly.

Some people colour code their instruments. I just like to have nice colours. So every handle is the same, each one will fit each blade.

The blades are 25 pounds each, regardless of which type you use. So you've got elevator types here. These are thicker bodied.

They are designed for rotation, so they're there to stretch the periodontal ligaments and compress the bone around the tooth socket. And you've got luxators which are finer and thinner. Luxator type blades are designed for cutting.

They're like little chisels. So they're there to sever the periodontal ligament. On the whole, most GP surgeons will use elevators, but there is something to be said for using a luxator to cut the periodontal ligament and an elevator to widen the space.

And myself, I chop and change between the two different kinds of blade. If you're starting out, elevated blades are probably where you want to start. We've got a webinar vet show offer, so if you order any three blades of your choice, you get a 4th blade for free.

N2 also run offers on their site. This is in addition to any offers that they're running. And if you quote that code webvet 443, when you make your order, then that will come through and that's valid until next Saturday for any orders placed by next Saturday.

And that's me done. Thank you very much. I look forward to Alex's talk, and if anyone's got any questions for me, I should be available on the chat through until the end of the session.

Right, so, we'll have a little look at the sides of, of dentistry that, that can go wrong and try and guide everyone on how to minimise the risk of issues, and try and sort of decipher what, what might cause a problem, also what might cause pain, and obviously how to, to minimise that. So, extraction complications to kick us off and we'll we'll, we'll go through these in sequence and, and hopefully make things easier and safer for you. OK, so, obviously there's things that we can identify before we start that might lead us into difficulty.

And that might well be the anatomy of, of our patients, of particular areas of particular teeth. Etc. So examples would of course be things like supernumerary roots, hooks on roots, fully shaped roots, so the morphology can be quite variable.

And then we can have things, of course, like resorption, ankylosis, etc. However, a lot of it also boils down to what we do and what technique we choose. So knowing that we've got something that might make our lives more difficult from before we even start is helpful because it may then modify our technique to reduce the chance of issues.

So what might we find afterwards? Well, obviously there's trauma that we cause, and the most common, of course, being fracture of teeth and particularly roots being left behind, as you see on the radiograph just here, and that's probably our most frequent complication that we'd run into. The bone can be damaged and obviously, as well as our, our heart tissues, we can have soft tissue issue as well.

And wherever we've got more trauma, we're far more likely also to get infection follow on. And we break down, of course, is, is not infrequent, sadly, and that may be to do with infection, but a lot of the time, probably the most common reason would be, particularly when we're doing our surgical extraction technique, is that we put too much tension on the flaps. So the mucosa really doesn't like tension at all.

So the first thing then, it would make sense to have a diagnosis, know exactly what we're up against before we start. And that's really going to boil down initially to our assessment of this mouth. How thorough have we been?

It starts very, very basically, and once we're into the mouth, we've got anaesthetized patients, it's down to that quality of probe and charge. So we don't want to underestimate how important it is because that is then going to guide what we consider worthy of radiograph and of course, by the time we combine those together, we'll have the vast majority of our information to know what it is that we're up against. That will then allow us, of course, to create a good treatment plan, something that's appropriate to this patient, to whatever time, skill, etc.

You've got, and also obviously to, to our quarry, to our particular tooth or area of the mouth that we're, we're planning on treating. And we can sort of look at what might go wrong ahead of time and create hopefully a plan A and a bit of a plan B as well. Oh, of course, if we think, no, this is not going to work, then we can sort of abandon ship at that point, and then discuss further with owners.

And again, that comes down to our own experience as well, so it might be the time you've got, the equipment you've got, and it might also be what experience and what confidence you have, that once you've started this operation, you're also going to be able to finish it in a good way. And that also comes down to making sure that our owners understand what it is that they're consenting to. So it's really important to cover ourselves by having consent forms that include a lot of the complications that we might well run into during extractions, so that Owners can't turn around and said, you never warned me, you never told me.

So, again, it's the old thing of, of, you know, is it a complication because we had informed consent, or if they didn't realise that this might happen, then of course it's a mistake and that is understandably when clients get a bit angry. And then of course it's beholden upon us that we're going to do a good job, so we need to be very careful, not become blase or try to speed our way through these procedures. We want to make sure that we do every element as well as possible.

So we'll start off with our diagnosis then, and here's the few radiographs that would give you the idea. So as I say, you know, supernumerary roots, clearly if you don't know it's there, you'd assume this was a two rooted tooth, as it normally is this pre-molar, and you'd probably leave this root behind or run into difficulty. Here we have some resorption.

This is internal resorption that's going on with this tooth. So this particular root is partially ankylose. It's gonna be very, very difficult to try and get out something that looks like a normal root from this particular tooth.

Dropping down then to our radiograph here of a dog with we've got a mandibular second molar here and you can see this curve, this sort of hockey stick shape curve to this route. So that tells you this might not be quite so straightforward and also that the path of withdrawal, the way that this route is going to exit that socket, it wouldn't be just vertical, that would be very difficult. It's going to have to sort of curve out.

So again, you, you know what to expect with that. And here you can see with our red arrow just how close this apical portion, the tip of the root, is to this area of lucency, which is our mandibular canal. In other words, a bony canal running along the mandible that is containing our neurovascular bundle, and we don't want to cause issue around this area or we're likely to get haemorrhage and or nerve damage.

And here's another example. So we have here our tooth that was missing, but actually our radiograph indicates that it's not missing. It's here.

It's roots are again sat within this mandibular canal. Not only that, but it's got a supernumerary root, so definitely not something to start work on. With 10 minutes to go before your first afternoon consultations.

In fact, it's something that I would have a very long think about and probably get opinion from a referral colleague, because these are the kind of things that are very, very likely to lead to nerve damage. And of course, we, you can see we've got an obvious issue with our neighbouring teeth too, hole there, so quite likely to fracture. OK, so we get our diagnosis and then we need to create our treatment plan and make sure that we work well and within our competency and with adequate consent.

So again, we've got some radiographs here, which would lead us to to talk to our owners ahead of time if we could perhaps determine what was likely to happen in a cat. We all know that they have a tendency, unfortunately, to tooth resorption, and some of them lead to weakening of roots, so we can see our little nibbled out lesion here, that's very, very likely to fracture. And here we've got our resorption, which leads to replacement with bone and therefore we end up with ankylosis.

Curvature on this route, a little bit of a bulbs tip that can make things more difficult, although actually that tooth looks otherwise normal. And then on this radiograph again, we've got this little nibbled out lesions here, little areas of tooth resorption. And on this route, again, quite advanced resorption, and we're getting replacement by bones who've got quite extensive ankylosis and and loss of normal root anatomy.

So if we know that we've got a cap with resorptive lesions, even if we don't quite know what type or to what extent, we would want to talk to our owner about the sort of effect that can have, that it makes our life difficult. We're more likely to get fractures, that we're more likely to potentially have great difficulty getting roots out of that boat. And don't forget where we have both our mandibular canal.

And so the lines denote the canal, the sort of roof and floor of the canal, and the red arrow there you'll see is pointing to our mental foramen. So again, these holes, these things that contain neurovascular bundles, you've got to be a bit careful of those. And here's one of the reasons why cats can be frustrating even if we don't have things like ankylosis.

And that's down to the shape of the root. Very often we've got a globular apical portion and then we've got this narrow neck area. And of course the bone in fills within that area too.

So when you try and get these teeth loose, very commonly, you'll find that it's spinning around a bit like a joystick. So you think, well, it's very loose, why is it not just loosening completely and and and being extracted in a simple fashion. And it's because, of course, you've got to try and get that globular apical portion.

So this part has got to come via a more narrow neck of bone. And to do that, we need to be very, very patient and allow time for that bone to just gently expand as we apply a little bit of tension to our root, and that that lump there, if you will, is pushing against it and will gradually ease past. If you rush it, of course, it's just going to snap at the point of least resistance, which is across the neck, leaving with a frustrating root tip behind in our bone.

So again, all of these things making our life difficult. We know we're on to difficulty with most cats in truth. They are fragile and tricky, even at the best of times.

So careful technique. Well, that's pretty obvious, but it's not always as easy as we would like, so let's have a little look at that. So if you look at our hand instruments, it's holding them correctly, so in a palm grip like this, and you can see that my finger there is very close to the edge of the blades.

So that if I were to slip, then my finger, my forefinger here, we will have a finger stop, so that would bump into it could be by my other fingers, which it usually would because they grip around the tooth that I'm trying to extract, and so pinch the area. So my, my hand is supporting this hand, obviously using the hand instrument would then the forefinger would bump into my finger, or sometimes it might bump into some tooth, but anything basically that prevents me doing an uncontrolled slip where we can cause real damage both to ourselves, our own hands, and also to our patient. So forefinger close to the edge of the blade, that's good.

And we want a nice straight line through the blade, handle, our finger, our wrist to our elbow. We also want to make sure that we've got clean instruments and not just clean, obviously sterile, so we would want them both sharp and, and also sterilised. And as you've already heard, a blunt instrument basically is a dangerous instrument.

You tend to use force, you don't have the same control, and the likelihood of slippage increases quite markedly. Then when we move on to our power instruments here, then we need to have a little think, if we're going to be removing bone and and working in areas where we've opened up flaps and things like that, which often we will with surgical extractions. We want to make sure that the fluids that we use are sterile, not not just dirty water from our dental unit.

So ideally, and what you'll see here is that I'm using either saline or Hartman's, but we don't want to use dirty water. And even if you put sterile water on a high speed dental unit, by the time it comes out the other end through your hand pieces, I'm afraid it's pretty dirty because of the biofilm, of course, that's within all those tubes. So we want to make sure that our our handpiece is sterile.

We want to make sure that our irriggan is physiological and sterile, and we want to make sure that we're not going to blast air pressure into our site. So this is something that's a dedicated, bone cutting unit that we would use in the maxillofacial departments in human hospitals as well as, I, I use myself on, on my animal patients. And it's designed for for all of this to be sterilised, so all of the tubing, everything gets sterilised, and we've got a little peristaltic pump which brings that fluid to me and I control the speed and the torque, which is all very well if you're a referral practise, but typically you don't have this, in general practise.

However, you do tend to have low speed on your dental units, and you can use a low speed hand piece that you've put through the autoclave on that instead. And again, rig up some sterile physiological fluids. So nice sharp instruments used with control.

Here actually, I've pulled my thumb of my supportive hand away from the tooth so that you can see the blade, but you can see again how close my forefinger is to the edge of the blade. And if this thumb was in the normal place, so up here, you really can't slip very far at all. It's feeling like you've always got control.

That's what you want to achieve. And here I'm using the the unit that you see here. And we're making sure that we're not going to get thermal irritation or trauma to the the bone because we've got that fluid right focused on our burn.

Now, the reason I mention about the air is because this can be a problem. And this is a patient, where it's happened. I've certainly seen it in cats, particularly, where unfortunately, the air that's blasted from high speed can then affect tissues.

So we get surgical emphysema. Now, most of the time that gives you a bit of a crinkly area or a sort of an inflated portion. You can see this gentleman's been somewhat inflated, .

But it can be dangerous, and this is what happened in this patient. Unfortunately, the, the air is tracked down and got into the mediastinum, which is why he's in hospital. So it can be dangerous, that's unusual, but we don't want it at all.

So using low speed is far preferable to high. So these complications that we get maybe of heart tissue, of course, we've talked about dental trauma. We'll look at that further and bone trauma is our other big issue.

Then, of course, infection is an issue, and, these are things that happen quite frequently, so we need to have on our consent forms. The soft tissue, so you slipping basically, either with a a hand piece, so low or high, we can make quite a mess of soft tissues with that. So we need to make sure that tongue, lips, etc.

Well out of the way, as well as our own hands, of course. And then slippage is the big thing with hand instruments where we don't have control, and then we end up penetrating somewhere we don't want. And flat breakdown from either damage to the flat, you know, from a rough technique, etc.

Or very, very commonly from too much tension. Infection again can follow, and again, just an example for you there of something fairly unpleasant and painful. There a rough technique can do this, it's typically in the mandible and our clot.

There and inflammation of the bone and it's it's very, very painful. So again, gentle technique is a good thing. Soft tissue?

Yeah, OK, well, let's look at this in a little bit more detail. So instrument slippage you said, and that's the obvious one. Making sure that we've got our finger stop is essential, that we have our full finger close to the tip of the blade, and that our instruments are sharp, not blunt.

Excess force, that's the big one really, isn't it? And again, that sort of goes hand in hand with blu blunt instruments, you end up trying to force things, and you just don't have the control you would like. So again, I'm controlling everything very, very closely.

It seems counterintuitive to have your fingers close together to stop slippage and damage to your own hands, but actually them close together means that there's no sort of pick up of speed and distance and then loss of control if, if you do have a bit of a slip. Having them close together definitely is the safest thing. So haemorrhage, clearly, that is certainly a possibility.

It tends to be from cut edges of gingiva actually, that's the main area. So if you do place some sutures, the light pressure that they place on the cut edge of the gingiva will usually give you the hemostasis that you need. You can get bleeding from vessels through bone, etc.

So we can get our immediate bleeding, so, yep, we're working away, we're cutting into things, we're doing surgery. No surprise if we get a bit of haemorrhage and a bit of it is to some extent useful because that allows us to have a nice clean blood clot in place in that alveolus. Once you've removed the root, that's good to do our healing.

But we may need a little bit of pressure. On occasion, we might need things like chemostatic sponges, etc. That would minimise your use of these adjunctive items because if they fall out, you've got a higher chance of infection of the socket.

So I would use them sparingly. Now delayed bleeding, this is generally, you know, the blood pressure comes up once they're into recovery, but also if you have used any of the local with adrenaline in, then the local wears off, as does the adrenaline, and you start to get a little bit more bleeding from your site. So again, you want to have really, really good hemostasis while your animal's anaesthetized and be really quite confident that that's not likely to cause issue, once they're back into recovery.

And if you're in doubt before you start with surgery, then doing a book on mucosal bleeding time is a good idea as well. The other thing that can happen actually is that if you've used rough technique on your clot lysers, then you can get very delayed bleeding with that, but it's relatively uncommon. Nerve trauma, not as uncommon as we'd like, but given that we're looking at a sensory nerve in this area, then how do we know?

And the answer is you don't really. So in people, we would get potentially pins and needles, you can get or a facial pain, or of course permanent numbness from that. So it could be temporary, it could be permanent, but even when we regard the nerve trauma.

The abnormal sensation is temporary, then we can be talking months with that. So again, we want to do everything we possibly can to avoid it in the first place, and knowing where these nerves and blood vessels are is a start and of course having control over our instruments. So flat breakdown, well, it's not good anyway, but particularly bad if we've also had damage to the underlying bone, for example, and in this location, as you'll see, we have an or a nasal fistula.

But whatever the underlying pathology or, or lack of pathology, you don't want your flap breaking down. So we need to think about our basic Halste's principles of surgery, gentle tissue handling, and as I say, minimise the tension. We want zero tension on flaps.

You also don't want movement. So suturing well, but not cranking down is good, making sure also that our suture lines are supported by boat. So infection more likely if we've had a rather traumatic experience of or our patient at least has, we probably both have, during the extraction.

So again, you're thinking gentle technique, coming back to surgery, it's still surgery, it's in the mouth, but yes, it's still surgery. So again, Halster's principles, nice and gentle. And obviously trying to main a good aseptic technique as far as you possibly can in the mouth.

So, you know, a little bit of chlorhexidine solution beforehand could be a nice thing to to use. So neurovascular As we've said, we've got this issue of, of potentially vessels being either lacerated or damaged in some way, and the same also for our, our nerves. And we've got this variation in abnormal sensation.

And the neuropraxia is the bruising. So even if you just sort of bump into that nerve, and you probably won't know, if you see one of the neurovascular bundles, or if you see that you're into a canal, you will have damage to that nerve. But even if you don't.

You may have that. So again, think about how long these roots are. Be aware that the apices, the tips of the roots, they are very, very intimately associated with our, our canals and therefore the neurovascular bundles within them.

So we don't want to use instruments too close to the apices, and if you've got your radiograph, of course you can actually see exactly that relationship. So er always err on the side of caution. If you do get bleeding that is not just from the gingiva, and it is from bone vessels, then you can sometimes use a little bit of, of, obviously you can use pressure, you can use digital pressure onto a swab, a sterile swab, but you can also use a bit of bone crushing in a very controlled focal way by using some forceps.

Now I have to say that's a lot easier said than done, quite often the sort of the area of bone around collapses and you still get a bit of ooze from that. And generally speaking, getting the flap closed over and possibly using some sort of dissolving hemostatic sponge, that's probably your, your, your best choice. If you've got a vessel to tie off, then, then of course do that.

But again, the likelihood of you actually seeing that commonly is, is very low. And watch out for these animals again, I'm sure the anaesthetist would say the same. You don't want to just abandon animals into recovery.

It's where we often have all sorts of dangers lurking, and one of those is people perhaps not noticing that our animal is now starting to bleed. And it can make a difference as their, blood pressure alters, depending on what we used as our pre-medicine, etc. So, that can be quite embarrassing when your owner comes to collect and unbeknown to you, you've now got a rather bloody animal, with bloody saliva all over.

Place, and, and of course, then you've got to ask them to perhaps delay when they take this animal home. So keep a good eye, have your nurses, make sure that they're doing proper rounds of our recovering patients, so that anything like that can be spotted before we've got an issue. They'd be really confident before you wake this animal up.

Yep, I've got good hemostasis. And I would also always put that in the notes as well, so it's recorded. So in the maxilla, of course, you've got to be a little bit careful about where things are, and you'll see our green arrow here is indicating the apex, the tip of our upper canine, and you'll notice just how high it is relative to our nasal cavity.

So that's certainly one condition, and sorry, one thing for consideration. The other is the proximity to this, our infraorbital foramone. And we have a neurovascular bundle emanating there, of course.

And so if we were trying to extract our upper canine, for example, we could be rather careful that if we're designing a flap, we're not going to inadvertently transect any of those branches from that infraorbital. So you've always got to think about what's lying under the mucosa and the gingiva. So what's under that soft tissue that I can't see, but I know is there that I have to be very wary of.

So again, just orientating yourself with the different school shapes of your patients is you. So have a good palpate, basically. If you've got a brachycephalic, it's going to be quite different to a dolochocephalic school, of course.

So we palpate, we find where things are, and that guides us as to how we're going to do safe surgery and how best to approach our particular tooth or teeth on this patient. Similarly, we have the proximity of the premolar. So this is our 3rd premolar, our 4th premolar, the roots here again, really, really close to both the foramen and of course under here our canal.

So the roots quite long. They basically lie here with both our caracal, our 4th premolar, and our 5th molar here. Those roots basically lie along the Floor of our infraorbital canal.

So if we're extracting these teeth, or if we're considering disease of these teeth, where perhaps you've got an abscess sat on the apex of a root, and we've got to think, OK, well, that's very, very close to our our infraorbital canal. And as we head further cordially, of course, our molars, we're getting closer and closer to the end of the hard palate and of course the next stop here is the eye. So we think about that in terms of the teeth, and we certainly think about it in terms of where we're going to place flaps and therefore be cutting with the scalpel blade and of course also where we are aiming our luxats, or elevators, these hand instruments that if the slip could end up penetrating into the canal, penetrating into the eye, the globe there will of course, unfortunately penetrating back here into the brain potentially.

And between the two, obviously we've got lots and lots of branches of our cranial nerves, and we've got venous plexus, arteries, etc. So out of sight, out of mind, no, it is something to worry about. We need to think about what's out there and be really mindful of our control.

And again, things aren't completely benign on palates, of course, we've got our major Palatine vessels there. So again, another neurovascular bundle. You can see, of course, how in this case it's a cat, and we've got our molar there, our one molar, and then, you know, our, our palate ends, so very, very easy to slip.

And particularly if we've got disease such as periodontitis, which affects our bone. Then we're going to have poor quality bone, often it's soft or it's thinned, and therefore again, penetration, slippage with an instrument often to somewhere we don't want is far more likely. So again, have all this in the back of your mind when you're working.

The idea isn't to scare you, but it is to make you aware, make you thinking about all these different elements that can make the difference between a good job and actually causing more harm than the good that we might have intended to do. So again, our, our Palatine vessel there. OK, be aware of where these things are.

OK, and you can see here this is where our mandibular foramen is or inferior alveolar foramen, and then we have our mandibular cow running all the way, of course, along each of the the left and the right mandibles, and the roots, as we said, they're intimately connected. So you can see here. Again, dog.

Mandible, we've got there our mandibular canal. If we take our first molar, our carnassial, you can see how that root actually spans the full height of the canal. So we'd have to be very careful if we're taking that tooth out.

And here we have our missing roots and our root that has been left in situ, unfortunately. And here you can see that we've lost the bone density. So unfortunately, in terms of trying to extract the root that was here, someone has perforated into the canal.

So bad news. Also just look at how broad the loss of tissue is. So the the actual alveolis was definitely not quite as wide as that, but it's had a rather traumatic extraction performed.

So think about where these things are and then where the exit as well. So we've got there our middle mental foramen, but don't forget we've got. An extra one here and also another just here.

So we've got a middle, and they've got our cordal mental forum which is rather smaller, and then we've got our rostral which just sits on the second incisor, so it's about here. The middle mental forum and basically sits right on the apex of our lower canine and also directly ventral to the medial root, this sort of rostral root, you might want to call it, of our second premolar. So we can do a sort of a best fit line down here along the route of the canine X marks the spot.

There it is generally quite easy to palpate and therefore you can feel it, you can find it, hopefully that means you can also protect it and avoid it. And then Typically our caudal sats sort of between the roots really of our third premolar here. So don't be surprised if you find another little area there.

It's, it's typical. And the same with our cats, of course, you can see how close these roots are, the apex, and then virtually, you know, nothing. It's a fraction of a millimetre between that apex and this canal, so slipping in a sort of a vertical fashion would not be good.

We're bound to get damage to our neurovascular bundle. So flat formation, well, we want to make sure that this thing survives so that we get good healing, reduced pain, there's a chance of infection, and of course if we have had or a nasal penetration of any type, and so a communication has been created, that we get healing to seal that over. So yeah, of course we want to close it over and place our sutures, and as I say, the important thing here is without any tension.

So if you've got an area that are flap, when just gently placed down does not cover, we're gonna have to think of ways to extend this flap in order to ensure that when it is sutured, it is zero tension covering the whole lot. So it's been advanced in other words. So here you can see this is, this whole thing's been advanced, not because we've cranked it down, but because we've used different techniques, which we'll show you a little later.

But this is definitely not what we want. If you're seeing blanching, if you've got stretching and it's like a, a drum, skin, then that's no good, it's going to break down, so you, you, you know, time to stop before you make matters worse. What about infection, yeah, this can cause issues.

So I've seen all of these things on, well, they show up particularly on people, so I've certainly seen them on, on lots of people, but also on animals as well, to some degree. So here we've got our sort of our classic swelling, this sort of hamster look, hamster cheeks where we've got swelling in this buckle area, and it's starting to affect just under the eye here. Also for this gentleman, you can see how he's got a black eye as a result of the the infection around his tooth, so it's trapped up between fascial planes, and we start to worry about the eye area because .

The vessels that are are are going into our our brain there, so our, our, our veins there, they don't have the same valves and therefore you can get brain infection which is clearly bad news. Here we can see in an elderly patient, I've seen this in particularly in cats, where you've got this massive area of, basically it's osteomyelitis, we've got inflammation infection of the bone here and your jaw just starts to disintegrate and you get breakdowns. So, there we need to get back to nice bleeding bone.

And we also tend to use fairly long courses of antibiotics in these situations. Obvious you want your cultural sensitivity, and get back to bleeding bone, and, and, and try and get that back to a healing situation. We can see here how it really has had a very bad effect on this particular person, all from an infected tooth.

And here again, and I've certainly seen this life threatening disease. It's called Ludwig's angina. It used to be a very common cause of death once upon a time, but it still does kill people even in hospitals in the UK once a month or more.

And this is where, again, we've had a tooth that's infected. I've seen this with a tooth that had a filling that should never have had a filling. And, unfortunately, if your infection decides to track underneath your tongue.

And behind the, the, the pharynx, then you can get occlusion of the airways, so you can't speak, you can't breathe, you can't swallow, unless someone finds you, gets you to hospital pretty quickly, then that will spell the end. So this is a classic sort of appearance. They look like they've been inflated.

Tongue is sort of stuck and, and, and raised up here. We've got our drains in, obviously, track your tube. So, certainly the, the gentleman that I saw was in intensive care for 3 weeks, propofolent fusion.

For about 2 of those, and we had 2 operations to sort it out. So it's really bad news. So really the take home from this is don't think that it's just the tooth with infection that can cause really serious problems.

I seen a dog recently, it's, it's scan revealed actually we've now got infection of the crib reform plate. So, yeah, teeth can do bad things if they're not treated properly and treated in good time. And hard tissues, well, often dental trauma.

And as you know, fractured roots are part and parcel of dentistry. Now I say that not to be blase, we don't want them, of course we don't want them, but that said, it is going to happen. The only way never to break roots is never to do any dentistry and take any teeth out.

So it is gonna happen, it's an accepted complication, but we want to minimise it. And most importantly, we want to know that if we've done it, we have done it, rather than not be sure or worst of all, to try and hide it from our clients. So the first thing is, you don't lever.

We do not use hand instruments like a crowbar. So a class one lever is an absolute no no. Never use an instrument that way.

When you get root tips that are left behind, and you think, oh, I'd like to try and get that, think first, do I think I can do it? Or do I think I might make something worse? And this goes for any tooth really, but is particularly something to consider very carefully when we've got retained roots.

What we really, really don't want is you to. Struggle away digging down a black hole, so do not dig down a blind hole, and that's a mantra to remember, don't dig down a blind hole because, In a certain proportion of cases, apart from struggling, what will happen is all of a sudden you'll be prodding and poking, and then that route will disappear, but not because it's popped out and you've now got everything extracted because it's migrated somewhere far worse, somewhere more difficult to get to and quite common areas for this. It can be an nasal cavity, but quite commonly, it will be your mandibular canal, that's probably the most common place that I then have to try and find these things and dig them out of.

And you're going to get nerve bruising, are you? You're going to get neuropraxia, that's for sure. And whoever it is that gets it out, and I would definitely recommend that that's a referral job.

It's got to try not to damage the nerve or blood vessels any further. And, and they can be quite tricky. So we can end up in our, in orbital, we can end up in our mandibular canal, we can end up in the nasal cavity, that kind of thing.

So if there's any likelihood that's going to happen, then stop before you make things worse. That's the main message. Take a radiograph if you possibly can, if you've got facilities to do that, which, which I would definitely recommend.

And get an opinion, but we don't want to pretend it hasn't happened, and we don't want to ignore it because at the end of the day, we've got to bear in mind it's animal's welfare. So thermal bone trauma is quite common where we are using our birds in, in deep areas. So for example, .

Trying to atomize roots is, is a no no. So that is not a treatment. It's an urban myth, basically, that people unfortunately have taken to their hearts because it's a sort of a get out of jail free card.

All you need to do is the root into a mush. Well, clearly that's not the case. I think, you know, if you think about treatment on yourself, you'd realise that's not appropriate.

So, If you do that, one of the issues is that you will tend not to get the required irrigation at that depth and therefore you start to get thermal issue for your bone and bone doesn't like changes in temperature, even a couple of degrees is a problem thermally. So we want to make sure that our irrigan is going to do the job it ought to. Fractured bone, yeah, again, if we slip, if we're too fast and forceful.

So, generally speaking, too much force, wrong direction, . Yeah, that, that's gonna cause issues. So excessive amounts, too quickly, wrong direction.

All of these things will lead to fracture either of bone or of roots, or quite often both. Crushing, yeah, so we want to expand our sockets to allow our roots to be removed. However, we don't want to do it excessively in crushed bone and splinter bone and things like that.

It should just be subtle, just enough, from the elastic, nature of, of bone to be able to remove that root. As we've said, penetration. So slipping further, so you're applying pressure, applying a bit too much, not got the control off it slips, particularly poor quality bone, either because we've not got very much so particularly, where we've got periodontitis or an abscess, something like that.

And also where there's not so much because we've got little tiny animals. So, you know, your little Yorkshire terrier with periodontitis is a classic example. There's not much bone, the bone's poor quality, it's easy to slip.

And then of course, because it's a small animal, everything's close together, so you're very close to its eye, it's brain, etc. So again, just try and be really, really careful. And dit it with our cats.

We don't want to leave little chunks of bone behind that hasn't got blood supply because, of course, we can get sequery and areas of infection and inflammation that just grumble up long, so we've got to be careful that we've removed things like that. We've mentioned dry socket already, so again, gentle technique is the key really here, and be aware that the mandible is far more likely to be affected than the maxilla, and that's because our bone supply is rather poorer in the mandible than the maxilla and the bone is more dense. And here it is again and If you're not too sure whether it is or it isn't, one is that it's extremely painful.

Anyone that's had it will be able to tell you that, and it's also very smelly. So it is not a subtle bad breath this. It is halitosis that you can really smell a mile off.

And classic timing is 3 to 5 days after extraction, which is why I like to warn people to keep a nose out, so to, to, to just sort of try and smell the animal's breath, during that healing period, and also to have them come back for recheck at sort of 5 days post-op. And as we've seen, osteomyelitis can be really destructive to the jaws. Here, unfortunately, Yvette has forgotten to remove the sectioned portions of molar.

So it's been sectioned, we've got exposed pulp. Clearly this is something that we really, really don't want to do. So this is, to be honest, just sloppy.

If you're going to do your charts, great, but use it, check, make sure that you don't wake an animal up having part done something. Now, if you've left roots behind, as there are here, again, just make sure you know, if you think, oh, I'm not sure I can get them, I think it might cause more trauma, fine, to stop. I would stop, irrigate with saline or Hartman's, and then close the area with a flap, and then pop the animal on some painkillers.

If there was any signs of infection there, then I'd also probably use 5 days of amoxicillin, and, and again, get an opinion, because ideally someone would get rid of those. So bearing it all in mind, trying not to make things worse. Now the circle here, this or the.

The oval that I've drawn, the the the green one here. You can see we've got a little bit of a tramline effect, can't you? So we've got a dark or a radiolucent line here, and then we've got radiodense material, which is more densing of our root.

And then we've got another little, this little parallel line of lucency. So if you see that, which you commonly will particularly on this tooth, it's showing you that you've got a little developmental rooves. So if we were to do A transverse section of this route, instead of being an oval or round in cross section, it's heart shaped, and this is kind of the inward fold of that heart, if you will, and it creates a bit of an anti-rotation lock.

So if you see that, you know, it's going to make your life more difficult because, as well as the issues we've got about the length of the route and where the canal is, we've got something that's clinging onto the the the bone basically. It doesn't want to be lost, which is great, generally speaking, because it's an important tooth for the animal. But if we've got disease of the tooth, and we need to remove it, it's what makes our life more difficult.

So again, a radiograph is going to give you that information to guide whether you do it at all today, whether it's you, whether it's someone else, whether it's a different day, whether it's when you've got more time, instrumentation, whether you refer it, etc. But it's going to guide again, your treatment plan. So this is the route migration we've talked about that is bad.

So this, we should not ever, ever do. This is digging around in a blind hole. Do not do it, it will only lead to tears for you and trauma for your patient.

And this is why, because what you're trying to do, and we're looking at a transverse section here, so we've got a pulp, our dentin, this hashed yellow is our alveolar socket bone, and then we've got our pink here of our periodontal ligament space, and this sort of bluey silver is the blade. So what we're trying to achieve is get our blade perfectly sat in our periodontal ligament space. And here we've got 2.

However, as you dig blindly down your hole here, you think you're in the right place, but most of the time you're just very, very slightly off, and you only need to be off by a fraction of a millimetre, and this blade is no longer in the periodontal ligament space, loosening things. It is on the edge of our dentine circumference, and as a result, as you dig around, it's actually applying pressure onto that and pushing it further into the socket. And hey presto, this kind of thing happens.

So that radiograph is is how it looks obviously the the root has been removed, but you can see that the bones been lost here. So unfortunately, at some point, the root disappears because it's gonna pop into our, in this case mandibular canal, which of course is bad news. It's space occupying region, as you might imagine, and we need to get rid of it, but this is, this is, as I say, this is time to ask for some help.

But ideally, you stop before you even start doing this and therefore it never gets to this stage. Ditto in the maxilla here, and digging around, it disappears, pop, and you know, it can go into nasal cavity, that kind of thing. So instead of digging around blind, which we must never ever do, we want to try and find our roots.

So we use our surgical technique. We've raised a flap, so we're onto the bone here, and then we've used our burr, ideally low speed with our sterile physiological irri irrigance. We find our root.

Oh, there it is, OK, so we can sort of positively ID it and I want to be able to positively identify the wall of that route. So I've taken it down a little further, bearing in mind where my canal might be. And then it means I can visualise it, I can directly see is my blade now just being, and I tend to use the word winkling, and I'm not sure that's very technical, but what I'm trying to say is really just with thumb and forefinger, we're not using pressure here, we're just trying to gradually ease a really fine blade into that periodontal ligament space and just start to feel that you've positively located it within the correct position.

And then gently working it around the circumference, bearing in mind different shapes of roots, etc. And sometimes we'll need to use different length bus as well if we need to go deep, and root forceps, root tip forceps, things like that. So there's all sorts of instruments we can use to help with this process, but ultimately, it's about positively IDing our route and where an instrument needs to go, and then using very, very delicate, gentle, patient technique to gently, gently loosen this root tip.

OK, well, what about or nasal communication? This is where we might have an abscess, severe periodontitis, classic here, this would be Daxund with a deep pocket on the palatal aspect of an upper canine. And so you're anticipating we've already got communication between the mouth and the nasal cavity, and the only thing that's plugging it really like a cork in a bottle is our tooth, which, of course, needs to be extracted.

So we take it out and oh dear me, we've now got a fistula potentially if it's been long established, or we, we, we might have used a rough technique or something and we've got this communication opened up. So we need to make sure that when we place the flap, that's going to be sealed, closed, and we no longer have this communication. So we want to make sure that we don't want make matters worse.

It may already exist because of disease, but often we will either cause it in the first place or exacerbate things. And one way we do that is with our hand instrument use. So we want to avoid tipping and gouging.

So when you use your elevator typically for upper canine extraction, then we want to make sure that it is parallel to the straight line axis of our route. We're not coming in from an angle, and this is common when people, they're sort of standing up and they're they're leaning that instrument down onto our animal in lateral recumbency. So you want to make sure that your, your instrument is coming straight into that space, not from above.

Because, sore, the way that I've coded this is green is good, and red is bad and sometimes I'll use amber to say, mm, with caution. So this is what we want, that's the angle we want straight along the route. And that's what we definitely don't want, because as you're working with this instrument, of course, at this angle, the tip of the instrument is just quietly digging a hole towards the nasal cavity, which is clearly not good.

And then we create a communication. Now, what I'd say actually is if, if you are in doubt about whether there is communication or not, when you take your tooth out, and you think, well, there isn't there, do not test the theory. Just assume that there is.

That's the safest thing to do. But if you test it, you'll only make matters worse. So no prodding and poking, no trying to shoot fluids up and see if they drain through the nose.

Just assume that you've got the communication and that we want to get a really good seal. To do that, we might well have to extend our flap, because as you know, Tension is bad. So what we can do then is with our flap here, we've raised it and we've, we're sort of folding it back and we've got our periosteum on the underside.

We can just section very, very delicately, the periosteum only. So you've got a flap that's that long. And then once we've done that cut, the elastic nature of the, the, the, the mucosa allows this suddenly to stretch out into a longer flap, which will allow closure without, the tension.

And in fact, it should go easily across, even over onto part of the palate there. So we get this sort of effect. And if we have tension and it all breaks down, then you end up with this rather large here and well established or nasal fistula, which clearly we don't want.

And they're harder and harder to fix as they become more established and people have had another go and another go. So your first chance is your best chance. So if you think that perhaps it's better in One else's hands, then it's good to say that from the word go.

Also notice that with upper canine extraction in cats, particularly, we quite often get the tip of our lower canine, damaging the lip here, and we can get even perforation as well as alteration. Personally, I tend to round these off and seal them. You can't just cut bits of tooth off and reshape tooth and not seal, in animals.

It's a little bit different in humans, but you, you, you can't just simply do that unfortunately, you do have to seal it. So, not always the, the, the sort of thing that you can do in general practise. But the main thing here is that you warn owners, if you're going to take out an upper canine and a cat, that this is a quite likely complication.

Irritation of the upper lip by the lower canine. Jaw fracture is the big one, really, not so common, but it's not infrequent, sadly. And again, it's all about force, isn't it?

We've not got an awful lot of bone there, so here's our lower jaw, this is where we had our lower canine, so not much bone because there was an awful lot of tooth root. So it's, you know, again, too much force, too quickly, wrong direction, we tend to fracture things. So if we've got other underlying factors as well, so loss of bone, poor quality bone, etc.

Then it makes it even more likely. We also tend to get it. We've got other big roots which is particularly with our first molar here.

Not much bone, you need to be very careful. And here you'll see, we've got pathology. And, you know, there we've got vertical bone loss, so periodontitis, we've got an abscess, etc.

We, we haven't got much bone. If we use too much force, it's going to break. And here with a cyst.

Same thing. And here's the little cause, that, that little unerupted tooth there. So again, you can get these jaws fractured very, very easily where we've got a cyst.

So be very careful if you're working between the canine, the lower canine, that is, and the 3rd incisor, or between the lower canine and the first premolar. There, take great care, hence the amber arrows. And what you don't want to do is use rotations.

That's a no, no. We just want to use a lookat here to sneak down that periodontal ligament space, and, and really want to think about doing that without the jaw noticing. So that's the kind of effect you're looking for.

We can work more safely on the lingual aspect, so the inner aspect of the tooth. Gentle, gentle, surgical technique, sorry. So, we're not applying rotational force there.

So get your X-ray, get your diagnosis. Think about what could go wrong, and make sure that you work in a suitable environment. That means you've got the right time, that you're confident that you can finish things.

You've got the equipment that you can see, again, leaving 10 minutes before, you've got to start consults, it's a recipe for great stress for you and also an issue for your patient, and we need to look after both of those. So don't start what you can't finish. And no, you can't just atomize roots if you think all is otherwise lost.

And I think this really says it all, premium nose, so first cause no harm. That's the main thing, always have it in the back of your mind before you start any surgery. That's great, Alex, thank you so much for that, so interesting, .

I suppose it makes you realise there was a question there, somebody saying, you know, my boss doesn't really think. We need dental radiography in the practise. How do I, encourage him, are there any papers?

I think my answer, and Alex, if you want to disagree with me, by all means do, but, just plonk this webinar on when it's on as a recording next week, have a lunch and learn in the practise with the nurses, get the boss in, buy in, buy some sandwiches and see what happens then. Yes, well, hopefully that, that might help do the trick. I mean, if we were to say, and I think it's going to come ultimately in the veterinary world, but, but in the human world, you know, if you didn't have an X-ray and, and something went wrong, then, then that would probably be your career down the spar, really.

You wouldn't have a leg to stand on. You know, it's just regarded as as negligent. Well, because it's not so common in the veterinary world, that's, that's not the case.

But one is, of course, patient welfare. That's got to be our primary aim. And then there's, you know, how good a job we can do.

There's also the avoiding problems, which then leads to dissatisfaction, stress, takes up more time. You know, you run into your consults and things like that. And the other thing I think is, if nothing else is of interest to them, let's hope that's not the case, but if it were, then these are X-rays you should be taking all the time.

These are very, very frequent surgeries. Therefore, they are a great revenue for the, the practise. You know, that you're not charging the same amount for each X-ray, but once you get used to it.

They're quick, you're doing it on pretty much every case, and therefore it's a great revenue stream for them. So, you know, it's all win-win really with X-rays. The only thing you've got to stumble over, the price isn't particularly bad, it's, again, you know, they, they're not massively expensive bits of kit, albeit they are, you know, some, some form of an investment.

And the only thing you've got to do, as with anything new, is learn how to do it, and obviously that's gonna slow you down for a little time and then you'll, you'll be flying once you've, you've really got it under your belt. Yeah, and I mean. That's how you get better at things is just to do it and get better at it, and things quicken up and you get less stressed about it, and suddenly you're doing it at a reasonable standard, aren't you?

Absolutely, and, and you know, it's, it's just progress isn't it? Once upon a time, people would have done orthopaedics and everything else without imaging things, but it's, it's sort of. I think we regard it as a no brainer on most things.

If we can't visually see it, we need some other form of imaging to be able to see it, which, of course, happens to be X-rays for dentistry, as it is for so many things. So, given that we can't see 60 to 70%, I the roots of of teeth, then you've you've got to do something else, an X-ray, otherwise you're just going to be, you know, blind to the vast majority of what's going on. And part of the problem is, you know, I qualified really without any dental training, and yet we, we were already doing a lot of dentistry and, you know, first practise, no, no sort of dental kit, it was a hacksaw.

Yeah, I remember it too, . In a sense, you're obviously in Nottingham, but I don't think across the board we're still taking dentistry and undergrad as seriously as we should do, are we? No, I think it's a short answer.

It's a bit of a, it's an odd situation really, . And I, I, I wonder if some of this is, is in similar to, to the human medics, you know, their, their curriculum, clearly it doesn't include dentistry. Well, that's because we've got dentists.

Whereas it a little different for, for the, for the vets, that there's this expectation that you're going to be doing and able to do everything, which is. It, it, I mean, it is in some ways regarded as ridiculous by, you know, by the human medics, by the dentists and things like that. They can't believe the sort of the breadth of what we're supposed to be able to do.

But yes, it's the thing that's kind of escaped, isn't it? The thing that is very, very common and yet is often you know, if present, minimal, in, undergrad training, which is a real shame, and we don't, it's not that we've got dentists all over the place to then, well, it doesn't matter if I don't, I don't know about teeth because that's a dentist's job. That just doesn't exist for us.

We've got no one to kind of fall back on, other than really the sort of the referral routes like yourself. I mean, and then I suppose partly, you know, come to lectures like this, but I know BVDA have always been very good at putting on practical courses, you know, at an affordable rate, you know, rather than maybe some of the companies that do charge quite a lot for them. This is the way forward, isn't it, really, is, is to go to some courses run by people like yourself and and it's such a practical subject that and there's lots of different ways of, of, of doing CPD these days, but yes, there's nothing like a wet lab, and so to, to move forward, you know, in the theories is great, but yeah, a wet lab, is definitely the, the best form.

A little . Push for for one of our little projects, which is the hollow vet. I got very interested in VR and AR and I actually went to a, a VR AR conference and we had, a dummy.

You put the VR, headset on, and I was actually injecting, the person's mouth so I could put it in the right place for the, anaesthetic. And it was, also haptic, so I could feel myself going through. The, the tissue and hitting the bone, so, you know, who knows in a few years if we, if we're we're supposed to be hearing about funding next week, if we get that we might be.

Helping with some of the the practical side as well. Right right couple of, couple of questions otherwise I'll get told off by Hillary. I know we're sort of slightly impinging on next hour, but, Hillary's asking, is there a good book on oral maxillary surgery, so if we can make a recommendation.

Yes, there are, there there there is . If you put in, oral and maxillofacial vein oral maxillofacial surgery, there is a, a book, which is by a num there's a number of, authors, thank you. Oral veterinary.

Yeah, you get a big black fronted tome. So it depends really if you're looking at extraction techniques or whether you're wanting to branch out into, you know, your jaw fractures, your oncological surgery, etc. So that one is very good in terms of covering that, that, that sort of maxillofacial side of things as well.

If you want something that is more oral surgery in terms of extraction wise. Then, there's there's a lot out there and basically I, I would have, you know, try and have a have a look through and see what's got the best photos, . Some of the Atlas type ones are quite good.

The AVA book, there's one by Cedric Toot, Cecilia Gral. There's there's all sorts out there, and to be honest, any of those will show you the the surgical. Techniques.

But again, you know, whether you read it or whatever, there's there's nothing like doing it and getting the feel and and seeing how the blood gets in the way and how the tissues stretch or don't stretch and how thin the periosteum is and so forth. We've got the book there, is it Vstrata and Loma? Well, that's right, yeah, just have a little look around for that.

Yeah, yeah, that's, that's definitely branching out into all all elements, yeah. I'm gonna do two very, very good questions. Hillary, is there a dental X-ray system that you would recommend?

Oh gosh. There's all sorts out there. There's all sorts.

This could be quite a long answer, really, but I think go for the best that you can afford is one thing. . If you're in one surgery, and, and that's your base, then I'd say that the easiest to learn is wall mounted.

If you're going to go for a mobile X-ray generator, then make sure it's a truly mobile one. In other words, one that looks like sort of a speeding gun or a giant camera, that kind of thing. Because the ones that are mobile that are on sort of a, a trolley, if you will, so they've got a, they've got a great big footprint.

They are not really mobile at all, they're a pain. So either go for wall mounted or, or, you know, a, a kind of a gun type handheld, but the good thing about wall mounted is that when you position it, it, you know, you can look back at it and go, right, is it right? Can I shall I tweak it, shall I twist it, that kind of thing, and let go, because it's got a groove on.

If you go for. Handheld, then obviously you are the boom arm, so it can have a steeper learning curve, but on the other hand, you can also, you know, it will travel around with you. Direct or indirect, pros and cons, I, .

Yeah, I don't know whether I'm supposed to mention manufacturers' names or not really. No, I think you're right if you want to. OK, I mean, I've found my system really good.

I've got the Fire CR that's fast, simple. It's just F F I R E. Yeah, yeah, that's, that's fast, it's, it's simple, it's user friendly, the nurses love it.

There's DR. I've looked at a few different DR, saw the shit, that's a nice, looking system. It's very fast.

So again, the thing to think about there is, do I want only a size 2, so a smaller plate, or would I like choice? If you want choice and you don't want any wires around, go for CR. If you don't mind about having a wire connected, no one's gonna trip over it or, you know, dislodge it, and you only want a size 2.

Then you might think that DR is, is a good choice. There's pros and cons to both, but always, whoever you choose, make sure they'll come along, show you it, and ideally, leave it for a trial for a week or something like that, so you get a proper handle on it. And the other thing is always get proper, expert training on it so that you know exactly how to do it and and how you derive your positions, because, it is a bit like learning to ride a bike, I'm afraid.

Once you've got it, you've got it, but you do need a bit of. Help generally getting to that point.