We're going to have our next speaker will be Annabelle McFadden. She's an RVC graduate who is who has started an EVDC residency position at Eastcot Vets in Swindon in dentistry and oral surgery. Annabelle's, subject, which will start in a couple of minutes, just so that we can allow time, for other, the other streams to swap over, will be surgical extraction techniques and complications.

Hi everybody, I hope you can all hear me OK. I'm going to talk to you today about surgical extraction, both the technique and complications. There's an awful lot to cover with this topic, and I've only got half an hour to talk to you, so I'll try and cover as much as possible, but if you've got any questions, feel free to ask.

So the field of dentistry regarding the extraction of teeth is known as exodontics, and really all extractions are a surgical procedure. The definition of a surgical extraction is one which requires incision of soft tissue and breakdown of the attachment apparatus. .

What we're really delving into today are open extractions, and these are those which require elevation of your mucop periosteal flap and bone removal. So these are typically the extractions which will involve a lot more time and technique, but when they're done well, they make you enjoy dentistry just that little bit more than I'm sure you already do. So indications for open extractions include all multi-rooted teeth.

The canine teeth in most cases, in order for you to be able to close, your extraction site to prevent or a nasal fistula formation. Periodontally healthy teeth showing resistance to extraction, and also any teeth which show abnormalities in root morphology. And we'll talk a little bit more about that later when we discuss, radiographs.

So when we think about technique, you need to begin with your preparation, so you're, fully organised and ready for the oral surgery that you're about to perform. So knowing your anatomy is important, for example, knowing about the location of important neurovascular structures that you might want to avoid, and also obviously knowing the anatomy of the of the tooth that you're planning to extract. Making sure you've got adequate light and magnification and a good set of loops can really help with this.

From my experience, there's a bit of a learning curve when you first use them, but, as soon as that passes, they, they are really invaluable, especially in feline dentistry, if you're doing a lot of cats or, when you're looking for root tips, which we'll talk about later. Make sure you've got all your instruments required for your procedure, and we'll discuss these as we go through the technique, and making sure that those that should be sharp are sharp, such as scalpel blades and your luxators, for example. And in preparing the oral cavity, you should always perform routine periodontal therapy first, and then rinse your oral cavity with chlorhexidine, and we use hexarinse, which is 0.12% chlorhexidine.

And then finally, as with any form of surgery, analgesia is really important. And where I work we're very big on using multimodal analgesia, and we've got our lovely anaesthetists to help with that. But generally, all of our patients having surgical extractions will have at the very least, a full opioid as part of their pre-medication.

And also regional nerve blocks placed with a local anaesthetic such as bupcaine or lidocaine. I don't have time today, unfortunately, to talk about nerve blocks, but there are some good, papers and textbooks that I can recommend if anyone would like, and they are super easy, so everyone really should be using them. So pre-extraction radiographs, so these are vital for any tooth to be extracted.

First of all, so you know the anatomy, and also in order just to make your life easier, when it comes to performing an extraction. Anything that makes your life easier is good. So there are so many reasons that extractions can be tricky, and if you know it's going to be tricky beforehand, or you can identify a way to reduce the trickiness, then you will be forever grateful for the radiograph that you've taken.

Examples of radiographic features that you want to know about beforehand might include the presence of a root fracture. Ankylosis, dilacerations, anatomical variations, and also the presence of, a large groove on the distal aspect of the mandibular first molar. So if we look at these radiographs here, the first radiograph on the left shows a mandibular first molar with beautifully dilacerated roots, which is the abnormal angulation or bend that you can see, in, in the roots.

The second image shows, this groove on the distal aspect of the medial root of the mandibular first molar, and you can often see this in large breed dogs. And you can imagine how this will prevent, rotation of the teeth roots, and therefore make your life difficult during extraction. So, knowing that this is there and passing a bear on this aspect of the teeth, to widen this section will make your life a lot easier.

And finally, in the third picture, you can see an anatomical variation of the 3rd premolar, which has got an extra root. So you can see it's got 3 roots instead of 2. And without knowing this prior to starting your extraction, you're gonna wonder why it's so difficult to extract this tooth.

And also, obviously, you need to make sure that all 3 roots are extracted. So once you're prepared and you've got your radiograph now you can obviously start your surgical procedure. So you want to start by creating a muco periosteal flap, and we'll look at some pictures in a video in a minute.

It can be helpful to use a beaver blade, which is on the image, on the slide, which is a mini blade with a cutting tip, or you can just use a number 15 blade, it's absolutely fine and suitable. You want to make a gingival incision around the tooth to be extracted, so you're incising through the gingival sulcus, and then you're creating vertical releasing incisions. And then releasing incisions should be made 90 degrees to the ginger alveolar margin, and then diverge at the mucca gingival junction to create a nice wide base platform.

We'll just, we'll look at that in a second. And then by introducing a periosteal elevator, which is the instrument on the right, into the sulcus, you can pry the gingiva from the bone and reflect your mucosa and the periosteum from the bone. So this image shows a nice broad-based muoperiosteal flap over a maxillary canine teeth, and you can see that it extends to the line angle of the adjacent teeth turning 90 degrees through the attached gingiva, and then at the mucogingivore junction it diverges.

Now one of the biggest mistakes is that this flap is made too small, so you need to make sure that the base is really nice and broad, to ensure that the flap, maintains a good blood supply. And also you want to be able to reflect the soft tissue, . Adequately for your extraction and obviously and to be able to protect it from any trauma, so, so don't make your flat too small, just make it nice and big, bigger the better.

So once you've created and reflected you're flat from the bone, as I said, you want to protect it, at all costs, and especially as you're about to use high speed bears and sharp instruments in the vicinity. So make sure all your tissue handling is very gentle. Never use instruments to hold your flap, edges, just use your fingers if you can.

And also when you are using your high speed instruments or or sharp instruments, try and reflect it and hold it back with a tongue depressor, or we use, small plastic white sticks, very simple, just to hold it out the way, but just make sure that you're protecting it, make your life a lot easier later on. So next you need to remove buckle alveolar bone. And this process is called an alveolectomy.

And this is to expose the root and the periodontal ligament of the tooth, to help you place your instruments to apply the force for extraction. So you want to remove as minimal an amount as possible, but as much as is required for extraction, which I know is a bit grey area, but generally younger patients require less, and older patients with narrow periodontal ligaments or ankylosis, or if there's areas of resorption that they're likely to require more. So another reason why your pre-extraction radiograph might guide you, in this process.

There might have been features of the tooth radiographically which give you reason to remove more bone in a certain area. For example, as I mentioned before, if there's a a groove on the, the, the root of the mandibular first molar. So a water-cooled round bear is best for the alveulectomy, and this can be done either with a slow speed or a high speed handpiece, but you do need to make sure that you, are using a water-cooled instrument.

And then multi root rooted teeth will need to be sectioned with a high speed tapered bear. And ideally this is started at the facation which you have exposed by your alveolectomy and then progressing coronally through the teeth. And these photos show some nice root sectioning of the maxillary 4th premolar teeth.

And if you just notice on the right picture how the crown of the medial roots have been removed before sectioning in order to expose the canals, just to help you guide where to section that tooth that's a useful tip for that tooth. Then you can luxate or remove the tooth. So this is generally achieved by using luxators and elevators and knowing how to use these instruments properly is obviously very important.

They should always be used with a short finger stop. So if the instrument slips, it only goes as far as beyond your finger, and that's the, the short finger stuff is, what's shown in the picture, at the bottom. Also, just knowing the difference between a luxator and an elevator.

So the luxator is the image on the left, the, the two on the left, and these are used to cut the periodontal ligaments, so you can see they're thinner and therefore they're sharper, and they're inserted into the periodontal ligament space and used in a cutting motion side to side, so you never should apply rotational forces, to a laxator cause they're just not strong enough, for rotation. An elevator on the other hand, which is the instrument on the right is thicker, stronger, and this can be used for those rotational forces to to stretch the periodontal ligament. You can use them in the long axis, as a first class lever or as a wheel and axle lever, and just making sure you're stretching the fibre in different directions, continuing until the tooth is mobile.

And this just requires patience and controlled forces that don't be tempted to rush or to use excessive forces because you won't achieve anything except just getting frustrated with yourself and increasing your risk of complications. And once the tooth is mobile, you can remove it from the alveolus. So before closing, it's also important to manage your alveolus, so, firstly by performing curettage and debridement of any granulation tissue, inside the alveolus, allowing a nice blood clot to form inside as well.

You should also perform an alveolar plasty to smooth your bone edges, and we do this using a round diamond bear just to, bevel and smooth any sharp edges before closure which may traumatise your flap. So again to try and decrease your risk of complications. And finally, a post extraction radiograph is recommended at this point to just document your completed extraction.

So closing the flap, I kind of wish I'd written tension free in bigger font and in red, just to kind of stress the importance of it. But tension-free closure is the most important principle here. And if you only take home one message from it this today is that if you don't have a tension free closure, you will get post-op descences.

So making sure that you do this part of the procedure well, and with good technique is very important. So you should already have your nice wide base flap. With your divergent releasing incisions, but in order to stretch the flap down over your extraction site, you need to perform a perioste periosteal releasing incision.

So the periosteum on the rear side of flat will not stretch, and so you have to cut this in order to allow a ten-free closure. And this is generally performed with scalp, a scalpel blade or fine scissors, obviously without cutting through the flap. So if we just watch this video, you can get it to work.

So I am just gonna skip forward because I'm just conscious I'm gonna run out of time. OK, so the flap's been lifted. And what I want you to watch now is releasing the periosteum with these fine scissors.

So you can see the way the flap is now, there's no way that flap would stretch down for you to close. If we just release that attachment. Just make sure you do it all the way along your flap.

And then you'll be able to see in a minute how stretchy that flat now becomes. You can stretch it right down. That So you should be able to place the flap down where you want it to be, and it should sit there without any tension, and that's how you know you're going to be able to achieve tension free closure.

And it can also be useful to just raise a few millimetres of the plate or lingual tissue from the bone to allow you some tissue to place your suture through. So use an absorbable suture, ideally with a waged on reverse cutting needle. And, the 3 millimetre rule, that I mentioned there is placing sutures 3 millimetres apart, 3 millimetres from the edge of the gingiva, and cutting your suture ends to 3 millimetres long.

So you can follow that rule as well. That's ideal. And so then here's a photo of that flap sutured down beautifully.

Right, so that's the first part on techniques, so the second half of the presentation is on complications. So as far as complications of surgical extractions go, the number one most important thing, as I've already said, is good technique, and if you do have good technique, your complication rate will hopefully be very low, but unfortunately, complications do occur. And it is important to go through these with the owner preoperatively, just so that they're aware that they can happen, and they do happen to all of us.

And so all surgical procedures should only be performed following informed consent, and we all know this is part of, our code of conduct. So just making sure that you do go through these preoperatively with the owner is very important. And the next, next, slides we'll go through, are some common complications and some tips on how to deal with them when they do occur.

So fractured root tips. So this is very common, despite all our best efforts, obviously they can be from poor technique or excessive force, but they can also occur due to factors such as, ankylosis, resorption, or those anatomical variations that we discussed previously. So again, highlighting the importance of a pre-extraction radiograph.

If it does occur, you do need to retrieve the root in most cases, it's seldom appropriate to leave a root, unless you really can't retrieve it, in which case, you need to inform the owner, and either obviously monitor or, or at least get some advice from your local referral dentist. If there's any clinical or radiographic evidence of periodontal or endodontic disease, then obviously it must be retrieved, or if you're treating an animal for stomatitis, so a cat for, gingerous stomatitis, then obviously it must be retrieved, as well. If it does happen, it's not the end of the world, just take a deep breath and then take an intraop radiograph and just so you can see exactly what it, what's left behind and where it is.

And try and keep in mind the anatomy of that area, so particularly the location of your neurovascular bundles, your mandibular canal. Your nasal cavity in the orbit, and you, the most important thing is that you need to be able to visualise this root tip in order to remove it. So if you're not sure that you can see it, one useful tip is to use a needle placed in the area that you, think the root tip remains and take a radiograph, and that can help localise it.

Or again, using loops for magnification, this is the time to kind of get your loops out, make sure you've got good lighting. And having an assistant with a suction tip in the area can also really help, just to remove any blood or debris which may be impeding your vision. And also you may need to remove my buckle alveola bone to help find it as well, and you know that's absolutely fine to do.

And once you can visualise it, a great bear to use is, is on this image here which is a a root tip bear, which is a long tapered bear. And you can use this to gently delineate circumferentially, around your, your root to remove alveolar bone to help you introduce your elevator, to extract the tip. And another really good instrument are those forceps, which are root tip extraction forceps, which are very helpful once your root tip is mobile and they have very fine tips and help you remove it.

So following on from this, another complication, following retrieval of a, of a fractured root tip would be displacement of a root tip, and places that they can go include the mandibular canal, such as in this image, the nasal cavity, and the maxillary sinus. Again, good gentle technique can minimise this risk, but you know, if it does occur, there may be a situation where you may need to consider a referral, or, you know, just give us a call for advice and we can advise on the best course of action. So trauma to your flap, again, really try and protect your soft tissue during your extraction and perform gentle tissue handling, as best you can, as we discussed before.

But if it does occur, you will need to trim away, damaged portion before you close. In some cases you may be able to suture the defect. But ultimately you need to make sure that you've got enough, healthy tissue to close, and that that that you're, you still have a tension-free closure that's been maintained.

And if you've had to trim enough away that you've lost that tension-free closure, then you, you will have to consider redesigning your flap. So normally this is just making longer releasing incisions, for example. But as we said before, if there's any tension, your flap will break down, so that is the number one priority.

So just trim away any trauma and then redesign your flap in order to gain your your attention for closure back. So this leads into dehiscence of your flap. And again, tension free closure, I know I keep mentioning it and a good flap design but all your tips for avoiding this are based on having good technique.

Also, the post-op care that you recommend to the owner can try and minimise the incidence of this. So we would always recommend soft food only, is fed up until, oral healing that you've monitored with post-op checks, as well as avoiding all chews and toys in the mouth, and we will routinely ask owners to make sure all toys are picked up from around the house before the dog goes home so that they don't get tempted to pick it up. Also, depending on the nature of the animal, sometimes we recommend that only lead walks are performed or that cats are kept indoors, just to make sure that nothing is picked up in that mouth and only soft food is going in that mouth until everything's healed up.

Treatment for dehiscents, generally depends upon its location, and also the state of the alveolus. So if the alveolus is intact and there's no necrotic bone present, generally, the site is left to heal by second intention, and we would see the animal back for post-op checks. And if after two weeks the surgical site doesn't show any evidence of healing, it would probably prompt then an examination under general anaesthetic.

And always remember, if you're not getting the healing that you're expecting, you might want to rule out other causes. For example, neoplasia, you might want to take a biopsy of the tissue. Also, always remember that in the presence of an or a nasal fistula, it's never appropriate to try to allow a defect to heal by second intentions, so in those cases you will unfortunately have to go and, repeat your closure.

Next slide covers iatrogenic trauma during surgical extraction to both teeth and the bone, and I think the one that most people worry about is jaw fracture, iatrogenic jaw fracture, of the of the mandible. And there will be certain cases where there is a higher risk of this occurring, including teeth with pre-existing periodontal or endodontic disease, where there may, already be a lot of bone loss around the tooth, and also in small breed dogs. So small breed dogs have a higher ratio of first molar height to mandibular height than large breed dogs, so this increases their risk for both pathogenic, and iatrogenic fractures.

And in any dog or cat, obviously the use of excessive force will increase this incident, so, just trying to, to limit the amount of force that you're using. All clients should be informed that this is a possible complication preoperatively, and if you take your pre-extraction radiographs and if you feel that, you know, you're not confident enough to minimise the risk in certain patients, then referral is always an option. If it does occur, then obviously inform the client that it has occurred.

And fracture stabilisation must be carried out, . It's also important to remember that in some small breed dogs with advanced periodontal disease, there really won't be much bone there at all. And even with, you know, the most beautiful extractions, you can, there is a risk of post-operative fracture, which is another important reason we're taking post-extraction radiographs, just to document that you didn't cause any rogenic trauma.

And in this case, you might want to recommend to the owner that they, they avoid all hard chees and toys for a number of weeks post-operatively. Another complication that that is reported is ophthalmic damage, and this mainly occurs associated with extraction of teeth in the caudal maxilla. Or occasionally from iatrogenic trauma from placing a maxillary nerve block.

So in mild cases, you may just get some retrobulb haemorrhage or swelling, which may result in exophthalmus, which generally just settles down itself, after a day or so, and cold compresses can help if if the animal will tolerate this. In worst case scenarios, you can get rupture or penetration of the globe. So just make sure that you're familiar with your regional anatomy.

And the location of the globe in relation to the caudal maxilla, especially in . Brachycephalic breeds. So use your controlled forces, use your short finger stop as we discussed earlier, and, and just be patient when extracting these cordal maxillary teeth.

If any ocular trauma does occur, then, in order to prevent a a a poor outcome or or loss of the eye, then early treatment or referral to a veterinary ophthalmology specialist is is probably recommended. And then finally, we've got lip entrapment. So this can be seen in cats following maxillary canine extraction, I think we've probably all seen this.

Most often it's temporary. The cat works out how to push the lip over the tooth, and it doesn't require any further treatment, but occasionally it can result in quite significant trauma and ulceration to the lip, and therefore obviously ongoing discomfort for the cat. So always discuss with the owner the potential for this to occur.

And in severe cases, crown reduction and root canal treatment of the mandibular canine or, or extraction of the mandibular mandibular canine may be indicated. Right, that's it. There's my motley crew, and if you've got any questions, just let me know.

Thank you very much, Annabelle. That's fantastic. There are quite a few questions here, we may not have time for them all, but perhaps I could ask Annabelle if you would answer them on the Q&A chat line, and then they'd be there for this afternoon, later on for people to read.

So the first one here, I've got, how do you decide which teeth require surgical extractions and which can be closed? OK, so I think I did do a slide on indications for surgical extraction, but, basically any multi-rooted teeth, I would recommend surgical extraction for, . Any kind of periodontally healthy teeth, you know, where they don't just kind of fall out, you probably want to do a surgical extraction for as well.

Any teeth with tooth resorption, any teeth with anatomical variations from your pre-extraction radiographs. So it's just kind of making that decision really on an individual basis, . But yeah, there is, there is, there was a slide on that in my presentation, but if you've got any particular examples, feel free to, to send them to me, can I can answer.

Thank you. And is there a limit on how large the flap can be? If you're removing all the cheek teeth, can you do one or two large flaps to close multiple teeth?

Mm, absolutely. So if you're extracting. All the teeth in a single quadrant, just do one big flap along the whole, you know, quadrant.

Don't do individual flaps for every teeth. And I'm sorry I didn't have time to go through each individual tooth, but, absolutely, in regards to that question, yeah, if you're doing a whole, a whole section, just do one big flap. Save you lots of time.

Much easier to close as well. When doing the flap, and I assume this, applies to the canine extraction flap, does the caudal incision affect blood supply to the flap? No, so as long as you just make it nice and wide based, and your nice divert you want to make it your angle divergent outwards, so you're, you're leaving it nice and wide based at the top.

You, you will have a completely adequate blood supply. I think the, the, as I said, the most common mistake is that people make it too narrow, so just make it nice and wide based and you'll be absolutely fine with your blood supply. Thank you.

And which of the following suture material is best? I realise this might be a monochryl, capricin or biocin. OK, it's like a, like a multiple choice question.

So we use monocryl, so a monofilament, absorbable suture. We generally use 4 knot in dogs and 5 knot in small dogs and cats. And that's what we generally use to close our, close our flats.

Thank you, and I should probably, add from our point of view of our partners that Moorel is the trade name by one manufacturer, but other, other, other versions are available. if, if a root tip is lost into the mandibular canal, does it always need to be removed? So that's a good question.

Not always, like sometimes it can be monitored, but, . We do worry that obviously you've got all your neurovascular structures in your mandibular canal, so there is a potential risk, for leaving a foreign object in there to obviously cause ongoing trauma and damage. So, I, if you're if you've done it and you're worried, take a radiograph, and, you know, email it to your.

Your local, dentistry specialist, and we can obviously give give you advice, inform the owner so that they know there's a root tip there, and, and get some advice and then we can, we can have a chat with you. We, we definitely get referrals for displaced, root tips, and we do remove them, but. It is kind of on an individual basis really.

Thank you. And I've got there, there are several more, but I've only got time for one, which I'm happy to answer them later on. I think is particularly important, to, to get over in the session.

Do you ever use simple con simple continuous suture patterns when closing flaps? Yeah, so what, what I was speaking about earlier, when we do a, a a a single flap in the whole quadrant, we will often use a simple continuous suture to close that. Absolutely.

It saves a lot of time and then you have less suture material present in the mouth, and especially when you're, you're treating for, full mouth extractions for chronic gingivous dermatitis in cats, you, you probably do want to limit the amount of suture material for plaque retention. That you have in your mouth, in the cat's mouth postoperatively, so, yeah, absolutely, doing a continuous suture pattern along those kind of flaps is, is absolutely fine. Thank you, Annabelle.

That was an amazing run through in just half an hour. Sorry, it was so like, so much. Absolutely brilliant, thank you.

And thank you to all our, all our speakers this morning, for an amazing set of presentations, and, Annabelle will be back later with her case presentation on feline jaw fracture repair.