OK, we're going to talk about elevation and luxation, techniques, and we're going to talk about elevation and luxation instruments. This is important for all of us in general practise that are doing dentistry on a regular basis. Very few of us have had any advanced training with dentistry, and yet we're doing dental operations almost more often than we're doing anything else.
There are certain techniques that you can use that will make your life much easier, and we're gonna go through those now. During this presentation, we're going to be using images of dentonomic instruments. These are instruments made by the company that I run.
Everything that we're talking about in terms of surgical technique and instrument care can be applied to virtually any veterinary dental extraction instruments. Our instruments will look slightly different. They are instruments with removable blades and a handle that can be reused over and over again.
The blades can be reused and sharpened, and we're gonna go through that later on. But again, the sharpening procedures are exactly the same as you would use on any surgical tool. So why are dental extractions difficult?
Why do we struggle? The major thing to understand is the anatomy of the tooth. So you've got the tooth sitting in a tooth socket.
The tooth is surrounded by a web of periodontal ligament, and that web is made up of a network of collagen and elastic fibres. The elastic fibres are important, they allow the periodontal ligament to stretch, and of course that's a good point of view from the dog and cat, when you're chewing. You're putting a lot of bite force through these teeth.
You want teeth that can adjust very, very slightly to the forces being placed on them. When it comes to extracting that tooth, everything's working against you. These fibres are designed to hold the tooth in place and of course you're trying to pull it out.
The space that that ligament sits in is only 0.1 to 0.3 millimetres wide, it's very, very thin indeed.
And that is extremely important surgically. So What we're needing to do, we all know that it's important to have sharp dental instruments. The reason for that, sharp instruments are thin instruments, and you need thin instruments so you can get into that 0.1 to 0.3 millimetre space.
What we're trying to do here is operate on ligament rather than operate on bone. If we're using blunt instruments, yes, of course it's hard because they don't cut that well, but what it means is a blunt instrument has got a thick edge. The thick edge will not be slipping down into that thin periodontal space.
And then the only way you can get that tooth out is by crushing and removing alveolar bone around the tooth until the socket is so destroyed that the tooth will come out. So it's much, much easier to operate on ligament rather than bone, and it's also much less traumatic to operate on ligament rather than bone. When we're using dental instruments, any extraction tool should be held like this.
So you want a palm grip with the index finger extended along the blade. What this means is you're getting better precision, like holding needle holders with your finger extended along them, you know where that instrument is going. You're also getting better resistance to slipping.
As your finger is down near the gingiva rather than way up away from the mouth, you can feel where you're placing the blade much more easily. And the main point, you will slip if you are doing dental surgery, sooner or later you will slip. If your finger is placed in this position, then when you slip, you're not gonna do major damage.
There are published reports of eye and brain penetrations in dog and cat dental surgery from people slipping with dental instruments, and more minor injuries are very, very common indeed. So palm grip is very important. What you will find is that shorter handled instruments, the stubby handles or the shaped handles that you can see in this picture are much easier to hold because they're sitting within your palm muscles.
The longer instruments that you see out there, the longer handled ones are mainly designed for human surgery. They use a different hand grip because of the position of the surgeon in relation to the patient. So on the whole, shorter handled instruments are more appropriate for veterinary dental surgery.
Now, we're mainly gonna go through surgical instrument technique, how to hold the instrument, how to use it. Please remember that there are vital vital aspects of, of dental surgery that we're not covering, particularly careful, safe anaesthesia and particularly analgesia is incredibly important. You are performing surgery, clean the site, disinfect the site, chart the site so you know what you're going to do and where you're going to do it, and radiograph teeth before extracting and ideally after extraction as well, so that you're planning correctly.
You know if there are extra tooth roots there, you know if there are bends on the end of the tooth roots so that you're gonna have difficulty mobilising and raising it up, that kind of thing. Prepare that tooth for surgery, so mobilise the gingiv, raise the gingiv or flap so you can access the tooth root directly. Cutting multi-rooted teeth into single rooted tooth fragments is very, very useful indeed.
It's virtually impossible to extract a multi-rooted tooth in one go without some pretty major bone damage. So using a dental drill to section those teeth before starting extraction is, is extremely good. And most importantly, you are undertaking a surgical procedure in a bony site.
It's not a dirty op, it should be treated as a clean up. So if you clean, remove the plaque, remove the tartar, disinfect your surgical site before you start, then your surgery is going to be much easier and much faster and definitely from your patient's point of view, much, much safer. So Instruments themselves, we've got 2 different kinds of extraction instruments.
They do 2 different jobs, you use them for 2 different reasons. In the picture that you can see here, luxation blades, these ones here, have got a thin blade, they're like a chisel or a scalpel blade, and they're used for cutting the periodontal ligament in that slim periodontal ligament space. Elevation blades, these guys down here.
Elevation blades are thicker. They are designed for applying force to stretch the periodontal ligaments, so they're thicker and they're tougher, and they used to gently lever the tooth around in the tooth socket over a period of time. So let's start with elevation technique, this is the most common technique that people use and it's the one that's generally easiest to learn.
Important point here, periodontal ligament is that web of collagen fibres and elastic fibres. It stretches slowly, it doesn't snap ever. So elevation technique involves applying a gentle graduated force to the periodontal ligament over time.
And we're talking about 10 to 30 seconds, generally. Different people have slightly different techniques, but the time aspect is important. This is not an instant thing.
What you're doing with an elevation blade, you're inserting it into the space between the alveolar bone and the top of the root. And then you're rotating it and applying force, and that force is levering the tooth from one side of the socket to the other. And because of that, it's not your technique of choice for slim, long, delicate routes.
If you use this on slim, long, delicate routes that haven't been mobilised properly, the chance of breaking that route is pretty high. The other problem with elevation is because of the force that you're using, you are going to be compressing the alveolar bone, you can't avoid that. And if you really overdo it with the force, things like jaw fractures become much more likely.
So remember it's a forceful technique. If you're applying force over a period of time, you can actually make things more gentle. So here's a picture describing the technique.
You're putting the blade in, you are not using the blade like a chisel to cut down to the base of this root, you're staying at the top at the gingival margin. You rotate the blade around its own axis, so it's a gentle twist until you feel some resistance to that twist. Once you feel some resistance to that twist, you hold pressure.
So it's not a wiggling movement, it's a single turn, hold, wait. And I normally count or I look at the clock and give it 1015, 30 seconds. Once you've given it that time, you will generally start to feel a little bit of lessening of resistance as the periodontal ligament starts to fatigue and stretch.
At that point, you can either put a little bit more pressure on to see if you can get it moving a little bit more or more generally, you'll move to another position around the axis of the tooth root and you'll try again. So you stretch the ligament around the circumference of the tooth root in order to loosen the tooth. These are images from Matthew Oxford at the New Forest Veterinary Dental Referral Service, and you can see him, this is extraction on a Jack Russell terrier.
So he's placing the elevation blade in. He's not putting much force on yet until he feels the resistance. He's turned, he's now holding, and you can see the tooth starting to mobilise.
He's putting a little bit more rotation on here, but he's not wiggling this blade. This is a single turn and rotation and hold. Once you've done that a few times, the tooth is then mobile enough, and you can start to to extract with forceps.
You can see here again, there's a small amount of movement on this tooth root, he's holding that rotation. And then he's going to another location. And repeating the, the technique.
So it's find your position, don't put force on until you've found a point where you can leave it between the alveolar bone like this. Rotate hold. Stretch And then you can repeat in that way if you need to.
And you can see there we've got a nicely mobilised tooth ready for extraction. Obviously it takes slightly longer than that in practise, but that is the technique. Luxation technique is very different.
So think of a luxation blade like a scalpel blade. You're inserting that blade into the periodontal space. You're not using it as a lever, you're using it to work down towards the root apex in order to cut the periodontal ligament.
It's a more delicate technique and it's a more precise technique than elevation. It does require less force, it does require more precision. Remember that you're handling a very thin, very sharp blade, so the palm grip that we were talking about before is absolutely vital.
You can't do without it. If you slip with a luxation blade, you will do a lot of damage either to your own hand or to the animal. So, palm grip is essential.
With luxation, we've got 3 stages, that is the way that I think about it. So stage number 1, you insert the blade directly into the periodontal space. You then rock and work the blades sideways down into the periodontal space.
A straight push is not particularly effective, so you gently work it from side to side, pushing down towards the apex. Do not ever use these blades as levers and we'll I'll show you why in a moment. So you're not trying to work the blade out or away from the tooth, you're trying to stay within the periodontal space itself.
And then the last stage is contouring of the blade around the tooth boot, so you're working it and rocking it down towards the apex and simultaneously contouring around the circumference of the tooth. Now for me personally, I'm in general practise, when I'm doing general practise dentistry, I find it quite difficult to combine stage 2 and stage 3, so I do them as separate steps. So I will insert the blade into the periodontal space, I will work it and rock it directly down towards the apex of the toothro.
And then I will move round sideways slightly and repeat step 2. So it is possible to separate step 2 and step 3 if you find that difficult, and that certainly works for me. Notice the difference between these two techniques.
If you're using an elevation technique, you are turning the blade around the axis of the blade or around the axis of the instrument. It's a twisting movement. With luxation you are turning the blade around the circumference of the root.
So you're not twisting a luxator, you're working around the tooth root, staying perpendicular to it at all times and staying within the periodontal space. So luxation is not a twisting movement, it's a cutting movement. And you'll see here Although it looks like we're twisting, we're not, that blade is being held against the tooth root and then it's the blade stays within the periodontal space as it cuts down.
So we're contouring around that tooth thread. We're using luxation here because these are thin delicate pre-molar tooth bids and elevation technique might well snap them. You can see that there was a gingival flap, and a bone flap being used there to reduce the amount of loading on on that tooth route as it was extracted.
So we'll just show you that again. Think contour around the root, not twist the instrument itself. Two techniques that you want to be careful with.
This is the classic one that I think we've all used at some stage or another, drilling for oil is what I call it. So it's a rapid twisting movement of the blade. Typically people use elevation blades with this technique, so it's a big fat chunky blade that you're trying to force into that 0.1 to 0.3 millimetre periodontal space.
Now why is that not useful? Well, to start with. Peridontal ligament takes time to stretch, time to fatigue.
If you're twisting rapidly, you're not giving it any time, root fracture becomes very likely indeed. You're also going to be wearing and crushing the edge of the alveolar bone, and that's removing the lever point that is so vital for correct elevation technique. You're going to make, particularly in something like a cat mandible, bone fracture, jaw fracture becomes very likely.
And also if you're fatiquing the edge of the instrument, and particularly if you're using thin edged instruments, you're more likely to get an edge fracture of your blade. The other classic technique is the crowbar, you try and wedge that instrument right down as far down that toothward as you can and then you use the instrument as a lever. People do this with both elevation blades and luxation blades, and it doesn't work.
Mainly you're going to get root fractures, you're gonna get bone fractures. You're going to crush the alveola bone here where that instrument is pushing against the bone and particularly with slim dental instruments, you're talking about a few millimetres worth of steel, it's going to bend. This is not an effective or fast way to remove teeth anyway.
There's an awful lot of ligament that's trying to hold that tooth in place and you're levering in a direction which doesn't do any good. So it's much more effective to stretch and fatigue the ligament or cut the ligament. Levering with these instruments just is, it takes a long time, it damages the dog or the cat, it damages the instrument.
It's not worth it. So avoid the drilling for oil, avoid the crowbar technique. Preparing for your tools.
So these are sharp, delicate surgical tools. Think about how you look after them. So all the instruments that we use should be decontaminated after surgery, enzymatic cleaning solutions are the most appropriate way of doing that.
Bear in mind, especially if you're using ultrasonic cleaners, people living in areas with naturally soft water, naturally soft tap water. That can form very alkaline solutions, particularly in an ultrasonic cleaner, and that can damage both steel and aluminium surgical instruments. If you use deionized or distilled water, particularly, well, ideally throughout the cleaning process, but specifically in the final rinse before they go into the ultrasonic cleaner while they're in the ultrasonic cleaner before they go into the autoclave.
Using deionized water is going to protect your instruments against extremes of water chemistry. Always sterilise your dental instruments. It's very, very important that you don't store dental instruments wet.
Disinfectant disinfectant solution storage is going to make it much more likely that you're going to get corrosion with those instruments, and that's going to damage and blunt the edge. And we want that nice, sharp, slim surgical edge for easy surgery. So auto clothe them to sterilise them, store them dry in an autoclave pouch or in a sealed autoclave case, and that's going to prevent corrosion, keep them sterile and safe for your next use.
And don't forget that when you're cleaning sterilising instruments. Both dogs and cats have got transmissible oral, bacterial and viral infections, so prevention of cross-contamination and proper sterilisation is as important for dentistry as it is for any other kind of surgery. So in terms of honing and cleaning, or honing and sharpening, I should say, sorry.
A lot of people want to know how to sharpen veterinary dental surgical instruments. And I would suggest don't sharpen. Sharpen implies taking metal off the edge and trying to reshape and re-engineer your dental instruments.
That's not very effective. Think instead of honing. If you sharpen an instrument, if you try and re-edge an instrument, you need to be very precise and you need to know what you're doing in terms of producing an edge that will do the job that you want to do.
The edges of luxation instruments and elevation instruments are completely different shapes, they're different angles. If you get the wrong shape, you will stop the instrument behaving in the way it's meant to behave. So what we're doing here is we're just realigning and straightening the edge that already exists.
You'll need to start this from a new undamaged instrument, and the idea is to take care of it and keep it undamaged. So you can see on the left, a sharp, undamaged blade edge, massively magnified. When you operate with it, you're pushing that blade edge down between bone and tooth enamel, which are the two hardest biological materials, and you can see that this has bent the edge over very, very slightly.
And you can feel this as a slight burr on the edge of the blade, it's like roughing on the edge of the blade. The next thing that you do is when you feel that roughening and see that burr when you're cleaning and maintaining these instruments, you want to be using something that's not particularly abrasive to bend and straighten and realign that edge. So what we're seeing here in this image is a very, very, very fine diamond honing card.
If you think about kitchen knives, you might use a steel, kitchen steel, or you might use a ceramic rod to sharpen kitchen knives on. You're not trying to grind and remove metal, you're trying to straighten and look after your blade edge. So what's happening, you're moving that card upwards and that's pushing the blade edge here back into a straight alignment.
That straightened edge is sharper, but because it's not got a big bird end on it, it's now thin and slim enough to enter the periodontal space. If it can enter the periodontal space, we can then operate effectively. So it's all about keeping slim straight edges.
Don't let your instruments get blunt and then try and sharpen them. Every time they've been used as part of your cleaning procedure, think about honing them to maintain the edges. So how do we check those edges?
The safest way to do it is by using a little spatula. I actually use a cocktail stick, that's the the best way that I've found. And you feel along the the top and the bottom of that blade edge where there's a little nick in the edge or a burr or a slight bend, you'll feel it as the burr stops you running that little cocktail stick along the blade.
So it'll run along and it'll stop at the burr. And if you're holding that gently, you will be able to feel the burr very easily indeed. What we then want to do is try and polish that burr out.
You want to be using appropriate gloves and appropriate eye protection. Some forms of sharpening can produce fine metal fragments, and you definitely don't want those going in your eyes. So here I'm using a very, very fine diamond cone.
And I'm using that to polish the inside the concave surface of an elevation blade. The concave service in this instance, the blade edge would have bent upwards, so I'm drawing that cone backwards just a few times in order to straighten the edge. Good honing should take no more than 2 or 3 seconds.
Think of a chef honing a kitchen knife on a steel. It's, it's a very quick procedure, you're not trying to sit there and grind those edges. So it's a few fairly light, fairly gentle strokes against that bent edge to straighten it out.
You then go back with your cocktail stick and you recheck the edge and make sure it's nice and smooth. Here we are honing the flat edge or the convex surface in some cases of the other side of the blade. So in this situation, this would be a downwards bend of the edge.
We felt that with a cocktail stick and then we're just polishing that off. And this actually is my favourite way of doing it. The one before is it's easier to get a match between the cutting edge of the blade and the card.
I find once you're used to it, holding it the other way up can be quite handy. But again, it's the same technique. You check with a cocktail stick, you find the burr, and then you try and polish that burr out using the sharpening instrument.
You can use a sharpening stone, you can actually use ceramic sharpensers as well for dental instruments. My preference is a super fine, diamond card and diamond cone, and those are easily available. If you're using a stone sharpener, you will have to lubricate it either with water or with oil, depending on the manufacturer's instructions.
The important thing is, particularly if you're using oil, all of that oil needs to be removed from the blade before you operate. You must make sure that when you're using any honing device, whether it's a stone or ceramic or diamond, that the blades are thoroughly cleaned and decontaminated. Beforehand, otherwise you're contaminating your sharpening equipment with potentially transmissible diseases.
So be very, very careful about that. In summary, 2 techniques, 2 different instruments, 2 different tooth roots that you want to be thinking about. Elevation blades are thicker edged, they're stronger, and they're designed to apply torsion to the tooth root, which moves the tooth root around in the socket and it stretches the ligament.
So elevation is the tough, strong roots that can accept that kind of force. Elevation is always applied over a period of time. Luxation is the more precise technique.
Think of it like a scalpel blade. You're inserting a much thinner blade into the periodontal space and you're cutting and pushing away at that periodontal ligament. Luxation is a technique that's more appropriate for long, thin, delicate roots.
It's a more precise technique. Be aware that it takes time to get good at that. Always think about contouring the blade around the tooth, but not twisting the instrument.
If you maintain those sharp, thin edged extraction tools, and if you think about those two surgical techniques, suddenly dental extractions become much more logical, they're easier, they're safer, they're quicker. And think about matching that tooth root and saying, well, that's what I'm going to elevate, or that's what I'm going to luxate. It makes your life much, much better.
Remember that the less force you put into it, the less brutal we are with the surgery, your patient will come round with much less pain. They're going to eat better afterwards, they're going to recover faster, it's much nicer all round. So think about using those thin precision edges and treating it as more of a surgical procedure instead of just basically a dental.
There's more information available on our website, that's the Dentonomic.com website. And there are interesting little bits and pieces that we put up on our Facebook page.
If you have any questions from this, if you go to us through the webinar vet or come onto our Facebook page and ask us directly, we'd be more than happy to help. Thank you very much for your time and happy dentistry.
