Hi everyone. Welcome to this master class in extraction technique. My name is Ingrid Tundo.
I'm a specialist in, dentistry, and I work in Scotland in Huddington, dental vets, and hopefully with this lecture, I'm gonna go through an overview of extraction techniques from, single rooted teeth to. Multi rot. It's gonna be a lot of information.
It's gonna be a dance CPD but hopefully you enjoy the talk and you're gonna get some nice information about extractions and what you can apply on your day to day practise. So, during this lecture, we're gonna go through equipment. I also gonna mention local anaesthesia because we always use local nerve blocks before any extractions.
And then we're gonna go through different instrumentations that we use to perform this type of, this type of procedures. We're gonna touch base on anatomical considerations when we exact it. And I'm gonna go through flap design.
And then at the end of the lecture, there are like nice videos about how to extract this, which technique you can use. So hopefully, that's gonna be a nice visual reminder of what you need to do in practise when you perform extractions. So, on this picture, so in this slide, you can see the picture from the book, the BSEVA manual in a smaller animal dentistry, and it's a table that we have it printed in our surgical theatres.
It's very simple and super clear. So let's say that the two drugs that we use more commonly for local anesthesias are lidocaine and buvacaine. The good thing about lidocaine is that it's got a quicker, onset and, vacaine is a shorter, is a longer onset, but, a longer duration.
So lidocaine, it's gonna be effective. Also in the table says a couple of minutes we wait at least until 10 minutes before performing our, surgical treatment, and it lasts at least for 2 hours. While we will be, will be back in, we wait up to 20 minutes before performing our incision, and this drug lasts until 6 hours post-op.
The strength of Bovivaca in that we use is 0.5%. I know that commercially you can find the 0.25, but 0.5 is is the one that we use.
And the volumes are really important. So we follow the volumes in this table. So I'd say that for the majority of cats, I use a 0.2 mL each block, so each quadrant and for dogs, it's gonna change based on the weight, but it's been proven that the volume.
It's not gonna affect the efficacy of the block if the block is performed correctly, meaning that of course you need the the right amount of volume. I always use the, the, the lowest volume on the range for my patients and our blocks are quite effective. So my suggestion is improve your techniques.
Use the adequate volume so that you can increase the . Or decrease the pain sensation during the procedure and in the post-op phase. Let's fly straight into our equipment.
So this is the surgical table that usually is laid out for me from my nurses. So you can see my periodontal kit, laxators we have the, the surgical kit we're gonna open in a second. Next slides hexins which are used from time to time depending on the case, surgical burst and block burst, gag if needed, so it helps to keep the, the mouth of the patients open.
We have lip retractor, local anaesthesia, suture materials, our blade, and some swabs. There it is, my surgical kit. So it's quite busy looking at it, if you're not used to many instruments that I might use more often than in general practise, but let's say that it doesn't really matter how many instruments you have in your kit.
The important thing is that are the instruments that you like to use for your procedures. So, for example, you will always need to have extraction forceps, extraction forceps that will fit nicely your hands, so not too big so that you have the right grip, and needle holders, couple of pair of scissors. And this is the specific scalpel that I use.
So it's a human. Scalpel and the blade, you see, is called the swan blade. It's not super expensive, piece of equipment and really makes your incision super precise and your the, the grip of this instrument fits very nicely in your hands, so you can see me holding these instruments with the modifying pen grip.
So essentially you're using the shorter muscles that you have in your fingers to be as precise as possible with your surgical incision. These are the berths that we use for exactions. So we have a round fiction grip bs that we use for osteectomy.
You can find them in the standard length or surgical length. Surgical length means they're like slightly longer than the standard length. I prefer lens, personally, it gives you more space and the, it just works better in my hands.
There are different size, so the, the smaller round birds, we use them for cats and dogs of smaller, small dogs, and you can get them larger for, for bigger patients. Then you have your cutting birds, cutting birds used to, they, they useful to, they used to, for separating the roots. Sorry about that.
So in multi-rooted the teeth use them to separate the roots and the classic that, that you probably find in your clinic as well is the 701L. And then we have the diamond bird that we use at the end after the extraction to smooth the surface of the bone, after we, we remove the, the roots from the alveola. So here are the, the birds in the block, so they get prepared in this block and the block can be sterilised so that they're all ready, ready to be used.
So you can see a standard. Standard length, round berths, surgical length, cutting berths, surgical length length, round berth, a couple of, diamond berths, and there is also on the top right, rugby shaped diamond berth. This one that you see in these slides is a very special bird.
It's called the roti bear. It's sort of like a long cutting bird, and it's super useful when you have retained two roots or fragment of retained two throats that are difficult to access. So it's quite long.
It's a very good piece of equipment to have in case you have complications during the extractions. Just be mindful when you use a bird like this because they tend to cut bone like butter. So you need to have full control of of the bear.
I tend to use a magnification glasses when I, when I perform procedures. I know they can be a little bit expensive, although nowadays you can find them on the cheaper side, if you like. I find that extracting teeth, especially in cats without loops, it's really intimidating, especially when you have a tooth resorption.
So, if you have the chance to invest on this type of piece of equipment, I would really recommend it because it's gonna make your life much, much easier. So these sets of luxit here, I'm not, this, this, this lecture is not sponsored by IM3, but these are the laxits that I use and I love. So this set, it's the, the set that I use for every extraction technique that I perform.
So you can see these luxits varies in size, so the tiny, one, the 1.3. Is very, very good for cats and small dogs or if you have retained to throats.
It's a very good piece of equipment and obviously you can get, the biggest size up to 5 millimetres. They're not super expensive, and, if you take care of them and you, sharp the, the, the blade, of the scissors, they can last for a very long time. And this is the way that I hold my laxators.
So this is a palm palm grip. So you are basically holding the, the handle of the laxative, where your palm is, and with the index, you can see that I am very close to the blade of the instrument so that I protect my patients doing the procedure. So even if my laxator, or even if I sleep, I protect the, the patients from .
From any injury with the, with the tip of my finger. This is really, really, really important, thing to keep in mind, because it's been reported in, in papers, the lax sitters that are not very well controlled, they can end up in nasal cavity or create, ocular damage. So, just really good, good to keep in mind how to hold your instruments.
And of course, we have periosteal elevators. Periosteal elevators are super important in to having kids because you will use them all the time to elevate the periosteum. So you can hold them with a modified pen grip, or with, with the palm grip, I'd say it's for smaller patients, modify pen grip, it's absolutely fine in a bigger patients, especially when you need to work on the touch change, .
Palm grip could be helpful because you're gonna, you know, be a little bit more vigorous with the, with your, elevation and both grips are, are absolutely fine, but obviously if you want to be precise, the modifying pen grip is the one to go to. OK, so in terms of like anatomical considerations, when we are extracting teeth, it's really, really important to know how many roots are we extracting. So I am confident that many of you know the anatomy.
Of the teeth in dogs and cats. So we obviously have in in dogs, some teeth with one, root, some with two roots and some with 3 roots, . Obviously, before extracting a tooth, a radiographic assessment of the tooth needs to be performed.
This is just gonna tell us so many informations about the tooth that needs to be extracted or it's gonna give us information, but if we didn't think needed extraction, but they might have a pediatrical pathology or other diseases that need to be treated. And so just to quickly go over the anatomy in the next few slides. So we have multiple teeth with the one root.
So the teeth with one root that we can extract with the close technique or with an envelope flap, and we're gonna see the different flaps in a few slides are top and bottom incisors. Top and bottom first, pre-molars and the last molars on the mandible. So you can see them highlighted in yellow.
Then we have the canines, and they do have one, root, but to extract this, teeth, we will have to create a mukogenivva flap. So this pictures are representing the incisors in dogs. So you can see how the lower incisors are quite straight.
Usually, they are not too difficult to extract, while the upper incisors, the, the first and the On the are usually OK and to extract, they're not very big, but you can see the third incisor, the banana shape of this tooth, sometimes it's causing challenges for the operator to extract this tooth because essentially this is a a smaller version of a canine tooth. So of all the incisors, the upper third incisors is the most difficult to extract. And now we're gonna assess the premolars and molars.
So as we just mentioned, the, the upper and lower first premolars have one root and usually they can easily be extracted with a closed technique or an envelope flap. And then on the upper jaws, the 3rd and the 2nd premolars have two roots. We'll definitely need to create a flap and section them before extracting them.
Then we have the 4th premolar and the 1st and the 2nd molars, they have 3 roots. I see the many colleagues find this extraction quite challenging. So, I'll show you a video on how to extract the maxillary for Primolar, later on, just to give you some, tips on how to make this, this, this procedure to be, easier.
Well, on the lower jaws, the, on the lower jaw, the 2nd, the 3rd, and the 4th premolar, two roots, and, they are very similar in, in shapes. Well, the first molar is a very big tooth, and the first molar with the upper 4th primolar are considered strategically tooth, meaning that dogs use them, to chew on the classic stick that they put on the side and they chew with the 4th primolar and the first molar. So if they are fractured, we do tend to save them, with the root canal treatment.
And then we have the last 2 molars. So the second molar has two roots. There's a tiny tooth, and the third molars got one root and as well it's quite tiny.
Special attention to maxillary for premolar. They are teeth that they get fractured quite commonly, and this is related to what we just mentioned earlier. They are the teeth that that occlude on the first molar, manoeuvre first molar, and they tend to be the one used for mastication.
So we often, might have to exact this teeth, so you're gonna see the anatomy in a little bit more depth. So we have 3 roots, one is the root, one misoaletta root, and 1 misubaka route. So this is how they look clinically.
So obviously you can only see the, the crown as usual and under the gum level, there are the three roots. So we're gonna explore a little bit better which type of flap design we're gonna use to, to extract the the maxilla for premotors. So when we have teeth with the large roots like canines or multi-rooted teeth and to extract them, we will, we will use flaps, to, to help us with the, the extraction.
But also when we extract the single rooted teeth that are small sized teeth, we or Especially I, I always do perform an envelope flap because we need to keep in mind that when we extract the tooth, we are working against the periodontal tissues. So the periodontal tissues are fighting as much as they can to keep the tooth in the alveolus. So what we are doing is working on the tissues that are holding the root into the alveolus.
So the periodontal tissues are genjiva, Alvera bone, and periodontal ligament. We also have the cementum but. Cemento doesn't really play a major role in in this.
So when we're expecting it to, the first thing we need to think is that, OK, we want to create an incision at the level of the gum. So what we're doing is, like you see in this picture, I take my blade and I am performing an envelope flap. An envelope flap is a flap, but essentially you are performing an incision at the level of the sulcus all around the tooth.
OK. So we're disengaging the soft tissues from all around the tooth. Another flap design I wanted to show you is the pedicle flap.
So here we are performing a flap where the incisions are again at the level of the sulcus, then we have two releasing incisions, OK? So again, we are working on the soft tissues. And while here we have a triangular flap, which is, the flap that I use more commonly.
It's probably my favourite type of flap. So instead of two raising incision, like we saw on the pedicle flap, we have one releasing incision. So, we start, always from the circus, and then we're gonna perform one releasing incision.
So we go right into the traction technique for an incisor. So the video, let's see if it's gonna work. So there you go.
Here we go with our envelope flap. So we're gonna cut all through the the tooth, and and then what we're gonna do, we're gonna use a laxator and we're gonna laxate the tooth and then we're gonna use our exaction forceps. And to remove the tooth from the alveolus.
OK, so in this video, we're gonna see the creation of a triangular flap in order to extract a maxillary for premolar. You can see in this picture that this tooth has a complicated crown fracture. Maybe it's not that obvious, but you can see the the surface of the crown.
So remember when we have a tooth, with palp exposure. We only have two options as treatment, either root canal treatment to preserve the tooth or extraction. There are no other alternatives when you have a tooth with part exposure.
There's no need of antibiotics. You might use anti-inflammatory, from the moment that you perform your diagnosis, until the moment that you're gonna perform your surgery, and there is no other wait and see, scenario. If the pup is exposed, the tooth needs to be treated, OK?
And so we're gonna perform, the section of this tooth VI triangular flap. We're gonna start our incision at the level of the, sulcus. So you see I, I keep, I hold the, the, the blade parallel to the tooth so that I try to go underneath.
the, the attached changeiva and off we go, creating a releasing incision. I want you to notice how I'm gonna go cut full thickness of the, soft tissues in this area. And I am going to release some of the pressure with my blade and the dorsal aspect of the third remolar.
And do you know which anatomical, which, which, anatomical structure is present in this area, dorsal to the third premolar. The neurovascular bundle of the infraorbital nerve. OK.
OK, so we have the infraorbital canal, infraorbital ramen, and then the infraorbital neurovascular bundle. So we need to be careful in that area not to damage the structure. After we created a flap, really, really important, we're gonna elevate that flap.
So we're gonna use our periosteal elevator. We're gonna start with the elevation of the attached geniva. Elevating the touch changeva is a tough job because the touch change bar is a structure that is not very elastic.
So it will require some time for you to, perform, the elevation of the flap. So do not rush, use your blade again if needed, and trying to go, Between the heart tissues, so the bone and the soft tissue and then trying to elevate the soft tissues in this manner, and you can think about using the periostellar elevator like a marmaid tail, so you go in between the heart tissues and the soft tissue and then you release it. Once you get to the mucosa, the mucosa is much more elastic, so you will have less resistance to elevate this part of the soft tissues.
And I am going to show you here something really important, something that it's essential to know when you perform extractions. So working on the periosteum. So the periosteum is the layer that is attached to the, to the jaw bone and is not elastic and it will always try to keep it.
Your flapping position, OK? So if you don't release it, so you don't cut the periosteum, the, you, you will, not have an elastic flap. And this is useful when you are raising a flap to expose the the elvear bone, but it's also essential when you're gonna close the flap to cover your surgical wound.
So, you can see how I'm using scissors to cut through the periosteum and you can also use a, a blade. The important things you remember the anatomy in the area, so we do not want to damage. The neurovascular bundle of the infraorbital canal and we do not want to damage the salivary ducts which are on the caudal aspect of the mouth and just dorsal to the first molar.
So here we go again, working on the periosteum, using our scissors, ensuring that we know where the anatomical structures are around our our flat, and we want less tension to expose the bone nicely so that we can perform our osteoectomy. So now we are using our round ber. So you see this white sticker, I use this white sticker to keep the soft tissues away so to protect my flap so that I don't injure my flap with my high speed.
And so what I do, I'm gonna brush the alveolar bone away from the surface of the roots. That's why it's really, really important for you to know the anatomy of the roots, to know exactly where, located or high speed to perform your osteoectomy. And so you can see in this video how very, very gently, keep the, keep the parallel to the long axis of the tooth and just very gently brushing away the alveolar bone.
The vular bone is only probably 0.5 of a millimetre. In thickness, so do not use the bare perpendicular to the tooth.
So 9 degrees towards the tooth, but just use with small superficial movement just to brush away and the bare bone from from the roots. So once you're happy with your osteoectomy, I, I'm often asked how much bone should I remove? Well, you know, it depends on the tooth.
It depends on your experience for me, if you're struggling to extract the tooth, it means that you need to remove more bones. Remember, we're always working on the periodontal tissues, OK. When we are extracting a tooth, we are working against the periodontal tissues that are keeping the root inside the alveolus, OK.
So the the, the periodontal tissues again are geniva, alveolar bone, and periodontal ligament. We also have the cement, but we do not really worry about it. So we worked on our soft tissues.
So we elevated our flaps. We worked on ouranga. Perfect.
We're working on our alveolar bone. We are performing our osteoectomy. Great.
And we're working on our periodontal ligaments. We're gonna use the loxit. To do that.
Now, once the flap is elevated, if you're still struggling exactly in tooth, you might want to revisit the osteoectomy. So you might need to perform more or you might need to use a better relaxation technique. OK, just always keep this in mind.
Now we're gonna section the tooth. So we have a cutting burr, and now we're gonna separate these three roots, OK. So remember the anatomy.
So off we go. And that's how we hold the bar, really important to separate the measurer bar. I keep an angle of 45 degrees so that I fully separate the measure roots.
One of the most common mistakes. They can see, people make is that they do not fully separate the media roots, meaning that then they struggle to extract the roots because they are still attached to each other. So really always ensure that the section of the roots is completed.
So it's, it is very clear in this picture how your sectioning needs to look like it, so it needs to be clear, clear section between the Vista root, the misobaca root, and the mesobaca rootta with the misoalleta root. OK, so now it's time to laxate a roots. So on we go on holding our laxator with our palm grip, inserting the blade of our laxators between the roots.
Then we're gonna go in, apply some pressure and then hold the instrument in place between 20 to 25 seconds, which is a long time. I appreciate that while we're doing the procedure, maybe more . Tempted to, perform small movements like screwing a screw on the wall or like something like short duration of movements, but really to laxate the ligaments, and you need to hold in position, traction on the ligaments so that you have a breakage of the soft tissues of the periodontal ligaments.
So, always keep in mind that once you're in with your laxator, if you manage to wiggle the laxator in a little bit more, the position of the laxator closest to the apex is gonna give you the best results. So the more further you can go with your laxator, the more effective your relaxation is gonna be. So always trying to gain some space and then move apt to the, to the root.
Once the relaxation is done, we can use our exaction forceps to remove the root from the alveolus. So we're gonna use the beak of the instruments to grasp the crown that we are working on and we can apply some rotation to get to again work on the ligaments that are still in place and trying to break all the ligaments that are still keeping the root in the alveolus. So really same here for the same here for the mesobaccal root.
So once you've done your your relaxation, you can get your extraction forceps and removing the root from the virus. So now we want to focus on the misoakal miso pale root. This is the most challenging route to extract probably of this tooth.
So I want you, next time that you extract this tooth to remove more bone from the mesopal root because no osteoectomy has been performed on these roots so far. OK. So we're gonna Go back to our rounder.
We're gonna remove some of the alveolar bone that is covering this root so that we can expose the, the root and then we're gonna use laxit again and RX action forces. So, once that relaxation is done, we can get exaction forceps. And as before, following the long axis of the tooth, so remember that the tooth is an inclination, so follow the long axis of the tooth.
Do not pull on, on an opposite direction of the long axis, otherwise you're gonna fracture the crown for sure. So try to remember the anatomy in the position of the meallearrota so that you follow the long axis of the tooth and you reduce the chances of fracturing this rota. So once the extraction of the three roots, is done, we're gonna use our, diamond bird to smooth, the surface, the surface of the, alveola.
So we're starting with the distal, alveolus, and then we move to the media, alveola. And this is They usually to reduce all the inflammation associated with the rough surface that are gonna be in contact with the flap. So we're gonna reduce any source of inflammation for a flap to increase the chances of healing without complications.
So off we go. Once we use our diamond where we're gonna just check with the finger, the, with the finger that everything is nice and smooth. And once we're happy with that, a very important step, we're gonna get back our periosteal elevator and we're gonna elevate the pale aspect of our .
Essentially of the, of the tooth that we extracted. So we're gonna work on the palatal the soft tissues on the palate, and that is just because we want to disengage the soft tissue from the alveolar bone because we're gonna smooth the bone again, again to increase the contact of the flap and increase of the chances of success for healing of our flap. So once we elevated the, the flap palately, we're gonna protect the soft tissues with the white stick.
The white stick, it's just a mixing a stick that you can buy from IM3 or you can use a coffee, a wooden stick, to stir the coffee. It's really cheap and a great idea to protect your soft tissues during this procedure. So we're gonna smooth the aspect of, of the alveolar bone as well.
And once we've done that, we need to work on our flapper, so you can see that there is some tension in this flap and we can't really close this flap at the moment because we still need to work on our periosteum. So, what we can do is using our forceps to do some plant dissection or just cut the periosteum and you will notice the periosteum is this white is translucent membrane and it is preventing your flap to be flexible. Now, the flap is staying nicely in place so we would be happy to, to close this up.
So I tend to start suturing this flap from the palatal side and always starting from the corner. So this is true for every triangular flap. So on we go, we get the pallet aspect and then the, the inside of our of our flap.
And this is our flap fully closed, so you can see the suture materials we use. It's the monoria 40, a simple interactive pattern, and 3 millimetres away from stitches and the cut of the suture materials 3 millimetres away from the knots, and those are, are the roots of our 4th primoor. So I just wanted to show you in the next few pictures, an extraction technique in a K9.
In this case, I use a pedicle flap, so you can see both releasing incision, one me and one distal and after obviously we perform the design of the flap, we're gonna elevator flap with our periosteal elevator exactly as we saw for the fourth primolar. You can see here how I'm using the scissors again for a plant dissection of the periosteum so that I can get my flap away and I can you know, free up the the vellar bones so I can start my osteoectomy. And I'm gonna get my round b.
Again, you can see how I hold the bur parallel to the long axis of the tooth and I'm gonna start brushing away the alveolar bone and I hold my flap away from my high speed so that my flap doesn't get injured during the procedure. Really, really important. And here is the osteoectomy performed.
So you see it's almost 2/3 of the alveolar bone on the surface of the, root that has been removed. And once we've done that, I also like to perform to sort of tunnels on the me in this aspect of the canine to make some space for my, laxator. You can see how I'm using the laxit on the medial aspect, so inserting the laxit between the root and the alveolar bone, applying pressure, and then you wait between 20 to 25 seconds to be be effective on the periodontal ligament.
So we're like working on, on the breakage of, of the ligament. And this is, this is me working on the distal aspect of the, of the tooth so that we are laxating the ligament all around the, all around the root. Once we're happy with our relaxation, we're gonna get our extraction forceps.
We're gonna grip as much as we can of the of the crown, and then with some, very gentle and rotational movement, we're gonna laxate all the main fibres and we're gonna extract the tooth. Again, as we show this index section of the 4th motor, we're gonna get out of diamond b and we're gonna smooth all the rough surface of the alveolar bone and make sure that everything is nice and smooth. Once that is done, again, also in this extraction, I'm gonna elevate the palatal aspect to perform the osteoectomy on the alveolar bone on the palatal aspect.
Then we're gonna suture the corners of the flap, and then in between and the and the releasing incisions. So remember, I haven't showed you the X-rays in this lecture, but obviously. Nerve blocks and the radiographic assessments are essential before extracting the tooth, flap design.
So, pick the flap that you think it's appropriate for the extraction you're doing, envelope flap, triangular flap, pedicle flaps, whatever is your choice. And remember, the flap needs to be free of tension, otherwise, it won't heal nicely. Do not rush the procedure.
If you fracture a rota, stop what you're doing, take an X-ray and make a plan, OK? I'm sure that you can enjoy extractions, I guess that this is actually fun. So I hope that the information I gave you were were helpful.
So, thank you very much for listening and please let me know if you have any questions and enjoy the TC. See you next one.
