Hello, I'm Doctor Nemec. I'm a board certified veterinary dentist in both the American and European veterinary dental colleges, as well as a fellow at the Academy of Veterinary Dentistry. Today we're gonna talk about extractions.
And if you know the lecture is called dental extractions made easy or not necessarily easy. They can be fairly straightforward, they can be pretty miserable. A lot of that really comes down to, that dreaded word of ankylosis, and I'll talk to you a little bit about that as we go.
So what you're gonna notice in this lecture, is that the techniques that I teach are counter to the majority of veterinary dentists out there. The kind of classic old school techniques for extractions, is to make a big flap and drill all all sorts of bone away, and then extract the teeth. And I will tell you, in our practise.
We do about 90% of our extractions closed. We do not make flaps for hardly anything, and that, yes, that includes carnasal teeth, that includes lower canines many times. And so when the benefits of minimally invasive surgery techniques are they typically are faster, again, except for when ankylosis enters your world, that's when, that's when you can waste a little bit of time trying to get it out because you can't elevate ankylosis.
But it decreases surgical time, which is good for you and your patient. If you haven't made a flap, there's really no way for it to dehiss. So we don't necessarily close them primarily.
The exception to that rule would be if you have a fistula, obviously you need to. So you're gonna look at this a little scans, but trust me, we do it all the time. If any of you guys have seen the the article on closed extractions of upper first molars, we've been doing it for years and there's gonna be some new ones coming out as well.
So, Without further ado, let's talk about minimally invasive surgical techniques. OK, so extractions are the most common problem in our surgical procedure and veterinary medicine. I mean by far, and people always say, well, no, spaying and neutering is, well, not necessarily.
Number one, hopefully you're only spaying or neutering a dog once, and there's 42 teeth in a dog and 30 in a cat. So you're gonna do extractions more commonly than you are going to do. Any other surgical procedure in veterinary medicine.
They can be quite complex. And one of the biggest challenges is that we just don't get trained in school. Oh, by the way, down here, this is my Instagram.
It's a QR code that'll take you to my Instagram. If you're watching this and you want to follow me for educational advice, it's certain, you can go ahead and click it on there with your smartphone and, and go right to my, my Instagram page. So, Like I said, unfortunately, the techniques that are taught in most vet schools, again, if you're taught at all, are outdated, so we typically utilise minimally invasive surgery, techniques whenever possible.
So if we want to talk about How do we succeed in extractions? Well, get some good equipment, right? You can't win an F1 race without, you know, having a nice car, proper techniques, and patience, patience, patience.
And yes, I know it's hard. None of you guys have patience, neither do I, but you absolutely need to do it, OK. So this is my textbook.
It's hard to get over in Europe if you guys are there. It's more expensive to ship the book than it is to actually purchase the book, but if you guys are watching this, and you want to pick it up, we will have a booth at the EBDF in France. All right, proper equipment, just really quick.
It improves efficiency. You, if you have nice sharp elevators, it's, it's going to significantly speed your extraction time, which is going to make money because you can do other things. It's gonna be less stress on you, so you're gonna have less pain, less chronic disease problems, you know, like, you know, carpal tunnels and all that kind of stuff.
So it's proper economics. You're gonna have way way way less morbidity for your patients because. Again, would you rather have surgery with a dull knife or a sharp knife?
So that's a welfare concern if using old outdated equipment. So it's just basically for you and your patient, having proper equipment is an ethically sound practise. This is serious, old school.
My old boss used to use it back in the 80s and he would pound on these teeth. And yes, he broke roots, and yes, he left, roots behind, and yes, he broke jaws. We don't do this anymore.
Dentistry is kinder, gentler. I tell people all the time, dentistry is zen. If you can't be zen, then you're not doing things correctly.
So there's two main types of elevators. OK. One is the standard elevator, and it's got a, it's cousin, the wingtip elevator.
So these are blunt at the tip. And they're only used to stretch and fatigue the periodontal ligaments, so they don't cut it. So when you go in, you're twisting, and the idea of the winged elevator is that you, you, it holds on to the tooth better, and then you can get a little bit better twist to it.
And I say they're relatively safe because they aren't really sharp at the tip, so they're not gonna slice through things quite as quite as often. This is what I use though. They're called luxating elevators or luxators.
They're sharp at the tip, I mean like knife sharp at the tip. They're used to cut as well as stretch the ligament, and it's supposed to be kind of used on a rock motion where you kind of push it in and rock it in, . And that way it's being way less way less aggressive and way less pressure on the Avias, so less chance of breaking the jaw anecdotally, and it, in my experience, I'm just telling you this is again anecdotal, it's faster.
It really is, especially for cat extractions. Usually they have a little curve over here which will kind of get it in there and kind of elevate it out. The one concern that we have with, well, there's two concerns we have with luxators.
Number one, people twist them too hard, and bend them. If you're bending, you're luxating elevators, you're twisting too hard. And then it, it is sharp, so it can go into bad places if you don't use it correctly.
OK. Extraction forceps, there's tonnes of types, sizes and manufacturers. Honestly, the human.
Equipment just does not work well for animals. It doesn't. They don't hold onto the teeth well.
They're too big. The large types create too much pressure, so you typically fracture the roots. So, you know, because again, when you're using, an elevator, you're kind of limited as to the amount of pressure you can put on the tooth because it's stuck between the tooth and the bone.
The problem is when you I start using an extraction forcep, you put a lever arm right on that that root right at the neck and it breaks. So we use small breed extraction forceps for all cases. If you can't get it out with a small breed of extraction forcep, you haven't done enough, OK.
So if you're gonna go into multi-rooted teeth, that's where we talk about sectioning. Sectioning, is where, and I know that there's a, a trend towards the, electric drills. I'll be honest, I don't really like them.
They have better torque than, than these do, but you don't get the air coolant as it comes through. I'm fine either way. I mean, whatever you guys have, it's, it's fine.
But you what you want to use. And this is again, this is Brook's preference is what I like to use. I like what's called a cross-cut taper fissure burr.
And the reason for this is you've got much more cutting area. Remember when you're using a burr, if you, if you've got a round burr or a pear shaped burr, you just got this little teeny tiny area of cutting area. When you have a a a cross-cut taper fissure, you have a lot more.
So a lot of times you could just section it through one time. These are the the the typical sizes. They do have 700s and some other ones that are similar.
For little teeny tiny dogs and cats, I like the 699. For most dogs might kind of go to, if you guys aren't American, you don't know what MacGyver is, but it's kind of like a, this is the jack of all trades, a Swiss Army knife. This is my Swiss Army knife, what it comes down to.
I can use it for most everything, and then 702 for large breeds, just because it's such a bigger tooth. If you're making flaps, again, we're not gonna talk in this lecture about making flaps. I'm sure that somebody else is gonna give a lecture on advanced extractions.
I'm happy to do it if you guys would like to hear. Again, I don't do it very often, but, I do, I do, I do do them on occasion, you have to, some kind of scalpel blade, it doesn't really matter. I'm not a big believer in 10s.
I like 1111 or 15 what I typically use. Something to create your flap with to lay your flap back after you've made your initial incision. There's tonnes of periosteal elevators.
I don't care which one you use. You can use your standard elevator if you want. I don't like to do that cause it tends to tear through the flap.
My favourite is what's called a moult 24. So it's 4 millimetres on one side, 2 millimetres on the other. It works really well.
And then LeGrange scissors again, every dentist has their own favourite type of scissors you guys use whatever. But this is a cur iris serrated on one side, smooth on the other. I really like it.
OK. And again, these are just the burrs that we're talking about for taking bone away. And again, yes, I know a lot of veterinary dentists use round burrs.
And there is an advantage to that cause you kind of use them from the side as opposed to that on the top and the head can get on the way in the way. But if I use the 702, I don't find that I have an issue with it. But the 2 to 4 round is gonna be fine.
And then I do like. I don't do veloplasty anymore. There's a whole long story, but I don't drill out the, granulation tissue.
But I will smooth out rough edges of bone. Closure, nothing, nothing magic. Just I like personally, 7 by 7.
There's no, there's no consensus on rattoos versus 7 by 7. It's just my favourite, which are ads and browns, some kind of absorbable suture. And here's the thing.
I know in Europe you really can't get gut, but that's what I use. I use gut. It works, it's gone in a week, it's gone in 2 weeks.
You know, I have a lot of clients complaining about, you know, how long monochro's there. It's fine. It's more, you know, it's more consistent as far as how long it's around.
So, it is nice in that way, but, please, in Brooks's opinion, there is zero indication for anything that lasts longer than than Brope or monocro PDS. I don't think. I guess any place in in closure of of of extractions.
And again, we just got, if you can get it, it's great. And this is a kit that I put together again, it would probably be a lot more expensive to ship it over to Europe. You got a lot of good manufacturers over there.
OK, quick break here. These are some of the exotics that I've worked on over the years. This is a mountain lion named Cascade.
And this is Doctor Robert Furman. This is back when he was my technician. He started with me at the general practise that I worked at when I first graduated from vet school, in 1998.
So for those of you guys that don't know and you haven't met him, he is a European diplomat. He went to school in Glasgow. He will be presenting in Nantes, finally getting him over there to, to get a certificate because of COVID and the war, etc.
Etc. But he's been with me well over half his life at this point. So Cascade was a cage tower, so she got root canals on her upper canines and crowns on her lower canines, and because she hadn't busted these yet, so we wanted to protect them.
For any of you guys that don't think that crowns work in animals, these lasted in her for 14 years. So, they, they do quite well. And this is her, she was hand raised by the by the technician.
So you could go in there and play with them. You can kind of see your crowns there, but this is me probably about 25 years ago. All right.
First step, obtain permission, preferably written, you know, I, I, I don't, I tell people all the time, I'm not sure what it's like over in Europe, but there's a lot of lawyers in California, and so the biggest complaint that I hear from veterinarians, or excuse me, from clients about their veterinarian, is that they pulled teeth without permission. I cannot stress this enough. If you don't have some kind of consent.
From the client, no matter how obvious it is. I mean, we all know about the fallout. So the fallouts is one thing.
But if you're gonna, especially if you're gonna charge the client for it, you need to have permission to do that. So the better pre-anesthesia exam you can do an estimate you can do, the better. Make sure you can contact the owner.
I'm telling you, you know, you can try, and I know, I'm sure that people in Europe are the same in America. They just don't answer their phone. So text them, you know, texting, I think is better.
You can, get, you know, maybe if you do a lot of dentistry in your practise, consider getting, you know, a practise phone because I know your nurses probably don't want, their text number going out to clients. And then if you give them a time window, and I tell people it's kind of like, when you have a a repairman coming over, that repairman comes over and like, well I'm, I'm gonna come over on Tuesday. Well, when?
Tuesday. Does that work for you? Do you wanna sit at home all day?
No. If you give your clients a window and say, well, your dog's gonna go first, so expect a call between 10 and 11 or between 12 and 2, it's a lot easier for the client. And you could put some guesstimates on there as far as the, you know, whether you're gonna need to do it.
Extractions or not, or how many extractions. But if you get it over your head and you can't get a hold of that client, yes, I know 98% of your clients will want you to have extracted that tooth, but the 2% are gonna ruin your life. So you have to figure out some way to do that.
OK. Dental radiographs, and this isn't A whole lecture on doing dental radiographs, but you gotta take dental X-rays. This is going to really speed your extractions, avoid complications.
There's just so much that you can't see, especially this, this, this guy up here, this ankylosis is just gonna kill you. So, Oh, I know this 3rd premolar needs to come out, you know, so I'm just gonna section into two pieces, we'll elevate it out, and we'll go from there. Well, then you section it, you hear that dreaded crack, and what do you got?
We got 123 roots. That's not proper, you know, you would have left a root behind or you would have struggled with it. This X-ray is really important for proper extractions.
Oh, Doctor nemic, that never happens. Yeah, it does. 10% of cats have 3 roots on their upper third premolar, so you've got to take these X-rays.
Resorption is a big one though. Everybody hates cat extractions. Well, not everybody, 99% of people hate cat extractions.
And the reason they do is because of ankylosis. Ankylosis is where the tooth and the bone becomes one. It doesn't necessarily mean there's resorption, and although it usually does, but it basically is the loss of the periodontal ligament.
And so the problem is once ankylosis enters your world, you can't elevate it. I mean, sometimes I'll, I'll take an X-ray and I won't look like I got a periodontal ligament, and I will be able to elevate it out, but it's pretty rare. So when we look at this X-ray, here's a TR here.
That's a classic tooth resorption. So we're going to section it. We're gonna try and work on it, and it shatters and shatters your drilling and cursing and shattering, and blah, blah, blah blah, right?
We've all been there. Well, there's nothing left. This is a crown amputation case.
There's no periodontal ligament. There's no root canal. There's no signs of any per hallucancies.
There's no periodontal disease. This you just do a happy dance, you cut it off, smooth it out, call it a day. So, I like to show on this X-ray though, these teeth are normal.
You don't have to take them out. But if you did, this is what ankylosis looks like. So this is that periodontal ligament right here, OK?
You can kind of see one there and there, but you don't see anything here on. This molar tooth, you don't see anything here. So if you had to take these teeth out, these are where I would look at them and go, yep, this is gonna be a surgical extraction.
I'm just gonna start with the flap and taking bone away. If it breaks, again, even if you're trying to do a closed, you have to go after them. OK?
But then again, this looks very similar here, right? Pretty classic looking, you know, TRs here. Here's the big wicked TR.
As soon as you touch this tooth, it's gonna shatter, right? I mean, there's nothing holding it together. But look at this.
You got normal periodontal ligaments, normal root canals, OK? Normal, Yeah, per lucies. You cannot crown amputate these teeth.
You've gotta have an X-ray if you're gonna do a crown amputation. And same thing here. I mean, you need to know about this.
I mean it's all being resorbed. This is a miserable case. If I were in your shoes, I would refer this as soon as I saw it.
OK. The last thing, peridontal disease. Yes, we, I could tell you that this tooth is with the probe all the way down to the bottom, needs to be extracted.
But if you don't know what this X-ray looks like, you're gonna break the jaw. I would have, to be honest, that is 0.3 millimetres of tooth down there.
If you look at this dog's wrong, jaws jaw wrong, it's gonna break. If you go in here with an elevator and you start cranking on it, you're gonna break the jaw, and you're have a really upset client. So this is where having this preoperative X-ray going oh, this is a problem, you know, mayday mayday, this is where you need to be on the phone with the client and telling them, hey, this, this tooth has to come out or the jaw is gonna break.
There's a decent chance I could break the jaw taking it out. I would recommend referral. If the client declines and you break the jaw, you just covered your rear end.
So that's where the communication comes in, but without this X-ray, if you break the jaw, sorry guys, and gals, you're in trouble. OK. Now why do we see this now?
Why do we worry about this now, with the lower first molars that we never had to worry about it in the past? Well, it's because we are dealing with small dogs. When I was in my residency 25, 30 years ago, basically all we did were big dogs, you know, Labradors, shepherds, Matlinaus did a lot of military working dogs, a lot of police dogs.
We did, I mean, I will tell you that 75% of my business 25 years ago was root canals and crowns. And nowadays is little dogs with the dance period. Why?
Because those are what pop what are popular now. When we shrunk these dogs, I'm sure most of you know this, but this is just a nice visual example. When we shrunk these animals down.
We shrunk their jaws more than we shrunk their teeth. And so small dogs have proportionally larger teeth than large breed dogs do. So on our right here, this is a Labrador retriever.
He's 40 kilogrammes, and he's got this huge 2 to 3 centimetres of bone down here. The low it's lower for smaller. You're not gonna break the jaw of a big dog taking the tooth out.
So what I tell people all the time is, you gotta take out the lower for small of a dog over 10 kg, say, they're not gonna break the jaw. If you got to take out this dog's tooth, anything under 5 kg, you've got a millimetre of bone there normally. So I don't even need an X-ray to tell me that this 4 kilogramme dog is gonna have a millimetre or two.
So if you've got to take out the loaf for small, even if it's normal, even if you don't have that period. On a loss on top of it. You still got to get worried about taking that tooth out.
And especially when they get under 2 kg. And yeah, I see one about once a week, and I see them all the time and you gotta be really careful with them. Again, if I was in your shoes and I had to take this tooth out, I would be referring the dog.
Yeah. So this is at the Santa Barbara Zoo. It's up the coast from Los Angeles, and this is a gorilla.
He is now passed. His name is Max. And so for those of you guys that are struggling with dental X-rays, this is taking dental X-rays with standard film, again, this is 20 years ago, standard film and a horse X-ray machine on a gorilla.
Trust me, you guys can do it. All right, really quick. This isn't a full pain management lecture.
I'm hoping that somewhere in this series, someone's talking about pain management, but really quick, why is it important? Because the animals just don't show their pain. They don't.
So you have to be a patient advocate, and not only from their pain management standpoint, but also because we know that pain decreases healing ability as well as infection fighting ability. So who gets drugs? Everybody gets drugs.
All dental procedures are somewhat painful, even if you're doing closed painting, I think they should get some kind of medication. So what should they get? Well, they should get a a combination of opiates.
If they can metabolically handle it, NSAIDs are great. And actually, in some studies, NSAIDs are better than opioids. The nice thing is they last for a full day, so you can give them an injection, even if they can't get meds into him that night, they have a full day.
I'm a huge believer in local analgesia. I'll talk to you really briefly about that, but again, I hope someone's doing something on nerve blocks. Microdoses of ketamine.
Determor and gabapentin. OK. We don't really use trazodone or tramadol very much anymore.
I just, we just don't think it works very well. So local anaesthesia, again, there should be a whole lecture on this. Complete local anaesthesia if that's done right.
That way you can really decrease your IO or CO to, to keep them safe under anaesthesia. It, it avoids wind up, so that, that kind of getting intense pain. Obviously, it's not a sole agent because they have to be asleep.
It can cause loss of sensation, you know, if you damage the nerves. So there are some veterinary dentists are against it. I think the risk benefit ratio is there.
You can block the eyeball. You can actually cats and small breed bra is valid, deviate dorsally into the eyeball. So we're really careful doing the infraorbital, and always aspirate to avoid invascular injection.
That's probably the biggest issue that you can have. OK? So this is again, back at the Santa Barbara Zoo.
As a sea lion named Sammy, and this is me working on him in his cage, my old, my old technician Don, our assistant Don, and he had squamous cell carcinoma on his tongue. So we did a whole glosectomy on him. If you ever want to see blood, cut the sublingual artery of a 500 pound sea lion.
It was pretty, pretty impressive. But he did well for a little bit, but he had some other issues as well. All right.
Getting into the actual extraction. Number one, cut the gingival attachment. Why?
Number one, it provides 15% of the retention. OK, so 15% of your job is done. But the big thing to me is that When you take a tooth out, if it's loose and you haven't cut the gingival attachment, sometimes it'll tear that gingival attachment.
So you always want to cut this first. You can use a blade or a luxator, but I like my periosteal elevator mostly. When you're doing this, you want to shove it all the way down to the bone.
The thing about it is, if you come in flat against the tooth, you, you're gonna slip off that ledge, and you usually make a hole in your flap. So in your tissue. So what I want to do it again, I'm not making a flap here.
I'm just cutting that attached gingiva, always angle 20 degrees towards the tooth. This will get under the thing called the dentinal bulge there, and then it will will catch on that little ledge of bone. OK, this is what it looks like.
Oh, sorry. To cut the gingival attachment. To do this, we take the elevator and angle it slightly, about 20 degrees towards the tooth.
That will avoid it slipping, then shove it all the way down into the periodontal ligament space. Take it out, move around the tooth, cutting all the way down to the bone. Again, you need to do this on the inside as well, 360 degrees around.
So that's a monkey. He's getting some teeth taken out as well. This is their non rebreather bag.
It's a balloon, and this is him saying thank you to my technician. Actually, that's Doctor Ferman back when he was my technician, working on him. OK.
Elevation, again, I am a big believer in small, sharp instruments. You, again, cutting rather than tearing, in my experience is much less invasive. So the first thing you need to realise is you've got to get your elevator into the periodontal ligament space, meaning between the tooth and the bone.
You've got to use an instrument that is smaller than the tooth you're working on. This instrument here is right on the edge of being too big, cause you really can't see tooth on either side. And remember it's curving, so you may not get it in.
This nice small elevator is going to fit between the tooth and the bone really, really, really, really well. And so from that standpoint, you don't have to put as much pressure down and it's gonna stay. In that periodontal ligament space.
So, when I am teaching extractions, it's always go small, go small, go small. OK. Then this is the longest and hardest part of doing elevation.
Place the instrument into the sulcus firmly, yet gently. You've got to be between the tooth and the bone. If you're between the tooth and the gum and you twist, you're gonna move the Gum, you're not gonna move the tooth.
So the problem is when you do that and you twist, if you don't move the tooth, so when you do this, you not to see that tooth moving. If the tooth doesn't move, you're not doing anything, OK? And you can sit there for a month and it's not.
Going to loosen it all. So you gotta make sure you get that instrument between the tooth and the, and the bone, and then twist gently. We say two finger pressure, you're not holding the instrument with two fingers, but it's all the pressure that you could put on it with two fingers.
And here's the critical point. Hold it for 10 seconds, and that's not one of you 10. No, it's 1 1000, 2, 1,003, 1,004, 1,005, 1,006, 1007, 1008, 1009, 10,010.
It's a long time. Some textbooks say 30 to 60 seconds. Why?
It does keep working, but I think they say 30 seconds, so they get 10, to be honest. But 10 seconds is the minimum. Why?
Because the, the peridontal ligament is very, very good at resisting short intense forces. So if you go like, you know, just twist twist twist twist. I see people doing all the time, you're just moving that tooth and it's not damaging the periodontal ligament.
And it's really good at, like, if you think of a dog chewing on a bone, I was just looking at some studies. The amount of bite force these dogs have. When they have this tremendous amount of bite force, then what they're doing is just biting slowly, right?
And then that periodontal ligament is a shock absorber. So if you clench your teeth for a while, you'll start feeling that pain. When you clench for too long, that's your periodontal ligament starting to get damaged by that pain.
So you've got to sit and you've got to hold it, and then it's gonna start, weaken. And then just move around the tooth slowly to loosen. I talked about this earlier.
You've got to be really careful when you're doing these extractions, because you can slip into bad places, especially if you're using a luxating elevator. And a lot of times you're using in, you're working in areas of diseased bone, that's gonna get easy. This can damage the eye, the nose, etc.
Especially, this is, I, I, I don't wanna keep you up at night, but here's the thing. When you are taking out the upper 4th premolar or the molars, upper molars of dogs, but especially small breed dogs, and especially small breed bracephalics, frenchies, Pekinese, Japanese chins, Shizu's losses, there's like no bone between the two roots and that eyeball, and you're just gonna slip right in there, so always be really careful when you're back there. So we recommend a finger near the tip there, and I can't stress this enough.
Patience, patience, patience, patience. And yes, I know, none of you have patience. I don't either, but you've got to use patience because once you break a root, then you gotta do a cursing dance, and then you gotta make a flap, and then you gotta drink throw bone away and then you have to make it into a surgical extraction.
It's always easier to extract an intact tooth than it is to remove tooth roots, plus it's better for your. Patient as well. Now, again, here's the big thing.
If you go in there and you're elevating, OK? You, you, you, you do it right, you cut the gingival attachment, and if necessary, we'll get to this in a minute, but you section it and you start working on this tooth and you're got your elevator, you know, you're getting between the tooth and the bone, or if you just can't get between the tooth and the bone, but you know you're between the tooth and the bone and you're twisting, and that sucker's just not moving. Then no matter what your X-ray is telling you, there's ankylosis and you switch over and you make a flap and you take bone away.
One of the big reasons I recommend people come take courses. With us is so that they can feel because when we do courses, some of the, the specimens have, you know, ankylosis, some of them don't. So feeling that it's like, oh, I see this tooth moving.
OK, it's gonna come out close versus, OK, this thing is not going at all. So. You're just not, if you've done it before where you've been able to elevate it and you get to the point where you just can't, then 98% ankylosis is there, then just, you know, abandon the, the chances of having a, a closed extraction, just go straight to a flat.
But I don't, honestly, I don't do it very often. So when you're elevating again, this 20 degree angle towards the tooth will help you avoid slipping off that and then just go in and elevate. The next step is elevation, to initiate elevation.
Insert the elevator between the tooth and the bone and push it again. Ideally, it should stay there. That's the sign that you're in the right spot.
And then give it a gentle twist. You should see the tooth move, not very much at the beginning, but it's going to move a little bit. Once you see that tooth move, hold it in position for a minimum of 10 seconds.
Yeah After you have held it for 10 seconds, take the elevator out. Find a different spot. Get the elevator between the tooth and the bone.
You continue this circumferentially around the tooth until it is loose. Another technique technique for elevation is called the wheel and axle. To do this, take a slightly larger elevator and hook it underneath the ledge and give a twist.
And you will see it move. This is a very good technique in premolars. Remember, you have to hold it for a minimum.
10 seconds. So that's a bobcat. He's getting some teeth extracted.
He's actually getting kitten teeth extracted. It was a privately owned bobcat. It's my old clinic that I used to work out of.
All right, then you're gonna extract the tooth. And again, using small re extraction forceps, grasp it gently. You shouldn't be cranking on this, and it should be really loose by this stage.
Again, you, I find that most veterinarians reach for their extraction forceps way too early. So you grab it low on the tooth to avoid that lever arm. And if it's not loose, if you're not getting, if it's not moving really well, then, then, then just stay with your elevator.
So, What you need to do is what I do with these premolars especially, is I grab it low on the tooth and I give a little twist. I just a gentle two fingerprint twist one direction, hold it for 10 seconds, go while I'm pulling out firmly, twist gently, and then go back the other direction for 10 seconds, then go back the first direction for 10 seconds. If it's not coming out, go back to your extraction force or your elevator and put away your extraction force set.
So, next, we're going to extract the tooth. We take the small extraction forceps, we'll grab the tooth low, and pull straight out. I don't mind a little twist, but it's a twist and a hole.
Oh yeah. Just like These teeth are big, and I think the problem is your clients just don't understand how big they are, so they'll complain about the cost just because they're like, just a little teeny tiny tooth, right? Well, this is your client's perception of the tooth.
This is your reality of the tooth. So the bottom line is you need to be doing something, to educate your clients and. Show it to them.
And, and, and if you get these guys out, these canines, you know, very rare to get the upper force out without sectioning them. When you have these teeth, show them to your clients. They'll, they'll get an appreciation.
I use it to convince them to do root canals. But in general practise, you can convince them to, to at least pay appropriately and take the pain management at home. I can't stress this enough.
Yes, I know that you know that you got it all. Trust me, I do. I'm wrong on a regular basis.
I'm telling you, I, I'm a board certified veterinary dentist. I'm really, really good at doing extractions. I've been wrong.
I'm usually wrong about twice a month on average. I mean, I do thousands of hundreds at least of extractions a month, and I'm wrong, not infrequently, especially in the small breed brachichocephalic for whatever reason. So you've got to take an X-ray because there's a lot of times that there's roots left behind.
We did a study. It's been a while and now more people are taking X-ray. But back, back about 15 years ago, my resident and I did a study on patients that had a, carnasal teeth extracted.
90% of carnesal teeth in dogs and cats in Southern California had retained roots. So please take X-rays. Unrelated problems, I've had like foxtails, which is a grass on being there that's caused the abscess and not actually the it, it is a legal document, and you're not all hot over there, but I'm sure that, you know, most of the groups would recommend that strongly because this is what we want to see, and that's what we see way, way, way, way, way too often.
And you can see the infection here. And again, was there any clinical signs? No, no.
The dogs just suffered. Then closure. OK, so, again, I have not made a flap.
I have not made an incision. It's gonna heal even if I don't put a stitch in. OK, they don't close ours usually.
So we don't have to close this. I tend to just because I want to hold the blood clot in, but this is about what my extraction sites are gonna look like. And yes, I know, most veterinary dentists say you have to close these.
I've been doing it for 30 years now. We have studies that show that you don't have to, OK? If you do it like this, it's gonna heal.
I mean, even if that if that dog went home and in 5 minutes busted that suture down, it would still granulate in. It absolutely would. It wouldn't if he had a fistula, but it would if you don't have a fistula, .
So I don't close those upper first molars, you know, I don't do anything like that. You just basically, the only reason I'm putting a suture in here is to hold the blood clot in. That's all I'm gonna do.
So let me go back to this, OK? If you noticed one thing I did not do, and this is another big difference in what I do and a lot of veterinary dentists do. If you noticed there was no step in there about debriding the aviolas, you know, debriding out that necrotic, not necrotic, but granulation tissue, flushing, all that stuff.
Because I don't do it, because there's no reason to. Now, I know a lot of people teach it, and then the reason is because it's, you know, kind of what we've always done. Everyone assumes that that's infected tissue that needs to come out.
It couldn't be further from the truth. So there are the tissue that's there. I granulation tissue, mostly, whether it's an abscess or paraonal disease.
Essentially, that tissue is inflammatory granulation tissue. So I stopped doing it honestly because when I would debride these granulation beds, it would just bleed and it would make it harder to close. And then after writing the second edition of the extractions book, and oh by the way, all these references are in that book if you want to see it.
But in China, especially they're doing a lot of studies like this. But basically what I would, what, what I found is that what they do and the reason that they don't do it on the human side, is because if you have that granulation bedded, that's all the tissue that is ready to heal. If you guys don't know this, the first tissue that Populates any wound, whether it's primary intention closure or secondary.
If you make an incision like you do a stay or and and and you close it primarily, the first tissue that goes into that incision site is granulation tissue. And then it heals. So the problem is that when you debride the granulation tissue, you delay the healing, cause now the body's gotta make that granulation tissue and then heal.
So it actually slows it down. Number 2 is that it's because you're, you're debriding this tissue and you're exposing the bone, it's much more painful. And there's studies out of China, like I said on the human side that shows that you get less bone.
And you get more trismus, so you can't open the jaw as much. There's all these negatives to debriding that granulation tissue and closing it primarily. So, I don't.
And there's no reason to anymore. Everyone's like, oh, well, it's in fact, you know, what about closure? And I'm like, you know, cause you get that inflammatory tissue that, especially in cats.
Take a bigger bite. Don't just try, don't try and suture through the inflamed area. Go a little deeper into the buckle mucosa and Clothes are from there.
It's just kind of like they teach in vet school. At least I was taught in vet school, take big bites of the linea. And that way you have more tissue there.
So if you're tearing through your gingiva, take a bigger bite. Take a deeper bite into the buckle mucosa, where it's healthy and it's gonna heal up really well. So yeah, like I said, I know it's radical.
I, I am, I'm from California. I could be radical if I want. But I've been doing it like this for a long time and now there's studies that actually support it.
Both some of ours that we've, Published in in the Journal of Veterinary Dentistry and more to come, I promise, but also from from China and other places on the human side. So that's a a tiger, that's actually the tiger that was in the movie Gladiator, if you guys ever saw that, that's the one that attacked Russell Crowe's character, and he's getting some root canals done. All right.
So that's a simple single rooted extraction. What I tell people all the time is if you can do a simple single-rooted extraction, you can take out any tooth in the mouth of a dog or a cat, with the exception of the lower canines. Those are pretty miserable.
But again, I do a lot of them, simple single rooted extractions. I mean, depends on if there's ankylosis or not. But if you're gonna go into multi-rooted extractions, then you're gonna have to do something.
More, you're gonna have to section them unless you can pluck them out. Why? Because their roots are divergent like this.
OK? Because they're divergent like this, there, you can snap these little pieces off because they come out and they kind of lock it in. So if you can pluck them out with your fingers, that's one thing.
If you can't, you're gonna have to section them. Again, I'm going back to my, my Swiss Army knife, my, my 701. Taper fish or bi, and you want to section it, OK, so here we go.
When it comes to extracting a multi tube, the first thing we're going to do is to section it. To section it, we want to find the furcation if we can. So again, take your periosteal elevator or an elevator and carefully tease back the tissue.
Vocational area. Now you can we can see this divot right here. That's the percation, which is where we're gonna section.
So when you're going to start, start at the furcation and cut away. Why? Number one, you found the furcation, you know where it where it's at, and oh by the way, if you have recession.
Like if you have, you know, gum recession where you can see the furcation, obviously you don't need to do this step. And no, I did not make a flap. I did not make any incision in the inner gingiva.
I just lay the lay this tissue back. So then what you're gonna do is you're gonna start at the furcation, get your your instrument going full speed and cut straight up like that. So, number one, it keeps it avoid, helps you avoid missing the furcation, cutting down onto the tooth, and then also helps you avoid cutting the cutting the gum.
So now we're going to section the tooth. You always want to start at the furcation and cut away. So what I will do is go through.
The location Circle and And now we have 2 simple single fruited. And then what you're gonna do is you're gonna go right back to what you're doing before, except this is how I start elevation of a multi-rooted tooth. The first thing I'll do is I'll take an elevator horizontally, OK?
So I, I like 90 degrees to the long axis of the tooth, and I'll put it between the two section pieces and give a little twist, really gentle. Why? That's two things.
Number one, if it doesn't move, if these if these two tooth pieces don't move opposite each other. Then you probably either one of two things is going on. Either you haven't fully sectioned it or it's ankle closed, one of the two.
That those are your only options, either they're ankle close or you haven't fully sectioned it. So if when you put this elevator between here and here, they don't, if they don't move, then you're, you're, you're not doing anything at all, OK? So if you do that and you, you twist and it's not moving, go back and and usually what I'll recommend is you take an X-ray to make sure there's not a ledge of bone right right on the top of this or ledge of tooth right at this bone line here.
And if there is section it some more, but if it's not working, then 99% is ankle close so you gotta make a flap. But I'll work here between these two root pieces for a good few minutes, just twisting gently and just moving them, creating purchase around the rest of the the tooth as well. After you've sectioned, the first thing we want to do is take a small elevator and put it between the tooth pieces and twist.
You should see them move easily away from each other. If they don't, something's wrong. So then twist, get them to move a little bit and count to 10.
Make sure that you're holding it in this position for a minimum of 10 seconds. And then, after I've done that, I will go the other direction. And count again.
And what you can see is this is moving the tooth more and more, developing more and more perches around the tooth. Sometimes I will even do this, which is pushing one side out and the other one in. And again, making sure to hold for a minimum of 10 seconds, and then going in the other direction, and you're seeing these two root pieces move further and further apart from each other, which is getting us more and more.
And then just go back and start doing your standard elevation, just like everything else that we've been doing, and then. And then, once you've gotten the piece nice and loose, just like with everything else, we take our extraction force out, we grab it low on the tooth. If you feel the bone and it's rough, then you would like to smooth it out.
We recommend using a coarse diamond burr on a high-speed hand piece. All you're doing. Feel the bone and it's rough, then you would like to smooth it out.
We recommend using a coarse diamond burr on a high-speed handpiece. All you're doing. So then to close, what I do is just tease back the gums to make sure they're nice and loose for suturing.
Note, they will not close edge to edge. So then And then for closure, just like with the simple thing, go ed tooth, we're just going to elevate this out. Stitch here.
St Yeah And that's what it should look like after everything is all said and done, and again, they didn't necessarily close edge to edge, I mean they are, but there's a little bit of tension. Again, it's gonna heal beautifully. So that is a lion.
He's getting some, he's also getting some root canals down. This is the friend of that tiger that I showed you a little bit before, and he's, he's also an actor, Kitty, although I'm, I'm pretty sure he's passed away by now. And that's him going out at the end of the day with my, my old technician again.
So that's my presentation. Again, that's my QR code if you want to, want to follow me on Instagram. I've got a lot of Fun stuff that we do, but obviously, you know, the best way to learn extractions is hands on.
I mean, there's just no I can lecture on and on and on, but until you, my hands on your hand or somebody's hands on your hand, you're feeling how much pressure you're putting on the teeth, you're feeling, you know, what ankylosis feels like, etc. Etc. Etc.
There's just no better way to learn than taking a lab. So I know they'll be teaching one, you know, in Nantes in, in May, you know, and then obviously, here's our, our training centre. I think it's, I think this is gonna be after .
The March 1. But if you guys are in the States, or if you want to come to the States, you know, and learn some great, I mean, there's, there's training centres all over Europe as well. So I cannot stress enough the value of going and having hands-on training, whether it's, you know, you know, locally or, or taking a trip to have it done.
So I'm going to sign off from Sunny California and, hope you guys have a great evening.