Closed and open tooth extraction

Alexander M. Reiter

doi:10.22233/9781905319602.12

British Small Animal Veterinary Association , 304 (2018); https://doi.org/10.22233/9781905319602.12

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Closed and open tooth extraction

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Author: Alexander M. Reiter
From: BSAVA Manual of Canine and Feline Dentistry and Oral Surgery
Item: Chapter 12, pp 304 - 337
DOI: 10.22233/9781905319602.12
Copyright: © 2018 British Small Animal Veterinary Association
Publication Date: September 2018

Abstract

Extraction of teeth (exodontics) is one of the most frequently performed procedures in small animal practice. Utilizing good instrumentation and applying proper techniques can help to provide a stress-free and controlled procedure. Operative Techniques: Maxillary canine tooth extraction in the dog; Mandibular canine tooth extraction in the dog; Maxillary fourth premolar tooth extraction in the dog; Mandibular first molar tooth extraction in the dog; Extraction of the maxillary canine and cheek teeth in the cat; Extraction of the mandibular canine and cheek teeth in the cat; Crown amputation and intentional retention of resorbing root tissue in the cat.

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Figures

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12.1

(a) Labial and buccal alveolar bone has been removed in this dog skull to visualize the roots of the left maxillary and mandibular teeth. Transparent plastic models are also available to review root anatomy, as shown here for (b) the maxillary and (c) the mandibular teeth in the cat. © 2018 British Small Animal Veterinary Association

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12.1 (a) Labial and buccal alveolar bone has been removed in this dog skull to visualize the roots of the left maxillary and mandibular teeth. Transparent plastic models are also available to review root anatomy, as shown here for (b) the maxillary and (c) the mandibular teeth in the cat.

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12.2

(a) Right mandibular first molar tooth in a dog. (b) Note the bony extensions (arrowed) within the empty alveoli. (c) These bony extensions correspond to indentations (arrowed) along the distal surface of the mesial root and to some extent the mesial surface of the distal root. © 2018 British Small Animal Veterinary Association

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12.2 (a) Right mandibular first molar tooth in a dog. (b) Note the bony extensions (arrowed) within the empty alveoli. (c) These bony extensions correspond to indentations (arrowed) along the distal surface of the mesial root and to some extent the mesial surface of the distal root.

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12.3

There are three basic types of lever: (a) first-class, (b) wedge and (c) wheel and axle. The arrows indicate the direction of force applied against the tooth as well as the direction the tooth is moved in. © 2018 British Small Animal Veterinary Association

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12.3 There are three basic types of lever: (a) first-class, (b) wedge and (c) wheel and axle. The arrows indicate the direction of force applied against the tooth as well as the direction the tooth is moved in.

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12.4

An assortment of friction-grip (FG) burs for use in a water-cooled high-speed dental handpiece: round carbide burs (left), cross-cut fissure burs (middle) and round medium-coarse diamond burs (right). L = long (i.e. the working end is longer than normal); S = surgical (i.e. the shank is longer than normal). (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.4 An assortment of friction-grip (FG) burs for use in a water-cooled high-speed dental handpiece: round carbide burs (left), cross-cut fissure burs (middle) and round medium-coarse diamond burs (right). L = long (i.e. the working end is longer than normal); S = surgical (i.e. the shank is longer than normal). (© Dr Alexander M. Reiter)

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12.6

Tooth extraction kit for the cat (larger versions of the instruments may be used in the dog). 1 = root tip elevators; 2 = winged luxating elevators; 3 = extraction forceps; 4 = root tip forceps; 5 = needle holder; 6 = suture scissors; 7 = curved Metzenbaum scissors; 8 = Adson 1 × 2 thumb forceps; 9 = scalpel handle; 10 = surgical curette; 11 = periosteal elevators. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.6 Tooth extraction kit for the cat (larger versions of the instruments may be used in the dog). 1 = root tip elevators; 2 = winged luxating elevators; 3 = extraction forceps; 4 = root tip forceps; 5 = needle holder; 6 = suture scissors; 7 = curved Metzenbaum scissors; 8 = Adson 1 × 2 thumb forceps; 9 = scalpel handle; 10 = surgical curette; 11 = periosteal elevators. (© Dr Alexander M. Reiter)

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12.7

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12.7 Close-up of the tips of a pair of Adson 1 × 2 thumb forceps. (© Dr Alexander M. Reiter)

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12.8

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12.8 (a) Fine dental luxators. (b) Close-up of the working tips. (© Dr Alexander M. Reiter)

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12.9

(a) Winged dental elevators (from left to right: sizes 1–4) whose curved blades should fit the circumference of a tooth. (b) Close-up of the working tips. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.9 (a) Winged dental elevators (from left to right: sizes 1–4) whose curved blades should fit the circumference of a tooth. (b) Close-up of the working tips. (© Dr Alexander M. Reiter)

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12.10

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12.10 Vertical rotation with (a) the elevator being inserted parallel to and in between two crown-root segments and then (b) rotated along its long axis.

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12.11

Horizontal rotation with (a) the elevator being inserted perpendicular to and in between two crown-root segments and then (b) rotated along its long axis. © 2018 British Small Animal Veterinary Association

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12.11 Horizontal rotation with (a) the elevator being inserted perpendicular to and in between two crown-root segments and then (b) rotated along its long axis.

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12.12

Extraction forceps with beaks that do not fully close but still fit the circumference of the teeth, crown-root segments or roots to be extracted. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.12 Extraction forceps with beaks that do not fully close but still fit the circumference of the teeth, crown-root segments or roots to be extracted. (© Dr Alexander M. Reiter)

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12.13

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12.13 (a) Small root tip elevators (‘teasers’) for removal of root remnants. (b) Close-up of the working tips. (© Dr Alexander M. Reiter)

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12.14

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12.14 Root tip forceps without (left) and with (right) ratchet mechanism for removal of root remnants. (© Dr Alexander M. Reiter)

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12.15

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12.15 1 metric (5/0 USP) synthetic, absorbable monofilament material with a swaged-on, taper-point, round, non-cutting needle. (© Dr Alexander M. Reiter)

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12.17

(a) Closed extraction of the right maxillary first incisor tooth (*) in a dog. (b) The gingival attachment is incised. (c) The tooth is elevated, (d) grasped with extraction forceps and (e) removed. (f) The wound is sutured closed. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.17 (a) Closed extraction of the right maxillary first incisor tooth (*) in a dog. (b) The gingival attachment is incised. (c) The tooth is elevated, (d) grasped with extraction forceps and (e) removed. (f) The wound is sutured closed. (© Dr Alexander M. Reiter)

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12.18

Closed extraction of the left maxillary third and fourth premolar and first molar teeth in a dog. (a) The gingival attachment is incised at 360 degrees around the teeth. The furcations between the roots are identified with a periodontal probe. Location of the fourth premolar tooth’s furcations between the (b) mesiobuccal and distal roots and (c) mesiobuccal and mesiopalatal roots. (d) Sectioning between the fourth premolar tooth’s mesiobuccal and distal crown-root segments is shown. (e) An occlusal view reveals completed sectioning of the three teeth. (f) A dental elevator is placed into the space created after sectioning the mesiobuccal from the mesiopalatal crown-root segments of the fourth premolar tooth and (g) is rotated along its long axis to stretch the periodontal ligament fibres. (h) The extraction sites are sutured closed, following the elevation of all crown-root segments, wound debridement and creation of a buccal envelope flap. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.18 Closed extraction of the left maxillary third and fourth premolar and first molar teeth in a dog. (a) The gingival attachment is incised at 360 degrees around the teeth. The furcations between the roots are identified with a periodontal probe. Location of the fourth premolar tooth’s furcations between the (b) mesiobuccal and distal roots and (c) mesiobuccal and mesiopalatal roots. (d) Sectioning between the fourth premolar tooth’s mesiobuccal and distal crown-root segments is shown. (e) An occlusal view reveals completed sectioning of the three teeth. (f) A dental elevator is placed into the space created after sectioning the mesiobuccal from the mesiopalatal crown-root segments of the fourth premolar tooth and (g) is rotated along its long axis to stretch the periodontal ligament fibres. (h) The extraction sites are sutured closed, following the elevation of all crown-root segments, wound debridement and creation of a buccal envelope flap. (© Dr Alexander M. Reiter)

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12.19

Open extraction of the right maxillary fourth premolar tooth in a dog. (a) There is usually not enough space for a dental elevator to be inserted between the maxillary fourth premolar and first molar teeth in the dog. (b, c) A cross-cut fissure bur is used to remove the dental bulge at the distal surface of the crown of the fourth premolar tooth. (d) This facilitates placement of the elevator during elevation of its distal crown-root segment. © 2018 British Small Animal Veterinary Association

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12.19 Open extraction of the right maxillary fourth premolar tooth in a dog. (a) There is usually not enough space for a dental elevator to be inserted between the maxillary fourth premolar and first molar teeth in the dog. (b, c) A cross-cut fissure bur is used to remove the dental bulge at the distal surface of the crown of the fourth premolar tooth. (d) This facilitates placement of the elevator during elevation of its distal crown-root segment.

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12.20

Open extraction of the right maxillary fourth premolar tooth in a dog. (a) A dental elevator is placed perpendicular to the long axis of the tooth between the mesiobuccal crown-root segment of the fourth premolar tooth and the distal aspect of the crown of the third premolar tooth. (b) A notch has been created with a bur at the neck of the mesiobuccal crown-root segment of the fourth premolar tooth. (c) This notch allows for additional elevator purchase. © 2018 British Small Animal Veterinary Association

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12.20 Open extraction of the right maxillary fourth premolar tooth in a dog. (a) A dental elevator is placed perpendicular to the long axis of the tooth between the mesiobuccal crown-root segment of the fourth premolar tooth and the distal aspect of the crown of the third premolar tooth. (b) A notch has been created with a bur at the neck of the mesiobuccal crown-root segment of the fourth premolar tooth. (c) This notch allows for additional elevator purchase.

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12.21

Open extraction of a deciduous right maxillary canine tooth in a dog. (a) Diverging releasing incisions are made. (b) A mucoperiosteal flap is raised. (c) Alveolectomy is performed. (d) The tooth is elevated and (e) extracted. (f) The wound is sutured closed. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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12.21 Open extraction of a deciduous right maxillary canine tooth in a dog. (a) Diverging releasing incisions are made. (b) A mucoperiosteal flap is raised. (c) Alveolectomy is performed. (d) The tooth is elevated and (e) extracted. (f) The wound is sutured closed. (© Dr Alexander M. Reiter)

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12.22

Open extraction of the left maxillary first molar tooth in a dog. (a, b) An incision is made from the buccal tissues dorsally, curving mesially in alveolar mucosa and gingiva, to the mesiobuccal line angle of the tooth (arrowed), creating a caudally pedunculated flap. (c, d) The flap is elevated, undermined, rotated and then sutured in place to completely close the extraction site without tension. (© Dr Margherita Gracis) © 2018 British Small Animal Veterinary Association

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12.22 Open extraction of the left maxillary first molar tooth in a dog. (a, b) An incision is made from the buccal tissues dorsally, curving mesially in alveolar mucosa and gingiva, to the mesiobuccal line angle of the tooth (arrowed), creating a caudally pedunculated flap. (c, d) The flap is elevated, undermined, rotated and then sutured in place to completely close the extraction site without tension. (© Dr Margherita Gracis)

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12.23

Vertical fracture of the mesial crown-root segment of the right mandibular first molar tooth in a 2-year-old Shi-Tzu dog following healing of a mandibular fracture at the same site. (a) Intraoral occlusal view and (b) lateral intraoral radiograph revealing the fractured piece of the tooth (arrowheads). (c) Root fragments (arrowed) remained deep in the alveoli following tooth extraction. (d, e) The fragment of the distal root was retrieved after further removal of alveolar bone, but visualization and extraction of the fragment of the mesial root (arrowed) was not possible due to significant haemorrhage from the inferior alveolar vessels. (f) Following haemostasis, the extraction site was sutured closed. (© Dr Margherita Gracis) © 2018 British Small Animal Veterinary Association

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12.23 Vertical fracture of the mesial crown-root segment of the right mandibular first molar tooth in a 2-year-old Shi-Tzu dog following healing of a mandibular fracture at the same site. (a) Intraoral occlusal view and (b) lateral intraoral radiograph revealing the fractured piece of the tooth (arrowheads). (c) Root fragments (arrowed) remained deep in the alveoli following tooth extraction. (d, e) The fragment of the distal root was retrieved after further removal of alveolar bone, but visualization and extraction of the fragment of the mesial root (arrowed) was not possible due to significant haemorrhage from the inferior alveolar vessels. (f) Following haemostasis, the extraction site was sutured closed. (© Dr Margherita Gracis)

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12.24

The same dog as in Figure 12.23 returned 2 months postoperatively. (a) Intraoral occlusal view showing healing of the extraction site. (b) Lateral and (c) occlusal intraoral radiographs, revealing the location of the fragment of the mesial root (arrowed) to be on the ventrobuccal aspect of the mandibular canal. (d) A full-thickness cutaneous incision was made over the ventral border of the mandible, and a small ostectomy was performed. (e) A radiograph was obtained with a radiopaque indicator in place to confirm the location of the fragment (arrowed). (f) Additional bone was removed to reach the root fragment, which was gently elevated. (g) A radiograph was obtained to confirm proper extraction. (h) The extraction site was sutured closed. (© Dr Margherita Gracis) © 2018 British Small Animal Veterinary Association

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12.24 The same dog as in Figure 12.23 returned 2 months postoperatively. (a) Intraoral occlusal view showing healing of the extraction site. (b) Lateral and (c) occlusal intraoral radiographs, revealing the location of the fragment of the mesial root (arrowed) to be on the ventrobuccal aspect of the mandibular canal. (d) A full-thickness cutaneous incision was made over the ventral border of the mandible, and a small ostectomy was performed. (e) A radiograph was obtained with a radiopaque indicator in place to confirm the location of the fragment (arrowed). (f) Additional bone was removed to reach the root fragment, which was gently elevated. (g) A radiograph was obtained to confirm proper extraction. (h) The extraction site was sutured closed. (© Dr Margherita Gracis)

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The arrow indicates the neurovascular bundle emerging at the infraorbital foramen. (© Dr Alexander M. Reiter) The arrow indicates the neurovascular bundle emerging at the infraorbital foramen. (© Dr Alexander M. Reiter)

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Fully extract any fractured roots by extending the labial/buccal alveolectomy using small elevators/luxators, as shown for the fractured mesial root of the left maxillary third premolar tooth. (© Dr Alexander M. Reiter)

Fully extract any fractured roots by extending the labial/buccal alveolectomy using small elevators/luxators, as shown for the fractured mesial root of the left maxillary third premolar tooth. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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$Image of Fully extract any fractured roots by extending the labial/buccal alveolectomy using small elevators/luxators, as shown for the fractured mesial root of the left maxillary third premolar tooth. (© Dr Alexander M. Reiter)$

Fully extract any fractured roots by extending the labial/buccal alveolectomy using small elevators/luxators, as shown for the fractured mesial root of the left maxillary third premolar tooth. (© Dr Alexander M. Reiter) Fully extract any fractured roots by extending the labial/buccal alveolectomy using small elevators/luxators, as shown for the fractured mesial root of the left maxillary third premolar tooth. (© Dr Alexander M. Reiter)

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Reduce the septal bone overlying the mesiopalatal root (following extraction of the mesiobuccal crown-root segment) to facilitate its removal. (© Dr Alexander M. Reiter)

Reduce the septal bone overlying the mesiopalatal root (following extraction of the mesiobuccal crown-root segment) to facilitate its removal. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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Reduce the septal bone overlying the mesiopalatal root (following extraction of the mesiobuccal crown-root segment) to facilitate its removal. (© Dr Alexander M. Reiter) Reduce the septal bone overlying the mesiopalatal root (following extraction of the mesiobuccal crown-root segment) to facilitate its removal. (© Dr Alexander M. Reiter)

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The arrow indicates the neurovascular bundle emerging from the middle mental foramen. (© Dr Alexander M. Reiter) The arrow indicates the neurovascular bundle emerging from the middle mental foramen. (© Dr Alexander M. Reiter)

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The asterisk (*) denotes the affected root of the left maxillary canine tooth. (© Dr Alexander M. Reiter) The asterisk (*) denotes the affected root of the left maxillary canine tooth. (© Dr Alexander M. Reiter)

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The double-headed arrows indicate the most coronal aspect of the cut root in relation to the alveolar margin. (© Dr Alexander M. Reiter)

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The double-headed arrows indicate the most coronal aspect of the cut root in relation to the alveolar margin. (© Dr Alexander M. Reiter) The double-headed arrows indicate the most coronal aspect of the cut root in relation to the alveolar margin. (© Dr Alexander M. Reiter)