Live from CVC San Diego: How to perform basic oral surgery: Keys to successful extraction

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In this session at CVC San Diego, Dr. Christopher Snyder says practitioners must thoroughly identify dental disease and bony pathology, offer appropriate treatment options, and perform extractions safely. Take your time, plan for the anticipated extractions and flap creation, properly anticipate potential complications, and correctly estimate the required time and charge appropriately. Not all extractions are identical, and your fees must not be set to undercharge clients or necessitate a hurried procedure.

Dr. Snyder stresses the importance of dental radiography to help you

• Anticipate the severity of complications that may occur with dental extraction (e.g. tooth ankylosis)
• Identify underlying pathology that may indicate further investigation (e.g. biopsy)
• Determine whether supernumerary or oddly shaped roots (root dilaceration) are present, which may hamper extraction.

A few tips for performing surgical extractions

Remember that most states define surgery as an act in which epithelium is incised. Enamel is of epithelial origin, so simply sectioning a tooth likely constitutes surgery. Typically, surgical extraction involves gingival and mucosal releasing incisions and flap creation. Principles of flap creation include:

• Making divergent vertical releasing incisions-A wide-based flap provides better vascular supply and flap flexibility as the tissue is advanced. Tension-free closure is paramount since tension is the primary reason for incision dehiscence.

• Making incision lines over line angles-Make the lines where the "faces" or surfaces of the tooth come together and where food would naturally be deflected away from the incision line.

• Making and closing incisions over areas supported by bone—Don't make mucogingival incisions over the buccal bone overlying the tooth roots. Make your incisions wider than necessary to ensure that suture lines are supported and avoid tension.

• Making vertical releasing incisions with a scalpel blade and extending them past the mucogingival line—You'll obtain flap stretch from the high elastin content in the mucosa. Use a periosteal elevator to elevate the flap, and remember that attached gingival fibers are oriented to resist forces in a coronal-to-apical direction. Thus, elevating the flap in an apical-to-coronal direction may simplify flap elevation.

• Sectioning teeth after removing buccal cortical bone and visualizing the furcation—Seeing the furcation and sectioning the tooth from the furcation toward the oral cavity prevents inadvertent cutting into root structure.

• Remembering, as you're removing buccal cortical bone or inspecting for remaining tooth roots, that cementum and dentin don't bleed, but that bone bleeds—And you'll have much difficulty isolating fractured roots or inspecting the alveolus for debris if  you can't see well. Use suction, a good light source, and magnification to see bleeding structures while you identify and elevate structures that don't bleed.

• Keeping in mind that amputating a crown is rarely necessary in dogs—Consider it only if there is no evidence of periapical pathology, if an extensive amount of root is not resorbed, and if the periodontal ligament cannot be seen. If extractions need to be cut short because of anesthetic complications, or if surgically exploring for a fractured root tip will cause more harm than good, close the extraction site and move on. Inform the client and radiographically evaluate the patient in six and 12 months to monitor the residual fragment. Leaving root fragments or performing crown amputation should be extremely rare in dogs.

• Using a very small cutting bur may help outline and create a trough in the periodontal ligament space, after you've removed the buccal cortical bone and sectioned the tooth—This allows easier placement of dental elevators and may be especially necessary in patients with evidence of ankylosis.

• Creating space, if needed, for the instruments to generate leverage during extraction—Dental crowding or the proximity of adjacent teeth may make placing luxators or elevators difficult. Selective removal of parts of the crown of the tooth being extracted may help. These kerfs may help save time when the distal roots of the maxillary fourth premolar are closely associated with the first molar or when the mandibular fourth premolar is in close association with the first molar.