Last month, we began a discussion of feline extraction techniques that will hopefully help you in your practice. Here are some additional tips and tricks to make the feline extraction process smoother.
When you embark on multiple extractions in the cat, start off with the mindset that some teeth are not going to be delivered intact, meaning you will need to retrieve some broken roots. For some of us, the stress level rises as soon as we hear that subtle snap indicating a broken root. The good news is, the more you put yourself in that position, the easier it is to deal with. Go into a procedure realizing the only given is that you will face adversity, but have the knowledge, surgical skills, and tools to meet the challenge. If that’s not currently the case, seek out every chance to improve, including continuing education opportunities allowing for practice on cadavers. This is the best way to learn without potential harm to your patients. If you lack surgical tools, make an investment that is sure to pay off, not only financially, but more importantly, in the satisfaction of a job well done.
Knowledge of flaps
See my September 2020 Veterinary Practice News article (bit.ly/2HYdnB2) on surgical flaps to refresh your memory regarding flap options, including envelope, triangle, and pedicle flaps. Triangle and pedicle flaps are an absolute necessity in cats due to their thin roots, which are often ankylosed to the surrounding bone. Use a 15C blade to make one or two releasing incisions to gain access to the bone overlying the roots. After finessing the attached gingiva from the bone with an EX-9 periosteal elevator, the flap can be retracted with a stay suture to provide visualization of the underlying bone.
Full speed ahead
Two options currently exist for efficient bone removal to create a window lateral to the firmly rooted tooth that needs to be removed. Air-driven, water-cooled, high-speed handpieces are low on torque, but high on RPMs, which allows for swift removal of the thin layer of alveolar bone lateral to the root. An electric-driven oral surgery handpiece is the other option many veterinary dentists have available in their operatories. This has high torque and adjustable RPMs; some units are water-cooled (any bur used on bone should be water-cooled). A bur, such as a #2 surgical-length carbide bur, is used to remove bone lateral to the root(s) of the tooth requiring extraction, while other burs (e.g. a 701 carbide bur) can be used to section multi-rooted teeth. A ½ surgical-length round carbide bur is very helpful for final removal of small amounts of bone near the root tip if necessary and for creating a moat around fractured root tips (Figure 1).
Tools of the trade
Now you are ready to remove the tooth from its alveolus. Having a variety of dental luxators and elevators is very helpful. Regardless of whether you are using a luxator or elevator, there is one nonnegotiable rule to keep in mind: The instrument’s handle must sit firmly in the center of your palm, with your index finger placed along the shaft and the tip of your index finger extending to the end. This avoids penetration of important structures, such as the eye and brain when the instrument slips from its intended position. Not every person’s index finger is the same length, but most people should consider investing in “stubby” instruments that have a shorter shaft.
Luxating versus elevating
Dental luxators have a thin, sharp tip that fits into the space between the tooth and bone, allowing you to cut the periodontal ligament attachments. As they are designed to be used as a miniature scalpel blade, they may break if used like an elevator. Dental elevators fit into the periodontal ligament space and are rotated to put gradual pressure on the tooth attachments by leveraging off the adjacent alveolar bone, resulting in tearing of the periodontal ligament. Some force is necessary when using elevators, but it should always be controlled force of a “twist and hold” manner. Using my nondominant hand, I grasp the maxilla or mandible while elevating with my dominant hand. This serves the purpose of providing tactile feedback of the forces being generated by the elevator, but it also protects the patient, since the thumb of my nondominant hand will usually be what the elevator runs into if it slips from its intended position. It is important to have a variety of elevators of different shapes (e.g. winged, straight) and sizes to conform to the shape of the crown-root segment you are trying to remove. The forces needed to extract fragile feline teeth are much less than those utilized in large dogs.
These tips will hopefully help during your next feline “extractionpalooza.” Best wishes for a better 2021!
John Lewis, VMD, FAVD, DAVDC, practices dentistry and oral surgery at Veterinary Dentistry Specialists and is the founder of Silo Academy Education Center, both located in Chadds Ford, Pa.