Shedding Light On Surgical Exodontics

Proper tools and strong knowledge are tremendous assets when extracting rooted teeth.

Many indications exist for extraction of a firmly rooted tooth. These include endodontic disease (when root canal therapy is not economically feasible or medically desirable), tooth resorption and crowding of persistent deciduous and permanent teeth.

Though tooth extractions occur daily in nearly every practice, many practitioners have not been taught how to effectively and efficiently extract firmly rooted teeth. Having the right tools makes all the difference.

Exodontics is a fancy word for extraction of teeth. Considering how much work it is to remove a firmly rooted or ankylosed tooth, the procedure deserves a fancier word than “pulling”! This article will discuss the necessary armamentarium and things a practitioner should look for when making purchase decisions.

  1. Do you have a dental X-ray unit?
    Preoperative dental X-rays are a must for firmly rooted teeth. Anatomic variation in root shape, size, curvature and even number of roots makes taking a preoperative radiograph a good thing.
     
  2. Do you have a high speed/low-speed dental unit?
    Whether compressor-driven or nitrogen-driven, a high-speed unit is an important tool to remove bone on the buccal surface of firmly rooted teeth to create a window and to minimize forces necessary to remove an intact root.

    Low-speed hand pieces, though lacking in RPMs, have quite a bit of torque, so depending on the procedure, low- and high-speed hand pieces complement each other well. If your practice cannot afford an air-driven unit, an electric micromotor can be useful with appropriate hand pieces and attachments. All of these are much better options than in the past, when diamond discs and Dremel tools were the norm.
     

  3. Have the right burs for your high-speed hand piece.
    Carbide burs are aggressive cutting burs and melt away bone like a hot knife through butter. Having access to a variety of sizes of round burs (4, 2, 1, 1⁄4) makes bone removal on the buccal surface of the root easy.

    A general rule of thumb is to remove 60 percent of buccal bone to expose the cervical and mid-root. If the root breaks during elevation, more bone may need to be removed both buccally and circumferentially to create a “moat”

    Use the smaller round burs for this purpose to minimize the likelihood of significant trauma to the neurovascular bundles at the apex of the root. Other carbide burs help in sectioning multirooted teeth, such as the 701 crosscut taper-fissure bur (good for cat teeth), and the 702 surgical length crosscut taper-fissure bur (good for dog teeth).

    Diamond burs are less aggressive and help “clean up the crime scene” by smoothing rough edges of bone before closing a flap over the site.
     

  4. Copyright University of Pennsylvania
    A. Which of these elevators is designed to fit in the periodontal ligament space of a firmly rooted tooth? Answer: The thinner, the better. PHOTO CREDIT: Copyright Unversity of Pennsylvania
    Copyright University of Pennsylvania
    B. From left, thumb forceps, Adson-Brown forceps and Adson (1×2) tissue forceps. Adson tissue forceps hold on but don’t cause excessive trauma. PHOTO CREDIT: Copyright Unversity of Pennsylvania
    Copyright University of Pennsylvania
    C. Extraction forceps, middle, are more effective than the forceps on the left when extracting crown/root segments in dogs and cats. Root tip forceps, right, are essential for removal of fractured root tips. PHOTO CREDIT: Copyright Unversity of Pennsylvania

    Periosteal elevators are essential for raising flaps.
    Raise a flap for extraction of firmly rooted teeth. This can be a challenge without having a variety of periosteal elevators, ranging in sizes appropriate for small cats to large dogs and everywhere in between. Double-ended periosteal elevators that are flat and sharp work best to allow lifting of the gingiva.

    Be careful at the mucogingival junction to avoid perforating the flap at its thinnest point. A pedicle flap involves divergent releasing incisions at each edge of the flap. This type of flap provides the most exposure.

    Blunt and sharp dissection of the periosteum from beneath the flap is accomplished by inserting a closed pair of Metzenbaum scissors—for small flaps, a 5-inch pair of curved Ragnell scissors works well—into the space between the mucosa and the periosteum at the edge of the releasing incision at the base of the flap.

    Once placed in this location, the scissors may be opened to stretch the periosteum and separate it from the mucosa.
     

  5. Dental elevators are not all created equally, and with good reason.
    Not everyone likes the same types of dental elevators. I use, almost exclusively, winged elevators in sizes 1 through 6. Even within the realm of winged elevators, there are differences in shape and thickness that make certain elevators preferable for a given situation.
    When you look at your winged elevator end-on, how thin is the metal? Will it be able to obtain purchase within the 250-micron space between the tooth and the alveolar bone? (See photo A.) Have a variety of dental elevators and root tip elevators available to effectively extract teeth and roots of varying sizes.
     
  6. Do your thumb forceps cause more trauma than they need to?
    When grasping gingiva or mucosa, choose thumb forceps that don’t lose their grip on the gingiva but at the same time don’t cause excessive trauma. Regular thumb forceps do not grasp well enough, resulting in multiple areas of crushing trauma to the gingiva.
    Rat tooth forceps (1×2 version) are a good option, but those found in a spay pack are too large to use for grasping gingiva and mucosa. Adson (1×2) tissue forceps are a great option, not to be confused with Adson-Brown tissue forceps, which have seven teeth on each side and may cause more trauma than necessary. (See photo B.)
     
  7. Do your extraction forceps work best on human or veterinary teeth?
    Extraction forceps work best when they are able to grasp the tooth with a good amount of contact area at the cervical portion of the tooth, or as far toward the root apex as possible. Extraction forceps designed for humans have a prominent bulge to wrap around the dental bulge of human molars and premolars. These are not optimal for veterinary teeth since there are only two small areas of contact. (See photo C.)

    Consider the shape of the tooth and reach for the extraction forceps after appropriate elevation to decrease the likelihood of hearing that dreaded crack.
     

  8. Do you have a bone curette in your practice that will allow for debridement of the socket of an infected tooth?
    A small bone curette with an easy-to-grasp handle is a must to allow for complete removal of diseased tissue from an infected alveolus. Coupled with copious lavage, this allows for surgical closure of all (even infected) extraction sites, which results in rapid healing and less postoperative bleeding from the extraction site.
     
  9. Do you have a dental X-ray unit to take postoperative radiographs?
    It’s worth stating twice: dental radiography is a must for not only diagnostic purposes but also for assessment of treatment and documentation of a job well done. One of the most common revelations of general practitioners after purchasing a dental X-ray machine is: “I can’t believe how many roots are present on postoperative X-rays that I thought I removed completely!”

Having the right tools and knowledge of their use are essential components for extraction of firmly rooted teeth, a.k.a. surgical exodontics.

John R. Lewis, VMD, FAVD, Dipl. AVDC, is an assistant professor of dentistry and oral surgery at the University of Pennsylvania School of V

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