Equine Intraoral Cheek Tooth Extraction

IN-DEPTH: DENTAL EXTRACTIONS—FROM CASE SELECTION TO RECOVERY

K. Jack Easley, DVM, MS, Diplomate ABVP (Equine)

1. Introduction (9) Neoplasia. Exodontia (removal of a tooth) should not be per- (10) Bitting discomfort. formed unless it has been determined beyond a Most indications are associated with nonfunc- doubt which tooth or teeth are problematic and that tional or infected teeth. Tooth removal is indicated all methods of medical, periodontic, and/or endodon- to relieve pain, preserve adjacent teeth, or prevent tic therapy have been exhausted to arrest the dis- the spread of infection systemically or to the proxi- ease process and preserve the tooth. Throughout mal tissues. the 20th century, exodontia has classically been the Exodontia can be simple or very time-consuming. It can also be frustrating and fraught with operative backbone of equine oral surgery.1 There are a wide and postoperative complications.2–7 The speciﬁc range of indications for tooth removal, most of which tooth involved, dental disease process, age of the depend upon which tooth or teeth in the arcade are animal, and number of teeth to be removed dictate causing a problem. Some common indications for the surgical technique and instruments used.8–12 tooth removal are associated with one of the Thorough treatment planning before beginning an following: extraction procedure will minimize complications (1) Interceptive orthodontics secondary to re- and produce realistic owner expectations. Some tained deciduous teeth. questions that should be posed prior to surgery in- (2) Periodontal disease secondary to diastema, clude the following: dental maleruptions, and displacements, supernu- (1) Which tooth (teeth) is the problem, and is it merary teeth, or malocclusion. suitable for intraoral extraction? (3) Endodontic (pulp) disease or apical infection (2) What is the overall health and temperament of usually associated with secondary osteomyelitis. the patient? (4) Paranasal sinus disease secondary to oral or (3) Has the owner been thoroughly informed about dental disease. the procedure and the possibility of another surgery, (5) Developmental dental disorders. complications, and costs involved? (6) Surgical consideration in oral or skull bone (4) Does the surgeon have the proper equipment, fractures. instrumentation, and training to complete the (7) Fracture or disease of the dental crown or root. procedure? (8) Occlusal trauma. (5) Is there a backup plan if the extraction fails?

NOTES

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Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb dainop 10 1-9 3266 IN-DEPTH: DENTAL EXTRACTIONS—FROM CASE SELECTION TO RECOVERY (6) At what point, should I use a different Dental wedging between the adjacent teeth may technique? block the eruption pathway of the tooth and compli- (7) Is the surgeon prepared to treat a possible cate extraction. Intraoral extraction may be com- associated bone or sinus infection? plicated by teeth with divergent roots; root (8) Who will provide aftercare and follow-up on dilacerations; increased number of roots; hyperce- the horse? mentosis or bullous roots; long, thin roots; and/or The earliest known method to remove diseased horizontally fractured roots. Teeth that are anky- cheek teeth in the horse was via the oral route.13 losed to the socket are also complicated to remove. Oral extraction has been practiced by veterinary Extraction procedures range from minor to major surgeons for centuries on severely diseased or loose surgical procedures, and practitioners should criti- teeth. Molar extraction forceps have been avail- cally evaluate their ability (training, experience, in- able for well over 100 years and until very recently strumentation, etc) before performing an exodontic have changed little in design. In the mid-20th cen- procedure. In aged animals with short reserved tury, with the advent of equine general inhalation crowns or in the case of advanced periodontal dis- anesthesia, which makes working in the mouth ease that has resulted in loosening of the tooth, around a mask or endotracheal tube difficult, oral extraction may be carried out digitally. In young extraction lost popularity. horses with apically diseased teeth and long re- Most 20th century veterinary literature limited served crowns firmly attached in the alveolus, ex- intraoral tooth extraction to teeth that were loose or traction will require more effort and expertise. presented in older horses with short dental It may be necessary in some juvenile horses to re- crowns.13–15 move permanent dentition before eruption, which For over 50 years, most equine teeth were re- may complicate an oral approach. Young animals moved surgically by trephination and retrograde re- with long reserved crowns may present an insur- pulsion. In more recent years, modern sedative mountable challenge to oral extraction. However, analgesic combinations and regional dental anesthe- clinical studies show a success rate of 70% to 90% for sia have allowed veterinarians to safely access the tooth removal via standing oral extraction.4 standing horse’s mouth. This has led to the devel- Several conditions must be present to have suc- opment of better oral extraction techniques and the cess utilizing intraoral extraction: manufacture of a wide variety of high-quality dental (1) An appropriate area for surgery that is quiet instruments. and clean with adequate work space. Oral tooth extraction should be the primary (2) An assistant(s) to steady the head and help method of tooth removal used by the veterinarian. with instrumentation and equipment use. Even though a retrograde approach to the sinus or (3) Proper restraint with a stocks, sedation/anal- periradicular area may be necessary to reach an gesia (nonsteroidal anti-inflammatory drugs, tran- existing secondary disease condition, oral extraction quilizers, continuous rate infusion (CRI), regional should be attempted first. Proper extraction tech- nerve blocks), and a head support or stand. nique based on sound dental surgical principles min- (4) A complete set of oral examination equipment imizes postoperative discomfort and encourages (speculum, light sources, mirrors, and/or endoscope). rapid healing of associated soft tissues. (5) Intra-operative radiography or fluoroscopy. The basic principles of tooth removal in humans (6) A set of dental extraction instruments. and small animals involve obtaining adequate ac- (7) The time and patience to allow proper extrac- cess to the periodontium for loosening, creating an tion technique. unimpeded pathway for removal of the tooth, and Advantages of standing intraoral extraction over using controlled force to elevate the tooth without other methods of tooth removal are listed below: damaging adjacent structures.16 The interdigitat- (1) Shortened postoperative socket healing time. ing contours of the long reserve crown and presence (2) Fewer surgical and postsurgical complications. of multiple roots on each tooth can make loosening (3) Standing surgery reduces the time pressure on and elevation of the hypsodont tooth very challeng- the surgeon and anesthetist and the recovery risk to ing in horses. Equine tooth removal also requires the patient. deformation of the dental sockets to open the erup- (4) There is minimal risk of damage to adjacent tion pathway of the tooth for elevation. structures (facial nerve, parotid duct, infraorbital Oral extraction can be performed on any tooth, but nerve, greater palatine artery, etc). several dental disease processes require special con- (5) Extraction leaves an intact alveolus in most sideration when planning surgery. Teeth with cases, reducing the risk of postoperative fistula gross pulp horn or infundibular caries have crowns formation. that may disintegrate during extraction. Diseased Disadvantages of standing intraoral extraction: caudal maxillary teeth often are associated with sec- (1) May be very time-consuming. ondary sinusitis, and surgical drainage of the si- (2) Special restraint is needed to access the mouth. nuses is required in this situation. The more (3) Special, costly instruments are required. caudally situated teeth are more challenging be- (4) An intact exposed crown is needed for loosen- cause of limited space in the back of the mouth. ing and extraction.

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Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb dainop 10 1-9 3266 IN-DEPTH: DENTAL EXTRACTIONS—FROM CASE SELECTION TO RECOVERY (5) Tooth reserve crown and root conformation and position can impede elevation from the alveolus. (6) A compliant patient is necessary for standing surgery. When oral extraction is not successful, the veterinarian should have a backup plan for surgical extraction. Such a surgical plan should consist of the following: (1) Minimally invasive transbuccal surgery to remove upper cheek teeth or lower 06–08 teeth. (2) Buccotomy and dental elevation through the lateral alveolar plate. (3) Retrograde repulsion with pin or punch. (4) Division of the tooth orally with extraction in 17–23 C fragments. O Surgical extraction is not reserved only for ex- L treme situations when oral extraction has failed. O When used appropriately on selected cases, surgical R extraction may be more conservative and cause less morbidity than intraoral extraction. Excessive Fig. 1. Three sizes of molar spreaders or separators. The width force might be required to extract a tooth orally, and and angle of the blades determines the amount of motion and separation produced when placed between two cheek this could lead to fracture of roots, adjacent bone, or teeth. Proper placement is critical to prevent fracturing the both. Surgical extractions often allow for more con- exposed crown of the tooth. trolled removal of bone and elevation of the tooth, leading to a more predictable outcome.

Intraoral Extraction Procedure Careful preoperative examination of the patient is head is restrained in a steel frame, dental halter, or important, and all aspects of the approach to ther- head stand. Regional anesthesia is helpful in gain- apy should be planned thoroughly before surgery. ing patient cooperation. Pain management stan- Radiographic and endoscopic examinations should dards of care require regional or local infiltration be carried out before and after surgery to support anesthesia for extraction of permanent teeth. A the clinical findings. When available, additional full-mouth speculum is needed to gain adequate ac- imaging techniques such as digital radiology, fluo- cess for working in the oral cavity. A headlight or roscopy, scintigraphy, computed tomography, and speculum light is essential for good visualization. MRI may be indicated. Oral photographs taken before and after surgery are A basic set of dental extraction instruments in- often helpful in documenting the surgery and ex- cludes the following: plaining the procedure to the owner and referring (1) Dental spreaders or separators with the proper veterinarian. size blade and angle of handle to fit between the A tooth with a healthy crown is loosened by plac- mesial and distal margins of the tooth to be ing a thin blade spreader between the mesial and removed. distal interdental spaces of the involved tooth (Fig. (2) Various molar extraction forceps to fit the 1). Special care must be taken to avoid loosening F1 crown of the tooth being removed. the 06 or 11 tooth when extracting a 07 or 10 tooth (3) Three- or four-pronged forceps for tooth (spread first on the side with the most support: elevation. between 07 and 08 or between 09 and 10). The (4) Dental fulcrum set. spreader blades are carefully placed between the (5) Extirpation or turning (offset head) forceps. teeth at the gingival margin and the handles closed, (6) Set of dental elevators, gingival elevators, bringing the blades partially together. Just picks, and curettes. enough force should be placed on the spreader to (7) Quick-release C-clamp or elastic band. slightly move the tooth. The blades are held in this (8) Steel or hardwood leverage bar. position, placing pressure on the periodontal liga- (9) General orthopedic instruments. ments, stretching them beyond the elastic limit over (10) Material to pack or cover the dental socket a 5- to 10-minute period. The spreader is removed (iodoform gauze, acrylic, base plate wax or polyvinyl and replaced on the opposite interdental space and siloxane impression material, Plaster of Paris, the handles again are closed, prying the teeth apart. honey sugar) (Appendix A). This process is repeated until the thin blade spread- Intraoral tooth extraction is best performed on the ers are easily closed both mesial and distal to the standing horse, although general anesthesia may be affected tooth. Teeth with split or damaged crowns necessary in a nervous or fractious animal. Seda- may not be suitable for spreading and can often be tive analgesics are administered, and the horse’s loosened with an equine dental elevator and forceps.

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C O L O R

Fig. 3. Several sizes and head configurations of box-head equine dental forceps. The size and shape of the head of the extraction forceps must be sized to fit tightly on the margins of the tooth crown. Most of these forceps are made with parallel jaws when properly seated on the tooth. The process of sizing a forceps for a particular tooth is similar to a mechanic choosing the right size C socket wrench. O L O R ping of the forceps requires immediate reexamina- tion with possible repurchasing of the crown. This Fig. 2. A set of equine gingival elevators and right-angle os- will help avoid abrading or breaking the tooth. teotomes. The blade angle and length can be used to a mechan- Torsion can be placed on the tooth with a steel or ical advantage when working in the deep recesses of the oral wooden leverage bar, using a rotating movement of cavity. the forceps handles (Fig. 4). This allows the tooth to move from side to side in the socket. Undue haste or excess force must be avoided. Care must also be taken to prevent crown damage from sudden Next, the gingival mucosa is separated from the movement of the horse’s head. Application of the buccal and lingual edges of the tooth crown with a thick blade spreaders at this point can be helpful, F2 sharp gingival elevator or osteotome (Fig. 2). This along with repeat forceps motion to encourage fur- will expose enough tooth surface area to allow for- ther loosening of the tooth. When the tooth begins ceps to be placed on the crown. It may be advan- to become mobile, a sucking sound can be heard and tageous to remove a collar of alveolar plate on the frothing blood can be seen around the margins of the buccal and/or lingual edge of the tooth crown with a tooth. Progress can be checked by removing the sharp right angle osteotome or periotome to allow the forceps to be placed more securely. When using the dental forceps or elevator on the palatal side of the upper teeth, care should be taken not to damage the palatine artery. The properly sized extraction forceps is placed on F3 the tooth crown (Fig. 3). The forceps can be secured with a quick-release C-clamp or length of rubber F4 elastic wrapped around the handles (Fig. 4). Max- imizing the purchase between the head of the forceps to the crown of the tooth is the most important aspect of instrument selection. Sagittally fractured cheek teeth may have food material stuck in C the fragment fissure: all such material should be O flushed/removed to allow the fragments to come L back together and permit better placement/pur- O chase of the extraction forceps on the clinical crown. R The forceps are then rocked from side to side in a Fig. 4. Adjustable quick-release C-clamp and rubber tubing lateral-to-axial oscillating movement. This motion used to secure the spreader or extraction forceps handles. The causes the tooth to rotate on its long axis in the 18-inch long, 1.5-inch diameter bar of locust wood can be used as socket. The forceps handle should be moved over a a leverage bar to place torque on the extraction forceps han- very short range of motion to ensure that the head of dles. Using this tool and technique, the tooth can be rocked the forceps stays engaged on the tooth crown. Slip- sideways in the dental socket during loosening.

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C O C L O O L R O R Fig. 5. A set of three- and four-pronged extraction forceps. These forceps provide a ﬁrm, nonslipping grip on the tooth Fig. 6. A set of fulcrums in a wide range of sizes is helpful in and aid in elevating the tooth from the socket. The three- elevating the tooth from the socket. A soft metal such as alumi- pronged forceps come in a right- and left-side design and are num and a design that distributes the compression force applied available in wide (upper) or narrow (lower) widths. to the forceps over a wide area of the dental arcade reduces the chance of iatrogenically damaging a tooth.

forceps and digitally palpating the crown for The extracted tooth should be examined to make mobility. sure it has been removed in its entirety and that no Keep in mind that the tooth is like a post in a hole. root fragments or slivers of crown have been left in A great deal of movement must be placed on the the socket. The alveolus should be examined digi- portion of the post above ground to be reflected in a tally and with an endoscope or dental mirror, and small amount of movement at the bottom of the post. any bone or tooth fragments must be removed. In a young animal with a short ratio of exposed Operative radiographs will confirm that the correct crown to reserved crown and root, more movement of the exposed crown is needed to result in movement at the apex in the alveolus. Conversely, in an old horse with almost the entire crown exposed, even a slight movement in the crown puts great pressure on the roots. The tooth is locked in place because the irregular shape of the reserve crown and roots mirrors the shape of the alveolus. The thin alveolar plate is relatively easy to deform into the spongy surrounding bone of a normal jaw. Diseased teeth may be surrounded by sclerotic bone, making tooth- loosening difficult. The combined process of dis- C rupting the periodontal ligament and deforming the O L contour of the alveolus is essential to completely O loosen the tooth and open a path for extraction. R Once the tooth is loose, the forceps should be re- positioned to get a firm grip on the crown. Use of a Fig. 7. A duck-billed and a four-prong reverse fulcrum for- 3- or 4-prong forceps allows the surgeon to get a firm ceps. These forceps allow for a fulcrum to be placed caudal to the grip on the dental crown, lessening incidence of slip- tooth being extracted. This allows better leverage in elevating page from the crown of the tooth as it is elevated the 06 from the socket. The prong forceps has an adjustable F5 (Fig. 5). A properly sized and shaped fulcrum or screw in fulcrum attached to the extended end of the forceps. F6 block is placed near the head of the forceps (Fig. 6). A reverse fulcrum forceps may be helpful to elevate F7 a 06 or 07 from the alveolus (Fig. 7). Gradual, firm traction will readily bring the loosened tooth from C its socket. The tooth must be extracted along its O L path of eruption to gain the best mechanical advan- O tage. Teeth of young horses that have long reserve R crowns and are located in the caudal recess of the oral cavity may require sectioning with a molar cut- Fig. 8. Extirpation or turning forceps with an off-set ter or Gigli wire saw to allow delivery into the oral head. This forceps is often confused with the smaller incisor cavity. A turning forceps may facilitate delivery of extraction forceps. This forceps is used to grasp and rotate or these long teeth into the oral cavity without section- turn a partially elevated caudal cheek tooth into the mouth so F8 ing (Fig. 8). that it can be removed without sectioning the tooth.

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Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb dainop 10 1-9 3266 IN-DEPTH: DENTAL EXTRACTIONS—FROM CASE SELECTION TO RECOVERY until the periphery of the dental socket is covered with healthy granulation tissue (5 to 10 days). The alveolus should be protected for several weeks from oral contamination with a patch or plug of dental acrylic, dental base plate wax, polyvinyl siloxane (PVS), or polymethylmethacrylate (PMMA). The entire plug should be about one-fourth the length of the reserve crown of the removed tooth to allow room for the formation of a blood clot and development of granulation tissue in the dental socket. When using dental acrylic, dental base plate wax, or PMMA, the plug should extend only slightly above the top of the gingiva so that it is not involved in chewing. After the plug is in place, its surface is molded carefully with a finger to build a slight flange over the gingival line, sealing the alve- C olus. When using PVS, this rubbery material O should be molded slightly below the gingiva to pre- L vent it from prematurely coming out of the socket. O Bone cement (PMMA) can be combined with radio- R opaque contrast media or antibiotics if needed. Fig. 9. A set of long dental handles with holes for removable If a hard setting material such as PMMA or dental picks, elevators, probes, and curettes, set at 45, 75, and 90 de- acrylic is used, the plug will need to be removed 6 to grees to the shaft. Tips of different lengths can be attached with 8 weeks after extraction. Removal may require a an Allen screw at a degree of rotation for an endless variety of four-pronged extraction forceps. Older horses with forces placed in the dental socket. shallow intact dental sockets do better with no dental packing or plug, leaving the sockets to fill with grass or soft, leafy hay. The objective of exodontia should be to carefully tooth has been removed and that the alveolus is free plan and execute the extraction and protect the den- of tooth and bone fragments. tal socket, thereby minimizing complications. De- Dental fragments and pieces of lose bone can often tailed descriptions for avoiding and managing be elevated from the socket with angled picks, ele- surgical and postsurgical complications can be found F9 vators, and curettes (Fig. 9). In human dentistry, in the literature.25–29 attempts at blind retrieval of small root tip fractures may prove excessively traumatic, and the risk of removal of small root fragments embedded in the Appendix A: Equine Dental Extraction Instrument Suppliers bone often outweighs the benefit. As a rule, root Pegasus Instruments, Manfred Stoll, 65329 Hohen- tips can be left in place if they are under 5 mm in stein, Germany. www.pferderpraxis-stoll.de. length, if there is no evidence of periapical pathol- Instrumentation Concept, Inc., 2936 Reward ogy, or if the removal process might damage adja- Lane, Dallas, TX 75220. 214-850-9142. www. cent structures, open the maxillary sinus, or cause instconcept.com. 24 uncontrollable hemorrhage. The same criteria Precision Technologies, T/A Herbst Manufactur- apply in most cases encountered in equine dentistry. ing, Kilpool Hill, Wicklow, Republic of Ireland. After surgery, lower cheek tooth sockets that are 35340467164. www.precisionvet.com. chronically infected or contaminated with oral de- Harlton’s Equine Specialties, 792 Olenhurst bris may need to be drained ventrally. This can be Court, Columbus, OH 43235. 800-247-3901. www. done using a quarter-inch Steinmann pin or a half- Harltons.com. inch trephine to create a hole in the ventral lateral Alight Equine Equipment, LLC, 80 Clinton Street, aspect of the mandible below the affected alveolus. Suite D 400, Hempstead, NY 11550. 888-653-1563. The open alveolus is protected by the placement of ϫ www.alequine.com. several 4 4 gauze sponges tied in the center to a th length of quarter-inch umbilical tape. The tape Medco Instruments, Inc., 7732 W. 96 Place, ends are passed into the empty alveolus through the Hickory Hill, IL 60457. 708-860-7413. www. oral cavity and out the drainage hole. The gauze medcoinstruments.com. roll is wedged firmly into the space between the Dr. Fritz Endoscopy. 502-938-8051. www.dr-fritz. opposing teeth and secured in the socket with um- com. bilical tape tied around another roll of gauze on the Butler Schein Animal Health, 400 Metro Place N., outside of the skin incision. The gauze should be Dublin, OH 43017. 888-691-2724. www.butlershein. changed every few days and the wound irrigated com.

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