IN-DEPTH: DENTAL EXTRACTIONS—FROM CASE SELECTION TO RECOVERY Equine Intraoral Cheek Tooth Extraction K. Jack Easley, DVM, MS, Diplomate ABVP (Equine) Author’s address: Equine Veterinary Practice, LLC, PO Box 1075, Shelbyville, KY 40066; e-mail: [email protected]. © 2012 AAEP. 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 278 2012 ր Vol. 58 ր AAEP PROCEEDINGS 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. AAEP PROCEEDINGS ր Vol. 58 ր 2012 279 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 veter- inarian should have a backup plan for surgical ex- traction. Such a surgical plan should consist of the following: (1) Minimally invasive transbuccal surgery to re- move 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