There are some required essentials if dentistry is to be performed to gold standard: 1) Patience, 2) Skill, 3) Dental radiographic equipment, 4) Specialised veterinary dental equipment.

Pattern recognition is a very important part of the skill set required in veterinary dentistry. Patterns that need to be recognised include gross dental anatomy, gross oral anatomy, neurovascular topography, dental radiographic anatomy, head and facial symmetry.

It must also be recognised that there is a bare minimum dental equipment set that is required to be able to perform dentistry to an acceptable level.

We need to perform dentistry without causing harm.

Most veterinary practices are ill equipped for veterinary dentistry. Veterinary dentistry has been inadequately taught (in most cases not taught) at veterinary schools - very few veterinary schools have dentistry departments and those that do provide some level of teaching rely on local private practitioners to teach the students (until universities create faculty positions for veterinary dental specialists, teaching by private practitioners will provide students with entry-level knowledge and skills). Recently, a Day 1, Year 1 and Year 3 competency document was formulated by the European Veterinary Dental College and the European Veterinary Dental Society that provides guidelines on targets to be met by universities in teaching under- and postgraduates.

Anatomy

The veterinarian needs to acquire/refresh their knowledge of anatomy of the head and oral structures; knowledge of dental formulae, normal number of roots per tooth, attachment of the tooth within the alveolus, shape of roots, and important structures adjacent to the crowns and roots is essential. What is it about some roots that makes them so much more difficult to extract than others?

Figure 1. Number of roots per tooth in dogs

Figure 2. Number of roots per tooth in the cat

Physics of Dentistry

Shape of the roots: curved (maybe in two planes - mandibular canine), divergent; cross-section: circular, triangular, oval, incorporating a developmental groove. Dilacerated, resorbed.

Teeth, "solid" structures, are maintained in the alveoli, also "solid" structures, by soft-tissue ligament fibres. Using excessive force to extract a tooth will either result in fracture of the tooth or the alveolus. It is therefore necessary to fatigue, sever and tear the ligaments to release the tooth during exodontics.

Luxation instruments are driven into the ligament space to not only sever the periodontal ligament but also compress the alveolar bone creating space for a more robust instrument allowing rotational leverage forces to be applied to the luxation/elevation instrument to fatigue and tear the ligaments further. When extracting numerous teeth, work on all crown-root fragments sequentially as the bleeding that occurs after trauma to the periodontal ligament increases the hydraulic pressure within the ligament space, helping to displace the tooth further. Extraction forceps can then be used to deliver the tooth. The forceps should be placed as low down the root as possible; firmly grasp the tooth; intrude the tooth into the alveolus; apply gentle but firm clockwise and anticlockwise rotation followed by extrusional force with similar rotations. If the tooth is not delivered, repeat the process. If, at the second attempt, it is not delivered, revert to further luxation prior to forceps manipulations. A tooth with a pronounced dilaceration of the root tip may fracture during forceps extraction and therefore additional time should be spent on luxating these teeth prior to forceps intervention.

Equipment

Modern dental equipment makes performing veterinary dentistry a pleasure. The investment in air-driven dental units can be recouped in a short period of time. These units enable us to do a more professional procedure in less time and with less trauma to the patient.

Minimum equipment required: Air-driven dental unit with high- and low-speed connections and hand pieces, three-way air-water syringe, incorporated (or free-standing) ultrasonic scaler.

Set of luxation instruments, set of elevation instruments (Coupland chisels, Wiggs modified winged elevators), root picks, extraction forceps, periosteal elevators Goldman Fox A&B or finer, fine needle holder, No3 scalpel handle and size 15 or 15c blades, iris scissors, suture scissors, Adson or Adson-Brown thumb forceps.

Additional requirements: Dental chart, anaesthetic monitoring chart, suture material (monofilament, synthetic, absorbable, fine, with a swaged-on, reverse-cutting needle. Round-bodied needles will not pass through gingiva or periosteum with ease and may result in the gingiva being torn.)

Radiography

Most of the tooth is encased in the alveolus and therefore it is essential to take diagnostic radiographs to be able to examine the subgingival part.

Although intraoral dental film is easy to use and freely available, the benefits of using digital dental radiography far outweigh the additional expense.

Tooth Extraction Techniques

Simple or Closed Extraction Technique

The simple extraction technique requires that the tooth attachment structures are severed and the tooth loosened and delivered from the alveolus without a surgical flap being raised. The gingival attachment can be incised using a scalpel blade, periosteal elevator or a periotome of sorts. A sharp luxator can also be used to sever the gingival attachment. The next step is to drive an appropriately sized luxator into the periodontal ligament space, advancing it as far as it will go. The instrument should be left in place for 10–15 seconds so that the ligaments on one side are being severed and cut, while on the other side they are compressed against the alveolar wall. The instrument is then removed and positioned on the other side of the tooth, and again it is driven as far apically as possible and left in place for 10–15 seconds. The instrument is then repositioned on the other side of the tooth and the process repeated. Once all four sides of the tooth have been loosened, begin luxating again at the first site. One can use the same luxator or one of larger dimensions. Each time the luxator is driven as far apically as possible, left in placed for 10–15 seconds, and then moved to another site. The tooth should now show signs of looseness and it may be possible to extract the tooth using a luxator, an elevator, or dental forceps. When using the elevator, it is driven apically and rotation force is applied to dislodge the tooth in the alveolus. If forceps are to be used, the tooth crown should be grasped as gingivally as possible, held firmly and the tooth intruded into the alveolus and a clockwise followed by anticlockwise rotational force applied. This further fatigues the ligaments and then an extrusion force combined with clockwise and anticlockwise rotation forces applied to deliver the tooth. If the tooth is not delivered on the first attempt using forceps, the tooth should be further loosened prior to further attempts at forceps extraction. It may be possible to place an apposing suture in the gingiva to keep the blood clot in place and prevent food impaction. Periodontally compromised multirooted teeth can be sectioned into as many crown-root fragments as there are roots present and extracted using the simple technique. The decision to extract a tooth using the simple technique should be based on radiographic evaluation of the tooth.

Open Extraction Technique

The open extraction technique requires that a mucogingival/mucogingivoperiosteal flap be raised. The gingival attachment is severed and reflected as described above and if a multirooted tooth is being extracted, the tooth should be divided into as many tooth-root fragments as there are roots using a high-speed dental bur. Once the tooth is sectioned, the flap is further raised to expose the buccal alveolar wall (juga). If necessary, vertical releasing incisions can be made at the rostral and caudal extents of the flap to give greater access. Some furcation bone should be removed and a small bony window created in the alveolar bone rostral and caudal to the roots to enable the luxator to be inserted into the periodontal ligament space. Once positioned in the periodontal ligament space, it should be driven as apically as possible and left in place for 10–15 seconds and then replaced as described above. Elevators and forceps can be used as previously described. When a palatal root is present, furcation bone between this root and its buccal counterpart should be removed to enable the palatal root to be luxated in a buccal direction.

When the tooth root-crown fragments have been extracted, the alveolar margin should be smoothed using a large-diameter round diamond bur so that the sharp shards do not puncture the oral mucosa/gingiva. Surgical flaps are closed using 5/0 monofilament, absorbable, synthetic suture material with a reverse-cutting swaged-on needle.

Under certain circumstances, and based on radiographic evidence, the crowns of teeth affected by type 2 resorptive lesions may be amputated and gingiva sutured closed. When indicated, an envelope flap is raised around the affected tooth and the crown is amputated at the neck of the tooth and the tooth substance is reduced to about 1 mm below the alveolar margin prior to suturing the flap closed.

In summary, there is an easier way to extract teeth: pattern recognition, patience, radiography, skill, and appropriate equipment will make dentistry easier and more fulfilling for the dental surgeon.