Equine Intraoral Cheek Tooth Extraction - AAEP Intraoral Cheek Tooth Extraction K. Jack Easley, DVM, MS, ... cheek teeth in the horse was via the oral route.13 Oral extraction has

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

Exodontia (removal of a tooth) should not be per-formed unless it has been determined beyond adoubt which tooth or teeth are problematic and thatall methods of medical, periodontic, and/or endodon-tic therapy have been exhausted to arrest the dis-ease process and preserve the tooth. Throughoutthe 20th century, exodontia has classically been thebackbone of equine oral surgery.1 There are a widerange of indications for tooth removal, most of whichdepend upon which tooth or teeth in the arcade arecausing a problem. Some common indications fortooth removal are associated with one of thefollowing:

(1) Interceptive orthodontics secondary to re-tained deciduous teeth.

(2) Periodontal disease secondary to diastema,dental maleruptions, and displacements, supernu-merary teeth, or malocclusion.

(3) Endodontic (pulp) disease or apical infectionusually associated with secondary osteomyelitis.

(4) Paranasal sinus disease secondary to oral ordental disease.

(5) Developmental dental disorders.(6) Surgical consideration in oral or skull bone

fractures.(7) Fracture or disease of the dental crown or root.(8) Occlusal trauma.

(9) Neoplasia.(10) Bitting discomfort.Most indications are associated with nonfunc-

tional or infected teeth. Tooth removal is indicatedto relieve pain, preserve adjacent teeth, or preventthe spread of infection systemically or to the proxi-mal tissues.

Exodontia can be simple or very time-consuming.It can also be frustrating and fraught with operativeand postoperative complications.2–7 The specifictooth involved, dental disease process, age of theanimal, and number of teeth to be removed dictatethe surgical technique and instruments used.8–12

Thorough treatment planning before beginning anextraction procedure will minimize complicationsand produce realistic owner expectations. Somequestions that should be posed prior to surgery in-clude the following:

(1) Which tooth (teeth) is the problem, and is itsuitable for intraoral extraction?

(2) What is the overall health and temperament ofthe patient?

(3) Has the owner been thoroughly informed aboutthe procedure and the possibility of another surgery,complications, and costs involved?

(4) Does the surgeon have the proper equipment,instrumentation, and training to complete theprocedure?

(5) Is there a backup plan if the extraction fails?

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

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(6) At what point, should I use a differenttechnique?

(7) Is the surgeon prepared to treat a possibleassociated bone or sinus infection?

(8) Who will provide aftercare and follow-up onthe horse?

The earliest known method to remove diseasedcheek teeth in the horse was via the oral route.13

Oral extraction has been practiced by veterinarysurgeons for centuries on severely diseased or looseteeth. Molar extraction forceps have been avail-able for well over 100 years and until very recentlyhave changed little in design. In the mid-20th cen-tury, with the advent of equine general inhalationanesthesia, which makes working in the moutharound a mask or endotracheal tube difficult, oralextraction lost popularity.

Most 20th century veterinary literature limitedintraoral tooth extraction to teeth that were loose orpresented in older horses with short dentalcrowns.13–15

For over 50 years, most equine teeth were re-moved surgically by trephination and retrograde re-pulsion. In more recent years, modern sedativeanalgesic combinations and regional dental anesthe-sia have allowed veterinarians to safely access thestanding horse’s mouth. This has led to the devel-opment of better oral extraction techniques and themanufacture of a wide variety of high-quality dentalinstruments.

Oral tooth extraction should be the primarymethod of tooth removal used by the veterinarian.Even though a retrograde approach to the sinus orperiradicular area may be necessary to reach anexisting secondary disease condition, oral extractionshould be attempted first. Proper extraction tech-nique based on sound dental surgical principles min-imizes postoperative discomfort and encouragesrapid healing of associated soft tissues.

The basic principles of tooth removal in humansand small animals involve obtaining adequate ac-cess to the periodontium for loosening, creating anunimpeded pathway for removal of the tooth, andusing controlled force to elevate the tooth withoutdamaging adjacent structures.16 The interdigitat-ing contours of the long reserve crown and presenceof multiple roots on each tooth can make looseningand elevation of the hypsodont tooth very challeng-ing in horses. Equine tooth removal also requiresdeformation of the dental sockets to open the erup-tion pathway of the tooth for elevation.

Oral extraction can be performed on any tooth, butseveral dental disease processes require special con-sideration when planning surgery. Teeth withgross pulp horn or infundibular caries have crownsthat may disintegrate during extraction. Diseasedcaudal maxillary teeth often are associated with sec-ondary sinusitis, and surgical drainage of the si-nuses is required in this situation. The morecaudally situated teeth are more challenging be-cause of limited space in the back of the mouth.

Dental wedging between the adjacent teeth mayblock the eruption pathway of the tooth and compli-cate extraction. Intraoral extraction may be com-plicated by teeth with divergent roots; rootdilacerations; increased number of roots; hyperce-mentosis or bullous roots; long, thin roots; and/orhorizontally fractured roots. Teeth that are anky-losed to the socket are also complicated to remove.

Extraction procedures range from minor to majorsurgical procedures, and practitioners should criti-cally evaluate their ability (training, experience, in-strumentation, etc) before performing an exodonticprocedure. In aged animals with short reservedcrowns or in the case of advanced periodontal dis-ease that has resulted in loosening of the tooth,extraction may be carried out digitally. In younghorses with apically diseased teeth and long re-served crowns firmly attached in the alveolus, ex-traction will require more effort and expertise.It may be necessary in some juvenile horses to re-move permanent dentition before eruption, whichmay complicate an oral approach. Young animalswith long reserved crowns may present an insur-mountable challenge to oral extraction. However,clinical studies show a success rate of 70% to 90% fortooth removal via standing oral extraction.4

Several conditions must be present to have suc-cess utilizing intraoral extraction:

(1) An appropriate area for surgery that is quietand clean with adequate work space.

(2) An assistant(s) to steady the head and helpwith instrumentation and equipment use.

(3) Proper restraint with a stocks, sedation/anal-gesia (nonsteroidal anti-inflammatory drugs, tran-quilizers, continuous rate infusion (CRI), regionalnerve blocks), and a head support or stand.

(4) A complete set of oral examination equipment(speculum, light sources, mirrors, and/or endoscope).

(5) Intra-operative radiography or fluoroscopy.(6) A set of dental extraction instruments.(7) The time and patience to allow proper extrac-

tion technique.Advantages of standing intraoral extraction over

other methods of tooth removal are listed below:(1) Shortened postoperative socket healing time.(2) Fewer surgical and postsurgical complications.(3) Standing surgery reduces the time pressure on

the surgeon and anesthetist and the recovery risk tothe patient.

(4) There is minimal risk of damage to adjacentstructures (facial nerve, parotid duct, infraorbitalnerve, greater palatine artery, etc).

(5) Extraction leaves an intact alveolus in mostcases, reducing the risk of postoperative fistulaformation.

Disadvantages of standing intraoral extraction:(1) May be very time-consuming.(2) Special restraint is needed to access the mouth.(3) Special, costly instruments are required.(4) An intact exposed crown is needed for loosen-

ing and extraction.

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(5) Tooth reserve crown and root conformation andposition can impede elevation from the alveolus.

(6) A compliant patient is necessary for standingsurgery.

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 thefollowing:

(1) Minimally invasive transbuccal surgery to re-move upper cheek teeth or lower 06–08 teeth.

(2) Buccotomy and dental elevation through thelateral alveolar plate.

(3) Retrograde repulsion with pin or punch.(4) Division of the tooth orally with extraction in

fragments.17–23

Surgical extraction is not reserved only for ex-treme situations when oral extraction has failed.When used appropriately on selected cases, surgicalextraction may be more conservative and cause lessmorbidity than intraoral extraction. Excessiveforce might be required to extract a tooth orally, andthis could lead to fracture of roots, adjacent bone, orboth. Surgical extractions often allow for more con-trolled removal of bone and elevation of the tooth,leading to a more predictable outcome.

Intraoral Extraction Procedure

Careful preoperative examination of the patient isimportant, and all aspects of the approach to ther-apy should be planned thoroughly before surgery.Radiographic and endoscopic examinations shouldbe carried out before and after surgery to supportthe clinical findings. When available, additionalimaging techniques such as digital radiology, fluo-roscopy, scintigraphy, computed tomography, andMRI may be indicated.

A basic set of dental extraction instruments in-cludes the following:

(1) Dental spreaders or separators with the propersize blade and angle of handle to fit between themesial and distal margins of the tooth to beremoved.

(2) Various molar extraction forceps to fit thecrown of the tooth being removed.

(3) Three- or four-pronged forceps for toothelevation.

(4) Dental fulcrum set.(5) Extirpation or turning (offset head) forceps.(6) Set of dental elevators, gingival elevators,

picks, and curettes.(7) Quick-release C-clamp or elastic band.(8) Steel or hardwood leverage bar.(9) General orthopedic instruments.(10) Material to pack or cover the dental socket

(iodoform gauze, acrylic, base plate wax or polyvinylsiloxane impression material, Plaster of Paris,honey sugar) (Appendix A).

Intraoral tooth extraction is best performed on thestanding horse, although general anesthesia may benecessary in a nervous or fractious animal. Seda-tive analgesics are administered, and the horse’s

head is restrained in a steel frame, dental halter, orhead stand. Regional anesthesia is helpful in gain-ing patient cooperation. Pain management stan-dards of care require regional or local infiltrationanesthesia for extraction of permanent teeth. Afull-mouth speculum is needed to gain adequate ac-cess for working in the oral cavity. A headlight orspeculum light is essential for good visualization.Oral photographs taken before and after surgery areoften helpful in documenting the surgery and ex-plaining the procedure to the owner and referringveterinarian.

A tooth with a healthy crown is loosened by plac-ing a thin blade spreader between the mesial anddistal interdental spaces of the involved tooth (Fig.1). Special care must be taken to avoid looseningthe 06 or 11 tooth when extracting a 07 or 10 tooth(spread first on the side with the most support:between 07 and 08 or between 09 and 10). Thespreader blades are carefully placed between theteeth at the gingival margin and the handles closed,bringing the blades partially together. Justenough force should be placed on the spreader toslightly move the tooth. The blades are held in thisposition, placing pressure on the periodontal liga-ments, stretching them beyond the elastic limit overa 5- to 10-minute period. The spreader is removedand replaced on the opposite interdental space andthe handles again are closed, prying the teeth apart.This process is repeated until the thin blade spread-ers are easily closed both mesial and distal to theaffected tooth. Teeth with split or damaged crownsmay not be suitable for spreading and can often beloosened with an equine dental elevator and forceps.

Fig. 1. Three sizes of molar spreaders or separators. The widthand angle of the blades determines the amount of motion andseparation produced when placed between two cheekteeth. Proper placement is critical to prevent fracturing theexposed crown of the tooth.



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Next, the gingival mucosa is separated from thebuccal and lingual edges of the tooth crown with asharp gingival elevator or osteotome (Fig. 2). Thiswill expose enough tooth surface area to allow for-ceps to be placed on the crown. It may be advan-tageous to remove a collar of alveolar plate on thebuccal and/or lingual edge of the tooth crown with asharp right angle osteotome or periotome to allowthe forceps to be placed more securely. When usingthe dental forceps or elevator on the palatal side ofthe upper teeth, care should be taken not to damagethe palatine artery.

The properly sized extraction forceps is placed onthe tooth crown (Fig. 3). The forceps can be securedwith a quick-release C-clamp or length of rubberelastic wrapped around the handles (Fig. 4). Max-imizing the purchase between the head of the for-ceps to the crown of the tooth is the most importantaspect of instrument selection. Sagittally frac-tured cheek teeth may have food material stuck inthe fragment fissure: all such material should beflushed/removed to allow the fragments to comeback together and permit better placement/pur-chase of the extraction forceps on the clinical crown.The forceps are then rocked from side to side in alateral-to-axial oscillating movement. This motioncauses the tooth to rotate on its long axis in thesocket. The forceps handle should be moved over avery short range of motion to ensure that the head ofthe forceps stays engaged on the tooth crown. Slip-

ping of the forceps requires immediate reexamina-tion with possible repurchasing of the crown. Thiswill help avoid abrading or breaking the tooth.Torsion can be placed on the tooth with a steel orwooden leverage bar, using a rotating movement ofthe forceps handles (Fig. 4). This allows the toothto move from side to side in the socket. Unduehaste or excess force must be avoided. Care mustalso be taken to prevent crown damage from suddenmovement of the horse’s head. Application of thethick blade spreaders at this point can be helpful,along with repeat forceps motion to encourage fur-ther loosening of the tooth. When the tooth beginsto become mobile, a sucking sound can be heard andfrothing blood can be seen around the margins of thetooth. Progress can be checked by removing the

Fig. 2. A set of equine gingival elevators and right-angle os-teotomes. The blade angle and length can be used to a mechan-ical advantage when working in the deep recesses of the oralcavity.

Fig. 3. Several sizes and head configurations of box-head equinedental forceps. The size and shape of the head of the extractionforceps must be sized to fit tightly on the margins of the toothcrown. Most of these forceps are made with parallel jaws whenproperly seated on the tooth. The process of sizing a forceps fora particular tooth is similar to a mechanic choosing the right sizesocket wrench.

Fig. 4. Adjustable quick-release C-clamp and rubber tubingused to secure the spreader or extraction forceps handles. The18-inch long, 1.5-inch diameter bar of locust wood can be used asa leverage bar to place torque on the extraction forceps han-dles. Using this tool and technique, the tooth can be rockedsideways in the dental socket during loosening.



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forceps and digitally palpating the crown formobility.

Keep in mind that the tooth is like a post in a hole.A great deal of movement must be placed on theportion of the post above ground to be reflected in asmall amount of movement at the bottom of the post.In a young animal with a short ratio of exposedcrown to reserved crown and root, more movement ofthe exposed crown is needed to result in movementat the apex in the alveolus. Conversely, in an oldhorse with almost the entire crown exposed, even aslight movement in the crown puts great pressure onthe roots. The tooth is locked in place because theirregular shape of the reserve crown and roots mir-rors the shape of the alveolus. The thin alveolarplate is relatively easy to deform into the spongysurrounding bone of a normal jaw. Diseased teethmay be surrounded by sclerotic bone, making tooth-loosening difficult. The combined process of dis-rupting the periodontal ligament and deforming thecontour of the alveolus is essential to completelyloosen the tooth and open a path for extraction.

Once the tooth is loose, the forceps should be re-positioned to get a firm grip on the crown. Use of a3- or 4-prong forceps allows the surgeon to get a firmgrip on the dental crown, lessening incidence of slip-page from the crown of the tooth as it is elevated(Fig. 5). A properly sized and shaped fulcrum orblock is placed near the head of the forceps (Fig. 6).A reverse fulcrum forceps may be helpful to elevatea 06 or 07 from the alveolus (Fig. 7). Gradual, firmtraction will readily bring the loosened tooth fromits socket. The tooth must be extracted along itspath of eruption to gain the best mechanical advan-tage. Teeth of young horses that have long reservecrowns and are located in the caudal recess of theoral cavity may require sectioning with a molar cut-ter or Gigli wire saw to allow delivery into the oralcavity. A turning forceps may facilitate delivery ofthese long teeth into the oral cavity without section-ing (Fig. 8).

The extracted tooth should be examined to makesure it has been removed in its entirety and that noroot fragments or slivers of crown have been left inthe socket. The alveolus should be examined digi-tally and with an endoscope or dental mirror, andany bone or tooth fragments must be removed.Operative radiographs will confirm that the correct

Fig. 5. A set of three- and four-pronged extraction for-ceps. These forceps provide a firm, nonslipping grip on the toothand aid in elevating the tooth from the socket. The three-pronged forceps come in a right- and left-side design and areavailable in wide (upper) or narrow (lower) widths.

Fig. 6. A set of fulcrums in a wide range of sizes is helpful inelevating the tooth from the socket. A soft metal such as alumi-num and a design that distributes the compression force appliedto the forceps over a wide area of the dental arcade reduces thechance of iatrogenically damaging a tooth.

Fig. 7. A duck-billed and a four-prong reverse fulcrum for-ceps. These forceps allow for a fulcrum to be placed caudal to thetooth being extracted. This allows better leverage in elevatingthe 06 from the socket. The prong forceps has an adjustablescrew in fulcrum attached to the extended end of the forceps.

Fig. 8. Extirpation or turning forceps with an off-sethead. This forceps is often confused with the smaller incisorextraction forceps. This forceps is used to grasp and rotate orturn a partially elevated caudal cheek tooth into the mouth sothat it can be removed without sectioning the tooth.



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tooth has been removed and that the alveolus is freeof tooth and bone fragments.

Dental fragments and pieces of lose bone can oftenbe elevated from the socket with angled picks, ele-vators, and curettes (Fig. 9). In human dentistry,attempts at blind retrieval of small root tip fracturesmay prove excessively traumatic, and the risk ofremoval of small root fragments embedded in thebone often outweighs the benefit. As a rule, roottips can be left in place if they are under 5 mm inlength, if there is no evidence of periapical pathol-ogy, or if the removal process might damage adja-cent structures, open the maxillary sinus, or causeuncontrollable hemorrhage.24 The same criteriaapply in most cases encountered in equine dentistry.

After surgery, lower cheek tooth sockets that arechronically infected or contaminated with oral de-bris may need to be drained ventrally. This can bedone using a quarter-inch Steinmann pin or a half-inch trephine to create a hole in the ventral lateralaspect of the mandible below the affected alveolus.The open alveolus is protected by the placement ofseveral 4 � 4 gauze sponges tied in the center to alength of quarter-inch umbilical tape. The tapeends are passed into the empty alveolus through theoral cavity and out the drainage hole. The gauzeroll is wedged firmly into the space between theopposing teeth and secured in the socket with um-bilical tape tied around another roll of gauze on theoutside of the skin incision. The gauze should bechanged every few days and the wound irrigated

until the periphery of the dental socket is coveredwith healthy granulation tissue (5 to 10 days).

The alveolus should be protected for several weeksfrom oral contamination with a patch or plug ofdental acrylic, dental base plate wax, polyvinyl si-loxane (PVS), or polymethylmethacrylate (PMMA).The entire plug should be about one-fourth thelength of the reserve crown of the removed tooth toallow room for the formation of a blood clot anddevelopment of granulation tissue in the dentalsocket. When using dental acrylic, dental baseplate wax, or PMMA, the plug should extend onlyslightly above the top of the gingiva so that it is notinvolved in chewing. After the plug is in place, itssurface is molded carefully with a finger to build aslight flange over the gingival line, sealing the alve-olus. When using PVS, this rubbery materialshould be molded slightly below the gingiva to pre-vent it from prematurely coming out of the socket.Bone cement (PMMA) can be combined with radio-opaque contrast media or antibiotics if needed.

If a hard setting material such as PMMA or dentalacrylic is used, the plug will need to be removed 6 to8 weeks after extraction. Removal may require afour-pronged extraction forceps. Older horses withshallow intact dental sockets do better with no den-tal packing or plug, leaving the sockets to fill withgrass or soft, leafy hay.

The objective of exodontia should be to carefullyplan and execute the extraction and protect the den-tal socket, thereby minimizing complications. De-tailed descriptions for avoiding and managingsurgical and postsurgical complications can be foundin the literature.25–29

Appendix A: Equine Dental Extraction Instrument Suppliers

Pegasus Instruments, Manfred Stoll, 65329 Hohen-stein, Germany. www.pferderpraxis-stoll.de.

Instrumentation Concept, Inc., 2936 RewardLane, Dallas, TX 75220. 214-850-9142. www.instconcept.com.

Precision Technologies, T/A Herbst Manufactur-ing, Kilpool Hill, Wicklow, Republic of Ireland.35340467164. www.precisionvet.com.

Harlton’s Equine Specialties, 792 OlenhurstCourt, Columbus, OH 43235. 800-247-3901. www.Harltons.com.

Alight Equine Equipment, LLC, 80 Clinton Street,Suite D 400, Hempstead, NY 11550. 888-653-1563.www.alequine.com.

Medco Instruments, Inc., 7732 W. 96th Place,Hickory Hill, IL 60457. 708-860-7413. www.medcoinstruments.com.

Dr. Fritz Endoscopy. 502-938-8051. www.dr-fritz.com.

Butler Schein Animal Health, 400 Metro Place N.,Dublin, OH 43017. 888-691-2724. www.butlershein.com.

Fig. 9. A set of long dental handles with holes for removablepicks, elevators, probes, and curettes, set at 45, 75, and 90 de-grees to the shaft. Tips of different lengths can be attached withan Allen screw at a degree of rotation for an endless variety offorces placed in the dental socket.



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Equine Intraoral Cheek Tooth Extraction - AAEP Intraoral Cheek Tooth Extraction K. Jack Easley, DVM, MS, ... cheek teeth in the horse was via the oral route.13 Oral extraction has