Ladies and gentlemen, welcome to the webinar vet tonight. My name is Mark Hedberg and I'll be your host tonight for this evening session on surgical extraction of the fractured upper caracal on a wait in the 208. It's my pleasure to welcome Jens here, Jan Ro.
Now, he's a diplomat of the European Veter Dental College since 2004 and he's run the veterinary dental referral clinic than die clinic. And I hope I've got that right in Denmark, near Copenhagen. Yes, he hosts many courses, theoretical and practical at his clinic and covers everything from basic procedures up to the advanced.
It's my further pleasure to welcome and thank Mars Pet Care for sponsoring the session. This is part two of the session and also welcome Mary Louise Bennett here for and thank you for supporting our course here. Well, a bit of a different format from normal here.
We'll have a, a presentation from Yens here. We'll have a few videos and then once the videos are complete, we'll throw the floor open for questions. So thank you once again for coming in, Yen.
It's over to you Thank you, Mark. Thank you for your introduction. And I also want to thank both the webinar be and also mass Pet care for inviting me to do this lecture, which is of course, in my opinion, very, very important that is looking at the extraction of the fractured upper kacal.
And and why do we want to look specifically on that? Well, that's because actually the upper Kacal very often fracture due to heavy chewing forces. These kacal are the primary chewing teeth in, in dogs.
And since the upper kal is a little bit weaker than the lower Kasal, the first molar in the mandible, we very often see fractures of the of the upper con like you would see in this picture where you have a complicated fracture of 208 with an exposed pulp. And that of course, needs needs to be addressed, no tooth with a complicated fracture, an exposed pulp will heal by itself. So it of course, needs to be addressed.
And what we do is we take an X ray, this is the actual X ray of this tooth. And you will see that from the X ray, you can see that the pulp goes all the way to the fractal line. And that's also what we see clinically.
We see the bleeding from the pulp and we can then determine on the X ray as well that this is a complicated fracture. We also see some radiolucent reaction about around the apex of the distal roof. So this is definitely a tooth which is painful but also needs treatment.
And one of the treatment choices could be to do an extraction of of this tooth. There was actually a pretty interesting study done by Maria Salter Rivera from the University of Pennsylvania five years ago together with the with the staff there, but they looked at these chewing forces and how much force it would need for a tooth to actually to actually fracture. And, and that showed that the average force that was, was was needed in, in these cases, was 1200 Newton.
And the angle of the of the biting would normally be an average of, of close to 60 degrees. And they looked at 24 teeth and found that half of them had complicated crown fractures. And, and further five of those teeth have complicated crown root fractures.
So it's pretty severe that a large number of these teeth actually carries a immediate pain and these to be addressed immediately. So, the the chewing force is the breaking point. And nuisance also shows us that actually there's a lot of chewing object that will be able to cause this factor because many of the Jews that are giving to dogs have a breaking point which is a lot higher than 1200 newtons.
And this is why we try to avoid, try to, keep people from feeding their, their dogs shoes that have a, a higher breaking point that the worst ones are now getting closer to Christmas is of course, an, it is bones, basically ox bones. It's also hooves and claws and, and yak milk, blocks as well. These these chewing objects that dogs like to chew on because they are tasty.
They very often cause fractures and most of the time it is fractures of the oration. So if you wanna look for, for shoes that you could say safe for the doctor to chew on, you should be looking for the V All Health Council's seat of acceptance. This seal actually looks for evidence-based facts that there is a help in the control of tar and, and the plaque, but it also looks into the negative side effects, being fractured teeth.
And if a tutor would show to have an increased number of, of fractured teeth due to the the hibi loads, it would lose the seat of acceptance as, as you can see, this is a stream dump from from the online vhc.org list of of approved Jes where the p dentist take advanced is, is one of them and also some of the products are very, very helpful there. I actually myself was a short time member of the BHC, the Council and evaluating these these two.
In, in diagnosing this, we we use the X ray and see in the, on the left hand side here, if you do a normal bating angle technique picture, it's sometimes difficult to distinguish whether the pulp is exposed or how much denting is over the pulp because you see the pulp is lying here in the middle of the circle and the fractal line is covers a lot bigger surface. And what we try to do in our x rays is to do a shoot. That is parallel the eight grade beans to the fracture line like we do in this picture where you can see that it's actually a small distance from the pulp and to the exposed dente on the outside.
So in a case like this where it's a very close meal exposure, we can actually save the tooth by doing a vital pulp therapy. In other cases, we will have a complete exposed pulp. And in those cases, we would do extraction or a full root canal therapy like I've done in this case right here.
So as you saw on the first couple of slides where like five hours, 24 teeth showed this complicated brown root fracture. We sometimes also see defects that goes below the gum line, even below the vela rims sometimes. And that when you remove that fragment, means that you will have a periodontal disease tooth.
Following that, it's also a weakened tooth due to the loss of substance. And sometimes you also have the pulpy due to the Nepal exposure. In this particular case case here, you can see that after removal of the loose fragment, you have this large defect sub gingerly on that tooth.
And on the X ray, you can even see that this is not a very fresh fracture because you have a large radiolucent area around that that group, all the three roots actually, but most obvious around the distal route right here. So this is actually definitely a tooth that is a candidate for surgical extraction. So when we look at these neal exposures, what we are looking at is is this is our rule of thumb to the distance of of dentine and the action to be taken.
These are not accurate numbers, but these are kind of a a guideline as to how to address when you're standing in the clinic and and looking at these fractured upper kacal. And what we use is that if you have more than two millimeters of dentine, you shouldn't have to worry about that. You can address seeing on the exposed dentine to prevent migration of bacteria into the deep layer of the dine.
But the pulp should be OK. And then of course, we remove any shabby if you have between one and two millimeter. I would recommend that you always do a ceiling and also maybe place a restoration.
Remember that on the Kacal, the restoration should be very thin, very thin layer because you cannot build up that tooth ground in a composite material because that will fracture off. And when it does that due to the fracture forces of the bonding, you might end up with having an excess amount of dentine fracture off together with the composite and that causing an open pulp exposure. So a very thin layer of restoration.
If you have a fracture with between half a millimeter and one millimeter, you will definitely have a Pulis in these pulps because it's so close to being exposed. And depending on the exposure time and the the area of of the exposed pulp. It can be either a a reversible pulpitis or irreversible pulpitis.
And our recommendation is that you, in these cases, do an invasive pulp evaluation, which basically means you drill a hole into that tooth and then evaluate the bleeding of the pulp. If you have a fresh pulp, you will have a fresh bleeding that spontaneous diseases within two minutes of time. If you have an an excessively inflamed pulp, it will continue to bleed.
Normally more than five minutes. And then the pulp is irreversibly inflamed and should be extracted or have a root canal therapy. If you have no bleeding at all, of course, that means the Pope is dead and you need to take action again being root canal therapy or extraction.
If you have less than half a millimeter, you should definitely go for an I pe no matter what and depending on the finding there, go for your further treatment that could be extraction trying to summarize this into one slide. II I and I do apologize for the next slide which has a lot of numbers and, and and and looks a little bit confusing but actually what it is it's trying to tell you what you do. If you see this fractured tooth in the clinic, you divide them into the complicated fractures and the uncomplicated fractures and then the group where you done don't really know whether it's complicated or uncomplicated.
So basically, if you have a complicated fracture in a in a AAA mature, do more than 10 months of age. If it's more than 48 hours old, you should go for root canal therapy on extraction because you would most likely have a irreversible pulpitis of that tooth. If it's less than 48 hours, you can try and do a vital pulse therapy.
Unless of course, you have excessive bleeding from that tooth in very young dogs with, with open Avis. The Pope can actually survive more than 48 hours. And it's, it's it's described in cases that it can survive up to three weeks, that's more than 20 days.
But we normally say an average of 10 days would be appropriate to distinguish between doing the root canal therapy or extraction or the vital p therapy. And because there is a difference between two days and 10 days, I have put in this small gray zone here, which is where you have to use your gut feel to evaluate whether this tooth could be saved with a vital pulse therapy, a root canal therapy or needs expression for the uncomplicated practices. As I mentioned on the previous slide, if you have more than two millimeters, you shouldn't be that concerned between one and two.
You should look to do a kind of seeding or restoration between half a millimeter and one millimeter. You definitely would like to go for an I PE and less than half millimeter and I pe as well. And depending on the outcome of that I pe, you then go for vital pulse therapy if the pulp appears fresh or a root canal therapy or extraction, if you have an excessive bleeding or dead pulp.
So I hope that kind of explains everything. For all the uncertain cases, please go and have the I PE done so that you can then judge on what you actually see on that b instead of waiting year in and year out for that tooth to change in color or create big periodical rau go ahead, do the IP straight ahead. That's our recommendation.
Of course, You do need to be able to do the vital pop therapy as a treatment. If you do these IP S if you don't do that, it doesn't really make sense, you might as well go for the extraction. Then when we do the extraction, my recommendation is to remove more bone that you think you should.
And that is because fracturing roots or even fracturing jaws during extractions. That happens when you are struggling with that root because you didn't remove enough bone. So my recommendation is to always remove 180 degrees around that tooth.
So we kind of loosen all the facial portion of a little bone covering that root and then in the height of around 80 maybe even sometimes 90 90% of that root. So you actually remove a lot of bone around that tooth. And then when you work with your loading instrument on the palatal side or lingual side of the lower jaw, but in this case, palatal side, then the root will then loosen and then chip facially and then more easily be removed without the risk of fracturing.
The root itself, make sure to preserve the root. When you remove the, the Alvear bone, don't remove bone tissue, sorry, the root tissue as well because that will weaken the root as well. So preserve the root, remove the bone with your B and then use your laxatives to do the rest of that, of that job.
When we look specifically at the upper Kacal, my method is to do a partial round the serving, extraction and brown amputation, amputation design. And what I do is I start by raising my full thickness flap, the red dotted line. And here and after having done that, then I do drill away the bone, 80 80% of the height of that route, 180 degrees around that coverage of elbow bone around the root on the measle and on the distal route.
After having done that, I separate the distal route from the two mesial, the mesial and the poll roots. And I do that in a line that is a elongation of the mesial portion of that distal route. So following that line is the, the green dotted line here.
That is where I divide my mission route from the two, sorry, my dit route from the two me routes. And after I've done this section in here, I then amputate the crowns of the two initial routes, the initial route and the Pola route. It's the blue dotted line here after having done that and then take my Luxor and gently extract the distal root.
Having done that, I then with my bird divide the two roots, the palatal and the initial root divide them by drilling into this figure of eight that I have the two roots looking like after the crowns have been amputated. And then I gently luxate my me root. After having loaded my me root, I then remove the pony coverage on the facial side of my pola root.
And then gently locate that. After that, I then smoothen my edges. I prepare my flap and suture it in to cover the the defect.
So this is a step that I will show in the in the videos. First, we will see one video that is performed on a cada case. And the second shorter video is on a live case.
Unfortunately, that live case didn't have a fracture but was a period case. So the coverage of bone around the tooth is not really very showing for the normal fractured teeth we see but you still will be able to see the procedure on a on a live case. So if you want to sign up for the the pedigree free oral care kit, you can scan this code right here or you can contact mass pet care directly.
But please look for that. This is the guidance to to improve the oral health of of your dogs. So, I think we would now then switch to the to the to the videos and then after the two videos that you will be able to put your questions and feel free doing the videos also in the chat to, to put your questions.
So we can kind of collect them and start answering the questions right after the two videos. So please shoot ahead and I'll do my my best to, to answer all your questions, but lean back and enjoy the videos, right? And just for a moment here.
Thank you very much, Jens really enjoyed that introduction there. And it's really, I, I loved seeing heat which is really broken down step by step per millimeter per step on this video. I want to show you how to do a surgical extraction of an upper Kacal.
I use a size 15 blade and a round handle. The round handle makes it easier to do nice incisions. I then cut from the mucosa and towards the more firm gal tissue to be able to control the exact positioning and size of my reading, releasing incisions.
I do a pinnacle flat with tube, releasing incisions and a broad base and a more narrow top towards the crown of the tooth. The incision line should be ending at the neighboring blind ankle so that you preserve the incidental pilla on both sides to get a better gingival healing on the persisting teeth that will stay in there. So I cut from the mucosa up to the ging tissue and then I cut along the ging sulcus and try to be gentle to preserve a very nice edge of that ging tissue because that is what you're going to suture onto the palatal side in the end.
So take really good care of that. And that is crucial in having a good healing with a less risk of flat direc in the mit side as well, serving the interdental pillar, gently handling the gentle tissue. If you have a deep pal pocket with thickened epithelium, you can do a reverse beel incision to leave that thickened epithelium onto the tooth and have a fresh edge on your flap to suture to loosening the flap.
The attached in tissue. I use a sharp pal elevator and work with that in a palm grip and starting at the corner of my flat, working my way down to the Muku gentle line instead of working from the Coronal part in the middle of the tooth and then down, then there's a risk of penetrating the flap at the minar line and that causes a bigger risk of flap di essence due to the poor blood supply of that flap. So what I do is I loosen the corner and then work my way alongside that Ingle junction to preserve a fine and healthy flat.
Also take care of the Muku junction in the corners. So you don't have a defect in there. And then when I come close to the other side, I will start at the other corner and then meet my loosening of the flag on the middle of the tooth and then raising the full thickness flap.
As I go beyond the, it attached into a tissue into the vela bone, make sure to have the periosteum in the flap. So it's a full thickness flap and a clean exposed vela bone because the periosteum is what you will have needing the healing of the of the ve bone after the extraction. So that part is very important to preserve as well.
You might be able to see here that when I go beyond the junction, you can see that I preserved my flap and very nice and clean and smooth edge, which is healthy and with a good blood supply. And then I need to now loosen that flap, full thickness, meaning I need to have the periosteum as a part of that flap. And you can see how I loosen the periosteum there and have that as a part of my flap.
And then I do some far enough up dorsally in this case to be able to expose the roots up to at least 80% of the whole root surface on the facial side. 180 degrees around the root. So I want to remove a lot of bone to be able to extract that tooth without the risk of root fractures.
But and when I manipulate and hold my flap, I use my pal elevator or I use my fingers. I do not use pliers because pliers can actually crush the tissue and cause a poorer healing due to the poor blood supply after having crushed that. So if you hold too firmly with the pliers on your flat, you might destroy the circulation of the ginger tissue at the most coronal part.
So here now you can see that I loosened up to be able to remove the bone from RB. I use a high speed bear with a cutting straight cutting fissure bear. In this case, it's a Lindeman type fissure bear which is my favorite.
And I start by creating a window just facial over the route, creating a window through the bone into the surface of that root. And when I do that, I start by drilling down into a depth where I can see a very thin red carpet which will be the parental ligament. And then I funnel that red carpet out to both sides measly and distally to be able to expose the whole root surface.
The vela bone is removed 100 and 80 degrees around the root surface and you follow the periodontal ligament space down on the metal side and on the digital side of that route. Still. While I do this, I gently hold back the soft tissue to avoid damaging that because that is what we'll be using to close the flap after the surgery.
After having expose the major route, I then moved to the digital route. I work with the straight cutting bird along the long axis of the tooth load to prevent leaking in to that growth and removing too much substance of the dine in the route, creating a more weak root that could fracture when I start locating the root. So preserving as much root as possible and then only removing the facial bone, copping the root.
And I tried to go as close as possible to the neighboring teeth. In this case, the 109 on the distal part and 107 on the initial part. But keeping at least one or two millimeters distance from the neighboring tooth routes after having expose the roots, I then split the tooth into two halves so that the one part will be the distal root.
And the other part, the two mis roots, the mesial and the P root. I split the route in a line which is a continuation of the line, holding the periodontal space from the visual part of the distal route. So I try to follow the same line as the route outlines because that will ease my access with the luxation afterwards.
Also, this means that I will split the tooth in a thin area of the crown. So I don't have to spend as much time in dividing the truth. It is in this area, we often see the facial slap fractures so that can add to the loss of two substance there.
And the less two substance you have to cut through the quicker the procedure will be. So now I gently cut through the crown after having split the two into two, I then amputate the crowns of the two mi routes, the mill and the pole route that is done to get a better overview of the two routes I have to expect after the meal route. And also to get better access with my Luxor to loosening the distal route.
And you can see I'm gently holding back the soft tissue with my periosteal elevator. I'm using a pencil grip on the turbine and a hand support to have the correct economical positioning of my arm and my shoulders resting on the lower jaw. Now I turn the turbine and then I do the crown amputation of the mill and the pell root.
If you are afraid of getting too close to the neighboring tooth here, the 107. In this case, you can stop the translation just before you end the crowns of the 108. And then you can use your Luxor or pal elevator to crack the last bit.
As soon as the crowns then are loosening, you will take your extraction forceps and then pull the crowns out. They will still be attached a little bit to the tangible tissue just at the margin on the palatal side, they loosens and you expect the crowds gently. And now you start with your Luxor locating the distal route and you will start by loosening the tooth, the gentle tissue in the palatal side, you have attached gentle tissue towards the crown in there.
You just loosen that with your Luxor and then you will start working your way down gently towards the apex of the tooth. Gently wiggling with your laxer and your distant control finger at the tip of that. And you can see that it easily loosens.
And as soon as it gets loose, then take your extraction forceps, grasp the crown and gently turn and pull, checking that the root tip is intact. And now you have a figure of eight showing the two routes, the palatal and the misha route. And you then let your cross section bird, your fissure bird, then divide these into two separate routes.
So to simply cut through the speaker of eight, leaving the two routes separated. After having done this, you then take your Luxor and work on the mis route on the palatal miso palatal and digital pale side. And like with the digital route, you then gently vibrate or quick, oh, you are located towards the apex and you will see that it easily loosens if it's a little bit too tight still when you feel that you can't take your burwell away a little bit more.
See, I work with the handle in my palm with the chip very close to my control finger. And then when it loosens, I take my extraction forceps, twist and check that the root tip is intact. And then I only have the palatal root left and I simply remove the facial part of that coverage of vela bone, which will be the inter particular septum from the elevators from the palatal root and the and the mesial root.
So I simply expose this root surface gently with my be. And after I've done that, I then take my Luxor just as I did with the measures route, I then go on the palatal misia, palatal and distal palatal corners of that route to press my Luxor gently dial along the long axis of the tooth route, vibrating with the tip and then gently working towards the apex until that route also loosens root fractures. Often happens when you are close to having the tooth root loosening.
So when you're close to the goal, you get overexcited and then you apply too much pressure. So as soon as you feel the root is starting to loosen, you just step back and take a deep breath and then gently work on and then take your extraction forceps to rotate the root and then gently pull it out with a retraction, the force Yeah, I'm working vibrating my laxer towards the apex. I have my distant control finger making sure that I don't suddenly slip up into the nasal cavity or up into the orbit.
So whatever I work with right hand or left hand, I still have my control finger close to the tissue to avoid any unnecessarily damage to the tissue. Gently twist the tooth long axes, retract and check for an intact and smooth surface of the apex. And now I will then take an X ray to check that all root remnants are out.
And then I will remove any spikes of P that can be irritating during the healing procedure. If the dog is chewing there to expose the elder bone and to also lift up the tint of tissue to be able to place my suture more easily. I then with my gut elevator, lift the petal part of the tial tissue, then I smoothen all the edges of the bone before preparing my flap and turing, checking for any spikes and just checking that I have access to the palatal tangible tissue.
And then I have to design my flap to be able to cover the defect because the periosteum on the inside of this full thickness flap is un easic. I have to split that and I prefer to do that with a blood dissection. So I take a sharp dissecting scissors and then I cut through a little opening and then I bluntly dissect that because by tearing this blunt, I avoid damaging nerves or vessels, they can be stretched but they won't be cut if you do this and blunt.
But since the periosteum is inelastic, if you do this bluntly, it will be tall and you then are able to move the flat more around because it gets doesn't because the connective tissue and the mucosa epithelium is elastic. So now you can see easily with no tension, I can place my flat back onto the defect and covering that suture. In that I always start by suturing placing one stage suture in each corner of the flap and then I fill in all the remaining shoes.
Afterwards, I place the sutures with a two millimeter martin to the edge. And then I normally keep like two millimeters between the sutures and I then cut fairly short edges. I cut them between two and three millimeters in length.
And I use preferably a monofilament suture, size 50 in small dogs and 40 in large dogs. Make sure that your sutures are tight in the knot, but not tight into the tissue. You should be able to see that you don't see any ischemic reaction in the tissue where, where the knots are located.
Because that will then cause a a greater risk for the essence of the flap. So make sure that you don't tighten the first part of the knot and when I do single interrupted knots, especially with the size 50 monofilament, I use an extra winding. So it's one bubble and then three single windings following that to make sure you can tighten the knot without tightening down into the soft tissue.
So here I will fill in with a couple of millimeters within between and this is the end result. Well, thank you very much for that. Right.
Setting up the following video here. So this is a like case of an extraction of an upper Kacal. In this case, the dog suffers from severe periodontal disease and many of the teeth have already been extracted previously.
So we will do the extraction but also extract the the 107. If I was only to expect the 108, I will do the releasing incision between 2107 and 108. But in this case, I will do my second releasing incision mis to 107.
So I have one broad flat covering both teeth since they both have to be extracted like I showed on the cadaver case. I will loosen my my gentle tissue with my pr elevator standing in the corner of my flap and then working alongside the mobile junction to prevent the flap from getting damaged from the loosening. And as you can see, there's a severe periodontal reaction with some bone recession as well.
So here I exposed the distal route. That 108, I didn't even see a only defect in the fur area which is a it caused by the periodontal disease. I then also exposed the region root.
And then having done that, I then split the tooth into the distal route and the to meal and palatal root. In this specific case, the palatal root is partly resolved. So we don't have a full root on that tooth.
The palatal root is, is partly resolved at the apex. So I've stopped by dividing the tooth in an ankle that is a or continuous angle of the ligament space from the, from the mesial part of the distal route. And having done that, I then amputate the crowns of the Meshal and palava root to improve my access to the distant road.
I then use my Luxor with a control thinker at close to the tissues and then I worked my way, the palatal sight down towards the apex until the tooth loosens. And I then take my extraction forceps and twist the tooth along the long axis of that tooth root by gently wiggling from side to side until it loosens. This end procedure with the extraction forceps is actually a cheering procedure by your tear, the penal ligament instead of cutting as you will do with your Luxor and then divided the two roots, the vial and the palatal and remove the facial bone over the potato root and then take my lux gently loosening that tooth until it's so load I can remote with, with my inspection forceps there and check the apex.
And then I will do some of the political route. But in this case, you would not see a full route because it's partly resolved, but I will remove the remaining parts of that two substance. And of course, check with the ad X ray that we don't have any root remnants left in there.
Before any closure, there was a small root fracture of the ras root. So I remove a little bit more bone and then with my ox to go down and loosen that apex, pull that out. It will be exposed to the remaining parts of the route and then extract that gently with the Luxor.
After having done that, we then split the third pre moder, the 107, which is also to be extracted and then gently divide two roots and extract them one by one with the Lueder and the extract in FPs. If I feel too much resistance, I will just take my turbine and remove a little bit more of the facial bone to be able to loosen that tooth and extract it gently without any risk of root fractures. After having finished the extraction, we then smoothen the bony surfaces, take an X ray to check for any root remnants and then su at the flap.
Well, thank you very, very much. That was a great video. Lovely, lovely explanation there.
It's really, really nice to see something in, in the line of fire, so to speak. I'd like to on behalf of everyone. Thank you very much for your, your time here this evening and we have a great number of questions that I'd love to get down to at least 10 in the Q and A s and a few more in the chat.
So, right. Let's start with something. So it's a question here.
How high up the palal root? Can you remove the facial bone? The questioner was told there's a blood vessel that can run between the mesial roots.
So get a bit concerned could hit this if they go too high towards the apex. Yeah, it's, it's, it's, it's a really good question. What you'll find out there is the infraorbital canal, which of course lies differently from door to door.
But you can, you can always look at the Rusal opening of the infraorbital canal to get an idea of where that is actually located, how high that is. But I would say that in 99% of the cases, you can remove 100% of the facial coverage of that of that route. It's still 1% left.
But you might have AAA small risk of going up there. And the intraorbital canal, the blood vessel there, the intra infraorbital artery is not a vessel. You would like to open up at this point.
So what you should do is like preserving maybe like five or 10% of that root coverage. And you will still be able to gently remove that because the the hardness of the bone surrounding that tooth is very fungus. So it is not that difficult and you will see very few root fractures if you remove this, maybe just 80% of that tooth.
In in that case, you're home safe regarding getting into the infra optal canal. Lovely. Thank you very, very much.
Question here. What's your preferred suture material and size? Oh, my first switch material is is a monofilament, size 50.
And that could be mono fasts or mono rill or whatever. But that would be my preferred. It's, it's obvious that the knots of the monofilament are not as stable as when you use poly filament.
But it gathers a lot less debris and causes less inflammation. So I normally use the monofilament because I think the healing is nicer. If I do large surgical resection, tumor, surgery like that in those cases, I like to do a polar filament sutures because in those cases, the sutures need to stay a little bit more crucial than a symbol flap and a surgical extraction.
Nice. Thank you. Thank you very much.
What do you do with your flap when the gingiva is very recessed. Oh, then I actually, sometimes I don't have any tangible tissue at all. And in those cases, I sued the mucosa down and one should be aware of the fact that the mucosa has, has more free nerve.
And so it's more painful for the patient to carry sutures in the mucosa compared to carrying sutures in the ginger tissue. So when possible, I will preserve my ginger tissue. But if I don't have ginger tissue, it's not a catastrophe.
So you can actually suture in the mucosa. What is more important is that if I have a very thickened epithelium on the, on the, on the on the two side, on the inside the, the, the the in the, in the pocket of that parental space. If that's very thickened, I will remove that before trying to shoot you because I don't want epithelium towards epithelium that gives a poor healing.
I would like to have fresh bleeding sides to have a, a more swift primary healing of that flap. Nice. Well, thank you, thank you very much there.
Question here from another one is, here we go. What do you do in case of severe ansis? Oh, then I swear to start with.
But normally, normally, actually, I will see that on my X ray and also when I plan my removal of bone, if I have, if I have a young dog which they tend to have a more wide parental space that are easier to loosen. Then I might only remove like 60 or 70% of the height that are available. If I have a very ankle lo tooth, I will remove more bone and I will maybe go even further than 100 and 80 degrees around that to drill away more of the bone to kind of lower that amount of attachment.
And then I just struggle a little bit more when you work with your Luxor and you try to press that towards the apex. Sometimes people tend to twist the luer away from the tooth to try and, and squeeze that tooth out. And I believe that that increases the risk of root fractures.
So if you want to work that way, what you should do is actually push your lax towards the tooth side of that pal space. In that case, you put your pressure on the vela bone moving down there more than on the tooth and that diminishes the risk of root fractures. So it's a little bit is a little bit different from what you think you should do.
You want to put that lox down and move away from the tooth, you should actually move towards the tooth and then we go into the bone and that gives a a bigger bigger chance of getting towards the apex without the fracture. Oh I never thought of one of one of those things that when it's explained, it's logical but it doesn't, it doesn't really occur to your first thought. Thank you.
Thank you. To me. It wasn't, it wasn't logical to me until I was, that was explained to me.
But, but having realized that in real life, it actually does make a difference. Right? Here we go.
This question here. Would you have any particular good resources you recommend? I have videos of nerve blocks for these extractions?
I think the internet is full of both good and bad videos and instructions and, and this could be an example as well. This video that will probably be available for some time that you can, that you can watch over and over again. I dream in my perfect world that at some point when I get older, I will have time to do instructed tutorial videos on all procedures.
I know that would be great. I don't have specific home pages that I would like to refer to, but I mean, there's a lot available in, in also good quality videos on the internet. OK.
Thank you. Another question. Do you get the question often about what do wild dogs do if they eat bones all the time?
And actually, it's a good question. But the simple answer is we don't have wild dogs. Because I mean, the dog is now domestic size has been so for centuries So it's not a wild animal anymore.
Having said that I do a lot of treatments in, in exotic like the large cats, like in, in, in tigers and lions and pandas and leopards, but also in bears. All these species that are carnivores that we will consider wild animals and they do have fractures. They live with them, they have their abscesses and they have their bone infections and they have the pain and the miserable lives caused by this.
So it's not a difference. They have exactly the same problems. No, thank you very much.
Question here. How do you make your choice between a Lux and an elevator if you do use some? Yeah.
The, the it's interesting because it's, it's in, in, in American literature. There's not been a very distinct distinguishing between the two, but there is actually the lux is very fine shot instrument that cuts the ligament while pressing it, maybe vibrating a little pressing that towards the apex. The elevator is a broader, more thick instrument that doesn't actually cut the ligament but actually is is pushed into the pal space and then twisted to tear the ligament.
And in my opinion, tearing the ligament increases the risk a lot to have root fractures. So I try to avoid doing elevator tearing method of of loosening that ligament. The only two they do this with is the upper canine, the 104 and 2041.
You can actually because of the suture lines and the bone inflammation of the, of the ins bone and the Maxillary bone, you can place your elevator there and you can luxate that sh out. But normally I prefer and I recommend to use Luxor and gently vibrate them towards the towards the apex. And there are many different brands on the market.
And, and, and try some and find your favorite one. Nice, nice. And of course, the ultimate question, how often do you sharpen them?
Yeah. They, I mean, we do in the clinic, we sharpen them on a weekly basis. But actually they are tested, they are tested after each use before they go into the auto play.
They are tested if they have any spikes or, or bursts that, that you can feel with your fingertip, they get a short, not a real sharpening, but just a correction of that. It just takes like five seconds to do that on a sharpening stone. It's, it's very easy, but we have a large weekly go through all the Luxor in a mechanical, sharpening machine where we do sharpen all the Luxor.
It really saves time to have Sharp Luxor. Yeah. Yeah.
I mean, if you remember going to some of the older clinics years back and you, you see the elevators or look like spoons and it's like, yeah, also remember that some of the, of the producers actually when you buy a new Lux, they're not always shop real shop. So sometimes you actually have to start by sharpening your new Luxor. So be aware of that.
All right, thank you. Question here. So, you know, we, we very much don't want to leave root tips behind, but life does happen.
So what are, what is the chances of future problems if you leave two or three millimeters of the root tip behind? Should you always, always always go get them out or is there like a little bit that's potentially? Ok.
Yeah. Well, the thing is that you can leave the root tip in, in theory, if it's a healthy root tip. So if the root tip is in place and it hasn't been wiggled around and the, the apical delta is intact and the pulp is not inflamed.
In that case, you can actually leave the root tip in with a good prognosis. So, if you have a totally fresh tooth and you amputate the crown and leave the roots, no charging them and you shoot the ginger bit over that, that should, in most cases heal with no problem. But the problem we have in real life is that the roots we are struggling with, they're always unhealthy, they've been wheeled around, they are infected, they are inflamed, they shouldn't be left in there.
If the root was fine, you wouldn't be taking the tooth out, would you? Exactly. Exactly.
So, what I normally say is, I mean, it's OK to leave root tips in. Only downside is you have to burn in hell forever. So if you don't want to go that way, take the root tip out or refer to someone who can do that.
There is one case though. And this, that's the the noninflammatory result of regions where the root is actually not there anymore. In those cases, you cannot remove the root because it's not present anymore.
And that is more like a gray zone area. And how much should I then drill away because you cannot extract the root, which is no longer there. Mhm.
Right. Thank you. Question here.
Does using a high speed handpiece ever cause bone necrosis? If you if you have insufficient water cooling, another thing I would like to emphasize is that it's been it's been used all over the world by this that they have air driven turbines to drill in bones. And that is actually not the artist treatment because there's a risk of embolic situations in these patients.
If you told some human surgeon that you are using a, a air driven turbine drilling directly into bone, they will, they will faint immediately. It's done by bets all over the world. I don't see a lot of problems, but in our clinic, we actually use electrical motors with an ankle piece.
So you have high speed. But an electrical motor, so you avoid these symbolic cases. And I urge all oral surgeons to use these electrical micro motors, they have a better to better control.
And also, I mean, when you stop drilling the electrical motor, it stops immediately, the turbine will continue a little bit. So it's, it's more safe for the patient and for you working quicker and better and it's not a big investment. So this would be my option to just tell everyone to go get a high quality electrical micro motor with water cooling and then up gear that also when you're talking about the birds and when they get blunt, make sure that you at all time have a water cooling on the whole surface of your bird.
If you use the long cutting Lindeman birds that I use, it's crucial that you give them time, you pull them back, open them to cap the cooling, go to the tip of that bird. And don't, you don't bury that bird into the two substance because it will get hot in there. So you have to sit and move and you will see in the video when I do my drilling, I will be moving my bird all time.
So I have the cooling covering the whole surface of that cutting parts of the bird. So not burying it in there because then it will cause overheating and necrosis. Nice.
Do you use a standard be or do you use the, a longer surgical be there is a question. Yeah, that's, that's depending on the size. I use a longer, lidi type on the larger dogs.
And in cats, of course, I use the smaller, pointed fissures, for the cats which have of course smaller teeth. But I use a cutting, fissure with a cutting tip, size, depending on the size of the patient. Right.
Well, thank you very, very much. I mean, we've answered something about 15 questions that we've got, I think another dozen open here, but we, we've come to the end of our time here. So I'd like to say thank you very, very much again to you for, for spending time here and all the preparation work you've done beforehand.
Thanks once again to Morris Pet Care and Mary Louise for sponsoring ladies and gentlemen. Thank you so very much again for coming tonight and see you next time.
