Patience, Planning and Time: Tips for Successful Extractions

By Paul Basilio

Travis J. Henry, DVM, DAVDC (NSS), DACVDC- EQ, has some invaluable insight to help you plan for equine intraoral extractions in your practice.

“Find somebody in your area that likes to perform extractions, get their phone number, and refer all your patients to them,” he joked here at the 65th Annual AAEP Convention in Denver.

In all seriousness, Dr. Henry touts a calm head, a solid plan and a clear day.

“You have to have patience in planning when you’re going to perform these,” he said. “These are not procedures you do at the end of the day when you’re tired, and they’re not procedures that you do when you’re the primary on-call veterinarian that day. They are procedures that you do when you’ve got an hour or 2 cushion on each side of the procedure so that you are not rushed.”

Starting out

Any plan for extraction should start with a thorough oral exam.

“You’re not going to jump in there and rip a tooth out of a horse’s head without looking at the rest of the oral cavity,” said Dr. Henry, owner of Midwest Veterinary Dental Services in Elkhorn, Wis.

Imaging is another necessity. Even if a tooth feels like it could come out with mild digital pressure, Dr. Henry still recommended a radiograph to see what lies beneath the gumline.

“I also make a point to obtain postoperative films,” he added. “I want to make sure that I’ve completed the job.”

Cheek teeth

When a plan is in place and it’s time to start the extraction, patience and a balanced application of force is crucial. For cheek teeth, the spreaders are often employed to provide interproximal pressure to push the tooth mesially and distally.

“You want to perform this procedure carefully and judiciously when you’re starting out,” he said, because it is easy to fracture crowns when too much force is applied.

“I like to start with the thinnest [spreaders]. Don’t buy a clunky pair of spreaders. Buy a thin pair when you’re starting out, because you want to apply that force carefully.”

Rotating the tooth to stretch the periodontal ligament is the next step. The ligament is great for holding teeth in place during normal chewing forces, but the fibers begin to break down after applying a force in a different direction for a certain time. The broken down fibers then allow the tooth to have some mobility.

“We’re also misshaping the alveolus,” Dr. Henry added. “We’re stretching the bone slightly away from the tooth to give ourselves more space.”

Once the tooth can be moved several millimeters in all directions, a lifting force applied with forceps and a fulcrum will hopefully lift the tooth into the mouth.

Advanced periodontal disease

It’s reasonable to expect a loose tooth in a horse with periodontal disease, but mobility does not always equal a cut-and-dry extraction.

“On radiography in a horse with periodontal disease, we’re looking for horizontal bone loss, vertical bone loss, widening of the periodontal ligament space and periodontal-endodontal lesions,” he said.

Dr. Henry described a case in which a horse was presented with a diastema between the 8 and 9 on the 300 quadrant. When he applied minimal digital pressure, the tooth was markedly mobile, and he thought he was in for an easy afternoon.

“When I performed the imaging, I could see that the tooth was not playing nicely,” he said. “There was a dilaceration of the distal root. Which means a severe curve in the shape of the root. I get concerned about these, because if you loosen the tooth and try to pull it straight up, you’re going to separate the root.”

To get the tooth out safely, he grabbed the tooth to see which way it could move easily. In this particular horse, the tooth was tipping and curving with the distal root, since most of the disease process was occurring along the mesial root.

“When I was spreading the tooth, I was careful not to spread a lot on the distal side, because I was going to increase the force on the curved root,” he explained. “When I got the tooth quite loose with axial movements, I grasped it as mesially as I could. With a small fulcrum—as little as 0.5 cm—I tried to lift the tooth. It curved its way up and out.”

Tooth resorption

Extraction may often be the easy part in horses with tooth resorption. The hard part is going back and finding all the leftover bits and pieces.

“If you don’t get those out, they’ll continue to fester,” he explained.

In 1 case, Dr. Henry had a patient whose presenting complaint was the teeth were falling out of its head. The horse had wide periodontal ligament spaces, marked tooth resorption and loss of attachment.

Following extractions, it appeared as if the procedure had gone cleanly, but a piece of tooth was still visible on postoperative radiography. The piece was not as dense as normal tooth roots, and it got left behind because of the resorptive process.

“When you recheck these horses in 2 to 4 weeks, I would caution you to recheck with a radiograph,” he said. “Not all tooth resorption is the same, and it is vital to remove all of the dental material for proper healing.”

Dr Henry emphasized the need to be patient and proactive in the extraction process. Don’t just keep doing the same thing over and over in the same surgery. If something is not working be ready to move on to another method to get the tooth extracted. It is always wise to think through the entire process before starting the surgery so that your plan includes several ways to accomplish the task and have the necessary instruments ready. One final note is that there are several hands-on courses that happen every year that are very beneficial for honing one’s skills at oral surgery.