It is important to achieve proper patient positioning for surgical extractions in dogs and cats. Veterinary dentistry presents challenges, however little things can often make the difference with efficiency and patient outcomes.
In veterinary dentistry it is important to achieve proper patient positioning for surgical extractions in dogs and cats. We want maximum working field exposure to ensure a functional working position. This includes bur position for bone removal and sectioning if we are working on a multi-rooted tooth. We also want to be able to have it so that when we place our luxator/elevator to gain purchase and progress with elevation we want to be able to use energy from our body to the patient's body in a forward motion. We don't want to be coming from up to down. When you look at this image of the mandibular canine tooth in a dog, that satisfies that requirement quite nicely because the crowns are facing us. In general, this is the desired position for the extraction most of the time. There are exceptions to that but most of the time the crown is facing us.
Here is an image of another tooth with the image the opposite of that above. This is how we normally think of viewing the mandibular canine because that is the orientation we normally observe with the mandible ventral as it is with the patient standing or sitting. Keep that in mind. Here’s the exposure that we achieve when when extracting this tooth with the proper bone removal technique . We take vestibular bone apically to the middle mental foramen making sure that we expose to the bone tooth interface mesial and distal. You can appreciate the foramen peeking out from underneath the gingiva where we’ve removed that vestibular bone. We’ve made our grooves with our 701/701 crosscut bur around that tooth and now we're ready to apply our luxator/elevator. However if the patient is positioned in this orientation it is very awkward to do so. Here we’re coming from the top and going kind of obliquely backward. We don't want to do that.
We want to have the patient like this so that the force for placement and elevation is more natural and easy for us to perform. We move from our body to the tooth moving in a crown to apex direction. We can apply more force, more easily if we are from our body to theirs. Think of it as a boxer trying to hit the opponent by raising his hand, and punching downward and caudal like the opposite image. Very awkward and not as effective as coming from the body to the opponent like the classic punch.
Let's go back to the first molar. Look at it as well. Here’s the flap exposure that we would recommend for extracting that tooth. This is an envelope flap into the sulcus adjacent to the mesial aspect of the 4th premolar and the distal aspect of the second molar. You can see we've got great exposure, the crowns are facing us, we can see the bone really well. Now we're prepared to remove the bone with our bur to facilitate the next step in that extraction.
With the maxillary first molar we always do a vertical releasing incision if extracting this tooth alone. Due to the camera angle the crowns facing are slightly ventrally oriented. We’ve now got really good exposure to the working surface.
First we section the two vestibular roots as seen above (already sectioned) Then when we go to section the palatal root from the two vestibular roots we move the patients head slightly so that the crowns are either going to be facing or facing more dorsal. Again this is so we can better visualize where we will place at crosscut tapered fissure bur in order to section the palatal root correctly as you see in this image. That’s the position that you would be in during that portion of the extraction. We also pretty much maintain that when we're doing our luxation and elevation.
Then when we close, we’re in that same orientation where literally the crown of that fourth premolar is pointing right at us. The palate is pointing right at us so the patient's head is more dorsal. Keep in mind that with proper ergonomics the operator is sitting with the head slight down looking at the patient. (see image below)
We have really good visualization in order to be able to close the extraction site when we extract that tooth.
Lastly, here's the maxillary canine. You can see the aylar ridge there which kind of outlines the tooth root in the bone. We haven't removed any bone there but, you can see where that tooth root goes. We’re all the way to the apex so we’ve got great exposure there in order to facilitate that extraction. Now, that being said, the majority of the extractions that you do, you're not probably going to have the luxury of an additional staff member that's trained in Veterinary Dentistry that can help you to retract tissue. It's good to learn to retract tissue by yourself as seen here. The exception of the small breed dogs and cats in the caudal oral cavity for closure or for root tip removal.
If you're in that space, especially closing a quadrant extraction on that mandible or closing a caudal tooth extraction site, it's great to have a technician to be able to hold. This is my Veterinary Dental technician Annie Mills. She's VTS in dentistry and one of the best instructors, if not the best in the world in veterinary technician dentistry. She is holding this patient's commissure back with the right hand and her left hand, between her middle finger and her index finger, she's holding that mouth open and steadying the back of the head with her thumb and pointing that pretty much directly at me so it makes it a very easy closure.
Proper patient positioning is crucial when doing extractions. Maximize your energy by following these recommendations to increase efficiency and minimize wear and tear on your muscles and joints. This will benefit you at the end of the day and extend to the end of your wonderful career in veterinary dentistry.