A Dental Extraction Site Management Protocol Utilizing a Synthetic Bone Graft Particulate Technique
The presence of a geriatric population of individuals is an increasingly common occurrence among the many captive groups of primate species. Routine dental and/or oral care of this group invariably reveals various degrees of advanced periodontal disease that requires the removal of one or more teeth. The surgical extraction of periodontally compromised teeth can present the clinician with a major surgical challenge. The likelihood of post-operative bleeding from a dental extraction site is increased by the normal suction component associated with the act of swallowing, as well as any elevation of the patient’s blood pressure commonly associated with pain. Proper management of all dental extraction sites, at the time of surgery, with emphasis upon preventative measures to minimize the possibility of life threatening post-operative complications, is an essential and necessary element of contemporary comprehensive oral care of exotic animals. An extraction site management protocol is the focus of this presentation.
The first concern of dental extraction site management is to minimize collateral or incidental trauma to the surrounding gingival tissues while the tooth is being removed, and to disinfect the oral cavity with a dilute solution of broad-spectrum antiseptic or antibiotic solution, prior to beginning the procedure. Use a #15 scalpel blade to cut the attachment of the gingiva to the crest of the alveolar bony ridge. Detach and retract the adjacent gingival tissue surrounding the tooth in order to provide adequate visual access to the underlaying alveolar bony ridge. Using an appropriately sized (#2, 4, or 6) round burr in a high-speed dental handpiece with both air and water coolant, create a narrow “moat” around the neck of the tooth into the crest of the alveolar ridge. With the aid of a straight elevator and/or a “cow-horn” forceps, apply directional “rocking” pressure to move the tooth away from the bony socket into the “moat” space on the opposite side of the tooth, thereby rupturing the underlaying periodontal ligament and gradually loosening the tooth. When sufficiently loosened, remove the tooth from its socket following standard oral surgical technique described for third molar impaction surgery in humans.
The second issue of concern is to thoroughly remove all of the infected, granulation tissue and debris from the socket site back to smooth, healthy bone, taking care not to damage the underlying anatomic structures like the mandibular nerve or the maxillary sinus. This is easily accomplished with two instruments, the double-ended Molt curette and/or a dental bone file, and on occasion a larger round burr in the high-speed dental handpiece. The copious use of water and H2O2 is highly recommended to assist in the cleaning of the extraction site. The socket is now properly prepared for the third step.
Closing the extraction site is the third major issue of concern, and is accomplished in three steps. The first step is to fill the clean extraction site about 3/4 full with a “wet sand” mixture of Bioglass® (Consil, Nutramax Laboratories, Inc., Baltimore, Maryland, USA), a synthetic bone graft particulate material moistened with any of the commonly available broad spectrum antibiotic solutions (enrofloxacin, amikacin, etc.). Step two is to place a firm layer of calcium sulphate (CapSet®, LifeCore Biomedical, Chaska, Minnesota, USA) prepared to the manufactures directions, over the Bioglass® to create a “barrier layer,” which also encourages epithelial “creep” and promotes healing. Step three is to suture the previously protected full thickness gingival flaps back over the filled socket site as firmly as possible. A post-operative program of antibiotics and analgesics for 7–10 days is recommended, and spraying the oral cavity once or twice a day with a broad-spectrum antibiotic or antiseptic solution when possible, will aid the healing process.
A post-operative radiograph of the freshly placed synthetic bone grafting materials is essential, and a matching follow-up radiograph should be scheduled for about 6 mo to document the replacement, regeneration and repair of the alveolar ridge.
Proven techniques applied in a timely fashion, have been shown to promote primary wound healing and minimize the risks of life threatening post-operative bleeding episodes associated with the removal of periodontally involved teeth in primates. These proven principles apply to all mammalian osseous surgery and/or extraction procedures.
The authors would like to thank Dr. Ron Kettenacker at Nutramax Laboratories, Inc., Baltimore, Maryland for his support of this work.