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Avoiding iatrogenic jaw fractures during dental extractions
Although dental extractions are often routine, they can present unique challenges that increase the risk of this traumatic complication that every veterinarian fears.
Not all dental extractions are as straightforward as presented in textbooks. Different cases present different challenges that require varied approaches. Because of the prevalence of periodontal disease and traumatic dentoalveolar injuries, these difficult cases aren’t going away. While presenting a session at the Fetch dvm360® Conference in San Diego, California, Jason W. Soukup, DVM, DAVDC, said it is vital to learn strategies that can help reduce the risk of complications in such situations, especially regarding the dreaded iatrogenic jaw fracture that can cause clinicians to fear performing extractions in the future.
Although this traumatic complication can be a source of anxiety for veterinary professionals, proper preparation and a better understanding of its underlying causes can mitigate those worries. “There’s no way I can stand up here and tell you exactly how you should do it every single time,” Soukup said. However, he added, “Every one of us should walk in there ready to extract a tooth with—not fear—but respect.”
Canine mandibular extractions
Soukup noted that the risk of iatrogenic jaw fractures can feel especially present with canine mandibular extractions. He said that although the risk may not be as high as perceived, it is a real possibility if care is not taken to consider the amount and placement of load during tooth elevation. This risk exists because the bone is relatively thin in some areas as the root makes up a significant percentage of the hard tissue volume of the rostral mandible. Soukup stated that this is particularly true on the mesiolingual aspect of the tooth, for which it is easiest to engage and elevate the tooth. All these factors converge to create a situation in which an iatrogenic jaw fracture is most likely to occur. Soukup said the best way to minimize the risk of fracture is through a combination of factors: removing sufficient alveolar bone, careful elevation, and avoiding the mesiolingual aspect of the tooth as much as possible.
Speaking on techniques for minimizing the risk of jaw fractures generally, not necessarily just with canine mandibular extractions, Soukup shared this helpful guideline: “You should remove 50% of the length of the bone if you don’t have a lot of experience. If you have zero experience, maybe it needs to be more, and if you have a lot of experience, maybe it needs to be less. What we’re really trying to do is to balance the goal of getting the tooth out without causing a fracture against causing a lot of excessive traumas.”
According to Soukup, removing more than 50% of the bone may cause excessive trauma and discomfort that may be unnecessary, but at the end of the day, it is up to the clinician to decide if it is required to avoid too much torque that can potentially cause a jaw fracture.
Soukup reassured attendees that most patients will completely recover from an iatrogenic jaw fracture with appropriate reduction and stabilization, although he suggested this procedure is typically best performed by a dental specialist. However, he advised, jaw fractures near the mandibular molar in patients with periodontal disease can be extremely challenging even for a dental specialist. Therefore, he recommended against general practitioners trying to handle this type of case.
Finally, Soukup advised the crucial step of warning clients about this possible complication on consent forms. “Protect yourself. You’ve got to be aware this is a complication, and the client has to be aware this is a potential complication, so it should go on your consent form,” he said.
Mandibular first molar in small-breed dogs
Soukup noted the mandibular first molar as another trouble area with iatrogenic jaw fractures. He listed 3 factors that make extracting this tooth a challenge in small-breed dogs: their large M1-to-mandibular height ratio, the volume of the mandible in this location being mostly made up of tooth root, and that the root apices often have severe curvature. These factors increase the risk of iatrogenic jaw fracture, and periodontal disease only makes it worse.
Soukup said the first line of defense against jaw fractions in this region is preventing chronic periodontal disease in the first place with proactive oral hygiene care. Once periodontal disease is present, the clinician must learn to evaluate the risks of the procedure while balancing those risks against one’s own skill and comfort level. Elements to consider in assessing risk include the quality and quantity of the existing alveolar bone, the size of the molar in relation to the mandible, and any “morphological variations—such as dilacerations—that tend to ‘lock’ the tooth in the alveolus.” Soukup recommended cases in which all these features are present, the risk of jaw fracture increases considerably, and a specialist referral may be the best option.
With lower-risk cases that can be taken on by the general practitioner, Soukup recommends a few strategies to minimize the risk of iatrogenic jaw fracture. These include appropriate exposure of buccal alveolar bone with the creation of a suitable mucoperiosteal flap, the removal of the appropriate amount of buccal alveolar bone, sectioning the mesial and distal aspects of the tooth before any elevation, a proper degree of force applied during elevation, and support to the ventral mandible by holding as much mandible in the hand or fingers as possible during elevation. He warns that any degree of dilaceration, absent other risk factors, may indicate the need for a specialist referral because it significantly inhibits the ability to elevate the tooth.
“Know what you’re getting into,” said Soukup, advising attendees to ensure they take radiographs prior to extraction to determine the best plan for tooth extraction. Additionally, examining the health of a tooth via radiographs may help the clinician determine if extraction is the best course of action in the first place. Finally, the veterinarian should verify a completed extraction and intact jaw by radiographing the empty alveolus after the procedure.
Although it would be impossible to address every situation in all possible cases, the strategies discussed during the Fetch dvm360® session can be implemented in the situations outlined by Soukup to help minimize the risk of iatrogenic jaw fracture. With fewer complications comes the confidence to perform successful extractions and less need for a specialist referral as well as happier patients.