Introduction When extractions go well, there is a sense of satisfaction with removing a source of chronic infection, inflammation and pain from our patients. But with a lack of formal training, less than adequate equipment and time constraints, complications and frustration are far too common. Here are some common issues that can arise to complications with dental extractions, and how to overcome them.

Not enough time
This may not seem like a direct complication, but when we get rushed and can’t be patient with elevation, that is when a lot of complications can arise. Our dental patients often have more advanced disease that becomes apparent once radiographs are taken, potentially requiring more anesthetic time than expected. Multiply this by the number of procedures you have scheduled, and it can become a nightmare. Solution: consider recommending ‘staged procedures’: get the general cleaning, probing and radiographs completed for accurate evaluation, extract the ‘easy’ ones, and plan to perform the oral surgery to extract the more complicated teeth at a later time. Prepare your clients ahead of time for this possibility, particularly in those smaller, older dogs that will likely have hidden problems. Not only does this avoid excessively long procedures, it gives you and your staff options to avoid having to rush. Sometimes the soft tissues and even bone will appear healthier 2-4 weeks later, and you can give a price break on induction. Also -during oral examinations, try to estimate the extent of disease, and assign a ‘degree of difficulty’ for the anticipated procedure.
This is not the stage of periodontal disease, but how difficult you feel the procedure may be and how much time it might take. On a scale from 1-3 ‘points’, then determine how many points total you want to handle in a day. If that total is 7 and you already have two patients with level 3 – only take one more ‘simple’ procedure, level 1.

Incorrect or dull instruments
Without the correct instruments that are sharpened regularly, extractions will be challenging. Sharpened tips are needed, as they are to be advanced into the periodontal ligament (PDL) in between tooth and bone, and that is not a wide space. Dull or thick instruments will never fit into the PDL space for optimal elevation forces. Straighter edge ‘luxators’ are helpful to ‘start’ opening up the PDL (1.3, 1.8) or to help elevator flatter surfaces of larger teeth such as canines. Winged elevators come in multiple sizes, and the size of the winged tip should fit the curve of the root, not too big, not too small. Solution: put together multiple extraction packs with appropriately sized instruments have have sharpness evaluated after each use! There are different methods of sharpening, some on YouTube. Have a few extra elevators available if you make some dull during a procedure, or even sharpen during the procedure.

More flap
Inadequate flap creation will limit your access to section multi-rooted teeth or expose enough of a canine tooth to remove sufficient alveolar bone. It is also important to incise the periosteum on the underside of the flap (especially on maxillary canines) to release the tension in order to close it adequately.

Incorrect sectioning
Having a decent flap to identify the furcation of a multi-rooted tooth is the first step. In many teeth, especially mandibular first molars and maxillary fourth premolars, it is optimal to remove a triangular piece of the crown to allow more direct access to each root. In the maxillary fourth premolars, this will also allow you to visualize the distal aspect of the furcation between the two mesial roots. Just sectioning over the crown of the palatal root will not section the tooth correctly, and starting elevation will just break the crown at this stage. Even if the tooth appears mobile, still section a multi-rooted tooth, especially the maxillary molars. As soon as you think you can just ‘wiggle’ it out, those thin, crooked roots will break off. Section the palatal root away from the two buccal roots, then separate between the two buccal roots. Occasionally there will be a ‘ribbon’ root with a ‘sheet’ of root formed along the length and between two roots; with no furcation, so watch out for those. Also watch out for a third root on a typical two-rooted tooth (premolars)

Incorrect evaluation of remaining attachment
The presence of a deep pocket, notably at the mesial aspect of a mandibular canine, may seem to indicate the need for extraction. However, you need to fully evaluate the extent of healthy alveolar bone and PDL around the root of the tooth. A deep ‘pocket’ may be present if the tooth is under- erupted, or if bone loss at the adjacent incisor has contributed to the probing depth. Determine if removal of the incisor and possible redundant gingival tissue at the site may allow you to leave the canine while lowering the gingival height around it, minimizing the pocket.

Assessment of periodontal ligament space
It is critical to evaluate the presence of the periodontal ligament prior to extraction. If the PDL is visible and there are no apparent root abnormalities (resorption, lack of PDL, ankylosis of root), then it is likely that you will be able to ‘fatigue’ the ligament for elevation. Excessive forces on a tooth with resorption or ankylosis will likely result in a root fracture; you might need to take out more alveolar bone to have a successful extraction.

Compromised bone
What’s worse that hearing that tooth crack? – hearing the jaw break! Always remember to offer the option of a referral if you feel the conditions at an extraction site may be beyond your comfort level; the owner can always decline, but note that in your records in case there is a problem. Here are a few problem spots:
Mandibular symphysis: with any mandibular incisor or canine extraction, always check for mandibular symphysis mobility first; it is often present in cats and small dogs and this may be their ‘normal’. If it is no worse after extraction, there is no need to stabilize it. If there has been a fracture, then circumferential wiring can stabilize it. Mandibular canines: even with a stable symphysis, the alveolar bone can be thin on the lingual aspect, even with large dogs. Really evaluate the radiographs for the integrity of the PDL; use a buccal-caudal-lingual approach and plenty of patience. Use the sharpened ‘luxators’ on the flat surfaces and winged elevator following the root distally on its dorsal surface. Cup the jaw with the opposite hand. Mandibular first molar: Extensive bone loss of this tooth is a common reason for extraction, and a common cause of pathologic (and iatrogenic) mandibular fractures. Complete bone loss at the distal root allows for easy elevation of it after sectioning the tooth, but the mesial root is usually solid. Shave off a bit of the crown to allow for elevator placement between it and the fourth premolars.
Use the flat elevators on the buccal and lingual aspects. Remove cancellous bone from the distal aspect of the mesial root – there is often an indentation that prevents rotation. Oronasal fistulas: An ONF (or OAF – oroantral fistula further caudal) may already be present and the reason for extraction, particularly of maxillary canines. Excessive elevation forces at the palatal aspect of the tooth, or rotation of the apex into the nasal can cause or exacerbate an ONF that is already present. Concentrating elevation effort at the mesial, distal and even buccal aspects can help elevate the tooth enough for removal. If an ONF occurs or is present, the most important aspect is having a wide-based mucoperiosteal flap so incision lines are place over bone, not the defect. The palatal edge must be freshened and released the flap by incising the periosteal fibers is critical.

Broken root tips
Once you have broken off the root tip, now you need to retrieve it without pushing it into the nasal cavity or mandibular canal. If there was apical bone loss to begin with, this complication becomes much more likely! In the maxilla, removing buccal bone to expose the entire root tip will often allow you to retrieve it without incident. In the mandibular, buccal bone can be removed on a larger patient, but too much bone loss can be detrimental to a small dog or cat. Instead, remove more of the cancellous bone in between the root spaces and try to preserve the cortical bone plates buccally and lingually. With a small round or cross-cut fissure bur, create a ditch around the root or remove the bone in the interdental space and try to elevate the tip with small elevators or root tip picks.

Root tips into mandibular canal or nasal regions
Excessive apical force can cause that root tip to drop into the mandibular canal or push up into the nasal cavity or sinuses. Since the tip is obviously loose, this is the best time to try to retrieve it; waiting 2 weeks or sending it for referral will complicate matters as fibrous tissue will grow around the piece. Expand the opening it fell through, similar to how you removed bone for getting to the root tip above. Take care not to injure the mandibular neurovascular bundle as you try to retrieve the root. Grasping for it is often like bobbing for apples, and it might move farther away. Sometimes making the opening larger and then flushing saline into the opening may be enough to dislodge the tip though the opening. Occasionally tips can be flushed rostrally or distally when in the nasal passages.

Damage to soft tissues: salivary ducts, sublingual swelling, air, tongue
Never forget the surrounding tissue when using a highspeed, air compression unit. Not only can the bur damage soft tissues, but pulverizing teeth and directing the spray or air can cause swelling and air emboli. Use a tongue depressor when sectioning mandibular teeth and lip retractors for better visualization. Now that you will be sharpening your instruments, be very cautious with any forward movement – hold the instrument so the tip just barely passes your fingertip. A small ‘ooops’ may scrape a little tissue; a big ‘oops’ can penetrate the infraorbital canal near the upper fourth premolar, the eye above the molars and there has even been a case of a brain abscess post extraction trauma.

Deciduous extractions
Deciduous extractions take the concepts of careful extraction to a higher level, as underlying permanent tooth buds can easily be damaged with incorrect forces. Again, the correct equipment (1.3 elevators) are essential and elevation forces should be avoided in areas where tooth buds are close (lingual aspect of mandibular canines), mesial aspect of maxillary canines). Retrieving broken roots with a single incision over the root is usually successful. Informing the owner that even with careful elevation, some changes to the enamel of the permanent tooth may occur, so monitor closely.

Dehiscence or non-healing extraction site
Adequate flap formation and release should minimize the chance of dehiscence, though with tension against the ONF flap with every breath, a small persistent opening is always possible. Full dehiscence of any site is less common, so make sure the patient is not self-traumatizing the site. A truly non-healing extraction site is concerning, and a biopsy should be considered to rule out an underlying neoplastic cause. Pyogenic granuloma or other trauma from remaining teeth In cats, extraction of the mandibular first molars can allow the sharp tips of the maxillary fourth premolars to contact the mandibular mucosa and cause chronic inflammation in the form of a pyogenic granuloma. Extraction of a feline canine can also result in chronic contact trauma. Gentle blunting (odontoplasty with bonding) of opposing teeth should be considered in these cases.

Summary
“Stuff” will happen with extractions – to all of us. Knowing how to minimize the changes and how to manage the problems when they occur benefits our patients.