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DENTISTRY: Fractured Teeth: Can They Be Saved?

This is one of the most common questions we get from both referring veterinarians and their clients. Every case is different, but there are many scenarios where saving a tooth may be advantageous. Consider the maxillary 4th premolar and its role in mastication, or the mandibular canine tooth and its contribution to the stability of the rostral mandible. In juvenile animals, a fractured tooth can arrest its development and requires time sensitive treatment in order to save it. Advancements in veterinary dentistry have allowed us to offer more treatment options than just extraction for a fractured tooth. Standard endodontic therapy or root canal is the most common treatment performed for a fractured tooth in a mature animal. Vital pulp therapy is utilized in a young animal where continued development of the tooth is desired, and should be performed within 48-hours of

a known fracture (Fig 1). Surgical endodontics can be performed in cases where a standard root canal is not possible or has failed (Fig. 2). Periodontal surgery can be combined with endodontic procedures to save teeth with minimal crown remaining. Crown lengthening procedures and metal crown placement can further expose and strengthen the remaining tooth structure (Fig. 3). Owners that wish to save teeth must be willing to provide adequate home dental care and return for regular follow up with dental radiographs. The success rate for standard endodontic treatment approaches 95% under ideal conditions, and would be expected to last the life of the pet. Something to consider the next time you see a broken tooth, give an owner the option, they may want to keep those pearly whites!

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Fig. 2 Surgical endodontic treat-ment of a maxillary canine tooth. The apex is surgically removed and the root canal is completed in a retrograde manner (A). Closure and completed restora-tion post-surgical endodontic treatment of the right maxillary canine tooth (B).

A

B

B

A B C

Fig. 1 Immature canine tooth in a dog. The apex is not closed and the walls of the tooth are very thin and weak (A). Vital pulp therapy could save the vitality of the tooth and allow it to continue to develop and strengthen (B).

Fig. 3 Mandibular canine tooth fracture (arrow) with extensive crown loss in a working dog (A). A mandibular canine post Type II surgical crown lengthening procedure was performed (B). The crown lengthened mandibular canine following full metal jacket crown placement (C).

A

issu es in De n tis try a n D H e a D & ne ck surg e ry Newsletter for referriNg veteriNariaNs wiNter 2014

ORAL SuRgERY:surgery? Not so fast!

Fortunately for oral surgeons, the oral mucosa is quick to heal and plentiful. It has a good amount of mobility that allows for the transposition of mucosa to cover defects, and excellent blood supply to help those flaps heal by primary intention. But what happens in those delicate cases where the mucosa isn’t quick to heal, and where there isn’t excess tissue? The palate is one of those tricky places in the mouth that doesn’t have much extra movement or mobility– it can be a difficult place to perform corrective surgery. It also has a more localized blood supply that should be preserved to promote healing. Unlike surgery in other areas in the mouth, palatal

surgery can be complicated by both the constant stresses of contact with the tongue and movement from respiration.

Acquired palatal defects with oronasal communication are relatively uncommon in dogs and cats, unless severe periodontal disease exists or prior extractions have been performed. Loss of maxillary and incisive alveolar bone due to severe periodontal disease is the most common cause of acquired oronasal fistulas. Other less common causes of acquired palatal defects include trauma (gun-shot wounds, foreign body penetration, elec-trocution injury, and “high-rise syndrome” in cats), pressure necrosis, neoplasia, aggressive maxillectomies, and radiation necrosis.

It is often challenging to close large caudal palatal defects. When surgical techniques are impractical due to a lack of autogenous tissue, compromised blood supply, or underlying pathology (such as autoimmune disease or neoplasia), the placement of a prosthetic appliance can greatly improve the quality of life in some

patients. The silastic nasal septal button is designed to treat nasal septal perforations in humans. It is made from a soft silicone that can be easily adapted to fit snuggly to the curvatures of the oral cavity. The simplicity and quick anesthesia required for placing the nasal septal button, along with minimal post-operative care, makes this technique a good option for palatal defects that are non-amenable to surgery.

SMALL MOuTHS, BIg HOLES: Closing Major oral Defects.

Unfortunately, often the diagnosis of oral neoplasia is made when the lesion is quite large in relation to the size of the mouth. In fact, the lesion can seem so large that all hope is lost and the owner is conveyed a grave prognosis based on the size of the lesion, regardless of the tumor type.

Oral reconstructive surgery techniques allow closure of oral defects that might seem intimidating or impossible to close based on the size of the defect following resection. The first step is to make the diagnosis by incisional or excisional biopsy. The next step is to make every attempt to remove the entire lesion including tumor-free margins of the lesion. Oncologic surgery guidelines recommend 1-2 cm of gross tumor-free tissue be included as part of the resected specimen. This parameter is more difficult to follow in the oral cavity of dogs because of the consistent small size of the mouth. A 2-cm margin might include half of the skull!

Therefore, pragmatic considerations dictate goals

that still prioritize removing the entire tumor and maximize margins of normal appearing tissue around the tumor. Maintaining function and providing acceptable cosmesis are also major factors when determining the surgical plan.

There are two primary sources of tissue in the oral cavity of dogs for the reconstruction of defects. The labial (buccal) mucosa provides lateral tissue that can be elevated and repositioned towards midline to aid wound closure following resection of mandibular or maxillary tumors. The hard palate mucoperiosteum can be elevated and transposed for repair of oronasal communication. This flap can be of extended length since the base of the flap is supplied by the greater palatine artery. In this case, the large oral melanoma required both of these tissue sources for maxillectomy wound closure. The patient was eating per os that evening and never looked back. The owner was thrilled!

DENTISTRY:Pediatric Dental abnormalities.

What could be cuter than a new puppy? Everyone is always happy to see a puppy in the examination room for a well visit. Excitement can turn to disappointment when you have to advise an

owner that there is a problem. One of the most common puppy problems referred to us is malocclusion. Most owners would never think to really examine their puppy’s mouth, and a breeder or adoption agency may have not been aware or not disclosed the problem. The good news is that there are treatments for malocclusion that will give the pet a functional and comfortable mouth. Most owners are only concerned with their pet being able to eat normally and not feel pain. Deciduous canine teeth can be extracted to remove any possible dental inpediment and allow the jaws to grow to their maximum potential. (Fig. 1). If malocclusion is still present after the permanent dentition has erupted, procedures such as crown reduction and vital pulp therapy can create a functional bite in one step (Fig. 2). Other abnormalities that we see are delayed exfoliation of deciduous teeth and eruption disturbances,

both of which can lead to malocclusion and should be treated as soon as they are noted. The rule is that a deciduous tooth and its permanent counterpart should not be present in the mouth at the same time (Fig. 3). This retention will cause displacement of the permanent teeth and dental crowding which can predispose the pet to periodontal disease. Eruption disturbances such as soft or hard tissue impaction of teeth can be successfully treated if performed at a young age (Fig. 4). Recognizing the malocclusion is half the battle; let us know if you need help treating it!

A

Fig. 1 Mandibular dis-tocclusion in a puppy (A). Extraction of the deciduous mandibular canines at this point may remove the dental inter-lock and potentially allow the mandible to grow to its full potential. Some mandibular distocclusion cases have significant jaw disparity (B).

Fig. 3 The nasal button is cut to fit appropriately (A) before final place-ment of the septal button within the oronasal fistula. One flange is inserted into the nasal cavity and the other lies flush within the oral cavity, effectively creating a barrier between the two cavities (B). The pliability of the silicone allows for easy adaptation to the curves of the oral soft tissues to prevent ulcerations or post-operative discomfort.

Fig. 2 Severely displaced base-narrow canine teeth (A) can be treated by crown reduction with vital pulp therapy and/or extraction (B). Either procedure pro-vides a functional and com-fortable bite in a dog with this type of malocclusion.

A

B

B

BA

BA

Fig. 1 An 11-year-old dog with a history of ischemic der-matopathy of the nasal planum was presented for clinical signs of oronasal communication (A). Intraoperative photographs show a large caudal palatal defect with thin, unpigmented mucoperiosteum surrounding the lesion (B). Three-years previously, the same patient had a whole-mouth extraction and the hard palate was diseased yet intact (C). Based on the previous diagnosis of ischemic dermatopathy, an autoimmune process of the palatal mucosa was also thought to be the cause of the palatal defect.

Fig. 4 T he 5-month postop-erative exami-nation showed the nasal septal button in place and improved clinical signs.

B

A

Fig. 3 A large maxillec-tomy was required in order to maximize a successful outcome (A). The maxillectomy wound closure begins with apposition of the caudal buccal mucosal flap (B).

BAFig. 4 A hard palate flap is elevated and rotated to complete the maxillary defect reconstruction (A). Expected wound healing was noted 2-weeks postoperatively with epthelialization of the hard palate donor site (B).

C

A

Fig. 4 Soft tissue impaction (arrow) in a puppy causing delayed eruption of multiple teeth (A). Operculectomy was successful in relieving the soft tissue impaction (B). The teeth began to erupt into their normal position shortly after this procedure.

B

B

A

Fig. 1 A large maxillary malig-nant melanoma in a 14-year-old Scottish terrier dog (A). Surgery begins with commissurotomy for greater access using a CO2 laser (B).

B

A

Fig. 2 CO2 laser soft tissue incisions are associated with decreased hemorrhage and pain (A). Osteotomies of the maxil-lary, palatine, and maxillary process of the zygoma (B) are required to mobilize the diseased maxillary segment.

A B

Fig. 3 The term “shark mouth” came to mind when this puppy was examined (A). Radiographs show retained deciduous man-dibular canine and incisor teeth (B) and multiple retained deciduous mandibular premolar teeth that are impeding eruption of the permanent dentition (C).

C

Fig. 2 The one-piece silastic nasal septal button is fab-ricated with a flex-ible post and two circular flanges for easy insertion (A and B). The posts range from 3-7 mm wide, and the flanges can range up to 30 mm in diameter, making this a good choice for obturating defects 5-25 mm in diameter.

B

A