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Management of dental and oral trauma

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Abstract

This chapter describes a range of endodontic treatments and techniques in operative dentistry, with extensive information on the management of oral bone and soft tissue trauma. : Vital pulp therapy; Standard root canal therapy (standardized filing technique and cold lateral condensation); Dental defect preparation and restoration; Interarch splinting; Circumferential wiring; Interdental wiring and splinting.

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Figures

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9.2 Preparation of the surgical field for crown reduction and endodontic treatment of the mandibular canine teeth in a dog. The patient was placed in sternal recumbency to enable concomitant work on both teeth. Sterile surgical drapes were used to delimit the oral cavity, and a rubber dam was placed to further isolate the teeth to be treated. A cuffed endotracheal tube and a pharyngeal pack are in place to decrease the chances of aspiration of fluids, debris, materials and small instruments. Excessive opening of the mouth is avoided using a short, not spring-held, mouth gag. (© Dr Margherita Gracis)
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9.3 Algorithmic approach to the endodontic treatment of immature teeth.
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9.4 Algorithmic approach to endodontic treatment of mature teeth.
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9.6 (a) Preoperative intraoral radiograph of an 8-month-old female Maltese dog with mandibular distocclusion and linguoverted mandibular canine teeth causing contact lesions on the hard palate mucosa. (b) Postoperative radiograph after crown reduction and vital pulp therapy of the mandibular canine teeth (teeth #304 and 404). (c) 3-month follow-up radiograph showing continued apexogenesis (arrowheads), dentine deposition (thicker dentinal walls) and dentinal bridge formation (arrowed). (d–f) Follow-up radiographs showing normal tooth development and absence of endodontic complications at (d) 2.5, (e) 5.5 and (f) 6.5 years of age. (© Dr Margherita Gracis)
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9.7 (a) Non-vital, discoloured left maxillary canine tooth in a 10-month-old female Rhodesian Ridgeback. (b) A Hedstrom file was inserted into the root canal through a coronal access opening. (c) The tip of the file (arrowed) extended beyond the apical stop into the periapical area. (d) An apexification procedure was performed, including total pulpectomy, debriding, shaping, disinfecting and drying the root canal, filling it with calcium hydroxide (CaOH) paste, and placing some cotton balls over the paste (*) to provide a base for the temporary restoration made of reinforced zinc oxide eugenol cement (arrowed). (e–g) The dog returned 4 months later for standard root canal therapy. (© Dr Alexander M. Reiter)
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9.8 (a) Vertical fracture of the mesiobuccal crown-root of the right maxillary first molar tooth in a 15-month-old female Husky. (b) Resection of the mesiobuccal crown-root segment was performed, followed by (c) standard root canal therapy of the distobuccal and palatal roots. (d) The access and hemisection sites were restored, and a periodontal flap was sutured in position. (© Dr Margherita Gracis)
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9.9 Radiographs of an extracted maxillary canine tooth of an adult dog. (a) A Hedstrom file has been inserted through the occlusal fracture site and bent to follow the curvature of the root canal. (b) An access hole has been created on the mesial surface of the tooth a few millimetres coronal to the imaginary gingival margin, and a file has been inserted into the root canal; note the bulge of dentine (*) mesial to the file. (c) Flattening of the bulge of dentine by means of filing or burring allows for a more direct approach to the root apex. (© Dr Margherita Gracis)
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9.10 Pulp tissue from a recently fractured right mandibular canine tooth in a 20-month-old male Labrador Retriever is removed with a barbed broach. (© Dr Margherita Gracis)
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9.11 (a) Complicated crown fracture of the left maxillary third incisor tooth in a 5-year-old Golden Retriever. The working length is measured with a: (b) thin Hedstrom file; (c) master apical file; (d) gutta-percha master cone. (e) Final radiograph following root canal obturation and access site restoration. (© Dr Margherita Gracis)
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9.12 (a) A paper point is inserted into the root canal of a left maxillary canine tooth after debriding, shaping and disinfecting. (b) Discoloration of a paper point used to dry the root canal of the right maxillary canine tooth in a different patient indicates haemorrhage and the need for further instrumentation or placement of a temporary endodontic medication. (© Dr Margherita Gracis)
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9.13 Radiographs of the left mandibular canine tooth (304) of a 4-year-old male Belgian Shepherd with irreversible chronic pulpitis of traumatic origin. Occusal views (a) before and (b) after, and lateral views (c) before and (d) after standard root canal therapy; a small amount of extruded zinc oxide eugenol cement is visible periapically in the after images. The portion of the pulp chamber coronal to the access hole was not opened and treated and therefore appears radiolucent. (© Dr Margherita Gracis)
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9.14 (a) An access restoration on the right maxillary canine tooth of a dog shows marginal leakage, evident as brownish discoloration of its margins; this restoration was also irregularly shaped and showed superficial porosity. (b) The restorative material was removed and replaced after radiographic confirmation of lack of endodontic complications. (© Dr Margherita Gracis)
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9.15 (a) Lateral view towards the mouth of a police dog showing a full crown at the right maxillary canine tooth and a partial crown at the right mandibular canine tooth; the opposite side has not yet undergone prosthodontic therapy. (b) Frontal view obtained in the same dog following completion of prosthodontic therapy. (© Dr Alexander M. Reiter)
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9.16 Discoloration and irreversible chronic pulpitis of traumatic origin affecting the right maxillary canine tooth in a dog. Orthograde access was performed, but the middle third of the root canal was obliterated. Surgical root canal therapy was therefore performed. (a) A semilunar flap was elevated in the alveolar mucosa over the apex of the tooth. (b) The apex and periapical areas were exposed following osteotomy, and about 3 mm of the apex was removed; cutting through the apex was performed at an angle of about 45 degrees to the long axis of the root, although an 80–90-degree angle would be preferable. (c) Following retrograde debriding, shaping, disinfecting and gutta-percha filling, a restoration was placed. (d) The mucosal flap was sutured and the coronal access site restored. (© Dr Margherita Gracis)
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9.17 (a) Lateral luxation of the left maxillary canine tooth in a 10-year-old Beagle caused by a fight with another dog. (b) Occlusal intraoral radiographic view showing lateral displacement of the crown and nasal displacement of the root. (c) Lateral intraoral radiographic view showing distal displacement of the crown and mesial displacement of the root. (© Dr Margherita Gracis)
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9.19 (a) Puppy with bilateral mandibular fractures treated by suturing of torn oral soft tissues and wearing of a tape muzzle for 2 weeks. (b) Dog with right caudal mandibular fracture treated with intraosseous wiring and tape muzzling; note that the muzzle is snug enough for dental interlock to be maintained, but loose enough for the tongue to protrude. (c) Cat with right mandibular fracture after gunshot injury; notice an additional third layer (*) of the muzzle that runs over the forehead, which seems essential in cats and short-nosed dogs. (© Dr Alexander M. Reiter)
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9.20 Interarch splinting performed for treatment of caudal mandibular fractures (a) between maxillary and mandibular canine teeth in a young adult cat and (b) between maxillary and mandibular canine and carnassial teeth in a young adult dog. (© Dr Alexander M. Reiter)
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9.21 (a) An adult cat presented with separation of the mandibular symphysis. (b) Circumferential wiring was performed. (c) The patient returned 12 weeks later, showing significant loss of bone around the wire radiographically (arrowed) and (d) clinically (*) after wire removal. (© Dr Alexander M. Reiter)
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9.22 (a, b) A 2-year-old dog presented with an unfavourable fracture of the left mandibular body between the third and fourth premolars (teeth #307 and 308); note the exposed apex of the mesial root of the fourth premolar tooth (*). (c) Interdental wiring (Stout multiple loop technique) was utilized for fracture reduction, followed by (d) resin splint application. (e) A postoperative radiograph was obtained. (f) The patient returned after 4 weeks for a radiographic re-examination and – due to relocation of the client and dog – early splint removal. (g) The dotted circle outlines the area of concern, which will need to be monitored clinically and radiographically for development of periodontal and/or endodontic disease. (h) The client sent a radiograph 5 months after splint removal, showing continued healing of the previous fracture site. Note a small indentation remaining at the ventral mandibular border (arrowed) and an enamel fracture at tooth #308 (*) probably sustained at the time of splint removal. (© Dr Alexander M. Reiter)
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9.23 (a) A 9-year-old male Golden Retriever was presented with a right caudal mandibular fracture in the area of a missing second molar tooth. (b) The fracture line ran in a caudoventral direction (unfavourable fracture), and there was radiological evidence of alveolar bone loss. (c, d) An intraosseous wire was placed from distal to the third molar tooth to between the roots of the first molar tooth, and the fracture site was debrided and grafted with bioglass. (e, f) The patient returned 7 weeks postoperatively; (g, h) the wire was removed and the wound was sutured closed. (© Dr Alexander M. Reiter)
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9.24 (a) A 7-year-old neutered female Bichon Frisé presented with a pathological right caudal mandibular fracture in the area of the distal root of the first molar tooth. (b) The first molar tooth was hemisected, its distal crown-root segment removed, and a temporary restoration placed in the remaining crown-root segment that was kept for anchorage of orthopaedic wire. (c, d) Two intraosseous wires (1 and 2) were placed in a near parallel fashion, and an additional wire (3) was started intraosseously in the caudal fracture segment, twisted over the extracted distal crown-root segment of the first molar tooth, looped around its remaining mesial crown-root segment, and continued rostrally as interdental wire. (e, f) The fracture site was debrided, rinsed and grafted with bioglass. (g–i) The patient returned 10 weeks postoperatively; (j, k) all wires were removed, the mesial crown-root segment of the first molar tooth was extracted, its alveolus was filled with bioglass, and the wound was sutured closed; (l) what may appear like a retained mesial root tip of the right mandibular first premolar tooth on a lateral view is actually just a bioglass filled alveolus on a more occlusal view. (© Dr Alexander M. Reiter)
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9.25 External skeletal fixation performed in a 1-year old dog. Frontal view with the mouth (a) closed and (b) slightly open. Note that the dog has a full permanent dentition which should have been used for anchorage of an interdental wiring and splinting device rather than choosing an invasive technique that has the potential of injury to the roots of the teeth and the neurovascular bundle in the mandibular canal. (© Dr Alexander M. Reiter)
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9.26 (a) An 8-year-old, neutered male Pomeranian presented with bilateral pathological mandibular fracture; note the lower jaw involuntarily hanging ventrally. (b) Intraoral radiography reveals a left mandibular body fracture. (c) Miniplate fixation was performed; only the left side is shown. (d, e) A radiograph was obtained to confirm proper fixation prior to wound closure; note that screw placement into the mandibular canal becomes challenging, if not unavoidable, with little bone height remaining. (f) The patient was fitted with a custom-made tape muzzle following bilateral miniplate fixation. (© Dr Alexander M. Reiter)
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9.27 (a) A 13-year-old female Chihuahua presented with bilateral pathological mandibular fractures. (b) Following removal of teeth affected by moderate to severe periodontitis, fracture site debridement and wound closure, the upper and lower lip margins were incised, and (c) the oral mucosa and skin were closed in separate layers, thus advancing the lip commissure more rostrally. Note the tension-relieving sutures placed using fluid line cut into small segments. (d) The dog returned after 2 weeks for a re-examination. As the lip margins had been incised in the labial mucosa and not at the mucocutaneous junction (which should have been done), some oral mucosa is visible on the outside, giving the patient a ‘Joker’ appearance. (e) The skin sutures were removed. While the oral aperture is smaller, bilateral commissuroplasty provided sufficient support for the tongue to be kept in the mouth as much as possible. (© Dr Alexander M. Reiter)
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9.28 Cat presenting with luxation of the left temporomandibular joint. (a) There is incomplete closure of the mouth due to shifting of the lower jaw to the right, resulting in maxillary and mandibular canine (full circle) and cheek teeth (dotted circle) on the opposite side making abnormal contact. (b) A dorsoventral radiographic view reveals that the left mandibular condylar process (* indicate its lateral and medial poles) is displaced rostrally (arrowed). R = right. (© Dr Alexander M. Reiter)
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9.29 Cat presenting with open-mouth jaw locking. (a) The mouth is wide open (arrowed) with the left mandibular dental arch positioned more ventrally and no contact between maxillary and mandibular teeth. (b) A dorsoventral radiographic view reveals the left mandibular coronoid process (*) contacting the zygomatic arch. R = right. (© Dr Alexander M. Reiter)
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9.30 (a) A kitten presented with progressive inability to open the mouth. Note the mixed dentition and mandibular distocclusion. (b) A dorsoventral radiographic view reveals bilateral temporomandibular joint ankylosis (dotted circles) with excessive new bone formation between the mandibles and the temporal bones. R = right. (© Dr Alexander M. Reiter)
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9.31 (a) A 3-month-old puppy was presented with upper lip avulsion after being grasped at its muzzle, lifted up and shaken repeatedly by another dog. (b) Cotton-tipped applicators were inserted through the nostrils to demonstrate the nasal vestibule (*) during wound debridement. (c) The wound was rinsed and sutured closed. (© Dr Alexander M. Reiter)
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9.32 (a) An 8-month-old kitten was presented with lower lip avulsion and other maxillofacial injuries following a car accident. (b) Thorough tissue debridement was performed, and then full-thickness holes were drilled through the mandibular body. (c, d) Mattress sutures were passed through the holes and the lip tissues. Rubber tube stents should have been placed to decrease the tension on the cutanous surface. (e) The lacerated gingiva and labial/buccal mucosa were directly sutured. Some sutures were also placed around the tooth crowns. (f) At the 7-week re-examination the tissues appeared completely healed. (© Dr Margherita Gracis)
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9.33 (a) A 2-month-old kitten presented with severe necrosis of the upper and lower lips, labial and buccal mucosa, alveolar mucosa, gingiva, palate and tongue 5 days after chewing on an electric power cord. (b) Following conservative treatment the patient was re-examined 5 months later. It had a significantly shorter tongue (rostral portion had sloughed off), a right lower lip defect (with previously exposed bone now fully epithelialized), and abnormally developed permanent teeth (underdeveloped right maxillary fourth premolar tooth, missing all right mandibular cheek teeth, mesioverted right maxillary canine tooth). (© Dr Alexander M. Reiter)
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9.34 Cat with thermal burns on its nasal planum, lips and tongue as a result of being fed soft food that had been carelessly warmed in the microwave. (© Dr Alexander M. Reiter)
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9.35 (a) A dog presented with gunshot trauma, showing severe haemorrhage from injured soft and hard tissues of the nose and upper jaw. This image shows the anaesthetized dog in the emergency room, before proper surgical preparation was implemented. (b, c) The same patient was re-examined 3 months and multiple surgeries later. Note the missing mandibular canine teeth (which had been extracted due to complicated fracture) and one large opening replacing the lost nasal planum and nostrils. (© Dr Alexander M. Reiter)
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9.36 (a) A dog presented with a non-healing wound in the sublingual region. (b) The wound was explored and a linear foreign body retrieved. (c) The wound was lavaged and sutured closed. (© Dr Alexander M. Reiter)
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9.37 Sialoceles (*) in dogs: (a) cervical, (b) pharyngeal and (c) sublingual locations. (© Dr Alexander M. Reiter)
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9.38 Different colour patterns of sialocele aspirates: (a) clear transparent; (b) brownish-yellow transparent; (c) brownish; (d) pink-red transparent; and (e) dark red. (© Dr Alexander M. Reiter)
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9.39 (a) A 10-month-old dog presented with a left-sided cervical sialocele. (b) The left ventral neck region was prepared for surgery. (c, d) A skin incision was made, the common capsule of the mandibular and sublingual glands incised, and an intracapsular dissection of gland and duct tissues performed. (e) The ducts of the two glands were dissected rostrally so that additional glandular tissue of the polystomatic part of the sublingual gland could be freed. (f) The ducts were ligated and the gland–duct complexes removed caudal to the ligation. (g) A Penrose drain was placed, exiting at an incision ventral to the initial skin incision; the drain was removed the following day. (h) The dog returned 2 weeks postoperatively for removal of skin sutures. (© Dr Alexander M. Reiter)
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9.40 (a) Fistulous opening on the mucosa of the left cheek of a 1.5-year-old French Bulldog that presented with a persistent left facial swelling and pain on mouth opening. Head computed tomography and ultrasonography revealed a linear foreign body in a thickened tubular structure that reached the left parotid gland. (b) The parotid gland and fistulous tract (which initially seemed to be a thickened salivary duct) were surgically excised and submitted for histopathological examination. The fistulous tract was incised and a thin blade of grass was retrieved. Chronic, severe, diffuse, purulent adenitis, presence of granulation tissue and purulent cellulitis were diagnosed histologically. (c) The skin was closed routinely and a Penrose drain applied for 24 hours. (© Dr Margherita Gracis)
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9.41 (a) A 2-year-old Domestic Shorthaired cat presented with a midline palatal fracture and tear of the hard palate mucosa following a fall from the third floor of a building. (b) A unilateral mucoperiosteal flap was elevated from the right side, carefully avoiding injury to the major palatine artery (arrowed). (c) Following marginal debridement, the flap was sutured to the opposite side of the defect. (d) A 5-week follow-up showed complete healing. Note that a spring-held mouth prop was utilized in this case, but its use should be avoided due to the reported risks of altered maxillary artery blood flow and occurrence of neurological deficits. (© Dr Margherita Gracis)
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9.42 (a) A cat presented with a fractured left maxillary canine tooth (arrowed) and a traumatic defect in the midline of the hard palate after falling from a window. (b) Note the wide separation (double-ended arrows) of the left and right incisive bones and maxillae. (c) Repair was accomplished by means of approximation and suturing of medially positioned flaps after creation of bilateral releasing incisions (arrowed) into palatal mucosa along the dental arches. (d) Interquadrant splinting (twisted wire reinforced with composite resin) was performed between the maxillary canine teeth to reduce the separation. (© Dr Alexander M. Reiter)
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9.43 (a) A 20-month-old neutered female crossbreed dog presented with a caudal hard palate defect sustained 3 weeks earlier due to gunshot injury. (b) Unequally long, full-thickness rotation flaps were elevated, carefully avoiding injury to both major palatine arteries (that were ligated and transected at the rostral margin of the flaps). (c) Note the small strip of connective tissue (arrowed) intentionally left attached to the bone in the midline. (d) The flaps were rotated over the defect (shorter one first, followed by the longer one) and sutured in position; note how the rostral aspect of the rotated longer flap has been sutured to the strip of connective tissue (arrowed) attached to the bone in the midline. Re-examinations were performed at (e) 5 days, (f) 2 weeks, (g) 5 weeks and (h) 11 weeks, demonstrating complete healing of the previous palate defect. (© Dr Alexander M. Reiter)
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9.44 (a) A dog of unknown age presented with a palate defect most likely resulting from electrical injury; note the lack of an oral vestibule on the right side due to fusion of the upper lip with the gingiva. (b) A self-retaining permanent obturator was fabricated with bis-acryl composite; there are sufficient overhangs orally (arrowed) and nasally (*) with the exception of the side of the obturator that faces the right margin of the defect (dotted line nasally, arrowheads orally). Note that the inside of the obturator has been made hollowed out (H) to allow for free passage of nasal air and fluids. (c) The obturator has been seated in position and marked (B = back, R = right, F = front and L = left) so that a person unfamiliar with the obturator knows how to replace it in case it falls out or needs to be removed for cleansing and nasal lavage. (© Dr Alexander M. Reiter)
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9.45 (a) A 9-year-old male crossbreed dog presented with a large palatal defect of neoplastic origin. (b) Alginate impressions of both maxillary and mandibular dental arches were taken, and stone models were made. A resin-based prosthetic appliance was then created, with retaining wires embracing the maxillary canine and fourth premolar teeth. (c) As mechanical retention was insufficient, the appliance was secured within the oral cavity with the help of composite buttons created on the labial and buccal surfaces of the teeth (*). A soft silicone-based material was added along the prosthesis margins to decrease tissue irritation and improve tissue adaptation (arrowed). (d) Right lateral view with the prosthesis and composite buttons (*) in place. Contact between the retaining wires and the gingival tissue should be minimal. The wires should not extend beyond the mucogingival junction to avoid trauma to the alveolar mucosa. (© Dr Margherita Gracis)
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