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TruTh & ConsequenCes in DenTisTry anD heaD & neCk surgery

UnerUpted teeth, What’s the Big deal? True or False - Missing teeth are uncommon and never a problem.False: Missing teeth are a very common oral examination finding in adult dogs and may be secondary to physiologic reasons, trauma, or breed predispositions, but what if they are not missing at all? What if the apparently missing teeth are unerupted, or impacted? How will you know for sure? Dental radiographs are indicated any time there is missing dentition. If the permanent tooth is not seen on the radiograph, then no treatment is needed. If, however, the “missing” tooth is impacted, then extraction of the tooth should be considered in order to prevent formation of a dentigerous cyst (Fig. 1). In cases of trauma, impacted teeth are usually unilateral and located in the area of the trauma (Fig. 2). Dentigerous cysts arise from a remnant of the developing dental fol-licle. When these cysts form, they can be very invasive and destroy the surrounding bone. Pathologic fractures can even occur if enough bone is destroyed by the expansile growth of the cyst. Treatment of the impacted tooth and associated cyst should occur as early as possible to prevent further damage. Early diag-nosis of impacted teeth with dental radiographs will reduce the chances of complications due to cyst formation. Treatment consists of extrac-tion of the impacted tooth and complete removal of the entire cyst lining with a curette. Cysts can recur if the epithelial lining is not completely removed. The defect in the bone created by the cyst should be filled with a bone graft or syn-thetic bone stimulating material to encourage bone formation in the affected area. The prognosis is excellent with extraction of the impacted teeth and removal of the cyst.

Fig. 1 Photographs of a 3-year-old Miniature Schnauzer with impacted mandibular first premolar teeth. An obvious swelling is seen on the right side (A). A cyst has developed surrounding the impacted tooth and is causing destruction of surrounding bone (B). The impacted tooth (arrow) is extracted (C) and the cystic lining curetted (D). The wound is closed (E) and a radiograph (F) confirms extraction and shows synthetic bone stimulating material placed in the bony defect.

Fig. 2 Photographs of a 7-month-old Labrador Retriever with a history of traumatic maxillary fractures at 3 months of age resulting in impaction of permanent left maxillary teeth (A). The dental radiograph shows bony impaction (B) requiring ostectomy and limited rhinotomy for extraction of impacted teeth (C). Ca

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Tru Th & Co nse q u e nCes in De n Tis Try a n D h e a D & ne Ck surg e ry NewsleTTer For reFerriNg veTeriNariaNs spriNg 2009

Bad disease: good oUtcome - neoplasms oF the oral cavity True or False - The results of surgery for oral neoplasms is generally poor.False: Neoplasms of the oral cavity are often malignant or have characteristics of malignancy with surgery often providing complete resection with long-term survival. Malignant melanoma, squamous cell carcinoma, fibrosarcoma, osteosar-coma, and acanthomatous epulis tend to be commonly diagnosed (Fig.1-3). The key is to make the diagnosis, the treatment and outcome may be better than you could imagine! Unfortunately, these neoplasms may be quite large before diagnosis

maxilloFacial traUma True or False - repair of maxillofacial trauma almost never results in malocclusion or damage to other oral structures.False: Maxillofacial trauma can result from dog bites, auto accidents, falls, or any number of events and can result in any number of injuries. First and foremost, the animals overall emergency status should be assessed and treated. There may be multiple maxillofacial injuries that will need to be addressed, but fortu-

nately most can wait until the patient is stable and certain to not have any neurologic, circu-latory, or respiratory complica-tions. Once the patient is stable, it can be referred for compre-hensive assessment of the max-illofacial injury. Some injuries such as maxillary fractures may require very little stabilization to heal while others such as man-dibular fracture may have very obvious negative effects on the animal’s ability to eat and func-tion normally (Fig. 1). One of the most important things to con-sider when treating maxillofacial trauma is the patient's occlusion. It is vital to preserve normal occlusion so that the animal will

have a functional bite once the injuries have healed. Repairing fractures without regard to the teeth or the occlusion can have a detrimental effect down the road on the patient’s quality of life. With oral fractures there are many techniques that can be utilized to allow for proper stabilization of the fragments without damag-ing tooth roots or interfering with mastication during the healing process. Most often we utilize a combination of interdental wires and acrylic (Fig. 2). The use of plates is generally discouraged because of the difficulty in obtaining normal occlu-sion without damage to tooth roots or other structures such as the mandibular neurovas-cular bundle. Each case is unique and will be thoroughly evaluated to determine the best treatment option based on the injury and the patient with the ultimate goal of a healed, functional maxillofa-cial structure.

periodontal disease aFFecting other organs True or False - periodontal disease has been shown to be associated with distant organ pathology.true: Recent studies have been published that support a long-standing report1 that there is an association between periodontal disease and diseases of internal organs such as the heart, liver, and kidneys.2-4 Owners often ask the question about how to care for their pet's teeth because they are familiar with how oral health can affect systemic well-being. It is recommended to brush the teeth of dogs and cats daily, or at a minimum

Fig.2 Pre- (A) and postoperative (B) radiographs of a left mandibular fracture in a dog showing expected bony healing 3-weeks following fracture repair.

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Fig.2 Photograph showing a biopsy site (arrow) with a diagnosis of malignant melanoma of the lip in a dog (A). Full-thickness lip resection (B) and wound closure (C) provided for a long-term successful outcome (D).

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Fig.1 Radiograph (A) and photograph (B) showing rostral mandibular squamous cell carcinoma in a cat. The lesion was completely resected (C) with a minimum of 2-cm gross and radiographic tumor-free margin. Follow-up 1-year later (D) indicated an excellent result.

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Fig.1 Photographs showing dogs with heavy periodontal disease burden (A and B) including disease so severe (C) yielding purulent fluid (arrow).

Fig.3 Photographs showing furcation exposure (A-C), including root exposure (arrows) indicative of refractory periodontal disease.

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Fig.1 Radiograph of a right mandibular fracture (A) in a cat. The fracture was repaired using wire and acrylic (B and C). Mild gingivitis following implant removal is transient (D).

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since owners rarely look in their pet's mouth. If large enough, hemorrhage from self-trauma during eating may be the first clinical sign reported by the owner. Although the lesion may look bad, or be located in a difficult area to operate, owners should be encouraged to seek information before making a decision that may result in prolonged discomfort or euthanasia. Work-up for oral neoplasms is the same as other neoplasms and includes 3-view thoracic radiographs performed by the referring veterinarian. The next step is biopsy, biopsy, biopsy. Biopsy results provide information to the owner, referring veterinarian, oncologist, and surgeon that provide the basis for treatment and prognosis. The surgical component of

1. DeBowes LJ, Mosier D, Logan E, et al. Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 1996; 13: 57-60. 2. Pavlica Z, Petelin M, Juntes P, et al. Periodontal disease burden and pathological changes in organs of dogs. J Vet Dent 2008; 25: 97-105. 3. Peddle GD, Drobatz KJ, Harvey CE, et al. Association of periodontal disease, oral procedures, and other clinical findings with bacterial endocarditis in dogs. J Am Vet Med Assoc 2009; 234: 100-107. 4. Glickman LT, Glickman NW, Moore GE, et al. Evaluation of the risk of endocarditis and other cardiovascular events on the basis of severity of periodontal disease in dogs. J Am Vet Med Assoc 2009; 234: 486-494.

frequency of 3 times each week. Other methods can be used to minimize the impact of periodontal disease such as medicated chews, dental barrier sealants, and water additives. What about out-of-control periodontal disease? That's right, the owner is unable to brush their pet's teeth and no one remembers when the teeth were cleaned last!! One recent study actually measured the surface area of dis-eased periodontal tissue and showed that greater amounts of periodontal disease had a greater impact on heart, liver, and kidney disease.2 Therefore, our goal is to remove the periodontal disease burden on other organs by extracting teeth that are doomed to be lost (Fig. 1). Why maintain teeth that have periodontal disease and contribute to the periodontal disease burden that negatively impacts other organs? Our goal is to treat patients and wake them up with a healthy mouth. Teeth with periodontal pockets > 5 mm, root exposure, or furcation (area between tooth roots) exposure are generally extracted since these pathologic changes allow rapid progression of periodontal disease and a refractory disease situation (Fig. 2 and 3). Owners need to understand that less is best when it comes to diseased teeth and the long-term health of their pet especially in cases with pre-existing heart disease.

Fig.2 Photographs showing severe periodontal disease pockets affecting the man-dibular first molar (A) and canine (B) teeth.

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treatment is often remarkably successful. Guidelines for resection include 1-2 cm gross tumor-free margins that often includes skin. Conservative surgery for neoplasms is associated with a high incidence of recurrence. The tumor may be incompletely removed if the surgeon is more concerned about wound closure com-pared with attaining tumor-free margins. The referral process is paramount to a positive outcome. No single veterinarian can manage these cases alone. The team approach works for management of these diseases. Everyone involved wants the tumor completely removed and the patient never looking back... especially the owner! Don't give up on these lesions... encouragement and biopsy begins the treatment pathway to a rewarding outcome.

Fig. 3 Photographs showing oral (A) and extraoral (B) views of fibrosarcoma in a dog. The maxilla and skin defects (C) were closed using buccal and hard palate mucoperiosteal flaps and cutaneous advancement flaps (D). Routine healing (E and F) has resulted in contin-ued normal cosmesis and a pain-free outcome 8-months later.