Complicated crown fracture (CCF) mandibular right canine tooth (404) – treated with coronal pulpectomy, direct vital pulp capping and restoration.
Crown/root fractures of maxillary right 1st (101) and 2nd (102), mandibular left 1st (301) and right 1st (401), 2nd (402) and 3rd (403) incisor teeth – treated with envelope flap and extraction.
Amity, a 30kg three year old black female speyed German Shepherd dog was presented to the referring veterinarian after she was involved in a car accident where she suffered oral trauma resulting in fracture of the maxillary right 1st (101) and 2nd incisor (201) incisor, mandibular left 1st (301), right 1st (401), 2nd (402), 3rd (403) incisors and canine (404) teeth. On presentation, an oral examination confirmed a complicated crown fracture with pulp exposure, loss of half the crown height resulting in a very sharp lingual edge that had lacerated the lateral border of the rostral tongue. There was gingiva trauma with open tooth sockets consistent with loss or trauma of the incisor teeth but no visible incisor teeth present suggesting avulsion or crown/root fractures, which required radiographic confirmation. She was placed on amoxycillin/clavulanic acid 13.75 mg/kg bid and carprofen 4 mg/kg sid for 48 hours prior to being referred for oral examination and treatment of the exposed pulp canal by direct pulp capping.
Once referred our examination confirmed the original diagnosis and the recommendation to the owner was a thorough oral examination under general anaesthesia, involving confirmation of pulp exposure and radiographs to confirm incisor tooth avulsion or fracture. Pre-anaesthetic blood work was within normal limits. An intravenous cathether was placed in the right cephalic vein and Hartman’s solution commenced at 10mg/kg/hr. 600mg cephazolin was administered at the time of pre-medication via a combination of buprenorphine 0.03mg/kg, acepromazine 0.05mg/kg and atropine 0.04mg/kg subcutaneously. 60 minutes later, anaesthesia was induced with alfaxolone 2mg/kg intravenously to effect over a 60 second period until she could be intubated with a #10 cuffed endotracheal tube and anaesthesia maintained on 1-3% isoflurane in 100% oxygen. Anaesthesia was monitored manually by a Diploma trained technician and a Cardell machine measuring temperature, sPo2, ECG and blood pressure.
Oral examination visually confirmed a complicated mid-crown fracture of the mandibular right canine tooth as evident by pulp exposure
, a small laceration to the rostral lateral tongue edge, and loss of the tooth crowns associated with 101, 102 , 301, 401, 402, 403 as evidenced by open tooth sockets.
Radiographs of the above were obtained which confirmed the canine fracture healthy periradicular tissues and a wide pulp , consistent with the age of the dog. We also observed retained roots and many crown/root fractures of the maxillary and mandibular incisor teeth. Our recommendation was to extract the incisor teeth roots and complete partial vital pulpectomy and direct pulp capping for the canine tooth.
Local anaesthesia was achieved using 1.5mls of 3% plain mepivacaine in an aspirating syringe placed with 0.5mls aliquots via bilateral mandibular mental blocks [MENTAL] and a right sided infra-orbital block and waiting 15 minutes for onset of action to occur. A #15 scalpel blade on a #3 handle was used to make a deep incision directly over the incisor tooth sockets in the maxilla extending from the right 3rd incisor (103) to the left 1st incisor (201) and in bone and remaining incisor teeth. A #4 Molt periosteal elevator was placed into the incision between the alveolar bone and attached mucosa to elevate an envelope muco-gingival flap on both the maxilla and mandible. The elevated flap was retracted and held in position allowing direct visualisation of the maxillary and mandibular alveolar bone and fractured teeth by an assistant holding Minnesota retractors against the buccal and lingual surfaces and buccal and palatal surfaces respectively. The pieces of partially attached crown/root fractures were removed by dissecting from the adjacent mucosa with a #15 scalpel blade. Once the pieces were removed, the retained roots were extracted by placing a sharp Cislak #2 winged dental elevator into the periodontal space occupied by the periodontal ligament with gentle controlled force and rotated in a clockwise direction until the periodontal ligament was both severed and expanded allowing haemorrhage and force to separate the tooth and bone and push the tooth out of the socket. Once the tooth root was loosened it was lifted from the socket where it was grasped with small dental forceps and removed from the tooth socket.
Following extraction of all of the maxillary and mandibular retained tooth roots, radiographs were taken to confirm complete extraction of all roots and fractured pieces from the maxilla and mandible
A gloved finger was used to palpate the height of the alveolar bone and any rough and sharp edges removed using a water-cooled round #4 diamond bur in a high-speed hand-piece. The buccal and lingual, and the buccal and palatal, edges of the flap were opposed and closed using 3/0 Safil Quick with simple interrupted sutures placed 2mm apart.
The canine tooth was cleaned with a saline soaked swab and sterilised by washing in 0.12% chlorhexidine. A sterile drape was placed over the tooth isolating it from the surrounding tissues and previous surgery site. The exposed infected pulp and 5mm of coronal pulp was removed with a sterile water-cooled #2 round diamond bur in a high speed hand-piece. Haemostasis was achieved with a saline soaked paper point left in contact with the pulp stump for 10 minutes. Once removed gently so as to not remove the fibrin clot, the severed pulp stump could be visualised 5mm below the fracture site. A 1mm layer of liquid calcium hydroxide paste was placed directly onto the exposed pulp stump using a calcium hydroxide applicator avoiding contact with the dentinal wall. A 2mm layer of light-cured glass ionomer was placed directly onto the hardened calcium hydroxide surface avoiding contact with the coronal dentine wall and set using a blue curing light. The remaining 2mm of pulp canal and exposed fractured dentine/enamel surfaces were prepared for a composite restoration using the acid technique. 37% phosphoric acid was placed onto the exposed tooth surface using a micro-brush and left for 30 seconds, removed using the same brush, washed with water from the air/water syringe and dried with the same syringe until a frosted appearance. It is importance to not over dry the surface, which will result in collapse of the intra-tubular collagen and reduced bonding and restorative strength. A thin layer of unfilled composite resin/bond was placed using a micro-brush to the etched tooth surfaces, air thinned using the air/water syringe and cured with the blue wave length using a curing light for 10 seconds. An A1 shade filled composite restorative was placed into the 2mm void within the pulp canal and over the coronal aspect of the fractured tooth using a plastic instrument to provide coverage and protection of the exposed dentine and enamel edges and re-establish normal tooth anatomy albeit to a shorted height. The composite was placed in 2mm increments and cured with a curing light for 10 seconds per cycle. Once coverage and anatomical form was achieved, the composite was smoothed using Soflex finishing disks commencing with the course disk in a slow speed hand-piece with a mandrel attachment under water cooling from the air/water syringe and progressing through the medium, fine and super fine disks. A final layer of unfilled resin was placed over the composite and tooth to seal the margin and provide a smooth finish. The resin was cured with the curing light for 10 seconds [post 404 tongue].
Radiographs were taken post-procedure to confirm placement of the calcium hydroxide, glass ionomer and composite material
The lacerated lateral tongue edge was debrided with a #15 scalpel blade, opposed and sutured with 4/0 Safil Quick using three simple interrupted sutures
Amity was awoken from anaesthesia and remained on intravenous fluids for approximately an hour and a half post-procedure, in total she received 750mls Hartmanns solution. She was given meloxicam 0.2mg/kg subcutaneously when sternal. The intravenous catheter was removed and she was discharged four hours post-procedure. Amity was prescribed amoxycillin/clavulanic acid @ 12.5mg/kg bid for 10 days and meloxicam 0.1 mg/kg sid with food for 5 days. A revisit appointment was scheduled for 7 days to check the integrity of the composite restoration, the healing of the muco-gingival flaps and tongue laceration.
Further post-procedure follow-up will be posted when Amity revisits for the post-op check and radiographs in 6 months to ensure the dentinal bridge forms and the tooth remains vital.