Dental bridging as a treatment for large oral fistulae in two horses

Chronic orocutaneous, oronasal, or orosinus fistulae can be challenging to repair. This report describes placement of a dental bridge as a treatment for oral fistulae and outcome in two horses. A 12-year-old, Westphalian gelding was presented for nasal discharge because of an oromaxillary fistula after dental repulsion of the Triadan 209 4 years earlier. The second case, a 5-year-old Oldenburg mare was presented for an orocutaneous fistula 7 weeks after dental repulsion of the Triadan 208. Both were treated by placing an 8-shaped cerclage wire, inserted through the rostral and caudal interdental spaces and crossing at the level of the missing tooth. Polymethylmethacrylate (PMMA) was then used to seal the fistula. No significant complications occurred during or after the surgery. In both cases clinical signs did not recur. In the first case the dental bridge is currently (5 years after the intervention) in place. In Case 2 the construction was removed after 1.5 years and the fistula had healed completely. This case report suggests that placing a dental bridge composed of cerclage wire and PMMA should be considered as an easy, noninvasive and efficient way to manage large oromaxillary or orocutaneous fistulae.     

Facial swelling associated with impaction of the deciduous and permanent maxillary fourth premolars in a dog with patent ductus arteriosus

A three-year-old Labrador retriever was referred for decreased appetite, a painful swelling in the region of the maxillary right fourth premolar, and a heart murmur indicative of patent ductus arteriosus (PDA) diagnosed 1.5-weeks prior to presentation. Oral examination and intraoral dental radiographs showed impaction of the maxillary right fourth premolar surrounded by reactive alveolar bone. Necrotic bone, remnants of the deciduous maxillary right fourth premolar, and the impacted permanent maxillary right fourth premolar were removed following surgical exploration of the area. The PDA was repaired without complication 2-weeks following oral surgery. The extraction site was healing appropriately, and the dog's inappetence and painful facial swelling had resolved.     

Treatment of horses for a facial or oral fistula

A sinocutaneous or nasocutaneous fistula is usually a sequel to a comminuted fracture of one or more facial bones, whereas an oronasal or oromaxillary sinus fistula occurs most commonly after a maxillary alveolus fails to fill with healthy granulation tissue after its tooth has been lost. Horses with a sinocutaneous or nasocutaneous fistula can be treated by covering the fistula with transposed muscle, which in turn is covered by adjacent skin or a free skin graft, or by covering the fistula with periosteum transposed from adjacent bone, itself covered by adjacent skin or left uncovered to heal by second intention. Horses with an oronasal or oromaxillary sinus fistula can usually be treated successfully by temporarily occluding the oral aspect of the fistula, to prevent feed from entering the fistula, until the apical end of the alveolus fills with healthy tissue. Other methods of treatment include covering the oral aspect of the fistula with a mucoperiosteal flap or filling the fistula with a transposed facial muscle.     

Oronasal fistula repair utilizing a temporalis muscle flap in a dog with severe trismus

A 9 yr old spayed female cocker spaniel presented for evaluation of an invasive maxillary squamous cell carcinoma. Curative intent surgery and radiation therapy allowed for local control of the neoplasm; however, the development of a persistent oronasal fistula prevented a complete recovery. A temporalis myofascial rotation flap allowed for successful resolution of the maxillary defect. Implementation of the flap was relatively simple and was associated with few complications.     

Use of a synthetic bone substitute to retard molariform tooth drift after maxillary tooth loss in ponies

OBJECTIVE: To evaluate the effect of alveolar bone substitute on post-extraction drift of maxillary cheek teeth in ponies. STUDY DESIGN: In vivo longitudinal experimental study. ANIMALS: Five ponies (5-7 years) with a healthy dentition. METHODS: Both maxillary 4th premolar teeth (Triadan 08) were surgically removed. One alveolus was filled with a biocompatible non-resorbable bone substitute (Bioplant 24), whereas the other healed by second intention. A polyvinylsiloxane plug and spring wire isolated the bone substitute from the oral environment. Pathologic changes to dentition and adjacent soft tissue were recorded. Tooth drift was calculated after 1 and 2 years. RESULTS: At 1 month, bone substitute material was incorporated into healthy tissue. Tooth drift was observed but differed significantly between control and treated sides at 2 years (P<.01). For both techniques, tooth drift differed significantly between years 1 and 2 (P<.001). Total drift in control arcades for year 1 was 10.69+/-2.12 mm and for year 2 was 9.08+/-0.87 mm, whereas for bone substitute arcades it was 9.90+/-1.60 mm for year 1 and 5.60+/-1.78 mm for year 2. CONCLUSIONS: Partial tooth replacement therapy after maxillary P4 extraction provided good healing in the immediate post-surgical phase. Alveolar filling with bone substitute material significantly slowed post-extraction tooth drift but did not stop it completely. Clinical Relevance- Important changes occur in equine dentition after maxillary cheek teeth removal. Further longer term observations are needed to fully validate study findings.     

Free tissue transfer of the rectus abdominis myoperitoneal flap for oral reconstruction in a dog

A five-month-old intact/male Boxer dog was presented 5-days following bite wound trauma to the maxillary region resulting in an oronasal fistula extending from the maxillary canine teeth to the soft palate. Multiple surgical procedures using local, buccal mucosal flaps failed to repair the oronasal fistula. Free tissue transfer of the rectus abdominis myoperitoneal flap using microvascular surgical techniques was successful in providing soft tissue reconstruction of the hard palate area. Complications of these surgical techniques included muscle contraction and subsequent muzzle distortion. Small, refractory oronasal fistulae at the perimeter of the myoperitoneal flap were repaired by primary wound closure.     

Angularis oris axial pattern buccal flap for reconstruction of recurrent fistulae of the palate

OBJECTIVE: To describe the use of an axial pattern flap based on the angularis oris artery and vein for reconstruction of palate defects. STUDY DESIGN: Clinical case report ANIMALS: Two dogs with recurrent oronasal fistulae. METHODS: Oronasal fistulae previously treated by buccal mucosal random pattern flaps that subsequently dehisced were repaired using an angularis oris-based buccal tissue axial pattern flap. This flap was developed by full thickness incision of the cheek tissue, excluding the skin, about the angularis oris vascular pedicle resulting in a vascularized flap covered by oral mucosa on one side. RESULTS: In one dog, the repair was intact and healed 6 months after surgery. In the second dog with a fistula that resulted because of radiation necrosis, approximately 95% of the defect healed with a small (<1.0 cm(2)) area of dehiscence. Repair of this persistent fistula with a random pattern buccal flap failed and this small fistula remained with minimal clinical signs. CONCLUSION: An axial pattern flap based on the angularis oris artery and vein can be used to repair difficult or recurrent palate defects. CLINICAL RELEVANCE: Angularis oris axial pattern flaps provide an additional effective option for repair of defects in the hard and soft palate to the distal gingival margin of the canine tooth or beyond, depending on skull conformation. Advantages of this flap include its highly vascular and robust character, high degree of mobility and a surface of tough buccal mucosa.     

Treatment of equine oro-nasal and oro-maxillary fistulae

Equine oro-nasal or oro-sinus fistulae are usually problematic disorders to treat. As these lesions are mainly a sequel to standard dental repulsions, it is obvious that safer exodontia techniques such as oral extraction should now be used. The initial treatment of such fistulae is to ensure that there is a healthy granulating alveolus, without any dental or alveolar sequestrae and that all epithelium lining the fistula is removed. Provided there is a tooth on either side of the fistula, the initial and usually successful treatment is the use of an acrylic alveolar plug attached to adequately prepared adjacent teeth. Reinforcing such prostheses with wire tied between adjacent teeth will stabilise such prostheses. For fistulae that extend far onto the hard palate or those at the Triadan 06 or 11 alveolar sites that cannot be treated by acrylic prostheses, a variety of surgical treatments including; mucoperiosteal sliding flap, transposition of facial muscles, maxillary bone flap or an ear cartilage graft are all potential therapies, but there  are no large, objective long-term reports on their success available.     

Complications of mandibular brachygnathism in a North African leopard

A 9-year-old, male North African leopard (Panhtera pardus) presented with mandibular brachygnathism and lingually displaced mandibular canine teeth causing a large left oronasal fistula, rhinitis and nasal discharge, and a right orocutaneous fistula. Surgical closure of the left oronasal defect, bilateral mandibular canine tooth crown reduction, and root canal therapy resulted in a positive clinical outcome. A small recurrent left oronasal fistula and the right orocutaneous fistula healed spontaneously after alleviating the occlusal contact with the mandibular canine teeth. At 12-months postoperatively, clinical signs of oral and dental disease had resolved.     

Repair of experimental plaque-induced periodontal disease in dogs

Forty mongrel dogs were used in this study for induction of periodontal disease by placing subgingival silk ligatures affecting maxillary and mandibular premolar teeth during a 12-month period. Experimental premolar teeth received monthly clinical, radiographic, and histometric/pathologic assessments. The results demonstrated significant increases in scores and values of periodontal disease parameters associated with variable degrees of alveolar bone loss. The experimental maxillary premolar teeth exhibited more severe and rapid rates of periodontal disease compared with mandibular premolar teeth. Histometric analysis showed significant reduction in free and attached gingiva of the experimental teeth. Histopathological examination of buccolingual sections from experimental premolar teeth showed the presence of rete pegs within the sulcular epithelium with acanthosis and erosive changes, widening of the periodontal ligament, and alveolar bone resorption. Various methods for periodontal repair were studied in 194 experimental premolar teeth exhibiting different degrees of periodontal disease. The treatment plan comprised non-surgical (teeth scaling, root planing, and oral hygiene) and surgical methods (closed gingival curettage, modified Widman flap, and reconstructive surgery using autogenous bone marrow graft and canine amniotic membrane). The initial non-surgical treatment resulted in a periodontal recovery rate of 37.6% and was found effective for treatment of early periodontal disease based on resolution of gingivitis and reduction of periodontal probing depths. Surgical treatment by closed gingival curettage to eliminate the diseased pocket lining resulted in a recovery rate of 48.8% and proved effective in substantially reducing deep periodontal pockets. Open root planing following flap elevation resulted in a recovery rate of 85.4% and was effective for deep and refractory periodontal pockets. Autogenous bone graft implantation combined with canine amniotic membrane as a biodegradable membrane was used in 18 premolar teeth and failed to improve advanced furcation defects in most teeth.     

Repair of a gingival cleft associated with a maxillary canine tooth in a dog

This case report describes repair of a gingival cleft located on the labial aspect of the maxillary left canine tooth in a client-owned dog. Multiple procedures were performed including elevation of a pedicle flap, granulation tissue removal, alveoloplasty and root planing, and placement of an osteoconductive bone graft material. The surgical site was closed with a laterally repositioned flap. Postoperative examinations were performed at 2 and 3-weeks without chemical restraint and at 3 and 10-months postoperatively under general anesthesia. At the 10-month postoperative examination, a broad band of gingiva surrounded the maxillary left canine tooth, and probing revealed absence of periodontal pockets. Intraoral dental radiographs indicated maintenance of alveolar bone height and incorporation of the bone graft material into alveolar bone.     

Computed tomographic description of the highly variable imaging features of equine oromaxillary sinus and oronasal fistulae

Oronasal and oromaxillary sinus fistulae are well‐documented complications following removal or loss of a maxillary cheek tooth. Diagnosis is currently based on a combination of oral examination, videoendoscopy, radiography, and computed tomography (CT). The objective of this retrospective, case series study was to describe the CT characteristics of confirmed oronasal and oromaxillary sinus fistulae in a group of horses. Inclusion criteria were a head CT acquired at the authors’ hospital during the period of 2012–2017, a CT diagnosis of oronasal or oromaxillary sinus fistulae, and a confirmed diagnosis based on a method other than CT. Signalment, clinical findings, oral examination findings, presence of a confirmed fistula, and method for confirmation of the diagnosis were recorded. A veterinary radiologist reviewed CT studies for all included horses and recorded characteristics of the fistulae. Seventeen horses were sampled. Fourteen oromaxillary sinus fistulae and three oronasal fistulae were identified. All fistulae appeared as variably sized focal defects in the alveolar bone. Defects frequently contained a linear tract of heterogeneous material interspersed with gas bubbles, considered consistent with food. Computed tomographic attenuation of the material (Hounsfield units, HU) varied widely within and between cases. In 16 of 17 cases, there was evidence of concurrent dental disease in addition to the fistulae. Although the gold standard diagnostic test remains identification of feed material within the sinus or nasal passages, findings from the current study support the use of CT as an adjunctive diagnostic test for assessing the extent of involvement and presurgical planning.     

True cementomas (cementoblastomas) associated with a nonvital left maxillary second premolar in an 11‐year‐old miniature horse

An 11‐year‐old miniature horse gelding presented for a left maxillary facial swelling and surgical removal of 2 ovoid mineralised masses located near the tooth roots of the left maxillary second and third premolars. Preoperative radiographs were performed to triangulate the location of the calcified masses for removal, and an oral examination revealed that the left maxillary second premolar was nonvital with multiple feed‐packed pulp exposures. Both the radiographs and oral examination indicated that the mineralised masses were associated with the nonvital second premolar. Therefore, the tooth was extracted intraorally, and the masses were removed via a maxillary trephine dorsal to the extracted tooth. Both masses were submitted for histopathology, which diagnosed the masses as true cementomas (cementoblastomas) with adenomatous hyperplasia of the surrounding nasal glandular tissue.     

Island palatal mucoperiosteal flap for repair of oronasal fistula in a dog

A two-year-old neutered/male mixed-breed dog had received partial maxillectomy for fibrosarcoma. An oronasal fistula occurred as a complication of the surgical procedure. An island palatal mucoperiosteal flap was developed and rotated to repair the oronasal fistula. Acute (1-month) and long-term (8-months) follow-up indicated appropriate healing of the transposed island palatal mucoperiosteal flap with resolution of clinical signs indicative of oronasal fistula.     

Transmaxillary anchored silicon embedded gauze plug in the post-operative treatment of a large oromaxillary fistula caused by a supernumerary cheek tooth

A 9-year-old Hungarian sport horse gelding was presented to the clinic in poor condition displaying malodorous bilateral purulent nasal discharge. Oral examination revealed the presence of supernumerary 111 and 211. Bilateral diastema formation between the third maxillary molars and the supernumerary teeth with deep periodontal pockets and massive food impactions were diagnosed endoscopically. Radiography revealed inhomogenous sinus opacities in the left and right paranasal sinuses. Following bilateral oral extractions of the supernumerary cheek teeth and third maxillary molars, bilateral oromaxillary fistula formations were diagnosed (about 17 mm diameter on the right side). Bilateral frontal and right-sided maxillary trephinations and resection of the right bulla of the maxillary septum were performed. Massive food impactions of the left and right paranasal sinuses were removed under endoscopic control. Repeated trans-endoscopic sinus lavage was performed post-operatively. After 2.5 months, the large right-sided oromaxillary communication was temporarily closed with a transmaxillary anchored, gauze-cored silicon plug on an outpatient basis. Follow-up examination after 187 days revealed complete closure of the oromaxillary fistula and absence of sinusitis. In a 1.5-year follow-up control, no pathological conditions were found.     

Treatment of chronic septic osteoarthritis of the antebrachiocarpal joint with a synovial‐cutaneous fistula utilising arthroscopic lavage combined with ultrasonic assisted wound therapy and vacuum assisted closure with a novel wound lavage system

This case report describes the successful management of a chronic multidrug resistant infection of the antebrachiocarpal joint with a synovial‐cutaneous fistula 7 weeks after initial trauma in a 14‐year‐old Icelandic stallion. Resolution of the multiresistant Enterobacter cloacae (extended‐spectrum β‐lactamase) infection from the joint and complete closure of the fistula was achieved by arthroscopic lavage under general anaesthesia repeated on 3 occasions, surgical debridement, ultrasound assisted wound therapy and vacuum assisted closure. Lavage of the wound with the vacuum assisted closure in place was facilitated via the novel VeraFlo instillation system consisting of specially designed therapeutic regulated accurate care pad tubing. The combination of these therapies resulted in resolution of the septic arthritis and fistula. Six weeks after admission the horse was discharged from the hospital with a completely healed wound and was not lame at a walk.     

Use of skin stretchers to elongate a peninsular thoracodorsal axial pattern flap for antebrachial wound closure in a dog

Objective: To describe preoperative use of skin stretchers to elongate a peninsular thoracodorsal axial pattern flap to close a large antebrachial wound on a dog. Study Design: Case report. Animals: A 21 kg, 7‐year‐old, male intact mixed breed dog. Methods: Two skin stretchers were applied to the site of the thoracodorsal axial pattern flap 4 days before surgery. The elastic cables connecting the adhesive pads were tightened daily to increase the skin available for a peninsular thoracodorsal axial pattern flap, which was created and rotated 180° to cover an antebrachial defect to a level 2 cm proximal to the carpus. Results: The entire flap survived; there was a small amount of incisional separation at the distal margin of the flap that healed without further treatment. Conclusion: Preoperative skin stretching provided additional skin for the axial pattern flap used.     

Oronasal fistula repair

Oronasal fistula is a relatively common complication associated with maxillary canine tooth extraction, problematic healing of maxillectomy, and repair of secondary cleft palate in small animals. Regardless of the clinical scenario associated with oronasal fistula, therapy requires surgical treatment. Principles for surgical repair of oronasal fistula include development of mucosal flaps with excellent vascular supply to transpose over the defect to restore continuity of the nasal and oral cavities. The specific surgical technique may vary but includes either single or double mucosal flaps. Oronasal fistula refractory to multiple attempts at surgical repair may be obturated by using a prosthodontic device.     

Oral surgery. Basic techniques

Some of the clinical problems most frequently seen in veterinary dentistry and their surgical solutions are discussed. Extraction of teeth, surgical repositioning of teeth, tooth transplant, oral abscesses of tooth origin, impaction of teeth, repair of maxillary canine oronasal fistula, and simple techniques for oral wiring are among the issues considered.     

Chronic rhinitis and dental disease.

Whenever an animal is examined because of chronic rhinitis, the dentition should be carefully examined to rule out the possibility of a primary dental problem. Oral examination under heavy sedation or general anesthesia is necessary to diagnose many of these cases. A periodontal probe is used in detecting deep periodontal pockets that extend into the nasal cavity or maxillary sinus. A dental explorer is used to reveal pulpal exposure secondary to dental fractures or rapid dental wear or attrition. Careful oral examination is used to localize any oronasal or oroantral fistula from a previously lost tooth. Dental radiographs help to reveal the extent of alveolar bone pathology. An assessment of all these findings will result in an accurate diagnosis of the primary cause of the chronic rhinitis, which will in turn facilitate appropriate treatment.