Dental fracture

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• Fracture of tooth may expose pulp which will become inflamed and infected leading to pain and likely eventual periapical abscessation.
• Cause : traumatic.
• Signs : painful (variable expression).
• Treatment : endodontics 'root canal therapy' (to save tooth), extraction.

Signs are often subtle and commonly evident only retrospectively after treatment!

• Mouth pain - variable and may not be expressed.
• Behavior change (aggressive, less interactive).
• Sleeping pattern change (may be increase or decrease, possible lethargy).
• Hypersalivation.
• Facial swelling.
• Difficulty/altered pattern of eating.

• Bleeding from mouth.
• Oral pain.

• Stone throwing is a common cause thus pebbled beaches/areas.

• Younger animals <3 years (due to thin tooth wall).

• Anecdotally males may be most frequently seen.

• None known; dogs prone to fighting/excitability/stone, bone or cage chewing likely.

• Avoid touching the area since severe pain can result in aggression.

• Extractions usually cheaper BUT possible complications may alter this (root remnants, jaw fracture).
• Endodontics (root canal therapy) - also requires post-operative radiographic monitoring.

• Lower (mandibular) canine extraction: jaw fracture.
• Upper (maxillary) canine extraction: iatrogenic oronasal fistula (ONF) formation.
• Root fragment retention.
• Endodontics is a referral discipline.
• Damage to adjacent dentition (especially in young animals - permanent dentition).

Pathogenesis

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• Trauma, eg catching stones, fights, RTA.
• Trauma when eating/chewing, eg bones, hard toys.

• Young animals (immature dentition).
• Playing habits.
• Diet.

• RTA.
• Cage biting.
• Chewing hard objects (including bones).
• Fights.
• Catching stones.
• High-rise injury.
• Carrying over-sized sticks.

• Exposure of pulp due to fracture      inflammation and infection of pulp ('pulpitis')  necrosis of pulp  periapical pathology (abscessation/granulation tissue/cyst). Tooth discoloration, from pulp necrosis, may occur.
• Pulp may still become inflamed (with potential pathology as above) even if not fully exposed as thin dentine is poorly protective.

• Immediate onset re discomfort and pulp compromise.
• Weeks to years re periapical pathology.

Diagnosis

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• Pain.
• Swelling.
• Bleeding.
• Infection.

• Pain.
• Altered behavior, eg more lethargic, less interactive, changed eating pattern.
• RTA.
• High rise injury.
• Recent fight.
• Catching or chewing stones/hard objects.

• Obvious tooth fracture       - 'complicated', ie pulp exposed (soft, pink-red/bleeding spot on fractured crown).
• Enamel +/- dentine fracture - 'uncomplicated'; underlying (but unexposed) pink pulp may be visible.
• Sensitivity/localized pain.

• Discolored tooth (gray/purple/brown).
• Soft brown-black spot on fractured tip of crown (remains of necrotic pulp)   .
• Draining fistula.

• Swelling - fluctuant, eg infra-orbital but varies with dentition affected.
• Swelling - boney (chronic inflammation and infection leads to boney change).

• Check for periapical pathology.
• Check for complications: longitudinal fractures, abnormal anatomy, etc.
• Check treatment technique is correct/successful.
• Intra-oral technique.
• Non-screen film best.

• Exposed pulp.
• Loss of enamel +/- dentine (full or near exposure).
• Discolored tooth.
• Facial swelling.

• Exposed pulp.
• Radiology.

Treatment

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Either

• A. Endodontics    - live or dead pulp, provided no periodontal disease or extensive absorption of alveolar bone affects that tooth .
  1. Root canal therapy: pulp is removed, root canal cleaned, shaped, filled and restoration placed   .
     Do not use for long axis tooth fracture, root fracture in coronal 2/3rds of root - instability likely
  2. Or Partial pulpotomy with pulp capping ('Pulpotomy') if immature animal with recent fracture, ie fresh and possibly still bleeding.
     Success greatest if least delay after incident (2-36 hours at most).

Or

• B. Extraction  : if long axis root fracture, root fracture in coronal 2/3rds if root, teeth with crown fracture and no endodontic treatment authorized, compromised teeth, eg periodontally.

Antibiosis

• 5-10 day course of clindamycin   or amoxicillin clavulanate   if treatment delayed or abscess apparent.

• Post-operative healing:
  • Extraction 5-10 days.
  • Endodontics 2 weeks (check restoration intact).
• Radiography: comparative films at time of surgery and approximately 6 months post-operatively:
  • Root canal therapy: show periapical pathology resolution (bone in-fill).
  • Partial pulpectomy + pulp capping: show thickening of dentinal wall and dentinal bridge over the pulp. No periapical pathology.

• Daily oral homecare (tooth brushing), avoid excessive trauma.

• Long-term monitoring: oral homecare checks advised every 3-4 months.

• Endodontic: repeat radiographs after (approximately) further 12 months, ideally for a total of 4 years. Root canal therapy may be required after tooth maturation following partial pulpectomy with pulp capping. In some cases only pulp capping is repeated (to 'refresh' the dressing).

Sequelae

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• Reasonable if pulpotomy performed while fracture fresh.
• Good if root canal therapy (pulpectomy).
• Excellent if clean extraction.

• Pulpotomy: presence of dentinal bridge over pulp, dentinal wall thickening and root apex closure demonstrated on radiograph 3-6 months after procedure and absence of apical rarefaction (black 'halo' due to bone loss, eg abscess), absence of clinical signs (discomfort, swelling, etc).
• Root canal therapy: absence of apical rarefaction (black 'halo' due to bone loss, eg abscess) demonstrated on radiograph 3-6 months after procedure, absence of clinical signs (discomfort, swelling, etc).
• Extraction: absence of clinical signs (discomfort, swelling, etc), absence of root remnants radiographically.

• Pulpotomy performed when pulp contaminated, post-operative discomfort.
• Root canal: poor endodontic technique (contamination).
• Poor surgical techinque.

Sources

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• Recent references from PubMed.
• Muir P & Gengler W R (1999) Interdental acrylic stabilization of canine tooth root and mandibular fractures in dogs. Vet Rec 145 , 43-45 PubMed.

• Gorrel C (2004) Veterinary Dentistry for the General Practitioner. W B Saunders.
• BSAVA Manual of Small Animal Dentistry , Crossley & Penman.

• Alex Smithson BVM&S MRCVS , Veterinary Dental, Oral & Maxillofacial Referrals, 6 George Street, Horwich, Lancs BL6 6BH, UK.

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