Authors of section

Author

Boaz Arzi

Executive Editor

Amy Kapatkin

General Editor

Frank Verstraete

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Wire reinforced intraoral splinting

1. Principles

The overall goal is to restore occlusion, normal anatomy and function.

Restoring and maintaining occlusion is the most important aspect of fixation of the mandibular fractures.

The image shows malocclusion assessed by palpation.

Dog mandible malocclusion assessed by palpation

Intraoral splints in small or brachycephalic dogs and cats are difficult to wire due to their anatomy. Therefore, composites may be used as the sole fixation method.

Dog mandible body bilateral simple fracture intraoral splinting

At least two substantial and periodontally stable teeth both rostral and caudal to the fracture line must be available for wiring. That means that a fracture caudal to the mandibular fourth premolar tooth is unsuitable for wiring.

Dog mandible body unilateral simple fracture wiring zone

2. Positioning and approach

This procedure is performed through the intraoral approach, with the patient placed in sternal recumbency.

wire reinforced intraoral splinting

3. Preliminary assessment

The fractured area is clipped to assess for penetrating injuries. If a penetrating wound is found, an exploratory surgery and debridement of the area is indicated to remove any foreign bodies (i.e. hair).

Pharyngeal intubation is needed to assess and maintain occlusion throughout and following the surgery.

A comprehensive intraoral examination must be performed to assess for any injury affecting occlusion, teeth trauma and periodontal tissues.

Dental radiographs and a CT are obtained to provide details about the dentoalveolar structures in relationship to the fractures.

Periodontal treatment (teeth scaling and polishing) is performed in preparation for composite bonding to the teeth.

4. Reduction

Reduction of the fracture is done digitally, bringing the teeth into normal occlusion, which realigns the bones.

Dog mandible body bilateral simple fracture reduction

Small loose bone fragments devoid of soft tissue attachments should be removed.

Teeth that are periodontally compromised as evident by dental radiography and charting should be removed from the fracture line prior to placing fixation.

Teeth that are periodontally stable but are fractured near the fracture line may be left in place. They should be temporarily treated endodontically by a partial coronal pulpectomy to provide pain relieve and avoid infection at the fracture site.

Root canal treatment or tooth extraction is performed when the fracture is healed.

5. Interdental wiring

The fracture is stabilized by applying interdental wires and composite.

Dog mandible body bilateral simple fracture wire reinforced intraoral splinting

Stout loop interdental wire technique

Appropriate size orthopedic wires are applied using the Stout loop interdental wire technique.

The Stout loop technique starts as a single loop around the first molar tooth with additional wire loop to tighten the wire around each tooth.

The knot of the wire should not interfere with occlusion and the ability of the patient to close the mouth. The knot of the wire can be placed on the lingual aspect when necessary.

Dog mandible body bilateral simple fracture Stout loop interdental wire technique

Risdon interdental wire technique

The Risdon technique starts as a double strand around the first molar tooth with additional individual wire loops connecting the double strand to each tooth.

The two double strands are closed together rostral to the incisor teeth.

The knot of the wire should not interfere with occlusion and the ability of the patient to close the mouth. The knot of the wire can be placed on the lingual aspect when necessary.

Dog mandible body bilateral simple fracture Risdon interdental wire technique

Alternative: Modified Risdon technique

The modified Risdon technique has the double strands ending at the mandibular canine teeth instead of rostral to the incisor teeth.

Note: this technique is used to avoid trauma to the gingiva of the incisor teeth and the lower lip.

Dog mandible body bilateral simple fracture modified Risdon interdental wire technique

At least two substantial and periodontally stable teeth both rostral and caudal to the fracture line must be available for wiring.

For example, a fracture at the level of the second and third premolar teeth can be wired from the distal aspect of the mandibular first molar tooth extending to the contralateral canine tooth.

Dog mandible body bilateral simple fracture wiring zone

6. Application of the composite

The composite should incorporate all the teeth in the wire fixation. If no wires are used, the composite should include at least two substantial and periodontally stable teeth both rostral and caudal to the fracture line.

Irrigate the teeth to be included in the composite. Acid-etch the teeth for 20-30 seconds. Thoroughly irrigate again and dry.

Note: it is paramount that the teeth remain dry throughout the application of the composite.

Dog mandible body bilateral simple fracture wire reinforced intraoral splinting acid etching

A composite temporization material is placed on the teeth and wires and contoured to avoid sharp edges or projections. Care is needed to avoid interference with occlusion and pointy edges.

Dog mandible body bilateral simple fracture wire reinforced composite application

Once the composite solidifies, it is smoothened with a Goldie bur on a straight handpiece or a diamond bur on a high-speed handpiece.

Dog mandible body bilateral simple fracture wire reinforced composite smoothening

7. Debridement and suturing

Wounds should be debrided followed by copious irrigation with sterile saline 0.9%. Soft tissue lacerations are sutured using 4.0 or 5.0 poliglecaprone 25 or other monofilament absorbable suture in a simple-interrupted fashion.

Note: in the oral cavity, due to abundant blood supply, aggressive debridement is rarely needed.

8. Aftercare

The splint should be cleaned at least once daily using 0.12% chlorhexidine gluconate solution. Another option is to use a water-flossing device.

The patient should wear an Elizabethan collar until removal of the construct.

The composite and the wire are kept in place for 6-8 weeks.

The composite and the wires are removed under general anesthesia using debonding forceps. The teeth involved in the fixation should receive periodontal cleaning as moderate to severe gingivitis is seen with the presence of an intraoral splint.

wire reinforced intraoral splinting

Endodontal follow up

Teeth that were traumatized by the initial injury should be followed up by root canal treatment or extractions. This is because the teeth lose their blood supply when the relationship with the supporting alveolar bone is disrupted and become non-vital. This in turn is a source for infection and pain and if not treated within 10 to 20 days of the trauma, inflammatory root resorption is likely to occur.