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).
A comprehensive intraoral examination is performed to assess for injury affecting occlusion, teeth and periodontal tissues.
Dental radiographs and a CT are obtained to provide details about the dentoalveolar structures in relationship to the fractures.
Periodontal treatments (teeth scaling and polishing) are performed to optimize composite bonding to the teeth.
Reduction of the fracture is typically done by digitally bringing the teeth into normal occlusion. This maneuver normally realigns the bones as well.
Note: Care should be taken to avoid vascular damage during the reduction as the bone edges may be very sharp.
The fracture is stabilized by applying interdental wires, composite, or a combination of both.
Appropriate size stainless steel wires are applied using a Stout loop interdental wire technique...
…or a Risdon technique.
At least two substantial teeth both rostral and caudal to the fracture line should be available for wiring. For example, a fracture at the level of the 3rd and 2nd premolar can be wired from the distal aspect of the maxillary first molar tooth extending all the way to the canine tooth or even to the contralateral canine tooth.
The wire loops should be placed at the buccal aspect of the maxillary teeth to avoid occlusion problems.
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 teeth both rostral and caudal to the fracture line.
The teeth to be included in the composite are acid-etched for 20-30 seconds. The teeth are thoroughly irrigated and dried.
Note: Care should be taken to avoid contamination of the teeth with saliva.
A composite temporization material is placed on the teeth and wires and contoured to avoid sharp edges or projections. Care is needed to avoid contact with the gingiva and the palatal aspect of the 4th premolar tooth and the first molar tooth because it can affect occlusion.
Once the composite solidifies, smooth the composite with a Goldie bur on a surgical handpiece or a diamond bur on a high-speed handpiece.
Debridement and suturing
Wounds should be conservatively 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.
The dog should be kept on soft food for one or two weeks after surgery.
Intraoperative intravenous administration and then oral antibiotics for one to two weeks is recommended. Antibiotics used should have an excellent oral cavity penetration and spectrum. Example: ampicillin at 20 mg/kg intravenous antibiotics followed by oral antibiotics amoxicillin/clavulanic acid at 15-20 mg/kg orally twice daily.
Pain medication, such as opioids and non-steroidal anti-inflammatory medications, are used for 7-14 days.
If the fracture involved the oral cavity, oral rinse with 0.05-0.12% chlorhexidine gluconate solution is recommended (not for maxillomandibular fixation).
Recheck is recommended in 10-14 days and at three and six months post-surgery.
If there are any signs of complications (i.e. purulent nasal discharge), CT and rhinoscopy are indicated.
The splint should be cleaned twice daily using 0.05-0.12% chlorhexidine gluconate solution. Another option is to use a water-flossing device.
The composite and the wires are kept in place for six to eight weeks. They are removed under general anesthesia using debonding pliers.
The teeth involved in the fixation should receive periodontal cleaning as moderate to severe gingivitis is commonly seen with the presence of an intraoral splint.