Authors of section

Author

Boaz Arzi

Executive Editor

Amy Kapatkin

General Editor

Frank Verstraete

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Intraoral splint fixation

1. Principles

The overall goal is to restore normal anatomical contour and allow for normal function.

Restoring and maintaining occlusion is the most important aspect of fixation of the rostral midface.

The image shows assessment of the malocclusion.

general considerations with midface fractures

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

intraoral splint fixation

At least two substantial teeth both rostral and caudal to the fracture line should be available for wiring. The composite, with or without the wiring, can be extended to the contralateral site, e.g. to include two canine teeth.

intraoral splint fixation

2. Positioning and approach

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

3. Intraoral examination

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.

intraoral approach to the maxilla

4. Reduction

Reduction of the fracture is done digitally bringing the teeth into normal occlusion. This maneuver realigns the bones as well. The teeth should occlude in a normal position unless malocclusion was present prior to the trauma.

Note: Care should be taken to avoid vascular damage during the reduction as the bone edges may be very sharp.

intraoral splint fixation

5. Fixation

Interdental wiring

The fracture is stabilized by applying interdental wires, composite, or a combination of both.

Appropriate size stainless steel wires can be applied using a Stout loop interdental wire technique...

intraoral splint fixation

…or a Risdon technique.

intraoral splint fixation

At least two substantial teeth both rostral and caudal to the fracture line should be available for wiring. For example, a fracture distal to the canine teeth would require the involvement of the third and fourth maxillary premolar teeth caudally, as well as both canine teeth.

The wire loops should be placed at the buccal aspect of the maxillary teeth to avoid occlusion problems.

intraoral splint fixation

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 fracture is reduced. The wire is secured. The teeth involved in the fixation are acid-etched 20-30 seconds. The acid-etch is removed by copiously rinsing the teeth. The teeth are dried.

Note: Care should be taken to avoid contamination of the teeth with saliva.

intraoral splint fixation

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.

intraoral splint fixation

Avoid composite placed at the palatal aspect of the fourth premolar tooth because it can affect occlusion.

intraoral splint fixation

Once the composite solidifies, smooth the composite with a Goldie bur on a surgical handpiece, or a diamond bur on a high-speed handpiece.

midface rostral comminuted

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.

6. Aftercare

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.

Homecare

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.

intraoral splint fixation

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.

intraoral splint fixation