Bad bite.

Traumatic malocclusion.

This week I am going to illustrate a problem with a story. The pup in these pictures has a single off set canine tooth due to an injury. Every time he closed his mouth the tooth would strike against the roof of his mouth causing chronic irritation to the soft tissue. This is a fairly common finding in both dogs and cats though it is typically a developmental issue and usually involves both canines. We call them base narrow canines and they can be very painful and can cause serious issues especially if the canines are allowed to break through the palate into the sinuses. Think chronic infection. The photo below is an 18 month old male dog. If you look at the canine tooth on the right of the photo and then look at the 7 o'clock position you can see the chronic wound his lower canine has been making in the roof of his mouth. There was also a fair amount of food material packed within this space. It does not require a large amount of mental gymnastics to see this as a potential source of infection and understand why treatment is recommended right away.  

Below is a side photo, note there is an endotracheal tube preventing complete closure of the mouth but you can see how the lower canine travels inside the upper canine. They should scissor together without really making contact.  

There are really only two treatment options for teeth like these. The first is to simply remove the tooth and in this case that is precisely what the owner decided to do. Removing a canine tooth in the mandible leaves a very large space in the bone that will eventually be filled in by the body. For a small period of time this will leave the mandible in a more vulnerable state. There is also a fair amount of pain associated with the recovery process. While pain can certainly be managed I would prefer to not ever cause it in the first place. The second treatment option would be to amputate the top part of the tooth to prevent it from contacting the roof of the mouth. If we do this, however, we leave the sensitive pulp tissue exposed. The best way to treat that is to remove the pulp and replace it with an inert substance. This is a root canal therapy, we discussed this last week. Root Canal

Below is the canine tooth before we began surgery. An injection of a local anesthetic has already been infiltrated around the nerve that supplies this tooth at this point.

Before undertaking this type of endeavor it is wise to get an x-ray and an idea of the amount of work ahead of you. Here is the x-ray of that tooth. It's going to be a pretty complicated extraction.

 

We make what appears to be a fairly large incision into the gingiva to gain exposure of the tooth and the surrounding periodontal tissue. This is for a few reasons, the first is that it is far easier to close and has less risk of breaking down, the second is that if we made an incision behind the tooth to make a flap we are disrupting the blood supply to the flap and could lose that tissue. It would be really hard to close this area without that flap of tissue. I actually ended up extending this incision to get more access. You'll notice that in the final photo.

After we have exposed the root of the tooth in its peridontal tissue we remove a fair amount of the supporting bone with a cutting bur on a handpiece that moves at 400,000 rpm. This allows us to easily remove the tooth without putting too much pressure on the jaw and causing a possible fracture. This photos are going to appear a little graphic.

 

After the proper amount of bone has been removed we can remove the tooth. Notice the large hole the root of the tooth left behind. I typically do not fill these with anything but I felt a lot better about leaving this one packed with a bone matrix. The x-ray following the photo shows the bone matrix within the socket and a little up at the top.

Once we have verified that all of the tooth material has been removed and that the bone is not jagged or protruding in any areas we are able to close the incision. This incision closed with 11 absorbable sutures.

I diagnose more traumatic occlusions in dogs and cats than I do Lyme disease and UTI's combined. They are fairly if not very common. The solution might seem drastic but a lifetime of chronic pain isn't a great alternative.

As an aside this is the tooth I removed from that dog's mouth. The part of the tooth you can see in the mouth ends right at 3.4 cm. The vast majority of this tooth and every tooth for that matter, exists below the gum line. This is why intraoral radiographs are so important to dentistry. Without them you can not evaluate or treat the entire mouth.

 

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