By Colleen Fox, DVM, Practice Limited to Dentistry
March 2016

Patient Name: Yellow

Age: 6-week-old M(I) Boykins Spaniel

Referred by: Dr. Chase, Academy Animal Care
History:  "Yellow," a 6-week-old intact male Boykins Spaniel, was referred to The COVE for an advanced dental evaluation after a malocclusion was noted during a well puppy visit by Dr. Chase of Academy Animal Care.  The owner reported no clinical signs and the puppy was growing at the same rate as his littermates. Pre­anesthetic lab work performed prior to presentation showed mild hypoproteinemia, mild anemia and mild elevation of the Alkaline Phosphatase, which are expected for his age.
Presentation:  On presentation, "Yellow" was in good body condition and was bright and alert. A mandibular  distoclusion was noted with a 13 mm overjet. The mandibular canine teeth were linguoverted,  causing traumatic defects to the hard palate adjacent to the maxillary canine teeth. The  remainder of his physical exam was within normal limits.

Diagnostics, Diagnosis, and Treatment: Following induction of general anesthesia and tracheal intubation, dental radiographs were performed to confirm the presence of appropriate adult dentition and to assess the roots of deciduous teeth. Bilateral inferior alveolar nerve blocks were performed with 0.5% Marcaine. A gingival incision was created along the root of the deciduous canine teeth and the alveolar bone was exposed using a periosteal elevator. Gentle elevation on the mesial and distal surfaces of the teeth was performed with deciduous elevators, taking care to avoid the lingual aspect and damaging the underlying tooth bud. The teeth were removed in their entirety and the gingiva was closed in a tension-free, simple interrupted pattern with 5­-0 Monocryl. The deciduous incisors were similarly extracted with deciduous elevators, without requiring gingival incisions. Post-extraction radiographs were performed to confirm complete extraction.
Outcome and Follow Up:  Recovery was uneventful. "Yellow" was discharged with instructions to the owner to provide a softened diet for 14 days while the extraction sites healed and to administer oral Metacam for the following 3 days. Extraction sites were checked after 2 weeks, and bite evaluation is planned when the adult dentition erupts around six months of age to determine if additional intervention is necessary.
Discussion:  Any class of malocclusion can be present in the deciduous phase. Jaw length discrepancies are more commonly seen at this stage, however. In some cases, the jaw may be genetically programmed for a normal bite and the malocclusion is temporary, due to varying growth rates in the maxilla and mandible. When the deciduous teeth are trapped by either a tooth or soft tissue, the normal growth rate and subsequent self-­correction is adversely affected. As with "Yellow," thorough oral exams during routine wellness visits allow for an early treatment plan, and early intervention maximizes the probability of a normal adult bite.
The deciduous teeth are much sharper than the corresponding permanent teeth, so trauma and pain from misalignment are initially significantly more intense. If occlusal trauma is present, extraction of the abnormally placed deciduous teeth should be performed as soon as possible to alleviate the trauma and pain and to remove the adverse dental interlock and allow unimpeded jaw movement. Ideally this is performed at 6­-8 weeks of age to provide maximal unimpeded growth of the jaw.
Extractions of deciduous teeth can be challenging, as the roots are proportionally much longer and thinner than in the corresponding permanent dentition. In addition, extreme care must be taken to avoid damaging the developing permanent tooth. Prior to eruption, the immature enamel is susceptible to damage, which can result in enamel hypocalcification. Current literature recommends closed extractions in cases with significant root resorption and a surgical approach when the tooth appears intact radiographically. Root fractures are a common complication of deciduous extraction attempts. A retained root tip can become infected or act as a foreign body, creating significant inflammation. In addition, retained root tips can deflect the permanent tooth from its normal eruptive path, contributing to malocclusion.
It is imperative that the client understands that, typically, treatment of a malocclusion by selective extraction of deciduous teeth is only the first step, unless the malocclusion is solely the result of adverse dental interlock. Depending on the severity and type of malocclusion present in the adult dentition, additional treatment options will include ball therapy, orthodontic appliances, and crown shortening with vital pulpotomy or selective extractions. 
Tech Tip
- By Mary, LVT
Did You Know?

Cut-to-size syringes are a better mouth gag to use in dental patients than spring-loaded mouth gags. A study of six healthy cats found compromised maxillary artery blood flow using spring-loaded gags and 42mm plastic gags (Martin-Flores et al., 2014). Spring-loaded mouth gags were also used in 16 of 20 cats with post-anesthetic blindness after dental or endoscopic procedures (Stiles et al., 2012). 
A range of lengths and sizes can be quickly made using 1mL to 5mL syringes. These stretch the lips less and give easier access to the molars and premolars.

The "For Veterinarians" section of our website has been updated with new information. 

Visit our new   Lunch and Learn page to see a list of our most requested Lunch and Learn topics, and to schedule a workshop at your practice. 

Our  Continuing Education page is constantly updated with new CE events, so be sure to check back often to see when a COVE team member will be speaking at a veterinary conference near you. 

Attending the 1st Flight Veterinary Conference in May? 

The conference will be held at the Hilton Garden Inn at Kitty Hawk, North Carolina from May 12-15, 2016. We are proud to announce that Merrilee Small, DVM, DACVIM (Cardiology) and Shelley Smith, DVM, DACVECC, will be leading presentations at the conference. 

Visit the 1st Flight Conference  website  or our  Continuing Education page for more details.
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