remove the tumor (B). tumor the remove was required to completely completely to required was (B). function lip restore and associated (A) (A) bone associated and to cheiloplasty and (A) tion tion of the adjacent teeth teeth adjacent the of tion - apposi mucosal includes - resec enbloc An 4 Fig. 2 Fig. Incompletely excised malignanttumors, andtumors that would besufficient,involving probably 2-3teeth(Fig. 3-5). relatively small, “mini” mandiulectomiesormaxillectomies For incompleteexcision ofossifyingandfibrous epulids, these tumorsemanatefromcells oftheperiodontal ligament. epulids requiretheremoval ofteethandassociatedbonesince (acanthomatous ameloblastoma). Completeremoval of a referralbasisisepulis, especiallyacanthomatous common incompletelyexcised tumorweencounteron in themouth where “extra” tissuefor woundclosureisat future surgery moreextensive anddifficult….especially surgery isrecommended,watchingandwaiting onlymakes to be. Althoughnoowner ishappytohearthat asecond to grow andat thistimeitisassmallever going do you adviseyour client? Well, the tumorwill continue was notcompletelyexcised. Asageneral practitioner, how to findthat indicates thepathology that report thetumor Itisnotunusualtoremove arelatively smalltumoronly What To Do When There Is Still Tumor Present? M Small issues in an B A B A Wound closure closure Wound outh s outcome while preserving normal function. outcome whilepreserving that maximizesasuccessful surgery allows moreconservative these “remaining” tumors quickly free margin. Again, removing require a minimum 1-cm tumor acanthomatous amelobastoma behave aggressively suchas (Fig. 1and2). nextThe most incompletely excised previously tumor we see that was melanoma is the most common common incats. Malignant squamous cellcarcinoma most diagnosed indogs, with most commonoraltumor Malignantmelanomaisthe problem. final surgery toalleviate the owner consideradefinitive, recommendation tohave the Therefore, itreallyisaneasy only goingtoregress over time. patient’s status is a premium.Additionally, the

, Big H primarily (B). primarily were unaffected (A) and the wound was closed closed was wound the and (A) unaffected were Fig. 5 Fig. ole A d Hea The ventral and the canine tooth canine the and mandible ventral The s : d &N

changes (B). (B). changes (A). There were no bony bony no were There (A). melanoma (A). A mar A (A). melanoma lar stability (C). (C). stability lar been incompletely removed removed incompletely been of a gingival malignant malignant gingival a of - mandibu provide to cortex where a fibrous epulis had had epulis fibrous a where ing incomplete excision excision incomplete ing maintained the ventral ventral the maintained This scar (arrow) is is (arrow) scar This 3 Fig. Fig. 1 Fig. completed mandibulectomy mandibulectomy completed 1-cm margins (B). The The (B). margins 1-cm performed with minimum minimum with performed ginal mandibulectomy was was mandibulectomy ginal A B C B A B eck S - follow tissue Scar

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The Center for Veterinary Dentistry and Oral Dr. Mark M. Smith and Dr. KendallTaney are partners in the Center for Veterinary Dentistry and Oral Surgery Surgery offers cutting edge knowledge and state-of- established in 2006. Dr. Smith is a Diplomate of the the-art equipment to help you manage your patients American College of Veterinary Surgeons and the American with dental and maxillofacial disease. Veterinary Dental College. He was Professor of Surgery and Dentistry at the VA-MD Regional College of Veterinary z Medicine at VirginiaT ech for 16-years before entering private practice in Root canal therapy 2004. Dr. Smith is Editor of the Journal of Veterinary Dentistry and co- z Restorations for caries and enamel defects author of Atlas of Approaches for General Surgery of the Dog and Cat. z Metal crowns to strengthen fractured teeth Dr. Taney is a Diplomate of the American Veterinary Dental z Surgery for neoplasms of the , mandible & College and a Fellow of the Academy ofVeterinary Dentistry. facial area She has practiced dentistry and oral surgery at the Center z Repair of maxillofacial fractures since 2006. She is a 2002 graduate of the VA-MD Regional z College ofVeterinary Medicine. She completed her residency Correction of congenital palate defects at the Center and has also performed internships in both z Surgical extraction of diseased multi-rooted teeth general medicine and surgery, and specialized surgery. and impacted teeth Dr. Emily Edstrom is a 2010 graduate of the Colorado State z Therapy for oral inflammation University School of . She completed a z Surgical management of diseases of the head rotating internship in small animal medicine and surgery at and neck VCA Veterinary Referral Associates in Gaithersburg, MD. She is a member of the American Veterinary Dental Society.

9041 Gaither Road, Gaithersburg, MD u20877 Phone: (301) 990-9460 Fax: (301) 990-9462u www.centerforveterinarydentistry.com issues in Dentistry and Head & Neck Surgery Newsletter for referring spring 2012

Beyond the Mouth: : : Laryngeal Masses…The Cork In The Teeth We Can Save! A B Too Much Of A Good Thing! A Airway! We have come a long way in Gingival enlargement, or gingival hyperplasia The larynx comprises only 3% of the surface veterinary medicine and what we as it is often called, is a common finding especially area of the upper and lower airways. However, can offer our patients. Veterinary in large brachycephalic breeds (Boxers) or when compromised by laryngeal disease, it can have dentistry as a is relatively brachycephalic-cross breeds. However, in many of devastating effects on pet function. Diseases such “new”, and the ability to save the patients we examine, it is an incidental finding. as laryngeal paralysis, laryngeal collapse, everted teeth is especially exciting in our Gingival enlargement should not be ignored as it laryngeal saccules, and laryngeal mass all compromise humble opinion! Many owners C D can expedite the progression of periodontal disease B the already limited airway at the larynx…the cork in are happily surprised to learn from by disrupting the normal periodontal structure of Fig. 1 Image of the laryngeal their that not all teeth the tooth. The supporting structure of the tooth, the airway. Clinical signs related to airway obstruction rhabdomyosarcoma compromis- include stridor, change in bark, exercise intolerance, ing the airway (black arrows). have to be extracted when there is or , includes the gingiva, epithelial fatigue, and hyperthermia from decreased heat Note the remaining functional a problem. So when is a root canal attachment, alveolar bone, periodontal ligament, exchange during panting. This latter clinical sign is a airway (white arrow). indicated? Fracture is the most and cementum. In a normal, healthy mouth, particularly life threatening consequence of laryngeal common scenario where teeth are Fig. 1 Indications for root canal include fractured the normal sulcal depth, or free gingival margin, disease and is most commonly noted in summer treated by root canal followed by (A and B), discolored (C), and luxated (D) teeth. should not exceed 0.5-3mm, depending on the C A months. The good news is that these clinical signs non-vital teeth. A non-vital tooth breed and size of the patient. Exuberant gingival usually have a slow, insidious onset. Unfortunately, may be suspected when the crown is discolored-pink, purple, or gray. Sometimes we see growth can cause an increased sulcal depth, owners may not notice these changes or may consider teeth that have been avulsed creating a pseudopocket where bacteria, plaque, them secondary to their pets advancing age. or luxated (Fig. 1). These teeth and debris are prone to accumulate. Once the A B Laryngeal tumors are rare (Fig 1). The clinical will need root canal therapy pseudopocket is present, no amount of brushing or signs are similar to those described previously. after they are replaced and home-care by an owner will prevent this build-up Treatment options include per os resection with long- stabilized. Dental radiographs of periodontal pathogens and debris, thus creating are always indicated to the perfect environment for inflammation, and B handled instruments. This technique is reserved for small lesions emanating from the laryngeal determine if a traumatized tooth eventually periodontal disease to flourish. What cartilages performed similar to a vocal chordectomy is a candidate for endodontic can be done? Fortunately, gingival enlargement procedure. Other techniques include exploratory therapy, and are also a way to can be corrected by performing gingivectomy of Fig. 1 Right (A), left (B), and rostral (C) preoperative views of gingival ventral laryngotomy with resection of the tumor or Fig. 2 The mandibular determine if a normal appearing the excessive gingival tissue. Radiographs should enlargement in a Boxer dog. Note partial laryngectomy. More aggressive surgeries such C canine teeth appear normal tooth needs a root canal. For also be performed to assess the health of teeth and how the teeth are covered as sub-total or complete laryngectomy require the (A), but radiographs of example, a routine radiograph bone and to rule out progressive periodontal disease. or nearly completely covered by gin- Fig. 2 Ventral laryngotomy shows additional procedure of permanent tracheosotmy for the teeth that were of the rostral mandible to assess Our treatment modality of choice for routine gival tissue! the laryngeal rhabdomyosarcoma extracted show a devitalized incisor teeth showed that the gingivectomy is radiosurgery that results in a compromising the airway (black upper airway by-pass. The case presented here had a slow onset of clinical evidenced by a mandibular canine root canals clean, controlled incision while cauterizing small arrows) and the endotracheal tube large root canal compared signs with a per os biopsy indicating a benign neoplasm. were incongruent, indicating vessels. Postoperative care includes NSAIDs (white arrow) [A]. The tumor with the opposite tooth (B). A was resected and the remaining The surgical plan included exploratory ventral The tooth was a good root that one tooth had stopped and narcotics for pain control, as well as a soft vocal process lateralized. The laryngotomy and temporary tube tracheostomy canal candidate (C). producing . There was diet for 2-weeks while the gingiva becomes cuffed tracheostomy tube allowed to provide airway by-pass for the administration of no gross evidence that the re-epithelialized. The critical component of anesthetic delivery and an unob- general anesthesia through the cuffed tracheostomy tooth was non-vital, however, the radiographs told a different story. The owner was prevention is at-home oral hygiene including structed surgical field (B). tube (Fig. 2). These procedures allowed for a clear happy to know that we could save her dog’s tooth with a root canal (Fig. 2). Root canals tooth brushing that should commence 2-3 weeks view of the lesion and an unobstructed surgical field. Unfortunately, the tumor in animals are performed exactly as they are in humans. Therefore, many owners are following the procedure. Professional teeth was a diagnosed as a rhabdomyosarcoma. The surgery provided an unobstructed aware of the process and expense involved in performing this procedure! Files are used cleaning should be performed at least annually, to clean and debride the canals and the canals are filled with an inert material. Finally and perhaps semiannually. Gingivectomy is glottis and the tracheostomy B site healed uneventfully (Fig. the fracture site and access points are restored (Fig. 3). It is recommended that dental mandatory for treatment and relatively frequent 3). The success of this surgery A B radiographs be taken of the tooth at each yearly cleaning to assess for any problems professional was based on a plan that allowed such as infection. We cleanings C for flexibility in approaching the have very stringent A B C (minimum larynx, including the possibility guidelines for rec- once/year) are of permanent tracheostomy if ommending root required for required. Upper airway surgery is canal resulting in an control and just another example of how your approximate 95% prevention Fig. 2 Right (A), left (B), and rostral postoperative views following radiosur- expectations may be exceeded success rate. of gingival Fig. 3 Postoperative view of the larynx showing a gical gingivectomy. The light pink, or by choosing the Center to help restored airway (A). Second intention wound healing Fig. 3 The technique for root canal includes cleansing and filing of the enlargement. “blanched,” appearance of the gingiva manage your patients’ needs! of the tracheosotmy site (arrow) was nearly complete canal (A), filling the canals with an inert material (B), and composite returns to a normal pink color shortly 2-weeks following surgery (B). restorations to restore the crown surface (C). following this procedure.