Saving the Canine’s Canine

A 24 kg female spayed four-year-old standard poodle presented for a second opinion to see if anything could be done to save the left maxillary canine affected by advanced periodontal disease.

Case Study: Lateral Sliding Flap to Treat Gingival Recession

A 24 kg female spayed four-year-old standard poodle presented for a second opinion to see if anything could be done to save the left maxillary canine affected by advanced periodontal disease. Conscious oral examination revealed moderate plaque and tartar covering the canines and cheek teeth. There was marked gingival recession as well as plaque and tartar covering the root of the left maxillary canine. Halitosis was also present. The dog’s teeth were professionally cleaned under general anesthesia a year prior. Treats were fed daily. Consistent home care for plaque or tartar prevention was not practiced.

The dog was placed under general anesthesia and intubated after preanesthesia CBC, serum profile, and urinalysis tests provided normal results. Under anesthesia, a tooth-by-tooth examination including probing and full mouth intraoral radiograph diagnostics were performed. There were no significant pathologic findings other than an 8 mm attachment loss level affecting the left maxillary canine tooth on the facial surface. In that this attachment loss was greater than 50% of the tooth root, stage 4 advanced periodontal disease was diagnosed (Figures 1a and 1b).

1_a.jpgFigure 1a: Marked gingival recession noted after dental scaling and polishing

1b.jpgFigure 1b: 8 mm attachment loss

Periodontal disease is considered progressive and painful; a discussion with the owner included options to care for the tooth including extraction versus performing a lateral sliding flap to eliminate the gingival recession. The client was alerted that home care including twice daily wiping the dog’s teeth to remove plaque would be required for the best postoperative prognosis. The client agreed to the stringent home care including use of accepted Veterinary Oral Health Council (VOHC.org) plaque control products.

Treatment and Outcome

After ultrasonic dental cleaning and polishing with fine grit pumice, the oral cavity was thoroughly irrigated. To increase the zone of keratinized attached gingiva covering the receded area, a laterally repositioned pedicle flap was performed.

  1. V-shaped incision was made using a #11 scalpel blade following the peripheral margins of the free gingiva in the recession (Figure 2).
  2. A reverse bevel incision extending to the underlying bone beginning at the free gingival margin and extending to the distal root of the second premolar was made.
  3. A vertical releasing incision angled slightly distally was created (Figure 4).
  4. A sharpened straight Molt#2 periosteal elevator was used to raise a full thickness flap closer to the recession area and a split thickness flap at the recipient site. The flap should be at least 1.5x the recipient site and extend into the alveolar mucosa to provide space for the zone of attached gingiva (Figure 5).
  5. A stay suture was placed to handle the caudal extent of the flap (Figure 6).
  6. Retained plaque and tartar were removed from the recipient site with a curette (Figures 7 and 8).
  7. The flap was positioned on the recipient site and sutured with 4-0 catgut on a reverse cutting P3 needle beginning at the coronal mesial point (Figure 9).

2-10.jpg

The dog was sent home on gabapentin (20 mg/kg) to decrease pain. The client was instructed to feed softened food for 10 days. On reexamination at two weeks, the flap was intact and residual sutures were removed. The owner was instructed to lightly wipe the dog’s teeth twice daily with dental wipes. The dog was reexamined at six weeks (Figure 10). Complete coverage of the gingival recession was clinically apparent. Follow-up plans included professional oral prevention, assessment, and treatment visits, and twice-daily dental wiping and use of a VOHC-accepted water additive were recommended. A good to excellent prognosis is expected.

Discussion

Gingival recession occurs secondary to the apical migration gingival margin. The distance between the cementoenamel junction and the gingival margin is the level of recession. The recession may extend past the mucogingival junction. Gingival recession is most caused by periodontal disease, trauma, and abnormal occlusal relationships.

The lateral repositioned pedicle flap preserves existing keratinized gingiva, allows thorough removal of plaque, calculus, and inflamed tissue from the area affected by periodontal disease, and generally gives a positive predictive result as long as optimum home care is practiced.

AAHA Dental Standards

Did you know? AAHA has many standards related to dental care. Here is a look at some of them.

  • All dental procedures must be performed under general anesthesia with patients intubated and supplemental oxygen being administered.
  • Veterinarians must perform thorough examinations of the teeth and structures of the oral cavity in patients presented for dental procedures.
  • Only properly trained practice team members may perform dental procedures.
  • Dental procedures with potential for aerosolization of infectious debris must be performed in a properly ventilated area set apart from other patients and practice team activities.
  • Practice team members should document an oral health assessment utilizing the AVDC guidelines for staging periodontal disease during a dental procedure.
  • Appropriate dental instrumentation and equipment should be utilized, including: 
    • Ultrasonic scaler/piezo scaler
    • High-speed drill
    • Hand instruments such as elevators, curettes, scalers, and probes
    • Low-speed polisher

Contact your AAHA support team to learn more, at 800-252-2242 or aaha@aaha.org

Additional Reading

Gorrel, C.E. and Hale, F.A. “Gingivectomy and Gingivoplasty.” In Oral and Maxillofacial Surgery in Dogs and Cats edited by Frank J.M. Verstraete and Milinda J. Lommer, 167–174. Philadelphia, PA: Saunders, 2012.

“Periodontal Flap Surgery.” In: Veterinary Periodontology edited by Brook A. Niemiec, 206–248. Ames, IA: Wiley and Sons, 2013.

“Treatment of the Exposed Root Surface.” In Veterinary Periodontology edited by Brook A. Niemiec, 249–253. Ames, IA: Wiley and Sons, 2013.

Wiggs, Robert B. and Heidi B. Lobprise. “Periodontology.” In Veterinary Dentistry Principles and Practice, edited by Robert B Wiggs and Heidi B. Lobprise, 186–231. Philadelphia, PA: Lippincott–Raven, 1997. 

Bellows_Jan.jpg
Jan Bellows, DVM, DAVDC, DABVP (canine and feline specialties), is in private practice in Weston, Florida. He is a frequent national and international lecturer on topics related to companion-animal dentistry. He is a past president of the American Veterinary Dental College and is currently the president of the Foundation for Veterinary Dentistry. He is a coauthor of the AAHA Dental Guidelines for Dogs and Cats (2010, 2013, and 2019) and the author of the books Feline Dentistry (2010) and Small Animal Dental Equipment, Materials and Techniques, Second Edition (2019).

 

Photo credits: Photos courtesy of Jan Bellows, DVM, DAVDC, DABVP

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