So good evening everybody, and thank you very very much for joining us for tonight's presentation, which is part of the webinarett's 2021 equine series. Tonight's presentation and the equine series has been very kindly sponsored by Bailey's Horse Feeds. So tonight we have a talk on managing equine dental fractures and we will be presented by Sam Hole.

Sam has spent over 20 years in the pursuit of providing better oral health care for horses via equine dental training both in the UK and the USA. It has 2 undergraduate degrees and 2 postgraduate veterinary certificates and a postgraduate veterinary diploma. Sam was awarded the Royal College Certificate in advanced veterinary practise in Equi Dentistry in 2012, the first to be awarded by the Royal College.

In 2015, Sam became a Royal College recognised advanced practitioner in both equine Dentistry and equine practise. In 2016, Sam became one of only a handful of clinicians to become a diplomat of of the EVDC via the equine fast track pathway by successfully passing the entrance exam. Sam has tutored on courses and spoken at conferences on equine dentistry for over 10 years and has authored and co-authored several journal papers on equine veterinary dentistry.

So if anyone has any questions, please type them into the question and answer box at the bottom of the screen, and then we'll hand, I will put them to Sam at the end of the presentation. So over to you, Sam. Thanks very much for your kind introduction and good evening to everyone, and I hope everyone's doing OK at the moment with what's going on, but maybe I can act as a little bit of light relief and discuss equine dental fractures, but any of you that, Deal with horses and and equine dentistry on a day to day basis will know that when teeth fracture or break, there's nothing light about it at all.

It's one way that can really ruin your day quite quickly, . About half this talk is actually on managing equine dental fractures, and I won't apologise too much for the misleading title. The first half is all about why a horse's teeth fracture and the, the, aopathogenesis and the typing of these sort of dental fractures, but if I just advertised it as a histopathology lecture on dental fractures, then I'm not sure so many of you would be in attendant.

So do bear with me, I'll get, it'll get more interesting towards the end regarding treatment options, etc. Etc. So, fractured teeth are commonly encountered in both first opinion and, and referral electine practise.

But only a relatively small percentage of horses with fractures show any clinical signs. And this is certainly bar out in my experience in practise. And in one study in 2015 by Henry Treme.

You know, 40% of cases were asymptomatic. You know, that's nearly half the horses with quite severe dental fractures are showing no signs at all, and that certainly is borne out with what I see in, in practise on a day to day basis, that horses just generally don't show overt clinical pain through dental disease and, and especially with dental fractures. And, and fractures can have been found to cause 20% of apically infected mandibular cheeky, so.

Fractures have quite a big part to play in in in why these teeth are are septic, uncomfortable, need to be extracted, etc. Etc. So clinical signs may include, as we've just discussed, there may be no clinical signs whatsoever, but they may include pain, mastatory problems, quitting as we all, traditionally know, but this could be dismastication, disprehension, weight loss, although again in, with modern horses, particularly that we see in this practise in the leisure industry, you know, a horse can have a very, very compromised mouth, and, and Mrs.

Smith is still feeding it 15 apples a day and it's, it's fat as butter. Halitosis, bitting behavioural problems, periodontal disease, facial swelling, pyrexia, these have all been stated and cited as, as clinical signs linked to dental fractures. So, let's have a little bit of a chat about the ATO pathogenesis of why teeth fracture and why we find them.

Well, obviously, trauma, kicks, crib biting, biting hard objects in the old days used to be using those old fashioned spool gags, was traditionally used for fracturing teeth. These are commonly talked about. However, in my experience, apart from incisor fractures, This doesn't tend to be white, especially cheek teeth fracture.

Dental disease commonly leads to fractures, and these have been termed both pathological and idiopathic fractures. And iatrogenically, so this means us, the practitioner has caused these fractures, and horses chewing on floats or dental spools, the coil gags as I just mentioned. Molar shears, when I first started doing dentistry, reducing large focal overgrowth was commonly done using molar shears or molar percussion instruments, and these had a big tendency to cause dental fractures.

And repulsion, . Repulsion again, when I started was the treatment and the, the methodology of choice for removing infected cheek teeth, and, and repulsion unfortunately has a high incidence of causing dental fracture, both to the tooth you're trying to remove and adjacent teeth. So fractured teeth can be described in several ways.

So it can be described according to their cause, as we've just talked about being traumatic fractures, idiopathic fractures, or arogenic fractures, and they can be cate catized by the dental tissues and the anatomy involved. So this could be an enamellymph. Fractions or a crack, enamel fracture, crown fracture, crown root fracture, root fracture, alveolar fracture, and these are all just terms to describe how the fracture configuration is, is presented.

And it can be used by the involvement of the endodontic system. So an uncomplicated dental fracture involves the enamin, the dentin, and the cementum, but doesn't involve the pulp, so it's a, a vital tooth and a non-vital fracture. And there can be a complicated fracture which involves enamel, dentin, cementum, and the pulp, and this is a, a non-vital tooth because it's a vital fracture.

I prefer to use the terms uncomplicated and complicated because vital tooth, vital fracture, non-vital tooth vital fracture can get a little bit confusing. The only issue I have with these terminology is an uncomplicated fracture can involve the dentin, but for me, dentin and polk need to be considered as one entity, because it's the pulpal dentin complex. So but if you have an uncomplicated fracture that's gone into the dentin, that can certainly lead to a complicated fracture if you get involvement and inflammation of the pulp.

So just do bear that in mind. So I quite like this AVDC classification. It's, it's geared towards small animal nomaculture and usage, but I do think it, it lends itself well to equine use and just characterises the different types of fracture and and the abbreviations to use them, so you can be a little bit more specific within your dental notes of how you're describing these fractures.

So, the prevalence, how common are these dental fractures and how often are we actually seeing them? So you can see from the slide here that the prevalence of dental fractures ranges from 0.5% all the way up to, you know, nearly 30%, and in one older, population of horses.

In a South African abattoir study, you know, nearly 60% of cases had some sort of dental fractures. So, so they can be pretty wide ranging the prevalence of these dental fractures, and, and I think like everything within dentistry, the more you look for them, the more you're likely to find these fractures. So, let's look at the prevalence in incisor and canine teeth and the, and the fractures that we see there.

They're not uncommon, as I said, quite often with incisors and canines, they can be traumatic in origin, and this made up up to 25% of referred cases in one studied by Dicksonettal in two in 1999. In another in that same study, 73% of cases with incisive fracture were caused by trauma. And again, as we said, this is because they're, they're roster within the skull, they're unprotected and they're there waiting to get kicked by their cohorts or land on their muzzle if they try and jump out of a lorry or something too quickly.

Nearly 7% of incisor fractures were classed as idiopathic, which means we didn't really know why, why that happens, and that's very different to the incidence of idiopathic cheek teeth fractures, and this is because of the high level of enamel type 2, OK. And incisors have a far higher level of type 2 enamel, where the cheek teeth have a far higher level of equine type 1 enamel, and type 1 enamel, the prisms are in a far more parallel structure, which means they like to fracture in that sagittal plane that we'll all be familiar with in cheek teeth where you get a sagittal or a parasagittal buckle fracture or, or palatal fracture for that one. In inside the teeth were usually fractured transversely, so across the crown like that, if you think of how a tree would snap.

And again, that's in sharp contrast to the cheek teeth where they tend to break down the middle like a stone was cracking. And 17% of incisor fractures were found in a PhD study of endangered donkeys on the border between Portugal and, and, Spain. And Zhao found that only a little over 6% of those were complicated fractures, that meant they were going into the pulp involving the pulp.

So, looking at the prevalence of cheek teeth fractures. So as low as 0.5% in first opinion practise in in Scotland, about 5% of donkeys, up to 7.5% of horses in a referral cohort, with 71% being mandibular, and, and far less, 30% being maxillary.

I have to say in my dental practise, those numbers aren't borne out. I would say I see a far more even distribution between mandibular and maxillary tooth fractures. And idiopathic fractures are more common in cheek teeth, as I said before, with nearly 50% of all fractured cheek teeth recognised in a referral equine population as being idiopathic.

OK, and, and 11% in the Swedish horse population. And there was no significant difference in the. Prevalence between peripheral caries affected cheek teeth and non-peripheral caries affected cheek teeth, in the study, which I think is quite interesting.

A lot of us in practise have this, this suspicion that, that peripheral caries weaken these teeth somehow, but this study doesn't bear that out. So looking at the individual types of cheek teeth, maxillary cheek teeth are overrepresented in idiopathic fractures with 68% of all fractured cheek teeth in a study by Eden and Dickson in 2008, and almost 3 times as many maxillary as mandibular cheek teeth fractures were in this class of idiopathic fractures. And especially the maxillary nines, I think anyone that does a fair volume of dentistry will, will be pretty familiar with the fact that if, if in doubt it's usually the upper nines, they're usually the ones causing you problems.

And this is borne out by the literature with 57% in that study from, from 2008, where E Dixon and, and 64% in, in, Ian Days's PhD work that was published in 2007. In the mandibular cheek teeth, 08s and 9s are overrepresented and combined to make 80% of all mandibular fractures. OK, and, and again these are considered to be idiopathic, but arogenic fractures.

Are reported as well. And as I said, commonly with a high rate with repulsions, 9% with attempted during a standard oral extraction, and that's why a standing oral extraction technique should be your, your first line and, and not a repulsion because the, the fraction. And complication rates with repulsions are up, you know, between 40 and 60%, depending on the, the literature you cite.

And, and these fractures are more likely in younger teeth because they're, they're more voluminous teeth with a hollow centre and they tend to be a little bit more, Capable for kind of exploding really. So going on to talk a little bit more about idiopathic fractures, and previously fractured teeth with no known history of trauma have been described as idiopathic fractures. And this has also been described as no known history of trauma, as I said in, in, in Ian Dacre's PhD study.

It's also been described as that those of no definitive aetiology, so we don't know what made them fractured, therefore we term them as idiopathic. And, and also it's been said that no predisposition to fracture is found on the majority of cheek teeth are fractured in Ian's PhD work, except idiopathic fractures caused by advanced infandibular carries. And that begs the question, if we do find marked pathology within these teeth.

Surely we need to postulate that that is possibly or probably the cause of, of the fracture and therefore maybe idiopathic fractures aren't the most suitable terminology for these fractures. So here's the sort of fracture that we're talking about, so this is. Commonly and and and previously been described as an idiopathic cheek tooth fracture.

OK, and, and what we can tell by looking at this tooth here is it has a midline sagittal fracture, well, para sagittalol going through pulps 3 and 4 and. And also a para sagittal, buckle fracture going through pulps, 1 and 2 on the buckle aspect as well. So this has got multiple fracture lines.

And, and why has this happened? We've got open pulps, we've got fracture lines going through pulps. So, you know, I would suggest this is a fracture that's borne out, out of, out of endodontic death rather than being idiopathic in its truest sense of the world.

So, usually, as I was just discussing, as a consequence of dental disease, with this infantdibular carries, that's been previously termed, infandibular hyperplasia, peripheral carries or pulp necrosis as I think has probably happened with the image that I was showing you on the previous slide. So I do think that we need more descriptive terminology, you know, such as infant dibular carries, related cheek teeth fractures, and, you know, or pulp necrosis induced fractures, etc. Etc.

And this was postulated by Dickson EA in their paper of 2040. So, let's look at some of the specific types of cheek teeth fracture configurations that have been described. So midline satitial fractures, straight down the middle of the tooth, you know, in, maxillary teeth, through the infedibula, and, and these account for 30, 20 or 20% of maxillary cheek teeth fractures.

Lateral slab fractures account for 52% or 50% of cases, and medial slab fractures between 11 and 30% of cases. So they, they can account for a big chunk of these fractured teeth. 42% of cheap teeth with idiopathic fractures had occlusa pulppa exposure, and again I think this begs the question of whether, you know, there was, poular disease but as a cause of why these went on to fracture.

And reduced dinal thickness was present in 25% of fractured teeth. So this shows that the endodontic system and the pulp has been under great stress and hasn't been allowed or been able to lay down the normal level of mineralization that you would expect with these teeth. So, this is a lovely image, this is from again from Ian Dacre's PhD work up at Edinburgh, and just shows the fractured configuration lines, and they do follow quite a marked pattern of, you know, lateral parasagal fractures, midline sagittal fractures or, .

Mal parasagittal fractures and you can follow these on the on the maxillary teeth, on the mandibular teeth, there's a little bit more variation, but by and large you're getting these fracture lines through pulp pawns 1 and 2, and then some variations between pulps and 3 and 4 and sometimes 34 and 5. So, fracture lines run through the infantivity of maxillary teeth teeth in a sagittal or a meso distal or a rostrocausal direction, and, and the range of these range from 0.5% all the way up to nearly 50% of maxillary cheek teeth fractures.

So there's a big range of prevalences with this confirmation of fracture. And again, as we've previously stated, especially tried in '09, the upper nines are massively overrepresented, accounting for up to 64% of all fractured maxillary cheeky. Most horses are aged between 9 and 12s that have fractured 09s and 100% of cases result in apical infection when they have these midline statital fractures, OK.

So, we're starting to build up a bit of a pitch here, so you've got, You know, nearly 30% of cases that have open pulps, you've got 25% of fractured teeth that get dentinal and that get mineral, thinning because they've fractured or prior to fracturing, you've got 100% of cases with . Midline sagital fractures that result in apical infections. So you're building up a, a picture here that most fractured teeth aren't well teeth and need something done about them, and that's a little bit in odds to what I was taught when I was trained in vet school that actually, you know, most fractured teeth, they'll be fine, just keep an eye on them, or maybe they won't be fine.

So again, midline satral fractures, infibicaries hyperplasia is also common, particularly in the upper nines, and 48% of infidilic carries have been found on ended. Scopic examination, according to Simhofer's paper in 2008, and only 3% of infanty in the 09 position are completely filled with normal cementum in a paper by Fitzgibbon, so that means that actually, These are full inindibly filled, top to bottom with cementum normal. Well if only 3% of cases are normal, probably means that maybe that isn't the norm and we've got to start picking up those, those differences.

22% of infidibuli in the 09 position were fully carious in that same paper, and again the 09s are 30 times more likely to be affected than the 11 by infindibular caries. And in the study, in the abattoir study in South Africa in 20,150, you know, over 90% of older courses had some degree of infant dibular caries, you know, it shows how widespread this disease process is and, and does it go on to cause, fractures also. So lateral slab fractures, the fracture line runs in the sagittal plane through pulps one and two.

Most common cheek tooth fracture when you look at both maxillary and mandibular teeth combined, and accounts for 48% of all fractured cheek teeth. With maxillary cheek teeth specifically ranges from 1% to 65% of prevalence. And in mandibular cheek teeth ranges from 1 to 93%.

24% of cases resulting in a kill infection again. So again, you're building up this picture that. A big percentage of these fractured cheek teeth go on to form, cause further problems, such as apical infection.

And, and is this because this represents a weak point across the crown running through these poke points? Well, quite possibly. Histologically, most fractures run through all three mineralized dental tissues and run perpendicular to type 1 enamel planes, like I was saying, these parallel planes of type 1 equine enamel run like this and they tend to shear those planes apart.

So, going on to medial slab fractures, fracture lines run through the pulps 3 and 43 and 534 and 5, maxillary cheek teeth fractures again range from 1% up to 33% of cases and when mandibular fractures 2.5% up to. 43%.

And I, and I've put these stars on there because quite often in a lot of the studies that looked at fractured cheek teeth, we had midline fractures, we had lateral fractures, and then you had all the other types of fractures. So quite often specific medial slab fractures haven't been cited in the literature, it's just been the other type of fractures that aren't midline fatal fractures or lateral or buckle, quite commonly fractures. So just a little word about fissure fractures, these are the fine transverse fractures or microfractures in the peripheral enamel that you quite often see going from pulp to pulp or the pulprading out to the peripheral enamel.

And, and, and these have been recording quite high prevalence, 54, 58%. OK, but interestingly, over 90% of these maxillary fissure fractures were associated associated with pulp horn number 4, and over 95% of fissure fractures in mandibular cheek teeth were associated with pulp horn number 1 and number 2. And I think this might have something to do with the way these teeth are being loaded within their mastatory cycle.

The most commonly found in mandibular cheek teeth, and especially the middle teeth in the arcade, the eights, nines, and 10s, and that would be borne out by what I see in practise on a daily basis. 30% of mandibular trident 9s are affected versus only, 7% of maxillary 09. So we do see far more of these, These fractures in the mandibular and teeth rather than the maxillary teeth.

They appear currently not to be clinically significant, but I think we maybe need to watch this space and follow a few more of these, these fissure fractures through on a more longitudinal basis. They don't appear to be correlated to primary dental disease, but some fissure factories can lead to pulp exposure and, and apical infection. And I think it's important though saying that we just maybe follow these through a bit more.

Some of these, these percentage here only accounting for 9% of infected maxillary cheek teeth and 9% of diseased mandibular cheek teeth. OK, they're quite low numbers compared to the 50s, 60s we've been talking about, but they're, you know. If your client's horse is one of that 1 in 10 that has got an a infection due to a fissure fracture, some of these fissure fractures warrant further investigation.

So hopefully you should all be familiar with these, just these little fissure fractures that quite often radiate either out buckily or longitudinally between the two cheeks. So here you've got one radiating out there and one going, going in a meso distal direction there as well. So, that's us got through the majority of the ATO pathophysiology of these fractured teeth and, and some data as to why maybe fractured teeth are a little bit more important as to pay a little bit more attention and just do some further diagnostics.

So, so how do we approach the diagnosis of these, these fractured teeth? Well, history is quite important, particularly with incising canine teeth. Have they been kicked in the face?

Have they been chewing a hay net or a, or a, or a bolt on a stable door? Clinical signs that we've talked about, but quite often, as we've also talked about, quite often they're asymptomatic and there are no discernible clinical signs. Full clinical examination I think is important, making sure there's no swelling of the head, no fever, no, increased heart rate, etc.

Etc. A full oral examination is obviously important, just a word of warning with this. If you think there might be any osseous fracture involvements, that's a jaw fracture, particularly mandibular fractures, do just be a bit cautious before you apply a full mouth speculum and open it because.

You know, if there is any doubt about there being an osseous or a bone fracture, you know, let the bone heal first. The tooth can always be diagnosed and extracted later and sometimes just if you're a little bit concerned, taking a radiograph to make sure you can't see any overt or comminuted fractures before you apply a speculum can be a very good plan. Full oral examination, obviously sedation is very important.

A good headlight or spec lights you can see what's going on within the oral cavity. He stand or a dental halter, oral mirror, all, all very important so you can fully diagnose any dental fractures. Additional imaging can be really, really helpful.

Oral endoscopy, I think for those of us that are using oral endoscopy routinely now, we wouldn't be without it. But there's nothing that you can't see with a dental mirror that you can suddenly see on a, on a dental endoscope, it's gonna give you the same thing. It's great for client education and showing them that the tooth is fractured and also obviously for recording images for presentations such as this.

Radiography, as I've just mentioned, is, is the cornerstone of, of, of dental, fracture diagnosis as well. And, and for some more complicated fractures, computer tomography is, is the gold standard, especially with surgical planning, 3D reconstruction and stuff can be very useful. There was a study by Manzo Diaz in 2015 that in 11 places, only 4 of which fractures were identified radiographically.

So I think that's, that's important to bear in mind, you've got a lot, a lot higher success rates of getting your diagnosis with CT than, than plain dental radio. So I now just want to talk a little bit about the sequela of these dental fractures, you know, why do we need to be worried about these dental fractures? You know, why won't they just be fine, we'll keep an eye on them.

Well, as I talked about, the pulp or the dentalal pulp complex is invariably involved in cheek teeth fractured and many incisor and canine fractures also. And, and some have been shown to clinically resolve without the development of, of apical or perios, . But this isn't usually the case, you know, with the, the paper here by Taylor and Dickson, you know, nearly 40% of cheek teeth required no specific treatment.

Well, that means 60% did. And again, of these 40% that required no specific treatment, how long were these teeth followed up going forward? How confident are we that those teeth actually were fine and, and stood the test of time going forward?

It was erroneously reported, you know, back, in the early noughties that slab fractures seldom involve the pulp cavity, but we now know thanks to Ian's PhD study, that, that this is not the case and fractures usually do involve the pulp horns and, and therefore usually run the risk of a further pathology occurring. So in my opinion, many most fractures result in pulpitis, pulp necrosis, and or apical or periaapical infraction. And 75% of cheek teeth associated with a mild severe apical infection, and 86% of fractured cheek teeth have exposed pulp.

OK, so that means they're gonna get pulpitis, you know, at the minimum, and potentially they're gonna go on. To get a full blown apical infection. And the remaining 14% are fractured through both infant dibula, and we know that 100% of midline sagittal fractures go on to get apical infection.

So we're, we're building quite a compelling argument here as to why, especially cheek teeth fractures and a lot of incisor and canine fractures, probably aren't going to be OK just to be left and monitored. So as you can see here, these are the pulp horns all in these teeth, and there's not a lot of overlying secondary dentin here, so just bear in mind, you know, it doesn't take a lot of these fractures to get into or very close to the sensitive dentin and pulp complex. So what are the swale, well.

Pulp vitality, as we've just talked about, has the pulp remained vital, repair of the dentinal pulp complex, and this depends on a magnitude of things, OK, the magnitude of the insult, is it mild, is it severe? The duration of the insult, chronic versus acute. The viability of the dentinal tubules involved, whether the bacteria colonises these tubules, whether the tubule can successfully sclerose itself, whether it becomes plugged with collagen, whether it becomes filled with the blast process, the age of the tooth, younger teeth tend to be a little bit more adaptable to.

Withstanding these insults, the, the length of the pulp space, the cellularity of the pulp, the vasculature nature of the pulps, the nerve supply, all of this tends to be a little bit more buoyant in a younger tooth and therefore it has the ability to, you know. Withstand these insults a little bit more significant. And if you take nothing else away from my presentation this evening, just take away this one slide, that a lack of clinical signs that we've already talked about aren't always present, does not equal endodontic health.

And when you get a fractured tooth, undoubtedly these, Dentinal tubules are going to be exposed and therefore you've got a portal into the dentinal pulp complex and the potential for this tooth to die, or at least become very unhappy for a period of time. There's nothing else, just this honeycomb picture of, of the dentinal tubules, just keep that in your mind when you're considering whether or not you think dental fractures are likely to be significant or not. So, what can happen once we get these fractures?

Well, we can get pulpitis as we've just talked about, we can get pulp canal obliteration, this might be by tertiary or reparative denting, could be by sclerosis that I mentioned previously, can get false pulp stones that are laid down very quickly to try and block off these dentinal tubules. You get external internal surface resorption. External internal inflammatory resorption, osseous resorption, traumatic or infected related alveolar bone loss, increased cheek teeth occlusal angle, sheer mouth because they're painful to chew on these teeth.

Perdontal or gingival reattachment can happen after these things. You can get pulp necrosis, we've talked about further tooth fracture of the tooth. Does go on to get necrosis, hypercementosis, I think anyone that's extracted a, a chronically fractured tooth in a geriatric course will be pretty familiar with the fact that they can, you can get hypercementosis and these cemental pearls laid down at the apices.

Ankylosis can occur, tooth movement, tooth discoloration. Achi or periole infraction that we've talked about can be very prominent, especially in these midline sensual fractures, periodontal disease, tooth loss, sequelli sinusitis in the caudal maxillary cheek teeth, which is never fun to deal with, oral sinus fistulation, osteomyosis, and osseous fracture are all potential sequelae of these dental fractures. So they do have pretty significant consequences.

So, finally getting to the title of my talk, and how are we gonna approach managing these dental fractures? Well, Treatment options for fractured teeth include conservative treatment, and again when I was at vet school, this was very much, you know, the considered wisdom of what you did. I'll just, you know, conservative treatment, they'll be fine.

And I think there is a time and a place for that, but even with this conservative treatment of some anti-inflammatories, some antibiotics, so I do think you need to monitor them. I think you need to monitor them quite carefully. Extraction or exigontia, oral simple or open extractions.

OK, I hate the term simple extraction because anyone that does a fair bit of dentistry will know that there's, there's nothing simple about an oral extraction, certainly of a fractured, a fractured tooth. And then there's surgical complicated and closed extractions. And then there's also some tooth preserving techniques, be that restorative or endodontic techniques.

But again, these have become quite fashionable in a modern equine veterinary dentistry, and I think they certainly have their place, but again, I think these techniques have to be monitored. Quite fastidiously going forward, you can't just think, oh, we've done a tooth preserving technique. We've filled the tooth, we've, we've done a root canal filling on the tooth and then just leave it and think it'll be fine.

I think we're not at that stage with equine veterinary dentistry yet, unlike with small animal and, and human dentistry. So, any fractured teeth, as I said earlier, should be left in situ, if there's any concern regarding associated supporting bone fractures. You can always take the tooth out later, OK?

Tooth removal, you know, can occur, you know, 68, 10 weeks once the osteo fracture healing has, has occurred, and this can be monitored radiographically, as I discussed earlier. So conservative treatment. Anti-inflammatories and antibiotic medication, I think is important, at least for the first kind of 14 to 21 days.

Slinting is possible in incisor teeth, I think in cheek teeth with horses, splinting is probably a little bit of a stretch, . Management of any associated maloclusion, using a motorised burr and reducing by approximately 4 to 5 millimetres has been described, and dietary modification, if they've got a painful fracture, let's give them soft processed food so they're not having to chew long stir forage and put a lot of, a lot of pressure on these fractured and compromised teeth. And as I said, monitoring for the squale we've talked about is, is really, really key for me in this area.

And, and that for me is a minimum of, of seeing them in 3 to 4 weeks, and a maximum of 3 months or 12 weeks. So that's sort of your, your time frame there. And how are you going to monitor these?

Well, I think you need to look at them clinically, I think you need to look at them radiographically, and if you've got any concerns and you've got access to CT then that would be fantastic. So, for me, extraction is indicated if there is no resolution of clinical signs, OK, or there's evidence of apical or perapical infraction. There are significant costs, technical challenges and associated risks with the extraction of any teeth, and these need to be discussed with the, with the owner.

And, and all teeth with complicated fractures require for me either extraction or an attempted tooth preserving technique and good follow-up. So, you know, if you have a fracture that's involving the pulp canal, you either need to take the tooth out or try and attempt a tooth preserving technique. Extraction, I still think for most practitioners, it's the therapy of choice for, for most fractured teeth, be it incised or cheek teeth, and it's the reason for extraction in, in 21 of cheek teeth that were extracted in a large study done by by Dicksonetta in 2005.

Extraction techniques and options. I'm sure most of you have heard or at least partially familiar with these oral extraction, again, I like the term or extraction because a simple extraction, especially with fractured teeth, I don't think does it justice. And unification of fragments using acrylic, followed by oral extraction has been described, oral pick extraction, aided now by oral endoscopy, and that was.

Proved to be very successful for Pete Ramsden and his study that he published in 2011. Sectioning has been published by Molly Rice and and Travis Henry. Minimally invasive trans buckle and minimally invasive trans buckle screw screw extraction techniques are very, very useful for these fractured tooth extractions.

Minimally invasive repulsion and simmon pin repulsion can be helpful in, in many situations. Classic retrograde repulsion. It's still a a tool to have in your arsenal, but it's, it's, it has a lot of complication rates, so that's probably got less out offaction and, and sometimes some very complicated, abnormality, lateral bucotomy, you know, is, is a valid option as well.

So hopefully most of you are familiar with, with all or simple extraction here has just been shown with a with a maxillary extraction on the left and a mandibular extraction on the, on the right. Oral pick aided extraction, usually you start off trying with oral extraction with forceps. It goes on to break further and you just hope at that point you've got it loose enough that you can get some joy with oral pick extraction.

And I said, using all, oroscopic guidance here is, is, is really, really helpful in these cases. Sectioning, I personally haven't done this very often, these are images from the rice and and Henry paper, but basically just increasing the interdental space so you can apply spreaders and get a little bit more per on trying to get those, those dental fractured fragments loose and extracted. Sectioning of, of the tooth is, is a little bit more in vogue now.

The problem you have in younger horses is that their teeth are so long or deep that actually suctioning all the way down to the apical region or the vocation is very challenging. In older teeth in, in, in more geriatric patients, for me sectioning is a little bit more of an option, but there's some pictures here at the top is. The conventional sectioning down to the furcation in a, in a small animal patient and, and then how you might go about it in a, these are 22 mandibular teeth that I'm showing sectioning with a, with a bar here.

Got to make sure that you also call these when you're doing these sectioning because they do generate an awful lot of heat when you're sectioning these teeth. Now that's not a big consequence to the tooth is it's gonna be extracted, but the surrounding bone and the surrounding teeth, you don't want to get collateral damage there. Minimally invasive, repulsion or styling pin revulsion.

For me, I generally only use this if there's just a small stubborn fragment I want to get out, unlike the picture on the right here with a whole tooth, it wouldn't be my go to, technique for those cases, and here, go from the top. If you've got a pre-existing fistula, I might be a little bit more pre, Inclined to go with it because you've already got access to that, and, and this is just a set of, of pins that are gone blades and direct market which is really handy for, for, for this procedure. So going on to minimally invasive trans buckle extraction or minimally invasive transbuckle screw extraction, there's a reduced complications associated with this technique the tra traditional repulsions, complication rates of only 26% in horses undergoing MTE in a recent study, and that's far less than the 40, 50, 60% that have been the.

Described with traditional repulsion techniques and, you know, 81% success with MTE extraction with a complication rate of, of only 16% in a from a paper in 2015 and over 90% of procedures were executed in the standard sedated horse. So this for me is if oral extraction doesn't. Isn't successful, you then don't get any joy with the, the horoscopic guided pick extraction.

MT would probably be my plan C. You need to be quite familiar with the buckle anatomy, there's a lot of things here you you don't wanna tangle with, particularly the dorsal and ventral, . Nerve branches, they could obviously have catastrophic, consequences if you get, Prolonged facial paralysis, especially if they're an athletic animal, parotids live reduct, you want to stay away from them as well, and that's why catheterizing that prize of this procedure is important.

And then obviously you've got your, your facial artery and vein which, well not catastrophic, it's advantageous to stay away from them. But obviously, access the area, trocar through the cheek once it's been local, using radiographic guidance to make sure that the placement of your trocar and your drill hole, etc. Etc.

Is in place and in a suitable location and angle. And these are just some images of, of the drill hole on the left, . Tapping the drill hole and then placing the screw on the right to try and get purchase on this tooth.

And, and then hopefully the, the dental remnant will be, will be, nicely extracted light in these images. And I apologise, some of these images aren't mine that I've credited also my video library of these, my laptop died, so I've had to borrow this video from, my colleague Justin Kane-Smith, formerly of Liverpool University, just to show you what it looks like when the, the tooth is, is being exuded out of the socket. So just the pins in place and just gentle tapping with the slot mallet, just making this, this tooth come out of its socket, and there we go, you can see it's then then come into the oral cavity there.

So finally just going on to talk a little bit about some of these two preserving techniques that I'm sure a lot of you have heard about and are are gaining more traction out there. So dentine restoration and sealing, if it's a, uncomplicated fracture, pole capping in a complicated fracture, partial, or vital pulpotomy, . And apexification in, in vital fractures is also, complicated fractures is also an option.

Pulp expiration or pulpectomy, and then obturation, which is a root canal treatment. So taking the inflamed or non-vital pulp out of the tooth and then cleaning the canal and then obduating that canal with a suitable material so it becomes inert. As I said previously, any tooth preserving technique requires diligent follow-up, repeat imaging to my mind to make sure that, that the tooth is, is, is not going on to cause any further problems.

And, and currently, to my mind, there's a lack of peer-reviewed case studies with long-term follow-up, to really, promote these tooth preserving techniques too much, but it's certainly the, the future of where we need to be looking to. One thing I just want to show is this, these lovely images by the Klepto paper show just how complicated the multiple pulp horns of the equine endodontic system are, and if you're thinking we need to try and instrument and obdurate all of these ribbon-like pulp canals, that's gonna be quite a challenge. So I think do just bear that in mind when you're thinking about the, the possible success or merits of these tooth preserving techniques.

So, talking about the management of these cases, all treatments and techniques have their advantages and their disadvantages, and a lot of these cases have quite high complication rates in, in as much as 60% of cases by one paper. They're 40% of oromaxillary fistulas, 20%. Persistent fragments, 13% persistent bleeding, 7% late laceration of the palatine artery, 13% bucotomy and seasonal infections, 13% alveolar sequeststers.

So there are a lot of things that can go wrong. That's not a reason not to. Implement any of these techniques if we think they're the right thing to solve the problem, but you do need to be aware of these complications and maybe have a slightly more in-depth conversation with the owner about the possible complications.

Insurance considerations, it's always good to have the insurance company on board before you, embark on these more, Involved techniques to have higher complication rates and careful counselling of the owners on the costs, risks, and out, and likely outcome can save you a lot of stress and heartache after. So, like most things within veterinary medicine, prevention is generally better than than cure. So the prevention of midline sagittal fractures secondary to infant dibular carries or hyperplasia, has been reported anecdotally.

We're still waiting for a good amount of peer-reviewed literature on this, but restorative materials such as dual cure flowable composites. Placed within the deprided inindibula and to give the two some mechanical strength and anecdotally, this is, this has had some very good success in a lot of our hands. But again, further peer reviewed research is, is really required to validate this technique a little bit further.

But these are some cases that I've taken out of some of my papers and stuff just to show these images of, of, of cleaning out these inindibula caries pretty extensively, then putting some calcium hydroxide in there to chemically clean them, then some acid etch to chemically clean them and and prepare the surface and then. Building up some, some light cu dual flow composite. And, and this is just one, I think this has been in this case from memory 5 or 7 years and it's still in situ, it's wearing quite well.

You can see a transverse fracture in there, but there was no movement to the restoration and some air bubbles worn out on the surface, but, but this restoration, I say, from memory had been in there 57 years and And the tooth hadn't gone on to fracture after the placement of this restoration. So I think there is certainly some merit in this, procedure. I think we maybe just need to get a little bit better at picking our cases and, and which inandibular lesions are likely to go on to progress and which aren't, and, and, and we're maybe a little way off of maybe figuring that out at this point.

So, just finally some take home messages for you. As I said, lack of clinical signs does not mean endodontic health of the tooth, and just bear in mind the, the pulp deninal complex and those little open dentinal tubules. Most if not all fractures have dentinal pulp complex involvement to my mind.

Maxillary cheek teeth commonly suffer pathological fracture, especially of the 09s and if midline sagittal fractures are present, 100% of these will go on to get apical or periaical infections. Personally, I believe that most other types of dental fracture will also go on to get apical or perioical infection in the fullness of time if we monitor them closely enough and for long enough. Lots of references and I'm quite happy to share these references with anyone if they want to email me after the presentation.

Afterwards I'm quite happy to take some questions and answer them as best I can. I'd just like to give a a final big thank you to the sponsors of this, this webinar and the equine webinar series for 2021, and Bailey's horse feed. I'm a big fan of Bailey's Horse feed, and I'm not just saying this because, They're sponsoring this webinar, and the high fibre, complete fibre nuggets are pretty much exclusively what I feed all my dental patients while they're here in the clinic.

We, we dissolve them down with some, some warm water to make a nice high fibre gruel and and all my dental and surgical patients will get them for at least the 1st 24 hours. If not 40, 72 hours, depending on how invasive their surgery was afterwards, and, and they seem to eat it really, really well in our hands in, in the clinic here. So I'm, I'm a big fan of babies's horse feed and certainly for, for, post dental surgery patients, the, the high fibre nuggets soaked down work really, really well in our hands.

Also, just a little nod to my colleagues here at Pool House equine Clinic, where we don't just see, see dental cases, we see a whole, whole host of other things and are now part of the IVD IVC, evidencia referrals network. So yes, thank you all very much for your attention this evening and, and just stay safe out there in this, this current situation. I hope you and all your loved ones are doing OK.

Well thank you very much Sam for that. That was really, really interesting. As a small animal veterinary nurse, I obviously never get to see any equine dental stuff, but so I found that really interesting.

So if anyone has any questions that you would like to put to Sam, if you just want to put in, you can type away into the question and answer box. I'll give you a little minute just to do that, and then we'll, throw them all at Sam. I didn't even run over for once, so I'm quite chuffed with myself.

I know, yeah, bang well, bang on time, got plenty of time for a couple of questions. So nice handy little hints there about the about the, the different, the food that you like to feed in-house as well, the bale is high fibre complete. I think that's a nice handy little tip for people to be able to take back to practise.

It takes a little bit of soaking down, it's a firm, large nugget, but yeah, a bit of boiling water and, and, you know, a couple of hours, you put a tea towel over the, over the bowl and stuff, and it soaks down really nicely, and then you know they're getting high fibre, a low sugar diet, and it's something that seems to be very palatable when they come round from sedation and some of my procedures there. They're sedated for quite a prolonged period of time, so we, we want something palatable, high fibre, get their, get their gut working after, so we tend to give them that with a, with a probiotic after surgery. Fantastic.

And are your patients, do you do, do you do like a standard sedation or, or, or are they anaesthetized? Yeah, so pretty much the vast majority now would be done under standing sedation with a constant rate infusion. With a diominine drip and then we would augment that with usually morphine, and yeah, probably now, it'd probably be a just a handful of cases that go under, under general, anaesthesia for dental procedures and, and they generally are the.

It's the temperament of the horse, then we're actually just they're not the sort of horse that you can be banging with surgical mallets or bone sores or drills and stuff like that around their head in a, in a, even in a sedated state. So that would probably make the majority of the things that now go for general anaesthesia and then there's still the. The weird and wonderful teeth that are very misshapen or tumours and stuff like that when we need the bucotomy access and, and where it has been described, I'm personally not brave enough to do a standing bucotomy, so we still do them under, under general anaesthesia.

Yeah, I can't can't imagine how difficult it is to try and get into a horse's mouth to be able to try and extract teeth in there, that must be a, that's a pretty impressive go in there. So it looks like we've got no questions coming through. So I think so I think we can end for this evening, so everyone can get back to everyone's asleep or I've answered all their questions.

Absolutely not. No, I think you've answered lots and lots of questions already and given everyone lots of things to take away to use in practise. So I I'd like to thank Sophie at the webinar vet in the background, doing all the technical stuff for us.

And then to Bailey's Horse Feeds for sponsoring tonight's presentation and the equine series. And again, thank you very much to Sam for that really, really interesting presentation. So, good night, everyone, and stay safe.