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Rocket is a three-year-old male neutered pure breed Boxer.
Reason for presentation:
Investigation of missing teeth which was identified during a yearly wellness examination, and an annual COHAT (Comprehensive Oral Health Assessment and Treatment) under general anaesthesia.
Date of Procedure:
April 4 2019
Figure 1: Clinical photograph showing missing 305. 405 was also identified as missing during dental charting and probing of teeth
Figure 2 and 3: Oblique and lateral views of the left rostral mandible. Note that 305 was unerupted, and the presence of crown-like shaped dental material within left rostral mandible. These abnormalities would be easily missed and remain undiagnosed unless these intra oral radiographs (CR7 Vet, iM3) were taken during the COHAT
Figure 4: Ventral-dorsal view of mandible showing the significant bone lysis (this lesion was confirmed as a dentigerous cyst following submission for histopathological examination). Note that 306 was deformed, and there was incomplete formation of 305 as well.Figure 5: Serosanguineous fluid obtained from the cystic 305 region by fine needle aspirate
Treatment for a Dentigerous Cyst
Basic procedures for dentigerous cyst were as follows:
Administration of left mandibular regional nerve block to contribute to multi-modal analgesia.
Creation of a mucoperiosteal flap to gain access to the cyst, as well as to assist visualisation.
Gently access the cystic structure through the alveolar bone within the mandible, by using highspeed hand piece with plenty of coolant.
Removal of abnormal dental structure (including unerupted tooth) based on the intra oral dental radiography. In this case, surgical extraction of 305 as well as malformed 306 was performed.
Gently remove of cyst lining as much as possible by using a dental curette (D1086 and D1087 oral curettes, iM3).
Submission of extracted teeth and cyst lining to a laboratory for histopathological examination for definitive diagnosis.
Defect flushed with copious amounts of sterile sodium chloride 0.9% solution.
Defect gently filled with Synergy bone grafting material (iM3).
Tension-free closure of mucoperiosteal flap using 4/0 or 5/0 fast-absorbing, synthetic suture such as Monosyn®.
Figure 6: Mix Synergy (Pure Synthetic Bone Graft) with a few drops of blood and gently load the graft into the site.Figure 7: Radiograpg (CR7, iM3) showing the bone grafting material (Synergy) at the extraction site of 305 and 306
Discharge Instructions to owners:
No kibble or other hard foods/ treats for two weeks to prevent trauma to the sutures and surgical site.
0.14% Chlorhexidine solution rinse (Hexarinse®) twice a day for two weeks, then once a day for one month.
NSAID (Meloxicam: 0.1mg/kg BW) was dispensed for five days, for analgesia and anti-inflammatory effects.
No hard chew toys until follow-up examination under general anaesthetic for assessment in five to seven months postoperatively
Histopathology Result for ‘Rocket’ via IDEXX Laboratory
Microscopic Description:
305: One of the submitted and examined sections is composed of normal appearing, but incompletely formed tooth. Two soft tissue sections composed of dense collagenous stroma area present with one section containing a small segment of stratified epithelium.
306: The examined sections are composed of normal appearing tooth with variably irregular borders.
Dentigerous cyst lining: Multiple fragments are submitted and examined. These fragments are composed of a collagenous-type stroma containing variable hemorrhage and bordered by stratified epithelium.
Diagnosis:
305: Incompletely formed tooth with dentigerous cyst lining.
306: Tooth with peripheral resorption.
Dentigerous cyst: Fragmented dentigerous cyst.
Comments:
As was determined clinically, there was a dentigerous cyst surrounding an incompletely formed 305 tooth. The tooth appears entirely excised, however I am unable to determine if there is complete excision of the cyst lining due to fragmentation. There is no evidence of significant inflammation within the examined sections. Tooth 306 contains peripheral areas of resorption, but is otherwise within normal limits. Odontogenic cysts are relatively rare in domestic animals, however various types, such as radicular cysts, dentigerous cysts, and keratocysts have been described in dogs. In this case, the cyst was determined to be a dentigerous cyst. Treatment of odontogenic cysts consists of surgical exposure and curettage of the cyst lining. The prognosis for cysts treated in this manner is good, with recurrence being uncommon.
Reference: Extensive Bilateral Odontogenic Cysts in the Mandible of a Dog. Vet Pathol 45:58 60 (2008). By Michelle L. Nobrega-Lee, DVM Diplomate, American College of Veterinary Pathologists.
Follow up COHAT on September 20th, 2019
During the five-month postoperative period, Rocket’s chewing behaviour was modified – no hard chew toys and no bones were given.
The owners reported no concerns in the last five months
Figure 8 and 9: Five months post operatively, intra oral dental radiographs (CR7 Vet, iM3) showed new bone formation at the site of the previous dentigerous cyst filled with Synergy bone grafting material.
Would you like to know more about Synergy Pure Synthetic Bone Graft?
What is Synergy?
Synergy is an advanced biosynthetic bone graft comprised of calcium phosphates that occur naturally in real bone. It is a biphasic combination of β-Tricalcium Phosphate (β -TCP) and Hydroxyapatite (HA).
How does it work?
These intelligent bioactive materials have the proven ability to stimulate bone formation.3 The β -TCP quickly releases calcium ions4 that cause clotting and release of platelet-de-rived growth factors. This cascade of mineral release and blood clotting provides the perfect environment for the stimulation of bone healing.
The cancellous-like porosity and surface structure encourage inward cell migration. As the β -TCP resorbs more space is created to support angiogenesis and bone formation1. The microparticles of HA provide a more long-lasting osteoconductive structure.
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