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Handling difficult dental cases

A complex odontoma case in a German Shepherd highlights the importance of a good diagnostic work-up

20 July 2018, at 11:08am

Nala, a healthy female neutered German Shepherd, was referred to North Coast Veterinary Specialists because of marked gingival swelling affecting the right caudal maxilla and right caudal mandible. The referring veterinarian identified the swellings on a routine examination. A comprehensive oral health assessment and treatment (COHAT) was performed for Nala.

Clinical findings

On the right side, there was marked gingival enlargement involving the caudal maxilla and mandible (Figure 1). In the right caudal maxilla, tooth 108 (right upper PM4) was missing and tooth 109 (right upper first molar) was partially erupted. In the right caudal mandible, tooth 409 (right lower first molar) was missing and tooth 408 (right lower PM4) was buccally rotated. There were also tooth-like projections piercing through the gingiva in the 104 (right upper canine), 108 and 409 sites.

FIGURE 1 Examination revealed a marked gingival enlargement involving the caudal maxilla and mandible on the right-hand side
FIGURE 1 Examination revealed a marked gingival enlargement involving the caudal maxilla and mandible on the right-hand side

It is important to offer intraoral radiographs when confronted with a missing tooth or teeth to see if the tooth is missing or impacted, or has associated pathology. In this case, a whole mouth series of radiographs were taken, utilising the iM3 CR7 and the large size 4 and 5 plate to reduce the number of exposures required for the series.

Radiographic findings

The caudal maxilla and caudal mandible showed several varying density structures and supernumerary teeth overlying the impacted (108/409) and partially erupted (109) teeth (Figure 2). Based on the clinical appearance, radiographic findings and age, a clinical diagnosis of multiple complex odontomas (considered benign odontogenic tumours) was made associated with the impacted/partially erupted teeth.

FIGURE 2  Radiography showed varying density structures and supplementary teeth overlying the impacted (108/409) and partially erupted (109) teeth in the caudal maxilla and mandible
FIGURE 2 Radiography showed varying density structures and supplementary teeth overlying the impacted (108/409) and partially erupted (109) teeth in the caudal maxilla and mandible

Treatment

Treatment consisted of enucleation of the odontomas and extraction of the impacted/partially erupted teeth as well as rotated tooth 408. Based on experience, block resection of these tumours is usually not required. The clinical diagnosis was confirmed on histopathology.

Pre-surgery nerve blocks were performed, and the odontomas were excised, followed by the extraction of the supernumeraries and careful sectioning and extraction of the multirooted teeth 108/109/408/409. The LED highspeed handpiece (iM3) proved very helpful in the extraction process due to the depth of impaction of teeth 108/409. No bone graft was required, and primary closure of wounds was performed.

Post-operative radiographs were taken to confirm the complete removal of the teeth (Figure 3). On recheck one week later, Nala was her normal self.

FIGURE 3 Complete removal of the teeth was confirmed with post-operative radiographs
FIGURE 3 Complete removal of the teeth was confirmed with post-operative radiographs

This case emphasises the importance of a good diagnostic work-up, which, in this case, included a full mouth series of intraoral radiographs with the larger size 4 and 5 plates (minimising the number of exposures required). The case also emphasises the importance of interpretation of these radiographs which assisted in coming to a quick clinical diagnosis. Management of this case was thus straightforward.

Remember that it is especially important when identifying a missing tooth (or teeth) in a young animal to always take intraoral radiographs to determine whether the tooth is truly missing or is impacted or has pathology associated with it.

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