A 5-year-old castrated male giant schnauzer presented for treatment of a previously diagnosed, unerupted left mandibular canine tooth (tooth 304). Evaluate the attached photo and radiograph. The left mandibular first and second premolars were previously extracted.
An unerupted, malformed tooth 304 is present and teeth 305, and 306 were radiographically missing with a retained tooth root in the region. Unerupted teeth may lead to dentigerous cyst formation with resulting regional bone loss.
An incision was made through the gingiva of the dorsal alveolar ridge with releasing incisions on both the buccal and lingual aspects of the mandible. The left mandibular third premolar was extracted to allow for better exposure (the left mandibular first and second premolars were previously extracted).
After creating a mucoperiosteal flap, bone was removed with a round carbide bur on a water-cooled high speed handpiece. After removal of the dorsal cortex, a piezoelectric surgery unit was used to expose the unerupted tooth and delineate the periodontal ligament space.
Dental elevators were used to gently elevate the tooth from the mandible. A root remnant of the previously extracted distal root of the mandibular second premolar was also identified and removed.
Due to the presence of significant amounts of cortical bone on the buccal, lingual and ventral surfaces of the mandible, no osteoconductive or osteoinductive substances were placed. The site was closed in two layers with 4-0 poliglecaprone 25 in a simple interrupted pattern.
What size burr do you use in a case like this?
What exactly was the purpose of the piezoelectric surgical unit used for? Is there soft tissue in that cavity? If so, could a CO2 laser been used in it’s place?
Thanks,
Ray
Hi Ray,
I generally use a #4 round bur. Not sure what Dr. Lewis used in this case. The piezo unit has the capacity for a number of tips. In this case a surgical bone removal bur was employed. No soft tissue in these cases. Just tooth with surrounding cyst and bone.
Take care,
Brett
What antibiotic, if any did you prescribe? What dosage amount and when and for how long administered?
No antibiotics are required in these cases.
Is there a problem with putting “consil” in the cavity?
I personally utilize a blood clot if possible, however bioglass or periomix are viable alternatives.
Wow, I’m impressed! I would have been pretty worried about breaking the mandible, but your post-extraction film is quite reassuring. Nice case!
Hi Brett,
Interesting case, in that the neurovascular bundle usually found in the mandibular canal has not had the chance to develop in its normal position due to the tooth not erupting and occupying the canal. That would have been my biggest concern. What steps can be taken to avoid it? I suppose that is why the piezo was used, as it is less traumatic to soft tissues(?).
Thanks
Sid Lehr
Did the surgeons encounter a neurovascular bundle? Pictures of that “encounter”, and how the nerve and artery were avoided would be very interesting. Would it not be a usual concern during such a surgery?
Hello Bob and Sid
This is Dr. Lewis’s response to your questions.
Brett
We were prepared to encounter a large neurovascular bundle (and took
precautions such as having blood type done and blood products ready) but
the reality was there was very little bleeding and the neurovascular
anatomy was not normal in this area. Using the piezoelectric surgical unit
around the periphery of the tooth was likely helpful in minimizing blood
loss. The tooth was surrounded by dense bone, and only caudal to the
extracted tooth could we subtly appreciate a mandibular canal filled with
soft tissue structures.
A piezoelectric handpiece was used in this case. Presumably in the absence of such a unit in the practice, a round bur in the water cooled high handpiece could have been used to reveal the retained tooth or are there contraindications to its use?
Did the dog receive a caudal mandibular nerve block?
Hi Dr. Culley,
Yes a round bur is fine. The dog would have had a caudal mandibular block.
Brett