Advanced Oral & Facial Surgery of the Triad

Posterior Maxillary Implant Case

This was a nice posterior maxillary (upper jaw) implant case done by Dr. Biggerstaff. This involved a 67 year old woman who had fractured tooth #13 (upper left maxillary second premolar).  Her dentist extracted the residual root and the socket was not bone grafted at the time (usually most sockets are bone grafted if a dental implant is planned for later).  The patient saw Dr. Biggerstaff for a consultation to have a dental implant replace the tooth.  The socket was allowed to heal, and after a few months, an implant was placed in the site.  Following a period of healing, or osseointegration, the implant was restored with a crown.  The patient now has a nice aesthetic and functional dental implant and crown to replace her missing tooth.  Image #1 shows the preoperative state with the fractured root of tooth #13 still in place.  Image #2 is a coronal slice of the patient’s initial cone beam CT scan (CBCT) showing the tooth socket.  Image #3 is a sagittal slice of the patient’s initial CBCT showing the tooth socket. Image #4 shows the implant in place on a coronal slice of the patient’s postoperative CBCT. Image #5 shows the implant in place on a sagittal slice of the patient’s postoperative CBCT. Image #6 shows the implant at the time of the crown impression. Image #7 shows the implant with the crown cemented into place.  Image #8 is a preoperative and final comparison.

Impacted Canine Exposure and Bracketing Case

This was a nice case that was done by Dr. Biggerstaff and involved a deeply impacted permanent canine tooth.  The patient was referred for exposure and bracketing of an impacted canine – tooth #11 (permanent left maxillary canine) – by her orthodontist when she was 13 years old.  The canine was very high in the upper jaw, and without intervention, would not have been able to erupt into the mouth and become functional.  The patient also had a retained tooth #H (primary left maxillary canine).  Once the braces were placed by the orthodontist, the surgery was then scheduled.  Her surgery involved removing the retained primary canine, exposing the permanent canine, and attaching a gold bracket and chain to the permanent canine so that it could slowly, over months, be pulled into the dental arch in order to become functional.  Usually the gold chain is attached to the arch wire of the patient’s braces about 1-2 weeks following their surgery.  Images #1, 2, and 3 show the preoperative and final radiographs.  One can see that the permanent canine was very high in the jaw bone, almost to the level of the nose.  Image #4 shows the patient at the conclusion of her orthodontic course after her b

races have been removed.

An Interesting Third Molar Case Involving a Coronectomy and Biopsy

This case done by Dr. Wes Parker illustrates why it’s a good idea to have your third molars (wisdom teeth) evaluated by an Oral and Maxillofacial Surgeon and possibly removed.  This was a 61 year old female who presented with pain and pericoronitis (a soft tissue infection commonly associated with wisdom teeth). She had an impacted tooth #32 (lower right third molar/wisdom tooth). She had 8 mm (deep) periodontal/gum pockets with bleeding on probing on the distal aspect of tooth #31. Her dentist as a teenager told her that she should not have her wisdom teeth removed. For the past 30 years, she reported periodic swelling and discomfort from the #32 area.  She was referred to Dr. Parker by her new general dentist in 2019. Her preoperative, panoramic radiograph showed a deeply impacted, distoangular tooth #32 with a well-defined, radiolucent (dark) lesion associated with the crown. The root apices of the tooth were in close proximity to the right inferior alveolar nerve and the inferior border of the mandible (lower jaw). We discussed doing an excisional biopsy of the lesion and a coronectomy of the tooth instead of an extraction in this case to both treat/remove the lesion and minimize the risk of nerve damage and a fracture of her mandible. A coronectomy procedure involves removing the crown and pulp contents of a noninfected, usually deeply impacted, wisdom tooth in order to minimize risk to the jaw and the nerve that provides sensation to the lower lip and chin.  The roots are left in place during this procedure.  This is in contrast to a standard extraction in which the entire tooth, crown and roots, are removed.  Image #1 shows the patient’s preoperative panoramic radiograph. Image #2 shows a coronal slice from her preoperative CBCT. Note the volume that the third molar occupies within her mandible, her thin bony cortices, and the proximity of the roots to both the right inferior alveolar nerve (lingual to roots) and the mandibular inferior border. Image #3 shows a one week postoperative PA. At this time, the biopsy was revealed to be an infected dentigerous cyst. Dentigerous cysts are common, benign cysts that form around impacted teeth, most often third molars/wisdom teeth.  If not removed, they can become quite large and destroy bone, and/or become secondarily infected.  Image #4 shows a three month postoperative PA. Image #5 shows a six month postoperative PA. Note the radiographic bone fill in the area of the previous crown and lesion. The radiographs show some initial slight coronal (upward) migration of the root complex, which subsequently ceased.  She is currently pain free, infection free, and has no periodontal probing depths greater than 2 mm on the distal of tooth #31. She is very happy and was gracious enough to allow us to share her case.

A Complex Extraction and Implant Case Involving the Maxillary Sinus

It amazes us how well people can heal sometimes.  This case, done by Dr. Wes Parker, involved a 45 year old male who was referred for a carious, necrotic (dead) tooth #14 (upper left first molar).  The patient also reported left sided sinus pressure and drainage. At his consultation, we obtained a Cone Beam CT (CBCT) scan. On his CBCT, you could see where the infection and inflammation from tooth #14 had eroded through the floor of the left maxillary sinus. We discussed this with him and scheduled surgery shortly after the consultation.  Dr. Parker removed tooth #14, cleaned out the pus and inflamed maxillary sinus lining through the socket. The inflamed, thickened sinus lining went almost up to the orbit (eye socket).  Dr. Parker then closed off the sinus communication.  Following this, Dr. Parker placed a bone graft over the sinus closure, and then sutured over that to close the wound.  The patient healed very well. He was compliant with the sinus precautions and medications that were prescribed.  Next, Dr. Parker proceeded with implant placement in the #14 site with a simultaneous indirect sinus lift or “sinus bump.” The implant placement surgery went well, and after about 5 months of healing time, the patient received a crown on the implant from his dentist.  Image #1 is a preoperative PA radiograph of the carious, necrotic, nonrestorable tooth #14 (upper left first molar). Image #2 is a coronal slice from the patient’s preoperative CBCT showing the necrotic tooth #14 with a periapical radiolucency and maxillary sinus inflammation stemming from the necrotic tooth. Image #3 is a sagittal slice from the patient’s preoperative CBCT showing the necrotic tooth #14 with a periapical radiolucency and maxillary sinus inflammation stemming from the necrotic tooth. Image #4 is a sagittal CBCT slice from the patient’s post extraction CBCT showing resolution of the sinus inflammation and measurements for the future dental implant. Image #5 is an immediate postoperative PA of the implant in the #14 site following implant placement with a simultaneous indirect sinus lift. Image #6 is a 5 month postoperative PA showing the healed, integrated implant prior to crown placement with a healed sinus lift bone graft above it and no sinus inflammation.