Cyst or Nasal floor extension: How should I handle this case?
I have a 14 year old male patient who had peripaical lesions develop around #11,12 [maxillary left canine and first premolar;23,24].  I then extracted both teeth 2 years aro.  #13 [maxillary left second premolar; 25] had been in horizontal version and was uprighted by the orthodontist.  The patient has now presented for implants and crowns to replace #11, 12.  My first question is why is there a large radiolucent lesion in the #11,12 area?  Is this an apical scar or cyst?  Viewing the radiographs it appears as though there is a continuity with the nasal cavity and maxillary sinus. What would be the best way to treat this lesion so that I can install implants later  on.  Should I first do a biopsy of the radiolucent lesion?  Should I do a bone graft? What material would you recommend?  Can I place implants in this site in a 14 year old male?  If not, what age would be appropriate? Is there a test I can do to determine when I can install the implants?
![]Recent OPG 5 days back aftr ortho treatment](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/athul-sunil-opg.png)Recent OPG 5 days back aftr ortho treatment
![]CT scan](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/athul-sunil1.jpg)CT scan
![]Cross section view in the edentulous area](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/Athul-Sunil-2.jpg)Cross section view in the edentulous area
21 Comments on Cyst or Nasal floor extension: How should I handle this case?
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CRS
10/17/2012
It is a residual cyst from the earlier pathology which probably not removed. The area needs an excision and bone graft with an onlay and bio active growth factors. The pathology needs to be excised and the ridge built up. Fourteen is too young for an implant growth needs to be complete. This should be referred to an oral surgeon, do the right thing for this patient the pathology was missed the first go around.If you don't understand basic ct anatomy you are in over your head. Do an excellent restoration of the implant when it is placed at age 19, don't make this kid your guinea pig.This is a significant alveolar defect which is not that easy to treat, I 've treated these cases.Good that you posted the case, that is what this blog is for. Oh and don't forget to have the surgeon remove the supranummerary bicuspid.
salim
10/18/2012
Excellent comment CRS you give him the right way and steps. in addition to all your advisment I thing the biopsy is also mandatory.
CRS
10/18/2012
Thank you salim I I agree on the biopsy also. Just want to give helpful information without judgement for both doctor and patient. We are all learning and hopefully the poster will take the advice and learn, it is not shameful to refer.
Mark nartey
10/23/2012
Any pre extraction radiograph?And what was your initial diagnosis before the extraction of the two teeth?
Dr. Tom Wierzbicki
10/23/2012
Regarding implants in a 14 year old, I agree with the previous comments, that is way too early. Definitely a biopsy of the cystic lesion in the 23/24 area is recommened as previously stated. However, my question is "Would you enucleate the cyst now?" Is the cyst symptomatic? If the cyst is not causing the patient any issues, I would monitor till the patient stops growing. My reasoning, if you enucleate the cyst now, you need to graft. But how long will your graft hold? 19 years of age is probably the earliest that you would want to place implants in for a male, and you may have to wait till they are older if they are still growing. So you need your graft to maintain volume for 5 years minimum - not likely to occur. Therefore, you will likely be grafting again once all growth has stopped. Also, what about facial growth, this is a 14 year old male, so he may just be coming into his growth spurt, meaning further changes in bone height. I think holding off with the cyst removal, grafting, and implants till all growth is complete is the safest.
Robert Wolanski
10/23/2012
Great advice. This is a potentially very complex case with lots of potential to go sideways. Thank you for posting it.
You may want to check your space to see if it is adequate for the contralateral aesthetic symmetry of the cuspid and bicuspid. It appears that you might be a bit short. The upper left second bicuspid appears to be a bit rotated which might give you some extra space. Another possibility is to consider having the upper left wisdom tooth erupt into occlusion and having your skilled oral surgeon perform a segmental osteotomy and grafting of the cyst. This has the advantage of then requiring only one implant for the cuspid, and eliminating the aesthetic challenge of creating an aesthetic papilla between the cupid and the bicuspid.
CRS
10/23/2012
Refer the patient to an omfs to remove the pathology and biopsy. Now that you have been advised it is failure to refer which is negligence. The graft will be fine. How big do want the cyst to get? And you don't know what it is!
OMS
10/23/2012
Can you say oral surgery consult? Don't do this case if you have to ask all those questions. It is unfair to a 14 yo patient.
Weekend courses don't equate to a good OMS!
Periodoc
10/23/2012
OMS: Yup.
E. Richard Hughes, DDS, F
10/23/2012
This is a case for an OMFS and perhaps an ENT. What would you do if this were your child? CRS hit the nail on the head.
Baker k. Vinci
10/24/2012
Richard, with a load of respect, do you really think an ENT consult is warranted. This happened after an extraction and is a potential implant site. Well trained oral surgeons spend 14-16 years getting to where we are. Lets keep it in bounds, eh? Bv
Nilo Faria
10/24/2012
First of all, the patinet is too young to get implants or grafts. O think you should wait until he reaches 18. Second, I think there is no lesion, just a lack of bone, which leads you to a bone graft at the right time, when he gets older. For now, in my opinion, you should make a provisional adhesive bridge to maintain the space opened and wait.
sergio
10/26/2012
You don't think there is a lesion?
I clearly see a border all the way around.
Even if it's just a traumatic cyst where it's empty inside, still you have to find out what it is. It appears too big to ignore and play the wait game.
CRS
10/25/2012
Nilo you are wrong, that is very very poor advice, hopefully the patient will get into the right hands. The patient is too young to have unbiopsied pathology in his jaw. It is negligent to get a ct scan and not refer the pathology for treatment. I suspect that the original follicular cyst was not removed and now there is a cyst that may eventually erode thru the buccal plate. So it may be missed twice. The horizontally impacted teeth should have been treated by an oms, perhaps they may have been exposed and brought into the arch or at least the follicle removed at extraction.Now there is a nice cleft developing in a child who has been thru ortho. Maybe the orthodontist will be smart enough to refer. Foolish not to listen to wise advie!
Mark nartey
10/26/2012
I thought the extraction of the two teeth was premature.if my initial diagnosis was a cystic lesion-globulomaxillary cyst etc,I would have enucleated the lesion,done root canal therapy and monitor for a while with radiographs and see what turns up.i would send the sample for histopath. report.There have been documented cases where root canal alone without enucleation have worked
Baker k. Vinci
10/27/2012
You know the globulo- maxillary cyst is no longer recognized by the world health organization. I believe we have relented to the fact that they are just lateral periodontal cyst. FYI. Bv
Baker k. Vinci
10/28/2012
Why are we looking at the inferior turbinate and the maxillary sinus? You need narrower slices of the alveolus. The 3d recon. is somewhat helpful, but we should be looking at the true ct, to gain any insight . Bvinci
dinnymick
10/28/2012
The history of this case is very sparse.Reasons for extraction should be paramount This case really need the history of the extracted canine and premolar.Why were they?
However .regardless of the pathology or not of the radiolucency the orthodontics appear unusual .Why is the left incisor left at a different height and angulation to the right lateral?No fixed retention has been placed on this tooth?
The second premolar appears rotated post ortho?
One wonders why the space was not closed using simple mechanics to advance the second premolar.The doomed wisdom tooth then gets to have a chew.With good management and best case the premolar could become the canine and no Implant .
At very least only one implant (.Implants are not the worlds best treatment option 100% of the time)
Wouldnt it be wise to move the second premolar mesially into the the space o
Baker k. Vinci
10/28/2012
Yuup, they are the last option. Nothing beats the natural tooth. Bvinci
Baker k. Vinci
10/30/2012
This kid will need a graft, even before ortho movement. A la alveolar cleft grafting. If this were my kid, I would have a pediatric ortho doctor call the shots. This is not an implant case! Bvinci
CRS
11/3/2012
I agree I had a similar case where an impacted tooth was removed I had to graft it and ortho managed to tip the teeth not horizontally move the teeth to correct the defect. The complicating factor was that this young man was receiving radiation and chemo for a benign brain tumor on that side. However we got a reasonable result but the perio will have to be monitored closely. These are not easy to fix needed to be done at the initial extractions.This is frustrating for me as an oms we don't get the cases at the get go,I hope the dds learns to refer,you don't know what you don't know.Then when there is a poor result it's an out of body experience that they did not contribute to.
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