IMPORT
When I opened my dental practice in Philadelphia in 2011, one of the first pieces of equipment I purchased was a cone beam unit, described below. Recently, he detected a serious, life-changing abnormality in a patient that a standard panoramic X-ray would not have been able to find.
CASE REPORT
This is not a routine new patient appointment
A few months ago, a new patient in her 20s visited my office for a routine hygiene appointment. He did not report any oral discomfort or pre-existing health conditions.
During the examination, it was determined that the patient had been in orthodontic treatment for an extended period of time — potentially too long. Visible signs of extensive root resorption were present, particularly in teeth Nos. 2 and 3, which were mobile.
2D radiographs also showed periodontal disease. Based on this preliminary evaluation, both teeth appeared to be potential candidates for extraction and implant placement (Figure 1).
Figure 1. Typical panoramic radiograph of teeth Nos. 2 and 3.
Although it is unusual for patients in their twenties to lose teeth due to periodontal disease, it can happen. The disease and associated bone loss is typically painless as it progresses, often leaving the patient unaware for years.
However, when probing the areas around teeth Nos. 2 and 3, there was no resistance and there appeared to be a 10mm pocket. To determine the exact nature of the problem, the hygienist took direct CBCT images of the patient.
An unexpected discovery
Within seconds, the CBCT x-rays were on my screen, revealing that this was no routine case. 3D x-rays showed a very large mass, about 1 inch in diameter, above teeth #2 and #3, entering the sinus with no bone surrounding it. The diagnosis of this mass was beyond the scope of practice of a general dentist. Furthermore, if these teeth were simply removed, there would be a 19 mm oral/anal communication between the vagina and the mouth. CBCT scans were necessary to prevent a disaster (Figure 2).
Figure 2a.
Figure 2b.
Figure 2c.—Figure 2. CBCT radiographs (I-MAX 3D [Owandy Radiology]) of teeth No. 2 and 3.
It is always necessary to have a radiologist evaluate any wide-field scan of suspected pathology, especially if it incorporates nondental structures.1 In this situation, I sent the CBCT scans to a radiologist at a local hospital, who reviewed them with a staff oncologist, who said flatly, “Don’t touch it! We must get her here at once!” He saw her the next day.
The patient was understandably devastated. She came into the office for a routine cleaning and it changed her life dramatically. Fortunately, biopsies performed at the hospital concluded that the golf ball-sized mass was not malignant. However, it turned out to be a fast-growing, locally aggressive vaginal granuloma, which the hospital’s surgeons successfully removed.
A long road ahead
As of this writing, I do not have a definitive prognosis from the hospital surgeons and ENT specialists. The patient is just beginning the early stages of sinus reconstruction, which will require multiple surgeries and bone grafts to close the hole between the sinus and the oral cavity.
The required bone grafting cannot be performed with the bone matrix commonly used in implant dentistry. Hospital surgeons will likely have to take bone tissue from her ribs or hip. Eventually, the patient will probably not be able to have traditional implants placed. One option being considered is zygomatic implant-based reconstruction.2
Even if cheek implants are a viable option, it will be many months—perhaps years—before this or any common cosmetic procedure is performed. The patient’s overall health and full recovery are of the utmost importance.
CONCLUSION
There is a silver lining to this complicated and urgent case: detecting this large mass in a very young patient now, instead of 10 to 20 years from now, when it could have become inactive and could also have resulted in a potential failure that will destroy the practice -to diagnose the treatment.
Cone beam units are an essential part of today’s diagnostic tools. There are many on the market, and for my practice, I chose the wall-mounted I-MAX 3D from Owandy Radiology. With its small footprint and 9 × 12-inch field of view, this unit proved invaluable for routine implant cases. Having a CBCT scanner in the office not only makes the results of implant placement more predictable, but it also helps prepare for the unexpected—and dentistry can often be unpredictable.
REFERENCES
- American Dental Association Council on Scientific Affairs. The use of cone-beam computed tomography in dentistry: Advisory statement from the American Dental Association’s Council on Scientific Affairs. J Am Dent Assoc. 2012;143(8):899-902. doi: 0.14219/jada.archive.2012.0295
- Aparicio C, Ouazzani W, Hatano N. The use of zygomatic implants for prosthetic restoration of severely resorbed maxilla. Periodontol 2000. 2008? 47:162-71. doi:10.1111/j.1600-0757.2008.00259.x
ABOUT THE AUTHOR
Dr. Gelbart is the owner of Independence Dental Group, a general and cosmetic dentistry practice in downtown Philadelphia. He can be reached at stevengelbart@idgpa.com.
Disclosure: Dr. Gelbart reports no disclosures.
