Fig. 2 - Clinical photographs taken during surgical removal of
kissing molars
The definitive treatment options considered were as follows:
Surgical removal of the lower 7s and 8s +/- UR8 under General
Anaesthetic
Surgical removal of lower left second and third molars
Coronectomies of involved molars (first suggested at initial visit, but
an unlikely long-term solution)
Monitoring of conditions with no active surgical intervention.
After discussion with the patient, it was clear that he was keen to have
surgical intervention due to the severity of the symptoms. A referral
was made to the local Oral and Maxillofacial unit with a provisional
plan to surgically extract the three pathologies and associated teeth.
On further discussion with the Oral and Maxillofacial consultant, the
treatment plan was modified to extract only the upper right 7 +/- 8 if
visible, and the lower left kissing molars only (which had an open oral
communication following marsupialisaton) due to the risk of damage to
the Inferior alveolar nerves.
Surgical extractions of the teeth were arranged under a general
anaesthetic. The lower left kissing molars were extracted using a
three-sided mucoperiosteal flap. This involved careful bone removal
followed by methodical sectioning of the crown and roots and finished
with curettage and enucleation of the cyst, making sure the inferior
alveolar nerve and bone were preserved to avoid paraesthesia and
mandibular fracture respectively.
The upper right molars were removed via a two- sided mucoperiosteal flap
and bone removed with caution to keep the maxillary antrum lining
intact. The cyst lining was punctured, releasing a yellow fluid. The
splayed roots of the upper right 7 proved difficult however were
extracted successfully following sectioning and elevation. The resulting
oro-antral communication from removal of the teeth was closed with
tissue from the buccal fat pad, and a 2 layered closure technique
employed. The patient was commenced on an antral regime following
recovery to avoid an oroantral fistula formation.
An uneventful recovery followed postoperatively, with simple analgesics
and chlorhexidine use. At a three month review complete soft tissue
healing had occurred and the patient reported no problems. Histology
reports confirmed the diagnoses of dentigerous cyst (see table
1 ). A one year review was arranged to ensure bony infill of the areas,
and monitor the lower right quadrant which was left untouched