Inland Empire Oral & Maxillofacial Surgeons

The Odontogenic Keratocyst – An Old Lesion Revisited

I remember one particularly hot Friday in the office, as I sat down to review some radiographs with a toddler and her mother, I was called out of the exam room by one of our staff members, who had a particularly concerning look on her face. It turns out we had not one, not two, but three patients we needed to fit into our already occupied schedule for the day because of pain and concerns of “dark spots on their x-rays.” It’s raining radiolucencies, I thought to myself, there must be something in the water. All sarcasm aside, it was both concerning and interesting to see such a relatively rare event become so ubiquitous. In the end, all went well and everyone was accommodated, with two cases I’d like to share below:

Case 1:
A 20-year-old male presented to our facility with a referral for a painful radiolucency of the right posterior mandible. Other than a two-year history of tobacco use, his past medical and surgical histories were unremarkable. On clinical exam, there were no mucosal changes, no palpable buccal or lingual swelling, and tooth #29, #30, #31 tested vital with no mobility, probing depths distal to #31 measured 7-8mm. On CBCT examination, the lesion exhibited a well-circumscribed, regular bordered radiolucency approximately 25mmx18mm in its greatest dimension in the right posterior mandible directly adjacent to #31. The lingual cortical plate was violated, however, the roots of tooth #31 remained intact. Additionally, the inferior pole of the lesion was contiguous with the superior aspect of the Inferior Alveolar nerve canal, but did not displace the nerve/canal (Figure 1). Tooth #32 was missing and, per patient report, had never developed. Differential diagnosis based on location and demographics included Dentigerous Cyst, Odontogenic Keratocyst, Ameloblastoma, Myxoma and Hemangioma in order of most to least likely diagnosis. After the risks, benefits and alternatives were discussed with the patient, he elected to undergo excisional biopsy under IV General Anesthesia.

A modified sagittal split-type incision was made in the right mandibular quadrant extending up the external oblique ridge and anterior ramus. A full thickness mucoperiosteal flap was reflected until the proposed site was sufficiently exposed. An 18-gauge needle and syringe were used to aspirate the lesion prior to excavation, which returned straw-colored fluid, confirming this was NOT a vascular lesion. A round bur under copious irrigation was used to unroof the superior aspect of the right mandible until a cystic lining was revealed. A series of straight and angled curettes were used to carefully enucleate the mass from the bony cavity and from the inferior alveolar nerve canal. The lesion was removed in its entirety without perforation of the lining (Figure 2). The residual defect was examined, and the borders were smoothened with a fine bone file and a limited peripheral ostectomy was performed in the distal and buccal aspects of the residual cavity. The distal root of #31 was also scaled thoroughly in the event of residual remnants of the cystic lining arising from a dentigerous origin. The wound was then copiously irrigated with sterile saline and closed in a double layered fashion with resorbable suture material (Figure 3).

Histopathologic report from an Oral & Maxillofacial Pathologist revealed a uniform cystic lining with surface parakeratin and palisading nuclei consistent with an Odontogenic Keratocyst.

Figure 1a) Case 1: Orthopantomogram exhibiting large right mandibular radiolucency

Figure 1b) Case 1: Axial slice CBCT exhibiting lingual cortical expansion and erosion

Figure 3) Case 1: Residual surgical defect after enucleation of cystic lesion. Note proximity to Tooth #31

Figure 2) Case 1: Large cyst removed in its entirety

Case 2:
A 19-year-old female presented with a one-week history of pain and swelling in the right mandibular quadrant. Her Medical and Dental History were unremarkable. On clinical exam, the ginigva in the area of the right retromolar pad was erythematous and tender to palpation. On radiographic exam, a well-circumscribed, regular-bordered radiolucency was noted 18mmx15mm in its greatest dimension. Tooth #30 and #31 were vital on testing, and did not exhibit sensitivity to percussion. Probing depths distal to #31 were 2-3mm. Similar to case #1, the lingual cortical plate was violated and the roots of tooth #31 remained intact. After discussion of the risks, benefits and alternatives, she elected for excisional biopsy of the lesion under IV General Anesthesia. The surgery was undergone in a manner identical to Case #1, with the following exceptions: The Inferior Alveolar nerve and tooth roots of #31 were not largely involved with the lesion and therefore a peripheral ostectomy was feasible in all areas of the residual cavity. The patient was then closed in a double-layered fashion with resorbable suture material and allowed to recover from general anesthesia in the usual manner.
Histopathologic report from an Oral & Maxillofacial Pathologist revealed a uniform cystic lining with surface parakeratin, palisading basal nuclei and moderately intense inflammatory infiltrate consistent with an Inflamed Odontogenic Keratocyst.

Figure 4a) Case 2: Orthopantomogram exhibiting moderate sixed right mandibular radiolucency

Figure 4b) Case 2: Lingual cortical erosion, roots remain intact

Figure 4c) Case 2: Coronal section exhibiting superior expansion and lingual cortical erosion. Note lack of Inferior Alveolar Nerve involvement

Figure 5) Case 2: Cyst removed entirely without perforation of the delicate lining, adjacent bone fragment

Of all the Odontogenic Cysts in Oral Cavity, the Odontogenic Keratocyst holds the record for both the most aggressive as well as the most recurrent. In 2005, the World Health Organization (WHO) renamed the Odontogenic Keratocyst (OKC) to the Keratocystic Odontogenic Tumor (KOT) to reflect its aggressive nature. However, due to the clear histologic evidence of its cystic lining, the term has not been accepted well in the community, as reflected in most recently published literature. Irrespective of the name, the idea that a cyst can behavior more like an aggressive tumor should shed some light on the pathophysiology of this all too common disease. Previously, attention was focused on the origin of the cyst, whether primordial (from the dental lamina or basal cells) or dentigerous (from the reduced enamel epithelium of a tooth) in origin. However, more attention should be given to the keratin lining, which gives us insight on the likelihood of recurrence. It’s now clear that OKCs with a parakeratinized layer behave more aggressively and should be followed more closely for signs of recurrence. Because the fibrous wall of the cystic lining can contain “daughter cells” or “satellite” lesions that can precipitate new OKC formation, the recurrence rate for this relatively benign disease can approach as high as 30%. It is for this reason that close radiographic surveillance is warranted, ideally for ten years or more. Prognosis for this all too common disease, however, is excellent, as the lesion is unlikely to destroy roots, does not exhibit neurotropism, and does not have a propensity for rapid proliferation. As always, early detection and treatment are key to a successful outcome.

Kirollos E. Zakhary DDS, MD


Immediate Provisional Restoration of Implants

Imagine this: you are out to dinner with a group of friends, and someone orders your favorite appetizer—bruschetta. As you take your first bite of this extra crispy bread sensation, you experience a sharp, intense pain in tooth #8, which is accompanied by the sound of a “crack.” At first you think that some idiot accidentally put a rock in the bruschetta. The truth of the situation, however, is that this was no rock; it was your crown that fractured to the gingival margin, leaving you toothless in front of your friends. Two thoughts cross your mind: “Great! How am I supposed to eat the rest of this bruschetta?” and “I know that I need to get an implant (because my general dentist always warned me about the fragility of this tooth and told me that an implant was the best solution), but I’ll have to wear some stupid flipper for 8 months!”

This scenario is not uncommon. It is funny, as I have surveyed many patients that have fractured a tooth, and the most common cause of such fractures is bread. I still believe that an implant is the best solution for most patients; however, over the course of my career, I have changed my treatment plan to include immediate provisional restoration (placement of an acrylic crown on the implant within a couple days of surgery) under ideal circumstances. I used to be scared of the potential risks of noncompliance and failure, but my experience and the literature do not support that fear. Don’t get me wrong—I still don’t trust the male species all that much when planning the treatment for these cases. I was once told by a prosthodontist that men are unreliable because most of them feel that if there is no pain from the implant surgery and a tooth is present, the immediate implant and provisional restoration can be used like a fully integrated implant or a natural tooth. Then again, I have had women who didn’t want to have immediate provisional restorations performed on their implants because they didn’t trust themselves either. I guess that I am damned with either sex.

According to two articles by Tarnow and Chu, there are eight benefits of immediate provisional restoration:

Advantages of Immediate Provisional Restoration

  1. There are fewer patient appointments overall.
  2. There is only one surgical procedure for the patient.
  3. The treatment time is shortened, as there is no need to uncover the implant (two staged procedure).
  4. A fixed provisional restoration is possible, as opposed to a removable appliance.
  5. There is an increase in patient comfort.
  6. The soft tissue can be sculpted with a tooth form rather than a cylindrical abutment.
  7. There is increased peri-implant soft tissue thickness.
  8. The alveolar bone can be preserved.

Tarnow and Chu et al.

When you think about it, the entire process is seamless. The patient’s maxillary and mandibular dentitions are digitally scanned before the tooth is removed. The tooth is atraumatically removed, and the implant is inserted to the appropriate torque value. The donor bone is placed in the gaps, and, if needed, a connective tissue graft is harvested and placed. A scan body is placed on the implant, and the area is digitally scanned. A stock healing abutment is then placed, and the digital file is sent to the dental laboratory for provisional crown fabrication. Either an Essex is given to the patient in the meantime, or, in most cases, the patient does not desire a replacement tooth at that time. The patient returns to the office 2-3 days later; the patient receives a numbing agent, and the provisional crown is inserted. The patient’s bite is checked, and the crown is modified to ensure that there is no occlusal contact. The patient is reminded multiple times and once more (especially if they are male) not to use this tooth under any circumstances; after that, the patient walks out happy. The patient is happy because everything was seamless and they don’t have to wear that “stupid” flipper. Over the next four months, not only is the bone consolidating around the implant, but the gingiva is healing around the provisional crown, allowing for the best outcome. More important, we have reduced the overall treatment time from nine to twelve months to four to five months, we have given a superior cosmetic result, and we have reduced the self-consciousness that some patients might feel while wearing a removable restoration. The only disadvantage is that we will still have to discourage the patient from eating bruschetta.


CASE: 57 year-old female presents to the office with pain on chewing for the last couple of months. She specifically points to tooth #12 as the culprit. The dental history for tooth #12 includes root canal therapy, post/core and crown. Clinically the tooth had a 6 mm periodontal pocket on the mesial and CT scan demonstrated bone loss on the mesial. Because tooth #12 had greater than 3mm beyond the apex to the sinus floor, the patient was an ideal candidate for extraction, implant, bone graft with immediate provisional restoration.


PHOTO #1: Pre op photo with crowns on 12, 13 and 14. No fistula was noted and the gingiva around the existing crown was healthy.


PHOTO #2: Post op photo with the implant and provisional restoration in place. Note that occlusion has been adjusted compared to the original crown. The provisional restoration was out of occlusion in all excursions.


PHOTO #4: Example of provisional crown


PHOTO #5: Example of provisional restoration

Matthew E. Dudziak, DDS, MD, MBA


Tarnow DP et al. Flapless Postextraction Socket Implant Placement in the Esthetic Zone: Part 1. The Effect of Bone Grafting and/or Provisional Restoration on Facial-Palatal Ridge Dimensional Change – A Retrospective Cohort Study. Int J Perio Rest Dent. Vol 34, #3, 2014. p 322-331

Chu SJ et al. Flapless Postextraction Socket Implant Placement in the Esthetic Zone: Part 2. The Effects of Bone Grafting and/or Provisional Restoration on Peri-implant Soft Tissue Height and Thickness – A Retrospective Cohort Study. Int J Perio Rest Dent. Vol 35, #6, 2015. p 803-809

Minimally Invasive Sinus Lift Bone Grafting

Sinus pneumatization after tooth loss reduces the vertical height of bone in the posterior maxilla. Dental implant placement for upper molar or premolar teeth may require sinus lift bone grafting to restore this lost vertical height needed to accommodate the fixture. If a large amount of bone is required, a lateral approach has been traditionally employed. This technique is invasive and postoperative recovery can be prolonged. An alternative, more minimally invasive approach can be employed, even for larger defects.

A 53 year old female presented with a severely pneumatized maxillary sinus and desire to replace tooth #13 with a dental implant. She had a lateral approach performed previously, which was abandoned due to a large sinus perforation. Pre-operative CBCT shows less than 2 mm of bone in the area of the proposed implant.

A.                     B.                          C.             D.

Figure 1. A. Preoperative CBCT B. Sinus osteotome showing implant position C. Dome formation indicating elevation of the sinus membrane D. Final position of implant, surrounded with particulate graft.

Using a piezosurgery handpiece and sinus osteotomes, particulate graft was packed into the site. Evidence of sinus elevation was evident by the radio-opaque dome visible on an intraoperative xray. The implant was placed with good insertion torque. The patient went on to recover well with minimal pain and swelling.


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Supernumerary Teeth

Hyperdontia is a dental developmental alteration resulting in an increased number of teeth. The occurrence of hyperdontia is between 1% and 3.5% in the permanent dentition and 0.3% and 0.6% in the primary dentition, respectively. It is found more commonly in males at a ratio of 2:1. Though the location of the supernumerary teeth may have some variability, the mesiodens, found behind the maxillary central incisors, is the most common, with some studies showing greater than 50% prevalence amongst all hyperdontia patients. The most common location for a supernumerary  is the anterior maxilla, followed by the premolar region and, lastly, the wisdom teeth.

Patient #1: 16 y/o female referred for asymptomatic wisdom tooth evaluation.  Supernumerary maxillary wisdom teeth incidentally found on CT scan.


Axial Cut CT Scan: Supernumerary teeth in close proximity to the roots of wisdom teeth.

Coronal 3-D CT Scan: Posterior view showing location of supernumerary teeth.

The two most common syndromes associated with supernumerary teeth are cleidocranial dysplasia and Gardner’s syndrome; these arealso seen in a higher prevalence of patients with cleft lip and palate. The etiology of hyperdontia is unknown, but common theories include genetic and environmental factors and the hyperactivity of the dental lamina theory.

Patient#2: As part of the orthodontic treatment plan, this 14 y/o male referred for removal of mandibular supernumerary teeth.  Patient has a history of retained primary teeth K and L with delayed eruption of teeth 20 and 21.  Some potential consequences if treatment option is observation: prevention of eruption, cyst formation and damage to adjacent teeth.

The clinical presentation associated with supernumerary teeth can vary from patient to patient. Because only 25% of the supernumerary teeth, specifically the mesodens, erupt into the oral cavity, the majority of the patients are asymptomatic. Clinical findings that raise the index of suspicion of a supernumerary tooth include the following: disruption in the eruption pattern or over-retained teeth, asymmetric eruption pattern, and ectopic eruption of either the primary or permanent dentition. If any these situations should arise, the clinical suspicion for a supernumerary tooth is high; the clinician should proceed with radiographic evaluation with a simple periapical x-ray. Though some of you may remember the SLOB rule radiographic technique to identify position (same lingual, opposite buccal), the cone-beam 3D scan is a more precise method to identify location, pathology, and consequences of possible surgical intervention.

Patient #3: 5 y/o male referred by pediatric dentist for evaluation of right maxillary swelling.  Patient recently lost teeth E and F.  Clinical exam: right maxillary swelling from right canine to contralateral incisor, missing teeth E and F, and tooth D mobile.  CT scan: displaced teeth 7 and 8, 15mm x 15mm x 17mm radiolucent lesion associated with a mesodens.  Observation is not an option, surgical intervention is necessary.

 The management of supernumerary teeth includes observation or surgical intervention. Common non-surgical complications associated with supernumerary teeth include the following: delayed or prevention of eruption and displacement or rotation of the permanent tooth, including possible diastema formation. Less common sequels of supernumerary teeth include the following: cyst formation, root resorption or dilaceration of the adjacent tooth root, and nasal eruption. Surgical intervention and the timing of the treatment of supernumerary teeth is based on the age of the patient, incidence of any existing current complications, the risk or anticipation of any future complications, and the risk of surgical intervention to the primary or permanent dentition.

Patient #4: 15 y/o female referred for evaluation and treatment of supernumerary teeth 3a and 4a and extraction of wisdom teeth.  Patient instructed to seek consultation after the completion of her orthodontics.  Patient is asymptomatic.  Possible consequences if surgery is performed: access to the teeth, damage to the root of tooth #3 and sinus communication.


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One of the major risks of removing the lower wisdom teeth is injury to the inferior alveolar nerve (IAN). The risk of injury to the IAN ranges from 0.35% to 8.4% during wisdom teeth removal. This causes numbness to the patient’s lip and chin on the side of the injury. In majority of cases, the numbness is temporary and full feeling is regained over weeks to months. For higher risk situations, there is an alternative procedure known as coronectomy or partial odontectomy, which involves removing the crown (top part of the tooth) only and leaving the roots behind. This substantially minimizes the risk of a nerve injury.

Figure 1. Clinical exam and CBCT shows the close proximity of the inferior alveolar nerve (in red) and wisdom teeth’s roots

The roots that are left behind can migrate over time. However, in only 3% of patients will this impair healing and require a second surgery for its removal. This second surgery is typically safer since the roots migrate away from the nerve.

Figure 2.  1 year post-op CBCT shows migration of the remnant roots after surgical coronectomy


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Immediate Implant Placement in Extraction Sockets

One of the obstacles a patient faces with dental implants is the length of treatment required. Traditionally, it takes two surgeries and up to eight months of healing after a tooth extraction to receive a new implant tooth. However, with improved implant surfaces and techniques,  we can now predictably place dental implants into the sockets of teeth immediately after extraction, with similar survival rates1. Everything can now be done in one surgery with only four months of healing.

Any site is a potential candidate as long as there is adequate bone both surrounding, as well as past the tooth root(s), to allow for an ideal restorative position with good initial stability.

A.     B.  

C.      D.  
Figure 1. Immediate implants placed in the following sites: (a) central incisor with implant supported provisional (b) lower molar (c) upper molar with simultaneous internal sinus lift bone graft and (d) upper premolar

Preoperative 3D imaging is helpful in visualizing the patient’s anatomy and screening the ideal candidate. Since there is limited bone available, a dental implant with aggressive threading is important to obtain good primary stability. Typically, the socket is larger than the diameter of the dental implant and a bone graft is required to fill the space. A large stock, or customized healing abutment, can then be used to contain the bone graft and allow for ideal soft tissue healing.

Figure 2. Anatomical PEEK (polyetheretherketone) healing abutments (Nobel Biocare) are biocompatible and can be placed on implants placed in molar sites.

Immediate implant placement in extraction sockets is a predictable procedure with favorable results. Immediate placement provides a tremendous benefit for patients as it eliminates the need for a second surgery and significantly reduces treatment time. With immediate placement patients can receive their new implant restoration four months after extraction, compared to the traditional eight month waiting period with two or more surgeries.


1. Chrcanovic BR, Albrektsson T, Wennerberg A. Dental implants inserted in fresh extraction sockets versus healed sites: a systematic review and meta-analysis. J Dent 2015 Jan; 43 (1): 16-41.

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Cheekbone Implants (Zygoma implants), Teeth in a Day

When we lose our teeth, our jaw slowly loses bone over time. For patients with no teeth, dentures become increasingly difficult to wear. Dental implants can help anchor a denture, but sometimes the bone loss is so severe, we need to explore other options.

A 50 year old patient presented with frustrations of a loose fitting denture. He was socially withdrawn because he was afraid the denture would fall out while talking. He could not enjoy his favorite meals. Lastly he hated the feeling of the denture covering the roof of his mouth. He was young and wanted to enjoy the rest of his life with permanent teeth.


We placed four implants in his cheekbone that emerged into her mouth to anchor teeth. We also replaced all his failing lower teeth with dental implants.

The patient was seen in the office recently and was extremely happy with his results. His confidence has soared and he could now enjoy chewing again.


The use of the zygomatic bone for anchorage of long oral implants was developed by Dr. Branemark and co-workers during the 1980s.1 The ideal candidate for this procedure are patients who have not had teeth for many years and wear an upper dentures that does not fit well despite multiple remakes and relines. Benefits of the zygomatic implant include:

  • Reliable and good stock of bone in the cheek
  • No bone grafting required
  • Ability to have teeth in the same day
  • Proven long term success


  1. Branemark PI, Grondahl K, Ohrnell LO, et al. Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results. Scand J Plast Reconstr Surg Hand Surg 2004;38(2):70–85.

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Teeth in a Day, All on Four

The way we treatment plan patients with hopeless and failing dentition has evolved with dental implants. “Patchwork dentistry” can subject the patient to long treatment plans and big investments for unpredictable results. A young male presented to our office with the desire for brand new smile.

Our treatment plan involved extracting his remaining teeth, placing dental implants and placing temporary teeth on those implants, all in one day! Using the latest in technology, we were able to plan the case virtually in a 3D environment.

The patient was able to go home the same day with new teeth!


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Reasons to Remove Wisdom Teeth

There is limited space. Wisdom teeth may contribute to crowding of teeth, prevent eruption of second molars and may cause shifting of teeth after braces.1

Figure 1. Developing tooth #32 preventing normal eruption of #31.

Early removal is better. Younger patients heal faster and easier. When roots are not fully developed, the chance of inferior alveolar nerve injury decreases. Complications and morbidity of surgery increase with older age.2

Figure 2. Fully developed #32 with increased risk for nerve injury.

 • They rarely provide any meaningful function. In terms of chewing ability and efficiency, there is little benefit for maintaining wisdom teeth.
Infection and inflammation are common. Partially erupted teeth cause gums problems and are difficult to keep clean. Even normally erupted wisdom teeth are difficult to access for appropriate hygiene. Resulting inflammation is hard to eliminate, can spread and may contribute to pre-term and low birth weight infants, diabetes, cardiovascular disease and stroke.3,4
Improve access to second molars. Placing crowns or distal restorations on second molars can be challenging when impacted third molars are present.
Prevent super-eruption. When one wisdom tooth is problematic, the opposing wisdom tooth should be removed in anticipation of super-eruption can cause trauma to soft tissues.
Prevent gum disease. Periodontal disease can begin with the third molars and spread to other teeth. Always probe wisdom teeth, even distal to second molars on unerupted ones, to assess for deep pocketing and bleeding.5

Figure 3. Elderly patient with previously unerupted tooth #17 presents with periodontal disease and bone loss which has also affected the second molar.

Impacted wisdom teeth can develop aggressive cysts or tumors. These lesions can be locally destructive and require extensive procedures to remove. Be on the lookout for any associated radiolucencies on x-ray. Even hyperplastic follicles can represent early cyst formation.


Figure 4.A (left) Large odontogenic cyst associated with impacted tooth #32. Figure 4.B (right) Hyperplastic follicle may represent early cyst formation.

Peace of mind! Wisdom teeth that are left behind require regular clinical and radiographic surveillance to assess for disease and/or pathology. They also require diligent oral hygiene and regular professional cleaning.

1. Harradine NW, Pearson MH, Toth B; The effect of extraction of third molars on late lower incisor crowding: a randomized controlled trial. Br J Orthod 25:117, 1998.
2. Chuang SK, Perrott DS, Susarla SM, Dodson TB; Age as a risk factor for third molar surgery complications. J Oral Maxillofac Surg 65(9): 1685-9, 2007.
3. White RP, Jr., Madianos PN, Offenbacher S et al.; Microbial complexes detected in the second/third molar region in patients with asymptomatic third molars. J Oral Maxillofac Surg 60: 1234, 2002a
4. Offenbacher S, Lieff S, Boggess KA, Murtha AP, et at; Maternal Periodontitis and Prematurity. Part 1: Obstetric Outcome of Prematurity and Growth Restriction. Ann Periodont 6: 164, 2001.
5. Elter JR, Offenbacher S, White RP, JR.; Association of third molars with periodontal pocketing. The dental ARIC study. J Oral Maxillofac Surg 62: 73, 2004.