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