PMC3977560_01
Panoramic radiograph. Note that it is aware of the presence of supernumerary tooth (a). Location through computed tomography. The blue line illustrates the parasagittal section which locates the supernumerary tooth (b). Supernumerary tooth (red circle) located in relation to the buccal cortex (c).
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In the review of the preoperative panoramic radiograph, no supernumerary tooth in the surgical area was observed (Figure 1(a)). Nevertheless, we found a diffuse supernumerary tooth near the buccal cortex in the parasagittal serial section analysis of the area for implant placement (Figures 1(b) and 1(c)), with a similar appearance, small and obliquely to the buccal cortex, at a lower premolar.
Removal by milling the coronal portion of the supernumerary tooth ankylosed to the vestibular cortex. Note the mesial and buccal relationship to the implant placed according to plan surgery. Black arrow shows the visualization of the supernumerary tooth crown near the buccal cortex after superficial osteotomy (a). Immersion endoscope (IE) visualization during the drilling of the radicular portion of the supernumerary tooth, observed with a yellowish color and apparently had two fused roots in an anterior portion (b).
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The implant (3.7 mm diameter and 11 mm length) was placed in the second premolar area previous to the supernumerary tooth removal to ensure the optimal primary stability (Figure 2(a)). Later for immersion endoscopy (IE), an endoscope of 1.9 mm diameter, with 30- and 70-degree view angles and continuous irrigation via the support sheath, was used, which permits either short distance observation (2-3 mm) or microscopic (up to 40x) visualization when there is direct contact with the site facilitated by the endoscope's terminus being immersed in saline solution (Figure 2(b)).
Schematic diagram of supernumerary tooth removal with endoscopic approach. (a) Support endoscopy (SE), an endoscope of 2.7 mm diameter and a 30-degree view angle, with support and irrigation, was used for drilling of the tooth. (b) Immersion endoscopy (IE), an endoscope of 1.9 mm diameter, with 30- and 70-degree view angles and continuous irrigation via the support sheath, was used, which permits either short distance observation or up to 40x visualization when there is direct contact with the site by saline solution. (c) Complete elimination of the tooth structure without affecting the bone wall. The bone defect created was inspected with SE. No communication with the implant and buccal bony wall fully retained was observed.
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To access the supernumerary tooth, an endoscopic approach was performed (schematic representation in Figure 3).
Endoscopic visualization techniques in oral surgery and implantology. (a) Support Endoscopy (SE). A Karl Storz optic (2.7 mm diameter) with support and irrigation sheath. (b) Immersion endoscopy (IE). Sterile equipment, Karl Storz optic (1.9 mm diameter) with supporting sheath to accommodate the 1.9 mm diameter optic connected to saline irrigation, tip modified to adapt to the dental alveolus.
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Tuttlingen, Germany) (Figure 4). The endoscopes were linked up with a Storz 487 B examination unit and a Xenon 300 W light fountain with 6000 K capacity (Karl Storz, Tuttlingen, Germany).
Total removal of supernumerary tooth (a). Support endoscope (SE) or macroscopic endoscopic control; note the integrity of the buccal cortex (red arrows) and no communication with the implant (black arrow) (b).
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No communication with the implant was found nearby, with the buccal bony wall fully retained and no remaining tooth structure (Figure 5).
Four-wall bony defect filled with particulate bone graft.
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Finally, the bone defect was filled with particulate bone graft (Figure 6), with the flap repositioned and sutured.