Extensive maxillary lesions: Refer this out due to potential malignancy?

Obviously you are an esteemed oral surgeon and your scenario is possible. What would be your procedure here ? Do you take the teeth out and do respective surgery if the tissue feels like foam at that appointment or do you send off for a biopsy to see what you have as the tissue heals? Is it more appropriate to do respective surgery in the presence of possible infection or wait until you have a dx from biopsy? Do you make the cancer ? More aggressive by removing infected teeth or can you better manage the area when the inflammation from the PD disease and tooth related infection is controlled? Certainly you will be better able to do cancer surgery than most GPs but I fail to see how you would do the preliminary extractions and Dx any different than a general dentist and there would be probably less time delay. It usually takes 3-4 weeks to get a patient to an OS where most dentist can have these out sooner and on the way to a Dx and alerting the OS of what is coming IMHO

We face an aggressive bone resorption caused by severe periodontal disease where nothing and can do to keep the maxillary teeth. I would make the tooth extraction and would wait two to four months, then do the rehabilitation.

Wow! this IS a conversation we in dentistry need to have- first let me say that if you look at the individual images vs the pan they don't appear to be from the same picture and if you are saying that the cloudy nature of the lesion on the left side of the side slice is disconcerting what about the cloudy nature above the bicuspids on the right slice . I think this is about the conebeam reformatting and these are not diagnostic or a true radiographic assessment of the areas. second I don't think any Gp is going to explore this region up tho the pts brain and keep going or do I think they would avoid referring this if the find an odd appearance after extraction of the teeth or tissue healing issues. All the problems the pt has that you mentioned will be the result of the extensive surgery to remove the lesion not because the GP took out the teeth and you are not going to be bailing out a dentist here you are going to be doing your job as part of a team. So tell me ,as oral surgeons, I am still waiting for what your first step is here- Im a general dentist - educate me on why you dont take the teeth out first or do you? do you do your biopsy before the extractions, during, or after healing ? How are you going to get primary closure here and why do you want it? When are you going to graft-are you going to graft into these infected sites and then attempt primary closure? Are you going to have a denture made for immediate insertion and if you are what is the dentist to do when you have pulled all of the tissue over for primary closure-- It is easy to discuss the procedures you are going to do but discuss the timing of this Are you going to extract and do the invasive resective surgery at the same appointment if you determine that the consistency of the tissue is odd or will you biopsy at this point and see what turns up? so if there is a funny tissue here will you continue to currette up into the sinus at this appointment before you know what you are dealing with? If it is cancer are they all treated the same or are some irradiated first or treated with chemo to decrease the size or do you just start removing tissue? What happens to the keratinized tissue when you do primary closure and now you send them to me to restore? I get primary closure with a resection but not with extractions that makes no sense to me You've placed implants at the bicuspid and cuspid retained by locators Im not aware of any study that confirms this as a successful procedure in the maxilla. It may be easy to put the implants in, get them parallel and place locators surgically this is a win for you the OS but it is a disaster waiting to happen to the GP that has to restore this -now the patient wants to know why the denture teeth break off or the denture breaks or the implants fail after a few years or the retainers are constantly replaced because the denture keeps getting loose Now the GP has to figure out what he is doing wrong because the implants integrated well,so it must be his fault - you as the OS are off the grid as far as the patient is concerned- the implant planning is all wrong but they integrated and the patient paid all that money and they expect it to work for you the OS to think that this would work in this case shows a lack of knowledge of the dynamics of removable prosthetics, occlusion and occlusal dynamics--This is the elephant in the room- the GP has deferred to the surgeons the decisions about implant placement and the surgeon has given him the answer. The truth is that the success of the case is based on an understanding of the occlusal forces on the prosthesis and the lack of posterior support that is available here-yes this is more about denture dynamics than fixed prosthesis- Put an upper denture in here and you will soon see what the dynamics are going to be on your implants It is easy to point out how you bail out the GPS and Periodontist for the things that show up in your office but Gps have been bailing out OS since implants were first placed It is the astute OS that learns the dynamics of the occlusion and treatment planning and the force dynamics that contribute to implant loss What I see is that surgeons understand surgery, GP understand restorative but we don't know as a collective group the dynamics of the systems when combined with implants- you can't understand this in a weekend course-When was the last time your surgeon attended a course on implant treatment planning and occlusion The more I learn about implants the more I see I don't know IMHO

Dr Bill my cases are treatment planned per the restorative doctor as it is restoratively driven surgery. My prostodontist likes four locators when appropriate in the maxilla, it is his call. Your questions were answered in my first post. I have attended many restorative courses but I still rely on my restorative colleague as he trusts me to perform the surgery per my judgement. I think you may be overthinking the process. I get very nice results I'm sorry that you have had such difficulties with your team. Funny but I treat you guys like the quarterback and I welcome the feedback, just hope you can hear my feedback. Perhaps the problem lies on the working relationships between team members. I know enough about occlusion and prosthetics to get into trouble so I respect my restoring doctor as he respects what I do and trusts it. Thanks for the comments!

Ditto, well said much more tactful than me!

perfect!

Tying to learn here--would your biopsy contain the root 16? if the biopsy comes out positive for a form of cancer what is your next step? If radiation is on the horizon as part of your the treatment would you have to consider removing the lower teeth also

As I do enjoy learning from your feedback doctor. I had a similar case on an older patient the mucosa was speckled and bleeding and he was a smoker. I biopsied and prepared the patient for the worst. I was very relieved to have a benign diagnosis on the worse case of perio I have ever seen, I still remember the case! My point is that knowing when to refer and having a backup system for the patient's benefit, cost and convenience is my philosophy. There is plenty of dentistry to do out there and I applaud many of these posters for seeing that and use our professional colleagues. It is pretty silly to take offense at surgical advice given by an oral surgeon with a lot of experience and hopefully humility. Sometimes I feel that I am using the "OMS" word! Thank you for your complement, it made my day!

That is perfect. Is there any concern working in an area of active infection? It seems to me that this could impact the surgery and increase the risk of post op infection