History of Present Illness

This is a 60-year-old white male who was referred to Dr. Mark Carlson an Oral and Maxillofacial Surgeon from Tacoma to evaluate a severe and localized bone loss in the upper right posterior maxilla (Fig 1). The referring general dentist noticed severe localized bone loss in the area of tooth #2. A panoramic radiograph revealed a wide area of bone destruction involving the right posterior maxilla and possibly the sinus floor (Fig 1). Tooth # 2 was extracted without complications. The extraction site was described as spongy in consistency. The patient was referred to Dr. Carlson for evaluation and treatment of the bony lesion. At this point the posterior maxilla was asymptomatic but was expansile and measured approximately 2.5 cm transverse by 2.1 cm anteroposterior dimensions. The extraction site of tooth #2 was open but no evidence of an oro-antral fistula. Dr. Carlson performed an incisional biopsy and curettage of the area and submitted the specimen for microscopic examination.

Figure 1. Panoramic view of the presentation in Dec 03 demonstrating destructive radiolucency involving the right posterior second molar tooth, distal bone and the maxillary sinus.