A Biopsy-ing We Will Go

Back to Dr W's office for the biopsy. Basically the plan is to drill into the bone and remove, as much as possible, the lesion and then send that material off to the pathologist to find out what it is. If it is a simple cyst, scraping it out is all that would be needed to get rid of the issue. If it is something more significant, more surgery might be needed. My vote is for the simple cyst.

I was given the choice of local anesthetic injection alone, with laughing gas, or IV sedation. I've never had a problem with dental work so I chose injection with the gas as a backup.  First, however are the photos. Dr. W is definitely old school on this. Lot's of photos both before, during and after. All photos both inside and outside looked normal for my age. No overt sign of my little friend.

Right

Left

View from the inside. The asterisk is where the lesion is.

 Next the numbing. I guess is was about 4-5 injections. Pretty quickly my entire right jaw, lip and chin were completely numb. A rubbery bumper goes in between the left molars to block my mouth open and a gauze sponge over my tongue. "All set?" Yep. Incision time...not feeling at all. Dr. W cut along the teeth at the gum line on the inside of my mouth. Cut. Suck. Cut. Suck. Peel the gum tissue off of the bone down to the floor of my mouth. I can't feel a thing.

The gum line is peeled down. This photo is reversed because he used a mirror to take it.

"So do you remember Dr. X during residency? Let me tell you a story..." Dr. W is very efficient with motion and can keep up both surgical progress and a steady flow of stories about people and experiences we both knew. It brings me back to a great time of life and keeps my mind off of what he is doing.

Now for the drill. Since the lesion is fully contained in the bone (...which is good thing. Lesions that erode through the bone into the soft tissue often require more extensive treatment.) he has to drill through the bone to get to it. From the panorex and CT scan he knows that it is centered at the roots of #28. Drill, drill, suck, suck, drill, drill. "There it is". More drilling. No pain, my nerves are ok too.

A view of the lesion. It is solid tissue, not a cyst. That needs to come out.

"It's a solid tumor rather than a cyst." The next step is to get that tissue out by picking and scraping (called currettage) in order to get as much of it out as possible. If this ends up being a minor issue, currettage will be the cure. The hole will fill in with bone fairly rapidly. If it is a more sinister problem, it will need further work. Dr. W is very careful not to scrape or pick at the roots of the teeth to protect each individual nerve.

The empty cavity

The tissue came out easily and according to Dr. W, it looked benign to the naked eye. Scrape, pick again until the cavity was empty of all the tissue he could see.

Irrigation (saline) was used to clear it out and the hole was stuffed with gelfoam (a collagen sponge that helps things clot). The gum tissue was then sutured back together. This was actually a really cool part from my surgeons eye. The suture weaved around the teeth and slings the gum back where it came from. From the outside, I couldn't tell anything had been done.

My little friend in the flesh

All back together after suturing

"The pathology will go to Louisville. They are the best at this type of stuff. They can take a while to get a result, so I'll call you with the results. See you in a week. Oh, and if you feel like it, grab a Werther's candy on the way out. They are really good."

Immediately after, I felt great...other than the big wound on my lip from biting it because it was numb. Unfortunately, the long acting local anesthetic did not last as long as expected. I was feeling great for about 3 hours, then the floor of my mouth REALLY started to hurt.

Clearly swelling from the hematoma in the soft tissues and the biopsy site was causing pain. I thought I would get by with ibuprophen, but I was glad he gave me the hydrocodone.

Jargon Alert:
hematoma /he·ma·to·ma/ (he″mah-to´mah) a localized collection of extravasated blood, usually clotted, in an organ, space, or tissue.

After a couple of days, however, my pain was well controlled with ibuprofen. The hardest part was avoiding that gum when I ate or brushed my teeth. After about 5 days, the sutures started coming apart (as they are supposed to) and I kept spitting out pieces of fishing line. Fun.

My follow-up in a week showed that my incision was healed and all looked good. The remaining sutures were removed. It's amazing how big such a small suture feels inside the mouth. True to form, the pathologists had not finished their report. "I'll call you just as soon as I know something" Dr. W says. "Grab a Werther's. Not the same family but they are really good."

And so we wait....