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Removal of Large Complex Odontoma Using Le Fort I Osteotomy
2018
REMOVAL OF LARGE ODONTOMA BY LE FORT I OSTEOTOMY
J Oral Maxillofac Surg 67:2018-2021, 2009
Removal of Large Complex Odontoma Using Le Fort I Osteotomy Jarkko T. Korpi, DDS,* Vesa T. Kainulainen, DDS, PhD,† George K.B. Sándor, MD, DDS, PhD,‡ and Kyösti S. Oikarinen, DDS, PhD§ Odontomas are defined as developmental malformations that are hamartomas of odontogenic origin.1 Odontomas are the most common of the odontogenic tumors and are classified into compound and complex types. In compound odontomas, all dental tissue, including dentin, enamel, cementum, and pulp, are present and resemble tooth-like structures. In complex odontomas, the dental tissues present as a disorganized mass. Compound odontomas are approximately twice as common as complex odontomas. The etiology of either type is unknown.2 The heaviest odontoma at removal was recorded at 0.3 kg.3 Treatment of odontomas consists of either serial surveillance or surgical extirpation. Small and medium-size odontomas can usually be removed without difficulty, depending on their proximity to neighboring structures. However, access to large odontomas can be problematic, especially for those encased in thick, dense bone. A version of the Le Fort I osteotomy was originally described as an approach to remove tumors from the
maxilla and was first described by Cheever as early as 1867.4 The osteotomy has become popular as a versatile treatment for a variety of dentofacial deformities. In 1987, Archer et al5 described the Le Fort I down-fracture technique for the removal of basilar artery aneurysms. In 1990, Sándor et al6 described a modification of Le Fort I osteotomy combined with a mid-palatal split for tumor removal in areas of difficult access, such as the base of the skull and upper cervical vertebra. The advantage of the Le Fort I downfracture approach is that it permits the removal of difficult to reach tumors with low morbidity. The Le Fort I approach can be adapted to ensure preservation of the preoperative occlusion. We describe a clinical case in which the removal of a large complex odontoma in the posterior maxillary sinus was facilitated by Le Fort I osteotomy. We also have reviewed other methods to access this potentially difficult anatomic area for comparison.
Report of a Case *Resident, Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu and Oulu University Hospital, Oulu, Finland. †Assistant Professor, Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu and Oulu University Hospital, Oulu, Finland. ‡Professor and Head, Department of Oral and Maxillofacial Surgery, University of Toronto, Toronto, ON, Canada; Professor of Tissue Engineering, Regea Institute for Regenerative Medicine, University of Tampere, Tampere, Finland; and Docent, University of Oulu, Oulu, Finland. §Professor and Head, Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu and Oulu University Hospital, Oulu, Finland. Address correspondence and reprint requests to Dr Sándor: Hospital for Sick Children, S-525, 555 University Avenue, Toronto, ON M5G 1X8 Canada; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6709-0033$36.00/0 doi:10.1016/j.joms.2009.04.105
An otherwise healthy 14-year-old boy was referred for the assessment of a radiopaque lesion in the right maxillary sinus area. A panoramic radiograph and posterior anterior cephalogram taken at the first visit disclosed an otherwise asymptomatic tumor with a 30-mm diameter (Figs 1A,B). No extraoral edema or tenderness to palpation was present. The right second molar appeared to be unerupted, and clinically detectable lateral bony expansion of the posterior right maxilla was seen. Axial computed tomography showed a large, radiopaque mass with well-defined borders surrounded by a radiolucent zone in the right maxillary sinus extending medially to the lateral nasal wall and posteriorly to the pterygoid plates (Fig 1C). On the basis of the clinical signs and radiographic evidence, a provisional diagnosis of a complex odontoma was made. The differential diagnosis included calcifying odontogenic cyst, calcifying odontogenic tumor, and fibro-osseous lesion. Surgical removal of the odontoma using a Le Fort I osteotomy to approach the tumor was planned. The operation was performed with the patient under hypotensive general anesthesia with left-sided nasal endotracheal intubation. A full-thickness mucoperiosteal incision was made in the maxillary vestibule at the Le Fort I level.
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KORPI ET AL
FIGURE 1. A, Preoperative panoramic radiograph and B, posteroanterior cephalometric projection showing large radiopaque mass in right maxillary sinus. C, Axial computed tomography scan demonstrating radiopaque nature of mass and slight bony expansion in right maxillary sinus. Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
Before down-fracture of the Le Fort I segment, 4 1.5-mm titanium miniplates were adapted to the not yet osteotomized anterior and lateral walls of the maxilla (Fig 2A). The titanium miniplates were removed temporarily, and a Le Fort I level osteotomy was performed using a reciprocating saw. The maxilla was down-fractured, and the tumor was visualized in the right maxillary sinus (Fig 2B). Using a series of chisels and curettes, the lesion was completely removed from the maxilla and its sinus (Fig 2B). No perforations of any of the walls of the sinus were evident. The maxilla was repositioned using the preadapted titanium miniplates to re-establish the preoperative occlusion (Figs 2C,D). The patient’s postoperative course was uneventful, and he was discharged from the hospital on the second postoperative day (Fig 3). The histopathologic examination confirmed the diagnosis of a complex odontoma (Fig 4). Six months after the initial surgery, the patient returned to the operating room, because he had requested the removal of the miniplates. The maxillary bone was observed to have fully healed at its anterior and lateral walls. No clinical or radiographic evidence was found of recurrence of the mass or any other complications after 18 months of follow-up.
Discussion Odontomas are usually diagnosed in the second decade of age and are most typically classified as mixed radiolucent and radiopaque odontogenic tu-
mors.2 Odontomas are considered hamartomas,1 and more than one half of these tumors are situated in or near the maxillary sinus.7-10 The treatment of odontomas is either serial observation or surgical removal. Odontomas situated in close proximity to the maxillary sinus can grow to a large size, filling the antral cavity, yet remaining asymptomatic. Osseous defects in the maxillary sinus walls can occur after conventional removal of large maxillary tumors. These bony defects can result in functional or cosmetic problems. The Le Fort I down-fracture approach can avoid some of these problems. The Le Fort I down-fracture provides excellent exposure of the tumor and avoids sacrificing large amounts of bone. The postoperative healing is predictable, without oroantral fistula formation. A more traditional approach to tumor removal from the maxillary sinus is the Caldwell-Luc antrostomy approach,2 directly through the anterior and lateral walls of the maxillary sinus. The Le Fort I downfracture approach provides superior visualization of large maxillary tumors compared with the CaldwellLuc antrostomy approach, particularly for tumors in the posterior maxilla, which can be difficult to see. The Caldwell-Luc antrostomy approach also tends to
2020
REMOVAL OF LARGE ODONTOMA BY LE FORT I OSTEOTOMY
FIGURE 2. A, Titanium miniplates positioned and Le Fort I osteotomy level drawn on anterior and lateral surfaces of maxilla. B, Maxilla down fractured at Le Fort I level, and odontoma visualized in right posterior aspect of maxillary sinus. This approach allows the surgeon the opportunity to reach in to the maxillary sinus and more easily remove the mass. C, Preadapted titanium miniplates have re-established preoperative occlusion postoperatively. D, Enucleated complex odontoma. Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
leave bony defects in the anterior and lateral walls of the maxillary sinus when large tumors are removed. These osseous defects might not regenerate, leaving permanent voids in the bones of these areas. If these voids are large enough, they can allow collapse of the
overlying soft tissues in the space normally occupied by the walls of the maxillary sinus. Although the Caldwell-Luc antrostomy approach might seem to be more direct, the Le Fort I approach
FIGURE 3. Postoperative panoramic radiograph with miniplates securing maxilla to its original position.
FIGURE 4. Histologic slide of tumor confirming diagnosis of complex odontoma. (Hematoxylin and eosin stain, original magnification ⫻100.)
Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
2021
THEODOTOU AND CILLO
provides the superior access needed for removal of large lesions in the posterior maxilla. The Le Fort I down-fracture is a routine procedure in oral and maxillofacial surgery. Its postoperative morbidity is low, and the results are predictable, without changes to the occlusion after surgery. The Le Fort I down-fracture approach also gives an excellent view of the entire maxillary sinus, allowing well-visualized, safe, and thorough removal of the tumor.
References 1. Kramer IRH, Pindborg JJ, Shear M: WHO International Histological Classification of Tumors: Histological Typing of Odontogenic Tumors (ed 2). Berlin, Springer-Verlag, 1992, pp 21-22 2. Singer SR, Mupparapu M, Milles M, et al: Unusually large complex odontoma in maxillary sinus associated with unerupted tooth. N Y State Dent J 73:51, 2007
3. Worth HM: Principles and Practice of Oral Radiographic Interpretation. Chicago: Yearbook Medical, 1963, pp 420-424 4. Moloney F, Worthington P: The origin of the Le Fort I maxillary osteotomy: Cheever’s operation. J Oral Surg 39:731, 1981 5. Archer DJ, Young S, Uttley D: Basilar aneurysms: A new transclival approach via maxillotomy. J Neurosurg 67:54, 1987 6. Sándor GK, Charles DA, Lawson VG, et al: Oral approach to the nasopharynx and clivus using the Le Fort I osteotomy with midpalatal split (translation). Int J Oral Maxillofac Surg 19:352, 1990 7. Owens BM, Scuman NJ, Mincer HH, et al: Dental odontomas: A retrospective study of 104 cases. J Clin Pediatr Dent 21:261, 1997 8. Regezi JA, Kerr DA, Courtney R: Odontogenic tumors: Analysis of 706 cases. J Oral Surg 36:771, 1978 9. Toretti EF, Miller AS, Peezick B: Odontomas: An analysis of 167 cases. J Pedod 8:282, 1984 10. Kaugars GE, Miller ME, Abbey LM: Odontomas. Oral Surg Oral Med Oral Pathol 67:172, 1989 J Oral Maxillofac Surg 67:2021-2025, 2009
Brugada Syndrome (Sudden Unexpected Death Syndrome): Perioperative and Anesthetic Management in Oral and Maxillofacial Surgery Nicholas Theodotou, BDS, DDS,* and Joseph E. Cillo, Jr, DMD, MPH† Brugada syndrome (BrS), first described by Brugada and Buogada1 in 1992, is a rare genetic disease characterized by abnormal electrocardiogram (ECG) findings and an increased risk of sudden cardiac death (SCD) by ventricular fibrillation. It is also known as sudden unexpected death syndrome. We report on the case of a patient with this disease and provide an overview of the perioperative and anesthetic treatment of the oral and maxillofacial surgery patient.
Received from the Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh, PA. *Resident. †Associate Program Director and Director of Research. Address correspondence and reprint requests to Dr Cillo: Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, 320 East North Avenue, Suite 0107, Pittsburgh, PA 15212; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6709-0034$36.00/0 doi:10.1016/j.joms.2009.04.043
Report of a Case A 55-year-old man presented to the oral and maxillofacial surgery clinic at Allegheny General Hospital (Pittsburgh, PA) with a chief complaint of pain and intraoral swelling of the right side of his mouth. The clinical and radiographic examinations revealed an odontogenic infection from numerous grossly carious and nonrestorable teeth. His medical history was significant for myocardial infarction associated with occlusion of the right coronary artery 5 years before presentation, hypertension, stable angina, mitral valve prolapse without regurgitation, claudication pain, hypercholesteremia, hiatal hernia, and Brugada syndrome. His surgical history was significant for 2 stents placed in the right coronary artery 5 years previously and an internal cardioverter-defibrillator (ICD) placed 1 year before presentation. The oral medications routinely taken by the patient were metoprolol 12.5 mg twice daily, aspirin 81 mg daily, pantoprazole 75 mg daily, and atorvastatin 40 mg daily. His social history was positive for tobacco, alcohol, and marijuana abuse. His medical history included myocardial infarction in 2001 and numerous visits to the emergency department with complaints of chest pain and dyspnea dating back to 1999. In 2005, he presented to the emergency department complaining of mid-chest pain and pressure and associated dyspnea. He had experienced occasional palpitations and
REMOVAL OF LARGE ODONTOMA BY LE FORT I OSTEOTOMY
J Oral Maxillofac Surg 67:2018-2021, 2009
Removal of Large Complex Odontoma Using Le Fort I Osteotomy Jarkko T. Korpi, DDS,* Vesa T. Kainulainen, DDS, PhD,† George K.B. Sándor, MD, DDS, PhD,‡ and Kyösti S. Oikarinen, DDS, PhD§ Odontomas are defined as developmental malformations that are hamartomas of odontogenic origin.1 Odontomas are the most common of the odontogenic tumors and are classified into compound and complex types. In compound odontomas, all dental tissue, including dentin, enamel, cementum, and pulp, are present and resemble tooth-like structures. In complex odontomas, the dental tissues present as a disorganized mass. Compound odontomas are approximately twice as common as complex odontomas. The etiology of either type is unknown.2 The heaviest odontoma at removal was recorded at 0.3 kg.3 Treatment of odontomas consists of either serial surveillance or surgical extirpation. Small and medium-size odontomas can usually be removed without difficulty, depending on their proximity to neighboring structures. However, access to large odontomas can be problematic, especially for those encased in thick, dense bone. A version of the Le Fort I osteotomy was originally described as an approach to remove tumors from the
maxilla and was first described by Cheever as early as 1867.4 The osteotomy has become popular as a versatile treatment for a variety of dentofacial deformities. In 1987, Archer et al5 described the Le Fort I down-fracture technique for the removal of basilar artery aneurysms. In 1990, Sándor et al6 described a modification of Le Fort I osteotomy combined with a mid-palatal split for tumor removal in areas of difficult access, such as the base of the skull and upper cervical vertebra. The advantage of the Le Fort I downfracture approach is that it permits the removal of difficult to reach tumors with low morbidity. The Le Fort I approach can be adapted to ensure preservation of the preoperative occlusion. We describe a clinical case in which the removal of a large complex odontoma in the posterior maxillary sinus was facilitated by Le Fort I osteotomy. We also have reviewed other methods to access this potentially difficult anatomic area for comparison.
Report of a Case *Resident, Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu and Oulu University Hospital, Oulu, Finland. †Assistant Professor, Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu and Oulu University Hospital, Oulu, Finland. ‡Professor and Head, Department of Oral and Maxillofacial Surgery, University of Toronto, Toronto, ON, Canada; Professor of Tissue Engineering, Regea Institute for Regenerative Medicine, University of Tampere, Tampere, Finland; and Docent, University of Oulu, Oulu, Finland. §Professor and Head, Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Oulu and Oulu University Hospital, Oulu, Finland. Address correspondence and reprint requests to Dr Sándor: Hospital for Sick Children, S-525, 555 University Avenue, Toronto, ON M5G 1X8 Canada; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6709-0033$36.00/0 doi:10.1016/j.joms.2009.04.105
An otherwise healthy 14-year-old boy was referred for the assessment of a radiopaque lesion in the right maxillary sinus area. A panoramic radiograph and posterior anterior cephalogram taken at the first visit disclosed an otherwise asymptomatic tumor with a 30-mm diameter (Figs 1A,B). No extraoral edema or tenderness to palpation was present. The right second molar appeared to be unerupted, and clinically detectable lateral bony expansion of the posterior right maxilla was seen. Axial computed tomography showed a large, radiopaque mass with well-defined borders surrounded by a radiolucent zone in the right maxillary sinus extending medially to the lateral nasal wall and posteriorly to the pterygoid plates (Fig 1C). On the basis of the clinical signs and radiographic evidence, a provisional diagnosis of a complex odontoma was made. The differential diagnosis included calcifying odontogenic cyst, calcifying odontogenic tumor, and fibro-osseous lesion. Surgical removal of the odontoma using a Le Fort I osteotomy to approach the tumor was planned. The operation was performed with the patient under hypotensive general anesthesia with left-sided nasal endotracheal intubation. A full-thickness mucoperiosteal incision was made in the maxillary vestibule at the Le Fort I level.
2019
KORPI ET AL
FIGURE 1. A, Preoperative panoramic radiograph and B, posteroanterior cephalometric projection showing large radiopaque mass in right maxillary sinus. C, Axial computed tomography scan demonstrating radiopaque nature of mass and slight bony expansion in right maxillary sinus. Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
Before down-fracture of the Le Fort I segment, 4 1.5-mm titanium miniplates were adapted to the not yet osteotomized anterior and lateral walls of the maxilla (Fig 2A). The titanium miniplates were removed temporarily, and a Le Fort I level osteotomy was performed using a reciprocating saw. The maxilla was down-fractured, and the tumor was visualized in the right maxillary sinus (Fig 2B). Using a series of chisels and curettes, the lesion was completely removed from the maxilla and its sinus (Fig 2B). No perforations of any of the walls of the sinus were evident. The maxilla was repositioned using the preadapted titanium miniplates to re-establish the preoperative occlusion (Figs 2C,D). The patient’s postoperative course was uneventful, and he was discharged from the hospital on the second postoperative day (Fig 3). The histopathologic examination confirmed the diagnosis of a complex odontoma (Fig 4). Six months after the initial surgery, the patient returned to the operating room, because he had requested the removal of the miniplates. The maxillary bone was observed to have fully healed at its anterior and lateral walls. No clinical or radiographic evidence was found of recurrence of the mass or any other complications after 18 months of follow-up.
Discussion Odontomas are usually diagnosed in the second decade of age and are most typically classified as mixed radiolucent and radiopaque odontogenic tu-
mors.2 Odontomas are considered hamartomas,1 and more than one half of these tumors are situated in or near the maxillary sinus.7-10 The treatment of odontomas is either serial observation or surgical removal. Odontomas situated in close proximity to the maxillary sinus can grow to a large size, filling the antral cavity, yet remaining asymptomatic. Osseous defects in the maxillary sinus walls can occur after conventional removal of large maxillary tumors. These bony defects can result in functional or cosmetic problems. The Le Fort I down-fracture approach can avoid some of these problems. The Le Fort I down-fracture provides excellent exposure of the tumor and avoids sacrificing large amounts of bone. The postoperative healing is predictable, without oroantral fistula formation. A more traditional approach to tumor removal from the maxillary sinus is the Caldwell-Luc antrostomy approach,2 directly through the anterior and lateral walls of the maxillary sinus. The Le Fort I downfracture approach provides superior visualization of large maxillary tumors compared with the CaldwellLuc antrostomy approach, particularly for tumors in the posterior maxilla, which can be difficult to see. The Caldwell-Luc antrostomy approach also tends to
2020
REMOVAL OF LARGE ODONTOMA BY LE FORT I OSTEOTOMY
FIGURE 2. A, Titanium miniplates positioned and Le Fort I osteotomy level drawn on anterior and lateral surfaces of maxilla. B, Maxilla down fractured at Le Fort I level, and odontoma visualized in right posterior aspect of maxillary sinus. This approach allows the surgeon the opportunity to reach in to the maxillary sinus and more easily remove the mass. C, Preadapted titanium miniplates have re-established preoperative occlusion postoperatively. D, Enucleated complex odontoma. Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
leave bony defects in the anterior and lateral walls of the maxillary sinus when large tumors are removed. These osseous defects might not regenerate, leaving permanent voids in the bones of these areas. If these voids are large enough, they can allow collapse of the
overlying soft tissues in the space normally occupied by the walls of the maxillary sinus. Although the Caldwell-Luc antrostomy approach might seem to be more direct, the Le Fort I approach
FIGURE 3. Postoperative panoramic radiograph with miniplates securing maxilla to its original position.
FIGURE 4. Histologic slide of tumor confirming diagnosis of complex odontoma. (Hematoxylin and eosin stain, original magnification ⫻100.)
Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
Korpi et al. Removal of Large Odontoma by Le Fort I Osteotomy. J Oral Maxillofac Surg 2009.
2021
THEODOTOU AND CILLO
provides the superior access needed for removal of large lesions in the posterior maxilla. The Le Fort I down-fracture is a routine procedure in oral and maxillofacial surgery. Its postoperative morbidity is low, and the results are predictable, without changes to the occlusion after surgery. The Le Fort I down-fracture approach also gives an excellent view of the entire maxillary sinus, allowing well-visualized, safe, and thorough removal of the tumor.
References 1. Kramer IRH, Pindborg JJ, Shear M: WHO International Histological Classification of Tumors: Histological Typing of Odontogenic Tumors (ed 2). Berlin, Springer-Verlag, 1992, pp 21-22 2. Singer SR, Mupparapu M, Milles M, et al: Unusually large complex odontoma in maxillary sinus associated with unerupted tooth. N Y State Dent J 73:51, 2007
3. Worth HM: Principles and Practice of Oral Radiographic Interpretation. Chicago: Yearbook Medical, 1963, pp 420-424 4. Moloney F, Worthington P: The origin of the Le Fort I maxillary osteotomy: Cheever’s operation. J Oral Surg 39:731, 1981 5. Archer DJ, Young S, Uttley D: Basilar aneurysms: A new transclival approach via maxillotomy. J Neurosurg 67:54, 1987 6. Sándor GK, Charles DA, Lawson VG, et al: Oral approach to the nasopharynx and clivus using the Le Fort I osteotomy with midpalatal split (translation). Int J Oral Maxillofac Surg 19:352, 1990 7. Owens BM, Scuman NJ, Mincer HH, et al: Dental odontomas: A retrospective study of 104 cases. J Clin Pediatr Dent 21:261, 1997 8. Regezi JA, Kerr DA, Courtney R: Odontogenic tumors: Analysis of 706 cases. J Oral Surg 36:771, 1978 9. Toretti EF, Miller AS, Peezick B: Odontomas: An analysis of 167 cases. J Pedod 8:282, 1984 10. Kaugars GE, Miller ME, Abbey LM: Odontomas. Oral Surg Oral Med Oral Pathol 67:172, 1989 J Oral Maxillofac Surg 67:2021-2025, 2009
Brugada Syndrome (Sudden Unexpected Death Syndrome): Perioperative and Anesthetic Management in Oral and Maxillofacial Surgery Nicholas Theodotou, BDS, DDS,* and Joseph E. Cillo, Jr, DMD, MPH† Brugada syndrome (BrS), first described by Brugada and Buogada1 in 1992, is a rare genetic disease characterized by abnormal electrocardiogram (ECG) findings and an increased risk of sudden cardiac death (SCD) by ventricular fibrillation. It is also known as sudden unexpected death syndrome. We report on the case of a patient with this disease and provide an overview of the perioperative and anesthetic treatment of the oral and maxillofacial surgery patient.
Received from the Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh, PA. *Resident. †Associate Program Director and Director of Research. Address correspondence and reprint requests to Dr Cillo: Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, 320 East North Avenue, Suite 0107, Pittsburgh, PA 15212; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6709-0034$36.00/0 doi:10.1016/j.joms.2009.04.043
Report of a Case A 55-year-old man presented to the oral and maxillofacial surgery clinic at Allegheny General Hospital (Pittsburgh, PA) with a chief complaint of pain and intraoral swelling of the right side of his mouth. The clinical and radiographic examinations revealed an odontogenic infection from numerous grossly carious and nonrestorable teeth. His medical history was significant for myocardial infarction associated with occlusion of the right coronary artery 5 years before presentation, hypertension, stable angina, mitral valve prolapse without regurgitation, claudication pain, hypercholesteremia, hiatal hernia, and Brugada syndrome. His surgical history was significant for 2 stents placed in the right coronary artery 5 years previously and an internal cardioverter-defibrillator (ICD) placed 1 year before presentation. The oral medications routinely taken by the patient were metoprolol 12.5 mg twice daily, aspirin 81 mg daily, pantoprazole 75 mg daily, and atorvastatin 40 mg daily. His social history was positive for tobacco, alcohol, and marijuana abuse. His medical history included myocardial infarction in 2001 and numerous visits to the emergency department with complaints of chest pain and dyspnea dating back to 1999. In 2005, he presented to the emergency department complaining of mid-chest pain and pressure and associated dyspnea. He had experienced occasional palpitations and