Radiology Blog: Cervical Pneumatocysts

November 27th, 2017

Chance finding on a 65-year-old-male of well defined very radiolucent region 3 mm wide in C3 and a similar one in C4.

Although not completely understood, some authors believe it is an extension from the intradiscal gas (vacuum phenomenon) 1. On follow up, these lesions changed to fluid-filled cavities and became granulation tissue later on 2. Some of these lesions enlarged in size 1.

Management: Follow up to detect any increase in the size is advised but usually no specific treatment is needed.

1. Kitagawa T, Fujiwara A, Tamai K et-al. Enlarging vertebral body pneumatocysts in the cervical spine. AJNR Am J Neuroradiol. 2004;24 (8): 1707-10. Pubmed citation
2. Yamamoto T, Yoshiya S, Kurosaka M et-al. Natural course of an intraosseous pneumatocyst of the cervical spine. AJR Am J Roentgenol. 2002;179 (3): 667-9. doi:10.2214/ajr.179.3.1790667 – Pubmed citation

Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist

3610 Leavenworth Court
Omaha, NE 68105-1200 USA
Tel: (402)-953-6264
Fax: (866)-420-4903

Radiology Blog: Soft Tissue Swelling

November 13th, 2017

Incidental finding in a 70-year-old-lady. Well-defined midline soft tissue swelling in the floor of the mouth 18 x 11 mm.

At first look it appears that the swelling is arising from the dorsum of the tongue. However, on searching more carefully you will notice that the lower anterior tooth is a few mm superior to the floor of the mouth which is seen as an undulating boundary between air and soft tissue.

The most posterior extent of the floor ends at the anterior boundary of the vertical soft tissue swelling. The swelling is of course the anterior portion of the tongue which has been raised, perhaps in response to “Put your tongue to the roof of your mouth.”

The moral of the story is do not make an immediate diagnosis until you have identified the normal anatomy in the volume to ensure everything is where it should be!

Dr Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist
Tel: (402)-953-6264
Fax: (866)-420-4903

Featured Team Member: Dr. Lang

November 2nd, 2017

At Metro West we teach the importance of oral health to our patients. In addition, we also strive to build personal relationships with each of our patients.

Each week we will feature a team member from our office so you may know who we are as not only healthcare professionals, but also as: parents, friends, garden enthusiasts, adventure seekers, musicians, etc. Our patients give us the honor of caring for them. We know your story; let us give you ours.

Our featured team member this week is Dr. Melissa Lang!

Dr. Lang grew up with her parents and an older brother in Independence, Kansas, a town with a population of about 10,000 people in southeastern Kansas. Dr. Lang moved to Nebraska to attend dental school at the University Of Nebraska Medical Center College Of Dentistry.

Upon completion of her Periodontics Residency, she enjoyed the region so well that she decided to start her private practice here.

Dr. Lang and her husband, Joe, have one son, Gabriel (age 4), and twin girls, Olivia and Riley (age 2). They also have one Himalayan cat, Bailey, who has a haircut like a lion. Some of Dr. Lang’s favorite hobbies are: running, hiking, boating, camping, fishing, baking, reading, and snowboarding in the winter.

Dr. Lang states her favorite store is Scheel’s; her family loves to spend time outdoors and she is able to find all of her outdoor needs there. One thing Dr. Lang can never leave home without is her cell phone. She always wants to be available now that she has children! Dr. Lang states her role model is her husband because he has a naturally curious mind, reads for self-development, and seeks to enjoy life with new, creative adventures.

“Tell me and I forget. Teach me and I remember. Involve me and I learn.” This is Dr. Lang’s favorite quote. As an Associate Professor at Creighton University, she sees that involvement of the students in clinical experiences enhances their learning experiences immensely.

Dr. Lang’s passion for patient care has made us grow as a team and we are excited to have her on board!

Monthly Radiology Blog: Osteoma in Right Posterior Ethmoid Air Cell

October 3rd, 2017

Chance finding in female 26 years in the axial and coronal views of well defined uniformly dense opacity 11 x 10 x 7mm in a right posterior ethmoid air cell.

This is most likely a benign Osteoma.

Osteomas are frequently found in the Frontal sinuses and less often in the Ethmoid air cells and maxillary sinuses. In the Frontal sinuses they can cause erosion of the inner cortical bone of the Frontal bone with inflammation of the meninges.

Surgical removal is usually uneventful with complete recovery of the patient. When found in dental CBCT images referral to an ENT surgeon is recommended.

Dr Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist
Tel: (402)-953-6264
Fax: (866)-420-4903

Radiology Blog: Soft Tissue Mass In External Auditory Canal

September 12th, 2017

The search for bilateral asymmetry in CBCT images cannot be over stressed. In the three images below a 30 year old male has an incidental finding of a soft tissue opacity 11 x 8 mm in the right external auditory canal.

The adjacent bone does not appear to be eroded or expanded so it could be a benign mass and an ENT referral is needed.

– Dr Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist

3610 Leavenworth Court
Omaha, NE 68105-1200 USA
Tel: (402)-953-6264
Fax: (866)-420-4903

Radiology Blog: Base of Tongue Swellings

August 19th, 2017

Just anterior to the epiglottis at the base of the tongue are two bilateral spaces, the Valleculae. These should be symmetrical spaces which are clearly seen on axial sections. However, in the section below there is a soft tissue nodule 8 x 10 mm in the right space.

In the images below, there are two nodules on the left side of the base of the tongue.

The differential diagnosis includes lymphoid hyperplasia (the lingual tonsils are in this region), benign and occasionally malignant tumors. The patient should have an examination by an ENT specialist.

-Dr. Douglas K Benn DDS, PhD
Oral and Maxillofacial Radiologist


July 14th, 2017

Something that most patient remember about dental pain is referred to tooth pain and tissue swelling. Sometimes this problem refers to the loss of vitality of a tooth but it can also be referred to periodontal problems. We will analyze the second scenario and we will compare it with the classical tooth that needs a root canal therapy by the endodontist.

The periodontal abscess is a localized purulent inflammation of the periodontal tissues. It can be classified according to the structure that it affects in gingival, periodontal and pericoronal abscess. The gingival abscess affects the marginal gingival and interdental tissues. The periodontal abscess is an infection located in the periodontal pocket and may result in destruction of the periodontal ligament and bone. The pericoronal abscess refers to the area next to a tooth crown that is not fully erupted in the mouth.

Periodontal Abscess
The periodontal abscess is typically found in patients with active periodontitis and in association with moderate-to-deep periodontal pockets. Periodontal abscesses often arise as an acute episode of a preexisting periodontal disease. Among the difference causes, the most common is the incomplete calculus removal from a gingival pocket. Abscesses can occur after periodontal surgery, after preventive maintenance, after systemic antibiotic therapy and recurrence of periodontal disease. Other causes of periodontal abscesses can be tooth perforation or fracture and foreign body impaction. The importance of periodontal abscesses is high. Their presence is a leading cause of tooth loss. However, proper treatment and constant follow up can help to retain affected teeth for many years.

Acute versus Chronic Abscess
Abscesses are categorized as acute or chronic. The acute abscess is often a sudden episode of an existing periodontal lesion with no liquid drainage through the gums. The result is a painful, red, smooth swelling of the gingival tissues. The tooth may be percussion sensitive and feel elevated in the socket. The chronic abscess form after the infection spontaneously drains or it’s treated by the periodontist.

Periodontal versus Pulpal Abscess
The following table summarizes the main differences between Periodontal and pulpal abscesses. Sometimes symptoms are mixed and do not help with correct diagnosis and an interdisciplinary consultation with the endodontist may be necessary

Treatment of the periodontal abscess includes the resolution of the acute lesion, followed by the management of the resulting chronic condition. Treatment options include drainage through pocket retraction or incision, scaling and root planning, periodontal surgery, systemic antibiotics or tooth removal*. The treatment of pulpal abscess is usually the completion of a root canal therapy by the endodontist that in severe case may have to associate this pathology with systemic antibiotics and drainage of the swelling for acute abscesses.

Acute abscesses can be a very bad experience for the patient. Due to complexity of appearance, it may be difficult to differentiate between endodontic and periodontal abscesses, It is important to urgently contact the periodontist that is trained to tackle and treat this pathology and improve the fate of the affected tooth.


*(Modified from Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Lindhe, J: Clinical periodontology, Copenhagen, 2000, Munksgaard).

The body of this article is referred to Carranza’s Clinical Periodontology, 12th Edition By Michael G. Newman, DDS, Henry Takei, DDS, MS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. ODONT.

– Lorenzo Mordini DDS, MS

Dental Implant Malposition

June 19th, 2017

Dental implants are a successful and predictable tools to replace missing teeth. If planned and executed with precision the risk of failure can be reduced to a minimum.

Among risk factors for implant placement one could list patient related risks and technique related risks. Among patient related, uncontrolled systemic diseases (diabetes), smoking and poor oral hygiene are the mayor risk factors.

As far as technical, malposition and mechanical parts breaking may lead to implant failure or disease.

We report a case where the implant on the central area of the upper jaw of the patient was placed partially outside the bone volume available.

Since the patient was already missing a tooth, a new plan was offered to replace it along with extraction of the failing implant and simultaneous replacement with a correct-positioned one.

Due to lack of bone, an augmentation was performed simultaneously in order to prevent future resorption of existing bone.

It has to be noted that the use of modern tools to explant existing implant and the use of digital implant planning with surgical computer guide, helped the surgeon to provide a correct and precise placement with a decrease of technical risks of failure.

– By Dr. Lorenzo Mordini

Fig 1 a, b. (below). Frontal and lateral view of the implant (crown right to the space) and missing tooth.

Fig 2.(below). Implant guided placement after malpositioned implant extraction with dedicated tools.

Fig 3 a, b.(below). Healing after implant placement and bone grafting.

Fig. 4 a, b (below). Radiographic image of implant (white image) that is outside the bone volume. In green, the digital plan of the new implants.

Fig 5 a, b (below). Software combining 3D radiograph with digital implants in order to create surgical guide.

Fig 6. (below). Radiographic image after placement of two new implants​