Surgical technique
The patient was requested to rinse his mouth with 2% chlorhexidine
mouthwash (Iran-Najo, Tehran, Iran) for 20 seconds, and then standard
surgical prepping and draping for oral surgery under local anesthesia
were performed. After topical application of 20% benzocaine gel
(Master-Dent, Dentonics, North Carolina, USA) for topical anesthesia of
the injection sites, local anesthesia was administered using lidocaine
plus 1:80000 epinephrine (Persocaine-E, DarouPakhsh, Tehran, Iran). The
incisive and bilateral greater palatine nerve blocks were administered
for total nasal floor anesthesia. The buccal vestibular infiltration
anesthesia was also administered to ensure a painless procedure. Next, a
full mucoperiosteal vestibular scalloped incision was made right above
the mucogingival junction (1-2 millimeters superior) from the lateral
incisor of the right side to the lateral incisor of the left side. Two
small releasing incisions were made at both horizontal ends of the first
incision posterosuperiorly for easier dissection and exposure,
considering a āVā shaped morphology around the upper lip frenulum. A
mucoperiosteal flap was elevated, and the caudal margins of the piriform
aperture and ANS were exposed with a periosteal elevator. Next,
subperiosteal dissection of the nasal mucosa was performed to expose the
impacted supernumerary teeth. The small amount of nasal floor bone above
the mesiodens was removed by a rotary bur under saline irrigation, and
the crowns of the two mesiodens were exposed (Figure 3). The
piezosurgery device was also used for safer bone removal to avoid damage
to the nasal mucosa and the adjacent structures i.e. the roots of the
adjacent permanent teeth and the nasopalatine nerve. Use of piezosurgery
to remove the small caudal bony part of the piriformis for better
exposure is beneficial when the crown extends more posteriorly to the
base of the nasal cavity. After elevating and extracting the mesiodens,
the sockets and the wound area were rinsed with saline to eliminate
debris. The wound was then closed with absorbable 4-0 vicryl suture
(polyglactin 910, Ehticon, New Jersey, USA) in one layer. The patient
experienced no pain or discomfort during the surgery, and there were no
postoperative complications such as nose bleeding or damage to the
adjacent teeth.