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 ā€œVā€ 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.