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Oral Surgery/Right Central Incisor Mishap


Dear Dr Ryan,

I am a 25 year old female medical graduate who has underwent several procedures to her right central incisor over the past 9 years;

At age 16 I got an abscess over this tooth and had a root canal done. All was well until 5 years later at age 21 when pain returned over that tooth and another root canal had been attempted. This was unsuccessful. The dentist attempted to clean it out properly over the course of a year to no avail as the pain persisted culminating in another tiny abscess. I was then referred to an oral surgeon who performed an Apicoectomy.

I was pain free for 6 months and then a dull discomfort returned. The dental surgeon took a ct scan and examined it properly, noting no pathology in the Ct scan except for a small lesion palatal to the apex. The flap of gum over the apex was re-opened. There were no signs of infection but the lesion was a hole in the palate. The dull discomfort persisted until I went to see another surgeon a year later who noted inglammation over the surface of that root and said that the best option would be to have it extracted.

I had it extracted July 2013. There was still minimal discomfort present up until Fenruary 2014 when the titanium implant and a Bone graft + PRP was done. The hole in the bone was noted and bone graft placed over it. I was symptom free throughout the rest of my journey.

However 6 months later when the crown was placed over the abutment the symptoms returned. I was fine for the first 10 days but a dull discomfort resurfaced. Another CT was done. It showed bone loss around the apex of the root of the titanium screw. The flap of gum over the screw was reopened and the surgeon noted that the titanium top was showing through the bone graft and hitting against the gum.There were no signs of infection. He did another bone graft.

Its been 3 months now. Healing seems to be going well but I am still symptomatic. I.e. I still feel discomfort (not pain) over the area f the bone graft. There are currently no signs of dental implant failure. He told me that it takes an average of four months to heal and hoepfully become asymptomatic again but I am worried that this will never happen. Is it possible that the Bone graft hasn't fully healed yet and until then I will remain with this slight discomfort ?

Thank you for your time !

Thank you for your question. When the apex of the implant is hitting the gum tissue, the discomfort may be coming from that area. Place you finger at the location of the apex of the implant and see if there is any discomfort. If there is, you may need additional procedures if the pain/discomfort does not subside. The ideal placement of the implant should be entirely in bone. I hope that helps.  

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James M. Ryan. DDS, MS; Board Certified Oral and Maxillofacial Surgeon


Dr. Ryan's expertise is in the field of Oral and Maxillofacial Surgery. Specifically, Dr. Ryan is an expert in Orthognathic Surgery. He holds uniques experience as the former Assistant Program Director of the Oral and Maxillofacial Surgery Residency Training Program at Washington Hospital Center where he trained residents to perform these complicated surgical procedures. Additionally, Dr. Ryan also has a tremendous amount of experience in reconstruction of the maxillofacial skeleton related to trauma and tooth loss. Dr. Ryan is an expert in 3 dimensional treatment planning for Orthognathic Surgery, Dental Implant Surgery and Wisdom Teeth removal. To learn more about Dr. Ryan, his full profile can be seen at


Diplomate of the American Board of Oral and Maxillofacial Surgery with current hospital affiliations at: Washington Hospital Center Holy Cross Germantown Hospital National Institute of Health/NIDCR

American Dental Association. American Association of Oral and Maxillofacial Surgeons. District of Columbia Society of Oral and Maxillofacial Surgeons. District of Columbia Dental Society. American Board of Oral and Maxillofacial Surgeons. Health Volunteers Overseas.

Journal of Oral and Maxillofacial Surgery Journal of The American Dental Association

S.U.N.Y @ Stony Brook- B.S. in Biochemistry, Stony Brook, NY. Northeastern University- M.S. in Perfusion Technology, Boston, MA. D.D.S.- New York University College of Dentistry, New York, NY. Certificate and Chief Resident- Washington Hospital Center, Washington, DC. Clinical Fellow- The Johns Hopkins Hospital, Baltimore, MD.

Awards and Honors
Dr. Ryan has received numerous awards including: 2006 American Association of Oral and Maxillofacial Surgeons Dental Student Award, Washington Hospital Center 2008 Nurses' Choice Physician Collaboration Award, 2009 Resident Research Summit Scholarship Award, and the 2011 Outstanding Surgical Attending in the Department of Oral & Maxillofacial Surgery at Washington Hospital Center. He has also authored/coauthored and published several journal articles and held several teaching positions,including assistant professor, while at NYUCD.

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