By: Victor M. Sternberg, D.M.D. 

July 1, 2026 

Many years ago a television show about sports, particularly the Olympics, featured Bill McKay who  began the Olympics with the words the thrill of victory and the agony of defeat. 

We in our profession, on a daily basis, experience hopefully more the thrill of victory and less the  agony of defeat, but they are both possible on a playing field of health care. 

I want to present two patients who represent opposite ends of this spectrum. 

First, the thrill of victory. 

The first patient came to our practice at age 15 years old with congenitally missing lateral incisors. 

She did not want to wear a flipper. The ridge was too narrow for implants. We took an alternative  road, since she didn’t want to wear a removable prothesis, by placing mini-implants where the two  laterals were, 

doing a bone graft at that time, 

and making her temps on the mini-implants.  

Several years later the ridge was wider and implants were placed. There was fortunately enough  bone on both laterals to comfortably place 2mm implants buccally lingually on either side of the  implants to ensure long term stability. 

Now, fifteen years later, she returns to our practice a grown woman. The radiographs taken demonstrate the long-term stability of the tissue and the implants and the restoration.  

The restorations currently are extremely aesthetic and the patient is more than happy with the outcome. One could quibble about the grayness of the laterals but that is dentists being more critical than patients are. We should always remember that beauty is in the eye of the beholder. 

Here is a case where the facial bone was very thin and over time the gingival receded and we had a  very challenging aesthetic issue since the metal exposure will not lend easily to covering up and  neither the threads of the implant. This is ultimately the result of inadequate facial bone at the time of implant placement. It’s one of the reasons we see dieback of bone in implants that are placed in thin  buccal bone, whether it be the mandible or the maxilla.

One of the issues of peri-implantitis is not just bacteria. If there is not enough bone between the  cortical plate and the implant, as the bone turns over there are no cells coming from the site of the  implant so we get dieback which will continue until we reach a level where the bone is thicker. This is not as big an issue except in the anterior region. 

Unfortunately, when the alveolar crest is too thin and even though the implants are encased in bone,  as the tissue turns over, a lack of cortical bone on the surface and the metal of the titanium do not  have enough cells to replace the bone, albeit bone loss horizontally and often tissue exposure. 

Now the agony of defeat from the standpoint of the patient’s current situation. 

In 2013 up until 2023, I presented a case of repeated biopsies of the lower right mandible in a 60- year-old woman. Each biopsy came back either mild to moderate dysplasia. Some of the lesions  grew back in weeks or less than three months. Over the course of the years, at least a dozen excisional biopsies were done, both by myself and an oral pathologist. In one case we not only  removed the dysplastic tissue but we removed all the tissue down to bone, assuming the epithelium  was the source of the repeated dysplasia. After these biopsies tooth #30 became mobile and was eventually removed. Shortly thereafter, dysplasia. 

Finally in 2023, for the first time, there was no dysplasia for a period of almost a year following the last excisional biopsy. 

Unfortunately, she came back and had severe bone loss on tooth #31, the one remaining molar. The bone loss was very rapid and the decision was made to remove the tooth and biopsy the tissue on the facial. Interesting enough it came back with no evidence of dysplasia.  

Approximately two months later she returned with a fistula tract distal to the tooth that was removed.  An x-ray was taken. The decision was made to open up the area with the fistula and a large amount  of granulomas-like tissue was removed from a bony crypt. At the same visit a 3D scan was taken.

At this point the lesion was no longer dysplastic it was a moderately differentiated carcinoma.

The patient is soon to undergo excisional surgery. Hopefully it is confined to the bony crypt and the  soft tissue around it. She will be seeing a well-known oncological surgeon who treated another  patient that I referred sixteen years ago who was turned away by two major hospitals indicating his carcinoma of the maxilla was not treatable and yet he is alive and well fifteen years later. Hopefully she will have the same outcome. 

The takeaway is that for some individuals, and this is one, there is a proclivity to develop changes in epithelium to morph into dysplastic lesions. These individuals, like this woman exhibited, have to be carefully followed. It turns out that this type of repeated dysplasia, as I discussed with the oral pathologist, seems to occur only in the posterior mandible in middle-aged individuals. 

As always, your comments are appreciated. 

Yours truly, 

Dr. Victor M. Sternberg 

By Westchester Center for Periodontal & Implant Excellence

December 31, 2023