CC
A 41-year-old male is referred to your office for extraction of a nonrestorable left maxillary first molar.
HPI
Four years earlier, the patient had undergone a root canal procedure because of extensive caries on the left maxillary first molar, without any complications. (Extractions of endodontically treated teeth have a greater probability of root fracture and displacement.) He did not pursue restoration of the tooth because of financial reasons and has now been referred for extraction of the failed root canal. He presented to his general dentist with a complaint of pain and mild gingival swelling adjacent to the left maxillary first molar.
PMHX/PDHX/medications/allergies/SH/FH
Noncontributory. The patient does not use tobacco.
Medical comorbidities that compromise wound healing (e.g., chronic steroid therapy, smoking cigarettes, diabetes, radiation therapy, and malnutrition) may increase the likelihood of persistent oral antral communications, requiring repeat surgical closure. However, the regional anatomy of the area, such as the length of the roots, extent of sinus pneumatization, and amount and quality of surrounding bone, is also important.
Examination
Intraoral. The patient has localized gingival edema and erythema of the left maxillary first molar, with no vestibular fluctuance. There is a 2-mm draining fistula on the buccal gingiva. A large carious lesion is present on the mesial–occlusal surface of the tooth. The left maxillary second and third molars (teeth #15 and #16) are missing, with significant resorption of the posterior maxillary ridge.
Imaging
The periapical or panoramic radiograph is the minimal imaging modality necessary before the extraction of a tooth. The panoramic radiograph allows better evaluation of the surrounding structures (e.g., the maxillary sinus). Evaluation of the size and shape of the tooth, degree of sinus pneumatization, and amount of bone is important for assessment of possible risks for oral antral exposure or root fracture.
For the current patient, the panoramic radiograph reveals a long palatal root of the left maxillary first molar that appears to partially project into the sinus. There is a loss of continuity of the maxillary sinus in the area of the palatal root (suggestive of a periapical scar secondary to the previous root canal or a pathologic process involving the maxillary sinus).
Labs
No laboratory testing is indicated before routine dentoalveolar surgery unless dictated by the medical history.
Assessment
Nonrestorable carious left maxillary first molar requiring extraction.
Preoperative assessment of this patient should alert the surgeon to the increased likelihood of root fracture or oral antral communication upon surgical removal of the left maxillary first molar. Well-informed patients are more accepting of necessary secondary procedures (e.g., oral antral closure, root retrieval from the sinus, or nerve repair).
Treatment
After injection of a local anesthetic with epinephrine, extraction of the left maxillary first molar was attempted using an elevator and forceps. Removal of the tooth revealed fracture of the palatal root with the root fragment retained within the palatal socket. A root tip pick was used to retrieve the fragment. During elevation, the root tip suddenly disappeared from the surgical field. Evaluation of the socket revealed a dark hole, suggesting that the fragment has dislodged into the maxillary sinus.
Upon diagnosis of a displaced root into the maxillary sinus, several maneuvers may be attempted to retrieve the fragment. It is possible for a fragment to be displaced below the Schneiderian membrane without actual dislodgment into the maxillary antrum. If the membrane appears intact, this diagnosis should be considered. In cases of dislodgment into the sinus, a perforation into the antrum may be visible. Asking the patient to exhale while pinching the nose may demonstrate air or bubbles exiting the socket, confirming the diagnosis of sinus perforation. Immediately on diagnosis, a small suction tip can be placed at the apex of the extraction socket in an attempt to remove the fragment. The procedure can be repeated with the patient placed in an upright position. If this maneuver fails, the maxillary sinus can be irrigated with normal saline followed by suctioning to allow root retrieval. If the root fragment cannot be visualized, the procedure should be aborted. The following two treatment approaches should be considered:
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Closure of the sinus communication, leaving the root fragment in place. The patient is subsequently monitored with panoramic radiographs to document the position of the root. In patients who are asymptomatic, with small fragments that are fixed in the antrum, it is possible to simply observe the root with serial radiographs.
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Closure of the sinus perforation followed by immediate or delayed removal of the root fragment via a Caldwell-Luc, transalveolar, or endoscopic sinus surgery. The root tip may change position secondary to the movement of ciliary cells of the epithelial cells of the maxillary mucosa, patient’s head position, and negative pressure caused by inhaling and the size of the ostium; therefore, updated imaging is imperative, preferable three-dimensional (computed tomography [CT] or cone-beam computed tomography [CBCT]).
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These treatment options are addressed in more detail in the Discussion section.
Complications
Displacement of a tooth or root fragment into the maxillary sinus in a known complication of maxillary dentoalveolar surgery. Although several preoperative findings (described earlier) can identify patients at risk, this complication can occur in any patient. Other possible complications of dentoalveolar surgery are listed in Box 31.1 .
Intraoperative complications
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Root fracture (increased incidence with age and root canal therapy)
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Injury to adjacent structures (lingual nerve, inferior alveolar nerve, mental nerve, greater palatine artery and vein, and adjacent teeth and restorations)
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Maxillary tuberosity fracture (seen with maxillary second and third molar extractions, with an increasing incidence with age)
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Oral antral communication
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Displacement of the tooth fragments (or entire tooth) outside of the tooth socket. Root fragments can be displaced into the maxillary sinus, inferior alveolar canal, infratemporal fossa (uncommon complication of maxillary third molar extractions), sublingual space (perforation of the lingual cortex above the mylohyoid attachment), or submandibular space (perforation below the mylohyoid attachment)
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Hemorrhage (bleeding in an otherwise noncoagulopathic patient is almost always easily controlled with local measures)
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Temporomandibular joint pain (secondary to acute temporomandibular joint muscle spasm, especially with preexisting internal derangement)
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Mandibular fracture (an uncommon but known complication of mandibular third molar extractions)
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Failure to achieve adequate local anesthesia
Postoperative complications
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Alveolar osteitis (dry socket)
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Wound infection
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Periodontal complications (loss of gingival attachment levels or development of periodontal pockets)
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Poor wound healing, causing delayed recovery
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Alveolar bone abnormalities or irregularities (may require repeat minor alveoplasty)
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Osteoradionecrosis
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Bisphosphonate-induced osteonecrosis of the jaws
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