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View from the Chairside: Post-op solution for a maxillary sinus exposure after an extraction

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By Dr. Elliott Gnidec

Dr. Elliott Gnidec is a practicing dentist in Woodstock (ON). He graduated in 1986 from the University of Western Ontario (UWO) and holds a Master’s degree in Biochemistry also from the University of Western Ontario. Currently, Dr. Gnidec is Adjunct Clinical Professor in Restorative Dentistry at the Schulich School of Medicine and Dentistry at UWO, is the Treasurer for the Oxford County Dental Society, Member of Continuing Education Committee for the Oxford County Dental Society, and the Liason between Schulich School of Medicine and Dentistry and JCDA/Oasis.

Here is a case that I recently encountered. A pulpotomy was performed on tooth #16 in September 2012. I discussed the options with the patient and awaited their decision.

In June 2013, the patient came back with a fractured filling on #16 and I once again discussed the treatment options with the patient. This time around, the patient decided to have the tooth extracted. Informed consent was given.

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Pre-extraction Radiographic Image 

XRay after extraction

Post-extraction Radiographic Image

The extraction of the tooth required sectioning after the coronal portion of the tooth fractured. The mesial and distal roots were removed without complication, but the palatal root fractured. The remaining palatal root was difficult to remove because it seemed as if it was in the sinus space or at least secured to the sinus floor.

I called my colleague to see if he could dislodge the root tip. With light illumination and some convection, the root tip was removed with an abscess attached to the tip. Looking at the extraction site, the palatal root site showed that the sinus floor had been destroyed revealing an opening of about 3 mm in diameter. The extraction site was packed with gelfoam and silk sutures.

I saw the patient the next day and he was fine. I followed up with him again 5 days after the extraction and the palatal site was now open to the sinus. Upon calling the oral surgeon’s office to see if they would see the patient to perform closure, I was informed that primary closure is not considered for the first 4 weeks and that the site should be packed tightly with gelfoam and followed for the next 4 weeks packing as required.

The patient was seen again 9 days after the last visit and the extraction site was starting to heal, but the palatal site still had a slight opening to the sinus. The area was packed again with gelfoam and I asked the patient to return in 2 weeks. Patient returned in 2 weeks and the extraction site was healing nicely with the palatal site closed. Will follow up as needed.

What would you have done, if you had encountered the same case? 

Share your experience with us. Email us at oasisdiscussions@cda-adc.ca

Do you have any particular question on this topic? Do you have any comments or suggestions? Email us at oasisdiscussions@cda-adc.ca

You are invited to comment on this post and provide further insights by posting in the comment box which you will find by clicking on “Post a reply“ below. You are welcome to remain anonymous and your email address will not be posted. 

 

10 Comments

  1. JCDA Oasis October 2, 2013

    On behalf of Dr. Gary Ford,

    An interesting case and hopefully a good resolution. When I have a sinus exposure, other than packing with gelfoam and closing with silk, not gut, sutures I also put the patient on sinus precautions, which are as follows:
    1) Rx Amox 250 mg 40 – 2 qid for 2 days, 1 qid till finished (if not allergic to Amox);
    2) Tylenol or Advil Cold and Sinus PRN for pain but recommended they take it at least for 48-72 hrs;
    3) no swimming x 3 weeks;
    4) no pinching of the nose while sneezing (good for the “chipmunk” effect which a patient did after a Leforte I);
    5) no vigorous nose blowing – but warning a patient that blood might seen as a result of it;
    6) saline rinses (Nettie pots); and
    7) warn the patient that a further surgical procedure might be required to get closure (usually referred to OFMS).
    As a side note, when ever I am extracting 6s or 7s I will warn patients exactly of this happening so it is not an oops. during the procedure.
    Best of luck.
    Dr Gary S.Ford, DDS, AEGD-2 yr residency, MAGD

    Reply
    1. Elliott Gnidec October 3, 2013

      Hi Gary,
      Thanks for your comment. I did not mention that the usual precautions were given to the patient as you stated, as I thought that would be standard procedure, but I did not give antibiotics and that is something I will certainly do in the future. Thanks again.

  2. Waji Khan October 7, 2013

    Hi Elliott,

    From the literature, uninfected sinus perforations less than 2mm heal spontaneously the majority of the time. If larger than this, then procedures like a buccal sliding flap or others like you did to provide a scaffolding for the sinus to heal work fairly well. The key points are to make sure that there is no infection so as Major Ford cited, antibiotics are required, sinus pathology is ruled out and that you have some form of direct or indirect primary closure. I like using Surgicel directly on the sinus membrane, it is robust, biocompatible and fairly inexpensive. I also like using silk suture as well, it forces the patient to come back!

    Reply
    1. Elliott Gnidec October 7, 2013

      Hi Waji,

      Thanks for the info. on the surgicel, will use in the future.

      Elliott Gnidec

  3. JLM October 7, 2013

    In the couple of times where I’ve had either a small oral-antral communication (less than 2mm) or if I was unsure (I don’t like getting pts to test by plugging their nose and blowing because that could cause one if I don’t have one yet), I have chosen to put something more sturdy like colla-plug because I found gel-foam to get too mushy and was worried that it wouldn’t stay in place/get dislodged easily or go into my perforation even though it was very small. (It is implied that I am using sinus precautions). Thoughts?

    Reply
    1. Waji Khan October 7, 2013

      Hi, anything to get direct or indirect sinus closure works well. As long as the sinus is not infected and there is no sinus pathology. I like surgicel or collaplug, both are fairly inexpensive and work well as a scaffolding. Buccal sliding flaps or the buccal fat pad necrosis techinique work really well too.

  4. mohammad taqi October 27, 2014

    It was a nice case , honestly I had a patient like this (palatal canal is exposed to sinus) I really don’t know what to do , I wouldn’t mind if you send me an email.

    Reply
  5. Aaliyah December 2, 2014

    Good article and helpful information. Thank you for sharing this to us. Thank you so much.

    Reply
  6. Anonymous March 18, 2015

    It’s a very nice article and it helpd me.

    Reply
  7. merlin May 25, 2015

    What if the sinus is infected by the palatal root tip pushed inside while trying to extract?

    Reply

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