/home/opencode/cpanel/stomaeduj_hacked/uploads/2019/09/Article-5-2-Miclotte.pdf ORAL SURGERY ROOT TIP MIGRATION INTO THE INFUNDIBULUM OF THE MAXILLARY SINUS AFTER Case Rreports COMPLICATED FIRST MOLAR EXTRACTION Isabel Miclotte1,2a , Laurence Verstraete1,2a , Constantinus Politis1,2b 1 OMFS-IMPATH Research Group, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium 2 Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium MD, DDS a MD, DDS, MHA, MM, PhD, Professor, Head b ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(2).art.5 Aim: To show how an unsuccessful retrieval attempt of a broken root tip of an upper OPEN ACCESS This is an molar could lead to dislocation into the maxillary sinus and and end up at the ostium Open Access article under the CC BY-NC 4.0 license. of the maxillary sinus, necessitating a FESS procedure for retrieval. Summary: An upper right first molar was removed with forcesp extraction. The Peer-Reviewed Article extraction was complicated with a root fracture. Manipulating the residual root tip Citation: Miclotte I, Verstraete L, Politis C. Root tip migration into the resulted in root tip dislocation into the maxillary sinus. It was decided to leave the root infundibulum of the maxillary sinus after tip at the bottom of the sinus, but in the following months the root tip migrated and complicated first molar extraction Stoma Edu J. 2019;6(2):125-128 got stuck into the ostium of the maxillary sinus. There, it was retrieved using functional Received: May 06, 2019 endoscopic sinus surgery (FESS). Revised: May 22, 2019 Key Learning Points: 1. Manipulating a residual root tip after forceps extraction of an Accepted: June 14, 2019 Published: June 18, 2019 upper molar significantly increases the risk of root tip dislocation into the maxillary *Corresponding author: sinus. 2. Broken root tips of upper molar roots protruding into the maxillary sinus need Prof. Dr. Constantinus Politis not to be removed when it concerns healthy vital pulps. 3. Retrieval attempts of broken Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, root tips can lead to dislocation of the root tip into the maxillary sinus if the roots Leuven, Belgium Kapucijnenvoer 33, 3000 Leuven, were protruding into the maxillary sinus or if an insufficient bony barrier separates the Belgium maxillary sinus from the alveolar socket. 4. Cone beam ct is the radiological exam of Tel: / Fax: 0032 (0)16332462, e-mail: constantinus.politis@uzleuven.be preference to locate a dislocated root tip in the upper jaw. 5. A root tip stuck at the Copyright: © 2019 ostium of the maxillary sinus is best removed with a FESS-procedure. the Editorial Council for the Keywords: Tooth extraction; Root tip fracture; Functional endoscopic sinus sugery. Stomatology Edu Journal. 1. Introduction Extraction of maxillary molars with multiple and 2. Case history separated roots carries a risk of root fracture. A 14-year-old female was referred by the orthodontic Moreover, fractured roots can be displaced into department for extraction of the four first molars (16, the maxillary sinus, potentially causing oroantral 26, 36, and 46) for orthodontic reasons (Fig. 1). Due fistula, sinusitis, cellulitis, and subdural empyema to the presence of deep restorations, it was decided [1]. Root displacement into the maxillary sinus to remove the first molars rather than remove four can be detected by imaging, which also provides premolars. The deep restorations on teeth 46 and 36 information regarding the root size and location were visible on a panoramic radiograph (Fig. 2). CBCT within the sinus. Some studies suggest that displaced root fragments should be left in the sinus. However, due to the potential development of complications, surgical removal of displaced root tips should always be considered. There are three major methods of removing root tips displaced into the maxillary sinus: a crestal approach, a bone window approach, and a more recently described endoscopic approach [2]. Here we report the case of a displaced root fragment from a first upper molar on the right side, which was located using cone-beam CT imaging (CBCT). Applying an endoscopic approach, the fragment was removed six months after the extraction, after Figure 1. Intra-oral picture of the upper teeth, showing a restored first mucosal healing, and in the absence of sinusitis. upper right molar. Stomatology Edu Journal 125 ROOT TIP MIGRATION INTO THE INFUNDIBULUM OF THE MAXILLARY SINUS AFTER COMPLICATED FIRST MOLAR EXTRACTION Case Rreports Figure 2. Panoramic radiograph showing close relation between the upper molars and the maxillary sinus. was not performed prior to extraction. The molars were removed using forceps extraction under local anesthesia, one at a time, in four sessions. The local Figure 3. Intra-oral picture of the upper teeth, showing a restored first anesthetic used was articaine 4% with 1:200,000 upper right molar. epinephrine (Septodont, France). The extractions of elements 26, 46, and 36 were uneventful. However, upon forceps extraction of element 16, the distovestibular root tip was fractured. Efforts were made to remove the displaced root tip using an apical pick instrument, and then with root tip removal forceps. However, the root tip disappeared cranially and could not be retrieved. The root tip was not detected by transalveolar endoscopy or apical X-ray (Fig. 3). CBCT was immediately performed, which revealed the root tip at the base of the maxillary sinus (Fig. 4). This position suggested perforation of the sinus membrane; therefore, the alveolus was filled with four leukocyte-rich and platelet-rich fibrin (L-PRF) membranes. It was decided not to make another immediate attempt to remove the lost root tip, but rather to observe the situation and to re- evaluate after four months. Healing was uneventful. Four months later, a new CBCT revealed that the displaced root tip had migrated towards the ostium of the right maxillary sinus (Fig. 5). Despite this position, the maxillary sinus showed no opacification, no mucosal thickening was visualized on CBCT, Figure 4. Panoramic radiograph showing close relation between the and the patients were asymptomatic. Two months upper molars and the maxillary sinus. later, a new CBCT was performed, showing the root tip at the same position. It was then decided to remove the root tip to prevent future complications. Believing that a Caldwell-Luc approach would be too traumatic, a functional endoscopic sinus surgery (FESS) procedure was proposed. The FESS procedure was performed under general anesthesia at the ear, nose, and throat (ENT) department. The root tip was retrieved. Further healing was uneventful. After healing of the four extraction wounds with Figure 5. Intra-oral picture of the upper teeth, showing a restored first an uneventful course, orthodontic therapy was upper right molar. immediately restarted. extractions and 0.94% after non-M3 extractions [3]. 3. Discussion Rarely, a fractured root migrates into the maxillary Dental extractions are a common oral procedure sinus. Such displacement depends on several factors, performed in dental and maxillofacial departments. including the surgical technique (elevating roots with The upper molar removal is sometimes accompanied excessive force) and the bony interface between the by root fracture or oro-antral communication. In alveolar socket and the sinus membrane. In a series a series of 2355 dental extractions, the incidence of 1596 maxillary third molar extractions, only one of oro-antral communication was 0.56% after M3 case of tooth or root fragment displacement into 126 Stoma Edu J. 2019;6(2): 125-128 http://www.stomaeduj.com ROOT TIP MIGRATION INTO THE INFUNDIBULUM OF THE MAXILLARY SINUS AFTER COMPLICATED FIRST MOLAR EXTRACTION the maxillary sinus was reported [4]. In another large and nerve injury. However, endoscopic procedures Case Rreports series, no root tip migration was reported [3]. require general anesthesia and their success When a displaced root fragment is detected before depends on the operator experience. alveolar socket healing, a crestal approach can be In the presently reported case, immediate retrieval attempted to remove the fragment. This method of the root tip displaced in the maxillary sinus involves enlargement of the socket to visualize the was attempted, but without success. Although fragment or to rinse the maxillary sinus with saline. the fragment was large, immediate performance The disadvantages of this technique include damage of a Caldwell-Luc procedure was considered too to the alveolar bone, which may negatively influence invasive in this young patient. After six months the healing procedure and the residual bone height of follow-up with repeated CBCT imaging, it was [2]. Some studies suggest leaving the root fragment deemed necessary to remove the fragment to avoid in the sinus if it is below 3 mm in size, and if there is future complications. Instead of the Caldwell-Luc no evidence of sinusitis or other local disease [1]. procedure, the less invasive FESS approach was When a displaced root fragment is diagnosed performed, with a successful outcome. after mucosal healing, fragment retrieval can be performed using a bone window approach or an 4. Conclusions endoscopic approach. The traditional method is Manipulating a residual root tip after forceps a Caldwell-Luc (bone window) approach in which extraction of an upper molar—when little bony fenestration of the anterior wall of the maxillary interface exists between the alveolar socket and sinus provides a clear vision and improves the the sinus membrane—significantly increases the surgical range. However, this procedure is associated risk of root tip dislocation into the maxillary sinus. with complications, such as severe reactive swelling Migration towards the ostium of the maxillary sinus and nerve damage [2]. is rare but possible. A FESS procedure is an efficient Alternatively, endoscopically-assisted procedures approach to retrieving the root tip from the maxillary are reliable and minimally invasive methods sinus ostium, while keeping sinus function intact. for removing root fragments displaced into the maxillary sinus. Access for an endoscopic procedure Author contributions can be obtained through the anterior maxillary sinus All authors contributed to reporting the case, wall, or through the middle or inferior nasal meatus performing the literature review, and drafting the (FESS) [2]. This technique provides direct visibility manuscript. of the surgical area and minimal risks of bleeding References 1. Huang IY, Chen CM, Chuang FH. Caldwell-Luc procedure for 4. Rothamel D, Wahl G, d’Hoedt B, et al. Incidence and predictive retrieval of displaced root in the maxillary sinus. Oral Surg Oral factors for perforation of the maxillary antrum in operations to Med Oral Pathol Oral Radiol Endod. 2011;112(6):e59-e63. remove upper wisdom teeth: prospective multicentre study. Br [Full text links] [CrossRef ] [PubMed] Google Scholar Scopus J Oral Maxillofac Surg. 2007;45(5):387-391. 2. Wang X, Li S. Removal of the residual roots displaced into the [Full text links] [CrossRef ] [PubMed] Google Scholar Scopus maxillary sinus via endoscopy. J Craniofac Surg. 2018;29(4):1034- 1036. [Full text links] [CrossRef ] [PubMed] Google Scholar Scopus 3. Miclotte I, Agbaje JO, Spaey Y, et al. Incidence and treatment of complications in patients who had third molars or other teeth extracted. Br J Oral Maxillofac Surg. 2018;56(5):388-393. [Full text links] [CrossRef ] [PubMed] Google Scholar Scopus Isabel MICLOTTE MD, DDS OMFS-IMPATH Research Group Department of Imaging and Pathology, KU Leuven Leuven, Belgium CV Dr. Isabel Miclotte was born in 1986 and was recognised as an OMFS surgeon in 2019. She will become senior resident of the department of Oral and Maxillo Facial Surgery at Leuven University Hospitals as of November 2019. Dr. Miclotte has published on complications of extractions and has elaborated guidelines for dento-alveolar surgery in patients under anticoagulant therapy. Her clinical focus is in orthodontic and orthognathic surgery. Stomatology Edu Journal 127 ROOT TIP MIGRATION INTO THE INFUNDIBULUM OF THE MAXILLARY SINUS AFTER COMPLICATED FIRST MOLAR EXTRACTION Questions Case Rreports 1. Which is the best radiographic exam to find a dislocated roottip of an upper molar tooth? qa. Apical radiograph; qb. Panoramic radiograph; qc. MRI; qd. Cone-beam CT scan. 2. Which root is most often involved in an oro-antral communication? qa. Third molar; qb. Second molar; qc. First molar; qd. First premolar. 3. Which is the best technique to retrieve a dislocated root tip of an upper molar tooth at the ostium of the maxillary sinus? qa. Denker technique; qb. Caldwell Luc technique; qc. FESS technique; qd. Rehrmann flap. 4. Which precaution could be taken to avoid dislocation of a root tip into the maxillary sinus? qa. Leaving a broken roottip undistrubed; qb. Frequent peroperative repeats of the Valsalva manoeuver; qc. Performing the extraction in a supine position; qd. Performing the extraction under general anaesthesia. 128 Stoma Edu J. 2019;6(2): 125-128 http://www.stomaeduj.com