Retained Root Tip in the Sinus: How To Proceed with Dental Implant Placement?

That is a preaty well unilateral inflamed sinus. I would prescribe Ciprofloxacin 500mg DID and some Fluticasone nasal spray DID for 15 days (OD for the following +/- 15days). Remove the root tip crestally during the antibiotic therapy, do a very good wound closure and stick a couple of Gelatamp with povidone-iodine. Wait 3 months +/- and rescan. If everything's OK sinus lift, wait 6 months and place implants. Let's hear some of the experts' opinions.

If you are not comfortable treating then ent/omfs should be consulted.

I would suggest that you attempt the removal of the root tip, closure of the oral antral fistula and sinus augmentation at the same surgery so that the next surgery the patient receives would be the placement of the implant. I suggest opening with a flap and removing all of the tissue from the socket and attempting to remove the tip through the hole into the sinus if it can be done without displacing the root tip further. If you are successful in retrieving the root tip then I would proceed with sinus augmentation and oral antral fistula repair as outlined on our web page. The only difference in your case I would use a flat cortical plate placed over the alveolar extraction socket as a cap. If you cannot easily retrieve the root tip through the extraction socket you need to be prepared to use a lateral wall approach but then proceed with the sinus augmentation and oral antral fistula repair. Then wait three months and place your implant. Make sure the patient is not using a cpap machine as this can make closing the fistula very difficult. Greg Steiner Steiner Laboratories

Appears to be a large mucocyst in the sinus and with the oral antral communication and the root tip would suggest a lateral approach lift the sinus membrane remove the cyst and root tip place a mrmbrane over the floor where the communication is and graft the sinus, fill the socket then place another membrane under the periosteum so that the socket is sandwiched between membrane with graft between them. wait 4 months then place implant and then allow 5-6 months before loading

It is not a mucous retention cyst(mucocele) but an inflammed sinus membrane. The suggested treatment is very risky. It would be appropriate to refer to an Oral Surgeon who will probably work with an ENT to use an intranasal approach and spare the maxillary lateral wall. Once the inflammation and infection is under control then the grafting/implant can be performed. Or the ENT may use a course of meds instead. How many infected sinuses have you managed? This is a lawsuit waiting to happen, it is appropriate to refer.

How interesting that two very competent surgeons prescribe a performance procedure which tick the boxes and others say hold on hold on a referral is what you should do. With some confident positive advice it's up to you Mr Opinion seeker where your confidence lies?

I read some articles of the access to the maxillary sinus, for consideration, and graft with endoscope technique using a minimally invasive flapless surgery. what could be removed the tip, and leave,intra sinus, antibiotic treatment, and later for the same via grafting.

This is too funny. I had the same situation happen to me also. Well, guess what I did? I treated the patient as if I were doing a lateral window and took out the root tip. It was not easy to do, but got it out. Generally speaking, if the patient is not allergic to penicillin, what has worked best for me is to have the patient on augmentin to lower the amount of membrane inflammation in the area. and if you are not comfortable with removing such a root tip, refer it out.

The CT clearly shows a very inflamed and (possibly) infected right sinus membrane, secondary to a retained root tip and oro-antral fistula. This is definitely not a mucus retention cyst. The thickened lining can be a blessing in disguise when you do a lateral approach, as it is thick enough to not tear easily during lifting with a blunt instrument. Having said that the palatal root tip is usually close to the median wall of the sinus, so be prepared to lift a good amount of the tissue before you can visualise it. After the root is removed, irrigate well with saline and then a slow-resorbing membrane can be used to separate the lining from the punctured floor, then graft the socket and layer with membrane again on top. Wait a solid 4 months before placing an implant at this spot, and then too preferably use a bone compression kit for your osteotomy. I'm not a specialist, so consult with an OMFS if you wish; they love playing in this neck of the woods. Good Luck!

Having treated many oral-antral fistula I can tell you that your first attempt is you best chance to close the defect. If you screw it up you can end up with a chronic condition that requires multiple procedures, and may be next to impossible to close. OMFS do not "like playing in this neck of the woods". We do it because we have to. Often after someone has mucked up the situation.weigh the advise your are given. You are the one who will have to answer for the results. I think there has been some advise given that is not really in your or the patients best interest.

I agree with previous comments made, start with ABx, and some topical/nasal spray steroids to bring down the inflammation - may result in less bleeding and better visualization when retrieving the root tip. Augmentin as suggested is a good course, but Biaxin is an appropriate second line therapy. Also, saline nasal rinses may help the patient out. From the CBCT, a lateral window will probably be needed to get good access to the root, and permit proper debridement of the subantral space for grafting. In my opinion, vertical augmentation is needed if an implant is to go into that site. I would leave the decision to graft the sinus only after the root is removed, and the site well debrided and irrigated - last thing you want to do is place graft material in the site and get that infected! If you do graft, you will need a barrier on the sinus floor, so that your graft does not fall out through the socket (obviously, you want to curette out the socket before any grafting). Regarding the socket, that should also be grafted, and you can cover it with a dPTFE membrane for healing, or cover with a pedicle CTG. I would place the patient on systemic steroids short term for the sinus augmentation, and extend the antibiotics after the augmentation for an additional week. Last but not least, if you don't feel comfortable, refer out.

This case screams referral I probably do 8-9 cases like this a year, I I thank god for everyone I can help. One miracle at a time folks, Get the root out and close the fistula. Once this is accomplished and you have a few months healing, then think about grafting. Some very bad advice here guys... This is a single tooth defect. It's not like you have a patient in a denture, there is no rush. If you graft this and it falls apart it will be a mess. A healthy maxillary sinus is a very resilient place. I know, I'm shoving implants in there all day long and getting away with it. This is not a healthy sinus. This should be treated as a compromised site. One step at a time. Once the fistula is closed and the sinus is healthy, this is routine stuff. Again, some very bad advice here...

Greg Steiner--- Are u refferring to an alloplastic cortical graft when u say "flat cortical plate"??? This sounds like a horrendously risky concept in a site like this. An oral antral fistula is both a chronically and acutely infected site. Where do you plan on getting tissue to cover this? This area is loaded with granulation tissues and has a compromised vascular bed. Have you done this with good success rates??? Sounds like something I may have tried in my residency... Again- if you just get the fistula to close this is a routine case for someone with experience in sinus grafting. You guys are turning this into a science experiment and pardon me for saying so, but giving terrible advice with zero biological rational.

This defines mismanagement . Yes we all make mistakes, but are you really going to treat this patient based on the responses generated here? If this goes to an ENT, the patient is going to get a FESS procedure, wether they need it or not. Send this to an omfs that understands that you simply remove the source of infection and wait. Augmentin has always worked well for me. Once the root is out, the communication will fix itself, in the non compromised patient. Bv

FESS= functional endoscopic sinus surgery . I have removed a tooth fragment this way, in a brittle diabetic, but don't send this to the ent please. I'm sure the doctor that broke this thing off, has already scared the patient to death. Your patient needs " comprehensive care", from a single doctor, that can treat the complication and ultimately do the sinus lift and implant. If this sinus infection " goes south ", a trial attny is going to find this question and " burn you down"! Bv

How do you like your cbct unit? With respect to the rules, regarding proprietary statements, I'll let you say the name, but I looked at several units and almost bought the I- kitty, but fortunately got the one you have. What a fantastic piece of equipment, eh? Bv

IMHO this surgical complication is best addressed by removal of the root tip through the original site. I would examine the condition of the soft tissue at the surgical site. It would be ideal to have some healthy tisssue to be able to extend and close over the secondary entry wound. If this was a destructive extraction perhaps this pause is beneficial. The root tip appears to be placed beyond where I expect the original socket to be. The position may be adjacent to a boney prominence of the socket wall that may project slightly (think stalagmite) in the sinus floor possibly (hopefully) under the membrane against the superior wall of the maxilla. Hard to tell from the scan. Going on thios assumption, delivery of the fragment through the socket seems a better avenue for removal. I am speculating that the sinus lesion (possible mucous retention cyst) was present long before this surgical complication occured two weeks earlier and would be best addressed with a separate removal following the intraoral root tip extraction. The removal of the possible cyst and conventional sinus lift graft could be elected to be done concurrently after the OAF was closed and the area stabilized. Please consider my comments as a guide to you choices in managing this case. Thank you for posting the case and allowing us to review our own strategies of management. Thanks to all who weighed in on this.

Hi Dr BJ , I occasinally get asked to removed things from the sinus and trying through the socket would be too difficult in my opinion. So usual lateral window to remove which should be easier to find as not floating in the sinus using a surgical suction. I would then graft the socket site after de-granulation with a synthetic fully bio-absorbable material close up and treat with ABs , Dexamethasone and a decongestant. Monitor with possibly another CBCT and re-enter a few weeks later as the window will still be patent but the lining would have healed and graft sinus again with synthetic graft. We have done over 20 cases where all the procedures including implant placement where done in one surgery with 100% success , BUT this is not protocol . It merely shows the bodies ability to heal . Peter

On the sagital view the root tip appear to be slightly above the socket, and the others views shows tear of the membrane but doesn't clearly shows the root tip into the sinus cavity is just possible that is between the socket and the membrane .The thickening of the membrane will probably help on keeping it in a good place for retrieving .Crestal approach remove root tip ,repair membrane, sinus and graft if you feel comfortable doing so at that time, otherwise come back at later time for the lifting. Best Wishes and please let us know the outcom

I couldn't agree more with sb oral surgeon . It is in the best interest of the patient to refer this patient to the appropriate oral surgeon for treatment. You are in over your head with a lack of training and experience in this area. The proper treatment will be determined by the treating oral surgeon and he/she will know how to treat in the most efficient manner. To become a better periodontist you need to know when to say NO.....

Just keep it simple. Get the root out first and focus on the sinus healing.(crestal or lateral….just be sure whatever you choose you can get it out!) What ever happened to one miracle at a time. Im not saying that grafting cannot be done at the same time, and im sure in the right experienced hands it can. But what is the rush? What harm can come from re entering this site in 4-6 months when all has healed, rescan, and then all you have to do is focus on grafting and implant placement. By the way love all the opinions here Sav

Let's go back to basics and sound surgical principals and not debate the surgical approaches not instrumentation. Problem(s) 1. Infected foreign body in sinus 2. Acute and probably infected sinus 3. preoperative radiographs should indicate if pre-existing mucouc retention cyst was present (?clinically significance) 4. Oro-antral communication. Size of bone dehiscence and not mucosal defect is the salient point. a.A mucosal defect is in fact much smaller that the bony opening. b.removal of the epitheliazed or connective tissue fistula is imperative if bony healing is anticipated. c. The infection should be treated to eliminate any acute infection and decrease bacterial load in the granulation tissue. This can be compared to a bioflilm where you cannot sterilize by chemotherapy. Treatment recommendation: Abx, possible need for saline irrigation of the sinus, this may demonstrate a complete communication through the ostium into the nose. If the ostium is not patient an antrostomy should be considered. Removal of the root with your favorite approach-du-jour. Removal of the fistulous tract. with double closure, again with clinician's choice based on clinical evaluation. Once this is accomplished and the pathology has been eliminated, then and only then should you consider moving forward to reconstruction. There are so many variables present that you cannot control them all. This is a conservative approach however remember that unless you have evidence that a particular treatment has proven efficacy some might view complicated multi modal care as experimentation. A position you must be able to defend.

DrOMS, you made excellent points. Good work!

Expose and remove the root tip. Graft the socket. Wait four months. Place an implant with an osteotome sinus lift.

Take the root-tip out is first choice.

You know it's funny but it seems in the dental community there is such a reluctance to refer. MD's do it all the time, it's too bad we are not trained to refer. Good Luck!

Again it's a lawsuit waiting to happen if you have not routinely managed sinus infections.

Hello again, everyone. Thank you for all of your wonderful suggestions. I referred the patient to an oral surgeon for the removal of the root tip and he recommended leaving it alone and proceeding with bone grafting after 2 months. Any opinions? Thank you.