Evaluation of clinical and radiographic warning signs for prediction of oroantral communication following tooth extractions.

OBJECTIVES: Oroantral communication (OAC) is a relatively common and mild complication of maxillary tooth extractions. Preoperative prediction of OAC can reduce treatment duration and prepare both operators and patients for the procedure. This study aims to identify alarming radiographic and clinical indicators that can predict OAC therefore assisting clinical decision making to practicing general dentists. METHODS: In this retrospective case-control study the OAC group consisting of 97 cases and a control group twice the size was established. Clinical data were collected, and measurements were conducted separately by two blinded observers on digital panoramic radiographs. Inter-rater reliability was assessed. In case of disagreement a third observer's results were utilized. The correlation between OAC and demographic data (age, sex), as well as various factors assessed on panoramic radiographs (including, but not limited to, the length of the root, root projection into the sinus, bone width, presence of mesial and distal adjacent teeth), was statistically evaluated. RESULTS: Inter-rater reliability was found to be excellent. Several factors were identified as potential predictors of OAC. According to our model, the strongest predictors were the distance between the cemento-enamel junction and marginal bone, extent of root projection into the sinus, presence of sinus recess around the roots, angulation, and absence of the mesial adjacent tooth. CONCLUSIONS: Well-defined measurements on panoramic radiographs may aid in predicting OAC. Further prospective investigations are necessary to confirm these indicators and address factors related to clinical examination and operation. CLINICAL RELEVANCE: We present several clinical and radiographic warning signs of OAC that can facilitate pre-extraction decision-making.

Incidental findings in patients who underwent cone beam computed tomography for implant treatment planning.

OBJECTIVES: The aim of this study is to determine the type, frequency, and location of incidental findings in the maxillofacial region in patients undergoing cone beam computed tomography (CBCT) scan for implant treatment.[5]. METHODS: In this study, 300 patients who underwent CBCT imaging for implant treatment planning were evaluated retrospectively. Patients were evaluated in four different categories, namely, maxillary sinus pathologies, temporomandibular joint (TMJ) findings, dentoalveolar findings, and soft-tissue calcifications. In maxillary sinus pathologies, we categorized patients by mucosal thickening, polypoidal lesion, air-liquid level, total opacification, oroantral fistula, periapical lesion related with maxillary sinus, antrolith, hypoplasia, and foreign body presence. In the TMJ findings category, we evaluated patients for erosion, osteophyte, sclerosis, flattening, and bifid condyle. For dentoalveolar findings, we looked for the residual root and impacted tooth. In soft-tissue calcifications, we examined patients for tonsillolith, sialolith, lymph node calcification, styloid ligament calcification, carotid artery calcifications, and osteoma cutis. RESULTS: Mucosal thickening was mostly seen in maxillary sinus pathology. One hundred and forty-eight (49.3%) of the patients had at least one TMJ incidental finding. We detected at least one impacted tooth in 17 (5.7%) patients' maxilla and 14 (4.7%) patients' mandibles. The most frequently seen calcification was styloid ligament calcification. There was no statistically significant relationship between the age groups and incidental findings (P > 0.05). CONCLUSIONS: Oral radiologists should be aware of incidental findings and evaluate the possibilities of underlying diseases in a comprehensive way, and if there is a concern about the finding, they should refer the patient to the relevant specialist.

The Use of Platelet-Rich Fibrin for Immediate Closure of Acute Oroantral Communications: An Alternative Approach.

Currently, the buccal advancement flap, palatal rotational flap, and buccal fat pad techniques are frequently used to close an oroantral communication (OAC). In this study, platelet-rich fibrin (PRF) clots were used for immediate closure of acute OACs after extraction of posterior maxillary molars. Acute oroantral perforations larger than 3 mm in diameter in 21 patients were treated uneventfully using PRF clots. None of the patients had systemic diseases or symptoms of sinus disease. After tooth extraction, the diagnosis of acute OAC was examined by the Valsalva maneuver (compressing the nostrils with the fingers and then blowing out air). After detection of an air leak, a modified ball burnisher instrument 3 mm in diameter was used to determine whether the perforation was larger than 3 mm. The postextraction socket of the tooth was cleaned with sterile physiologic saline solution and the cavity was filled with PRF. PRF clots were sutured to the gingiva to prevent them from migrating to the sinus and for stabilization. On the seventh day of follow-up, healthy granulation tissue was observed; during the third week of follow-up, epithelialized oral mucosa was detected at the extraction site in all cases. The use of PRF enables the closure of OACs without primary flap closure or any other surgical interventions. Thus, the use of PRF for immediate closure of acute OACs will make the treatment of OACs less traumatic and easier and will eliminate the need for special surgical expertise.

Endoscopic Repair of Persistent Oroantral Communications Using the Caldwell-Luc Approach.

In this article, a novel endoscopic technique used to close oro-antral fistulas will be described. In the technique described here, 24 cases were surgically treated between May 2011, and November 2014. Under endonasal endoscopic examination following partial inferior uncinectomy, the natural ostium of the maxillary sinus was identified; through this tract, a curved aspirator was advanced into the sinus. If present, we extracted endoscopically tissues causing obliteration of the ostium through the Caldwell-Luc antrostomy, taking care to preserve the integrity of the natural ostium. In the technique described here, endoscopic examination using the Caldwell-Luc approach, the inside of the maxillary sinus is explored fully, existing infection and polyps are eliminated locally, and natural patency of the maxillary sinus ostium can be achieved. The graft used to obliterate the oroantral fistula can be easily harvested from the bone of the anterior wall of the maxillary sinus by accessing the surgical entry tract.

Computed tomographic description of the highly variable imaging features of equine oromaxillary sinus and oronasal fistulae.

Oronasal and oromaxillary sinus fistulae are well-documented complications following removal or loss of a maxillary cheek tooth. Diagnosis is currently based on a combination of oral examination, videoendoscopy, radiography, and computed tomography (CT). The objective of this retrospective, case series study was to describe the CT characteristics of confirmed oronasal and oromaxillary sinus fistulae in a group of horses. Inclusion criteria were a head CT acquired at the authors' hospital during the period of 2012-2017, a CT diagnosis of oronasal or oromaxillary sinus fistulae, and a confirmed diagnosis based on a method other than CT. Signalment, clinical findings, oral examination findings, presence of a confirmed fistula, and method for confirmation of the diagnosis were recorded. A veterinary radiologist reviewed CT studies for all included horses and recorded characteristics of the fistulae. Seventeen horses were sampled. Fourteen oromaxillary sinus fistulae and three oronasal fistulae were identified. All fistulae appeared as variably sized focal defects in the alveolar bone. Defects frequently contained a linear tract of heterogeneous material interspersed with gas bubbles, considered consistent with food. Computed tomographic attenuation of the material (Hounsfield units, HU) varied widely within and between cases. In 16 of 17 cases, there was evidence of concurrent dental disease in addition to the fistulae. Although the gold standard diagnostic test remains identification of feed material within the sinus or nasal passages, findings from the current study support the use of CT as an adjunctive diagnostic test for assessing the extent of involvement and presurgical planning.

An unusual foreign body in the maxillary sinus: Dental impression material.

Foreign bodies in paranasal sinuses are very rare and most of them are encountered in the maxillary sinus. These foreign bodies may be organic or inorganic and can enter the maxillary sinus through an oro-antral fistula. The oro-antral fistula is formed by a break in the bony segment of the maxillary sinus floor and usually arises subsequent to maxillary premolar and molar extractions. A 63-year-old female patient evaluated for a nonhealing, left, toothless palate lesion and chronic headache occurring over 4 years. Radiography and computed tomography revealed bone discontinuity in the left floor of the maxillary sinus and calcifications within the antrum. A blue foreign body, later identified as dental impression material, was removed by intranasal endoscopy. A careful oral examination is recommended prior to prosthetic restorations. In addition, paranasal sinus foreign bodies should be surgically removed to prevent secondary soft tissue reactions.

Chronic oroantral fistula: combined endoscopic and intraoral approach under local anesthesia.

OBJECTIVE: To evaluate the outcome of combined surgical treatment of oroantral communications associated with chronic maxillary sinusitis. PATIENTS AND METHODS: 8 consecutive patients affected by complicated oroantral fistula were included in the study. The protocol consisted of: clinical, endoscopic and radiological preoperative evaluation (panoramic tomogram and computed tomography); systemic antibiotic and steroid therapy 2 weeks before surgery; one-stage surgical procedure under local anaesthesia consisting in uncinectomy with enlargement of the osteomeatal complex through endoscopic nasal approach associated with the closure of the oroantral communication by means of a mucoperiosteal flap; postoperative antibiotic and cortisone-based therapy. Follow-up consisted of weekly clinical evaluation during the first month, and nasal endoscopy at 3, 8 and 24 weeks after surgery. RESULTS: After surgical treatment, all patients were symptom-free and had no endoscopic and radiological evidences of maxillary sinusitis at the 6-month follow-up. No recurrent oroantral fistulas were found. CONCLUSIONS: The current prospective study showed that a one-stage, combined endoscopic and intraoral approach under local anaesthesia represents a feasible and minimally invasive procedure for the long-term effective treatment of chronic complicated oroantral communications. Moreover, it represents an easily applicable approach also in outpatient clinics with minor patient discomfort.

Clinical and radiological characteristics of oro-antral communications/fistulae due to implant dentistry procedures: A cross-sectional retrospective study.

OBJECTIVES: Assess the unique clinical and radiological sequelae following oro-antral communications/fistulae (OAC/OAF) due to implant dentistry vs other etiologies. MATERIALS AND METHODS: A structured form served to collect data from medical records. All consecutive patients who underwent surgical closure of OACs/OAFs between 2003 and 2020, at a single center were included. Demographic, radiological, clinical, operative and postoperative characteristics were collected. The differences between groups (cases with implant dentistry etiology [IDE] vs cases with other etiologies) were assessed statistically. RESULTS: Data were gathered from 121 cases. The findings show that IDE cases were more likely to be of older age (OR = 1.07, CI [1.02, 1.13] P = .02); to have a foreign body in the maxillary sinus (OR = 21.04, CI [4.34, 114.92] P < .01); to have fluid passage (OR = 11.40, CI [1.87, 118.73] P = .02) and purulent discharge through the fistula (OR = 3.52, CI [0.86, 16.34] P = .09). CONCLUSIONS: Clinical and radiological sequelae due to OACs/OAFs secondary to implant dentistry procedures are more severe compared to other etiologies. The suggested pathogenesis is foreign body reaction. Early and accurate diagnosis of the foreign body location, followed by its early removal is recommended.

Can CT predict the development of oroantral fistula in patients undergoing maxillary third molar removal?

PURPOSE: In maxillary wisdom tooth extraction, the necessity of CT is unknown. The purpose of this study was to investigate whether CT adding to orthopantomography is useful for predicting oroantral perforation during maxillary third molar extraction. METHODS: Various risk factors for oroantral perforation during maxillary third molar extraction were investigated by univariate and multivariate analyses. We analyzed those of all patients and the patients who underwent CT, respectively. The proximity of the roots to the maxillary sinus floor (root-sinus [RS] classification) and Archer classification were assessed using panoramic radiography. The number of roots and vertical relationship were assessed using CT. RESULTS: A total of 604 out of 3299 patients underwent CT adding to orthopantomography. In all cases, multivariate analyses except for CT findings showed that the RS classification type III/IV and the Archer classification Type B/C/D in panoramic findings were significantly correlated with oroantral perforation as radiological findings. In cases for which CT was performed, multivariate analyses showed that one root (OR 12.87) and the vertical relationship Type D (OR 5.63) in CT findings, besides the RS classification type III/IV (OR 4.47) in panoramic findings, were significantly related to oroantral perforation. CONCLUSION: The RS classification and the Archer classification in panoramic findings can predict the risk of oroantral perforation. The usefulness of CT adding to orthopantomography is limited. However, when the relationship between the upper wisdom tooth and maxillary sinus floor (RS classification) is unclear, to check whether the number of roots is one and the apex of one root is projecting into the maxillary sinus in CT findings, is useful for the prediction.

Chronic maxillary sinusitis associated with dental impression material.

A 62-year-old man was referred for routine treatment of hyperplasia of the mucosa in the anterior lower jaw. An oroantral fistula was detected in the right superior alveolar ridge. The patient had no complaints. Plain radiographs showed a radiopaque foreign body in the posterior region associated with opacification of the maxillary sinus. Computed tomography showed the same hyperdense foreign body located in the posterior lower part of the sinus and an abnormal soft tissue mass in the entire right maxillary sinus. When asked about sinusitis, the patient mentioned occasional episodes of pus taste and intermittent crises of headache lasting for one week. The patient has been edentulous for 20 years. Sinus debridement was performed and the oroantral fistula was closed. The clinical suspicion of the presence of zinc oxide-eugenol paste was confirmed by microscopical and chemical analysis. After 6 months of follow-up, the fistula continued to be closed and sinusitis did not recur. This clinical case of maxillary chronic sinusitis illustrates a different odontogenic origin.

Alveolar cleft closure by distraction osteogenesis with skeletal anchorage during consolidation.

Intraoral distraction osteogenesis (DO) has been widely used for the reconstruction of various dentoalveolar defects. However, its use in the management of alveolar clefts is relatively new. This method allows the closure of the cleft via the regeneration of new alveolar bone and attached gingiva through the distraction of a dento-osseous segment. It eliminates the need for a donor site for autogenous bone grafting and possible graft failure. However, the relatively long consolidation period required for the use of intraoral DO devices may result in soft tissue irritation that would compromise patient cooperation, especially in children. In the case presented, the intraoral DO technique was used for the treatment of a unilateral residual alveolar cleft and an implant was subsequently placed in the regenerated bone. A miniplate was also placed to serve as a skeletal anchor to enable the early removal of the distractor device. The distractor was removed before the beginning of the consolidation phase.

Delayed retrieval of a displaced maxillary third molar from infratemporal space via trans-sinusoidal approach: a case report and the review of the literature.

AIM: The aim of this case report is to present the trans-sinusoidal pathway used to remove a displaced maxillary third molar from the infratemporal fossa and review the English literature regarding the techniques used. CASE REPORT: A 21-year-old male patient was referred with the findings of an oroantral fistula on the left maxillary vestibular first molar region and slight restriction of mouth opening. The patient underwent a maxillary sinus surgery in order to remove a sinus retention cyst via Caldwell-Luc access in a dental clinic 4 years ago. A computerized tomography scan showed the inverted third molar to be located in the infratemporal fossa, just between zygomatic arch and lateral pterygoid plate. The tooth was accessed through the remaining lateral bone defect from the Caldwell-Luc approach of the lateral sinus wall. The bone defect was extended. The posterior bony wall of the maxillary sinus was removed via a surgical burr. After that, the displaced tooth was exposed. The tooth was mobilized via Warwick James elevator downwards and removed with a forceps. CONCLUSION: Access for surgical removal of the tooth from the infratemporal fossa is not only difficult but also has potential for morbidity due to the structures running through it. Wide incision in the maxillary sulcus and blunt dissection are reported with lower success rates and usually necessitate a second intervention via extraoral route. Trans-sinusoidal approach might be an old fashioned but relatively successfully attempt in the removal of the upper third molars from the infratemporal fossa. Considering the time of removal, if no symptoms were present, it is beneficial to wait for a couple of weeks thus facilitating development of fibrous surrounding around the tooth.

Maxillary sinusitis and periapical abscess following periodontal therapy: a case report using three-dimensional evaluation.

BACKGROUND: Maxillary sinusitis may develop from the extension of periodontal disease. In this case, reconstructed three-dimensional images from multidetector spiral computed tomographs were helpful in evaluating periodontal bony defects and their relationship with the maxillary sinus. METHODS: A 42-year-old woman in good general health presented with a chronic deep periodontal pocket on the palatal and interproximal aspects of tooth #14. Probing depths of the tooth ranged from 2 to 9 mm, and it exhibited a Class 1 mobility. Radiographs revealed a close relationship between the root apex and the maxillary sinus. The patient's periodontal diagnosis was localized severe chronic periodontitis. Treatment of the tooth consisted of cause-related therapy, surgical exploration, and bone grafting. A very deep circumferential bony defect at the palatal root of tooth #14 was noted during surgery. After the operation, the wound healed without incidence, but 10 days later, a maxillary sinusitis and periapical abscess developed. To control the infection, an evaluation of sinus and alveolus using computed tomographs was performed, systemic antibiotics were prescribed, and endodontic treatment was initiated. RESULTS: Two weeks after surgical treatment, the infection was relieved with the help of antibiotics and endodontic treatment. Bilateral bony communications between the maxillary sinus and periodontal bony defect of maxillary first molars were shown on three-dimensional computed tomographs. The digitally reconstructed images added valuable information for evaluating the periodontal defects. CONCLUSION: Three-dimensional images from spiral computed tomographs (CT) aided in evaluating and treating the close relationship between maxillary sinus disease and adjacent periodontal defects.

Rhinosinusitis associated with post-dental extraction chronic oroantral fistula: outcomes of non-surgical management comprising antibiotics and local decongestion therapy.

OBJECTIVE: A non-surgical approach for managing rhinosinusitis associated with chronic oroantral fistula resulting from tooth extraction was evaluated. METHODS: Twenty-six consecutive patients (15 males and 11 females) aged 28-72 years (mean, 49.81 years) were administered local decongestion therapy for 2 weeks and antibiotics for 10 days. Patients showing a reduction in Sino-Nasal Outcome Test 22 scores after two weeks continued to receive local decongestion therapy weekly for up to six weeks, while those not showing any improvement underwent surgical management. RESULTS: At 2 weeks, 17 patients (65.38 per cent) showed an improvement in rhinosinusitis (33.39 per cent mean reduction in Sino-Nasal Outcome Test 22 scores). The primary determinant of response was fistula size. At 6 weeks, sinusitis resolved completely in all 17 patients, and the fistula closed in 16 of these. Final Sino-Nasal Outcome Test 22 and Lund-Mackay scores showed no significant difference between the surgically treated and non-surgically treated groups. CONCLUSION: Local decongestion therapy along with antibiotics may promote resolution in this subset of rhinosinusitis patients.

Technical note: oroantral fistula: improved imaging with a dental computed tomography software program.

Oroantral fistula (OAF) is an uncommon complication in oral surgery. About 5% of all extractions of maxillary premolars or molars may result in communication to the antrum. Small fistulae, 1-5 mm in diameter may close spontaneously, but larger fistulae usually require surgical closure. Pre-operative determination of the size of the fistula is often unreliable leading to difficulties in planning subsequent clinical management. We report a method for the precise determination of the size of the OAF using a dental computed tomography (CT) software program.

Treatment of oroantral communications after tooth extraction. Is drainage into the nose necessary or not?

Seventy-six patients with oroantral communications after tooth extraction and chronic maxillary sinusitis were treated as follows: bacterial cultures were taken in all of them and maxillary sinuses were irrigated with an antibiotic from the cephalosporin group. Then, in 36 patients, drainage using the Caldwell Luc procedure was performed, including a naso-antral window. In all patients operations were completed by closing oroantral communications with flaps of the mucosa of the alveolar process close to the fistula. Antibiotics according to antibiogram were administered to all patients at least 10 days after surgery. Retrospective comparison between the results obtained in the first group and those in the second group 1, 3 and 6 months after operation was based on objective findings (condition of the oroantral communication, maxillary sinusitis), side effects (pain, numbness of the operated area, headache) and control radiographs (clear maxillary sinus or with mucosal thickening). The study suggests that transnasal drainage is not required in maxillary sinus surgery and in the closure of oroantral communications. Equally good results are achieved by treating with antibiotics and without drainage of the maxillary sinus into the nose.

[Contribution of panoramic tomography in exploration of maxillary sinuses (author's transl)]. / Apport de la radiographie panoramique dans l'exploration des sinus maxillaires.

Panoramic tomography (orthopantomography) is useful in exploration of maxillary sinuses, specially of its floor and its connection with teeth alveoles. Interest of this examination in the diagnosis of sinusian cyst of polypus, apical teeth cyst growing in the sinus, fistula from mouth to sinus, repeating sinusitis by dental infectious focus, sinusian stranger corps and finally, in the schedule or surveillance of the extension of sinus maxillary cancer to the posterior wall, particularly to the pterygomaxillary fossae.

Diagnosis of an odontogenic keratocyst with computed tomography.

The CT scan aided diagnosis here of two odontogenic keratocysts in the maxillary sinus. The CT scan defines borders and provides insight into the contents of lesions and a three-dimensional view of an area of specific interest. In terms of diagnostic value, the CT scan has a definite advantage over other radiographic techniques. The treatment of maxillary odontogenic keratocysts was discussed, and the importance of postoperative observation was emphasized.

[Odontogenic sinusitis. An evaluation and the radiologic checkup protocol after a Caldwell-Luc intervention]. / Sinusite odontogena. Valutazione e protocollo radiologico di verifica dopo interventi secondo Caldwell-Luc.

A homogeneous group of 30 patients who were operated over a 5-year period for odontogenic sinusitis using a buccosinusal communication following Caldwell-Luc's technique were studied. A marked discrepancy between the conventional X-ray picture and the clinical picture emerged from these 30 case studies. So as to find an explanation for this discrepancy, all patients underwent CAT tests. On the basis of a critical evaluation of the results obtained it is suggested that patients be followed using a postoperative instrumental control protocol.