Impaksi m3dengan Sinus

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Case ReportRemoval of an Upper Third Molar from the Maxillary Sinus

Klinger de Souza Amorim, Vanessa Tavares da Silva, Rafael Soares da Cunha,

Maria Luisa Silveira Souto, Carla Rocha So Mateus, and Liane Maciel de Almeida Souza

Dentistry Department, UFS Universidade Federal de Sergipe, Avenida Doutor Jose Tomas DAvila Nabuco, Bloco ,Apartamento , Bairro Farolandia, - Aracaju, SE, Brazil

Correspondence should be addressed to Klinger de Souza Amorim; [email protected]

Received August ; Revised January ; Accepted January

Academic Editor: ommaso Lombardi

Copyright Klinger de Souza Amorim et al. Tis is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Te maxillary sinus or antrum is the largest o the paranasal sinuses. It is located in the maxillary bone and has a proximity to theapexes o upper molars and premolars, which allows it to orm a direct link between the sinus and the oral cavity. Dislocation o aoreign body or tooth to the interior o a paranasal sinus is a situation that can occur as a result o car accidents, rearm attacks, oriatrogenic in surgical procedures. Tereore, it is necessary to know how to treat this kind o situation. Tis studys objective is toreport the case o a -year-old emale patient, leucoderma, who sought treatment rom the Surgical Unit at the Dental Faculty othe Federal University o Sergipe. She had a history o pain and edema in the right side o the genian region and two ailed attemptsat removing dental unit (DU) . Te extraoral clinical exam revealed intense edema o the lef hemiace with signs o inection,

excoriation o the labial commissure, hematoma, a body temperature o C, and a limited ability to open her mouth. Te patientwas medicated and treated surgically. Te tooth was removed rom the maxillary sinus with caution, as should have been doneinitially.

1. Introduction

Te maxillary sinus, or antrum, is the widest o the paranasalcavities, occupying the entire maxillary body. It is describedas a triangular pyramid whose base is the lateral nasal walland whose apex aces the zygomatic process o the maxillarybone [,]. It has a large volume, capillary ragility, and prox-imity to the apexes o some o the upper teeth, namely, the

molars and premolars, which allows it to orm a direct con-nection between the sinus and the oral cavity.

Although oreign bodies within the paranasal sinuses areobserved rarely, objects can become lodged in the paranasalsinuses as a result o caraccidents, rearm attacks, psychiatricdisorders, or iatrogenic in surgical procedures. Te upperthird molar can become dislocated within the maxillary sinuscavity during dental surgery; this rare circumstance accountsor ..% o iatrogenic cases o oreign body entrapmentin paranasal sinuses []. When such a dental dislocation doesoccur, it can usually be attributed to inadequate use o extrac-tors in the context o an atypical anatomical relationshipbetween the tooth and the maxillary sinus.

Imaging exams are necessary to help in the diagnosticprocess. Te most commonly used method is orthopantomog-raphy, butWaters method, side prole, and computedtomog-raphy are also used []. When dislocation o a tooth to themaxillary sinus is diagnosed, surgical planning to remove itis needed.

Tis report describes a clinical case o a patient whosethird molar was iatrogenically dislocated to the interior o themaxillary sinus. So the clinical conduct and surgery used toresolve this case are presented at the report.

2. Case Report

A -year-old emale patient, leucoderma, sought treatmentrom the Surgery Unit at the Dental Faculty o the FederalUniversity o Sergipe. She had a history o pain and edema inthe right side o the genian region afer two ailed attempts toremove the dental unit (DU) . She brought in a panoramicX-ray taken prior to those two surgeries.

During the extraoral clinical exam, intense edema o thelef hemiace with signs o inection, excoriation o the labial

Hindawi Publishing CorporationCase Reports in DentistryVolume 2015, Article ID 517149, 5 pageshttp://dx.doi.org/10.1155/2015/517149


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Case Reports in Dentistry

F : X-ray beore any intervention.

F : X-ray with the DU into the maxillary sinus.

commissure, hematoma, and a limited ability to open themouth were observed. Te case was characterized as level seriousness []. Te patient had a body temperature oC. On the preoperative X-ray exam, the presence o dentalinclusion or DUs , , , and was observed. DU had

vertical impaction and intimacy with the maxillary sinus, andDU had mesioangular impaction. DU had horizontalimpaction (class branch and class B depth), and DU was totally vestibularized with horizontal impaction (class branch and class B depth) [] (Figure ).

As an initial measure, antibiotics ( mg/ mL amoxi-cillin + mg/ mL sulbactam every hours over days)and analgesic ( mg paracetamol + . mg codeine phos-phate every hours) were prescribed. Supplement supportconsisted o g o vitamin C once a day and mg oB complex once a day. Te patient was directed to placewet, lukewarm compresses on the sore area or days andto remain hydrated by consuming mL o liquid every

hours.A new panoramic X-rays was requested to clariy the

diagnosis. One week later, the patient has overcome herinection with new X-rays that showed the presence o tooth in the interior o the maxillary sinus (Figure ). Becauseo the trauma she had endured rom her previous surgeries,it was administered Corahs dental anxiety scale [], whichshowed that she was moderately anxious.

Te patient was sent to receive a computed tomographyexamination o the maxilla by volumetric acquisition tobetter locate DU (Figure ). Afer tomography, the surgicalplanning was conducted. Tree surgical procedures wereplanned to remove DUs , , and , and the displaced

DU rom the maxillary sinus. One-week interproceduralinterval was applied between the interventions.

For the rst two surgeries, mg o the phytotherapeuticmulungu minutes beore surgery was given to the patientas an anxiolytic measure. For the third surgery or removalo DU rom the maxillary sinus, mg o midazolam was

given minutes beore surgery to reduce her anxiety. Asprophylactic antibiotic therapy, gramsamoxicillin was givento her hour beore surgery []. For all three operations, aprotocol using dexamethasone ( mg, intramuscularly) waschosen minutes beore the procedure as a prophylacticagainst postoperative edema []. Te patients arterial pres-sure (AP), heart rate (HR), and oxygen saturation (O

2 Sat)

were monitored throughout all three surgeries and they weremaintained without changes.

Te anesthesia or the operation on DUs and wasachieved with % lidocaine + : , epinephrine (. mL)in a Vazirani-Akinosi block and % articaine with : ,epinephrine (. mL) in an oral nerve block. Te drugs were

injected as preconized at current literature [] and the surgi-cal technique or DUs and ollowed the recommendedprotocol [].

Te anesthesia or the operation to remove DU wasachieved by application o an upper posterior alveolar nerveblock with % articaine + : , epinephrine. It was taken minutes afer applying the alveolar nerve anesthetic beoreproceeding with the surgery to avoid the need to block thegreater palatine nerve []. Te surgical technique ollowedthe preconized protocol []. mg o paracetamol every hours or h was prescribed as a postsurgical analgesic[]. For the third operation, to remove DU , a blockageo the upper posterior and middle alveolar nerve with %

articaine + : , epinephrine, waiting minutes orpalatal diffusion, was made []. Te tooth was removed romthe maxillary sinus using the Caldwell Luc operation, whichwas originally described in the late s as an approachto the maxillary sinus accessing it through the labiogingivalsulcus to canine ossa incision. By this technique, there isbone resection o the sinus vestibular wall, which is openand provides access to the removal o the oreign body romthe maxillary sinus, and then the sinus must be irrigatedand the suture must be made, relaxing at health bone , .Postoperatively, another mg dose o dexamethasone to takein the evening and paracetamol ( mg every hours or hours) were prescribed.

Te ollowing postoperative instructions were explainedto the patient or each o the surgeries she received.

() Avoid exposure to sun, hot and hard ood, andphysical exertion, at least until removal o the stiches.

() Consume liquid or sof and cold ood only or at least hours (milk, juice, etc.).

() Rest andsleep with your head elevated (remain seatedwhen resting and place pillows under your head atbedtime), and avoid lowering it.

() Resume normal brushing o the teeth and tongue, butavoid the operated area.


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Coronal tooth cut 18 Sagittal tooth cut 18

F : Computed tomography examination o the maxilla by volumetric acquisition to better locate DU .

F : X-ray or postoperative evaluation.

() Rinse gently times a day with an oral antiseptic,starting hours afer the surgery.

() Use ice compresses externally (on the ace) during the

rst hours or periods o minutes ollowed by restor minutes.

() Spread Vaseline or lip protector on the lips to keepthem lubricated and prevent chapping.

() I you suffer rom a high ever, edema, difficultyopening your mouth or more than days, persistentpain, or excessive bleeding, get in touch with usimmediately.

() Adhere rigorously to the prescribed medicationschedule.

Afer the nal surgery, a new panoramic X-ray or post-operative evaluation was obtained, and it showed no evidenceo any complications (Figure ).

3. Discussion

Because o their proximity to the upper teeth, the maxillarysinuses are the most important paranasal sinuses in dentistry[, ]. Te close relationship between these anatomicalstructures requires a surgeon who is sufficiently cautious andsensitive to deal adequately with the case. Ofen, the distancebetween the root apex and the sinus mucosa is showed to bereduced to millimeters, making the transposition o a dentalelement to the maxillary sinus possible, mostly the upperthird molar [, , ], as can be seen in this report. According

to some authors the present iatrogenic case can be causedby excessive apical orce during the use o extractors andincorrect surgical techniques [, ]. However, in thesecircumstances, the proessionals need to be prudent andcautious in their handling o the case to reduce the traumacaused by the accident and to attain the desired result [].

Te panoramic X-ray was used or this diagnostic, andit is the most common imaging approach used to conrmthe location o elements dislocated to the maxillary sinus,although it can cause a distortion o around % [].Nevertheless, computed tomography offers the clearest viewand a three-dimensional view, which makes it indispensableor the evaluation and proper handling o cases such as theone presented here [, ]. In the present case, panoramic X-ray and computed tomography were used to determine withprecision the location o the translocated tooth. However,in some cases, the procedure can be completed with onlypanoramic X-rays [,].

In cases o accidental dislocation o ragments to the inte-rior o the maxillary sinus, some authors agree that the mostacceptable treatment is removal to prevent uture inection[, ]. However, inection is not a certain outcome sincesinuses have beenobserved to be healthy despite the inclusiono oreign material []. Te ideal circumstance is that anydislocated oreign body be taken out during the same surgicalprocedure in which it was dislodged, i possible. However,the sinus can remain asymptomatic or several months beorean acute inection develops. Te patient in the present reportshowed classic signs o an inection caused by dental materialinside the right maxillary sinus. Peterson et al. recommend

that a tooth dislocated to the maxillary sinus be removed afera period o to weeks, since there is brosis during theinitial healing period that can stabilize the tooth, making itspositioning rmer [].

In the present case, the Caldwell-Luc operating techniquewas used. Te main advantages o this technique in thiscase were good visualization o the operative eld (whichacilitates better access to the sinus), prior experience withit in the surgeons routine, and the absence o seriouscomplications. Despite the act that there are reerences in theliterature about acial asymmetry, nervous lesion, dental pulpdevitalization, and oroantral stulas being complicationsassociated with the Caldwell-Luc procedure [], there is


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a scientic consensus that such morbidities are related notonly to the technique used butalso to the surgeons experience[]. Another well-known technique is the transalveolarprocedure, but it is only indicated when the already existingopening is larger than the oreign body to be removed [].Normally, it is used only as the rst and immediate attempt

to recover root remains [, ]. Te advent o endoscopyhas also helped with the process o removing small oreignbodies rom paranasal cavities [, ]. It allows sufficient

visualization o the surgical eld, has low morbidity, and iseasily accepted by patients. However, a lack o specializedmanpower and the lack o logistical resources available inmost public and private services have made routine use oendoscopy impractical [].

Te results o the patients Corah scale anxiety testindicated that she was moderately anxious []. Moreover,she said that she was very anxious about the surgery toremove the tooth rom the maxillary sinus, since previoussurgeries on that D.U. had not been successul. Tereore,a benzodiazepine anxiolytic ( mg midazolam) was givenbeore that nal operation. For the other extractions, thepatient was calmer. Tereore, or those earlier procedures,a phytotherapeutic anxiolytic (two mg capsules oEryth-rina mulungu) wasprescribed because it does notaffectmotorcoordination [].

Iatrogenic can occur in various elds o dentistry,even during relatively noninvasive treatments. Tereore, allpatients undergoing dental procedures should be told aboutthe risks and possibilities o complications. In this case,removing the tooth dislocated to the maxillary sinus requireda second surgical period. Nonetheless, the proessional onthis case was able to proceed with X-ray planning, surgery,andappropriate medication. Te best way to avoid dental dis-location to the maxillary sinuses is through careul preopera-tive evaluation. Beore every surgical procedure, dental teamsshould request the appropriate complementary exams andevaluate whether the proessional has the ability to perormthe procedure that needs to be done in a sufficiently cautiousway. Tey also need to make sure that any complications canbe resolved, i possible, thereby leaving the patient ree romdisorders, such as that described in this case report.

Conflict of Interests

Tere is no conict o interests regarding the publication othis paper.

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