CASE REPORT : Apical surgery of a maxillary molar creating a maxillary sinus window using ultrasonics: a clinical case


















Introduction
The roots of maxillary molar teeth are often in close relationship to the floor of the
maxillary sinus (Oberli et al. 2007). Eberhardt et al. (1992) reported a mean distance of
1.97 mm between the posterior maxillary teeth and the floor of the maxillary sinus. In
some cases, the apexes protrude into the sinus, in such cases, apical surgery via the
maxillary sinus may be considered. Ericson et al. (1974a,b) performed periapical surgery in
159 maxillary premolars and molars, with an aperture of the wall or floor of the maxillary
sinus in 18% of the cases. According to these authors, the introduction of foreign bodies
within the maxillary sinus during the operation may cause thickening of the sinus lining
with symptoms of maxillary sinusitis. Jerome & Hill (1995) recommend using gauze to
block the maxillary sinus and thus avoid penetration by foreign bodies. However, Watzek
et al. (1997) found no statistically significant differences in sinusal mucosa healing
between patients with and without intraoperative membrane perforation after 146
apicoectomies.
The use of ultrasonics to create a window in the lateral wall of the maxillary sinus has
been reported for sinus floor elevation procedures in conjunction with dental implants
(Torrella et al. 1998, Vercellotti et al. 2001, Stu¨ binger et al. 2005). However, this approach
has not been reported in apical surgery to date. In addition, magnification and visualization
devices such as the surgical microscope and endoscope have been used to enhance
visibility during dental procedures to identify perforations, isthmuses, microfractures and
accessory canals and to check the marginal adaptation of the root-end filling (Feldman
1994, von Arx et al. 2002).
A clinical case of apical surgery on a maxillary molar tooth through the maxillary sinus is
presented, using ultrasonics to create a window in the lateral wall of the maxillary sinus

Report
A 37-year-old female patient, with sporadic swelling in the right maxillary region and
tenderness to percussion of the maxillary second right molar was referred for treatment
by her dentist (Fig. 1). The panoramic and intraoral radiographs revealed a radiolucent
periapical lesion on the second molar, close to the maxillary sinus (Fig. 2). The tooth had
previously been root filled and restored with a metal-ceramic crown. The root-end filling
was of good quality. Following the clinical (pain, swelling) and radiological (periapical
radiolucency) diagnoses, the treatment options included apical surgery with access via the maxillary sinus to eliminate the periapical lesion. This course was decided upon after
discussion with the patient


















Figure 1 : The maxillary right second molar had been restored with a crown, and the patient presented with repeated swelling in the buccal sulcus


Surgery was carried out under local anaesthesia with 4% articaine and 1 : 100.000
adrenaline (Inibsa, Llic¸a of Vall, Barcelona, Spain). A full flap was raised from mesial of
the right first molar to distal of the second to access the lateral wall of the maxillary sinus.
Ultrasonics were used to create a right lateral maxillary sinus window (Piezon Master
Surgery, EMSElectro Medical Systems S.A, Nyon, Switzerland) (Fig. 3). The SL2 retrotip
(PiezonMaster Surgery, EMS Electro Medical Systems S.A) was used to create the
sinus window regulating the flow rate and the ultrasonic power. Using the SL3 retrotip
(Piezon Master Surgery, EMS Electro Medical Systems S.A) and with ultrasonic power
set at minimum (Fig. 4), the lining of the sinus was exposed but remained intact. The
periapical tissue was removed with a curette and a gauze was placed to block the
maxillary sinus and avoid the penetration of foreign bodies. The root-end was resected
with a 2.5-mm round tungsten carbide bur, and the cut root face was inspected with an
endoscope (Medi Pack Pal Karl Storz & Co, Tuttlingen, Germany) (Fig. 5). A root-end
cavity was prepared using an ultrasonic retrotip (Piezon Master 400, EMS Electro
Medical Systems S.A, Nyon, Switzerland) (Fig. 6). Root-end filling was accomplished with MTA(ProRoot , Denstply, Tulsa, OK, USA) (Fig. 7 and 8). The flap was sutured with 3-0
silk suture (Lorca-Marin , Murcia, Spain) (Fig. 9 and 10)





















Figure 2  : The radiograph shows a radiolucency around the apices of the maxillary second molar that are close to the maxillary sinus





















Figure 3 :  A full-thickness trapezoidal flap is raised. Using ultrasonics, a window is created in the lateral wall of the maxillary sinus




























Figure 4 Using an ultrasonic insert, the sinus lining is carefully dissected from the floor of the sinus.




Amoxicillin (Clamoxyl ,
GlaxoSmith Kline, S.A, Madrid, Spain) 500 mg/8 h for 7 days; ibuprofen (Bexistar ,
Laboratorio Bacino, Barcelona, Spain) 600 mg/8 h for 3 days; and 0.12% chlorhexidine
digluconate (GUM , John O.Butler Co, Chicago, USA) 3 times a day for 7 days were
prescribed during the postoperative period. In addition, the patient was instructed in
maintaining good oral hygiene and asked to refrain from smoking during the first week
after surgery. There were no intraoperative complications, and healing was uneventful.
























Figure 5 : Endoscopic image after root-end resection showing the gutta-percha points


























Figure 6 Endoscopic image after preparation of the root-end cavity; the mesial canal has an isthmus

























Figure 7  : Endoscopic image after root-end cavity filling with MTA





At the12-month follow-up, the tooth had no clinical signs or symptoms, and healing was
judged radiographically to be progressing (Fig. 11


Discussion
In 40% of cases, the roots of the first and second maxillary molars are close to the floor of
the maxillary sinus (Wallace 1996). As a result, accidental perforation of the maxillary sinus
has been described when performing the osteotomy during apical surgery of these teeth
(Ericson et al. 1974a,b, Ioannides & Borstlap 1983, Freedman & Horowitz 1999, Oberli
et al. 2007). In a retrospective study on apical surgery, Oberli et al. (2007) reported
accidental perforation of the sinus floor (oro-antral communication) in 22% of 113 treated
maxillary premolars and molars. However, in the present clinical case, a window was
intentionally created in the lateral wall of the maxillary sinus to allow apical surgery through
the maxillary sinus. The window was prepared with ultrasonics similar to sinus floor elevation procedures in implant dentistry (Torrella et al. 1998, Vercellotti et al. 2001,
Stu¨ binger et al. 2005).






























Figure 8 : Intraoperative image after root-end cavity filling























Figure 9 : The flap is sutured


This technique has certain advantages compared to conventional
techniques using rotary instruments, as it reduces the risk of perforating the sinus lining,
improves vision and access to the surgical area and provides more conservative and
controlled bone cuts (Torrella et al. 1998). In the present case, the sinus lining was not
perforated, although according to Stu¨ binger et al. (2005), this may still be damaged if
excessive force is applied with the piezosurgery instrument. In this clinical case, and
following the instructions of Jerome & Hill (1995), gauze was used to cover the maxillary
sinus and thus avoided penetration by foreign bodies.
Endoscopy has been reported to provide outstanding vision and ease of use (Bahcall
et al. 1999). Bahcall et al. (1999) used an endoscope to improve visibility of the surgical
field in apical surgery, improving the quality of the surgery. However, Taschieri et al.






















Figure 10 : Postoperative radiograph


























Figure 11 Radiograph at the 12-month follow-up.


(2006) found no statistically significant difference in treatment outcome comparing
magnification loupes to endoscopy. In the present clinical case, the endoscope allowed
examination of the cut root face, the prepared root-end cavity and the root-end filling.

Conclusion
Ultrasonics were used to create a window in the lateral wall of the maxillary sinus without
perforation of the sinus membrane and to allow apical surgery of a second maxillary molar
through the maxillary sinus. Ultrasonic removal of bone offers more control compared to
conventional bone removal with a handpiece and bur.

Disclaimer
Whilst this article has been subjected to Editorial review, the opinions expressed, unless
specifically indicated, are those of the author. The views expressed do not necessarily represent best practice, or the views of the IEJ Editorial Board, or of its affiliated Specialist
Societies.


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