Page 30 - GP Spring 2022

A Tale of Two Molars: A Case Study
Figure 1. Radiographs of #14 and #15. a. This radiograph shows the tracing of the fistula to #15. b. Periapical image
of #14 and #15. c-d. Bitewing images of the two teeth.
By Madison Cox, Jonathan Fayzakov, Angela De Bartolo, DDS, Niloufar Amintavakoli, DDS, MS, and Analia Veitz-Keenan, DDS

a.
ABSTRACT 2021 when she was prescribed amoxicillin apical radiolucencies making it difficult to
Background: When a tooth has already re- (500 mg #21) and her pain has since de- distinguish which one had the sinus tract. A
ceived root canal treatment but still has a per- creased to a manageable level. gutta-percha cone was used to trace the si-
sistent infection, there are only a few treat- nus tract to tooth #15.
ment options. Apicoectomy and nonsurgical Extraoral Exam
retreatment are the most popular options in Extraorally, the patient did not display any To evaluate the prognosis of #14 and #15,

this scenario, with extraction as the final and asymmetry or lymphadenopathy. The tem- a CBCT was taken. The perforation of the
a.
b.
least desirable outcome. This makes it even poromandibular joint exam revealed pop- buccal cortical plate was easily seen coming
more important to appropriately determine ping on the right. The patient reported that from #15 (Figure 2). Additionally, there was
the prognosis of infected teeth. she sometimes has jaw pain, but she never an oro-antral communication between the
had any limitations in opening. All other mesiobuccal root and the floor of the sinus.
Case presentation: A 26-year-old female aspects of the extraoral exam were within This could explain the patient’s symptoms
presented with a referral to have #14 extract- normal limits. of a runny nose, sinus pain on the left side,
ed. She reported that there was a history of and a recent sinus infection: the patient
pain in the area, but not as much recently. Intraoral Exam could be suffering from maxillary sinus-
Her medical history was significant for sinus Intraorally, the patient had two crowns on itis of odontogenic origin. Thickening of

c.
d.
infections and runny nose. After a thorough #14 and #15, both with open margins that the Schneiderian membrane was observed
clinical examination, a draining fistula was could be felt clinically. A sinus tract was corresponding to a chronic inflammatory
Figure 2. The CBCT image of the palatal and mesiobuccal roots of #15 is shown below. The red arrows point to the
found intraorally that was traced to #15. A visible on the buccal mucosa between #14 response of the membrane to the oro-an-
perforation of the buccal cortical plate due to the fistula while the green arrow points to the oro-antral
CBCT was ordered to better evaluate the area and #15. Additionally, multiple composite tral communication (Figure 2). Tooth #14
1
communication and the corresponding thickening of the Schneiderian membrane.
and determine a prognosis for the two teeth. restorations and
amalgam res-
Conclusion: Due to the poor prognosis of torations were
#14 and #15, extraction was the best option noted on other
for the patient. Follow-up included confirm- teeth.
ing that any communications with the sinus
were closed and ensuring that the bone graft There was gen-
had adequately healed so implants could eralized mild Figure 2. The CBCT image of the palatal and mesiobuccal roots of #15 is shown
eventually be placed. to moderate Figure 3. The CBCT image of the palatal and distobuccal roots of #14 is shown below. a. The red arrow points to
below. The red arrows point to the perforation of the buccal cortical plate due to
the perforation of the maxillary sinus and b. the green arrow points to the apicoectomy material found in the sinus.
gingival inflam- the fistula while the green arrow points to the oro-antral communication and the
KEY WORDS: Apicoectomy, nonsurgical mation. Probing corresponding thickening of the Schneiderian membrane.
retreatment, extraction depths and clin-
ical attachment levels ranged from 2-5 mm showed evidence of a sinus perforation
CLINICAL REPORT with generalized bleeding upon probing in at the apex of the distobuccal root (Figure
A 26-year-old female presented with a re- all four quadrants. However, it is important 3a), which was presumed to have occurred
ferral to get #14 extracted. The patient had a to note only two pockets had probing depths during the apicoectomy, since apicoectomy
chief complaint of, “I need to get this tooth of 5 mm, the distobuccal of #14 and the material was seen near the site of perfora-
extracted.” It used to hurt really bad but mesiobuccal of #15, with most of the other tion in the maxillary sinus (Figure 3b).
stopped after I took antibiotics.” She also pockets between 2-3 mm. Detectable plaque
expressed interest in getting an implant and was seen throughout the mouth but calculus
implant crown to replace the tooth. was limited to the mandibular anterior teeth.
Medical History Radiographic Findings
Medical history was significant for a recent Open margins were seen on the crowns on
sinus infection, sinus pain on the left side, #14 and #15 (Figure 1). Additionally, the
and a persistent runny nose. finish line on the distal margin for #14 was
on composite. Both #14 and #15 had peri- a.
Figure 1. Radiographs of #14 and #15. a. This radiograph shows the tracing of the fistula to #15. b. Periapical image
For medications, she was taking Balcoltra of #14 and #15. c-d. Bitewing images of the two teeth. b.

(0.1 mg) as a contraceptive and Cholecal-
ciferol (1,250 mcg). Neither of these was a
concern related to possible dental treatment. About the Authors:
Dental History a. b. Madison Cox is a student at NYU College of Dentistry in the class of 2022.
The patient reported orthodontic treatment
around ages 12-14 and had a permanent lin-
gual retainer on her mandibular anteriors.
She had not been to the dentist in two years a.
but was returning due to pain associated b.

with #14. Both #14 and #15 have had initial c. d. Figure 3. The CBCT image of the palatal and
root canal treatment, nonsurgically retreat- Figure 1. Radiographs of #14 and #15. a. This
Figure 2. The CBCT image of the palatal and mesiobuccal roots of #15 is shown below. The red arrows point to the distobuccal roots of #14 is shown below. a. The
perforation of the buccal cortical plate due to the fistula while the green arrow points to the oro-antral
communication and the corresponding thickening of the Schneiderian membrane. fistula to
ed, and had apicoectomies. The pain associ- radiograph shows the tracing of the red arrow points to the perforation of the max-
About the Authors:
ated with #14 started at the end of January #15. b. Periapical image of #14 and #15. c-d. illary sinus and b. the green arrow points to the
Bitewing images of the two teeth. apicoectomy material found in the sinus.
www.nysagd.org l Spring 2022 l GP 30 Madison Cox is a student at NYU College of Dentistry in the class of 2022.

Figure 3. The CBCT image of the palatal and distobuccal roots of #14 is shown below. a. The red arrow points to Jonathan Fayzakov is a student at NYU College of Dentistry in the class of 2023.
the perforation of the maxillary sinus and b. the green arrow points to the apicoectomy material found in the sinus.

a.

Dr. Angela De Bartolo is a Clinical Associate Professor at NYU College of Dentistry in the Department of
Cariology and Comprehensive Care and she is a Group Practice Director.
Jonathan Fayzakov is a student at NYU College of Dentistry in the class of 2023.

Dr. Angela De Bartolo is a Clinical Associate Professor at NYU College of Dentistry in the Department of
Cariology and Comprehensive Care and she is a Group Practice Director.