Endo treated root in the sinus: Precautions for implant?
A 27 year old patient presented with excellent oral hygiene and wants an implant supported replacement for the upper right first molar. The tooth was extracted two years back somewhere else and the fresh radiograph shows a retained root (endodontically treated).
New Updated Photos on March 2, 2020:
The CBCT revealed the position of the root to be somewhat lateral compared with the planned implant position. The patient had no sinus symptoms and had already seen an ENT surgeon after he had been informed about the root’s proximity with the sinus. He was not willing to have a bridge and also was against the removal of the root since it had not bothered him all this time (probably because he wanted to escape an invasive surgery as of now). Keeping all these in mind a crestal sinus lift was done, membrane and graft placed respectively, and a mesially tilted 4.5mm wide and 8mm long implant (Dentium Superline 3) was placed and excellent primary stability was achieved. Please share your valuable thoughts.
20 Comments on Endo treated root in the sinus: Precautions for implant?
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Dennis Flanagan DDS MSc
2/20/2020
That is probably residual endo cement but should be removed. A lateral approach would probably be best and simultaneous implant placment.
Ed Dergosits DDS
2/21/2020
You only suspect residual endo cement? There is clearly a root there. I would suspect it is positioned between the sinus membrane and the bony floor of the sinus space. A lateral approach will be needed to access this root.
PerioProsth
2/20/2020
I had a case like this about 8-9 years ago. Ext #14 was done by a GP. after RCT failed. One of the roots was Fx and pushed into the Sinus. Pt was never informed until she went to get an implant with and OS and that was when she had found out what had happened, then she came to me for replacement of the missing tooth. She finally decided to have a bridge, But she was suing the GP for the NOT telling her what he had done.
So BE CAREFUL with the legal aspects is this case and evaluate all aspects and i highly recommend a consultation with an OS to cover yourself. You may not get the chance to do the Implant yourself, but think if it is worth the time you MAY loose, if it get complicated with the dental boards, etc.
Dr. Gerald Rudick
2/20/2020
The xray shows the separated root lying in an unusual position, that tells me that it is floating in the sinus. I would consult with an Otolarygnologist and have him/her scope the area, and approach it from the sinus to remove it. After it is removed, there is a good possibility of working from outside the sinus to rebuild the bone to eventually have a dental implant.
Wally
2/20/2020
Need CT for further evaluation
gndds
2/20/2020
In my opinion a lateral window should be raised, the sinus membrane elevated, tooth extracted thru the sinus, then bone graft and if primary stability can be achieved, implant placed at same time. If not enough bone remaining, then graft and wait to place implant.
Eddie
2/20/2020
Where exactly in sinus is the root ?
I think a CBCT will pinpoint the position by mm
Perhaps if it’s further lateral is mode then sleeping there under the membrane away from Potential implant position Then no need for the invasive window surgery
Richard Hughes
2/20/2020
Obtain a CBCT and remove by the lateral approach. You should be able to lift the membrane and repair with a collagen membrane, graft and place a tapered implant all in one visit.
Carlos Boudet, DDS DICOI
2/20/2020
A CBCT is required and provides the necessary information for a consult with the OS or ENT and his or her recommendations.
Follow the recommendations.
Marshall morgan
2/20/2020
Make no plans until evaluation with CBCT. If the decision is to remove, it should be simple from the lateral aspect.
Timothy Carter
2/20/2020
All of the comments are good provided the patient wants an implant. Given the medial-distal space and the apparent drift of the second molar this patient should get a 3 unit bridge instead. Assuming no ortho to upright the second molar
nalmoc
2/21/2020
As many has already mentioned it, CBCT is a must. Not only for clinical aspect of the case but also for legal aspect. If you feel comfortable with lateral window approach, you will need to retrieve the root tip and try to augment the sinus that way. The chance of sinus graft failure and implant failure in the future is most likely high due to possible endo sealant that we cannot see or bacteria from failed endo treated tooth. If possible get a dental surgeon (OS or Perio) involve. At this point I would not recommend an ENT consultation because I don't think it's needed yet unless patient is having sinus symptoms.
Greg Kammeyer, DDS, MS, D
3/2/2020
I agree that the root should be removed. Likely a source of chronic low grade bacteremia.
If you are comfortable with lateral window sinus grafting, this should be straight forward. If not an OMFS or Periodontist would be.
Carlos Boudet, DDS DICOI
3/2/2020
The patient's wishes may not be in his best interest in this case.
The root is not floating and could have been localized and removed prior to placing the implant.
Placing the implant without removing the root increases your chances of complications and places the implant in a position that also compromises the restoration.
Timothy Carter
3/2/2020
I am still curious as to why an implant had to be placed in this case with the obvious loss of M-D space. It seems that a bridge would be appropriate.
Mwjddd,ms
3/2/2020
This is a difficult situation all the way around. Do not let the patients wishes over rule your better judgement. You're the professional. This is not a case for a three unit bridge because the premolar has endo and a shaky looking post. Not a good bridge abutment. An implant is a good solution but not when it's angled like this. Also, the cover screw is not seated. Better treatment is to remove the root, graft sinus (if needed via lateral or osteotome technique) then place the implant correctly. I always plan for long term success, not short term expediency.
Frank
3/2/2020
1-The cover screw is not fully in place. Did you screw iot more?
2-Impression taking will be difficult if I am not mistaken about the angled implant and the molar beeing in the way.
I thik this is a bad compromise. In one appointmentbyou could have removed the root, grafted the sinus and placed the implant.
Why compromise like this?
It is not the standard of care I would want for my patients or my familly.
Maite Moreno Delgado DDS
3/2/2020
In the short term, I suggest sincerely a carefull removal of the root, considering that it is an infected item that may lead to more seriuous subsequent conditions in the patients body. If possible in a hospital and with at least one night stay, bacterial test and specific antibiotics prescribed. In the long term, then think in dental implants.
DLJ
4/20/2020
Please Doctors , use some common sense..
Is this situation asystematic? any swelling? how does this present clinically? Think!
Health History.. how long has the root been there?
If all is negative... leave it , and periodically follow up..
sometimes the best treatment is no treatment..... you will learn after years of
experience....
implant could have been placed more vertical so angle of abutment and crown is positioned /angled more favorable .. for what it is worth now, possibly angled abutment crown it and be done
Jere & Peggy Johnson
6/16/2020
I absolutely agree with DLJ. Whoever displaced this root into the antrum was clearly negligent in failing to inform your patient and taking action to get it removed. However, it is symptom free, there is no sign of infection, it is lying below the sinus membrane and the cross-sectional imaging shows it is partly enclosed in bone. There is no indication to remove it but it is essential you cover your back by pointing it out to your patient and explaining there is a risk, albeit extremely small, of future infection.
You have managed to avoid it with your implant placement and sinus lift, but the implant is badly angled. It will probably need a custom designed angled abutment and a crown.
Incidentally, it's just as well that the ENT surgeon your patient saw did not attempt to remove the root via an endoscopic approach - he would have had a heck of a job finding it!
