Large lesion extending into sinus: advice?

Last Updated: Feb 04, 2019

I have begun the initial work-up started on this patient. There are several issues that I see we need to work through. Most of us are doing cone beam ct imaging and now we can see the full extent of the lesion. I was curious about:
1- If there has been any research on the success or limitations with endo based on the size and extent of the lesion? It would be good to know some odds going forward so this can be part of the evaluation and conversation in treatment planning.
2- I know several on this site have treated this type of extension into the sinus. Is this an OS and ENT sequenced procedure assuming the tooth is coming out? Any experience here or advice would be helpful. Do you extract, do minimal curettage or aggressive curettage? Do you wait and revaluate changes in the sinus, and if so, how long do you wait and what are you looking for? Or is this not going to resolve and needs to be cleaned out via some access and would that be the plan?
3- When you have a maxillary molar that in your curettage and digital views has apparent granulation tissue into the sinus, how aggressive do you get with your curettage when you know there is a possibility you will, or could, perforate the sinus membrane and make things worse? In other words, will the lesion resolve itself?

14 Comments on Large lesion extending into sinus: advice?

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roadkingdoc

02/03/2019

I would ask whats wrong with a couple endos? The abutments look periodontaly sound.

Dr. Gerald Rudick

02/04/2019

I would agree with Roadking…...before considering extracting and playing in the sinus, I would opt for doing endodontics, and wait and watch to see if the lesion clears up by itself....good luck!!

Carlos Boudet, DDS DICOI

02/04/2019

It seems that the most conservative way to address this is to endodontically treat the affected teeth. The lesions should heal if the endo is done properly.

roadkingdoc

02/04/2019

My judgement tells me to let my trusted endodontist tackle this one and we treat many endo cases. With some luck you get the easy part a potential new bridge. To me alternative tx plan would be to remove both abutment teeth and place implants anterior to second molar resulting in first molar occlusion only. Good luck thanks for posting.

Dr Dale Gerke, BDS, BScDe

02/04/2019

You have posed a very interesting question in regards to endo treated teeth. Recently Dr Ove Peters, presented his finding on this subject to the RACDS (he reviewed many lesions post endo treatment using 3D scanning). His conclusion was that there were many “areas” which remained obvious after treatment and he categorised them. The vast majority remained non symptomatic but the question remained, were the areas pathological or simply a resolved area that had not ossified? Unfortunately the webinar I viewed is not available but I am sure if you Google Dr Ove Peters, DMD, MS, PhD you will find other webinars or papers published by him. I think his research will answer your questions.

Bill M

02/05/2019

Thanks for all of your inputs. Thanks Dr Dale The question is about predictability related to the size of the endo lesion in 3-D with endo treatment, Do any of you follow your cases with follow up CTs so you would actually know the changes in your lesion? The second part is how does an OS handle this extraction. I do a lot of surgery and I am aware of the ones that can impact my quality of life of which this is one. I will leave this to the specialist from both an endo and surgical perspective. I just wanted to add to my knowledge base. Is there a surgeon that would contribute to this question?

Vipul Shukla

02/04/2019

If the bridge is solid, i.e. not mobile and no periodontal pocket reading gives signs of a root fracture, then as noted by posters above, the diagnosis of chronic peri-apical periodontitis due to necrotic pulps can be made. Conservative two-appointment RCTs through the abutments with possibly an extra appointment in between for dressing change should take care of these two LEOs. For technique, ensure the cleaning and shaping extends not only to clinical apex, but slightly beyond. CaOH dressing should reach the end and make long intervals between appointments. Just before the obturation, agitate special anti-anaerobic solutions like Q-Mix 2 in 1 for 5 minutes for predictable results. When in doubt, refer to an endodontist. Patient will love you way more for a conservative non-surgical solution to this common scenario!

Vipul Shukla

02/04/2019

One more thing, the left side first molar roots need to be removed, and do consider socket preservation technique to make the site ready for an implant. Lastly, upper left second premolar needs endodontic testing. May be non-vital, needing another RCT. Lot of work here! Chop chop!

CRS

02/05/2019

Sorry as an Oral Surgeon who treats these successfully often I would advise referral to an experienced OMS who knows how to manage an oral antra communication repair. I would not waste time on endo since the bacteria are already seeding the sinus and bloodstream. You’ll realize I’m the only one telling you the truth. Watching and waiting on this just gives the inflammatory process a head start which can affect overall health including cardiac. Good luck and do the right thing for the patient.

Raul Mena

02/05/2019

The best endodontic instrument to test this case is called “FORCEPS” it is not only the periapical lesión and the sinus involvement , but also bifurcation involvement.

Dr. Gerald Rudick

02/05/2019

I personally know CRS, and she is a bright and talented oral surgeon......but lets just put age before beauty for just a moment......It was not that long ago, that Dr. Hilt Tatem Jr. showed us that we dentists could work within the sinus and get rid of pathological situations, and regenerate bone in order to place dental implants..... Endodontics has been around for a long time, and there are many documented cases such as these two teeth, that have been endodontically treated, and the teeth can be retained and the pathology will have disappeared......so I go by my initial suggestion and say try to keep the teeth, and do endodontics...and watch the situation over a few months......if the lesions do not clear up.... you can now start to believe in miracles and approach it from the sinus grafting approach, and smile when you hear Hilt's name mentioned; as well you can buy him a drink when you will see him at the next AAID meeting.

Bill

02/06/2019

Any inputs from endo on chances for success

Randy

02/06/2019

Keep it simple: treat the teeth endodontically and see how it resolves. I don't think that two periapical lesions are going to push a healthy patient over the edge as regards cardiac health. Also, it's much easier to treat mucogingival problems or bone loss affecting natural teeth than it is for implants, so keep the teeth if possible. You might look at the work of Dr. Danny Melker to see what is possible regarding long term (30 years plus) maintenance of what we might think of as "hopeless" teeth.

Dr Bill Woods

02/17/2019

I believe that most dental schools look toward both options for endo and or implants with s 5-15 year reasonable success rate in mind. I wouldn’t hesitate to perform endo on the bi. If endo is successful on the molar then great but I would not retreat it at all. Such a well circumscribed lesion looks as it would be easily corrected without violating the sinus membrane given the cortical plate surrounding it and would be a great recipient sight for a bone graft and implant later on. And as to Danny Melker’s course in Tampa, it was one of the best clinical courses I’ve ever attended.

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