I'm posting this just to review how this complication can be managed. This gentleman was referred to my oral surgery practice because the dentist at a corporate emergency dental clinic inadvertently pushed a maxillary second molar root (#15) into the maxillary sinus. He is a nonsmoker and takes no medications.

[image:Pre_op_Panorex.jpg]

I re-anesthetized the area well, and irrigated out the socket and confirmed that there were indeed no roots in the alveolar ridge. I could see a 4x4 mm hole at the apex of the mesiobuccal socket where there was no longer any sinus mucosa. I created a buccal flap by making a releasing incision that started just mesial to the socket and extended apcially and anteriorly. I used a round bur to enlarge the existing perforation enough that I could then pass a Frasier suction into the sinus, and I tried to blindly grab the root with the end of the suction, to no avail. Before enlarging the hole any further, I decided to get a CBCT to help my localize the root better so I knew which direction the suction needed to go.

[image:Coronal_CBCT.jpg]

Seeing that the root was quite medial and superior, I enlarged the hole further so that I could pass a larger oral surgery suction in that direction, and was able to retrieve the root.

Next it is important to obtain primary closure over the sinus perforation. A buccal advancement flap works well for this. I made another releasing incision just distal to the socket, not quite as long as the first one, and then scored the flap periostium with the back of a scalpel. Once I had enough laxity in the flap, it was brought across the socket and sutured to the palatal side with Vicryl suturers (long lasting dissolvable) and the releasing incisions were reapproximated with chromic gut sutures (medium duration dissolvable).

My sinus precautions for the patient are to avoid intraoral positive pressure (like blowing up a balloon) or negative pressure (sucking on a straw) for three weeks. I ask smokers to stop for a year. Okay, I really tell them to do as much as they can to stop for the first three weeks. I warn them that they may have some bloody nasal discharge on the affected side for a couple days. I tell them not to panic if they drink a fluid and some of it escapes out the nostril -- however that should go away once the flap has healed like it should. The buccal flap usually creates some facial swelling that can be addressed with ice packs. I will prescribe pain medications and a prophylactic antibiotic for 5-7 days. I will re-evaluate them at three weeks post-op to verify that they are healing well. All patients are told that if their sinus repair breaks down that they may need a secondary procedure in the future.

This patient had no insurance, and the referring doctor had generously volunteered that their office would pay for his services. This included CBCT D0364, sinusotomy for root retrieval D7560, and primary closure of a sinus perforation DD7261. I thought that the most diplomatic thing for me to do was to charge 50% of the normal fees, and the referring dentist was very pleased with that.

In situations like this I always comment to the patient that every good doctor can -- and will -- have complications, and that I hope they don't hold any bad feelings for their referring doctor. The most important thing is to recognize the problem, and make sure that anything that should be done to address it professionally. As long as you explain what has happened and that you will do everything possible to make it better, then the patient knows you have their best interests at heart.