Analysis of post-extraction consequences of posterior maxillary molars on antral sinus in periodontitis patients: A preliminary qualitative two dimensional panoramic study (Prevalence study)

Sinus pneumatization is a continuous physiological process that occurs naturally and causes an increase in the volume of paranasal sinuses. Pneumatization is also frequently observed following extraction of teeth in the posterior maxilla. This leads to an increase in the sinus volume and height at the expense of the edentulous alveolar ridge. These changes may affect treatment planning if dental implants are indicated to replace extracted teeth. Using a novel method to align and compare two panoramic radiographs taken before and after tooth extraction, we aimed to examine post-extraction dimensional changes in the maxillary sinus and alveolar ridge by superimposition of preand post-treatment panoramic radiographs. Twenty-two pairs of panoramic radiographs were analyzed retrospectively for changes in alveolar ridge and maxillary sinus dimensions following at least 6 months from tooth extraction. Pre- and post-extraction radiographs were matched and then superimposed using a fixed reference unit. Measurements included the distance from bone-crest to sinus-floor and to sinus-roof, as well as distance from sinus-floor to sinus-roof and maxillary-sinus sagittal circumference. The mean difference between pre- and post-extraction bone-crest to the sinus-floor radiographic measurements was statistically significant ($P =$ 0.001) with a mean change of 1.2 mm. The difference between pre- to post-extraction bone-crest to sinus-roof measurements was insignificant ($P =$ 0.094) with a mean change of 0.9 mm. The distance between pre- and post-extration sinus-floor to sinus-roof was significantly increased in an average of 1 mm ($P =$ 0.001) along with an increase in sinus sagittal circumference from 993.9 $\pm $ 295.7 mm to 1096.6 $\pm$ 312.5 mm ($P <$ 0.0001). In conclusion, a moderate increase in maxillary sinus dimensions concurrent with crestal resorption may be anticipated after extraction of maxillary posterior teeth, leading to an overall decrease in alveolar bone height.

Closure of Oroantral Communications: A Review of the Literature

Extraction of Maxillary Teeth Using Articaine Without a Palatal Injection: A Comparison Between the Anterior and Posterior Regions of the Maxilla

A group of 43 patients requiring tooth extraction after radiotherapy for nasopharyngeal carcinoma (NPC) was studied retrospectively to determine the incidence of post-extraction complications. It was found that because of the method used in the delivery of radiation, extraction of maxillary posterior teeth resulted in the greatest risk of complications (28.9 per cent), including a 10.5 per cent risk of osteoradionecrosis (ORN). Based on the findings, a protocol was established for the dental care of such patients. It was concluded that when extraction of maxillary posterior teeth was necessary, prophylactic antibiotics were not sufficient to prevent the complication of delayed healing. The risk of ORN was 10.5 per cent within the field of maximal radiation dose. Hyperbaric oxygen may be the better choice of preventive measures. However, in view of the low risk of ORN, wholesale prescription of hyperbaric oxygen therapy may not be indicated. An additional patient who had tooth extraction two weeks prior to radiotherapy was included to show that if adequate time for wound healing was not allowed, ORN could develop.

Introduction: extraction of maxillary posterior teeth is considered one of the main cause of Oroantral communication (OAC) due to the close proximity of the roots to the maxillary sinus. Aim of study: Evaluation of Buccal Pad of Fat versus Leukocyte Platelet Rich Fibrin (L-PRF) in the management of oroantral communication. Materials and Methods: This study was carried out on twelve patients with oroantral communication. They were divided into two equal groups, six patients in each. In Group I, the patients were treated with buccal fat pad technique. While in group II, the patients were managed with L-PRF technique for OAC closure. Patients were followed up for 1,3,5,7 days post-operative then weekly for 4 weeks. Results: There was significant difference between the two groups regarding pain, and swelling however, no significant difference between both groups regarding infection during different follow up periods. No recurrence for the oroantral communication was observed in all patients of both groups after 4 weeks postoperatively. Conclusion: The goal of closing an oroantral communications was to prevent infection of the maxillary sinus through separating the oral cavity from maxillary sinus .

Materials and Methods: The present study included 2165 patients (2500 teeth were extracted) attending Oral Surgery clinic of the teaching hospital at College of Dentistry/ Mustansiriyah University during the period from October 2016 to May 2017. The patients’ ages ranged between (15-77 years). A standard case sheet for Oral Surgery clinic was filled with all the necessary information such as age, gender, tooth to be extracted and reasons of tooth extraction.
 Results: Dental caries and its complications were the primary cause of teeth extraction with (80.3%) followed by periodontal diseases (13.4) and other causes (6.4%). Tooth extraction due to dental caries was higher in males (59.2%) than females (40.8%). Tooth extraction due to periodontal diseases was also high in males (72.2%) compared to females (27.8%) with high significance (p= 0.000). In age groups 30-39 years and 40-49years, extraction due to dental caries was found equally high being 22.4%, while extraction due to periodontal diseases was high in age group ≥60 (38.3%) and in age group 50-59 (32.6%) with high significance (p = 0.000). Extraction of maxillary posterior teeth constituted (44.9%) and mandibular posterior teeth (37.8%), the posterior teeth were the most common teeth extracted because of caries, while mandibular anterior teeth (27.5%) followed by maxillary posterior teeth (26.6%) were the most common teeth extracted due to periodontal diseases with high significance (p = 0.000).
 Conclusion: Dental caries was the primary cause for tooth extraction followed by periodontal diseases. There was a significant correlation between the reasons for tooth extraction and the patient’s gender, age and tooth position. The study showed the need for a comprehensive preventive plans and effective educational campaigns to reduce the need for tooth extraction among adults and increase patient’s awareness toward better oral health status.

Oroantral fistula (OAF) refers to a permanent connection between oral cavity and maxillary sinus. The extraction of maxillary posterior teeth is the most common reason of OAF. Multiple techniques are available to repair this defect. The most used procedures involving local flaps include buccal flap, buccal fat pad (BFP), and palatal rotating flap. We here present an original technique of management of oroantral fistula with displacement of the root into sinus using BFP.

INTRODUCTION: Oroantral fistula is an epithelialized, pathological and unnatural communication between the oral cavity and the maxillary sinus. OBJECTIVES: The aim of this study was to evaluate the use of buccal antrostomy bone as a graft for closure of oroantral fistula clinically and radiographically. MATERIALS AND METHODS: A prospective study was done on 10 patients complaining of oroantral fistulae following extraction of maxillary posterior teeth. The bony defect of the oroantral fistula was closed by anterior wall of maxillary sinus as a graft material and fixed to the surrounding bone using N-Butyl-2-Cyanoacrylate (Histoacryl®), then covered by buccal advancement flap. The patients were followed up clinically after 4, 6, 8 and 12 weeks postoperatively Radiographic evaluation was performed by cone beam computed tomography (CBCT) preoperatively and after 12 weeks postoperatively. RESULTS: Evaluation of the patients revealed that proper healing of the wound occurred in most of the patients except in 3 patients whose bone graft was exposed and removed. Radiographicaly, significant amount of bone was formed comparing the preoperative and postoperative CBCT of the patients. CONCLUSIONS: According to the results of the present study, it is concluded that the use of the buccal antrostomy wall as a bone graft fixed with N butyl cyanoacrylate proved successful results in closure of large oroantral fistula.

Oroantral communications (OACs) are frequently iatrogenic, most commonly occurring after the extraction of maxillary posterior teeth in close proximity to the maxillary sinus. They may also result from tumor surgery, implant placement, trauma, or orthognathic surgery involving the maxilla. An untreated OAC creates a pathological communication between the oral cavity and the maxillary sinus, often leading to maxillary sinusitis and a significant deterioration in the patient’s quality of life. Numerous surgical techniques have been described for the management of OACs, ranging from mucosal flap procedures to the use of bone substitutes or highly conservative alternative methods. However, recurrence after treatment has been reported, and selecting the most appropriate technique according to the clinical situation remains challenging. This study aims to highlight the usefulness of a pedicled buccal fat pad flap in the reconstruction of oroantral communications.

For many dental patients, palatal injection proves to be a very traumatic experience. Diverse methods have been suggested to reduce the discomfort of palatal injection. Nevertheless, the reliability of these methods is not obviously evident and they are not found to be universally effective. The desirable method to evade pain during palatal injection is just not to have one. Hence, the present study aims at investigating if lidocaine hydrochloride could provide palatal anesthesia in maxilla when only a buccal infiltration anesthesia is done for teeth extraction. One hundred and fifty patients requiring extraction of maxillary teeth were included in the study. Patients were randomly allotted to two groups, study and control. Patients in study group received a single buccal infiltration of 1.5mL of lidocaine with epinephrine for extraction of maxillary teeth. Patients in control group received 1.5mL of buccal and 0.3mL of palatal infiltration of lidocaine with epinephrine for the extraction. After achieving adequate palatal anesthesia the tooth was extracted with consistent technique. Pain level experienced by the patients during injection procedure and during tooth extraction was rated in an 11-point pain rating scale. Time taken to achieve palatal anesthesia following a single buccal infiltration of anesthetic solution was evaluated by regular pin-prick evaluation of palatal tissues. The overall success rate of palatal anesthesia achieved with a single buccal infiltration is 81.3%. The success rate reduced as we proceed from anterior to posterior maxilla. Time taken to achieve successful palatal anesthesia by single buccal infiltration is 7-9min. The extraction of permanent maxillary anterior teeth and premolars is possible by depositing local anesthesia to the buccal vestibule of the tooth without palatal supplementation. However, the extraction of permanent maxillary posterior teeth with similar technique would result in fewer success rates suggesting its avoidance.

PurposeThe aims of this study were first, to compare panoramic radiography with cone-beam computed tomography (CBCT) for evaluating topographic relationships, such as the classification of maxillary posterior teeth and their distance to the maxillary sinus floor; and second, to determine the relationship between maxillary sinus pathology and the presence of apical lesions.Materials and MethodsIn total, 285 paired CBCT and panoramic radiography records of patients (570 maxillary sinuses) were retrospectively analyzed. Both imaging modalities were used to determine the topographic relationship of the maxillary posterior teeth to the sinus floor. Mucosal thickening >2 mm was considered a pathological state. Data were analyzed using the chi-square, Wilcoxon, and Mann-Whitney U tests. Odds ratios (ORs) and confidence intervals (CIs) were calculated.ResultsThe closest vertical distance measurements made between posterior maxillary teeth roots and the maxillary sinus on panoramic radiography and CBCT scans showed statistically significant differences from each other (P<0.05). Compared to panoramic radiography, CBCT showed higher mean values for the distance between the maxillary sinus floor and maxillary posterior teeth roots. The CBCT images showed that at least 1 apical lesion adjacent to the right maxillary sinus increased the risk of maxillary sinus pathology by 2.37 times (OR, 2.37; 95% CI, 1.58-3.55, P<0.05).ConclusionPanoramic radiography might lead to unreliable diagnoses when evaluating the distance between the sinus floor and posterior roots of the maxillary teeth. Periapical lesions anatomically associated with maxillary sinuses were a risk factor for sinus mucosal thickening.

To measure and analyze the thickness of the maxillary sinus mucosa under different relationships between the maxillary posterior teeth apex and the maxillary sinus floor on cone beam CT (CBCT). A total of 987 patients requiring implant surgery due to dentition defect or loss were selected from Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from January 2020 to December 2022. The maxillary posterior teeth most closely related to the maxillary sinus were observed on CBCT, the tooth position and root apex were recorded, and the vertical distance between the apex of the posterior tooth and the base of the maxillary sinus was measured. According to the distance between the root apex and the maxillary sinus floor, the posterior teeth were divided into three categories: Class Ⅰ: the distance between the root apex and the maxillary sinus floor (d ＞0 mm); Class Ⅱ : the root apex was attached to the maxillary sinus floor and the cortical bone of the maxillary sinus floor was continuous (d=0 mm); Class Ⅲ : apical protrusion into the maxillary sinus floor(d＜0 mm). The thickness of the thickest part of the maxillary sinus floor mucosa was measured. The distance between the root and the maxillary sinus floor and the thickness of the maxillary sinus mucosa were compared under different root-sinus floor relationship, and the correlation analysis was performed. SPSS 26.0 software package was used to analyze the data. Among the 1974 maxillary sinuses of 987 patients, there were 450 maxillary sinuses with Class I relationship between the posterior root apex and the maxillary sinus floor, while 126 (28%) of the maxillary second molar proximal root and the maxillary sinus floor were the most closely related. In ClassⅠrelationship, the average distance from root to the maxillary sinus floor was (2.9±2.7) mm, and the average thickness of the maxillary sinus mucosa was (2.9±4.0) mm. There was no correlation between the distance from root to the maxillary sinus floor and the thickness of the maxillary sinus mucosa. There were 808 maxillary sinuses with ClassⅡ relationship between the posterior root apex and the maxillary sinus floor, among which 132 (16.3%) maxillary first molars had the closest relationship with the maxillary sinus floor. In Class Ⅱ relationship, the average thickness of the maxillary sinus mucosa was (3.0±4.6) mm. There were 249 maxillary sinuses with Class Ⅲ relationship between the posterior tooth root apex and the maxillary sinus floor, among which 87 (34.9%) palatal roots of the maxillary first molar were the most closely related to the maxillary sinus floor. The average distance from the root to the maxillary sinus floor was (-1.9±-1.4) mm, and the average thickness of maxillary sinus mucosa was (2.4±4.9) mm. There was a positive correlation between them (r=0.18, P=0.004). The most common relationship between the posterior maxillary tooth apex and the maxillary sinus floor is Class Ⅱ. The palatal root of the first molar is most closely related to the maxillary sinus floor, the mesiobuccal root of the second molar ranks second. The thickness of the maxillary sinus mucosa varies on the relationship between the different maxillary posterior teeth apex and the maxillary sinus floor. The average thickness of the maxillary sinus mucosa in Class Ⅲ is thicker than Class Ⅱ and Class I. In Class Ⅲ, as the distance from the apices to the maxillary sinus floor increases, the thickness of maxillary sinus mucosa increases.

To test whether or not alveolar ridge preservation reduces vertical changes in the posterior maxilla compared to spontaneous healing following tooth extraction. Forty subjects requiring extraction of maxillary posterior teeth with root apices protruding into the maxillary sinus floor were consecutively enrolled. Patients were randomly assigned to either one of two surgical interventions: an alveolar ridge preservation procedure using collagenated bovine bone mineral and a resorbable collagen membrane (test) or no grafting (control). Cone-beam computed tomographies were taken immediately and at 6months after surgery, prior to dental implant placement. Based on radiographic data, the level of the sinus floor remained stable over time (baseline to 6months) in the test group (-0.14mm [-0.31, -0.02]). In the control group, the sinus floor level shifted more coronally (-1.16mm [-1.73, -0.61]) than the test group (p<0.05). The test group demonstrated a significantly larger residual bone height than the control group at 6months (7.30mm [6.36, 8.20] vs. 4.83mm [3.94, 5.76], respectively, p<0.05). Implant placement without any additional sinus augmentation procedure was performed in 42.9% of test group cases, whereas in all of the subjects in the control group an additional augmentation procedure was needed (100% of the cases). Alveolar ridge preservation in the posterior maxilla maintained the vertical bone height more efficiently and resulted in less need for sinus augmentation procedures at 6months compared to spontaneous healing.

Is CBCT Helpful in Estimating the Risk for Oroantral Communication During Maxillary Posterior Tooth Extraction?

Even after the invention of the modern injection techniques, palatal injection still remains a painful experience for patients, and this pain is attributed to the presence of rich nerve complement and displacement of palatal mucosa during anesthesia. The aim of the present study was to demonstrate if lidocaine HCl could provide palatal anesthesia if given buccally during maxillary tooth removal without the need for a palatal injection. The study group consisted of 75 patients, and 25 were controls. All the patients in the study group had unilateral extractions. In 75 patients, 2 ml of 2% lidocaine HCl with 1:80,000 epinephrine was injected into the buccal vestibule of tooth indicated for extraction without palatal injection. After 8 min, the extraction of maxillary tooth was carried out. Twenty-five subjects in the control group underwent same protocol with palatal injection. All the patients completed a faces pain scale (FPS) and a 100 mm visual analog scale (VAS) after extraction. Unpaired t test and Chi-square test. According to VAS and FPS scores, when comparison was carried out between permanent maxillary tooth removal with and without palatal injection, the difference in the pain levels were not statistically significant (P>0.05). The extraction of permanent maxillary tooth is possible by depositing 2 mL of lidocaine to the buccal vestibule of the tooth without the need for palatal anesthesia.