UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4054
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Braz Dent Sci 2024 Jan/Mar; 27 (1): e4054
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Odontogenic maxillary sinusitis associated with foreign body
displacement after tooth extraction: report of an unusual case
Sinusite maxilar odontogênica por corpo estranho após extração dentária: relato de um caso incomum
Michelle Bianchi de MORAES1 , Luis Augusto de ALMEIDA-SILVA2 , Juliana dos Santos LUPP2 ,
Thayna Isabele Stopiello COSTA2 , Gieyse Nogueira de OLIVEIRA2 , Luiz Augusto Rodrigues dos SANTOS1 ,
Fernando Vagner RALDI1
1 - Universidade Estadual Paulista, Instituto de Ciência e Tecnologia de São José dos Campos, Departamento de Diagnóstico e
Cirurgia. São José dos Campos, SP, Brasil.
2 - Universidade Estadual Paulista, Instituto de Ciência e Tecnologia de São José dos Campos, Departamento de Biociências e Diagnóstico
Bucal. São José dos Campos, SP, Brasil.
How to cite: Moraes MB, de Almeida-Silva LA, Lupp JS, Costa TIS, Oliveira GN, Santos LAR, et al. Odontogenic maxillary sinusitis associated
with foreign
body displacement after tooth extraction: report of an unusual case. Braz Dent Sci. 2024;27(1):e4054. https://doi.org/10.4322/
bds.2024.e4054
ABSTRACT
Background: Odontogenic maxillary sinusitis caused by a foreign body presents diagnostic and therapeutic challenges due
to its infrequent occurrence and unique characteristics compared to sinusitis originating from other sources. Case Report:
Illustrating such fact, this report presents the clinical case of a 37-year-old woman referred complaining of pain in the same
region where she had extracted her upper right rst molar ve days before. The intraoral examination revealed the presence
of an orice in the region, suggesting oroantral communication. Imaging exams revealed opacication of the right maxillary
sinus and the unexpected presence of a highly radiodense object. With the diagnosis of maxillary sinusitis due to a foreign
body established, the surgical approach initially consisted of administering preoperative medication, preceded by access to
the maxillary antrum using the Caldwell-Luc technique. The object was found and removed, consisting of a surgical drill.
At follow-up there was complete absence of symptoms and complete closure of communication. Conclusion: Cases of
odontogenic maxillary sinusitis caused by drill detachment after tooth extraction are fairly uncommon. A thorough clinical
evaluation proved to be essential and the Caldwell-Luc access was effective, safe and with good postoperative results, even
with the absence of standardized diagnostic and management methods.
KEYWORDS
Foreign body; Maxillary sinusitis; Oral surgery; Oroantral stula; Retained surgical instrument.
RESUMO
Contexto: A sinusite maxilar odontogênica causada por corpo estranho apresenta desaos diagnósticos e terapêuticos
devido à sua ocorrência infrequente e características únicas em comparação com sinusites originadas de outras fontes.
Relato do Caso: Ilustrando tal fato, este relato apresenta o caso clínico de uma mulher de 37 anos de idade encaminhada
com queixa de dor em mesma região que havia extraído o primeiro molar superior direito cinco dias antes. Ao exame
intraoral vericou-se a presença de um orifício na região, sugerindo comunicação oroantral. Os exames de imagem revelaram
opacicação do SM direito e a inesperada presença de um objeto altamente radiodenso. Com o diagnóstico de sinusite maxilar
por corpo estranho estabelecido, a abordagem cirúrgica consistiu inicialmente na administração de medicação pré-operatória,
precedida pelo acesso ao antro maxilar através da técnica de Caldwell-Luc. O objeto foi encontrado e removido, consistindo
em uma broca cirúrgica. Ao acompanhamento houve ausência completa dos sintomas e total fechamento da comunicação.
Conclusão: Casos de sinusite maxilar odontogênica causada por descolamento da broca após extração dentária são bastante
incomuns. Uma avaliação clínica minuciosa mostrou-se primordial e o acesso de Caldwell-Luc ecaz, seguro e com bons
resultados pós-operatórios, mesmo com as ausências de métodos de diagnóstico e manejo padronizados.
PALAVRAS-CHAVE
Corpo estranho; Sinusite maxilar; Cirurgia bucal; Fístula oroantral; Instrumento cirúrgico retido.
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Braz Dent Sci 2024 Jan/Mar; 27 (1): e4054
Moraes MB et al.
Odontogenic maxillary sinusitis associated with foreign body displacement after tooth extraction: report of an unusual case
Moraes MB et al. Odontogenic maxillary sinusitis associated with foreign body
displacement after tooth extraction: report of an unusual case
INTRODUCTION
The paranasal sinuses are pneumatic
anatomical bone cavities composed of four groups:
the maxillary, ethmoid, frontal, and sphenoid
sinuses. Procedures performed near these sinuses
are common and can inadvertently cause injuries
to the mucosal lining, leading to an inammatory
process known as sinusitis. Among these cavities,
the maxillary sinus (MS) is the most affected, with
odontogenic origin as the most prevalent source
of maxillary sinusitis, caused by pathological,
traumatic or iatrogenic conditions such as insertion
of foreign bodies (FBs) [1-3].
Odontogenic maxillary sinusitis caused by
FB diagnosis is challenging due to its infrequency
and differences compared to sinusitis originating
from other sources. Failures in the systematic
clinical examination and in the request for
complementary imaging exams contribute to
the difculty in diagnosing this condition [3,4].
These negligence factors often complicate the
therapeutic approach, which typically involves
treating both sinusitis and the underlying
odontogenic cause, thereby prolonging and
worsening the patient’s clinical condition [1].
To highlight the diagnostic and therapeutic
challenges involved, this report presents an
unusual clinical case of odontogenic maxillary
sinusitis caused by the displacement of a surgical
drill in the MS after tooth extraction.
CLINICAL CASE
A female patient, 37 years old, with no
signicant medical history, was referred to the
Surgery and Diagnosis department, complaining
of headache, nasal congestion, pressure on
the right side of the face and pain in the same
region where her right upper first molar had
been extracted ve days earlier. On extraoral
examination, no facial alterations were identied.
However, during intraoral examination, an
opening was noted in the alveolar region of the
tooth, suggesting an oroantral communication.
For the initial evaluation, a panoramic
radiograph (PR) was requested, which revealed
a relative radiopacity in the right MS and a highly
radiopaque image parallel to the sinus floor
and perpendicular to the long axis of the teeth,
indicative of a spherical surgical drill (Figure 1).
Subsequently, cone-beam computed tomography
(CBCT) was performed to assess the position,
displaying three-dimensional axial, coronal, and
sagittal sections, demonstrating opacication of
the MS and the intensely hyperdense metallic
FB (Figure 2A, B, and C). Based on the clinical
and radiographic findings, the diagnosis of
odontogenic sinusitis resulting from a FB was
established.
To control the painful symptoms was
initially instituted the use of 3 drops of Decadron
(Dexamethasone 5mg + Neomycin 3.5mg +
Phenylephrine hydrochloride 5mg) three times
a day for three days. The surgical procedure was
scheduled for four weeks later, and the patient was
closely monitored during this period. On return
patient’s return, partial closure of the oroantral
communication was observed, although she
reported occasional pain relapses. One hour before
surgery, prophylactic administration of antibiotic
(Amoxicillin 500mg + Potassium Clavulanate
125mg) and steroidal anti-inflammatory drug
(Dexamethasone 4mg) was given to manage pain
and prevent infection.
Under local anesthesia with mepivacaine
hydrochloride 2% (20mg/mL) + epinephrine
1:100.000 (µg/mL), an incision was made over
the alveolar ridge, extending from the region of the
upper rst molar on the right side to the second
premolar and extending to the vestibular sulcus
of the canine tooth on the same side (Figure 3A).
After subperiosteal detachment, the anterior
maxillary bone portion was exposed and access was
performed using the Caldwell-Luc technique, which
consisted of osteotomy with a rotary instrument
and access to the MS cavity (Figures 3B and C).
The metallic instrument, corresponding to a
surgical drill, was found and accidentally sucked.
Figure 1 - PR showing an intensely radiopaque foreign body in the
floor of the right MS.
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Braz Dent Sci 2024 Jan/Mar; 27 (1): e4054
Moraes MB et al.
Odontogenic maxillary sinusitis associated with foreign body displacement after tooth extraction: report of an unusual case
Moraes MB et al. Odontogenic maxillary sinusitis associated with foreign body
displacement after tooth extraction: report of an unusual case
All secretion present inside the sinus were removed
by abundant irrigation with saline solution.
To confirm the removal of the surgical drill, a
transoperative PR was performed, which revealed
successful removal (Figure 4). Finally, the access
to the MS was closed using a collagen membrane
(Geistlich Bio-Gide®, 25 x 25 mm.) and the
surgical bed was sutured (Figure 3D).
Postoperatively, the patient continued with the
preoperative antibiotic and anti-inammatory therapy
for seven and two days, respectively. Additionally,
Lexoprofen 60mg was prescribed for five days,
along with three days of Decadron and ve days of
Figure 2 - A - CBCT in sagittal section showing the correct positioning of the object in the right MS; B and C - CBCT in coronal and axial
sections showing, respectively, an intensely hyperdense image surrounded by an opaque area in the right MS.
Figure 3 - A - Incision and detachment region; B and C - Surgical access to the MS using the Caldwell-Luc technique; D - Closure of the access
with a collagen membrane.
Figure 4 - Transoperative PR showing successful removal of the drill
previously present in the right MS.
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Braz Dent Sci 2024 Jan/Mar; 27 (1): e4054
Moraes MB et al.
Odontogenic maxillary sinusitis associated with foreign body displacement after tooth extraction: report of an unusual case
Moraes MB et al. Odontogenic maxillary sinusitis associated with foreign body
displacement after tooth extraction: report of an unusual case
Rinosoro® (Sodium Chloride 9mg, Benzalkonium
Chloride 0.1mg, and Distilled Water q.s.p. 1mL)
for external use. The suture was removed after
seven days, showing satisfactory signs of healing in
the operated region and oroantral communication
(Figure 5A, B and C). After fteen days, complete
remission of symptoms, along with full repair and
closure, were observed (Figure 5D).
DISCUSSION
The development of MS begins in the third
month of fetal life and ends with the eruption of
permanent teeth between 12 and 14 years of age,
when it reaches an average volume of 15 to 20 ml.
Although these dimensions remain relatively
stable, some individuals present continuous
expansion and pneumatization, what projects
the sinus oor towards the maxillary alveolar
bone [5]. This characteristic provides an intimate
anatomical proximity of the MS to the roots of
the upper molars and premolars, increasing the
probability of complications, such as oroantral
communication, which occurs more frequently
after tooth extraction, becoming a gateway for
FB [1].
While literature reports the iatrogenic
insertion of various dental materials in the MS,
the displacement of drills is a rare occurrence.
In a literature review by Hara et al. [6] examining
treatment methods for FBs in the MS, it was
found that out of the 402 cases investigated, only
19 (4.7%) involved different dental equipment,
including drills. Similarly, in the retrospective
study of foreign bodies of dental iatrogenic origin
displaced in the maxillary sinus conducted by
Tilaveridis et al. [7], there was 1 case (3.7%) of
iatrogenic displacement of a dental bur among
the 27 cases identied. The persistence of these
FBs can lead to sequelae, such as sinusitis [6].
Currently, the diagnostic criteria for
odontogenic sinusitis are extremely heterogeneous,
as demonstrated in the systematic review conducted
by Allevi et al. [8], wherein the radiographic
criterion was the most used, revealing the need
for more comprehensive clinical evaluations
and highlighting the diagnostic challenge of this
pathology. In addition to sinusitis, other sequelae
such as mucous cyst, FB granuloma and, in more
severe cases, pneumonia or lung abscess due to
pneumatic aspiration, reasons why preventive FB
removal is widely recommended [9].
Figure 5 - A - Appearance of the sutured tissue 7 days after the surgical procedure; B - Occlusal view of the tissue showing closure of the
oroantral communication after 7 days; C - Aspect of the mucosa without sutures, after 7 days; D - Mucosa showing complete healing and
closure of the oroantral communication 15 days after the surgical procedure.
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Braz Dent Sci 2024 Jan/Mar; 27 (1): e4054
Moraes MB et al.
Odontogenic maxillary sinusitis associated with foreign body displacement after tooth extraction: report of an unusual case
Moraes MB et al. Odontogenic maxillary sinusitis associated with foreign body
displacement after tooth extraction: report of an unusual case
Standardized management methods for
removing objects displaced to MS are scarce
in the literature, which makes it difficult to
assess the effectiveness of different therapeutic
approaches [10]. Factors such as FB size and
location inuence the appropriate choice [11]. It is
suggested that functional endoscopic sinus surgery
be considered the gold standard for the treatment
of FB in MS [8]. However, the inability of most
dental professionals to perform this procedure [10]
and the need for ample visualization of the cavity
are disadvantages of this technique [12]. These
aspects are not observed when Caldwell-Luc
surgical access technique is employed, which
offers ample space for the removal of FBs of
different sizes and positions [12], which is why
this technique was used in this report.
CONCLUSION
Odontogenic maxillary sinusitis caused by
drill detachment after tooth extraction is an
infrequent event. The need for surgical planning
to avoid or predict oroantral communication is
evident, especially in approaches involving upper
posterior teeth. With the lack of established
diagnostic criteria, a complete clinical and
radiographic evaluation become mandatory
procedure. Although further studies are needed
to standardize management methods, the
Caldwell-Luc technique has been shown to be
effective, safe and with good postoperative results
in removing the FB.
Author’s Contributions
MBM: Conceptualization, Methodology,
Software, Validation, Formal Analysis and
Writing – Original Draft Preparation. LAAS:
Software, Investigation and Writing – Original
Draft Preparation. JSL: Investigation and Writing –
Original Draft Preparation. TISC: Software and
Data Curation. GNO: Writing – Review & Editing.
LARS: Writing – Review & Editing. FVR: Project
Administration, Conceptualization, visualization,
Formal Analysis and supervision
Conict of Interest
The authors have no proprietary, nancial,
or other personal interest of any nature or kind
in any product, service, and/or company that is
presented in this article.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-for-prot sectors.
Regulatory Statement
This report followed the ethical principles
of research in human beings, having been
submitted and approved by the Ethics Committee
in Research in Human Beings of the Faculty of
Dentistry of São José dos Campos – UNESP, under
protocol CAAE: 70969823.4.0000.0077.
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Braz Dent Sci 2024 Jan/Mar; 27 (1): e4054
Moraes MB et al.
Odontogenic maxillary sinusitis associated with foreign body displacement after tooth extraction: report of an unusual case
Moraes MB et al. Odontogenic maxillary sinusitis associated with foreign body
displacement after tooth extraction: report of an unusual case
Juliana dos Santos Lupp
(Corresponding address)
Universidade Estadual Paulista, Instituto de Ciência e Tecnologia de São José dos Campos,
Departamento de Biociências e Diagnóstico Bucal. São José dos Campos, SP, Brasil.
Email: Juliana.lupp@unesp.br
Date submitted: 2023 Sept 19
Accept submission: 2024 Jan 15
