Postextraction sinus lining prolapse
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A 67 year old man presented for treatment of a “fractured tooth”. The maxillary right second molar crowned tooth had drifted into the site of the previously extracted first molar. It had sustained distal caries that weakened the mesiodistal and palatal roots and was deemed unrestorable. The proximity of the antrum and radiographic opacification was noted on the periapical radiograph. After local anesthesia (1.6cc articaine 4%, Septocaine), the tooth was sectioned using an air driven surgical handpiece and #558 surgical burrs. The roots were carefully removed, and the socket inspected and carefully debrided. No sinus perforation was found. A collagen plug was placed in the socket and retained with a 3-0 chromic suture. Since no sinus lining perforation was found, no sinus instructions were instituted.

After 4 weeks, the patient presented with a complaint of a soft yellow protrusion that he was able to push back into the healing socket but would not stay in place (Figures 2 and 3). Upon examination, the red and yellow protrusion was pushed up into the socket but immediately again protruded with respiration. There was no pain or bleeding nor airflow communication with the sinus. The lesion appeared to be an obvious prolapse or herniation of the sinus lining. Cutting into the prolapsed lining or biopsy was deemed contraindicated due the risk for an oral antral fistula formation.

The protruding soft lining was carefully cleaned with chlorhexidine (Peridex) and rinsed with saline. The prolapsed lining was pushed superiorly into the socket to the perceived level of the sinus floor and held with two collagen plugs. A buccal fat pad pedicle flap was made and held with mattress technique 3-0 black silk sutures for primary closure (Figures 4 and 5). Sinus care instructions were given that included no nose blowing and proper sneezing technique. The patient returned in 10 days for suture removal. There was no pain, signs of infection, or oral antral communication.

After 5 weeks at follow up, the patient reported sensing a small perforation at the wound site. There was no air flow communication. This was monitored in hopes of a spontaneous complete closure. Oral amoxicillin clavulanic acid (Augmentin, Sandoz) was instituted for 1 week along with an over the counter sinus decongestant nasal spray, oxymetazoline (Afrin), and instructions. The patient was followed for 3 additional weeks. The site healed uneventfully with no oral antral communication or fistula (Figure 6). After 10 postoperative weeks, there has been no occurrence of an oral antral communication or prolapse.Caries was subsequently treated, and the patient prescribed a fluoridated oral daily rinse (0.2% neutral sodium fluoride, Prevident Rinse, Colgate).

Source:https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.3505?af=R
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