Treatment difficulties in the upper second molar with sinus involvement – clinical case report

Introduction

Current dental treatments are based on increasingly complex techniques. Innovation in this field is very easily accepted, with new treatment methods being discovered every year. The emergence and development of new equipment and medical materials also contribute to this situation.

The maxillary sinus represents an anatomical entity whose floor exhibits recesses extending between individual roots of maxillary teeth that can present conditions of dental origin. The symptoms of these conditions are very evident, often having a major impact on the quality of life⁽¹⁾. Frequently, the maxillary sinus penetrates between the roots of the teeth, their apices being part of the sinus floor⁽²⁾.

Teeth with sinus relation are, in the descending order of their involvement frequency in sinus pathology: first molar, second molar, third molar, first premolar and, less commonly, the canine⁽¹⁾.

Current endodontic therapy consists of three basic steps: the diagnostic stage, in which the pathology is identified and a treatment plan is created, the second stage, in which the root canals are prepared by removing their contents and the endodontic space will be shaped to receive the canal filling, and the third stage, the actual root canal filling, in which the endodontic space is filled with an inert material to ensure a good seal⁽³⁾.

Clinical case

A 47-year-old female patient presented to the dental office with radiating pain in the left maxillary arch and in the area of the left maxillary sinus. The pain was spontaneous, continuous, very severe and, also, caused by hot and cold stimuli. An objective exam revealed a vital 27 tooth, with a coronal filling and secondary tooth decay on the occlusal and distal surfaces of the tooth. The tooth had intense pain upon biting and percussion, without fistula. The initial radiography revealed an intact periapical bone and a large coronal destruction, covered by composite filling (Figure 1). Also, the tooth had a proximity to the maxillary sinus. The diagnosis of irreversible pulpitis was made.
 

Before starting the treatment, the informed consent was obtained from the patient.

At the first appointment, after local anesthesia, access cavity was performed using a round diamond ISO 16 high-speed bur, under rubber dam isolation. All interferences from hard accessing of the pulp chamber were eliminated with Endo-Z bur (Dentsply Sirona) until smooth chamber walls were obtained. Coronal interferences in the initial part of the root canals were eliminated using ultrasonic devices: the ultrasonic tip ET 20 and Newtron Booster Acteon (Acteon Satelec, Switzerland). Due to the complexity of the case, only the palatal canal and the distal-buccal canal were rotary prepared until X2 Protaper Next instrument (25.06) (Dentsply Sirona) in the first appointment. The mesiobuccal canal was enlarged ultrasonically with ET 20 tip and manually in the coronal part using ISO 10 and 17 Profinder Senseus files (Dentsply Sirona), till the files had enough space to negotiate the apical part of the canal. Moreover, the glide path was performed using ProGlider instrument (Dentsply Sirona) for this canal.

The working length was determined using apex locator (VDW Gold GmbH, Munich, Germany). The canals were irrigated with 2 ml 2.5% sodium hypochlorite using a 30 G needle placed at 1 mm shorter than working length, after each rotary instrument used. An inter-appointment treatment with calcium hydroxide was applied, and a temporary coronal filling with Ketac Molar (3M ESPE, Germany) was set.

For the mesiobuccal canal, a supplementary radiography was necessary to confirm the working length, placing a 20 ISO gutta-percha cone inside the canal (Figure 2).
 

At the second appointment, the palatal canal was rotary prepared until X3 (30.06) instrument and the mesiobuccal canal until X2 Protaper Next instrument (25.06).

Final irrigation consisted of 5 ml 2.5% sodium hypochlorite, sonic agitation using the Endoactivator instrument (Dentsply Sirona), followed by 5 ml EDTA 17%. Then, the canals were flushed with 5 ml saline solution, dried with paper points and obturated using the continuous wave technique and AH Plus sealer (Dentsply Sirona), avoiding any overextension with sealer or gutta-percha. A temporary coronal filling with Ketac Molar (3M ESPE, Germany) was set, and the patient was advised to do the postoperative radiography (Figure 3).
 

The patient was recalled after five days for final restoration. At the clinical examination, we recorded the absence of pain or tenderness to percussion, no bite-discomfort, and the absence of pain to palpation. The final composite restoration was applied.

After four years, the patient presented for dental problems to another tooth, and on this occasion, we were able to see a new radiograph of the tooth (Figure 4). At the clinical examination, we recorded the success of the endodontic treatment, along with the absence of pain, no loss of function or bite-discomfort, and a good quality of coronal restoration.
 

Discussion

The success of endodontic treatment performed on maxillary teeth that have a relationship with the maxillary sinus depends on the quality of the chemomechanical treatment and canal obturation, which have implications both on the causative tooth and its periapical bone, as well as on the nearby maxillary sinus.

It is essential to avoid accidents that may occur during an endodontic treatment, such as penetration beyond the apex into the maxillary sinus with endodontic files, irrigation solutions, medicaments, or filling materials. In case of pulpal inflammation, the instrumentation and filling should be confined to the root canal⁽⁵⁾.

Teeth with old coronal filling and secondary caries tend to deposit secondary and tertiary reactive dentin at the entrance of the root canals, in order to reduce inflammation spreading in the root canals⁽⁵⁾. In the clinical case, a large part of the working time in the first session was dedicated to removing coronal interferences at the entrance of the root canals. This allowed access to the root canals and the creation of a glide path. The most difficult to open was the mesiobuccal canal, where the largest deposit of secondary dentin was present. The use of ultrasonic tips in these cases and the radiological confirmation of the working length of the canal are essential. Additionally, the second molar is located more distally in the arch, making treatment more challenging and dependent on the extent of mouth opening⁽⁶⁾.

In case of difficulties in preparation, the treatment cannot be completed in a single session, although it is recommended and we would like it to be so. However, the most important thing is to perform the treatment correctly, even though it takes multiple sessions. In this case, the endodontic treatment was completed in two sessions due to the complexity of the case. Both in the canal preparation and filling, accidents and incidents that could affect the maxillary sinus were avoided.

Maintaining the long-term result of treatment depends on the accuracy of execution, as well as the integrity of the coronal restoration, which in this clinical case were very good.

Conclusions

The endodontic treatment of the upper second molar must take into account its relationship with the maxillary sinus. The therapeutic procedures should be performed with great precision, avoiding the occurrence of accidents and incidents that may lead to dental-related conditions of the maxillary sinus.

Acknowledgements. Author Mihai Mitran had the same contribution as the first author.

Autori pentru corespondenţă: Irina-Maria Gheorghiu E-mail: irina.gheorghiu@umfcd.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.