|Year : 2015 | Volume
| Issue : 3 | Page : 117-122
Maxillary sinusitis as a complication of infected dens invaginatus in maxillary lateral incisor: A case report
Paras Mull Gehlot, Vinutha Manjunath, Mysore Krishnaswamy Manjunath
Department of Conservative Dentistry and Endodontics, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
|Date of Web Publication||28-Aug-2015|
Paras Mull Gehlot
Department of Conservative Dentistry and Endodontics, JSS Dental College and Hospital, JSS University, Sri Shivarathreeshwara Nagar, Mysore - 570 015, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Maxillary sinusitis can have various origins, including odontogenic origin. Case Report: We describe a case of maxillary sinusitis in a 25-year-old female patient who experienced pain and swelling in the right maxillary region as a complication of infected maxillary lateral incisor. Clinical and radiographic examinations revealed dens invaginatus (DI; Oehler's type III) associated with apical pathosis in the maxillary right lateral incisor, with a large periapical lesion involving the adjacent four teeth. Nonsurgical root canal treatment using calcium hydroxide medicament was carried out for all five teeth, which resulted in gradual diminution of sinusitis, and the patient remained asymptomatic. Discussion: This paper emphasizes the following: (i) the challenges posed by DI for root canal treatment because of its anatomical complexity; (ii) a nonsurgical approach in the management of a large periapical lesion, using calcium hydroxide medicament; and (iii) the interdisciplinary management of conditions of common clinical concern for medical and dental practitioners, for successful outcome.
Keywords: Dens invaginatus (DI), dental operating microscope, dental origin, endodontic treatment, maxillary sinusitis, nonsurgical treatment, tooth malformation
|How to cite this article:|
Gehlot PM, Manjunath V, Manjunath MK. Maxillary sinusitis as a complication of infected dens invaginatus in maxillary lateral incisor: A case report. Dent Hypotheses 2015;6:117-22
|How to cite this URL:|
Gehlot PM, Manjunath V, Manjunath MK. Maxillary sinusitis as a complication of infected dens invaginatus in maxillary lateral incisor: A case report. Dent Hypotheses [serial online] 2015 [cited 2021 Jan 18];6:117-22. Available from: http://www.dentalhypotheses.com/text.asp?2015/6/3/117/163817
| Introduction|| |
The close anatomic proximity of the root apices of teeth to the maxillary sinuses makes dental disease a potential source for the spread of disease into the maxillary sinuses. , The cause of maxillary sinusitis of odontogenic origin is approximately 10-12%. , The likely routes of infection or injury to the maxillary sinus due to odontogenic causes are:
Dens invaginatus (DI) is a developmental anomaly of teeth occurring due to a deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissues.  There is controversy regarding the factors responsible for DI. However, a few proposed factors are the distortion of the enamel organ during tooth development, rapid and aggressive proliferation of part of the internal enamel epithelium invading the dental papilla, and focal failure of the growth of internal enamel epithelium.  The maxillary lateral incisors are the most commonly involved teeth and the reported prevalence of adult teeth affected with DI is 0.3-10%.  Oehler classified invaginations into three classes depending on their extent on radiography from the crown into the root.  Type I is a minor form occurring within the confines of the crown, not extending beyond the level of the external cementoenamel junction (CEJ). Type II is characterized by invagination extending apically beyond the CEJ and never reaching the periodontal ligament or periradicular tissue. Type III is characterized by invagination extending through the root, communicating laterally (Type III A) or apically (Type III B) with the periodontal ligament. There is usually no communication with the pulp. The first clinical sign of DI is the presence of a deep lingual pit, but diagnosis is made on the basis of radiographic evidence.  The invagination allows the entry of irritants, such as bacteria, into the area that is separated from the pulpal tissue only by a thin layer of enamel and dentin; this predisposes to development of dental caries and pulpal and periapical pathosis. ,
- Periapical granuloma or cyst;
- Iatrogenic, with instruments extending beyond the apex during root canal treatment;
- Iatrogenic oroantral fistula, during extraction of maxillary posterior teeth;
- Periodontal disease. 
A periapical lesion may develop, possibly evolving from a microbial infection into a chronic inflammatory lesion. Periapical or radicular cysts are inflammatory jaw cysts affecting the teeth with infected and necrotic pulp. These cysts occur as the direct sequelae of chronic apical periodontitis.  Because of the anatomical complexity, endodontic treatment of teeth with DI can be challenging to the clinician.
We present a referred case of maxillary sinusitis of dental origin, with a large periapical lesion associated with five maxillary teeth (with type III dens in the lateral incisor), which was managed with a conservative, nonsurgical approach.
| Case Report|| |
A 25-year-old female patient was referred for dental consultation by a private ear, nose, and throat (ENT) specialist. The patient gave a history of having undergone nasal surgery (Caldwell-Luc) for foul odor, swelling, and discharge from the nose 2 months earlier. However, the nasal discharge recurred and was associated with intraoral swelling and pain. On examination, a large swelling was noted over the roof of the mouth on the right side, present since the past 10 days. On palpation, the intraoral swelling was tender, soft, and fluctuant [Figure 1]a]. The occlusion was normal and there were no missing teeth; mild enamel hypoplasia was noted, with deep caries present in relation to the maxillary right second premolar. Teeth nos. 11, 12, 13, 14, and 15 were tender to vertical percussion, and responses to thermal and electric pulp tests were negative. The adjacent teeth, i.e., 21 and 16 showed a positive response to pulp vitality testing. On closer examination, the clinical crown of the maxillary right lateral incisor was larger mesiodistally, compared to the contralateral tooth, with a prominent cingulum and the presence of a foramen cecum [Figure 1]b]. Intraoral radiographic examination with relation to 11, 12, 13, 14, 15, and 16 revealed type III dens invagination of the right maxillary lateral incisor, obliterated pulp canal of right maxillary central incisor, and a large periapical radiolucency extending from the right maxillary central incisor to the right second premolar [Figure 2]a, 2d, and [Figure 3]a].
|Figure 1: Clinical photographs of right maxillary lateral incisor. (a) Palatal swelling (b) Palatal view showing deep pit (foramen cecum) (arrow) (c) Access to invagination and first regular (distal) canal (asterisk) (d) Opening for second regular canal (mesiopalatal) (arrow) (e) Final configuration of three canals (f) Canal orifices after obturation|
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|Figure 2: Intraoral periapical radiographs (a) Preoperative-right maxillary lateral incisor with invagination and large periapical radiolucency (b) Postoperative - three canals of right maxillary lateral incisor obturated with thermoplasticized gutta-percha technique (c) Postoperative - obturation of 11, 12, 13, 14, and 15 (d) Preoperative - right maxillary canine, first and second premolar (e) Postoperative - obturation of first and second premolar|
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|Figure 3: Intraoral occlusal radiographs (a) Preoperative (b) Follow-up (6 months)|
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The initial, preoperative coronal computed tomography (CT) scan originally advised by the ENT specialist revealed an ill-defined radiolucent (hypodense) lesion extending from the anterior teeth to the premolar region. Anterior bulging of right nasal floor was evident, extending till premolar region. Thickening of the lining of the right maxillary sinus and also obliteration of the inferior and middle conchae, causing blockage of sinus opening, were evident [Figure 4]a-f]. The findings were suggestive of an infected radicular cyst. However, aspiration biopsy was suggestive of an inflammatory cyst.
|Figure 4: CT scan images: coronal sections in anteroposterior direction, showing different aspects of periapical pathology and its extension|
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A diagnosis of type III DI (type III B) in relation to the maxillary right lateral incisor and chronic apical periodontitis in relation to 11, 12, 13, 14, and 15 was established. The treatment planning consisted of nonsurgical endodontic treatment-the patient was very apprehensive and slightly upset because the previous surgery (by the ENT specialist) had not given her any relief, and thus she did not consent to undergo one more surgery in the same region. Endodontic treatment was initiated in teeth nos. 11, 12, 13, 14, and 15 under rubber dam. Spontaneous drainage of pus was noted in 12, 13, 14, and 15. The working length was determined and the canals were slightly overinstrumented with a no. 10-size K-file (Mani Inc., Tochigi, Japan). The canals were cleaned and shaped, and intracanal calcium hydroxide dressing (RC Cal. Prime Dental Pvt Ltd., Thane, India) was placed in all the teeth and temporized. On the subsequent visit, the patient was asymptomatic and obturation was done by the lateral condensation technique [Figure 2]c and e].
The endodontic treatment for the right maxillary lateral incisor was carried out under a dental operating microscope (OPMI pico, Carl Zeiss, Oberkochen, Germany). In the first session, access to the invagination and one regular (distal) root canal was gained [Figure 1]c]. On the subsequent visit, an opening was detected, which was identified as a second regular canal (mesiopalatal) [Figure 1]d]. Access to the three canals was widened using Gates Glidden drills nos. 2, 3, 4, and 5 (Mani Inc., Tochigi, Japan) [Figure 1]e]. Following working length determination, canal irrigation was performed with 1% sodium hypochlorite using passive ultrasonic activation (Varios 750, NSK Nakanishi Inc., Tochigi, Japan). After repeated intracanal calcium hydroxide dressing, the tooth was asymptomatic and the canals were obturated with warm gutta-percha technique (Elements Obturation Unit, SybronEndo, Orange, California, USA) [Figure 1]f and [Figure 2]b]. A 6-month follow-up revealed the initiation of osseous healing [Figure 3]b]. However, long-term follow up was not possible, as the patient migrated to a different place, and this is one of the limitations of our report.
| Discussion|| |
Sinusitis (rhinosinusitis) is an infection of the maxillary sinus and, based on the signs, symptoms, and course of the disease, can clinically be classified as acute, subacute, recurrent, and chronic. , Due to close proximity of the maxillary sinus floor to the root apices of the posterior maxillary teeth, the symptoms associated with maxillary sinusitis can be mistaken for those of pulpal/dental origin.  An examination that elicits discomfort on palpation of the infraorbital region in addition to a diffuse, unilateral, lingering pain in the maxillary teeth is highly suggestive of maxillary sinus involvement.  In addition, pain that varies with changes in head position is suggestive of sinusitis. Also, percussion sensitivity of the maxillary posterior teeth can provide valuable information for diagnosis. However, in the absence of concurrent pulpal disease, these teeth will respond as normal to vitality testing procedures.
In the present case, the patient reported to an ENT specialist for the initial treatment, due to nasal discharge; she underwent a surgical procedure, and on the recurrence of swelling she was subsequently referred to a dental hospital. Thus patients who initially seek consultation with ENT specialists may have an intraoral condition, such as a periapical abscess, periodontal infection, deep caries in a maxillary posterior tooth, or the recent extraction of tooth, which may be the primary cause of a sinus problem. Hence, an ENT specialist should be aware of the possibility of odontogenic infections spreading from the teeth into the neighboring maxillary sinus, producing symptoms of both dental and sinus disease. Patients who have dental problems may initially present with conditions such as periapical abscess, periodontal infection, deep cavities in teeth in the posterior maxillary, or a recent extraction.  If a periapical dental infection or dental/oral surgery procedure violates the integrity of the Schneiderian membrane, infection will likely spread into the sinus, leading to sinusitis. 
In the present case, the maxillary lateral incisor was affected by the developmental anomaly DI; it got infected, leading to periapical infection. The lateral incisor is the most likely cause of the periapical lesion, which expanded to involve the adjacent teeth (11, 13, 14, and 15) in the quadrant. There was no site of entry for microbial infection, except for the maxillary second premolar that was asymptomatic with deep caries, indicating that the tooth had become nonvital because of the periapical infection. However, the periapical pathology in the maxillary premolar that was due to deep caries and pulpal involvement could have contributed to the broader pathology in this case.
The treatment options for large periapical lesions range from conventional nonsurgical root canal treatment with long-term calcium hydroxide therapy to various surgical interventions.  It is a general belief that large cyst-like periapical lesions and apical true cysts caused by root canal infection are less likely to heal after nonsurgical root canal therapy. 
Periapical surgery (enucleation with apicoectomy) was considered initially, but the patient did not consent to undergo the surgical procedure. Additionally, the disadvantages of this treatment included the need to perform apicoectomy of all affected teeth, possibly resulting in damage to the floor of the nose or the maxillary sinus,  and alteration of the crown-root ratio. Hence, a judicious treatment planning favored an initial non-surgical conservative approach. 
Root canal infection is the primary cause of cyst-like periapical lesions, regardless of size.  The rationale for a nonsurgical approach to the management of large cyst-like lesions was suggested by Bhaskar, in view of the fact that if instruments are extended 1 mm beyond the apical foramen, the inflammatory reaction that develops destroys the cyst lining and converts the lesion into a granuloma. Once the causative factors (root canal infection) are eliminated, the granuloma heals spontaneously.  Bender has added that penetration of the apical area to the center of the radiolucency might help in resolution by establishing the drainage and relieving pressure.  Some endodontists maintain that true cysts (those containing cavities completely enclosed by epithelial lining) can be successfully treated only by surgical means,  but the current endodontic philosophy for the treatment of large periapical lesions involves initial use of nonsurgical root canal treatment.  Caliskan in a long-term study demonstrated that nonsurgical root canal treatment using calcium hydroxide in teeth with cyst-like large periapical lesions containing cholesterol crystal can be an alternative treatment to surgical therapy.  Due to its antimicrobial action and ability to stimulate tissue repair, calcium hydroxide was used as an intracanal medicament before obturation. ,
Other conservative options include surgical decompression, a procedure used to reduce large, periapical lesions without periapical curettage.  In the present case, the patient gave a history of surgery (Caldwell-Luc) by an ENT specialist that had reduced the swelling after the procedure; however, after a few days the swelling and nasal discharge recurred, as the dental infection, which was the primary cause of pain and swelling, had not been eliminated.
Teeth with DI pose challenges for root canal treatment because of their anatomical complexity.  Several treatment regimens have been suggested for teeth affected by DI, such as prophylactic or restorative treatment, conventional root canal treatment, combined root canal and surgical treatment, and intentional replantation and extraction. ,,, Treatment of a tooth with type III DI, extending to the apical area, and associated large, periradicular lesion is usually complicated.  Historically, nonsurgical root canal treatment has been considered impractical with type III DI because of the challenge in adequately cleaning the root canal without the removal of dens.  However, technological advancements in operating microscopes and ultrasonic instruments have now made this option possible. , Utilization of a dental operating microscope is useful at this stage because it provides magnification and better illumination of the canal system. , The use of cone-beam computed tomography (CBCT) in the diagnosis, management, and follow-up of teeth with anomaly has been beneficial.  The large and irregular canal volume of DI makes proper shaping and cleaning difficult.  Hence, irrigation supported by ultrasonic cleaning of root canals has been recommended to improve debridement of the complex root canal space.  Obturation with warm gutta-percha techniques, such as vertical condensation or thermoplastic filling technique, has been recommended.  However, if the apical anatomy is not conducive to gutta-percha techniques, then a mineral trioxide aggregate (MTA) apical barrier could be placed, followed by backfill with gutta-percha.  If endodontic treatment fails or is deemed impossible, apical surgery may be required.
| Conclusion|| |
- In this era of superspecialization, interdisciplinary consultations play a very important role prior to diagnosis or treatment planning. The close proximity of the maxillary sinus to the oral cavity makes it a common clinical concern for ENT specialists and dental practitioners.
- DI can be easily be overlooked, as it can present with anatomical variations, and many of the patients with this anomaly are asymptomatic.
- Hence, clinicians should be aware of this anomaly when patients present with pulpal or periapical lesions, in the absence of any history of trauma or primary/secondary caries.
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The authors do not have any financial support.
Conflicts of interest
There are no conflicts of interest.
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