Sinus Perforations Following Teeth Extractions

A common, but preventable complication following extraction of upper posterior teeth: Perforation of maxillary sinus with potential sinusitis or persistent oral-antral-fistula (OAF).

The issue is that peri-apical x-ray is a poor imaging tool for assessment of the relationship of sinus floor to roots (second premolars to third molars). Many extractions are done without thorough assessment of this relationship which can lead to sinus perforation complications resulting in chronic disease.

If the sinus floor is noted to be ‘curving’ around the roots or if there is a periapical lesion on a PA x-ray, a CBCT should be obtained for proper diagnosis and planning. Here is the protocol we recommend in high risk cases:

✅ Recognize high risk cases (periapical lesions, ‘curving’ of the sinus floor around roots, low sinus floor)
✅ Obtain a CBCT
✅ Discuss the potential complication with patient and advise of treatments necessary should perforation be encountered
✅ Be prepared for management of sinus perforation using the 3-layer socket grafting technique
✅ Provide detailed sinus precaution instructions
✅ Provide appropriate post-operative antibiotics
✅ Monitor healing closely with 10 day and again in 3 weeks follow up appointments.

With proper diagnosis and preparation, such complications can be prevented and leave patients happy and healthy.

One more pearl: extraction of endodontically-treated teeth are the most difficult as teeth become brittle and fracture quite easily during extraction. Retrieval of roots in such situations adds another risk factor if displaced into sinus.

Dr. H. Ryan Kazemi is a board-certified oral and maxillofacial surgeon in Bethesda, MD