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Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 35-38

A rare case of vestibular sinus tract: A periodontist enigma

Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication1-Jul-2016

Correspondence Address:
Disha Nagpal
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-4696.185191

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Sinus tract occurs commonly in teeth with periapical/periodontal infection but the formation of a vestibular opening, causing esthetic compromise and food lodgement, is uncommon. Definitive treatment of a chronic sinus tract requires treatment of the original problem, that is, the necrotic pulp treated by endodontic therapy or by extraction of the tooth. However, at times endodontic therapy may not be adequate necessitating periodontal intervention. The present case had vestibular opening communicating with root canal of concerned tooth appearing ten years after trauma. The diagnosis of such cases can only be made after careful evaluation and the treatment plan has to be modified from the conventional. The success of such cases depends on the regular follow up as presented here and careful observation after each phase of treatment.

Keywords: Odontogenic infection, sinus tract, vestibular opening

How to cite this article:
Nagpal D, Bhushan K, Prakash S. A rare case of vestibular sinus tract: A periodontist enigma. J Dent Allied Sci 2016;5:35-8

How to cite this URL:
Nagpal D, Bhushan K, Prakash S. A rare case of vestibular sinus tract: A periodontist enigma. J Dent Allied Sci [serial online] 2016 [cited 2023 Jan 30];5:35-8. Available from: https://www.jdas.in/text.asp?2016/5/1/35/185191

  Introduction Top

One of the most difficult problems to understand and manage in dentistry are odontogenic infections which may be low-grade, well-localized infections that require only minimal treatment, to life-threatening fascial space infections.[1] The various sources are pulp necrosis, periodontal infections, pericoronitis, or trauma.[2] Sinus is a tract leading from an enclosed area of inflammation to an epithelial surface and is one of the sequelae of inflammatory disease.[3] This is rarely accompanied by pain or swelling because of pus drainage. However, when diagnosed, it may be the only sign of pathology and should not be overlooked.[4]

A rare case of vestibular opening in the lower front teeth region communicating with root canal of mandibular left central incisor appearing 10 years after trauma is presented here with treatment and follow-up.

  Case Report Top

A 60-year-old female patient reported to the dental outpatient department with a chief complaint of discolored lower front tooth and an opening in the same area near the lip since 2 years [Figure 1]. Patient gave a history of fall 10 years back, but the tooth was asymptomatic then. The patient was a known hypertensive since 12 years and on regular medication for the same.
Figure 1: Preoperative clinical view

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On clinical examination, mandibular left central incisor was found to be discolored. A sinus opening was noted in the labial vestibule. Intraoral periapical showed a periradicular radiolucency [Figure 2]. The root canal therapy was instituted immediately for discolored tooth during which it was found that the irrigant which was flushed into root canal drained out through the opening in the vestibule. Calcium hydroxide was used as an intracanal medicament. The root canal was obturated with gutta-percha using lateral condensation technique [Figure 3]. The patient was observed for the next 2-3 months.
Figure 2: Preoperative radiograph (intraoral periapical)

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Figure 3: Radiograph immediately after completion of root canal treatment

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The periradicular radiolucency subsided [Figure 4] but the vestibular opening was still present. Patient now complained of food lodgement in the same area and its unesthetic appearance requiring periodontal intervention. The surgical access was gained through the opening already present [Figure 5]. It was then widened mesiodistally for better visualization and instrumentation, and a sinus opening was seen just below the concerned tooth [Figure 6]. A thorough curettage was done through the same [Figure 7]. It was planned to follow a minimally invasive surgical technique. After the debridement, the area was closed using 5-0 vicryl sutures (simple interrupted) [Figure 8] and the periodontal dressing was placed [Figure 9]. After 1 month, the area healed completely, and the opening no longer persisted. Three months postsurgery (6 months follow-up), the vestibular opening has been closed, and periradicular area healed [Figure 10] and [Figure 11].
Figure 4: Radiograph just before surgical access

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Figure 5: Surgical access gained through sinus opening already present

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Figure 6: Surgical access widened mesiodistally and a sinus opening seen below the concerned tooth

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Figure 7: A thorough curettage done through sinus opening

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Figure 8: Surgical site closed using vicryl sutures after debridement

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Figure 9: Periodontal dressing placed

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Figure 10: Three months postsurgery (6 months after the first visit). Note that sinus opening is no longer evident

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Figure 11: Three months postsurgery (radiographic view)

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  Discussion Top

The sinus tract in the oral cavity is usually considered to be of pulpal origin, but it can also be caused by periodontal disease.[2] On the basis of clinical appearance, the differential diagnosis of such a lesion includes pustules, actinomycosis, osteomyelitis, pyogenic granulomas, furuncles, neoplasms, squamous cell carcinomas, epidermal cysts, chronic tuberculosis, and gumma of tertiary syphilis.[5] In the present case, the apparent cause of sinus formation was pulp necrosis in mandibular left central incisor. Although the tooth was intact with no carious lesion and with no periodontal attachment loss, the pulp necrosis might have occurred as a consequence of an accidental trauma. In the mandible, infections of anterior teeth usually erode through the labiocortical plate and above the associated musculature, resulting in vestibular abscess which is a most common odontogenic infection. Sometimes the abscess establishes a chronic sinus tract that drains to the oral cavity; the patient will thus experience no pain and seek no treatment.[1]

Definitive treatment however requires treatment of the original problem, that is, the necrotic pulp treated by endodontic therapy or by extraction of the tooth.[1] In the present case, however, an attempt has been made to save such a tooth. In this case, it is peculiar that patient did not give a history of any vestibular/periapical abscess formation immediately after the trauma and 9 years following trauma, a vestibular opening developed.

Most of the cases reported in the literature with primary endodontic and secondary periodontic involvement show that the lesions usually heal completely after endodontic treatment without any periodontal treatment.[6] However, in the case reported here 2-3 months after the adequate endodontic treatment although healing of periradicular tissues was satisfactory elicited by decrease in size of radiolucency, still the lesion did not heal completely as sinus opening was still present. This communication was esthetically disturbing, caused food lodgement and could lead to reinfection, thus, necessitating its closure through periodontal intervention.

Since there was a decrease in periapical radiolucency following endodontic treatment, the absence of any bony defect in the apical area, and the obturating material did not extrude through the canal, apicoectomy was contraindicated.[7]

  Conclusion Top

Pulpal and periodontal problems are responsible for more than half of the tooth mortality.[8] In the case of secondary periodontal involvement, root canal therapy is instituted immediately and the results evaluated after 2-3 months to see if periodontal intervention is required. Prognosis of such a lesion depends on periodontal treatment and patient response.[6] This case report presents a rare case where an interdisciplinary approach is required for the treatment of a chronic lesion. Sometimes, the usual treatment protocol is not adequate, and thus the treatment has to be modified accordingly.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Flynn RT. Principles of management and prevention of odontogenic infection. In: Miloro M, Larsen P, Ghali GE, Waite P, editors. Peterson's Principles of Oral and Maxillofacial Surgery. Hamilton, Ontario: BC Decker; 2004. p. 409-35.  Back to cited text no. 1
Herrera D, Roldán S, Sanz M. The periodontal abscess: A review. J Clin Periodontol 2000;27:377-86.  Back to cited text no. 2
Loomba A. Sinus tract mimicry: A case report. J Oral Health Community Dent 2011;5:52-5.  Back to cited text no. 3
Slutzky-Goldberg I, Tsesis I, Slutzky H, Heling I. Odontogenic sinus tracts: A cohort study. Quintessence Int 2009;40:13-8.  Back to cited text no. 4
Cherrick HM, Wood NK. Pits, fistulas and draining lesions. In: Wood NK, Goaz PW, editors. Differential diagnosis of oral lesions. St. Louis, Baltimore: CV Mosby Co.; 1985. p. 199-201.  Back to cited text no. 5
Sunitha VR, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal — Endodontic continuum: A review. J Conserv Dent 2008;11:54-62.  Back to cited text no. 6
Johnson BR, Fayad MI, Witherspoon DE. Periradicular surgery-management of root end. In: Hargreaves KM, Cohen S, Berman LH, editors. Cohen's Pathways of the Pulp Expert. St. Louis, Missouri: Mosby Elsevier; 2011. p. 747.  Back to cited text no. 7
Bender IB. Factors influencing the radiographic appearance of bony lesions. J Endod 1982;8:161-70.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]


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