What is the recommended treatment for an impacted molar tooth protruding into the left maxillary sinus antrum?

Management of Impacted Maxillary Molar Protruding into the Maxillary Sinus

For an asymptomatic impacted maxillary molar protruding into the maxillary sinus, the recommended approach is initial observation with periodic radiographic monitoring, reserving surgical extraction only for symptomatic cases or when complications develop. 1

Initial Diagnostic Workup

Imaging Protocol

• Obtain CBCT imaging immediately to fully assess the three-dimensional relationship between the impacted molar and the maxillary sinus floor, as 2D panoramic imaging is significantly inferior for evaluating these critical anatomical relationships 1

• CBCT is specifically indicated as the essential imaging technique for assessing the relationship between upper molars and the maxillary sinus floor, with strength of recommendation A 1

• The CBCT should be as targeted as possible following the ALARA principle to minimize radiation exposure while providing adequate surgical planning information 1

Clinical Assessment

• Evaluate for any signs or symptoms of sinusitis including facial pain, nasal obstruction, mucopurulent drainage, headache, tenderness, decreased sense of smell, or nasal bleeding 1

• Document whether the tooth is completely asymptomatic, as this significantly influences management decisions 1, 2

• Assess for any history of recent dental procedures, trauma, or infection that may have contributed to the impaction 3, 4

Treatment Algorithm

For Asymptomatic Cases

Monitor conservatively with periodic radiographic follow-up every 2 years, as spontaneous resorption can occur over time without major pathological changes 2

• This approach is supported by case reports demonstrating that impacted deciduous and permanent molars in the maxillary sinus can undergo nearly complete resorption (up to 90%) over 7-year follow-up periods without intervention 2

• Continue monitoring until complete resorption or until symptoms develop 2

For Symptomatic Cases

Proceed with surgical extraction using a modified Caldwell-Luc intraoral approach when the patient experiences sinusitis symptoms, pain, swelling, or other complications 1, 4

• The intraoral approach is preferred over functional endoscopic sinus surgery because it preserves intranasal anatomy, does not remove the uncinate process, and does not enlarge the natural ostium 1

• Perform copious saline irrigation of the surgical site to remove debris and reduce infection risk 1

• Achieve primary tension-free closure of the soft tissue envelope 1

Medical Management Considerations

Initiate antibiotic therapy (3-4 weeks) if odontogenic sinusitis is present, ensuring coverage for both aerobic and anaerobic organisms including anaerobic streptococci, Bacteroides, Proteus, and Coliform bacilli 3

• Odontogenic sinusitis accounts for approximately 10-12% of maxillary sinusitis cases and requires extended antibiotic coverage compared to standard sinusitis therapy 3

• If symptoms persist despite medical therapy, surgical intervention becomes necessary 3

Critical Decision Points

When to Operate vs. Observe

Surgery is indicated only when:

• Patient develops symptoms of sinusitis (pain, discharge, obstruction) 1, 3
• Medical management of sinusitis fails after appropriate antibiotic trial 1
• Radiographic evidence shows progressive pathological changes rather than resorption 2
• Oroantral communication develops 1, 3

Observation is appropriate when:

• Patient remains completely asymptomatic 1, 2
• No signs of infection or sinusitis are present 2
• Serial imaging shows stable or regressing tooth structure 2

Common Pitfalls to Avoid

• Do not rely solely on panoramic radiography for treatment planning, as it dramatically underestimates the true anatomical relationships and cannot adequately assess the extent of sinus involvement 1

• Avoid premature surgical intervention in asymptomatic cases, as this creates unnecessary surgical trauma and risk of complications including chronic sinusitis, oroantral fistula, and sinus obliteration 1, 2

• Do not use functional endoscopic sinus surgery as first-line surgical approach, as patients may experience long-term complications including water entering the sinus during swimming due to uncinate process modification 1

• Ensure adequate antibiotic duration (3-4 weeks minimum) if treating odontogenic sinusitis medically, as shorter courses frequently fail 3

Postoperative Management (If Surgery Performed)

• Prescribe systemic antibiotics given the removal of material from contaminated sinus space 3

• Instruct patient to avoid nose blowing for at least 1 week and restrict flying, diving, forceful sneezing for at least 6 weeks 5

• Recommend saline nasal sprays throughout the day to maintain moisture and facilitate healing 5

• Schedule close follow-up to monitor for proper mucosal healing, recurrent bleeding, or signs of persistent sinusitis 5

• Advise immediate return if fever >101°F, increasing pain, vision changes, or facial swelling develops 5