Dentaltown New Grad Edition 2019 - 36

Fig. 1: Preoperative periapical radiograph
of maxillary right third molar tooth.

Fig. 2: Radiograph taken immediately after
crown fractured off roots during extraction
procedure.

Fig. 4: CBCT axial slice through tooth #1 socket
clearly demonstrates root within the alveolar
socket and lack of perforation into the maxillary
sinus.

Case 1
A 53-year-old woman presented to her dentist with pain in
her upper right third molar. The tooth was fully erupted and had
a restoration with recurrent decay (Fig. 1). A decision was made
to remove the tooth. The dentist gave local anesthesia and applied
dental elevator and forceps. Because of the decay, the crown fractured
off, and the dentist spent the next 30 minutes trying to remove
the remaining roots. He obtained a new periapical radiograph to
determine how much root remained (Fig. 2).
He continued working away until the situation changed drastically.
He was sure that he had pushed the root into the maxillary sinus,
because he saw "something yellow" coming out of the socket, which
he assumed was sinus fluid. An urgent phone call was made to my
office and the patient was sent to see me, accompanied by one of
his dental assistants.
To get a better assessment of the location of the root and its
position in the right maxillary sinus, a CBCT scan was taken when
the patient arrived at my office. Figs. 3 and 4 make it apparent that
the root was still in the socket and not in the sinus.
Then what was this report of a yellow fluid coming out of the
extraction socket? My clinical exam immediately solved the mystery.
There was a bright yellow, lobular soft solid mass coming from the
buccal vestibule, just distal to the socket (Fig. 5). It took mere seconds

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NEW GRADS 2019 // dentaltown.com

Fig. 3: Panoramic CBCT projection shows
residual root still present in alveolar socket.

Fig. 5: Clinical intraoral photograph shows
extrusion of the buccal fat pad from the
maxillary right third molar surgical site.

to make the diagnosis: This dentist had just been introduced to the
buccal fat pad. Reflection of the flap had perforated the buccinator
muscle and exposed this normal anatomical structure.
Under local anesthesia, the exposed buccal fat pad was resected,
the remainder packed superior to the buccinator muscle, and the
mucosa was sutured closed. The root of tooth #1 was then easily
removed.
So, what do we learn, and what concerns does this case raise? I
have no issue with the dentist trying to remove the erupted tooth.
That is something easily done by most general dentists. The first
issue is continuing for 30 minutes and muddling through repeated
attempts to elevate a stubborn tooth without a plan. This only
fatigues the patient and the dentist, and the case rarely ends well.
In absence of more advanced training, this doctor should have
referred the patient much earlier.
Secondly, exposing the buccal fat pad is also not an issue.
Oral surgeons do it all the time when removing deeply impacted
high third molars. The difference is that we know the anatomy
of the area we are working in, know that buccal fat pad exposure
is a risk and do our best to avoid it, and then know immediately
what to do if it happens. Thirdly, the inability to distinguish the
difference between yellow sinus drainage versus globs of fat is a
concern. No clinician should ever begin any procedure unless they
are intimately familiar with the biological and anatomical terrain.
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