Figure 4 Photographs of clinical appearance on both buccal and palatal
sides; A1) Pre-operative, buccal view; A2) Pre-operative, palatal view;
B1) 6-month follow up, buccal view; B2) 6-month follow up, palatal view;
C1) 9-month follow up, buccal view; C2) 9-month follow up, palatal vie
Discussion
Considering the proximity of the apices to the lingual or palatal plate
in mandibular and maxillary molars, the presence of lingual or palatal
fistula is to be anticipated more probably than buccal (9). A single
fistula is typically observed; however, bilateral sinus tracts are
commonly associated with vertical root fractures (10). There was no
previous case reporting bilateral sinus tracts in a non-fractured tooth.
The case presented here highlights the importance of thorough diagnostic
evaluation and the potential for unusual presentations in dental
practice.
A correct diagnosis is often considered three-fourths of the remedy,
emphasizing the importance of accurately determining the origin of a
lesion (odontogenic or non-odontogenic) for effective management.
Patients with odontogenic lesions in atypical locations may undergo
numerous surgical excisions, radiotherapy sessions, multiple biopsies,
and various antibiotic treatments. However, since these treatments do
not address the odontogenic origin of the lesion, the sinus tract
frequently recurs (11).
Previous studies highlighted the need for timely intervention and the
benefits of using imaging techniques for accurate diagnosis (12, 13).
Cone beam computed tomography (CBCT) is particularly useful in
diagnosing complex endodontic issues. It provides a three-dimensional
view of periapical lesions and surrounding anatomical structures (14).
However, in the present case, due to the unsuccessful root canal
therapy, Clear periapical lesion, not accepting the patient to receive
radiation, as well as the patient’s concerns, due to financial regards,
CBCT evaluation was not done. However, clinical evaluation of probing
depth helped rule out the VRF diagnosis.
Once a dental origin is correctly diagnosed, several differential
diagnoses should be considered, including tumors (15), cysts (16), or a
simple chronic dental infection. Treatment for odontogenic lesions can
range from non-surgical approaches to more advanced surgical procedures.
When a sinus tract persists, the well-epithelialized cord-like tissue
often hinders healing through conventional endodontic treatment by
preventing complete disinfection, allowing bacteria to persist in the
periapical lesion. In cases of chronic odontogenic sinus tracts, root
canal treatment alone may be insufficient, requiring the removal of the
cord-like tract from the alveolar bone or its complete excision through
surgery like Apicoectomy (17, 18).
This case report highlights the rare occurrence of bilateral maxillary
sinus tracts in a maxillary first molar with no vertical root fracture,
emphasizing the value of thorough diagnostic evaluations and advanced
imaging techniques. The nine-month follow-up period, provides valuable
insights into the long-term outcomes and management of such conditions.
However, the single-case basis limits generalizability. Further research
with larger sample sizes is needed to confirm these findings and develop
standardized guidelines.
Conclusion
This case report highlights the importance of diagnosing bilateral sinus
tracts of dental origin, noting that they do not necessarily indicate
vertical root fracture (VRF) in all cases. Endodontic treatment is
generally effective in managing these tracts and preventing recurrence.
While endodontic surgical intervention may sometimes be required, it is
typically not the first-line treatment. Tooth extraction may be
considered as a definitive solution, but given that healing can take
longer than six months, sufficient time should be allowed before moving
to extraction and implant treatment plans.