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.