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Cutaneous sinus tract caused by vertical root fracture
0099-2399/97/2309-0593503.00/0 JOURNALOF ENDODONTICS Copyright © 1997 by The American Association of Endodontists
Printed in U.S.A.
VOL. 23, NO. 9, SEPTEMBER1997
CASE REPORT Cutaneous Sinus Tract Caused by Vertical Root Fracture Chiu-Po Chan, DDS, Shih-Hao Chang, DDS, Chuan-Chuan Huang, DDS, Suefang Kung Wu, DDS, MS, and Sung-Kung Huang, DDS
This report presents a rare case of odontogenic cutaneous sinus tract caused by a vertical root fracture. The root-fractured molar was probably caused by an accidental blow by a cow 3 years ago. Despite all treatments by physicians and surgeons for nearly 1 year, the sinus tract recurred repeatedly. After diagnosis and extraction of the fractured molar by the dentist, the sinus tract healed uneventfully in a month.
Odontogenic cutaneous sinus tracts in the face and neck region are rare and may present a diagnostic problem (1). Patients with such condition usually seek help from surgeons or dermatologists rather than dentists. They may undergo multiple biopsies or excisions, but the sinus tracts recur repeatedly. Odontogenic cutaneous sinus tracts are usually caused by apical periodontitis associated with caries (1, 2). Recently Caliskan et al. (3) reported trauma of lower anterior teeth causing crown fracture and pulpal necrosis, resulting in the occurrence of extraoral sinus tracts. Conventional root canal therapy and, sometimes, extraction are effective in achieving healing of odontogenic cutaneous sinus tracts in a few weeks. In general, it is not necessary to treat the skin lesion, except for esthetic reason (4). The purpose of this report is to present a case of cutaneous sinus tract originated from a fractured root caused by trauma. Despite all repeated treatments by physicians and surgeons, the lesion was resolved only after diagnosis and extraction of the involved tooth by a dentist.
FiG 1. Extraoral sinus tract with purulent discharge on the left cheek.
removed later. He was hit in the same region of the mandible by a cow about 3 years ago, and no specific treatment was performed. Two years later, a sinus tract with recurrent purulent discharge appeared on the left cheek near the mandibular border. Surgical removal of this sinus tract was performed 4 to 5 times by physicians and surgeons. Traditional Chinese herb medicine was also tried. All of them failed, so he came to our dental department with a dressing inserted in the extraoral sinus tract. Initial intraoral examination showed moderate attrition over anterior and posterior teeth. A fistula over the buccal vestibule was found near the lower left first molar. A mesiodistal oriented crack line was noted on the occlusal surface of the same tooth (Fig. 2). Pulp vitality tests showed that it had a negative response while other teeth had normal responses. Periodontal examination showed a generalized deposition of calculus and moderate periodontitis. Probing pocket depths were recorded after scaling. An abrupt 12 mm deep pocket was found at the mesiolingual side of the lower left first molar. Other probing data on the same tooth were 8 mm mesiobuccally, 6 mm buccally, 5 mm distolingually, and 3 mm lingually and distobuccally. The probing pocket depths of the left lower second molar were 5 mm
CASE REPORT A 37-year-old male, with a chief complaint of recurrent facial sinus tract and purulent discharge on the left cheek (Fig. 1), presented to the dental department of this hospital in October 1987. Past medical history revealed that this patient had undergone a traffic accident with mandibular fracture 12 years ago. Three pins were placed in his left mandible at that time. The pins were 593
594
Chan et al.
Journal of Endodontics
FIG 2. A fistula was noted on the buccal vestibule, a mesiodistal oriented crack line was present on the occlusal surface of the lower left first molar.
FIG 4. A. inserted gutta-percha point shown on the periapical radiograph pointing to the mesial side of the lower left second molar. B. Inserted lacrimal probe shown on the panoramic radiograph pointing also to the mesial side of the lower left second molar. FIG 3. Periapical radiograph showing an obvious vertical root fracture on the mesial root of the lower left first molar.
mesially, 6 mm buccally and lingually, 4 mm distolingually, and 3 mrn distobuccally. Periapical radiographs revealed an obvious vertical root fracture of the mesial root of the lower left first molar and a radiolucent lesion measuring 5 x 11 mm around the fractured root (Fig. 3). Gutta-percha points were introduced into the sinus tract and the buccal fistula. A lacrimal probe was also introduced into the sinus tract. Interestingly, all of them led to the mesial surface of the marginal bone of the lower left second molar (Fig. 4A,B). An exploratory surgery was performed at the next visit. A full thickness mucoperiosteal flap was reflected at the lower left posterior region. A shallow, broad circumferential bony defect was noted at the mesial and buccal sides of the second molar. A vertical root fracture with large bony defect was also identified at the mesial root of the first molar (Fig. 5). The extraoral sinus tract seemed to be originated from the apex of the mesial root of the first molar. Extraction of the first molar, debridement of the wound, and root planing of the second molar were performed before closme of flaps. Apical granulation tissue was also removed for histologic examination. The pathologic
report demonstrated a pseudoepitheliomatous hyperplasia with submucosal chronic inflammation and fibrosis. The diagnosis was connective tissue with chronic inflammatory reaction, consistent with a partially epithelium-lined sinus tract. When the patient returned about 1 month later, both the extraoral sinus tract and the intraoral fistula were completely resolved. Only a depressed scar remained on the left side of his cheek (Fig. 6). The patient was followed for more than 7 years with no more symptoms.
DISCUSSION Most of the odontogenic cutaneous sinus tracts arising from apical pathoses are caused by pulpal degeneration or necrosis. The apical infection may spread through the marrow space then perforate the cortical bone. In soft tissue, the infection may spread through the path of least resistance between fascial spaces and finally perforate a mucosal or cutaneous surface (2, 4). The major factors influencing the spread of cutaneous sinus tracts are bacterial virulence, body resistance of the patient, lower resistance of the connective tissue in the fascial spaces, and posi-
Vol. 23, No. 9, September 1997
Cutaneous Sinus Tract
595
FIG 5. Flap reflection showing the vertical root fracture with large bony defect at the mesial root of the first molar. A shallow bony defect was found on the mesial side of the second molar.
Therefore, we postulate two possibilities. First, it originated from the second molar. For some unknown reason, the infection did not spread through the periodontal pocket that was least resistant. Second, it arose from the first molar. The sinus tract was formed even before the periodontal pocket had developed. In time the infection also spreaded distally and posteriorly to the area involving the second molar. There might have been an acute curvature that the gutta-percha points and lacrimal probe could pass through, thus the tracing pointed to the second molar. We prefer the latter supposition because it explains the clinical manifestations better. Histologic evidence of the presence of sinus tract at the apex of the first molar also supports the source of infection being from the first molar. Vertical root fractures are fairly common, especially in nonvital teeth. Common causes of vertical root fractures are volumetric expansion of endodontic pins or posts due to corrosion, excessive pressure during placement of endodontic posts, wedging action of inlays, and excessive pressure during lateral condensation of the gutta-percha when obturating root canals (7, 8). Excessive occlusal force or trauma may also cause vertical root fractures. According to the past history, the vertical root fracture in this case was probably due to the blow from a cow 3 years ago. Diagnostic signs of vertical root fractures include a sharp cracking sound at the time of root canal filling, radiolucent fracture lines or osseous defects on the radiographs, deep narrow periodontal pockets, and visible fracture lines (9). Intraoral sinus tracts caused by vertical root fractures were also reported by Meister et al. (10). However, vertical root fracture causing an extraoral cutaneous sinus tract has not been reported ]n the literature. The principle of treating such cases remains the same, that is, to remove the source of dental infection. The cutaneous sinus tracts caused by low grade chronic infection seldom cause pain or other significant discomfort. Patients seldom relate the symptoms to dental infection, and they usually go to dermatologists or plastic surgeons for help. Misdiagnosis and delay in proper treatment often take place. Therefore, when treating cases of facial sinus tracts of unknown cause, physicians or surgeons should always consult dentists to rule out a dental origin even if there is no complaint of dental symptoms.
FiG 6. Resolution of the sinus tract 1 month after extraction of the involved tooth, leaving only a depressed scar.
The authors are at the Dental Department, Chang Gung Memorial Hospital, Taipei, Taiwan, R.O.C. Address requests for reprints to Chiu-Po Chart, DDS, Dental Department, Chang Gung Memorial Hospital, No.199, Tung-Hwa N.Rd. Taipei, Taiwan, R.O.C.
tion of the apex of the affected tooth relative to muscle attachments (5, 6). There are two questions making this case interesting. First, does the infection always spread through the least resistant route? Second, what is the infection origin, the first or the second molar? Tracing of the sinus tract using the lacrimal probe or gutta-percha points both showed that the origin was from the second molar. However, exploratory surgery revealed that there was no significant lesion except for a shallow, broad circumferential bony defect at the mesial and buccal surfaces of the second molar. On the other hand, there were vertical root fracture, deep bony defect, and fistula associated with the first molar. Histological examination also demonstrated the presence of pseudoepitheliomatous hyperplasia consistent with sinus tract formation at the apex of the first molar. The occurrence of extraoral sinus tract in this case, no matter which tooth the origin is, should be considered as a rare phenomenon. Infection usually spreads through the path of least resistance. However, if the principle is always true, the infection in this case was supposed to be relieved through the periodontium and the periodontal pockets, which were the least resistant around the tooth.
References 1. Sakamoto E, Stratigos GT. Bilateral cutaneous sinus tracts of dental etiology: report of case. J Oral Surg 1973;31:701-04. 2. AI-Kandari AM, AI-Quoud OA, Ben-nail A, Gnanasekhar JD. Cutaneous sinus tracts of dental origin to the chin & cheek: case report. Quint Int 1993;24:729-33. 3. Caliskan MK, Sen BH, Ozinel MA. Treatment of extraoral sinus tracts from traumatized teeth with apical periodontitis. Endod Traumatol 1995;11: 115-20. 4. Grossman IL. Endodontic Practice. 9th ed. Philadelphia: Lea & Febiger Co; 1978:89-96. 5. Kaban LB. Draining skin lesions of dental origin: the path of spread of chronic odontogenic infection. Plast Reconstr Surg 1980;66:711-17. 6. Azaz B, Taicher S. Facial sinus tracts of denta~origin in children. J Dent Child 1976;43:167-71. 7. Rud J, Andreason JO. A study of failure after endodontic surgery by radiographic, histologic & stereomicroscopic methods. Int J Oral Surg 1972; 1:311-28. 8. Lommel TJ, Meister F Jr, Gerstein H, Davies EE, Tilk MA. Alveolar bone loss associated with vertical root fractures. Oral Surg 1978;45:909-19. 9. Pitts DL, Natkin E. Diagnosis and treatments of vertical root fractures. J Endodon 1983;9:338-46. 10. Meister F Jr, Lommel TJ, Gerstein H. Diagnosis and possible causes of vertical root fractures. Oral Surg 1980;3:243-53.
Printed in U.S.A.
VOL. 23, NO. 9, SEPTEMBER1997
CASE REPORT Cutaneous Sinus Tract Caused by Vertical Root Fracture Chiu-Po Chan, DDS, Shih-Hao Chang, DDS, Chuan-Chuan Huang, DDS, Suefang Kung Wu, DDS, MS, and Sung-Kung Huang, DDS
This report presents a rare case of odontogenic cutaneous sinus tract caused by a vertical root fracture. The root-fractured molar was probably caused by an accidental blow by a cow 3 years ago. Despite all treatments by physicians and surgeons for nearly 1 year, the sinus tract recurred repeatedly. After diagnosis and extraction of the fractured molar by the dentist, the sinus tract healed uneventfully in a month.
Odontogenic cutaneous sinus tracts in the face and neck region are rare and may present a diagnostic problem (1). Patients with such condition usually seek help from surgeons or dermatologists rather than dentists. They may undergo multiple biopsies or excisions, but the sinus tracts recur repeatedly. Odontogenic cutaneous sinus tracts are usually caused by apical periodontitis associated with caries (1, 2). Recently Caliskan et al. (3) reported trauma of lower anterior teeth causing crown fracture and pulpal necrosis, resulting in the occurrence of extraoral sinus tracts. Conventional root canal therapy and, sometimes, extraction are effective in achieving healing of odontogenic cutaneous sinus tracts in a few weeks. In general, it is not necessary to treat the skin lesion, except for esthetic reason (4). The purpose of this report is to present a case of cutaneous sinus tract originated from a fractured root caused by trauma. Despite all repeated treatments by physicians and surgeons, the lesion was resolved only after diagnosis and extraction of the involved tooth by a dentist.
FiG 1. Extraoral sinus tract with purulent discharge on the left cheek.
removed later. He was hit in the same region of the mandible by a cow about 3 years ago, and no specific treatment was performed. Two years later, a sinus tract with recurrent purulent discharge appeared on the left cheek near the mandibular border. Surgical removal of this sinus tract was performed 4 to 5 times by physicians and surgeons. Traditional Chinese herb medicine was also tried. All of them failed, so he came to our dental department with a dressing inserted in the extraoral sinus tract. Initial intraoral examination showed moderate attrition over anterior and posterior teeth. A fistula over the buccal vestibule was found near the lower left first molar. A mesiodistal oriented crack line was noted on the occlusal surface of the same tooth (Fig. 2). Pulp vitality tests showed that it had a negative response while other teeth had normal responses. Periodontal examination showed a generalized deposition of calculus and moderate periodontitis. Probing pocket depths were recorded after scaling. An abrupt 12 mm deep pocket was found at the mesiolingual side of the lower left first molar. Other probing data on the same tooth were 8 mm mesiobuccally, 6 mm buccally, 5 mm distolingually, and 3 mm lingually and distobuccally. The probing pocket depths of the left lower second molar were 5 mm
CASE REPORT A 37-year-old male, with a chief complaint of recurrent facial sinus tract and purulent discharge on the left cheek (Fig. 1), presented to the dental department of this hospital in October 1987. Past medical history revealed that this patient had undergone a traffic accident with mandibular fracture 12 years ago. Three pins were placed in his left mandible at that time. The pins were 593
594
Chan et al.
Journal of Endodontics
FIG 2. A fistula was noted on the buccal vestibule, a mesiodistal oriented crack line was present on the occlusal surface of the lower left first molar.
FIG 4. A. inserted gutta-percha point shown on the periapical radiograph pointing to the mesial side of the lower left second molar. B. Inserted lacrimal probe shown on the panoramic radiograph pointing also to the mesial side of the lower left second molar. FIG 3. Periapical radiograph showing an obvious vertical root fracture on the mesial root of the lower left first molar.
mesially, 6 mm buccally and lingually, 4 mm distolingually, and 3 mrn distobuccally. Periapical radiographs revealed an obvious vertical root fracture of the mesial root of the lower left first molar and a radiolucent lesion measuring 5 x 11 mm around the fractured root (Fig. 3). Gutta-percha points were introduced into the sinus tract and the buccal fistula. A lacrimal probe was also introduced into the sinus tract. Interestingly, all of them led to the mesial surface of the marginal bone of the lower left second molar (Fig. 4A,B). An exploratory surgery was performed at the next visit. A full thickness mucoperiosteal flap was reflected at the lower left posterior region. A shallow, broad circumferential bony defect was noted at the mesial and buccal sides of the second molar. A vertical root fracture with large bony defect was also identified at the mesial root of the first molar (Fig. 5). The extraoral sinus tract seemed to be originated from the apex of the mesial root of the first molar. Extraction of the first molar, debridement of the wound, and root planing of the second molar were performed before closme of flaps. Apical granulation tissue was also removed for histologic examination. The pathologic
report demonstrated a pseudoepitheliomatous hyperplasia with submucosal chronic inflammation and fibrosis. The diagnosis was connective tissue with chronic inflammatory reaction, consistent with a partially epithelium-lined sinus tract. When the patient returned about 1 month later, both the extraoral sinus tract and the intraoral fistula were completely resolved. Only a depressed scar remained on the left side of his cheek (Fig. 6). The patient was followed for more than 7 years with no more symptoms.
DISCUSSION Most of the odontogenic cutaneous sinus tracts arising from apical pathoses are caused by pulpal degeneration or necrosis. The apical infection may spread through the marrow space then perforate the cortical bone. In soft tissue, the infection may spread through the path of least resistance between fascial spaces and finally perforate a mucosal or cutaneous surface (2, 4). The major factors influencing the spread of cutaneous sinus tracts are bacterial virulence, body resistance of the patient, lower resistance of the connective tissue in the fascial spaces, and posi-
Vol. 23, No. 9, September 1997
Cutaneous Sinus Tract
595
FIG 5. Flap reflection showing the vertical root fracture with large bony defect at the mesial root of the first molar. A shallow bony defect was found on the mesial side of the second molar.
Therefore, we postulate two possibilities. First, it originated from the second molar. For some unknown reason, the infection did not spread through the periodontal pocket that was least resistant. Second, it arose from the first molar. The sinus tract was formed even before the periodontal pocket had developed. In time the infection also spreaded distally and posteriorly to the area involving the second molar. There might have been an acute curvature that the gutta-percha points and lacrimal probe could pass through, thus the tracing pointed to the second molar. We prefer the latter supposition because it explains the clinical manifestations better. Histologic evidence of the presence of sinus tract at the apex of the first molar also supports the source of infection being from the first molar. Vertical root fractures are fairly common, especially in nonvital teeth. Common causes of vertical root fractures are volumetric expansion of endodontic pins or posts due to corrosion, excessive pressure during placement of endodontic posts, wedging action of inlays, and excessive pressure during lateral condensation of the gutta-percha when obturating root canals (7, 8). Excessive occlusal force or trauma may also cause vertical root fractures. According to the past history, the vertical root fracture in this case was probably due to the blow from a cow 3 years ago. Diagnostic signs of vertical root fractures include a sharp cracking sound at the time of root canal filling, radiolucent fracture lines or osseous defects on the radiographs, deep narrow periodontal pockets, and visible fracture lines (9). Intraoral sinus tracts caused by vertical root fractures were also reported by Meister et al. (10). However, vertical root fracture causing an extraoral cutaneous sinus tract has not been reported ]n the literature. The principle of treating such cases remains the same, that is, to remove the source of dental infection. The cutaneous sinus tracts caused by low grade chronic infection seldom cause pain or other significant discomfort. Patients seldom relate the symptoms to dental infection, and they usually go to dermatologists or plastic surgeons for help. Misdiagnosis and delay in proper treatment often take place. Therefore, when treating cases of facial sinus tracts of unknown cause, physicians or surgeons should always consult dentists to rule out a dental origin even if there is no complaint of dental symptoms.
FiG 6. Resolution of the sinus tract 1 month after extraction of the involved tooth, leaving only a depressed scar.
The authors are at the Dental Department, Chang Gung Memorial Hospital, Taipei, Taiwan, R.O.C. Address requests for reprints to Chiu-Po Chart, DDS, Dental Department, Chang Gung Memorial Hospital, No.199, Tung-Hwa N.Rd. Taipei, Taiwan, R.O.C.
tion of the apex of the affected tooth relative to muscle attachments (5, 6). There are two questions making this case interesting. First, does the infection always spread through the least resistant route? Second, what is the infection origin, the first or the second molar? Tracing of the sinus tract using the lacrimal probe or gutta-percha points both showed that the origin was from the second molar. However, exploratory surgery revealed that there was no significant lesion except for a shallow, broad circumferential bony defect at the mesial and buccal surfaces of the second molar. On the other hand, there were vertical root fracture, deep bony defect, and fistula associated with the first molar. Histological examination also demonstrated the presence of pseudoepitheliomatous hyperplasia consistent with sinus tract formation at the apex of the first molar. The occurrence of extraoral sinus tract in this case, no matter which tooth the origin is, should be considered as a rare phenomenon. Infection usually spreads through the path of least resistance. However, if the principle is always true, the infection in this case was supposed to be relieved through the periodontium and the periodontal pockets, which were the least resistant around the tooth.
References 1. Sakamoto E, Stratigos GT. Bilateral cutaneous sinus tracts of dental etiology: report of case. J Oral Surg 1973;31:701-04. 2. AI-Kandari AM, AI-Quoud OA, Ben-nail A, Gnanasekhar JD. Cutaneous sinus tracts of dental origin to the chin & cheek: case report. Quint Int 1993;24:729-33. 3. Caliskan MK, Sen BH, Ozinel MA. Treatment of extraoral sinus tracts from traumatized teeth with apical periodontitis. Endod Traumatol 1995;11: 115-20. 4. Grossman IL. Endodontic Practice. 9th ed. Philadelphia: Lea & Febiger Co; 1978:89-96. 5. Kaban LB. Draining skin lesions of dental origin: the path of spread of chronic odontogenic infection. Plast Reconstr Surg 1980;66:711-17. 6. Azaz B, Taicher S. Facial sinus tracts of denta~origin in children. J Dent Child 1976;43:167-71. 7. Rud J, Andreason JO. A study of failure after endodontic surgery by radiographic, histologic & stereomicroscopic methods. Int J Oral Surg 1972; 1:311-28. 8. Lommel TJ, Meister F Jr, Gerstein H, Davies EE, Tilk MA. Alveolar bone loss associated with vertical root fractures. Oral Surg 1978;45:909-19. 9. Pitts DL, Natkin E. Diagnosis and treatments of vertical root fractures. J Endodon 1983;9:338-46. 10. Meister F Jr, Lommel TJ, Gerstein H. Diagnosis and possible causes of vertical root fractures. Oral Surg 1980;3:243-53.