Unsuccessful endodontic treatment led to an infection that disrupted cortical bone continuity, resulting in a large defect that formed a depression on a 19-year-old’s face. The case report was published on February 20 in the International Journal of Surgery Case Reports.
The woman’s facial dimple improved within a week following root end surgery to treat an odontogenic cutaneous sinus infection and a course of antibiotics, and the facial depression was gone at her two-week follow-up. This case highlights the importance of knowing that extraoral lesions may have dental origins, which facilitates early diagnosis and affects treatment planning, the authors wrote.
“It is crucial to achieve an accurate diagnosis and employ appropriate investigative methods to facilitate prompt treatment and minimize complications such as asepsis, osteomyelitis, and patient discomfort,” wrote the authors, led by Dr. Ashraf Mahlobi of the oral and maxillofacial surgical department at Tishreen University Hospital in Syria.
A 19-year-old healthy woman
The woman had no underlying diseases, but she had a depression on her face. The dermatology department referred her to the oral and maxillofacial surgical department. Two weeks prior, she reported swelling in the same area before the dimple appeared.
Asymptomatic decrease on the facial skin surface without any pigmentation or pus. All images courtesy of Mahlobi et al/Int J Surg Case Rep.
She underwent a cone-beam computed tomography scan that confirmed a bony defect at the apex of the mesiobuccal root of the upper first molar, where the continuity of the buccal plate was impaired, the authors wrote.
A cone-beam computed tomography scan showing a bony defect at the apex of mesiobuccal root of the upper first molar.
The woman's medical history revealed that the upper first molar had undergone recurring endodontic treatment. A decrease in the skin's surface at the level of the apical region of the buccal roots occurred upon touch. The clinician and patient agreed that an apicoectomy would be done to eliminate infection in the root of the molar.
During the procedure, a trapezoidal full-thickness flap was raised, exposing the molar’s buccal aspect. A cordlike structure was identified, making raising the flap more difficult.
The cordlike lesion was removed along with related inflammatory tissue, including a possible sinus tract, to promote buccal plate healing. The apex was removed, the area was irrigated, and the root tip was sealed. Bone graft materials were used to augment the buccal plate so the resorption that occurred during the infection could be fully restored, they wrote.
There was a significant reduction of the facial dimple on the skin surface seven days postoperatively.
After seven days, the sutures were removed, and she was kept on systemic antibiotics for a week. The patient maintained good oral hygiene, experienced no pain after the procedure, and the normal contour of her facial skin was restored two weeks after the procedure, the authors wrote.
Early detection, better treatment planning
Odontogenic cutaneous sinus is a rare but extensively documented condition in the literature. Its diagnosis remains complex. It requires a thorough medical history-taking, a clinical examination, and imaging to ensure early and accurate diagnosis, they wrote.
“By identifying the tooth associated with the lesion, unnecessary medications and incorrect interventions can be avoided, ensuring the implementation of appropriate treatment,” Mahlobi and colleagues wrote.
A frontal view confirms full healing six months postoperatively.
