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Extra-oral fistula in nostril - Courtesy ROOTS
The opinions and photographs within this web page are not ours. Authors have been credited for the individual posts where they are. - Photos courtesy of Marga - www.rxroots.com

From: Marga Ree
Sent: Tuesday, January 10, 2006 11:15 AM
To: ROOTS
Subject: [roots] Extra-oral fistula in nostril This 9 year old kid sustained a trauma on his front teeth 2 years ago, at the age of 7. Intrusion 11. He was referred for AP of 11. He showed a very unusual, extra-oral fistula, in his right nostril, see pics. I tried to trace the fistula with a gp cone, but this was too painful. When he returned for the first treatment session, the swelling in his nose was even worse. Ca(OH)2 for 1 month, and swelling was completely gone. I placed an apical plug of MTA, and brought him back for a composite build-up. Funny enough, after placement of the MTA, the swelling returned for a short period of time. Today I did a 6 week follow-up, and the swelling in his nostril had disappeared.

Regarding 12, on some rads it looked like resorption was going on, thermal and EPT test: neg. I was very much in doubt, and decided to do a test cavity. After 2 seconds, he responded pos. I will see him again in 6 months.- Marga Absolutely incredible. Beautiful documentation. I have never seen a lesion like that. Bravo - Gary Marga, I've seen several of these. They were on adults and involved long standing abscesses...much like the extra-oral fistulations we see on the face. I've seen one on the lateral side of the nose. That was on an alcoholic homeless man passing through. The police brought him in. We extracted the tooth and we was on the road again. Guy Interesting ! For me it was the first time that I saw a fistula like this. Thanks for your input Guy.- Marga Dear Marga, Extraordinary as usual. Did you use any kind of barrier before placing the MTA? What will happen to the MTA outside the canal? ( I am asking because I just finished a c-shaped upper molar and had a small amount of MTA beyond the foramen.- Jörg Jörg,I used calcium sulphate as an extraradicular barrier, but nevertheless extrusion of MTA took place. I think this will not impair healing, although it doesn't have "the look". I will keep you informed. - Marga Marga: Would you be kind enough to detail the technique you use to place the CaSO4 barrier............my understanding is that Dr. T. prefers that nothing interface with MTA but tissue and yet, frankly, the excess if it occur doesn't set (well) if at all. This would be most informative.......thank you.- Kendo

Kendo, I use calcium sulphate hemi hydrate 98% medical grade as an extra-radicular matrix, prior to the application of MTA, in cases where there is a wide open apex and I might expect extrusion of MTA. I cannot support its use for this purpose with the available lit, and I only have my own clinical experience (and that of other colleagues) to rely on. I have the impression that I can obtain a closer adaptation of MTA to the canal walls, when an extraradicular barrier is used. An open apex doesn't provide any resistance when you try to condense the MTA in place, meaning that you are inclined to condense it maybe too cautiously. Moreover, it has been shown that the use of ultrasonics provides a radiographically denser MTA fill with fewer voids (Lawley et al. 2004), and again, my experience with a barrier and the use of ultrasonics is a better adapted MTA plug than without the use of a barrier, it simply gives you more control, and that is what I like about it. Calcium sulphate has had a documented history of safe orthopaedic use for more 100 years (Dreesman 1892), and it has been used as a bone substitute in orthopaedics and oral surgery. According to Sottosanti (1992) and Pecora et al. (1997) it has potential applications in dentistry in guided tissue regeneration and it is a bioresorbable and biocompatible barrier. It is resorbed from 4-8 weeks (Pecora et al. 1997, Yoshikawa et al. 2002). Pecora et al.(2002) used it in through and through osseous defects and reported that it improved the clinical outcome. Murashima et al. (2002) found it to be effective in bone regeneration on both large osseous defects and through and through lesions. It has been reported to be osteoconductive, is applied easily and not expensive. I apply the calcium sulphate with a messing gun ( I use the MAP system and Dovgan guns) and take all the efforts to prevent the calcium sulphate contaminating the walls of the canal, because it can interfere with the close adaptation of MTA. Therefore the tip of the messing gun must preferably reach beyond the AF. Ca sulphate is placed in small increments, and confirm the placement with a radiograph. It's radiopacity is similar to that of dentin. It sets in 1-2 minutes, so after the confirming the proper location on a rad, MTA can be applied immediately. Take care: If you are using a messing gun for ca sulphate you have to work very fast, in order to prevent the setting of the material in the application tip. It sets within no time, and once the tip has become clogged, it usually means that you have to discard the tip. - Marga Gary: Virtually every extraoral fistulation I’ve seen has been mandibular and obviously chronic and long standing. Infection will generally take the path of least resistance, which in the maxilla tends to be the thin less dense buccal plate. But leave it to marga to find something different and unusual. I’m still thinking about that eel sandwich. Guy: The only upper ones I've seen have been in the area of the nose. I think sometimes we forget just how close the apexes to some of these teeth are to the inner nostril. I haven't seen one in a good while. I think better ER care and a more knowledgeable public is making them rarer and rarer. The last one was on the homeless man that the police brought in for care.
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