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CASE STUDY: Removal of tooth root via Caldwell-Luc approach

Jul 28, 2016
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Case Study 2

Patient history

A 31 year old male patient presented with a broken tooth root in the left maxillary sinus. Two days prior, he’d undergone dental treatment for the extraction of tooth 27. During the course of this treatment, the tooth root had been dislodged into the left maxillary sinus.

On the post-operative OPG (orthopantomogram – a wide view x-ray of the lower face), the fractured root was visible at the base of left maxillary sinus.

This patient had no known allergies and no other relevant medical history. He was not taking any medication.

A CBCT was obtained to accurately determine the three dimensional position of the fractured root.


The diagnosis made was a fractured root of tooth 27 located in the left maxillary sinus. The main risk associated with leaving the fractured root in situ was left maxillary sinusitis.


The agreed upon treatment was the removal of the tooth root via the Caldwell-Luc approach. Under local anaesthesia, the lateral wall of the left maxillary antrum was opened and the fractured tooth root was identified and removed.


The procedure was performed successfully and, during the post-operative follow-up, the patient indicated his satisfaction with the treatment.