Sinus Floor Augmentation in Presence of Mucocele Eroding Maxillary Sinus Wall: A Case Report With 3 Years Follow-Up

The maxillary mucocele is a slow-growing aggressive lesion and a mucous-containing sac lined with epithelium that occurs due to ductal obstruction and self-limiting injury. Rarely, it may be associated with non-specific symptoms. It is characterized by bone resorption due to its expanding behavior. Reduced height of bone and sinus pneumatization associated with pathologic lesions located in the floor of maxillary sinus may impede sinus augmentation. Therefore, careful diagnosis and management of pathology before sinus floor elevation is important in determining its recurrence and prognosis.

We reported a case with small mucocele on right pneumatized antrum with insufficient residual bone height for implant placement. Radiograph in the region of teeth #3 and #4 revealed a homogeneous solitary radiopaque mass. Cone-beam computed tomography revealed irregular osteolysis of the lateral wall of the sinus. It was excised through Caldwell-Luc technique and simultaneous sinus augmentation was performed. Later, delayed implant restoration was performed. No complication or recurrence was reported during 36 months of follow-up.

The excision of mucocele on sinus floor and simultaneous sinus augmentation obviates the need for the extended treatment period. The clinician must be habituated with the anatomy and pathology of the maxillary sinus to evade any non-essential complications following lateral sinus floor augmentation procedure. A diminutive mucocele should not be regarded as a contraindication for sinus augmentation; sometimes it manifests with bone erosion. The prompt diagnosis and careful evaluation are needed to avoid future complications during implant therapy.