A 30-year-old male reported to our emergency department with a complaint of pain and swelling in the left cheek and pus discharge from the oral cavity for two weeks. The patient had a positive history of COIVD-19 diagnosed by RT-PCR test. The patient was hospitalized for ten days, where he received steroids (tablet Methylprednisolone 16mg BD for five days) and supportive oxygen therapy and was discharged after a negative RT-PCT report for SARS-CoV-2. A week after the discharge, the patient experienced dull pain in the left maxillary posterior teeth, which became mobile after two days. He visited a general dental practitioner who initiated root canal treatment in the left maxillary first and second premolar and molar teeth. After multiple appoints for almost one month, the patient was not relieved of his pain and noticed pus discharge from the sulcus area. He visited another dentist, who extracted the left maxillary second premolar tooth. One week after the extraction, the patient developed a swelling on the left side of the face and reported to the emergency department. Contrast-Enhanced Computed Tomography (CECT) scan of the face revealed diffuse erosion of the walls of the left maxillary sinus, floor of the orbit, palatine part of left maxilla, and multiple geographic lytic lesions (Figure 1). These findings were suggestive of left maxillary osteomyelitis with associated soft tissue/ sinonasal Mucormycosis. The pus KOH was negative; therefore, a provisional diagnosis of bacterial osteomyelitis of the left maxilla was made, and systemic antibiotic therapy was initiated, planned for surgery and underwent debridement via sub labial approach. The procedure was explained to the patient and written informed consent was obtained. The necrotic anterior wall of the maxilla and the alveolar process was removed along with the left maxillary canine, premolar, and molars (Figure 2). The histopathologic examination of excised tissue showed the presence of hyaline aseptate hyphae, which were suggestive of mucormycosis. Systemic antifungal medication (inj. Liposomal amphotericin B) was started immediately. During the hospital stay, the patient complained of mobility of remaining maxillary teeth on the left side and for which a dental referral was made. On intraoral clinical examination, left maxillary incisors were grade II mobile and did not respond to the electric pulp test. An intraoral periapical radiograph revealed a diffuse radiolucent lesion with relation to left maxillary central and lateral incisors (Figure 3A&B). A diagnosis of pulp necrosis was made, and radiographic lesions were considered as representations of mucormycosis. The access opening was made and extirpated pulp tissue was sent for histopathologic examination. Histology revealed dense fibrotic pulp tissue with interspersed numerous basophilic diffuse calcifications showing peripheral stromal retraction, mild lymphoplasmacytic infiltrate, and congested blood vessels suggestive of necrosis of pulp with pulpal calcifications (Figure 3C). Periodic acid-Schiff (PAS) and Grocott's methenamine silver stain (GMS) showed no fungal organisms in the pulp tissue. Calcium hydroxide was used as an interappointment intercanal medicament, and the root canal treatment was completed in two visits. A CECT scan was repeated after completing the cumulative target of 3g of Liposomal Amphotericin, which showed some residual disease with osteomyelitic bone involving zygoma and remanent of maxillary bone on the left side. The lesion was debrided entirely during the second surgery, along with excision of a part of the left zygomatic bone and the left maxillary lateral incisor extraction. After the initial healing of the surgical site and stabilization of the disease, the patient was discharged with advice to use oral antifungals (Posaconazole tablet 300mg /day) for one month.
The iatrogenic oroantral fistula created after surgical debridement was classified as Armany class II defect and managed by obturator prosthesis (Figure 4A&B). After the initial healing of the surgical site, an alginate impression (Algiplast, DPI, Mumbai, India) of the maxilla was made, extending into the surgical defect and covering all the defect's margins, blocking all unfavourable margins undercuts with a wet gauge piece. The cast was obtained by pouring the impression with type III dental stone (Kalstone, Kalabhai Karlson Pvt. Ltd, India) and trimmed carefully to avoid deliberate posterior and lateral extension loss. A wrought wire clasp was added in the areas that would not interfere with the occlusion of opposing teeth. Baseplate wax was adapted over the cast, and wax-up was done. This wax-up, along with cast was flasked, dewaxed in a conventional manner, and packed with heat cure acrylic resin (Trevalon, Dentsply, India) and cured. The palatal surface of a lid was made by adapting a sheet of cold-cure acrylic resin along the finish line seen on the obturator.
After finishing and polishing of obturator, it was delivered to the patient. The patient was instructed regarding the insertion and removal of the prosthesis and the maintenance of proper hygiene of both the defect and prosthesis. He was recalled after 24 hours following placement of the intermediate obturator to assess its function and examine the defect area for the early signs of irritation. Any necessary adjustments were made, and the patient was scheduled for the recall visits after one week for bite registration, followed by trying in for the missing teeth. Final wax-up of the obturator was done and which was followed by acrylization in heat cure polymer. The final obturator was finished, polished, and delivered to the patient, and aesthetic and functional rehabilitation was completed (Figure 4C,D&E).