Case Report/Clinical Techniques
Orbital Abscess during Endodontic Treatment: A Case Report
Eduardo Henrique Pantosso de Medeiros, DDS, Andr
e Oliveira Pepato, DDS, MSc,
C

assio Edvard Sverzut, DDS, PhD, and Alexandre Elias Trivellato, DDS, PhD
Abstract
Introduction: Orbital infections may result in perma-
nent morbidity because of the severity of infection.
Furthermore, delayed diagnosis or treatment of orbital
infections can lead to intracranial complications and
even death. The majority of orbital infections develop
from paranasal sinus infections, cutaneous infections,
and periorbital trauma. Dacryocystitis and odontogenic
infection are also accounted as potential etiologies but
are scarcely reported in scientific literature. Methods:
The patient revealed a history of having endodontic
treatment on left maxillary second molar performed
2 weeks previously. Moreover, she exhibited signs of
facial pain accompanied by sinusitis symptoms, fever,
and nasal obstruction the week after this endodontic
procedure. The patient presented proptosis, impairment
of ocular motility to the right side, facial tenderness,
palpebral erythema, and referred decreased visual
acuity. Intraoral exam revealed root fragments of left
maxillary first molar and an extensive carious lesion
on left maxillary second molar. Computed tomography
enabled the observation of frontal sinus, left-sided
maxillary, opacity of sphenoidal and ethmoidal sinuses,
and apical lesion of left maxillary first and second
molars, all suggesting the presence of their apex in
the maxillary sinus. In addition, images revealed ocular
proptosis and presence of high-density areas suggestive
of pus in the medial orbital wall region. Results: The
patient was submitted to surgical drainage under
general anesthesia approximately 8 hours after the clin-
ical evaluation. Conclusions: Early detection of orbital
infection, proper diagnostic tests, and treatment may
provide successful outcomes of this rarely occurring
disease. (J Endod 2012;38:1541–1543)
Key Words
Dental infection, odontogenic orbital abscess, orbital
infection
From the Department of Oral and Maxillofacial Surgery and
Periodontology, School of Dentistry of Ribeir~ao Preto, University
of S~ao Paulo, Ribeir~ao Preto, S~ao Paulo, Brazil.
Address requests for reprints to Dr Alexandre Elias Trivel-
lato, Department of Oral and Maxillofacial Surgery and Peri-
odontology, School of Dentistry of Ribeir~ao Preto, University
of S~ao Paulo, Av do Caf
e, s/n- Campus USP, 14040-904 Ribeir~ao
Preto, S~ao Paulo, Brazil. E-mail address: eliastrivellato@forp.
usp.br
0099-2399/$ - see front matter
Copyright ª 2012 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.06.039
JOE — Volume 38, Number 11, November 2012
O rbital cellulitis is usually a complication of paranasal sinus infection (1–4) and may
result in permanent morbidity because of the severity of associated infection (5).
Intraorbital abscess may be formed as a result of a progressive and localized cellu-
litis. Less common etiologies include periocular trauma and history of surgical inter-
vention, skin infections, dental surgery and infection, upper respiratory tract
infection, varicella, and other systemic infections. Retrograde spread of infection can
lead to complications such as cavernous sinus thrombosis, meningitis, cerebritis, brain
abscess, or death (1, 3, 4, 6–8).
In the preantibiotic era many patients with periorbital cellulitis had permanent loss
of vision and died of central nervous system complications. Nowadays, despite antimi-
crobial and surgical management, a substantial amount of patients with subperiosteal
abscess still develop various visual sequelae (6, 8). Some signs and symptoms related to
orbital infections are proptosis, chemosis, and extraocular muscle dysfunction. Not
uncommonly noted is decreased visual acuity (1).
In the context of odontogenic infections, spreading of dental infections beyond the
immediate proximity of the alveolar process is common and contributes substantially to
the epidemiology of patients admitted to surgical maxillofacial units. On the other hand,
early involvement of the orbit after infections of dental origin is an extremely rare event
(3). Because of the scarcity of reports on this subject, this article reports the successful
management of a healthy patient presenting with an orbital abscess caused by compli-
cation derived from root canal treatment of a maxillary second molar.
Case Report
The present case took place at the Santa Casa Hospital of Ribeir~ao Preto/SP, Brazil.
During the oral and maxillofacial team evaluation the patient revealed a history of having
endodontic treatment on left maxillary second molar performed 2 weeks previously.
Furthermore, the patient revealed that 1 week after that endodontic procedure, she
exhibited signs of facial pain accompanied by sinusitis symptoms, fever, and nasal
obstruction. During facial exam, the patient presented proptosis, impairment of ocular
motility to the right side, facial tenderness, palpebral erythema, and referred decreased
visual acuity. Intraoral exam revealed root fragments of left maxillary first molar and an
extensive carious lesion on left maxillary second molar (Fig. 1A–C).
Further diagnosis consisted of helical computed tomography (CT) imaging in axial
scan to evaluate regional anatomic integrity of the face. Image analysis enabled the
observation of frontal sinus, left-sided maxillary, opacity of sphenoidal and ethmoidal
sinuses, and apical lesion of left maxillary first molar and left maxillary second molar, all
suggesting the presence of apex in the maxillary sinus. In addition, images revealed
ocular proptosis and presence of high-density areas suggestive of pus in the medial
orbital wall region (Fig. 1D). Because of the CT results, surgical draining was indicated
and performed under general anesthesia to effectively treat this comorbidity. Amoxi-
cillin 875 mg and clavulanic acid 125 mg were adopted as early empiric antibiotic
therapy and administered intravenously every 6 hours. Ketoprofen 100 mg every 8 hours
was prescribed as anti-inflammatory and pain control therapy. Additional analgesic
medication was prescribed and given intravenously every 6 hours if needed. Complete
blood cell count and coagulogram exams were solicited. White blood cell count
revealed mild leukocytosis.
The patient underwent surgery under general anesthesia approximately 8 hours
after the clinical evaluation. This interval was required to collect blood sample and
accomplish the imaging exams; moreover, this interval was also recommended by
the anesthetists owing to the last food intake of the patient.
Orbital Abscess during Endodontic Treatment 1541
Case Report/Clinical Techniques

Figure 1. Preoperative clinical aspects. Proptotic left globe, periorbital swelling preventing spontaneous opening of the eye, subconjunctival ecchymosis, and
impairment of ocular motility to the right side (A and B). CT scan in axial view. Maxillary sinus filled with pus. Close relationship between upper molar root apexes
and maxillary sinus (C). Intraoral view of residual root of tooth #26 affected by extensive carious lesion (D).

Before surgery, sampling of purulent material by means of a punc- Discussion

ture incision was performed for culture and antibiogram tests. Surgical
drainage of pus into the maxillary sinus was accomplished with the Cald-
well–Luc technique. Drainage of pus out of the orbital cavity was per-
formed by the superior medial palpebral technique and inferior
palpebral technique. It was noted that a large amount of pus drained
from the superior medial incision; nevertheless, only serosanguineous
fluid could be drained from the inferior palpebral incision. Left maxillary
second molar, the primary infectious source, and left maxillary first
molar, a potential source for future infections, were extracted. The extrac-
tions and treatment of alveolar spaces enabled the visualization of an or-
oantral communication in the dental alveolus left maxillary second molar,
thus confirming the close proximity of the tooth with the maxillary
antrum. Such communication was closed with the aid of the buccal fat
pad of the left cheek. After drainage, Penrose drains were placed in sub-
ciliary incisions and intraoral approach and were sutured. Penrose
drains were kept in for 3 days and removed when the clinical state showed
great improvement. Results from culture and sensitivity were negative.
On the fourth day after surgery, intravenous antibiotic therapy was
switched to oral amoxicillin (875 mg) and clavulanic acid (125 mg)
every 6 hours for the duration of 2 weeks. The patient was discharged
on the fourth day after surgery.
Three weeks after surgery, patient had significant improvement of
clinical symptoms with no sequelae (Fig. 2).
Odontogenic orbital infection can rarely occur as a result of a tooth
abscess, exacerbated periapical lesions, extraction, or dental surgery
(3, 8).
The orbital septum delineates these infections into preseptal and
postseptal disease, which is important because the latter has the poten-
tial to cause severe complications. The orbital septum acts as a barrier
to the spread of infection from the skin to the deeper structures, limiting
the inflamed orbital subcutaneous tissue to the front of the orbital
septum and avoiding exophthalmos. Pupillary reflex should be within
normal limits in this form of infection. Transition to postseptal orbital
infection can occur through breaching of the orbital septum. CT has
been shown to be very useful in the differential diagnosis of preseptal
or postseptal cellulitis (5, 6).
Orbital abscess or orbital cellulitis is usually a result of paranasal
sinuses (approximately 84%). Other causes are periorbital trauma,
orbital reconstruction, ascending thrombophlebitis, infection of the
nasal septum, infected penetrating keratoplasty, skin infections, vari-
cella, and upper respiratory tract infection or complication of purulent
otitis media. Odontogenic orbital infections are less common and
account for 2%–5% of all orbital cellulitis cases. In a small number
of cases systemic disease may be the cause of orbital cellulitis such
as subacute bacterial endocarditis, influenza, scarlet fever, herpes

1542 de Medeiros et al. JOE — Volume 38, Number 11, November 2012

Figure 2. Three weeks after surgery, patient exhibits good scar repair and
absence of facial edema, subconjunctival ecchymosis, and ocular motility
impairment.
simplex, or herpes zoster (1–4, 6, 8). We described a patient who
underwent a root canal procedure 2 weeks before the onset of
symptoms that was the most likely trigger of the orbital abscess.
Microorganisms involved in odontogenic infections can enter the
orbit because of the intimate relation of the orbit to the surrounding
sinuses, and its extensive vascular communication with congruent
structures increases the susceptibility to infection arising from nearby
tissues. Three basic routes of spread of infection have been described
for odontogenic orbital infection (4, 6, 8–10). In the present case, an
apical abscess of the left maxillary second molar invading the left
maxillary sinus could be seen with CT. From the maxillary sinus the
infection gained access to the orbit.
Orbital abscesses exhibit common signs and symptoms such as che-
mosis, periorbital edema of the eyelid, reddening, hyperthermia, prop-
tosis, extraocular muscle dysfunction, and decreased visual acuity
(1, 5, 10). Further pursuit of diagnosis includes advanced imaging
techniques such as CT, and it is indicated if patient presents with
proptosis, ophthalmoplegia, decreased visual acuity, and extreme
palpebral edema that prevent an adequate ophthalmologic examination
or obscure the patient’s awareness of any change in vision (2, 8). This
patient presented with eyelid edema, erythema, ophthalmoplegia,
decreased visual acuity, and fever, and CT was indicated and proved to
be a helpful tool in the assessment of postseptal abscess.
Postseptal orbital infection can be depicted by CT or magnetic
resonance imaging. Both methods are able to illustrate the extent of
soft tissue involvement, coexisting inflammatory lesions in the paranasal
sinuses, and intracranial complications. When appropriately per-
formed, CT can reveal odontogenic sources of infection that are not clin-
ically suspected for presenting signs and symptoms that are often
nonspecific. There are only few reported cases of imaging for odonto-
genic orbital cellulitis, and these cases are limited to exclusive imaging
of the orbit (10). Thus, imaging plays a key role in the diagnosis of
odontogenic orbital cellulitis. The findings of dental infection on CT
scans include abnormal periapical density, loss in definition of the
lamina dura, widening of the periodontal ligament (PDL) space, and
unilateral or asymmetrical severe sinus hyperdensity ipsilateral to the
infected orbit (10). This patient reported recent endodontic treatment
JOE — Volume 38, Number 11, November 2012
Case Report/Clinical Techniques
of left maxillary second molar. Tomographic findings suggesting odon-
togenic etiology were apical hypodensity in first and second maxillary
left molars, increased PDL space of the same teeth, and hyperdensity
of the left maxillary and ethmoidal and frontal sinuses.
Treatment of these lesions depends on the location and progres-
sion of the infection. Preseptal cellulitis can be successfully treated
with antibiotic therapy; however, if there is radiographic evidence of
an orbital abscess, poor vision on initial presentation, or worsening
of orbital signs and/or worsening vision while on therapy, drainage of
the orbital abscess and involved sinuses is recommended (4, 5, 8,
10). In the presented case, at the earliest presentation the visual
difficulties were associated to an ocular hypomotility, and further
tomographic display of an abscess in the orbit indicated surgical
treatment as first choice of treatment.
Even with surgery, the appropriate antibiotic therapy is extremely
important for solving the case (6). Culture and sensitivity tests were
negative; however, this it is not uncommon for head and neck sites.
Sterile cultures have been reported in 25% of cases of infectious process
in this region (3).
Odontogenic orbital cellulitis is usually polymicrobial, with prolif-
eration of both aerobic and anaerobic species. Initial treatment consists
of empiric antibiotic coverage for aerobic gram-positive and anaerobic
organisms but should also cover for typical oral pathogens (8). Thus,
we used amoxicillin and clavulanate to establish antibiotic coverage
against these types of microorganisms.
The aim of treatment is to reestablish visual acuity, contain the
spread of orbital infection, and avoid possible fatal complications
(4). The incidence of visual loss in cases of odontogenic orbital cellu-
litis reached up to 46% of severe vision loss (8). Other sequelae
reported for orbital infections are meningitis, cavernous sinus throm-
bosis, brain abscess, hemiparesis, seizures, subdural empyema, supe-
rior orbital fissure syndrome, orbital apex syndrome, and death (1–6,
8–10). In this case, no permanent visual or systemic sequelae were
observed. Therefore, it can be concluded that early detection of
orbital infection, proper diagnostic tests, and treatment can provide
successful outcomes of this rarely occurring disease.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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