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Treatment of dental implant-related maxillary sinusitis with functional endoscopic sinus surgery in combination with an intra-oral approach

Ki-Young Nam, Jong-Bae Kim

Department of Dentistry, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea

Abstract (J Korean Assoc Oral Maxillofac Surg 2014;40:87-90)

The present report describes the case of a patient who underwent maxillary sinusitis right after dental implant installation with sinus lifting. Computed tomography scan revealed a dental implant (#16) was protruded inside the right maxillary sinus and confirmed the obstruction of ostium. A symptom remission was gained with the dual approaches combined by functional endoscopic sinus surgery and an intra-oral approach. Fully recovered function and healing of sinus were identified after 10 months follow-up. We report the case of sinusitis caused by protrusion of implants with sinus floor lift pro-cedures and propose that practitioners should be aware of the possible its complications and management.

Key words: Maxillary sinusitis, Dental implants, Endoscopy[paper submitted 2014. 2. 28 / revised 2014. 4. 14 / accepted 2014. 4. 16]

suchasCaldwell-Lucapproach,inferiormeatalosteotomy

ororo-antralfistulaclosurehavebeenpopularoptionsforthe

treatmentofpost-opsequelae.However, these techniques

havebeeninsufficientforfullrecoveryofmaxillarysinus

function.Forcompleterecoveryofmaxillarysinusfunction

andrapidresolutionofsinusitis,functionalendoscopicsinus

surgery(FESS)isrecommended,whichisfavoredoverthe

Caldwell-Lucapproachbecauseofpositiveoutcomessuchas

shorterhospitalstayandlowermorbidity6.Wereportacase

ofmaxillarysinusitisrelatedtofailedosteotomesinuseleva-

tiontechniqueaswellassuccessfulmanagementwithFESS

incombinationwithanintra-oralapproach.

II. Case Report

A39-year-oldfemalewasreferredtoourdentaldepart-

mentduetoconsiderablepainintherightzygomaareawith

headacheintherighttemporalregion.Thepatienthadahis-

toryofextractionof#16approximately5monthspriordueto

averticalcrack,andunderwentsingledentalimplantinstal-

lationwiththeosteotometechniquefor#16inalocaldental

clinic3dayspriortopresentation.Panoramicviewrevealed

thatthesingleimplantwasprotrudingintotherightmaxil-

larysinusandtheradiopacityof thesinuswas increased.

(Fig.1)Medicaltherapywasadministered,includingempiri-

I. Introduction

Rehabilitationofmasticatoryfunctionafterdentalimplants

areplacedinthepartialorfulledentulousareahasbecome

routine;however,implantationcanoccasionallybecompro-

misedbyanatomicallimitationsaswellasthestatusofal-

veolarboneandsurroundingsofttissue.Implantationaround

theposteriormaxillaarea isoftenchallengingbecauseof

alveolarboneresorption,sinuspneumatizationorotherrea-

sons1.Toovercometheseproblems,maxillarysinuslifting

andsinusbonegraftingareoftenrecommended,although

theseprocedureshaveuncommoncomplicationssuchas

maxillarysinusitisandinfection.Inadequatemaxillarybone

thickness,alongwithpoorsurgicalplanningandlackofex-

perience,isalsoassociatedwithprotrusionofimplantsinto

themaxillarysinus2,3orgraftingmaterialmigrationtothe

paranasalsinuses(PNS)4,5.Generally, intraoralapproaches

CASE REPORT

Ki-Young NamDepartment of Dentistry, Keimyung University Dongsan Medical Center, 56, Dalseong-ro, Jung-gu, Daegu 700-712, KoreaTEL: +82-53-250-7805 FAX: +82-53-250-7802E-mail: nkyp@dsmc.or.kr

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

CC

Copyright Ⓒ 2014 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.

http://dx.doi.org/10.5125/jkaoms.2014.40.2.87pISSN 2234-7550·eISSN 2234-5930

J Korean Assoc Oral Maxillofac Surg 2014;40:87-90

88

plant.(Fig.2)Itwasunclearwhetherbonegraftinghadbeen

performed.Water’sviewalsorevealedincreaseddensityand

hazinessintherightmaxillarysinus.(Fig.3)Basedonthis

evidenceofobstructionoftheostiumoftherightnasalcav-

ityandinfectionofthemucoceleoftherightmaxillarysinus,

weconsultedanotolaryngologistandconcludedthatanintra-

oralapproachalonewouldnotbesufficienttoremovethe

mucoceleandpotentiallyscatteredgraftparticles.Implant

removalwasalsoconsideredbecausethefixturewasloose;

therefore,FESSwasperformedincombinationwithanintra-

oralapproachundergeneralanesthesiafollowedbyadmis-

sionofthepatient.Theoperationwasconductedbycoopera-

tiveteamapproach,includinganoral-maxillofacialsurgeon

andotolaryngologist.Aftertheendoscopewasinsertedinto

thenose,cottonsoakedwithepinephrinewasappliedtothe

middlemeatusfor5minutes,thencottonwasremoved.The

middleturbinatewaswidelyexcisedsothatpusandinfected

bonegraftparticlescouldbeflushedfromthesinuscavity.

Theostiumwasexposedbyremovaloftheuncinateprocess

inthemiddlemeatustoaccesstoostiumandtheethmoidal

sinus.Edematous,hyperplasticnasalmucosawithinthesi-

nuswasenucleatedafterthenaturalostiumwassurgically

enlarged(Fig.4),thenthesinuswasirrigatedwithnormalsa-

lineuntilnoadditionalfree-floatingparticleswereobserved.

Duringthisprocedure,removalofthesinusmucosaofthe

maxillarywasnotattempted.Implantremovalandprimary

closureoftheoro-antralfistulawereperformed.(Fig.5)The

patientreceivedpolyvinylacetalabsorbentnasalpackingfor

calantibiotics(penicillin,clindamycin),non-steroidalanti-

inflammatorydrugs,expectorantsandantihistamines,which

wereprescribedtomitigatesymptoms;however,thepatient

showednoimprovementafter4weeksoffollow-up,andthe

persistenceofsignsandsymptomsofdiscomfortindicated

thatfurtherinvestigationwasneeded.Coronalviewcomput-

edtomography(CT)revealeddefinitesignsofsinusitiswith

opacificationoftherightmaxillarysinusaswellasethmoidal

sinus,andconfirmedthatadental implantwasprotruding

approximately5mmintothesinuswithadisplacedbone

fragmentfromthesinusfloorattheapicalportionoftheim-

Fig. 3. Water’s view computed tomography revealed increased density and haziness in the right maxillary sinus.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 1. Panoramic view taken 5 days after right maxilla sinus bone grafting and #16 implantation revealed dental implant protrusion into the right maxillary sinus.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 2. Paranasal sinuses computed tomography revealed muco-sal thickening and opacification with air bubbles in the right maxil-lary sinus and the protrusion of an implant fixture into the sinus, along with a bony fragment (arrow).Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

Treatment of dental implant related maxillary sinusitis

89

ciliaryclearanceisamajorclinicalproblem.Thestagnation

ofsecretionsandobstructionofexcretionfromandventila-

tionwithinthemaxillarysinusarepredisposingfactorsforsi-

nusinfection7.Theareabetweenmiddleturbinateandlateral

nasalwalloftenhastheanatomicalvariance;therefore,ede-

maofthemucosacanresultinobstructionoftheostiumand

dysfunctionofmucociliaryfunction.Maxillarysinusfloor

1week,nocomplicationsoccurredandsymptomsimproved

graduallyoverthehealingperiod.Theradiopaquephaseof

thesinuscavitywasremarkablydecreasedintherightmaxil-

larysinus1weekpostoperatively,thoughmucosalthicken-

ingwasstillobserved.(Fig.6)However,fullrecoveryofthe

sinuswasevidencedontransversedentalCTatthe10-month

follow-upvisit.(Fig.7)

III. Discussion

Inmanycasesofmaxillarysinusitis,dysfunctionofmuco-

Fig. 4. Endoscopic view, after uncenectomy and maxillary sinus ostium enlargement.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 5. An intra-oral approach allowed for the removal of the mo-bile dental implant and closure of the oro-antra fistula.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 6. Computed tomography revealed that opacification of the right maxillary sinus was decreased 1 week postoperatively. Mu-cosal thickening of the sinus wall had also decreased.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 7. Transverse dental computed tomography scanning re-vealed complete recovery of the right maxillary sinus with normal mucosal thickness 10 months after surgery.Ki-Young Nam et al: Treatment of dental implant-related maxillary sinusitis with func-tional endoscopic sinus surgery in combination with an intra-oral approach. J Korean Assoc Oral Maxillofac Surg 2014

J Korean Assoc Oral Maxillofac Surg 2014;40:87-90

90

sinuslifting.Dentalsurgeonsperformingsimilarprocedures

shouldbeawareofthepossiblecomplicationsthatcanarise

fromforeigndebrisinvadingthemaxillarysinus.

Conflict of Interest

Nopotentialconflictofinterestrelevanttothisarticlewas

reported.

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lifthasbeenreportedtocausepostoperativesinusitis8.The

elevationoftheSchneiderianmembranecouldaffectasinus

homeostasisandleadtosinusitisbytemporalobstructionof

aphysiologicalsinusdrainagethroughtheostio-meatalunit

(OMU)9.Mucosal inflammationcausedbymisplacedim-

plantscansimilarlycausemucosalinflammationandstenosis

of theOMUwithdetrimentaleffectsonsinusventilation.

Recommendedtreatmentfordentalimplant-relatedsinusitis

typicallyinvolvessurgicalrestorationforproperdrainageand

ventilationofthesinus,interruptingthedescribedsequence

ofeventsthatleadtosinusinfection.

FESSisarelativelyrecentsurgicalprocedureusedinthe

treatmentofmaxillarysinusitis.ItwidenstheOMUtofacili-

tatesinussecretionfromthePNSintothenasalcavity,asthe

patient'snormalanatomicalstructuresarepreserved10.FESS

isabletotreatOMUalterationsandremovedisplaceddental

implants, thoughitdoesnotallowforremovalofimplants

thatprotrudeintothesinus,asinthepresentcase2.Intraoral

approachesareamoresuitablemethodforaddressingoro-

antralfistulasandremovingimplantsfromwithinthesinus,

buttheycannotrepairOMUalterationsandotheraspectsof

sinusitis7.Simpleeliminationoftheirritatingstimulus,such

asexposedordisplacedimplant,couldalsobeconsidered.

Reports in the literature indicated that implantexposure

greaterthan4mmfromthesinusfloorcangiverisetosinus-

itisorrhinosinusitis11.Inthisreport,theimplantfixturewas

removedduetonotonlytheexposedlength(5mm),butalso

thesignificantlackofinitialstability.

Thoughfurtherstudiesareneededtoevaluatetheefficacy

ofFESSintreatingrecalcitrantimplant-relatedsinusitisand

itsabilitytopreventrecurrence,thecombinationofFESSand

anintra-oralapproachshouldbeconsideredausefuloption

fortherestorationofnormalnaso-sinushomeostasis2.The

authorsreportfavorableresultsofthisdualapproachinthe

treatmentofmaxillarysinusitisfollowingimplantationwith