TECHNICAL STRATEGY
Endoscopic Sinus Surgery in Sinus-Oral Pathology Filippo Giovannetti, MD, PhD, Paolo Priore, MD, Ingrid Raponi, MD, and Valentino Valentini, MD, PhD Objective: Oral surgery is compounded by safe and well-known techniques and presents a low rate of complications. When the superior alveolar ridge is approached, surgery may result in oroantral fistula or tooth or implant dislocation in maxillary sinus. Those conditions lead to development of the maxillary sinusitis that, if underestimated, may evolve in orbital cellulitis and cerebritis or cerebral abscess. Our work aimed to compare the surgical techniques suitable for treatment of those complications and define the better surgical strategy. Methods: Between 2005 and 2010, 55 patients, presenting with displaced or migrated oral implants in the paranasal sinuses, with oroantral communication or with paranasal sinusitis of odontoiatrogenic origin, were visited and referred for treatment in the Maxillofacial Surgery Department of the University of Rome ‘‘La Sapienza.’’ Surgical treatment consists of one of the following procedures: functional endoscopic sinus surgery (FESS); intraoral approach to the sinus with Caldwell-Luc technique; and oroantral fistula closure with a local flap, alone or combined with FESS. Results: The study group consisted of 55 patients: 28 female and 27 male patients aged 43 to 78 years (mean, 60 years). All had undergone oral surgery before our first visit: 17 patients had a prosthetic implant surgery (3 lateral-approach sinus augmentation and 15 implant placement). Seventeen patients had tooth extractions, 7 did root canal treatments, and 14 had sinus maxillary augmentation. Conclusions: Functional endoscopic sinus surgery has slowly taken the place of the Caldwell-Luc technique in treating odontogenic maxillary sinusitis. Advantages of FESS are the less invasivity, the preservation of sinus anatomy and physiology, the reduction of recovery time, and oral rehabilitation without loosening efficacy compared with the previous transoral approach. Key Words: Oral, endoscopic, oral implant, maxillary sinus, infection (J Craniofac Surg 2014;25: 991Y994)
B
ecause of the close anatomic relationship of the maxillary sinuses to the dentoalveolar complex, complications of oral surgical procedures, such as sinus augmentation, dental elements extraction, From the Maxillofacial Surgery Department, Faculty of Medicine and Surgery, Sapienza University, Rome, Italy. Received June 17, 2013. Accepted for publication November 17, 2013. Address correspondence and reprint requests to Dr. Filippo Giovannetti, Maxillofacial Surgery Department, Faculty of Medicine and Surgery, Sapienza University, Via Casal Ferranti 95, 00173, Rome, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000608
The Journal of Craniofacial Surgery
and implant placement, could involve maxillary sinus and other paranasal sinuses. Although high success rates are reported, this kind of surgery may result in long-term complications such as oroantral fistula (OAF), teeth or implant displacement, and graft infection with consequent sinusitis. Augmentation of the maxillary sinus floor is a well-documented technique that facilitates placement of dental implants in the posterior atrophic maxilla. It was first introduced by Tatum1 and Boyne and James.2 The morbidity and other complications of maxillary sinus augmentation are chronic or acute sinusitis, cyst, mucocele, disturbed wound healing, hematoma, and sequestrum of bone. The most common potential complication of open sinus lift surgery is sinus membrane perforation during the procedure, which occurs at a rate of 7% to 35%3,5 and may result in leakage of graft material into the sinus, sinus infection, OAF, and impairment of the physiologic function of the sinus if left untreated.6Y9 Prosthetic rehabilitation of partially or totally edentulous patients with implantsupported prosthesis has become common practice in recent decades with reliable long-term results.10 The placement of oral implants is well documented, and successful procedures have been developed.11Y16 In some cases, prosthetic implant rehabilitation of the posterior maxillary region may be challenging because of unfavorable local conditions and wrong planning,17 which may lead to the intrasinusal displacement of the implant. Such factors are represented by excessive sinus pneumatization, lack of bone, alveolar ridge reabsorption, poor bone quality, and undetected communication with the maxillary sinus.18 Relevant signs may not follow implant migration in the sinuses, but it is possible to develop sinus infection, which can prevent the closure of the surgical site, causing an OAF. Oroantral fistulae can be both a cause and a consequence of a maxillary sinusitis.19 Usually, they result from unsuccessful healing of Schneiderian membrane perforation after tooth extractions or oral prosthetic surgery. The surgeon has 2 treatment options to manage these complications: transoral approach via the canine fossa (Caldwell-Luc approach) and transnasal endoscopic approach.20Y24 Although in literature many cases of complications after oral surgery have been reported, few are those on their surgical management and comparison of the different approaches.25Y28 The aim of the present work was to compare the efficacy of the endoscopic transnasal surgery and of the transoral open surgery in treating oral surgery complication and define the better surgical procedure.
PATIENTS AND METHODS Between January 2005 and January 2010, 55 patients, presenting with displaced or migrated oral implants in the paranasal sinuses, oroantral communication, or with paranasal sinusitis of odontoiatrogenic origin, were visited and referred for treatment in the Maxillofacial Surgery Department of the University of Rome ‘‘La Sapienza.’’ The first visit included data on background factors: disease course and treatment before admission collection; a general health evaluation; analysis of signs and symptoms related to paranasal sinus infection, such as mucopurulent rhinorrhea or chronic or intermittent cephalea; facial pain; and oral inspection, to evaluate the presence of oroantral communications. A preoperative radiographic evaluation was carried out with panoramic radiography and computed tomography of the maxilla (Fig. 1).
& Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
991
The Journal of Craniofacial Surgery
Giovannetti et al
& Volume 25, Number 3, May 2014
The Caldwell-Luc approach is performed under general anesthesia using a sublabial incision made in the buccal sulcus from the left lateral incisor to the ipsilateral first molar tooth. The mucoperiosteal flap was raised and elevated to a point at which the left inferior orbital nerve can be identified and protected. An anterior hole was made into the sinus through the thin bone of the whole canine fossa by a bur. The sinus lining was incised to permit foreign bodies and/or inflammatory product removal. After abundant irrigation, a Foley-type catheter is placed inside the sinus through its natural ostium and left in place inflated. The mucoperiosteal flap is then sutured with 3-0 resorbable filament. Foley catheter is removed within 4 days after surgery.
RESULTS FIGURE 1. Preoperative computed tomography scan shows the implant dislocated in the maxillary sinus.
After surgery, patients were clinically followed up weekly in the first month, monthly until the end of the first year, and annually thereafter, to exclude signs and symptoms of relapsing sinusitis and/or oroantral communication. Where functional endoscopic sinus surgery (FESS) was performed, clinical follow-up consists of endoscopic control (without local anesthesia).
Surgical Procedures According to radiological findings, one of the following surgical protocols was used: FESS, intraoral approach to the sinus with Caldwell-Luc technique, combined FESS and intraoral approach, and OAF closure with local flaps. Functional endoscopic sinus surgery was always performed under general anesthesia with oral intubation. If possible, carefully controlled hypotension is useful to minimize bleeding during the procedure29 because it was shown that pronounced intraoperative bleeding correlates with higher failure rates in endoscopic sinus surgery.30 The endoscopic technique always consisted of a partial uncinectomy and in a middle meatal antrostomy with enlargement of the maxillary sinus ostium, no matter what the diagnosis is. By doing this, it is possible to enter the maxillary sinus for removal of displaced implant or teeth (Fig. 2) or sinus drainage by the recreation of adequate patency of the maxillary ostium. In case of sinusitis extended from maxillary sinus to the other sinusal compartments, the procedure could include an ethmoidectomy (anterior and/or posterior) or the opening of the sphenoethmoidal recess.
FIGURE 2. Endoscopic removal of implant.
992
The study group consisted of 55 patients: 28 female and 27 male patients aged 43 to 78 years (mean, 60 years). All had history of oral surgery at the first visit: 17 had prosthetic implant surgery (3 lateral-approach sinus augmentation and 15 implant placement), 17 had tooth extractions, 7 did endodontic treatments, and 14 had sinus maxillary augmentation. Oroantral fistula was present at the first examination in 29 cases (52.73%), whereas sinusitis symptoms, such as postnasal drainage of the secretions, nausea, cephalea, muffled hearing, and nasal congestion, was found in 42 (76.4%). Oroantral fistula and sinusitis were found together 19 times (35%). Three patients (5%) had implant displacement without OAF or sinusitis. We performed Caldwell-Luc intraoral approach in 32 (58%), FESS in 20 (36%), and a combination of endoscopy and transoral fistolectomy in 3 cases (6%); one was an implant removal. Hospitalization after surgery varied from 2 to 5 days (mean, 3.5 days). Postoperative recovery was uneventful in all cases treated with FESS. In 12 of 32 patients treated by Caldwell-Luc intraoral approach, immediate postoperative complications were observed. Three of them presented OAF persistence; 2 had suture dehiscence; maxillary region paresthesia was referred in 5 cases, and 2 patients still had cephalea. Eight had sinusitis relapse and underwent endoscopy revisions. All of those patients had soft-tissue tenderness. Complete recovery of paranasal sinus function and disappearance of signs and symptoms of sinusitis, as demonstrated clinically, endoscopically, and radiographically, occurred in all patients treated with endoscopic approach (Fig. 3), whereas 12 patients, who presented with sinusitis and underwent Caldwell-Luc intervention, showed recurrence of symptoms. One patient, who underwent implant removal and closure of oroantral communication with an intraoral approach, presented 2 years after surgery with a relapse of maxillary sinusitis and purulent secretion from the nose and the oral cavity. Radiographic
FIGURE 3. Postoperative computed tomography scan.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Endoscopic Surgery in Oral Pathology
TABLE 1. Results of Clinical Studies on Caldwell-Luc for Treatment of Odontogenic Pathology Authors
No. Patients Caldwell-Luc Surgery Postoperative Complications Recurrence Rate Success Rate Surgical Revision Follow-up Period
Galindo et al26 (2005) Kluppel et al41 (2010) Ridaura-Ruiz et al33 (2009) Huang and Chen34 (2012) Our experience
2 2 9 50 32
1 2 6 50 All
Not reported Not reported Not reported All All
No No No 4% 38%
100% 100% 100% 96% 63%
No No No 3 8
6 mo 6 mo 6 mo Up 12 mo 5Y2 y
TABLE 2. Results of Clinical Studies on FESS for Treatment of Odontogenic Pathology Revision Overall Success Total Cases Cases With OAF Odontogenic Cyst Sinusitis Fungus Ball Foreign Bodies Recurrence Surgery Rate, % Lopatin et al35 (2002) 70 17 Costa et al36 (2007) Chiapasco et al17 (2009) 27 14 Andric37 (2010) Albu and Baciut31 (2010) 104 4 Hajiioannou et al38 (2010) Chiapasco et al43 (2012) 20 Our experience 20
39 5 19 14 30 4 20 14
10 7 V V 50 V V V
control demonstrated complete radiopacity of the previously treated sinus. The patient was reoperated on under general anesthesia using FESS in association with closure of the oroantral communication with a buccal flap. After reintervention, recovery was uneventful, and no other episodes of paranasal sinusitis occurred. Among endoscopically treated patients, one presented pain in the maxillary region 2 months after surgery, and one has intranasal synechia; the complications rate was about 5%. No recurrence of sinusitis was observed. The success rate of FESS alone or in association with an intraoral approach was 95%, whereas the success rate of the intraoral approach was 62%. The mean follow up was 2 years (6 months to 4 years).
DISCUSSION AND CONCLUSIONS Caldwell-Luc technique was the first to be described and used.23Y31 Many authors have published their results by using it,17,32,41,42 among others Huang and Chen33 are the most representative. In a recent study, they collected 50 patients with sinus pathology of dental origin, referring a 4% rate of postoperative complication (Table 1). The use of FESS in treating oral surgery complication is a recent acquisition.30,34Y37 Lopatin et al34 were the first who reported 70 cases of odontogenic sinusitis treated by endoscopic sinus surgery. Later, other authors presented their experience in applying the endoscopic technique and principles to the oral surgery complication treatment.35,36 Albu and Baciut30 were the first in 2010 to publish a prospective study on this issue, including 104 patients with oroantral communication and 307 with rhinogenic sinusitis. It is of interest that no statistically significant differences in failure rates were noted comparing these 2 groups of patients (7% in odontogenic vs 9% in rhinogenic group). Still, somewhat higher failures rates (13%) were noticed in cases with OAF. Surgical technique was similar to other studies, including puncture of the sinus in the canine fossa for better visualization of the alveolar recess. Again, there were no significant intraoperative and postoperative complications (Table 2). In summary, all these studies reported essentially the same surgical procedure, applying principles of FESS for the treatment of
6 2 13 14 70 V 8 10
21 3 27 V 24 V 7 4
3 (8%) No 4 No 4 (13%) No 4 No
3 No 1 No 9 No 1 No
95 100 85 100 91 100 80 100
Follow-up Period 1Y3 y 6 mo to 2 y 9 12 mo 6 mo to 2 y 6 mo 6 mo to 2 y 1Y6 y 6 mo to 4 y
rhinogenic sinusitis in patients with oroantral communication. In all cases, middle meatal antrostomy was performed that presents substantial difference to Caldwell-Luc procedure. In our study, we have compared the 2 main surgical techniques to manage oral surgery complications. Our results show that the Caldwell-Luc approach is the most affected by postoperative complications and primary pathology recurrence rate (Table 3). On the other hand, the transnasal functional endoscopy surgery is a minimally invasive technique, with low morbidity levels and an optimal compliance that allows improvement of symptoms for many years after surgery (mean follow-up, 2 years): precisely, we observed a success rate of 95% compared with 62% of Caldwell-Luc approach. In our series, when OAF was present, its closure in association with FESS has led to a complete resolution with no postoperative relapses, whereas 3 of 32 cases treated with Caldwell-Luc approach had recurrence of fistula. It can be concluded that FESS must be considered as the first choice for treatment of oral surgery complications involving the maxillary sinus. That is because nowadays with well-documented and standardized procedures it allows not only the removal of foreign bodies but also a simultaneous treatment of hyperplastic, hypertrophic, or infected mucosa. Such treatment has proven to be less aggressive than the transoral approach preserving the integrity of mucociliary function and reducing recovery time. We suggest to limit the use of Caldwell-Luc approach for the removal of displaced tooth or foreign bodies when of considerable size.
TABLE 3. Our Experience Caldwell-Luc No. patients Immediate complication Recurrence Revision surgery Success rate
32 12 12 8 63%
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FESS 20 2 0 0 95%
Combined 3 No 1 1 66%
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REFERENCES 1. Tatum OH. Maxillary and sinus implant reconstruction. Dent Clin North Am 1986;30:207 2. Boyne P, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Maxillofac Surg 1980;17:113 3. Mantovani M. Otolaryngological contraindications in augmentation of the maxillary sinus. In: Testori T, Del Fabbro M, Weinstein R, Wallace S, eds. Maxillary Sinus Surgery and Alternatives. Chicago, IL: Quintessence Publishing; 2009:42Y52 4. Padoan G, Testori T, Galli F, et al. Role of endoscopic rehabilitation of the ostiomeatal complex (FESS) in maxillary sinus surgery. Ital Oral Surg 2011;5:193Y216 5. Ziccardi VB, Betts NJ. Complications of maxillary sinus augmentation. In: The Sinus Bone Graft. Jensen OT, ed. Chicago, IL: Quintessence; 1999:201Y208 6. Mazor Z, Peleg M, Gross M. Sinus augmentation for single-tooth replacement in the posterior maxilla: a 3-year follow-up clinical report. Int J Oral Maxillofac Implants 1999;14:55 7. Misch CE. The maxillary sinus lift and sinus graft surgery. In: Contemporary Implant Dentistry. St Louis, MO: Mosby; 1999:469Y495 8. Jensen J, Sindet-Pedersen S, Oliver AJ. Varying treatment strategies for reconstruction of maxillary atrophy with implants: results in 98 patients. J Oral Maxillofac Surg 1994;52:210 9. Pikos MA. Maxillary sinus membrane repair: report of a technique for large perforations. Implant Dent 1999;8:29 10. Gokcen-Rohlig B, Yaltirik M, Ozer S, et al. Survival and success of ITI implants and prostheses: retrospective study of cases with 5-year follow-up. Eur J Dent 2009;3:42Y49 11. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the rehabilitation of deficient edentulous ridges with oral implants. Clin Oral Implants Res 2006;17:136Y159 12. Chiapasco M, Zaniboni M, Rimondini L. Dental implants placed in grafted maxillary sinuses. A retrospective analysis of clinical outcome according to the initial clinical situation and a proposal of defect classification. Clin Oral Implants Res 2008;19:416Y428 13. Del Fabbro M, Testori T, Francetti L, et al. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodont Rest Dent 2004;24:565Y577 14. GoeneoˆC ¸ R, Bianchesi C, Huerzeler M, et al. Performance of short implants in partial restorations: 3-year follow-up of Osseotite implants. Implant Dent 2005;14:274Y280 15. Romeo E, Ghisolfi M, Rozza R, et al. Short (8 mm) dental implants in the rehabilitation of partial and complete edentulism: a 3-year to 14-year longitudinal study. Int J Prosthodont 2006;19:586Y592 16. Ten Bruggenkate CM, Asikainen P, Foitzik C, et al. Short (6-mm) nonsubmerged dental implants: results of a multicenter clinical trial of 1 to 7 years. Int J Oral Maxillofac Implants 1998;13:791Y798 17. Chiapasco M, Felisati G, Maccari A, et al. The management of complications following displacement of oral implants in the paranasal sinuses: a multicenter clinical report and proposed treatment protocols. Int J Oral Maxillofac Surg 2009;24(suppl):237Y259 18. Zijderveld SA, van den Bergh JPA, Schulten EAJM, et al. Anatomical and surgical findings and complications in 100 consecutive maxillary sinus floor elevation procedures. J Oral Maxillofac Surg 2008;66:1426Y1438 19. McDermott NE, Chuang SK, Woo VV, et al. Complications of dental implants: identification, frequency, and associated risk factors. Int J Oral Maxillofac Implants 2003;18:848Y855 20. Kitamura A. Removal of a migrated dental implant from a maxillary sinus by transnasal endoscopy. Br J Oral Maxillofac Surg 2007;45:410Y411 21. Martı´n-Granizo R, Naval L, Costas A, et al. Use of buccal fat pad to repair intraoral defects: review of 30 cases. Br J Oral Maxillofac Surg 1997;35:81Y84
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22. Nakamura N, Mitsuyasu T, Ohishi M. Endoscopic removal of a dental implant displaced into the maxillary sinus: technical note. Int J Oral Maxillofac Surg 2004;33:195Y197 23. Penttila´ MA, Rautiainen ME, Pukander JS, et al. Endoscopic versus Caldwell-Luc approach in chronic maxillary sinusitis: comparison of symptoms at one-year follow-up. Rhinology 1994;32:161Y165 24. Skoglund LA, Pedersen SS, Holst E. Surgical management of 85 perforations to the maxillary sinus. Int J Oral Surg 1983;12:1Y5 25. Borgonovo A, Fabbri A, Boninsegna R, et al. Displacement of a dental implant into the maxillary sinus: case series. Minerva Stomatol 2010;59:45Y54 26. Galindo P, Sanchez-Fernandez E, Avila G, et al. Migration of implants into the maxillary sinus: two clinical cases. Int J Oral Maxillofac Implants 2005;20:291Y295 27. Guler N, Delilbasi C. Ectopic dental implants in the maxillary sinus. Quintessence Int 2007;38:e238Ye239 28. Ramotar H, Jaberoo MC, Koo Ng, et al. Image-guided, endoscopic removal of migrated titanium dental implants from maxillary sinus: two cases. J Laryngol Otol 2010;124:433Y436 29. Eberhart LH, Kussin A, Arndt C, et al. Effect of a balanced anaesthetic technique using desflurane and remifentanil on surgical conditions during microscopic and endoscopic sinus surgery. Rhinology 2007;45:72Y78 30. Albu S, Baciut M. Failures in endoscopic surgery of the maxillary sinus. Otolaryngol Head Neck Surg 2010;142:196Y201 31. Gu¨ven O. A clinical study on oroantral fistulae. J Craniomaxillofac Surg 1998;26:267Y271 32. Ridaura-Ruiz L, Figueiredo R, Guinot-Moya R, et al. Accidental displacement of dental implants into the maxillary sinus: a report of nine cases. Clin Implant Dent Relat Res 2009;11(suppl 1):e38Ye45 33. Huang YC, Chen WH. Caldwell-Luc operation without inferior meatal antrostomy: a retrospective study of 50 cases. J Oral Maxillofac Surg 2012;70:2080Y2084 34. Lopatin AS, Sysolyatin SP, Sysolyatin PG, et al. Chronic maxillary sinusitis of dental origin: is external surgical approach mandatory? Laryngoscope 2002;112:1056Y1059 35. Costa F, Emanuelli E, Robiony M, et al. Endoscopic surgical treatment of chronic maxillary sinusitis of dental origin. J Oral Maxillofac Surg 2007;65:223Y228 36. Andric M. Endoscopic surgery of the maxillary sinuses in oral and maxillofacial surgery practice: a literature review. Hellenic Arch Oral Maxillofac Surg 2010;2:57Y68 37. Hajiioannou J, Koudounarakis E, Alexopoulos K, et al. Maxillary sinusitis of dental origin due to oroantral fistula, treated by endoscopic sinus surgery and primary fistula closure. J Laryngol Otol 2010;124:986Y989 38. Cutler JL, Duncavage JA, Matheny K, et al. Results of Caldwell-Luc after failed endoscopic middle meatus antrostomy in patients with chronic sinusitis. Laryngoscope 2003;113:2148Y2150 39. Raghoebar GM, Vissink A. Treatment for an endosseous implant migrated into the maxillary sinus not causing maxillary sinusitis: case report. Int J Oral Maxillofac Implants 2003;18:745Y749 40. Kluppel LE, Santos SE, Olate S, et al. Implant migration into maxillary sinus: description of two asymptomatic cases. Oral Maxillofac J 2010;2:136Y159 41. Lee KC, Lee SJ. Clinical features and treatments of odontogenic sinusitis. Yonsei Med J. 2010;51:932Y937 42. Chiapasco M, Felisati G, Zaniboni M, et al. The treatment of sinusitis following maxillary sinus grafting with the association of functional endoscopic sinus surgery (FESS) and an intra-oral approach. Clin Oral Implants Res 2012;24:623Y629
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Endoscopic Sinus Surgery in Sinus-Oral Pathology Filippo Giovannetti, MD, PhD, Paolo Priore, MD, Ingrid Raponi, MD, and Valentino Valentini, MD, PhD Objective: Oral surgery is compounded by safe and well-known techniques and presents a low rate of complications. When the superior alveolar ridge is approached, surgery may result in oroantral fistula or tooth or implant dislocation in maxillary sinus. Those conditions lead to development of the maxillary sinusitis that, if underestimated, may evolve in orbital cellulitis and cerebritis or cerebral abscess. Our work aimed to compare the surgical techniques suitable for treatment of those complications and define the better surgical strategy. Methods: Between 2005 and 2010, 55 patients, presenting with displaced or migrated oral implants in the paranasal sinuses, with oroantral communication or with paranasal sinusitis of odontoiatrogenic origin, were visited and referred for treatment in the Maxillofacial Surgery Department of the University of Rome ‘‘La Sapienza.’’ Surgical treatment consists of one of the following procedures: functional endoscopic sinus surgery (FESS); intraoral approach to the sinus with Caldwell-Luc technique; and oroantral fistula closure with a local flap, alone or combined with FESS. Results: The study group consisted of 55 patients: 28 female and 27 male patients aged 43 to 78 years (mean, 60 years). All had undergone oral surgery before our first visit: 17 patients had a prosthetic implant surgery (3 lateral-approach sinus augmentation and 15 implant placement). Seventeen patients had tooth extractions, 7 did root canal treatments, and 14 had sinus maxillary augmentation. Conclusions: Functional endoscopic sinus surgery has slowly taken the place of the Caldwell-Luc technique in treating odontogenic maxillary sinusitis. Advantages of FESS are the less invasivity, the preservation of sinus anatomy and physiology, the reduction of recovery time, and oral rehabilitation without loosening efficacy compared with the previous transoral approach. Key Words: Oral, endoscopic, oral implant, maxillary sinus, infection (J Craniofac Surg 2014;25: 991Y994)
B
ecause of the close anatomic relationship of the maxillary sinuses to the dentoalveolar complex, complications of oral surgical procedures, such as sinus augmentation, dental elements extraction, From the Maxillofacial Surgery Department, Faculty of Medicine and Surgery, Sapienza University, Rome, Italy. Received June 17, 2013. Accepted for publication November 17, 2013. Address correspondence and reprint requests to Dr. Filippo Giovannetti, Maxillofacial Surgery Department, Faculty of Medicine and Surgery, Sapienza University, Via Casal Ferranti 95, 00173, Rome, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000608
The Journal of Craniofacial Surgery
and implant placement, could involve maxillary sinus and other paranasal sinuses. Although high success rates are reported, this kind of surgery may result in long-term complications such as oroantral fistula (OAF), teeth or implant displacement, and graft infection with consequent sinusitis. Augmentation of the maxillary sinus floor is a well-documented technique that facilitates placement of dental implants in the posterior atrophic maxilla. It was first introduced by Tatum1 and Boyne and James.2 The morbidity and other complications of maxillary sinus augmentation are chronic or acute sinusitis, cyst, mucocele, disturbed wound healing, hematoma, and sequestrum of bone. The most common potential complication of open sinus lift surgery is sinus membrane perforation during the procedure, which occurs at a rate of 7% to 35%3,5 and may result in leakage of graft material into the sinus, sinus infection, OAF, and impairment of the physiologic function of the sinus if left untreated.6Y9 Prosthetic rehabilitation of partially or totally edentulous patients with implantsupported prosthesis has become common practice in recent decades with reliable long-term results.10 The placement of oral implants is well documented, and successful procedures have been developed.11Y16 In some cases, prosthetic implant rehabilitation of the posterior maxillary region may be challenging because of unfavorable local conditions and wrong planning,17 which may lead to the intrasinusal displacement of the implant. Such factors are represented by excessive sinus pneumatization, lack of bone, alveolar ridge reabsorption, poor bone quality, and undetected communication with the maxillary sinus.18 Relevant signs may not follow implant migration in the sinuses, but it is possible to develop sinus infection, which can prevent the closure of the surgical site, causing an OAF. Oroantral fistulae can be both a cause and a consequence of a maxillary sinusitis.19 Usually, they result from unsuccessful healing of Schneiderian membrane perforation after tooth extractions or oral prosthetic surgery. The surgeon has 2 treatment options to manage these complications: transoral approach via the canine fossa (Caldwell-Luc approach) and transnasal endoscopic approach.20Y24 Although in literature many cases of complications after oral surgery have been reported, few are those on their surgical management and comparison of the different approaches.25Y28 The aim of the present work was to compare the efficacy of the endoscopic transnasal surgery and of the transoral open surgery in treating oral surgery complication and define the better surgical procedure.
PATIENTS AND METHODS Between January 2005 and January 2010, 55 patients, presenting with displaced or migrated oral implants in the paranasal sinuses, oroantral communication, or with paranasal sinusitis of odontoiatrogenic origin, were visited and referred for treatment in the Maxillofacial Surgery Department of the University of Rome ‘‘La Sapienza.’’ The first visit included data on background factors: disease course and treatment before admission collection; a general health evaluation; analysis of signs and symptoms related to paranasal sinus infection, such as mucopurulent rhinorrhea or chronic or intermittent cephalea; facial pain; and oral inspection, to evaluate the presence of oroantral communications. A preoperative radiographic evaluation was carried out with panoramic radiography and computed tomography of the maxilla (Fig. 1).
& Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
991
The Journal of Craniofacial Surgery
Giovannetti et al
& Volume 25, Number 3, May 2014
The Caldwell-Luc approach is performed under general anesthesia using a sublabial incision made in the buccal sulcus from the left lateral incisor to the ipsilateral first molar tooth. The mucoperiosteal flap was raised and elevated to a point at which the left inferior orbital nerve can be identified and protected. An anterior hole was made into the sinus through the thin bone of the whole canine fossa by a bur. The sinus lining was incised to permit foreign bodies and/or inflammatory product removal. After abundant irrigation, a Foley-type catheter is placed inside the sinus through its natural ostium and left in place inflated. The mucoperiosteal flap is then sutured with 3-0 resorbable filament. Foley catheter is removed within 4 days after surgery.
RESULTS FIGURE 1. Preoperative computed tomography scan shows the implant dislocated in the maxillary sinus.
After surgery, patients were clinically followed up weekly in the first month, monthly until the end of the first year, and annually thereafter, to exclude signs and symptoms of relapsing sinusitis and/or oroantral communication. Where functional endoscopic sinus surgery (FESS) was performed, clinical follow-up consists of endoscopic control (without local anesthesia).
Surgical Procedures According to radiological findings, one of the following surgical protocols was used: FESS, intraoral approach to the sinus with Caldwell-Luc technique, combined FESS and intraoral approach, and OAF closure with local flaps. Functional endoscopic sinus surgery was always performed under general anesthesia with oral intubation. If possible, carefully controlled hypotension is useful to minimize bleeding during the procedure29 because it was shown that pronounced intraoperative bleeding correlates with higher failure rates in endoscopic sinus surgery.30 The endoscopic technique always consisted of a partial uncinectomy and in a middle meatal antrostomy with enlargement of the maxillary sinus ostium, no matter what the diagnosis is. By doing this, it is possible to enter the maxillary sinus for removal of displaced implant or teeth (Fig. 2) or sinus drainage by the recreation of adequate patency of the maxillary ostium. In case of sinusitis extended from maxillary sinus to the other sinusal compartments, the procedure could include an ethmoidectomy (anterior and/or posterior) or the opening of the sphenoethmoidal recess.
FIGURE 2. Endoscopic removal of implant.
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The study group consisted of 55 patients: 28 female and 27 male patients aged 43 to 78 years (mean, 60 years). All had history of oral surgery at the first visit: 17 had prosthetic implant surgery (3 lateral-approach sinus augmentation and 15 implant placement), 17 had tooth extractions, 7 did endodontic treatments, and 14 had sinus maxillary augmentation. Oroantral fistula was present at the first examination in 29 cases (52.73%), whereas sinusitis symptoms, such as postnasal drainage of the secretions, nausea, cephalea, muffled hearing, and nasal congestion, was found in 42 (76.4%). Oroantral fistula and sinusitis were found together 19 times (35%). Three patients (5%) had implant displacement without OAF or sinusitis. We performed Caldwell-Luc intraoral approach in 32 (58%), FESS in 20 (36%), and a combination of endoscopy and transoral fistolectomy in 3 cases (6%); one was an implant removal. Hospitalization after surgery varied from 2 to 5 days (mean, 3.5 days). Postoperative recovery was uneventful in all cases treated with FESS. In 12 of 32 patients treated by Caldwell-Luc intraoral approach, immediate postoperative complications were observed. Three of them presented OAF persistence; 2 had suture dehiscence; maxillary region paresthesia was referred in 5 cases, and 2 patients still had cephalea. Eight had sinusitis relapse and underwent endoscopy revisions. All of those patients had soft-tissue tenderness. Complete recovery of paranasal sinus function and disappearance of signs and symptoms of sinusitis, as demonstrated clinically, endoscopically, and radiographically, occurred in all patients treated with endoscopic approach (Fig. 3), whereas 12 patients, who presented with sinusitis and underwent Caldwell-Luc intervention, showed recurrence of symptoms. One patient, who underwent implant removal and closure of oroantral communication with an intraoral approach, presented 2 years after surgery with a relapse of maxillary sinusitis and purulent secretion from the nose and the oral cavity. Radiographic
FIGURE 3. Postoperative computed tomography scan.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Endoscopic Surgery in Oral Pathology
TABLE 1. Results of Clinical Studies on Caldwell-Luc for Treatment of Odontogenic Pathology Authors
No. Patients Caldwell-Luc Surgery Postoperative Complications Recurrence Rate Success Rate Surgical Revision Follow-up Period
Galindo et al26 (2005) Kluppel et al41 (2010) Ridaura-Ruiz et al33 (2009) Huang and Chen34 (2012) Our experience
2 2 9 50 32
1 2 6 50 All
Not reported Not reported Not reported All All
No No No 4% 38%
100% 100% 100% 96% 63%
No No No 3 8
6 mo 6 mo 6 mo Up 12 mo 5Y2 y
TABLE 2. Results of Clinical Studies on FESS for Treatment of Odontogenic Pathology Revision Overall Success Total Cases Cases With OAF Odontogenic Cyst Sinusitis Fungus Ball Foreign Bodies Recurrence Surgery Rate, % Lopatin et al35 (2002) 70 17 Costa et al36 (2007) Chiapasco et al17 (2009) 27 14 Andric37 (2010) Albu and Baciut31 (2010) 104 4 Hajiioannou et al38 (2010) Chiapasco et al43 (2012) 20 Our experience 20
39 5 19 14 30 4 20 14
10 7 V V 50 V V V
control demonstrated complete radiopacity of the previously treated sinus. The patient was reoperated on under general anesthesia using FESS in association with closure of the oroantral communication with a buccal flap. After reintervention, recovery was uneventful, and no other episodes of paranasal sinusitis occurred. Among endoscopically treated patients, one presented pain in the maxillary region 2 months after surgery, and one has intranasal synechia; the complications rate was about 5%. No recurrence of sinusitis was observed. The success rate of FESS alone or in association with an intraoral approach was 95%, whereas the success rate of the intraoral approach was 62%. The mean follow up was 2 years (6 months to 4 years).
DISCUSSION AND CONCLUSIONS Caldwell-Luc technique was the first to be described and used.23Y31 Many authors have published their results by using it,17,32,41,42 among others Huang and Chen33 are the most representative. In a recent study, they collected 50 patients with sinus pathology of dental origin, referring a 4% rate of postoperative complication (Table 1). The use of FESS in treating oral surgery complication is a recent acquisition.30,34Y37 Lopatin et al34 were the first who reported 70 cases of odontogenic sinusitis treated by endoscopic sinus surgery. Later, other authors presented their experience in applying the endoscopic technique and principles to the oral surgery complication treatment.35,36 Albu and Baciut30 were the first in 2010 to publish a prospective study on this issue, including 104 patients with oroantral communication and 307 with rhinogenic sinusitis. It is of interest that no statistically significant differences in failure rates were noted comparing these 2 groups of patients (7% in odontogenic vs 9% in rhinogenic group). Still, somewhat higher failures rates (13%) were noticed in cases with OAF. Surgical technique was similar to other studies, including puncture of the sinus in the canine fossa for better visualization of the alveolar recess. Again, there were no significant intraoperative and postoperative complications (Table 2). In summary, all these studies reported essentially the same surgical procedure, applying principles of FESS for the treatment of
6 2 13 14 70 V 8 10
21 3 27 V 24 V 7 4
3 (8%) No 4 No 4 (13%) No 4 No
3 No 1 No 9 No 1 No
95 100 85 100 91 100 80 100
Follow-up Period 1Y3 y 6 mo to 2 y 9 12 mo 6 mo to 2 y 6 mo 6 mo to 2 y 1Y6 y 6 mo to 4 y
rhinogenic sinusitis in patients with oroantral communication. In all cases, middle meatal antrostomy was performed that presents substantial difference to Caldwell-Luc procedure. In our study, we have compared the 2 main surgical techniques to manage oral surgery complications. Our results show that the Caldwell-Luc approach is the most affected by postoperative complications and primary pathology recurrence rate (Table 3). On the other hand, the transnasal functional endoscopy surgery is a minimally invasive technique, with low morbidity levels and an optimal compliance that allows improvement of symptoms for many years after surgery (mean follow-up, 2 years): precisely, we observed a success rate of 95% compared with 62% of Caldwell-Luc approach. In our series, when OAF was present, its closure in association with FESS has led to a complete resolution with no postoperative relapses, whereas 3 of 32 cases treated with Caldwell-Luc approach had recurrence of fistula. It can be concluded that FESS must be considered as the first choice for treatment of oral surgery complications involving the maxillary sinus. That is because nowadays with well-documented and standardized procedures it allows not only the removal of foreign bodies but also a simultaneous treatment of hyperplastic, hypertrophic, or infected mucosa. Such treatment has proven to be less aggressive than the transoral approach preserving the integrity of mucociliary function and reducing recovery time. We suggest to limit the use of Caldwell-Luc approach for the removal of displaced tooth or foreign bodies when of considerable size.
TABLE 3. Our Experience Caldwell-Luc No. patients Immediate complication Recurrence Revision surgery Success rate
32 12 12 8 63%
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FESS 20 2 0 0 95%
Combined 3 No 1 1 66%
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Giovannetti et al
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* 2014 Mutaz B. Habal, MD
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