The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
FIGURE 6. Panoramic radiograph at 1 year of follow-up.
FIGURE 4. A, Total closure right after surgery. B, Aspect of the area 1 week postoperative.
oroantral fistula, with reported total cure of headache with sinusitis treatment together with an otolaryngologist.
DISCUSSION Oroantral communication is an unnatural communication between the oral cavity and maxillary sinus, and when it fails to close spontaneously, it remains patent and is epithelialized so that oroantral fistula develops,7 as occurred in the case presented. Surgical closure of an antral perforation is indicated if the opening is greater than 4 to 5 mm at the time of injury, if a sinus disease is present whatever the size of the opening, and if the communication is persistent.8 As presented in this case, the formation of the fistula was confirmed by the latency and chronicity of constant communication with purulent depth, beyond the patient's pain complaints. Numerous surgical techniques have been described in the literature, mostly based on mobilizing the tissue and advancing the resultant flap into the defect.7 Techniques, from soft tissue–only closure to the use of composite closures involving alloplastic materials such as gold, acrylic, or bone grafts, have been described. Soft tissue– only flaps include the buccal advancement flap, buccal fat pad flap, a combination of the buccal fat pad and advancement flap, the buccinator myomucosal flap, and the vascularized palatal island flap.5 The authors decided to use the Bichat fat pad because of its reliability, ease of harvest, low complication rate, rich blood supply, simple procedure, and minimal discomfort to patient1 in association an advancement flap. The main disadvantage observed in this form of treatment was reported in a case displaying loss of the oral vestibule, wherein the patient would need to undergo sulcoplasty technique. However, because of the initial clinical status of the patient, this disadvantage becomes easily minimized for the restoration of homeostatic oroantral balance. Amazingly, this technique also improves the physiologic functions of the cheek, for example, suppleness and elasticity.3 Therefore, as observed in the clinical case, there is the possibility of obtaining successful use of buccal fat for closing oroantral fistula, even the most unfavorable ones. The use of pedicle of the buccal fat pad for reconstruction of defects including oroantral communications is already more than consolidated in the literature, being easy to perform and convenient for
FIGURE 5. One-year follow-up after surgery.
both the patient and the operator. Furthermore, it is located in the same surgical field as the defect to cover, therefore diminishing the risk of infection.1,3
Júlio César Silva de Oliveira, DDS, MSc Rafael Santiago de Almeida, DDS, MSc Leonardo Perez Faverani, DDS, PhD Ana Paula Farnezi Bassi, DDS, PhD Celso K. Sonoda, DDS, PhD Eloá Rodrigues Luvizuto, DDS, PhD Department of Surgery and Integrated Clinic Araçatuba Dental School Univ Estadual Paulista Júlio de Mesquita Filho Araçatuba–UNESP Araçatuba, São Paulo, Brazil [email protected]
REFERENCES 1. Bither S, Halli R, Kini Y. Buccal fat pad in intraoral defect reconstruction. J Maxillofac Oral Surg 2013;12:451–455 2. Shoja MM, Tubbs RS, Loukas M, et al. Marie-francois xavier bichat (1771–1802) and his contributions to the foundations of pathological anatomy and modern medicine. Ann Anat 2008;190:413–420 3. Yeh C-J. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130–133 4. Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J Maxillofac Surg 1977;5:241–244 5. Weinstock RJ, Nikoyan L, Dym H. Composite three-layer closure of oral antral communication with 10 months follow-up—a case study. J Oral Maxillofac Surg 2014;72:266.e261–266.e267 6. Godfrey PM. Sinus obliteration for chronic oro-antral fistula: a case report. Br J Plast Surg 1193;46:341–342 7. Batra H, Jindal G, Kaur S. Evaluation of different treatment modalities for closure of oro-antral communications and formulation of a rational approach. J Maxillofac Oral Surg 2010;9:13–18 8. Nezafati S, Vafaii A, Ghojazadeh M. Comparison of pedicled buccal fat pad flap with buccal flap for closure of oro-antral communication. Int J Oral Maxillofac Surg 2012;41:624–628
Existence of and Predisposing Factors for Implant Periapical Lesions To the Editor: One potential reason for increasing risk of implant success is the existence of an infectious lesion limited to the apical part of the implant: an implant periapical lesion (IPL).1–3 On x-ray, an IPL appears as a radiolucent image involving the apex of a clinically stable dental implant. An IPL shows a normal appearance in the bone tissue for the coronal section of the implant.3–6
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
The literature contains few reports on this topic. Therefore, the objective of this retrospective study was to research the existence of and predisposing factors for IPLs among patients treated with dental implants at an implant dentistry clinic in Brazil.
MATERIALS AND METHODS Experimental Design The clinical and x-ray records of 56 patients treated with implants at the Undergraduate Implant Dentistry Clinic of the Dental Faculty of the Integrated Faculties of Adamantina between 2004 and 2011 were retrospectively reviewed (UNISALESIANO Research Ethics Committee case number 456/2012); thus, the patients who did not return for follow-up were excluded. In total, 132 implants were analyzed, including 29 Morse Taper (MT) and 103 external hexagonal (EH) implants (Neodent, Curitiba, Parana, Brazil). Panoramic x-rays from the planning and follow-up phases of the implant installation period were used as control images, which were compared with new (panoramic and periapical) x-ray images obtained between November and December 2012.
X-ray Evaluation Obtaining X-ray Images Panoramic x-ray examinations using T-MAT G/RA film (Eastman Kodak Company, Rochester, NY) were performed on each patient in the postoperative period. During the follow-up period, new ultraspeed periapical x-ray examinations (Eastman Kodak Company, Rochester, NY) were performed with the help of a positioner (Rinn XCP; Dentsply Rinn, Elgin, IL) and the standard paralleling technique.
Analysis of the X-rays Three examiners analyzed the x-rays under standardized conditions using a magnifying glass (Unicoba Imp. e Exp. Ltda, Sao Paulo, Brazil) and a negatoscope (Palmetal Metalúrgica, Parada de Lucas, Rio de Janeiro, Brazil). The films were mounted on a black paper mask that occupied the whole length of the negatoscope, thereby reducing interference from lateral luminosity.
Selection of Cases Through X-ray Examinations X-ray images in the literature were used as the pattern for selection.1,5,7,8 Implants with x-rays showing a radiolucent image involving the apex and a clinically stable coronal part (ie, the bone tissue had a normal x-ray appearance) were considered suggestive of an IPL.
Statistical Analysis Two-way analysis of variance (ANOVA) was used to verify the influence of the existence of the lesion, the different implant connection types (EH vs MT), and the area where the implant was installed. Values of P < 0.05 were considered statistically significant. The Holm-Sidak post hoc test was used to analyze significant results. All statistical analyses were performed with the Sigma Plot 13 statistical software package (San Jose, CA).
apical area. These patients did not show clinical symptoms, and xray changes were not observed in the coronal portions. Therefore, the lesions were classified as inactive IPLs. Any notable findings on the lateral or vertical percussion test or with bilateral palpation around the implanted teeth were not observed (Fig. 1).
Analysis of the Prosthetic Connections and Areas Where the Implants Were Placed The predominance of IPLs was evaluated on the basis of the different connection types (EH and MT), but any statistically significant differences were not observed (P = 0.451; Fig. 2). Similarly, no statistical differences (P = 0.311) were observed when the relationship between the existence of an IPL and the different areas where implants were placed (in front of or behind the maxilla or mandible) was evaluated. However, statistical difference between the implants without an IPL and those with an IPL (P = 0.023) was observed, as shown in Figure 3.
Adjacent Teeth in the Arch and Antagonistic Teeth Any clinical or x-ray relationship with the adjacent teeth was not observed. All adjacent teeth were uncompromised, had a normal appearance in their coronal portion, and were without periapical or periodontal lesions. Similarly, none of the 7 implants exhibited any occlusive overload (premature contact) in opening or closing the mouth, laterality, or protrusion after the clinical examination.
DISCUSSION Numerous studies have shown the longevity of dental implant therapy, which is becoming increasingly accessible to different social classes. However, some pathologies, such as IPLs, become more frequent with this form of treatment.9,10 In the current study, few IPLs were identified, and this fact is in accordance with the literature.9 Moreover, those IPLs that were found were all inactive. Various authors have pointed to exogenous contamination as a possible cause of IPLs.1,3–5 The analysis of the clinical and x-ray examinations did not identify any link with infectious processes in the adjacent teeth. All of the surgical cases were performed in a university implant dentistry clinic, which followed a rigorous asepsis protocol. Contamination was not present on the day of the examination, although it was not possible to evaluate whether it might have been present previously. In this way, Lefever et al1 and Quirynen et al11 suggested that the occurrence of an IPL might be associated to an endodontic pathology, such as a lesion in the adjacent teeth or a contaminated surgical perforation from the remains of a previous lesion in the tooth. In this study, this association was unable to be observed, although such a pathology would have coexisted with the adjacent implant for a considerable
RESULTS Clinical Evaluation and the Presence of an Image Suggestive of an IPL Through an analysis of the patients' x-ray images, 7 implants, all in the mandible, in 7 patients, exhibited a radiolucent image in the
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FIGURE 1. A and B, Periapical x-ray images of inactive IPLs. A radiolucent image can be observed in the apical area of the implants (arrows).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
in the posterior area. However, some studies have indicated an association with a greater number of IPLs installed in the maxilla.8,15 Any statistical difference for this aspect in the current study was not observed. Placed implants should be periodically examined. Any radiolucent image in the apex of the implant should be followed up with an x-ray as soon as possible to prevent acute exacerbation and a total loss of its integrity.3 Additional controlled studies are needed to trace the correct diagnosis, prognosis, and etiology for IPLs.
CONCLUSIONS
FIGURE 2. Relationship between the existence of an IPL and the prosthetic connection. a indicates not statistically significant using the 2-way ANOVA (P > 0.05).
period. It was not possible to estimate whether there were adjacent lesions previously, or even lesions in the alveolar bone before implant installation. Therefore, until not proven otherwise, the findings by Lefever et al1 and Quirynen et al11 should be considered as potential factors that might predispose a patient to an IPL. Other controlled studies are needed to prove this hypothesis. An IPL may be associated with the excessive heating of the bone during osteotomy or with the space left afterward when the implant is not sealed within the length determined by osteotomy.3–5,8 Implants in our sample group were placed by apprentice surgeons who had not yet finished their training. Therefore, the previously mentioned factors may be related to the development of IPLs in our study. Finally, some authors have reported that bone microfracture caused by overload in the implant is related to the etiology of IPL.3–5,8 None of the cases in this study reflected this fact; when occlusion was evaluated, overloading in the installed prostheses was not verified. Nevertheless, although microfracture can also be verified in the bone integration phase,9 nearly all of the cases treated in the undergraduate clinic followed a 2-stage surgical protocol. The treatment of active IPLs has been described in the literature.3,7,12–16 No specific treatment is required for inactive lesions, except for periodically evaluating the lesion.8,13 This procedure was the practice followed in the cases reported in this study. Similar to that reported by Zhou et al,12 a predominance of IPLs in the mandible was observed, with most being associated with implants placed
Within the limitations of this study, no conclusive relationship between IPLs and the predisposing factors evaluated was found. For safety reasons, it is recommended that implantations be avoided in clinical situations where there is any predisposing factor related to the occurrence of these lesions. Victor Eduardo de Souza Batista, DDS Department of Dental Materials and Prosthodontics, Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil [email protected] Jean Paulo Rodolfo Ferreira, DDS, MSc Department of Dentistry, Adamantina Dental School, Faculdades Adamantinenses Integradas Sao Paulo, Brazil Joel Ferreira Santiago Jr, DDS, MSc Department of Health Sciences University of Sacred Heart, USC Bauru Sao Paulo, Brazil Daniel Augusto de Faria Almeida, DDS, MSc Department of Dental Materials and Prosthodontics Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil Fellippo Ramos Verri, DDS, MSc Department of Dental Materials and Prosthodontics Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil Eduardo Piza Pellizzer, DDS, MSc Department of Dental Materials and Prosthodontics Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil
ACKNOWLEDGMENT The authors thank the Foundation for the Development of Unesp (Fundunesp).
REFERENCES
FIGURE 3. Relationship between the existence of an IPL and the installation area of the implant. * and ** indicate statistically significant difference (P = 0.023 using the 2-way ANOVA with the Holm-Sidak post hoc test).
1. Lefever D, Van Assche N, Temmerman A, et al. Aetiology, microbiology and therapy of periapical lesions around oral implants: a retrospective analysis. J Clin Periodontol 2013;40:296–302 2. Buhara O, Uyanik LO, Ayali A, et al. Active implant periapical lesions leading to implant failure: two case reports. J Oral Implantol 2014;40:325–329
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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3. Flanagan D. Apical (retrograde) peri-implantitis: a case report of an active lesion. J Oral Implantol 2002;28:92–96 4. Silva GC, Oliveira DR, Vieira TC, et al. Unusual presentation of active implant periapical lesions: a report of two cases. J Oral Sci 2010;52:491–494 5. Scarano A, Di Domizio P, Petrone G, et al. Implant periapical lesion: a clinical and histologic case report. J Oral Implantol 2000;26:109–113 6. Quaranta A, Andreana S, Pompa G, et al. Active implant peri-apical lesion: a case report treated via guided bone regeneration with a 5-year clinical and radiographic follow-up. J Oral Implantol 2014;40:313–319 7. Romanos GE, Froum S, Costa-Martins S, et al. Implant periapical lesions: etiology and treatment options. J Oral Implantol 2011;37:53–63 8. Tözüm TF, Sençimen M, Ortakoğlu K, et al. Diagnosis and treatment of a large periapical implant lesion associated with adjacent natural tooth: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e132–e138 9. Peñarrocha-Diago M, Maestre-Ferrín L, Cervera-Ballester J, et al. Implant periapical lesion: diagnosis and treatment. Med Oral Patol Oral Cir Bucal 2012;17:e1023–e1027 10. Toniollo MB, Macedo AP, Rodrigues RC, et al. Three-dimensional finite element analysis of stress distribution on different bony ridges with different lengths of morse taper implants and prosthesis dimensions. J Craniofac Surg 2012;23:1888–1892 11. Quirynen M, Vogels R, Alsaadi G, et al. Predisposing conditions for retrograde peri-implantitis, and treatment suggestions. Clin Oral Implants Res 2005;16:599–608 12. Zhou Y, Cheng Z, Wu M, et al. Trepanation and curettage treatment for acute implant periapical lesions. Int J Oral Maxillofac Surg 2012;41:171–175 13. Sussman HI. Periapical implant pathology. J Oral Implantol 1998;24:133–138 14. Nedir R, Bischof M, Pujol O, et al. Starch-induced implant periapical lesion: a case report. Int J Oral Maxillofac Implants 2007; 22:1001–1006 15. Bousdras V, Aghabeigi B, Hopper C, et al. Management of apical bone loss around a mandibular implant: a case report. Int J Oral Maxillofac Implants 2006;21:439–444 16. Penarrocha-Diago M, Maestre-Ferrín L, Penarrocha-Oltra D, et al. Inflammatory implant periapical lesion prior to osseointegration: a case series study. Int J Oral Maxillofac Implants 2013;28:158–162
Concerning the Article ‘’Neutrophil-Lymphocyte Ratio: A New Predictive and Prognostic Factor in Patients With Bell Palsy” To the Editor: In our study entitled ‘’Neutrophil-to-lymphocyte ratio as a novel-potential marker for predicting prognosis of Bell palsy,”1 the 54 patients, who were followed up because of Bell palsy for a period of 1 to 3 years, were scanned and classified according to the House-Brackmann grading system. At posttreatment period, the patients with House-Brackmann grades I and II were regarded as satisfactory recovery, and those with House-Brackmann grades III to VI were regarded as ‘’nonsatisfactory.” The mean neutrophil-to-lymphocyte ratio (NLR) and neutrophil values in patients with Bell palsy were significantly higher than the control group (P = 0.001 and P < 0.001, respectively). In addition, NLR levels were higher in nonsatisfactory recovered patients compared with satisfactory recovered ones (P < 0.001).
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We agree with you, while evaluating Bell palsy patients, that NLR might be taken into account as a novel potential marker to predict the patients’ prognosis. We thank the authors for their valuable contributions and opinions. Abdulkadir Bucak, MD Department of Otorhinolaryngology, Faculty of Medicine Afyon Kocatepe University Afyonkarahisar, Turkey [email protected]
REFERENCE 1. Bucak A, Ulu S, Oruc S, et al. Neutrophil-to-lymphocyte ratio as a novel-potential marker for predicting prognosis of Bell palsy. Laryngoscope 2014;124:1678–1681
Endoscopic Sinus Surgery and Intraoral Approaches in Sinus Oral Pathology To the Editor: Because our group has been treating sinus oral pathology for more than 10 years and supporting the use of nasal endoscopy, it has been both a pleasure and a personal gratification seeing how maxillofacial colleagues embraced endoscopic surgery. Therefore, we read the article by Giovannetti and colleagues1 with keen interest and peculiar attention. We especially appreciated the comprehensive point of view over what the authors call “sinus oral pathology,” an emerging group of conditions loosely related to the traditional nosologic entity of “odontogenic sinusitis.” Nevertheless, if we consider the whole broad spectrum of sinonasal complications of dental disease or treatment (SCDDTs), we think that the article would greatly take advantage of including other relevant etiologies, such as periimplantitis,2 pulpitis and failed endodontics,3 as well as periodontitis,4 which affect a conspicuous number of patients. The authors did propose sound therapeutic options, although they did not specify which protocols should be adopted in each different clinical scenario. Our group already published a comprehensive article on this subject.5 Unfortunately, the authors, despite citing our other works, did not compare their approach with our indications: a comparison between the 2 groups' experiences and results could have been interesting and useful. A major point that would take advantage from a direct comparison is combining endoscopic endonasal techniques and oral approach in selected SCDDT scenarios. Indeed, even if most available data show that ESS is superior in terms of results to more traditional oral approaches, even when treating chronic sinusitis limited to the maxillary sinus,6 we strongly believe that multidisciplinary treatment coupling endoscopic endonasal techniques and oral approaches is pivotal both in diagnosing and treating odontogenic sinonasal conditions. In contrast to what Giovannetti and colleagues say, in our hands, oral accesses prove effective in particular conditions such as displacement of implants into the maxillary sinus, where there is no inflammatory reaction to control (exclusive oral access), and pivotal in granting a complete visualization of the maxillary alveolar recess (combined approach), © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
FIGURE 6. Panoramic radiograph at 1 year of follow-up.
FIGURE 4. A, Total closure right after surgery. B, Aspect of the area 1 week postoperative.
oroantral fistula, with reported total cure of headache with sinusitis treatment together with an otolaryngologist.
DISCUSSION Oroantral communication is an unnatural communication between the oral cavity and maxillary sinus, and when it fails to close spontaneously, it remains patent and is epithelialized so that oroantral fistula develops,7 as occurred in the case presented. Surgical closure of an antral perforation is indicated if the opening is greater than 4 to 5 mm at the time of injury, if a sinus disease is present whatever the size of the opening, and if the communication is persistent.8 As presented in this case, the formation of the fistula was confirmed by the latency and chronicity of constant communication with purulent depth, beyond the patient's pain complaints. Numerous surgical techniques have been described in the literature, mostly based on mobilizing the tissue and advancing the resultant flap into the defect.7 Techniques, from soft tissue–only closure to the use of composite closures involving alloplastic materials such as gold, acrylic, or bone grafts, have been described. Soft tissue– only flaps include the buccal advancement flap, buccal fat pad flap, a combination of the buccal fat pad and advancement flap, the buccinator myomucosal flap, and the vascularized palatal island flap.5 The authors decided to use the Bichat fat pad because of its reliability, ease of harvest, low complication rate, rich blood supply, simple procedure, and minimal discomfort to patient1 in association an advancement flap. The main disadvantage observed in this form of treatment was reported in a case displaying loss of the oral vestibule, wherein the patient would need to undergo sulcoplasty technique. However, because of the initial clinical status of the patient, this disadvantage becomes easily minimized for the restoration of homeostatic oroantral balance. Amazingly, this technique also improves the physiologic functions of the cheek, for example, suppleness and elasticity.3 Therefore, as observed in the clinical case, there is the possibility of obtaining successful use of buccal fat for closing oroantral fistula, even the most unfavorable ones. The use of pedicle of the buccal fat pad for reconstruction of defects including oroantral communications is already more than consolidated in the literature, being easy to perform and convenient for
FIGURE 5. One-year follow-up after surgery.
both the patient and the operator. Furthermore, it is located in the same surgical field as the defect to cover, therefore diminishing the risk of infection.1,3
Júlio César Silva de Oliveira, DDS, MSc Rafael Santiago de Almeida, DDS, MSc Leonardo Perez Faverani, DDS, PhD Ana Paula Farnezi Bassi, DDS, PhD Celso K. Sonoda, DDS, PhD Eloá Rodrigues Luvizuto, DDS, PhD Department of Surgery and Integrated Clinic Araçatuba Dental School Univ Estadual Paulista Júlio de Mesquita Filho Araçatuba–UNESP Araçatuba, São Paulo, Brazil [email protected]
REFERENCES 1. Bither S, Halli R, Kini Y. Buccal fat pad in intraoral defect reconstruction. J Maxillofac Oral Surg 2013;12:451–455 2. Shoja MM, Tubbs RS, Loukas M, et al. Marie-francois xavier bichat (1771–1802) and his contributions to the foundations of pathological anatomy and modern medicine. Ann Anat 2008;190:413–420 3. Yeh C-J. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130–133 4. Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J Maxillofac Surg 1977;5:241–244 5. Weinstock RJ, Nikoyan L, Dym H. Composite three-layer closure of oral antral communication with 10 months follow-up—a case study. J Oral Maxillofac Surg 2014;72:266.e261–266.e267 6. Godfrey PM. Sinus obliteration for chronic oro-antral fistula: a case report. Br J Plast Surg 1193;46:341–342 7. Batra H, Jindal G, Kaur S. Evaluation of different treatment modalities for closure of oro-antral communications and formulation of a rational approach. J Maxillofac Oral Surg 2010;9:13–18 8. Nezafati S, Vafaii A, Ghojazadeh M. Comparison of pedicled buccal fat pad flap with buccal flap for closure of oro-antral communication. Int J Oral Maxillofac Surg 2012;41:624–628
Existence of and Predisposing Factors for Implant Periapical Lesions To the Editor: One potential reason for increasing risk of implant success is the existence of an infectious lesion limited to the apical part of the implant: an implant periapical lesion (IPL).1–3 On x-ray, an IPL appears as a radiolucent image involving the apex of a clinically stable dental implant. An IPL shows a normal appearance in the bone tissue for the coronal section of the implant.3–6
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
319
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
The literature contains few reports on this topic. Therefore, the objective of this retrospective study was to research the existence of and predisposing factors for IPLs among patients treated with dental implants at an implant dentistry clinic in Brazil.
MATERIALS AND METHODS Experimental Design The clinical and x-ray records of 56 patients treated with implants at the Undergraduate Implant Dentistry Clinic of the Dental Faculty of the Integrated Faculties of Adamantina between 2004 and 2011 were retrospectively reviewed (UNISALESIANO Research Ethics Committee case number 456/2012); thus, the patients who did not return for follow-up were excluded. In total, 132 implants were analyzed, including 29 Morse Taper (MT) and 103 external hexagonal (EH) implants (Neodent, Curitiba, Parana, Brazil). Panoramic x-rays from the planning and follow-up phases of the implant installation period were used as control images, which were compared with new (panoramic and periapical) x-ray images obtained between November and December 2012.
X-ray Evaluation Obtaining X-ray Images Panoramic x-ray examinations using T-MAT G/RA film (Eastman Kodak Company, Rochester, NY) were performed on each patient in the postoperative period. During the follow-up period, new ultraspeed periapical x-ray examinations (Eastman Kodak Company, Rochester, NY) were performed with the help of a positioner (Rinn XCP; Dentsply Rinn, Elgin, IL) and the standard paralleling technique.
Analysis of the X-rays Three examiners analyzed the x-rays under standardized conditions using a magnifying glass (Unicoba Imp. e Exp. Ltda, Sao Paulo, Brazil) and a negatoscope (Palmetal Metalúrgica, Parada de Lucas, Rio de Janeiro, Brazil). The films were mounted on a black paper mask that occupied the whole length of the negatoscope, thereby reducing interference from lateral luminosity.
Selection of Cases Through X-ray Examinations X-ray images in the literature were used as the pattern for selection.1,5,7,8 Implants with x-rays showing a radiolucent image involving the apex and a clinically stable coronal part (ie, the bone tissue had a normal x-ray appearance) were considered suggestive of an IPL.
Statistical Analysis Two-way analysis of variance (ANOVA) was used to verify the influence of the existence of the lesion, the different implant connection types (EH vs MT), and the area where the implant was installed. Values of P < 0.05 were considered statistically significant. The Holm-Sidak post hoc test was used to analyze significant results. All statistical analyses were performed with the Sigma Plot 13 statistical software package (San Jose, CA).
apical area. These patients did not show clinical symptoms, and xray changes were not observed in the coronal portions. Therefore, the lesions were classified as inactive IPLs. Any notable findings on the lateral or vertical percussion test or with bilateral palpation around the implanted teeth were not observed (Fig. 1).
Analysis of the Prosthetic Connections and Areas Where the Implants Were Placed The predominance of IPLs was evaluated on the basis of the different connection types (EH and MT), but any statistically significant differences were not observed (P = 0.451; Fig. 2). Similarly, no statistical differences (P = 0.311) were observed when the relationship between the existence of an IPL and the different areas where implants were placed (in front of or behind the maxilla or mandible) was evaluated. However, statistical difference between the implants without an IPL and those with an IPL (P = 0.023) was observed, as shown in Figure 3.
Adjacent Teeth in the Arch and Antagonistic Teeth Any clinical or x-ray relationship with the adjacent teeth was not observed. All adjacent teeth were uncompromised, had a normal appearance in their coronal portion, and were without periapical or periodontal lesions. Similarly, none of the 7 implants exhibited any occlusive overload (premature contact) in opening or closing the mouth, laterality, or protrusion after the clinical examination.
DISCUSSION Numerous studies have shown the longevity of dental implant therapy, which is becoming increasingly accessible to different social classes. However, some pathologies, such as IPLs, become more frequent with this form of treatment.9,10 In the current study, few IPLs were identified, and this fact is in accordance with the literature.9 Moreover, those IPLs that were found were all inactive. Various authors have pointed to exogenous contamination as a possible cause of IPLs.1,3–5 The analysis of the clinical and x-ray examinations did not identify any link with infectious processes in the adjacent teeth. All of the surgical cases were performed in a university implant dentistry clinic, which followed a rigorous asepsis protocol. Contamination was not present on the day of the examination, although it was not possible to evaluate whether it might have been present previously. In this way, Lefever et al1 and Quirynen et al11 suggested that the occurrence of an IPL might be associated to an endodontic pathology, such as a lesion in the adjacent teeth or a contaminated surgical perforation from the remains of a previous lesion in the tooth. In this study, this association was unable to be observed, although such a pathology would have coexisted with the adjacent implant for a considerable
RESULTS Clinical Evaluation and the Presence of an Image Suggestive of an IPL Through an analysis of the patients' x-ray images, 7 implants, all in the mandible, in 7 patients, exhibited a radiolucent image in the
320
FIGURE 1. A and B, Periapical x-ray images of inactive IPLs. A radiolucent image can be observed in the apical area of the implants (arrows).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
in the posterior area. However, some studies have indicated an association with a greater number of IPLs installed in the maxilla.8,15 Any statistical difference for this aspect in the current study was not observed. Placed implants should be periodically examined. Any radiolucent image in the apex of the implant should be followed up with an x-ray as soon as possible to prevent acute exacerbation and a total loss of its integrity.3 Additional controlled studies are needed to trace the correct diagnosis, prognosis, and etiology for IPLs.
CONCLUSIONS
FIGURE 2. Relationship between the existence of an IPL and the prosthetic connection. a indicates not statistically significant using the 2-way ANOVA (P > 0.05).
period. It was not possible to estimate whether there were adjacent lesions previously, or even lesions in the alveolar bone before implant installation. Therefore, until not proven otherwise, the findings by Lefever et al1 and Quirynen et al11 should be considered as potential factors that might predispose a patient to an IPL. Other controlled studies are needed to prove this hypothesis. An IPL may be associated with the excessive heating of the bone during osteotomy or with the space left afterward when the implant is not sealed within the length determined by osteotomy.3–5,8 Implants in our sample group were placed by apprentice surgeons who had not yet finished their training. Therefore, the previously mentioned factors may be related to the development of IPLs in our study. Finally, some authors have reported that bone microfracture caused by overload in the implant is related to the etiology of IPL.3–5,8 None of the cases in this study reflected this fact; when occlusion was evaluated, overloading in the installed prostheses was not verified. Nevertheless, although microfracture can also be verified in the bone integration phase,9 nearly all of the cases treated in the undergraduate clinic followed a 2-stage surgical protocol. The treatment of active IPLs has been described in the literature.3,7,12–16 No specific treatment is required for inactive lesions, except for periodically evaluating the lesion.8,13 This procedure was the practice followed in the cases reported in this study. Similar to that reported by Zhou et al,12 a predominance of IPLs in the mandible was observed, with most being associated with implants placed
Within the limitations of this study, no conclusive relationship between IPLs and the predisposing factors evaluated was found. For safety reasons, it is recommended that implantations be avoided in clinical situations where there is any predisposing factor related to the occurrence of these lesions. Victor Eduardo de Souza Batista, DDS Department of Dental Materials and Prosthodontics, Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil [email protected] Jean Paulo Rodolfo Ferreira, DDS, MSc Department of Dentistry, Adamantina Dental School, Faculdades Adamantinenses Integradas Sao Paulo, Brazil Joel Ferreira Santiago Jr, DDS, MSc Department of Health Sciences University of Sacred Heart, USC Bauru Sao Paulo, Brazil Daniel Augusto de Faria Almeida, DDS, MSc Department of Dental Materials and Prosthodontics Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil Fellippo Ramos Verri, DDS, MSc Department of Dental Materials and Prosthodontics Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil Eduardo Piza Pellizzer, DDS, MSc Department of Dental Materials and Prosthodontics Aracatuba Dental School, Universidade Estadual Paulista Araçatuba Campus Sao Paulo, Brazil
ACKNOWLEDGMENT The authors thank the Foundation for the Development of Unesp (Fundunesp).
REFERENCES
FIGURE 3. Relationship between the existence of an IPL and the installation area of the implant. * and ** indicate statistically significant difference (P = 0.023 using the 2-way ANOVA with the Holm-Sidak post hoc test).
1. Lefever D, Van Assche N, Temmerman A, et al. Aetiology, microbiology and therapy of periapical lesions around oral implants: a retrospective analysis. J Clin Periodontol 2013;40:296–302 2. Buhara O, Uyanik LO, Ayali A, et al. Active implant periapical lesions leading to implant failure: two case reports. J Oral Implantol 2014;40:325–329
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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3. Flanagan D. Apical (retrograde) peri-implantitis: a case report of an active lesion. J Oral Implantol 2002;28:92–96 4. Silva GC, Oliveira DR, Vieira TC, et al. Unusual presentation of active implant periapical lesions: a report of two cases. J Oral Sci 2010;52:491–494 5. Scarano A, Di Domizio P, Petrone G, et al. Implant periapical lesion: a clinical and histologic case report. J Oral Implantol 2000;26:109–113 6. Quaranta A, Andreana S, Pompa G, et al. Active implant peri-apical lesion: a case report treated via guided bone regeneration with a 5-year clinical and radiographic follow-up. J Oral Implantol 2014;40:313–319 7. Romanos GE, Froum S, Costa-Martins S, et al. Implant periapical lesions: etiology and treatment options. J Oral Implantol 2011;37:53–63 8. Tözüm TF, Sençimen M, Ortakoğlu K, et al. Diagnosis and treatment of a large periapical implant lesion associated with adjacent natural tooth: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e132–e138 9. Peñarrocha-Diago M, Maestre-Ferrín L, Cervera-Ballester J, et al. Implant periapical lesion: diagnosis and treatment. Med Oral Patol Oral Cir Bucal 2012;17:e1023–e1027 10. Toniollo MB, Macedo AP, Rodrigues RC, et al. Three-dimensional finite element analysis of stress distribution on different bony ridges with different lengths of morse taper implants and prosthesis dimensions. J Craniofac Surg 2012;23:1888–1892 11. Quirynen M, Vogels R, Alsaadi G, et al. Predisposing conditions for retrograde peri-implantitis, and treatment suggestions. Clin Oral Implants Res 2005;16:599–608 12. Zhou Y, Cheng Z, Wu M, et al. Trepanation and curettage treatment for acute implant periapical lesions. Int J Oral Maxillofac Surg 2012;41:171–175 13. Sussman HI. Periapical implant pathology. J Oral Implantol 1998;24:133–138 14. Nedir R, Bischof M, Pujol O, et al. Starch-induced implant periapical lesion: a case report. Int J Oral Maxillofac Implants 2007; 22:1001–1006 15. Bousdras V, Aghabeigi B, Hopper C, et al. Management of apical bone loss around a mandibular implant: a case report. Int J Oral Maxillofac Implants 2006;21:439–444 16. Penarrocha-Diago M, Maestre-Ferrín L, Penarrocha-Oltra D, et al. Inflammatory implant periapical lesion prior to osseointegration: a case series study. Int J Oral Maxillofac Implants 2013;28:158–162
Concerning the Article ‘’Neutrophil-Lymphocyte Ratio: A New Predictive and Prognostic Factor in Patients With Bell Palsy” To the Editor: In our study entitled ‘’Neutrophil-to-lymphocyte ratio as a novel-potential marker for predicting prognosis of Bell palsy,”1 the 54 patients, who were followed up because of Bell palsy for a period of 1 to 3 years, were scanned and classified according to the House-Brackmann grading system. At posttreatment period, the patients with House-Brackmann grades I and II were regarded as satisfactory recovery, and those with House-Brackmann grades III to VI were regarded as ‘’nonsatisfactory.” The mean neutrophil-to-lymphocyte ratio (NLR) and neutrophil values in patients with Bell palsy were significantly higher than the control group (P = 0.001 and P < 0.001, respectively). In addition, NLR levels were higher in nonsatisfactory recovered patients compared with satisfactory recovered ones (P < 0.001).
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We agree with you, while evaluating Bell palsy patients, that NLR might be taken into account as a novel potential marker to predict the patients’ prognosis. We thank the authors for their valuable contributions and opinions. Abdulkadir Bucak, MD Department of Otorhinolaryngology, Faculty of Medicine Afyon Kocatepe University Afyonkarahisar, Turkey [email protected]
REFERENCE 1. Bucak A, Ulu S, Oruc S, et al. Neutrophil-to-lymphocyte ratio as a novel-potential marker for predicting prognosis of Bell palsy. Laryngoscope 2014;124:1678–1681
Endoscopic Sinus Surgery and Intraoral Approaches in Sinus Oral Pathology To the Editor: Because our group has been treating sinus oral pathology for more than 10 years and supporting the use of nasal endoscopy, it has been both a pleasure and a personal gratification seeing how maxillofacial colleagues embraced endoscopic surgery. Therefore, we read the article by Giovannetti and colleagues1 with keen interest and peculiar attention. We especially appreciated the comprehensive point of view over what the authors call “sinus oral pathology,” an emerging group of conditions loosely related to the traditional nosologic entity of “odontogenic sinusitis.” Nevertheless, if we consider the whole broad spectrum of sinonasal complications of dental disease or treatment (SCDDTs), we think that the article would greatly take advantage of including other relevant etiologies, such as periimplantitis,2 pulpitis and failed endodontics,3 as well as periodontitis,4 which affect a conspicuous number of patients. The authors did propose sound therapeutic options, although they did not specify which protocols should be adopted in each different clinical scenario. Our group already published a comprehensive article on this subject.5 Unfortunately, the authors, despite citing our other works, did not compare their approach with our indications: a comparison between the 2 groups' experiences and results could have been interesting and useful. A major point that would take advantage from a direct comparison is combining endoscopic endonasal techniques and oral approach in selected SCDDT scenarios. Indeed, even if most available data show that ESS is superior in terms of results to more traditional oral approaches, even when treating chronic sinusitis limited to the maxillary sinus,6 we strongly believe that multidisciplinary treatment coupling endoscopic endonasal techniques and oral approaches is pivotal both in diagnosing and treating odontogenic sinonasal conditions. In contrast to what Giovannetti and colleagues say, in our hands, oral accesses prove effective in particular conditions such as displacement of implants into the maxillary sinus, where there is no inflammatory reaction to control (exclusive oral access), and pivotal in granting a complete visualization of the maxillary alveolar recess (combined approach), © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
