Q U I N T E S S E N C E I N T E R N AT I O N A L

ORAL SURGERY

Jong Seok Park

Facial skin fistula as a postoperative complication related to maxillary sinus grafting: A case report Jong Seok Park, DDS 1*/Bong Chul Kim, DDS, MSD2*/Boyoung Choi, DDS, PhD2/Jun Lee, DDS, PhD3,4 Maxillary sinus elevation has become an important surgical procedure in dental implant surgery. This procedure may induce a variety of postoperative complications including infection, perforation of the sinus membrane, and maxillary sinusitis. However, postoperative infections are relatively infre-

quent. In this report, an unusual form of infection resulting in a facial skin fistula following maxillary sinus elevation is described. (Quintessence Int 2015;46:145–148; doi: 10.3290/j. qi.a32640)

Key words: complication, dental implant, infection, maxillary sinus elevation

Atrophy of the alveolar ridges in an edentulous posterior maxilla often restricts the volume of bone available for the positioning of dental implants.1 Therefore, maxillary sinus elevation has become an important procedure in dental implant surgery to increase bone volume in atrophic posterior maxillary alveolar ridges.2 Maxillary sinus elevation may result in a variety of postoperative complications such as infection, bone sequestration, perforation of the sinus membrane, and maxillary sinusitis. Additionally, oroantral fistula is one of the most important postoperative complications.3 Complications can also occur resulting from a preexisting sinus condition.4 Postoperative infections are

1

Resident, Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea.

2

Assistant Professor, Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea.

3

Associate Professor, Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea.

4

Associate Professor, Wonkwang Bone Regeneration Research Institute, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea.

*

Jong Seok Park and Bong Chul Kim contributed equally to this study.

Correspondence: Professor Jun Lee, Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, 77 Dunsan-ro, Seo-gu, Daejeon, Korea. Email: [email protected]

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comparatively rare, with reported infection rates ranging from 2% to 5.6%.1 Herein, a rare case of infection resulting in facial skin fistula following maxillary sinus elevation is reported.

CASE REPORT A 44-year-old man visited the Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, with complaints of swelling and pain in the right mid-face. He had a dental history of a right maxillary sinus elevation procedure performed at a local dental clinic 7 days prior to visiting the clinic. On physical examination, swelling, tenderness, and redness were observed in the right paranasal area. This was spreading to the orbital area, resulting in the closure of his right eyelid (Fig 1). A panoramic radiograph revealed a grafted bone level on the right maxillary sinus (Fig 2). A right maxillary sinus elevation had been performed by a lateral window approach and an allogenic bone material (Allo-bone, Daewoong Pharmaceutical Company; particle size: 250–710 μm) had been grafted.

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Fig 1 Photograph of the patient taken during his first visit. Swelling and redness are present in the right paranasal area and spreading to the orbital area, resulting in the closure of the right eyelid.

a

b

The patient’s medical and family histories were unknown. Upon urine analysis, glucose was detected. The patient’s blood sugar level was 304 mg/dL. For further evaluation, he was referred to the Department of Internal Medicine. On medical examination, the patient was diagnosed with diabetes mellitus. To modulate his diabetes mellitus, the patient received 5 units of insulin pump therapy subcutaneously before every meal. The patient also had a history of smoking approximately one pack of cigarettes a day for the past 25 years. The patient was admitted to the Daejeon Dental Hospital. Antibiotic therapy was initiated as per routine admission procedures with 1 g second generation intravenous cephalosporin three times a day, 200 mg intravenous aminoglycoside twice daily, and 500 mg intravenous metronidazole three times a day. On the following day, an intraoral incision and drainage was performed in the right posterior maxillary area, and two silicone drains were inserted. Infected grafted particles were partially removed by incision and drainage. Urban et al5 reported a planned treatment regimen for sinus

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Fig 2 Panoramic radiograph obtained during the patient’s first visit. Allo-bone material had been grafted through a lateral window technique onto the right maxillary sinus floor.

Figs 3a and 3b Computed tomography scans obtained on postoperative day 5. (a) Coronal view: grafted bone particles and pus formation are observed in the right maxillary sinus (yellow arrow). (b) Sagittal view: pus has formed in the infra-orbital space (white arrows).

graft infection; after a surgical approach to maxillary sinus, loose membrane pieces were removed and grayish bone graft particles were irrigated with sterile saline. All patients received a systemic antibiotic and antiinflammatory medication for 1 week following surgery.5 On postoperative day (POD) 5, computed tomography scans revealed grafted bone particles floating in the right maxillary sinus. An enhancing lesion was observed (Fig 3a), with pus spreading to the orbital area (Fig 3b). Further, a facial skin fistula had formed that was extruding the grafted bone material (Fig 4). By POD 7, facial swelling and tenderness had decreased remarkably. However, the skin fistula remained and bone particles were still being extruded through it. The patient experienced no pain or discomfort. On POD 10, the patient was discharged from the hospital. The patient remained free of infection until the 6-month postoperative follow-up. The facial skin fistula had closed and no more grafted bone particles were being extruded. There was no pain or swelling in the right paranasal area. However, a facial skin scar had formed around the paranasal area (Fig 5).

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a

b

Figs 4a and 4b (a) Photograph of the lesion on postoperative day 5. A skin fistula formed that was extruding the grafted bone material (red circle). (b) An enlarged photograph of the lesion on postoperative day 5.

Fig 5 A photograph taken during the 4-month postoperative follow-up visit. The fistula is closed, and a facial skin scar formed around the right paranasal area.

DISCUSSION

other factors.4 These factors may result in postoperative complications. Sinus membrane perforation is the most commonly encountered intraoperative complication.15 A systematic review showed that the mean perforation rate was 3.8% (range, 0% to 21.4%) when using the transcrestal approach.16 Another intraoperative complication is excessive bleeding, which is often associated with the laceration of an intra-osseous artery while using a lateral window approach.17 Additional reported complications that are associated with maxillary sinus elevation procedures include infection, wound dehiscence, sinusitis, oral-antral fistula, and loss of stability of the grafted bone.3,5,14,16 Although sinus membrane perforation can cause infections such as sinusitis in the maxillary sinus, they are typically not severe. Furthermore, there is no documented report of a maxillary sinus infection causing a facial skin fistula. In this case, the fact that grafted bone materials were extruded from the skin fistula suggests that a loss of grafted bone stability could have been the cause of infection leading to the facial skin fistula. We planned to remove the infected graft particles; however, we believed that alleviating the patient’s chief complaints should first be addressed. Therefore, we performed incision and drainage, and infected graft particles were partially removed. After that time, the patient’s condition improved. Therefore, we considered that the

Sinus elevation is a predictable procedure for a pneumatized maxillary sinus and resorbed posterior maxillary alveolar bone. Autogenous bone from intraoral and extraoral sites, mineralized or demineralized freeze-dried allogenic bone, xenogenic bone, alloplastic bone, growth factor, or a combination of these materials are used as graft materials for sinus elevation.6-11 If autogenous bone is required in sinus elevation, extraorally harvested bone grafts are recommended.12 There are reports that heterologous graft materials are just as effective, and sometimes even superior to autologous grafts. In particular, deproteinized bovine bone can be a good alternative graft material to autologous bone for the purposes of sinus elevation.13 Some procedures are performed without any bone grafting. The patient in this study received allogenic bone material as a graft on the right maxillary sinus floor. In the current literature, there is no compelling evidence that supports the selection of autologous bone, allograft bone, or xenograft biomaterials as an ideal graft for sinus elevation procedures.14 There are various factors that can cause infection after maxillary sinus elevation. For example, there could be a loss of stability of the grafted bone, a pre-existing sinus condition, a membrane perforation, diabetes mellitus, poor early-infection management, smoking, and

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potential disadvantages of additional treatment to remove the residual graft particles outweighed the advantages. Floating grafted bone materials are known to cause infection after maxillary sinus elevation. Moreover, undetected diabetes mellitus could be another compounding factor. Diabetes can enhance the expression of tumor necrosis factor-alpha, which has been ascribed to the apoptosis of osteoblasts and their precursors.18 This enhanced apoptosis is suggested to be damaging to the bone healing process.19 Furthermore, this patient had been smoking approximately a pack of cigarettes a day for 25 years. If the patient continued smoking following maxillary sinus elevation surgery, he would have been more susceptible to infections. Barone et al20 reported that the combination of smoking and an onlay bone graft noticeably increased the rate of postoperative infections following a sinus graft. The present case suggests that when maxillary sinus elevation is performed, loss of grafted bone stability can result in an infection spreading to the infra-orbital area. A severe form of such an infection can result in facial skin fistula. Therefore, careful grafting of bone onto the maxillary sinus floor and stability of the grafted bone materials are necessary to prevent postoperative infection. Moreover, clinicians should assess the general health of the patient and be aware of systemic diseases like diabetes mellitus prior to surgery, because diabetes mellitus increases susceptibility to infection.21 Further, postoperative care is very important, especially abstinence from smoking. Maxillary sinus elevation is a very useful procedure that increases the volume of maxillary alveolar bone to facilitate dental implants. Clinicians should be well acquainted with both the nuances of the procedure and its complications in order to obtain the best possible prognosis for their patients.

ACKNOWLEDGMENT This work was supported by Wonkwang University in 2014. This study was approved by the local Ethics Committee of the Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea after obtaining written consent from the patient.

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VOLUME 46 • NUMBER 2 • FEBRUARY 2015

Facial skin fistula as a postoperative complication related to maxillary sinus grafting: A case report.

Maxillary sinus elevation has become an important surgical procedure in dental implant surgery. This procedure may induce a variety of postoperative c...
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