Maxillary Sinusitis Caused by Dental Implants Extending into the Maxillary Sinus and the Nasal Cavities Matteo Biafora, MD, Giacomo Bertazzoni, MD, & Matteo Trimarchi, MD Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy The article is associated with the American College of Prosthodontists’ journal-based continuing education program. It is accompanied by an online continuing education activity worth 1 credit. Please visit www.wileyhealthlearning.com/jopr to complete the activity and earn credit.
Keywords Sinusitis; dental implants; endoscopic surgery. Correspondence Matteo Trimarchi, Department of Otorhinolaryngology, San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milano, Italy. E-mail: [email protected] The authors deny any conflicts of interest. Accepted August 28, 2013
Abstract This report describes the case of a patient who underwent osseointegrated dental implant placement. The implants were misplaced inside the nasal fossae and in the right maxillary sinus, causing chronic purulent sinusitis. CT scan without contrast showed signs of right maxillary sinusitis and confirmed the misplacement of four dental implants that surfaced into the nasal cavities. The imaging also revealed the presence of another implant that emerged inside the maxillary sinus. The patient underwent functional endoscopic sinus surgery with complete symptom remission at the long-term follow-up. We propose that sinusitis caused by protrusion of implants and by sinus floor lift procedures could share common physiopathological patterns and predisposing factors.
doi: 10.1111/jopr.12123
Osseointegration of dental implants and placement of implantsupported prostheses is a widely used technique considered reliable for the replacement of missing dental elements.1,2 However, implant osseointegration can be challenging due to low bone density and thinness of edentulous alveolar ridges, particularly in the maxillary bone of elderly patients. This unfavorable anatomical condition can cause instability of endosseous implants and is responsible for a greater failure rate of osseointegrated implants placed in the maxilla compared to mandibular implants.3 Inadequate maxillary bone thickness, along with poor surgical planning and lack of experience, are also associated with protrusion of implants in the maxillary sinuses4-6 and/or nasal cavities7 or implant migration to the paranasal sinuses.8-16 Displacement or partial surfacing of a dental implant in the maxillary sinus is usually uneventful, but it may episodically be associated with oroantral fistulae and/or sinusitis,17 while extension of dental implants in the nasal cavity can be associated with rhinosinusitis and rhinitis.7 Such complications of dental implants can benefit from conservative medical therapy, but surgery is needed for recalcitrant disease. The main surgical option for treatment of dental implant-related rhinosinusitis is FESS (Functional Endoscopic Sinus Surgery), which is favored over the Caldwell-Luc operation because of shorter hospital stays and lower morbidity.18 Surgery can include removal of the implants, but the necessity of this procedure is still controversial.18
We report a rare case of rhinosinusitis arising from protrusion of dental implants in both nasal fossae and the right maxillary sinus. The patient refused to remove the implants, and rhinosinusitis treatment with FESS was performed to restore physiological maxillary sinus drainage and ventilation without modification of the existing implants.
Clinical report A 38-year-old woman presented with a 2-year history of recurrent nasal obstruction, nasal discharge, and facial pain. Her past medical history revealed that 2 years before she had undergone osseointegrated dental implant placement surgery in another country to replace dental elements missing after facial trauma related to a car accident. No maxillary sinus floor augmentation procedure was performed. No other data regarding the implantation procedure were available. Her medical and family histories were otherwise unremarkable; she was taking no medications and had no known drug allergies. The patient underwent otorhinolaryngological evaluation. Nasal endoscopy showed the emergence of two dental implants penetrating the inferior turbinates in each nasal fossa, along with signs of right maxillary sinus infection. Medical therapy was therefore performed, and the patient was administered two consecutive standard cycles of antibiotics (first cycle with amoxicillin-clavulanic acid, second cycle with levofloxacin)
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Figure 1 Preoperative CT imaging; coronal CT (A) protrusion of implants (p) in the nose, inferior turbinate (it) involvement and unscathed middle turbinates (mt); axial CT (B) dental implants (p) in the right maxillary sinus and in the nose and their relationship with inferior turbinates (it); sagittal CT scans show an intranasal implant (C); and the implant protruding in the maxillary sinus (D).
and over-the-counter nasal saline douches. Short-term followup after medical treatment revealed persistence of signs and symptoms of infection and warranted further investigation. A subsequent maxillofacial CT scan without contrast showed signs of right maxillary sinusitis and confirmed the misplacement of four dental implants that surfaced into the nasal cavities. Imaging also revealed the presence of another implant that emerged inside the maxillary sinus (Fig 1). Removal or resection of the apices of the misplaced implants was proposed to the patient, but she refused to undergo any procedure that would involve her implants directly. For that reason, the patient underwent FESS under general anesthesia. The nasal mucosa was decongested using intranasal cotonoids soaked in a solution of carbocain and adrenalin 1:200,000. The nasal mucosa surrounding the uncinate process was subsequently infiltrated with the same solution. Intraoperative nasal inspection with a 0◦ rigid endoscope allowed clearer visualization of the implants inside the nose (Figs 2A– C) and the right maxillary sinus. The mucosa surrounding the portion of the implant that protruded into the right maxillary sinus appeared hyperemic, indicating a local inflammatory reaction. Purulent secretions flowed out of the right maxillary sinus ostium (Fig 2A). Aeration and drainage of the right maxillary sinus were restored through partial inferior uncinectomy and middle antrostomy using a 0◦ rigid endoscope. We then proceeded with irrigation of the sinus with saline solution to wash out the purulent secretions. Finally, the mucosa of the sinus was inspected 228
with a 70◦ rigid endoscope. No macroscopic alterations were detected. The postoperative period was unremarkable. The patient was dismissed the day after surgery, and antibiotic therapy was prescribed. Short-term follow-up examination and nasal endoscopy 10 days later did not show any signs of rhinosinusitis. No recurrence of symptoms was reported at long-term followup examination, 1 year after surgery. Nasal endoscopy confirmed resolution of the disease (Fig 2D).
Discussion The pathological link between exposure or displacement of dental implants in the maxillary sinus and sinusitis has not been fully elucidated.19 Similarly, only hypotheses have been made on the mechanisms underlying the association between implant extension into the nasal cavity and rhinosinusitis.7 Dental implant exposure and displacement in the maxillary sinus of experimental canine models have consistently been unsuccessful at causing sinusitis and rhinosinusitis.19-21 In particular, Jung et al, in their experiments on dogs, observed that when implants penetrated the sinus floor less than 2 mm, the healing mucosa covered the implants spontaneously. In contrast, when the implants penetrated the sinus floor more than 4 mm, the apices of the implants remained exposed. Despite this, there was no apparent difference in signs of sinusitis in either experimental group.20 These observations were later confirmed in humans.21 Nonetheless, reports in the literature indicate that
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 227–231
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Sinusitis Caused by Implants into Maxillary Sinus and Nasal Cavities
Figure 2 Intraoperative nasal endoscopy shows, in middle nasal fossa, (A) purulent secretions flowing out of the maxillary sinus area (m) and middle (mt) and inferior (it) turbinates; endoscopy in left (B) and right (C) inferior nasal fossae shows bilateral protrusion of dental implants (p), the
area of the maxillary sinus (m) and inferior (it) and middle (mt) turbinates; and long-term follow-up right maxillary sinus (m) endoscopy (D) shows implant protrusion (p), healthy mucosa, and absence of secretions.
implant extension in the sinuses and into the nasal cavities can give rise to sinusitis or rhinosinusitis.4-7 Conversely, if the implants are covered by normal mucosa, no alterations of the sinus arise, as noted by Br˚anemark et al.19 Retrospective CT imaging of patients with implant penetration greater than 4 mm in the sinuses and no history of maxillary sinusitis showed that more than half of the patients presented mucosal swelling limited to the floor of the maxillary sinus, but no signs of rhinosinusitis in the follow-up period (6 to 10 months).21 Also, maxillary sinus floor lift has been reported to cause postoperative sinusitis.22 The lifting of the Schneiderian membrane affects sinus homeostasis and leads to sinusitis by transiently obstructing physiological maxillary drainage through the ostiomeatal complex (OMC).23 The temporary or permanent blockage of the OMC may be caused by impaired ciliary activity, inflammation and edema of the ostiomeatal mucosa, excessive elevation of the maxillary sinus floor, or herniation of bone graft fragments through the sinus floor into the OMC.23 The negative effects on sinus homeostasis described can give rise to sinusitis in predisposed patients, as highlighted by Timmenga et al.24 It has therefore been hypothesized that mucosal thickening could mimic the detrimental effects of sinus floor elevation on the OMC and affect sinus drainage and aeration, thus causing sinusitis in predisposed patients.21 A similar pathologic mechanism has been hypothesized for sinusitis after placement of
zygomatic implants, although oroantral communication is also thought to be an important factor.25 Involvement of the OMC is also thought to be present in rhinosinusitis related to osseointegrated implants surfacing in the nasal fossae.7 The implants, covered with crusts and debris, could act as a foreign body and irritate the surrounding mucosa, causing swelling of the OMC. Moreover, the implants could alter nasal airflow, thereby increasing mucous secretion and scar formation. The interaction of the described alterations of nasal physiology has been proposed as a cause of rhinosinusitis in predisposed patients by Raghoebar et al.7 For the patient presented here, probably both the dental implants extending into the maxillary sinus and nasal fossae are equally responsible for the development of the patient’s condition. Mucosal inflammation caused by misplaced implants on both sides of the OMC can similarly cause mucosal inflammation and stenosis of the OMC with analogous detrimental effects on sinus ventilation. Treatment of recalcitrant dental implant–related sinusitis is primarily surgical and it aims at restoring proper drainage and ventilation in the sinus, interrupting the described sequence of noxious events that lead to sinus infection.23 The desired outcome can be reached either through elimination of the irritating stimulus represented by the displaced or surfacing implant, or through restoration of adequate OMC patency, sinus drainage, and ventilation.17
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FESS allows treatment of OMC alterations and removal of displaced dental implants, if present, but it does not allow removal of implants that emerge into the sinus.4,12,15,17 Intraoral approaches are more suitable to address oroantral fistulae and remove implants that are displaced or emerge into the sinus, but they do not address OMC alterations and sinusitis properly.5,17 Proposed surgical treatments of intranasal protruding implants feature implant removal or resection of their apical portion.7 In our patient, FESS was sufficient to cause lasting symptom remission, and it was not necessary to remove the implants. Probably, the presence of the implants ceased to be a crucial factor in the pathogenesis of the patient’s sinusitis after improvement of sinus drainage and ventilation. Sinusitis caused by protrusion of implants and sinusitis associated with sinus floor lift procedures seem to share common physiopathological patterns and predisposing factors. Nonetheless, the role of the ear, nose, and throat (ENT) specialist in the assessment of factors that predispose to sinusitis is recognized and well defined only in sinus lift procedures.23,26 On the other hand, the relatively low rate of ENT complications in osseointegrated dental implant placement27 has never prompted the organization of a systematic preoperative ENT work-up. Further studies could help to assess the actual impact of preoperative ENT evaluation in the prevention of dental implant-related sinusitis in predisposed patients; however, we believe that simple anamnestic questions on sinonasal health and careful avoidance of implant protrusion greater than 4 mm, together with standard preliminary CT scan evaluation and dental examination, could similarly result in reduction of such rare complications. Another problem raised by this case concerns the responsibilities of the dental surgeon who placed the implants. An adequate work-up before implant placement can help the surgeon to avoid or minimize protrusion of implants,17 while patient follow-up is advisable to reduce delayed diagnosis of complications, as in our patient; however, she underwent implant placement surgery abroad, to save money. Seeking dental treatment in another country has been labeled dental tourism.28 Today the number of dental tourists traveling from Western to Eastern Europe seeking less expensive dental care is increasing.29,30 It is evident that this growing trend raises problems of professional accountability and makes proper follow-up difficult to arrange.28,30
Conclusion Our report shows that FESS can be a successful surgical procedure for the treatment of rhinosinusitis related to dental implants. Further studies are needed to evaluate the efficacy of FESS in treating recalcitrant dental implant–related rhinosinusitis and its ability to prevent recurrences. FESS allows resolution of the infection and restoration of proper sinus ventilation, preventing recurrence without removing the misplaced implants.
References 1. Albrektsson T, Donos N: Implant survival and complications. The Third EAO consensus conference 2012. Clin Oral Implants Res 2012;23:163-201 230
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2. Leonhardt A, Grondahl K, Bergstrom C, et al: Long-term follow-up of osseointegrated titanium implants using clinical, radiographic and microbiological parameters. Clin Oral Implants Res 2002;13:127-132 3. Esposito M, Grusovin MG, Rees J, et al: Effectiveness of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic review. Eur J Oral Implantol 2010;3:7-26 4. Ueda M, Kaneda T: Maxillary sinusitis caused by dental implants: report of two cases. J Oral Maxillofac Surg 2002;50:285-287 5. Quiney RE, Brimble E, Hodge M: Maxillary sinusitis from dental osseointegrated implants. J Laryngol Otol 1990;104:333– 334 6. G¨umr¨u O, Koc¸ak H: Acute maxillary sinusitis from a dental implant: an unusual case report. J Marmara Univ Dent Fac 1996;2:551-553 7. Raghoebar GM, van Weissenbruch R, Vissink A: Rhino-sinusitis related to endosseous implants extending into the nasal cavity. A case report. Int J Oral Maxillofac Surg 2004;33:312-314 8. 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;20:291-359 9. Felisati G, Lozza P, Chiapasco M, et al: Endoscopic removal of an unusual foreign body in the sphenoid sinus: an oral implant. Clin Oral Implants Res 2007;18:776-780 10. Guler N, Delilbasi C: Ectopic dental implants in the maxillary sinus. Quintessence Int 2007;38:238-239 11. Kluppel LE, Santos SE, Olate S, et al: Implant migration into maxillary sinus: description of two asymptomatic cases. Oral Maxillofac Surg 2010;30:155-159 12. 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;33:195-197 13. El Charkawi HG, El Askary AS, Ragab A: Endoscopic removal of a implant from the maxillary sinus: a case report. Implant Dent 2005;14:30-35 14. Kim JW, Lee CH, Kwon TK, et al: Endoscopic removal of a dental implant through a middle meatal antrostomy. Br J Oral Maxillofac Surg 2007;45:408-409 15. Kitamura A: Removal of a migrated dental implant from the maxillary sinus by transnasal endoscopy. Br J Oral Maxillofac Surg 2007;45:410-411 16. Iida S, Tanaka N, Kogo M, et al: Migration of a dental implant into the maxillary sinus. A case report. Int J Oral Maxillofac Surg 2000;29:358-359 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;38:1273-1278 18. Chen YW, Huang CC, Chang PH, et al: The characteristics and new treatment paradigm of dental implant-related chronic rhinosinusitis. Am J Rhinol Allergy 2013;27:237-244 19. Br˚anemark PI, Adell R, Albrektsson T, et al: An experimental and clinical study of osseointegrated implants penetrating the nasal cavity and maxillary sinus. J Oral Maxillofac Surg 1984;42:497-505 20. Jung JH, Choi BH, Zhu SJ, et al: The effects of exposing dental implants to the maxillary sinus cavity on sinus complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:602-605 21. Jung JH, Choi BH, Jeong SM, et al: A retrospective study of the effects on sinus complications of exposing dental implants to the maxillary sinus cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:623-625
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22. Timmenga NM, Raghoebar GM, van Weissenbruch R, et al: Maxillary sinusitis after augmentation of the maxillary sinus floor: a report of 2 cases. J Oral Maxillofac Surg 2001;59: 200-204 23. Pignataro L, Mantovani M, Torretta S, et al: ENT assessment in the integrated management of candidate for (maxillary) sinus lift. Acta Otorhinolaryngol Ital 2008;28:110– 119 24. Timmenga NM, Raghoebar GM, Boering G, et al: Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 1997;55:936-939 25. Chrcanovic BR, Abreu MH: Survival and complications of zygomatic implants: a systematic review. Oral Maxillofac Surg 2013;17:81-93
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26. Cote MT, Segelnick SL, Rastogi A, et al: New York state ear, nose, and throat specialists’ views on pre-sinus lift referral. J Periodontol 2011;82:227-233 27. Zimbler MS, Lebowitz RA, Glickman R, et al: Antral augmentation, osseointegration, and sinusitis: the otolaryngologist’s perspective. Am J Rhinol 1998;12:311-316 28. Barrowman RA, Grubor D, Chandu A: Dental implant tourism. Aust Dent J 2010;55:441-445 29. Legido-Quigley H, Glinos I, Baeten R, et al: Patient mobility in the European Union. Br Med J 2007;334:188-190 30. Groene O, Poletti P, Vallejo P, et al: Quality requirements for cross-border care in Europe: a qualitative study of patients’, professionals’ and healthcare financiers’ views Qual Saf Health Care 2009;18:15-21
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Keywords Sinusitis; dental implants; endoscopic surgery. Correspondence Matteo Trimarchi, Department of Otorhinolaryngology, San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milano, Italy. E-mail: [email protected] The authors deny any conflicts of interest. Accepted August 28, 2013
Abstract This report describes the case of a patient who underwent osseointegrated dental implant placement. The implants were misplaced inside the nasal fossae and in the right maxillary sinus, causing chronic purulent sinusitis. CT scan without contrast showed signs of right maxillary sinusitis and confirmed the misplacement of four dental implants that surfaced into the nasal cavities. The imaging also revealed the presence of another implant that emerged inside the maxillary sinus. The patient underwent functional endoscopic sinus surgery with complete symptom remission at the long-term follow-up. We propose that sinusitis caused by protrusion of implants and by sinus floor lift procedures could share common physiopathological patterns and predisposing factors.
doi: 10.1111/jopr.12123
Osseointegration of dental implants and placement of implantsupported prostheses is a widely used technique considered reliable for the replacement of missing dental elements.1,2 However, implant osseointegration can be challenging due to low bone density and thinness of edentulous alveolar ridges, particularly in the maxillary bone of elderly patients. This unfavorable anatomical condition can cause instability of endosseous implants and is responsible for a greater failure rate of osseointegrated implants placed in the maxilla compared to mandibular implants.3 Inadequate maxillary bone thickness, along with poor surgical planning and lack of experience, are also associated with protrusion of implants in the maxillary sinuses4-6 and/or nasal cavities7 or implant migration to the paranasal sinuses.8-16 Displacement or partial surfacing of a dental implant in the maxillary sinus is usually uneventful, but it may episodically be associated with oroantral fistulae and/or sinusitis,17 while extension of dental implants in the nasal cavity can be associated with rhinosinusitis and rhinitis.7 Such complications of dental implants can benefit from conservative medical therapy, but surgery is needed for recalcitrant disease. The main surgical option for treatment of dental implant-related rhinosinusitis is FESS (Functional Endoscopic Sinus Surgery), which is favored over the Caldwell-Luc operation because of shorter hospital stays and lower morbidity.18 Surgery can include removal of the implants, but the necessity of this procedure is still controversial.18
We report a rare case of rhinosinusitis arising from protrusion of dental implants in both nasal fossae and the right maxillary sinus. The patient refused to remove the implants, and rhinosinusitis treatment with FESS was performed to restore physiological maxillary sinus drainage and ventilation without modification of the existing implants.
Clinical report A 38-year-old woman presented with a 2-year history of recurrent nasal obstruction, nasal discharge, and facial pain. Her past medical history revealed that 2 years before she had undergone osseointegrated dental implant placement surgery in another country to replace dental elements missing after facial trauma related to a car accident. No maxillary sinus floor augmentation procedure was performed. No other data regarding the implantation procedure were available. Her medical and family histories were otherwise unremarkable; she was taking no medications and had no known drug allergies. The patient underwent otorhinolaryngological evaluation. Nasal endoscopy showed the emergence of two dental implants penetrating the inferior turbinates in each nasal fossa, along with signs of right maxillary sinus infection. Medical therapy was therefore performed, and the patient was administered two consecutive standard cycles of antibiotics (first cycle with amoxicillin-clavulanic acid, second cycle with levofloxacin)
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Figure 1 Preoperative CT imaging; coronal CT (A) protrusion of implants (p) in the nose, inferior turbinate (it) involvement and unscathed middle turbinates (mt); axial CT (B) dental implants (p) in the right maxillary sinus and in the nose and their relationship with inferior turbinates (it); sagittal CT scans show an intranasal implant (C); and the implant protruding in the maxillary sinus (D).
and over-the-counter nasal saline douches. Short-term followup after medical treatment revealed persistence of signs and symptoms of infection and warranted further investigation. A subsequent maxillofacial CT scan without contrast showed signs of right maxillary sinusitis and confirmed the misplacement of four dental implants that surfaced into the nasal cavities. Imaging also revealed the presence of another implant that emerged inside the maxillary sinus (Fig 1). Removal or resection of the apices of the misplaced implants was proposed to the patient, but she refused to undergo any procedure that would involve her implants directly. For that reason, the patient underwent FESS under general anesthesia. The nasal mucosa was decongested using intranasal cotonoids soaked in a solution of carbocain and adrenalin 1:200,000. The nasal mucosa surrounding the uncinate process was subsequently infiltrated with the same solution. Intraoperative nasal inspection with a 0◦ rigid endoscope allowed clearer visualization of the implants inside the nose (Figs 2A– C) and the right maxillary sinus. The mucosa surrounding the portion of the implant that protruded into the right maxillary sinus appeared hyperemic, indicating a local inflammatory reaction. Purulent secretions flowed out of the right maxillary sinus ostium (Fig 2A). Aeration and drainage of the right maxillary sinus were restored through partial inferior uncinectomy and middle antrostomy using a 0◦ rigid endoscope. We then proceeded with irrigation of the sinus with saline solution to wash out the purulent secretions. Finally, the mucosa of the sinus was inspected 228
with a 70◦ rigid endoscope. No macroscopic alterations were detected. The postoperative period was unremarkable. The patient was dismissed the day after surgery, and antibiotic therapy was prescribed. Short-term follow-up examination and nasal endoscopy 10 days later did not show any signs of rhinosinusitis. No recurrence of symptoms was reported at long-term followup examination, 1 year after surgery. Nasal endoscopy confirmed resolution of the disease (Fig 2D).
Discussion The pathological link between exposure or displacement of dental implants in the maxillary sinus and sinusitis has not been fully elucidated.19 Similarly, only hypotheses have been made on the mechanisms underlying the association between implant extension into the nasal cavity and rhinosinusitis.7 Dental implant exposure and displacement in the maxillary sinus of experimental canine models have consistently been unsuccessful at causing sinusitis and rhinosinusitis.19-21 In particular, Jung et al, in their experiments on dogs, observed that when implants penetrated the sinus floor less than 2 mm, the healing mucosa covered the implants spontaneously. In contrast, when the implants penetrated the sinus floor more than 4 mm, the apices of the implants remained exposed. Despite this, there was no apparent difference in signs of sinusitis in either experimental group.20 These observations were later confirmed in humans.21 Nonetheless, reports in the literature indicate that
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 227–231
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Sinusitis Caused by Implants into Maxillary Sinus and Nasal Cavities
Figure 2 Intraoperative nasal endoscopy shows, in middle nasal fossa, (A) purulent secretions flowing out of the maxillary sinus area (m) and middle (mt) and inferior (it) turbinates; endoscopy in left (B) and right (C) inferior nasal fossae shows bilateral protrusion of dental implants (p), the
area of the maxillary sinus (m) and inferior (it) and middle (mt) turbinates; and long-term follow-up right maxillary sinus (m) endoscopy (D) shows implant protrusion (p), healthy mucosa, and absence of secretions.
implant extension in the sinuses and into the nasal cavities can give rise to sinusitis or rhinosinusitis.4-7 Conversely, if the implants are covered by normal mucosa, no alterations of the sinus arise, as noted by Br˚anemark et al.19 Retrospective CT imaging of patients with implant penetration greater than 4 mm in the sinuses and no history of maxillary sinusitis showed that more than half of the patients presented mucosal swelling limited to the floor of the maxillary sinus, but no signs of rhinosinusitis in the follow-up period (6 to 10 months).21 Also, maxillary sinus floor lift has been reported to cause postoperative sinusitis.22 The lifting of the Schneiderian membrane affects sinus homeostasis and leads to sinusitis by transiently obstructing physiological maxillary drainage through the ostiomeatal complex (OMC).23 The temporary or permanent blockage of the OMC may be caused by impaired ciliary activity, inflammation and edema of the ostiomeatal mucosa, excessive elevation of the maxillary sinus floor, or herniation of bone graft fragments through the sinus floor into the OMC.23 The negative effects on sinus homeostasis described can give rise to sinusitis in predisposed patients, as highlighted by Timmenga et al.24 It has therefore been hypothesized that mucosal thickening could mimic the detrimental effects of sinus floor elevation on the OMC and affect sinus drainage and aeration, thus causing sinusitis in predisposed patients.21 A similar pathologic mechanism has been hypothesized for sinusitis after placement of
zygomatic implants, although oroantral communication is also thought to be an important factor.25 Involvement of the OMC is also thought to be present in rhinosinusitis related to osseointegrated implants surfacing in the nasal fossae.7 The implants, covered with crusts and debris, could act as a foreign body and irritate the surrounding mucosa, causing swelling of the OMC. Moreover, the implants could alter nasal airflow, thereby increasing mucous secretion and scar formation. The interaction of the described alterations of nasal physiology has been proposed as a cause of rhinosinusitis in predisposed patients by Raghoebar et al.7 For the patient presented here, probably both the dental implants extending into the maxillary sinus and nasal fossae are equally responsible for the development of the patient’s condition. Mucosal inflammation caused by misplaced implants on both sides of the OMC can similarly cause mucosal inflammation and stenosis of the OMC with analogous detrimental effects on sinus ventilation. Treatment of recalcitrant dental implant–related sinusitis is primarily surgical and it aims at restoring proper drainage and ventilation in the sinus, interrupting the described sequence of noxious events that lead to sinus infection.23 The desired outcome can be reached either through elimination of the irritating stimulus represented by the displaced or surfacing implant, or through restoration of adequate OMC patency, sinus drainage, and ventilation.17
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 227–231
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FESS allows treatment of OMC alterations and removal of displaced dental implants, if present, but it does not allow removal of implants that emerge into the sinus.4,12,15,17 Intraoral approaches are more suitable to address oroantral fistulae and remove implants that are displaced or emerge into the sinus, but they do not address OMC alterations and sinusitis properly.5,17 Proposed surgical treatments of intranasal protruding implants feature implant removal or resection of their apical portion.7 In our patient, FESS was sufficient to cause lasting symptom remission, and it was not necessary to remove the implants. Probably, the presence of the implants ceased to be a crucial factor in the pathogenesis of the patient’s sinusitis after improvement of sinus drainage and ventilation. Sinusitis caused by protrusion of implants and sinusitis associated with sinus floor lift procedures seem to share common physiopathological patterns and predisposing factors. Nonetheless, the role of the ear, nose, and throat (ENT) specialist in the assessment of factors that predispose to sinusitis is recognized and well defined only in sinus lift procedures.23,26 On the other hand, the relatively low rate of ENT complications in osseointegrated dental implant placement27 has never prompted the organization of a systematic preoperative ENT work-up. Further studies could help to assess the actual impact of preoperative ENT evaluation in the prevention of dental implant-related sinusitis in predisposed patients; however, we believe that simple anamnestic questions on sinonasal health and careful avoidance of implant protrusion greater than 4 mm, together with standard preliminary CT scan evaluation and dental examination, could similarly result in reduction of such rare complications. Another problem raised by this case concerns the responsibilities of the dental surgeon who placed the implants. An adequate work-up before implant placement can help the surgeon to avoid or minimize protrusion of implants,17 while patient follow-up is advisable to reduce delayed diagnosis of complications, as in our patient; however, she underwent implant placement surgery abroad, to save money. Seeking dental treatment in another country has been labeled dental tourism.28 Today the number of dental tourists traveling from Western to Eastern Europe seeking less expensive dental care is increasing.29,30 It is evident that this growing trend raises problems of professional accountability and makes proper follow-up difficult to arrange.28,30
Conclusion Our report shows that FESS can be a successful surgical procedure for the treatment of rhinosinusitis related to dental implants. Further studies are needed to evaluate the efficacy of FESS in treating recalcitrant dental implant–related rhinosinusitis and its ability to prevent recurrences. FESS allows resolution of the infection and restoration of proper sinus ventilation, preventing recurrence without removing the misplaced implants.
References 1. Albrektsson T, Donos N: Implant survival and complications. The Third EAO consensus conference 2012. Clin Oral Implants Res 2012;23:163-201 230
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