Q U I N T E S S E N C E I N T E R N AT I O N A L
IMAGING
Marius Karl Wolf
Preoperative 3D imaging in maxillary sinus: Brief review of the literature and case report Marius Karl Wolf, DMD1/Claudio Rostetter, MD 1/Bernd Stadlinger, MD, DMD2/Michael Locher, MD, DMD3/ Georg Damerau, DMD 2 Objective: The purpose of the present case report is to document the removal of a radix in antro without a hemorrhagic complication in presence of a posterior superior alveolar artery (PSAA) with a 2.8 mm diameter following a radiographic 3D planning by cone beam computed tomography (CBCT) scan. Furthermore, a brief literature overview on studies describing the existence and the variance of the PSAA is provided. Method and Materials: A foreign body removal in the right maxillary sinus was performed on a 33-year-old healthy man by using the lateral window osteotomy. The preoperative CBCT scan showed three arteries in the lateral maxillary sinus wall at a distance of 24.6 mm, 19.5 mm, and 13.5 mm to the alveolar crest. Results: By removing a foreign body out of the maxillary
sinus a vessel with a diameter of nearly 3 mm was exposed. Due to CBCT scan planning and the use of piezosurgery it was possible to avoid any damage to the vessel during the operation. The postoperative healing was uneventful and no complications occurred. Conclusion: Although laceration of vessels with a large diameter during lateral window osteotomy is not life-threatening it may compromise visualization and reduces the surgical outcome. Therefore, 3D imaging is recommended for the minimization of intra- and postoperative complications and for the localization of any foreign body in relation to other anatomical structures. This is of special interest in case of anatomical variances of blood vessels. (Quintessence Int 2015;46:627–631; doi: 10.3290/j.qi.a33930)
Key words: complications, cone beam computed tomography, lateral window osteotomy, maxillary sinus, posterior superior alveolar artery, radix in antro, vascularization
Symptomatic foreign bodies in the maxillary sinus should be removed. There are three ways of removing these foreign bodies: via the alveolus, via the nose, or via access through the lateral facial wall of the sinus. During removal of foreign bodies, maxillary sinus floor augmentation, or implant installation, hemorrhagic 1
Assistant Doctor, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Zurich, Switzerland.
2
Senior Consultant, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Zurich, Switzerland.
3
Head of Oral Surgery Department, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Zurich, Switzerland.
Correspondence: Dr Marius Karl Wolf, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Plattenstrasse 11, 8032 Zurich, Switzerland. Email: [email protected]
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
complications may occur as a result of injury to the lateral artery.1,2 Therefore, exact knowledge of the anatomy and a sufficient radiographic evaluation of the maxillary sinus are essential preoperatively.2,3
ANATOMICAL BACKGROUND The maxillary sinuses are the biggest paranasal sinuses situated bilaterally in the upper jaw.4 The maxillary sinus of an adult has the shape of a three-walled pyramid. Keeping this image in mind, the pyramid base would be located at the lateral nasal wall and the pyramid top would be pointing towards the zygomatic process of the maxilla. The orbital floor builds the cranial part and the alveolar pro-
627
Q U I N T E S S E N C E I N T E R N AT I O N A L Wolf et al
IOA ASAA EA
MA PSAA
IA
Fig 1 Vascularization of the maxillary sinus: ASAA, anterior superior alveolar artery; EA, extraosseus anastomoses; IA, intraosseus anastomoses; IOA, infraorbital artery; MA, maxillary artery; PSAA, posterior superior alveolar artery. Modified and reprinted with kind permission, from Kqiku.14
cess builds the caudal one. The natural ostium forms the connection to the nasal cavity. It is located in the superior portion of the medial wall of the sinus.5 The maxillary sinus is lined with a respiratory epithelial layer called the sinus membrane. Due to the beating of the respiratory cilia in the direction of the ostia, the sinus stays sterile.6 The vascularization of the maxillary sinus (Fig 1) is supplied by the maxillary artery, the larger terminal branch of the external carotid artery. After entering the pterygopalatine fossa, the maxillary artery gives off three branches for the maxillary sinus. The posterior superior alveolar artery (PSAA), the infraorbital artery (IOA), and the anterior superior alveolar artery (ASAA). The PSAA and the IOA share a common trunk in the pterygopalatine fossa. Then the PSAA enters the posterior superior alveolar foramina and gives off alveolar and dental branches. The dental branches supply the pulp tissue of the posterior maxillary teeth through the apical foramen of the teeth. The alveolar branches supply the periodontium of the posterior maxillary teeth. Dental and alveolar branches also supply the maxillary sinus. The IOA emerges through the inferior orbital fissure into the orbit and subsequently travels in the infraorbital canal. From the IOA the ASAA and orbital branches emerge. As well as the PSAA, the ASAA gives off alveolar and dental branches. The periodontium of the anterior maxillary teeth is supplied by the alveolar branches and the pulp tissue is supplied by the dental branches. The PSAA, the
628
IOA, and the ASAA anastomose together. This so-formed anastomosis is a variable formation of intraosseous, intramaxillary, extraosseus, and extramaxillary blood vessels. The alveolar branches of the PSAA, the inferior branches of the IOA, and the alveolar branches of the ASAA compose the extraosseus anastomoses (EA). Intraosseus anastomoses (IA) are constructed by the dental branches of the ASAA and PSAA. There can be several variations in maxillary sinus vascular connections.3,6-8
CASE REPORT The removal of a foreign body from the right maxillary sinus was performed in a 33-year-old healthy man. The patient presented himself for the first time in our clinic. Being asked about previous dental treatments the patient reported that he had no general dentist. The last treatment the patient remembered was the extraction of the maxillary right first molar during an emergency treatment 1 year previously. He declared that he had not had a regular dental checkup during the last 10 years. The reason for his visit was recurrent sensations of pressure above his right maxilla since 6 months. He had been taking antibiotics for the previous 10 days because of inflammation of the maxillary sinus. The clinical examination did not show evidence of trigeminal nerve pathology. The maxillary right first and second premolars were deeply decayed by dental caries (Fig 2) and demonstrated negative percussion. The second premolar showed a fistula formation. The maxillary right second molar showed negative percussion. The maxillary right third molar had a positive CO2 test and negative percussion. The general dental health status was insufficient. The initial panoramic radiograph (Cranex Exel D, Soredex; 65Kv, 5mA) (Fig 3) showed a circumscribed white opacity in the right sinus consistent with the presence of a foreign body; furthermore, the second premolar showed a cystic lesion at the apex. In the context of this paper other pathologies detected on the radiograph are not described. The described foreign body resembled a dislocated root tip in the maxillary sinus which may have originated from the previous extraction of the first molar.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Wolf et al
Fig 2 The maxillary right first and second premolars before extraction.
a
b
Fig 3
Panoramic radiograph showing the radix.
Figs 4a to 4c Preoperative CBCT scan of (a) coronal, (b) axial, and (c) sagittal view, showing the radix.
c
1 2 3
12 3 Fig 5 CBCT scan on sagittal view presenting the three vessels (1, 2, and 3) inside the lateral sinus wall.
Fig 6 CBCT scan on coronal view for the measurements of the height from the alveolar bone crest to the lower border of the PSAA in the premolar region (distance 1 = 13.5 mm, 2 = 19.5 mm, 3 = 24.6 mm).
In view of these findings, cone beam computed tomography (CBCT; KaVo 3D eXam, KaVo; voxel size 0.3 mm, 120 kV, 5mA; software eXam vision 3D v1.6.1.10, KaVo) was performed to enable the localization of the suspected foreign body and to delineate the topographic features of the sinus (Fig 4). Using CBCT, the diagnosis of a foreign body within the maxillary sinus was confirmed. It was located lying above the sinus membrane. The mucosa of the basal sinus in the area of the foreign body showed a thickening which may be due to chronic inflammation. Furthermore, the CBCT showed three vessels in the lateral sinus wall, hereafter
described as vessels 1, 2, and 3 (Fig 5). Vessel 1 was located most caudal with a distance of 13.5 mm to the alveolar crest. Vessels 2 and 3 had a distance of 19.5 mm and 24.6 mm to the alveolar crest, respectively (Fig 6).
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Surgical approach The surgical procedure was performed under local anesthesia. Both maxillary right premolars were extracted using dental forceps due to their deeply decayed state. The cystic lesion in the region of the second premolar was removed in one piece without opening the sinus, and sent for histologic analysis. The
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Fig 8 Endoscopic view of the maxillary sinus showing the radix. Fig 7
Clinical image of the vessel prepared.
incision started in the vestibule of the sulcus of the first molar followed by a midcrestal incision including a vertical releasing incision distally of the canine. The lateral wall of the sinus was exposed by performing a mucoperiosteal flap. The osteotomy for the lateral window was performed using a ball-shaped diamond and the piezosurgery unit (Piezosurgery 3 unit, Mectron). The crossing vessel was preserved without damage (Fig 7) as it had been previously located on the CBCT scan. After penetrating the sinus membrane with a scalpel, the maxillary sinus was inspected endoscopically (Karl Storz Endoskope, Model 20045020 – Tele Pack X). The endoscopic view showed a foreign body that resembled a tooth radix (Fig 8). It was removed (Fig 9) and the sinus membrane was closed with a resorbable 6.0 one node suture. It was not necessary to cut the periosteum for a tension-free repositioning of the mucoperiostal flap, so no membrane had to be placed to cover the approach to the sinus as it was covered by the closed sinus membrane and the intact periosteum. The postoperative healing was uneventful and the sutures were removed 10 days later. The histologic analysis of the region of the maxillary right secondary premolar resulted in a radicular cyst. The maxillary left third molar and mandibular left second and third molars were removed during subsequent dental sessions. The 6-month follow up of the patient showed no signs of inflammation, infection, fistula formation, suppuration, or other pathologies. The clinical symptoms of recurrent pressure in the maxilla had resolved completely. The patient was sent to a private practice for general dental treatment.
630
Fig 9 Removal of the radix through the lateral window.
DISCUSSION This case report confirms the importance of careful diagnostic workup preoperatively. Using CBCT scanning, the position of the foreign body and the course of the vessels could be determined precisely. Previous studies have advised the removal of dislocated teeth or segments of teeth from the sinus.9 Failure to remove such foreign bodies may cause dysfunction of ventilation and promote sinusitis. The foreign body can be located either inside the maxillary sinus, below the sinus membrane, or even beneath the vestibular mucosa. To determine their exact location, 3D imaging is required. In this case a CBCT scan was the method of choice. The intraosseous artery is likely to cause bleeding complications in approximately 20% of normally positioned lateral window osteotomies.5,10 As a rare but clinically significant hemorrhagic complication, another case report described an ongoing bleeding of the PSAA after transcrestal sinus augmentation that led even to hospitalization of the patient.11 Computed tomography (CT) studies have shown the existence of anastomoses of the IOA and the PSAA in the lateral part of the sinus. Elian et al10 analyzed this parameter in CT scans of left and right sinuses and showed an overall occurrence of 52.9%. Two other studies analyzing CT scans of maxillary sinuses have shown a comparable occurrence of 52%2 and 55%.12 Cadaver studies have shown the existence of this anastomosis in 100% of cases studied.13,14 Table 1 gives a summary of these studies. Damage of the PSAA with a large diameter may cause intensive bleeding. Although hemorrhagic complications through the PSAA are not described as life threatening,
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Wolf et al
Table 1
Data summarized from literature N total patient/ cadaver
N total of sites
Data acquisition
Prevalence PSAA
Distance in premolar region (mm)*
Area of measurement
Distance in molar region (mm)*
Area of measurement
200
400
CT images
52%
18.9 ± 4.2
Premolar
15.4 ± 4.0
Molar
Elian et al
50
100
CT images
53%
16.4 ± 3.5
Not reported
16.4 ± 3.5
Not reported
Mardinger et al12
104
208
CT images
55%
19 ± 4.6
Second premolar
16.9 ± 4.4
First molar
Solar et al13
Not reported
18
Cadaver autopsy
100%
18.9–19.6
Not reported
18.9–19.6
Not reported
Kqiku et al14
10
20
Cadver autopsy
100%
14.6
Second premolar
14.5
First molar
Watanabe et al16
235
280
CT images
29–59%
24.1
Premolar
15.4
First molar
Study Kim et al2 10
*Distance from the inferior border of the PSAA to the alveolar crest.
pre-surgical detection of the PSAA of larger diameter on the CT images is optimal in order to reduce complications during surgery.2 In case an artery is in the lateral sinus wall, the risk of bleeding intra- and postoperatively is increased.15 In a radiographic study of Kim et al,2 the diameter of the PSAA was on average 1.52 +/- 0.47 mm (mean +/- standard deviation) and usually larger in males. Watanabe et al16 described in 2014 the diameter between 1.1 to 1.3 mm. In the present case, the diameter of the PSAA was 2.8 mm. Detecting the distance from the inferior border of the PSAA to the alveolar crest in the premolar and molar areas using CT images may give useful information prior to maxillary sinus surgery via the lateral approach.2 In the present case report, the distance from the inferior border of the artery to the alveolar crest in the premolar region was 13.5 mm (Fig 6). Previous studies have described similar results, with the distance between the alveolar crest and the PSAA in the molar region being 15.45 ± 4.04 mm, 16.0 ± 3.5 mm, and 15.4 ± 5.4 mm.2,10,16
CONCLUSION This case report discusses the location and the size of the PSAA in the context of the removal of foreign bodies from the maxillary sinus by performing lateral window surgery, as this technique is often used by the general practitioner. Therefore, 3D imaging is recommended to localize the foreign body and to determine the course and the size of the PSAA, as this might influence the surgical procedure. The variations in maxillary vascular connections of large diameter inside the bony wall can be detected by CBCT scan and may help to avoid hemorrhage during surgery.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
REFERENCES 1. Apostolakis D, Bissoon AK. Radiographic evaluation of the superior alveolar canal: Measurements of its diameter and of its position in relation to the maxillary sinus floor: a cone beam computerized tomography study. Clin Oral Implants Res 2014;25:553–559. 2. Kim JH, Ryu JS, Kim KD, Hwang SH, Moon HS. A radiographic study of the posterior superior alveolar artery. Implant Dent 2011;20:306–310. 3. Ella B, Sédarat C, Noble Rda C, et al. Vascular connections of the lateral wall of the sinus: surgical effect in sinus augmentation. Int J Oral Maxillofac Implants 2008;23:1047–1052. 4. Schumacher GH. Anatomie-Lehrbuch und Atlas. Leipzig: JA Barth, 1991. 5. Van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000;11:256–265. 6. Lambrecht JT, Böhlck I, Dierck, P. Ist die Kieferhöhle physiologischerweise keimfrei? In: Watzek G, Matejka M (eds). Erkrankung der Kieferhöhle. New York: Springer, 1986:31–37. 7. Zijderveld SA, van den Bergh JPA, Schulten EAJM, ten Bruggenkate CM. Anatomical and surgical findings and complications in 100 consecutive maxillary sinus floor elevation procedures. J Oral Maxillofac Surg 2008;66:1426–1438. 8. Testori T, Rosano G, Taschieri S, Del Fabbro M. Ligation of an unusually large vessel during maxillary sinus floor augmentation. Eur J Oral Implantol 2010;3:255–258. 9. Lambrecht JT. Odontogene Kieferhöhlenerkrankung. In: Fortschritte der Kiefer- und Gesichts-Chirurgie. Zurich: Band 40, 1995:106–113. 10. Elian N, Wallace S, Cho SC, Jalbout ZN, Froum S. Distribution of the maxillary artery as it relates to sinus floor augmentation. Int J Oral Maxillofac Implants 2005;20:784–787. 11. Jensen SS, Eriksen J, Schiodt M. Serve bleeding after sinus floor elevation using the transcrestal technique: a case report. Eur J Oral Implantol 2012;5:287–291. 12. Mardinger O, Abba M, Hirshber A, Schwarzt-Arad D. Prevalence, diameter and course of the maxillary intraosseous vascular canal with relation to sinus augmentation procedure: a radiographic study. Int J Oral Maxillofac Surg 2007;36:735–738. 13. Solar P, Geyerhofer U, Traxler H, Windisch A, Ulm C, Watzek G. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res 1999;10:34–44. 14. Kqiku L. Arterial blood architecture of the maxillary sinus in dentate species. Croat Med J 2013;54:180–184. 15. Greenstein G, Cavallaro J, Romanos G, Tarnow D. Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry: a review. J Periodontol 2008;79:1317–1329. 16. Watanabe T, Shiota M, Gao S, Imakita C, Tachikawa N, Kasugai S. Verification of posterior superior alveolar artery distribution in lateral wall of maxillary sinus by location and defect pattern. Quintessence Int 2014;45:673–678.
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IMAGING
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Preoperative 3D imaging in maxillary sinus: Brief review of the literature and case report Marius Karl Wolf, DMD1/Claudio Rostetter, MD 1/Bernd Stadlinger, MD, DMD2/Michael Locher, MD, DMD3/ Georg Damerau, DMD 2 Objective: The purpose of the present case report is to document the removal of a radix in antro without a hemorrhagic complication in presence of a posterior superior alveolar artery (PSAA) with a 2.8 mm diameter following a radiographic 3D planning by cone beam computed tomography (CBCT) scan. Furthermore, a brief literature overview on studies describing the existence and the variance of the PSAA is provided. Method and Materials: A foreign body removal in the right maxillary sinus was performed on a 33-year-old healthy man by using the lateral window osteotomy. The preoperative CBCT scan showed three arteries in the lateral maxillary sinus wall at a distance of 24.6 mm, 19.5 mm, and 13.5 mm to the alveolar crest. Results: By removing a foreign body out of the maxillary
sinus a vessel with a diameter of nearly 3 mm was exposed. Due to CBCT scan planning and the use of piezosurgery it was possible to avoid any damage to the vessel during the operation. The postoperative healing was uneventful and no complications occurred. Conclusion: Although laceration of vessels with a large diameter during lateral window osteotomy is not life-threatening it may compromise visualization and reduces the surgical outcome. Therefore, 3D imaging is recommended for the minimization of intra- and postoperative complications and for the localization of any foreign body in relation to other anatomical structures. This is of special interest in case of anatomical variances of blood vessels. (Quintessence Int 2015;46:627–631; doi: 10.3290/j.qi.a33930)
Key words: complications, cone beam computed tomography, lateral window osteotomy, maxillary sinus, posterior superior alveolar artery, radix in antro, vascularization
Symptomatic foreign bodies in the maxillary sinus should be removed. There are three ways of removing these foreign bodies: via the alveolus, via the nose, or via access through the lateral facial wall of the sinus. During removal of foreign bodies, maxillary sinus floor augmentation, or implant installation, hemorrhagic 1
Assistant Doctor, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Zurich, Switzerland.
2
Senior Consultant, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Zurich, Switzerland.
3
Head of Oral Surgery Department, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Zurich, Switzerland.
Correspondence: Dr Marius Karl Wolf, Division of Cranio-Maxillo-Facial and Oral Surgery, University of Zurich, Plattenstrasse 11, 8032 Zurich, Switzerland. Email: [email protected]
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
complications may occur as a result of injury to the lateral artery.1,2 Therefore, exact knowledge of the anatomy and a sufficient radiographic evaluation of the maxillary sinus are essential preoperatively.2,3
ANATOMICAL BACKGROUND The maxillary sinuses are the biggest paranasal sinuses situated bilaterally in the upper jaw.4 The maxillary sinus of an adult has the shape of a three-walled pyramid. Keeping this image in mind, the pyramid base would be located at the lateral nasal wall and the pyramid top would be pointing towards the zygomatic process of the maxilla. The orbital floor builds the cranial part and the alveolar pro-
627
Q U I N T E S S E N C E I N T E R N AT I O N A L Wolf et al
IOA ASAA EA
MA PSAA
IA
Fig 1 Vascularization of the maxillary sinus: ASAA, anterior superior alveolar artery; EA, extraosseus anastomoses; IA, intraosseus anastomoses; IOA, infraorbital artery; MA, maxillary artery; PSAA, posterior superior alveolar artery. Modified and reprinted with kind permission, from Kqiku.14
cess builds the caudal one. The natural ostium forms the connection to the nasal cavity. It is located in the superior portion of the medial wall of the sinus.5 The maxillary sinus is lined with a respiratory epithelial layer called the sinus membrane. Due to the beating of the respiratory cilia in the direction of the ostia, the sinus stays sterile.6 The vascularization of the maxillary sinus (Fig 1) is supplied by the maxillary artery, the larger terminal branch of the external carotid artery. After entering the pterygopalatine fossa, the maxillary artery gives off three branches for the maxillary sinus. The posterior superior alveolar artery (PSAA), the infraorbital artery (IOA), and the anterior superior alveolar artery (ASAA). The PSAA and the IOA share a common trunk in the pterygopalatine fossa. Then the PSAA enters the posterior superior alveolar foramina and gives off alveolar and dental branches. The dental branches supply the pulp tissue of the posterior maxillary teeth through the apical foramen of the teeth. The alveolar branches supply the periodontium of the posterior maxillary teeth. Dental and alveolar branches also supply the maxillary sinus. The IOA emerges through the inferior orbital fissure into the orbit and subsequently travels in the infraorbital canal. From the IOA the ASAA and orbital branches emerge. As well as the PSAA, the ASAA gives off alveolar and dental branches. The periodontium of the anterior maxillary teeth is supplied by the alveolar branches and the pulp tissue is supplied by the dental branches. The PSAA, the
628
IOA, and the ASAA anastomose together. This so-formed anastomosis is a variable formation of intraosseous, intramaxillary, extraosseus, and extramaxillary blood vessels. The alveolar branches of the PSAA, the inferior branches of the IOA, and the alveolar branches of the ASAA compose the extraosseus anastomoses (EA). Intraosseus anastomoses (IA) are constructed by the dental branches of the ASAA and PSAA. There can be several variations in maxillary sinus vascular connections.3,6-8
CASE REPORT The removal of a foreign body from the right maxillary sinus was performed in a 33-year-old healthy man. The patient presented himself for the first time in our clinic. Being asked about previous dental treatments the patient reported that he had no general dentist. The last treatment the patient remembered was the extraction of the maxillary right first molar during an emergency treatment 1 year previously. He declared that he had not had a regular dental checkup during the last 10 years. The reason for his visit was recurrent sensations of pressure above his right maxilla since 6 months. He had been taking antibiotics for the previous 10 days because of inflammation of the maxillary sinus. The clinical examination did not show evidence of trigeminal nerve pathology. The maxillary right first and second premolars were deeply decayed by dental caries (Fig 2) and demonstrated negative percussion. The second premolar showed a fistula formation. The maxillary right second molar showed negative percussion. The maxillary right third molar had a positive CO2 test and negative percussion. The general dental health status was insufficient. The initial panoramic radiograph (Cranex Exel D, Soredex; 65Kv, 5mA) (Fig 3) showed a circumscribed white opacity in the right sinus consistent with the presence of a foreign body; furthermore, the second premolar showed a cystic lesion at the apex. In the context of this paper other pathologies detected on the radiograph are not described. The described foreign body resembled a dislocated root tip in the maxillary sinus which may have originated from the previous extraction of the first molar.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Wolf et al
Fig 2 The maxillary right first and second premolars before extraction.
a
b
Fig 3
Panoramic radiograph showing the radix.
Figs 4a to 4c Preoperative CBCT scan of (a) coronal, (b) axial, and (c) sagittal view, showing the radix.
c
1 2 3
12 3 Fig 5 CBCT scan on sagittal view presenting the three vessels (1, 2, and 3) inside the lateral sinus wall.
Fig 6 CBCT scan on coronal view for the measurements of the height from the alveolar bone crest to the lower border of the PSAA in the premolar region (distance 1 = 13.5 mm, 2 = 19.5 mm, 3 = 24.6 mm).
In view of these findings, cone beam computed tomography (CBCT; KaVo 3D eXam, KaVo; voxel size 0.3 mm, 120 kV, 5mA; software eXam vision 3D v1.6.1.10, KaVo) was performed to enable the localization of the suspected foreign body and to delineate the topographic features of the sinus (Fig 4). Using CBCT, the diagnosis of a foreign body within the maxillary sinus was confirmed. It was located lying above the sinus membrane. The mucosa of the basal sinus in the area of the foreign body showed a thickening which may be due to chronic inflammation. Furthermore, the CBCT showed three vessels in the lateral sinus wall, hereafter
described as vessels 1, 2, and 3 (Fig 5). Vessel 1 was located most caudal with a distance of 13.5 mm to the alveolar crest. Vessels 2 and 3 had a distance of 19.5 mm and 24.6 mm to the alveolar crest, respectively (Fig 6).
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Surgical approach The surgical procedure was performed under local anesthesia. Both maxillary right premolars were extracted using dental forceps due to their deeply decayed state. The cystic lesion in the region of the second premolar was removed in one piece without opening the sinus, and sent for histologic analysis. The
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Fig 8 Endoscopic view of the maxillary sinus showing the radix. Fig 7
Clinical image of the vessel prepared.
incision started in the vestibule of the sulcus of the first molar followed by a midcrestal incision including a vertical releasing incision distally of the canine. The lateral wall of the sinus was exposed by performing a mucoperiosteal flap. The osteotomy for the lateral window was performed using a ball-shaped diamond and the piezosurgery unit (Piezosurgery 3 unit, Mectron). The crossing vessel was preserved without damage (Fig 7) as it had been previously located on the CBCT scan. After penetrating the sinus membrane with a scalpel, the maxillary sinus was inspected endoscopically (Karl Storz Endoskope, Model 20045020 – Tele Pack X). The endoscopic view showed a foreign body that resembled a tooth radix (Fig 8). It was removed (Fig 9) and the sinus membrane was closed with a resorbable 6.0 one node suture. It was not necessary to cut the periosteum for a tension-free repositioning of the mucoperiostal flap, so no membrane had to be placed to cover the approach to the sinus as it was covered by the closed sinus membrane and the intact periosteum. The postoperative healing was uneventful and the sutures were removed 10 days later. The histologic analysis of the region of the maxillary right secondary premolar resulted in a radicular cyst. The maxillary left third molar and mandibular left second and third molars were removed during subsequent dental sessions. The 6-month follow up of the patient showed no signs of inflammation, infection, fistula formation, suppuration, or other pathologies. The clinical symptoms of recurrent pressure in the maxilla had resolved completely. The patient was sent to a private practice for general dental treatment.
630
Fig 9 Removal of the radix through the lateral window.
DISCUSSION This case report confirms the importance of careful diagnostic workup preoperatively. Using CBCT scanning, the position of the foreign body and the course of the vessels could be determined precisely. Previous studies have advised the removal of dislocated teeth or segments of teeth from the sinus.9 Failure to remove such foreign bodies may cause dysfunction of ventilation and promote sinusitis. The foreign body can be located either inside the maxillary sinus, below the sinus membrane, or even beneath the vestibular mucosa. To determine their exact location, 3D imaging is required. In this case a CBCT scan was the method of choice. The intraosseous artery is likely to cause bleeding complications in approximately 20% of normally positioned lateral window osteotomies.5,10 As a rare but clinically significant hemorrhagic complication, another case report described an ongoing bleeding of the PSAA after transcrestal sinus augmentation that led even to hospitalization of the patient.11 Computed tomography (CT) studies have shown the existence of anastomoses of the IOA and the PSAA in the lateral part of the sinus. Elian et al10 analyzed this parameter in CT scans of left and right sinuses and showed an overall occurrence of 52.9%. Two other studies analyzing CT scans of maxillary sinuses have shown a comparable occurrence of 52%2 and 55%.12 Cadaver studies have shown the existence of this anastomosis in 100% of cases studied.13,14 Table 1 gives a summary of these studies. Damage of the PSAA with a large diameter may cause intensive bleeding. Although hemorrhagic complications through the PSAA are not described as life threatening,
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Wolf et al
Table 1
Data summarized from literature N total patient/ cadaver
N total of sites
Data acquisition
Prevalence PSAA
Distance in premolar region (mm)*
Area of measurement
Distance in molar region (mm)*
Area of measurement
200
400
CT images
52%
18.9 ± 4.2
Premolar
15.4 ± 4.0
Molar
Elian et al
50
100
CT images
53%
16.4 ± 3.5
Not reported
16.4 ± 3.5
Not reported
Mardinger et al12
104
208
CT images
55%
19 ± 4.6
Second premolar
16.9 ± 4.4
First molar
Solar et al13
Not reported
18
Cadaver autopsy
100%
18.9–19.6
Not reported
18.9–19.6
Not reported
Kqiku et al14
10
20
Cadver autopsy
100%
14.6
Second premolar
14.5
First molar
Watanabe et al16
235
280
CT images
29–59%
24.1
Premolar
15.4
First molar
Study Kim et al2 10
*Distance from the inferior border of the PSAA to the alveolar crest.
pre-surgical detection of the PSAA of larger diameter on the CT images is optimal in order to reduce complications during surgery.2 In case an artery is in the lateral sinus wall, the risk of bleeding intra- and postoperatively is increased.15 In a radiographic study of Kim et al,2 the diameter of the PSAA was on average 1.52 +/- 0.47 mm (mean +/- standard deviation) and usually larger in males. Watanabe et al16 described in 2014 the diameter between 1.1 to 1.3 mm. In the present case, the diameter of the PSAA was 2.8 mm. Detecting the distance from the inferior border of the PSAA to the alveolar crest in the premolar and molar areas using CT images may give useful information prior to maxillary sinus surgery via the lateral approach.2 In the present case report, the distance from the inferior border of the artery to the alveolar crest in the premolar region was 13.5 mm (Fig 6). Previous studies have described similar results, with the distance between the alveolar crest and the PSAA in the molar region being 15.45 ± 4.04 mm, 16.0 ± 3.5 mm, and 15.4 ± 5.4 mm.2,10,16
CONCLUSION This case report discusses the location and the size of the PSAA in the context of the removal of foreign bodies from the maxillary sinus by performing lateral window surgery, as this technique is often used by the general practitioner. Therefore, 3D imaging is recommended to localize the foreign body and to determine the course and the size of the PSAA, as this might influence the surgical procedure. The variations in maxillary vascular connections of large diameter inside the bony wall can be detected by CBCT scan and may help to avoid hemorrhage during surgery.
VOLUME 46 • NUMBER 7 • JULY/AUGUST 2015
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