The treatment of sinusitis following maxillary sinus grafting with the association of functional endoscopic sinus surgery (FESS) and an intra-oral approach

Management of Oral Surgery-Related Complications

This article reviews the optimal management of oroantral fistulas, implants protruding into the maxillary sinus, implants completely displaced into the sinus(es), and infected bone grafts used for sinus augmentation. For each scenario, multidisciplinary management strategies will be considered based on whether there is concurrent infectious odontogenic sinusitis. A multidisciplinary approach with oral surgeons and otolaryngologists is often mandatory to ensure optimal therapeutic outcomes.

Dental Evaluation: Oral Surgery-Related Complications

The article provides an in-depth review focused on diagnosing oral surgery-related complications that may cause odontogenic sinusitis (ODS). It emphasizes the importance of evaluating patients with prior oral surgical procedures to determine whether the prior procedure is an ongoing infectious source of the ODS. Specifically, diagnostic evaluations will be described for detecting oroantral communications and fistulas, dental implant dislocation or protrusion, and whether implants and graft placed in maxillary sinuses are infected. It highlights the role of different oral examination techniques, optimal imaging modalities, and the importance of otolaryngologic collaboration to evaluate for infectious ODS.

Surgical Drainage and Simultaneous Sinus Floor Augmentation in Patients with Chronic Maxillary Sinusitis

Chronic maxillary sinusitis accompanied by severe thickening of the sinus mucosa, blockage of the ostium, and patient-reported symptoms requires preoperative assessment and treatment by an otolaryngologist before maxillary sinus floor augmentation (MSFA). Prescription of antibiotics and nasal saline irrigation are the first choice of treatment; however, endoscopic sinus surgery is considered when the treatment's effect is limited and drug resistance is observed. Nevertheless, MSFA performed in the presence of sinus pathologies have been reported to have favorable results when the lesions are managed properly. This report presents cases of two patients who required MSFA but were diagnosed with chronic maxillary sinusitis (case 1 with nasal sinusitis and case 2 with dental sinusitis). After 2 weeks of antibiotic therapy, endoscopic surgery was recommended due to minimal changes in the size of the sinus lesion; however, the patients refused because of improved self-reported symptoms. Therefore, intraoral surgical drainage was planned as an alternative treatment. A large bony window was prepared at the lateral wall of the maxillary sinus, and a long intentional incision was made to improve access for the suction tip in various directions and depths into the sinus cavity. Thorough suction of the purulent exudate and saline irrigation were performed through this access. The size of the perforated area was reduced along with the elevation of the Schneiderian membrane from the sinus floor, and simultaneous bone grafting with implant placement was performed. Prosthesis was delivered after 6-8 months. At 1-year follow-up after loading, favorable outcomes of implant survival and maintenance of augmented bone height were observed, with no recurrence of postoperative sinusitis. Within the limitations of the present case report, thorough sinus drainage and saline irrigation during maxillary sinus floor augmentation resolved sinus infection in patients with chronic maxillary sinusitis with short-term clinical outcomes.

A Unique Case of Supernumerary Teeth Erupting Inside a Maxillary Sinus Osteoma

Introduction: Ectopic foreign bodies in the maxillary sinus occur rarely. Ectopic tooth eruption rarely occurs in the orbit, nasal cavity, maxillary sinus, and elsewhere. Ectopic eruption of teeth in the maxillary sinus is most commonly associated with wisdom teeth and is rarely associated with supernumerary teeth. This rare phenomenon may be accompanied by chronic recurrent sinusitis with headaches and facial pain. However, fibro-osseous lesions in the paranasal sinuses are discovered incidentally on X-ray images and are often asymptomatic. Osteoma is the most common fibro-osseous lesion that develops in the paranasal and nasal sinuses. Osteomas rarely cause serious symptoms such as orbital lesions and intracranial invasion. Case Presentation: We report a rare case of exostosis containing supernumerary teeth within the maxillary sinus. A characteristic pedicled bone lesion with a clear border on computed tomography was the undefined orthopantomogram radiopacity in the maxillary sinus, and the lesion contained supernumerary teeth. As the patient had chronic nasal congestion, the tumor was surgically removed. Pathologically, the surgical specimen revealed an osteoma. The patient's symptoms of chronic sinusitis disappeared. Because the patient had no history of midface trauma or surgery, the supernumerary teeth were speculated to have migrated during a reactive osteogenic process caused by chronic sinusitis. Conclusions: A foreign body in the maxillary sinus can be easily diagnosed by computed tomography. Surgical removal is recommended if the foreign body is symptomatic or occupies more than half of the maxillary sinus. This can help resolve chronic sinusitis symptoms and prevent serious complications in the future.

Pathogenic factors of maxillary sinus mucosal thickening observed by cone-beam computed tomography (CBCT)

OBJECTIVE

To explore the pathogenic factors associated with maxillary sinus mucosal thickening with Cone-beam computed Tomography (CBCT).

METHODS

From 2016 through 2020, 93 patients with periapical periodontitis or periodontitis in the maxillary posterior dental region were selected.

RESULTS

The preoperative thickness of the periodontitis group was significantly higher than that of the periapical periodontitis group (P < 0.05). The difference achieves statistical significance for the comparison of the thickness change with various severity of inflammation (F = 54.824, P = 0.000), the change with time (F = 312.741, P = 0.000). and the change with the interaction severity of inflammation and time（F = 86.132, P = 0.000).

CONCLUSIONS

Patients with maxillary sinus mucosa thickening caused by periodontitis and periapical periodontitis should be extracted their infectious teeth and get thoroughly debridement. Maxillary sinus augmentation can perform favorable efforts 3-6 months after extracting teeth.

Simultaneous management of chronic maxillary sinusitis from dental origin and the relevance of nasal septal deviation: A retrospective evaluation of 65 cases

PURPOSE

Dental origin constitutes most chronic unilateral maxillary sinusitis (CMS) and is referred to as dental chronic maxillary sinusitis (DCMS). Recently, dental implants and related surgical procedures have become more prevalent. We present an evaluation of the simultaneous treatment of DCMS.

MATERIALS AND METHODS

A retrospective review of records from 395 patients with CMS treated at our medical center from 2015 to 2020 found 65 patients diagnosed with DCMS. Statistical analyses were performed using the records data.

RESULTS

Four patients were excluded. The final study population included 35 males and 26 females with a mean age of 55. 29 % were post-dental implant placement or related pre-prosthetic procedures. Presenting symptoms included middle meatus edema (72 %), pus in the middle meatus (70 %), and nasal secretion (39 %). Clinical findings included septal deviation (39 %), among them 87 % deviated toward the diseased sinus, OAF (49 %), and nasal polyposis (16 %). In 32 patients, the OAF was closed in one layer using a local mucoperiosteal flap. In 29 patients, the closure was done in two layers, including a buccal fat pad (BFP) regional flap. One patient had a reopened OAF, and five patients required revision surgery. 92 % of patients in this study had complete clinical and radiological resolution of the DCMS.

CONCLUSIONS

Relevance of nasal septal deviation in association with DCMS is present. There is no distinct difference in the manner of OAF closure if it is done in a simultaneous procedure. One stage combined multidisciplinary surgical procedure is sufficient to treat DCMS.

Odontogenic Sinusitis from Classical Complications and Its Treatment: Our Experience

Odontogenic sinusitis (ODS) refers to the maxillary sinus infection, which is secondary to either adjacent infectious dental pathologies or procedures. The aim of this retrospective study is to report the experiences of the department of integrated therapies in otolaryngology (Campus Bio-Medico Foundation, Rome, Italy) in classifying and treating patients that are affected by odontogenic sinusitis derived from "classic complications". A total of 68 patients responding to the criteria and to the definition as a classical odontogenic complication were included. The surgical therapy consisted of a combined oral and nasal simultaneous approach for 28 patients (43%), a combined non-simultaneous approach for 4 patients (6%), a nasal only approach for 14 patients (21%), and an oral only approach for 20 patients (30%). All the patients presented a complete resolution of the symptoms. The choice of performing a nasal, oral, or combined approach is based on the presence of anatomical elements that facilitate sinusitis and reinfection occurrence, such as deviated nasal septum, concha bullosa, or obstructed osteo-meatal complex. The correct use of validated classification, the pre-operative CT scan, a multidisciplinary approach, and an appropriate presurgical examination are the necessary elements to obtain a good success rate.

Real-Life Experience in the Management of Sinonasal Complications of Dental Disease or Treatments

Diagnosis and management of sinonasal complications of dental diseases or treatment (SCDDT) may be challenging. We aimed to report our real-life experience in patients treated with endoscopic endonasal approach describing data about symptoms, etiology, extension of the disease and success rate. We evaluated retrospectively data about 262 patients diagnosed as SCDDT and managed from August 2015 to May 2022. In 44.65% cases, maxillary sinus complications were determined by a dental disorder; the remaining 55.34% of cases were iatrogenic. Patients were managed according to our multidisciplinary protocol including ENT, dental, and radiological evaluation. Treatments were planned with a personalized approach, based on the patient’s clinical characteristics; all patients were treated with an endonasal endoscopic mini-invasive conservative approach. Combined dental treatment was performed simultaneously in 152/262 (58%) of patients; in the remaining cases, it was postponed after surgery. The overall treatment success rate (symptom resolution and endoscopically observed maxillary sinus healing) was 96.5%. At 15 days after surgery, we observed a significant improvement in the quality of life. The mean post-operative Sinonasal outcome test-22 (SNOT-22) score was significantly lower compared to baseline (6 versus 43.4; p < 0.05). Our study showed that endoscopic sinus surgery can be a successful procedure for treatment of SCDDT, leading to fast resolution of sinonasal symptoms and improving the quality of life. Furthermore, the technique allows removal of migrated dental material or dental implants even in challenging cases.

Endodontic sealer-induced maxillary sinusitis: intraoral surgical approach and implant placement at a site of failed nasal endoscopic surgeries

A 28-year-old male patient was referred from an otorhinolaryngologist for managing unilateral chronic maxillary sinusitis (MS). The patient had undergone two functional endoscopic sinus surgeries (FESS), although the MS was not resolved. Based on his dental history, endodontic treatment had been done on the symptomatic area. A leak of endodontic sealer and peri-apical lesion on tooth #14 was found on cone-beam computed tomographic examination. Extraction of tooth #14 and the modified Caldwell-Luc operation were performed to remove the endodontic sealer material and relevant inflammatory tissue. The sinus membrane lining was maintained as much as possible during the surgery. Implant placement was performed on the tooth extraction site. All clinical symptoms disappeared after the surgery. Radiographic and endoscopic examination revealed successful osseointegration of the implant and complete resolution of the MS. FESS alone may not be sufficient to treat MS derived from dental origin. For unilateral MS, dental history should be carefully checked.

Sinus augmentation procedure via the lateral window technique-Reducing invasiveness and preventing complications: A narrative review

Sinus augmentation has become an integrated surgical phase in posterior maxillary implant prosthesis reconstruction. Since the residual alveolar bony height usually requires additional volume particularly at this anatomical region, sinus floor augmentation is advocated routinely. Over the years, Implant success rate is proved to be comparable to the one in the pristine bone, which is well documented in the literature. Anatomical aspects as well as surgeon skills are at most importance to achieve predictable outcome. In this narrative review, the different osteotomy techniques, the indications toward 1 or 2-stage approaches, the control of the Schneiderian membrane integrity as well as the management of intra- and post-operative complications are thoroughly discussed according the current data. In light of the excellent long-term implant success rate concurrent with the application of contemporary advanced techniques of the sinus augmentation via the lateral wall osteotomy approach, reduce invasiveness and less complication occurrences are well documented. A well-codified patient selection involving the rhinologist as an integral medical team would be significantly beneficial toward early diagnosis. In-depth knowledge of the anatomy, execution of a well standardized surgical technique, and understanding the complication etiology and their management are prerequisites for reducing patient morbidity to minimal discomfort and predictable successful outcome.

Treatment of Sinusitis Following Dental Implantation: A Systematic Review and Meta-Analysis

BACKGROUND

Implantological procedures aimed at rehabilitating upper jaw edentulous patients (dental implant placement and/or maxillary sinus grafting) can sporadically result in sinusitis. In these patients, endoscopic sinus surgery is the most commonly employed treatment, but clinical scenarios and comprehensive management strategies are extremely heterogeneous across studies.

OBJECTIVE

We sought to systematically define treatment strategies and related success rates for sinusitis following dental implantation, detailing different current treatment choices and concepts.

METHODS

Adopting a PRISMA-compliant review framework, systematic searches were performed in multiple databases using criteria designed to include all studies published until November 2020 focusing on the treatment of human sinusitis following dental implantation. We selected all original studies, excluding case reports, specifying treatment modalities with objective treatment success definitions. Following duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for treatment modalities and success rates, which were pooled in a random-effects meta-analysis.

RESULTS

Among 581 unique citations, eight studies (181 patients) were selected. Seven studies were retrospective case series. All studies relied on endoscopic sinus surgery, often coupled with intraoral accesses, and assessed therapeutic success endoscopically. The pooled treatment success rate was 94.7% (95% confidence interval, 91.5%-98%). Failures were treated in seven of 15 cases with further antibiotic therapies and in another seven cases with surgical revision. A single patient was lost to follow-up.

CONCLUSIONS

Endoscopic sinus surgery appears to be the most frequent treatment of choice for sinusitis following dental implantation, with excellent success rates. The protean clinical picture drawn from the selected studies calls for the standardization of diagnostics and definitions in this field to enable direct comparisons between the results of different studies. The role of postoperative antibiotic therapies, which have been employed unevenly across studies, should also be prospectively investigated.

Odontogenic Maxillary Sinusopathies: a Radiological Classification

Purpose

Before implant surgery, a preoperative radiological evaluation is recommended for recognizing maxillary inflammatory conditions. In order to avoid a failure of the dental procedure and prevent medical-legal consequences, it is necessary to treat patients suffering of maxillary sinus pathologies. The classification proposed in our study aims to standardize the reference values for mucosal thickening and to verify their association with the odontogenic or disventilatory causes of sinus pathology.

Methods

The maximum mucosal thickness was measured at the level of the maxillary sinus floor: mucosal thickness was present when greater than 1 mm and was classified according to its extension within the sinus cavity.

Results

Imaging data of 270 adult patients were included, performed for dental diagnosis and treatment planning, and they were divided into four main classes: Class I (85 pt.), mucosal thickness lesser than 2 mm, not pathological. Class II A (52 pt.), mucosal thickness between 2 and 5 mm, localized to the maxillary sinus floor: it is still considered non-pathological, and a "wait-and-see" approach is recommended. Class II B (46 pt.), mucosal thickness greater than 5 mm but localized at sinus floor: pathological mucosa with odontogenic etiology, requiring dental treatment. Class III A (39 pt.), mucosa thicker than 5 mm and concentric, most likely due to sinus ventilation disfunction: it requires maxillary antrostomy. Class III B (30 pt.), sinonasal manifestations such as nasal polyposis, retention cysts, mucocele, dental foreign body: pathological mucosa to be treated with ESS. Class IV (12 pt.), oroantral fistula: nasal endoscopic or oral approach.

Conclusions

Our classification intends to suggest the better therapeutic option, in case of sinus pathology, according to the entity and pathogenesis of the mucosal thickening, in order to reduce complication and failure rate of dental surgery.

Analysis of the Radiological Changes of the Sinus Membrane Using Cone Beam Computed Tomography and Its Relationship with Dental Treatments. A Retrospective Study

Simple Summary

Changes in the sinus membrane, in the form of thickening or opacification, usually pose problems of differential diagnosis between rhinological and odontogenic causes, given the similarity in their clinical behaviour. The interrelation between tooth roots and the possibility of maxillary sinus involvement seems to be a key determinant. Moreover, the role played by iatrogenic factors, especially surgical interventions, such as dental extractions, or impacted teeth, as well as implant treatments, must be considered. The contribution of new imaging procedures, such as conventional computed tomography or cone beam computed tomography, has triggered an increase in the identification of dental aetiology as a cause of the unilateral opacification of the anterior paranasal sinuses with the predominant involvement of the maxillary sinus.

Abstract

The aim of this study was to identify the most relevant dental factors and iatrogenic causes in the development of pathological changes to the sinus membrane and to analyse their possible influence on the development of odontogenic sinusitis. A descriptive, observational study was designed, with 276 patients who had been evaluated via cone beam computed tomography, analysing possible sinus thickening factors, such as apical infections, endodontic treatments, periodontitis, radicular cysts and impacted teeth, as well as iatrogenic factors caused by implant treatments or the development of oroantral communications produced during tooth extraction manoeuvres. Among the dental factors, periodontitis (47.1%), apical pathology (23.5%) and endodontic treatments (23.1%) were the predominant causes of sinus membrane thickening that most frequently produced an occupancy between 2 and 10 mm. Regarding the implant treatments, the placement of implants through the floor of the maxillary sinus was the main cause (9.8%), followed by sinus elevation techniques (6.2%). Dental extraction was the first cause of oroantral communication (5.0%), being the procedure that caused the greatest thickening of the sinus membrane. This study highlights the importance of dental treatments and iatrogenic factors in sinus pathology, and the need for diagnostic interrelations between the different specialists who address this pathology.

Management of sinus graft infection-a systematic review

Sinus graft infections are rare but serious complications, as they are associated with significant morbidity and sinus graft loss. The aim of this study was to systematically review the management of sinus graft infection in order to define which protocols should be implemented. The terms searched in each database were "sinus graft infection management", "maxillary sinus lift infection", "maxillary sinus graft infection", "maxillary sinus elevation infection", and "maxillary sinus augmentation infection". The management of the sinus graft infection was assessed. The outcomes evaluated were maxillary sinus health and dental implantation results. The initial search yielded 1190 results. Eighteen articles were included, reporting a total of 3319 patients and 217 sinus graft infections. Drainage was performed with an intraoral approach in 13 studies, an endoscopic approach in two studies, and a combined approach in three studies. In every study, a disease-free sinus was finally obtained in all patients, but the outcomes of the graft and the dental implant were more varied. It is not possible to define the best treatment protocol for sinus graft infections based on the published data, since the level of evidence is poor. Management is very heterogeneous. This review highlights the necessity of surgical treatment associated with antibiotic therapy.

ENT and dentist cooperation in the management of odontogenic sinusitis. A review

Odontogenic sinusitis represents by definition a border condition between otolaryngology and dental science and, from a holistic perspective, cannot be managed without a proficuous collaboration between specialists. This review focus on the different scenarios currently considered by international literature as related to odontogenic sinusitis and sinonasal complications of dental disease or treatment. Consequently, this review will cover all paranasal sinuses infections caused not only by dental disease (e.g. periodontitis and caries), but also by dental procedures (extractions, endodontics and the like), implantological procedures, pre-implantological (maxillary sinus grafting) and medication-related osteonecrosis of the jaw. After dealing with the odontogenic sinusitis diagnostic process and general principles of treatment, we will thoroughly cover odontogenic sinusitis scenarios treatment following an aetiology-based approach. This literature review shows that, albeit more prospective and rigorous studies are badly needed for determining the best treatment for each patient affected by odontogenic sinusitis, the sheer variety of scenarios that may be encountered should be enough to encourage mutual collaboration between ENTs and dentist. Such collaboration is required both to perfect diagnostic and treatment and to provide a solid scientific and medico-legal foundation for each intervention proposed to patients.

Endoscope-controlled maxillary sinus floor elevation: a review of the literature

A systematic review of the literature was conducted to assess the safety and efficacy of endoscope-assisted maxillary sinus elevation. PubMed, Embase, Web of Science, and the Cochrane database were searched for articles in English. Published studies involving patients who had undergone endoscope-assisted maxillary sinus floor augmentation were selected. The validity of the included articles was evaluated. After going through full texts, a total of 12 studies met the eligibility criteria and were included. It was concluded that endoscope-controlled maxillary sinus floor elevation was a viable and beneficial method, providing direct visualisation of the integrity of the mucosa and placing of bone graft material. The endoscope could be inserted into the maxillary sinus lumen, subantral space below the Schneiderian membrane, or through the alveolar crest. With the endoscope, perforations can be detected and managed precisely. However, high-quality clinical trials are still needed to validate the predictability and advantages of this surgical procedure.

Diagnosing odontogenic sinusitis: An international multidisciplinary consensus statement

BACKGROUND

Odontogenic sinusitis (ODS) is distinct from non-odontogenic rhinosinusitis, and often requires multidisciplinary collaboration between otolaryngologists and dental providers to make the diagnosis. The purpose of this study was to develop international multidisciplinary consensus on diagnosing ODS.

METHODS

A modified Delphi method was used to assess for expert consensus on diagnosing bacterial ODS. A multidisciplinary panel of 17 authors with ODS expertise from 8 countries (8 otolaryngologists, 9 dental specialists) was assembled. Each author completed 2 of 3 surveys (2 specialty-specific, and 1 for all authors). Thirty-seven clinical statements were created, focusing on 4 important diagnostic components: suspecting ODS; confirming sinusitis in ODS; confirming different dental pathologies causing ODS; and multidisciplinary collaborative aspects of diagnosing ODS. Target audiences were all otolaryngologists and dental providers.

RESULTS

Of the 37 clinical statements, 36 reached consensus or strong consensus, and 1 reached no consensus. Strong consensus was reached that certain clinical and microbiologic features should arouse suspicion for ODS, and that multidisciplinary collaboration between otolaryngologists and dental providers is generally required to diagnose ODS. To diagnose ODS, otolaryngologists should confirm sinusitis mainly based on nasal endoscopic findings of middle meatal purulence, edema, or polyps, and dental providers should confirm dental pathology based on clinical examination and dental imaging.

CONCLUSION

Based on multidisciplinary international consensus, diagnosing ODS generally requires otolaryngologists to confirm sinusitis, and dental providers to confirm maxillary odontogenic pathology. Importantly, both dental providers and otolaryngologists should suspect ODS based on certain clinical features, and refer patients to appropriate providers for disease confirmation.

Histological Aspects of a Novel Technique Used for the Management of Infections Secondary to Sinus Bone Grafting

Recently, a technical note describing a promising method for the management of infections after sinus bone grafting by irrigating the corresponding area with hydrogen peroxide based solution with an aid of a drain has been published. The aim of this paper was to present the histological and radiological results of the above mentioned technique. A total of 17 patients who have presented with infections secondary to sinus bone grafting enrolled in the study. During implant placement, bone was collected from the originally grafted site with a trephine burr for radiological examination via micro-computed tomography and histological examination. According to the results of the current study, Bio-Oss acted as a scaffold, and mature fibrous bone formed trabeculae, which assembled to an interlinked trabecular structure. Average results obtained from the microradiography confirmed the higher percentage of Bio-Oss (27.21% ± 3.31%) at the corresponding area; whereas the amount of newly formed bone was slightly lower (6.79% ± 1.13%) As a conclusion, this simple and minimally invasive technique might be beneficial in avoiding removal of bone graft material and could help in rescuing the former laborious procedure.

Functional Endoscopic Sinus Surgery for Paranasal Sinusitis Originating From a Peri-implantitis-Triggered Infection in the Augmented Maxilla: A Case Report

The aim of this case report was to report the course of treatment for advanced paranasal sinus infection triggered by peri-implantitis, managed using functional endoscopic sinus surgery (FESS), with outcomes. A nonsmoking male patient received sinus augmentation with implant placement on his left posterior maxilla 15 years ago. Possibly due to noncompliance to maintenance, peri-implantitis developed and progressed into the augmented bone area in the maxilla. Eventually, maxillary sinusitis occurred concomitantly with a spread of the infection to the other paranasal sinuses. Implant removal and intraoral debridement of inflammatory tissue were performed, but there was no resolution. Subsequently, FESS was performed, with removal of nasal polyp and sequestrum. After FESS, the patient's sinusitis resolved. Histologically, the sequestrum was composed of bone substitute particles, necrotic bone, stromal fibrosis, and a very limited cellular component. Two implants were placed on the present site, and no adverse event occurred for up to 1 year after the insertion of the final prosthesis. Peri-implantitis in the posterior maxilla can trigger maxillary sinusitis with concomitant infection to the neighboring paranasal sinuses. FESS should be considered to treat this condition.

Emphysema after Sinus Grafting: Importance of Patient's Information, Early Diagnosis, and Management

The sinus elevation procedure is a safe and predictable technique that allows the placement of implants in atrophic posterior maxillae. However, some recommendations have to be followed by the patient to ensure reliable healing. It is particularly important to avoid inducing trauma in the region concerned and through the sinuses. This report describes a rare complication that occurred after the grafting of a sinus, which was attributed to a violent sneeze a few hours after the intervention. The diagnosis of emphysema following air entry was confirmed by the suddenness of the swelling and associated crepitation, and by the radiographic observation of a delimited radiolucent zone in the grafted sinus. The immediate diagnosis and subsequent management prevented further adverse events. This case report supports the need for complete comprehensive instruction of patients after oral surgery, swift diagnosis, and management of emphysema.

Maxillary Sinusitis Associated With Peri-implantitis at Sinus Floor Augmented Sites: Case Series

PURPOSE

The purpose of this case series was to investigate treatment outcomes of maxillary sinusitis associated with peri-implantitis at sinus floor augmented sites for a 3-year follow-up.

MATERIALS AND METHODS

Eighteen implants in 8 patients diagnosed with maxillary sinusitis associated with peri-implantitis were reviewed. Four patients were treated with implant removal and antibiotics, and 4 patients were treated with implant removal, the modified Caldwell-Luc operation (CLOP), and antibiotics. Seven patients, who had 7 survived implants, were followed up to 3 years after treatment. The characteristics between failed and survived implants were compared. Radiographic parameters of survived implants were analyzed using the Friedman test.

RESULTS

Eleven failed implants from 8 patients exhibited approximately 10-mm pocket depths and mobility at diagnosis. Seven survived implants from 7 patients exhibited no significant changes in crestal bone loss at the facial side for 3 years after the treatments. Sinus mucosal thickening was significantly reduced during the 3-year follow-up after the treatments.

CONCLUSION

The progression of peri-implantitis in sinus floor augmented sites may lead to maxillary sinusitis. To confirm the efficacy of the intraoral approaches, such as the modified CLOP, systematic clinical studies with a large sample size and a long-term follow-up should be conducted.

Factors influencing long-term survival rates of implants placed simultaneously with lateral maxillary sinus floor augmentation: A 6- to 20-year retrospective study

OBJECTIVES

To evaluate the long-term influence of residual bone height (RBH), sinus membrane perforation and the presence of voids on the survival of implants placed simultaneously with lateral maxillary sinus floor augmentation (MSFA).

MATERIALS AND METHODS

A total of 207 patients (613 implants) who underwent MSFA from 1999 to 2003 and followed up until 2018 were included in this study. RBH and marginal bone loss were assessed using a series of panoramic and periapical radiographs. Cumulative survival rates (CSR) with log-rank tests and hazard ratios of implant failure according to RBH, membrane perforation, and the presence of voids were assessed.

RESULTS

The overall 10-year and 20-year CSRs were 95% (95% CI: 84.95%-85.05%) and 85% (95% CI: 84.95%-85.05%), respectively. CSR was significantly higher for implants with ≥3 mm RBH (n = 260, 92.4%) than those with <3 mm RBH (n = 353, 78.8%) (p = .002). CSR of non-smoking group (n = 312, 90.0%) was higher than that of smoking group (n = 301, 77.1%) (p = .009). There was no significant difference in the hazard ratio of implant failure between the perforated membrane group (n = 245) and the non-perforated group (n = 368). In two out of 11 patients with voids, the inflammation of peri-implantitis progressed into voids, resulting in severe bone resorption.

CONCLUSIONS

The survival of implants placed in <3 mm of RBH, even though it showed a lower CSR, could be considered acceptable. Neither sinus membrane perforation nor the presence of voids appeared to affect implant survival as long as supportive maintenance therapy with proper oral hygiene was provided.

Combined endoscopic and intra-oral approach for chronic maxillary sinusitis of dental origin-a prospective clinical study

AIMS AND OBJECTIVES

The traditional Caldwell-Luc approach for maxillary diseases has been criticized for its shortcomings such as removal of a large amount of bone, numbness of the teeth, flap dehiscence, and recurrent sinusitis. On account of its minimal invasiveness and physiological approach, functional endoscopic sinus surgery (FESS) has come to replace the Caldwell-Luc approach for the treatment of chronic rhinosinusitis. Chronic maxillary sinusitis of dental origin (CMSDO) is a less common variant on the chronic rhinosinusitis spectrum whose treatment involves simultaneous management of both the diseased maxillary sinus and the dental source of infection. Thus, this study was undertaken to assess the efficacy of FESS when combined with an intra-oral approach for the treatment of CMSDO.

MATERIAL AND METHODS

Eighteen patients with CMSDO in the age group of 18-50 years were treated with a combined endoscopic and intra-oral approach (buccal advancement flap with/without buccal fat pad) in this study. The patients were followed up for a total duration of 18 months. The primary outcome measurements were the SNOT-22 Quality of Life questionnaire and the Lund and Mackay CT Scan Scoring Criteria. The Friedman test was used to assess improvement in the above variables and the level of significance was set at 0.05.

OBSERVATIONS AND RESULTS

There was a statistically significant reduction (p < 0.05) in both the above parameters at all post-operative intervals. Two patients presented with epistaxis (immediate post-operative phase) and synechiae (second week follow-up interval). Both complications were successfully resolved. Two patients showed recurrence at the 6th-month interval for which they underwent revision surgery successfully. Overall, results were maintained even at the 18th month follow-up interval.

CONCLUSION

The endoscopic approach appears to be a reliable, minimally invasive technique associated with less morbidity and stable long-term results. Thus, a multi-disciplinary approach between maxillofacial surgeons and otolaryngologists is essential in the treatment of CMSDO.

Effect of Sphenopalatine Ganglion Block With Bupivacaine on Postoperative Pain in Patients Undergoing Endoscopic Sinus Surgery

Background

Postoperative pain is one of the most complications in endoscopic sinus surgery. We aimed to evaluate the effect of the sphenopalatine ganglion block (SPGB) with bupivacaine on postoperative pain in patients undergoing endoscopic sinus surgery.Methods and Materials: In this clinical trial, 40 patients who indicated functional endoscopic sinus surgery were selected and then divided into 2 parallel groups as intervention and control. The intervention group was received 1.5 mL of bupivacaine 0.5% (injected to sphenopalatine ganglion) and while control was injected 1.5 mL of normal saline at the same injection site. Also, the visual analogue scale (VAS) was recorded immediately after anesthesia, along with 6, 12, 24, 48 h, 7 days, and 21 days after the operation for all patients.

Results

Immediately after anesthesia, as well as 6, 12, and 24 h after the operation, VAS in the intervention group was significantly lower than in the control group (P < .05, for all). However, there were no significant differences between the 2 groups regarding VAS 48 h as well as 7 and 21 days after surgery (P > .05, for both). Also, the rescue analgesia in the intervention group was significantly lower than in the control group (P = .01).

Conclusion

SPGB with bupivacaine 0.5% (1.5 mL) was a simple, effective, safe, and noninvasive method for the management of postoperative pain in the patients undergoing endoscopic sinus surgery.

Odontogenic rhinosinusitis and sinonasal complications of dental disease or treatment: prospective validation of a classification and treatment protocol

Purpose

Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) represent a heterogeneous group of conditions that often require multidisciplinary care. The present study aims to prospectively validate a classification and treatment protocol for SCDDT patients.

Methods

One hundred twenty-eight consecutive patients (73 females and 45 males, mean age 52.4 years) affected by SCDDT not responding to dental and medical therapy were classified and surgically treated according to the proposed protocol. The protocol classified patients into three aetiology-based groups (preimplantologic, implantologic, and related to traditional dental diseases and procedures, respectively). The groups were further divided into classes according to the presence of oro-antral communications and/or dislocated dental hardware. Each condition was treated according to the class-related, protocol-defined treatment, by either a transnasal or combined transnasal/transoral approach. All patients were successfully classified according to our protocol. None of the proposed classes were redundant, and no condition fell outside the definitions.

Results

The surgical treatment protocol proved to be adequate and effective, in that 125 of the 128 patients completely recovered after surgical treatment.

Conclusions

The term SCDDT and the consequent classification proposed by the authors appear, therefore, to be nosologically correct. Furthermore, the protocol-related proposed treatment appears to be clinically sound, with a success rate nearing 98%.

Unusual Etiology and Diagnosis of Oroantral Communication due to Late Implant Failure

Oroantral communication (OAC) rarely occurs long after implant placement. The present report describes the rare etiology and the difficulty of the diagnosis of an uncommon OAC occurring 10 years after the implant placement in the posterior maxilla. The difficulty of the diagnosis lies in the absence of clinical symptoms of sinusitis and presence of multiunit prosthesis hiding implant failure. This case report supports the need for sinus check-up during a routine implant examination.

Complications related to bone augmentation procedures of localized defects in the alveolar ridge. A retrospective clinical study

PURPOSE

This retrospective clinical study aims to evaluate complications after augmentation of localized bone defects of the alveolar ridge.

METHODS

From standardized registrations, the following complications related to bone augmentation procedures were recorded: soft tissue dehiscence, infection, sensory disturbance, additional augmentation procedures needed, and early implant failure.

RESULTS

A total of 223 patients (132 women, 91 men; mean age 23.5 years; range 17-65 years) with 331 bone defects had bone augmentation performed into which 350 implants were placed. Soft tissue dehiscence occurred in 1.7 % after GBR procedures, 25.9 % after staged horizontal ridge augmentation, and 18.2 % after staged vertical ridge augmentation. Infections were diagnosed in 2 % after GBR procedures, 12.5 % after sinus floor elevation (SFE) (transcrestal technique), 5 % after staged SFE, 11 % after staged horizontal ridge augmentation, and 9 % after staged vertical ridge augmentation. Additional augmentation procedures were needed in 2 % after GBR procedures, 37 % after staged horizontal ridge augmentation, and 9 % after staged vertical ridge augmentation. A total of six early implant failures occurred (1.7 %), four after GBR procedures (1.6 %), and two (12 %) after staged vertical ridge augmentation.

CONCLUSIONS

Predictable methods exist to augment localized defects in the alveolar ridge, as documented by low complication rates and high early implant survival rates.

Odontogenic and rhinogenic chronic sinusitis: a modern microbiological comparison

BACKGROUND

Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) play a relevant, often underappreciated role in paranasal sinus infections. Treating SCDDT patients requires tailored medical and surgical approaches in order to achieve acceptable success rates. These approaches differ from common rhinogenic sinusitis treatment protocols mostly because of the different etiopathogenesis. Our study comprehensively evaluated microbiology and antibiotic resistance in SCDDT patients and compared findings with a control group of patients affected by rhinogenic sinusitis.

METHODS

We performed microbiological sampling during surgery on 28 patients with SCDDT and 16 patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Colonies were isolated, Gram-stained, and the species identified using classic biochemical methods. These results were confirmed by DNA pyrosequencing, and then the resistance profile of each SCDDT isolate to various antibiotics was tested.

RESULTS

Microbial growth was observed in all SCDDT patients, whereas samples from 60% of patients in the control group failed to yield any bacterial growth (p < 0.001). Anaerobes grew in 14% of SCDDT patients as compared to 7% of CRSwNP patients (p = 0.42). Of the isolates from SCDDT patients, 70% were susceptible to amoxicillin/clavulanate, whereas all isolates were susceptible to levofloxacin, teicoplanin, and vancomycin. Of the staphylococci identified, 80% were capable of producing beta-lactamase.

CONCLUSION

Given the extent of microbiological contamination within the maxillary sinus of SCDDT patients, these infections should be regarded as a different class of conditions from rhinogenic sinusitis. Our findings support the need for different approaches in the treatment of SCDDT patients.

Endoscopic sinus surgery in sinus-oral pathology

OBJECTIVE

Oral surgery is compounded by safe and well-known techniques and presents a low rate of complications. When the superior alveolar ridge is approached, surgery may result in oroantral fistula or tooth or implant dislocation in maxillary sinus. Those conditions lead to development of the maxillary sinusitis that, if underestimated, may evolve in orbital cellulitis and cerebritis or cerebral abscess. Our work aimed to compare the surgical techniques suitable for treatment of those complications and define the better surgical strategy.

METHODS

Between 2005 and 2010, 55 patients, presenting with displaced or migrated oral implants in the paranasal sinuses, with oroantral communication or with paranasal sinusitis of odontoiatrogenic origin, were visited and referred for treatment in the Maxillofacial Surgery Department of the University of Rome "La Sapienza." Surgical treatment consists of one of the following procedures: functional endoscopic sinus surgery (FESS); intraoral approach to the sinus with Caldwell-Luc technique; and oroantral fistula closure with a local flap, alone or combined with FESS.

RESULTS

The study group consisted of 55 patients: 28 female and 27 male patients aged 43 to 78 years (mean, 60 years). All had undergone oral surgery before our first visit: 17 patients had a prosthetic implant surgery (3 lateral-approach sinus augmentation and 15 implant placement). Seventeen patients had tooth extractions, 7 did root canal treatments, and 14 had sinus maxillary augmentation.

CONCLUSIONS

Functional endoscopic sinus surgery has slowly taken the place of the Caldwell-Luc technique in treating odontogenic maxillary sinusitis. Advantages of FESS are the less invasivity, the preservation of sinus anatomy and physiology, the reduction of recovery time, and oral rehabilitation without loosening efficacy compared with the previous transoral approach.

Redefining boundaries in odontogenic sinusitis: a retrospective evaluation of extramaxillary involvement in 315 patients

BACKGROUND

Odontogenic sinusitis and "sinonasal complications of dental disease or dental treatment" (SCDDT) have been assumed to be limited to the maxillary sinus. Nevertheless, many patients also show more extensive sinonasal involvement and, occasionally, also have associated bilateral disease. We evaluated the incidence of extramaxillary extension over an 11-year period in our clinic.

METHODS

We retrospectively evaluated 315 surgically treated SCDDT patients. Sinonasal involvement was assessed with presurgical imaging and confirmed with intraoperative findings. Patients were subsequently categorized into 3 groups, based on the sinonasal extension.

RESULTS

In 40.3% of patients the sinonasal condition was limited to the maxillary sinus. Forty-one percent of patients had unilateral extramaxillary involvement, and in 18.7% of patients, we found bilateral involvement.

CONCLUSION

Complete presurgery evaluation with endoscopy and a computed tomography (CT) scan in SCDDT patients is essential. SCDDT patients not responding to medical and dental treatment should be addressed with a planned approach targeting the extramaxillary extension, which may necessitate a combined oral and endonasal approach. It is unclear whether disease in the maxillary sinus contralateral to the primary maxillary sinus demonstrating odontogenic-induced disease is incidental, associated, or represents a subclinical odontogenic infection.

Aperture width of the osteomeatal complex as a predictor of successful treatment of odontogenic maxillary sinusitis

Odontogenic maxillary sinusitis (OMS) is an inflammatory disease caused by the spread of dental inflammation into the sinus. The long-term administration of antibiotic medicine and/or treatment of the causative tooth are the usual initial treatments. These initial treatments are not always effective, and the reason is not well understood. The purpose of this study was to identify factors of significance that may contribute to the results of the initial treatment of OMS. Thirty-nine patients were studied, divided into two groups according to the results of initial treatment: effective or non-effective. The effective group comprised 20 patients who were cured by initial treatment. The non-effective group comprised 19 patients who required an additional operation. The duration of symptoms, spread into the other sinuses, aperture width of the osteomeatal complex (OMC) on the side of the maxillary sinus, and anatomical variations in the sinuses were compared between the groups. The only significant difference found was in the aperture width of the OMC, which was significantly narrower in the non-effective group than in the effective group. The aperture width of the OMC may be a significant predictor of the effectiveness of initial treatment of OMS.

Treatment of dental implant-related maxillary sinusitis with functional endoscopic sinus surgery in combination with an intra-oral approach

The present report describes the case of a patient who underwent maxillary sinusitis right after dental implant installation with sinus lifting. Computed tomography scan revealed a dental implant (#16) was protruded inside the right maxillary sinus and confirmed the obstruction of ostium. A symptom remission was gained with the dual approaches combined by functional endoscopic sinus surgery and an intra-oral approach. Fully recovered function and healing of sinus were identified after 10 months follow-up. We report the case of sinusitis caused by protrusion of implants with sinus floor lift procedures and propose that practitioners should be aware of the possible its complications and management.

Late recovery from foreign body sinusitis after maxillary sinus floor augmentation

A 55-year-old male patient was referred to our clinic with signs and symptoms of recurring sinusitis after a right maxillary sinus floor augmentation for implantological purposes. Investigations showed an antibiotic-resistant ethmoidomaxillary sinusitis resulting from bone graft infection and displacement of previously inserted xenograft material into the maxillary sinus. The patient thus underwent a surgical procedure combining nasal endoscopy and oral surgery in order to remove the infected graft and restore sinusal drainage. The procedure was apparently successful but sinusitis relapsed after surgery and persisted despite 2 weeks of antibiotic therapy and local medications. A CT scan showed persistence of grafting fragments in the maxillary sinus. A new surgical procedure was scheduled while a more accurate endoscopic local medication was performed. Six hours after the treatment, the patient spontaneously expelled the fragments and promptly recovered. The patient successfully underwent another maxillary sinus floor augmentation procedure 6 months later.

How the simplest dental implant procedure can trigger an extremely serious complication

A 62-year-old man came to our attention after an operation in a small dental outpatient clinic where only a single dentist was working. The man was showing complications after insertion of a dental implant in the anterior segments of the mandible. Bleeding led to a slow swelling of the neck with airway obstruction. Only an immediate intervention by a mobile emergency unit and prompt tracheal intubation avoided death by asphyxia. The patient was then transferred to our hospital. We inspected the patient and we performed a CT scan that showed complete airway obstruction. First, we performed a tracheotomy in order to ensure the airway patency and then we identified the source of bleeding: the mylohyoid artery placed anomalously close to the mandible. After clamping and tying the artery, the bleeding resolved. One day after the procedure, the tracheotomy was closed; the patient was discharged after 3 days.

Dual antrostomy optical window for visualising sinus cavity during implant restoration

The authors report a case of maxillary sinusitis that developed after placement of four dental implants. Although one implant failed due to infection, the remaining dental implants were functional. A polyp had been identified on CT scan before implantation. Discussion of the possible odontogenic aetiology of the maxillary sinusitis led to consideration of explantation. Both middle and inferior meatal antrostomy were performed for utilisation as optical windows during postoperative care, allowing direct visualisation of the sinus cavity. The characteristics of the nasal mucosa were evaluated during a series of dental treatments including implant removal, sinus floor elevation and re-implantation.