During dental implant placement, it might be useful at times to redirect the osteotomy by lifting the floor of the maxillary sinus or by compressing the poor quality bone of an osteotomy site by means of an osteotome. 1 Some situations require the use of a surgical mallet to force the osteotome into the desired position. The osteotome transmits and directs the forces delivered by the mallet into the bone. These traumatic forces can cause a concussion of the labyrinth. This structure is located in the inner ear, medial to the middle ear structures. It is important for balance and equilibrium. Trauma to the head could cause a concussion of the labyrinth and result in vertigo. Vertigo is an important symptom of inner ear vestibular disorder. Positional vertigo is a feeling of spinning when the patient turns the head in a particular manner or assumes a certain position. Positional vertigo has been associated with minor and major head trauma. 2,3
A 67-year-old female patient presented for dental implant treatment to the maxillary left posterior sites 12, 13, and 14. She was examined and evaluated, and endosseous dental implant and fixed partial denture treatment was decided on. Three endosseous maxillary left implant osteotomies were made using drills and osteotomes, and the implants were installed uneventfully. The osteotomes were tapped at each site of the 3 sites with a surgical mallet to compress the maxillary bone. Just after the procedure, before leaving, she noticed a slight dizziness or lightheadedness in certain head positions. A consultation was made with an ear, nose, and throat physician who diagnosed her condition as labyrinthine concussion with benign positional vertigo. The patient was told to refrain from heavy lifting and to restrict her physical activity. Her symptoms lessened daily and the situation was totally resolved in 2 weeks.
Review of Anatomy
The inner ear or labyrinth consists of 2 parts, the osseous labyrinth and the membranous labyrinth. The osseous labyrinth is contained in the petrous portion of the temporal bone and consists of 3 parts: the vestibule, semicircular canals, and the cochlea (Fig. 1). These 3 tiny bone cavities are lined with a very thin fibroserous membrane similar to periosteum and filled with a clear fluid, the perilymph. The membranous labyrinth is suspended in the perilymph. The vestibule is the central portion of the labyrinth located between the cochlea and semicircular canals and measures approximately 3 mm × 5 mm. There are 3 semicircular canals: superior, posterior, and lateral. They are unequal in length, approximately 0.8 mm in diameter, and open into the vestibule by means of 5 orifices for the 3 canals at end dilations named the ampulla. The cochlea resembles a small snail shell and is approximately 5 mm × 9 mm. The semicircular canals and vestibule contain equilibrium receptors. Receptors in the semicircular canals respond to alterations in direction of movement. During head rotation, the endolymph in the semicircular canals lags and then moves in the opposite direction to the head’s movement causing stimulation of hair cells that send an impulse through the vestibular nerve, a division of the vestibulocochlear nerve, to the cerebellum. The vestibule contains macula receptors that sense the body’s static equilibrium. Otoliths (also called otoconia or statoconia) in the vestibule are small fragments of calcium salts that are present in a gelatinous mesh. These move with head position and stimulate the hair cells that in turn transmit a signal to the brain to sense balance. 4,5
The most common cause of positional vertigo is labyrinthine concussion resulting in repositioning of otoliths or liberation of free-floating debris. Placing a dental implant, especially in the maxilla, using an osteotome technique could expose the patient to a minor trauma to the osseous labyrinth. This trauma could result in the patient experiencing positional vertigo. Although most patients can withstand this minor head trauma without sequelae, some patients could experience this outcome. In more serious situations, the patient’s gait could be imbalanced and the eyes could show nystagmus (a constant involuntary cyclical movement of the eyeball in any direction). Symptoms usually wane in several days but could persist for several weeks. Chronic posttraumatic vertigo can result if the otoliths become detached and settle on the ampulla of the posterior semicircular canal and excessively deflect during head motion. This will present as an episodic positioning vertigo. Vertigo can also result from traumatic leakage of perilymph into the middle ear. Rarely, a perilymphatic fistulization or leakage could occur after physical trauma and could result in vertigo and hearing loss. This could require surgical repair but the surgeon must be extremely cautious in selecting these non-Ménière’s patients for surgery. 6–8
Head position by hyperextension of the neck during osteotome trauma could be a factor in this complication by positioning the labyrinth in such a way as to make it more susceptible to vertigo by allowing a repositioning and resettling of the otoliths. Patients with degenerative cervical spine disease could be particularly susceptible to traumatically induced vertigo by cervical proprioceptive dysfunction.
To minimize the trauma from osteotome malleting, it could be useful to first use the smallest size osteotome (2.0 or 3.25 mm) and then use increasing sizes until the desired size is attained rather than first going to the desired size. Drills could be required between osteotome applications if the bone is harder than anticipated. During osteotome sinus lifts, positioning the initial smallest osteotome at the base edge of the osteotomy, and then overlapping successive positions, makes it possible to lift the sinus lining and bone. After this, a large osteotome can be used to finally lift and detach the lining–bone complex.
There are few treatments for labyrinth disorders. Benign positional vertigo is a self-limiting condition and is treated by limiting physical activity, especially lifting. Head maneuvers directed by a physical therapist could be necessary if symptoms persist. Symptomatic treatment is useful. Medications such as antihistamines, anticholinergic, and sedative–hypnotics are used for brief periods and best administered to patients with prominent symptoms. Acute severe vertigo could be lessened with 2.5 to 5.0 mg diazepam intravenously, and associated nausea and vomiting relieved with an antiemetic delivered intramuscularly or by rectal suppository (25 mg prochlorperazine intramuscularly or 25 mg rectally every 6 hours). A combination of medications could succeed where a single one fails to control the patient’s symptoms. Bed rest, physical maneuver, and habituation exercises can be successful, or surgery could be considered after extreme selectivity if conservative treatment fails. Selective destruction of the vestibular hair cells by injection of 80 mg/mL gentamycin diluted 1:1 with bicarbonate into the middle ear with a spinal needle can render 80% to 90% relief of symptoms. 6
In time, some patients could exhibit emotional symptoms. There has been good success reported in treating positional vertigo with controlled head maneuvers of several different techniques (including heels overhead), psychologic and coping strategies. 9–13 Head maneuvers could be more effective than treatment with medication. 14
There does not seem to be a universally accepted diagnostic protocol for traumatic vertigo. Referral to an appropriate medical specialist, an otolaryngologist (ear, nose, and throat), or neurologist could be in order for some situations.
Positional vertigo has been associated with minor head trauma. It is not known what magnitude of malleting of an osteotome will result in a labyrinthine concussion. It behooves the implant surgeon to use as little force as necessary to minimize trauma to the bone and labyrinth. The use of gradually increasing sizes of osteotomes could help minimize the trauma induced to the head. Avoiding extreme neck extension could minimize susceptibility to labyrinthine concussion. The head trauma delivered by the osteotome could cause a detachment and repositioning of an otolith in the labyrinth or liberation of debris. This could result in a benign positional vertigo, which is treated with restrictions to physical activity, especially lifting. The condition is considered to be self-limiting within a few days’ to a few weeks’ duration. If the condition persists, or becomes more serious, supervised head maneuvers and other treatments can be instituted. Prochlorperazine could be given for nausea and vomiting. In very highly selected cases, surgery or chemical ablation could be necessary.
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11. Cohen HS, Jerabek J. Efficacy of treatments for posterior canal benign paroxysmal positional vertigo
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13. Furman JM, Cass SP, Briggs BC. Treatment of benign vertigo using heels-over-head rotation. Ann Otol Rhinol Laryngol
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Abstract Translations [German, Spanish, Portugese, Japanese]
AUTOR: Dennis Flanagan, DDS*. * Privat praktizierender Arzt. Schriftverkehr: Dennis Flanagan DDS, 1671 West Main St., Willimantic, Conn. 06226. Telefon: 860 - 456–3153,Fax: 860 - 456–8759. eMail: [email protected]
Konkussion des Ohrlabyrinths und Positionsschwindel nach Präparation des Osteotomiefeldes
ABSTRACT: Zur Einpflanzung mehrerer Zahnimplantate im Oberkiefer wurde eine Osteotomie durchgeführt. Es wird von einem Fall berichtet, bei dem die Osteotomiebehandlung Positionsschwindel als mögliche Folgeerscheinung nach sich zog. Dem Patienten wurde physische Schonung und die Vermeidung von Hebelasten verordnet, so dass die Beschwerden nach zwei Wochen verschwanden. Der vorliegende Bericht diskutiert auch das Krankheitsbild der Konkussion des Ohrlabyrinths sowie die adäquaten Behandlungsmöglichkeiten. Um Komplikationen bei der Osteotomie zu vermeiden, wird empfohlen, kleinschrittig mit einem Ostetom geringer Gröβe zu beginnen und die Größe allmählich zu steigern. Außerdem sollte bei Einsatz des Osteotoms der Patient so gelagert werden, dass es zu keiner Überstreckung des Nackens kommt.
SCHLÜSSELWÖRTER: Zahnimplantate, Osteotom, Konkussion des Ohrlabyrinths, Positionsschwindel, postoperativ
AUTOR: Dennis Flanagan, DDS*. *Práctica privada. Correspondencia a: Dennis Flanagan, DDS, 1671 West Main St., Willimantic, CT 06226. Teléfono: 860-456-3153, Fax: 860-456-8759. Correo electrónico: [email protected]
Conmoción del laberinto y vértigo de posición después de la preparación del sitio con un osteótomo
ABSTRACTO: Se informa un incidente de vértigo de posición asociado con la técnica de osteótomo para la instalación de múltiples implantes dentales. Los síntomas desaparecieron luego de dos semanas de actividad física restringida y prohibición de levantar objetos. Se incluye una discusión de la conmoción del laberinto y tratamientos. Las sugerencias para la prevención son usar osteótomos de tamaño pequeño primero y luego progresar a tamaños más grandes y evitar la posición de la cabeza con extensión del cuello durante el uso del osteótomo.
PALABRAS CLAVES: Implantes dentales, osteótomo, conmoción del laberinto, vértigo de posición, postoperatorio
AUTOR: Dennis Flanagan, Doutor em Ciência Dentária*. *Clínica particular. Correspondência para: Dennis Flanagan DDS, 1671 West Main St., Willimantic, Conn. 06226. Telefone: 860-456-3153, Fax: 860-456-8759. E-mail: [email protected]
Concussão Labiríntica e Vertigem Posicional Após a Preparação do Local para o Osteótomo
RESUMO: É relatado um incidente de vertigem posicional associado à técnica por osteótomo para instalação de implantes dentários maxilares múltiplos. Os sintomas foram resolvidos após duas semanas de atividade física restrita e proibição de pegar peso. Há uma discussão sobre concussão labiríntica e tratamentos. As sugestões para prevenção são usar tamanhos pequenos de osteótomos primeiro e depois progredir para tamanhos maiores e evitar a posição da cabeça na extensão do pescoço durante o uso do osteótomo.
PALAVRAS-CHAVE: Implantes dentários, osteótomo, concussão labiríntica, vertigem posicional, pós-operatório