The proximity of the maxillary sinus often poses problems for the placement of implants in the posterior maxillary region. This is especially evident with sinus pneumatization that sometimes reaches just a few millimeters above the crest of the alveolar ridge.1–4 Placement of immediate implants in the posterior maxilla may create unexpected problems because of the possible undetected communication with the maxillary sinus and poor bone quality that might lead to the displacement of the implant into the sinus. This report addresses this problem and its management.
A 19-year-old female medical student was referred to the Dental Implant Center with a displaced implant in the maxillary sinus. The referring doctor provided a complete history of the case. He reported that she presented at his office with a failed endodontic treatment in her maxillary left first molar. The root canal treatment had been done 3 years earlier without restoration to protect the tooth. The coronal part of the molar was missing completely. The roots were separated and resorbed due to caries that attacked the bifurcation area. The patient desired this molar to be restored for better function of this side. On clinical and radiographic examination (e.g., periapical and panoramic views) (Figs. 1 and 2), it was found that the remaining roots could not be saved or used for future restoration and that the adjacent teeth were completely sound. Tracing the maxillary sinus floor level in the panoramic radiograph revealed that the distance between the sinus and the alveolar ridge crest was from 10–13 mm (after calculation of the magnification). The referring dentist indicated that two treatment plans were initiated. The first included extraction of the affected roots and restoring the missing area with a three-unit fixed partial denture to be supported by the second molar and second premolar. The second plan included removal of the roots and immediate replacement with a wide implant in the bifurcation bone in the extraction site. The two treatment plans, their merits, and possible complications were discussed with the patient. The patient gave written informed consent for the second treatment alternative. She was enthusiastic about the idea of keeping the neighboring teeth sound.
After administration of local anesthesia, atraumatic extraction of the affected roots was carried out during surgery. Curettage and debridement of the sockets with small curettes and bone file with copious cleaning with saline took place. The patient was asked to blow air from the nose while closing the nostrils (i.e., Valsalva maneuver) to detect any oroantral communication. No such communication was detected at that time. Examination of the interseptal bone revealed a minimal amount of bone at that area. It was decided to insert the implant between the mesial and distal roots. The bone drill for a wide implant (6 × 1 m; Centerpulse Dental, Encino, CA) was used at the selected site to make the osteotomy. Poor bone quality was evident during drilling. The implant was hand ratcheted in place. During insertion of the healing cap, the entire implant slipped vertically and disappeared into the socket. Many attempts were made to reach the slipped implant, but unfortunately, none succeeded. Periapical and panoramic radiographs revealed that the implant was inside the sinus on top of the second molar and was completely inaccessible from the socket of the first molar (Figs. 3–5). The decision was made to leave the implant in place and monitor the patient closely. Antibiotic and analgesic were prescribed. No signs or symptoms of oroantral communication were evident at that stage. However, after a few days, swelling of the left side of the face started to develop. At that time, an operation to get the implant out from the sinus was recommended. The plan was to try to remove the implant through a subantral approach with an endoscope. If the implant was not accessible via this approach, a buccal window approach would be tried. In either approach, the socket of the extracted molar would be closed with combined buccal and palatal flaps.
Computed tomography images of paranasal sinuses were used to locate the exact site of the implant (Fig. 6A). Examination of the computed tomography images revealed an infection around the implant that manifested as complete opacification of the maxillary sinus (Fig. 6B). Preoperative antibiotic (amoxicillin, 4 × 750 mg over 5 days; SmithKline Beecham, Cairo, Egypt) and analgesic medication (paracetamol, 4 × 500 mg; Cetal EIPICO, Cairo, Egypt) were administered under general anesthesia. The patient was prepared and draped to insure strict asepsis. The oral cavity and skin of the face were disinfected with betadine solution. General anesthesia was administered, and an inferior orbital nerve block was also given. With the assistance of the endoscope (Karl Storz Hopkins, Tuttlingen, Germany) (Fig. 7), 30° and 70° degree, 4-mm optic equipment was connected with a Storz Endoscopy 487 B examination unit. A 300-W xenon light fountain (Karl Storz Hopkins) with 6.000-K capacity served as the light source. Through nasal transillumination from a hole in the ipsilateral nostril, the ear, nose, and throat (ENT) surgeon was able to open and drain the sinus through a middle meatal antrostomy. However, because of the medioanterior position of the implant, it was not possible to locate it by the endoscope through the nasal approach. Thus, the sublabial approach was initiated as planned.
A horizontal crestal incision, positioned slightly toward the palatal aspect, was performed throughout the entire length of the edentulous area opposite to the first and second molars. Another vertical anterior releasing incision was made at the level of the mesial aspect of the second premolar area. Posteriorly, the vertical releasing incision was placed just anterior to the maxillary tuberosity. A full-thickness flap was then elevated, exposing the anterior wall of the sinus and the base of the zygomatic bone. An elliptically shaped window was prepared using a round diamond bur mounted on a high-speed contra-angle. This buccal window measured 8 × 15 mm. The buccal window bone was then removed. Following exposure of the Schneiderian membrane, a small opening was made into the membrane. The ENT surgeon induced the endoscope through this opening and was able to locate the implant and remove it with an angled artery forceps. A thorough cleaning with saline was performed to clean the sinus from any infection. The sinus infection was drained via an inferior antrostomy.
The flap was closed on top of the extraction site to obtain a tension-free closure. This technique entails raising a full-thickness mucoperiosteal flap through two vertical parallel incisions, which were already made during the window approach, and extended toward the vestibule. The flap was then reflected and further extended to the vestibule. A periosteal slitting incision was made horizontally at the base of the flap, after which multiple incisions in the periosteum were made to lengthen and release the flap as required. The flap was then released and extended to cover the socket and sutured to the freshened edges of the palatal mucosa. This approach allows for an edge-to-edge tension-free closure that improves wound healing and reduces postoperative complications.5,6 The patient received antibiotic, analgesic, and topical 12% oral rinse with chlorhexidine mouthwash (Oraldene, Alkan Pharma, Cairo, Egypt), which were prescribed for 1 week postoperative. The patient was followed up for 2 months. The infection and swelling of the face subsided. Inspection of the wound closure revealed no tears or perforations. The test for oroantral communication was negative.
Communication of the maxillary sinus with the oral cavity during extraction of maxillary teeth is considered one of the most tedious problems dentists encounter. Many complications may arise due to failure to close this communication immediately after extraction or recurrence of the fistula some time later. This has led to development of many surgical techniques to close oroantral fistulae.5–7 These techniques aimed to maintain a tension-free socket seal despite the deficiency in soft tissue available for this closure. This is achieved either by undermining and releasing the soft tissue margins to approximate the wound edges or by applying special surgical procedures to achieve the same goal.8 In this report, an immediate implant in the socket of the first maxillary molar slid into the maxillary sinus accidentally during insertion. One approach was to leave it where it was, as long as no complications arose. However, due to development of a severe infection around the implant in the sinus, the decision was made to remove the implant and close the oroantral communication. The decision to use ENT endoscopy instead of a blind conventional window approach to the maxillary sinus was preferred because of 1) the medioanterior position of the implant into the sinus, 2) the possibility of tearing or perforating the sinus membrane, and 3) the possibility of the patient developing sinusitis.
Endoscopy in the field of ENT surgery is a well known tool in both diagnostics and treatment. It is also a great aid in the removal of foreign bodies from the antrum (i.e., maxillary sinus), ethmoid, and frontal sinus.9 Endoscopy allows optimized visualization to the surgical field to detect any possible mucosal perforation and to offer minimal morbidity and high acceptance by the patients.10
Endoscopy has been used originally in conjunction with dental implant surgery to assess the results after sinus floor augmentation via antroscopy or to control a transalveolar augmentation.11–13 This is achieved through a 5-mm approach to the maxillary sinus to perform an antroscopy in the center of the canine fossa. Recently, it has been used in subantral laterobasal sinus floor augmentation, which depends on an entrance located directly anterior to the zygomatic buttress at the basal aspect of the anterior sinus wall.14
Although the patient in this report was a young female, her case was considered to be compromised because of the poor bone quality between the sinus and the alveolar ridge. This may have been due to decay at the interseptal bone, which induced infection that affected the bone quality at that area. Reports have documented that the residual bone in this area is often type IV in quality.2–4 Variables in the sinus anatomy are reported to be present in 20 to 58% of cases.15,16 It is also known that the antral mucosa can be torn easily17 and that major bone deficits in the posterior maxilla result in a very thin, low-density antral floor (residual alveolus) of 1 to 3 mm in height in some cases.18,19 In a recent study,20 Smiler documented increased implant loss in female patients who received bone grafts compared with male patients. This was considered related to the difference in the quality of bone grafts (e.g., reduced bone density in female patients). Most clinicians who place endosseous implants concur that patients with advanced maxillary bone loss will typically demonstrate residual bone of reduced mineralization, particularly in the posterior region, regardless of age.3,19
Many investigators followed Boyne and James's work utilizing the Caldwell-Luc technique.20–23 The buccal subsinus augmentation is likely the most widely used technique today when an increase in bone height in the maxillary posterior region is required for placement of endosseous implants. The Caldwell-Luc procedure offers maximal exposure for the removal of foreign bodies that may be large or in a very anterior, posterior, or lateral position that makes endoscopic removal difficult. It also allows the clinician to view the amount of bone needed for the grafting procedure.23 In an effort to shorten the course of therapy and lessen the financial encumbrance to the patient, Summers24 introduced the bone-added sinus floor elevation procedures in 1994. This technique simplified the augmentation that is often mandated in the atrophic posterior maxilla in anticipation of prosthetic reconstruction. Such a therapeutic approach may not be indicated in the presence of significant buccolingual bone atrophy.25
The main complications of sinus surgery are maxillary sinusitis, infection with possible failure of the grafts, loss of implants after stage 1 surgery, and oroantral fistulae.26 Management of complications, from sinus perforation to sinus infection, were reported. The perforation is divided into small and large perforations. The small perforation can be handled with a collagen membrane, whereas the large one requires postponing of the surgery until complete healing occurs. Sinus infection should be managed by an ENT surgeon. Broad spectrum antibiotics are usually the treatment of choice, along with antianaerobic medication.27
Slippage of an implant into the maxillary sinus is an exceptional complication. It has been described as a rare complication and reported only twice in a report that discussed different maxillary sinus complications.27 In one case, an implant dislocated in the maxillary sinus; and in the other, the implant projected into the maxillary sinus during abutment connection after 6 months, leading to sinusitis. The same study that reported removal of the implant from the maxillary sinus was carried out using the Caldwell-Luc approach. Ueda et al28 and Quiney et al29 also reported cases of sinusitis caused by implants that were dislodged or penetrated into the maxillary sinus and required retrieval. In the present study, no disadvantageous preconditions were evident beforehand. The quantity of bone as calculated from the radiographs was sufficient. The Valsalva maneuver is one of the few possibilities for recognition of perforations. In this case, no oroantral communication was detected in any stage. However, one recent report demonstrated limited effectiveness of the Valsalva maneuver in recognizing a possible sinus perforation and indicated that it is best assessed with endoscopy.30 Management of this complication was addressed. Removal of the implant was performed with the aid of endoscopy. This was performed through a buccal window approach to the sinus instead of the conventional subantral approach.
Immediate implant placement in the posterior maxilla may entail many problems, including undetected communication with the sinus that may complicate and compromise the procedures. Endoscopy, through a buccal window approach to the sinus, proved to be a helpful tool in the removal of an implant from the maxillary sinus.
The authors claim to have no financial interest in any company or any of the products mentioned in this article.
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Abstract Translations [German, Spanish, Portugese, Japanese]
AUTOR(EN): Hussein G. El Charkawi, BDS, MSc, MS (USA), PhD*, Abdel Salam El Askary, BDS**, Ashraf Ragab, MD***. *Professor der Prothetik, Fakultät für Oral- und Zahnmedizin, Universität von Kairo, Kairo, Ägypten. **Privat praktizierender Arzt, Alexandria, Ägypten. *** Professor (ENT), medizinische Fakultät, Universität von Kairo, Kairo, Ägypten. Schriftverkehr: Hussein G. El Charkawi, PhD, 4 El Nabawy El Mohandes St., Agouza, Kairo –Ägypten. Telefon: 012 2150439, Fax: 202 –3460352. eMail:[email protected]
Entfernung eines Implantats aus dem Oberkiefersinus mittels Endoskopie: eine Fallstudie
ZUSAMMENFASSUNG: Bei unmittelbarer Implantatsetzung kann es in sehr seltenen Fällen zu Komplikationen durch das Abgleiten eines Implantats in den Oberkiefersinuskommen. Diese Studie greift daher eine Methode auf, bei der das in den Oberkiefersinus verlagerte Implantat mit Hilfe einer Endoskopie mit bukkalem Eintrittsfenster entfernt wird. Des Weiteren wird das mögliche Management einer so selten auftretenden Komplikation angesprochen.
SCHLÜSSELWÖRTER: bei Implantierung auftretende Komplikation, Endoskop, unmittelbar eingesetzte Implantate
AUTOR(ES): Hussein G. El Charkawi, BDS, M.Sc., MS/EE.UU., Ph.D.*, Abdel Salam El Askary, BDS**, Ashraf Ragab MD***. *Profesor de Prostodóntica, Facultad de Medicina Oral y Dental, Cairo University, Cairo, Egipto. **Práctica Privada, Alejandría, Egipto. ***Profesor de Otorrinolaringología, Facultad de Medicina, Cairo University, Cairo, Egipto. Correspondencia a: Hussein G. El Charkawi, Ph.D., 4 El Nabawy El Mohandes St., Agouza, Cairo-Egypt. Fax: 202-3460 352, Teléfono: 012 2150439. Correo electrónico:[email protected]
Extracción endoscópica de un implante del seno maxilar: Informe de un caso
ABSTRACTO: El deslizamiento de un implante en el seno maxilar es una complicación excepcional que puede ocurrir durante la colocación inmediata del implante. En este estudio, se informe la extracción de un implante desplazado en el seno maxilar con la ayuda de endoscopía a través de una ventana bucal. La atención de dicha rara complicación también se explica.
PALABRAS CLAVES: complicación del implante, endoscopía, implantes inmediatos.
AUTOR(ES): Hussein G. El Charkawi, Bacharel em Odontologia, Mestre em Ciências, Mestre em Ciências (EUA), PhD*, Abdel Salam El Askary, Bacharel em Ciências**, Ashraf Ragab, Médico***. *Professor de Prostodontia, Faculdade de Medicina Oral e Dentária, Universidade do Cairo, Cairo, Egito. **Clínica Particular, Alexandria, Egito. ***Professor de ENT, Faculdade de Medicina, Universidade do Cairo, Cairo, Egito. Correspondência para: Hussein G. El Charkawi, PhD, 4 El Nabawy El Mohandes St., Agouza, Cairo –Egypt. Fax: 202 3460 352. Telefone: 012 2150439, E-mail:[email protected]
Remoção Endoscópica de um Implante do Seio Maxilar: Relato de Caso
RESUMO: O escorregamento de um implante para dentro do seio maxilar é uma complicação excepcional que pode ocorrer durante a colocação imediata do implante. Neste estudo, a remoção de um implante deslocado para dentro do seio maxilar dom o auxílio de endoscopia via abordagem da janela bucal é relatada. A administração de complicação tão rara também é tratada.
PALAVRAS-CHAVE: complicação no implante, endoscópio, implantes imediatos.