Importance of ENT assessment in stratifying candidates for sinus floor elevation: a prospective clinical study

Mucosal cyst aspiration in conjunction with maxillary sinus elevation: A clinical cohort study

INTRODUCTION

Patients with mucosal cysts in the maxillary sinus require special consideration in patients who require implant therapy for the restoration when undergoing implant therapy for the restoration of the posterior maxillary dentition. Treatment strategies for these clinical situations remain controversial in the literature. Thus, this study seeks to describe a safe and effective therapeutic strategy for sinus augmentation in patients with pre-existing maxillary antral cysts.

METHODS

A total of 15 patients and 18 sinuses were consecutively enrolled in this cohort study and underwent maxillary antral cyst treatment by needle aspiration and simultaneous maxillary sinus augmentation (MSA). During surgical procedures, threeimplants (Zimmer Biomet, Indiana, USA) were positioned in 11 sinuses and two implants (Zimmer Biomet, Indiana, USA) were positioned in 5 sinuses.

RESULTS

Overall implant success and survival rates were 100% and 97.8%, respectively at 1 year and 5-year follow-ups. Crestal bone resorption averaged 0.3 ± 0.2 mm 5-year post-loading, showing bone stability. Implant survival rate at 5-year follow-up expressed predictability of the technique comparable to historical data when MSA was performed alone. Crestal bone resorption averaged 0.3 ± 0.2 mm 5 years post-loading and shows bone stability utilizing mucosal cyst aspiration with concomitant MSA procedures. Quality of life evaluation at 1-week post-op showed similar results to published historical data. In 81% (13 sinuses), the CBCT examination at 5-year follow-up showed no cyst reformation, in 19% (3 sinuses) cyst reformation was visible, but smaller in size when compared to the pre-op CBCT evaluation, and all the patients were asymptomatic.

CONCLUSIONS

Maxillary sinus mucosal cyst aspiration with concomitant MSA, may be a viable option to treat maxillary sinus cyst.

Endodontic Surgery of the Palatal Root of a Maxillary Molar Associated with Simultaneous Management of a Maxillary Sinus Lesion

This case report describes a particular application of endodontic microsurgery with a palatal approach in the presence of a radiopaque lesion inside the maxillary sinus. The patient presented complaining of pain related to the first maxillary molar and events of nasal obstruction and facial pain in the cheek and nasal area. The endodontic orthograde treatment and retreatment were done, respectively, 7 and 4 years earlier. The cone-beam computed tomography (CBCT) scan taken before the treatment showed two separate lesions: one associated with the palatine root of the molar and another one inside the maxillary sinus. The patient agreed to solve both problems in one surgical step: endodontic surgery of the palatine root with palatal access with the simultaneous asportation of a lesion from the maxillary sinus floor. Complete bone healing of the periapical area and the maxillary sinus was visualized on intra-oral radiographs, and CBCT was taken one year after the treatment. As far as the authors know, no one in literature has ever described this approach and solved in such a conservative way both the problems at the tooth and in the maxillary sinus.

How to avoid intraoperative and postoperative complications in maxillary sinus elevation

Maxillary sinus floor elevation, via the lateral approach, is one of the most predictable bone augmentation procedures performed in implant dentistry. but both intra- and postoperative complications can occur, and some of them are severe. Our aim is as follows: To review the pertinent literature on the topic, especially assessing the risk factors related to complications. To give clinical recommendations to minimize intra- and postoperative complications with the ultimate scope of improving the standard of clinical care and patient safety.

Effect of Sinus Floor Augmentation with Platelet-Rich Fibrin Versus Allogeneic Bone Graft on Stability of One-Stage Dental Implants: A Split-Mouth Randomized Clinical Trial

Rehabilitation of an edentulous posterior maxilla with dental implants is challenging, and sinus floor augmentation could be considered as an important surgical procedure for bone augmentation in this region before implant placement. Platelet-rich fibrin (PRF) is a new-generation platelet concentrate with simplified processing: its application in sinus floor augmentation has been widely investigated in literature. However, the biological properties and actual efficacy of this product remain controversial. This study assessed the effect of sinus floor augmentation with PRF versus freeze-dried bone allograft (FDBA) on stability of one-stage dental implants. This split-mouth randomized clinical trial evaluated 10 patients who required bilateral sinus floor augmentation. PRF and L-PRF membrane were used in one quadrant while FDBA and collagen membrane were used in the other quadrant. Implant stability was assessed by resonance frequency analysis (RFA) immediately, and 2, 4, and 6 months after implant placement. The implant stability quotient (ISQ) was compared over time and between the two groups using repeated measures ANOVA and independent sample t-test. The mean ISQ significantly increased over time in both groups (p < 0.001). The increase was greater in the PRF group (p < 0.05). Within the limitations of this study, PRF yielded superior results compared with FDBA regarding the stability of one-stage dental implants.

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.

A Successful Treatment Regimen for the Prevention of Sinusitis after Maxillary Sinus Floor Elevation Surgery in a High-Risk Case

Maxillary sinus floor elevation (sinus lift) is a widely recognized dental-surgical approach for dental implant placement. However, for an otorhinolaryngological high-risk patient with severe anatomic-structural impairments of the maxillary sinus drainage pathway, surgical intervention is recommended before sinus lift to avoid postsinus lift maxillary sinusitis. Here, we show a case that postsinus lift maxillary sinusitis in such a high-risk patient was noninvasively prevented by the collaboration of otorhinolaryngologist and dentist. A 48-year-old Japanese male intended to undergo a sinus lift for dental implant placement by periodontist. Otorhinolaryngologist found septal deviation, concha bullosa, the presence of Haller cell, and nasal mucosal swelling by the nasal allergy, while no sinusitis and diagnosed him as a “high-risk case” for postsinus lift maxillary sinusitis. The patient was administered preoperative topical steroid and leukotriene receptor antagonist in addition to perioperative antibiotic prophylaxis so that his complication was noninvasively prevented. Thus, this case suggested that consultation from dentist to otorhinolaryngologist provides benefit to the patients who have been diagnosed as “high-risk case” for postsinus lift maxillary sinusitis.

Classification of sinonasal pathology associated with dental pathology or dental treatment

BACKGROUND

The pathologies of the posterior teeth in the first and second quadrant and their treatments can be associated with pathology of the maxillary sinus in up to 30% of the cases. Sinus lift surgery in order to place dental implants have increased their incidence. It is necessary, therefore, to address sinonasal pathology (SN) related to dental pathology (DP) or dental treatments (DT) from an interdisciplinary point of view by establishing collaborative working groups between Dentistry (DEN) and Otolaryngology (ENT), as well as by developing registries and establishing coordinated diagnosis and treatment protocols of sinonasal pathology. The aim of this study was to present a brand new and useful classification that relates dental pathology and dental treatments performed on antral teeth with sinonasal pathology to facilitate communication between dentists and otolaryngologists.

METHODS

A review of the literature was performed and a classification which related dental pathology and treatments to sinonasal pathology was developed.

RESULTS

Six categories are described in our system: absence of sinonasal or dental pathology (0); patients with dental pathology associated (1) or not (4) with sinonasal pathology; 2 and 5- patients with dental treatment not associated (2) or associated (5) with sinonasal pathology; and patients with sinonasal pathology without dental pathology (3). The classification has applications in diagnosis (association and possible causal relationship between the sinonasal and dental pathology) and in the treatment of these pathologies simultaneously or sequentially.

CONCLUSIONS

This classification integrates the presence or absence of dental pathology or dental treatment, and its association or not it with sinonasal pathology. Moreover, it facilitates the communication between dentists and otolaringologists and eases the registration of information and the planning of dental, implant and sinus lift treatments.

Risk factors in lateral window sinus elevation surgery

Maxillary sinus augmentation is the most predictable of the pre-prosthetic surgical procedures. There are, however, known and well-documented complications that can and do occur. The most common are the intraoperative complications of sinus membrane perforation and bleeding, and the postoperative complications of sinus graft infections, sinus infections, and sinusitis. The majority of these complications can be prevented, or their incidence greatly reduced, through a thorough understanding of maxillary sinus anatomy, the multifaceted etiologies of these conditions, and the steps that can be taken to avoid them. This volume of Periodontology 2000 will discuss both the preoperative and intraoperative procedures that will prevent these untoward outcomes and the necessary treatment modalities that will limit their adverse effects.

Preoperative Maxillary Sinus Imaging and the Outcome of Sinus Floor Augmentation and Dental Implants in Asymptomatic Patients

OBJECTIVES

Preoperative maxillary sinus imaging findings have been suggested to be associated with complications and outcomes of sinus lift and dental implant procedures; nonetheless the evidence is controversial. The aim of this study was to examine the association between preoperative maxillary sinus imaging findings and outcomes of sinus lift and dental implant procedures in asymptomatic patients.

METHODS

We included all patients who underwent maxillary sinus lift and dental implant procedures between 2014 and 2017. Maxillary sinus imaging findings were extracted from pre-procedural dental computed tomography scans, and outcomes of the procedures were assessed.

RESULTS

A total of 145 procedures were included. No sinonasal symptoms were reported preoperatively. In 46% of cases maxillary sinus imaging was abnormal. The most common imaging finding was peripheral mucosal thickening (38%). Sinus floor cyst/polyp was identified in 13% of the cases, of which 47% occupied more than 50% of the sinus volume. Partial or complete opacification of the maxillary sinus was documented in 3% of cases. The sinus ostium and ostiomeatal complex were obstructed in 7% and 1%, respectively. Mucosal perforation was documented in 22% of cases and was inversely related to mucosal thickening (P = 0.011). Other minor post-operative complications did not correlate with radiological findings. Post-surgical sinusitis was not observed in any of the patients regardless of pre-surgical imaging findings.

CONCLUSIONS

Incidental maxillary sinus imaging findings such as mucosal swelling, cysts or polyps, regardless of their severity or size, and maxillary ostial obstruction may not need to be addressed prior to sinus augmentation and dental implant procedures in asymptomatic patients. Patients with complete sinus opacification should be referred to an otolaryngologist prior to surgery. Further controlled trials, in larger cohorts, are needed to corroborate our findings.

Association of dental and maxillary sinus pathologies with ear, nose, and throat symptoms

OBJECTIVES

To investigate the correlation between cone-beam computerized tomography (CBCT) findings in the maxillary sinus, ear-nose-throat (ENT) symptoms and dental pathologies in asymptomatic patients.

MATERIALS AND METHODS

A total 81 patients were referred for CBCT and filled a standard ENT visual analog scale (VAS) questionnaire. CBCT images were analyzed for sinus ostium obstruction, Schneiderian membrane thickening, sinus floor turbidity, and the presence of polyps. Dental pathologies were evaluated with the aid of CBCT images, periapical X-rays, and clinical examination. A possible correlation between the CBCT findings and the ENT/dental parameters was examined by applying Student's t test and the chi-squared test.

RESULTS

Despite being asymptomatic, most of the 81 patients reported ENT symptoms in the questionnaire, thereby indicating that these symptoms were mainly subclinical. A significant correlation was found between the presence of polyps in the sinus and a decrease in smell/taste. Obstruction of the sinus meatus was associated with coughing; turbidity was associated with ear congestion. Thickening of the Schneiderian membrane showed an association with both coughing and ear congestion. The mean number of missing posterior teeth correlated with postnasal drip and nasal congestion. Periapical pathology was associated with nasal discharge/runny nose.

CONCLUSION

The results emphasize the need to evaluate ENT symptoms when radiographic findings are identified in CBCT.

A paradigm for evaluation and management of the maxillary sinus before dental implantation

OBJECTIVES

To determine a paradigm for evaluating and managing maxillary sinus conditions before dental implantation via preoperative sinonasal assessment.

STUDY DESIGN

Prospective cohort study.

METHODS

Eighty-four patients who underwent dental implantation with or without sinus augmentation were included. Maxillary sinus conditions were classified into groups 1 to 6 according to cone-beam computed tomography (CT) findings: 1) nonspecific findings, 2) solitary polyp or cyst, 3) mucosal thickening, 4) air-fluid level or fluid accumulation, 5) near-total opacification of the maxillary or other paranasal sinus, and 6) calcification spots in the maxillary sinus. Dental implantation with or without sinus augmentation was suggested with postoperative sinus observation (groups 1-3), after medication for acute sinusitis (group 4), and after comprehensive treatment of chronic or fungal sinusitis (groups 5-6). Intraoperative and postoperative sinus-related complications were recorded.

RESULTS

Two patients (groups 1 and 3) developed acute rhinosinusitis after sinus augmentation; both recovered completely with medical treatment. Schneiderian membrane perforation occurred during sinus lift surgery in six patients (group 1): five recovered after conservative medical therapy and close observation, whereas one required endoscopic sinus surgery and recovered well. No chronic rhinosinusitis developed after dental implantation.

CONCLUSION

Craniofacial CT is crucial for pre-dental implantation sinonasal evaluation. The risk of dental implant-related chronic rhinosinusitis is low for patients with cysts, polyps, or mucosal thickening in the maxillary sinus. However, preventive endoscopic sinus surgery is recommended for patients with incurable chronic rhinosinusitis, fungal sinusitis, and large polyps or cysts.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1261-1267, 2018.

Predoctoral and Postdoctoral Education on Cone-Beam Computed Tomography

OBJECTIVES

As the use of cone beam computed tomography (CBCT) in dentistry continues to grow, questions related to appropriate radiation safety, training, and interpretation arise. Recognizing this need, the American Dental Association published an advisory statement for the safe use of CBCT in dentistry and recommended that guidelines for appropriate training be established. The purpose of this study was to assess radiation safety concerns related to CBCT and identify voids in current education on CBCT for the predoctoral dental curriculum and continuing dental education.

METHODS

A survey was mailed to general practitioners, oral surgeons, and periodontists in the Georgia Dental Association (n = 415).

RESULTS

One hundred twenty-one surveys were received for a response rate of 29%. Sixty-eight percent of practitioners reported using CBCT, with 89% having used it for over 2 years. Few (12.4%) had experience with CBCT in dental school. Interest in continuing dental education on CBCT was reported at 59.8% and 43.6% for current users and nonusers of CBCT, respectively. Approximately 50% reported using precautionary radiation safety measures, and the methods used were varied.

CONCLUSIONS

Although a higher survey return rate would allow for stronger evidence, this project identified some areas of education voids including radiation safety and the factors that contribute to patient dose; CBCT basics including instruction on the limitations of CBCT; CBCT anatomy and pathology with additional time dedicated to the paranasal sinuses; and interpretation.

Multidisciplinary Management of Candidates for Maxillary Sinus Augmentation by a Surgeon and ENT Specialist

Maxillary sinus augmentation has been shown to be a predictable treatment option for placing dental implants in areas of posterior maxilla with lack of sufficient residual alveolar bone height.¹ The transalveolar (crestal) and the lateral window are the main techniques for the maxillary sinus augmentation with the goal of creating a space beneath the Schneiderian membrane in which to place various grafting materials in order to increase alveolar bone height.

One-Step Maxillary Sinus Augmentation in Association With Endoscopic Sinus Surgery: Case Series and Review of the Literature

INTRODUCTION

Sinonasal anatomical anomalies and inflammatory conditions may reduce success rates of maxillary sinus elevation (MSE) procedures used to allow implant placement in the atrophic posterior maxilla. Approaches combining endoscopic sinus surgery (ESS) and MSE were firstly proposed by our group and have already been described in the literature. This article aims to re-evaluate the procedure in a larger sample of patients comparing results and indications with the pertaining literature.

MATERIALS AND METHODS

Thirty-three patients (19 men and 14 women, mean age 52.79 ± 11.95 years) underwent combined ESS/MSE with 48 MSE procedures performed.

RESULTS

No intraoperative complications were reported. An uneventful and complete graft integration was obtained after 6 months in all but one patient. All patients completed prosthetic rehabilitation within 9 to 12 months.

CONCLUSION

Combined ESS and MSE has proven to be a safe and reliable procedure, which can be proposed to selected patients presenting with reversible sinonasal contraindications to MSE and should be no more considered an experimental procedure.

Correlations between anatomic variations of maxillary sinus ostium and postoperative complication after sinus lifting

OBJECTIVES

The maxillary sinus mucosa is reported to recover to preoperative sterility after sinus floor elevation. However, when drainage of maxillary sinus is impaired, recovery can be delayed and maxillary sinusitis can occur. Therefore, in this study, we investigated the correlations between anatomic variants that can interrupt the ostium of the maxillary sinus and incidence of complication after sinus lifting.

MATERIALS AND METHODS

The subjects are 81 patients who underwent sinus lifting in Wonkwang University Dental Hospital (Iksan, Korea). Computed tomography (CT) images of the subjects were reviewed for presence of nasal septum deviation, anatomic variants of the middle turbinate, and Haller cells. Correlations between anatomic variations and occurrence of maxillary sinusitis were statistically analyzed.

RESULTS

Patients with anatomic variants of ostio-meatal units, such as deviated nasal septum, concha bullosa or paradoxical curvature of the middle turbinate, or Haller cells, showed a higher rate of complication. However, only presence of Haller cell showed statistically significant.

CONCLUSION

Before sinus lifting, CT images are recommended to detect anatomic variants of the ostio-meatal complex. If disadvantageous anatomic variants are detected, the use of nasal decongestants should be considered to reduce the risk of postoperative sinusitis.

Implantology and otorhinolaryngology team-up to solve a complicated case

PURPOSE

The aim of this article was to highlight the importance of the collaboration between implantologists and ear, nose, and throat (ENT) specialists to treat complex cases.

MATERIALS AND METHODS

A 46-year-old patient underwent a maxillary sinus elevation and implant placement 3 years before but because of a severe postop infection, the patient was treated with functional endoscopic sinus surgery (FESS) and lost the graft and the implants. Later, the patient consulted us and was referred to an ENT specialist because of sinus opacity. She underwent a second functional endoscopic sinus surgery (FESS); various ENT consultations and computer tomographies (CTs) were performed to assess sinus health.

RESULTS

After having confirmed with sinus health, sinus elevation, implant placement, and loading were performed with success.

CONCLUSION

Collaboration between the implantologist and ENT specialist is necessary to distinguish between nonpathological membrane thickening because of the healing process after FESS and a pathological thickening due to infection.

Sinus grafting and simultaneous removal of large antral pseudocysts of the maxillary sinus with a micro-invasive intraoral access

Large antral pseudocysts of the maxillary sinus (APCs) may hamper the elevation of the Schneiderian membrane during sinus grafting and may impair osteo-meatal complex patency after sinus augmentation. Therefore, these should be removed prior to or at the time of sinus grafting. This study presents a new technique that combines enucleation of large APCs during sinus grafting via a lateral approach with preservation of the Schneiderian membrane periosteal layer. Twelve patients underwent a sinus graft via lateral approach during the years 2004-2012. Simultaneous APC removal was achieved through a small additional bony access, preserving the integrity of the periosteal layer of the Schneiderian membrane. Nineteen implants were inserted at the time of sinus augmentation or during a second stage. Prosthetic rehabilitation was started at 4-6 months after implant placement. No patient developed surgical complications or APC recurrence. The survival rate of implants and related prostheses was 100% over a mean follow-up of 50 months (range 12-96 months) after completion of the prosthetic restorations. This technique may represent an effective procedure to achieve APC removal at the time of sinus grafting, preserving the integrity of the Schneiderian membrane periosteal layer.

Evaluation of anatomical considerations in the posterior maxillae for sinus augmentation

The edentulous posterior maxilla is considered a clinical challenge during dental implant treatment for many dental practitioners. This is because its insufficient bone quality, deficient alveolar ridge, spiny ridges, undercuts, and sinus pneumatization are often encountered after tooth loss. To overcome these problems, several approaches have been developed and are currently used, including sinus augmentation and bone augmentation. Today, two main procedures of sinus floor elevation for dental implant placement are in use: a two-stage technique using the lateral window approach, and a one-stage technique using a lateral or a crestal approach. In this study, we deal with the anatomic relations of the structures of the maxillary sinus during sinus augmentation. These anatomical findings can help in complications and potential injuries of the maxillary sinus procedures. It can be suggested that pre-operative evaluation is helpful for diagnosis and treatment planning and minimizing complication during the surgery.

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Introduction. Maxillary sinus surgery is a reliable and predictable treatment option for the prosthetic rehabilitation of the atrophic maxilla. Nevertheless, these interventions are not riskless of postoperative complications with respect to implant positioning in pristine bone. Aim. The aim of this paper is to report the results of a clinical consensus of experts (periodontists, implantologists, maxillofacial surgeons, ENT, and microbiology specialists) on several clinical questions and to give clinical recommendations on how to prevent, diagnose, and treat postoperative infections. Materials and Methods. A panel of experts in different fields of dentistry and medicine, after having reviewed the available literature on the topic and taking into account their long-standing clinical experience, gave their response to a series of clinical questions and reached a consensus. Results and Conclusion. The incidence of postop infections is relatively low (2%–5.6%). A multidisciplinary approach is advisable. A list of clinical recommendation are given.