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Sinonasal complications resulting from dental treatment:
Outcome-oriented proposal of classification and surgical
protocol
Giovanni Felisati, M.D.,
1
Matteo Chiapasco, M.D.,
2
Paolo Lozza, M.D.,
1
Alberto Maria Saibene, M.D.,
1
Carlotta Pipolo, M.D.,
1
Marco Zaniboni, D.D.S.,
2
Federico Biglioli, M.D.,
3
and Roberto Borloni, M.D.
4
ABSTRACT
Background: Odontogenic sinusitis is a relevant infectious condition of the paranasal sinuses. The widespread use of dental implants and reconstructive
procedures for dental implant placement has led to new types of complication. To the authors’ knowledge, no publication has extensively examined sinonasal
complications resulting from dental treatment, and no classification system allowing standardization and comparison of results is currently available. This
study was designed to (a) analyze the results obtained from surgical treatment of complications resulting from dental procedures combining functional
endoscopic sinus surgery (FESS) and an intraoral approach and (b) propose a new classification system and standardized treatment protocols for sinonasal
complications resulting from dental procedures.
Methods: A total of 257 patients consecutively treated with FESS (136 in conjunction with oral surgery) were included in the study. Different clinical
situations were integrated into a new classification system based on the pathogenesis and clinical aspects of each case, with the aim of identifying homogenous
treatment groups. Results were evaluated for each class.
Results: Of the 257 patients, 254 were successfully treated with surgery performed according to the proposed protocols. Three of 257 patients required a
second surgery, after which they completely recovered. Complications of implant and preimplant surgery (maxillary sinus floor elevation) showed longer
recovery times.
Conclusion: The results obtained are very encouraging. The majority of patients (254/257; 98.8%) were successfully treated with the proposed protocols.
These results seem to indicate that the rationalization of surgical treatment protocols according to the initial clinical situation may significantly improve the
clinical outcome.
(Am J Rhinol Allergy 27, e101–e106, 2013; doi: 10.2500/ajra.2013.27.3936)
O
dontogenic sinusitis (OS) is a relevant infectious condition of the
paranasal sinuses, accounting for 10–30% of cases of maxillary
sinusitis
1,2
and 8% of conditions treated by endoscopic nasal surgery.
3
OS may follow (a) an endodontic infection, (b) sinus penetration of
endodontic material, (c) dislocation of tooth fragments into the max-
illary sinus (MS), (d) opening of an oroantral communication (OAC),
(e) penetration of dental implants into the MS, or (f) tears of the MS
mucosa and penetration of grafting materials during augmentation
procedures (e.g., MS floor elevation, also known as sinus lift).
4,5
The incidence of OS due to the latter two causes is rapidly increas-
ing. Dental implants and associated procedures intended to acquire
the required bone volume have become common. These procedures
present a very limited complication rate; however, their widespread use
among dentists has made sinonasal complications fairly common in the
ear, nose, and throat (ENT) practice. These infections are mainly caused
by infections of the MS after the penetration of grafting materials or
implants, resulting in rupture of the Schneiderian membrane.
6
The authors consider even “classic” dental sinusitis (e.g., that after
endodontic infection and abscess) a complication of dental treatment
because virtually all patients undergo dental treatments before show-
ing sinonasal complications.
The management of complications resulting from dental treatments
represents an area of expertise for ENT and oral/maxillofacial sur-
geons. Frequently, the participation of two or more of these specialists
is needed to treat each patient, especially a patient with long-term
chronic conditions that involve other paranasal sinuses.
In 2002, the authors conceived a standardized, team-based surgical
approach aiming to resolve these pathologies with a single procedure.
This approach has been made possible by sinonasal endoscopy (func-
tional endoscopic sinus surgery [FESS]), which allows the perfor-
mance of minimally invasive procedures and offers several advan-
tages when treating the clinical situations described in this study. The
surgical approach was based on availing FESS procedures to restore
sinonasal homeostasis with minimal invasiveness, removing any for-
eign body from the nasal cavities and using oral approaches to treat
OACs, dominate hard-to-reach areas (e.g., alveolar recess), to remove
failed implants and, broadly speaking, to treat underlying dental
conditions. The approach was gradually extended to new conditions
encountered and finally condensed into a surgical protocol following
the classification (see Materials and Methods section).
Results concerning the use of FESS for MS pathologies of dental or
implantological origin (e.g., removal of implants dislocated into the
MS) have been reported.
7–9
Costa et al.
10
proposed the combined
treatment of dental pathologies in a limited sample of patients.
The aims of this study, based on 10 years of experience and a
wide-ranging case series, are the following: (a) to propose a new
classification system to create homogeneous categories of sinonasal
complications resulting from dental treatment that are not responsive
to medical therapy and (b) to suggest rational treatment protocols
according to the initial clinical situation.
MATERIALS AND METHODS
We included in this study a total of 257 consecutive patients (145
female and 112 male patients; age, 16–86 years; mean age, 51.5 years)
who were diagnosed with sinonasal complications resulting from
dental treatment between 2002 and 2011. All patients were diagnosed
and treated in one of the following units: (a) the Units of Otolaryn-
gology, Oral Surgery, and Maxillofacial Surgery, all part of the De-
partment of Health Sciences, San Paolo Hospital, University of Milan,
Italy, and (b) the Unit of Maxillofacial Surgery, Istituto Stomatologico
Italiano, Milan, Italy.
From the Units of
1
Otolaryngology,
2
Oral Surgery, and
3
Maxillo-Facial Surgery,
Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy,
and
4
Unit of Maxillo-Facial Surgery, Istituto Stomatologico Italiano, Milan, Italy
The authors have no conflicts of interest to declare pertaining to this article
Address correspondence to Giovanni Felisati, M.D., Via A. di Rudinì, 8, Milan 20142,
Italy
E-mail address: alberto.saibene@gmail.com
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All patients presented with sinonasal complications resulting from
dental procedures that did not respond to medical treatment. All
underwent a combined evaluation by ENT and oral/maxillofacial
surgeons. Each patient was treated accordingly to the aforementioned
standard protocol depending on the presenting condition. The FESS
approach was combined, if needed, with an intraoral approach; based
on team consensus and classification guidelines, 121 (47.1%) patients
underwent FESS and the remaining 136 (52.9%) patients underwent a
combined approach.
All patients received perisurgical and postsurgical antibiotic therapy
lasting 8–10 days (Table 1). Antibiotic therapy was nonrandomized. The
different regimens are because of a change in the treatment plan on
realizing the clinical superiority of quinolone postoperative treatment for
these patients. In patients with postoperative bacterial sinusitis, specific
antibiotic therapies were prescribed according to the results of cultural
examination. All patients were instructed to perform nasal washes with
saline and to apply nasal gomenol oil for 30 days after surgery.
All patients underwent ENT examinations at 7, 30, and 60 days
after surgery. In cases of persistent infection, patients were examined
weekly and, after complete recovery, underwent ENT examination
after 7, 30, and 60 days. The average follow-up duration was 25.2
months (range, 12–42 months).
Classification and Ranking System
Patients were retrospectively divided at the end of the study into
three groups according to initial dental treatment (Table 2): group I,
preimplantological treatment (Fig. 1); group II, implantological treat-
ment (Fig. 2); and group III, dental treatment (Figs. 3 and 4). The
groups were then subdivided into classes (Table 2).
It has to be emphasized that all patients included in group III had
a clear temporal and causal connection between the dental treatment
and the appearance of ENT symptoms. These included (but were not
limited to) failed endodontics, complicated dysodontiasis, and severe
periodontal disease of the upper jaw. To avoid overdiagnosing odonto-
genic conditions, patients were included only if the ENT specialist and
the dentist/maxillofacial surgeon agreed on the odontogenic focus. Fur-
thermore, the differentiation between fungal and bacterial sinusitis was
defined not only by radiological appearance but also by histological
analysis of the intraoperative specimen (hyphae demonstration).
To help the classification of the most complex patients, we devised a
ranking system, where group I held the highest rank. Therefore, to
classify a case the clinician has to start from group I downward to group
III and from class 1 downward to class 3, as explained in the flow chart
(Fig. 5). The ranking system mirrors the disruption of sinonasal homeo-
stasis, which is remarkably more extensive in group I patients.
A patient with ethmoidomaxillary sinusitis and OAC after a sinus
lift procedure (Fig. 6) is a good ranking example. His condition was
classified as class 1 and was consequently treated, although it also
fulfilled the requirements for group III, which holds a lesser rank.
Surgical Protocols
The surgical approach was summarized into a surgical protocol
that relates to specific groups and classes according to the classifica-
tion (Table 2).
Table 1 Antibiotic prophylaxis: Drugs, doses, and number of patients treated
Group Perisurgical Therapy Therapy during
Hospitalization
Therapy after Discharge No. of
Patients
Cephalosporin
therapy
Intravenous cephazolin, 1 g Intravenous cephazolin, 1 g
b.i.d.
Oral cefuroxime axetil, 500 mg b.i.d.,
for 6–7 days
135
Quinolone
therapy
Intravenous levofloxacin,
500 mg, or intravenous
ciprofloxacin, 200 mg
Intravenous levofloxacin,
500 mg q.d., or
intravenous
ciprofloxacin, 200 mg
b.i.d.
Oral levofloxacin, 500 mg q.d., or
oral ciprofloxacin, 500 mg b.i.d.,
for 8–9 days
122
Table 2 Classification of sinonasal complications resulting from dental treatment: Homogeneous pathogenesis and treatment groups
according to surgical treatment protocols
Group Class Condition Treatment No. of
Patients
I—Preimplantological treatment
complications
1 Sinusitis after MS lift with OAC Combined: FESS ⫹ infected material
removal ⫹ OAC repair
25
II—Implantological treatment
complications
2a Peri-implant osteitis with
sinusitissubperiosteal implant with
sinusitis
Combined: FESS ⫹ implant removal
⫹ OAC repair
24
2b Implant dislocation with sinusitis and
OAC
Combined: FESS ⫹ implant removal
⫹ OAC repair
2
2c Implant dislocation with sinusitis Implant removal ⫹ FESS 17
2d Implant dislocation without sinusitis Canine fossa approach with
endoscopic aidtransnasal
endoscopy with or without
antrostomy depending on the
localization of the implant
14
III—“Classic” dental treatment
complications
3a Bacterial or fungal sinusitis with
OAC
Combined: FESS ⫹ OAC repair 64
3b Bacterial or fungal sinusitis FESS 111
OAC ⫽ oroantral communication (please note that the authors refer with this term both to preoperative OACs and perioperative, or iatrogenic, OACs); FESS ⫽
functional endoscopic sinus surgery; MS ⫽ maxillary sinus.
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Group I. A combined approach is mandatory. The fundamental
steps are wide antrostomy and accurate transnasal and transoral
removal of the infected grafts. This procedure is frequently anatom-
ically awkward, and endoscopy proves useful in inspecting the MS
through the oral access (usually via the OAC created by the infection).
In patients with involvement of non-MS, FESS must extend to all
cavities involved.
Complications after complex procedures involving the MS, such as
Le Fort I osteotomies (three patients), were also observed. This sce-
nario requires the same treatment as that for sinus lift complications,
and these patients were therefore assigned to group I.
Group II. In the presence of peri-implant osteitis or subperiosteal
implants with sinusitis (class 2a), the FESS procedure should be
coupled with the removal of all infected implants and closure of the
OAC.
11,12
Subperiosteal implants represent a peculiar scenario be-
cause of their high failure rates.
13
Such failures stem from infection of
the metal frame, which may lead to bone loss and opening of multiple
OACs and oronasal communications. Therefore, the closure of the
Figure 1. Complication resulting from preimplantological treatment. Coronal
maxillofacial computed tomography scan showing inflammatory involvement of
the right maxillary sinus after failed maxillary sinus floor elevation. The bony
graft is displaced into the maxillary sinus (MS). Left oroantral communication
(OAC) can be seen. This patient was classified as class 1 (maxillary sinusitis
after MS lift) and was treated with functional endoscopic sinus surgery (FESS)
combined with transoral removal of the infected graft and repair of the OAC.
Figure 2. Complications resulting from implantological treatment. Coronal
maxillofacial computed tomography scan showing left ethmoidal and max-
illary sinusitis with peri-implant osteitis. This patient was classified as class
2a (peri-implant osteitis with sinusitis) and treated with functional endo-
scopic sinus surgery (FESS) combined with transoral removal of the implant.
Figure 3. Complications resulting from classic dental treatment. Coronal
maxillofacial computed tomography scan showing right ethmoidal and max-
illary sinus (MS) involvement with oroantral communication (OAC) and
molar dysodontiasis. The patient was classified as class 3a and treated with
functional endoscopic sinus surgery (FESS), teeth extraction, and commu-
nication repair, followed by quinolone antibiotic therapy.
Figure 4. Complications resulting from classic dental treatment. Coronal
maxillofacial computed tomography scan showing right maxillary sinus
(MS) involvement with the pathognomonic “iron-like” signal that often
characterizes fungus balls. This patient had previously undergone endodon-
tic treatment. The patient was classified as class 3b and treated with
functional endoscopic sinus surgery (FESS).
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OACs will be more complex, requiring local flaps (Rehrmann flap
and/or buccal fat pad flap).
In the case of implant displacement presenting with sinusitis and
OAC (class 2b) the surgeon will have to repair the OAC in addition to
the FESS treatment.
Implant displacement presenting with sinusitis (class 2c) requires
an FESS procedure extended to all sinuses involved with a wide
middle antrostomy and removal of the implant.
In cases of displaced dental implants with no sign of sinusitis (class
2d), the surgeon can choose between an approach from the canine
fossa (traditional, endoscopic, or with a “bone window” pedicled to
the MS mucosa) or a transnasal endoscopic approach with or without
middle antrostomy depending on the localization of the implant.
Group III. This group comprises complications resulting from “stan-
dard” dental procedures presenting as bacterial or fungal sinusitis.
Bacterial and/or fungal sinusitis with OAC (class 3a) requires a
combination of FESS and intraoral procedures with the aim of closing
the communication with local flaps (Rehrmann flap and/or buccal fat
pad flap). Patients presenting only with sinusitis (class 3b) should be
treated with an FESS procedure extended to all involved cavities. We
would like to stress the necessity of the removal of all purulent or fungal
discharge from the involved sinuses as well as any foreign bodies (e.g.,
dental cement and teeth) with the aid of saline and H
2
O
2
irrigation.
RESULTS
Hospitalization durations ranged from 1 to 4 days (mean, 1.36 days;
median, 1 day).
Group I
Twenty-four of 25 patients were successfully treated with a single
procedure and 1 of 25 were successfully treated with a second pro-
cedure. Complete healing was achieved within 30 days from surgery in
21 of 25 patients, within 45 days in 1 of 25 patients and in ⬎60 days in 2
patients after specific antibiotic therapy. Finally, one patient with undi-
agnosed peri-implant osteitis was treated by removal of the infected
implant during the second procedure and recovered completely.
Group II
All 57 patients were successfully treated. Complete healing was
achieved in 55 patients after a single procedure. Two patients re-
quired a second surgical procedure: one patient had undiagnosed
peri-implant osteitis and the other suffered from OAC reopening.
Group III
This group included 116 patients with bacterial sinusitis and 59
patients with fungal extramucosal sinusitis. Complete healing was
achieved in all cases. Eleven of 116 patients with bacterial sinusitis
before surgery showed pathological drainage 7 days after surgery.
Ten of these patients, who had previously received cephalosporins,
were subsequently treated with a quinolone (oral levofloxacin, 500
mg q.d. for 15 days) and achieved clinical resolution, and one of them
achieved clinical resolution after treatment with an antibiogram-
oriented antibiotic.
DISCUSSION
To the authors’ knowledge, few available studies have examined
the treatment of sinonasal complications after dental treatment. Avail-
able data are limited to a few occasional reports, most concerning
complications of implant procedures
7–9,14,15
and preimplantological
procedures.
16–19
Only one article reporting on a small case series (17
patients) described a modern combined approach to OS,
10
and Albu et
al.
20
proposed an alternative technique (canine fossa puncture) in a
study of 56 patients with chronic maxillary OS. Generally speaking,
comprehensive classifications of OS and thorough descriptions of
related treatment guidelines are lacking. Some articles have empha-
sized etiology-based treatment of OS, which requires the identifica-
tion and treatment of the underlying dental problem.
21,22
The classification system presented in this study is easy and uni-
vocal, with a different treatment protocol for each class. The results
obtained appear remarkably positive, with a very encouraging suc-
cess rate compared with the majority of OS case series available.
23
In
a more extended article focusing on all kinds of FESS procedures,
Albu et al.
20
reported a 7% overall OS recurrence rate and a 13%
recurrence rate in cases of OAC, whereas in the present study only
1.2% patients required a second surgical procedure. It has to be noted
though that the different antibiotic regimens used by Albu et al. could
affect the outcomes presented in their study.
Nevertheless, the retrospective design of our study, comprised of a
mixed cohort with no control groups, somehow limits the impact of
conclusions. Specifically, we could not establish how many patients
(if any) would have reached the same positive outcome by removing
the odontogenic focus and using further antibiotic therapy without an
FESS procedure (although many of our patients did undergo previous
dental treatments without showing any improvement and all of the
patients enrolled had already received empiric antibiotic therapies
unsuccessfully). This remark is especially true for group III patients
suffering from bacterial sinusitis, and the remaining patients showed
nasal complications that were definitely unlikely to be successfully
treated without an endoscopic procedure.
Figure 5. Classification process flow chart. Flowchart of the classification
process allowing the surgeon to univocally classify any given case, even
when multiple criteria are fulfilled, according to the ranking system pro-
posed.
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The authors also stress the importance of choosing a quinolone for
perisurgical and postsurgical therapy, which accelerated healing
times in all three groups of patients compared with cephalosporin
treatment. Surely our observation represents only an anecdotical re-
port with no evidence-based validation.
Separate analyses of the three groups showed that complications
resulting from preimplantological procedures (group I) represent the
most complex challenge. Therefore, these scenarios have been as-
signed the highest rank. These patients present a greater surgical
complexity that always requires a combined approach and higher
rates of prolonged therapy and reintervention.
Group II comprises implantological complications. The cases of
peri-implant osteitis have been grouped together with subperiosteal
implants (class 2a). It is evident how these two implants differ sub-
stantially in the extent of the damage to the sinus floor; however, the
treatment and approach remain the same. The identification of osteitis
may occasionally be difficult and patients (and the dentist) often
oppose the removal of the fixture. However, supported by the current
literature,
11,12
we advise the removal of all potentially infected im-
plants in close proximity to the sinus. Our approach may be further
reinforced by the fact that the two patients in this study who pre-
sented with persistent postsurgical sinusitis required a second surgi-
cal procedure to address an unrecognized peri-implant osteitis. Class
2b, which includes cases with implant dislocation with sinusitis and
OAC, requires the adjunctional closure of the latter and the presence
of a maxillofacial/oral surgeon is therefore pivotal. Cases with dis-
placed implants with sinusitis (class 2c) require FESS procedures to
restore patency of the maxillary ostium and treatment of other even-
tually involved paranasal sinuses. In cases of dislocated implants
without sinusitis (class 2d), three surgical options have been sug-
gested
24
(see Surgical Protocols section). To gain easy access through
the canine fossa, specific instruments (antral retriever)
25
and tech-
niques (bone flap on mucosal pedicle)
26
are available.
In group III complete healing was observed at the 30-day postsur-
gical examination in all but one patient. The only patient who did not
achieve complete healing within 30 days was subsequently treated
with specific antibiotic therapy. Bacterial and fungal sinusitis differ in
pathogenesis and in the need for long-term antibiotic therapy. Bacte-
rial sinusitis often requires long-term antibiotic therapy, whereas
fungus balls, consistent with the data in the literature, do not require
antibiotic/antifungal therapy other than standard perioperative and
postsurgical antibiotic therapy. Bacterial OS is one of the most fre-
quent chronic maxillary inflammatory conditions.
2
The authors decided to limit fungal forms to fungus balls only,
excluding invasive forms and allergic fungal sinusitis, because the
latter two conditions usually are not of odontogenic origin. Fungus
balls represent an extramucosal, noninvasive condition that is com-
monly diagnosed in patients with a history of chronic/recurrent
maxillary sinusitis and is frequently related to dental pathology,
endodontic treatment, tooth extraction, or implantological or preim-
plantological surgery.
27–29
Success rates of fungus ball treatment ap-
proached 100% in the majority of case series.
29–31
CONCLUSIONS
The results obtained in this study are very positive from diagnostic
and therapeutic points of view. Complete healing of the sinonasal
infection was obtained in all patients. Only 3 of 257 patients required
a second surgical procedure.
The classification system was applied to separate groups that re-
spond differently to treatment: treatment complexity was the basis for
ranking individual cases into different classes. Results from this study
show that patients who require long-term postsurgical medical ther-
apy invariably belong to groups I and II.
Multidisciplinary treatment is a prevailing solution, allowing a
combination of different surgical skills in a single surgical procedure
and the reduction of rehabilitation times. Surgeons should identify
cases requiring multidisciplinary treatment and clarify the role of
each specialist with the aid of the proposed classification system.
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