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Sinonasal Complications Resulting from Dental Treatment: Outcome-Oriented Proposal of Classification and Surgical Protocol


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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. 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. 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. 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.
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Sinonasal complications resulting from dental treatment:
Outcome-oriented proposal of classification and surgical
Giovanni Felisati, M.D.,
Matteo Chiapasco, M.D.,
Paolo Lozza, M.D.,
Alberto Maria Saibene, M.D.,
Carlotta Pipolo, M.D.,
Marco Zaniboni, D.D.S.,
Federico Biglioli, M.D.,
and Roberto Borloni, M.D.
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)
dontogenic sinusitis (OS) is a relevant infectious condition of the
paranasal sinuses, accounting for 10–30% of cases of maxillary
and 8% of conditions treated by endoscopic nasal surgery.
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).
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.
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.
Costa et al.
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.
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
Oral Surgery, and
Maxillo-Facial Surgery,
Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy,
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,
E-mail address:
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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
Therapy after Discharge No. of
Intravenous cephazolin, 1 g Intravenous cephazolin, 1 g
Oral cefuroxime axetil, 500 mg b.i.d.,
for 6–7 days
Intravenous levofloxacin,
500 mg, or intravenous
ciprofloxacin, 200 mg
Intravenous levofloxacin,
500 mg q.d., or
ciprofloxacin, 200 mg
Oral levofloxacin, 500 mg q.d., or
oral ciprofloxacin, 500 mg b.i.d.,
for 8–9 days
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
I—Preimplantological treatment
1 Sinusitis after MS lift with OAC Combined: FESS infected material
removal OAC repair
II—Implantological treatment
2a Peri-implant osteitis with
sinusitis⶿subperiosteal implant with
Combined: FESS implant removal
OAC repair
2b Implant dislocation with sinusitis and
Combined: FESS implant removal
OAC repair
2c Implant dislocation with sinusitis Implant removal FESS 17
2d Implant dislocation without sinusitis Canine fossa approach with
endoscopic aid⶿transnasal
endoscopy with or without
antrostomy depending on the
localization of the implant
III—“Classic” dental treatment
3a Bacterial or fungal sinusitis with
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
Subperiosteal implants represent a peculiar scenario be-
cause of their high failure rates.
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
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.
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
and preimplantological
Only one article reporting on a small case series (17
patients) described a modern combined approach to OS,
and Albu et
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.
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.
a more extended article focusing on all kinds of FESS procedures,
Albu et al.
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-
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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
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-
(see Surgical Protocols section). To gain easy access through
the canine fossa, specific instruments (antral retriever)
and tech-
niques (bone flap on mucosal pedicle)
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.
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.
Success rates of fungus ball treatment ap-
proached 100% in the majority of case series.
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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maxillofacial computed tomography scan
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nus involvement after failed maxillary si-
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... As a result, otolaryngologists should carefully examine maxillary dentition on imaging studies, especially in the setting of unilateral maxillary sinus disease [19]. ODS caused by dental caries and periapical pathology represent a distinct type of ODS and its management differs from sinusitis caused by dental treatments [20]. ...
... Our analysis of ODS treatment, however, does not assess the third option of concurrent dental and ESS treatment, with high reported success rates (90% to 100%) [2,12,20]. Nonetheless, we consider that performing both dental and ESS treatment is not always necessary since additional surgery is associated with higher risks, and many of the ODS produced by odontogenic infections resolve by dental treatment alone. ...
... Felisati et al. [20] proposed a classification of ODS according to aetiology and named. Group III of 'classic' dental disease and treatment complications was further divided into classes according to the presence of the associated OAF. ...
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Background: Odontogenic sinusitis (ODS) is frequently encountered in ENT practice; however, there are no guidelines regarding its management. This study aims to analyse the results of endoscopic sinus surgery versus dental treatment in ODS. Additionally, we aim to demonstrate the benefit of associating endoscopic sinus surgery (ESS) to surgical closure of chronic oroantral fistulas (OAF) by comparing mean time to healing in patients who opted or not for concurrent ESS. Methods: Records of patients with ODS were reviewed. Group one consisted of patients with ODS caused by periapical pathology undergoing either endoscopic sinus surgery (ESS) or dental treatment. Resolution of ODS was considered treatment success and was compared between the two treatment strategies. Group two included patients with ODS and associated chronic oroantral communication. Time to healing was compared between patients undergoing OAF closure alone versus patients receiving associated ESS, using the Log-Rank test to correlate Kaplan-Meier curves. Results: 25 patients from a total of 45 in group one underwent dental treatment alone, and 20 opted for exclusive ESS treatment. The failure rate was 40% for patients treated with ESS compared to 4% (one patient) for dental treatment. ODS resolved in all patients in the second group, but the mean time to healing was half (10 days) when ESS was complementary to OAF closure. Conclusion: The present study represents the first estimator of the role ESS plays in OAF treatment. Nonetheless, it provides proof of the importance of first addressing dental problems in odontogenic sinusitis.
... Fifty-five publications were eligible based on their title and abstract, of which 37 were excluded: 26 case reports, two technical notes, three overviews, one consensus statement, one article in Russian, one article in Chinese, two unavailable full texts, and one article reporting mixed data of sinus graft infection with other causes of sinusitis. Finally, 18 articles were included [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] . ...
... A total of 3319 patients were included in these 18 articles, with 217 sinus graft infections. Two studies were prospective 17,26 and 14 were retrospective [14][15][16][18][19][20][21][22][23][24][25]28,29,31 ; two studies did not clearly state their design 27,30 (Table 1). ...
... Eligibility criteria could be divided into two types: studies including patients who underwent sinus grafting with or without simultaneous DI placement (n = 8) 18,[21][22][23]25,27,28,30 , and studies including only patients with infectious complications (n = 10) [14][15][16][17]19,20,24,26,29,31 . Every study assessed the management of the sinus graft infection. ...
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.
... The shared statement emerging from the modified Delphi method consensus are resume in Table I and will be further integrated in the following sections of this review. The most complete existing classification of ODS, defined as the group of sinonasal complications resulting from dental disease or treatment (SCDDT), has been proposed by our group in 2013 10 , and has been prospectively vali-dated 11 and adopted by other groups, both nationally and internationally 12,13 . The classification (reported in Table II along with the number of patients treated at our institution from 2012 onwards) successfully tries to integrate different etiologies and possible (often multidisciplinary) treatments for possible ODS scenarios. ...
... While cases pertaining to this aetiology may appear extremely varied in presentation and sinus involvement, there are several standpoints than can help the collaboration between otolaryngologist and dental surgeon. A simple but nevertheless fundamental distinction is between patients with and without OAC (Fig. 3), as originally proposed by Felisati et al. 10 . The former tend to uniformly require a combined approach for OAC closure and sinus drainage, that yields its best results when performed during the same surgical session 25,26 . ...
... Cases in which dental implants are, at least apparently, osseointegrated require the most careful planning and diagnostic workup (Fig. 5). While multidisciplinary statements suggest primary endoscopic surgery aimed at treating the patient without removing the implant 9 , the surgeon must take into account that failure to recognize an unstable and infected implant is a frequent cause of treatment failure 10,34,35 . Indeed, unnecessary implant removal might enhance the risk of OAC and inevitably burdens patients with further oral rehabilitation costs. ...
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La collaborazione tra otorinolaringoiatra e odontoiatra nel trattamento delle sinusiti odontogene. Riassunto: Le sinusiti odontogene rappresentano per definizione una condizione al confine tra otorinolaringoiatria e odontoiatria e, da un punto di vista olistico, non possono essere gestite in assenza di una proficua collaborazione tra specialisti diversi. Questa review si focalizza sui diversi scenari attualmente considerati nella letteratura internazionale come correlati alle sinusiti odontogene e sulle complicanze naso-sinusali di patologia o trattamento odontoiatrico. Conseguentemente, questa review andrà a trattare tutte le infezioni dei seni paranasali causate non solo dalla patologia di interesse odontoiatrico (es. parodontite e carie), ma anche conseguenti a trattamenti odontoiatrici classici (estrazioni, endodonzia, et similia), procedure implantologiche, procedure pre-implantologiche (rialzo del seno mascellare) e osteonecrosi del mascellare da farmaci. Dopo aver trattato la diagnosi delle sinusiti odontogene e i principi generali di terapia, ci focalizzeremo sulla gestione specifica dei singoli quadri di patologia. Questa revisione della letteratura mostra che, per quanto siano fortemente necessari un numero maggiore di studi prospettici per determinare il miglior approccio terapeutico per ciascun paziente affetto da sinusite odontogena, il mero numero di scenari diversi che si possono incontrare dovrebbe essere sufficiente a stimolare la mutua collaborazione tra otorinolaringoiatri e odontoiatri. Tale collaborazione è necessaria per perfezionare la fase diagnostica e di trattamento e per realizzare un solido fondamento scientifico e medico-legale per qualsiasi proposta terapeutica venga rivolta ai pazienti.
... Table 2 reports the characteristics and demographics of the included studies. Five articles were retrospective case series 11,[18][19][20][21] , while three were prospective cohort studies 12,22,23 . Concerning the level of evidence, a single study was rated as a level 2 study according to the OCEBM scale, while the remaining seven studies were rated as level 4 studies. ...
... There is an inherent need to balance the management of osseointegrated, healthy implants, which should be left in place, with that of diseased, peri-implantitis-affected fixtures, whose removal is often required for definitive sinonasal healing 21 . Although longitudinal studies have proven that osseointegrated implants protruding in the maxillary sinus do not represent per se a risk factor for sinusitis development 28 , it is widely accepted that non-osseointegrated fixtures are an infection focal point and should be carefully evaluated both during the initial workup and in the case of recurrences 7 . ...
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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.
... In circumstances that require greater access, the Caldwell-Luc approach has been used historically [28]. This was followed by a transoral approach through the anterior wall of the maxillary sinus or via the canine fossa [4,34,47]. However, with technical advances, trans-nasal endoscopic sinus surgery (ESS) has become the main form of treatment for maxillary sinusitis, including for that of odontogenic origin [14,48]. ...
... Combined dental and ESS management consistently demonstrates high success rates of 90-100% in the management of OMS refractory to medical management [5,20,34,36,38,40,[45][46][47]52,53]. Furthermore, Saibene et al., proposed a treatment protocol which combines dental and surgical input with a 97.6% success [53]. ...
Full-text available
Odontogenic maxillary sinusitis (OMS) is an inflammatory condition affecting the paranasal sinuses and is commonly encountered by both Otorhinolaryngologists and Dentists. However, there is an ongoing debate regarding the best sequence of management. Clinicians are faced with the dilemma of first addressing either the affected tooth or the affected sinus. This paper provides a review of the current literature on the aetiology, presentation, and management of OMS, as well as our experience in managing this condition. Overall, the causative pathology of the patient’s OMS, their symptoms, and the risk of surgery should drive decision making with regards to sequence of management.
... When compared to the Caldwell-Luc technique, endoscopic sinus surgery has clear advantages, such as minimal incisions, no scar in the oral cavity, reduced hospitalization time, minimal invasiveness, offering the possibility to treat the odontogenic source and concomitantly solve sinusal problems while maintaining the functionality of the maxillary sinus, and a much lower rate of complications [91]. Felisati [92] treated 220 patients endoscopically with a 99% success rate, but the author simultaneously treated the odontogenic source and the sinus infection. Dundar [93] and Safadi [94] used the endoscope to extract implants from the maxillary sinus. ...
Full-text available
The maxillary sinus is a structure at the border of specialties: otorhinolaryngology and maxillofacial surgery. Due to this fact, regarding etiology, it can be affected by both the rhinogenic and odontogenic path and can impose diagnostic difficulties. The etiopathogenic mechanisms that can affect the Schneiderian membrane are mainly inflammatory, iatrogenic, traumatic, and tumorous in nature. From a microbiological point of view, the bacteriology is polymorphic, including both aerobic and anaerobic species in acute OS, the predominating species in acute OS being aerobic, and in chronic anaerobic germs. The role of fungi in the determination of this pathology and in the production of the biofilm that leads to resistance to antibiotic treatment is also discussed. The present paper aims to present the etiopathogenesis, bacteriology, clinical manifestations, as well as treatment of odontogenic sinusitis (OS) from an updated perspective through reviewing the literature. If unilateral maxillary sinusitis is usually due to odontogenic causes, this does not clinically exclude the possibility of strictly rhinogenic causes in the occurrence of sinusitis. This underlines the important role of complex oral and rhinological clinical examination as well as the role of preclinical examinations in specifying the certainty diagnosis. Simple radiography, orthopantomography, CT, and CBCT are compared in terms of diagnostic accuracy. The treatment of OS is complex, involving medication, dental, and surgical measures. The value of endoscopic surgery is emphasized, comparing its advantages over the classic Caldwell-Luc technique.
... A final interesting point relates to sinus surgery extent in ODS patients undergoing ESS. While most studies to date have described opening all diseased sinuses based on preoperative imaging,13,14,35,37,38 two prospective series from a single institution have demonstrated success with maxillary antrostomy alone in uncomplicated ODS patients even with frontal sinus involvement. ...
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Odontogenic sinusitis (ODS) is more common than historically reported, and is underrepresented in the sinusitis literature. ODS is distinct from rhinosinusitis in that it is infectious sinusitis from an infectious dental source or a complication from dental procedures, and most commonly presents unilaterally. ODS clinical features, microbiology, and diagnostic and treatment paradigms are also distinct from rhinosinusitis. ODS evaluation and management should generally be conducted by both otolaryngologists and dental providers, and clinicians must be able to suspect and confirm the condition. ODS suspicion is driven by certain clinical features like unilateral maxillary sinus opacification on computed tomography, overt maxillary dental pathology on computed tomography, unilateral middle meatal purulence on nasal endoscopy, foul smell, and odontogenic bacteria in sinus cultures. Otolaryngologists should confirm the sinusitis through nasal endoscopy by assessing for middle meatal purulence, edema, or polyps. Dental providers should confirm dental pathology through appropriate examinations and imaging. Once ODS is confirmed, a multidisciplinary shared decision-making process should ensue to discuss risks and benefits of the timing and different types of dental and sinus surgical interventions. Oral antibiotics are generally ineffective at resolving ODS, especially when there is treatable dental pathology. When both the dental pathology and sinusitis are addressed, resolution can be expected in 90%-100% of cases. For treatable dental pathology, while primary dental treatment may resolve the sinusitis, a significant percentage of patients still require endoscopic sinus surgery. For patients with significant sinusitis symptom burdens, primary endoscopic sinus surgery is an option to resolve symptoms faster, followed by appropriate dental management. More well-designed studies are necessary across all areas of ODS.
... About 60% of iatrogenic sinusitis derives from dental treatments, out of which at least 45% is due to surgical trauma (post-extraction, sinus lift, or implant surgery), formation of OAC, and subsequent dislocation of foreign bodies inside the maxillary sinus (implants, roots, bone grafts). [1] Felisati et al. [20] (2013) reported odontogenic sinusitis as due to dental implant placement in 30% cases, tooth extractions about 20%, and to endodontic procedures for about 15%. Troeltzsch et al. [21] (2015) verified that 75% (on overall 174 cases) of symptomatic unilateral sinusitis is due to odontogenic causes, and at least 65% is subsequent to dentoalveolar surgery. ...
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Surgical procedures in posterior area of maxillary might cause an oroantral communication and iatrogenic sinusitis. An undetected oroantral communication can cause the penetration of foreign bodies, such as dental impression materials, in the maxillary sinus, thereby contributing to persistent sinusitis. Given the occurrence of a very rare clinical and medicolegal case of persistent and drug‑resistant sinusitis due to radiologically undetected fragments of silicone paste for dental impression in the maxillary antrum, a literature review was pursued through sensitive keywords in relevant databases for health sciences. All retrieved articles were considered and data about the kind of impression materials thrusted into the maxillary sinus, the diagnostic issues, the reported range of symptoms, and the occurrence of medicolegal issues were analyzed. The diagnosis resulted to be quite challenging and belatedly especially in case of healed oroantral communication and when the material retained in the maxillary sinus has similar radiodensity compared to the surrounding normal or inflammatory tissues. The case was then discussed in comparison with the reviewed literature for both clinical and medicolegal issues. Hints were provided to professionals to face the challenging diagnosis in similar rare cases and to avoid the possible related litigation.
... Numerous articles [15] and consensus conferences [16] have discussed which classification should be applied, but there is no defined one yet, therefore no classification was used in this study. Felisati's 2013 [17] classification proposes ESS as a treatment for any case of maxillary sinusitis; however, as our data suggest, it is not always necessary. ...
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The physiological behavior of paranasal sinuses depends on the potency of the ostiomeatal complex and on normal mucociliary function. The interruption of this delicate equilibrium can lead to pathological conditions such as sinusitis. Anywhere between 10% and over 25% of cases of maxillary sinusitis have an odontogenic origin, such as: dental infection; alveolar dental trauma; or iatrogenic causes, such as extractions, endodontic therapies, maxillary osteotomies or placement of endosseous implants. The resolution of sinus pathology is related to the resolution of odontogenic pathology. Aim: to evaluate the therapeutic efficacy of a combined oral and endoscopic approach in the treatment of chronic odontogenic sinusitis vs. oral dental management through a case control study. Materials and Methods: all patients showing signs and symptoms of odontogenic sinusitis with obliteration (appreciable radiopacity in CT) of unilateral maxillary sinus between January 2018 and September 2019 at Padua University Hospital were enrolled in this retrospective study. The exclusion criteria were: maxillary sinusitis without odontogenic origin, or resolution with a systemic antibiotic therapy; and presence of anatomical abnormalities that promote the onset of rhinosinusitis. The patients were divided into two groups: one group was treated with a combined surgical approach under general anesthesia (Functional Endoscopic Sinus Surgery-FESS and simultaneous closure of oroantral communication with Bichat’s fat pad advancement); while the other group was treated only with an intraoral approach under local anesthesia and conscious sedation (closure of oroantral communication with Bichat’s fat pad advancement). The variable “success of the surgical procedure” in the two groups was compared by a Student test (with p < 0.05). Results: among the patients enrolled, 10 patients (aged between 42 and 70) made up the case group and the other 10 patients (aged between 51 and 74) constituted the control group. There was no statistically significant difference in success between the two groups (p < 0.025). Conclusions: according to this case study, an exclusive annotation invasive intraoral approach seemed to be comparable to the transoral endoscopic combined method. However, during diagnosis it is necessary and fundamental to distinguish between odontogenic and rhinogenic sinusitis in order for the resolution of odontogenic sinusitis to be achieved.
... [13][14][15] Extent of ESS should also be considered. While most studies to date have reported addressing all diseased sinuses during ESS, 13,[16][17][18][19] recent series have demonstrated maxillary antrostomy alone to be successful regardless of sinusitis extent. 20,21 Choosing the optimal ODS treatment is difficult due to low publication volume and quality 22 and logistical challenges of coordinating multidisciplinary care between otolaryngologists and dental specialists. ...
Objectives Treatment of odontogenic sinusitis (ODS) due to apical periodontitis (AP) is highly successful when both dental treatment and endoscopic sinus surgery (ESS) are performed. Variation exists in the literature with regard to types and timing of dental treatments and ESS when managing ODS. This study modeled expected costs of different primary dental and sinus surgical treatment pathways for ODS due to AP. Study Design Decision-tree economic model. Methods Decision-tree models were created based on cost and treatment success probabilities. Using Medicare and consumer online databases, cost data were obtained for the following dental and sinus surgical treatments across the United States: root canal therapy (RCTx), revision RCTx, apicoectomy, extraction, dental implant, bone graft, and ESS (maxillary, ± anterior ethmoid, ± frontal). A literature review was performed to determine probabilities of dental and sinus disease resolution after different dental treatments. Expected costs were determined for primary dental extraction, and ESS pathways, and sensitivity analyses were performed. Results Expected costs for the three different primary treatment pathways when dental care was in-network and all diseased sinuses opened during ESS were as follows: dental extraction ($4,753.83), RCTx ($4,677.34), and ESS ($7,319.85). Conclusions ODS due to AP can be successfully treated with primary dental treatments, but ESS is still frequently required. Expected costs of primary dental extraction and RCTx were roughly equal. Primary ESS had a higher expected cost, but may still be preferred in patients with prominent sinonasal symptoms. Patients' insurance coverage may also impact decision-making. Level of Evidence N/A Laryngoscope, 2021
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Dental disease is a recognised cause of sinusitis. We perceived an increased incidence of sinusitis secondary to dental disease in recent years. This study reviews the incidence of odontogenic sinusitis, its clinical features and treatment. Medical records of patients with odontogenic sinusitis were identified using the senior author's clinical database and Hospital Information Support System data (January 2004 to December 2009). Twenty-six patients were identified, nine females and 17 males (age range, 17-73 years). Rhinorrhoea and cacosmia were the commonest symptoms (81 and 73 per cent, respectively), with presence of pus the commonest examination finding (73 per cent). Causative dental pathology included periapical infection (73 per cent), oroantral fistula (23 per cent) and a retained root (4 per cent). In all 26 cases, treatment resulted in complete resolution of symptoms; 21 (81 per cent) required sinus surgery. The number of patients with odontogenic sinusitis undergoing surgery has steadily increased, from no cases in 2004 to 10 in 2009 (accounting for 8 per cent of all patients requiring sinus surgery). Reduced access to dental care may be responsible. The incidence of odontogenic sinusitis appears to be increasing. The importance of assessing the oral cavity and dentition in patients with rhinosinusitis is therefore emphasised.
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This review evaluated (1) the success of different surgical techniques for the reconstruction of edentulous deficient alveolar ridges and (2) the survival/success rates of implants placed in the augmented areas. Clinical investigations published in English involving more than 10 consecutively treated patients and mean follow-up of at least 12 months after commencement of prosthetic loading were included. The following procedures were considered: onlay bone grafts, sinus floor elevation via a lateral approach, Le Fort I osteotomy with interpositional grafts, split ridge/ridge expansion techniques, and alveolar distraction osteogenesis. Full-text articles were identified using computerized and hand searches by key words. Success and related morbidity of augmentation procedures and survival/success rates of implants placed in the augmented sites were analyzed. A wide range of surgical procedures were identified. However, it was difficult to demonstrate that one surgical procedure offered better outcomes than another. Moreover, it is not yet known if some surgical procedures, eg, reconstruction of atrophic edentulous mandibles with onlay autogenous bone grafts or maxillary sinus grafting procedures in case of limited/moderate sinus pneumatization, improve long-term implant survival. Every surgical procedure presents advantages and disadvantages. Priority should be given to those procedures which are simpler and less invasive, involve less risk of complications, and reach their goals within the shortest time frame. The main limit encountered in this literature review was the overall poor methodological quality of the published articles. Larger well-designed long-term trials are needed.
Zusammenfassung Das subperiostale Implantat (SI) wurde erstmals in den 1940er Jahren beschrieben. Die nichtakzeptablen Langzeitergebnisse der subperiostalen Gerüstimplantate stehen im Gegensatz zu den gut dokumentierten Ergebnissen für enossale Implantate. Es gibt heute keine Indikation mehr für subperiostale Gerüstimplantate oder andere auf Weichgewebe gelagerte Konstruktionen. Die vorliegende retrospektive Auswertung dokumentiert Komplikationen, die nach der Versorgung mit Gerüstimplantaten auftraten. Häufige Komplikationen sind freiliegende Implantatanteile, Entzündungen, Infektionen, Fistelbildung und Implantatmobilität. Nach der Entfernung der Gerüstimplantate sind häufig hoch atrophe Kiefer zu sehen. Bei diesen atrophen Kiefern war die Versorgung der Patienten mit enossalen Implantaten in einigen Fällen ohne autologe Knochentransplantation vom Becken nicht möglich. Unsere Ergebnisse der Patientenauswertung stimmen mit Ergebnissen anderer Studien darin überein, dass Patienten mit subperiostalen Gerüstimplantaten in regelmäßigen Abständen nachuntersucht werden müssen. Subperiostale Implantate sollten bei wieder auftretenden Komplikationen unbedingt entfernt werden. Zur weiteren Therapie ist dann das gesamte Spektrum der präprothetischen Chirurgie erforderlich.
Paranasal fungus ball can cause chronic rhinosinusitis. Removal via functional endoscopic sinus surgery is usually performed; however objective data on the overall benefit and patient satisfaction are very scarce. The study focuses on the clinical outcome and the quality of life following endoscopic surgery due to fungus ball sinusitis. Forty patients diagnosed with fungus ball sinusitis who underwent functional endoscopic surgery were included. Epidemiologic data, pre-, intra- and postoperative findings were recorded. Surgical success, the detailed benefit and the health-related quality of life were objectively assessed 1 year after the surgery based on a standardized questionnaire (modified SNOT 20) and the Glasgow Benefit Inventory. Health-related quality of life improved significantly in >90% of patients (p < 0.05). There were no serious complications or recurrences. As the treatment of choice functional endoscopic sinus surgery of paranasal fungus ball sinusitis is associated with exceptionally high patient satisfaction.
Endoscopic sinus surgery (ESS) including middle meatus antrostomy (MMA) has been advocated as the technique of choice in the treatment of maxillary chronic odontogenic sinusitis (COS). However, recently the endoscopic canine fossa puncture (CFP) has been proposed as an alternative surgical technique of accessing the entire antrum when pathology is limited only to the maxillary sinus. This study was designed to assess the outcomes of the CFP approach versus ESS (comprising MMA) in the management of COS. A prospective study was performed on patients with COS produced by odontogenic infections (periapical granulomas or small inflammatory cysts of the molars or bicuspids), oroantral fistula (OAF), large odontogenic cysts, and maxillary foreign bodies (dental fillings, teeth roots, and implants). Patients were randomly allocated into two groups: 56 patients underwent CFP and in 54 patients the maxillary sinus was approached through MMA. After a mean follow-up of 18.5 months, recurrence rates were compared between the two groups. During the follow-up period, OAF recurred in 10 patients: 4 in the MMA group (7.4%) and 6 in the CFP group (10.7%). The difference is not statistically significant (p = 0.39, Fisher exact test). In patients with COS a conservative approach with avoidance of endonasal surgery is suggested: in COS without a fistula, CFP at the time of dental treatment will be sufficient. In OAF cases, CFP yielded similar results with MMA. Nevertheless, additional study with a larger sample and a longer follow-up is required to validate these results.
For well over 100 years, it has been appreciated that maxillary dental infections can cause sinusitis. This insight has been largely overlooked with the advent of functional endoscopic sinus surgery (ESS) and its emphasis on the osteomeatal complex. We review several recent case series and reviews of odontogenic sinusitis that characterize and discuss emerging diagnostic modalities in odontogenic sinusitis. In recent publications on odontogenic sinusitis, up to 40% of chronic bacterial maxillary sinus infections are attributed to a dental source, which is far higher than the previously reported incidence of 10%. Plain dental films and dental evaluations frequently fail to detect maxillary dental infection that can be causing odontogenic sinusitis. However, sinus computed tomography (CT) or Cone Beam Volumetric CT (CBVCT) are far more successful in identifying dental disease causing sinusitis. The microbial pathogens of odontogenic sinusitis remain unchanged from earlier reviews; however, the clinical findings in odontogenic sinusitis are better described in recent reviews. Successful treatment of odontogenic sinusitis requires management of the odontogenic source and may require concomitant or subsequent sinus surgery. Odontogenic sinusitis is frequently recalcitrant to medical therapy and usually requires treatment of the dental disease. Sometimes dental treatment alone is adequate to resolve the odontogenic sinusitis and sometimes concomitant or subsequent ESS is required. Evaluation of all patients with persistent chronic rhinosinusitis (CRS) should include inspection of the maxillary teeth on CT scan for evidence of periapical lucencies. Unilateral recalcitrant disease associated with foul smelling drainage is especially characteristic of odontogenic sinusitis. High-resolution CT scans and CBVCT can assist in identifying dental disease.
Removal of antral foreign bodies after implantation is mandatory to avoid infectious processes and may be a troublesome question. Different surgical approaches could be considered, with several limitations and morbidities. We present a new tool (Antral Retriever) conceived to remove antral dental implants or any other migrated material through a minimally invasive canine fossa approach, under continuous endoscopic view and local anesthesia. Antral Retriever enables the surgeon to successfully remove antral foreign bodies through a canine fossa approach under continuous endoscopic visualization and local anesthesia, with minimal discomfort for the patient
Reconstruction of the posterior edentulous maxilla with dental implants has become a popular practice worldwide. However, the poor bone quality and quantity in this area is sometimes related with complications. Dental implant displacement into the maxillary sinus is a rare complication. In the present paper, we present two patients with three implants displaced into the maxillary sinus. The implants were removed soon after their displacement, using the classic intraoral approach, through the anterior wall of the maxillary sinus. The operation was performed under local anesthesia for both of the patients. The postoperative course was uneventful for both of the patients without any wound dehiscence. Recovery remained uneventful, without any signs of postoperative sinusitis. Implant displacement into the maxillary sinus is of rare occurrence and usually related to inadequate bone quality and quantity. Dental implants into the maxillary sinus usually act as foreign bodies and should be removed, to avoid the development of sinus complications. Removal of dental implants from the maxillary sinus can be performed either with functional endoscopic sinus surgery, or with intraoral operation through the anterior maxillary wall especially in fresh cases and in the presence of oroantral communication.
Ten to twelve percent of all cases of maxillary sinusitis derive from odontogenic origin. The purpose of this study was to report the use of cone-beam computed tomography (CBCT) scanning in elucidating dental pathology as an etiology of maxillary sinusitis. Intraoral periapical radiographs and CBCT scanning were performed in the evaluation of three patients presenting with pain, sinus congestion, or respiratory complaints. In the first case, extractions of impacted third molar and adjacent nonrestorable tooth were performed. In the second two cases, endodontic therapy was done. Radiologic follow-up with CBCT scanning or medical computed tomography scanning was performed 6 to 12 months after dental procedures were performed. All three patients presented with severe sinusitis that resolved after appropriate dental treatment. The first patient also showed marked improvement of chronic bronchitis after completion of dental treatment. In all patients, complete or near total resolution of sinusitis, including eradication of mucous retention cyst, was confirmed by post-treatment CBCT or computed tomography scanning. These cases show the utility of CBCT scanning in evaluating patients presenting with concurrent sinus and dental complaints. In these three patients, maxillary sinusitis of odontogenic origin responded well to the eradication of dental etiology.
Endoscopic sinus surgery (ESS) is reported to improve symptoms in approximately 85% of patients. Reasons for failure include misdiagnosis, technical inadequacies, underlying severe hyperplastic disease, biofilm, and immunodeficiency. Only one previous case of unrecognized odontogenic maxillary sinusitis has been cited in the literature as a reason for failure to improve with sinus surgery. This study was designed to characterize clinical and radiographic findings in patients who fail to improve with ESS because of an unrecognized dental etiology. Five patients, with odontogenic maxillary sinusitis with prior unsuccessful ESS, were prospectively enrolled. Demographics and clinical aspects including duration of illness, prior sinus surgeries and therapies, and radiographic data were assessed. Five adults underwent an average of 2.8 sinus surgeries with persistence of disease and symptoms until their dental infection was treated. Duration of symptoms ranged from 3 to 15 years. In four of five patients, the periapical abscess was not noted on the original CT report but could be seen in retrospect. Three of five patients had been seen by their dentists and told they had no dental pathology. All five patients underwent dental extractions and one patient underwent an additional ESS after dental extraction. These procedures led to a resolution of sinusitis symptoms in all five patients. Unrecognized periapical abscess is a cause of ESS failure and the radiological report frequently will fail to note the periapical infection. Dentists are unable to recognize periapical abscesses reliably with dental x-rays and exam. In patients with maxillary sinus disease, the teeth should be specifically examined as part of the radiological workup.