- Email: [email protected]
Maxillary sinusitis caused by dental implants: Report of two cases
UEDA AND KANEDA
was in an 82-year-old woman; however, only three other cases, in addition to the present one, have been recorded in patients over the age of 64.4 The lesion in our patient was located in the mandibular molar region and had no relation to an unerupted tooth. It appeared as a vascular-rich tumor mass intraorally, and caused hypesthesia. Massive calcification and mitotic figures were also peculiarities seen in this case. In a review of the radiographic literature,2‘6 almost all AOTs were reported to have a cystic appearance, and the prevalent location was in the anterior maxillary region in association with an impacted tooth. In our case, there was no cystic radiolucency and no impacted tooth, but there was a mixed radiolucent-radiopaque area in the mandible. The distribution of the specks of radiopacity within the soft-tissue mass was suggestive of the extraosseous type of Pindborg’s tumor, Gorlin’s cyst, or fibro-osseous lesion. The massive radiopacity in the mandibular body gave an impression of gigantiform cementoma. The ill-defined radiolucency and the perforation of the buccal plate suggested a malignant tumor. Toida et al3 reported 126 cases of AOT, but no preoperative diagnosis of malignancy was made. Therefore, we believe the radiographic findings in our case are quite unique. Radiopacity at the periphery of the tumor is also atypical in AOT and confused the clinical diagnosis of the lesion. The dense mass was suspected to be of odontogenic origin because of the close relationship of the osteodentin or cementumlike tissue and the tumor tissue. Only normal bone marrow was seen in the area of the increased radiolucency.
J Oral Maxillofac 5O:285-287.
Pulsation and a bleeding tendency were observed in our case. These findings led the oral surgeons to believe the lesion might be a vascular tumor. Philipsen and Bim6 found a pronounced vascularity in the stroma of the lesions reported by them. They considered it to be a secondary phenomenon, with no indication of the vascular proliferation being neoplastic. An increased vascularity of the stroma was observed in the extraosseous gingival portion of the present tumor. Enucleation and curettage2*3 are recommended treatment for AOT; however, a mandibular resection has been reported.5 In our case, an en bloc resection of the mandible was performed because of the extensive involvement of the mandible and the high risk of fracture.
References
1. Shafer WG, Hine MK, Levy BM: A Textbook of Oral Pathology (ed 4). Philadelphia, PA, Saunders, 1983. p 289 2. Giansanti JS, Someren A, Waldron CA: Odontogenic adenomatoid tumor (adenoameloblastoma). Survey of I 11 cases. Oral Surg Oral Med Oral Path01 30:69, 1970 3. Toida M, Hyodo 1, Okuda T, et al: Adenomatoid odontogenic tumor: Report of two cases and survey of 126 cases in Japan. J Oral Maxillofac Surg 48:404, 1990 4. Philipsen HP, Reichart PA, Zhang KH, et al: Adenomatoid odontogenic tumor: Biologic profile based on 499 cases. J Oral Path01 Med 20: 149, 1991 5. Meyer I. Giunta JL: Adenomatoid odontogenic tumor (adenoameloblastoma): Report of case. J Oral Surg 32:448, 1974 6. Philipsen HP, Bim H: The adenomatoid odontogenic tumour. Ameloblastic adenomatoid tumour or adeno-ameloblastoma. Acta Path01 Microbial Stand 75:375, 1969
Surg
1992
Maxillary Sinusitis Caused by Dental Implants: Report of Two Cases MINORU
UEDA, DDS, PHD,* AND TOSHIO
Received from the Department of Oral Surgery, Nagoya University School of Medicine. Nagova. Janan. * Associate Professor- . _ t Professor. Address correspondence and reprint requests to Dr Ueda: Department of Oral Surgery, Nagoya University School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466, Japan. 0 1992 American
Association
0278-2391/92/5003-0014$3.00/O
of Oral and Maxillofacial
Surgeons
KANEDA,
DDS, PHD~
Many types of complications have been reported following treatment with dental implants. IV3Local infection of the per&implant tissue is the most common complication, and in such cases there can be extensive resorption of the bone surrounding the implant. Implants inserted close to the maxillary sinus also provide a route for spread of infection from the mouth following poor oral hygiene. When the maxillary dental im-
286
MAXILLARY SINUSITIS CAUSED BY DENTAL IMPLANTS
FIGURE 1. Panoramic radiograph of case 1 showing implant and connection screw in the maxillary sinus.
plant is infected, sinusitis occurs easily due to local spread of inflammation.4 Another cause of maxillary sinusitis is an implant becoming displaced into the sinus and, acting as a foreign body, causing chronic infection. In this article, we present two cases of maxillary sinusitis resulting from improper placement of dental implants. Report of Cases Case I A 36-year-old woman presented with unilateral facial pain and swelling in the left maxillary molar region. Two months
FIGURE 3. Gccipitomental radiograph of case 2 showing bilateral opacity of the maxillary sinuses.
before, she had had three titanium implants installed into the left maxillary alveolus by her dentist for use as anchors to support a permanent dental bridge. Her maxillary alveolus had remained tender since insertion of the implants. On examination of the oral cavity, the gingiva in the op erative site was found to be swollen, red, and tender. A panoramic radiograph showed a slightly opaque left maxillary sinus containing a dislodged implant and a connection screw. Also, the radiograph showed a wide defect in maxillary alveolar bone where the implant had been inserted (Fig 1). The dislodged implant and the screw were removed via a sublabial antrostomy under local anesthesia and the infected alveolar bone was curetted. The patient had an uneventful recovery and was continued on antibiotic treatment for I month.
Case 2
PIGURE 2. Panoramic radiograph of case 2 showing alumina screw implants inserted bilaterally posterior regions of maxilla. The last implant on each side penetrates into the maxillary sinus.
A 46-year-old housewife was admitted to the Department of Oral Surgery, Nagoya University Hospital, on June 26, 1988 because of bilateral cheek swelling and pain. The patient had been treated by her dentist with four alumina ceramic implantsS in the posterior region bilaterally 5 years before. Intraoral examination showed severe gingival swelling and abscess formation. The alveolar bone around the implants was extensively resorbed and the implants were mobile. A panoramic radiograph showed that the posterior implant on both sides projected into the antrum (Fig 2). The occipitomental radiograph (Water’s position) showed bilaterally opaque maxillary sinuses (Fig 3). A diagnosis of bilateral maxillary sinusitis caused by incorrectly placed implants was made.
287
UEDA AND KANEDA
On removal of the bridge, the implants could be removed easily because they were merely supported by connective tissue. An oroantral fistula remained in the site of the posterior implant on both sides. The infected connective tissue around the implant was curetted and antibiotic therapy was administered for 2 weeks, with resolution of the infection. The oroantral fistula closed spontaneously 2 weeks after antibiotic therapy.
Discussion Dental implant therapy for occlusal reconstruction provides considerable convenience for the partially edentulous patient, and its use has recently become more popular. To make such therapy successful, the implant must be stable in the jaw bone after the healing period. Many types of dental implants have been developed for clinical use and they can be divided into two groups, osseointegrated and nonosseointegrated, according to the connection made between the bone and the implant. In the nonosseointegrated group, the implant is supported by connective tissue that has grown between it and the surrounding bone.5 This type of implant has a critical limitation of use depending on the alveolar bone quality and number of residual teeth. In the second case, the quantity of maxillary alveolar bone was minimal because the floor of the maxillary sinus was very near the alveolar ridge. Also, the treatment plan was considered inadequate, since such a long-span bridge was placed using nonosseointegrated implants. The implants used in the first case were meant to be inserted into the alveolar bone to a depth just short of the maxillary sinus. However, the third implant accidentally perforated into the maxillary sinus and fell into it. Because of insufficient maxillary ridge bone depth, and its cancellous nature, if the fixture penetrates into the maxillary sinus during installation, there is a possibility that it will accidentally become displaced into the sinus during the healing period. Carlsson6
stated that the radiographic examination should not be done during the healing period because of the detrimental effects of ionizing radiation on healing and remodeling of bone tissue. Our first case indicated to us that if the maxillary sinus perforation is involved during implant installation, radiographic examination for maxillary sinusitis should be done even in the healing period. The operative technique involving drilling and installation of implants is also a very important factor for success in dental implant therapy in the maxilla. Since the bone of the maxilla is softer than that of mandible, and the cortical bone is very thin, the operator should always confirm the tight fixation of the implants. If the implant is not adequately stabilized, and is thought to be mobile, it should be removed. To avoid complications, great care should be taken when placing implants in the maxilla, particularly if the bone is chronically infected from previous dental sepsis. Also, in the elderly edentulous patient, resorption of the maxillary alveolus may occur to a point where it is too small to support even osseointegrated implants. In such cases dental implant therapy may be contraindicated. References 1. Mason ME, Triplett RG, Sickels JV, et al: Mandibular fractures through endosseous cylinder implants: Report of cases and review. J Oral Maxillofac Surg 48:3 11, 1990 2. Mason ME, Triplett RG, Alfonso WF: Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 48:201, 1990 3. Davies JM, Campbell LA: Fatal air embolism during dental implant surgery: A report of three cases. Can J Anaesth 37: 112, 1990 4. Quiney RE, Brimble E, Hodge M: Maxillary sinusitis from dental osseointegrated implants. J Laryngol Otol 104:333, 1990 5. Kawahara H, Hirabayashi M: Single crystal alumina for dental implants and bone screw. J Biomed Mater Res 14:597, 1980 6. Alm Carlsson G: Dosimetry at interface: Theoretical analysis and measurements by means of thermoluminescent LF. Acta Radio1 1332, 1973 (suppl)
was in an 82-year-old woman; however, only three other cases, in addition to the present one, have been recorded in patients over the age of 64.4 The lesion in our patient was located in the mandibular molar region and had no relation to an unerupted tooth. It appeared as a vascular-rich tumor mass intraorally, and caused hypesthesia. Massive calcification and mitotic figures were also peculiarities seen in this case. In a review of the radiographic literature,2‘6 almost all AOTs were reported to have a cystic appearance, and the prevalent location was in the anterior maxillary region in association with an impacted tooth. In our case, there was no cystic radiolucency and no impacted tooth, but there was a mixed radiolucent-radiopaque area in the mandible. The distribution of the specks of radiopacity within the soft-tissue mass was suggestive of the extraosseous type of Pindborg’s tumor, Gorlin’s cyst, or fibro-osseous lesion. The massive radiopacity in the mandibular body gave an impression of gigantiform cementoma. The ill-defined radiolucency and the perforation of the buccal plate suggested a malignant tumor. Toida et al3 reported 126 cases of AOT, but no preoperative diagnosis of malignancy was made. Therefore, we believe the radiographic findings in our case are quite unique. Radiopacity at the periphery of the tumor is also atypical in AOT and confused the clinical diagnosis of the lesion. The dense mass was suspected to be of odontogenic origin because of the close relationship of the osteodentin or cementumlike tissue and the tumor tissue. Only normal bone marrow was seen in the area of the increased radiolucency.
J Oral Maxillofac 5O:285-287.
Pulsation and a bleeding tendency were observed in our case. These findings led the oral surgeons to believe the lesion might be a vascular tumor. Philipsen and Bim6 found a pronounced vascularity in the stroma of the lesions reported by them. They considered it to be a secondary phenomenon, with no indication of the vascular proliferation being neoplastic. An increased vascularity of the stroma was observed in the extraosseous gingival portion of the present tumor. Enucleation and curettage2*3 are recommended treatment for AOT; however, a mandibular resection has been reported.5 In our case, an en bloc resection of the mandible was performed because of the extensive involvement of the mandible and the high risk of fracture.
References
1. Shafer WG, Hine MK, Levy BM: A Textbook of Oral Pathology (ed 4). Philadelphia, PA, Saunders, 1983. p 289 2. Giansanti JS, Someren A, Waldron CA: Odontogenic adenomatoid tumor (adenoameloblastoma). Survey of I 11 cases. Oral Surg Oral Med Oral Path01 30:69, 1970 3. Toida M, Hyodo 1, Okuda T, et al: Adenomatoid odontogenic tumor: Report of two cases and survey of 126 cases in Japan. J Oral Maxillofac Surg 48:404, 1990 4. Philipsen HP, Reichart PA, Zhang KH, et al: Adenomatoid odontogenic tumor: Biologic profile based on 499 cases. J Oral Path01 Med 20: 149, 1991 5. Meyer I. Giunta JL: Adenomatoid odontogenic tumor (adenoameloblastoma): Report of case. J Oral Surg 32:448, 1974 6. Philipsen HP, Bim H: The adenomatoid odontogenic tumour. Ameloblastic adenomatoid tumour or adeno-ameloblastoma. Acta Path01 Microbial Stand 75:375, 1969
Surg
1992
Maxillary Sinusitis Caused by Dental Implants: Report of Two Cases MINORU
UEDA, DDS, PHD,* AND TOSHIO
Received from the Department of Oral Surgery, Nagoya University School of Medicine. Nagova. Janan. * Associate Professor- . _ t Professor. Address correspondence and reprint requests to Dr Ueda: Department of Oral Surgery, Nagoya University School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466, Japan. 0 1992 American
Association
0278-2391/92/5003-0014$3.00/O
of Oral and Maxillofacial
Surgeons
KANEDA,
DDS, PHD~
Many types of complications have been reported following treatment with dental implants. IV3Local infection of the per&implant tissue is the most common complication, and in such cases there can be extensive resorption of the bone surrounding the implant. Implants inserted close to the maxillary sinus also provide a route for spread of infection from the mouth following poor oral hygiene. When the maxillary dental im-
286
MAXILLARY SINUSITIS CAUSED BY DENTAL IMPLANTS
FIGURE 1. Panoramic radiograph of case 1 showing implant and connection screw in the maxillary sinus.
plant is infected, sinusitis occurs easily due to local spread of inflammation.4 Another cause of maxillary sinusitis is an implant becoming displaced into the sinus and, acting as a foreign body, causing chronic infection. In this article, we present two cases of maxillary sinusitis resulting from improper placement of dental implants. Report of Cases Case I A 36-year-old woman presented with unilateral facial pain and swelling in the left maxillary molar region. Two months
FIGURE 3. Gccipitomental radiograph of case 2 showing bilateral opacity of the maxillary sinuses.
before, she had had three titanium implants installed into the left maxillary alveolus by her dentist for use as anchors to support a permanent dental bridge. Her maxillary alveolus had remained tender since insertion of the implants. On examination of the oral cavity, the gingiva in the op erative site was found to be swollen, red, and tender. A panoramic radiograph showed a slightly opaque left maxillary sinus containing a dislodged implant and a connection screw. Also, the radiograph showed a wide defect in maxillary alveolar bone where the implant had been inserted (Fig 1). The dislodged implant and the screw were removed via a sublabial antrostomy under local anesthesia and the infected alveolar bone was curetted. The patient had an uneventful recovery and was continued on antibiotic treatment for I month.
Case 2
PIGURE 2. Panoramic radiograph of case 2 showing alumina screw implants inserted bilaterally posterior regions of maxilla. The last implant on each side penetrates into the maxillary sinus.
A 46-year-old housewife was admitted to the Department of Oral Surgery, Nagoya University Hospital, on June 26, 1988 because of bilateral cheek swelling and pain. The patient had been treated by her dentist with four alumina ceramic implantsS in the posterior region bilaterally 5 years before. Intraoral examination showed severe gingival swelling and abscess formation. The alveolar bone around the implants was extensively resorbed and the implants were mobile. A panoramic radiograph showed that the posterior implant on both sides projected into the antrum (Fig 2). The occipitomental radiograph (Water’s position) showed bilaterally opaque maxillary sinuses (Fig 3). A diagnosis of bilateral maxillary sinusitis caused by incorrectly placed implants was made.
287
UEDA AND KANEDA
On removal of the bridge, the implants could be removed easily because they were merely supported by connective tissue. An oroantral fistula remained in the site of the posterior implant on both sides. The infected connective tissue around the implant was curetted and antibiotic therapy was administered for 2 weeks, with resolution of the infection. The oroantral fistula closed spontaneously 2 weeks after antibiotic therapy.
Discussion Dental implant therapy for occlusal reconstruction provides considerable convenience for the partially edentulous patient, and its use has recently become more popular. To make such therapy successful, the implant must be stable in the jaw bone after the healing period. Many types of dental implants have been developed for clinical use and they can be divided into two groups, osseointegrated and nonosseointegrated, according to the connection made between the bone and the implant. In the nonosseointegrated group, the implant is supported by connective tissue that has grown between it and the surrounding bone.5 This type of implant has a critical limitation of use depending on the alveolar bone quality and number of residual teeth. In the second case, the quantity of maxillary alveolar bone was minimal because the floor of the maxillary sinus was very near the alveolar ridge. Also, the treatment plan was considered inadequate, since such a long-span bridge was placed using nonosseointegrated implants. The implants used in the first case were meant to be inserted into the alveolar bone to a depth just short of the maxillary sinus. However, the third implant accidentally perforated into the maxillary sinus and fell into it. Because of insufficient maxillary ridge bone depth, and its cancellous nature, if the fixture penetrates into the maxillary sinus during installation, there is a possibility that it will accidentally become displaced into the sinus during the healing period. Carlsson6
stated that the radiographic examination should not be done during the healing period because of the detrimental effects of ionizing radiation on healing and remodeling of bone tissue. Our first case indicated to us that if the maxillary sinus perforation is involved during implant installation, radiographic examination for maxillary sinusitis should be done even in the healing period. The operative technique involving drilling and installation of implants is also a very important factor for success in dental implant therapy in the maxilla. Since the bone of the maxilla is softer than that of mandible, and the cortical bone is very thin, the operator should always confirm the tight fixation of the implants. If the implant is not adequately stabilized, and is thought to be mobile, it should be removed. To avoid complications, great care should be taken when placing implants in the maxilla, particularly if the bone is chronically infected from previous dental sepsis. Also, in the elderly edentulous patient, resorption of the maxillary alveolus may occur to a point where it is too small to support even osseointegrated implants. In such cases dental implant therapy may be contraindicated. References 1. Mason ME, Triplett RG, Sickels JV, et al: Mandibular fractures through endosseous cylinder implants: Report of cases and review. J Oral Maxillofac Surg 48:3 11, 1990 2. Mason ME, Triplett RG, Alfonso WF: Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 48:201, 1990 3. Davies JM, Campbell LA: Fatal air embolism during dental implant surgery: A report of three cases. Can J Anaesth 37: 112, 1990 4. Quiney RE, Brimble E, Hodge M: Maxillary sinusitis from dental osseointegrated implants. J Laryngol Otol 104:333, 1990 5. Kawahara H, Hirabayashi M: Single crystal alumina for dental implants and bone screw. J Biomed Mater Res 14:597, 1980 6. Alm Carlsson G: Dosimetry at interface: Theoretical analysis and measurements by means of thermoluminescent LF. Acta Radio1 1332, 1973 (suppl)