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Orbital and Periorbital Emphysema Following Maxillary Sinus Floor Elevation: A Case Report and Literature Review
Accepted Manuscript Orbital and peri-orbital emphysema following maxillary sinus floor elevation: a case report and literature review Roberto Farina, Antonio Zaetta, Luigi Minenna, Leonardo Trombelli PII:
S0278-2391(16)30504-3
DOI:
10.1016/j.joms.2016.06.186
Reference:
YJOMS 57342
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 21 May 2016 Revised Date:
24 June 2016
Accepted Date: 24 June 2016
Please cite this article as: Farina R, Zaetta A, Minenna L, Trombelli L, Orbital and peri-orbital emphysema following maxillary sinus floor elevation: a case report and literature review, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.06.186. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Orbital and peri-orbital emphysema following maxillary sinus floor elevation: a case report and literature review Roberto Farina
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Full-Time Researcher, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy Full-Time Researcher, Operative Unit of Dentistry, University-Hospital of Ferrara, Italy Chair of Oral Surgery, School of Dentistry, University of Ferrara, Italy
Antonio Zaetta
Luigi Minenna Part-time faculty, School of Dentistry, University of Ferrara, Italy
Leonardo Trombelli
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Clinical fellow, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy
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Director, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy Director, Operative Unit of Dentistry, University-Hospital of Ferrara, Italy Chair of Periodontology, School of Dentistry, University of Ferrara, Italy
Running title: Orbital and peri-orbital emphysema following sinus lift
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Conflict of interest: The Authors declare that they have no conflict of interest
Corresponding Author: Dr. Roberto Farina, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy; Corso Giovecca 203, 44121 Ferrara Italy. Tel. +39 0532 205277; Fax +39 0532 202329; e-mail: [email protected].
For the Journal of Oral and Maxillofacial Surgery, Ferrara 21 may 2016
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ABSTRACT
During the last 150 years, subcutaneous emphysema was described as a rare complication in dentistry, the etiology of which may reside in maneuvers performed by either the patient (e.g., sneezing while mouth closed, blowing the nose) or the dental professional through the use of specific dental instruments (e.g., dental drill, air syringe, etc). Irrespectively of the etiology, air is
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forced through the soft tissues, thus originating a rapid swelling of the area. According to the most recent literature reviews, the iatrogenic etiology is the most frequent. In the following case report, the first case of emphysema related to the orbital and peri-orbital region (OPE) occurring following
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a maxillary sinus floor elevation procedure is described.
ACCEPTED MANUSCRIPT INTRODUCTION Subcutaneous emphysema (SE) is a condition characterized by rapid swelling due to the forced introduction of air or gas into the soft tissues, possibly favored by the loss of integrity of the latter. 1,2
SE is typically characterized by crepitus on palpation. Also, it can be occasionally associated
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with pain or functional defects due to local compression. 2 In dentistry, SE is described as a rare event. Two literature reviews reported 74 and 32 clinical cases of SE in the periods 1960-1993 and 1994-2008, respectively. 1,2 More recently, additional anecdotal reports have been published on the
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topic. 3-33
dental professional.
1,2
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In dentistry, the etiology of SE can be related to maneuvers performed by either the patient or the In the former case, specific maneuvers associated with air emission (e.g.,
sneezing while keeping the mouth closed, blowing the nose, playing wind musical instruments) may force air into the soft tissues layers at sites where the integrity of the oral mucosa has been partially or completely lost.
1,34
The most recent literature reviews, however, seem to indicate that 2
In this context, SE can be caused by the air flow
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the iatrogenic etiology is the most prevalent.
generated by dental instruments (e.g., dental drill, air syringe) and vehicled into the root canal system, deep periodontal pockets and soft tissue wounds. Dental procedures requiring the use of
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such instruments (e.g., dental extractions, treatment of periodontal and peri-implant diseases with laser or air-flow technology, orthognatic surgery, restorative and endodontic treatments, and
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maxillary sinus floor augmentation) have been previously associated with SE occurrence. 1,33
The periorbital SE is a SE localized to the face or its portions, with typical involvement of the malar and periobital region. This specific form of SE has been previously associated with dental procedures in the maxillary posterior sextants intervention.
35,36
27,33
, but may occur in absence of professional
The present case report illustrates a case (the first, at the best of our knowledge)
of emphysema of the orbital and peri-orbital area (here defined as orbital and periorbital emphysema, OPE) occurred following a maxillary sinus floor augmentation procedure. Particular
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emphasis has been given to the description of the clinical manifestation of OPE as well as its odontostomatologic and ophthalmologic management.
MATERIALS & METHODS Study design and ethical aspects
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The present study is a case report. All the clinical procedures were performed in full accordance with the Declaration of Helsinki (1975) as revised in Tokyo (2004) and the Good Clinical Practice Guidelines (GCPs). The patient was willing and fully capable to comply with the clinical
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procedures, and a written informed consent was obtained prior to the initiation of treatments.
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Case presentation
The patient was a caucasian, 49-year-old, non-smoker female, previously treated with non-surgical and surgical therapy for aggressive generalized periodontitis at the Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy. The patient was enrolled in a supportive periodontal therapy program based on 4-month recall intervals. The third and second
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molars and the disto-buccal and palatal roots of the first molars had been extracted 10 years before, and the patient was willing to rehabilitate the right maxillary posterior area with a fixed prosthesis. According to the oral rehabilitation plan, the placement of a 9.5 mm - long and 4.0 mm -
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wide implant distal to the residual root of the first maxillary molar was programmed. The residual bone height of 4 mm of the edentulous area (as evaluated by pre-operative computerized
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tomography), however, prevented the insertion of an implant of the programmed dimensions. Since no systemic or local contraindications to oral and implant surgery were identified, the patient underwent a bone augmentation procedure.
Surgical procedure In order to augment the vertical dimensions of the residual bone crest, a maxillary sinus floor elevation was performed. Antibiotic premedication was performed with 2 gr of amoxicillin one hour before surgery. Local anesthesia was administered by infiltration with mepivacaine + epinephrine 1:100.000 (Carboplyina 20 mg, Dentsply, Rome, Italy; 4 cartidges of 1.8 mL each).
ACCEPTED MANUSCRIPT A crestal incision was placed in the edentulous area. The incision was continued intrasulcularly at the buccal aspect of the residual root of the first molar, and a release incision was placed mesial to the root. A triangular, mucoperiosteal flap was raised to expose the lateral wall of the maxillary sinus. Access to the sinus cavity was obtained according to the lateral window technique.
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A
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10 mm x 8 mm window was prepared by abrasion of the lateral bony wall of the maxillary sinus with a piezoelectric instrument (Piezosurgery® Touch; Mectron s.p.a., Carasco, Genova, Italy). Manual instruments (6577 & 6578 kramer-nevins sinus lift instrument, acute angles & obtuse
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angles; 709 & 710 implant surgery instrument; Hu-Friedy, Milan, Italy) were used to elevate the sinus membrane. The Valsalva maneuver, as assessed immediately after either the preparation of
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the lateral window or the elevation of the sinus membrane, was negative (Figure 1a). The space underneath the elevated membrane was grafted with a bovine-derived xenograft (BioOss®, 0.25 - 1 mm granules; Geistlich Biomaterials Italia, Thiene, Italy). A 9.5 mm - long and 4.0 mm - wide implant (SPI Element Inicell®, Thommen Medical AG, Grenchen, Switzerland) was
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placed (Figure 1b). Primary stability was obtained, and a healing screw was placed. Then, a second xenograft apposition was placed buccal to the implant fixture to seal the lateral access to the sinus. The total amount of xenograft used was 2.5 g. The lateral window was covered by a 13
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mm x 25 mm resorbable collagen membrane (Bio-Gide®; Geistlich Biomaterials, Thiene, Italy), without fixation devices (Figure 1c). A submerged healing protocol was adopted, and the flap was
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sutured with interrupted and internal mattress, poliglycolic acid sutures (Vicryl® 5/0; Ethicon, Sommerville, US) (Figure 1d). Following surgery, the patient was given verbal and written postoperative instructions, including a cold and soft diet for the first postoperative days, as well as the abstention from blowing the nose and performing oral hygiene in the surgerized area for 2 weeks following surgery. A 0.2% chlorhexidine mouthrinse (Curasept® ADS 0,2%; Curaden Healthcare S.p.A., Saronno, Varese, Italy; rinsing t.i.d. for 1 minute) was prescribed for the first 2 weeks post-surgery. Also, the patient was instructed to assume ibuprofen-based anti-inflammatory therapy (Brufen® 600mg; Abbott, Rome, Italy) pro re nata.
ACCEPTED MANUSCRIPT Clinical management and resolution of OPE Onset and clinical aspect On the first day following surgery, the patient was visited under urgent request, reporting that she had roughly blown her nose a few hours following surgery. This maneuver had been immediately
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followed by rapid swelling of the right hemiface at the level of the periorbital and orbital area. Also, the patient referred a sight alteration (“…things appear as seen through a frosted glass…”), and did not experience either pain or discomfort. At visit, periorbital swelling was observed homolateral to
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the surgerized area, in association with a substantial limitation of the palpebral fissure. Swelling was accompanied by the presence of vescicle-like lesions on the eye sclera (Figures 2a,b).
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Crepitus on palpation was evident at the zigomatic and subpalpebral areas. Primary stability of the implant and primary intention closure of the wound were maintained. No displacement of the xenograft was evident in the periapical radiograph. Antibiotics (Augmentin®; GlaxoSmithKline S.p.A, Verona, Italy, 1 g b.i.d. for 6 days) were prescribed, and the patient was instructed to
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continue the prescribed anti-inflammatory therapy.
An ophthalmological visit was performed at 2 days after surgery. No alteration of the visual acuity was detected. The examination of the right orbit with a slit-lamp showed orbital edema with
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hyperemia and congestion, modest chemosis and transparency of the cornea. Extrinsic ocular muscles and ocular tone were normal. Ocular fundus (retina and optic nerve) had a well-defined
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pink optic papilla. No alteration of the orbital soft tissues were observed with ecography. Medication with dexamethasone and tobramycin (Tobradex® eyedrops; Novartis Italia, Origgio, Varese; 1 drop q.i.d. for 5 days) was prescribed.
Resolution At 2 days following surgery, swelling of the hemiface had substantially reduced, and a residual erythema of the sclera was observed with complete remission of the eye vescicles. The palpebral fissure was still limited compared to the contralateral eye (Figures 2c,d). The patient reported neither sight alterations nor pain. The complete remission of the clinical signs of OPE was
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observed at 10 days post-surgery (Figures 2e,f). At 6 months following implant surgery, the patient was successfully rehabilitated with an implant-supported prosthesis.
DISCUSSION In the present article, a case of orbital and peri-orbital emphysema (OPE) occurring after a sinus
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augmentation procedure was described. Immediately after the patient had blown the nose, OPE manifested with swelling of the right hemiface at the level of the periorbital and orbital area, and was accompanied by vescicle-like lesions on the eye sclera and a sight alteration. Following
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diagnosis of OPE, pharmacological therapy was administered, consisting of antibiotics and corticosteroids. Clinical signs were monitored, and complete resolution was observed at 10 days
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after the manifestation of the event. OPE did not affect the success of either the bone augmentation procedure or the implant-supported rehabilitation.
Subcutaneous emphysema (SE) has been recognized as a potential complication of dental procedures for more than 100 years. The first report on SE in the facial area was published in
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1900, describing the case of a patient who manifested the clinical signs of SE immediately after playing horn after the extraction of a mandibular premolar.
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Although the etiology of SE has
gradually moved from the patient to the dental professional with the introduction of new tecnologies 1,2
, the incidence of this complication is still partly ascribed to
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(e.g., air driven hand-pieces)
inappropriate maneuvers performed by the patient.
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At the best of our knowledge, this is the first
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case report on an emphysema of the orbital area occurred following maxillary sinus floor elevation due to the inobservance of postoperative instructions. Previous authors reported on emphysema following sinus augmentation with a lateral approach, but swelling was limited to the periorbital area and no involvement of the eye and orbital tissues was reported.
27
Recently, Stacchi et al.
observed an adverse event involving the orbital soft tissues following a maxillary sinus floor elevation with transcrestal approach.
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Although the clinical manifestation of the event was similar
to that reported for OPE in this study, the nosological entity described by Stacchi and colleagues differed from OPE in terms of etiology. More specifically, the lesion (i.e., conjunctival chemosis) was infective in nature, being a consequence of an acute sinusitis occurred following sinus
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augmentation. Therefore, an early differential diagnosis appears to be critical for the appropriate management of OPE. 2
In the present case report, OPE resolved in absence of professional interventions. As frequently reported in the literature, SEs occurring in the facial area following dental procedures usually 1,2,10,22,23
However, SE can be occasionally associated with pain or
functional defects due to local compression.
2,24
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resolve spontaneously.
Also, when spreading along the fascial planes to
distant areas, SE may cause life-threatening complications due to compression on areas such as 24
Therefore, early diagnosis of SE is critical to evaluate
if surgical drainage of the accumulated air is indicated.
24
In order to perform an early differential 27,25,28
it must be kept into consideration
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diagnosis and avoid inappropriate treatment approaches,
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mediastinum and parapharyngeal spaces.
that SEs involving the periorbital area may share some characteristics (topography and rapid onset of tissue swelling, in particular) with different nosological entities, such as vascular events mediated by histamine (angioneurotic edema or Quincke's edema), reactions.
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25,28
hemorrage,
27
and allergic
In the facial area, SE diagnosis should be based on anamnesis, as well as visual and
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palpatory examination. In particular, rapid onset of tissue swelling (as observed during the dental procedure or referred by the patient) and crepitus on palpation should be identified. Moreover, the eventual involvement of the soft tissues of the orbital and eye (necessary to classify SE as OPE)
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should manifest as transparent, vescicle-like lesions on the eye sclera.
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The case of OPE described here was caused by the inobservance of postoperative instructions a few hours after a sinus lift procedure. Therefore, the prevention of OPE following sinus lift surgery should be primarily based on clear and detailed verbal and written postoperative instructions, to be administered by trained and qualified personnel. At OPE diagnosis, the patient was prescribed antibiotics and corticosteroids as a complement to the anti-inflammatory administered following surgery. At present, no universally accepted indications on the need for a pharmacological treatment are currently available for the management of SE in the facial area. Several authors, however, agree on the importance of antibiotics and corticosteroids. While the rationale of the former is to avoid the invasion of the emphysematous tract by oral (or sinusal) pathogens and limit
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the incidence of secondary infections such as cellulitis and fascitis, corticosteroids should reduce the inflammatory response of the tissues. 2
OPE did not affect the success of either the augmentation procedure or the implant-supported rehabilitation. It may be speculated that the primary stability of the implant fixture obtained at
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placement as well as the quality of wound closure and stability at the incision margin may have significantly contributed to contrast the sudden increase in intra-sinusal pressure due to nose blowing. In order to prevent OPE occurrence following sinus augmentation and concomitant
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implant placement, therefore, it seems of paramount importance to check implant stability (eventually delaying implant placement if primary stability can not be obtained), and obtain
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complete and passive wound closure with an appropriate suturing technique.
The present case report showed that OPE may occur due to nose blowing following maxillary sinus augmentation and concomitant implant placement. OPE resolved in absence of professional interventions (i.e., surgical drainage) and did not affect the success of either the augmentation
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procedure or the implant-supported rehabilitation.
ACKNOWLEDGMENTS
The patient was enrolled in a clinical trial supported by a research grant by Regione EmiliaRomagna (Programma di Ricerca Regione-Università, Bando Giovani Ricercatori “Alessandro Liberati” 2013; project PRUA1GR-2013-00000168), and by a research grant of the Osteology Foundation, Lucerne, Switzerland (project #13-063). The authors wish to express their gratitude to Dr. Giovanni Franceschetti, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy, for his help in manuscript preparation.
ACCEPTED MANUSCRIPT DISCLOSURE STATEMENT The Authors have no conflict of interest to declare related to this study. Within 12 months before the submission of this manuscript for publication, Dr. Farina reports research grants from Regione Emilia-Romagna, research grants from Osteology Foundation,
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personal fees from Colgate, personal fees from Dental Trey, outside the submitted work; Dr. Minenna reports personal fees from Colgate, personal fees and non-financial support from Geistlich, outside the submitted work; and Dr. Trombelli reports grants and personal fees from
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Geistlich, grants and personal fees from Straumann, grants and personal fees from Thommen, grants from Nobel Biocare, personal fees from Procter & Gamble, personal fees from Colgate,
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outside the submitted work.
ACCEPTED MANUSCRIPT REFERENCES 1. Heyman SN, Babayof I: Emphysematous complications in dentistry, 1960-1993: An illustrative case and review of the literature. Quintessence Int 1995;26:535-543. 2. McKenzie WS, Rosenberg M: Iatrogenic subcutaneous emphysema of dental and surgical origin: a
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37. Boyne PJ: Restoration of osseus defects in maxillofacial casualties. J Am Dent Assoc 1969;78:767. 38. Boyne PJ, James RA: Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613.
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FIGURE LEGEND Figure 1a. Creation of a window into the lateral wall of the maxillary sinus. Figure 1b. Implant fixture protruding into the grafted sinus cavity.
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Figure 1c. Resorbable collagen membrane covering the lateral access to the sinus. Figure 1d. Wound closure. Figure 2a. View of the face at 1 day following surgery.
Figure 2c. View of the face at 2 days following surgery.
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Figure 2b. View of the right eye at 1 day following surgery.
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Figure 2d. View of the right eye at 2 days following surgery. Figure 2e. View of the face at 10 days following surgery.
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Figure 2f. View of the right eye at 10 days following surgery.
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S0278-2391(16)30504-3
DOI:
10.1016/j.joms.2016.06.186
Reference:
YJOMS 57342
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 21 May 2016 Revised Date:
24 June 2016
Accepted Date: 24 June 2016
Please cite this article as: Farina R, Zaetta A, Minenna L, Trombelli L, Orbital and peri-orbital emphysema following maxillary sinus floor elevation: a case report and literature review, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.06.186. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Orbital and peri-orbital emphysema following maxillary sinus floor elevation: a case report and literature review Roberto Farina
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Full-Time Researcher, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy Full-Time Researcher, Operative Unit of Dentistry, University-Hospital of Ferrara, Italy Chair of Oral Surgery, School of Dentistry, University of Ferrara, Italy
Antonio Zaetta
Luigi Minenna Part-time faculty, School of Dentistry, University of Ferrara, Italy
Leonardo Trombelli
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Clinical fellow, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy
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Director, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy Director, Operative Unit of Dentistry, University-Hospital of Ferrara, Italy Chair of Periodontology, School of Dentistry, University of Ferrara, Italy
Running title: Orbital and peri-orbital emphysema following sinus lift
Number of tables: 0 Number of figures: 2
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Conflict of interest: The Authors declare that they have no conflict of interest
Corresponding Author: Dr. Roberto Farina, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy; Corso Giovecca 203, 44121 Ferrara Italy. Tel. +39 0532 205277; Fax +39 0532 202329; e-mail: [email protected].
For the Journal of Oral and Maxillofacial Surgery, Ferrara 21 may 2016
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ABSTRACT
During the last 150 years, subcutaneous emphysema was described as a rare complication in dentistry, the etiology of which may reside in maneuvers performed by either the patient (e.g., sneezing while mouth closed, blowing the nose) or the dental professional through the use of specific dental instruments (e.g., dental drill, air syringe, etc). Irrespectively of the etiology, air is
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forced through the soft tissues, thus originating a rapid swelling of the area. According to the most recent literature reviews, the iatrogenic etiology is the most frequent. In the following case report, the first case of emphysema related to the orbital and peri-orbital region (OPE) occurring following
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a maxillary sinus floor elevation procedure is described.
ACCEPTED MANUSCRIPT INTRODUCTION Subcutaneous emphysema (SE) is a condition characterized by rapid swelling due to the forced introduction of air or gas into the soft tissues, possibly favored by the loss of integrity of the latter. 1,2
SE is typically characterized by crepitus on palpation. Also, it can be occasionally associated
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with pain or functional defects due to local compression. 2 In dentistry, SE is described as a rare event. Two literature reviews reported 74 and 32 clinical cases of SE in the periods 1960-1993 and 1994-2008, respectively. 1,2 More recently, additional anecdotal reports have been published on the
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topic. 3-33
dental professional.
1,2
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In dentistry, the etiology of SE can be related to maneuvers performed by either the patient or the In the former case, specific maneuvers associated with air emission (e.g.,
sneezing while keeping the mouth closed, blowing the nose, playing wind musical instruments) may force air into the soft tissues layers at sites where the integrity of the oral mucosa has been partially or completely lost.
1,34
The most recent literature reviews, however, seem to indicate that 2
In this context, SE can be caused by the air flow
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the iatrogenic etiology is the most prevalent.
generated by dental instruments (e.g., dental drill, air syringe) and vehicled into the root canal system, deep periodontal pockets and soft tissue wounds. Dental procedures requiring the use of
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such instruments (e.g., dental extractions, treatment of periodontal and peri-implant diseases with laser or air-flow technology, orthognatic surgery, restorative and endodontic treatments, and
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maxillary sinus floor augmentation) have been previously associated with SE occurrence. 1,33
The periorbital SE is a SE localized to the face or its portions, with typical involvement of the malar and periobital region. This specific form of SE has been previously associated with dental procedures in the maxillary posterior sextants intervention.
35,36
27,33
, but may occur in absence of professional
The present case report illustrates a case (the first, at the best of our knowledge)
of emphysema of the orbital and peri-orbital area (here defined as orbital and periorbital emphysema, OPE) occurred following a maxillary sinus floor augmentation procedure. Particular
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emphasis has been given to the description of the clinical manifestation of OPE as well as its odontostomatologic and ophthalmologic management.
MATERIALS & METHODS Study design and ethical aspects
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The present study is a case report. All the clinical procedures were performed in full accordance with the Declaration of Helsinki (1975) as revised in Tokyo (2004) and the Good Clinical Practice Guidelines (GCPs). The patient was willing and fully capable to comply with the clinical
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procedures, and a written informed consent was obtained prior to the initiation of treatments.
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Case presentation
The patient was a caucasian, 49-year-old, non-smoker female, previously treated with non-surgical and surgical therapy for aggressive generalized periodontitis at the Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy. The patient was enrolled in a supportive periodontal therapy program based on 4-month recall intervals. The third and second
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molars and the disto-buccal and palatal roots of the first molars had been extracted 10 years before, and the patient was willing to rehabilitate the right maxillary posterior area with a fixed prosthesis. According to the oral rehabilitation plan, the placement of a 9.5 mm - long and 4.0 mm -
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wide implant distal to the residual root of the first maxillary molar was programmed. The residual bone height of 4 mm of the edentulous area (as evaluated by pre-operative computerized
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tomography), however, prevented the insertion of an implant of the programmed dimensions. Since no systemic or local contraindications to oral and implant surgery were identified, the patient underwent a bone augmentation procedure.
Surgical procedure In order to augment the vertical dimensions of the residual bone crest, a maxillary sinus floor elevation was performed. Antibiotic premedication was performed with 2 gr of amoxicillin one hour before surgery. Local anesthesia was administered by infiltration with mepivacaine + epinephrine 1:100.000 (Carboplyina 20 mg, Dentsply, Rome, Italy; 4 cartidges of 1.8 mL each).
ACCEPTED MANUSCRIPT A crestal incision was placed in the edentulous area. The incision was continued intrasulcularly at the buccal aspect of the residual root of the first molar, and a release incision was placed mesial to the root. A triangular, mucoperiosteal flap was raised to expose the lateral wall of the maxillary sinus. Access to the sinus cavity was obtained according to the lateral window technique.
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A
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10 mm x 8 mm window was prepared by abrasion of the lateral bony wall of the maxillary sinus with a piezoelectric instrument (Piezosurgery® Touch; Mectron s.p.a., Carasco, Genova, Italy). Manual instruments (6577 & 6578 kramer-nevins sinus lift instrument, acute angles & obtuse
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angles; 709 & 710 implant surgery instrument; Hu-Friedy, Milan, Italy) were used to elevate the sinus membrane. The Valsalva maneuver, as assessed immediately after either the preparation of
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the lateral window or the elevation of the sinus membrane, was negative (Figure 1a). The space underneath the elevated membrane was grafted with a bovine-derived xenograft (BioOss®, 0.25 - 1 mm granules; Geistlich Biomaterials Italia, Thiene, Italy). A 9.5 mm - long and 4.0 mm - wide implant (SPI Element Inicell®, Thommen Medical AG, Grenchen, Switzerland) was
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placed (Figure 1b). Primary stability was obtained, and a healing screw was placed. Then, a second xenograft apposition was placed buccal to the implant fixture to seal the lateral access to the sinus. The total amount of xenograft used was 2.5 g. The lateral window was covered by a 13
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mm x 25 mm resorbable collagen membrane (Bio-Gide®; Geistlich Biomaterials, Thiene, Italy), without fixation devices (Figure 1c). A submerged healing protocol was adopted, and the flap was
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sutured with interrupted and internal mattress, poliglycolic acid sutures (Vicryl® 5/0; Ethicon, Sommerville, US) (Figure 1d). Following surgery, the patient was given verbal and written postoperative instructions, including a cold and soft diet for the first postoperative days, as well as the abstention from blowing the nose and performing oral hygiene in the surgerized area for 2 weeks following surgery. A 0.2% chlorhexidine mouthrinse (Curasept® ADS 0,2%; Curaden Healthcare S.p.A., Saronno, Varese, Italy; rinsing t.i.d. for 1 minute) was prescribed for the first 2 weeks post-surgery. Also, the patient was instructed to assume ibuprofen-based anti-inflammatory therapy (Brufen® 600mg; Abbott, Rome, Italy) pro re nata.
ACCEPTED MANUSCRIPT Clinical management and resolution of OPE Onset and clinical aspect On the first day following surgery, the patient was visited under urgent request, reporting that she had roughly blown her nose a few hours following surgery. This maneuver had been immediately
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followed by rapid swelling of the right hemiface at the level of the periorbital and orbital area. Also, the patient referred a sight alteration (“…things appear as seen through a frosted glass…”), and did not experience either pain or discomfort. At visit, periorbital swelling was observed homolateral to
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the surgerized area, in association with a substantial limitation of the palpebral fissure. Swelling was accompanied by the presence of vescicle-like lesions on the eye sclera (Figures 2a,b).
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Crepitus on palpation was evident at the zigomatic and subpalpebral areas. Primary stability of the implant and primary intention closure of the wound were maintained. No displacement of the xenograft was evident in the periapical radiograph. Antibiotics (Augmentin®; GlaxoSmithKline S.p.A, Verona, Italy, 1 g b.i.d. for 6 days) were prescribed, and the patient was instructed to
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continue the prescribed anti-inflammatory therapy.
An ophthalmological visit was performed at 2 days after surgery. No alteration of the visual acuity was detected. The examination of the right orbit with a slit-lamp showed orbital edema with
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hyperemia and congestion, modest chemosis and transparency of the cornea. Extrinsic ocular muscles and ocular tone were normal. Ocular fundus (retina and optic nerve) had a well-defined
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pink optic papilla. No alteration of the orbital soft tissues were observed with ecography. Medication with dexamethasone and tobramycin (Tobradex® eyedrops; Novartis Italia, Origgio, Varese; 1 drop q.i.d. for 5 days) was prescribed.
Resolution At 2 days following surgery, swelling of the hemiface had substantially reduced, and a residual erythema of the sclera was observed with complete remission of the eye vescicles. The palpebral fissure was still limited compared to the contralateral eye (Figures 2c,d). The patient reported neither sight alterations nor pain. The complete remission of the clinical signs of OPE was
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observed at 10 days post-surgery (Figures 2e,f). At 6 months following implant surgery, the patient was successfully rehabilitated with an implant-supported prosthesis.
DISCUSSION In the present article, a case of orbital and peri-orbital emphysema (OPE) occurring after a sinus
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augmentation procedure was described. Immediately after the patient had blown the nose, OPE manifested with swelling of the right hemiface at the level of the periorbital and orbital area, and was accompanied by vescicle-like lesions on the eye sclera and a sight alteration. Following
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diagnosis of OPE, pharmacological therapy was administered, consisting of antibiotics and corticosteroids. Clinical signs were monitored, and complete resolution was observed at 10 days
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after the manifestation of the event. OPE did not affect the success of either the bone augmentation procedure or the implant-supported rehabilitation.
Subcutaneous emphysema (SE) has been recognized as a potential complication of dental procedures for more than 100 years. The first report on SE in the facial area was published in
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1900, describing the case of a patient who manifested the clinical signs of SE immediately after playing horn after the extraction of a mandibular premolar.
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Although the etiology of SE has
gradually moved from the patient to the dental professional with the introduction of new tecnologies 1,2
, the incidence of this complication is still partly ascribed to
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(e.g., air driven hand-pieces)
inappropriate maneuvers performed by the patient.
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At the best of our knowledge, this is the first
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case report on an emphysema of the orbital area occurred following maxillary sinus floor elevation due to the inobservance of postoperative instructions. Previous authors reported on emphysema following sinus augmentation with a lateral approach, but swelling was limited to the periorbital area and no involvement of the eye and orbital tissues was reported.
27
Recently, Stacchi et al.
observed an adverse event involving the orbital soft tissues following a maxillary sinus floor elevation with transcrestal approach.
39
Although the clinical manifestation of the event was similar
to that reported for OPE in this study, the nosological entity described by Stacchi and colleagues differed from OPE in terms of etiology. More specifically, the lesion (i.e., conjunctival chemosis) was infective in nature, being a consequence of an acute sinusitis occurred following sinus
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augmentation. Therefore, an early differential diagnosis appears to be critical for the appropriate management of OPE. 2
In the present case report, OPE resolved in absence of professional interventions. As frequently reported in the literature, SEs occurring in the facial area following dental procedures usually 1,2,10,22,23
However, SE can be occasionally associated with pain or
functional defects due to local compression.
2,24
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resolve spontaneously.
Also, when spreading along the fascial planes to
distant areas, SE may cause life-threatening complications due to compression on areas such as 24
Therefore, early diagnosis of SE is critical to evaluate
if surgical drainage of the accumulated air is indicated.
24
In order to perform an early differential 27,25,28
it must be kept into consideration
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diagnosis and avoid inappropriate treatment approaches,
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mediastinum and parapharyngeal spaces.
that SEs involving the periorbital area may share some characteristics (topography and rapid onset of tissue swelling, in particular) with different nosological entities, such as vascular events mediated by histamine (angioneurotic edema or Quincke's edema), reactions.
32
25,28
hemorrage,
27
and allergic
In the facial area, SE diagnosis should be based on anamnesis, as well as visual and
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palpatory examination. In particular, rapid onset of tissue swelling (as observed during the dental procedure or referred by the patient) and crepitus on palpation should be identified. Moreover, the eventual involvement of the soft tissues of the orbital and eye (necessary to classify SE as OPE)
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should manifest as transparent, vescicle-like lesions on the eye sclera.
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The case of OPE described here was caused by the inobservance of postoperative instructions a few hours after a sinus lift procedure. Therefore, the prevention of OPE following sinus lift surgery should be primarily based on clear and detailed verbal and written postoperative instructions, to be administered by trained and qualified personnel. At OPE diagnosis, the patient was prescribed antibiotics and corticosteroids as a complement to the anti-inflammatory administered following surgery. At present, no universally accepted indications on the need for a pharmacological treatment are currently available for the management of SE in the facial area. Several authors, however, agree on the importance of antibiotics and corticosteroids. While the rationale of the former is to avoid the invasion of the emphysematous tract by oral (or sinusal) pathogens and limit
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the incidence of secondary infections such as cellulitis and fascitis, corticosteroids should reduce the inflammatory response of the tissues. 2
OPE did not affect the success of either the augmentation procedure or the implant-supported rehabilitation. It may be speculated that the primary stability of the implant fixture obtained at
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placement as well as the quality of wound closure and stability at the incision margin may have significantly contributed to contrast the sudden increase in intra-sinusal pressure due to nose blowing. In order to prevent OPE occurrence following sinus augmentation and concomitant
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implant placement, therefore, it seems of paramount importance to check implant stability (eventually delaying implant placement if primary stability can not be obtained), and obtain
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complete and passive wound closure with an appropriate suturing technique.
The present case report showed that OPE may occur due to nose blowing following maxillary sinus augmentation and concomitant implant placement. OPE resolved in absence of professional interventions (i.e., surgical drainage) and did not affect the success of either the augmentation
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procedure or the implant-supported rehabilitation.
ACKNOWLEDGMENTS
The patient was enrolled in a clinical trial supported by a research grant by Regione EmiliaRomagna (Programma di Ricerca Regione-Università, Bando Giovani Ricercatori “Alessandro Liberati” 2013; project PRUA1GR-2013-00000168), and by a research grant of the Osteology Foundation, Lucerne, Switzerland (project #13-063). The authors wish to express their gratitude to Dr. Giovanni Franceschetti, Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Italy, for his help in manuscript preparation.
ACCEPTED MANUSCRIPT DISCLOSURE STATEMENT The Authors have no conflict of interest to declare related to this study. Within 12 months before the submission of this manuscript for publication, Dr. Farina reports research grants from Regione Emilia-Romagna, research grants from Osteology Foundation,
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personal fees from Colgate, personal fees from Dental Trey, outside the submitted work; Dr. Minenna reports personal fees from Colgate, personal fees and non-financial support from Geistlich, outside the submitted work; and Dr. Trombelli reports grants and personal fees from
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Geistlich, grants and personal fees from Straumann, grants and personal fees from Thommen, grants from Nobel Biocare, personal fees from Procter & Gamble, personal fees from Colgate,
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outside the submitted work.
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FIGURE LEGEND Figure 1a. Creation of a window into the lateral wall of the maxillary sinus. Figure 1b. Implant fixture protruding into the grafted sinus cavity.
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Figure 1c. Resorbable collagen membrane covering the lateral access to the sinus. Figure 1d. Wound closure. Figure 2a. View of the face at 1 day following surgery.
Figure 2c. View of the face at 2 days following surgery.
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Figure 2b. View of the right eye at 1 day following surgery.
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Figure 2d. View of the right eye at 2 days following surgery. Figure 2e. View of the face at 10 days following surgery.
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Figure 2f. View of the right eye at 10 days following surgery.
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