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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 89-92

Displaced dental implant in the maxillary sinus: A case report and literature review


1 Otorhinolaryngology.Head and Neck Surgery Department, King Fahd University Hospital, Imam Abdulrahman Bin Faisal University, Riyadh, Saudi Arabia
2 Department of Otorhinolaryngology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
3 College of Medicine, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
4 College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia

Date of Submission27-May-2020
Date of Decision27-Jun-2020
Date of Acceptance30-Jul-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Abdulaziz Al Enazi
Otorhinolaryngology-Head and Neck Surgery,King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Khobar
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_23_20

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  Abstract 


Dental implants (DIs) have been widely used to replace missing teeth worldwide. However, complications such as displacement or migration of DIs into the maxillary sinus may occur. Immediate removal of displaced DIs s (DDIs) is usually recommended to avoid these complications. Here, we report our experience with a rare case of displacement of a maxillary sinus implant that was managed with endoscopic sinus surgery (ESS). A 52-year-old healthy male was referred by his clinician to the rhinology clinic due to a DDI. An earlier sinus computed tomography scan revealed a displaced implant located posteriorly and inferiorly in the maxillary sinus. A displaced maxillary sinus implant should be removed immediately to prevent any eventual complications such as mucosal changes or secondary sinusitis. The authors recommend ESS as the treatment of choice.

Keywords: Dental implants, displacement, foreign body, maxillary sinus


How to cite this article:
Al Enazi A, Al Maddah J, Alghamdi O, AlSudari S. Displaced dental implant in the maxillary sinus: A case report and literature review. Saudi J Otorhinolaryngol Head Neck Surg 2020;22:89-92

How to cite this URL:
Al Enazi A, Al Maddah J, Alghamdi O, AlSudari S. Displaced dental implant in the maxillary sinus: A case report and literature review. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2021 Jan 20];22:89-92. Available from: https://www.sjohns.org/text.asp?2020/22/2/89/305462




  Introduction Top


Dental implant (DI), also known as an artificial tooth root, refers to a surgical suture that is placed into the jawbone to replace the root of a missing tooth. In other words, it serves to hold a replacement tooth or bridge. An implant in the maxillary sinus may get displaced during surgery or use owing to poor bone quality, untreated membrane perforation, and application of excessive force during installation (Ding et al., 2015; Eltas et al., 2015; Iida et al., 2000). Other factors that may influence implant displacement include poor primary stability and the lack of surgical experience (Kluppel et al., 2010). Moreover, insufficient bone quality may complicate placing the implant into the posterior tissue of the maxillary bone (Nogami et al., 2016). Displacement of a DI may result in complications such as infection of the paranasal sinuses. For example, several studies have reported that foreign objects in the maxillary sinus can cause infections due to impaired mucociliary flow and tissue reactions. Moreover, serious side effects, such as fungal infections and cancer, have been reported in some patients (Eltas et al., 2015; Felisati et al., 2007; Fusari et al., 2013; Nogami et al., 2016), necessitating the immediate removal of displaced DIs (DDIs) (Iida et al., 2000). However, if the removal is delayed, antibiotics and nasal decongestants should be used to control the infection before removing the displaced implant (Testori et al., 2012). There exists no consensus on the preferred approach to manage DDIs inside the sinus cavity, and three different approaches are commonly used to remove materials displaced into the maxillary sinus, as follows: suction from the socket of an extracted tooth, the classical open surgery using the canine fossa (the Caldwell–Luc approach), and endoscopic sinus surgery (ESS) (Chrcanovic et al., 2009; de Jong et al., 2016). Although isolated ESS has several advantages, it does not effectively remove large foreign materials, especially those located in the posterior and inferior aspects of the sinus (Tsodoulos et al., 2012). Nevertheless, it is considered the gold standard for sinonasal pathologies requiring surgical intervention, including removal of foreign bodies from the nose or sinuses (Lai and Stankiewicz, 2015). Thus, the majority of displaced maxillary implants are managed by ESS. Here, we report a rare case of displacement of maxillary sinus implant that was successfully removed using the endoscopic approach.


  Case Report Top


A 52-year-old male, known case of cardiac disease, was referred to the rhinology clinic for evaluation of the DDI in the left posterior maxillary sinus 1 week after dental implantation. The patient complained of facial pain and nasal discharge. Physical examination showed purulent nasal secretions, whereas rhinoscopy revealed no polyps or signs of abnormal anatomy. However, the displaced implant was not visible on endoscopic examination through the nose. Radiographic examination with a panoramic view showed the DDI inside the maxillary sinus cavity. Immediately following implant displacement, an attempt was made by the dentist to remove it under local anesthesia but failed. The patient was prepared for ESS. Preoperatively, the patient had undergone a computed tomography (CT) scan of the sinus 1 week after displacement, which showed the implant located posteriorly and inferiorly in the maxillary sinus. There was evidence of an oroantral fistula and maxillary sinus inflammation [Figure 1]. The patient was on aspirin due to cardiac disease. Cardiac consultation and stoppage of blood thinner was done preoperatively. Furthermore, antibiotics were administered for acute sinusitis. The DDI was successfully removed using ESS.
Figure 1: (a) Coronal view CT scan showing the displaced dental implant in the left maxillary sinus. Sagittal view CT scan of the paranasal sinus showing foreign body in the maxillary sinus (c) Axial cut paranasal sinus CT scan showing displaced dental implants in the maxillary sinus. The radiological findings show loose hyperdense dental implant inside the left maxillary sinus. A bone defect is seen at the site of the left first molar tooth with communicating opening between the left maxillary sinus and the mouth cavity. There was evidence of an oroantral fistula and maxillary sinus inflammation (b) Fluids, mucosal thickening, and possible associated sinusitis at the left maxillary sinuses are seen. Ostiomeatal units appear normal and patent on both sides. Right maxillary, sphenoid, ethmoid, and frontal sinuses are normally pneumatized. CT, computed tomography; DDI, displaced dental implant; FB, foreign body

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Surgical procedure

The ESS was performed 3 weeks after imaging studies. Rhinologist and maxillofacial surgeons joined the surgery. Informed consent has been obtained before the surgery. The endoscopic approach is explained to the patient. The nose was prepared by packing it with gauze soaked in xylocaine with adrenaline 1:100,000 dilution. A zero-degree 4 mm and 30° telescope were used to examine the nasal cavities and to carry out the endoscopic surgery. Maintaining a bloodless operative field achieved through adequate nasal preparation and adequate anaesthesia. Under General anaesthesia with endotracheal intubation and packing of the pharynx with wet gauze. The patient is placed in the supine position with the head up, 30 – 45 degrees, over a head rim and properly draped. The inferior meatus and the middle meatus were examined. The middle turbinate is identified and displaced medially. Antrostomy and uncinectomy were carried out to gain access. Intraoperative findings revealed oroantral fistula, mucosal changes in the maxillary sinus including purulent secretions inside the sinus cavity, and negative cultures. The DDI was identified slightly posterior to the natural ostium of the maxillary sinus [Figure 1] and [Figure 2]. The DDI had migrated from the maxillary sinus against the gravity and away from its original source. It was removed successively. The sinus was cleaned and rinsed. Surgical repair of the oroantral fistula was done by the maxillofacial team at the same time of the procedure. The patient recovered quickly using standard postoperative care including 500-mg cefuroxime twice daily for 10 days and nasal steroid spray (triamcinolone, two puffs per nostril twice daily). The sinus healed completely after several weeks. Although the patient was administered an additional course of antibiotics (875 mg amoxicillin–clavulanate twice daily for 10 days), due to persistent clinical and endoscopic evidence of maxillary sinus inflammation, endoscopic nasal examination at 6 months of follow-up revealed that the patient was doing well and was free of symptoms.
Figure 2: (a and b) X-ray view: displaced dental implant in the maxillary sinus

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  Discussion Top


DIs are considered the treatment of choice for missing teeth by the majority of dentists. However, the greatest challenge associated with DIs is the complications arising from them, such as implant displacement and risk of infections. For instance, a study conducted by Raikar et al. reported 3.3% implant failure in the mandibular posterior, 2.2% in the maxillary posterior, 2.1% in the maxillary anterior, and 1.0% in the mandibular anterior.[10] Further, the dorsal segment of the maxilla has unique anatomical characteristics and limitations. The loss of a tooth implies that the necessary stimulus for maintaining bone trophism disappears, resulting in alveolar bone resorption, i.e., the close relationship between the sinus floor and the alveolar crest in the posterior maxillary region is lost.[11] These problems have been successfully resolved using short implants and lifting of the sinus in the posterior edentulous maxilla. These techniques allow safer implant positioning in the back of the edentulous maxilla; however, an implant displacement in the maxillary sinus may occur during surgery or following use.[4] Furthermore, other complications, such as maxillary sinus pneumatization and thin residual alveolar bone, may cause DIs to migrate into the maxillary sinus during placement or after prosthetic restoration. In addition, the biting force of the patient on the implant prosthesis and surrounding structures may result in implant displacement. Patients undergoing simultaneous implant placement and bone grafting after sinus elevation are at a high risk of implant displacement.[12] Another factor is the reduced height of the residual alveolar ridge, particularly implant placement in the bone, with a minimum height of below 4 mm and simultaneous sinus grafting.[13] Bioinert materials, such as commercially pure titanium (Cp titanium) and titanium alloys, or bioactive ceramics, such as hydroxyapatite, tri- and tetracalcium phosphate, and bioglass, are extensively used in DIs.[14] Of these, titanium is the most commonly used element in DIs due to its high biocompatibility and mechanical and physical properties, such as resistance to corrosion, high strength, and low weight.[15] Surgery should be performed immediately after the implant displacement to minimize mucosal inflammation and to prevent unnecessary complications during surgical removal. In our case, the patient was operated within 1 week after radiology findings. However, the patient was referred to our clinic 6 months after dental implantation. Several methods, such as suction through the bone alveolar defect, Caldwell–Luc approach, functional endoscopy sinus surgery, and transoral endoscopy approach via canine fossa, are used to remove a DI from the maxillary sinus.[5],[11] ESS is a safe and minimally invasive procedure to remove DIs and other foreign bodies in the maxillary sinus.[16] In our case, we used the endoscopic sinus approach. Previous evaluations of undesirable outcomes of endoscopic maxillary sinus surgery have identified few causes of failure. According to a study, an additional surgery was required in 2%–18% of patients.[17] Hence, endoscopic endonasal technique is the treatment of choice to remove foreign bodies from the maxillary sinus.[18] ESS has been used for chronic refractory sinusitis, nasal polyps, sinus polyps, choanal atresia, closure of the cerebrospinal fluid leak, management of epistaxis, and biopsy and excision of selected tumors. Moreover, technological advances have facilitated the use of this method to view and remove a foreign body from the antrum.[19]

Endoscopy is a less-invasive procedure with minimized operating time and fast postoperative recovery. It offers superior visibility with limited incision and preservation of the sinus integrity.[3] Therefore, an endoscopic approach is considered the first treatment choice for the removal of dental materials displaced into the maxillary sinuses.[20]


  Conclusions Top


Endoscopy sinus surgery is recommended for early surgical removal of DDIs due to the decreased effort, time, and patient discomfort. Maxillary sinusitis occurring after dental implantation should be controlled with proper measures, including antibiotics and nasal decongestants, before surgical intervention to remove DIs. Furthermore, a critical analysis of the literature and future studies should be performed to find the appropriate surgical approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Nogami S, Yamauchi K, Tanuma Y, et al. Removal of dental implant displaced into maxillary sinus by combination of endoscopically assisted and bone repositioning techniques: A case report. J Med Case Rep 2016;10:1.  Back to cited text no. 3
    
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Eltas A, Dundar S, Eltas SD, Altun O, Yolcu U, Saybak A, et al. Accidental displacement of dental implants into both maxillary sinuses during surgery. J Oral Implantol 2015;41:601-3.  Back to cited text no. 4
    
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estori, Tiziano, Lorenzo Drago, Steven S. Wallace, Matteo Capelli, Fabio Galli, Francesco Zuffetti, and Andrea Parenti et al. 2012. “Prevention And Treatment Of Postoperative Infections After Sinus Elevation Surgery: Clinical Consensus And Recommendations”. International Journal Of Dentistry 2012: 1-5. doi:10.1155/2012/365809.  Back to cited text no. 6
    
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Chrcanovic BR, Custódio AL. Surgical removal of dental implants displaced into the maxillary sinus. Serb Dent J 2009;56:139-47.  Back to cited text no. 7
    
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Tsodoulos S, Karabouta I, Voulgaropoulou M, Georgiou C, et al. Atraumatic removal of an asymptomatic migrated dental implant into the maxillary sinus: A case report. J Oral Implantol 2012;38:189-93.  Back to cited text no. 8
    
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Raikar S, Talukdar P, Kumari S, Panda S, Oommen V, Prasad A, et al. Factors affecting the survival rate of dental implants: A retrospective study. J Int Soc Prevent Communit Dent 2017;7:351-5.  Back to cited text no. 10
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Chiapasco M, Zaniboni M, Rimondini L. Dental implants placed in grafted maxillary sinuses: A retrospective analysis of clinical outcome according to the initial clinical situation and a proposal of defect classification. Clin Oral Implants Res 2008;19:416-28.  Back to cited text no. 13
    
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