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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 92-95

Successful retrieval of dental implant from maxillary sinus by interdisciplinary approach in a high altitude as a complication during prosthetic phase: A rare case report


1 Corps Dental Unit
2 Armed Forces Clinic, New Delhi, India
3 Field Hospital

Date of Submission13-Jan-2020
Date of Acceptance20-May-2020
Date of Web Publication15-Jul-2020

Correspondence Address:
Vikas Dhir
Corps Dental Unit, 903511 C/O 56 APO

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODD.JODD_3_20

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  Abstract 


Dental implants are one of most predicatble procedures for rehabilitation of jaws. One of the rarest complications is of the displacement of dental implant into the maxillary sinus. One such interesting rare case report has been presented here which has been managed by an interdisciplinary approach by successful retrieval of implant from maxillary sinus by a combined approach (Endoscopic Medial Meatus Antrostomy and Caldwell Luc procedure) in high altitude area.

Keywords: Complications, dental implant, interdisciplinary approach, maxillary sinus, retrieval


How to cite this article:
Dhir V, Saini S, Rao S, Padha K. Successful retrieval of dental implant from maxillary sinus by interdisciplinary approach in a high altitude as a complication during prosthetic phase: A rare case report. J Dent Def Sect. 2020;14:92-5

How to cite this URL:
Dhir V, Saini S, Rao S, Padha K. Successful retrieval of dental implant from maxillary sinus by interdisciplinary approach in a high altitude as a complication during prosthetic phase: A rare case report. J Dent Def Sect. [serial online] 2020 [cited 2020 Oct 30];14:92-5. Available from: http://www.journaldds.org/text.asp?2020/14/2/92/289750




  Introduction Top


Rehabilitation of edentulous jaws using dental implants has been a predictable, preferred, and a successful modality, which has been a common practice.[1] A very low incidence of complications is associated with this operative procedure. One of the rare complications with incidence of 0.6-3.8% is the displacement of dental implant into the maxillary sinus, which can be during surgical or prosthetic phase.

One such rare case report has been presented here, which has been managed by an interdisciplinary approach by successful retrieval of implant from maxillary sinus by a combined approach (Endoscopic Medial Meatus Antrostomy and Caldwell Luc procedure) in high-altitude area.


  Case Report Top


A 32-years-old serving soldier male came to dental center with a desire to have a permanent restoration of the upper missing tooth. His medical history was nil contributory. His dental history revealed that he had caries and underwent endodontic treatment for it which later got fractured and was extracted 2 years back. He had no deleterious habits.

Extraoral examination revealed that his face was symmetrical, jaw opening was adequate, there was no masticatory muscle tenderness, and no lymph adenopathy present. Intraoral examination revealed that his oral hygiene was good, and soft tissue/mucosa was healthy. Twenty-six was missing. Gingival biotype was normal, periodontium was healthy, and the width of attached gingiva generally was adequate and keratinized gingiva adequate/present. There was absence of any active apical infection in 26, and the width of attached gingiva was adequate. Keratinized gingiva was adequate. Interocclusal distance at 26 region was 7 mm. Buccolingual width was adequate-8 mm. Occlusion was Class-I.

Diagnosis – 26 edentulous with Kennedy's class-I in maxillary arch.

Investigations – complete blood count was within normal limit (WNL). Bleeding time, clotting time & prothrombin time were within normal limits. Intraoral periapical X-ray revealed that in 26 region, there was no other adjacent or periapical pathology and D2 / 3 quality of bone. Mesiodistal width in 26 region was 8.5 mm, and the available bone height was 4.5 mm.

Treatment plan – Consent/motivation/instructions for patient. Indirect sinus lift along with implant placement in 26 region, Provisional restoration in 4 months, final restoration/Porcelain fused to metal crown after 4–5 months. Review and follow-up at 1, 3, 6, and 12 months.

Surgical procedure

Under aseptic conditions, infiltrative local anesthesia was given and a scalpel blade no 15 was used to give midcrestal incision and extended along gingival sulcus of 26 region. A flap was gently raised with periosteal elevator. Using a surgical stent as a guide, a round bur was used to initiate the implant site preparation in order to place implant in desired position. Then sequential drills were used in graduating size as per the manufacturer's instructions and implant site was under prepared to 3.8. Osteotome was used to elevate sinus lining along with 2cc novabone putty. A tapered, nanopore surface myraid plus implant D4.5/L-8 mm was inserted into the prepared site up to torque of 45 Ncm [Figure 1]. Antibiotics and anti-inflammatory drugs along with chlorhexidine mouthwash was prescribed for 1 week. Postoperative instructions were given. The patient was reviewed regularly at 1st and 2 week and subsequently at 1st, 3rd, and 4th months of follow-up.
Figure 1: a - Preop x-ray. b - Postop x-ray with indirect sinus lift. c - Preop intraoral photo. d - Intraop intraoral photo with indirect sinus lift procedure

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After 4 months in prosthetic phase, punch technique was used to remove cover screw and place gingival former. As soon as attempt was made to remove cover screw, implant got displaced into maxillary sinus. Radiovisiography was taken which confirmed the same [Figure 2]. Oroantral communication was closed using collagen plug and buccal advancement flap. A combined interdisciplinary approach was planned for retrieval of implant along with ear, nose, and throat surgeon/otolaryngologist.
Figure 2: Implant follow-up after 4 months (a) Implant in position (b) Implant lost in sinus during prosthetic phase (c) Paranasal sinuses view showing implant displaced superiorly in the maxillary sinus

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Under general anesthesia (GA) and aseptic conditions, medial meatus antrostomy was performed and implant retrieval was attempted by endoscopy sinus surgery (ESS) [Figure 3]. As implant could not be retrieved by ESS procedure, subsequently, Caldwel Luc procedure was carried out. A vestibular incision was given and left maxillary antrum was exposed. A 2.5 cm × 2 cm bony window was created. Zero degree endoscope was used to visualize the implant which has migrated towards the orbital floor. Through this bony window, implant was retrieved [Figure 4]. After establishing hemostasis, incision line was sutured with 3 (0) silk. The patient was followed up for 2 months [Figure 5].
Figure 3: (a-d) Endoscopy sinus surgery procedure through medial meatus antrostomy in sequence

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Figure 4: a - Caldwell luc procedure. b - Post suturing. c - Implant retrieved after procedure

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Figure 5: a - Postop X-ray at 2 months. b - Postop intraoral photograph at 2 months follow up

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  Discussion Top


One of the rare and uncommon complications is the displacement of dental implant into the maxillary sinus. This can be an early complication in surgical phase or rarely can be in late prosthetic phase or follow-up period.[1] Implant displacement may result due to initial lack of primary stability, intrasinusal/nasal pressure changes, incorrect distribution of occlusal forces. But, the main cause of it may be inadequate bone height in posterior maxilla.[2]

Implant should be removed because they can cause sinusitis or sinus pathology.[2] Implant can be removed by endoscopic sinus surgery by medial meatus antrostomy as a minimally invasive approach or Caldwel Luc approach.[3]

Minimally invasive endoscopic nasal surgery and ESS has been a preferred modality via medial meatus antrostomy (MMA) as it is a conservative approach. Caldwel Luc operation is used where implant is displaced superiorly and cannot be visualized by the endoscope. This procedure is highly predictable but quite aggressive.[3],[4],[5],[6],[7],[8]

In this case, first ESS through MMA was attempted under GA. As retrieval was not possible, Caldwel Luc approach was used and retrieval was done via lateral window using endoscopic visualization.

A retrospective study was carried out on 14 patients to analyze factors influencing implant migration into maxillary sinus. Available bone height was below 6 mm in majority of cases. 50% (12) of cases did not receive any site preparation/augmentation technique prior to implant insertion. 33% (5) of case were treated by osteotome technique. But, only one case received grafting. Therefore, 73.3% of sites did not receive any biomaterials to increase available bone height.[2]

Some complicating factors which can cause displacement of implant in maxillary sinus region include lack of primary stability, Type IV bone quality, occlusal traumatic forces, site infection, and membrane perforation/tear. These can be prevented and managed.[9]

When performing indirect sinus lift using bone added osteotome sinus floor elevation technique, strong consideration should be given to minimize the bacterial load at the time of surgery by use of presurgical antiseptic rinsed, postsurgical antibiotics. In order to achieve primary stability when elevating by osteotomes, tapered and a rough surface implant should be preferred which will aid in optimal primary stability. Also, at least 5 mm of vertical bone height should be available to ensure higher success.[9]

Undersize preparation is also recommended to obtain coronal stability. In less dense bone, use of osteotome is preferred to drilling. Wide diameter, tapered rough implant should be used in a under prepared site.

Premature loading should be avoided by submerging implant and/or removal of pressure points if removable interim prosthesis is given.

Membrane perforation should be avoided by proper diagnostic radiography cone-beam CT (CBCT), drilling short of sinus by at least 1 mm, not extending osteotome beyond sinus boundary and careful force during malletting with graft. Fugazzotto principle of 2 × 2 rule for anticipating maximum elevation should be followed.

Reiser mentions that in Class-1 membrane tear (<2 mm with exposure of implant into sinus cavity and loss of doming) graft and blood clot would serve as a vital scaffold allowing spontaneous healing of the membrane.[10]

A study of Gonzalez S on crestal approach for Maxillary sinus augmentation in patients with less than equal to 4mm of residual alveolar bone has shown 100% success rate and a viable technique with residual bone height less than 4 mm.

In our present case, membrane tear could have taken place during surgical stage although precautions of short and undersize drilling, infection prevention, use of osteotome along with putty were used. The limitation in this high altitude was that no CBCT facility was available and therefore could not be done.


  Conclusion Top


A proper patient selection, treatment planning, diagnostic imaging (CBCT/CT), as well as the application of appropriate sinus augmentation techniques are few critical aspects, which will minimize these complications of implant displacement into the sinus.

One such complication for retrieval of implant was explored via interdisciplinary approach in order to avoid future sinus pathology and specific treatment protocol as it a very technique sensitive procedure and more difficult to execute than conventional procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kluppel LE, Se S, Olate S, Filho FW, Moreira RW, de Moraes M. Implant migration into maxillary sinus: Description of two asymptomatic cases. Oral Maxillofac Surg 2010;14:63-6.  Back to cited text no. 1
    
2.
Galindo-Moreno P, Padial-Molina M, Avila G, Rios HF, Hernandez-Cortes P, Wang HL. Complications associated with implant migration into the maxillary sinus cavity. Clin Oral Implants Res 2012;23:1152-60.  Back to cited text no. 2
    
3.
González-García A, González-García J, Diniz-Freitas M, García-García A, Bullon P. Accidental displacement and migration of endosseous implants into adjacent craniofacial structures: A review and update. Med Oral Patol Oral Cir Bucal 2012;17:e769-74.  Back to cited text no. 3
    
4.
Nakamura N, Mitsuyasu T, Ohishi M. Endoscopic removal of a dental implant displaced into the maxillary sinus: Technical note. Int J Oral Maxillofac Surg 2004;33:195-7.  Back to cited text no. 4
    
5.
El Charkawi HG, El Askary AS, Ragab A. Endoscopic removal of an implant from the maxillary sinus: A case report. Implant Dent 2005;14:30-5.  Back to cited text no. 5
    
6.
Kim JW, Lee CH, Kwon TK, Kim DK. Endoscopic removal of a dental implant through a middle meatal antrostomy. Br J Oral Maxillofac Surg 2007;45:408-9.  Back to cited text no. 6
    
7.
Kitamura A. Removal of a migrated dental implant from the maxillary sinus by transnasal endoscopy. Br J Oral Maxillofac Surg 2007;45:410-1.  Back to cited text no. 7
    
8.
Sgaramella N, Tartaro G, D'Amato S, Santagata M, Colella G. Displacement of dental implants into the maxillary sinus: A retrospective study of twenty-one patients. Clin Implant Dent Realt Res 2016;18:62-72.  Back to cited text no. 8
    
9.
Rosen PS. Complications with the bone added osteotome sinus floor elevation: Etiology, prevention and treatment. In: Froum SJ, editor. Dental Implant Complications. UK: Wiley Blackwell; 2010. p. 310-24.  Back to cited text no. 9
    
10.
Reiser GM, Rabinowitz Z, Bruno J, Damoulis PD, Griffin TJ. Evaluation of the maxillary sinus membrane response following elevation with the crestal osteotome technique in human cadavers. Int J Oral Maxillofac Implants 2001;16:833-40.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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