Removal of foreign bodies from maxillary sinus:A report of three cases: A Case Report

Abstract

The maxillary sinus is the largest paranasal sinuses and displacement of foreign bodies into it is rarely reported in literature. It is necessary to know how to treat this
kind of situation. The treatment for this complication is the surgical removal of the foreign bodies. We report three cases of foreign bodies (implant, impacted third
molar and root) displaced into the maxillary sinus. The foreign bodies were removed soon after their migration, using the Caldwell-Luc approach, through lateral wall of the maxillary sinus. The operations were performed under local anesthesia and postoperative recoveries were uneventful, without any signs of postoperative sinusitis for both of the patients. In conclusion, Caldwell-Luc technique is a simple approach for the removal of foreign bodies into the maxillary sinus. The great advantage of this technique is that it is performed under local anesthesia and provides direct visualization.

Keywords

Introduction

Largest of paranasal sinuses, maxillary sinuses are the pyramidal shaped cavities localized within the maxillary bone bilaterally. This pyramidal base, an apex of which pointing toward the zygomatic process forms by the lateral wall of the nasal cavity. The upper wall is bounded by the base of the orbit, and the lower wall is bounded by maxilla’s processus alveolaris.¹ The lowest part of the lower wall is 3-5 mm below the nasal cavity and close to the first molar and the second premolar. Maxillary
sinus volume has a natural tendency to increase among life, and especially when premolars and molar teeth are extracted, maxillary sinus may expand downward.¹ Factors that play role in the process of pneumatization of the maxillary sinus are absence of tooth roots after tooth extraction and atrophic resorption of maxillary alveolar crest.² Resorption of the bones can occur in the toothless alveolar crest with wide maxillary sinuses. In such cases, dental implant application is needed together with the sinus lift procedure.² Migration of foreign bodies to paranasal sinuses is a rare but significant condition. Among the reasons for this condition are; clinicians or surgeons with less experience in surgery, perforations during sinus wall lift procedures, implants placed without sinus floor elevation in the excessively pneumatized maxillary sinus, false graft technique, poor anatomical knowledge and maxillary teeth closely related to the maxillary sinus.³ In this case report, we describe the removal of a dental implant, an impacted third molar and a tooth root with the CaldwellLuc approach in three different patients with maxillary sinus displacement.

Case Presentation

Case 1An eighteen-year-old healthy female patient was referred to our department for the assessment of maxillary right third molar which was accidentally displaced into the maxillary sinus. According to the patient’s history, the patient underwent an unsuccessful surgical procedure under local anesthesia performed by a clinician for removal of her impacted right maxillary third molar. The localization of the tooth was detected in the right maxillary sinus with panoramic radiography. (Figure 1A-1B) The cone beam computed tomography (CBCT) taken the next day showed that the tooth was in the apical region of the molar teeth (Figure 1C). The surgical procedure was performed under local anesthesia. The surgical intervention began with the Caldwell-Luc lateral wall approach and the elevation of a trapezoidal full-thickness mucoperiosteal flap was performed. (Figure 1D) The buccal aspect of the flap was raised to access the maxillary sinus bony wall. A low-speed straight hand-piece with a circular diamond bur was used to perform spherical osteotomy. Immediately afterward, the upper third molar was identified and removed with a surgical aspirator and a clamp (Figure 1E). The postoperative healing was uneventful 3 month follow-up period.Case 2A 59-year-old male was referred to our department for the removal of a dental implant that had been displaced to the left maxillary sinus. While the healing cap was being attached, the implant displaced to sinus because of a successful primary stabilization did not occur. The clinical findings were supported by radiological examination and it was seen that the implant was at the apex of the left upper second molar. (Figure 2A) Because the patient did not have an acute infection, surgical removal of the implant under local anesthesia was decided. The surgical procedure was performed under local anesthesia. The crestal incision and vertical relaxing incisions were made for CaldwellLuc operation. After removal of the full thickness flap, a rectangular window was removed on the lateral wall of the sinus with a round bur under irrigation of saline solution. (Figure 2B) The granulation tissues inside the sinus were removed with a sinus curette. The implant was removed with surgical aspirator and hemostat (Figure 2C). The postoperative recovery was uneventful 3 month follow-up period.Case 3A forty-five-year-old female patient was referred to us for her maxillary sinus displaced root after tooth extraction. According to the patient’s history, it has been learned that the left maxillary sinus area has pain and pressure sensation. Vestibular sulcus has sensitivity in palpation. Oroantral fistula findings were not found. Radiological examination revealed root presence in the left maxillary sinus. (Figure 3) It was determined that there was no acute condition in the patient and it was decided to remove the root with the Caldwell-Luc approach under local anesthesia. The surgical procedure was performed under local anesthesia. The surgical intervention began with the CaldwellLuc access bilaterally and the elevation of a trapezoidal fullthickness mucoperiosteal flap. The buccal aspect of the flap
was raised to access the maxillary sinus bony wall. The rectangular bone window was removed with the help of piezo-surgery (Figure 4A). The sinus membrane is perforated and the root is reached. (Figure 4B) L-PRF was applied to the surgery area and the removed bone piece was fixed with the aid of a mini screw
(Figure 4C-4D). Postoperatively, amoxicillin 1000mg, naproxen 550mg, cetirizine 5mg, pseudoephedrine 125mg, % 0,12 chlorhexidine mouth rinse twice a day were prescribed for a week. The postoperative course was uneventful and the patient was asymptomatic in the three months period of follow-up.

Discussion

Because of the anatomical proximity of the upper teeth and dental implant placement in this area, maxillary sinuses are the most important among the paranasal sinuses for clinicians and surgeons in dentistry. Because of this close anatomic relationship, a careful clinical and radiological examination is needed before surgeries made in this area.³ Maxillary sinus-related complications in dentistry are maxillary sinusitis, oroantral fistula formation and migration of foreign bodies into maxillary sinus.⁴ The displacement of foreign bodies into the paranasal sinuses is a rare condition, and migraine usually occurs into the maxillary sinus. However, case reports about migrated implants into ethmoid and sphenoid sinuses are also available in the literature.⁵ In such cases, sometimes no symptoms may be observed and this can occur with routine radiographic examinations. Sometimes it causes an infection in maxillary or other paranasal sinuses.⁶ The causes of this complication include the incorrect extraction technique, poor anatomical information, reduced visualization of the surgical field, and complications
experienced during sinus lifting operation.⁷ In the treatment, there are the following methods as standard Caldwell-Luc operation, transoral functional endoscopic sinus surgery, transnasal functional endoscopic sinus surgery.⁸ Surgeries using the standard Caldwell-Luc approach are under local anesthesia. With this method, sinusoid approach is essential by opening a window on the lateral wall of the maxillary sinus. The approach is direct from the opened window and this
method is advantageous for the experienced clinician. Comparing the Caldwell-Luc surgery with endoscopic sinus surgery, the main disadvantage of endoscopic sinus surgery is the need for general anesthesia. If the foreign bodies are close to the anterior or inferior wall of the maxillary sinus, it is almost impossible to obtain these objects with a transnasal approach.⁸ In this case report, we preferred to receive foreign bodies from the maxillary sinus via Caldwell-Luc operation under local anesthesia.

Conclusion

As a result, migration of foreign bodies to maxillary sinuses as a result of the surgical procedures performed is an undesirable complication. Careful clinical and radiological examination is necessary to avoid such complications. The Caldwell-Luc lateral wall approach is a simple method for removing maxillary sinus
displaced foreign bodies. The biggest advantage is that it is performed under local anesthesia and provides direct visualization.

Declarations

References

1. Costa FS, Bellotti A, Farah GJ, Daniel AN, Camarini ET, Rezende de Moraes Ferreira AC. Surgical management of impacted teeth using three-dimensional computed tomography. J Craniofac Surg. 2011;22(6):2344-2347. doi:10.1097/scs.0b013e318231e304
   Article · PubMed · Google Scholar
2. Tung TC, Chen YR, Santamaria E, Chen CT, Lin CJ, Tsai TR. Dislocation of anatomic structures into the maxillary sinus after craniofacial trauma. Plast Reconstr Surg. 1998;101(7):1904-1908. doi:10.1097/00006534-199806000-00019
   Article · PubMed · Google Scholar
3. Chanavaz M. Maxillary sinus: anatomy, physiology, surgery and bone grafting related to implantology: eleven years of surgical experience (1979-1990). J Oral Implantol. 1990;16:199-209.
   PubMed · Google Scholar
4. Jung JH, Choi BH, Zhu SJ, Lee SH, Huh JY, You TM, et al. The effects of exposing dental implants to the maxillary sinus cavity on sinus complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102:602-605. doi:10.1016/j.tripleo.2005.10.061
   Article · PubMed · Google Scholar
5. Haben CM, Balys R, Frenkiel S. Dental implant migration into the ethmoid sinus. J Otolaryngol. 2003;32:342-344. doi:10.2310/7070.2003.11442
   Article · PubMed · Google Scholar
6. Galindo-Moreno P, Padial-Molina M, Sánchez-Fernández E, Hernández-Cortés P, Wang HL, O’Valle F. Dental implant migration in grafted maxillary sinus. Implant Dent. 2011;20:400-405. doi:10.1097/id.0b013e31822b9d2d
   Article · PubMed · Google Scholar
7. González-García A, González-García J, Diniz-Freitas M, García-García A, Bullón 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-e774.
   PubMed · Google Scholar
8. Felisati G, Lozza P, Chiapasco M, Borloni R. Endoscopic removal of an unusual foreign body in the sphenoid sinus: an oral implant. Clin Oral Implants Res. 2007;18:776-780. doi:10.1111/j.1600-0501.2007.01409.x
   Article · PubMed · Google Scholar

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →