A 54-year-old woman who attended the Oral Surgery, Oral Implantology and Maxillofacial Surgery Service of the Teknon Medical Center in December 2005 was referred by her otolaryngologist.
The reason for consultation was the assessment of a possible right maxillary sinusitis of approximately one year of evolution and its association with implant-supported rehabilitation in the first quadrant.
This hemiarch was rehabilitated in February 2001 with four implants (at position 1.2, 1.3, 1.5 and 1.6) that were removed 10 months later due to a peri-implantitis that caused significant bone loss resulting from treatment failure.
In 2002, three implants were sequentially placed (1.2 in a first intervention and 1.3 and 1.6 subsequently) without performing any bone regeneration procedure, which were prosthetically loaded together with a 1.5-point fixed rehabilitation in 2003.
The patient reported permanent cacosmia and halitosis as the main symptoms.
The onset of symptoms suggestive of sinus syndrome dates back to 2004.
Since then, he describes several acute episodes of infection in which the clinical manifestations became more evident: local pain and pressure sensation in the affected jaw, associated with the presence of purulent secretion and nasal sputum more evident in the morning.
These exacerbations resolved after the administration of different antibiotics, whose names do not remember, but the discomfort persisted despite treatment for more than one year.
In the intraoral examination the patient presents a moderate chronic periodontitis in the remaining teeth and a partial edentulism with multiple dental absences: two fixed prostheses in upper jaw and one removable inferior articulated by the sector.
The gingiva adjacent to all implants is swelling, erythematous and bleeding on examination, more markedly in the implant position 1.6.
The implant in position 1.3 shows severe bone loss and exposure of its two coronal thirds.
In the orthopantomography performed in the first visit, it is observed that the implant in position 1.6 is almost entirely within the right maxillary sinus, the base of the same perforation dibuja intu se of great perforation.
Implant in position 1.3 presents a significant loss of bone support and 1.2 is insinuated inside the nostrils.
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Computed tomography (CT) is requested to study more comprehensively the case and the degree of sinus involvement, finding a homogeneous opacification in the right maxillary sinus compared to the contralateral: occupation of mucosal aspect in sinus floor solution.
The implant in position 1.6 is clearly visualized inside it with an associated radiopaque image that in the radiological report is translated as bone graft that accompanies it, apparently not integrated.
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Once the existence of an oral communication of more than two years of evolution has been confirmed, and established this as the cause of the chronic maxillary sinusitis that the patient suffers, it is established as a plan of treatment autologous bone reconstruction plan.
Prior to the surgical phase, the two upper fixed rehabilitations (1.6 to 1.2 implant-supported and 1.1 to 2.6 dental-supported) were removed and a provisional prosthesis was made in the second quadrant.
On January 24, 2006, surgical intervention was performed under local anesthesia and conscious intravenous sedation with midazolam, propofol and remifentanil.
Locoregional paraapical supraperitic high anesthesia was performed throughout the vestibular area of the first quadrant, with palatal reinforcement.
The anesthetic agent used was Articaína 4% + 1:100,000 (Labors Inibsa, Barcelona, Spain).
The horizontal incision is made by the sulcus of the affected implants, with two discharges in distal of 1.2 and of the implant in position 1.6, which were extended to the bottom of the vestibule removing the full thickness of a flap.
The implant in position 1.3 is easily removed due to its little bone support, however it was necessary to use a trephine to extract the implant in position 1.2.
Upon removal of the implant in position 1.6, it is observed, surprisingly, the presence of a resinous material adhered to its entire surface, with probably retentive purposes, and that will greatly contribute to the surrounding bone destruction.
The bone defect created in the residual alveolar ridge is very important.
The entire pathological sinus mucosa was read and a sample was sent for subsequent anatomopathological analysis.
A nasal antrostomy is prepared by placing a drainage tube to promote proper aeration and drainage of the maxillary sinus.
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Autologous bone defects required the opening of a second surgical field in the menu.
Local anesthesia was induced in vestibule bottom of the lower intercanine sector. A modified semilunar flap was then used to remove the bone from the lower intercanine area with a scraper to regenerate 1.3.
The loss of substance was such in the third (1.6) that there was no support to admit any material.
A collagen membrane BioGide® (Geistlich Biomaterials, Wolhusen, Switzerland) was used to seal the oroantral communication and a pediculate edge flap was prepared to achieve tissue destruction.
Through a vertical incision of 1 cm in length over the perithelium defect healing process, Bichat's fat ball was exposed, dissected and bone displaced towards the nipple.
Subsequently, the palatal mucosa was sutured without tension using a resorbable suture of 4/0 (Vicryl®, Johnson & Johnson, New Brunswick, USA).
Finally, the mucoperitic flap was repositioned without tension in the vestibular zone, leaving the alveolar part of the adipose graft exposed to the oral cavity without the need to place a surgical dressing or cement.
The prescribed postoperative medication was: Augmentine® (GlaxoSmithKline, Madrid, Spain) 875/125 mg: 1 capsule every 8 hours for 15 days, Enantyum gelini tablet (Labor 8 days).
Regarding postoperative instructions, special emphasis was placed on avoiding situations that would increase intranasal pressure, such as sneezing or other maneuvers of Valsalva, ingestion of liquid or crushed foods the following week after surgery.
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The postoperative course was uneventful.
Postoperative controls were scheduled the following day, at 3 and 7 days, and drainage was removed at this last visit.
The patient reported no discomfort and almost complete analgesic medication.
The wound was in good condition, with a small erythematous zone at the bottom of the vestibule and a change in color and appearance of the part of the adipose graft that had been exposed.
We recommend extreme oral hygiene.
The suture points were removed after 15 days: the wound closure at this time was complete.
Histological analysis confirmed sinus mucosa with marked edema and dense chronic inflammatory infiltrate.
Periodic postoperative controls and consultations with the otolaryngologist were performed to monitor the case.
Six months after the surgery, the patient had complete symptomatology due to lack of evidence of pathology orthopantomography findings.
