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Maxillary Sinusitis Caused by Dental Implants Extending into the Maxillary

Sinus and the Nasal Cavities

Article in Journal of Prosthodontics · January 2014

DOI: 10.1111/jopr.12123 · Source: PubMed

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Maxillary Sinusitis Caused by Dental Implants Extending into
the Maxillary Sinus and the Nasal Cavities
Matteo Biafora, MD, Giacomo Bertazzoni, MD, & Matteo Trimarchi, MD
Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy

The article is associated with the American College of Prosthodontists’ journal-based continuing education program. It is accompanied
by an online continuing education activity worth 1 credit. Please visit www.wileyhealthlearning.com/jopr to complete the activity and
earn credit.

Keywords
Sinusitis; dental implants; endoscopic
surgery.
Correspondence
Matteo Trimarchi, Department of
Otorhinolaryngology, San Raffaele Scientific
Institute, Via Olgettina 58, 20132 Milano,
Italy. E-mail: trimarchi.matteo@hsr.it
The authors deny any conflicts of interest.
Accepted August 28, 2013
Abstract
This report describes the case of a patient who underwent osseointegrated dental
implant placement. The implants were misplaced inside the nasal fossae and in the
right maxillary sinus, causing chronic purulent sinusitis. CT scan without contrast
showed signs of right maxillary sinusitis and confirmed the misplacement of four
dental implants that surfaced into the nasal cavities. The imaging also revealed the
presence of another implant that emerged inside the maxillary sinus. The patient
underwent functional endoscopic sinus surgery with complete symptom remission at
the long-term follow-up. We propose that sinusitis caused by protrusion of implants
and by sinus floor lift procedures could share common physiopathological patterns
and predisposing factors.

doi: 10.1111/jopr.12123

Osseointegration of dental implants and placement of implant-
supported prostheses is a widely used technique considered re-
liable for the replacement of missing dental elements.1,2 How-
ever, implant osseointegration can be challenging due to low
bone density and thinness of edentulous alveolar ridges, partic-
ularly in the maxillary bone of elderly patients. This unfavor-
able anatomical condition can cause instability of endosseous
implants and is responsible for a greater failure rate of osseoin-
tegrated implants placed in the maxilla compared to mandibu-
lar implants.3 Inadequate maxillary bone thickness, along with
poor surgical planning and lack of experience, are also asso-
ciated with protrusion of implants in the maxillary sinuses4-6
and/or nasal cavities7 or implant migration to the paranasal
sinuses.8-16
Displacement or partial surfacing of a dental implant in the
maxillary sinus is usually uneventful, but it may episodically
be associated with oroantral fistulae and/or sinusitis,17 while
extension of dental implants in the nasal cavity can be asso-
ciated with rhinosinusitis and rhinitis.7 Such complications of
dental implants can benefit from conservative medical ther-
apy, but surgery is needed for recalcitrant disease. The main
surgical option for treatment of dental implant-related rhinosi-
nusitis is FESS (Functional Endoscopic Sinus Surgery), which
is favored over the Caldwell-Luc operation because of shorter
hospital stays and lower morbidity.18 Surgery can include re-
moval of the implants, but the necessity of this procedure is still
controversial.18
We report a rare case of rhinosinusitis arising from protru-
sion of dental implants in both nasal fossae and the right max-
illary sinus. The patient refused to remove the implants, and
rhinosinusitis treatment with FESS was performed to restore
physiological maxillary sinus drainage and ventilation without
modification of the existing implants.
Clinical report
A 38-year-old woman presented with a 2-year history of recur-
rent nasal obstruction, nasal discharge, and facial pain. Her
past medical history revealed that 2 years before she had
undergone osseointegrated dental implant placement surgery
in another country to replace dental elements missing af-
ter facial trauma related to a car accident. No maxillary si-
nus floor augmentation procedure was performed. No other
data regarding the implantation procedure were available.
Her medical and family histories were otherwise unremark-
able; she was taking no medications and had no known drug
allergies.
The patient underwent otorhinolaryngological evaluation.
Nasal endoscopy showed the emergence of two dental implants
penetrating the inferior turbinates in each nasal fossa, along
with signs of right maxillary sinus infection. Medical ther-
apy was therefore performed, and the patient was administered
two consecutive standard cycles of antibiotics (first cycle with
amoxicillin-clavulanic acid, second cycle with levofloxacin)

Journal of Prosthodontics 23 (2014) 227–231 

C 2014 by the American College of Prosthodontists 227
Sinusitis Caused by Implants into Maxillary Sinus and Nasal Cavities Biafora et al

Figure 1 Preoperative CT imaging; coronal CT (A) protrusion of implants (p) in the nose, inferior turbinate (it) involvement and unscathed middle
turbinates (mt); axial CT (B) dental implants (p) in the right maxillary sinus and in the nose and their relationship with inferior turbinates (it); sagittal CT
scans show an intranasal implant (C); and the implant protruding in the maxillary sinus (D).

and over-the-counter nasal saline douches. Short-term follow-
up after medical treatment revealed persistence of signs and
symptoms of infection and warranted further investigation.
A subsequent maxillofacial CT scan without contrast sh-
owed signs of right maxillary sinusitis and confirmed the
misplacement of four dental implants that surfaced into the
nasal cavities. Imaging also revealed the presence of another
implant that emerged inside the maxillary sinus (Fig 1). Re-
moval or resection of the apices of the misplaced implants was
proposed to the patient, but she refused to undergo any proce-
dure that would involve her implants directly.
For that reason, the patient underwent FESS under general
anesthesia. The nasal mucosa was decongested using intranasal
cotonoids soaked in a solution of carbocain and adrenalin
1:200,000. The nasal mucosa surrounding the uncinate pro-
cess was subsequently infiltrated with the same solution. Intra-
operative nasal inspection with a 0◦ rigid endoscope allowed
clearer visualization of the implants inside the nose (Figs 2A–
C) and the right maxillary sinus. The mucosa surrounding the
portion of the implant that protruded into the right maxillary
sinus appeared hyperemic, indicating a local inflammatory re-
action. Purulent secretions flowed out of the right maxillary
sinus ostium (Fig 2A).
Aeration and drainage of the right maxillary sinus were re-
stored through partial inferior uncinectomy and middle antros-
tomy using a 0◦ rigid endoscope. We then proceeded with irri-
gation of the sinus with saline solution to wash out the puru-
lent secretions. Finally, the mucosa of the sinus was inspected
with a 70◦ rigid endoscope. No macroscopic alterations were
detected.
The postoperative period was unremarkable. The patient was
dismissed the day after surgery, and antibiotic therapy was
prescribed. Short-term follow-up examination and nasal en-
doscopy 10 days later did not show any signs of rhinosinusitis.
No recurrence of symptoms was reported at long-term follow-
up examination, 1 year after surgery. Nasal endoscopy con-
firmed resolution of the disease (Fig 2D).
Discussion
The pathological link between exposure or displacement of
dental implants in the maxillary sinus and sinusitis has not
been fully elucidated.19 Similarly, only hypotheses have been
made on the mechanisms underlying the association between
implant extension into the nasal cavity and rhinosinusitis.7
Dental implant exposure and displacement in the maxillary
sinus of experimental canine models have consistently been
unsuccessful at causing sinusitis and rhinosinusitis.19-21 In par-
ticular, Jung et al, in their experiments on dogs, observed that
when implants penetrated the sinus floor less than 2 mm, the
healing mucosa covered the implants spontaneously. In con-
trast, when the implants penetrated the sinus floor more than 4
mm, the apices of the implants remained exposed. Despite this,
there was no apparent difference in signs of sinusitis in either
experimental group.20 These observations were later confirmed
in humans.21 Nonetheless, reports in the literature indicate that

228 Journal of Prosthodontics 23 (2014) 227–231 

C 2014 by the American College of Prosthodontists
Biafora et al
Figure 2 Intraoperative nasal endoscopy shows, in middle nasal fossa,
(A) purulent secretions flowing out of the maxillary sinus area (m) and
middle (mt) and inferior (it) turbinates; endoscopy in left (B) and right (C)
inferior nasal fossae shows bilateral protrusion of dental implants (p), the
implant extension in the sinuses and into the nasal cavities can
give rise to sinusitis or rhinosinusitis.4-7 Conversely, if the im-
plants are covered by normal mucosa, no alterations of the sinus
arise, as noted by Brånemark et al.19
Retrospective CT imaging of patients with implant penetra-
tion greater than 4 mm in the sinuses and no history of maxillary
sinusitis showed that more than half of the patients presented
mucosal swelling limited to the floor of the maxillary sinus,
but no signs of rhinosinusitis in the follow-up period (6 to 10
months).21
Also, maxillary sinus floor lift has been reported to cause
postoperative sinusitis.22 The lifting of the Schneiderian mem-
brane affects sinus homeostasis and leads to sinusitis by tran-
siently obstructing physiological maxillary drainage through
the ostiomeatal complex (OMC).23 The temporary or perma-
nent blockage of the OMC may be caused by impaired ciliary
activity, inflammation and edema of the ostiomeatal mucosa,
excessive elevation of the maxillary sinus floor, or herniation of
bone graft fragments through the sinus floor into the OMC.23
The negative effects on sinus homeostasis described can give
rise to sinusitis in predisposed patients, as highlighted by Tim-
menga et al.24
It has therefore been hypothesized that mucosal thickening
could mimic the detrimental effects of sinus floor elevation on
the OMC and affect sinus drainage and aeration, thus causing
sinusitis in predisposed patients.21 A similar pathologic mech-
anism has been hypothesized for sinusitis after placement of
Journal of Prosthodontics 23 (2014) 227–231 
C 2014 by the American College of Prosthodontists
Sinusitis Caused by Implants into Maxillary Sinus and Nasal Cavities
area of the maxillary sinus (m) and inferior (it) and middle (mt) turbinates;
and long-term follow-up right maxillary sinus (m) endoscopy (D) shows
implant protrusion (p), healthy mucosa, and absence of secretions.
zygomatic implants, although oroantral communication is also
thought to be an important factor.25
Involvement of the OMC is also thought to be present
in rhinosinusitis related to osseointegrated implants surfac-
ing in the nasal fossae.7 The implants, covered with crusts
and debris, could act as a foreign body and irritate the sur-
rounding mucosa, causing swelling of the OMC. Moreover,
the implants could alter nasal airflow, thereby increasing mu-
cous secretion and scar formation. The interaction of the de-
scribed alterations of nasal physiology has been proposed as
a cause of rhinosinusitis in predisposed patients by Raghoebar
et al.7
For the patient presented here, probably both the dental im-
plants extending into the maxillary sinus and nasal fossae are
equally responsible for the development of the patient’s condi-
tion. Mucosal inflammation caused by misplaced implants on
both sides of the OMC can similarly cause mucosal inflam-
mation and stenosis of the OMC with analogous detrimental
effects on sinus ventilation.
Treatment of recalcitrant dental implant–related sinusitis is
primarily surgical and it aims at restoring proper drainage and
ventilation in the sinus, interrupting the described sequence of
noxious events that lead to sinus infection.23 The desired out-
come can be reached either through elimination of the irritating
stimulus represented by the displaced or surfacing implant, or
through restoration of adequate OMC patency, sinus drainage,
and ventilation.17
229
Sinusitis Caused by Implants into Maxillary Sinus and Nasal Cavities
FESS allows treatment of OMC alterations and removal of
displaced dental implants, if present, but it does not allow re-
moval of implants that emerge into the sinus.4,12,15,17 Intraoral
approaches are more suitable to address oroantral fistulae and
remove implants that are displaced or emerge into the sinus, but
they do not address OMC alterations and sinusitis properly.5,17
Proposed surgical treatments of intranasal protruding implants
feature implant removal or resection of their apical portion.7
In our patient, FESS was sufficient to cause lasting symptom
remission, and it was not necessary to remove the implants.
Probably, the presence of the implants ceased to be a crucial
factor in the pathogenesis of the patient’s sinusitis after im-
provement of sinus drainage and ventilation.
Sinusitis caused by protrusion of implants and sinusitis as-
sociated with sinus floor lift procedures seem to share common
physiopathological patterns and predisposing factors. Nonethe-
less, the role of the ear, nose, and throat (ENT) specialist in the
assessment of factors that predispose to sinusitis is recognized
and well defined only in sinus lift procedures.23,26 On the other
hand, the relatively low rate of ENT complications in osseoin-
tegrated dental implant placement27 has never prompted the or-
ganization of a systematic preoperative ENT work-up. Further
studies could help to assess the actual impact of preoperative
ENT evaluation in the prevention of dental implant-related si-
nusitis in predisposed patients; however, we believe that simple
anamnestic questions on sinonasal health and careful avoidance
of implant protrusion greater than 4 mm, together with standard
preliminary CT scan evaluation and dental examination, could
similarly result in reduction of such rare complications.
Another problem raised by this case concerns the responsi-
bilities of the dental surgeon who placed the implants. An ade-
quate work-up before implant placement can help the surgeon
to avoid or minimize protrusion of implants,17 while patient
follow-up is advisable to reduce delayed diagnosis of complica-
tions, as in our patient; however, she underwent implant place-
ment surgery abroad, to save money. Seeking dental treatment
in another country has been labeled dental tourism.28 Today
the number of dental tourists traveling from Western to Eastern
Europe seeking less expensive dental care is increasing.29,30 It
is evident that this growing trend raises problems of profes-
sional accountability and makes proper follow-up difficult to
arrange.28,30
Conclusion
Our report shows that FESS can be a successful surgical pro-
cedure for the treatment of rhinosinusitis related to dental im-
plants. Further studies are needed to evaluate the efficacy of
FESS in treating recalcitrant dental implant–related rhinosi-
nusitis and its ability to prevent recurrences. FESS allows res-
olution of the infection and restoration of proper sinus venti-
lation, preventing recurrence without removing the misplaced
implants.
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