The sinus elevation procedure is a predictable technique to allow for placement of dental implants in the posterior maxilla when the height of the alveolar ridge is limited. The sinus elevation can be performed by various techniques. In the crestal approach, bone graft is utilized to hydraulically elevate the sinus membrane through an osteotomy prepared in the alveolar crest. The implant can be placed either immediately or at a later surgery. This is a case report of an oroantral communication that developed as a complication to a sinus elevation surgery performed with the crestal approach. A 54-year-old female patient presented for dental implant treatment. The patient reported sleep apnea and smoking. Full-thickness flap was reflected in the posterior maxilla and using trephines, an osteotomy was prepared, 1 mm short of the sinus. The trephined core of bone was pushed into the sinus using osteotomes. Particulate bone graft was introduced through the osteotomy to elevate the sinus membrane, and a collagen membrane was used over the bone graft. Six days after surgery, the patient returned to the clinic with an oroantral communication. The patient reported that she was using a positive-pressure breathing mask at night because of sleep apnea. A flap was extended to the tuberosity area and was rotated palatally to achieve closure. The use of the pressure breathing mask was discontinued. The oroantral communication was successfully closed. Relatively few complications have been reported using the osteotome sinus elevation technique. The use of a positive pressure mask may have complicated a sinus elevation surgery. Other factors that may have contributed to this complication include smoking and delayed healing of the area.
The maxillary sinus is the main anatomic limitation to placing implants in the posterior maxilla. The sinus elevation procedure is a predicable way to allow for placement of dental implants in the posterior maxilla when the height of the alveolar ridge is limited.1,2 The osteotome sinus elevation technique (also known as indirect sinus elevation or crestal or coronal approach)3–5 is a less invasive method where bone graft is utilized to hydraulically elevate the sinus membrane through an osteotomy prepared in the alveolar crest in areas with insufficient bone height. Dental implants can be placed at the time of augmentation or later. Very few complications have been reported following sinus elevation procedures.6–8 To prevent complications, the clinician should identify and minimize factors that compromise healing, including smoking and erroneous oral hygiene practices. Also, the patient should be advised to avoid practices that may cause postoperative trauma.
This report describes a case of oroantral communication following the use of the osteotome technique. The approach used to close the communication is presented, and the possible etiology of the incident is discussed.
A 54-year-old woman presented for an implant consultation. The medical history was noncontributory. The patient gave a history of sleep apnea and reported smoking 1 pack of cigarettes per day. An oral and periodontal exam revealed a defective 3-unit bridge in the upper right quadrant (#2–4) with Miller class II mobility. Tooth #2 showed 70% bone loss and probing depths 6–7 mm. The patient was interested in having the bridge removed and 2 dental implants placed in the areas of #2 and #3 (Figure 1a).
Following initial periodontal treatment with scaling and root planing, the patient presented to the clinic of periodontics for extraction and socket grafting of #2. The area was anesthetized, and the bridge spanning from #2–4 was sectioned distal to #4 leaving the mesial abutment intact. Tooth #2 was extracted, the socket was debrided, and the granulation tissue was removed. One-half milliliter of freeze-dried bone allograft (FDBA) (Musculoskeletal Transplant Foundation, Edison, NJ) was used to graft the socket, and absorbable collagen wound dressing (Collaplug, Integra, Plainsboro, NJ) was placed over the bone graft. The area was sutured with 4-0 chromic gut suture in a criss-cross fashion, and complete closure was obtained. The patient was given postoperative instructions, and antibiotics and pain relievers were prescribed. The patient was seen for postoperative visits every 2 weeks for the first month then monthly for 2 months. At no time did the tissue covering the grafted extraction site fully heal leaving a 2-mm fistula that appeared to communicate with the bone graft.
Three months after extraction, the patient was scheduled for an exploratory surgery of the area with the possibility of performing a sinus lift procedure (Figure 1b). The patient began taking antibiotics (amoxicillin/clavulanic acid tablet, 500 mg/125 mg) and a methylprednisolone dose pack the day before the procedure and was to continue both for 7 days. Following local anesthesia, 50 mL of blood was drawn from the patient and platelet-rich plasma (PRP) was prepared following an established protocol (SmartPRep Office, Harvest Technologies Corporation, Plymouth, Mass).9 A vertical releasing incision was placed on the mesial facial of #4 and a crestal incision was carried distally to the tuberosity area (Figure 2a). A full-thickness flap was elevated facially and lingually revealing the previously grafted socket (#2) with granulation tissue present and very little or no bone fill. The socket was debrided and rinsed with sterile saline. Using a trephine drill of 3-mm diameter, an osteotomy was prepared in the area of #3 (pontic site) 1 mm inferior to the sinus floor, as confirmed by periapical radiograph. The trephined core of bone was fractured and pushed into the sinus using osteotomes (Figure 2b). A large, 5-mm osteotome was placed into the apical area of the extraction socket of #2 to up-fracture the area into the sinus (Figure 2c). FDBA was mixed with PRP, placed into both areas, and osteotomes were used to advance the material into the sinus (Figure 2d). A collagen membrane (Ossix, ColBar LifeScience Ltd, Herzliya, Israel) was placed over grafted sites and interrupted chromic gut and 4.0 polyglactin (Vicryl, Ethicon, Somerville, NJ) sutures were placed, and PRP was applied over the area (Figure 2e and f). Postoperative instructions were given. The patient was instructed to avoid blowing her nose, and to rinse gently with chlorhexidine gluconate 0.12%.
Six days later the patient returned to the clinic and claimed the surgical site had “opened up.” She also reported that when she was drinking water, it would come through her nose. Clinically, the sutures were broken and the flaps open (Figure 3a). The bone graft was lost. Upon questioning the patient about possible causes, she reported using a continuous positive airway pressure (CPAP) breathing mask at night because of the sleep apnea.
The area of the upper right maxilla was anesthetized. Both buccal and lingual flaps were deepithelialized, a distal vertical releasing incision was placed at the distal extent of the wound, and the buccal flap was rotated mesially from the tuberosity area to cover the site (Figure 3b). Interrupted 4.0 polyglactin sutures with insertion of the needle further away from the lips of the flaps were used for closure (Figure 3c). Postoperative instructions were reviewed, including her abstaining from using her CPAP mask at night. The patient was followed every 2 weeks for 2 months, and the area appeared to be healed with complete closure by the end of the first month (Figure 3d).
Contact with the patient was lost; however, the patient presented again for treatment 4 years later. The patient had quit smoking. A new treatment plan was devised: tooth #4 was now hopeless and was extracted. The soft and hard tissue healing was normal (Figure 4a and b). Sinus elevation using the lateral window approach was performed, and the patient discontinued the use of the CPAP device during healing. Healing was uneventful and the sinus elevation was successful.
This report presents a case of an oroantral communication after sinus grafting on a patient using a CPAP mask. This procedure was originally performed to vertically augment a deficient ridge to prepare for future implant placement surgery. Few complications have been reported following sinus elevation procedures.6–8 Reported complications include oroantral communication,10 paroxysmal positional vertigo,11 membrane perforation,12 sinusitis, mucocele formation, loss of graft material, and failure of implants to osseointegrate.13
The factors that possibly contributed to the development of the oroantral communication include the use of the CPAP mask, the history of smoking, the poor healing of the socket prior to the sinus elevation surgery, the flap design, and the suturing technique.
Smoking is a factor known to delay healing following periodontal and oral surgery.14,15 Heat as well as toxic by-products of cigarette smoking have been implicated as risk factors for impaired healing, and may affect the success and complications of oral surgical procedures.15 Therefore, smoking cessation is recommended in patients undergoing such procedures.16 However, it is not clear if the effects of smoking may be abrogated by perioperative discontinuation only. A systematic review by Theadom and Cropley17 concluded that longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications; however, an optimal period of preoperative smoking cessation could not be identified from the available evidence.
Proper flap design and suturing technique are paramount for a successful outcome in oral surgery. In this case, the existing nonhealing socket in the area being operated possibly complicated the sinus elevation. A crestal incision was performed avoiding the socket; a suturing technique with sutures away from the flap margins, such as mattress sutures, to minimize pressure on the flaps should have been employed. The use of platelet-rich plasma has been reported to accelerate soft tissue healing, by stabilizing the wound and providing growth factors.10,18 However the use of PRP is no substitute for improper surgical technique or disturbance of the healing postoperatively.
Postoperative instructions following sinus elevation surgery suggest that the patient should avoid nose blowing and sneezing to prevent increased pressure in the operated sinus. The patient was using a CPAP breathing mask at night because of sleep apnea. CPAP devices are generally safe and have very few and rather mild oral complications, such as occlusal alterations, myofacial pain, gingival irritation, and xerostomia.19 This device would cause an increase in the pressure in the sinuses. Additionally, a CPAP mask may dry the nose and cause irritation and sneezing; an increase of nasopharyngeal problems during treatment with CPAP masks has been reported.20 There have been few reports of serious complications with CPAP masks, especially on patients who had trauma or surgery in the area of the head or thorax, such as a case of development of pneumopericardium following coronary artery bypass graft surgery,21 and a report of a patient with fracture of the base of the skull who developed pneumocephalus following respiratory therapy with CPAP via a face mask.22 There is also a report of subcutaneous emphysema on the face and left neck on a man who sustained mild facial trauma to the left side of his head.23 In all of the reported cases, discontinuation of the CPAP device ameliorated the symptoms. We were unable to find any report of such complication following oral and sinus surgery.
To the knowledge of the authors, this is the first report of a possible association between use of a CPAP mask and complication of a sinus elevation procedure. It is likely that the combination of factors reported above (smoking, technique, CPAP) contributed to the development of the oroantral communication. It may be recommended that prior to oral surgery, especially surgery involving the maxillary sinus, patients are asked on the use of CPAP devices. Consultation with the patient's physician and possibly discontinuation of CPAP therapy should be considered.
The oroantral communication was treated with a flap that was released further than the previous flap and with modified suturing technique, with an attempt to achieve nontension closure. Mattress sutures were employed and a slow-resorbing suture was used. Different approaches have been used to treat oroantral communications. Most include mobilization of a pediculated flap24; the buccal fat pad has also been successfully used.25 Clinicians should be familiar with techniques aimed at closing oroantral communications.10,26
In conclusion, this is a case of an oroantral communication that occurred as a complication of an osteotome sinus elevation procedure. Factors that may have contributed to this complication include the surgical technique, the preexisting delayed healing, and smoking. Also, the use of a CPAP device may have complicated the postoperative sequelae. To the knowledge of the authors, this is the first report of a possible association between the use of a CPAP mask and the complication of a sinus elevation procedure. Because of the possibility of increased nasopharyngeal problems and increased sinus pressure in patients using such devices, their use should be reported in medical history and taken into consideration before sinus elevation is performed.
Private practice, Monroe, La.
Private practice, Volos, Greece.