Removal of Displaced Foreign Body From the Maxillary Sinus ... · Daegu, for the removal of a tooth...

Removal of Displaced Foreign Body Fromthe Maxillary Sinus Using Replaceable BonyWindows and Saline Irrigation, Followed by

Suctioning of the Foreign BodyDong-Seok Sohn, DDS, PhD,* Heui-Seung Jung, DDS,† Ki-Hyun Kim, DDS,‡ Kyung-Jin Song, DDS,§

Hee-Won An, DDS,� and Kyung-Ho Min, DDS¶

Aforeign body can be displaced

into the maxillary sinus duringdental surgery. Dental implants

can migrate into the maxillary sinusdue to poor bone density and/or poorinitial stability in the posterior max-illa.1 Other foreign bodies, such astooth roots or metallic objects, can mi-grate into the sinus due to the doctor’sinexperience.2–4 Migrated foreign bod-ies in the sinus can cause significantcomplications such as inflammatoryreactions, sinusitis, and fungal infec-tions,5–8 and the dental implant can bedisplaced into the sphenoidal sinus.9

To extract displaced foreign bodiesfrom the sinus, the Caldwell-Luc ap-

proach or the lateral window ap-proach, combined with endoscopicsurgery, antrally or transnasally, havebeen reported.5–11 However, when theCaldwell-Luc or lateral window ap-proach is performed without a sinusgraft, the access window may not bereplaced by a new bony wall in thelateral wall of the sinus.12,13 To removeforeign bodies, the use of endoscopy isdefinitely effective; but this procedure,which requires specific training andequipment, has some disadvantages.11

The aim of this report is to present asimple procedure to remove a foreignbody using saline irrigation and suction-ing of the foreign body from the sinus,and how to maintain the integrity of thelateral wall of the maxillary sinus usinga replaceable bony window after the re-moval of foreign body.

CASE REPORT 1A 27-year-old man was referred,

by his family dentist, to the Depart-

ment of Oral and Maxillofacial Sur-gery, Catholic Medical Center ofDaegu, for the removal of a tooth rootthat intruded into the maxillary sinus.The root was displaced by impropermanipulation of an elevator during theextraction of a severely decayed rightmaxillary second premolar. Radio-graphic examination showed the dis-placed tooth root in the sinus (Fig. 1).The patient did not complain of anyproblems associated with the sinus.The patient was scheduled to have theintruded root removed using a replace-able bony window. A sinus graft wasnot planned. Prophylactic Flomoxefsodium (Flumarin; Ildong Pharmaceu-tical Co., Korea, 500 mg iv) was ad-ministered 1 hour before surgery onApril 5, 2007. After the administrationof a local anesthetic solution (2% li-docaine with 1:100,000 epinephrine),a vestibular incision was made, andthe mucoperiosteal flap was elevatedto expose the lateral wall of the max-

*Chairman and Professor, Department of Dentistry and Oraland Maxillofacial Surgery, Daegu Catholic University Hospital,Daegu, Republic of Korea.†Clinical Professor, Department of Dentistry and Oral andMaxillofacial Surgery, Daegu Catholic University Hospital;Private Practice, Seo-Mun Dental Clinic, Daegu, Republic ofKorea.‡Clinical Professor, Department of Dentistry and Oral andMaxillofacial Surgery, Daegu Catholic University Hospital;Private Practice, Goodwill Dental Hospital, Busan, Republic ofKorea.§Clinical Professor, Department of Dentistry and Oral andMaxillofacial Surgery, Daegu Catholic University Hospital;Private Practice, Susung Union Dental Clinic, Daegu, Republicof Korea.�Clinical Professor, Department of Dentistry and Oral andMaxillofacial Surgery, Daegu Catholic University Hospital;Private Practice, Neul Gippen Dental Clinic, Seoul, Republic ofKorea.¶Clinical Professor, Department of Dentistry and Oral andMaxillofacial Surgery, Daegu Catholic University Hospital;Private Practice, Sung Shim Bubu Dental Clinic, Daegu,Republic of Korea.

Reprint requests and correspondence to: Dong-SeokSohn, DDS, PhD, Department of Oral andMaxillofacial Surgery, Daegu Catholic UniversityHospital, 3056-6 Daemyung 4-Dong, Nam-Gu, Daegu705-034, Republic of Korea, Phone: (53) 650-4288,Fax: (53) 622-7067, E-mail: [email protected]

ISSN 1056-6163/11/02002-001Implant DentistryVolume 20 • Number 2Copyright © 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e31820faf53

Various surgical techniques forthe removal of a foreign body frommaxillary sinuses have been re-ported. However, the access windowin the lateral wall of the maxillarysinus cavity is not replaced by abony wall when sinus grafting is notperformed. The replaceable bonywindow provides an access windowinto the sinus cavity and maintainsthe integrity of the lateral wall ofthe sinus cavity after the removal

of a foreign body from the sinus.Saline irrigation and suction aresimple and quick techniques toremove foreign bodies from the si-nus. This technique does not re-quire special equipment, includingthat of endoscopy. (Implant Dent2011;20:1– 000)Key Words: displaced foreign body,replaceable bony window, sinusgraft, ultrasonic piezoelectric bonesurgery, platelet-rich fibrin block

IMPLANT DENTISTRY / VOLUME 20, NUMBER 2 2011 1

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illary sinus. A saw insert with a thinblade (S-Saw, Bukboo Dental Co.,Daegu, Korea), connected to an ultra-sonic piezoelectric device (Surgybone,Silfradent srl, Sofia, Italy), was usedto make the replaceable bony window.The inferior osteotomy was made 2 to3 mm above the sinus floor and theanterior vertical osteotomy was made

2 mm distal to the anterior verticalwall of the maxillary sinus. Both os-teotomies were created perpendicu-larly to the inside of the maxillarysinus lateral wall to facilitate the pre-cise replacement of the bony windowafter removal of the foreign body fromthe sinus. The distal osteotomy wasmade approximately 15 mm awayfrom the anterior vertical osteotomy.The height of the vertical osteotomywas approximately 10 mm (Fig. 2).The bony window was detached care-fully to expose the sinus membrane.An approximately 1-cm long incisionwas made through the sinus mem-brane. The suction apparatus was in-truded into the sinus, and normalsaline was injected into the sinus cav-ity at the same time. The root, floatingin the saline flow, was removed bysuction within 1 minute (Fig. 3) Afterthe removal of the root, the bony por-tion of lateral window was repositioned(Fig. 4). Flaps were sutured using PTFEsutures (Cytoplast, Osteogenic Biomed-ical, Texas, USA) to achieve passiveprimary closure. Postoperative Cefdito-ren pivoxil (Meiact; Boryung Pharm.,Seoul, Korea) 300 mg three times perday was used for 7 days and the sutureswere removed 10 days postoperatively.

CASE REPORT 2A male patient, aged 42 years,

was referred to our Department for theremoval of an intruded implant in thesinus. Crestally approached sinus aug-mentation and simultaneous implantplacement was performed at sites 3, 4,and 5 by a private practitioner onMarch 18, 2009. The implant was sta-ble at the time of surgery, but 3months postoperatively, a radiogramrevealed intrusion at implant site 4(Fig. 5). The cause of the implant in-trusion seems to be the perforation ofthe sinus membrane, according to ourcareful examination of a postoperativecone beam CT scan. The same surgi-cal procedure as seen in case report 1was performed to remove the intrudedimplant from the sinus. The implantwas suctioned to the lateral windowand picked up with a dental pincette(Fig. 6). The sinus membrane was el-evated carefully, and the surface of thesite 4 implant was exposed. The mem-

brane elevation was extended over thesite 3 implant. Colla tape was adaptedto seal the membrane perforation, anda 5.0-mm wide implant (Uni implantSystem, Busan, Korea) was placed si-multaneously at site 4 (Fig. 7). Fourpieces of platelet-rich fibrin blockwith concentrated growth factors weremade by special centrifugation (Medi-fuge, Silfradent srl, S.Sofia, Italy), andinserted into the new compartment ofthe sinus as an alternative to bonegrafting (Fig. 8). The bony portion ofthe window was replaced and the flapswere sutured using PTFE sutures (Fig.9). Implants were uncovered, at a pri-vate practice, after 6 months of heal-ing and all implants were stable. Conebeam CT scans revealed bone forma-tion at sites 3 and 4 in the sinuses(Fig. 10).

DISCUSSION

The displacement of a foreignbody into sinuses is a common com-plication. Displaced foreign bodiescan cause serious complications if notremoved from the sinus.6–11 Varioussurgical methods for the retrieval offoreign bodies have been reported.1–11

The Caldwell-Luc approach, the lat-eral window approach, or endoscopictransantral/transnasal surgery are com-monly used procedures for the re-trieval of foreign bodies. TheCaldwell-Luc approach has some dis-advantages such as postoperativenumbness, paresthesis, facial asym-metry, and dental problems.14,15 Thelateral window approach provides bet-ter direct vision to verify the foreignbody in the sinus than an approachthrough the alveolar socket, and sinusbone grafting could be followed afterthe removal of the foreign body fromthe sinus. However, the lateral win-dow or Caldwell-Luc approach for theretrieval of a foreign body violates theintegrity of the lateral wall of the sinusand the access window may not bereplaced by a bony wall if the sinusbone graft is not performed at thesame time (as shown after the classicCaldwell-Luc operation).12,13 In addi-tion, a sinus graft is not indicated in allpatients after the removal of a foreignbody from the sinus. Sinus grafting is

Fig. 1. Radiogram showing residual root inthe right maxillary sinus.Fig. 2. Tilted osteotomy was performed tomake a replaceable bony window using apiezoelectric saw insert.Fig. 3. The root was suctioned with a salineflow by an aspirator.Fig. 4. Note the precisely repositioned bonywindow.

2 REMOVAL OF DISPLACED FOREIGN BODY FROM THE MAXILLARY SINUS • SOHN ET AL

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contraindicated when the patients havea history of sinus-related pathology orseverely perforated sinus membranes.In addition, except for displaced den-tal implants into the sinus, a bone graftis not required in most patients afterthe removal of a foreign body from the

sinus. The replaceable bony windowmaintains the integrity of the lateralwall of the sinus after the removal ofthe foreign body. A piezoelectric sawinsert-assisted osteotomy has some ad-vantages such as speed, precision, andminimal bone loss.16 –18 The lateral

bony window made by the piezoelec-tric saw insert with a thin blade isprecisely repositioned, whether bonegrafting in the sinus was performed,because of the tilted osteotomy intothe sinus and the minimal bone lossduring osteotomy.19,20 The replaceablebony window acts as a homologousbarrier over the bone graft in the sinus.Replaceable bony windows not onlyprevent soft tissue invasion into thegrafted site as a barrier but also act asosteoinductive/osteoconductive sub-strates for new bone formation in thesinus and new bony wall in the lateralwall of sinus.19,20 Previous studiesreported the potency for new bone for-mation with replaceable bony win-dows in the maxillary sinus withoutbone grafts in humans.19,21 Histologi-cal evidence to confirm new boneformation, in human sinuses, with re-placeable windows and no bone graftsfor sinus augmentation has been pre-viously reported.19 As an alternative tobone grafting for sinus augmentation,patient’s blood, gelatin sponges,platelet-rich plasma, and platelet-richfibrin blocks with concentrated growthfactors grafted in the new compart-ment under the elevated sinus mem-brane has shown successful new boneformation in the sinus.22–26 Endoscopicsurgery is less invasive than theCaldwell-Luc approach and effec-tively verifies the presence of a for-eign body in the sinus.7,10,11 However,endoscopic surgery is limited to aspecialist with special training, and re-quires special equipment.11 Saline irri-gation through a small incision site ofsinus mucosa into the sinus cavity mo-bilizes displaced foreign bodies in thesinus, and a surgical suction apparatusaspirates the saline and foreign body atthe same time. This technique is asimple and quick method to retrieve aforeign body out of the sinus, and doesnot require special instruments, as en-doscopy does.

CONCLUSION

Replaceable bony window regen-erates new bony walls at the site ofaccess windows, without additional si-nus bone grafting, and maintains theintegrity of the lateral wall of the max-illary after the removal of the foreign

Fig. 5. Radiogram showing the migrated implant into the sinus.Fig. 6. The implant was suctioned by aspirator and picked up with a dental pincette.Fig. 7. The placement of a wide body implant at site 4 after elevation of the sinus membrane.Fig. 8. A platelet-rich fibrin block with concentrated growth factors (CGF) was grafted underthe elevated sinus membrane to accelerate new bone formation in the sinus.Fig. 9. The bony window was repositioned precisely into the access window.Fig. 10. Cone beam CT view showing bone formation at sites 3 and 4 after 6 months ofhealing.



body from the sinus. Saline irrigationinto the sinus cavity and simultaneoussuctioning of the foreign body, whichdoes not require special equipment, isa less invasive and simpler methodthan endoscopy.

Disclosure

The authors claim to have no fi-nancial interest in any company or anyof the products mentioned in this article.

REFERENCES

1. Iida S, Tanaka N, Kogo M, et al. Mi-gration of a dental implant into the maxillarysinus. A case report. Int J Oral MaxillofacSurg. 2000;29:358-359.

2. Smith JL II, Emko P. Management ofa maxillary sinus foreign body (dental bur).Ear Nose Throat J. 2007;86:677-678.

3. Dimitrakopoulos I, Papadaki M. For-eign body in the maxillary sinus: Report ofan unusual case. Quintessence Int. 2008;39:698-701.

4. Sethi A, Cariappa KM, Chitra A. Rootfragment in the ostium of the maxillary sinus.Br J Oral Maxillofac Surg. 2009;47:572-573.

5. Ueda M, Kaneda T. Maxillary sinus-itis caused by dental implants: Report oftwo cases. J Oral Maxillofac Surg. 1992;50:285-287.

6. Macan D, Cabov T, Kobler P, et al.Inflammatory reaction to foreign body(amalgam) in the maxillary sinus misdiag-nosed as an ethmoid tumor. Dentomaxillo-fac Radiol. 2006;35:303-306.

7. Selmani Z, Ashammakhi N. Surgicaltreatment of amalgam fillings causing iat-rogenic sinusitis. J Craniofac Surg. 2006;17:363-365.

8. Burnham R, Bridle C. Aspergillosisof the maxillary sinus secondary to a for-

eign body (amalgam) in the maxillary an-trum. Br J Oral Maxillofac Surg. 2009;47:313-315.

9. Felisati G, Lozza P, Chiapasco M, etal. Endoscopic removal of an unusual for-eign body in the sphenoid sinus: An oralimplant. Clin Oral Implants Res. 2007;18:776-780.

10. Ucer TC. A modified transantral en-doscopic technique for the removal of adisplaced dental implant from the maxillarysinus followed by simultaneous sinus graft-ing. Int J Oral Maxillofac Implants. 2009;24:947-951.

11. Nakamura N, Mitsuyasu T, OhishiM. Endoscopic removal of a dental implantdisplaced into the maxillary sinus: Techni-cal note. Int J Oral Maxillofac Surg. 2004;33:195-197.

12. Unger JM, Dennison BF, Duncav-age JA, et al. The radiological appearanceof the post-Caldwell-Luc maxillary sinus.Clin Radiol. 1986;37:77-81.

13. Ohba T, Morimoto Y, Nagata Y, et al.Comparison of the panoramic radiographicand CT features of post-Caldwell-Luc maxil-lary sinuses. Dentomaxillofac Radiol. 2000;29:280-285.

14. Murray JP. Complications aftertreatment of chronic maxillary sinus dis-ease with Caldwell-Luc procedure. Laryn-goscope. 1983;93:282-284.

15. DeFreitas J, Lucente FE. TheCaldwell-Luc procedure: Institutional re-view of 670 cases: 1975–1985. Laryngo-scope. 1988;98:1297-1300.

16. Sohn DS, Ahn MR, Lee WH, et al.Piezoelectric osteotomy for intraoral har-vesting of bone blocks. Int J PeriodonticsRestorative Dent. 2007;27:127-131.

17. Lee HJ, Ahn MR, Sohn DS. Piezo-electric distraction osteogenesis in theatrophic maxillary anterior area: A casereport. Implant Dent. 2007;16:227-234.

18. Sohn DS. Color Atlas, Clinical Appli-cations of Piezoelectric Bone Surgery. Seoul:Kunja Publishing Co.; 2008:47-160.

19. Sohn DS, Lee JS, Ahn MR, et al.New bone formation in the maxillary sinuswithout bone grafts. Implant Dent. 2008;17:321-331.

20. Sohn DS, Moon JW, Lee HW, et al.Comparison of two piezoelectric cuttingtips for lateral bony window osteotomy: Aretrospective study of 127 consecutivecases. Int J Oral Maxillofac Surg. In press.

21. Lundgren S, Andersson S, GualiniF, et al. Bone reformation with sinus mem-brane elevation: A new surgical techniquefor maxillary sinus floor augmentation. ClinImplant Dent Relat Res. 2004;6:165-173.

22. Steigmann M, Garg AK. A compar-ative study of bilateral sinus lifts performedwith platelet-rich plasma alone versus allo-plastic graft material reconstituted withblood. Implant Dent. 2005;14:261-266.

23. Hatano N, Sennerby L, LundgrenS. Maxillary sinus augmentation using si-nus membrane elevation and peripheralvenous blood for implant-supported reha-bilitation of the atrophic posterior maxilla:Case series. Clin Implant Dent Relat Res.2007;9:150-155.

24. Moon JW, Moon KN, Sohn DS.New bone formation in the maxillary sinuswith elevation of sinus membrane and graftof absorbable gelatin sponge: Case seriesreports. Implantology. 2008;12:46-53.

25. Sohn DS, Moon JW, Moon KN, etal. New bone formation in the maxillary si-nus using only absorbable gelatin sponge.J Oral Maxillofac Surg. 2010;68:1327-1333.

26. Sohn DS, Moon JW, Moon YS, etal. The use of concentrated growth factors(CGF) for sinus augmentation. J Oral Im-plant. 2009;38:25-35.

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Dong-Seok Sohn, DDS, PhD, Heui-SeungJung, DDS, Ki-Hyun Kim, DDS, Kyung-Jin Song, DDS,Hee-Won An, DDS, Kyung-Ho Min, DDSEntfernung verschobener Fremdkorper aus dem Oberkiefer-sinus unter Verwendung austauschbarer knocherner Fensterund salzhaltiger Spulungen und anschließender Absaugungdes Fremdkorpers

ZUSAMMENFASSUNG: Es wurde bereits uber verschie-dene chirurgische Methoden zur Entfernung eines Fremdkor-

pers aus dem Sinus des Oberkiefers berichtet. Allerdings wirddabei das Zugangsfenster in der lateralen Wand der Sinush-ohle im Oberkiefer nicht durch eine knocherne Wand ersetzt,sofern keine Sinustransplantierung durchgefuhrt wird. Dasaustauschbare knocherne Fenster bietet ein Zugangsfenster indie Sinushohle hinein und erhalt die Integritat der lateralenWand der Sinushohle nach Entfernung des Fremdkorpersaus dem Sinus. Salzhaltige Spulungen und die Absaugungstellen einfache und schnelle Methoden da, um einenFremdkorper aus dem Sinus zu entfernen. Diese Technikerfordert keine spezielle Ausrustung, inklusive das einerEndoskopie.


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2010;25(3):571-576.

SCHLUSSELWORTER: verschobener Fremdkorper, aus-tauschbares knochernes Fenster, Sinustransplantat, Ultraschall-Piezoelektrische Knochengewebschirurgie, ThrombozytreicherFibrinblock

SPANISH / ESPAÑOLAUTOR(ES): Dong-Seok Sohn, DDS, PhD, Heui-SeungJung, DDS, Ki-Hyun Kim, DDS, Kyung-Jin Song, DDS,Hee-Won An, DDS, Kyung-Ho Min, DDSExtraccion de un cuerpo extrano desplazado en el seno delmaxilar usando ventanas oseas reemplazables e irrigacionsalina, seguido por la aspiracion del cuerpo extrano

ABSTRACTO: Se han reconocido varias tecnicas quirurgicaspara la eliminacion de un cuerpo extrano de los senos maxi-lares. Sin embargo, la ventana de acceso en la pared lateral dela cavidad del seno maxilar no se reemplaza con una paredosea cuando no se realiza el injerto del seno. La ventana oseareemplazable ofrece una ventana de acceso a la cavidad delseno y mantiene la integridad de la pared lateral de la cavidaddel seno luego de la extraccion del cuerpo extrano del seno.La irrigacion salina y aspiracion son tecnicas rapidas y sim-ples para eliminar cuerpos extranos del seno. Esta tecnica norequiere equipos especiales, incluso los de endoscopía.

PALABRAS CLAVES: Cuerpo extrano desplazado, ventanaosea reemplazable, injerto del seno, cirugía osea con ultra-sonido piezoelectrico, bloque de fibrina rica en plaquetas

PORTUGUESE / PORTUGUÊSAUTOR(ES): Dong-Seok Sohn, Cirurgiao-Dentista, PhD,Heui-Seung Jung, Cirurgiao-Dentista, Ki-Hyun Kim, Cirurgiao-Dentista, Kyung-Jin Song, Cirurgiao-Dentista, Hee-Won An,Cirurgiao-Dentista, Kyung-Ho Min, Cirurgiao-DentistaRemocao de corpo estranho deslocado da cavidade maxilarusando-se janelas osseas substituíveis e irrigacao salina,seguidas por succao do corpo estranho

RESUMO: Diversas tecnicas cirurgicas para a remocao deum corpo estranho das cavidades maxilares foram relatadas.Contudo, a janela de acesso na parede lateral da cavidademaxilar nao e substituída por uma parede ossea quando oenxertamento da cavidade nao e realizado. A janela osseasubstituível fornece uma janela de acesso a cavidade e man-tem a integridade da parede lateral da cavidade apos a re-mocao de um corpo estranho da cavidade. A irrigacao salinae a succao sao tecnicas simples e rapidas para remover corposestranhos da cavidade. Essa tecnica nao exige equipamentoespecial, incluindo o da endoscopia.

PALAVRAS-CHAVE: corpo estranho deslocado, janela os-sea substituível, enxerto da cavidade, cirurgia piezoeletricaultrassonica do osso, bloco de fibrina rica em plaquetas

RUSSIAN /��: Dong-Seok Sohn, �� , �� , Heui-Seung Jung,�� , Ki-Hyun Kim,�� , Kyung-Jin Song,�� , Hee-Won An,�� , Kyung-Ho Min,�� , �� ! � ��

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TURKISH / TURKCEYAZARLAR: Dong-Seok Sohn, DDS, PhD, Heui-SeungJung, DDS, Ki-Hyun Kim, DDS, Kyung-Jin Song, DDS,Hee-Won An, DDS, Kyung-Ho Min, DDSYenilenen kemiksel pencere,e serum fizyolojik irigasyonu,ve ardından emme kullanılarak maksiler sinusten yabancıcisim cıkarılması

OZET: Maksiler sinuslerden yabancı bir cismin cıkarılmasınailiskin olarak cesitli cerrahi teknikleri bildirilmistir. Ancak, sinustegreft yapılmadıgında maksiler sinus boslugunun yan duvarındaacılan erisme penceresi kemik bir duvarla kapatılmaz. Kemikpencerenin tekrardan kapatılabilmesi, sinus bosluguna erisimsagladıgı gibi sinusten yabancı cisim cıkarıldıktan sonra sinusboslugunun yan duvarının butunlugunu de korur. Serum fizyolojikile irigasyon ve emme, sinusten yabancı cisimlerin cıkarılmasındakullanılan basit ve hızlı yontemlerdir. Bu teknik, endoskopi de dahilolmak uzere ozel ekipmanın kullanılmasını gerektirmez.

ANAHTAR KELIMELER: Yabancı cisim cıkarılması, ye-nilenen kemik pencere, sinus grefti, ultrasonik piezoelektrikkemik cerrahisi, trombositten zengin fibrin blok


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