After the implant surgery in the posterior maxillary region (especially when the lateral wall of the maxillary sinus is lifted or the top of the alveolar ridge is lifted and the implant is placed at the same time), there is a risk of the implant entering the maxillary sinus due to the negative pressure in the maxillary sinus during respiration, because the bone wall immediately adjacent to the implant is subject to degeneration and necrosis and new bone formation due to the surgical process, so that the secondary stability of the implant is not established for 1-4 weeks and the initial stability gradually decreases. The implant may enter the maxillary sinus as a result of negative pressure during breathing. For the management of this complication, Federico Biglioli et al. from the Department of Maxillofacial Surgery, University of Milan, Italy, introduced an intra-oral approach with a window in the bone wall of the maxillary sinus with a tip, which was found to be safe, easy and effective for the removal of oral implants entering the maxillary sinus under local anesthesia. Between January 2002 and June 2012, 36 patients (19 men and 17 women) who presented with ectopic oral implants into the maxillary sinus were removed using this method. Surgical techniques: (i) Before the extraction procedure, a panoramic film scan was performed to clarify the position of the implant in the maxillary sinus. (ii) All patients received local infiltration anesthesia (mepivacaine epinephrine injection) for the buccal vestibular sulcus and hard palate mucosa, plus infraorbital nerve block anesthesia in 10 patients. (iii) The incision level ranged from the cuspid area to the molar area, with the option of making additional incisions at the vestibule or at the top of the alveolar ridge, proximally and distally, depending on the surgical need. ④The lateral wall of the maxillary sinus is exposed after lifting the mucoperiosteal flap until the position of the infraorbital nerve is clearly defined. ⑤ The size is judged according to the surgical need and a rectangular mark is made, and 2 pairs of round holes are made with a small diameter ball drill to meet the postoperative requirements for fixation of the bone cap. ⑥Saw the proximal, distal and inferior ends of the rectangle (including the maxillary sinus bone wall and the internal sinus cavity mucosa) along the marked lines, noting that the sinus cavity mucosa should be sharply incised rather than torn off. (7) The marker line at the upper end of the rectangle should be carefully dissected, unlike the other 3 sides where only the bone wall is dissected with the sinus cavity mucosa intact. This creates a mucosal hinge that allows the lid of the window to rotate outward or inward and preserves the blood supply to the window to avoid postoperative bone resorption. Once the bone window is successfully opened, the sinus can be fully visualized and the implant can be easily removed. Sometimes, the periphery of the implant may be surrounded by hyperplastic or hypertrophic sinus cavity mucosa, in which case it is necessary to scrape the mucosa carefully and slightly, not to remove the whole mucosa. ⑨ Saline flush the sinus cavity extensively to reduce the chance of infection. ⑩ Close the wound, reposition the bone window in its original position with absorbable sutures through the previously created circular hole, and suture the mucoperiosteal flap. Figure 1. Surgical procedure for ectopic entry of the implant into the maxillary sinus (a) Preoperative panoramic film positioning. (b) Rectangular bone window is created and 2 pairs of circular holes are made with a small diameter ball drill. (c) The maxillary sinus is opened to search for the implant after preserving the mucosa of the superior sinus cavity. (d) At the end of the procedure, the bone window is repositioned and sutured through the circular holes. (e) A computed tomography scan 4 months after surgery shows a healthy maxillary sinus profile and the “disappearance” of the margins of the bone window. Postoperative antibiotic prophylaxis and analgesic treatment were given as appropriate, and oral hygiene was maintained with chlorhexidine mouthwash for 2 weeks. Patients should be instructed not to blow their nose or pinch their nose when sneezing for 3 weeks. When examined 6-12 months after surgery, the surgical scar had almost completely resolved, and CT scans showed no residual maxillary sinus inflammation and nearly complete ossification of the bony margins. Twelve of the 36 patients underwent maxillary sinus floor lift at the same site 12-18 months later, and 17 implants were reinserted 6-9 months after the lift and the denture was restored after completion of osseointegration. The implant retention rate was 100% and there were no maxillary sinus or implant adverse reactions. In combination with the authors’ experience, we can see that the oral approach to the maxillary sinus with osteotomy is simple and safe for the removal of foreign bodies from the maxillary sinus. The procedure can be performed under local anesthesia, with a short operative time, quick recovery and, importantly, does not interfere with the later surgical operation of the implant.
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