M.

Chiapasco The treatment of sinusitis following

G. Felisati
M. Zaniboni
maxillary sinus grafting with the
C. Pipolo association of functional endoscopic
R. Borloni
P. Lozza
sinus surgery (FESS) and an intra-oral
approach

Authors’ affiliations:
M. Chiapasco, M. Zaniboni, Unit of Oral Surgery,
Department of Medicine, Surgery, and Dentistry, S.
Paolo Hospital, University of Milan, Milan, Italy
G. Felisati, C. Pipolo, P. Lozza, Unit of
Otorinolaryngology, Department of Medicine,
Surgery, and Dentistry, S. Paolo Hospital,
University of Milan,Milan, Italy
R. Borloni, Unit of Maxillofacial Surgery, Istituto
Stomatologico Italiano, Milan, Italy
Corresponding author:
Matteo Chiapasco
Clinica Odontoiatrica
Via Beldiletto 1/3 – 20142 Milano, Italy
Tel.: +02 50319000
Fax: +02 50319040
e-mail: matteo.chiapasco@unimi.it
Key words: bone regeneration, bone substitutes, functional endoscopic sinus surgery, guided
tissue regeneration, sinus floor elevation, sinusitis, surgical techniques
Abstract
Aim of the study: To present the results of a prospective study on the management of infectious
complications following maxillary sinus floor elevation procedures with a combined endoscopic
(FESS) and intra-oral approach.
Materials and methods: From 2005 to 2009, twenty consecutive patients were diagnosed for
sinusal chronic infectious complications refractory to medical treatment following maxillary sinus
floor elevation and grafting procedures. All patients were treated with a combination of
functional endoscopic sinus surgery (FESS) through a transnasal approach and an intra-oral
approach, performed by an ear, nose, and throat team and an oral and maxillofacial team,
respectively, in the same surgical session under general anesthesia.
Results: In 16 of 20 patients, the 4-week endoscopic control demonstrated a complete clinical
healing and recovery of the normal sinus ventilation and drainage. In two patients, the persisting
sinusitis at the 4-week control was successfully treated (8th week) with an antibiotic therapy based
on the antibiogram carried out on the bacterial culture obtained by the aspiration of the sinusal
content. In one patient, the persisting sinusitis (3 months after surgery) was successfully treated
with the aspiration of the infectious material from the maxillary sinus. In one patient, finally, it
was necessary to perform a second combined surgical treatment to treat the persisting sinusitis.
Discussion and conclusions: In this study, a relevant number of cases of chronic infectious
complications following sinus floor elevation procedures are presented. To the authors’
knowledge, it is the first time that well-defined treatment protocols based on a combined
endoscopic (FESS) and intra-oral surgical approach are proposed. The positive, albeit preliminary,
results obtained in this study seem to validate this treatment modality.

Date:
Accepted 26 January 2012
To cite this article:
Chiapasco M, Felisati G, Zaniboni M, Pipolo C, Borloni R,
Lozza P. The treatment of sinusitis following maxillary sinus
grafting with the association of functional endoscopic sinus
surgery (FESS) and an intra-oral approach.
Clin. Oral Impl. Res. 00, 2012, 1–7
doi: 10.1111/j.1600-0501.2012.02440.x
The rehabilitation of partially or totally eden-
tulous patients with implant-supported pros-
theses has become common practice in the
last decades, with reliable long-term results
(Albrektsson et al. 1986; Lindquist et al.
1996; Buser et al. 1997; Arvidson et al. 1998;
Lekholm et al. 1999; Weber et al. 2000; Leon-
hardt et al. 2002).
However, local conditions of the edentu-
lous alveolar ridges may be unfavorable for
implant placement. In particular, the poster-
ior edentulous maxilla has frequently pre-
sented a challenge for the oral surgeon
because of the lack of bone, due to alveolar
ridge resorption and maxillary sinus expan-
sion. Moreover, the low quality of the resid-
ual bone can further reduce the long-term
outcome of implants placed in this area.
For these reasons, maxillary sinus floor ele-
vation and grafting via either a lateral or a
crestal approach have become a very common
procedure in recent years, with predictable
results and a generally low post-operative
complication rates (Chiapasco et al. 2006a,
2006b, 2009a, 2009b). Although rare, compli-
cations following sinus floor elevation and
grafting may present, with a 3% incidence, as
maxillary sinusitis and/or infection of the
grafting material, occasionally associated
with the formation of oro-antral communica-
tions in particular in cases of chronic sinus
infection (range: 0–10%). The main cause of

© 2012 John Wiley & Sons A/S 1

Chiapasco et al
The treatment of sinusitis
these complications is represented by the per-
foration of the schneiderian membrane during
the elevation of the sinus floor followed by
the dislocation of the grafting material and/or
dental implant into the sinusal cavity and
subsequent contamination of the material
determining a foreign body reaction and
infection (Chanavaz 1990; Timmenga et al.
1997; Raghoebar & Batenburg 1999; Chiapas-
co et al. 2006a, 2006b; Katranji et al. 2008;
Pjetursson et al. 2008; Chiapasco et al. 2009a,
2009b). However, it was demonstrated that
part of these complications occurred in
patients with a history of sinusitis or sinus
clearance dysfunctions, due to diffuse antral
mucosa hyperplasia, partial or total sinusal
ostium obstruction, or anatomic alterations
in the nasal cavities (that may represent an
obstacle to the sinusal drainage through the
natural ostium in the middle meatus) such as
relevant septum deviation, relevant turbinate
hyperplasia, and the presence of the concha
bullosa (Timmenga et al. 1997; Sambataro
et al. 2003; Schwartz-Arad et al. 2004; Pignat-
aro et al. 2008; Mantovani 2009; Wallace
2010; Testori et al. 2011). Infection may be
limited to the maxillary sinus treated with
floor elevation and grafting, but it may also
diffuse to other paranasal cavities and, in the
most severe cases, involve the orbital cavity
and the anterior and middle cranial fossae
(Quiney et al. 1990; Timmenga et al. 2001;
Alkan et al. 2008; Li & Wang 2008). More-
over, sinus infection may determine the for-
mation of oro-antral communications with
chronic suppuration often associated with the
expulsion of grafting material particles from
the fistula. It is therefore mandatory to treat
these complications as soon as possible and
following safe and reliable treatment proto-
cols.
In case of sinus infection in conjunction
with an oro-antral communication following
a sinus floor elevation procedure, the tradi-
tional approach has been represented for
many years by the sinusal toelette with
intra-oral approach, with the aim of removing
the infected grafting material from the sinu-
sal cavity, in association with an inferior me-
atal antrostomy (Caldwell–Luc approach) and
with the closure of oro-antral communica-
tions (if present) with local flaps (El-Hakim
& el-Fakharany 1999; Katranji et al. 2008;
Andric et al. 2010).
Nevertheless, due to the fact that in case
of infectious complications following maxil-
lary sinus floor elevation and grafting, (i)
other paranasal cavities may be involved (eth-
moid, frontal sinus, sphenoid sinus) that can-
not be treated via and intra-oral approach; (ii)
2 | Clin. Oral Impl. Res. 0, 2012 / 1–7
a primary or secondary ostium obstruction
determined by hyperplasia of the reactive
mucosa is often present, sometimes associ-
ated with secondary medialization of the
uncinate process that further hinders the
sinus ventilation and drainage; and (iii) pre-
disposing conditions (septum deviation, con-
cha bullosa, hypertrophic turbinates, etc.)
may be present, the sinusal toelette with an
intra-oral approach in association with an
inferior meatal antrostomy may prove to be
insufficient to obtain a complete recovery of
the sinusal functions.
It was indeed demonstrated that in case of
maxillary sinusitis, the treatment of choice is
nowadays represented by a transnasal endo-
scopic approach, internationally known as
FESS (Functional Endoscopic Sinus Surgery)
(Schaefer et al. 1989; Stammberger 1989; Bus-
aba & Kieff 2002). This approach, besides
being definitely more conservative in compar-
ison with the traditional Caldwell–Luc tech-
nique, demonstrated to be the only one that
allows the correction of the ostium obstruc-
tion, the treatment of other paranasal sinuses
involved in the infection, and of the previ-
ously cited predisposing anatomic factors.
On the other hand, the FESS approach
alone may not be sufficient for the complete
removal of the infected grafting material
from the maxillary sinus (due to the impossi-
bility of reaching every portion of the sinus
with the available surgical instruments) and
does not allow the closure of oro-antral com-
munications, if present.
Therefore, the most appropriate approach
for the treatment of maxillary sinusitis fol-
lowing sinus floor elevation and grafting
might be a combination of FESS and intra-oral
surgery. While this type of combined approach
has already been described for the removal of
dental implants migrated into the maxillary
sinus (Chiapasco et al. 2009a, 2009b), to the
Authors’ knowledge, it has never been sys-
tematically proposed or described for the
treatment of maxillary sinusitis subsequent to
sinus floor elevation and grafting.
The aim of this study was therefore to
present the Authors’ experience with this
approach in the treatment of infectious com-
plications following sinus grafting procedures
on a sample of 20 consecutively treated
patients.
Materials and methods
From January 2005 to December 2009, 20
patients (14 women and six men) with ages
ranging from 34 to 65 years (mean: 49.2 years)
who previously underwent (2–12 months
before) sinus floor elevation and grafting with
a lateral approach in dental private practices,
were referred to our departments (1. Unit of
Otolaryngology, Department of Medicine,
Surgery, and Dentistry, San Paolo Hospital,
University of Milan, Milan, Italy; 2. Unit of
Oral Surgery, Department of Medicine, Sur-
gery, and Dentistry, San Paolo Hospital, Uni-
versity of Milan, Milan, Italy; 3. Unit of
Maxillofacial Surgery, Istituto Stomatologico
Italiano, Milan, Italy). The three centers coop-
erate since 2005 and all patients were exam-
ined by a joint team of maxillofacial and ENT
surgeons.
All patients reported that, days after under-
going a sinus grafting procedure (range: 3–
12 weeks after), one or more of the following
symptoms appeared: (i) pain and/or feeling of
tension to the face; (ii) visible swelling of the
cheek/paranasal area/inferior orbital area,
sometimes associated with cutaneous redden-
ing; (iii) chronic suppuration, sometimes
associated with the expulsion of grafting
material from the mouth and/or nose.
All patients presented one or more oro-
antral fistulae, with the smallest ones being
inspectable only with a surgical probe and
the larger ones being clinically visible.
Seventeen of 20 patients had been treated
with unilateral sinus lift (two of them, #2
and 13, in association with implant place-
ment), while three had been treated with
bilateral sinus lift. Antibiotic therapy was
administered to all patients by their dentists
(penicillins, penicillin in association with
clavulanate, cephalosporins, macrolides) to
treat the post-operative infection, but with
only partial remission of signs and symptoms
related to sinus infection.
Clinical evaluation of the patients at our
units was associated with instrumental exam-
ination by means of: (i) panoramic radiograph;
(ii) cranio-facial CT scan; (iii) nasal endoscopy
(Karl Storz GmbH & Co. KG, Tuttlingen,
Germany). When available, radiographic exam-
inations carried out prior to sinus floor eleva-
tion were evaluated: these were often limited
to periapical or panoramic radiographs. From
these radiographs, it was impossible to clearly
define the maxillary sinus situation before
sinus grafting. In two patients, only CT scans
of the maxilla obtained with a software dedi-
cated to dental implant planning (Denta-scan
or similar) were available, and showed no sign
of pre-existing sinus floor pathology. None-
theless, it was impossible to evaluate the
entire maxillofacial complex, including the
ostium of the maxillary sinus, the other para-
nasal cavities and the nose.
© 2012 John Wiley & Sons A/S
 Chiapasco et al
The treatment of sinusitis

In 8 of 20 patients, nasal endoscopy and
CT scans showed the presence of infection
limited to the treated maxillary sinuses; in
eight patients, infection involved also the
ethmoidal cells, and in four patients, infec-
tion involved the maxillary sinuses, the eth-
moidal cells, and the frontal sinus. None of
the patients presented infection of the sphe-
noidal sinus. In 7 of 20 patients, a variable
amount of grafting material (particulated
autogenous bone and alloplastic materials)
was found inside the maxillary sinus cavity,
both in contact with the sinus floor and
sparse in different areas of the sinus (see
Table 1).
All patients presented a total or sub-total
clouding of the treated sinuses associated
with obstruction of the ostium. In seven
patients (#1, 2, 3, 7, 15, 19, 20), concomitant
conditions that further determined the
obstruction of the ostium, such as the con-
cha bullosa, relevant septum deviation, and
hyperthophy of the turbinates, were observed
(see Table 1).
Due to the presence of: (i) sinusitis, often
involving other paranasal cavities; (ii) ostium
obstruction; and (iii) oro-antral fistulae, in all
patients a transnasal endoscopic approach
(FESS – Functional Endoscopic Sinus Surgery)
performed by the ENT team associated with
an intra-oral approach performed by the MF
team were used in the same surgical session,
under general anesthesia.
The FESS had not only the objective of
eliminating infection in the involved parana-
sal cavities, and removing the infected graft-
ing material from the maxillary sinus, but
also that of widening the ostium and remov-
ing any obstacle to the correct sinus drainage
and clearance.
The intra-oral approach had the objective
of: (i) removing the grafting material not
reachable with endoscopy (inferior portion
and anterior recess of the maxillary sinus) or
already consolidated on the sinus floor; (ii)
closing the oro-antral communications by
removing fistulae and performing a closure
with local flaps. In some cases, endoscopy
was used also from the intra-oral side to thor-
oughly check for residual granules of grafting
material after transnasal procedures and
intra-oral toelette were performed.
Antibiotic therapy (Ceftriaxone, 2 g at
anesthesia induction, and 2 g/day in the fol-
lowing 7–10 days) was administered to all
patients via intra-muscular injection.
In one patient (#7), who developed a bacte-
rial infection associated with aspergillosis
(fungus ball, as confirmed by laboratory anal-
ysis), this therapy was associated with oral
administration of Levofloxacin (500 mg/day
for 15 days).
Endoscopic phase (FESS)
The endoscopic phase always represented the
first part of the surgical intervention, carried
out in all cases under general anesthesia with
oro-tracheal intubation. First, inferior uncin-
ectomy was performed to expose the ostium,
followed by a wide middle antrostomy that
allowed for the removal of pus and infected
grafting material dislocated inside the maxil-
lary sinus. No attempt to entirely remove the
sinus mucosa (differently from the traditional
Caldwell–Luc technique) was carried out: only
hypertrophic or polypoid tissue was removed,
with the objective of reducing as much as pos-
sible bone exposure inside the sinus.
In cases in which maxillary sinus infection
was associated with ethmoidal cells and/or
frontal sinus infection, these latter were trea-
ted by a thorough endoscopic toelette.
In cases in which concomitant conditions
such as the concha bullosa or middle turbi-
nate hypertrophy were present (#1, 7, 15, 19,
20), these latter were treated in the same sur-
gical session via endoscopic approach, to
eliminate every possible obstacle to the func-
tional recovery of the sinusal functionality.
Intra-oral phase
Once the FESS phase was completed, the
intra-oral phase began without the placement
of nasal packing, to permit a final control at
the end of the surgical intervention.
A full thickness mucoperiosteal flap was
elevated in the lateral-posterior maxilla to
obtain the exposure of the antero-lateral wall
of the maxillary sinus. The flap was designed

Table 1. Patients’ demographic and clinical data

Associated Date FESS +
Pts. Sex Age First surgery Complications factors intra-oral Complications – treatment of complications
#1 F 54 LSL MSin + ESin CB 2005 No
#2 M 45 LSL + IIm MSin + ESin + AMM SD 2006 Sinusitis relapse due to perimplantitis –
Second FESS + IO with complete healing
in 4 weeks
#3 M 55 RSL MSin + ESin + AMM SD 2006 Persisting sinusitis – transnasal aspiration
with complete healing in 3 weeks
#4 F 51 RSL MSin + ESin No 2007 No
#5 F 34 RSL MSin No 2008 No
#6 F 55 LSL MSin + ESin No 2008 No
#7 F 57 LSL MSin + FB CB + TurbHyper 2008 No
#8 M 59 LSL MSin + ESin + FSin No 2008 Persisting sinusitis – antibiotic therapy with
complete healing in 10 days
#9 M 41 LSL MSin + ABM No 2009 No
#10 F 45 RSL MSin + ESin No 2009 No
#11 F 47 LSL MSin + ESin + FSin No 2009 No
#12 F 50 LSL + RSL MSin + ESin bilateral No 2009 No
#13 F 51 LSL + IIm MSin + ESin + FSin No 2009 No
#14 F 55 RSL MSin + AMM No 2009 No
#15 F 59 SLS + RSL MSin bilateral SD + TurbHyper 2009 No
#16 F 65 LSL MSin + AMM No 2009 No
#17 M 37 LSL MSin + AMM No 2010 No
#18 F 44 RSL MSin + AMM No 2010 Persisting sinusitis – antibiotic therapy with
complete healing in 6 days
#19 M 35 LSL + RSL MSin + ESin bilateral + AMM TurbHyper 2011 No
#20 F 44 LSL MSin + ESin + FSin TurbHyper 2011 No

LSL, left sinus lift; RSL, right sinus lift; IIm, immediate implants; MSin, maxillary sinusitis; ESin, etmoidal sinusitis; FSin, frontal sinusitis; FB, fungus ball; SD,
septum deviation; AMM, alloplastic material migration; ABM, autogenous bone migration; CB, concha bullosa; TurbHyper, turbinate hypertrophy.

© 2012 John Wiley & Sons A/S 3 | Clin. Oral Impl. Res. 0, 2012 / 1–7
Chiapasco et al
The treatment of sinusitis

according to the position and dimension of the
oro-antral communications, to allow a safe
removal of the fistulae and a competent
suture. The window used for the initial sinus
grafting attempt was used (widened if neces-
sary) to gain access to the maxillary sinus and
to remove the remnants of the infected graft-
ing material. These were generally localized
on the floor of the maxillary sinus and in its
anterior recess, as these areas are not easily
reachable via the transnasal approach. In the
two patients who had received dental implants
in conjunction with sinus floor elevation (#2,
13), a partial penetration of the implants into
the sinus was observed: these were covered by
a layer of septic material, and were therefore
removed to eliminate any source of possible
infection that could lead to relapse.
In total, five implants were removed, and
fistulae were excised.
Before suturing the flaps, an additional
endoscopic control was performed to verify
the completion of the toelette of the maxil-
lary sinuses. Sutures were then applied, after
careful flap mobilization by means of perio-
steal incisions, to allow a tension-free, water-
tight closure of the surgical wound. In 8 of
20 patients, who presented large oro-antral
communications due to the inadequate tech-
nique used for sinus floor elevation, to the
subsequent chronic infection, and to the
removal of implants that penetrated into the
sinus cavity, a double layer closure of the
communications was performed. The first
layer was represented by a buccal fat pad flap
sutured to the palatal side of the communica-
tion, while the second layer was represented
by then by a buccal mucosal flap, sutured to
the palate over the buccal fat pad flap.
Finally, after nasal and sinusal hemostasis
was checked by direct inspection, a nasal
package was applied.
Results
Post-operative recovery was uneventful for
all patients, with a hospitalization period of 1
or 2 days. The nasal package was removed
the day after the surgical intervention, and
patients were instructed to (i) follow an anti-
biotic therapy (2 g/day in the following 7–
10 days); (ii) perform nasal flushings with
sterile saline and nasal applications of Mup-
irocin ointment; (iii) avoid blowing their nose
for 15 days; (iv) follow a soft diet for 10–
15 days; (v) maintain a thorough oral hygiene
with the aid of 0.2% chlorhexidine mouth-
washes until suture removal.
Sutures were removed 10–12 days after sur-
gery; post-operative controls were scheduled
at 2–4–8–12–24–48 weeks, and annually
thereafter. These controls, performed with
nasal endoscopy, were associated at the 24-
week appointment with a radiographic re-
evaluation by means of cranio-facial CT
scans in cases in which a reconstructive/
implant rehabilitation was planned as a fur-
ther step for the prosthetic rehabilitation of
the patients.
In 16 of 20 patients, complete healing of
the infected sites after surgery was obtained,
together with the restoration of normal max-
illary sinus ventilation and drainage, and
ostium patency.
In 6 of 10 patients who undertook radio-
graphic re-examination at the 24 weeks con-
trol, the CT scans showed normalization of
the sinus mucosa, while in the remaining
four cases, a residual thickening of the
mucosa was observed: this, however, had no
negative effects on the normal naso-sinusal
functionality.
In 4 of 20 patients (#1, 3, 8, 18), despite an
adequate antrostomy, a persisting suppura-
tion with spontaneous drainage was still
present 4 weeks after surgery, although in
absence of the usual symptoms of maxillary
sinusitis such as pain and feeling of tension.
These patients underwent transnasal endo-
scopic aspiration of suppurative material
samples followed by culture examination
associated with antibiogram. The presence of
Staphylococcus Aureus was confirmed in two
cases (#8, 18). According to the results of the
antibiogram, a new antibiotic therapy with
Levofloxacin (750 mg/die for 15 days) was
administered to the two patients for whom
the presence of Staphylococcus Aureus was
confirmed, and complete healing was
achieved in 10 and 6 days, respectively. As
far as the two other patients are concerned,
culture examinations were negative and the
attempt to treat the persisting infection with
broad-spectrum antibiotics was unsuccessful.
In one case (#3), a second transnasal endo-
scopic aspiration allowed the evacuation of
the septic material and a subsequent sponta-
neous expulsion of three fragments of graft-
ing material led to complete healing within
3 weeks. In the other case (#2), a second
combined FESS and intra-oral procedure was
performed: septic material was found into the
maxillary sinus, and the apex of an implant
(affected by peri-implantitis) placed in the
canine region was found to protrude in the
anterior recess of the sinus. The infected
material and implant were removed, and a
few days after surgery, all signs of infection
rapidly regressed, until complete healing that
occurred after 4 weeks.
None of the 20 treated patients showed
signs of relapse after a follow-up period rang-
ing from 1 to 6 years.
A clinical case is presented in Fig. 1a–p.
Discussion
The literature concerning infectious compli-
cations following sinus floor elevation and
grafting is based solely on case reports and
case series with a very limited patient sample
(Quiney et al. 1990; Regev & Smith 1995;
Raghoebar & Batenburg 1999; Maksoud 2001;
Timmenga et al. 2001; Katranji et al. 2008).
This seems to be determined by the fact
that post-operative complications, in particu-
lar infection, after sinus lifting procedures
may be relatively uncommon, or rarely pub-
lished.
As sinus floor elevation and grafting for
implantological purposes has become nowa-
days a routine treatment, it is likely that in

Fig. 1. (a) Panoramic radiograph taken 4 weeks after a left maxillary sinus floor elevation procedure. The sinus was grafted with alloplastic materials: a diffuse sinus opacifica-
tion is visible. (b) CT scans demonstrate a complete obliteration of the maxillary sinus, the involvement of the middle nasal meatus, and the opacification of the left ethmoidal
cells. A large erosion of the inferior wall of the maxillary sinus determined by the sinus lifting procedure and by the subsequent infection that caused the erosion of the alveolar
bone and the formation of an oro-antral fistula. (c)–(d) the endoral view shows a large fistula in the molar region with relevant suppuration and oro-antral communication. Allo-
plastic material granules were expelled from the fistula. (e) during the first endoscopic phase, a relevant suppuration in the middle meatus is evident. (f) after uncinectomy and
maxillary sinus ostium enlargement, it is possible to apirate the suppurative material that invaded the maxillary sinus, and to remove the majority of the grafting material used
for sinus floor elevation. During the same phase, the endoscopic toilette of the ethmoidal cells was also performed. (g)–(h) the intra-oral phase allowed the removal of the oro-
antral fistula, of the residual grafting material in the anterior recess of the sinus, and the hyperplastic soft tissue surrounding the fistula. The large opening on the lateral/infe-
rior wall of the sinus was caused during the sinus floor elevation procedure. (i)–(j) the large oro-antral communication is closed with a first layer of tissue represented by the
buccal fat pad and an overlying second layer represented by a Rehrmann mucosal flap closed with a water-tight suture. (k) endoscopic control 6 months after the surgical inter-
vention shows the restitutio ad integrum of the maxillary sinus: the healthy mucosa and a large ostium allowing the correct drainage and ventilation of the sinus are visible. (l)
–(m) control CT scans confirm the normalization of the naso-sinusal complex, the patency of the enlarged sinusal ostium, and the normal radiolucency of the maxillary sinus
and ethmoidal cells. (n) endoral control after 6 months: the complete healing of the soft tissues and the closure of the oro-antral communication are visible.

4 | Clin. Oral Impl. Res. 0, 2012 / 1–7 © 2012 John Wiley & Sons A/S
 Chiapasco et al
The treatment of sinusitis

(a) (b)

(c)

(g) (k)

(d)

(h) (l)

(e)

(i) (m)

(f)

(j)
(n)

© 2012 John Wiley & Sons A/S 5 | Clin. Oral Impl. Res. 0, 2012 / 1–7
Chiapasco et al
The treatment of sinusitis
the coming years this treatment will gain
wider application and that the complications
related to its use will be more frequent. To
this day, however, due to the limited number
of reported cases and the paucity of informa-
tion available, no well-designed protocols
have been proposed for the treatment of
infectious complications related to maxillary
sinus floor elevation.
The only aspects supported by significant
data reported in the literature are the follow-
ing: (i) post-operative complications after
sinus grafting procedures are more frequent in
patients with a history of sinusitis prior to
the surgical intervention (Timmenga et al.
1997); (ii) some risk factors related to anoma-
lies/alterations of the maxillary sinus-ostium-
middle meatus complex exist, such as the
concha bullosa, turbinate hypertrophy, signif-
icant septum deviation, and these alterations
can interfere with the normal ventilation and
clearance of the maxillary sinus (Timmenga
et al. 1997; Schwartz-Arad et al. 2004; Pignat-
aro et al. 2008; Mantovani 2009; Wallace
2010; Testori et al. 2011); (iii) the treatment
of sinusitis refractory to medical therapy, irre-
spective of their origin (odontogenic or non
odontogenic) should not be treated with the
traditional Caldwell–Luc approach anymore,
because it proved to be ineffective with
respect to the recovery of the physiological
sinusal functions (Stammberger 1986;
Stammberger et al. 1987; Penttilä et al. 1994).
For the first time to the Authors’ knowl-
edge, a relevant survey of chronic/inveterate
infectious complications following maxillary
sinus floor elevation and grafting in associa-
tion with specifically designed treatment pro-
tocols based on the combined FESS-intra-oral
approach is presented in this study.
As far as FESS is concerned, a relevant
number of studies have demonstrated how
this procedure can be considered a relevant
improvement as compared with the tradi-
tional Caldwell–Luc approach for several rea-
sons: (i) it is less invasive; (ii) it allows for
the recovery of the normal sinusal function,
characterized by the spontaneous drainage
from the natural ostium (even if widened),
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6 | Clin. Oral Impl. Res. 0, 2012 / 1–7
and not through an inferior meatotomy that
does not permit, as widely demonstrated, an
adequate sinus drainage; (iii) it eliminates the
need for total sinus mucosa removal, as origi-
nally proposed by Caldwell and Luc; the
mucosa, if left in place, once infection is
treated, will recover to its original aspect and
function in the majority of cases; (iv) by
means of the transnasal endoscopic approach,
it is possible to surgically manage in a mini-
mally invasive way the other paranasal cavi-
ties possibly involved in the infection, which
would not be reachable via an intra-oral
approach; (v) by means of the endoscopic
approach, it is possible to correct/eliminate
the anatomic risk factors that might contrib-
ute as co-factors to infection relapse.
As far as this latter aspect is concerned, it
is worth stressing that, even in healthy
sinuses, the ostium-meatal complex generally
has a small diameter. The presence of ana-
tomic anomalies such as the concha bullosa,
a relevant septum deviation, and turbinate
hypertrophy may further reduce the sinusal
clearance. In healthy conditions, these anom-
alies may be silent. On the contrary, in case
of sinusal infection, the concomitant reactive
hypertrophy of the mucosa of the ostium-
meatus complex may contribute to render the
sinus drainage very difficult or impossible,
with scarce possibilities of compensation and
healing. With the FESS approach, it is possi-
ble in one single surgery to treat all these
aspects and factors and promote the func-
tional recovery of the sinus, once the primary
cause of infection is eliminated (the septic
material dislocated into the sinusal cavity).
It is worth noting that one of the first stud-
ies that underlined the role of pre-existing
naso-sinusal pathologies in augmenting the
risk of complications following sinus lifting
has been published by Timmenga et al.
1997). After that publication, this aspect has
not been adequately developed. It is instead
fundamental, in the light of data reported by
Timmenga et al. in 1997 and in our study, to
perform a thorough clinical and radiographic
analysis prior to any implant treatment
involving the maxillary sinus. For this scope,
Andric, M., Saranovic, V., Drazic, R., Brkovic, B. &
Todorovic, L. (2010) Functional endoscopic sinus
surgery as an adjunctive treatment for closure of
oroantral fistulae: a retrospective analysis. Oral
Surgery Oral Medicine Oral Pathology Oral
Radiology and Endodontics 109: 510–516.
Arvidson, K., Bystedt, H., Frykholm, A., von Ko-
now, L. & Lothigius, E. (1998) Five-year pro-
spective follow-up report of Astra Tech Implant
CT scans limited to the alveolar process and
the floor of the maxillary sinus (such as Den-
taScan used for implantological purposes) are
not recommended, because they do not allow
to evaluate the naso-sinusal complex in its
entirety, and to obtain adequate information
regarding the other paranasal cavities and
possible anatomic anomalies that may act as
co-factors for the development of infectious
complications after the sinus grafting proce-
dures. Only cranio-facial CT scans with
axial, coronal, and sagittal slices can provide
all the information needed for diagnosis and
treatment planning, as they allow to detect
possible contraindications and/or risk factors
to sinus floor elevation often silent from a
clinical point of view. The early identifica-
tion of these conditions permits their elimi-
nation before or during the sinus grafting
procedure, as already proposed by some
Authors (Rosenlicht 1999; Chiapasco et al.
2006a, 2006b; Pignataro et al. 2008).
As far as the intra-oral approach is con-
cerned, it allows to complete the FESS treat-
ment with procedures that it is not possible
to perform from the nasal access, such as (i)
the removal of infected implants with apical
portions penetrating into the maxillary sinus;
(ii) the removal of infected grafting material
not retrievable via the endoscopic approach;
and (iii) the closure of oro-antral communica-
tions.
Conclusions
Results from this study seem to demonstrate
that, even if infrequent, infectious complica-
tions following sinus floor elevation and
grafting may cause clinical situations some-
times very serious, and not treatable with a
simple medical therapy or with a single sur-
gical approach, be it endoscopic or intra-oral.
It was demonstrated, instead, that a combina-
tion of FESS and an intra-oral approach can
be considered the best option for the long-
term resolution of these complications and
for the restoration of a normal naso-sinusal
homeostasis.
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