20 Development of Sinusitis After Sinus Floor Elevation Surgery: A Systematic Review Huda Moutaz Asmael, B.D.S. M.Sc. (1) ABSTRACT Background: Maxillary sinusitis can arise after sinus floor elevation surgery and should be treated immediately to prevent further complications which included dental implants failure, graft lost, and oro-antral fistula. This is the first systematic review to assess the incidence, causes, and treatment of sinusitis after sinus lift surgery. Materials and methods: An electronic search included MEDLINE (PUBMED) data base site was carried out for articles involving development of sinusitis after sinus lift surgery from September 1997 up to April, 8, 2017. The search was done and reviewed by two independent authors. Results: The total results of electronic search were (182) abstracts and articles, the extracted articles which involved development of sinusitis after sinus lift surgery were (25) studies. Of the 25 articles only (8) articles fit the inclusion criteria. Maxillary sinusitis was calculated for all selected studies and it was ranged from 2.12% to 12.7% with average of 5.4 %. Conclusion: Maxillary sinusitis could be developed after sinus lift surgery with average of 5.4 % and the patients with previous maxillary sinus disease showed to be at increased risk of sinusitis after sinus lift surgery. Keywords: Sinusitis after sinus lift; sinus lift complication; systematic review. (Received: 26/7/2017; Accepted: 23/8/2017) INTRODUCTION One of the major postoperative complications after sinus floor elevation surgery is sinusitis. The post-surgical sinusitis etiology can arise from two origins; either from earlier chronic infection of the maxillary sinus which is triggered by post-surgical inflammatory changes or from communication with bacteria of oral cavity via perforation of Schneiderian membrane (1). It is very important to treat sinusitis after maxillary sinus lift surgery as soon as possible because the infection may spread to other paranasal sinuses. In addition to that sinus infection may cause oro-antral fistula, loss of graft material and failure of dental implants (2-6). The aims of this study were to present the results of the previous studies which involved development of sinusitis after sinus lift surgery and to assess the incidence of the maxillary sinusitis after sinus floor elevation surgery. MATERIALS AND METHODS An electronic search was carried out in MEDLINE (PubMed) data base site for articles published in the literature from September 7991 up to April, 8, 1077 and limited to studies on human trials. The following keywords were used in the search: sinusitis after sinus lift, sinus lift infection, sinus lift complication and sinusitis after sinus floor elevation surgery. (1) Assistant lecturer at department of Oral and Maxillofacial Surgery, College of Dentistry, University of Baghdad. The search process is demonstrated in diagram 1. Inclusion criteria: 1. Researches involving RCT (randomized clinical trials, prospective and retrospective studies. 2. Studies involving sinusitis development after sinus lift surgery. 3. Studies with at least 6 months of follow-up after sinus lift surgery. 4. Studies on humans only. 5. Articles in English language only. 6. Healthy patients with no systemic diseases that may influence on the maxillary sinus health. Exclusion criteria: 1- Case reports and case series with less than 10 patients. 2- Studies published in other languages than English. 3- Experimental studies (on animals). 4- Studies involving complications after sinus lift other than maxillary sinusitis. 5- Studies with less than 6 months follow-up period. 6- Patient with systemic diseases that may had an effect on maxillary sinus health. Selection of studies Titles and abstracts of the articles were examined initially by two independent reviewers (authors) for the chance of inclusion in this systematic review. J Bagh College Dentistry Vol. 30(4), December 2018 Development of Ali Riyadh Raouf, B.D.S. (2) (2) Ministry of Health, Baghdad, Iraq Ali Khalid Saaed, B.D.S. (2) 21 Diagram 1: The search process. RESULTS The total results of electronic search were 182 abstracts and articles. The reviewed abstracts were 130, the extracted articles which involved development of sinusitis after sinus lift surgery were 25 studies. Of the 25 articles 17 studies were excluded and only 8 articles which fit the inclusion criteria were involved in this research. The characteristic data for each study was summarized in table 1. The average of sinusitis was calculated for all studies and it was 5.4 %. Seventeen articles were excluded from this research because of the following points: 1- Five articles were excluded because they were case reports. 2- One study excluded because it was involving various types of localized lateral alveolar ridge and/or sinus floor augmentation procedures performed before implant placement. 3- Seven articles were excluded because of missing data and not standardized criteria. 4- Three articles were excluded because they written in German language. 5- One article was excluded because the sinusitis complication was not related only to sinus lift surgery but to other causes like odontogenic causes. DISCUSSION Development of sinusitis after sinus lift surgery among the selected studies in this research ranged from 2.12% to 12.7% (10,14). Causes of sinusitis (according to the authors in the selected studies) were as follow: 1- Sinusitis due to sinus membrane perforation as mentioned in two studies (10,12). Nolan et al. (10) reported Sinusitis with percentage of (12.7%) in his study. Of the sinuses presented with sinusitis, 85% have Schneiderian membrane perforation. In contrary three other studies reported that the most common intraoperative complication was Schneiderian membrane perforation, which did not show any relation to postoperative sinusitis (7,9,14). 2- Sinusitis due to assumed long implant 10-16 mm as reported in one study (8). 3- The risk of postoperative sinusitis was increased in patients who had previous chronic sinusitis and in cases in which a large amount of graft was used for sinus augmentation as reported in one study (11) 4- Risk of postoperative sinusitis was associated with sinus elevation width, smoking and sinus membrane perforation (12). CONCLUSION According to this research, sinusitis can developed after sinus lift surgery with average of 5.4 %. Patients with previous maxillary sinus diseases appeared to be at increased risk of sinusitis development after sinus lift surgery. REFERENCES 1. Stuart J. Dental implant complications: etiology, prevention, and treatment. John Wiley & Sons, 2015. 2. Quiney RE, Brimble E, Hodge M. Maxillary sinusitis from dental osseointegrated implants. J Laryngol Otology. 1990: 104: 333–4. 3. Timmenga NM, Raghoebar GM, van Weissenbruch R. Maxillary sinusitis after augmentation of the maxillary sinus floor: a report of 2 cases. J Oral Maxillofac Surg. 2001: 59: 200–4. 4. Alkan, Alper, Nükhet Çelebi, and Burcu Baş. Acute maxillary sinusitis associated with internal sinus lifting: report of a case. Eur J Dent 2008; 69-72. 5. Li J, Wang HL. Common implant-related advanced bone grafting complications: classification, etiology, and management. Impl Dentist. 2008: 17: 389–401. 6. 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. 2013;24(6):623-9. 7. Timmenga, Nicolaas M.. Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 1997; 55(9): 936-9. 8. Cannizzaro, Gioacchino, . Early implant loading in the atrophic posterior maxilla: 1-stage lateral versus crestal sinus lift and 8 mm hydroxyapatite-coated implants. A 5-year randomised controlled trial. Eur J Oral Implant 2013; 6: 1. 9. Vazquez, Jose C. Moreno, Complication rate in 200 consecutive sinus lift procedures: guidelines for prevention and treatment. J Oral Maxillofac Surg 2014; 72(5): 892-901. 10. Nolan, Patrick J., Katherine Freeman, , Richard A. Kraut. Correlation between Schneiderian membrane 17 articles excluded 8 articles fit the inclusion criteria J Bagh College Dentistry Vol. 30(4), December 2018 Development of 22 perforation and sinus lift graft outcome: a retrospective evaluation of 359 augmented sinus. J Oral Maxillofac Surg 2014; 72(1): 47-52. 11. Kayabasoglu, Gurkan, . A retrospective analysis of the relationship between rhinosinusitis and sinus lift dental implantation. Head Face Med 2014; 10(1): 53. 12. Schwarz, Linda, . Risk factors of membrane perforation and postoperative complications in sinus floor elevation surgery: review of 407 augmentation procedures. J Oral Maxillofac Surg 2015; 73(7): 1275-82. 13. Chirilă, Lucian, . Management of acute maxillary sinusitis after sinus bone grafting procedures with simultaneous dental implants placement–a retrospective study. BMC Infect Dis 2016; 16(1): 17. 14. Sakkas, Andreas, Effect of Schneiderian membrane perforation on sinus lift graft outcome using two different donor sites: a retrospective study of 105 maxillary sinus elevation procedures. GMS Interdisc Plast Reconstr Surg DGPW 2016; 5 J Bagh College Dentistry Vol. 30(4), December 2018 Development of Table 1: Summery of the percentage, causes, and treatment of maxillary sinusitis after sinus lift surgery in the selected studies. Treatment Causes of sinusitis Total N of membrane perforations Diagnosis of sinusitis Clinically and/or Radio- graphically N of Sinusitis and ratio Type of Bone substitute N of sinus Augment- ation Types of sinus lift procedure N of patients Year Study Sinusitis symptoms disappear after treatment with decongestants and antibiotics Patients with a predisposition for this condition N: 29 Only 1 case developed sinusitis *Questionnaire *Conventional radiographic examination *Nasoendoscopy N:2 R:4.4% Autogenous bone grafts 85 NM 45 1997 Timmenga et.al (7) NM Assumed long implant 10-16mm NM NM N:1 R: 2.5% Organic bovine & autogenous bone NM lateral and crestal approach 40 2013 Cannizzaro et al (8) NM NM N:52 No relation to Postoperative complications NM N:6 R:4.7% NM 202 NM 127 2014 Vazquez Moreno et al (9) Antibiotics Sinus membrane perforation N: 150 17 of them developed sinusitis (11.3%) NM R: 12.7% NM 359 NM 208 2014 Nolan et al (10) Patients who had an intraoral fistula, the infected graft materials were removed from sinus cavity and they were placed on a 10-day course of clindamycin. *Patients who suffer from chronic sinusitis * large amount of graft N: 8 No one developed sinusitis *Questionnaire *Satisfaction * radiographic examination, and nasal endoscopic 3 of the 4 patients presented with purulent exudative leakage from an intraoral fistula, and 1 patient had symptoms of mild acute sinusitis. N:4 R:4.2% Cortico-cancellous mineralized allograft bone (145) 51 bilateral 43 unilateral Lateral approach 94 2014 Kayabasoglu et al(11) NM * Sinus membrane perforation * Smoking *Sinus elevation width N: 35 11 of them developed sinusitis Clinical symptoms and patient compliance N:34 R:8.4% A mixture of autologous bone and deproteinized bovine bone substitute (Bio- Oss) 407 Lateral approach 300 2015 Schwarz Linda et al (12) Removal of the graft material and implants. The sinus cavity was irrigated with metronidazole solution and an antibiotic therapy was prescribed for the patient which include clindamycin and metronidazole for 10 days Patients developed infections received *xenografts (3 cases) *xenograft + allograft mix (1 case) *alloplastic grafts (1 case) NM “The clinical signs of infection: headache, locoregional pain, cacosmia, inflammation of the oral buccal mucosa and rhinorrhea or unilateral nasal discharge”. N:5 R:4.3% *Xenograft *Allograft *Xenograft and allograft mix *Alloplastic *Xenograft and alloplastic mix 151 Lateral window technique 116 2016 Chirilă et al (13) Antibiotics prescribed for the patients and the graft had to be removed. The patients were not treated with implants anymore Sinusitis developed in patient with no membrane perforation and with no history of maxillary sinus diseases N: 11 No one developed sinusitis (Clinical signs of infection) headache nasal congestion , pain on the operated facial site, fever or redness N:2 R:2.12% Autogenous bone 501 Lateral wall approach 99 2016 Sakkas et al (14) Abbreviations: N: Number; NM: Not mentioned; R: ratio.