10.14639/0392-100X-suppl.1-41-2021-12
Odontogenic sinusitis represents by definition a border condition between otolaryngology and dental science and, from a holistic perspective, cannot be managed without a proficuous collaboration between specialists. This review focus on the different scenarios currently considered by international literature as related to odontogenic sinusitis and sinonasal complications of dental disease or treatment. Consequently, this review will cover all paranasal sinuses infections caused not only by dental disease (e.g. periodontitis and caries), but also by dental procedures (extractions, endodontics and the like), implantological procedures, pre-implantological (maxillary sinus grafting) and medication-related osteonecrosis of the jaw. After dealing with the odontogenic sinusitis diagnostic process and general principles of treatment, we will thoroughly cover odontogenic sinusitis scenarios treatment following an aetiology-based approach. This literature review shows that, albeit more prospective and rigorous studies are badly needed for determining the best treatment for each patient affected by odontogenic sinusitis, the sheer variety of scenarios that may be encountered should be enough to encourage mutual collaboration between ENTs and dentist. Such collaboration is required both to perfect diagnostic and treatment and to provide
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Giovanni Felisati
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ENT and dentist cooperation in the management of odontogenic sinusitis. A review
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Giovanni Felisati
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Head and Neck Department, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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ENT and dentist cooperation in the management of odontogenic sinusitis. A review
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41(SUPPL.1):S116-S123; doi: 10.14639/0392-100X-suppl.1-41-2021-12




ENT and dentist cooperation in the management
of odontogenic sinusitis. A review
La collaborazione tra otorinolaringoiatra e odontoiatra nel trattamento delle sinusiti
odontogene
Alberto Maria Saibene, Carlotta Pipolo, Roberto Borloni, Giovanni Felisati
Head and Neck Department, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy


SUMMARY
Odontogenic sinusitis represents by definition a border condition between otolaryngology
and dental science and, from a holistic perspective, cannot be managed without a proficu-
ous collaboration between specialists. This review focus on the different scenarios currently
considered by international literature as related to odontogenic sinusitis and sinonasal com-
plications of dental disease or treatment. Consequently, this review will cover all paranasal
sinuses infections caused not only by dental disease (e.g. periodontitis and caries), but also
by dental procedures (extractions, endodontics and the like), implantological procedures,
pre-implantological (maxillary sinus grafting) and medication-related osteonecrosis of the
jaw. After dealing with the odontogenic sinusitis diagnostic process and general principles
of treatment, we will thoroughly cover odontogenic sinusitis scenarios treatment following
an aetiology-based approach. This literature review shows that, albeit more prospective and
rigorous studies are badly needed for determining the best treatment for each patient affect-     Received: October 30, 2020
ed by odontogenic sinusitis, the sheer variety of scenarios that may be encountered should        Accepted: January 23, 2021
be enough to encourage mutual collaboration between ENTs and dentist. Such collabora-
tion is required both to perfect diagnostic and treatment and to provide a solid scientific and   Correspondence
medico-legal foundation for each intervention proposed to patients.                               Alberto Maria Saibene
                                                                                                  Head and Neck Department, ASST Santi Paolo e
KEY WORDS: rhinosinusitis, paranasal sinus, endoscopy, computed tomography,
                                                                                                  Carlo, Department of Health Sciences, Università
Guidelines, dental implants, dental disease, maxillary sinus grafting, maxillary sinus, cone-     degli Studi di Milano
beam computed tomography                                                                          via di A. di Rudini 8, 20142 Milan, Italy
                                                                                                  E-mail: alberto.saibene@gmail.com
RIASSUNTO
Le sinusiti odontogene rappresentano per definizione una condizione al confine tra otori-         Funding
nolaringoiatria e odontoiatria e, da un punto di vista olistico, non possono essere gestite       None.
in assenza di una proficua collaborazione tra specialisti diversi. Questa review si focalizza
sui diversi scenari attualmente considerati nella letteratura internazionale come correlati       Conflict of interest
alle sinusiti odontogene e sulle complicanze naso-sinusali di patologia o trattamento odon-       The Authors declare no conflict of interest.
toiatrico. Conseguentemente, questa review andrà a trattare tutte le infezioni dei seni para-
nasali causate non solo dalla patologia di interesse odontoiatrico (es. parodontite e carie),       How to cite this article: Saibene AM, Pipolo
ma anche conseguenti a trattamenti odontoiatrici classici (estrazioni, endodonzia, et simi-         C, Borloni R, et al. ENT and dentist coop-
lia), procedure implantologiche, procedure pre-implantologiche (rialzo del seno mascella-           eration in the management of odontogenic si-
re) e osteonecrosi del mascellare da farmaci. Dopo aver trattato la diagnosi delle sinusiti         nusitis. A review. Acta Otorhinolaryngol Ital
odontogene e i principi generali di terapia, ci focalizzeremo sulla gestione specifica dei          2021;41(SUPPL.1):S116-S123.        https://doi.
singoli quadri di patologia. Questa revisione della letteratura mostra che, per quanto siano        org/10.14639/0392-100X-suppl.1-41-2021-12
fortemente necessari un numero maggiore di studi prospettici per determinare il miglior
                                                                                                  © Società Italiana di Otorinolaringoiatria
approccio terapeutico per ciascun paziente affetto da sinusite odontogena, il mero numero
                                                                                                  e Chirurgia Cervico-Facciale
di scenari diversi che si possono incontrare dovrebbe essere sufficiente a stimolare la mutua
collaborazione tra otorinolaringoiatri e odontoiatri. Tale collaborazione è necessaria per
                                                                                                                 OPEN ACCESS
perfezionare la fase diagnostica e di trattamento e per realizzare un solido fondamento
scientifico e medico-legale per qualsiasi proposta terapeutica venga rivolta ai pazienti.         This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
PAROLE CHIAVE: rinosinusite, seni paranasali, endoscopia, tomografia computerizzata,              Commercial-NoDerivatives 4.0 International) license. The
linee guida, impianti dentali, rialzo del seno mascellare, seno mascellare, tomografia            article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
computerizzata cone beam                                                                          only in the original version. For further information: https://
                                                                                                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                        Multidisciplinary management of odontogenic sinusitis




Introduction                                                     Table I. Multidisciplinary consensus statements on odontogenic sinusitis
                                                                 (from Craig et al., 2020 9, mod.).
Since it was first described in the Forties, odontogenic si-       Optimal management of ODS involves a shared decision-making process
nusitis (ODS) has represented a common ground for otolar-          between the otolaryngologist, dental provider, and patient, where the
yngologists and dental surgeons 1.                                 benefits and risks of dental treatment and ESS are discussed
ODS is far from being the only condition where otolar-             For complicated ODS (orbital or intracranial involvement), patients should
                                                                   undergo ESS, opening all diseased sinuses on CT scan
yngology meets with other specialities, but it is somehow
                                                                   For ODS patients who have treatable dental pathology, and have minimal or
unique in this duality. Where most multidisciplinary teams         tolerable sinonasal symptoms, primary dental treatment should be pursued
are usually required for treatment, properly trained special-      Oral antibiotics alone are not appropriate in the management of ODS due
ists should also cooperate for diagnosis 2.                        to dental pathology amenable to dental treatments
No single specialist is usually capable of both correctly di-      Once the dental pathology causing ODS has been treated adequately,
agnosing an inflammatory process of the paranasal sinuses,         patients should be followed for at least 1 to 2 months post-treatment to
adequately calibrating the tools recommended by interna-           monitor for sinusitis resolution
tional consensus 3,4, and evaluating the status of teeth and       Balloon sinus dilation may not be appropriate in patients undergoing sinus
                                                                   surgical intervention for ODS given the degree of inflammation and need
dental prosthetics alike, especially given the high complex-
                                                                   for definitive sinus drainage
ity rate the latter achieved in the last decade 5.
                                                                   For ODS patients who have treatable dental pathology and have failed
Despite the term ODS referring literally to the inflamma-          primary dental treatment, ESS should be pursued
tory process of the paranasal sinuses due to diseased teeth,       For ODS patients who have treatable dental pathology, but have significant
as in the first description of the condition, contemporary         sinonasal symptoms, primary ESS combined with subsequent dental
scientific literature stretched the term to include other          treatment should be pursued
loosely related causes 6. As a result, ODS covers all para-        For ODS due to maxillary dental implants, primary ESS should be pursued
nasal sinuses infections caused not only by dental disease         in efforts to preserve the dental implant
                                                                 CT: computed tomography; ESS: endoscopic sinus surgery; ODS: odontogenic sinusitis.
(e.g. periodontitis and caries) but also by dental procedures
(extractions, endodontics and the like), implantological
procedures, pre-implantological maxillary sinus grafting
                                                                 dated 11 and adopted by other groups, both nationally and
and medication-related osteonecrosis of the jaw (MRONJ).         internationally 12,13. The classification (reported in Table II
A composite figure, therefore, emerges, where a complex          along with the number of patients treated at our institution
interplay between otolaryngologists and dental surgeons          from 2012 onwards) successfully tries to integrate different
becomes most often mandatory to understand the bigger            etiologies and possible (often multidisciplinary) treatments
picture and correctly manage the patient.                        for possible ODS scenarios. In this review, after dealing
ODS management becomes even more peculiar if we take             with ODS diagnostic process and general principles of
into account that this protean group of sinonasal conditions     treatment, we will thoroughly cover ODS treatment follow-
lacks shared definition and diagnosis guidelines and the ro-     ing a similar aetiology-based approach:
bust literature on the subject is plagued by extreme hetero-     • diagnosis of ODS;
geneity in defining cases and reporting outcomes. It has to      • general principles of ODS treatment;
be noted though that, despite guidelines on rhinosinusitis       • ODS resulting from dental disease or dental treatments;
being extremely vague on this subject 3, ODS is almost uni-      • ODS following maxillary sinus grafting;
versally considered a completely different condition from        • ODS following dental implants placement;
rhinosinusitis (RS), both in its acute and chronic forms, in     • ODS during medication-related osteonecrosis of the jaw
terms of pathogenesis, microbiology and response to treat-          (MRONJ).
ments 7,8.
A recent multidisciplinary consensus statement 9 addressed
some issues in ODS management after careful revision of          Review
scientific literature. The shared statement emerging from        Diagnosis of ODS
the modified Delphi method consensus are resume in Ta-           As a recent systematic review of ODS literature confirmed 6,
ble I and will be further integrated in the following sections   studies on the subject are hindered by the general lack of a
of this review.                                                  diagnostic consensus. While RS diagnosis requires symp-
The most complete existing classification of ODS, defined        toms to be confirmed 3,4,14, many studies diagnose ODS only
as the group of sinonasal complications resulting from           on the basis of radiological and, less frequently, endoscopic
dental disease or treatment (SCDDT), has been proposed           signs only 6. Furthermore, not all authors agree on which
by our group in 2013 10, and has been prospectively vali-        etiologic scenarios to include under the term ODS (and



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Table II. Sinonasal complications of dental disease and treatment classification, with treated cases since 2002.
 Group                                           Class                  Scenario                   Proposed treatment                    No. of patients   Rate (%)
 I                                                      1a                 Sinusitis following           FESS + material removal                46          8.97%
 Preimplantological treatment                                           preimplantologic surgery             + OAC closure
 complications
 II                                                     2a              Sinusitis with peri-implant     FESS + implant removal +                49          9.55%
 Implantological treatment complications                                     osteitis and OAC                 OAC closure
                                                        2b               Sinusitis due to implant       FESS + implant removal +                 7          1.36%
                                                                           dislocation with OAC               OAC closure
                                                        2c               Sinusitis due to implant        FESS + implant removal                 26          5.07%
                                                                         dislocation without OAC
                                                        2d             Implant dislocation without        implants removal (either              22          4.29%
                                                                                  sinusite                endoscopic or transoral)
 III                                                    3a                    ODS with OAC                  FESS + OAC closure                  129        25.15%
 Classic dental disease or treatment
 complications
                                                        3b                         ODS                              FESS                        234        45.61%
FESS: functional endoscopic sinus surgery; OAC: oro-antral communication; ODS: odontogenic sinusitis.



Table III. Summary of recommendations.
 Clinical scenario                                                                                         Multidisciplinary management
 General ODS treatment principles                                                                                      Mandatory
                                                                                  - concurrent multidisciplinary management for OS with intraorbital or intracranial
                                                                                                  complications or patients with severe symptoms
                                                                               - two-step multidisciplinary management for conservatively treatable dental problems
                                                                                                            in patients with mild symptoms
 Diagnosis of ODS                                                                                               Strongly recommended
 ODS resulting from dental disease or dental treatments                                                                Mandatory
                                                                                    - concurrent multidisciplinary management for existing or expected oro-antral
                                                                                                                    communications
                                                                               - two-step multidisciplinary management for conservatively treatable dental problems
 ODS following maxillary sinus grafting                                           Mandatory in case of graft infection and displacement for graft removal and OAC
                                                                                                                         closure
 ODS following dental implants placement                                       Strongly recommended for implant removal, mandatory for implant removal in case of
                                                                                                        primary ESS failure or for OAC closure
 ODS during MRONJ                                                                                                    Recommended
ESS: endoscopic sinus surgery; MRONJ: medication-related osteonecrosis of the jaw; OAC: oro-antral communication; ODS: odontogenic sinusitis.



even on whether or not the term ODS should be used at                                     exams is more complex. Computed tomography (CT) and
all). Therefore it seems licit to include until further notice                            cone-beam CT (CBCT) are both commonly used for di-
all the aforementioned etiologies. The strong recommen-                                   agnosing sinusitis and identifying the dental problem 17,18,
dation emerging from the literature 7 is that both sinusitis                              albeit with different peculiarities (as a general rule, stand-
AND the odontogenic focus need to be identified for a cor-                                ard CT scan provide a better resolution and contrast for the
rect diagnosis of ODS. Consequently, a strict collaboration                               sinonasal cavities and a better visualization of soft tissues
between the ENT surgeon and an oral surgery specialist is                                 alike, while CBCTs – which represent nevertheless a con-
strongly recommended in order to combine the expertise                                    tinuously evolving technology – usually allow for easier
required to avoid ODS overdiagnosis (blatantly inducing                                   diagnosis of dental conditions). However, dental specialists
consequent overtreatment) and underdiagnosis (which is                                    may further require employing techniques such as ortho-
a known frequent cause of treatment failures in sinus sur-                                pantomography and periapical radiographs to complete the
gery) (Fig. 1) 15,16. While the clinical examination, both                                dental study. Such examination should surely be ordered
dental and otolaryngological, is straightforward, and the                                 only by the dental surgeon in selected cases, as not to ex-
use of nasal endoscopy mandatory, the choice of imaging                                   pose the patient to unnecessary radiation.



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                                                                                     case of ODS with orbital or intracranial complications 9.
                                                                                     Again, opening the maxillary sinus together with the ante-
                                                                                     rior ethmoid, which represents another frequently adopted
                                                                                     surgical choice aimed at restoring a good osteomeatal com-
                                                                                     plex patency, needs further prospective validation before
                                                                                     entering routine clinical use.
                                                                                     Last, before delving into the specific etiological pictures, it
                                                                                     seems reasonable to raise a warning to the ENT specialist
                                                                                     dealing with ODS, a warning that may sound redundant
                                                                                     to specialists used to approach this condition. While ODS
                                                                                     may appear as a “simpler” version of RS, where the aeti-
                                                                                     ology can be rapidly identified without resourcing to en-
                                                                                     dotypes and interleukin-mediated inflammatory responses,
                                                                                     the interplay between teeth and sinuses is extremely com-
                                                                                     plex, and dental causes are often elusive or uncertain. Fur-
                                                                                     thermore, teeth represent an irreplaceable health asset for
                                                                                     patients, while dental and/or implantological treatments
                                                                                     impose hefty financial and healthcare costs, so any dental
                                                                                     procedure, avulsions first and foremost, have to be sup-
                                                                                     ported by case-specific clinical evidence. Following these
                                                                                     considerations, the statement “a shared decision-making
                                                                                     process between the otolaryngologist, dental provider, and
Figure 1. Sagittal CT image showing an odontogenic cyst extending into the           patient, where the benefits and risks of dental treatment and
body of the sphenoid sinus. Odontogenic sinonasal pathology could represent          endoscopic sinus surgery (ESS) are discussed” opening
a matter of difficult differential diagnosis in some patients. A strict collabora-   Craig and colleagues’ consensus 9 should become a mantra
tion between otolaryngologist and dental specialist is often therefore required      in treating ODS, not to turn the ENT-dentist dialogue into a
also in diagnostic terms.
                                                                                     dangerous Mexican standoff with the patient.

General principles of ODS treatment                                                  ODS resulting from dental disease or dental treatments
While it is almost impossible to cover in this review any                            The most classic aetiology of ODS represents, at the same
single clinical picture and the grey areas in between in the                         time, the widest and most diverse chapter to explore.
galaxy of ODS, there are several general principles that                             Among dental conditions capable of inducing sinusitis it
                                                                                     is worth citing periapical infections, caries-related tooth
should be taken into account when dealing with this group
                                                                                     decay, unerupted teeth (Fig. 2) and odontogenic cysts in-
of conditions, some of which are also reported in Craig and
                                                                                     fections; classic dental treatments which may lead to ODS
colleagues’ statement 9.
                                                                                     are represented by failed endodontic treatments (either
Patient with limited sinusitis symptoms and dental pathol-
                                                                                     incomplete or overflowing into the sinus) and extractions
ogy amenable to conservative treatment should seek dental
                                                                                     (resulting in either oro-antral communications – OAC – or
treatment, with endoscopic sinus surgery reserved for non-                           displacement of tooth/dental fragments/dental tools frag-
healing or relapsing patients. On the other hand, patients                           ments into the sinonasal complex) 12,24.
with severe symptoms or orbital/intracranial complications                           While cases pertaining to this aetiology may appear ex-
should be treated with a combined approach right from the                            tremely varied in presentation and sinus involvement, there
diagnosis, thus allowing for sinus drainage and resolution                           are several standpoints than can help the collaboration be-
of the etiological dental focus.                                                     tween otolaryngologist and dental surgeon.
While endoscopic sinus surgery has an undebated role in                              A simple but nevertheless fundamental distinction is be-
ODS treatment, the extent of said surgery is still a mat-                            tween patients with and without OAC (Fig. 3), as originally
ter of debate, since some authors 19,20 proposed that mid-                           proposed by Felisati et al. 10. The former tend to uniformly
dle antrostomy is enough to warrant patient healing. While                           require a combined approach for OAC closure and sinus
prospective validation of these approaches is required, at                           drainage, that yields its best results when performed during
present opening all sinuses involved in ODS 21-23, while be-                         the same surgical session 25,26. The same principle applies
ing the most frequent approach, is recommended only in                               whenever an iatrogenic OAC formation is expected during



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Figure 2. Coronal CT image showing unerupted teeth which determined a
sinusitis process involving the ipsilateral maxillary sinus, ostiomeatal complex
and, partially, anterior ethmoid sinus. Furthermore, the infection progressively
led to the formation of oro-antral communication. A combined approach was
performed in order to drain and ventilate the involved sinuses via an endo-
scopic approach and to remove the unerupted teeth and close the oro-antral         Figure 3. Intraoperative photograph of oroantral communication. A vestibular
communication from an intraoral approach.                                          Rehrmann flap has been raised in order to provide a tension-free closure of
                                                                                   the communication.

ODS treatment (e.g. when the dental surgeon planned the
extraction of a tooth with roots extending into the maxillary                      vertical height before grafting. Immediate implant place-
sinus or when a large odontogenic cyst requires an intraoral                       ment can be proposed only if the initial vertical bone height
approach for its removal). Also, in these cases, a combined                        is enough to warrant implant stability, with the graft provid-
intraoral-endonasal approach should be preferred.                                  ing only a further reinforcement). Sinus complications may
Patient without OAC or where an iatrogenic OAC is not                              follow MSG mainly because of Schneiderian membrane
expected can be managed with ESS alone. In these cases,                            perforation during the grafting, with consequent migration
the dental treatment can be performed during a different                           of the graft inside the sinus, or due to the unnoticed presence
surgical session, which should precede ESS in low to mild                          of otolaryngological contraindications to grafting. Given the
symptomatic patients and follow ESS in heavily sympto-                             significant disruption of the maxillary sinus homeostasis en-
matic patients 9.                                                                  suing the sinus floor elevation, some authors postulated that
                                                                                   a healthy sinus, with a patent ostium and efficient mucocili-
ODS following maxillary sinus grafting                                             ary clearance, was a basic requirement for avoiding sinusitis
Maxillary sinus grafting (MSG) is a common pre-implan-                             processes 27,28. While the collaboration between otolaryngol-
tologic procedure which gained increasing popularity from                          ogist and dental surgeons in evaluating candidates to MSG
the mid-eighties in patients lacking enough vertical bone                          in order to minimize complications is almost mandatory,
height to warrant safe dental implant positioning. The pro-                        this topic goes beyond the scope of this chapter (see also 29).
cedure aims at promoting osteoinduction and osteoconduc-                           Nevertheless, treating ODS ensuing MSG is another matter
tion by positioning grafts (ranging from autologous bone to                        of strict cooperation between these specialists. To navigate
hydroxyapatite) underlying the maxillary sinus Schneiderian                        this scenario and evaluate the requirement of combined ap-
membrane from an intraoral approach. Implant placement                             proaches, several points must be taken into account: 1) dislo-
might be immediate or delayed, i.e. following the consolida-                       cation of grafting material into the sinus; 2) development of
tion of the newly formed bone, according to the initial bone                       a sinusitis process; and 3) the presence of an OAC.



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                                                                                nasal approach is required to open the ostiomeatal complex
                                                                                and ventilate the sinus. As a general rule, if the graft is not
                                                                                displaced into the sinus, oral access for graft removal is not
                                                                                required.
                                                                                Last, the presence of residual OAC communication must be
                                                                                properly evaluated also in post-MSG patients. A residual
                                                                                OAC, which often appears in correspondence to the bony
                                                                                window used for grafting, makes an intraoral approached
                                                                                closure mandatory.

                                                                                ODS following dental implants placement
                                                                                ODS may follow implants placement going awry for three
                                                                                main reasons: 1) implants may lose (or never achieve at
                                                                                all) osseointegration and dislocate into the mouth/sinuses
                                                                                leaving an OAC behind; 2) implants may dislocate into the
                                                                                sinuses, sometimes leading also to sinusitis, or 3) implants
                                                                                may develop peri-implant osteitis (or peri-implantitis) and
                                                                                act as a Trojan horse in allowing bacteria to reach the oth-
                                                                                erwise sterile sinusal spaces 31.
Figure 4. Endoscopic view of the right maxillary sinus obtained via a trans
alveolar approach. A combined approach, both in operative and visualization     The first scenario requires a combined approach were sinus
terms, is required in post maxillary sinus grafting patients in order to com-   drainage is achieved endoscopically and OAC closure is
pletely remove the displaced and infected grafting material, in this specific   performed transorally. Implants displaced into the sinuses
case along with a non-osseointegrated implant.
                                                                                may be retrieved either transorally or via nasal endoscopy
                                                                                according to position and surgeons’ preference.
First and foremost, if an acute infection follows MSG, ap-                      The second scenario, sinusal implant displacement, must
propriate imaging should be used to identify whether the                        be treated endoscopically in case of sinusitis, draining si-
grafting dislocated into the sinus. If the graft is still con-                  nuses and removing the implant. In case of implant dis-
fined under the Schneiderian membrane, it will be up to the                     placement without sinusitis, the retrieval can be performed
dental specialist to follow specific post grafting guidelines                   either transorally, via a bony window or canine fossa ac-
counselling whether trying to salvage the graft with appro-                     cess, or endoscopically 32,33.
priate antibiotic therapy or removing it via the same oral                      Cases in which dental implants are, at least apparently,
approach used when performing the MSG 27. If the graft is                       osseointegrated require the most careful planning and di-
displaced into the sinus, neither the oral approach nor nasal                   agnostic workup (Fig. 5). While multidisciplinary state-
endoscopy is single-handedly enough to remove all the par-                      ments suggest primary endoscopic surgery aimed at treat-
ticles. In these patients, a combined approach is mandatory,                    ing the patient without removing the implant 9, the surgeon
with a wide antrostomy and oral access allowing the use                         must take into account that failure to recognize an unsta-
of angled scopes and curved instruments to ventilate the                        ble and infected implant is a frequent cause of treatment
sinus and remove the particles (Fig. 4). In our experience,                     failure 10,34,35. Indeed, unnecessary implant removal might
a thorough particle removal, pivotal in maximizing thera-                       enhance the risk of OAC and inevitably burdens patients
peutic success rates in these patients, can be achieved only                    with further oral rehabilitation costs. Intraoral radiographs,
employing scopes and instruments both through the nose                          orthopantomography and careful dental clinical evaluation
and the oral access, in order to allow the best maxillary                       can help in minimizing risks at both ends of the spectrum,
sinus visualization 30.                                                         though only sharing the diagnostic and therapeutic plan
Secondly, the specialist should investigate whether a sinus                     with the patient allows tailoring the treatment. In these pa-
inflammatory process has taken place, with careful clini-                       tients, multidisciplinary collaboration represents more of
cal evaluation of the patient coupled with endoscopy and/or                     a diagnostic need than a therapeutic tool. For the sake of
appropriate imaging. Even in the few cases where sinusitis                      completion, it has to be noted that implant penetration in
ensues MSG but without graft infection and displacement                         the maxillary sinus is not per se an indication to implant
(e.g. if the sinusitis ensues months after the grafting, leav-                  removal and does not necessarily imply the development of
ing enough time for osseointegration), an endoscopic endo-                      a sinusitic process over time 36.



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                                                                                 and treatments and providing a solid scientific and medico-
                                                                                 legal foundation for each intervention proposed to patients.

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