Risk factors contributing to early implant failure following sinus augmentation: A study of a challenging cohort.

BACKGROUND: Sinus augmentation has become a more predictable and successful procedure as the knowledge of its indications and complications increased. However, knowledge of risk factors leading to early implant failure (EIF) among challenging systemic and local conditions is insufficient. OBJECTIVES: The present study aims to assess risk factors for EIF following sinus augmentation in a challenging cohort. METHODS: A retrospective cohort study conducted during a period of 8 years in a tertiary referral centre providing surgical and dental health care. Implant and patient variables including age, ASA (American Society of Anesthesiology) physical status classification, smoking, residual alveolar bone, type of anaesthesia and EIF were collected. RESULTS: Cohort was comprised of 751 implants placed in 271 individuals. EIF rates at the implant and patient level were 6.3% and 12.5%, respectively. EIF was found to be higher among smokers (patient level: χ2 (1) = 8.74, p = .003), ASA 2 physical classification patients (patient level: χ2 (2) = 6.75, p = .03), sinuses augmented under general anaesthesia (patient level: χ2 (1)=8.97, p = .003), higher bone gain (implant level: W = 12 350, p = .004), lower residual alveolar bone height (implant level: W = 13 837, p = .001) and multiple implantations (patient level: W = 3016.5, p = 0.01). However, other variables such as age, gender, collagen membrane and implant's dimensions did not reach significance. CONCLUSIONS: Within the limits of the study, we can conclude that smoking, ASA 2 physical status classification, general anaesthesia, low residual alveolar bone height and numerous implants are risk factors for EIF following sinus augmentation in challenging cohorts.

Histopathological and histomorphometric analysis of glandular odontogenic cyst-A diagnostic aid.

OBJECTIVES: Compare recognized microscopic parameters, including variations in width, plaque-like thickenings, intra-epithelial microcysts, clefts, mucous, hob-nail, ciliated and clear cells, between glandular odontogenic cyst (GOC) and GOC-like cysts, investigate the extent of cyst circumference exhibiting these features, and inflammation. MATERIALS AND METHODS: Archival records of cysts with histological features of GOC evaluated between 2000 and2020 were retrieved. Slides were revised, and the expression of features throughout the cyst wall was analyzed. Cysts with at least 5 features were classified as GOC, cysts with 3-4 features as GOC-like. RESULTS: The study included 74 cysts, 47 males M, 25 females (2 unknown gender), aged 19-81 years, 62 (83.8%) GOC, 12 (16.2%) GOC-like. Mandible was involved in 44 (59.5%), maxilla in 30 (40.5%), 18 (25%) were associated with unerupted teeth. Cyst classified as GOC had significantly higher rates of all parameters investigated, (except ciliated and clear cells), than GOC-like cysts (p ≤ 0.05). 26 (40.6%) cases showed GOC features in >50% of cyst circumference, 21 (32.8%) involved 25-50%, 17 (26.6%) <25%. More than 50% circumference involvement was highly and independently predictive for a diagnosis of GOC, <25% was highly and independently predictive for GOC-like (p = 0.003). Hobnail cells (p = 0.008) and plaque-like thickenings (p = 0.038) were significantly more frequent in inflamed cysts. CONCLUSION: Besides the number and type of histological features, GOC can be characterized by their distribution within the cyst circumference (focal Vs diffuse), and it may serve as a new diagnostic aid. It is suggested that GOC and GOC-like may represent a single spectrum.

Ultrasonographic Features of Salivary Glands after Radioiodine Therapy in Patients with Thyroid Cancer.

OBJECTIVE: Chronic sialadenitis is the most common complication of radioactive iodine (RAI) treatment. The aim of the study was to ascertain sonographic features of the major salivary glands in patients with papillary thyroid cancer (PTC) treated with RAI. METHODS: The database of a tertiary medical center was retrospectively searched for consecutive patients who underwent total thyroidectomy for PTC in 2011-2020 with ultrasound follow-up after 1 year. Changes in ultrasound features of the major salivary glands were compared between patients treated or not treated with RAI postoperatively. RESULTS: The cohort included 158 patients, of whom 109 (69%) were treated postoperatively with RAI (mean dose, 131 mCi) and 49 were not (control group). Sonographic changes were observed in the major salivary glands in 43% of the study group and 18% of the control group (p = 0.002), including coarse echotexture, decreased echogenicity, fibrosis, and atrophy. Higher RAI doses were significantly correlated with the prevalence and severity of glandular changes (p < 0.0001). CONCLUSION: RAI treatment following thyroidectomy is associated with a dose-response effect and adverse changes in the major salivary glands and should be prescribed carefully. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1271-1275, 2023.

Screw-Type Collar vs. Non-Screw-Type Collar Implants-Comparison of Initial Stability, Soft Tissue Adaptation, and Early Marginal Bone Loss-A Preclinical Study in the Dog.

BACKGROUND: Implant neck characteristics may affect initial implant stability, soft tissue healing, and early marginal bone loss (EMBL) at second-stage surgery. The null hypothesis was that, following two-stage implant insertion, rough surface, non-screw-type collar implants will present lower EMBL at 2nd-stage surgery than rough-surface, screw-type collar implants. METHODS: The study comprised seven male beagle dogs (mean weight 10.57 ± 2.8 kg; range 9-17 kg). A novel implant design was developed, composed of 2 parts: an apical part resembling a regular threaded implant, and a coronal non-screw-type collar, 4.2 mm long, served as the study group, whereas standard threaded implants served as control. Twenty-eight implants were placed: two on each side of the mandible. All implants were sand-blasted/acid-etched and of similar dimensions. Each dog received four implants. To assess location (anterior vs. posterior) impact on the outcomes, implants were placed as follows: group I-posterior mandible right-non-screw-type collar implants; group II-anterior mandible right-similar non-screw-type collar implants. To assess the collar-design effect on the outcomes, implants were placed as follows-Group III-anterior mandible left-control group, screw-type collar implants; Group IV-study group, posterior mandible left-non-screw-type collar implants. The following parameters were measured and recorded: insertion torque, soft tissue healing, early implant failure, and EMBL at 2nd-stage surgery. RESULTS: No statistically significant differences were noted between groups I and II regarding all outcome parameters. At the same time, although insertion torque (55 N/cm) and early implant failure (0) were similar between groups III and IV, group III presented significantly poorer soft tissue healing (1.43 vs. 0.14) and increased marginal bone loss (0.86 vs. 0 mm). CONCLUSIONS: When a two-stage implant protocol was used, rough-surface non-screw-type collar implants led to superior outcomes at 2nd-stage surgery. Implant location did not affect the results. The significance of this result in preventing EMBL awaits further research.

Minimizing MRONJ after Tooth Extraction in Cancer Patients Receiving Bone-Modifying Agents.

BACKGROUND: Medication-related osteonecrosis of the jaws (MRONJ) is a mucosal lesion of the maxillofacial region with necrotic bone exposure. MRONJ is believed to be multifactorial. Tooth extraction is debatably a risk factor for MRONJ. The targets of the present study were to examine MRONJ occurrence in patients using bone modifying agents (BMAs) for oncology indications and undergoing a dental extraction, and to assess whether suspected predisposing factors can predict MRONJ. MATERIALS AND METHODS: This retrospective, cohort study included all patients fitting the inclusion criteria and a large tertiary medical center. Data were obtained from the hospital's medical records using a structured questionnaire. RESULTS: We performed 103 extractions on 93 patients. Local inflammation/infection of the extraction site was most associated with a complication (p = 0.001) OR = 13.46, 95% CI = (1.71, 105.41), OR = 13.5. When the indication for extraction was periodontal disease, vertical root fracture, or periapical pathosis, the odds of developing MRONJ were 4.29 times higher than for all other indications (p = 0.1), OR = 4.29, 95% CI = (1.16, 15.85). A significant association was found between the time of onset of BMA treatment and time of extraction and the development of MRONJ, OR = 3.34, 95% CI = (1.01, 10.18). Other variables did not correlate with the development of MRONJ. CONCLUSION: Local inflammation/infection and onset of BMA treatment prior to extraction yield a 10.23 times higher chance of developing MRONJ following tooth extraction. Future protocols should use this information to minimize MRONJ incidence.

The Development of Large Radicular Cysts in Endodontically Versus Non-Endodontically Treated Maxillary Teeth.

Background and Objectives: Large radicular cysts of the maxilla present a clinical challenge, as they may cause recurrent infection, severe alveolar bone loss and disruption of the nasal and maxillary sinus floors. The aim of this study was to evaluate the effect of previous root canal treatment on the clinical presentation of large maxillary radicular cysts. Materials and Methods: All cases of radicular cysts treated at the Oral and Maxillofacial Surgery Department of a tertiary public hospital over a period of six years (2012-2018) were evaluated. Histologically confirmed radicular cysts of the maxilla with a maximal dimension of over 15 mm were included. Demographic data of the patients, clinical presentation and radiographic features of the lesions were analyzed. Results: A total of 211 inflammatory cysts were treated in the study period, of these 54 histologically diagnosed radicular cysts in the maxilla were found to have a maximal dimension of over 15 mm. The mean age of patients with large maxillary radicular cysts was 43.3 years, 57.6% of which were male and 42.4% female. The lateral incisor was the most common tooth affected (46.3%). The mean size of the large radicular cysts was 25 mm. Then, 83.8% of the cysts were observed in teeth with previous endodontic treatment. Teeth without endodontic treatment presented clinically with significantly fewer acute symptoms in comparison to teeth with previous endodontic treatment. Conclusions: the vast majority (83.8%) of large maxillary radicular cysts were associated with endodontically treated teeth. Previous endodontic treatment was correlated to increased frequency of clinical symptoms.

Surgical Treatment of Sialolithiasis Leads to Improvement in the Complete Blood Count.

Sialolithiasis is a chronic disease in which a sialolith (salivary stone) causes recurrent inflammation of the affected salivary gland. Anemia of inflammation is a well-described pathology in which a chronic inflammatory disease leads to a reduction in the red blood cell count, hemoglobin and hematocrit values. In this retrospective cohort study, we aim to find whether removal of the sialolith and alleviation of the inflammation affect the complete blood count results. We examined data regarding forty-nine patients who underwent surgery for the removal of a submandibular gland sialolith using the duct-stretching technique. Complete blood counts two years before and after the surgical procedure were collected. The average pre-procedure and post-procedure values were calculated for each patient to establish the average blood profile. The pre- and post-procedure values were compared to evaluate the effect of the surgical treatment on the blood profile. We found that the average blood count values for patients with sialolithiasis were towards the lower end of the normal range. Post-surgery, a significant increase in hematocrit, hemoglobin and red blood cell count was observed, which was more pronounced in the older age group and in patients with co-morbidities. We conclude that sialolith removal surgery is associated with significant improvement in the complete blood count values, especially in the elderly and in patients and with co-morbidities. The speculated pathogenesis is relative anemia of inflammation.

Radioiodine therapy induced sialadenitis versus chronic idiopathic sialadenitis-Presentation and outcomes.

BACKGROUND: This study explores the unique characters of high dose radioactive iodine (RAI) induced chronic sialadenitis. METHODS: A retrospective study of patients having received salivary endoscopy and followed in our outpatient clinic. RESULTS: A total of 100 patients met the inclusion criteria, 75 were diagnosed with chronic idiopathic sialoadenitis and 25 with radio-iodine induced sialoadenitis (RIS). The main complaint in both groups was swelling of the parotid gland. Pain, dysphagia, and xerostomia were observed considerably more in the RIS group. During sialo-endoscopy, fibrosis of the Stensen's duct was more common in the RIS group (p = 0.003). RIS patients group generally managed better with interventional endoscopic treatment alone (80% vs. 46%). CONCLUSION: RIS patients have distinct clinical characteristics. There may be a collateral muscular damage to the masticatory muscles. Fibrosis and parenchymal damage are major findings during sialendoscopy. Sialendoscopy is a safe and efficient treatment for RAI induced sialadenitis.

The unique characteristics of sialolithiasis following drug-induced hyposalivation.

OBJECTIVES: Assess clinical, imaging, operative, and post-operative characteristics of drug-induced vs. non-drug-induced sialolithiasis that are termed 'other etiologies of sialolithiasis.' MATERIALS AND METHODS: Data collected from a retrospective cohort of 96 patients who underwent intra-oral sialolith removal operations were categorized as patient disease characteristics, physical examination results, and imaging and therapeutic features. Patients were divided into two groups based on having drug-induced sialolithiasis (DIS) vs. other etiologies of sialolithiasis (OES). Patients who consumed any medication for chronic conditions were regarded as DIS. Statistical analyses were conducted to elucidate differences and similarities between the two groups. RESULTS: There were 60 patients in the DIS group and 36 in the OES group. DIS patients were significantly older (average age 57.9 vs. 39.8 years, respectively), with no gender predilection. Statins and anti-hypertensive medications were most commonly consumed. Presenting symptoms including number of past swellings, salty tasting saliva, pain, and antibiotic treatment were similar between the groups; mealtime-related swelling of the gland was noted in a higher proportion of OES patients (51.5% vs. 37%, respectively). Analysis of sialolith size and location from fixed anatomical landmarks on the mandible were not different between groups, and the most frequent sialolith location was the hilus gland in DIS vs. intra-glandular in OES patients. Sialolith removal operation time was significantly shorter for DIS patients (45 ± 11.5 vs. 61.1 ± 18.1 minutes). CONCLUSION: Drug-induced sialolithiasis may be regarded as a unique entity with a typical clinical age, presenting symptoms, imaging characteristics, and surgery duration. CLINICAL RELEVANCE: Clinicians should be aware of the above-mentioned differences when treating patients with sialolithiasis and anticipate a more challenging sialolith removal procedure for other etiologies of sialolithiasis, possibly due to underlying anatomical factors of the duct system. When treating drug-induced sialolithiasis, clinicians can expect a shorter operation time with a similar success rate and hospitalization time as with a younger, healthier population with other sialolithiasis etiologies.

Is inferior meatal antrostomy still relevant? A 12-year analysis of 93 oroantral fistulae closure with concomitant Caldwell-Luc operations.

OBJECTIVE: The aim of this study was to retrospectively evaluate clinical outcomes after closure of oroantral fistulae with concomitant Caldwell-Luc operations (OFCLOs) with or without inferior meatal antrostomy (IMA). STUDY DESIGN: Records from consecutive OFCLOs carried out over a 12-year period at the oral and maxillofacial surgery department at a single medical center were reviewed. Background data included age, sex, medical status, indications, and etiologies. Outcome data included operative time, hospitalization time, and postoperative use of analgesics and complications. RESULTS: From 2002 to 2013, 54 male patients (58%), 39 female patients (42%) (mean age 50 years; range 12-84 years) underwent OFCLOs. IMA was carried out in 66 cases (70%). All patients had minimal complications. We found statistically significant shorter operating times (72 vs 84 minutes), shorter postoperative hospitalization times (4.1 vs 5.6 days), lower need of analgesics (1.44 vs 2.88 per day), and fewer complications (11% vs 38%) when IMA was not used. CONCLUSIONS: IMA during OFCLOs carries increased morbidity without apparent benefits. Its routine use should, therefore, be discontinued.

Sialolithiasis-Do Early Diagnosis and Removal Minimize Post-Operative Morbidity?

Background and objectives: Sialolithiasis is an inflammation of a salivary gland due to obstruction of salivary flow by a sialolith. We aim to assess potential factors that may predict lower morbidity following endoscopically assisted per-oral sialolith removal. Materials and Methods: Retrospective cohort study. Retrospective review of 100 records of patients with sialolithiasis, following surgical sialolith removal. A single medical center (Department of oral and maxillofacial surgery-Rabin Medical Center, Beilinson & Hasharon-Israel) survey. Data were gleaned from the patient files based on a structured questionnaire. Factors that may predict morbidity were evaluated using linear regression equation. Results: 59 of the subjects were men and 41 were women. The mean age of the patients in the study was 50 ± 17.5 years. Sialolith volume and past antibiotic treatment were positively associated while age was negatively associated with hospitalization duration. Conclusion: Early sialolith diagnosis and removal may lower postoperative morbidity.

Evaluation of Surgical Treatment of Oroantral Fistulae in Smokers Versus Non-Smokers.

Background and Objectives: Smoking has been found to interfere with wound healing processes. Therefore, the purpose of this study was to compare surgical treatment of oroantral fistulae (OAFs) in smokers and non-smokers. Materials and Methods: Medical records of all consecutive patients who underwent surgical closure of OAFs between 2003 and 2016 at the oral and maxillofacial surgery department, Rabin Medical Center, Israel were reviewed. Patients' demographic data, preoperative signs and symptoms, surgical method of repair, and postoperative complications were recorded. Results: The cohort consisted of 38 smokers and 59 non-smokers. Age and gender distributions were similar in both groups. The main etiology in both groups was tooth extraction, followed by pre-prosthetic surgery in smokers and odontogenic infection in non-smokers (p = 0.02). Preoperative conditions were not significantly different between smokers and non-smokers in terms of size of soft tissue fistula and bony defect, chronic sinusitis and foreign bodies inside the sinus. OAFs were repaired by local soft tissue flaps without consideration of smoking status. Smokers experienced more moderate-severe postoperative pain (p = 0.05) and requested more weak opioids (p = 0.06). Postoperative complications included infection, delayed wound healing, residual OAF, pain, sensory disturbances and sino nasal symptoms. These were mostly minor and tended to be more frequent in smokers (p = 0.35). Successful closure of OAFs was obtained in all patients except one smoker who required revision surgery. Conclusions: Smokers may be more susceptible to OAFs secondary to preprosthetic surgery. In this cohort, there was no statistically significant difference in outcome between smokers and non-smokers in terms of failure. However, smokers tended to have more severe postoperative pain and discomfort and to experience more postoperative complications. Further studies with larger sample sizes should be conducted to validate these results.

Preoperative Maxillary Sinus Imaging and the Outcome of Sinus Floor Augmentation and Dental Implants in Asymptomatic Patients.

OBJECTIVES: Preoperative maxillary sinus imaging findings have been suggested to be associated with complications and outcomes of sinus lift and dental implant procedures; nonetheless the evidence is controversial. The aim of this study was to examine the association between preoperative maxillary sinus imaging findings and outcomes of sinus lift and dental implant procedures in asymptomatic patients. METHODS: We included all patients who underwent maxillary sinus lift and dental implant procedures between 2014 and 2017. Maxillary sinus imaging findings were extracted from pre-procedural dental computed tomography scans, and outcomes of the procedures were assessed. RESULTS: A total of 145 procedures were included. No sinonasal symptoms were reported preoperatively. In 46% of cases maxillary sinus imaging was abnormal. The most common imaging finding was peripheral mucosal thickening (38%). Sinus floor cyst/polyp was identified in 13% of the cases, of which 47% occupied more than 50% of the sinus volume. Partial or complete opacification of the maxillary sinus was documented in 3% of cases. The sinus ostium and ostiomeatal complex were obstructed in 7% and 1%, respectively. Mucosal perforation was documented in 22% of cases and was inversely related to mucosal thickening (P = 0.011). Other minor post-operative complications did not correlate with radiological findings. Post-surgical sinusitis was not observed in any of the patients regardless of pre-surgical imaging findings. CONCLUSIONS: Incidental maxillary sinus imaging findings such as mucosal swelling, cysts or polyps, regardless of their severity or size, and maxillary ostial obstruction may not need to be addressed prior to sinus augmentation and dental implant procedures in asymptomatic patients. Patients with complete sinus opacification should be referred to an otolaryngologist prior to surgery. Further controlled trials, in larger cohorts, are needed to corroborate our findings.

Bone remodeling in onlay beta-tricalcium phosphate and coral grafts to rat calvaria: microcomputerized tomography analysis.

This study was conducted to establish the efficiency of microcomputerized tomography (micro-CT) in detection of trabecular bone remodeling of onlay grafts in a rodent calvaria model, and to compare bone remodeling after onlay grafts with beta-tricalcium phosphate (TCP) or coral calcium carbonate. Ten rats received calvarial onlay blocks-5 with TCP and 5 with coral calcium carbonate. The grafts were fixed with a titanium miniplate screw and were covered with a collagen resorbable membrane. Three months after surgery, the calvaria were segmented, and a serial 3-dimensional micro-CT scan of the calvarium and grafted bone block at 16-micrometer resolution was performed. Image analysis software was used to calculate the percentage of newly formed bone from the total block size. Newly formed bone was present adjacent to the calvarium and screw in all specimens. The mean area of newly formed bone of the total block size ranged from 34.67%-38.34% in the TCP blocks, and from 32.41%-34.72% in the coral blocks. In the TCP blocks, bone remodeling was found to be slightly higher than in the coral blocks. Micro-CT appears to be a precise, reproducible, specimen-nondestructive method of analysis of bone formation in onlay block grafts to rat calvaria.

Complications of maxillary sinus augmentations in a selective series of patients.

OBJECTIVES: The purpose of this case series was to describe late complications of maxillary sinus augmentation procedures, including paranasal sinusitis and oroantral fistula, and to discuss the definitive surgical methods of treatment. STUDY DESIGN: The case series included 13 patients hospitalized for a failed lateral-approach maxillary sinus augmentation, performed by a dental practitioner, with or without simultaneous implant placement. Data on patient gender and age, presenting signs and symptoms, radiographic appearance, method of repair, and follow-up were recorded. RESULTS: There were 7 female and 6 male patients aged 53-74 years. Twenty-six of the total 34 implants inserted failed, of which 7 were displaced into the sinus. All patients had maxillary sinusitis, and 2 also had an inflammation of other paranasal sinuses. Ten patients presented with an oroantral fistula. Review of the files of the referring practitioner revealed the preoperative presence of chronic maxillary sinusitis in 4 patients and an odontogenic cyst in 1. Caldwell-Luc operation served as the definitive surgical treatment. All fistulas were successfully closed by a palatal rotation advancement flap (8 patients) or a buccal flap (2 patients). CONCLUSIONS: Thorough clinical and radiographic evaluation is necessary before sinus procedures to minimize complications. Total elimination of sinusitis and other pathologic conditions is recommended before maxillary sinus augmentation and implant surgery.