Laughter-Induced Transient Vision Loss in a Patient With Silent Sinus Syndrome.

BACKGROUND: To report a patient with silent sinus syndrome (SSS) who experienced transient ipsilateral monocular vision loss during intense laughter. METHODS: Case report. RESULTS: Our patient's transient vision loss completely resolved after maxillary sinus decompression and during 7 months of follow-up. CONCLUSIONS: Although the precise mechanism of our patient's vision loss remains undetermined, we suspect that the vascular supply to the eye and/or the optic nerve was compromised as the result of the combination of laughter (causing Valsalva maneuver and increased intrathoracic pressure) and SSS.

Hyaluronic Acid Versus Ultrasonic Resorbable Pin Fixation for Space Maintenance in Non-Grafted Sinus Lifting.

PURPOSE: An ultrasonic resorbable pin (SonicWeld, KLS Martin, Mühlheim, Germany) was compared with hyaluronic acid (Hyaloss Matrix, Anika Therapeutics, Bedford, MA) for their ability to maintain space in non-grafted sinus lifting. MATERIALS AND METHODS: A comparative split-mouth study was designed and implemented. Six women and 4 men were included (mean age, 56.7 yr). The primary predictors hyaluronic acid (HA) application and ultrasonic resorbable pin fixation (URPF) were coded as binary variables. The primary outcome variables were height of alveolar bone (HAB) and reduction in sinus volume (RSV). Secondary outcomes were bone density and implant survival. RESULTS: The postoperative mean HAB was significantly higher than the preoperative mean HAB on the 2 sides (P < .05). Mean increases in HAB and RSV on the URPF side were significantly greater than those on the HA side (P < .05). In total, patients were treated with 40 implants. No type I bone quality was identified; 14 (35%) implants were inserted in type II bone, 22 (50%) in type III bone, and 6 (15%) in type IV bone. There was no statistically meaningful difference between the 2 sides for implant survival or bone quality. At 6 months, all implants were clinically stable and the definitive prostheses were functional, resulting in a survival rate of 100%. CONCLUSIONS: There was sufficient bone height to eventually place implants on the 2 sides in all patients. The 2 techniques yielded predictable outcomes in implant survival and bone quality. However, HAB and RSV were considerably greater on the URPF side.

Pre-clinical evaluation of the osteogenic potential of bone morphogenetic protein-2 loaded onto a particulate porcine bone biomaterial.

AIM: The objective of study was to determine the osteogenic potential of bone morphogenetic protein-2 (BMP-2) loaded onto a particulate porcine bone mineral (PBM) biomaterial using a sinus augmentation model. METHODS: Release kinetics of BMP-2/PBM was determined in vitro. Eight rabbits received BMP-2/PBM or PBM alone into contra-lateral sinus sites. The animals were killed following a 2-week healing interval for micro-CT and histometrical analysis. RESULTS: Approximately 40% of the BMP-2 was released from PBM over the first 3 days in vitro; release maintained at a reduced level through day 21. In vivo, total augmented implant volume did not differ significantly between treatments. However, local bone formation was enhanced in the BMP-2/PBM group compared with PBM control (10.5% versus 6.6%; p = 0.03), specifically in the central aspect of the PBM implant (14.2% versus 5.5%; p < 0.01) and adjoining the Schneiderian membrane (11.9% versus 5.0%; p < 0.05). There were no significant overall differences in residual biomaterial and fibrovascular tissue. CONCLUSION: Bone morphogenetic protein-2 enhanced local bone formation in the rabbit maxillary sinus model following implantation using a PBM carrier.

Mesenchymal phosphaturic tumour: early detection of recurrence.

The case of a recurrent phosphaturic mesenchymal tumour of the maxillary sinus 10 years after the first surgical excision is reported. The neoplasm first presented with paraneoplastic osteomalacia causing a pathological femur fracture. A right maxillary sinus tumour was identified and treated thereafter. The patient had no local symptoms and serum electrolytes returned to normal after surgical removal of the tumour. However, 10 years later, the patient's urine Ca and P levels increased and an octreoscan detected a new tumour in the right maxillary sinus. Early diagnosis prevented the effects of the paraneoplastic activity of the neoplasm. This case emphasises the importance of specific, close follow-up, because the neoplasm rarely produces local signs indicating its position. To our knowledge, this is the first reported case of a late relapse presenting without relevant symptoms (local pain or swelling or pathological fractures).

Symmetrical craniofacial hypertrophy in patients with tertiary hyperparathyroidism and high-dose cinacalcet exposure.

We are reporting on a series of two patients with end-stage renal disease on hemodialysis, presented for surgical parathyroidectomy secondary refractory hyperparathyroidism. Both patients had failed maximized medical managements, including higher-than-usual doses of the calcimimetic cinacalcet (270 and 180 mg/day, respectively). On physical exam, both patients had marked symmetrical craniofacial hypertrophy with coarse distortion of facial features, similar in appearance to past reports of Sagliker syndrome. On X-ray and computed tomographic exam, they had peculiar areas of bone absorption on the skull, imitating the radiologic appearance of multiple myeloma. Bone biopsy of the maxilla, however, did not show the expected brown tumor, but rather described only fibrosis and reactive bone formations. This phenotype developed while being on cinacalcet, progressed despite escalation of therapy, and improved only after parathyroidectomy. Both patients developed massive "hungry bone syndrome" after parathyroidectomy necessitating prolonged i.v. calcium infusion. This pattern of severe facial distortion likely represented an adverse consequence of severe tertiary hyperparathyroidism, along with supraphysiologic dose of cinacalcet administration and 25-hydroxy vitamin D deficiency in sensitive individuals. The genetic base of this observation remained unexplained.

Platelet Rich Fibrin (P.R.F.) in reconstructive surgery of atrophied maxillary bones: clinical and histological evaluations.

INTRODUCTION: Maxillary bone losses often require additional regenerative procedures: as a supplement to the procedures of tissue regeneration, a platelet concentrate called PRF (Platelet Rich Fibrin) was tested for the first time in France by Dr. Choukroun. Aim of the present study is to investigate, clinically and histologically, the potential use of PRF, associated with deproteinized bovine bone (Bio-Oss), as grafting materials in pre-implantology sinus grafting of severe maxillary atrophy, in comparison with a control group, in which only deproteinized bovine bone (Bio-Oss) was used as reconstructive material. MATERIALS AND METHODS: 60 patients were recruited using the cluster-sampling method; inclusion criteria were maxillary atrophy with residual ridge < 5mm. The major atrophies in selected patients involved sinus-lift, with a second-look reopening for the implant insertion phase. The used grafting materials were: a) Bio-Oss and b) amorphous and membranous PRF together with Bio-Oss. We performed all operations by means of piezosurgery in order to reduce trauma and to optimize the design of the operculum on the cortical bone. The reopening of the surgical area was scheduled at 3 different times. RESULTS: 72 sinus lifts were performed with subsequent implants insertions.We want to underline how the histological results proved that the samples collected after 106 days (Early protocol) with the adding of PRF were constituted by lamellar bone tissue with an interposed stroma that appeared relaxed and richly vascularized. CONCLUSIONS: The use of PRF and piezosurgery reduced the healing time, compared to the 150 days described in literature, favoring optimal bone regeneration. At 106 days, it is already possible to achieve good primary stability of endosseous implants, though lacking of functional loading.

Late diagnosis of an occult tumour - what lessons can we learn?

OBJECTIVE: Malignant tumours of the nasal cavity and paranasal sinuses are rare and late presentation of a maxillary sinus tumour is common due to the vague nature of the symptoms which can delay diagnosis. METHODS: We report a female with a maxillary sinus tumour who was initially diagnosed with chronic idiopathic facial pain (CIFP) and sinusitis, which subsequently led to a delay in diagnosis and treatment of her tumour. RESULTS: There was no clinical extra- or intra-oral pathology, however, she had varying clinical presentations of facial pain, anosmia, loss of gustatory function, and infra-orbital nerve paraesthesia. CT and MRI scans confirmed obliteration of the left maxillary sinus by a solid mass involving ethmoid and sphenoid sinuses and some cranial nerves. Biopsy confirmed a poorly differentiated carcinoma of the ethmoid and sphenoid sinuses and invasion of the cavernous sinus. CONCLUSION: A morbid, but hidden tumour was left undiagnosed due to the unusual presentation of the patient's symptoms. It is essential that all patients are managed holistically and thorough historical, clinical and radiographic examination and appropriate investigations are carried out to prevent unnecessary and potentially time-wasting treatment.

Histologic and histomorphometric results of three bone graft substitutes after sinus augmentation in humans.

The aim of this study was to compare the histological behavior of three bone graft materials placed in human. The comparison was made among Bio-Oss® (BO), Engipore® (EP), and PepGen P-15® (P-15). Five biopsies for each group of biomaterial, retrieved 6 months after sinus lift augmentation, were analyzed. The investigation was carried out using light microscope (LM), scanning electron microscope (SEM) with an energy dispersive spectrometer (EDS), and circularly polarized light microscope (CPLM). Under LM, the amount of newly formed bone was significantly higher in BO than P-15 (P < .05), while the amount of residual graft material was significantly higher in P-15 than BO (P < .05). The extension of marrow spaces was significantly higher in EP than both BO and P-15 (P < .05). SEM-EDS analysis showed a Ca/P ratio of 1.8 for BO, 2.2 for EP, and 1.5 for P-15. Under CPLM, BO showed no significant difference for transverse (18.4 ± 2.7%) and longitudinal (16.3 ± 1.8%) bone collagen fibers (P = .195); EP showed a significant difference between transverse (4 ± 0.7%) and longitudinal (7.6 ± 2.5%) bone collagen fibers (P = .015); finally, P-15 showed no significant difference for transverse (3.8 ± 1.6%) and longitudinal (4.9 ± 1.2%) bone collagen fibers (P = .279). No investigated biomaterial was completely resorbed, but all the residual particles demonstrated a close bone integration to form a hybrid tissue. BO particles appeared perfectly osseointegrated in the trabecular bone. EP showed a tendency to concentrate the bone apposition into the microporosities; P-15 particles appeared bridged by newly formed bone trabeculae.

The crestal approach: antral membrane elevation via a post graft.

The crestal approach to elevating the antral membrane by a resorbable StemVie Post is a modification of the sinus lift technique. This technique can add 4 to 10 mm bone height for severely atrophic ridges in areas that are difficult to access through a lateral window. The procedure is minimally invasive, simple, predictable, and has less postoperative morbidity because of smaller flap design and minimal osteotomy. If sufficient alveolar bone is present for stabilization, an implant can be placed simultaneous with antral elevation and graft. The StemVie Post completely resorbs and is replaced by the patient's own bone.

Back-scattered electron imaging and elemental analysis of retrieved bone tissue following sinus augmentation with deproteinized bovine bone or biphasic calcium phosphate.

OBJECTIVES: To compare resorption of a synthetic biphasic calcium phosphate (BCP) bone-graft substitute with deproteinized bovine bone (DBB) used for human maxillary sinus augmentation. MATERIALS AND METHODS: Eleven patients underwent bilateral maxillary sinus floor augmentation with DBB in one side and a BCP (40%beta-tricalcium phosphate (beta-TCP) and 60% hydroxyapatite) in the contralateral side. Simultaneously, with the augmentation on each side a microimplant was placed vertically from the top of the alveolar crest penetrating the residual bone and the grafting material. Eight months after initial surgery the microimplants were retrieved with a surrounding bone core. The composition of residual graft material and surrounding bone was analysed by scanning electron microscopy and energy dispersive X-ray spectroscopy. RESULTS: Residual graft material of both types was present as 10-500 mum particles in direct contact with, or completely surrounded by, newly formed bone; smaller particles were also present in non-mineralized tissue. In the case of BCP the bone-graft substitute interface showed evidence of superficial disintegration of particles into individual grains. Median Ca/P ratios (at.%), determined from >200 discreet sites within residual graft particles and adjacent bone, were: DBB: 1.61 (confidence interval [CI] 1.59-1.64); BCP: 1.5 (CI 1.45-1.52); DBB-augmented bone: 1.62 (CI 1.59-1.66); BCP-augmented bone: 1.52 (CI 1.47-1.55); P=0.028 for DBB vs. BCP and DBB- vs. BCP-augmented bone. The reduction in Ca/P ratio for BCP over the healing period is consistent with the dissolution of beta-TCP and reprecipitation on the surface of calcium-deficient hydroxyapatite. CONCLUSION: The beta-TCP component of BCP may be gradually substituted by calcium-deficient hydroxyapatite over the healing period. This process and superficial degranulation of BCP particles may influence the progress of resorption and healing.

Sinus membrane lift using a water balloon followed by bone grafting and implant placement: a 28-case report.

PURPOSE: The objective of this study was to assess the efficacy and safety of a minimally invasive sinus lift using an inflatable water balloon followed by bone grafting and implant placement. MATERIALS AND METHODS: A total of 28 patients with a single tooth missing in the posterior maxilla underwent a water balloon sinus lift, followed by bone grafting and implant placement. Baseline bone height was 4.92 +/- 1.24 mm. Implant site preparation employed a pilot drill and osteotomy followed by water balloon elevation. The mean inflated balloon volume was 0.67 +/- 0.17 mL. Bio-Oss was filled under the elevated sinus membrane using a dedicated instrument. Twenty-eight total implants (diameter: 3.8 to 5.0 mm) were placed. Pre- and postoperative panoramic films or computed tomographs (optional) were taken for every case to measure and compare the results of the sinus membrane lift using a water balloon. Postoperative patient reactions including swelling, discoloration, discomfort, hematomas, and disability were recorded. RESULTS: Successful sinus membrane water balloon lifting procedures were performed in 26 cases; two procedures were aborted due to sinus membrane perforation. A total of 26 implants were placed. The mean inflated balloon volume was 0.67 +/- 0.17 mL and radiographic examination showed the mean elevated height by balloon to be 10.9 +/- 2.06 mm. Computed tomography showed the bone graft distributing evenly around implants. Patients were extremely pleased with the results and needed very little medical attention after surgery. The mean follow-up was 15.9 +/- 2.94 months. One implant was lost due to infection. CONCLUSION: The use of a water balloon to elevate the sinus membrane is a truly minimally invasive technique and is associated with very little discomfort. This method has encouraging results, is easy to learn, and is associated with low complication rates.

Autologous platelet concentrates for bone graft enhancement in sinus lift procedure.

BACKGROUND: Autologous platelet (PLT)-rich plasma has been reported in some studies to promote osteogenesis. The goal of this study was to demonstrate that osteogenesis gained by mixing autologous PLT concentrates (APCs) with a small quantity of autologous bone graft could give a sufficient quality to lead to dental implant placement. The second goal was to compare this osteogenesis with that obtained by a traditional method (iliac bone graft), through clinical, radiologic, and histologic methods. STUDY DESIGN AND METHODS: Eighteen patients needing bilateral sinus floor augmentation were enrolled. One sinus was grafted with iliac crest bone alone, and the other sinus with a small quantity of bone and APC. Panoramic view, computed tomography scan, and biopsies were performed 6 months after the initial surgery to compare ossification. RESULTS: The adjunction of APCs permitted a 60 percent reduction of bone graft required for sinus floor elevation. The bone obtained with APCs had the same histologic and mechanical characteristics as the bone obtained by traditional graft. CONCLUSION: Topical use of APCs might be helpful in bone reconstruction. No clinical, radiologic, or histologic osteogenesis inhibition of high PLT concentration was observed. The resulting osteogenesis was adapted to dental implant placements.

Histologic and elemental microanalytical study of anorganic bovine bone substitution following sinus floor augmentation in humans.

BACKGROUND: Histologic data regarding the use of anorganic bovine bone (ABB) in humans are scarce. This study was a histologic evaluation and an examination of the elemental composition of ABB particles and adjacent bone in humans. METHODS: Ten biopsies were retrieved 20 months after maxillary sinus augmentation in five patients. The investigation was carried out using light microscopy in brightfield, fluorescence, and circularly polarized light and scanning electron microscopy (SEM) with energy-dispersive x-ray spectroscopy. RESULTS: The regenerated tissue consisted of 38% +/- 2.1% newly formed bone, 36% +/- 1.3% marrow spaces, and 29% +/- 1.8% residual ABB particles. Under polarized light, the newly formed bone was characterized by randomly oriented collagen fibers. Under fluorescence, the biomaterial showed close apposition to bone; under SEM, several projections of newly formed bone were seen penetrating the ABB particles. ABB and bone were distinguished by the lighter gray color of the biomaterial in back-scattered electron images; ABB particles were surrounded and linked by newly formed bone. Elemental analysis gave average calcium/phosphorus ratios (atomic %) approximately 1.9 for ABB and 1.4 for bone. Relatively high concentrations of calcium and phosphorus in the biomaterial decreased gradually toward the interface with bone. CONCLUSION: The persistence of ABB in the human tissue after 20 months might have been related to the relatively high calcium content of the biomaterial as well as the absence of proteins.

Rhinocerebral zygomycosis: an increasingly frequent challenge: update and favorable outcomes in two cases.

Zygomycosis or mucormycosis is an increasingly frequent life-threatening infection caused by opportunistic fungal organisms of the class Zygomycetes. The pathognomonic feature is the presence of invasive aseptate mycelia that are larger than other filamentous fungi with the hyphae exhibiting right angle and haphazard branching. Usually classified as rhinocerebral, disseminated, and cutaneous types, this classification serves as important predictor of pathogenesis and outcome. These occur mostly in immunosuppressed patients including individuals with diabetes (43% exhibit the rhino-cerebral form) and patients with organ transplants and hematologic malignancies. Without early aggressive treatment, the disease follows a dismal and fatal course. The prognosis has not shown any appreciable change in the past 40 years with a stagnant mortality rate of 44%. We present 2 cases of rhinocerebral zygomycosis (RCZ), in a 58-year-old male and a 63-year-old female; both were poorly controlled diabetic patients with maxillary lesions suggestive of osteomyelitis. The patients were leading a near normal life with minimal discomfort or signs and symptoms of underlying mycosis. Most of the health care professionals treating these patients often overlooked the disease or recommended inadequate therapy. Despite long delays and inadequate initial therapy these patients survived with little outward morbidity. The prognosis for this condition may therefore be considered less dire than previously thought.

Maxillary sinus augmentation using granular calcium sulfate (surgiplaster sinus): radiographic and histologic study at 2 years.

The main goal of sinus augmentation is the formation of vital bone to allow tissue integration of endosseous implants to support prosthetic rehabilitation. The aim of the present investigation was to evaluate the radiographic and histologic results when granular medical-grade calcium sulfate hemihydrate was used as a grafting material in sinuses. Forty implants plus grafting material were placed in 10 patients, representing 15 sinuses, using a one-stage technique. Radiographs were taken prior to sinus augmentation, monthly until 6 months postoperatively, 9 and 12 months after implant placement, and annually thereafter. Bone biopsies were harvested from all patients for histologic and histomorphometric evaluation.

Effect of platelet-rich plasma with autogenous bone graft for maxillary sinus augmentation in a rabbit model.

PURPOSE: To evaluate the effect of platelet-rich plasma (PRP) on autogenous bone graft remodeling during sinus augmentation in a rabbit model. MATERIALS: Twelve New Zealand White rabbits were divided randomly into 3 groups based on their time of sacrifice (2, 4, and 8 weeks). All animals underwent a general anesthetic and harvesting of an autogenous bone graft from the right iliac crest with subsequent bilateral maxillary sinus augmentation. PRP was prepared via standard approved technique by acquiring 21 cc of autogenous blood and performing differential centrifugation to obtain PRP. One cc of PRP was produced that was mixed with bovine topical thrombin and calcium chloride. The left maxillary sinus received only autogenous bone, while the right maxillary sinus received a mixture of PRP mixed with autogenous bone, thus each animal acted as its own control. Equal volumes of bone were inserted in each maxillary sinus. Animals were sacrificed at 2, 4, and 8 weeks and all specimens were harvested for peripheral quantitative computed tomography (pQ-CT), static, and dynamic and histomorphometric analysis. RESULTS: Student t tests were performed comparing bone density via pQ-CT analysis, histomorphometric parameters of total bone area, and bone apposition rate. PRP had no statistically significant effect on bone graft healing in maxillary sinus augmentation when compared using standard pQ-CT, static, and dynamic histologic criteria. CONCLUSION: This study fails to find a direct stimulatory effect of PRP on healing of autogenous bone grafts using pQ-CT, static, and dynamic histomorphometric analyses.

Maxillary sinus augmentation using prehardened calcium sulfate: a case report.

Prehardened medical-grade calcium sulfate hemihydrate was placed as a grafting material for sinus floor elevation in the left posterior maxilla. After 8 months of healing, three titanium plasma-sprayed screw implants (Biolock) were placed. At the same time, a bone biopsy was harvested for histologic evaluation. The specimen was processed according to standard techniques for hard tissue histology. In both the grafted area and the previously existing area of sinus floor, the histology showed complete calcium sulfate resorption and the bone was primarily of lamellar structure. In the 5-month radiograph, a new trabecular design appeared from the periphery of the grafted area, and on the 8-month radiograph, the graft material was no longer detectable and the augmented area was filled by new tissue showing a trabecular design. This case report documented that medical-grade calcium sulfate hemihydrate, when used as a grafting material for augmentation of the sinus floor, may lead to proper osseointegration of dental implants.

Prospective study on the augmentation of the maxillary sinus with calcium sulfate: histological results.

BACKGROUND: The main goal of the sinus elevation procedure is the formation of vital bone to allow the tissue integration of endosseous implants to support prosthetic restorations in the edentulous posterior maxilla. The ideal graft material is yet to be found. The present study investigated the histologic results of a sinus augmentation procedure performed with calcium sulfate as the grafting material. METHODS: The clinical trial consisted of 2 groups: a first (control) group of 12 patients (15 sinuses) in which the material was carefully placed but not stratified. In the second (test) group, 45 patients (50 sinuses) were treated by modifying the application. The calcium sulfate was putty-like in consistency and placed as it hardened in layers, avoiding fluid contamination. The histologic samples were collected, either at 9 months, at the uncovering procedure (for implants placed simultaneously with grafting material), or at 6 months at the time of implant insertion (for implants placed at a later stage). RESULTS: The augmentation procedure resulted in good, new tissue formation within the sinuses when clinically and radiographically evaluated. The technique used in the test group produced a reduction in the graft shrinkage during healing, therefore slowing down the material resorption rate. Histologically, new bone formation with progressive lamellar maturation was found in both groups. Some particles produced by calcium sulfate resorption were still present after 6 months in the test group specimens, but no longer detectable after 9 months. Samples from the control group showed a mean histomorphometric bone density of 34.25% +/- 10.02, while samples from the test group showed a mean value of 55.54% +/- 19.82. CONCLUSIONS: The results of this study indicate that calcium sulfate appears to be an effective material for sinus augmentation, yielding vital bone suitable for implant integration. In addition, the technique used in the test group seemed to improve the quality and quantity of bone formation.

Short-term healing following the use of calcium sulfate as a grafting material for sinus augmentation: a clinical report.

Because of the frequent lack of bone in the posterior maxilla, sinus augmentation has become a commonly practiced treatment modality. Many different materials have been used for augmenting the sinus, and the ideal graft is yet to be found. The present article reports the results of sinuses grafted with calcium sulfate in 2 patients. Bone biopsies were harvested 9 months after the augmentation procedure. In the first patient, 3 titanium threaded-cylinder implants were placed in the grafted area after 9 months, while in the second, 1 acid-etched, screw-shaped titanium implant was placed simultaneously with the graft. Light microscopic evaluation revealed new bone formation with ongoing remodeling and progressive lamellar maturation in the specimens. No remnants of the alloplastic material were detectable in any section, either within the bone or in the medullary tissue. When reevaluated at the uncovering procedure, the implants were radiographically and clinically judged to be osseointegrated. These observations suggest that, when used in the appropriate form and with the proper technique, calcium sulfate is a promising graft material for sinus augmentation, producing adequate quantity and quality of new bone for implant placement.