Orbital and maxillary sinus wall fractures as a late complication of endosteal implants



    Table of Contents CASE REPORT Year : 2022  |  Volume : 30  |  Issue : 2  |  Page : 53-55

Orbital and maxillary sinus wall fractures as a late complication of endosteal implants

Can Ekinci1, Furkan Ozdogan1, Gizem Basyazici2, Cengiz Cetin1
1 Department of Plastic, Reconstructive and Esthetic Surgery, Eskişehir Osmangazi University School of Medicine, Eskişehir, Turkey
2 Department of Neurosurgery, Eskişehir Osmangazi University School of Medicine, Eskişehir, Turkey

Date of Submission29-Sep-2021Date of Acceptance18-Jan-2022Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Can Ekinci
Department of Plastic, Reconstructive and Esthetic Surgery, Eskişehir Osmangazi University School of Medicine, 26480, Meşelik, Eskişehir
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_55_21

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A 63-year-old woman applied to us with a complaint of ecchymosis on the left half of her face and left subconjunctival hemorrhage after talking on her cell phone. There was no history of trauma or known medical diseases, but the patient had multiple endosteal implants, nine of them from 12 years ago, and a recent one on her left maxilla from last year. After detailed anamnesis, it is learned that the patient was not using any bisphosphonate treatment, but she was on Vitamin D treatment due to Vitamin D deficiency and using mirtazapine and alprazolam for anxiety. However, her T-score calculated for osteoporosis was above −2.5. All of the maxillofacial examinations were normal except for suspicious step deformity in the palpation of the left infraorbital rim. However, on the computed tomography imaging, it showed that there were fractures on the left lateral and infraorbital wall and left inferior maxillary sinus wall. MRI imaging ruled out any possible fracture caused by an aneurysmal bone cyst. With all these findings and careful examinations, the cause of these fractures was considered a late complication of her dental implants.

Keywords: Dental implants, endosteal implants, maxillary sinus fractures, orbital wall fractures


How to cite this article:
Ekinci C, Ozdogan F, Basyazici G, Cetin C. Orbital and maxillary sinus wall fractures as a late complication of endosteal implants. Turk J Plast Surg 2022;30:53-5
How to cite this URL:
Ekinci C, Ozdogan F, Basyazici G, Cetin C. Orbital and maxillary sinus wall fractures as a late complication of endosteal implants. Turk J Plast Surg [serial online] 2022 [cited 2022 Mar 23];30:53-5. Available from: http://www.turkjplastsurg.org/text.asp?2022/30/2/53/340453   Introduction Top

Endosteal implants are widespread treatment modality for edentulous patients and can serve to solve serious functional and psychological problems associated with bad dentures. However, mandibular fractures associated with placement of endosteal implants have been well documented, especially in patients with severely atrophic mandible and osteoporosis.[1],[2],[3] Although such fractures are quite rare, 0.2% in patients with edentulous mandible treated with endosteal implants,[3] they are considered one of the most severe complications of endosseous implant placement.

In this report, on the other hand, we are going to present spontaneous orbital and maxillary sinus wall fractures in a patient with a history of endosteal implants. The uniqueness of this case is that it is the first orbital and maxillary sinus wall fracture associated with endosteal implants to our knowledge.

  Case Report Top

A 63-year-old woman with a history of hematoma on the left half of her face and scleral hemorrhage a month ago after talking on her phone is applied to the emergency department in another center with a complaint of ongoing left scleral hemorrhage. After normal examination findings by an ophthalmologist, they asked for a paranasal computed tomography imaging. It showed that there were nondisplaced fractures on the left lateral and infraorbital wall and left inferior and anterior maxillary sinus walls, and one of the molar endosteal implants was indented into the right inferior maxillary sinus wall. Furthermore, both maxillary sinuses had inflammatory mucoperiosteal thickening which was more prominent on the right side [Figure 1] and [Figure 2].

Figure 1: Computed tomography images showing left lateral and infraorbital wall and left inferior and anterior maxillary sinus wall fractures

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Figure 2: Maximum intensity projection computed tomography imaging showing fracture line between left maxillary sinus wall and infraorbital wall

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The patient was referred to us as a tertiary and maxillofacial trauma center. After detailed anamnesis, it was learned that the patient has not have any trauma history, but she had nine endosteal implants 12 years ago and a recent one on her left maxilla last year. She was not using any bisphosphonate treatment but was using Vitamin D drops for Vitamin D deficiency and antidepressant medications (mirtazapine and alprazolam) for anxiety. Furthermore, her T-score for bone density was between −1 and −2.5 ruling out osteoporosis but indicating low bone mass.

All of the maxillofacial examinations were normal including equal range of ocular movement in all directions and no diplopia, but suspicious step deformity was present in the palpation of the left infraorbital rim. The patient was referred to the ophthalmology department for more elaborative examination, and their examination revealed normal findings. Although rarely seen in the jaw or maxilla, since aneurysmal bone cysts (ABCs) can cause spontaneous fractures,[4],[5] the patient was also referred to the neurosurgery department to rule out any possible ABCs of the maxilla or infraorbital wall. Orbital MRI was asked, and no ABC was detected, but there was a minimal indentation of retro-orbital fat into the left maxillary sinus suggesting blowout fracture [Figure 3].

Figure 3: Magnetic resonance imaging image showing minimal indentation of retro-orbital fat into the left maxillary sinus

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After a multidisciplinary council by the plastic, reconstructive, and esthetic surgery, neurosurgery, ophthalmology, and dentistry departments, the cause of the spontaneous fractures is considered to be originating from endosteal implants. It was decided to follow up the patient regularly and do not operate at the moment since no apparent dysmorphism or ocular symptoms were present.

  Discussion Top

Edentulous patients usually experience functional and psychological problems due to their bad dentures. Usually, the gold standard method in the treatment is dental implants.[2] However, there can be frightening complications like mandibular fractures, especially in severely atrophic mandibles and osteoporotic patients. Although it is quite rare, 0.2% in a study including 916 patients,[3] it is still well documented and reported in different studies.[1],[2],[3] Orbital and maxillary sinus wall fractures, on the other hand, have not been seen in the literature before according to our knowledge.

In this report, we presented a patient with nine endosteal implants who had 12 years ago, and a recent one on her left side implanted last year; who is admitted with a spontaneous left lateral and infraorbital wall, and left inferior maxillary sinus wall fractures while talking on the cell phone. Although the patient was not using any bisphosphonate treatment and her T-score was between −1 and −2.5, she still had some underlying risk factors such as low bone density, Vitamin D deficiency, and use of antidepressant medications.

Low bone density and osteoporosis are well known as responsible factors in spontaneous fractures or fractures caused by trauma. Since architectural deterioration of the bone tissue is seen in osteoporosis, bone fragility is increased leading to fractures. There are studies that showed osteoporosis as a facilitating factor for the mandibular fractures in patients with endosseous implants.[6],[7] Although our patient was not osteoporotic, she had low bone density and was on Vitamin D treatment. Therefore, it might be quite important to check the bone density levels regularly even years after implantation and keep it in normal levels to prevent fractures including not only mandible but also orbital and maxillary sinus walls.

Another underlying cause for the fractures in our patient might be the use of antidepressant drugs. Although they are widely used by the society ensuring their overall safety, they might be quite dangerous in a patient with endosteal implants. There are studies showing antidepressant drug use decreases bone mineral density causing significant increases in the risk of fractures.[8],[9] Although there is no study directly linking antidepressant use with the increased risk of mandibular fractures, there is a study showing significantly decreased bone density in the mandible after using antidepressant drugs.[10] Therefore, as in our case, the use of antidepressant drugs might be one of the underlying causes of the fractures in patients with dental implants and these patients should use these types of drugs more carefully to avoid the risk of viscerocranium fractures.

Multidisciplinary approach was very important in the diagnosis and treatment of our patient in various aspects. Since ABCs can cause bony destruction leading to spontaneous fractures, ruling out this rare condition in the differential diagnosis was crucial.[4],[5] Cranial magnetic resonance imaging was asked by the department of neurosurgery in order to rule out any possible ABCs; however, no ABCs but a blowout fracture was demonstrated. With the history of a recent implant on the left maxilla, it was suggested by the department of dentistry that tightening the implant firmer than normal may cause instant or late fractures of the maxilla or mandible. Its mechanism is similar to a screw on a glass that is tightened more than its threshold. The glass becomes very fragile such that even a light touch may shatter it and this might be the same mechanism underlying the fracture in our case. Therefore, a consensus was made by the multidisciplinary team suggesting the cause of the spontaneous fractures as the dental implant that the patient had recently.

  Conclusion Top

Although endosteal implants help to solve functional and psychological problems effectively in patients with bad dentures, they might also cause rare but serious fractures of viscerocranium. In this report, we presented first orbital and maxillary sinus wall fractures in the literature associated with endosteal implants to our knowledge. Low bone density and antidepressant use are suggested as underlying risk factors for these fractures, and treatment of osteoporosis and careful use of antidepressants might prevent fractures in patients with endosteal implants.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References Top
1.Kan JY, Lozada JL, Boyne PJ, Goodacre CJ, Rungcharassaeng K. Mandibular fracture after endosseous implant placement in conjunction with inferior alveolar nerve transposition: A patient treatment report. Int J Oral Maxillofac Implants 1997;12:655-9.  Back to cited text no. 1
    2.Chrcanovic BR, Custódio AL. Mandibular fractures associated with endosteal implants. Oral Maxillofac Surg 2009;13:231-8.  Back to cited text no. 2
    3.Raghoebar GM, Stellingsma K, Batenburg RH, Vissink A. Etiology and management of mandibular fractures associated with endosteal implants in the atrophic mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:553-9.  Back to cited text no. 3
    4.Matt BH. Aneurysmal bone cyst of the maxilla: Case report and review of the literature. Int J Pediatr Otorhinolaryngol 1993;25:217-26.  Back to cited text no. 4
    5.Kalantar Motamedi MH. Aneurysmal bone cysts of the jaws: Clinicopathological features, radiographic evaluation and treatment analysis of 17 cases. J Craniomaxillofac Surg 1998;26:56-62.  Back to cited text no. 5
    6.Mason ME, Triplett RG, Van Sickels JE, Parel SM. Mandibular fractures through endosseous cylinder implants: Report of cases and review. J Oral Maxillofac Surg 1990;48:311-7.  Back to cited text no. 6
    7.Tolman DE, Keller EE. Management of mandibular fractures in patients with endosseous implants. Int J Oral Maxillofac Implants 1991;6:427-36.  Back to cited text no. 7
    8.Torvinen-Kiiskinen S, Tolppanen AM, Koponen M, Tanskanen A, Tiihonen J, Hartikainen S, et al. Antidepressant use and risk of hip fractures among community-dwelling persons with and without Alzheimer's disease. Int J Geriatr Psychiatry 2017;32:e107-15.  Back to cited text no. 8
    9.Xing D, Ma XL, Ma JX, Wang J, Yang Y, Chen Y. Association between use of benzodiazepines and risk of fractures: A meta-analysis. Osteoporos Int 2014;25:105-20.  Back to cited text no. 9
    10.Agacayak KS, Guler R, Ilyasov B. Evaluation of the effect of long-term use of antidepressants in the SSRI group on bone density with dental volumetric tomography. Drug Des Devel Ther 2019;13:3477-84.  Back to cited text no. 10
    
  [Figure 1], [Figure 2], [Figure 3]
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