Maxillary sinus implant removal : modified Caldwell-Luc technique

The installation of immediate implants after tooth extractions is becoming a common practice in the dental clinic. During this surgical procedure, complications such as the displacement of dental implants into the maxillary sinus may occur due to the close relationship between the floor of the maxillary sinus and the upper teeth. In these cases, treatment consists of removing the implant that has been displaced in order to prevent future complications such as maxillary sinusitis and oroantral fistula. The present study aims to present a clinical case in which the removal of the maxillary sinus implant was performed using the modified Caldwell-Luc Technique. The patient sought a private clinic for extraction of the left upper second molar and oral rehabilitation with implants. Even with little bone height between the floor of the maxillary sinus and the crest of the alveolar ridge, the professional opted for immediate implant installation after extraction, but when returning after 90 days, the implant had moved into the sinus. The implant was removed using the modified Caldwell-Luc technique, which consists of making a bone window in the lateral wall of the maxillary sinus, removing the fragment, replacing the bone window, and suturing the previously folded flap. Therefore, it can be concluded that the Caldwell-Luc technique benefits the closure of the bone defect, avoids fistulas and the area of ​​fibrosis in the membrane, being an effective and viable alternative for removing implants in the maxillary sinus region.


Introduction
Introduced in the late 1970s, the concept of implants installed immediately after tooth extraction has become increasingly popular in dental clinics over the past few years. This growing success is largely due to the preservation of the patient's aesthetics, reduction of Development, v. 9, n. 9, e901997936, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7936 4 clinical and surgical time, maintenance of alveolar walls and especially by avoiding alveolar bone resorption, common after a certain period of tooth extraction, which has been reflected in good prognosis (Del Fabbro, Boggian &Taschieri, 2009 andHegde, Prasad, Shetty &Shetty, 2013).
However, the posterior region of the maxilla proves to be a challenge to perform this procedure right after extraction, when compared to other regions of the maxillary-mandibular complex, this because of its lower bone quality, presenting thin bony cortical and bone The displacement of foreign bodies into the maxillary sinus, such as a dental implant, may or may not be associated with signs and symptoms of sinus infection, but due to their  After receiving all the necessary guidance, opting for the treatment modality and complying with the procedures to be adopted, the patient signed the free and informed consent form, so that the treatment plan could be carried out with written consent.
For surgery, a preoperative drug regimen consisting of Dexamethasone 8 mg was prescribed, one hour before the procedure. Facial asepsis was performed with 10 mg / mL chlorhexidine digluconate and oral asepsis with 0.12% chlorhexidine digluconate. Anesthesia was performed with Mepivacaine 2% with adrenaline 1: 100000 in the regions of the posterior superior alveolar nerve, major palatine nerve and also through the infiltrative terminal technique in maxillary fornix.
The intraoral surgical technique for accessing the maxillary sinus through the modified Caldwell-Luc access, under local anesthesia, was chosen as the treatment method. Initially, the Novac-Peter incision was made and the mucoperiosteal flap was elevated to allow visualization of the surgical field, then a bone window was opened in the lateral wall of the maxillary sinus, through osteotomy with a trephine drill (10mm) coupled to an implant contra-angle under irrigation with saline solution (0,9%) (Figures 2A and 2B). After making the window, the sinus membrane was gently incised in order to enter the maxillary sinus and access the implant there.
Once located, in the second premolar and first molar region, the apprehension was performed with the aid of the surgical sucker ( Figure 2C). Perforations were made in the bone fragment removed from the maxillary sinus wall and in the vicinity of the surgical store in order to Development, v. 9, n. 9, e901997936, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7936 stabilize the bone fragment through sutures with nylon 4.0 suture thread ( Figure 2D). The membrane was sutured with Vicryl 6.0 thread and, finally, the flap was repositioned and sutured with Nylon 5.0 suture thread ( Figure 2E).  Figure 2B: Bone window construction region after using the trephine drill. Figure   2C: Removal of the dental implant from inside the maxillary sinus with the aid of a surgical sucker. Figure 2D: Bone fragment removed from the lateral wall of the maxillary sinus with perforations made to facilitate subsequent suture. Figure 2E: Bone fragment repositioned and already sutured in the place where the bone window was opened.
Source: Personal archive. Figure 2 shows the steps of the surgical procedure to perform the modified Caldwell-Luc access to remove the dental implant from inside the maxillary sinus. In A, the sinus lateral wall osteotomy is performed with a trephine drill under abundant irrigation, in B the bone aspect is evidenced after the osteotomy, in C the removal of the dental implant from inside the cavity is shown with the aid of a surgical sucker and in D the bone fragment removed from the Development, v. 9, n. 9, e901997936, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7936