ORIGINAL ARTICLE

SINUSCOPY IN PATIENTS WITH TITANIUM IMPLANTS IN THE NOSE AND SINUSES

Björn Petruson

From the Ear, Nose, and Throat Department, Sahlgrenska University Hospital, Göteborg, Sweden

Scand J Plast Reconstr Surg Hand Surg 2004; 38: 86–93

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Abstract. Foreign bodies in the nose and sinuses can cause chronic infections. Long titanium fixtures through the
maxilla to the zygomatic bone were followed up with a sinuscope in 14 patients after more than one year. There
were no signs of infection or inflammation in the mucosa around the fixtures.
Key words: sinuscopy, titanium implant, zygoma.

Correspondence to: Professor Björn Petruson, Ear-nose-throat Department, Sahlgrenska University Hospital, SE
413 45 Göteborg, Sweden. (E-mail: barbro.svensson@branemark.se)

Accepted 25 June 2003

It has been known for more than 300 years that, in rare Foreign bodies in the nasal cavity
cases, suppurative sinusitis can lead to the formation of Children are more likely than adults to insert objects,
antral stones, which in turn produce chronic infections such as pieces of paper, rubber, cotton, herbs, beads or
For personal use only.

in the sinuses (4). Since the beginning of this century,
radiographs have been helpful in diagnosing foreign
bodies and chronic infections in the sinuses. When the
sinuscope came into common use, about 25 years ago,
it became easier to inspect the maxillary sinuses
directly and to evaluate the condition of the antral
mucosa in a way that could previously be done only by
operation. Our knowledge of mucosal reactions has
therefore increased and the reliability of the diagnosis
of foreign bodies has improved.
In the late 1960s the osseointegration method was
introduced for the treatment of total edentulism (5). A
long-term follow-up study showed that 78% of the 229
osseointegrated implants in the maxilla were stable at
15 years, compared with 86% in the mandible (1). At
15 years, at least 92% of the maxillas had continuously
stable prostheses, while the figure for the mandible was
99% at 15 years. The lower survival rate for implants in
the maxilla is the result of there being only small
volumes of bone available below the nose and maxil-
lary sinuses; the residual bone is often thin as a result of
absorption.
To provide better support for implants in the maxilla,
and to avoid iliac bone grafts, it is possible to use long
fixtures through the maxilla to the zygomatic bone. The
aim of this study was to assess the reactions in the nasal
and maxillary mucosa with a sinuscope after implants
had been placed in the maxillary cavities.
 2004 Taylor & Francis. ISSN 0284–4311
DOI 10.1080/02844310310023909
stones, into their noses and then forget about them
(3, 14). Careless physicians or surgeons may leave
cotton sponges, tampons, and (broken) pieces of
metallic instruments in the nose postoperatively. The
symptoms of a foreign body are usually one-sided nasal
occlusion with mucopurulent discharge and swollen
nasal mucosa. After a while, the patient starts to sneeze,
and develops headaches, nosebleeds, and (in some
cases) fever. The treatment is to remove the foreign
body at once.
Non-metallic foreign bodies in the sinuses
Usually these foreign bodies have been left by a doctor
or dentist. During an operation a tampon might be left,
silicone sheets are used to substitute for the orbital
floor, plastic tubes are used to increase antral ventila-
tion, drugs are instilled, and talcum powder from
gloves may irritate the mucosa. A dentist may use too
much filling material, leave the root of a tooth or
tampons in the sinus, with or without disinfectant
chemicals. The signs are similar to those in the nose:
unilateral mucopurulent discharge often with an
unpleasant smell caused by anaerobic bacteria, nasal
occlusion, and pain in the cheek. The treatment is to
remove the foreign body with a sinuscope through
which you can inspect the mucosa, which looks
swollen and inflamed (18, 19).
Scand J Plast Reconstr Surg Hand Surg 38
 Titanium implants at sinuscopy 87

Table I. Presentation of the examined patients with titanium implants in the nose and sinus
Implants visible
Bone grafts ‡ Zygomatic Implants visible in maxillary
fixtures fixtures in the nose sinus
Case Sex Age Examined (months
No. (years) after implants) Right Left Right Left Right Left Right Left
1 M 62 42 0 0 ‡ ‡ - - n n
2 F 47 26 0 0 ‡ ‡ - - - n
3 F 62 53 0 0 0 ‡ - - ? c
4 F 59 44 0 0 ‡ ‡ n n - u
5 F 62 16 ‡ 0 ‡ ‡ - - c n
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6 F 67 60 ‡ ‡ 0 0 - n n -
7 F 72 24 ‡ ‡ 0 0 - - c ?
8 F 68 20 ‡ ‡ ‡ ‡ - - c -
9 F 66 35 ‡ ‡ ‡ ‡ - - ? n
10 F 46 59 ‡ ‡ ‡ ‡ - - n n
11 F 59 64 ‡ ‡ ‡ ‡ - - c c
12 F 62 59 ‡ ‡ ‡ ‡ - - c n
13 F 44 53 ‡ ‡ 0 0 - n ? ?
14 M 59 19 ‡ ‡ 0 0 - c - -
n = implants not covered, c = implants covered with mucosa,
- = no implants visible, ? = not examined, 0 = no implants.

Metallic foreign bodies in the sinuses Rhinoscopy and sinuscopy

In war it is common for shrapnel to find its way into the All the nasal cavities were thoroughly examined
maxillary sinuses. In peacetime airgun or shotgun through an endoscope. In all but one patient, one or
bullets are more common. The symptoms depend on both maxillary sinuses were examined under local
For personal use only.

the chemical composition of the metal and on the
amount of dirt covering the metal surface (13).
There is usually hyperplasia of the mucosa within a
month, particularly close to the foreign body. After
some time, a chronic infection usually develops, but
there might also be periods without symptoms. The
treatment is to remove the metallic foreign body.
PATIENTS AND METHODS
Patients
This study comprises 14 consecutive patients examined
between September 1992 and January 1997. The mean
age at follow up was 59 years, there were two men and
12 women and the mean (SD) follow-up period after
insertion of the fixture was 41 (17) months.
Grafting procedures and installed fixtures
In nine patients, bone grafts were taken from the iliac
crest, while in one a tibial graft was used. The method
for bone grafting and the installation of conventional
fixtures was described by Brånemark in 2001 (7).
All the grafting procedures to the palate were done at
the same time as the fixture was inserted into the
zygoma (8). Zygomatic fixtures were inserted bilater-
ally in nine patients and unilaterally in one (Table I).
anaesthesia. The findings related to the mucosa,
secretion, and fixtures were recorded on videotape.
Method
How to improve the ventilation and visualisation of
the maxillary sinus in patients with titanium fixtures
in the zygoma. There are two ways to reach the
maxillary sinus from the nose: through an opening
lateral to the inferior turbinate in the inferior meatus
or through an antrostomy in the middle meatus lateral
to the middle turbinate. To be sure to get the best
result, I usually use both methods.
Antrostomy in the middle meatus. This is a stan-
dard procedure known to most rhinosurgeons and pre-
sented in textbooks by Draf, Stamberger and Wigand,
for example (18, 19). You can use a headlamp, endo-
scope, or microscope when you remove the uncinate
process and the ethmoidal bulla and enlarge the
natural ostium of the maxillary sinus (Fig. 1).
Antrostomy of the inferior meatus. To make sure
that the opening does not close, I always remove the
anterior and inferior square centimetre of the inferior
turbinate with a conchotome (Fig. 2). It is now easy
to see the lateral nasal wall, which is opened with the
elevator knife, leaving the bone and attached mucosa
as a door with a posterior hinge (Fig. 3). The door is
removed with a small concha punch leaving an
opening 1 cm wide into the maxillary sinus (Fig. 4).

Scand J Plast Reconstr Surg Hand Surg 38

 88 B. Petruson
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Fig. 3. The lateral nasal wall is opened with an elevator

knife (Petruson).

Fig. 1. Antrostomy in the middle meatus.

A silicone or Portex tube of suitable length is inserted

into the sinus and anchored with a suture through the
anterior part of the nasal septum (Fig. 5).
For personal use only.

To improve nasal breathing during healing, another

tube can be placed on top of the first. This breathing
tube extends to the nasopharynx. After a week the tubes
are taken away. It is now easy to inspect the zygomatic

Fig. 4. A part of the lateral nasal wall is removed.

Fig. 2. Removal of the anterior and inferior square

centimetre of the inferior turbinate with a conchotome Fig. 5. Tubes are inserted into the sinuses and anchored with
(Petruson). a suture for one week.

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Fig. 6. With an endoscope the zygoma fixture in the
maxillary sinus can be inspected.
fixtures in the maxillary sinus with an endoscope (Fig.
6).
RESULTS
In four patients, five implants were visible in the nasal
floor, four of which were uncovered and one was
For personal use only.
covered with mucosa, with no signs of infection or
inflammation (Table I, Fig. 7).
Sinuscopy was done in 23 of 28 possible sinuses; no
fixtures were installed in four sinuses and one patient
experienced pain during the sinuscopy, despite suffi-
cient local anaesthesia. Nine of the fixtures through the
maxillary sinuses were not covered by mucosa, eight
were covered, and in six sinuses no fixtures were
Fig. 7. Case 4. An implant coming up through the left nasal
floor with the inferior turbinate above.
Titanium implants at sinuscopy 89
Fig. 8. Case 4. The implant is partly covered with mucosa in
the left maxillary sinus.
visible. When the examination was made there were no
signs of infection or inflammation around the fixtures
(Figs. 8–10). There was no increased secretion.
Case 11 had had frequent sinusitis before the im-
plants were inserted and was therefore operated on and
given a new endonasal opening in the inferior meatus
on both sides.
Case reports
Case 1. A man born in 1933, who had implants
inserted in September 1991, and a prosthesis in April
1992, was examined in March 1995.
In the right maxillary sinus, a fixture in the lower
Fig. 9. Case 2. The implant is not covered with mucosa
where it enters the left side of the zygoma.
Scand J Plast Reconstr Surg Hand Surg 38
 90 B. Petruson

Fig. 11. Position of the fixture in case 1.

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Fig. 12. Position of the fixture in case 2.

Fig. 10. Case 1. The implant is not covered when it exits the
left side of the palate.

lateral part was not covered by mucosa. The mucosa

was normal in the two regions where the implant
entered the bone and the osteum was open.
In the left maxillary sinus, a fixture could be seen in
the lateral part of the cavity. In the central part it rested
Fig. 13. Position of the fixture in case 3.
against normal mucosa but was otherwise not covered
by the mucosa other than in the proximal and distal
For personal use only.

parts, where it was anchored in the bone. The mucosa

in the cavity was normal (Fig. 11).
Case 2. A woman born in 1945, who had implants
inserted in June 1993, and a prosthesis in March
1994, was examined in March 1995.
The right maxillary sinus was small, probably as a
result of previous infections. The mucosa was normal.
No fixture could be seen. Fig. 14. Position of the fixture in case 4.
In the left maxillary sinus, a fixture in the distal part
was covered with mucosa, while in the central part it
was not covered. The surrounding mucosa was thin and
the osteum was open (Fig. 12).
Case 3. A woman born in 1933, who had implants
inserted in October 1990, and a prosthesis in June
1992, was examined in March 1995.
The right maxillary sinus was not examined as no
fixtures had been inserted. Fig. 15. Position of the fixture in case 5.
In the left maxillary sinus, a fixture was visible for
1.5 cm in one lower lateral part. It was covered with In the right maxillary sinus, no fixture could be seen.
mucosa without any signs of inflammation (Fig. 13). In the left maxillary sinus, there was a fixture in the
Case 4. A woman born in 1936, who had implants lower lateral part with thin mucosa covering the distal
inserted in June 1991, and a prosthesis in March part. The mucosa in the cavity was normal (Fig. 14).
1992, was examined in March 1995. Case 5. A woman born in 1930, who had implants
In the right nasal floor, there was a fixture, covered inserted in April 1991, and a prosthesis in November
with normal mucosa. 1991, was examined in September 1992.
In the left nasal floor, there was a fixture covered In the left maxillary sinus, there was a fixture almost
with a small crust. The mucosa around the fixture was 2 cm long in the lower lateral part of the cavity. It was
normal. covered with mucosa, with the exception of a few mm

Scand J Plast Reconstr Surg Hand Surg 38


Fig. 16. Position of the fixture in case 6.
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Fig. 17. Position of the fixture in case 7.
Fig. 18. Position of the fixture in case 8.
For personal use only.
Fig. 19. Position of the fixture in case 9.
Fig. 20. Position of the fixture in case 10.
Fig. 21. Position of the fixture in case 11.
Titanium implants at sinuscopy 91
in the proximal part where it was uncovered. The
mucosa looked normal (Fig. 15).
Case 6. A woman born in 1925, who had implants
inserted in September 1987, and a prosthesis in June
1988, was examined in September 1992.
In the right maxillary sinus, two fixtures were visible
in the floor, one about 2 mm long and covered with
normal mucosa, the other about 5 mm long, with the
proximal part covered with normal mucosa.
In the left nasal floor, there was a fixture partly
covered with a crust. The mucosa was normal (Fig. 16).
Case 7. A woman born in 1920, who had implants
inserted in September 1990, and a prosthesis in May
1991, was examined in September 1992.
In the right maxillary sinus, a fixture could be seen as
a shadow under normal mucosa in the lower medial
part of the cavity (Fig. 17).
Case 8. A woman born in 1929, who had implants
inserted in May 1993, and a prosthesis in February
1994, was examined in January 1997.
The mucosa in the floor of the nose was normal.
In the right maxillary sinus, the zygomatic fixture
was covered with normal mucosa.
In the left maxillary sinus, no fixture was seen and
the mucosa was normal (Fig. 18).
Case 9. A woman born in 1931, who had implants
inserted in February 1994, and a prosthesis in
October 1994, was examined in January 1997.
In the left maxillary sinus, four or five threads of the
fixture were not covered proximally by normal mucosa.
The distal part was covered with normal mucosa (Fig.
19).
Case 10. A woman born in 1940, who had implants
inserted in February 1992, and a prosthesis in
October 1992, was examined in January 1997.
In the right maxillary sinus, the fixture was un-
covered proximally for 1 cm, while the surrounding
mucosa was normal.
In the left maxillary sinus, the fixture was partly
covered with normal mucosa for 1 cm (Fig. 20).
Case 11. A woman born in 1938, who had implants
inserted in September 1991 and a prosthesis in May
1992, was examined in January 1997.
In the right maxillary sinus, the fixture was com-
pletely covered with normal mucosa for a distance of
1 cm.
In the left maxillary sinus, the fixture was completely
covered with normal mucosa for more than 1 cm (Fig.
21)
Case 12. A woman born in 1935 who had implants
inserted in February 1992, and a prosthesis in
October 1992, was examined in January 1997.
In the right maxillary sinus, the fixture was covered
with normal mucosa.
In the left maxillary sinus, the central part of the
Scand J Plast Reconstr Surg Hand Surg 38
 92 B. Petruson
Fig. 22. Position of the fixture in case 12.
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Fig. 23. Position of the fixture in case 13.
Fig. 24. Position of the fixture in case 14.
For personal use only.
fixture was uncovered. The proximal part and distal
parts were covered with normal mucosa (Fig. 22).
Case 13. A woman born in 1948 who had implants
inserted in May 1989, and a prosthesis in March
1990 was examined in September 1992.
In the left nasal floor, a fixture was visible, with no
inflammatory reaction in the adjacent mucosa. There
was no abnormal secretion (Fig. 23).
Case 14. A man born in 1943, who had implants
inserted in January 1991, and a prosthesis in Septem-
ber 1991, was examined in September 1992.
In the left nasal floor, a fixture with a few mm
covered with normal mucosa was visible. There was no
increase in secretion.
No implants were visible in the maxillary sinuses
(Fig. 24).
DISCUSSION
It has long been known that foreign bodies such as
tampons in the nose or the sinuses may cause in-
flammatory reactions and infections (14). Reactions to
metals depend on the composition and quality of the
metal (13).
The invention of zygomatic fixtures made it inter-
esting to find out how the mucosa of the maxillary sinus
reacted to the titanium implants, as they transverse the
Scand J Plast Reconstr Surg Hand Surg 38
maxillary sinus on their way from the palate to the
zygoma (6, 8).
These results show that there were no signs of
inflammatory reactions in the surrounding mucosa
when the nose and maxillary sinuses were examined
with an endoscope. The titanium implants were
covered with mucosa in some cases, while in others
they were partly covered, but even in those cases the
mucosa looked normal. There were no signs of
infection around the implants or increased secretion.
It is possible to assess the condition of the nasal and
maxillary sinus mucosa with the eye through an
endoscope and confirm the finding with video record-
ings or by biopsying the mucosa to look for inflam-
matory cells. No biopsy specimens were taken, so that
we did not create an inflammatory reaction in the
biopsy area.
The soft tissues in the oral cavity adhere tightly to
the titanium and create a barrier to inflammatory
processes (2).
It has been assumed that the mucous membrane of
the paranasal sinuses is normally sterile. An infection
of the sinuses is therefore usually preceded by a nasal
infection and is caused by direct propagation through
the ostia (11).
Over the past few years it has been noted that there is
considerable production of nitric oxide in normal
maxillary sinuses (15).
Different studies have shown that nitric oxide with a
concentration found in the sinuses has high antimicro-
bial activity against a remarkably wide range of
pathogenic micro-organisms, including viruses, bac-
teria, and fungi (9, 10, 12, 16, 17). The nitric oxide
produced in the maxillary sinuses may therefore be
another important explanation of why no infections are
found around titanium implants.
It is, however, possible that a patient with a zygo-
matic implant may contract an upper respiratory tract
infection, which might close the maxillary osteum,
resulting in sinusitis. When a patient with zygomatic
implants contracts sinusitis, which might be chronic, it
is important to restore the ventilation to the sinuses
surgically.
In conclusion, there seems to be no increased risk of
inflammatory reactions in the normal nasal and maxil-
lary mucosa in regions where titanium implants pass
through the mucosa.
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