Dental Implants and Tooth Fragments in the Sinus: A New Algorithm Achieves Full Recovery in All Patients

When a dental implant slips into the maxillary sinus during placement, or a tooth root migrates upward through thin bone, the consequences can extend far beyond the mouth. The displaced material becomes a foreign body lodged inside an air-filled cavity lined with delicate mucosa, and in many patients it triggers a stubborn, one-sided sinus infection that resists antibiotics and nasal sprays. A research team at Campus Bio-Medico University in Rome has now distilled five years of surgical experience into a structured treatment algorithm for exactly this problem, and their retrospective analysis of 48 patients reports complete foreign body removal and complete symptom resolution in every single case.

The study, published in Frontiers in Oral Health, examined patients treated between December 2020 and November 2025 at the Department of Integrated Therapies in Otolaryngology. Of 165 consecutive patients evaluated for suspected sinonasal disease, 111 had sinusitis without any foreign body, 6 carried a maxillary foreign body without sinusitis, and 48 presented the combination that formed the core of the analysis: odontogenic maxillary sinusitis accompanied by a foreign object in the sinus. The male-to-female ratio in the overall cohort was almost exactly even, at 1.01, and 129 of the patients suffered the chronic form of the disease, defined by symptoms persisting for more than three months, while 26 presented acutely.

Odontogenic sinusitis, as the condition is known, occupies a distinctive position in sinus pathology. Under the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 classification, it is categorized as a secondary chronic rhinosinusitis, a localized disease with an anatomically unilateral distribution. The dominant mechanism is periapical or periodontal infection arising from a maxillary posterior tooth, in which inflammatory exudate erodes through the bone separating the dental apex from the sinus floor and drains into the cavity. Periapical lesions account for roughly 73 percent of cases, oroantral fistulae for 23 percent, and retained teeth for 4 percent, according to figures cited in the literature. The disease develops unilaterally in over 90 percent of cases, and between 85 and 90 percent of patients experience symptoms on the same side as the dental problem.

Recognizing the condition remains a diagnostic challenge. The most frequent complaints are facial pain or pressure, postnasal drip, nasal obstruction, and unilateral purulent discharge often accompanied by a foul odor or taste, yet dental pain is frequently absent, which can steer clinicians away from the true cause. Computed tomography typically shows partial to complete opacification of the maxillary sinus in 70 to 100 percent of cases, but dental pathology is reportedly overlooked in 60 to 70 percent of scans by radiologists unless a targeted dental assessment is performed. This blind spot is precisely why the Roman team insists on a multidisciplinary diagnostic pathway: preoperative CT scans were independently reviewed by at least three specialists, a radiologist, an otolaryngologist, and an oral surgeon, while endoscopic findings were evaluated jointly by at least two specialists before any surgical decision was made.

The foreign bodies themselves vary widely in composition and origin. Tooth roots, root canal filling materials, fractured tooth fragments, dental implants, and impression substances can all enter the sinus through apical migration, traumatic manipulation during dental procedures, or an oroantral fistula. Dental implants deserve particular attention. Accidental displacement usually occurs intraoperatively, linked to excessive site preparation, insufficient primary stability, or inadequate planning, but delayed migration years after placement has also been documented, potentially driven by peri-implantitis or bone resorption from improper occlusal load distribution. Resorption of the alveolar ridge combined with progressive pneumatization of the sinus reduces the available bone height in the posterior maxilla, which is both a major predisposing factor for displacement and a contraindication to implant placement in that region.

The surgical toolkit described in the paper centers on three routes of access. The nasal approach, an endoscopic middle meatal antrostomy, involves removing the uncinate process and enlarging the natural sinus ostium to clear diseased mucus while preserving healthy mucosa and its basement membrane, thereby maintaining mucociliary function; the widened opening can also serve as the corridor for foreign body extraction, though the proximity of the orbit and infraorbital nerve demands considerable expertise. The oral approach is a modified mini Caldwell-Luc procedure, in which a full-thickness mucoperiosteal flap is elevated over the canine fossa, a bony window is created in the anterior sinus wall, and the Schneiderian membrane is incised to access the cavity; the antrostomy typically exceeds 3 to 4 millimeters to admit a pediatric endoscope. This modification reduces the facial swelling and paresthesia associated with the traditional Caldwell-Luc operation and speeds recovery. Where an oroantral communication or fistula exists and the foreign body is small enough, the fistulous tract itself can serve as the removal route, after which the defect is closed with local flaps for small to medium gaps of 5 to 8 millimeters, or with cortico-cancellous grafts covered by resorbable collagen membranes, sometimes reinforced with a heterologous cortical lamina, for larger defects.

What distinguishes the Roman algorithm is its explicit integration of three variables that previous flowcharts treated more loosely: the status of the ostiomeatal complex, the size and position of the foreign body, and the presence or absence of an oroantral defect. The decision logic runs roughly as follows. In patients without ostiomeatal obstruction and without an oroantral defect, foreign bodies smaller than 1 to 2 centimeters are approached nasally if they sit superiorly or adhere to the sinus roof, and orally via the mini Caldwell-Luc if they lie inferiorly or are embedded in inflammatory tissue in the deep recesses; bodies larger than 2 centimeters require an endoscopically assisted lateral approach. In patients without sinusitis but with an oroantral fistula, the fistular route is preferred when the foreign body fits through the tract, with simultaneous fistula closure. When odontogenic sinusitis is present, signaled by ostiomeatal complex obstruction, the calculus shifts decisively toward combined surgery: small foreign bodies without a fistula are managed with a combined or purely nasal approach, large ones demand a simultaneous endoscopic and lateral procedure, and the coexistence of a fistula adds a fistular step for closure after nasal removal. For tiny foreign bodies under 1 to 2 millimeters, the team even endorses a wait-and-see policy when clinically appropriate, sparing the patient an operation altogether.

The outcomes lend the algorithm considerable weight. Among the 48 patients with sinusitis and a foreign body, 32, or 67 percent, underwent the combined oral and nasal approach in a single operative session, 12, or 25 percent, were treated orally alone, and 4, or 8.33 percent, nasally alone. Complete removal of the foreign body and complete resolution of symptoms were achieved in all cases, with no major complications and no revision surgeries over a mean follow-up of six months and a minimum of three. Within the broader cohort, ostiomeatal complex obstruction was observed in 77 cases, and 73 patients carried an oroantral defect alongside the foreign body. Under Felisati’s classification, 8 cases were pre-implantological complications, 37 were implantological complications, and 115 were classical complications, reflecting how heavily dental procedures and implant surgery feature in the origins of this disease.

The findings align with a growing international consensus that odontogenic sinusitis is best managed jointly by otolaryngologists and oral surgeons. Felisati and colleagues previously reported a 98.8 percent success rate across a prospective series of 257 patients using a cause-specific algorithm, while a prospective study by Kocum and colleagues found that a one-stage combined ENT and dental approach was used in 94 percent of 364 patients with a 97 percent success rate. The Roman team acknowledges the limitations of its own design: the analysis is descriptive rather than comparative, no formal statistical superiority testing was performed given the small size of subgroups such as the four nasal-only patients, and follow-up relied on clinical symptom resolution rather than systematic radiologic assessment or patient-reported outcome measures. Even so, the authors argue that the relatively large number of patients with maxillary sinus foreign bodies and the consistent application of a predefined algorithm make the results directly applicable to routine practice.

The broader message for patients and clinicians alike is that a displaced dental material in the maxillary sinus is rarely a trivial finding. Surgical removal is recommended when the foreign material causes or contributes to sinusitis, and the choice of route, nasal, oral, fistular, or a simultaneous combination of these, should be dictated by the anatomy of each case rather than by habit or specialty allegiance. As the authors put it in their conclusion, the simultaneous combined approach overcomes the anatomical and technical limitations of each individual access, providing wider visualization and more comprehensive access to the sinus cavity, reducing the risk of recurrence or complications, and representing, in their view, a new frontier in the management of foreign bodies in patients suffering from odontogenic sinusitis. Larger prospective and multicenter studies will be needed to confirm which patient subgroups benefit most, but for now the Rome algorithm offers one of the most detailed roadmaps available for a problem that sits, quite literally, at the intersection of two surgical disciplines.

Subject of Research: Surgical management of maxillary sinus foreign bodies in odontogenic sinusitis using a multidisciplinary treatment algorithm

Article Title: Maxillary foreign body management in odontogenic sinusitis: an algorithm based on a single centre experience

Article References: Sabatino, L., Lopez, M. A., Valentini, M., Mattaroccia, M., Iafrati, F., Di Giovanni, S., Moffa, A., & Casale, M. (2026). Maxillary foreign body management in odontogenic sinusitis: an algorithm based on a single centre experience. Frontiers in Oral Health, 7, Article 1945885. https://doi.org/10.3389/froh.2026.1945885

Image Credits: AI Generated

DOI: 10.3389/froh.2026.1945885

Keywords: odontogenic sinusitis, maxillary sinus, foreign body, dental implants, middle meatal antrostomy, Caldwell-Luc, oroantral fistula, endoscopic sinus surgery, multidisciplinary surgery, ostiomeatal complex, treatment algorithm, oral and maxillofacial surgery