Association between maxillary sinus fungus ball and sinus bone grafting with deproteinized bovine bone substitutes: a case-control study

Abstract

Objective. To evaluate the association between sinus bone graft and the development of fungus ball (FB) of the maxillary sinus. Study Design. The charts of all patients seen for surgical treatment of maxillary sinus FB following sinus bone grafting between 2006 and 2014 were reviewed. The charts of 49 participants were selected from our internal registry for comparison as controls. The association between FB and age, gender, smoking habits, associated co-morbidities, and bone grafting material was evaluated. FB of the maxillary sinus was estimated by using an odds ratio with a Yates' correction. P values were computed using Fisher's exact test, and the statistical significance was set at a P value < .05. Results. All 13 cases (100%) with FB of the maxillary sinus had received anorganic bovine bone as the bone substitute (P ¼ .0001). There were significantly more women in the case group than in the control group (84.6% in the cases vs 40.8% in the controls; P ¼ .01).Conclusions. This study demonstrated a significant association between a specific deproteinized bovine bone substitute use as sinus bone graft material and subsequent development of FB of the maxillary sinus. (Oral Surg Oral Med Oral Pathol Oral Radiol 2016;121:e143-e147) Fungus ball (FB) represents the most common form of noninvasive extramucosal fungal infection involving the paranasal sinuses and is encountered in almost 28.5% of patients suffering from chronic maxillary sinusitis. 1-3 Aspergillus fumigatus is, by far, the most frequent causative agent found in Europe, and the root canal overfilling with the passage of zinc oxide endodontic sealers into the maxillary sinus is the most commonly recognized risk factor for the development of FB in up to 84% of patients. [1][2][3][4][5][6] Although this form of sinusitis typically affects healthy adults and has a striking female predominance, several pathologic conditions, such as diabetes, immunodeficiency diseases, and immunosuppressive and chronic corticosteroid and antibiotic treatments have been pointed out as potential predisposing factors favoring the colonization and subsequent overgrowth of the fungal hyphae. [1][2][3] Since its first report in 1980 by Boyne and James, grafting of the maxillary sinus floor has rapidly become the most common surgical procedure used to increase the subantral alveolar bone height of the posterior maxilla for subsequent dental implant placement. 7 Although reported as a predictable and reliable procedure, sinus bone graft has, nevertheless, been associated with several intra-and postoperative complications, such as sinus membrane perforation, maxillary sinusitis, wound dehiscence with graft exposure, and graft infection. In most cases, complications resolve with no need for further surgery and with no substantial impact on implant survival; however, in some cases, complications may lead to complete loss of the graft material, thus compromising the subsequent implant-supported dental restoration. [8][9][10][11][12][13][14][15][16][17] Although the literature co...

The long-term risks and complications of bovine-derived xenografts: A case series

“…[32] Interestingly, Scolozzi et al demonstrated association between deproteinized bovine bone (Bio-Oss) substitute and development of fungus ball in the maxillary sinus. [9] Fungus ball represents the most common form of fungal infection involving paranasal sinuses, encountered in 28.5% of patients suffering from chronic maxillary sinusitis. The frequent causative agent is Aspergillus fumigatus .…”

“…[345] However, bibliographical data reporting on clinical complications are scarce and the long-term safety is rarely addressed in dental literature; the risk of bovine spongiform encephalopathy (BSE). Reported complications have included as follows: acute and chronic sinusitis, maxillary fungus ball, material displacement, immune reactions, chronic inflammation, foreign body reaction,[678910] and the risk of disease transmission (variant Creutzfeldt–Jakob disease). [1112]…”

Aspergillus fumigatus biofilm formation on different bone substitutes used in maxillary sinus augmentation: an in vitro analysis

“…In case of membrane perforation or tearing, an intra-operative complication occurring with an incidence varying from 5 to 20% depending on the surgical technique [22], a dissemination of the biomaterial in the maxillary sinus cavity is a possible event. Bone substitute granules in contact with the respiratory environment could be easily colonized by resident fungi, also considering that a temporary impairment of the mucociliary clearance always occurs after sinus surgery [23]: nevertheless, very few studies were published on this topic [10, 16].…”

“…In a recent retrospective study, Scolozzi et al hypothesized the physiopathological role of a bone substitute, by demonstrating a significant association between a specific anorganic bovine bone (BioOss, Geistlich, Wolhusen, Switzerland) and subsequent development of FB [10]. The results of the present study, testing five different biomaterials of three different classes (allografts, xenografts, and alloplasts), do not support this finding by showing no significant differences among the various grafts in promoting adhesion and biofilm formation of A. fumigatus .…”

“…Furthermore, a recent case-control study suggested a significant association between the use of a specific bone substitute (anorganic bovine bone) as sinus grafting material and subsequent development of FB [10]. Although both lateral and transcrestal sinus floor elevation have been reported as predictable and reliable techniques [11, 12], they have also been associated with several postoperative complications [13, 14], such as graft infection both from fungal and bacterial pathogens [10, 15]. When a biomaterial is grafted in the maxillary sinus, especially in case of Schneiderian membrane tearing or perforation, it may get in contact with the respiratory environment.…”