7mm of the implant is in my sinus: options?

Since you are having symptoms something needs to be done. Implants can be tolerated in the sinus such as a zygoma implant. It may be possible to graft around the integrated implant if the sinus is healthy by a lateral approach and a membrane placed over the implant ala giant tear technique (Pikos) it could work vs removing the implant and causing more damage or it could exacerbate the sinus symptoms but I think it would be worth a try. The more important X-ray is the cross section, like the preop, with the implant in place to see if there is inflammation of the sinus membrane. Usually a sinus lift is performed in this situation but implants can tolerated in the sinus. There could be another cause such as a blocked osteum what does the ENT advise?

I'm a little confused here how are you able to obtain CBCT images as a patient are you working with someone? What is concerning is there is only partial information a cross section with the implant in place would be helpful. Have you consulted another dentist who is familiar with placing implants? There can be many reasons for sinus infections , your comment about the entire sinus being infected and possible bone infection and a bone graft healing seems to be escalating the situation. Why is a consumer posting dental questions on this blog?

Your first question about access to images is interesting given the new regulatory framework. As per Meaningful Use Stage 2 guidelines for the ARRA act signed into law in 2009, starting this year providers must, "Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP." This health information includes CBCT images. My guess it that since many dentists and oral surgeons operate independently and many do not take Medicare, they might remain unaware of the new Meaningful Use guidelines and laws. However, widespread adoption throughout the entire healthcare system of all the meaningful use guidelines over the next few years, will certainly makes its way into dentistry making it seem almost commonplace for patients to have access to all of their medical images (luckily most dentists and oral surgeons already comply with many of the guidelines and have no problems providing patients with their personal CBCT data upon request).

Thanks for the info but that was not my question. Who ordered the CBCT? I don't think a patient is able to order films on themselves. That's the person who should be giving advice on treatment..

When the pain in my sinus persisted after the placement of the implant, I repeatedly asked the placing dentist if the implant could be the cause. He said no, that "because he had the CBCT, he was able to avoid damage to the sinus membrane". The pain continued and a sinus infections began to come and go. I had no history of sinusitis or allergies. I decided to get orthodontics and in preparation another CBCT was taken, that is when the cause of my problems was identified. I went to an ENT who performed surgery to open and clear my sinus, and during the surgery took photos of the implant protruding into the sinus cavity. I wanted to have the implant removed immediately, but because of the amount of infection, I was advised to wait to have the implant removed. I have since relocated and my new dentist is concerned about the damage that may be caused by removing the implant. This is why I wrote the appeal for advice.

I would advise having an oral surgeon remove the implant and repairing the oral antral communication. You may end up with a bridge or a couple of grafting surgeries for another implant perhaps ortho to close the spot.If you are going to have orthodontics the implant will interfere with treatment. The sinus is not tolerating the implant. Another option to try would be the grafting procedure I posted however since there is only 3mm of implant integrated the removal should not be that bad. The problem is getting someone to correct this it is not easy. What needs to be weighed is damage and repair in removal vs chronic sinus infections. Good luck

I would not try to fix this implant. While theoretically you could open a lateral window and graft the intra-sinus portion of the implant, this is a horrible idea for the following reasons: 1. The implant surface is contaminated by whatever infectious or inflammatory process has been going on. It has no blood supply, and while grafting may paint a pretty radiographic picture, it is not good medicine. (The ENT's would slam this approach as ridiculous.) An infectious disease specialist would equate this to sewing a dead cat into a persons chest and expecting them to do well. 2. The least invasive procedure, and what I believe to be the standard of care here, is removing the implant. 100 NCm of reverse torque would probably do it. If the patients osteum is patent, and it should be as they just had sinus surgery, the risk of an oral astral fistula is low. Primary closure would be easy with very minimal flap release. 3. The first step in comprehensive care of a dental patient is treating acute infection. Get the implant out. Then orthodontics, then scan and treatment plan for another attempt at implant (done correctly with pre-implant grafting of course) or a bridge. Unfortunately, this patient has lost confidence in implants, and I don't blame him. The sinus is a very forgiving environment. Every once in a while this happens, and recognizing when to give up is important.

Just for the sake of argument have you ever repaired a giant tear of the sinus membrane with the Pikos technique? Zygomatic implants traverse the sinus also. But due the chronic nature of the infection and the poor placement I would also remove, now when it is removed either by counter torque or trephine a hole will be created which will need to be closed primarily that's what I was referring to. Never had the opportunity to sew a dead cat to a patient's chest or been slammed by an ENT. Obviously the sinus can't clean itself with a 7 mm implant protruding into it. Hopefully not too big of a floor defect will be created and the area will heal. Going back in will be difficult due to scar tissue, when we close o-a communications usually it is a fibrous and soft tissue repair, rarely bone will form unless some kind of barrier is placed. Just thinking out of the box, personally I wouldn't want to fix this one. But thanks for reading and developing such a passionate response!

One other idea but I don't have a ct of the implant in place so it is speculative. See how on the cross section there is a ledge with I think a blood vessel running thru it, a nice niche for a graft; why not remove the implant, reflect what you can, place a membrane and graft the sinus floor at removal and plug the defect with primary closure. Then there is bone in the defect and increased alveolar height and the alveolar cleft Is repaired. It could also be staged which is prudent. That way the patient could have ortho to close the space of an implant depending on what you get. Nothing wrong with a short implant either or a bridge. Just thinking out of the box.

If you have the cross-section of the implant in place then please post. It is the most definitive slice for your situation. The reconstruct does not help at all.

Sympathy to the patient! No info re the status of the implant. Is it integrated good peri implant status. Is the patient able to function on the crown without symptoms. Would be necessary to see good ct of the impant sinus and surrounding bone. All being favourable l would give serious consideration to the following approach: 1. Lateral approach and sinus lift taking care to avoid increasing size of the perforation as the membrane is teased off the implant. 2. Resect the implant as low as possible given the access ie not to reduce bone buccal to the implant. Residual part of the implant is cleared of its threads so remaining with dome shaped nub of smooth titanium. Understood there are serious issues re heat generation during the procedure. Therefore copious irrigation light pressure during drill work and time given for heat to dissapate. 3. Vigorous irrigation of the sinus via the perforation followed by suture if feasable. 4. Placement of membrane under the membrane which will help to close the perf whose margins will be coapted as the sinus membrane is moved in centripetal direction 5. Placement of graft as carrying out elective sinus lift graft 6. Closure

to continue..... I believe this procedure could salvage the case. The source of the infection eliminated and the sinus rendered intact and opportunity for repair and sinu health with resolution of symptoms and youve saved the implant snd crown. No pain and happy patient. Dead cat gone.

I like it, I just think it would be tough to prevent the titanium from getting all over the sinus lining, the membrane could re establish itself over the implant stub, the problem could be with so much of the implant body removed one could get really close to where the abutment screw housing is and compromise the integrity of the implant strength. I think you either remove or graft around it. Removal is more mainstream, one could remove, lift, repair the membrane with a patch replace with a new implant or just repair and call it a day since the patient has had significant problems and may not be a good candidate another implant. We are all just guessing until a procedure is tried and it heals.

Take the implant out...let it heal for 4-5 months.. Have a sinus lift done and place a new implant.. or bridge.. The sinus will heal. I have seen it heal in many tough situations. This is the least of them..

There is good literature in sinus grafting without a radio-opaque bone substitute. One reason to do so is that it shows up on a radiograph, but it is not necessarily the only acceptable technique. If the fixture is symptomatic, it needs to be addressed. Have the ENT call the dentist and discuss the case. If the ENT is recommending removal, then out it should come.

As a UK surgeon I'm always intrigued by the US approach to surgery. (a) This gentleman/lady needed a single upper molar implant. All he/she needed for assessment was a long cone periapical x-ray or an OPG. What was the rationale behind a CT scan with 3D reconstruction, especially one including the whole of the midface, both orbits, plus the anterior cranial fossa and brain stem? (b) Why did the eminent dentist ignore the scan and place an 11mm implant in 3mm bone. Common sense tells me it would be impossible to do this without perforating the antral membrane. What was he hoping to achieve? (c) He/she has a Class II Div ii malocclusion with mildly proclined lower incisors, an incomplete overbite, a normal FMP and an adverse lip/chin profile. Why did the orthodontist need another CT scan with 3D reconstruction, this time involving the whole of the head and upper cervical spine. Whatever happened to clinical examination backed up with a lateral ceph? (d) It appears that the ENT surgeon performed sinuscopy (and FESS?). I assume the coronal CTs showed some sort of antral pathology to justify this, not just dollar bills. We have no way of knowing without seeing a coronal view. Wouldn't it have been commonsense to have advised removal of the implant first? (e) Is edward serious in advising opening the antrum, slicing off the implant flush with the antral floor (with an angle grinder?), grinding off any remaining threads, and covering the bomb crater with some foreign material? Ouch! (f) My advice, for what it is worth, is (i) ask some kind soul to remove the crown and abutment and place a low profile cover screw (ii) wait a month or two to allow the gum defect to shrink down as much as posslble (iii) Raise a small flap and remove the implant with a suitable gizmo such as the Neo Biotech kit. This will leave a small oro antral communication. It should be possible to achieve primary soft tissue closure but if not the OAC will probably heal so long as a cover plate is fitted. It is all a matter of clinical judgement at the time. Don't let the dentist shove anything up the hole (iv) Do nothing more until the aches and pains have resolved and the antrum is clear (v) If you're brave enough to risk another implant go to a different dentist. (g) One last thing. I do hope your orthodontist hasn't recommended mandibular advancement surgery!!!

Interesting how one can make a treatment plan without seeing the actual image. This is all moot without the post of cross section.

I'd fully recommend ask to ENT the right time to remove the implant. Then go to another maxilofacial surgeon, implantologist or periodontist to remove the implant and perform a graft technique or GBR (guided bone regeneration technique) and wait at least 6 months prior to place another implant or bridge. I would not place an 11mm implant in a 3mm remaining bone.

Follow the advice given above by sboms. Do it quickly and allow the sinus to heal. The sinus will heal fine with a patent ostium. The membrane is remarkably resilient.

My heart goes out to the patient, but there is more radiographic images posted than many dentists cases so...... is this a legal consult and if so pretty tricky, if not I apologize in advance for my suspicious nature. Regardless the banter gives me pause for thought thank you!

Hi Ms Patient. Apologies for the flippancy of my previous post, but I really do think there is a difference between the UK and the US approach to treatment. We believe in two principles - "primum non nocere" and "KISS". (a) There is no doubt you have been subjected to unneccessary irradiation. So far as the first CT was concerned, you were only having one implant placed. This would be routine bread and butter work for any implantologist. Clinical examination would have confirmed your UL6 ridge width was sufficient to take a 4mm diameter fixture and a good quality periapical or unilateral OPG would show how much subantral bone was available. The CT was simply not necessary. (b) Since you only had 3mm of subantral bone you needed some form of augmentation i.e. a sinus lift. There are arguments over whether this can be carried out from below (Summers technique) or via a lateral window, whether this can be done at the same time as implant placement or as a staged procedure, and what sort of augmentation material is best. However, I don't think any implantologist would feel comfortable putting this pattern of molar implant into just 3mm bone (c) I don't see how your surgeon justified putting in an 11mm implant when he knew 8mm would be sitting in space. It simply defies logic. Whether it gave rise to your recurrent sinus infections is open to argument but it can't be helping. (d) If the implant is uncomfortable you have only two choices: accept the status quo, or have it removed in the hope your symptoms will settle. It's really no great deal to remove an implant which is sitting in 3mm bone, so long as the surgeon has the right equipment. But if you opt for this don't forget the KISS principle! Just have the implant removed. No slicing off at bone level, no foreign material, no nothing. As sbrs says above, primary soft tissue closure should be easy and the risk of a fistula is very small. Once everything has settled down you can decide whether to risk another implant but in my opinion a bridge (or better still nothing) would be a better option. (e) As for the mandibular advancement surgery, well that's another issue. However, one cannot help wondering why someone aged 50 would subject themselves to this. Clearly you had no functional indications so I assume it was purely cosmetic. Fair enough (although the complication rate increases significantly as you get older), but I still don't see why you needed a CT of your whole face, most of your cranium and upper spine with 3D reconstruction to plan a routine sagittal split osteotomy. I hope it all went well and you don't have a numb lower lip to add to all the other aches and pains. I'm sure everything will sort itself out in the end but don't forget the more surgical interventions you let yourself in for, the more the risk of chronic neuropathic pain.

Totally agree with John , and yes in the UK , sadly we are the number 1 in medico legal . Anatomy and Implant placement , especially with all the modern diagnostics should be the basics of Implant Dentistry and it is unthinkable that sinus augmentation was not planned ! Anyway best to remove with Neobiotech , will be out in seconds without any collateral damage and allow to heal . The lining will heal very quickly and could re-do soon but in this case best to leave for a longer period to assess all the other issues. I prefer a lateral window with DASK , which will take only a few minutes to enter and lift with safety and then a fully bio-asborbable synthetic to regenerate only host bone in the sinus as feel long term "foreign material " may not be best in this case . Regards Peter

Hi Ms Patient (Don't know your proper name) No, there is no need. If you think about it, removal of the implant will leave a 4mm diameter hole in the sinus membrane. Just like any other 4mm hole in the skin it will heal across within a few days. The hole in the underlying bone will also reduce in size but there will probably be a small, 2-3mm,residual defect which will fill in with scar tissue. If someone tries to "repair" the membrane (a) they will have to gain access, which means more disruption of the surrounding tissues, and (b) it would not be possible to pull the edges of the hole together because the lining is bound down to the bone. Patching the hole in the antral lining with some form of artificial material would be a pointless exercise and would introduce foreign material which could become infected, etc. Once the tenderness and sinus pains have completely resolved (and only if they've completely resolved), say in a year, it might be OK to consider another implant. Personally, though, I would be inclined to go for a safer option and choose a bridge. Incidentally, I must defend my American colleagues. I'm sure 99% of them would give the same advice. There are always outliers in every group who feel they have to find a complex solution to a simple problem and we Brits are no exception! Here's wishing you all the best for the future. I'm sure it will all come right in the end.

Is #13 abscessed?

In an ideal world we should be trying to post information to the patient on line. but do not forget that as a doctor you are treating or advising a patient without being a patient of record, and you may be liable for any opinion posted regarding a case to an individual patient. Respectfully

I do not have a comment, but would like to ask a question about this situation and hope someone can help me. If a implant is 7 mm into the sinus, I presume the membrane will be torn, is there a distance in mm, 2 or 3, where an implant can be slowly inserted and the membrane not tear? Secondly, if 7mm is in the sinus and membrane do heal, will it heal around the bone implant connection, and thus the implant "in" the sinus, or is there a possibility that the membrane can heal and grow over the implant, and therefore the implant will be "out" of the sinus. Thank you.

Nothing specific to ad to what the patient needs to do or has done by now. Nel poses the question is there a safe sinus intrusion by an implant without a sinus perforation. Having been at this over 25 years the best thing I can say is that it's patient specific. However most patients that I have treated in this fashion do fine probably because of careful protocol rather than anything else. Keeping the intrusion minimal is key , however no matter what you do The schneiderian membrane will grow back and it will often grow right around an implant that is minimally intruding. I have many cases where the patients have declined a sinus lift and with an informed consent had implants that would intrude up to 3mm with no ill effects whatsoever. It's not ideal but sometimes compromise is met with an informed patient. Typically in cases like that I am "bumping or up fracturing the sinus floor(there are single use kits for this) and tenting the membrane either by light dissection or by simply loading the osteotomy site with graft material just prior to implant placement. This puts a minor amount of bone volume apically to the implant, and over time, as I am able to track these, in some cases I can detect bone apposition. Again, there is no concrete answer as to what's safe and what will create issues. Treatment plan it ideally and go from there.

Drd, thank you very much for your time and answer.

Patient, There is absolutely no need to do any repair of the sinus membrane. I, as does every maxillofacial surgeon, routinely completely cut through the membrane during Lefort I osteotomies. Very few and I mean very few, sinus issues after the membrane has been completely torn. It will heal quite well after the implant has been removed.

I would agree with another colleague here please see a surgeon to take out the implant and repair membrane .once the infection has resolved then you could further discuss the options with the dental practitioner or the surgeon.

Thank you everyone for your comments. I hope to have the implant removed later this summer. I want to find an oral surgeon who agrees with a "less is more" approach. I'll comment after the removal.

Hey,.. if the ENT cleaned out the sinus infection, why would he have to do it again? If the implant is a problem as you think it is, just remove it. Why make a big deal over this? kw