Complications after sinus lift and implant: recommendations?
One week prior, I did a sinus lift and placed an implant in 26 region. Now my patient feels numb in 21 and 22. Everything appears normal. The lips and gingiva there appear normal. 23, 24 and 25 feel normal. What could be causing this? What do you recommend that I do? Thank you for your help.
18 Comments on Complications after sinus lift and implant: recommendations?
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Doc
4/2/2018
Hmmm, I don't see what would cause this sensation based on your treatment. I would map the area of numbness your patient is feeling and get some more info about the sensation he/she is describing. This is a tough one and I'm looking forward to reading further comments.
Z
4/2/2018
Any PA of the teeth in question? Based on the need for Endo on that premolar with the post in this x ray and the calcified canal in the other, I would guess the patient has an unrelated Endo problem. I can't think of an anatomical connection in the posterior sinus that would only affect two anterior teeth, and teeth alone without associated soft tissue. Had a patient a few years back with CC of numbness due to PAP on #8.
Dr Saad Yasin
4/3/2018
1_There might be slight injury of the sensory nerve supplying the affected area during reflection of the flap or local aneasthesia
2_Endo problims of the premolars
2_
Dr D
4/2/2018
It does not answer your question, but actually brings a question to the ongoing discussion: Prosthetically, it seems that molar is far away from the premolar, which will create a huge mesial cantilever and questionable implant cleansability over time...
Dr Saad Yasin
4/3/2018
Wait for more weeks and see if the numbness disappered.before doing any thing
WJ Starck DDS
4/2/2018
This shouldn’t be such a mystery.
You managed to injure the anterior and/or middle superior alveolar nerves, and/or the infraorbital nerve during your dissection.
Place the patient on a Medrol dosepak; the paresthesia should resolve spontaneously unless you severely injured the infraorbital branch of V2
Rocky
4/2/2018
The paresthesia started after 1 week for few days nothing was soposed to happen.
I supose it will be a healing pressure of the bone graft that presses some nerve for a few days and ir will resolve soon.
ROBERT CADALSO JR DDS/MS
4/2/2018
Have an endodontic evaluation of the second bicuspid the root canal is failing
Neil Bryson
4/2/2018
Your problem could be caused by the infection at apex if second bicuspid. Without anterior X-ray, it is difficult to analyze the anterior numbness but could also be an endo problem there.
It might be wise to remove second bi and place another implant there and have a more acceptable and hygienic bridge when you finish
Matt Helm DDS
4/2/2018
WJ Stark DDS is correct! The most likely possibility is that you inadvertently injured the anterior or middle superior alveolar nerves, or the infraorbital nerve in surgery. You also may have been dealing with an anatomical variation, unbeknownst to you . It is highly unlikely that the failed endo and PAP on the 25 is the cause of paresthesia in 21 and 22. It is also possible that the 24 is no longer vital, and who knows what the condition of the 23 is, which is why you should do pulp vitality tests on 21 through 24. You may find that the 24 is barely vital or even non-vital considering its almost calcified canals.
I also don't see the rationalle for placing that implant so distanced from the 25 distally. Two implants, one closer to tooth 25, would have made more sense from a restoration standpoint.
That said, you should have included at least a periapical radiograph of the problem teeth (21 and 22).
Rocky
4/2/2018
The distance is because of a bone anomalia presented after making the flap that was in my eyes not worth risking the implant and making also another vestibular bone graft. It was like a small hole going more than 5mm deep and to small for grafting but to dangerous braking the vestibular part of the arch during implant insertion with apropriate torque.
Thanks for your opinion.
Matt Helm DDS
4/3/2018
Rule nr 1: always strive for an ideal outcome whenever and wherever possible. In this case, this means that if the patient has antagonist occlusion in that area, you should have planned for two implants. The way this implant is placed will make it very difficult to restore two molars, unless you cantilever a distal one, which is not advisable here. As it is, the distance of this implant from tooth 25 is great enough that you have already created a mesial cantilever point and therefore a fulcrum, jeopardizing the implant’s long term success.
Your case planning was off from the start. You should have been able to deal quite easily with that small vestibular defect. You should have grafted it appropriately, placed a membrane over it, and burried the implant for 6 months. That way, you would have been able to place the required second implant at the appropriate distance for a truly proper prosthetic outcome. And you should have (and indeed could have) done this all in one surgical stage, so as not to subject the patient to two surgeries. I mean, you were doing a sinus lift here, so why not do it all properly, in one stage? Nothing difficult here, unless you are trying to rush — or unless you were looking for the easy way out — expecting primary stability and early restoration, which is always a mistake. I know that many patients want everything “yesterdayâ€, but it is up to us to educate them that this is implant surgery and not just screwing screws into a piece of wood! It is also up to us to educate them as to the desired/needed outcome and its benefits.
This implant is placed too distally! And remember: one poorly positioned implant (in a case like this) can be a lot worse than waiting a little longer for healing but being able to restore properly. You should always try to visualize the final restoration! ALWAYS!
Chris Smith
4/2/2018
I would suggest Pulp sensibility tests for 21,22 and verify PA radiograph. If vital , wait and observe symptoms over the next few months. The 24/25 seem to be splinted PFM crowns. The 25 has a chronic PA area , for which I usually refer to my Endodontist for retreatment ( Get their opinion on 21/22,24 as well) . The 26 implant is in a prosthetically more difficult position mesiodistally. Maybe the implant crown can be fabricated to provide occlusal support , but maintains a mesial diastemma to eliminate an excessive mesial cantilever and improve contours for hygiene.
Ernest
4/3/2018
Hi, could someone explain how infraorbital branch of V2 gets damaged yet patient has sensitivity in the lip and gingiva, yet not have sensitivity on his teeth. Also, how do you damage anterior superior/middle alveolar nerve, by doing sinus lift.
WJ Starck DSS
4/3/2018
It could have been injured by traction (e.g., from a retractor) or from local anesthetic injection. Not sure why you think those branches couldn’t be injured from s sinus lift. Also, don’t forget that there can be aberrant anatomical variations that place anatomic structures in places you don’t necessarily expect them.
The other possibility is that those teeth decided to become necrotic at the exact same time as your sinus lift. That seems unlikely to me.
The good news is is that most nerve injuries recover completely. Good luck, let us know how it turns out
Here is an anatomical drawing:
https://en.wikipedia.org/wiki/Anterior_superior_alveolar_nerve
Dok
4/3/2018
Surgery related nerve tissue compression in this area should heal with time. Re-assure the patient. Of course the prosthetics on the pemolars should be re-done with re-treatment of the RCT on the second bicuspid and vitality testing on the first bicuspid. The lab can easily widen the mesial/distal diameter of the second premolar crown ( kinda make it look like a molar ) when all three teeth are restored together to allow for good contours on the implant molar.
Ajay Kashi, DDS, PhD, FIC
5/2/2018
I have never encountered numbness following a procedure in the sinus area albeit this cannot be ruled out. Some things to consider in my opinion would be:
1. Interviewing the patient to assess if this is a true parasthesia or complete anesthesia. If it is parasthesia majority of the cases fully recover over time. If it is a true anesthesia it is most likely not a dental issue or it could be a combined dental/neurological problem and will need further medical evaluation
2. Very critical how the patient is interviewed. Never ask the patient if they are feeling numb unless they bring it up to you themselves. Always ask the patient how they are feeling and wait for their response. It is very critical to do it this way so as not to influence the patient's response (as numbness is a subjective symptom)
3. Mapping the area thoroughly every 2 weeks for 1-2 months (parasthesia mapping templates are available in the literature)
4. Critical to assess response to cold, hot, light touch, response to sharp pinch and light pressure. All these have to be mapped thoroughly if you suspect parasthesia over a large area or a true anesthesia (they have to be done every time the patient is seen for follow ups until the symptoms disappear or patient reports that they are feeling better)
5. In case of no improvement in 30-45 days it is important to refer patient to a OMFS/neurosurgeon for a second opinion.
Having said all this I still feel that this could be a one off thing most likely due to a pre-existing infection in the area of the surgery and the patient is still recovering from the procedure.
Key things to remember in cases of numbness is thorough documentation - this will be important not only from a clinical standpoint but also from a medico-legal perspective.
GO
2/13/2020
I had sinus lift in early Dec 2019 on upper first molar on left side of face. Still have numbness and pressure in gum area, that also radiates to upper lift. Getting frustrated. Told oral surgeon, who didn't seem too concerned and said should resolve over time. How much longer should I wait.
