After sinus elevation significant flap dehiscence: what to do?
I did a sinus lift through a lateral window and delivered a synthetic bone graft material one week ago. I installed one implant into the graft. I closed the window after tacking down a collagen membrane and achieving primary closure of the surgical flap. The patient was healthy and a preoperative CBVT scan [cone beam volumetric tomography] showed a healthy sinus. I prescribed amoxicillin post-operatively. When the patient returned, there was a significant flap dehiscence but no pain, no swelling and no purulent drainage from the surgical site. Patient has a bad taste and has green sputum. A second CBVT scan showed everything intact in the sinus and no abnormal findings. What should I do?
15 Comments on After sinus elevation significant flap dehiscence: what to do?
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CRS
5/21/2013
Couple of options, switch antibiotics to Levaquin, use sudafed and afrin nasal spray. Watch closely for resolution and advise the patient. The graft may partially take or need to be removed due to infection. Oral chorhexidine is also helpful. On your CT is the OMC clear? The fact that the flap is breaking down could mean the infection is draining thru the osteotomy since it is the weakest and most dependant part vs a full blown sinus infection since the pressure is alleviated. I'd have to see what the flap looked like to determine if the flap broke down leading to the infection sort of a chicken and egg question. I had this happen and was able to save part if the graft. The key was getting aggressive with the meds and hygiene. I'm assuming the implant is buried and the patient is not smoking, panorex would help fo more info. The time frame on this is 10-14 days and the health of the flap will guide you. You want to avoid an o-a communication. Good Luck
Gregori Kurtzman, DDS, MA
5/21/2013
green sputum indicates an infection present. My recommendation is get the patient back asap open whats left of the flap and debride the area removing any loose particles. flush the area with saline with Doxycycline mixed in to it. clean the inside of the flap then resuture the flap back making sure to over suture it so it doesnt tear out again. place the patient on augmentin 500mg 56 tabs 1 q6h and metronidazole 500mg 56 tabs 1 q6h have the patient use warm salt water rinses alternated with CHX rinses and have them back in 3 days to check it
CRS
5/22/2013
The sinus infection is treated with decongestants and checking to see if the OMC is blocked which is a very likely cause of purulent sinusitis. Not wise to open this a lateral OA communication may develop. Never resuture an infected flap it will fail again, it needs to granulate in, it's not a piece of fabric. The additional surgery at this time may necrose the flap and you will lose the graft entirely. Check the OMC ,post op swelling can also cause occlusion. Good Luck
Carter
5/22/2013
i agree with CRS. The OMC is very important for sinus management and most of CBVT d'ont show it.
Before any futur surgery take a correct diagnosis. Can you show the second CBVT?
Thank
Baker Vinci
5/22/2013
Medium and large fov scanners will show the complex. Most dentist are not proficient in reading this portion of the scan.
Doctor X
5/22/2013
Please give us pano rx?!!
Baker Vinci
5/22/2013
Why did you place a membrane? In my experience the periosteum is the best membrane available. I would not do anything at this time unless you started to see the foreign bodies begin to get rejected. Bv
Baker Vinci
5/22/2013
I would however change antibiotics . Bv
Baker Vinci
5/22/2013
In efforts to improve an obstructed omc complex, I will start the patient on a weeks worth of steroids( medrol dose pack ) and antibiotics one week prior. If there is a true obstruction I will do a standard FESS when the sinus lift is done. Why use a membrane? The question is constructive. If you make a crestal incision and the window is away from the margin of the flap, the membrane is prohibitive, in my opinion and just another foreign body . I never tac a membrane for small grafts. Just a personal preference that has worked quite well for me. I'm not sure if I have ever had a refractory infection with a graft. I rarely get primary closure, unless it is mandated or occurs without excessive undermining. I hope this is helpful. Keep it simple. Bvinci
CRS
5/23/2013
Dear DV, perhaps the membrane was originally used to contain the graft,but I thought is was to prevent epithelial in growth and allow the graft to mature. I use prgf with my graft so I probably don't need the extra membrane. I only elevate the sinus membrane where I plan to place the implants I don't go all the wall to the medial wall and so far have not had a OMC blocked. I like the steroid idea have you ever tried an intra nasal steroid? And if you think about it I don't place a membrane when I close and OA communication. I suspect in this case due to the infection timing and the sputum the OMC is blocked, love to see a CT sinus scan thanks for reading haven't heard your sage advice for a while!
Baker Vinci
5/23/2013
Yuup, lost email on my phone and was too lazy to re-connect. Someone permanently borrowed that phone, so the salesman was kind enough to set it up on my new I-5. I agree with the prevention of ingrowth, but if the incision is crestal and the window is the appropriate distance away, it should not be an issue. Yes, I do believe in nasal steroids and prescribe them often. I will even have the patient use a vasoconstrictor spray, during the critical stage ??????? B Vinci
Dr.Enkhbaatar
5/22/2013
i think maybe you need to remove all bone graft material
sherman Lin
5/22/2013
Yes switch antibiotic, Levaquin is my choice of regiment. Most likely your suture line sat on top of the membrane instead of underlying bone .Tissue does not stick to the membrane surface, and as the tissue contract it pulled the flap open.
Just switch the antibiotics and let nature take it's course.
Tony Collins
5/23/2013
I agree with Baker Vinci that the periosteum is the best membrane - I never use man-made membranes for sinus lifts.
Sherman Lin is probably right about the suture-line position.
A photo or 2 and cbvt picture might help gain the best advice
CRS
5/25/2013
Give us a panorex or give us Barabas!
