Intermittent spontaneous cheek swelling after sinus lift: recommendations?

Dr Sanjay, thanks for your insights. A cbct analysis was done, and everything seems to be within normal expected progression of healing. However we were thinking alone the lines of a possible foreign. No signs of infection at this time. However the tooth adjacent to the sinus lift and bone has a root canal with a post that was done several years ago. we are investigating the possibility that this may also be involve. Pt was covered with augmentin for 14 days. Do you think a biopsy of the graft site will be prudent?

I agree with CRS. This doesn't act like an infection at all. Large swellings don't just disappear, even with antibiotics. Furthermore, large swellings of infectious etiology, are painful. Forget the CBCT, there is way too much reliance on CBCT technology replacing good clinical skills. If it occurs again, an US would be the most appropriate diagnostic aid to determine air vs fluid collection in the buccal tissues. My bet is on an air emphysema.

You're kidding right?

It is very difficult to do a sterile surgery when doing a standard lateral window technique. For example when an autograft is used 50% of the sinus grafts become infected. The reason is obvious because harvesting the graft and delivering the graft in a oral environment makes it nearly impossible to keep the graft sterile. Likewise with the patients swallowing and moving it is also difficult to keep the site sterile especially so if you are trying to spoon in allograft. Due to the porosity of an allograft if any bacteria are introduced to the area colonization is likely that will not respond to antibiotic therapy. Greg Steiner Steiner Biotechnology

I think you are an expert, this case without actually seeing and being there is unusual. For me there is a diagnostic " feel" with post op sequela an abscess or cellulitis has a certain pattern of development which this does not fit. The only other thing I could compare it to is a subperiosteal abscess which I have seen 4-6 weeks post op in mandibular third molars due to surgical debris under the flap. These usually are incised and drained. In a case like this at the second occurance I would have conservatively cleaned out the flap. With all the antibiotics an area if fluctuance would have developed and abscesses need to be drained otherwise a fistula can develop. If one is not trained in management of post operative sequela it would be difficult to know this. Experience matters but also understanding how to follow the patient post operatively is important. I think most dentists immediately go to prescribing an antibiotic without a working diagnosis. I have seen many real causes masked by this. Now if a tooth is suspected, removing any restorations and checking it under a microscope as an endodontist does would rule out that cause. Patients can get unusual facial swellings from other systemic causes also. It is helpful when doing these more advanced cases to rely on advanced training in management of sequela. The knee jerk response of putting a patient on an antibiotic is not always the best, culture and sensitivity is also an option when working with facial cellulitis.Seems like a lot of speculative guessing here, hope the patient gets better!