Recurrent Maxillary Sinus Infections in Implant Case: Corrective Actions?

1. These images, while pretty, do not give me any information to answer your question. From the one sagital image you provided, I see very little alveolar bone height, and a septum. I'm not sure how you could place an implant here without some kind of sinus intervention. 2. The fact is this, before your surgery this patient had no sinus trouble. Now he does. The first step in curing infection is eliminating the source. The source is your implant, and it should be removed. 3. Without more info, your question cannot be answered. You need to show multiple slices through the area. Sinus mucosa that is inflamed or infected will be easily detected. Also, the position of your implant in relationship to the sinus will be cleared up. My hunch is that your fixture has perforated the membrane causing chronic inflamation leading to infection. The inflamation stops the normal drainage of the sinus, then you get infection. 4. Do you know how to read these images??? The reason I ask is because your choice of diagnostic images is totally inappropriate. 5. It takes more than a fancy machine to be a surgeon. Sorry for the inflamatory remark, but that seems to be the case here. I DO work with many general dentists who are great at reading these images.

Continued from above- The Adjacent teeth are heavily restored. Is it possible that they are infected contributing to the problem? On your sagital image, the PDL of the anterior tooth is widened suggestive of apical periodontitis.

Can you please publish the sectional images of the implant

Patient had recent sinus surgery to open passages and clear scarred and infected tissue and no other causes of infection were seen. Implant was seen in the sinus and membrane had been breached. ENT is now trying to clear the bone infection prior to removal of the implant and bone graft.

From the two radiographic images supplied of the before and after implant placement, it looks to me like two different people. Gerald Rudick Motreal

Why was an 11mm fixture placed in an area which preoperatively looks as though there may be only 5-7mm of bone? You can't fool the body and it's normal healing and function. In my opinion this case was doomed from the start without sinus grafting. Do your ENT a favor and get that implant out of that sinus. The patient will experience relief much more quickly. The source of the problem is the implant. Fix that then the sinus problem will resolve in turn. I am sorry to be critical but I don't understand the reasoning behind placing this implant given all the pre-op info that was available to you with a CBCT.

Dr T, YOU ARE ANSWERING YOUR OWN QUESTIONS WITH YOUR HINDSIGHT SUMMARY. 1) AN 11MM IMPLANT WAS PLACED AND "BREACHED" THE SINUS LINING. 2) NO GRAFTING PROCEDURE WAS DONE TO RAISE THE SINUS LINING AND ALLOW FOR PROPER PLACEMENT OF AN 11MM LONG IMPLANT 3) SINUS SURGERY WAS NEEDED TO HELP CLEAR THE INFECTED TISSUE- SOURCE OF THE INFECTION IS THE CONTAMINATED IMPLANT SURFACE. YOU SHOULD: PLACE PATIENT ON AUGMENTIN AND FLAGYL TO CONTROL INFECTION REMOVE THE IMPLANT GRAFT AND CLOSE ORAL ATRAL COMMUNICATION WITH COLLATAPE AND BIOOSS FABRICATE A 3 UNIT PFM TEMPORARY BRIDGE AND COMPLETE RESTORATION WITH A PFM BRIDGE (THE ROAD TO THIS HELL WAS PAVED WITH GOOD INTENTIONS) IN THE FUTURE- USE YOUR 3D IMAGES TO ACCURATELY DIAGNOSE AND PROPERLY SELECT/ PLACE YOUR DENTAL IMPLANT. IN THIS CASE, IF INADEQUATE BONE WAS PRESENT YOU SHOULD HAVE AUGMENTED WITH AN INTERNAL SINUS LIFT (SUMMERS) AND AVOIDED THE SCENARIO YOU DESCRIBED.

Pray you do not get sued because you had cone beam scans and did not graft when placing a 11mm implant. You had more information than most have right now in offices and did not know what to do with the information. Even a poor lawyer for the plaintiff would have a field day. If the patient sues, you are pretty much hosed. Good luck and refer if you do not know what you are doing next time.

Dear Dr T, Don't worry! Plan your case with ENT surgeon 1) start Augmentin 2)Open sinus and have your ENT clear up the sinus 3) Sterile the implant surface and graft(Novabone) the sinus till 2-4mm above the apex of the implant 4) close the surgery and continue augmentin for 7 days You and your patient should live happily ever after!! God Bless

Plz remove the implant & place the patient under amox+clav.take ENT opinion. sinus debribement wud be required. Go for a fixed prosthesis instead.

dont worry docter if possible remove implant

Dr Gordon Do not use a xenograft here in an infected site this could lead a an infinately worse senario. Peter

Please do it better Dr. Gordon! Take care of your patients and build human bone. ...…I know that non-resorbable Bio-Oss presents hyperplasia or >> tissue build up, not conducive to implant support. However, materials >> that do not resorb or rather take very long (e.g. 10 to 30 years) to >> leave the body have been identified as ceramic, glass, plastic T.C.P >> and Bio-Oss. >> >> Such materials will be transferred to the lymph nodes, lungs and >> spleen for farther processing. This type of non-resorbing bone grafts >> interfere with the function of this organs. Furthermore, the cells in >> the body that remove such “non-resorbing” materials begin to >> deplete and eventually your body’s immune system gives up. There >> are several clinical and scientific papers to mention such findings >> in animal and human studies including my paper… Schlegel und Donath [25] konnten bei 126 klinischen Biopsaten mit einem Nachsorgezeitraum bis zu sechs Jahren keine Resorptionszeichen nachweisen. BIO-OSS--a resorbable bone substitute? Department of Oral Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany. Abstract BIO-OSS is an allergen-free bone substitute material of bovine origin, used to fill bone defects or to reconstruct ridge configurations. Seventy one patients (39 female, 32 male) received 126 BIO-OSS implantations. Some health parameters or habits were documented to eliminate possible risk factors of influence. The diameter of jaw defects filled with BIO-OSS was measured. There was a significant influence of the defect size on the healing result. In X-ray controls, BIO-OSS served to identify the surrounding native bone. The density of the BIO-OSS areas was higher than in control sites. These radiological results were supported by bone biopsies. Histologically, the permanency of the BIO-OSS was still recognizable after 6 years and longer. The ingrowth of newly formed bone in the BIO-OSS scaffold explained the increased density of the implanted regions. There were no clinical signs of BIO-OSS resorption. Therefore, we can assume that form corrections achieved by BIO-OSS insertions will last. PMID: 10186966 [PubMed - indexed for MEDLINE] # paul carie May 31st, 2009 I can’t believe you guys. I had bio oss used on me 5 years ago. Never resorbed, still having chunks that have migrated everywhere taken out, gross sinus problems because of migration into the sinus. Dysguesia also. Why would any of you use this product? My dentist has photos of chunks he has been taking out. The company should be sued as well as the people who use this garbage. # david salzman September 13th, 2009 I have bio oss attaching and spreading everywhere. Some has been taken out, the implant was taken out. I now have a glob of this garbage attached above #16, some in the soft palate by 16. Salty bitter taste coming from there as well. Do any of you folks know of someone who can remove some of these particles. My ENT just removed several pieces from my upper lip. The bio oss was originally placed in #14, obviously did not stay there. Cannot believe anyone in good conscience would use this stuff. Please let me know if any of you know of someone in your profession who would take this on.

Please see additional images that were just added from the case.

(a) I agree absolutely with the various contributors who have pointed out that all this fancy radiology was totally inappropriate for a single implant. We seem to be reaching a stage where no-one feels able to place an implant without a CT scan. All that was needed was an OPG. (b) The post op CT certainly appears to show most of the fixture lying within the antrum, which is not good practice. However this wouldn't normally give rise to chronic sinus infection. After all a zygomaticus implant sits happily within the antrum without setting up infection. (c) What objective evidence is there that the patient has an infected sinus? It looks clear as a bell on the xrays. Lots of people with ill defined face ache blame it on their sinuses. Was there any real indication for FESS and did the ENT surgeon actually see any infection when he operated? You know what they say - "It's a poor ENT surgeon who can't look up a nose and see a dollar bill nestling there!" Twenty years ago your patient would probably have had a submucous resection/SMR to "cure" his symptoms; ten years ago he would have had a septoplasty (an expensive SMR);today he has FESS (plus a septoplasty if the ENT chap has a yacht to run as well as a Ferrari)

Next time use this formula to arrive at the correct implant size...2x-2 where x is the height of available bone. So if you have 5 mm of pre op bone then the final implant lenght would be 8 mm requiring a3mm lift. If that is not sufficient then you need to augment. Instead you went for a home rum and perforated the sinus. You need to remove the implant before the patient develops a C Diff infection orMERSA infection.

Some great things happened here as far as collaboration between colleagues. Sometimes words were strong which is ok,just remember the courage to seek help from others in this noble profession of ours. Great feedback from all and a great learning experience for me. Please, allow all Docs to be able to let their hair down by making this a safe and non judge mental place to seek assistance,we are all human,we all make mistakes and our brothers and sister Docs should always be there should we get into a jam. Congrats to all.

Dr. T, First whoever says that you need to place bone into the sinus for implant placement is not looking at the literature. What you need is an intact Schneiderian membrane. Second if you have the technology at your office for CBCT then use it for every case. Thirdly, I would remove the implant,achieve primary closure, let the site heal, come back graft with something that will turn into bone, wait, place your implant again. Good luck

I suppose that all those colleagues that made strong remarks in this case, they have never made mistakes before! I am very disappointed at this attitude. Our colleague needs help, so all of you who have made the mistakes in the past and have much more experience ... humble yourselves !! May God help us all.

...just been away in India lecturing on exactly that , Bio-oss will NEVER bio-resorb , Geislith is very economical with the truth in many different areas ( they say there is no organic component to Bio-Oss which is another hard to believe story , which I will have some news on shortly). I try to tell other dentists to beware and always have a Geislich representative in the room who is noting what I say which is a bit excessive. Hope all goes well... ...I agree with you. BioOss may very well be the casus of the inflammation. It is a xenograft (bovine) and is a large dense graft material (sintered). I believe in some people that BioOss may cause a reaction like those that had leaking silicone brest implants or proplast TMJ implants. This is just an opinion. As per the nerve.... I will also try to find some German doctors for you... ...materials worldwide and so am often faced with reports of issues like what has occurred in your case . I personally find this very distressing as there are safe alternatives , but big companies and teaching institutions manipulate the truth and thus the patients suffer... ...There is the un-truth that this does not happen and I have had my issues with Gieslich in the past. In the UK there is a special fund for "out of court" settlement when this occurs... ...It is very difficult to distinguish delayed hypersensitivity to Bio-Oss and infection. Take photos, radiographs and biopsy the graft site. Histology will be able to distinguish between an immune response and a bacterial infection. If it is delayed hypersensitivity it would be worthy of publication because most of these cases are misdiagnosed as infections... ...I have posted the histology of Bio-Oss proteins and clinical photos of Bio-Oss delayed hypersensitivity on my cases but how do I get the images to the gallery for your evaluation? Any help is appreciated...

It is really great to learn so much from the experienced colleagues as I still consider myself as a beginner.regarding bio-oss I am thinking there is so many big names is implant dentistry who do recommend bio-oss for example Daniel Buser or even Carl Misch. It cannot be that bad for the body if recognized authorities put their names on the line to support use of bio-oss. Simon Milbauer

Daniel Buser was planned as a speaker for the workshop with Geistlich at the Osteology Congress in Cannes which will be very soon. That for several weeks. Now in the last days the speaker has changed and it is Karl-Ludwig Ackermann who is speaking everytime about unresorbable Bio-Oss. Why?

To Truth- I'm really tired (as are we all) about your diatribes concerning bio-OSS. I my self have never had an issue with hundreds of cases and long term follow up. Please stop turning every issue into a "bio-OSS and giestlich are the devil" rant. It's boring, and I feel like I'm getting dumber just reading your posts at this point. To the dentist who posted the original question- What did your ENT recommend. I would be surprised if he has not suggested removal of the implant.

I think I would have done a sinus lift and immediate placement of a 10mm implant. The osteotome technique works great for gaining 3mm of bone. However this was not the case and we have complications. Tooth #4 may have a problem and require RCT. Next it looks to me that the zygomatic process is fractured... was the patient in an accident? I think I would remove the implant and look into the the possible need of #4 rct and inquire about possible fracture of zygomatic process. Good luck to you and your patient.

First of all I am totally disgusted with the harsh language some of the commentators have used against this poor guy who is trying to be courageous and honest ! This is why we get into trouble in our profession ! It is because of people like Dr. Cota who think they are GOD and have never made a mistake in his life and is quick with the abusive language !! We are ALL learning about implant placement and it is an ongoing process and will be for masny years to come . From what I can see , you plced an implant that was a little too long . A summers technique would have worked as you already have over 5mm of bone . Grafting has NOTHING to do with the success , it will naturally remodel and new deposition will take place if you grafted or not. What probably happened was that you drilled too far too fast and tore the membrane instead of stopping at the floor and gently lifting it . Is the implant stable ?? There are no straight answers but if you can salvage it with an ENT it would be best and worth a try .

The preop image shows what appears to be a periapical lesion and a perforation of that lesion into the sinus with increased radiopacity between the lesion and the sinus septum. I have made the same mistake. I placed three implants with a sinus lift (with bone graft material) and the patient developed a post operative sinus infection. After closer evaluation of the preop radiographs a periapical lesion that drained into the sinus was found on the adjacent canine. Endodontic therapy was performed on the canine and the sinus infection resolved, the graft material was retained and the implants integrated. However, in your case the implant is in the sinus and surly contaminated with bacteria. If the anterior tooth is determined to have a periapical lesion first treat this infection. I would then remove the implant because integration to this surface is unlikely and the patient does not need a surgery with a low chance of success. If you just remove the implant without grafting your patient will likely develop an oral antral fistula. I agree that grafting with Bio-Oss is the worst of options but the main problem is putting any macroporous graft like Bio-Oss in an infected site. The bacteria colonize the macropores and the result is an artificial osteomyelitis that antibiotics cannot reach. Use a microporous graft material and any bacteria will be restricted to the surface of the graft material and therefore exposed to the patient's immune system and antibiotics. This is a difficult case even for an experienced surgeon because the bone on the mesial will tend to migrate your osteotomy burs to the distal resulting in a sinus perforation. Good luck and thank you for sharing. Greg Steiner Steiner Laboratories

No zygomatic fracture is present - that is normal anatomy, a bony suture

Dr Cota i've done what u suggest with Novabone andloved it.The handling is 10 times better to Bio-oss.This things sticks just in the place u want, the way u want.And the results are identical to the BioOss results!very good idea

Dear Eric, It is ok for you not to agree with me, but I have never used abusive language,infact my language is very encouraging, also it is because I have had failures and restored that failure successfully I am able to comment, my suggestions are positive without fault finding nor debating the treatment plan. What has happened has happenned, I can only try and help our respected colleague with suggestions I myself have done, please do go thro my message thanks, hope I have only clarified