Ruptured schneidarian membrane and allograft displaced: best course of action?

Hi ! It will be good to see x-ray before surgery intervention. Do You have some idea how much bone graft did you put in ? What is clinical picture at that moment ? When it was done?

How much is a "load" of allograft? Can't see much on the posted film. In a healthy sinus a small amount of graft will work it's way out of the osteum. If it doesn't block the osteum it may be okay. I am assuming that the patient is on an antibiotic and decongestant. At this point it is appropriate to refer to either an OMS or ENT for management I would not advise further surgery at this point, however removing the implant and letting the material drain from the iatrogenic oral antral communication and closing it after the tissues are healthy is an option so is removal thru a nasal antrostomy is a another good approach. It will be difficult with a lateral approach since lifting a perforated membrane will tear it further so a Pikos technique of removal and repair is used.i advise getting some help on this one

Oops forgot to mention Caudwell-Luc! Probably the easiest way to manage keeping the implant in place.

CRS I suggest you look again at the x-ray. I can see a lot of gubbins in there. May work its way out so long as the patient is content to be blowing sand into his handkerchief for the next few months, but why not refer the patient to your friendly local ENT surgeon and ask him to suck it out with the aid of a sinuscope. Decongestants won't get you far and could cause rhinitis medicamentosa. Please don't use a Cauldwell Luc approach. It's pretty well obsolescent for this sort of problem and has a significant morbidity - numb teeth and so forth. As for the implant, I would be inclined to leave it in. There appears to be enough bone for primary stability so it should survive.

John T, your eyesight is a lot better than mine in regards to gubbins it is a poor quality film and I can't see much.The operator should know how much mateial was placed in the perforation, it s not a rupture. However I pretty much already stated what you commented on. Also have not had a problem with numb teeth with a Caudwell Luc if performed properly the take home is this, when foreign material gets incorporated in the sinus membrane it is difficult to visualize, it can be under the membrane or in the sinus proper. A scope with an ENT is the way to go after time has passed. At the emergent surgical procedure, a Caudwell Luc is a way to retrieve foreign material but I assume you know this. Thanks for your comment.

CRS, we both got his name wrong! Must have been having a senior moment. His name was George Caldwell. If you enlarge the OPT by clicking on it you will see a large "cloud" of foreign material filling up most of the posterior half of the antrum. Of course you would need to CT to assess its volume.

Has the patient complained? If not, maybe you can wait and see what happens. Won't the graft resorb anyway if left alone? If you're that concerned, perhaps implant removal with sinus irrigation and suction through the implant site would satisfy your desire to remove the material? kw

OK, I hear what you are saying. HOwever, I have retrieved many roots (palatal and buccal) through a hole like that with irrigation/suction/ blowing nose,.. sitting upright etc. . I've done this without regard for the Schniderian membrane without apparent consequence. Of course, you have to reflect enough flap to go tension free which can be easier said than done....... What I don't get is why it wouldn't just resorb over some period of time? I mean it's not like it is HA........ Don't get me wrong,.. I don't know the answers here. kw

Don't worry too much.Wait and see!

kurt: - With regard to your first point, sucking a displaced tooth root out of the antrum is an entirely different proposition. With regard to the second - I don't want to be teaching my grandmother to suck eggs but the whole point of most particulate xenograft materials, BioOss and such like, is that they act as a scaffold for ingrowing bone and take many months to resorb, if at all.

First of all what was the graft material cocktail? Depending on that, I expect some of the cloud of graft material settle down and consolidate over time. Place the patient on some Augmentin 875mg bid for 10 days plus a decongestant. On the follow up assess the based on the their sympltoms if any and follow up with your friendly ENT if necessary. Let us know if the patient experienced any signs or symptoms. Human body is very resilient and works in mysterious ways. Its time to wait and see for couple of weeks. All the best!

This iatrogenic complication needs to be referred to an ENT colleague who will do an endoscopic procedure. The dentist is heading down a slippery slope with these very poorly advised posts from people who don't have a clue. The patient's well being comes first. Actually John T pointed out that some of the graft has started to migrate towards the ostium which may become blocked if more material gets there. This is appropriate management so get on with it, or you can build a fire and sing some songs!

I agree with CRS. You can perform a Caudwell-Luc and clean out the contents and remove the implant. Revisit later and carefully start over.

depending on time after surgery and quantity of bone substuite in sinus if qty small particle follow up by IOPR, do not touch, it may disolove it self, if qty large and time of osseointegration is short remove implant by reverse torque (ratchet) and do irrigation + suction particles and use collagen plug and re-implant to close exposure and follow up by x-ray, may you consult ENT specialist if problem large qty left? endoscopy?

If the patient asymptomatic wait up and see. Allograft will partially resorbs, partially get kicked out from osteum, if it's intact. But the concern ma be missing bone on the distal of the implant, I would also check #2 if it Is vital. Posable PA infection may cause a problem later when patient is off antibiotics. ENT if the patient asymptomatic only very friendly one, To remove the graft and implant may be an option in a case of symptoms appeared. Lateral wall approach will be disaster, will have to remove most of the membrane. Through the implant site suction an irrigation. Good luck, please keep updates.

If the patient asymptomatic wait up and see. Allograft will partially resorbs, partially get kicked out from osteum, if it's intact. But the concern ma be missing bone on the distal of the implant, I would also check #2 if it Is vital. Posable PA infection may cause a problem later when patient is off antibiotics. ENT if the patient asymptomatic only very friendly one, To remove the graft and implant may be an option in a case of symptoms appeared. Lateral wall approach will be disaster, will have to remove most of the membrane. Through the implant site suction an irrigation. Good luck, please keep updates. By now you should know more

Just to update. I had a Cone Beam CT done to see where the graft material had gone the next day after surgery. The vast majority had settled around the implant. The Pt. was asymptomatic. We decided to monitor. She has remained asymptomatic and subsequent panorex images seem to show the graft material is resorbing. The implant remains stable. 4 months post op I plan to check implant stability. If all is well, we will restore the implant.