Severe bilateral maxillary sinusitis after sinus lift: Recommendations?

Dear Colleague! I had two cases like that,when even pus(!) came out of the nose.After 2 weeks Amoxicillin 3 g per day everything was fine.I did not even have to reopen again and to remove the infected graft.This was about 5 years ago and the implants are still tight.Maybe it was just good luck,but I tried it and it worked. Good luck to you,too

Part of the fun of using xenografts possibly? Peter

You said "severe bilateral maxillary right sinusitis" and I assume you intended to say bilateral sinusitis. If one sinus is involved then infection is likely. However if both sinuses are involved you may have infection but you may be dealing with an intense immune response to antigens in the low temperature xenograft. In an infection you will have purulent exudate (puss) and in an immune reaction to cross species proteins you will have a clear serous exudate. Do you have any draining tracts that allow you to evaluate the fluid exudate? Is the mucosa over the graft intensely inflamed? An infection will clear up with antibiotics or removal of the graft material. However if you are dealing with an immune response to the xenograft this is potentially much more severe. I advise you make the proper diagnosis ASAP because you have time with an infection but with an immune response you do not. Greg Steiner Steiner Laboratories

I think you have to check if you over raised the sinus membrane especial-in the medial side as this cause obstruction of sinus opening

Hi there. I just want to know if the coming out of the pus does not indicate that the wound is healing? Because i have seen with many wounds that as they heal pus usually comes out...

Refer to an ENT colleague, period.

Or refer to an OMFS colleague skilled in sinus surgery! OMFSs are closer colleagues to most dentists than ENTs (unless you're an OMFS), by the way. Period.

Did you do a pre-op CT or CBCT to evaluate for any sinus pathology including an occluded ostium? Were there any antibiotics or corticosteroids pre-op? I would refer to ENT for evaluation at this point.

Depending on where you practice...I would refer to an OMS. Its been my experience in dealing with this a few times, that ENT's often are not aware of the procedures that are performed for sinus augmentations and tend to over treat the patient and may even give them information that may not be in your best interest. I have had a lawsuit brought on after one of my patients saw an ENT, who told him that the apex of my implant was in the sinus and should be removed. I hope this helps.

Augmentin 875bid for 20 days and a nasal/sinus rinse should be your first choice of antibiotics. Also , you need to evaluate if the membrane was perforated and the graft is coming out into the sinus. Then refer to an ENT or OMFS depending on their attitude towards you. ENTs are generally nicer where as some OMFSs try to belittle you.

Don't remove the graft or implant, especially if you didn't perforate the membrane. Please send this to an omfs. There are plenty of dental colleagues that treat this, routinely. Bv

Dear colleagues, Thank you for your comments. To clarify, I meant severe bilateral sinusitis (not RHS only) following bilateral sinus elevations and BioOss grafts. And yes, I did have a pre-operative CT indicating no problems with patency of the ostium. As mentioned, pre-operatively there was only a mucous retention cyst on the RHS (nothing LHS), which was elevated with the membrane in tact during the procedure. Medially the elevation was not overextended. There were no clinical signs of suppuration or inflammation, and there was no pain or congestion for the patient. Following this post I actually saw this patient, removed the two implants that had a relation with the sinus grafts, curetted out the sinus graft material and granulation tissue leaving the Schneiderian membrane still in tact, irrigated with saline and Clindamycin and closed up. IV Ampicillin was administered, and Dexamethasone. Some small remnants of "hard" material in the periphery of the grafted sites was retained. The schneiderian membrane appeared very normal in parts, and thicker/fibrous in other parts. There was no suppuration or oro-antral fistula. I have continued her on a second regimen of oral Amoxicillin and Metronidazole, Dexamethasone (5 days 4mg), oral decongestants and also prescribed very regular saline nasal spray use. Rather than relying on the sinus elevations, 5 short implants (Ankylos A8) were instead placed in the highly resorbed (but sufficiently wide) anterior maxilla as a first stage surgery. I am planning to review again radiographically and likely with a new CT to assess the situation in approx 3 weeks, following a further regimen of antibiotics. If required, I will then refer for ENT or OMFS assessment. I am not an OMFS but practice almost exclusively implantology. I am interested in Greg Steiner's comments on cross species immune reaction presenting with clear serous exudate. I had not come across this before with Bio-Oss. Does anyone have any further experience with that complication? I would imagine it would be incredibly rare. In retrospect, I could have injected a needle through the membrane to check for any exudate.

Do u have ct views of before and after sinus lift. Augmentin and dexa 12 mg are the rx of choice starting day before and continuing for 1wk after. Always mix graft with cinda encef and recently with metro also. Anaerobic bacteria gas bubble has formed sometimes in the body of graft but no pus or infection or a failure of implants or the closure of omc or the need of graft removal but I never use bio OSS..... Always mfdba with iv antibiotics I have several p/o ct of the gas in the sinus graft but has not been of clinical significance. But I am sure one day this will happen to me too and I will have to remove the graft along with the implants and start over .......referral not needed Doc pl show the ct x sections .....which ct do y have.....my prexion gives great3d sinus views Sam Jain, DMD Center for Implant Dentistry Fremont CA

Dr M As I said just one of thoose things that can happen when using xenografts or allografts and is rare but can be an issue for the patient even leading to long term issues. We have done bilateral cases using a synthetic in one and xenograft in the other and the patient observations were repeated over the few cases which were much lower pain and swelling on the synthetic side . We are hoping to write it up when time is available. This may suggest some sort of foreign body response , but will need more research . A collegue had an infection issue with an allograft case which took a few years to resolve which was not good for his state of mind . Infections will occur as anaerobic oral bacteria are introduced into an area but it is how they appear to be retained and thrive in some graft materials that is interesting. Since using synthetics nine years ago there has not been single issue. Peter

Good question; how do you know the ostoe-complex is closed? The only way to know is with a scope or a ct scan. I strongly discourage putting any xenograft into the sinus and expecting bone to form around the apical portion of the implant. Secondly, why are you not grafting medially? There are several articles that have come out in the last 2 years, that clearly suggest that the medial aspect of the augmentation maybe the most important. Wow, this patient must be very confused. Not sure why you asked the question, but that doesn't matter now. I would have to guess that there was some perforation of the membrane. I would encourage having one of your omfs colleagues remove any cyst greater than 50% of the volume of the sinus that is being grafted, or at least have it decompressed trans-nasally. It does make sense, that if the retention phenomena was large enough and in the "wrong" place, it could obstruct the natural "drain". This however is unlikely, if you had bilateral prurulent sinus disease. I agree, the abx. regemine you prescribed, is a mite weak. Bv. Vinci Oral/Facial Surgery. Baton Rouge, La.

"I strongly discourage putting any xenograft into the sinus" Generally xenografts are too risky in the sinus. Please keep attention with the Schneiderian membrane and unresorbable animal substitutes for the human bone!

The questions are: How many patients live without any knowledge with diffuse xenograft particels in the sinus and soft-tissue? CT scans are necessary. What will be in ten years with those patients? Do they have infections?

If one really studies the science about particulate xenograft materials, they would come to the conclusion that they do not resorb, do not facilitate the production of bone and in some cases produce sclerotic bone. The large and hard particle size is hard on the RES etc.

Without an xray it is hard to say but the membrane was possibly over elevated causing a mechanical obstruction. I don't go all the way to the medial wall since I'm not placing implant there and the graft can shift medially anyway. That can also cause an osteomeatal complex blockage by allowing less room for post op swelling. I like to use a very small amount of bio-oss for the post op radiograph and use cortical-cancellous with a prgf binder or prp is also good. Was the pt placed on post op decongestants? Smoker? I also give iv steroids to keep the swelling down, similar management to an o-a communication. The reason I suggested an ENT (or OMS) is to cover you legally since these two specialties manage sinus complications on a regular basis. It is not shameful to defer to a more experienced colleague. You handled it appropriately but I think it would have been less stressful to get advice from a live colleague vs an online blog. We don't have to manage everything. Next time you may not be so lucky and have a lawyer call.