Sinus Lift Complication after using Summer’s Osteotome Technique?

Dear Dr B., I love doing osteotome lifts and I do not want you to think that this will happen every time. This is probably due to the release of of calcification particles in the semicircular canals of the inner ear. These calcifications cause vertigo when the fluid is unable to flow. It creates a "sea sick" feeling. I would refer her to an ENT that specializes in Vertigo. They will give her exercises fo moving the head in different positions to free up the canals. In the mean time suggest she take one of theover the counter "sea sick" pills. It will help a little. This condition could and would have happened reguardless of the surgery.

Was the patient experiencing a sinus infection and/or hx of inner ear infection at the time of the internal sinus lift? Either of these could have been disrupted when force was applied to floor of the sinus.

Dear Dr. B Dr. Knecht is absolutely right. I had it happen to my patient once and it went away within 2 months. There are a couple of articles about the benign paroxysmal positional vertigo if you wnat to read up on it. "Benign paroxysmal positional vertigo as a complication of interventions with osteotome and mallet"

which one is the Summer osteotome Technique and where is there for more information. Maybe he has intoxication for antibiotic.? Dr. Cardenas

Most likely caused by dislodging otoliths in the inner ear. Very often they will form concretions in the middle ear. Force trauma can cause some of them to dislodge and float in the cochlear fluid. When a patient is in a supine position, these "ear stones" float around the cochlear cilia and give the impression that the patient is moving, hence the diagnosis of vertigo. Whenever possible, try to mitigate the effects of mallet pressure on the sinus floor and make sure you are at mid-sinus, not angled torwards the medial or lateral wall.

Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder and occurs due to head motion resulting in temporary vertigo. There are two main hypotheses to explain the development of BPPV.First, the cupulolithiasis theory, which is based on the attachment of otolithic debris to the cupula in crista ampullaris and the theory of canalithiasis, which is based on free-floating debris in the canal.There are always some debris or particles present in posterior semicircular canal. The presence of vertical upbeating and rotatory-type nystagmus toward the lower ear and the nystagmus developing in the opposite direction along with the occurrence of vertigo when brought back to sitting position confirm the diagnosis.A horizontal variant of BPPV was has also been reported on patients with positional vertigo and horizontal direction-changing positional nystagmus. The symptoms can be produced by rolling the head while the patient lies in a supine position.The treatment consists of canalith repositioning maneuvers appropriate for the semicircular canal involved.The problem with the above mentioned patient is the sustained vertigo for about two months.In those cases that the SOMMER's osteotome technique has been used to elevate the maxillary sinus floor followed by some CNS signs or symptoms, it is prudent to check the patient for Battle's sign, CSF otorrhea, radiographic detection of linear midface fractures and even the Caloric Test.

Dear Dr B I'm just adding my bit to confirm the feelings of Dr Knecht and others above. One of my patients experienced this exact complication several years ago after a summers procedure. A diagnosis of Benign Positional Paroxysmal Vertigo was made by an ENT surgeon and was successfully managed within a few weeks by excercises. At the time I was very concerned and could find no similar reports in the literature. I am therefore pleased to see it reported here. Perhaps this is something that we shoulf be informing our patients of in our consent procedures - any comments?

I have been researching my current symptoms and came across your site. I had (3) lower dental implants back in Nov 07. Aside from some normal discomfort all was fine until a few days passed. I started experiencing what I now have determined is vertigo. I consulted with my surgeon and he thought the medicine (ie hydrocodone & pennicilin) may be the problem. He said a few patients had similar issues. About a week and a half later the symptoms went away. Unfornuately, two weeks ago Jan 08 I had a fall off a horse which resulted in a back fracture and a concussion. After a few days on oxycodone I started experiencing the vertigo again. Once again thought it may be the medicine, thinking my symptoms were classified as dizziness. Now the symptions are much more intense, room spinning, definately worse than than before. I am glad I have found your site, I knew this began back when I had the surgery not when I recently experienced a consussion.

Tonya This sounds like a possible labrynith concussion Ie inner ear which can lead exactly to the symptoms you describe(in addition to medication)Discuss the possibility with your Dr; ENT or neurologist.

The bottom line is anytime you use osteotome on a patient you can cause vertigo or you can cause a concussion. Give trhe patient Valium 10 mg BID for 7-10 days. This may help. Also try using a motorized bone expander. Works just as well and won't cause a problem.

Although I have vever had this happen to one of my Summers lift patients, I altered my technique and am more conservative and deliberate about the malleting. I now do not use the smaller summers osteotomes, just a 4 or 5mm. I widen the osteotomy as needed to 5mm and take a PA to make sure I am on the cortical plate, not 2 or 3mm away. Then I set my guard 3mm longer than the site and briefly taap it into place until it is against the plate and then firmly tap the osteotome for the upfracture. It will release much better this way and there is less of a concussive effect. Midsinus is preferable. Then any other superior maneuvers are with hand instruments. It works well. I use only the 5mm now. I dont repetively hammer. For what its worth. many thanks to Dr. Craig Cooper for this tidbit. Bill

I am curious how valium can help this condition. Bill

I have never used the Summer's technic for sinus lift, though I have observed it several times. I prefer to use the Hydraulic Sinus Lift Procedure which I learned from Leon Chen. It is completely atraumatic. So far, the patients I have done it on have no more post-op pain than the implant placement itself.

Benzodiazapines are excellent at reducing the symptoms of vertigo.

I used to be happier with my lateral window lifts compared to the rare Idirect lifts that I performed until I began to do the Summer's sinus lift a little more often. Felt, it was more conservative and left behind far less post-surgical 'morbidity'. However, the relative comfort for both the clinician and patient during the Lateral Window Lift as compared to the experience of the Internal Sinus Lift has definitely go to be the clincher. Given that the Lateral Window technique has its share of post surgical implications, if one is adequately trained and has the benefit of appropriate instrumentation (I use a Piezo for my window), the gruesome malleting, the possibility of BPPV (in reality that is more often than not, palmed off by both clinician and patient as an issue to the implant placement itself)and the possibility of accidentally perforating the membrane occasionally from uncontrolled instrumentation or packing of graft, can all be avoided regularly.

I have had extensive surgery from an Oral Surgeon who did a bone graft from my hip to my upper jaw - after upper teeth removed. I healed well. The Oral Surgeon placed 12 3I implants and did a compleate face and brow lift. 5 of the implants failed (and face and brow lift a complete failure.) After a few mos - he replaced the missing 5 - recharing me for everything - except for the implants. 4 of those also failed again - the only one to survive was implant #14. I should add that following that - my entire face swolled extensive - eyes almost shut. I called the Dr - his receptionist said that was normal, my friends insisted I go in - Dr was not there - but another Dr treated me and gave me strong antibitics and I think steroids. During remainder healing time - surgeon said I was fine - even tho on several occasions I would complain of very mild discomfort on implant 14 area - upon lightly pressing gum - felt like bruising sensation. He insisted I was fine and sent me on for final restoration of a permentent prostetesis - $25,000 worth - after the $50,000 I spent at the Oral Surgeon. Within 2 days my gum area swolled greatly at the implant 14 area. Oral Surgeon said I had implantitis. I am beside myself at this point and cannot sleep. The prothedonist said he felt that we can probably work with this. There is detached gum tissue and you can feel the implant ridge. I no longer trust this Oral Surgeon and went to another. He said if I was not willing to remove the prostesis and remove the #14 implant - then the next thing was to have a graft from the roof of my mouth or to take antibiotics for the rest of my life! Please - good Surgeons - please give me your insight. Much appreciated

DANA Impossible for us to advise you accurately on this It sounds like you have had a very rough time I would strongly suggest you see another Surgeon for an opinion You wil certainly need a full work up and x rays and total re assessment There is no other way Wish you the very best

DANA: Dr S is correct. there is very little info to go on in trying to determine the reason for failure. There are too many variables to even list. If you are experiencing problems, get some advice from another clinician and be prepared to give him or her all pertinent information, including records from your oral surgeon. For the number of implants you have, this thing should have taken a great amount of time to plan, do the surgery, time to heal, and provisional restorations before the final restoration. How long of a process was involved from the first surgery to prosthesis placement? And remember, this is only one of the variables. Im just curious. Bill

How long do you usually wait before loading fixtures that were placed in conjunction with a Summer's Osteotome Technique? Also, do you always do this as a two stage procedure?

DANA Like all before me, I feel that a lot of variables are to be considered before one can really point out to the actual causation of the "failure" of Implants as well as face/brow lift procedures you have had done. In my time as a practising Maxillofacial surgeon and Oral Implantologist, I have had clinical situations when I was stumped for reason myself!! Let me ask if you are : - a Diabetic - a Smoker - someone who has had risk of cmpromised blood supply either by virtue of previous medicaions etc, or have exposed yourself to harsh sunlight after surgery Cheers Dr Jeevan Aiyappa

DANA Sorry to hear about those implant failures and failures in face & brow lift. As a doctor I strongly recommend you to take a second opinion with another equally talented surgeon. I do not know the circumstances of your case and what went wrong but it is time for a second opinion. If you are a diabetic or a smoker/tobacco user, the future of even the few survived implants isn't good, do keep that in mind. Best wishes

Can someone give me step by step of "their" Summer's technique?

Great site to recommend. I'm a 35yr old who lost the front tooth (#13 I think) 22 years ago, three months ago I traveled abroad and got an implant there using the Summers technique (no idea what it means), the dentist was a bit concerned -because the bone was too thin there- and after two days he tapped on it to guarantee attachment to the bone (truly a discomfort). I took antibiotics for 2 weeks but once ended I got a lump in the gum and the sensibility is different in that point, I can't say is numbness b/c I feel my tongue touching it but it might be similar to it. I took antibiotics again and the lump seemed to go down a bit but my kidneys were not liking the antibiotics for so long so I stopped it. Now, three months afterwards, the lump is still there, to the touch is kind of hard -it doesn't look like a gum infectious inflammation-, not too red and the weird sensibility is still there. I have a bridge that doesn't touch the implant and serves as protection I think and I can see the end of it, I try to keep it clean and my long distance doctor doesn't seem worried with that lump there. Any advice?

Kent, I recommend seeing a local dentist/periodontist/oral surgeon who is experienced placing dental implants. I can't say for sure but it sounds like this implant may need to be removed and the site grafted with additional bone. Best wishes, Paul

The implant is mostlikely ok, but you induced a transient vertigo by way of using the osteotomes and mallet. Have her see an ENT for exercises and meds. In the furure tell all patients when using the mallet that there is a possability of vertigo etc. It's noy malpractice but her rxn to the slight surgical trauma.

Terry, read Norman Cranin's Atlao of Oral Implantology also check out The Journal of Oral Implantology. These are excellent sources. So is Jensen's Text.

I have seen this complication several times (once in my own patient) following an osteotome surgical technique in the posterior maxilla. In all cases, the dx was BPPV (vertigo) -- I'm not going to detail the condition (you can take the time to do a search on it) -- In my experience (3-4 cases), the patients found relief through the positional exercises used to "reset" the otoconia (canaliths) in their more normal positions. Your ENT's diagnosis will usually be idiopathic BPPV, but if you were smacking on your patient with a glorified hammer for the better part of an hour you'll know better. The Epley and Semont Maneuvers (do some more research) brought relief to all of these cases I was involved with. I also recall a case where an ENT "concluded" the cause of the vertigo must be viral. Again, had he been present for the surgery on the maxilla he might have thought differently. The MOST IMPORTANT point here (after the recommendation to suggest the postural exercises to make things right again the inner ear and reposition those pesky canalith particles) is that there are MANY MANY MANY alternatives to the traditional Summer's technique (certainly for vertical augmentation). Drill 1mm-2mm inferior to the maxillary sinus and use a single tap to infracture the floor. Use hydrostatic techniques, currete techniques, balloon techniques, piezosurgery, the IIT sinu-lift system, or a lateral approach. If you're not familiar with with at least three of the above methods, you probably should be referring your cases to a specialist who isn't relying on a technique that outlived its usefulness a few years after it was first published in 1987. PS You tell 'em Bruce K!

I am going to have 5 dental implants. I first need to have a sinus lift and I am very worried because I have very bad sinuses. I always have a discharge along with sinus pressure and sometimes dizziness. Is it safe for me to have a sinus lift or should I go with the shorter implants which will also go into the sinus cavity. Please let me know what you suggest.

I just placed 2 implants in the site of 14 and 15. I previously did a ridge preservation procedure to increase the thickness of the future surgery site. A scan was done and it was noted a good site at 14 and the need for a Summer's bump procedure for 15. I place 2 3.8 by 9mm implants and used osteotomes to gently raise the sinus membrane. I had the pt breath thru his nose and noticed very, very slight bubbling at 15 osteotomy. I placed grafting material in the site and placed the implants. I was unable to torque 15 much so did it by hand. Post op xray looks good. I also put the patient on a perforated sinus regimine. Based on these variables, what can be expected?

Dear Dr. Barry Lasko, If you preeceded the implant or particulate graft material by a collagen membrane, there should be no problem. Dr. Phil Boyne showed in his studies that the bone in the sinus will grow vertical by aprox 4mm. This is somewhat dependent on the shape of the alex of the implant. Thus in a word, not much will happen and you will mostlikely be ok. Follow the area with non-digital radiographs.

I just did a post op on my implant patient. Both implants were stable and clean, no drainage of any kind and he did not have any pain or other symptoms. Thanks for the input.

what are the different sinus lift techniques ,published

During the dental procedure, it IS possible, with all the drilling involved, that this person's C2 vertebrae in their neck was put OUT OF PLACE, and has remained in improper alignment, thus causing the dizziness. I would suggest finding a qualified (there are many)chiropractor to have this put BACK into alignment. I had this happen to me, after a lot of drilling away of a tooth, to prepare for placement of a crown. After my chiropractic visit, I was PERFECTLY okay. I don't know if that is this person's solution, but well worth trying. Nothing is worse than that dizziness. The C2 vertebrae will affect equilibrium. Hope this helps. God bless and good luck.

Teresa, It may be possable that this is an issue. I go to a chiro but do not know alot about chiro. However, during the Sommers lift, the otoliths in the middle ear are displaced and have to settle in for the vertigo to go away...Dr. R. Hughes