Sinus Lift Complication Case: How Should I Proceed?
Dr. M asks:
Please refer to the images below.
I did a sinus lift two and half weeks ago. There was a rupture of the sinus membrane in the mesial part of the sinus not more than 4 mm. I proceeded with the lift placed a collagen membrane covering the defect and fill the sinus, then bended the membrane outwards so it would cover the entrance too. The patient had antibiotics prior and then 8 days after surgery.
For the first 8 days the patient didn’t complain about anything. During the second week he complained that when he blew his nose there was some discharge from his nose I put him on antibiotics (augmentin + metronidazole). He got a lot better two days after.
Today almost 3 weeks after there appears to be a small oroantral fistula. But when the patient does the Valsalva maneuver no discharge is visible from the fistula. The post-operative perapical radiograph is within normal limits. Any advice on how I should proceed?
Nasal discharge and oroantral fistula after sinus lift
Small fistula
24 Comments on Sinus Lift Complication Case: How Should I Proceed?
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Dr M.
10/11/2010
I would like to add there was a fault on the design of the flap, the distal incision was made too close to the window. The patient was also under nasal spray to help with the congestion. Everything seems healed, the place where there's what looks like to be a an oroantral fistula the stiches broke loose.
Bruce GKnecht
10/12/2010
I agree this is scar tissue. I have had opennings into the sinus and it happens more with smokers. If you do get one PRF is a great way to help close the openning and hel the site. I have a power point on a case where i tried to close it three times with membranes adn tight suturing and it would open up agian. finally PRF did the trick. The patietn still is smoking. Ha!
Dr M.
10/12/2010
I saw the patient today he was asymptomatic just hope the antibiotics isn't masking something worse.
Vaartjes
10/13/2010
Hi, a part of the problem was that you used the membrane to cover the rupture also as the only menbrane for closing the window. Combined with the flap outline close to the window an oro-antral passage could easily be created.
Reopening and cleaning the area with the fistula is needed and then primary closure with probably a new membrane is advisable.
Dr. MP
10/13/2010
I have this similar problem with a smoker. I tried a membrane for closure but was unsuccessful. The procedure that was successful was the buccal fat pad technique. The fistula should be remove before positioning the buccal fat pad. Primary closure was obtain with this smoker,the area healed very well and I didn't have to use an expensive membrane.
younus
10/13/2010
what is prf?
Tony
10/13/2010
yes, what is PRF ?
peter fairbairn
10/13/2010
Platelet rich fibrin
OsseoNews
10/13/2010
A good discussion on this PRF can be found at this link:
http://www.osseonews.com/benefits-of-prp-and-prgf-does-the-clinical-experience-support-the-literature/
Ziv Mazor
10/13/2010
Dr M,
Seems to me you will get over it just with the antibiotics.Patching the perf with PRF is the best solution.Second choice would be a pericardial collagen membrane.
It also seems you were afraid to fill more graft material and I doubt whether you would end up with enough vertical height.You might need to do a closed lift on second stage.
Ron Neff
10/13/2010
The apices of the lateral (and canine?) need attention, a chronic source of infection here will doom all the other well intented solutions.
Dr M.
10/13/2010
I filled it up with around 2cc of Nuoos from Ace, but i agree i could have placed more but was afraid of enlarging the perforation.
Robert J. Miller
10/13/2010
PRF is the preferred material to close a sinus perforation and as a covering on the ridge at flap closure. As an autologous membrane with live cells, it will speed up the rate of closure of the membrane. But one more important aspect is it's bacteriocidal properties. When you prepare a lateral wall sinus opening, virtually 100% of them end up with some type of bacterial component, either from a residual apical granuloma, or from the mouth by contamination with your instrumentation. Post-op antibiotics will have mixed results as there is no blood supply to the graft complex. Additionally, mixing the graft with metronidazole will keep anaerobes from proliferating and a have a profound effect on graft density. Check out the Osseonews course listing for the latest PRF course offerings.
RJM
Dr.Moshirabadi
10/13/2010
Dear Colleague:
Dont worry !! You should wait for 2 mounth' then asseess and evaluate the signs & symptoms of surgical site .If surgical site hasnot any symtomps & signs "GO HEAD"
Otherwise you should intervene in surgical site and evacuate the foreign bodies (bone grafts) and close OAF.
Be patient!!!
Dr. Mehdi Jafari
10/14/2010
Sir,
Forget about PRF or stuff like that.They'll do nothing over a void contaminated area.Cover the perf. using a pedicled vascularized buccal fat pad transfer flap and then cover the whole area by a muco-periosteal flap in which the periosteum is cut-released.Don't waste the time.
Dr.Moshirabadi
10/15/2010
Dear Dr Jafari:
Why buccal fat pad in this stage ? there arent symptoms & signs of OAF or sinusitis any more . Furthermore if any infection , OAF and/or sinusitis manifest, you should be evacuate any forign bodies first , then repair the sinuse window deffect with autogenous ,bone block graft , next open naso antral window for drainage, and ultimatly close the oral mucusa with vestbular muausa or in sever cases with buccal fat pad.
Dr. Mehdi Jafari
10/16/2010
Sir,
Actually, I disagree with using any type of membrane (either of biologic or of synthetic origin) to be used for closure of persistent oro-antral fistulas.Of course before any attempt to repair the penetration,all kinds of infective processes or foreign body reactions ought to be eradicated.
psbudi
10/17/2010
dear dr. Robert J Miller,
What kind of Metronidazole do you use to mix with bone graft? Crushed from metronidazole tablet or what?
thank's
Robert J. Miller
10/18/2010
We use metronidazole for injection 5mg/ml in a 100 ml bag manufactured by Baxter Healthcare. You can find a distributor in your area of the world. We do not crush metronidazole tablets. The binder in the tablet will cause a foreign body reaction and delay healing.
RJM
Greg Steiner
10/19/2010
If there is a fistula there is infection. I agree with Dr. Neff that if the lesion on the anterior teeth have not been treated then endodontic therapy should be done ASAP. However I do not see any thickening of the membrane in the anterior portion of the sinus so infection of the sinus from the bicuspid is questionable. The Nu-Oss granules will be infected and the only way this infection will be resolved will be to lose the granules either by removing them or by the body sequestering them out through the fistula or the sinus. For a sterile technique that does not use granules Google Steiner Sinus Lift. I would allow a few weeks for antibiotics and the body to resolve the fistula but if it persists I would open the site and debride any granulation tissue. It is obvious that there is no consensus on the best way to treat oral antral fistulas and that is one of the reasons we have developed OsseoConduct cortical plates but we are still a few weeks from FDA approval.
carlos m. cardenas
11/3/2010
My opinion is : Entrie again clean all the sinus membrane irrigation with clorhexidine , close fistule and put Membrane Reabsorbible type BioMend Extend, Antibioticorapy, and Metronidazole, and control.drein nasoantral is required.
Dr. Mark Chishom
11/9/2010
First, I agree with patience. I would keep this patient on abx as long as there is active infxn. Caution your sinus lift patients not to blow their nose after surgery especially if there is a perf. Keep them on decongestants like sudafed and Afrin ( no more than 5 days). I know what I am getting ready to say is not popular.....but I always use at least 50% autogenous bone in sinus lifts mixed with PRP. I have rarely had an infection in 12 years even with membrane tears. I attribute that largely to using more of the patient's "stuff" and
Not alloplasts and allografts or xenografts. If you do perf you will lose more volume of your graft then you want.
ttmillerjr
11/14/2010
Dr. Miller,
Can you give me the research showing that adding metronidazole to the graft decreases risk of infection.
Robert J. Miller
11/15/2010
Implant Dentistry:
June 2009 - Volume 18 - Issue 3 - pp 220-229
doi: 10.1097/ID.0b013e31819b5e3f
Clinical Science and Techniques
The Relevance of Choukroun's Platelet-Rich Fibrin and Metronidazole During Complex Maxillary Rehabilitations Using Bone Allograft. Part II: Implant Surgery, Prosthodontics, and Survival
Simonpieri, Alain DDS*; Del Corso, Marco DDS†; Sammartino, Gilberto MD, PhD‡; Dohan Ehrenfest, David M. DDS, MS, PhD§
