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Slight Exudate and Swelling 2-3 weeks Post Lateral Sinus Lift: Thoughts?

Last Updated: Jan 01, 2016

Every year, I perform numerous direct sinus lifts using a lateral window and grafts. Lately, I have been having several cases with the same type of post-op complication.

The surgery is uneventful, where I enter the sinus through a lateral window and place an allograft/xenograft mix, and cover the window with a membrane. Tension free primary closure is obtained using 3.0 PGA sutures, and I do use a periosteal releasing incision of the buccal flap to make sure the flap is not under any tension. Patient is put on antibiotics, analgesics, and dexamethasone. In addition Ancef [cefazolin] is used on a collagen membrane in the superior wall, and also mixed into the graft particulate.

About 2-3 weeks post-op, patient has a mild swelling. Intraorally on palpation, slight exudate is seen along the anterior releasing incision line. I have re-opened the flap in these situations, irrigated and debrided, as I would like to correct the problem to help salvage the graft. When I do open them, I find that the exudate/infection, is coming more apical, around the base of the flap, and NOT from the lateral window/graft, i.e. the graft is intact. In analyzing the few times this has happened, I am thinking that possibly some loose graft particulate has gotten trapped in the base of the flap, or in one of the periosteal releasing incisions, and has led to a localized infection. What is your analysis?

7 Comments on Slight Exudate and Swelling 2-3 weeks Post Lateral Sinus Lift: Thoughts?

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CRS

1/2/2016

Sounds like a subperiosteal abscess, be sure to irrigate any surgical debris prior to closure. Similar to a deep third molar impaction subperiosteal abscess. I don't like placing antibiotics in graft or membrane, hard on the new cells migrating into area, not necessary. Systemic is better.

David Levitt

1/5/2016

What materials did you use? This sounds like a mild foreign body reaction.

Gregori Kurtzman, DDS, MA

1/5/2016

What graft material are you using and are you adding any liquid to it? At this point I would place them on clindamycin and metronidazol for 10 days and have them rinse orally with CHX.

1/6/2016

use a 50/50 mix between Mineross (allograft) and MinerossX (bovine) and use Misch's approach where I place a piece of collagen with Ancef IV form onto the collagen , and any remaining Ancef I add to the graft material

Alessandro aversa

1/7/2016

I dont see any need to perform a periosteal incision in surgery like this. You are not adding marerial outside sinus lateral wall. Avoid it and everything will be easier and safer.

CRS

1/10/2016

Your initial post gives you the diagnosis, the area where the exudate is coming from tell you it is a subperiosteal abscess, also the timing 2-3 weeks later is diagnostic. This happens with third molar surgery when the material gets trapped under the periosteum. Just irrigate under flap prior to closure. Using antibiotics in the graft or afterwards is not the correct procedure, irrigation of the flap is the way to go. Nothing wrong with releasing incision in the flap it allows you access and you can see the base of the flap for debris. An envelope flap will actually make it more likely to get debris caught under the flap. The antibiotic in the surgical site is actually an irritant does nothing to help, systemic is better, amoxicillin or ampicillin better choice for sinus flora. Sounds like just tweeking your surgical technique is all that is needed.ðŸ˜Š

Irbad Chowdhury DMD, FICO

1/15/2016

I agree with Dr. Kurtzman. If exudate, swelling and fever is present post-op, I usually prescribe Clindamycin. Which works well.

slightly mobile implant bone loss treat slight bulge over the buccal cortex is intervention necessary