Hematoma After Sinus and Graft Procedure

I have read an article regarding bleeding complications during and after sinus lift procedures but I do not quite remember where and who is the author but it mentioned that:There are several possibilities for bleeding during or after lateral sinus lift procedures 1)The lateral nasal artery, an extention of the sphenopalantine artery which originates from the maxillary artery, can course intraosseously on the medial wall of the sinus.injuring this artery may be possible during elevation of the sinus lining from the medial wall ,a vigorous curetage during elevation ,mayabrade the bone and lacerate the artery where the bone may be very thin . 2)there are small capillary branches running transversely on the lateral wall of the schendrian membrane especially on the 2nd bicuspid and 1st premolar area , laceration of this branch can lead to a bleeding or hematoma. 3) doing the transverse incision in the premolar area when planning and raising the flap may injure a small artery that ascends down through the mucosal flap which cannot be mentioned intra operatively because of the pressure of the retractor or by the vasoconsrictor used , but it could lead to a significant hematoma post operativly after 6 hours of surgery. To avoid such complications (which are really rare), place your transverse incision always in the canine area even if the sinus lifting is in the molar regeon, and start reflecting the membrane from the anterior and lower part of the sinus bacckwards to the psterior an dinferior border, and try to be extra gentle while dissecting aand elevating the medial wall. As for your case now if there is no obvious bleeding from the flap borders , nothing should be done and the hematoma will subside spontaneously in 10 days, good luck for next time,

May be the origin of hematoma is from outside the antrum.Sometimes during anesthetic injection for tuberosity blocks the needle may hurt or penetrate the pterygoid venous plexus and a very large hematoma may form at that side of the face.Because the blood pressure is lower in veins (in comparison to arteries 0 and the the flow is slower,it may be seen within 24-48 hours after the injection.

Source of bleeding resulting in hematoma could be from any where as mentioned by Dr. Emmad, but more probable cause could be injury to pterygoid plexus as mentioned by Dr. Jafari.

It is my own experience, hematoma due to injury to plexus started right away before I start surgery.

When ever there is surgery there will be bleeding. Some of the preceeding comments have exponded on the varied areas that can cause "more than usual" bleeding, leading to a hematoma. Additionally, some time the flap is scored to get primary closure. The scoring can introduce the bleeding into facial plains. I warn my patients that even though we are working on the upper jaw, they may get "brusing" in their cheek or neck. Additionally, some patients are on medication that thin the blood and cause more bleeding than we would want which can result in a hematoma. I would advise antibiotics to be continued for a few days after the swelling is gone. The swelling and hematoma should start to go down after the 3rd or 4th day post op. Hope things work out.

Dr. Salloum is right. Hematoma usually comes from this sources. Liver problems or coagulation deficiencies also helps. Most of the extraoral hematomas comes from an artery that is inside the bone and that can be injuried during the bone window procedure. Corticoids, ice and some enzymes will help in treating this situation.

Whar enzymes?

Hematoma post sinus lift is a common complication after sinus augmentations.It will fade away within 4-7 days.Since hematomas tend to get infected care should be taken to take antibiotics at least for 10 days. Reasons for hematoma development are numerous including vessel injuries,High blood pressure,capillary fragility,overextended flaps etc.

Of course there are zillian causes of excessive bleeding which can lead to hematoma which includes many medical conditions like liver problem, bleeding or cloting disorders,vasculitis,lupus,medicines like aspirin or anti cougulants,or vitamins def.of vit K,B12, Folic acid ect. But are'nt we supposed to rule out those problems before we do surgery? I would rather investigate more about any herbal if patient is taking like ginseng,garlic, ginger which are very silent causes of excessive bleeding. Also thin fragile elderly ladies are also prone to develop hematomas. Treatment includes 1, Compression of area if possble to reduce bleeding. 2,Elevation of head by extra pillows during sleep. 3,Ice packs for few hours on and off. 4,Moist heat apllication after 2days. 5,ANTIBIOTICS TO PREVENT ANY INFECTION.

The patient may have simply blown his-her nose. The first time one sees an air embolism, it is hard to believe.

Dear gentlemen,being on any kind of anticoagulant therapy or having any bleeding disorder, is a contraindication to placing implants.So, we assume that the clinician should have known this in the first place and during the pre-operative workup of the patient.In that case, having any bleeding tendency would be ruled out.We should only think about something technical or an anatomical abnormality.

Just follow-up for this hematoma case. I talked to the patient over the phone (on day 7 ) and she said "swelling has subsided a lot " but just a localized swelling (like a small ball ) on below her left eye(about 1 cm below) and side of her nose, and slight numbness over the swollen area (lower eyelid, upper lip,and corner of the mouth were not numb ),apart from that she felt reasonablly comfortable so she hadn't taken any analgesics.(only antibiotics) She is coming back on day10 for suture removal or Follow-up. The only possibility that I can think of as a cause of this hematoma is during the procedure of making releasing incision and blunt dissection of the periosteum to place tension free sutures. And she is taking a lot of health supplements which I need to double check. The swelling has been there from day1-2 and she had no other medical conditions that needed my attention except her allergy that made her nose a bit runny. From her CT-scan (ore-op), 2 retention cysts were found on her left sinus (exactly over the lateral window area ) and after ENT consultation, she has been using her antihistamine spray to control her allergy and I lifted the cyst without rupturing. What do you think of the cause of this numbness ? Just because of local swelling or possible nerve damage ??? I really appreciate your feedback and advice, this is my first time to try this web site and I couldn't be happier. Thanks !

Whenever performing a sinus lift procedure, expect some mild localized to mod. extraoral facial swelling. However, to minimize complication, pt. should always be instructed not to blow their nose for the next 3-5 days post-op., and can be placed on decongestant. No vigorous work-out for 1 week. Ice pak should be placed immediately up to 24 hours. Then warm pak/towel only on 3rd day post-op and thereafter. Patient should avoid drinking anything cold after the third day on for following 10days. Please note that allergy adds to her difficulty in breathing through her nose. Any upper respiratory congestions can contribute to her airway disturbance and constant nose blowing!!! Reexmine her habits and med. hx. are important.

The numbness is sometimes caused by swelling in the localized area, near the infraorbital formaen. The soft-tissues can swell stretching the branches of the infra-orbital nerve to cause hypoesthesia. With time, when the swelling does subside, the hypoesthesia will disappear, since the nerve is no longer being strained. If the branches were lacerated during your "scoring" of periosteum then expect long-term hypoesthesia or even permanent paresthesia. And also another note, I believe we are all capable clinicians, so I assume A) you've checked out the medical history and medications list so that you dont just perform a sinus lift on someone taking COUMADIN or has a congenital coagulopathy, B) that youve given the proper post-operative instructions such as sinus precautions, decongestants and reduce physical exertion, C) Hematoma causes extensive bruising, and tissue emphysema normally does not. If you can not do the above, you shouldn't be practicing dentistry much less performing sinus lifts and placing implants.

Julius, There are a multitude of reasons your patient may have experienced the complication. Sinus grafting procedures are complex and require a complete evaluation of the proposed graft site prior to surgery. A complete medical evaluation of the patient prior to surgery is essential. Patients with a history of seasonal allergy and sinus disease should be sent for a pre-op sinus CT to read by a radiologist before filling the antrum with bone. A sinus without adeqated posterior drainage is a panfacial sinusitis waiting to explode. The 'take home' message is that unless a doctor is trained and experienced in managing potential complications, he/she should consider referring the patient to a colleague with adequate training. Panfacial sinusitis is a very serious complication of sinus grafting and requires admission to the hospital.

Simple reasons: Bleeding after surgery. It is normal specially after the anesthetic wears off. Swelling because of the trauma of surgery. normal too. It does not matter who or what caused the bleeding or the swelling. What is important is the care. Good antibiotics. Tons of ice day of surgery. Close follow ups to check for infections of the hematoma. Dr. Vergara Periodontist Houston

to sfloms ... great response ...

Please help. I have a sinus lift graft surgery, upper left mouth, starting from where tooth 13 was going inside for 2 implants later, on Mar 18, 2008. 1 1/2 week after surgery I thought I was completely healed, no sign of problem, but at the middle of third week I have an infection started, front upper gum below upper lip erupted, letting out pus and bone graft material. My right cheek swollen and tight feeling all the time. It's almost 2 months now, I started with penicillin, then amoxycillin then back to penicillin, then 14 days in azithromycin. Along those times swelling at the cheek have gone done to a 2 from 1 to 10 being worst. I still have the swelling and tightness at the cheek. I'm concerned to stop the antibiotics for reasons that the infection might come back. Now June 16 have a new antibiotic prescribe, I think it's called avelox. Please let me know what's causing the swelling on the right cheek. Do I have a internal bleeding from one of the nerves? Do I still have the infection. My implant surgeon said that after avelox, he would remove the graft and redo the whole thing if the swelling hasn't stop, which by now is down to about 1.5 form 1 to 10 being worst. Along the antibiotic treatment it was on and off as in it was getting better then it will swell again to around 2 or 3. Please provide possible cause and possible remedy. Ed

You may want to review my artice, posted in the RochelleGriffith.com website, for medical legal implications for decisions made for patients or with their "informed consent".

dear dr when i inter to sinuslift and cut the artery how can i do with this problem. thanks