Implant Site Preparation: Treatment of Asymptomatic Foreign Bodies on the Sinus?

If I was planning on placing another implant in that area, I would probably remove it. On the other hand, if no treatment was planned, I'd probably leave it alone. My .02.

I would take it out. There is no telling when those tissues could become inflamed. I especially would not want to put my implant in underneath it. At a minimum, do a consult with an ENT you have a relationship with. They can help make the assessment. DO a scan of the sinus and scope it. IT might be less difficult to take out than you think. DO you have a radiograph you would like to share?

While leaving it may not cause an immediate problem, nothing good can come from leaving it there. I would remove it or send it to an ENT for removal. Caldwell Luc, headlamp, remove w/ hemostat or suction, resorbable membrane, suture, sleep well knowing you would not like to leave an implant in your own sinus.

Removing the implant will probably be easier than you think. After 1 year the implant has probably fibrosed down which makes it easier. Sometimes foreign body removals can be a nightmare because of localizing what you want to find. But in this case you know the implant will be in the sinus. One more trick I want to add to the ones suggested by Dr. Kim are packing the sinus with iodoform packing, then removing the packing, sometimes the foreign body will come out with it.

I am the oral surgeon who posted this. Yes removal would be quite easy, that's not my question, in fact, I've done the procedure a few times. My question is, for assymtpomatic foreign bodies i.e. dental implants, does medical necessity require its removal?? I do have scans on this patient, there has been no change in sinus mucosa over area, and as stated before, he is completely assymptomatic. He does not plan to restore the area, osseonews altered my original post. Issues that I'd like addressed are: 1. Medical - legal implications 2. Unfriendly ENT presence in my neighborhood, I don't want ot see this case end up in court. 3. Do you think I am ethically obligated to recomend removal? 4. Are there any treatment consensus protocols that aren't anecdotal?

I suggest that you remove the implant - leaving the implant may cause chronic sinusitis. Do a Caldwell-luc (simple procedure use aseptic technique) In reviewing the other comments I agree that a scan of the sinus should be done, I do not see the need to scope it. However I disagree with packing the sinus with a iodoform and removing the packing hoping the foreign body will come with it. This method does not seem predictable. Carl E. Misch, DDS, MDS, PhD Misch International Implant Institute

With regard to medico-legal implications, in your informed consent this is one of the attendant risks associated with placement of implants in posterior maxilla. The fact that the event took place is not an actionable offense. Your responsibilty to the patient is to apprise them that it, in fact, took place and explain all possible sequalae. As far as unfriendly ENT's are concerned, they seem to be endemic. YOU are the specialist in this type of procedure. When you describe an ethical obligation to recommend removal, the only obligation to to discuss ALL potential causes of action, removal being one of them. In your due diligence, as you have described, you have taken periodic scans and find the case to be asymptomatic. Doing a Caldwell-Luc could potentially PRODUCE a sinusitis with it's attendant problems. In the absence of any clear pathology, I would do no more than monitor the case from time to time as you have done. Robert J. Miller, DDS

I agree with Dr.Miller.If there are no issues (including chronic sinusitis as Dr. Misch has pointed out) to be dealt with sinus in relation to embedded implant,Why not just monitor the situation periodically,unless there is a need for another implant in that site.

It seems that at least two questions have to be asked. Where in the sinus and what is the foreign boddy? I would consult the ENT literature and fing a friendly ENT.

My concern will the implant be stable in a car accident or a bumpy ride in an airplane or other trauma?

Why wasn't a sinus lift done to begin with?

Dennis Flannagan, D.D.S. wrote an excellent article that appeared in one of this years Journal of Oral Implantology. Said article addresses several of the issues on this topic. It's an informative article, and well researched.

Lets get our speciality out of the gutter and do the right thing, even though the implant is asymptomatic, if you were to lose a drill into the sinus would you leave it. An implant into the sinus is no different, of course the ENT is going to look at a CT and think what in the world is wrong with dentists doing implants. An antrostomy is a simple procedure and should have been done once the implant was perforated into the sinus at the time of surgery. Situations like this are what make us look bad, dealing with our own complications and dealing with problems like this elevates our status in the medical and dental community. No specialist would leave that in there and if dentists are performing procedures and don't have all of the necessary tools and knowledge to manage the entire case, even when an implant goes into the sinus, then don't do that procedure. Also, if there was enough bone to begin with, than this would not be an issue, it sounds like a basic treatment planning problem, and a subantral augmentation should have been done in the first place in order to provide primary stability to the implants in the posterior maxilla. I think that it is great that general dentists and specialists are doing implant procedures, but anyone who picks up a scalpel and prepares an osteotomy should anticipate the possible complications that may come along with the procedure and have the training to manage those complications, other wise implant dentistry will continue to keep getting black eyes from the public and others in the community.

A local OMFS also thought that a Caldwell-Luc was just another simple procedure. After surgery to remove an implant, the patient developed an oro-antral fistula which ultimately compounded into a pan-sinusitus. We need not only to be prepared for the consequences of an implant dislodging in the antrum, but also be prepared for complications of revision surgery. We teach our residents that, if an implant is pushed into the sinus DURING implant surgery, they should be prepared to immediately do a Caldwell-Luc to remove it. If it is found that if an implant dislodges well after initial healing has taken place, we recommend periodoc scans to determine if the implant is within the sinus and can freely move or is in the zone between the bone and the sinus. If it freely moves, we always recommend removal. If it it fibrosed between the membrane and ridge, we recommend apprising patients of the potential risks of removal. More often, the patient opts NOT do the second surgery and the case is monitored over time. The operative words here are that, sometimes, discretion is the better part of valor. RJM

I agree with Dr. Misch...take it out. Better done electively as a controlled procedure rather than urgently with the patient infected or symptomatic. I think this question would be more difficult if it were a small to medium size root tip, but an implant is rather large and not a natural part of the patient's body.

Before the advent of dental implants, the oral and maxillofacial surgeons used the Caldwell-Luc procedure, which involves opening the anterior wall of the maxillary sinus, to remove the maxillary teeth roots or even third molars which had accidentally displaced into the Antrum. Recent developments in diagnostic and surgical techniques using nasal and sinus endoscopy have provided much less invasive methods for visualization and removal of these foreign bodies.Some authors have warned that the surgical intervention for the removal of any foreign body from the sinus may trigger inflammation or even malignant changes. Connolly and White were the first to remove a projectile patricle from the maxillary sinus using an endoscopically controlled inferior meatotomy. Pagella has reported the removal of titanium implant fixtures from the maxillary sinus by means of sinus endoscopy through the canine fossa and not the inferior meatus. The method reported by Pagella was a step forward in regards to minimizing invasive surgery, but it seemed the surgoen(s) had no visual control over the foreign body. It is now suggested that it is much easier and safer to use two windows (an inferior meatal window and a small one at the canine fossa) than to use only one single small access at the lateral wall. The inferior meatal antrostomy also provides both intraoperative and postoperative benefits, including facilitating the observation of the status inside the maxillary sinus and an additional safe drainage (if needed) after the operation.

I agree with Dr Hack & Misch: There is no benifit to having a foregin body in the sinus. We have all seen teeth that looked fine radiographically and caused localized & systemic infections. Rember C reactive protein > disrupting arterial plaque > systemic health issues. I also would judge implant dentistry poorly if I were an ENT and we left implants in sinus' regardless of who placed the implant. I doubt an ENT would see it as WNL. Greg Kammeyer, DDS, MS Solutions Dental Implant Centre'