Patient with Failed Prior Sinus Lift and Implants: Recommendations?

Dr. D. asks:

This patient presented with a history of prior maxillary left sinus lift and bone graft with implants placed in # 12 and 14 sites [maxillary left first premolar and first molar; ,24, 26]. The sinus lift had been accomplished with a lateral window approach. The graft and implants failed shortly after and were removed. The patient also developed a sinus tract to the failed implant and bone graft site. A CBVT shows the deficient space available between the floor of the maxillary sinus and the alveolar ridge and the need for a repeat sinus lift and bone graft which I will be doing. In addition I will be placing a third implant in #11 site [the maxillary left canine; 23]. At the time of surgery, a lateral window approach was used for access and the membrane was elevated. A yellow area on the bone was identified and was probably due to a bacterial infection. That area was thoroughly debrided. The sinus floor was grafted with allograft mixed with PRGF and covered with a cross-linked collagenous membrane. Implants were placed in #11 and 12 sites. I was unable to achieve primary stability in #14 area and did not place the implant. I achieved primary closure without tension and prescribed antibiotics and steroids.

At 4 weeks post-operative the patient returned with congestion in the nasal passages and and a small perforation in the flap over the alveolar crest and graft particles were leaking out. The patient was referred to an ENT specialist who prescribed Amoxicillin with clavulanic acid plus Metronidazole as well as decongestant drugs. When the CBVT scan was repeated, there was no connection between the sinus and oral cavity. However the perforation in the flap persisted and bone particles continued to be lost through it. What do you recommend that I do at this point?

Cone beam after the first failed sinus lift approach

2nd surgery

perforation of the buccal mucosa 4 weeks after the second attempt of the sinus lift

43 thoughts on “Patient with Failed Prior Sinus Lift and Implants: Recommendations?

  1. dear colleague, the clinical image that you provide suggests an ongoing infection of the graft :exposure of the graft particles to the oral fluids means infection and so the capacity of this biomaterial to be a scaffold for bone cells is ruined.I woud thorougly curette this exposure and if necessary remove the whole graft .do not expect too much from antiobiotics, it s like for onlay bone autograft on the posterior mandible, the issue is blood supply and premature exposure , if the two are missing , it does not work.
    In the situation of the patient with altered healing capacities from previous attempts, the preferred material in my hands would be autogenous bone because you dont have the osteo inductionwith allografts .
    you should tell to your patient before he gets frustration that you may have to remove some or the whole graft before beeing in more trouble with recurrent infections,unfortunately you cannot say that there is no connection between sinus and the mouth, other where do these particles come from?…
    friendly, best regards GC
    (I had that before]
    “Experience is the name given to our failures.”

  2. Fellow Colleague: We all have failures and “get” to work through them. My first question on any failure is “WHY?” immediately followed with a “Can I do any better?” I was wondering if you figured out “why” it failed to begin with? (ie patient health/comorbidity factors, early implant placement without sufficient de novo bone, a detailed history of previous surgery- how, what, when, how long etc, and treatment of the subsequent infection prior to redoing the surgery)
    As we all know, lots of different techniques work so perhaps the simple answer to your question is: if you did the exact same thing as dentist #1, then why did you think you’d do any better? I don’t mean that to be insulting in any way but without the above details, I’d be nervous to suggest that anyone will be able to give you the magic antidote for this patient!

  3. Am I just dreaming, or have we seen this before? Why in the world would you send a dental complication, to a non dentist? Almost all ent’s are oblivious to what we are doing here and secondly, why repeat the same thing over again, just after it failed? You can go back four months and see my response to this if you would like. Good luck with this one! Bv

  4. I would consider this failing so the decision is wait or try a heroic measure. I see marginal erythema around area of graft loss only. Is the patient febrile also? I assume the ent felt there was sinusitis hence the augmentin. If you assume it’s a failure would you consider it foolish to take a split thickness palatal harvest and “tuck” the harvested graft up under the defect? What more could you lose?

  5. I look at a lot of ct’s and it appears to me, based on this ct, that the graft didn’t fail, but the implant did. Is that calculus/materia alba, at the cej of the anterior most teeth? Bv

  6. Clinically, a perforation of oral mucosa with graft particles being exfoliated is a sign of a potentially serious infection of the entire graft.
    The only predictable and safest action to take, for the well-being of this patient, is to remove the entire graft as well as the associated implant, debride the grafted sinus area thoroughly, and let nature heal.

    Academically, one may try to pin-point those factors that may have contributed to this infection;but, perhaps there would be too many to mention. However, it may be worth to develop a series of possible causes:

    1- How old is this patient & are there any health issues of any kind.
    2- Does the patient smoke, or consume any other addictive substances of any kind and, is this a highly stressed or psychologically depressed individual.
    3- Does the patient have a history of sinus issues of any kind. If so, was an ENT consulted during treatment planning.
    4- What was the state of the sinus health at the time of surgery.
    5- Did the surgical procedure adhere to strict aseptic conditions and proper intra-oral pre-op debridement.
    6- Was the Schneiderian membrane inadvertently & unknowingly perforated during the procedure.
    7- Was the patient appropriately pre-medicated with adequate pharmacology prior to the procedure to carry him/her through the surgery and adequately beyond.
    8- Did the sinus graft mix include an antibiotic.
    9- Was the patient provided with appropriate pre-op and post-op instructions, and, if so, did the patient adhere to these instructions.
    10- and so on.

    This limited list of possible entry points for bacterial contamination leading to causes for failure indicates that in this very busy and complex procedure of sinus augmentation with simultaneous implant placement, the risk of failure is elevated. A post-op infection can happen, and it must be dealt with aggressively.

    Although a referral to ENT is not unwise, an infected graft will not be helped by administration of antibiotics, simply because of a lack of blood supply in the graft area proper. The infection likely started in the sinus graft area, led to a quick deterioration of the collagen membrane and overlying mucosa, and subsequent loss of the allograft granules.

    This “round 2″ failure should lead one to take a serious look at all possible factors.

    Hope this eventually all works out fine.

    MM

  7. Mario, if you suggest going in and removing all the graft material , then should the material used in this case, ever be used? It amazes me that so many want to “wack off the serpents head”,before you even know if it’s poiseness ! This is why so many come on this site and” gag “at some of the suggested treatment philosophies. I am trying to be helpful, when I encourage grafting with something, that is so biocompatible that you will never need to remove it, even if it perforates into the middle cranial fossa, or into the region behind the frontal sinus. What did the ENT say? I would bet he rolled his eyes at the patient and said, what is a dentist doing in your sinus! Do yourselves a favor and find an OMFS in your area, that is well versed in treating sinus disease. I have yet to meet an ent, that fully understood, what a sinus lift was, nor have I met one that has ever done one. The ent’s in my area rarely if ever, even use the ” Caldwell ” procedure, even when it is clearly indicated. Let’s let dentistry be practiced, by dentist! Bv

  8. The handling of cases like these makes dentists look really silly in the eyes of ENT’s and the medical community.
    Also, beware of partials over surgical sites and bone grafts. Looks like the partial beat the heck out of this area and probably aided bacterial ingress.
    I’ve quoted Einstein before on this site,
    Definition of insanity- doing the same thing over and over and expecting different results.

    • As far as putting the partial over a freshly grafted site; you are just begging for failure. They can go a couple of months, with the area exposed. If you or the patient aren’t keeping these areas clean, they are gonna fail! Bv

  9. General health improvement, no partial!, and PRGF mixed with particulate graft materials would have given you a shot at this. Get out of trouble by eliminating infection! Provisional on11 if it survives, THROW THE PARTIAL AWAY, then start over as above. Good luck!! If patient wants fixed enough to go through this twice, they’re probably willing to do without partial to ensure success!

  10. Hello Colleagues,

    Earlier I suggested removal of the entire graft.

    It is possible that the entire graft is infected.

    I am not making any statement about the appropriateness of the particular grafting material used in this case … we know that the literature supports the use of a variety of materials with varying degrees of success.

    The real issue here is to try to explain how to arrive at a working diagnosis that take into consideration the well-being of the patient.

    If one believes that there is an infection here that could potentially compromise this patient in any way whatsoever, then the only solution is to remove all materials placed in the area of the sinus, thus giving mother nature a chance to heal.

    Then, because this was a “round 2″ failure, one must examine very carefully the relative interaction of 4 main factors …

    … 1… The Patient with the associated dental/medical/anatomical risk factors.
    … 2 … Treatment Approach and the associated risks with consideration to evidence-based documentation in the literature, as well as case difficulty level.
    … 3 … Biomaterials with the associated characteristics and evidence based documentation in the literature.
    … 4 … Clinician experience, judgement and skill levels.

    Have a great day!

    MM

  11. Said it all there Mario and Bv , most ENTs do not realise what we are doing there which is strange but true .
    This can be all about materials , as Bv says use something that it does not matter if the material is spread around.
    Always use materials that are Bio-compatible , Bacterio-static and I think fully bio-absorbed to return the body to its healthy state .
    HA is not needed here as it is not functional and distorts the value of diagnostic radiographs as we wuold need a core sample to assess wether there is bone or not.
    BTcP fits the criteria for safety for our patients maybe used with CaSo4 .
    Having used allografts many years ago ,they work well but I have had colleagues have infections when they have been used and it was a few sleepless nights , I preferred to avoid that so changed.
    Peter

  12. Is the patient wearing a removable prosthesis and, if so, did that have anything to do with the failure? It almost looks as if there is irritation from a flipper.

    • Jim, I agree the flipper, in my practice, is never used. The Essex temp may not be very pretty, but it takes all of the load off of graft sights between teeth and if there is no posterior stop, the patient wears nothing at all. I guess I have written this ten times on this site. Bv

      • All the cases I have done so far……no temps. Told the patient you have been without teeth for years….4-6 months longer is not an issue. I agree….essex temps are a good alternative. I have also done maryland bridges in the anterior if the patient won’t wear a flipper. Costs more money but works well….just more work on my part.

  13. I do sinus lifts every week and I have not had a post operative sinus infection in years. In addition I never put antibiotics in the sinus with the graft material and only use a standard dose of augmentin. You cannot do the surgery as described with sterile technique. A well done study showed that sinus lifts using autografts resulted in a 50% infection rate. The reason for this is that you are putting graft material in the sinus that has macropores(trabecula) and when bacteria or virus are present the result is an artificial osteomyelitis that will not respond to antibiotics. Use a graft material that does not have macropores and your potential for infection will be greatly reduced. Greg Steiner Steiner Laboratories

  14. Greg, I’m not putting my grafts into the sinus. Is there a study that follows the autologous graft placed, below the intact sinus membrane. I have had a single sinus infection, at the site of an intact membrane, with real bone and it resolved, with conservative care . So 50 percent of my grafts should have failed. I knew I was pretty good, but wow, I have really beaten the odds. I would like to suggest your studies’ validity, is probably a bit shy. There is a place for allografts, xenografts, alloplast and growth factors, somewhere in the maxillofacial region, but when the area is going to “bear a load”, I’m going with real bone. I will mix my autograft with min. or demin. bone and growth factors. Just a preference, based on a fair amount of experience and science. Bv

    • Bv I do think you are very good and that you have fewer complications than most of us and I am not being sarcastic. When I said 50% of sinus autografts become infected I did not say that 50% of sinus autografts fail. Please see J Periodontol. 2012;83(2):162-73. Epub 2011 May 16. Periodontopathogen and epstein-barr virus contamination affects transplanted bone volume in sinus augmentation. If you do not buy my artificial osteomyelitis concept why would you and most practitioners recommend the removal of infected graft material? You treat infected graft material just like you treat osteomyelitis. Look at osteomyelitis and infected graft material histologically and they look the same to me. Bacteria in pores that antibiotics cannot penetrate. Greg Steiner Steiner Laboratories

      • Greg, if you look at this weeks scenarios and past “threads”, I condem the removal of infected graft material. I specifically said, that if you are placing something, that may have to be removed in the event that there is an infection, then you have chosen the wrong graft material. I don’t expect you to read all that I have written, but this is but one of the reasons, I am such an autologous graft advocate. I’ve just never heard of the “artificial osteo .”, so please excuse my ignorance. This is why I am here. I’ve also never heard of an EBV infection, In dental grafting. I would not be surprised if the areas were colonized with viruses or bacteria. But this is very common issue. Maybe the new literature is calling the cloninization of bugs, artificial osteo.. Sorry for thinking ” out loud”! Respectfully bv

  15. Now Greg , I maybe totally wrong, but didn’t you suggest that the sinus was sterile, which conversely caused me to respond with a sarcastic response, sometime ago. The majority of grafts discussed on this blog are never sterile.” Surgically clean”, would even be a stretch. I would bet, however, that of all the intraoral surgical sites, the intact sinus, would be the cleanest. Bony macro pores and artificial osteomylitis ? This why I am on the site. I could “google up” artificial osteomylitis and not appear so ignorant, but did I just wake up from a coma? Rip van Vinci

    • BV, you obviously have some of the most experience here. I am a general DDS who has been restoring implants for over 20 years but just started placing them this past October. I have done 30 so far and am picking “easy” ( if there is such a thing ) cases at this point. Recently, I did a sinus bump on a case in #4 area with an osteotome to tent the membrane before placement ( I did not tap the implant, I used an OCO TSI screw type implant to place with a final torque of 55 n/cms). My question is then…..is it better to not place bone graft and collatape and then the implant when doing this? My implant was about 2-3 mm into the sinus so I did not put any grafting material. I placed the implant and took the radiograph and you can see the down fracture of the floor of the sinus and the intact membrane. Follow up xrays show good integration so far and no sinus issues. Please comment. I am here to learn as much as I can. I love doing implants but I have much to learn. thank you for your time, JIM

    • BV My post was specific to autografts because harvesting bone in the oral cavity often results in contaminated graft material as detailed quite well in the reference I provided. But my real point is why cause the trauma and deal with the resulting potential contamination with autographs when beta tricalcium phosphate has been shown to be equally effective in sinus augmentation. The sinus is probably the easiest place to regenerate bone so why not keep it simple. Greg Steiner Steiner Laboratories

  16. Jim, there are easy cases. I rarely tap implants in the maxilla and going 1-2 mm into the sinus, Is of little consequence, in my opinion. I do however, think you are obligated to graft something around the coronal aspect of the fixture, in that it is rare to get 360 of bone around the platform. I do believe, that if the space of lacking bone is small, a membrane is all that is needed. Most first premolars, in my experience, miss the sinus, but there are obviously exceptions. I personally like torque values at the 70+ degree mark, but be careful, when approaching these values. Some implant platforms will break and retrieving the fractured implant placed that tightly, can be very challenging . I hope this helps. Bv

    • Thank you very much for the info. Will there be bone filling in where thre membrane was ‘tented “then? ( i.e at the apex of the implant) or will bone never regererate there if no graft is placed apically?

  17. Jim , the short answer is yes. As long as the membrane is in tact. My problem with that technique is, do you really know, if the membrane is intact. Good scientific studies have proven that bone will grow in the ungrafted sinus, as long as space is maintained. This is why, dr Steiner is getting good results. He is essentially maintaining space, with his synthetics. I choose to place bone, simply because I didn’t know any better and retrospectively, if I do get an infection, I am less worried about foreign body removal. If your implant is long/wide enough, your patient is going to get a good result, even of the sinus is slightly perforated. I would suggest waiting at least 4 months to load and at that time I would only gradually bring it into occlusion. In addition, I would like to address the suggestion, that my autogenous grafts are contaminated. We set up every case as if it’s an organ transplant and go so far as to prep the harvest sight, that is typically closed and sterile. So, until the graft is placed into the “clean” in tact sub membrane space, it is sterile. So, dr Steiner , all the grafts discussed on this site are contaminated, I agree, but there is a lot we can do to dilute the floral count. Lastly, there are lots of harvest sites, that can be used, with very little morbidity to the patient. Bv

  18. Ok, so I cannot assume that the membrane is intact if I see a continuous membrane above the implant via a periapical xray? Is there any cost-effective way to obtain a post op image that will positively confirm whether or not the mambrane has been even slightly perforated? ( i.e symptoms of patient. bleeding from the nose, etc)

  19. also, why does the diameter of the implant affect prognosis? Again, sorry for all the questions but just rying to learn…thanks!

  20. Sorry , I just misread one of your questions and stated that typically the first pre is anterior to the sinus and I realized you were replacing the second. Don’t think you can go wrong waiting the full six months. The greater surface area of titanium that is ” integrated ” to bone, is considered by most, very important. Just as the canine is the ” cornerstone” of the arch. Of the single rooted teeth, it has the longest and widest root . It is not important to know if your implant is 1-2 mm exposed, into the sinus, now that it’s in. Everyone, that has done a lot of sinus lift procedures, has a couple of successful implants with metal exposure, in the sinus.

  21. Makes sense….thanks. I placed a 5 x 10 mm in the #4 area and am happy with he placement and healing so faras I saw the patient for a 1 month post op after seeing her initially 1 week after placement. Post op xray looks nice at this point and the patient is assyyptomatic ( that doesn’t always factor as we know. I also place implants in #20 and #30 area and post op raidiographs show uneventful healing. Plan is to restore #20 and #30 four months after placement and then rstore #4 two months later. Thanks for your help. May I ask where do you practice, training, interests, etc? JIM

    • Baton Rouge, trained at university of miss./ tenn./florida/texas( southwestern- parkland ). Interest -killing ducks and catching white perch, good music( wsp, GD, Dylan , zep,ray lamontagne,young, Mofro ) and golf( for the right bet). Also have some relative interest in my four kids and wife. Ha. Jim , I’m a frustrated farmer, that loves doing what I do, buy would rather be driving a tractor. Bv

  22. Jim for your question why is the diameter of the implant affect the prognosis this is because of engineering law when two different material in contact exposed to force the load well be distributed to upper area of contact , so load distribution over implant is different than natural tooth where the load is distributed over the surface area of the tooth but in case of implant is mostly confined to upper third that is why the diameter of the implant affect the the prognosis

  23. I agree with Greg there are always going to be bacteria around in the mouth , patient may have a quick meat pie for supper after the surgery.
    BUT what you put in the sinus can have a bearing on the severity and longevity of any infection for the reasons stated by Greg .
    Over the years have used Autogenous and allografts with great success but they have their drawbacks in donor site pain and as we see with allografts possible infection issues . I stopped using it when the bodies went missing in NJ.
    So BTcP and CaSO4 seems to be a viable solution and we always 1 stage and load at 4 months as core samples have shown over 90% of the graft has been turned over to host bone by 8 to 12 weeks dependant on patient physiology .
    And yes the patients , you know the person actually in the chair , they much prefer it with most cases not needing any pain medication the following day possibly due to less foriegn body response.
    Peter

  24. Peter, I also agree with Greg , with regards to the “sinus” and the fact that just about anything will allow that area to regenerate bone, as long as space is maintained and the membrane is in tact. When discussing the full “table of options”, I’m finding more people are opting for real bone( autogenous ), but unfortunately, they rarely even hear the option. Almost every complication, that comes my way, when asked, the patient almost never knows, what graft was used . This is the first big red flag, in my opinion. I typically spend more consult time discussing this part of the procedure, than the actual implant. I think the suggestion of , the second surgical sight and the pain associated with it, is a bit ” overstated ” and a fair “marketing ploy”, at best. Patients just don’t complain, that much, when bone is trephined from the buttress or the ramus. I do get more complaints, when the trephine approach and the block procedure, is done at the chin. It all boils down to, what is routine to the practitioner . Jim, I would encourage you to look at some of the “pull out ” studies, done with implants with lots of intact surface area vs those that don’t have as much. Bv

  25. Hi BV , Agree with you , and having just spent a day listenning to Mike Pikos who I suspects is on a similar page to you understand.
    Although there is “research” to say you can put nothing in and by merely tenting the lining you get bone I do not see it and even when there is a small area where I have not got graft material too it does not look that good even years later, so Isuspect a “scaffold ” is needed.
    Also agree on the other comments about the consent issues of materials .
    Regards
    Peter

  26. I have done many sinus lift without any bone augmentation obtaini g a 100% of prognosis 3 hears later, be sure that just maintining the space under tbe membrana a d the sinus floor you will have bone in less than a year

  27. What percentage of graft infection is due to the graft going in infected or infection occurring after surgery?

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