Entered the Nose Area While Raising the Flap During Implant Surgery: Best Way to Manage This?
Dr. C. asks:
I recently installed dental implants in the #7 and 8 areas [maxillary right central incisor and maxillary right lateral incisor; 11,12] in a patient with a severely resorbed maxilla. There was inadequate alveolar bone height – about 6mm — for the conventional installation of appropriate length implants. While raising the full thickness flap I entered the nose area. After installation of the implants I place an alloplastc resorbable putty bone graft and a membrane which I tacked in place for a guided tissue regeneration procedure. The day after surgery the patient presented with a fever. I placed the patient on amoxicillin and metronidazole and on the second day after surgery her fever returned to normal. Any chance the fever may be due to some graft getting in the nose? What is the best way to manage a situation like this? Is there a protocol when you enter the nose??
16 Comments on Entered the Nose Area While Raising the Flap During Implant Surgery: Best Way to Manage This?
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Dr Ali
7/26/2011
Very interesting. Never read about that. Maybe some OMFS could reply
Ziv Mazor
7/26/2011
Hello Dr C
Frequently in a resorbed maxilla there is inadequate bone height at the anterior region.Sometimes our treatment of choice is what we call "nose lift"- meaning penetrating intentionally to the nasal space elevating the nasal memmbrane with simultaneous implants placement.Recently we have published on this issue in clinical implant dentistry and related research 2010.
The fever does not seem to be related to the procedure.
Dr. C
7/26/2011
I am an OMFS. I don't believe violation of the nasal floor is the problem here. It is way too soon for infection to develop. You must try to close the nasal mucosa. If it is a large perforation you may develop a communication with the nose and the implant that will lead to implant failure and the nasal membrane may not close. Make sure the patient does not stick a finger in the nostril and monitor for healing. However, too soon for fever to mean infection. It takes longer for the body to launch the mechanisms necessary to create an infection than 24 hours. The patient may be dehydrated, have excessive edema, etc.. Also try using a tympanic thermometer rather than an oral one. By the way what was the fever? I would not consider it abnormal up to 100.5.
Baker vinci
7/26/2011
It's not unusual to plan a nasal lift procedure, and just as you would plan a sinus lift , sometimes the mucosa is violated. If the implant is just 1 or 2 mm into the aperture, you may not have any problems. If you are far enough into the nose where function is affected, I suggest you remove the implant and either place a shorter one or come back and do a formal nasal lift. This is a case where cbct planning would have been a great help. Unless the patient experienced rubor, tumor,and calor, then the slightly elevated temp. Was coincidental . This may also be a case for vertical augmentation. Management of a nasal infection , especially at the anterior aspect is quite simple. Get a post op cbct . If the mucosa was not violated ,the pt may spontaneously grow bone. Bv
Baker vinci
7/26/2011
I'm going to suggest attempting to close the mucosa is impractical, even in the hands of a specialist. If the perforation is minor , the nasal mucosa will probably repair itself. The best analogy I have to offer is exposed questionably dead bone on the lingual aspect of a lower third molar extraction sight just my opinion! Bv
DrC
7/28/2011
I agree with Baker Vinci. Closing nasal mucosa is difficult. It is size dependent was my point. Everything else you said is right on target
Baker vinci
7/28/2011
Did the pt go to sleep for case? Number one cause for postoperative fever in that scenario would be atelectesis. Again ,Which Is of little concern. Get an omfs to show you how to lift the nasal mucosa in this area . In my opinion nasal lifts are a lot easier than trad. Sinus lifts, and management of complications are quite simple as well. Hope this doesn’t disturb my omfs collegues , but if our dental collegues are gonna do these cases, I feel an obligation to help. Just as if I were gonna have to something the gp was more proficient at, I would get his help. As one great philosopher said, CAN’T WE ALL JUST GET ALONG. good day . Bv
Dr C
7/29/2011
Thanks very much everyone for the feedback!
I may not have described the situation right in the first case. I did not place an implant. It was a vertical augmentation case. So I am not discussing the nasal lift. I just over raised the flap so I reached the nostril area while raising the buccal flap. So I think that there is no membrane covering that area of the nose. I think that the membrane only exists on the floor of the nose. Am I mistaken?
The patient had a fever of 38 Celsius degrees the first day. Nothing then. She had a large edema which almost closed her eye for a couple of days. Just did the week post op. She is perfectly fine now. The flap has not opened, and no membrane exposed.
Dr C
7/29/2011
Baker Vinci, atelectesis, you mean as a lung problem?? No history of that. How do you think this may be associated with the post op fever?
Baker vinci
7/30/2011
Assuming the patient was put to sleep, the number one cause for idiopathic fever is atelectesis . Your right that is a lung problem! It is not uncommon that during the first 24 hours post general anesthesia for the end alveoli to to not be adequately ventilated, this subsequently causes a spike in fever, hence the reason for incentive spirometry protocols. As far as where is the nasal mucosa, from the earlier query . It runs up the entire lateral aspect of the piriform apeture and back from the rim at least 25mm. I wouldn't concern myself too much with one day of 38 degree temps. Bv
Baker vinci
7/30/2011
Dr. C , as you know, obtaining vertical heigth with a cortical block is challenging, and the most you can hope to obtain is about 2-3 mm maximum. I have learned this from personal experience and a lot of reading . I will reiterate , when I suggest having someone show you how to lift the nasal mucosa. Your graft is better protected, has a better blood supply and less likely to breakdown with nasal lift grafting. The only other way to get true effective vertical growth is via transport ( distraction ) or sandwich grafting. Bv
Dr C
8/1/2011
Baker V. your comments have been enlightening. Thanks.
It was not a general anesthesia case. Just slight sedation ( no IV, only pills ).
The patient is fine now. I actually did a simultaneous horizontal and vertical augmentation with particle graft and membrane. has worked for me before many times in getting 2-3mm of height. In this case I had 7mm to the nose and I just wanted an 8,5mm Imp.
But I think u r right. i should look into the nasal lift.
Any chance you got any literature on the nose anatomy u just mentioned?
I would love to see pictures of that. I got the Sobbota Atlas but there is nothing in there on the nasal membrane. Do you think Grey's has that?
I mean, every textbook has the bone anatomy and the circulation of the nose, but its really hard to find the membrane
Baker vinci
8/2/2011
I will gladly find an article that is easy to pull off the net. One good source would be any text that describes a lefort 1 osteotomy. Any text with authors R.V. Walker, Epker, Ellis,Wolford and or company on orthognathic surg. . Will try and get more specific tomorrow. Bv
Dr C
8/9/2011
Thank you very much. If you could post a link you seem to find really educative please do. Thx Bv
Baker vinci
8/12/2011
Dr.c , sorry it's been a long week. It might be easier for me to send you just a portion of text. Send your e-mail or fax to my address ,one of the ladies in my office will get it to you. Bv .or just put fax number on this sight ,will send Monday.
Dr C
10/2/2011
BV i checked your site, but cant find your email. I probably am not allowed to upload personal info here
