Implant in the sinus, removal and closure: recommendations?

This patient had an implant placed on the upper left side about a year ago which penetrates into the sinus. I plant to explant it and seal the opening. I do not believe that I will be able to graft. Any recommendations on how to proceed?



20 Comments on Implant in the sinus, removal and closure: recommendations?

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STEVEN KOLLANDER
8/9/2016
Remove implant. Wait a few weeks. Let site heal. Then simultaneous sinus lift and graft the socket. Wait about six months. Place implant.
Gregori M Kurtzman DDS, M
8/9/2016
the width of the implant is narrow so I think you can counter rotate it out and then do a crestal lift then place a wider fixture and close with primary closure
Dr Sanjay Jamdade
8/10/2016
Hi Doctor Kurtzman! What if the sinus lining is damaged or infected in some way after implant removal?
dr Zoran Milankov
8/9/2016
Hi there, Take it out, clean it, wait for 3-4m, than place the bicon implant All the best,
STEVEN KOLLANDER
8/9/2016
Even if your considering a Bicon without performing a sinus lift, you're going to have to graft the site. But I would strongly recommend that you do this with a conventional sinus lift. You don't want this to fail a second time.
Dr. Gerald Rudick
8/9/2016
PROCEED VERY CAUTIOUSLY...... THE IMPLANT IS NOT STABLE AND WHEN YOU ENGAGE THE HEALING COLLAR WITH YOUR SCREW DRIVER....THERE IS A GOOD CHANCE YOU WILL FORCE IT INTO THE SINUS........ ADVICE....BEFORE ENGAGING YOUR SCREW DRIVER, LASSOO THE IMPLANT WITH A PIECE OF DENTAL FLOSS, SO IN CASE IT MOVES, YOU CAN HOLD IT AND PREVENT IT FROM SLIPPING INTO THE SINUS. Once out, let the soft tissue close over, and wait about a month before going back and grafting......best to use a PRF membrane to line and cushion the sinus membrane before placing the particulate graft material.
Irbad Chowdhury DMD, FICO
8/18/2016
This is great advice Dr Rudick. Many inexperienced doctors have run into this problem.
John T
8/9/2016
What was the dentist hoping to achieve with this single implant? There are no natural teeth present. Was it intended to carry a locator for an overdenture? If so wouldn't it be possible to remove this implant - which appears to be a no-hoper in any case - and place a new fixture further mesially at the same time? This would avoid the need for sinus lifts and so forth. It's not really possible to formulate a treatment plan without more clinical information, a panoramic x-ray, photos, etc.
Peter Fairbairn
8/10/2016
Agree John , possibly no scan and was fooled by the anatomy ..... as could have placed 2 mm mesially or even angled with no Sinus involvement ........ hence if not sure scan ..... as the poster has said later others all failed as well ... As Dr Kurtzman say care on removal as Implant in Sinus and its removal will bring another whole learning curve .... Peter
Hardeek Patel
8/9/2016
Previous dentist had hoped to do a FMR, i removed the implants on the other sides as they were all failing, Patient had very thin ridge, they were all placed too far facial. I plan do a bilateral sinus lift once this all heals. ( Ex dentist had taken "live" patient course overseas and was "ready" to full arch.
David
8/11/2016
I would place patient on Augmentin 875 mg for 10 days. (Assuming not allergic to Pen/Amox). Take off cover screw and back out implant all the way out. Place resorbable membrane Cytoplast on superior, mesial and distal walls of sinus like an umbrella against sinus with mfdb allograft soaked in flagyl (assuming Pt not allergic). Make sure not to push bone into sinus. Gently place bone graft. Place non-resorbable Cytoplast Membrane over mfdba and suture with ptfe sutures (try to get primary closure). Place glue stich and make sure patient does not blow nose for 10 days.. Place of nasal steroid nasonex and Claritin d for10 days. I have done several of these with great success and be able to go back in 4 mo later and place new implant. I would agree though in this case move implant more mesially so no risk to already compromised site. Good luck and keep us updated.
John T
8/11/2016
Sorry David, but I fundamentally disagree with your treatment plan. All Dr Patel needs to do is remove the implant and pop in a stitch. The explantation site will heal in the same way as an extraction socket. A 10 day course of high dose Augmentin would be appropriate for the management of life threatening pneumonia but not for a failing dental implant the size of a small wood screw! This indiscriminate chucking about of antibiotics is wholly irresponsible. Intranasal steroids and antihistamine are unnecessary and there is no need to graft the socket - which is only about 3mm in diameter at it's widest point. It really worries me when I read some of the hugely complex treatments proposed for simple problems.
STEVEN KOLLANDER
8/11/2016
agreed
David
8/11/2016
Ok, thanks for sharing. This is how we were trained in my residency but I'm open to all recommendations. Thanks. David
John T
8/11/2016
David I'm sure the microbiologist in the hospital where you trained would not approve of a 10 day course of Augmentin 825/125 before removal of a non-infected fragment of titanium embedded in the upper jaw. Microbial antibiotic resistance has become a major issue, particularly in the USA. To quote from your CDC (Centers for Disease Control and Prevention): "Each year in the United States at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of their infections". These are not small numbers. Also to quote from a publication by your National Institute of Health: "It is apparent that a modern epidemic of overdiagnosis afflicts high-income countries with tangible and financial costs of the unnecessary management of overdiagnosed disease". In other words KISS! You can look up the KISS Principle on Wikipedia
David
8/11/2016
John- again thank you for your response. I respect that and will reconsider my protocols. That is why I am here. To stay current and open to all trends and ideas. Thanks again, David Ps my residency was done in 1999 and I try to stay as current as possible by reading and courses. I appreciate this information. So quick question, for you, how do you feel about the thread on this that talked about the zpak as the best antibiotic as of late for dental implant surgery?
Hardeek Patel
8/11/2016
Wow, What a great opportunity to learn from the maesters. I will be seeing her tomorrow and will keep you guys posted. Thanks again for being an invisible mentors.....
John T
8/11/2016
David Please don't get me wrong, I'm not aiming my concerns at you alone but at the general tendency for this discussion site to overcomplicate what should be fairly simple surgery. With regard to your choice of antibiotic I suggest you should not be asking "Which antibiotic?" but "Do I need to prescribe an antibiotic at all?" If you're prescribing it as a surgical prophylactic you should also be asking "How long?" There is plenty of evidence that a single pre-operative dose and a single post-op dose is all that is necessary. With regard to the "best" antibiotic why not just give amoxicillin or perhaps co-amoxiclav. There's no evidence that azythromycin is more active against the common oral and respiratory pathogens (although if your patient also has chlamydia Zithromax would kill two birds with one stone!). There's not a lot to choose between the two with regard to side effects - amoxicillin has a higher incidence of rashes but azithromycin has a 12% minor side effect rate and about a 1% incidence of significant side effects such as jaundice, palpitations and chest pain. Azithromycin also has an increase in cardiovascular deaths , usually due to arrhythmias, compared with amoxil. As for cost you folks in the USA are always ripped off by the drug companies anyway. In the UK a 7 day course of amoxicillin 250mg costs 95p ( about $1.10) whereas a 4 capsule pack of azithromycin will set you back £9.64 (about $12). I know a zippy name like Zithromax Z-Pak sounds as though it must be doing you good but you don't want to believe everything the drug salesmen tell you.
Irbad Chowdhury DMD, FICO
8/18/2016
Great advice on this thread. I would carefully remove the implant using Dr. Rudicks protocol then graft the sinus via the old osteotomy. Expect some graft material to enter the sinus. Wait 5 months for healing then place another fixture. I wider implant at time of removal will not work due to lack of bony support apically and distal (due to pneumatization of the sinus floor)
hp
8/23/2016
OK so the implant was intergrated rather nicely, I still removed it as there was a defect on the buccal. I curetted the area, placed an osteogen plug on the sinus perforation, secured with suture. Checked the patient for healing last week and everything is well so far.

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