Implant Slipped into Sinus: What Should I Do?

Take it out through a lateral window using a surgical suction as soon as possible , or refer to ENT who can remove it through the Ostium . I will post a case of removal of an implant ( through lateral window ) and re-implantation in the same osteotomy and grafting at the same time. The case was then loaded at 5 months. Peter

By the way TELL the patient , and deal with it . Good luck Peter

Human mistakes can happen. Your patient need the information.

What do you mean you didn't tell the patient? That's unacceptable. I try not to criticize people asking questions on this blog, but something has to be said here. Mistakes happen to everyone, I'm a board certified periodontist and I make mistakes. The biggest mistake you made was not slipping the implant into the patient's sinus, it's not telling him. Do that ASAP then refer to a specialist to remove the implant through a lateral window. Good luck.

To follow up on my previous comment. You should consider prescribing amoxicillin 500 mg, one tab tid for 7 days. Or even better (more specific to sinus infections) Levaquin 500mg, one tab qd for seven days. A decongestant might also help such as Sudafed. Thanks for sharing this case with us.

hello, The implant can also be removed non surgically by an ENT surgeon using an endoscope. I guess this will save the patient of the surgcal and mental trauma and the patient will show better compliance. All the very best.

I am only a relative beginner in the field of implant dentistry and don't have this level of experience as the other colleagues on this forum,hence will not elaborate on further actions in terms of treatment. But, as the docs above will give you this advice: TELL THE PATIENT, refer to OMFS as soon as. Follow the development of the case closely as you would if it involved your family member. I wish you all the best with this case.

For starters, thanks for sharing this with all of us, it takes credit to do that which isn’t easy, hence makes me think this blunder was a genuine mistake and it might have given you a few sleepless nights AND lastly you are seriously wanting to un-do this night mare. Tell the patient ASAP. Be composed as you tell him or her, dont look like you've committed a heinous crime even if you think you have or it was because you took the case casually or because of incompetence. I don’t think adding a bit of spice to the story is a good idea, like telling the patient "it seems like your implant has slipped into the sinus in the last few days and that does happen sometimes, we're gonna have to retrieve it...."….My suggestion is to tell the truth. Apologize to the patient once you know they’re cool about it. Call a good ENT and discuss the case with him/her before calling the patient. I think you can easily get this piece out through a lateral window, but get an OMFS consult and do the procedure at your clinic. Also, identify what happened, although I have a feeling you know exactly what happened. Not that its important right now, but for future reference be careful. Best of Luck.

let the patient know right away. If the patient knows you took post op x ray and didn't say anything about the implant, then goes to another doc( OS, Ent, or another gp ) and he or she says the implant's in the sinus, then you really are SCREWED. Deal with it now be honest with the patient. Be ready to do any to undo the damage even if that means paying another specialist to fix the problems. Good luck!

I am very sorry u r going through this night mare but not to worry, I would evaluate the patient's character and if he is as such that he won't be cool with it then I would tell him that u need to consult with ENT because of the symptoms e is developing and go with him to the ENT office and remove it ASAP. I have in my consent form this complication so that helps too, I wd not recommend lateral wall because of the post op morbidity,

I am sorry to hear this happen to you. We all deal with similar complications at some stage of out implant career. So there is nothing to be ashamed about especially if you have placed implants in the mandible then patient should have some faith in you. Let the patient know about the situation, also if quality of bone was poor at placement then it be worth mentioning to patient as you have placed a short implant on the other side which may give complications in the longer run as i believe you considering 3 unit bridge on that? all the best you still have 80% success so far in that patient so its not end of the world.

Mr. Smith during your surgical appointment one implant was not positioned as we had planned. It is the implant furthest in back on the upper right. It passed all the way through the bone and is now above the bone. After the procedure, we took an x-ray which I have discussed with several speacialists in the area to determine treatment options. I think your best option is to go to Dr. Jones who is a respected local oral surgeon. He is familiar with this situation, has treated it before, and we are both confident he will be able to correct it. Sherry has all of the contact information that you need, and she will help you schedule an appointment for an evaluation at his office. I know that this is an inconvenience for you, and I apologize for that. But After Dr. Jones removes the implant, and places a new one, we will be on track to complete your treatment as we had planned.

This is very unfortunate. As an OMS, I see this complication far too often from my dental colleagues. First of all, when placing a posterior maxillary implant, in your informed consent discussion you should have mentioned this possible complication of the surgery. Secondly, when it happened, the patient should have been told immediately and referred to an OMS office. There is no need for an immediate ENT referral, as many OMS are versed in using an endoscope to access the maxillary sinus through the natural ostium. Most times, due to the implant size, it is better to remove through the implant osteotomy if the osteotomy cannot be reused or through a lateral window. If the sinus membrane is not that damaged, sometimes a sinus lift and replacement of the implant can be done at the same visit. Otherwise, close up and let things heal and wait for another day after the fixture is retrieved. Antibiotics,and nasal decongestants should be prescribed if the patient cannot be seen immediately. What really upsets me on this implant forum is that practitioners that do not have the proper training and experience in placing dental implants are attempting to do the procedures. If you cannot handle ALL the complications of any surgery that you perform, refer the case to someone who can do it. It is less sweat for you and better for the patient! This goes for any surgery, extractions, perio surgery, bone grafting, etc. I can tell you that when specialists see this type of complication walk through their door, it upsets them because they feel that the case should have been referred to them to begin with and the patient would not have had the problem from the start. We all have complications, but what separates the men from the boys is how they are handled. If you can't fix the complications, don't do the surgery!

Ok, I as well give you credit for posting this case. With that said I'd like to give you some worthwhile advice. You are not qualified or trained to do implants properly. The maxilary left implants are mis-aligned. The mesial implant is against the root adjacent to it, the distal implant also has perforated the sinus floor. On the right side aside from the obvious oops the other implants have perforated the sinus floor. If this case was done in the United States it is going to cost you. You have committed an indefenseable mistake by not informing the patient if all of the issues I just mentioned. It indicates either neglect or ignorance. My advice is refer the patient ASAP to an oral surgeon who is a good friend to remove the implant and pray hard that this is a forgiving patient. I would also inform your malpractice carrier of this incident and gave them advise you of any legal next steps.

To the OMS; "If you can't handle all the complications...." So if you (as OMS)break the PFM in front of the 3rd molar your extracting (that's a complication) can you handle it?... or refer to a prost. Doesn't that put you in a diferent position ...hmm. Complications are best handled by prevention!. Know your limits and most of all, the limits of the procedures your doing.... If one would need to know how to handle all the posible complication...no one would practice.

I will not criticize the skills of the dentist; just by viewing the panorex, he/she certainly does have plenty of experience and talent. The only wrongdoing was not to inform the patient at the time of the implant slipping through the osteotomy. In more than 40 years of placing implants,I have at least 6 "floaters" in the sinus cavity. Some are implants themselves, others are implants with either a healing collar or an abutment. Years ago when an infected root was accidentally displaced into the sinus during an extraction, there was cause for worry.....this was an infected root! The implants with their prosthetic parts are titanium, and were sterilized previous to installation... a Caldwell Luc operation boring a hole in the lateral wall is not necessary. The ENT specialists who I have consulted with, just say to give a preliminary course of antibiotics and nasal decongestants, and leave it alone.......I have never seen a problem caused, and months later the area can be regrafted and the next implants will most probably ossiointegate ..... if the dentist or the patient want it removed, it can be done very easily through the nasal cavity without destroying the Schneidarian membrane as would occur using a surgical aspiration technique through the osteotomy or a Caldwell Luc window. Judging by the extensive work the patient had done by this dentists, there is probably a good relationship between them....and the matter will be considered closed....do take the patient out for a nice dinner after the case is completed..... we are dentists; scientific and artistic people; we are not lawyers who look to the bottom of the sea for their prey....keep up the good work.

An addendum to my comment, I have followed these patients for years after, and take periodic panorex radiographs, and it is very interesting to see the floating implants move about aimlessly, and silently....doing no harm whatsoever. If individuals like Leonard Linkow, O Hilt Tatum, Gershkoff and Goldberg, Ralph Roberts, etc would have been cowards, the world of dental implants would never have come about. If anyone is interested in seeing subsequent radiographs of floating implants, please contact me Gerald Rudick dds Montreal, Canada

These implants look to be bicon's. The way they are placed (tapped in) makes this complication a greater possibility. They do however, make an attachment that is suppose to prevent this. Did you use the sinus attachment? #1 Call the patient immediately and let them know the truth. Be professional and communicate to the patient that the treatment is not to your standard.#2 Yeah, the implant should come out. If you are comfortable with lateral sinus lifts, do it. If not, refer. I would agree with the OS comment about complications. When you are implanting fixtures into some one's body you should have a grasp of what to do when complications arise. I believe your patient would expect that. If you continue to do maxilary implants, take a sinus lift course (I suspect you haven't) and be a better surgeon.

I, too, am an oral and maxillofacial surgeon. The comment "if you can't handle ALL the complications you should refer" is absurd and ridiculous. First off that comment should read: "if you can't handle the LIKELY complications, you shouldn't do the procedure". This I fully endorse and agree with. Why? If in the course of an iliac crest havest, you puncture the gut; are you, the oms, prepared to explore the bowel? BS, no you're not. When repairing a sinus fracture you get a dural tear; are you, the OMS, comfortable in that? Good luck with that in court if you don't get neurosurg involved. Here's another one: you get into an AVM or intractable bleeding. You're not going to call interventional radiology to coil that? Again, good luck with that. You wouldn't even pass the boards without bringing in expert c/s in certain cases. I whole heartedly agree with knowing when to refer. BUT, I think the point is well-made. In this instance the provider not only didn't know to make a referral but didn't know the appropriate course of action for the dilemma. How pathetic is that? Imagine the family physician who cuts moles off including cancerous ones but thinks that as long as most of the brown stuff is gone you're alright? Would we all be so kind? It's sickening how we continue to accept substandard practice here and just say "ahhh it's okay - it happens to all of us". When are we going to expect a little more out of our profession? Remember, first do no harm? Remember "do good"? Is this sort of coddling helpful to our profession? We do residencies to learn advanced procedures under the supervision of graduated specialists. Specialists see the common complications and generally know how to treat them. Generalists, from what I've seen - since I supervise GPRs - rarely see complications and certainly don't know the first thing about treating them. I'm sure you can get better but, damn NOBODY can be good at everything. I've been taking out teeth - for example - for 10 years; I still find some difficult. I can't believe this post is for real. I think it's a fishing trip for flaming. Let's see: lack of informed consent, poor surgical procedure, poor patient care, infamiliarity with basic protocol... The ADA stipulates: non-malficience, beneficence, patient autonomy. All were broken here. Don't sit there all and do the "poor dentist" thing. Stand up for your profession!

I completely agree with Marcus above. He summed it up very well. As a periodontist I see many cases like this where the person placing the implants has never seen a complication (because he either had a weekend course or a course over a few months and did not see longterm results or is "just learning on the fly in the office with an implant rep.") and does not know what to do when complications happens. As specialists, you always learn from every case how to do things better as each case is different but you have to have a good understanding of what you are trying to do and how to handle complications when they arise (it is not a matter of if but when they occur). You can not get this in a few hours at a seminar which is why we as specialists go years to school to specialize in a certain aspects of dentistry. Hell, if you wanted me to do RCT on #8 or a crown prep on #12 you can forget it, I do not do that on a daily basis and would not be able to do it. Yes, I was trained on these procedures in dental school but have not done this in so long I would not be comfortable in doing so at this point on a patient even though I technically could. However, I do surgery every day and have been trained for this for years and feel very confident in doing these procedures. REMEMBER, WHEN YOU PLACE IMPLANTS OR DO SURGERY YOU ARE HELD AT THE SAME STANDARD OF CARE THAT A PERIODONTIST OR OMFS IS HELD AT WHEN HANDLING THE CASE. If you can not accept this you should not do surgery or place implants--that is why there are specialists that go to school to do this daily. You should let the patient know what happened ASAP and get the implant out ASAP (endoscopy or lateral window--lateral window is not painful as described above) before you get an infection you can not control and are looking at an expensive lawsuit (undiagnosed or treated perio disease and implant surgery are the most litigated areas of dentistry currently). Right now, if you have a patient who wants to sue you are already hosed and had better settle ASAP using a good lawyer to help you (however, if you want to take a weekend course on law and defend yourself that is your right as well--good luck). Try to get the patient to a competent specialist ASAP and inform the patient what has occurred. Let this be a lesson to you before placing implants in poor bone in the maxillary posterior area (or any area unless you are trained to do so) close to the sinus. Also, contact your insurance carrier (many times they charge extra if you do implant surgery and want to know you are placing them--have you already let them know you do implant surgery so you are covered for this in the first place?) ASAP and pray you are not sued as you would lose this case hands down. There is no defense for this and I do not know of any specialist that coud defend you at this point--even if they wanted to do so. Good luck.

Hello Just remove the implant surgically through lateral window only if you know how to do that else refer to one of your seniors ASAP without any panic.

Remove by way of a lateral window.

Some brutally honest and prophetic statements made here. As an expert reviewer in dental malpractice cases, there was certainly a breach in not informing the patient of the complication. But, quite honestly, that's all that I can point to. Did the clinican go through a process of informed consent? Was this one of the potential complications that was covered? If so, only the omission is the actionable offense. And I must agree with most of the points made in the preceding comments with one notable exception. When we are placing implants, the statement made was that we are held to the standards of the periodontist or OMFS. When I checked the ADA website, I found the following codified definitions for both specialties: Oral and Maxillofacial Surgery: Oral and maxillofacial surgery is the specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region. (Adopted October 1990) Periodontics: Periodontics is that specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues. (Adopted December 1992) The notable absence of the mention of Oral Implantology in both specialties is what makes this rather troubling. Virtually every specialist I have crossed paths with in 30 years of dentistry did anywhere from 0-12 implants in their program. Do these number make them qualified to be the arbiters of the standard of care in this discipline? At this time, the ONLY credentialing agency that reflects true experience is Diplomate of the American Board of Oral Implantology. It is recognized by the courts in California and Florida (soon to be several more states). If there are specialists who believe they should receive recognition for their experience in this field, let them take the board exam. Short of that, there is only one intellectually honest route that we can take: make Oral Implantology the next ADA specialty and have clinicans who are appropriately trained to treat all of these potential complications. It is, simply, the right thing to do. RJM

(((I think you need to take a comprehensive course in implantology, befor you touch the next implant pt.))) the 5 implants have all problems to be disscussed. talk to an expert colleague to handlr the problem . call the pt. and tell him about the complication arised and take him/her to be treated asap. and appologise for the unwanted complication, and asure the pt. that you never leave the pt. w/this problem, and explain that you will solve the problem. good luck.

TK May worded it beautifuly. RJM was most enlightening. I would talk to the patient by rehearsing TK May's script, knowing full well(reassured) that there is currently no specialist register called Oral Implantologist. After referring to a better trained colleague, take more courses, be more careful and don't panic - just be honest when things go wrong.Honesty is the best policy. Would appreciate if you could inform us how everything concluded when all is over.

# Sb oms April 18th, 2011 Once again, a perfectly decent question ruined by truth and the bio-OSS chronicles. Man, I’m sick of your comments. Here’s an idea, start your own blog and leave us alone. Excuse me Sb oms! Question: 1.) Allografts, synthetcial graft materials are resorbable. Patients will have human bone in the jaw. 2.) With autologous bone as well. 3.) Bio-Oss (Bone from cows is unresorbable). Patients have cow in the human bone. Why do you use Bio-Oss?

Hi Dr. TS, This sounds odd but ask your patient to tap their head forward vigoriously a few times. Take another OPG to see if the implant is lodged or is mobile with in the sinus. If you have CBCT, better. Attain informed consent your patient about this need to reenter as one implant position is not ideal and needs removal. Restart Augmentin. With a lateral wall approach, and with good forceful saline irrigation and lighting, the implant may be visually right at the window. Irrigation and lighting is the key! You might have to decide on aborting and removing your existing graft- Good luck

Stand up for your profession! pray you are not sued un-do this night mare My suggestion is to tell the truth TELL THE PATIENT

Dr. Miller is absolutly correct. The only actionable mistake is the failure to inform the patient of the problem. There have been numerous studies that indicate that the chance of being sued decrease when the Dr is truthful. The next big mistake would be to attempt to remove the implant if you do not have adaquate training.Refer this patient to an expert. Someone who has spent a fair time doing sinus procedures. You should always tell a patient when ---- happens. You have a legal and ethical responsibility.I think that is what I find even more upsetting the breach of ethics in what appears to be an attempt sweep the problem under the rug.

I am disturbed by the suggestion for need of a "specialty" dedicated to implants. I don't know to whom the previous poster was speaking but, in our OMS program we placed well over 200 implants for each chief; not to mention the 100 or so placed pre-chief. I doubt this is an exception. Now, quantity of implants in no way equates with quality nor does it equate with the skill of surgical comfort and ability to address comfort with complications. For example, anyone can sink 50 implants and pick those cases avoiding potential problems (e.g. thin ridges, sinus involvement, nerve proximity). Does that make them a "specialist"? Hell no. Does medicine have knee implant specialists? Oh, well, ya they do - they're called orthopedic surgeons. There's no knee implant specialist! Why do we feel this need to market a portion of the profession by using absurd labels like "implant specialist"? I've placed many implants. I certainly don't feel the need to post it with a credential or advertise a counter in the phone book... "over 1000 implants served"... Uh boy! Give ME a break - indeed! A professional will undergo the procedure(s) with which they feel comfortable and feel they can benefit the patient. A crook will undergo a procedure under the guise of knowing what what they're doing without doing justice to the patient or the profession under which they practice. Half the time I can take or leave an implant procedure and certainly never pressure the patient. Poor economic practice? Maybe. But I'm not an economist. I'm a dentist. Anyway, I digress; the ability to place implants is predicated on the sum of the individual's qualifications. For example, if you can't lay a flap are you qualified to place an implant? If you can't stop hemorrhaging should you be laying advanced flaps? For Christ's sake, there's enough money to be made in restoring an implant. If that's all you care about. If the general dentists want a society to get training to place implants, great. You won't - ever - create some specialty on the qualification of "implants placed" and expect oral and maxillofacial surgeons and periodontists to jump and embrace that.

All of the advice given here was good advice..certainly the part about informed consent or telling the patient the implant fell into the sinus. Being able to remove or not depends on your expertise. If you have someone else do it, make sure you reimburse the patient. And one more thing.... Learn how to do sinus lifts..instead of placing short implants into super soft bone.

Lateral window and suction. Fill the sinus with saline, suck it out and the implant should come with it. FWIW, there's no way I'd leave an implant floating around in my head!

Patients have pain and inflammations because of unresorbable Bio-Oss with proteins from cows.

Of course you have to inform patient that this happened bu not to scare the patient. You must open lateral window, make small window, perforate membrane, irrigate, and try to use surgical suction to get the implant out.

No big deal, i had the same case, just do a lateral window, if the implant is not visible, ask the patient to hold his nose and blow. By this, the implant will be blown towards the window. Take it out, suture and thats it! Just cover the patient with augmentin, dexamethasone and painkiller. then your done. Reuse the implant preferbly in another visit. Dont complicate things by doing this and that, keep it simple as your patient wont be happy going through this surgery.

If you do not know the procedure to perform, first of all, refresh your anatomy. Then read on risks and complication. Finally watch lateral window on Youtube! Don worry its simple. Im a 2 year old dentist, how hard can it be if i had performed. Cheers brother!!

Based on the pano, it doesn't seem like the implants are in the best (or even good) position. Sorry, but this is the fact. You have to get better at placing implants, and taking a miniresidency will help you tremendously. I cannot add anything to all the advices given to you here. However I am more then displeased by the "I AM GOD" attitude of the OMS and perio specialists. I am curious what is the standard of care you are held when placing the implants? Do 300 implants make me closer to being a specialist or not? Being an Assoc Fellow of AAID makes me better/worse than a 55 year old specialist (OMS or perio) who didn't take any formal education in implants during their residency? Lets not forget than when the implants were introduced to US we had the same attitude from the OMS, however the GP were the ones who really jumped in to do research and innovation! And remember when you started, how good your implants were, and how were the doctors who really were your mentors. Did they tell you: "Get the hell out of my residency and forget you are a doctor!"? So before being gods, look in the mirror, and you may like what you see, but for sure, most of us don't PS It may be showing that it is my first post, but I lost my previous login, sorry