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