Implant Patient’s Cheek Swelling after Sinus Lift and Bone Graft: Recommendations?

What was the graft material , as some can lead to extensive issues when infection around . Clindamycin another good ab for this situation. Swelling post op no issue but here could be a problem Maybe if no improvement time to call ENT. Regards

Dear Dr N. These are the classical signs of a graft infection. You need to use a broad-spectrum antibiotic for a decent length of time (i.e. two weeks). Remember that the graft does have a blood supply, so your antibiotics need to diffuse through the graft. Personally, I would give co-amoxiclav (Augmentin) 625mg tds for 14 days. I wouldn't personally add in the metronidazole but you certainly have covered everything if you have. Quick intervention with a long course of broad-spectrum antibiotics will completely resolve about two-thirds of sinus graft infections. For that one-third that recurs, you need to remove the graft and any implants within it. Sorry Peter, but clindamycin is not a good antibiotic for sinus graft infections, (see Steven Wallace research). I hope that helps, Bill Schaeffer

Sorry, that should have read - "Remember that the graft does NOT have a blood supply, so your antibiotics need to diffuse through the graft." Bill Schaeffer

Thank you Dr. Schaeffer for mentioning my father's work!! Yes Clindamycin is not the first choice here at all. These sinus graft infections are troublesome because as mentioned above, the graft has no blood supply. I would do a superficial wound exploration after a few days of antibiotics. Irrigate under the flap, remove any graft material that looks suspicious, and close with a small drain. If you are lucky, you can get this thing to close without loosing the entire graft. Anti-biotics alone are not enough. If it does not improve dramatically in a week or two, clean the whole thing out. You don't want this thing to silently fester for the next 6 months and then find your implants non-integrated. Get it cleaned up quickly or get it out and re-attempt in 3-4 months with greater attention to every detail!!!

If there's no improvement, I would remove the graft and irrigate profusely with saline. It's rare but these things can get nasty, even deadly, if not treated. Once infection sets in, the graft won't take anyway so there's no use leaving it in.

Actually, I disagree with surgically exploring the site and removing the graft right now. It's horrible when a graft gets infected, both for the patient and the surgeon, but two-thirds of them (Hilt Tatum's figures and not mine - though they match my own, far lesser experience as well) can be completely resolved without additional surgery by the prompt use of a 2-week course of broad-spectrum antibiotic. Why a blood-borne antibiotic should be able to treat an infected graft that doesn't have a blood supply is yet another of the wonderful things that amazes me in implant dentistry. I have no idea how it can work - and yet it often does (thank goodness!) But please do NOT keep giving antibiotics if the first 2-week course doesn't work. In that instance, take the graft (and any implants within it) out. Kind Regards, Bill Schaeffer

Hi Bill, great summation , agreed we also only use Augmentin and metronidazole routinely in surgery but was just suggesting an alternative ( albeit not to Wallaces liking)as asked. It was what was suggested by a collegue who has done sinus augmented since the 70s. Fortunately or luckily ( or merely we not do enough) we have not had a sinus infection in the last 10 years , or it could possibly be that we have only used bacterio-static graft materials (again not suggested by Wallace) for the last 6 of them that has helped. Regards Peter

Sorry mis-wrote as well, not liking but research which I will read , so stand corrected. Merely stating that different materials respond to infection in different ways. Peter

I have reason to believe that the problem that developed only after three weeks on nothing problematic could stem from another source, and not from the initial surgery. I recently commented on the comparison of the lateral wall sinus lift versus the Summer Technique closed technique. How many of us saw a circus act of a huge elephant standing on a glass cup and the fragile cup supporting this tremendous compressive force and not breaking? The answer is quite simple, all the walls were intact, and the shape was arched in such a way to support the force. An edentulous posterior maxilla, that is quite thin, can stand the forces of mastication because it is well engineered including having occasional internal buttresses. The thin cortical shell of the maxilla we are discussing, has has a window cut into it laterally, and three occlusal holes of 4.5mm in diameter......this structure has been seriously weekend. At the three week point, some additional force was placed on the cortical shell and a fracture occurred, causing a swelling in the cheek because of the sharp underlying fragments. It would be best to have a CBCT scan done to verify the integrity of all the walls, and sending this person to the ENT department of the local hospital. They may recommend nasal lavages with antibiotics,and other tricks to clear out the infection, that we in the dental world are not familiar with....I am really curious if a stress fracture did occur considering all the holes that were poked in that thin posteriior maxilla

Augmentin 625mg tid and metronidazole for 14 days is a must while monitoring the situation every 48 hours or so, along with a possible gentle peridex irrigation at drainage site, if clinically appropaite. Has anyone also employed hyperbaric oxygen? Tatum used to use this when a case would go south. If it does not respond, or gets worse, everything come out STAT.

Since 3 implants are in there possibly in a sea of infection, is there any difference in the resolution of waiting as opposed to a sinus augmentation that does NOT have implants surrounded by infection? Thanks. I hope all goes well with this one. Bill

Have patient have a CBCT or CT scan maxilla now, Nasal endoscopy for visual inspection of sinus. Nasal decongestants with oral antibiotics as prescribed. The graft is infected and compromised as with the 3 implants. Recommend surgical debridement and curettage of graft and removal of 3 implants. Wait 3 months and start again. Danger is chronic sinus pathology and its spread to other para-nasal sinus sites.

dR. DuCoin: Good Points made.

Thank You all for answers. Graft was Bio Oss and covered with Bio Gide. Patient has been for a week on atb therapy ( Augmentin 1g, metronidazol 400mg) and nasal decongestant and is getting better, swelling is resolving. He is going to take that therapy for a week more and then I'll see what do next. What do you think what is better-should I leave it if it completely resolves (and maybe risk infection one day again) or remove graft and implants (and how to explain that to patient)? Thank You in advance for help.

Getting a sinus graft infection 3-4 weeks after surgery is, in my experience, the classical time for it. It happens. Two-thirds of these graft infections will COMPLETELY RESOLVE with a single 2-week course of broad-spectrum antibiotics. One-third of them will recure (usually after a further 2-3 weeks). If that happens, I advise removing the graft and any implants within it. So, to answer your recent question, I would NOT automatically book the patient in to having the graft removed. Be completely open and honest with the patient (I'm sure you would be) but GIVE IT A CHANCE. Good luck and let us know how you get on. Kind Regards, Bill Schaeffer

If it smells bad and looks bad, possibly it's an infection. It may also well be some mini artery vessels in the sinus area, especially the posterior lateral nasal artery branches, may be ruptured during the healing instead of during the procedure for some reason. Then large swelling would be expected.

Why you guys keep using bio-oss for sinus lifts?!?!?!?!? It is proven that even the patient's blood can do the job, or at least use some resorbable alloplastic material like bioactive glass. Bio-oss is xenograft meaning that it is reeeally hard to resorb and if u check recent pubmed ull see that it may carries some ''cow'' still in it! Its good only for perio surgery because it stays there and doesnt resorb. Dont be victims of the industry, just read the literature.

Coxsakie: Thank you!

Well said, graft materials in the sinus are best fully bio-absorbed , return the body to its previous healthy state. Alas numerous letters have been sent to me with issues of long term effects of sinus infections. Regards Peter

The reason bovine xenograft (Bio-Oss) is so widely used is that it works so well. Are there alternative options? Of course - though none so widely researched as Bio-Oss. Coxsakie is right in that it is possible to place implants into pneumatised sinuses surrounded by just blood clot - though that may be technically challenging and any additional teeth that are lost in the future will need yet another sinus surgery. The previous posters are right that Bio-Oss does not resorb to any great extent, (though they seem to miss the fact that the large spaces within and between the particles get filled with host bone), but that is exactly why it works so well. Lose additional teeth and the graft will still be around to use without additional grafting. Can Bio-Oss get infected? Of course, in exactly the same way as any other biomaterial and also in the same way as a sinus full of a blood clot. Of far more importance than the material is the way the surgery is performed and the case selection. There are no magically good materials and no villainously bad ones! Kind Regards, Bill Schaeffer p.s. I have no financial interest in any biomaterial or implant system

Thank you once again bill schaeffer you and i think alike

Dr. N There is another possibility. As Coxsakie states there is still cow in Bio-Oss. Bio-Oss is not anorganic and retains osteoid proteins that can cause a nasty delayed hypersensitivity. If it is infection it will be purulent. If it is delayed hypersensitivity to the proteins in Bio-Oss you will find granules of Bio-Oss in the fistula with a serous exudate. Either way you have a failed graft. If it is infection you will never get the bacteria out of the pores of the graft material. If it is delayed hypersensitivity it will fester until the graft material is expelled.

Dr. N It is very difficult to distinguish delayed hypersensitivity to Bio-Oss and infection. Take photos, radiographs and biopsy the graft site. Histology will be able to distinguish between an immune response and a bacterial infection. If it is delayed hypersensitivity it would be worthy of publication because most of these cases are misdiagnosed as infections.

Oh, come on..... Sudden onset of pain and fluctuant swelling, 3 weeks after sinus graft surgery, which has resolved with antibiotics. Why is anyone even doubting the diagnosis. This is quite obviously an infection. I was stunned when my first one of these resolved COMPLETELY with a 2-week course of antibiotics. It is utterly illogical that a blood-borne antibiotic should work on a porous infected graft that doesn't have a blood-supply - but it simply does happen! Two-thirds of these infections will comnpletely resolve. One-third will need to all come out. Give it a chance. As for the Cow in Cow-bone read below; Kind Regards, Bill Schaeffer Biomaterials. 2001 May;22(9):1005-12. Protein-chemical analysis of Bio-Oss bone substitute and evidence on its carbonate content. Benke D, Olah A, Möhler H. Institute of Pharmacology and Toxicology, Swiss Federal Institute of Technology (ETH) and University of Zurich, Switzerland. The natural bone substitute Bio-Oss is used in periodontal and maxillofacial surgery to fill bone defects and permit reossification. Recent reports have suggested the presence of TGFbeta and of substantial amounts of protein in Bio-Oss and have questioned its position as a biologically inert material and its safety in clinical applications (Hönig et al., Plast Reconstr Surg 1999;103:1324; Schwartz et al., J Periodontol 2000;71:1258). Bio-Oss was therefore subjected to a detailed biochemical, histochemical and biophysical analysis. In three different types of extracts of Bio-Oss no evidence for the presence of protein based on SDS-PAGE and silver staining was detected. In addition, as shown by Western blotting, there was no immunochemical evidence for the presence of the potential growth-inducing factor TGFbeta. Furthermore, micropolished sections of Bio-Oss failed to be stained with McNeal's Tetrachrome as did microtome sections treated with Goldner's Trichrome. However, Bio-Oss was strongly stained with the protein dye Coomassie blue. This staining was virtually irreversible and is attributed to the carbonate content of Bio-Oss which was detected by thermogravimetry-mass spectrometry. Thus, within the limits of the assay conditions, Bio-Oss does not contain protein material to a measurable extent.

I am traveling so it will take a few days before I can provide you with the research that establishes protein in Bio-Oss. But I would also be happy to show the protein in a histologic slide. Is there a way to post images on this site? I can also provide you with photos of delayed hypersensitivity with Bio-Oss if you are interested.

You can post images by clicking on the "Post Cases" link at the top left of the menu at the top of the page. Right under the "Home" tab.

People get sinus infections without us. The definitive answer is to have the patient tested by an allergist.Have your patient bring the graft material with him/her to the allergist. Will this become a standard of care?

Dr Pace, If this were an allergy, would it have got better with antibiotics?

It is not delayed hypersensitivity to Bio-Oss because I grafted site after extraction on another side 5 weeks ago and it is ok. Now, patient is ok, sweeling resolved and now I have to wait if everything will be alright I'll put implants in function in 8-10 months. Thank you everybody for suggestions and help.

Dr N - thanks for the update and glad to hear that your patient's symptoms have resolved. Let us know how you get on when you do the next stage. Kind Regards, Bill Schaeffer

I have posted the histology of Bio-Oss proteins and clinical photos of Bio-Oss delayed hypersensitivity on my cases but how do I get the images to the gallery for your evaluation? Any help is appreciated.

What is Bio-Oss? Is it only a filler or is the result natural bone? What does resorption mean? Bio-Oss: A resorbable bone substitute?

BioOss resorbes at a slow rate. It is sintered thus very hard and is rough on the RES.

What about the resorption of Geistlich Bio-Oss®? Geistlich Bio-Oss® is resorbed very slowly. It is not possible to say how long this takes. Studies show that the amount of Geistlich Bio-Oss® in the augmentation material declines steadily. Other studies show that Geistlich Bio-Oss®, like endogenous bone, is subject to slow remodeling (approx. 3 times in a lifetime). This could indicate that Geistlich Bio-Oss® is recognised by the body as natural bone. It used to be believed that a bone substitute had to be resorbed as quickly a possible. These days, it is known that the slow breakdown of Geistlich Bio-Oss® gives the bone augmentation material volume stability. BIO-OSS--a resorbable bone substitute? Schlegel AK, Donath K. Department of Oral Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany. Abstract BIO-OSS is an allergen-free bone substitute material of bovine origin, used to fill bone defects or to reconstruct ridge configurations. Seventy one patients (39 female, 32 male) received 126 BIO-OSS implantations. Some health parameters or habits were documented to eliminate possible risk factors of influence. The diameter of jaw defects filled with BIO-OSS was measured. There was a significant influence of the defect size on the healing result. In X-ray controls, BIO-OSS served to identify the surrounding native bone. The density of the BIO-OSS areas was higher than in control sites. These radiological results were supported by bone biopsies. Histologically, the permanency of the BIO-OSS was still recognizable after 6 years and longer. The ingrowth of newly formed bone in the BIO-OSS scaffold explained the increased density of the implanted regions. There were no clinical signs of BIO-OSS resorption. Therefore, we can assume that form corrections achieved by BIO-OSS insertions will last. PMID: 10186966 [PubMed - indexed for MEDLINE] etc.

The material is too hard and dense thus poor resorption. Some patients report post op inflammation for a long period of time. I question the use of this material.

German doctors insert Bio-Oss in the jaws of children. What will happen in the future? Nobody knows when Bio-Oss resorbs.

Comment on DR N March 6th,2010. It was not clear what he did. He said the patient is "ok". Did he remove the 3 implants? and will put them back after 8-10 months?

I have had a sinus lift in conjunction with a dental implant and the result has been disastrous. The mucus is vile and smells of death....literally. I have had both oral and sinus infections in the past (a few over a 40 year lifespan) and nothing could compare to how disgusting this infection is. My doctor went on vacation right after my surgery and his partner put me on a z-pak to manage the infection until he returns. I literally could not live with this smell and would rather never have done this surgery at this point...I pray my Dr will put me on a stronger ab come Monday and that the implanted bone is not too far gone. At least now I understand...