Sinus lift complication: thoughts?

We did an internal sinus lift and placed an Osstem implant 4×8.5mm in site 25.  The pre-op residual bone height was 3mm.  I did a bone graft with Botiss Cerabone which appears on the post-op CBCT to be dislodged and penetrates into the sinus.  I assumed this was caused by a perforation in the Schneiderian membrane.  I prescribed amoxicilin 875mg + clavulonic acid 125mg.  Any recommendations on how to proceed?

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21 thoughts on “Sinus lift complication: thoughts?

    1. It is really hard to do an internal lift with so little bone base the lateral approach should have been used and here’s why look at the bone voids around the sides of the implant. There is very little bone to integrate into the implant most likely will fail. Remove it if you are comfortable doing a giant tear repair à la Pikos otherwise refer cuz you may dislodge the implant into the sinus when you attempt removal. What is the restorative plan and did you use a surgical guide the placement appears to be random might not be restorable.

  1. You are doing sinus lifts and don’t know how to handle this complication? Now you need to remove the implant, remove the foreign body in the sinus from a lateral approach and let it heal. I would then refer to someone who can handle any future complications. Basic stuff for SL’s…

  2. There Is only one thing to do: remove implant and graft, wash the sinus with saline and antibiotic, close everything and let it heal for three to four months and then re-enter with a lateral approach. Asap. Ciao

    1. Refer to an ENT or OMS ASAP to remove the stuff out otherwise you are looking at a massive infection and possibly closing of the sinus meatuses which causes severe pain and infection and maybe a lawsuit

  3. This is why I am very interested in using only CGF to tent up the membrane for new bone formation in the sinus. I feel any type of nonautogenous material should be avoid in the sinus if possible. Since a hiossen implant was used, I’m guessing the doctor used hiossen’s CAS kit to internally raise the membrane then the tear occurred when he began placing the graft material. The doctor most likely did not push the membrane up enough, so upon pushing the graft material, it tore the membrane. If he had used just CGF and a tear was there anyways, he most likely could have just left the implant and it would osseointegrate just fine.

  4. There are worse situations that can occur in dentistry. You need to refer this patient to an oral surgeon who can be very helpful. You will hopefully learn a great amount from this case.

    1. You are working beyond your skill and knowledge base. Acknowledge the problem and refer to someone who is skilled in this technique and can correct the situation do not let it escalate. Then take advanced courses and upskill in reconstruction of the posterior partially or fully edentulous arch before you do any more such cases and then under guidance, and not just on cadavers!

  5. I would agree with most of the posters that the implant and the graft need to come out. You need to take it out before there is a major infection because the ostium will get blocked and then you have a perfect environment for the bacteria to proliferate because the sinus becomes like a stagnant pool. Doing a crestal approach with this small amount of crestal bone was not the ideal approach.

  6. There are well known basic principles related to implant insertion and reconstructive surgery of the jaws. In this case, the preoperative image analysis is key. Residual bone height and width is vital. The minimum remaining bone height that allows effective primary stability of the implant should be about 6 mm. Less than that could be a risk. Of course, there are another factors that I will not mention in my comment.

  7. I think you are being a bit harsh on this guy. Lots of the remarks are patronising and unhelpful. Beating up people who are willing to admit there mistakes is a sure way to empty this forum. Schniderian membrane tears are a recognised complication of internal sinus grafts.
    Internal sinus lifts are tricky as it’s not always easy to detect a tear and if the membrane is very thin or damaged the graft is going to be pushed into the sinus.
    If it’s any consolation the studies show a not insignificant amount ofundetected tears using a lateral approach as well!
    Like most problems, it is what it is. You will need to wash out the sinus via lateral window approach. Ideally you need an endoscopic camera to do this properly which probably means a referral to an os or ent unless you have the skill and equipment to do it yourself

  8. Should have been a lateral approach. Need to get particulate out of sinus before it clogs the ostium and end up with a more horrible mess. Im assuming your experience with the sinus lift procedure is limited, so if I were you, I would refer to ENT who is a good friend and PAY FOR THE ENTIRE CORRECTIVE PROCEDURE. Even the most skilled ENT surgeons have a hard time clearing particulate bone material out of the sinus. Sometimes it takes multiple procedures to get it all out. It’s like trying to remove gravel sand from Berber carpet!

    Don’t do a sinus lift unless you’re ready to handle the complications that arise. The fact that your asking in a forum leads me to believe that this issue is far beyond your level of expertise. I know it’s a hard pill to swallow and a burst to your ego, but forget about that and think of the patient that has to actually deal with negative sequele of poor technique.

    Take a respected course on implants and not a weekend crash course. Misch institute or the preceptorship for dental implants at UTSA in San Antonio, Tx are two that I highly recommend.

    Implant needs to be taken out, graft material taken out, perforation fixed, and a lot of prayer! You’re not the first one to do that and won’t be the last. Don’t give up on implants, use it as a HUGE learning experience. Good luck

  9. I think the surgeon who posted the case has been very truthful we need to give positive advise .The bone hight was less it should be at least 5 mm.I am sure all of us doing direct/indirect sinus lift have had problems sometimes,thankfully sinus is very Forgiving.

  10. I agree with Jason B
    Comment
    This is a forum to help and assist . Obviously the operator is feeling that he is in trouble . We all know that boundaries are pushed whether it is in general dentist or specific specialties.
    So as an oral surgeon or ENT you never did a procedure that you could not handle ?
    Suggestion is to refer and learn
    Thanks

  11. An unfortunate situation and maybe a step learning curve for the practitioner.
    I agree with most comments and stick to basic principles – need adequate residual bone for the crestal technique and I get a bit wary about placing an implant into graft material with only 3mm of bone to provide primary stability – my preference.
    Not knowing the patients history etc , on the face of what is presented I think referral to a surgeon for a lateral sinus approach and graft first…- you would get more graft height- and then later place an implant…probably of at least 10-12 mm.
    I get the impression with implantology people are reluctant to refer certain procedures to oral surgeons and try and “do it all” themselves in the shortest possible time..?? we cant force biology and nature. Patients are not stupid and we should not be scared to refer…..if you have a good relationship with your surgeon the work will go back to you with less hassle.

  12. H!I Doc:
    If you are comfortable with lateral approach. Open lateral, remove implant. Now you get access from both sides. Remove the tissue & graft scooping or suction (carefully). Refresh on anatomy. Not a big deal. If not, Get help of a oral surgeon friend. PRF & collagen membranes in these situations help a lot.
    Please explain to patient and let him know that these things happen. Patient will be comfortable. Take care of him. There is no lawsuit if the the patient is comfortable.
    I have been invited as an expert in the court several times. Been doing sinus lifts before it was published. I have also successfully tried doing sinus augmentation without a membrane. Relax and be honest. You will be fine 🙂

  13. I think you got bunch of incentives not to do it again. How is the patient? In addition what you prescribed, Flonase will keep the ostium functioning. If the patient symptomatic definitely remove. best with/by oral surgeon (friend). And if its not symptomatic, small chance but the body can take care of what not needed. If you chose to remove it (option1 best) remove the implant and suctioned as much as u can and close (primory close). come back 3 month and so on. Good luck.

  14. remove graft and implant under AB cover ASAP before patient end up emergency.
    use lateral approach in this case, good luck.

  15. Hello,

    I would like to thank each and everyone of you for your honest opinions and suggestions. I really appreciate it.
    The admin altered my case description. I did not say for a fact that the sinus membrane was perforated. I just assumed it and on the CBCT it seems perforated. The Osstem CAS kit was used during the procedure.
    I did another CBCT 12 days post-op. See pictures below.

    Now it seems that the sinus membrane is not perforated. The graft is not seen in the same position as in the first pictures. It looks like it is positioned on the sinus floor, just under the membrane. Part of it seems missing (?).
    The patient did not have any complications / symptoms / swelling. He did not have any bone graft material coming out through his nose. Not even bleeding from his nose.

    Now the way I see it there are two possibilities:

    1. The bone graft is located on the sinus floor, under the membrane. The proximity of the implant makes it difficult to see it on the CBCT, since the implant has much higher radiodensity (radiopacy).

    2. The graft material is displaced somewhere else, not visible on this CBCT.

    What are your thoughts?

    Thank you and best regards
    D

    CASE PHOTOS
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