Sinus Graft Complicationsstuartortonjonesinstitute.co.uk/PDFs/Implantology/5... · Sinus Graft...

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Sinus Graft Complications

Sinus Graft Complications

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Opaque Sinuses on X-ray

Refer to ENT Surgeon

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Sinus Graft Complications• During the Procedure• Immediate Post-operative• Delayed Post-operative• At Implant Placement

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Sinus Graft Complications• Between Implant Placement

and the Restorative Stage• At the Restorative Stage• Late Complications

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Complications during the Procedure during

• Incision Making• Flap Elevation• Window Separation

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Complications during the Procedure during

• Lining Elevation• Graft Placement• Suturing

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• Haemorrhage• The Presence of Pus• The Presence of Serous Fluid• Poor Visibility

Complications during the Procedure

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Visibility and Accesscan be improved by

Good Retraction

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The Tatum Sinus Retractor

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Tip Turned Down to avoid the Infra-orbital Bundle

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The Tatum Sinus Retractor

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The Tatum Sinus Retractor

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The Tatum Sinus Retractor

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by Fibre Optics Visibility can be improved

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Difficulties in Incision Making

• Incision too near Window Site • A Remote Incision reduces

the Chance of a Graft Infection

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Difficulties in Incision Making • Bleeding from the Palatal Artery• Avoid cutting Vertically towards

the Palatal Artery• Cut as Horizontally as possible

out towards the Ridge

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Beware of the Greater Palatine Artery

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Beware of the Greater Palatine

Artery

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Keep the Handle close to the Ridge on the Opposite Side

Cut Outwards towards the RidgeNot Upwards

This reduces the Chance of Cutting the Palatal Artery

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Difficulties in Flap Reflection • Incision not to Bone• Absence of the Lateral Wall

of the Sinus• Perforation of the Lateral Wall

of the Sinus• Perforation of the Lining

A Lining Tear

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Difficulties in Flap Reflection • Tearing the Flap• Consider aborting the Procedure• due to the Possibility of Graft

Infection

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Difficulties in Window Separation• Cut not through Bone• Lower Cut below Floor of Sinus• Cut too far Anteriorly• Presence of a Buttress• Lining Perforation

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Difficulties in Lining Elevation• Perforation of the Lining • Thin Linings tend to tear more

easily• The Presence of Buttresses

complicates Lining Elevation

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Buttresses

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Difficulties in Lining Elevation• Peduncles (Small Bumps in the

Sinus Floor)

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Undulations over Roots

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Undulations over Roots

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Undulations over Roots

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• Bleeding during Lining Elevation• Due to Arteries in the Lateral Wall • May be seen on Cat Scans

Difficulties in Lining Elevation

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Controlling Bleeders in Bone

Difficult due to Poor Access and Visibility

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Controlling Bleeders in Bone

Tap or Press Blunt Instrument on the Bleeder

to Crush Bone around It

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Bleeding Case History • Bilateral Sinus Grafts were

performed• Both Sinuses bled profusely• Linings were elevated by Feel only• It was not possible to identify

the Bleeding Points

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Bleeding Case History • Sinuses were packed with Gauze

soaked Lignocaine with 1:50.000 Adrenaline

• Both Sinuses filled up with Blood on removal of the Gauze

• Collatape and Irradiated Bone was added

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Implants were successfully placed

and restored at a Later Date

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Sudden Spontaneous Presence of Pus

Difficulties in Lining Elevation

Pus Present

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Cause of Lining Perforation• Inadequate Instruments• Thin Linings• Operator Error

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• Spontaneous Closure• Layering • Suturing• Use of Membranes• Abort the Procedure

Lining Perforation Management

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• Stop elevating near the Tear• Elevate away from Tear• Increase Elevation up

the Posterior Wall

When a Tear occurs

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for Overlapping Torn EdgesThis allows more Free Lining

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Finally return to the Site of the Tear

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Place Collatape over the TearThis helps glue the Layered Lining

Together

Fold the Lining over the Tear

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The Hole may close Spontaneously

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due to Poor Access and Poor Visibility

Posterior Tears are the Most Difficult to repair

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and the Laying will NOT stay togethereven with Collatape

consider Suturing the Edges of the TearOr

Place a Longer Lasting Membrane

If the Lining is Thick enough

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Do not attempt to sutureThin Sinus Linings

An increase in the Size of the Tear will usually occur

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If the Tear is near the Lateral Wall of the Sinus

consider suturing the Torn Edgesto Upper Aspect of Bony Window

if the Lining is Not Thin

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The Window

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A Tear

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Drilling the Holes in the Upper Border of the Window

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The Holes in the Upper Border of the Window

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Suturing the Lining

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Pulling the Lining over the Hole

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Difficulties in Graft Placement• Graft not packed consistently

in all Areas• Voids in the Graft being Left

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Graft Material Preparation• Open the Antibiotic Bottle First• Tap the Bottle on a Worksurface• This Loosens the Antibiotic

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Graft Material Preparation• Pour the Antibiotic into a Sterile Cup• Add the Graft Material afterwards• Mix the Graft Material

and the Antibiotic

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Do Not empty the Graft Material into the Sterile Bowl FirstIf the Antibiotic Bottle is then

inadvertently Dropped into the Graft Material

the Graft Material is then Contaminated

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Always empty the Antibiotic into the Sterile Bowl First

Then add the Graft Material

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Graft Material pushed through

the Lining

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Immediate Post-operative Complications

• Partial Closure of the Eyelid• Pain

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Swelling

1 day Post-operatively

1 day Post-operatively

1 Month Postoperatively

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Antibiotics Prescribed• Metronidazole• Co-trimaxazole

1 Week Later

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Bruising

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5 days Postoperatively

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15 days Postoperatively

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One Day Post-operatively

One Day Later

Second Day After

Progress of Facial BruisingBruising progressively moves along the

Superficial Fascial PlanesBruising progressively moves

down the Face to the Neck and then down the Upper Chest

Progress of Facial BruisingBruising progressively changes

From Reddish blueto a Yellow Colour

Third Day After

Fourth Day After

Seventh Day

Eighth Day

Progressing Down onto the Cheek

Twelfth Day

Twenty first Day, 3 Weeks Later

Twenty-first Day, 3 Weeks Later

4 Weeks Later

Slight Bruising

4 Weeks Later

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Bleeding• Intra-orally

Not Common• Nose Bleeds

Occasional

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Cotton Rolls inserted

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Immediate Post-operative Complications

PainVaries from Mild to Moderate

Rarely Severe

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Immediate Post-operative Complications

Suture Line OpeningOccasionally

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Immediate Post-operative Complications

InfectionOccasionally

due to Infra-orbital Nerve Damage

Altered Sensation in the Upper Lip and Cheek

Case 1

Sinus Graft Upper Left Side13/12/03

Immediate Post-operative Numbness of Left Lip and Cheek

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The Infra-orbital

Bundle

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The Infra-orbital Bundle

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due to Infra-orbital Nerve Damage

Altered Sensation Detection

Test using a Cotton Pellet and a Sharp Object

for Altered Sensation

Draw a Diagram in the Patient’s Records

Itchy Feeling to touch

Unbearably Itchy

Feels like Little Creatures like Tiny Worms Crawling

over the Cheek

9 Months Later 10/08/04

95% Better

Case 2

Sinuses Previously Grafted using Bone from the Hip

Sinuses Grafting unsuccessful

Irregular Bony Nodules removed from Both Maxillary Sinuses 12/02

Post-operative Alteration in Sensation

Pins and Needles on

Touch2 Years Later

Numb Area

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Delayed Post-Operative• Pain• Infection • Swelling

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Delayed Post-Operative• Acute Sinusitis• Chronic Sinusitis• Nasal Discharge• Oral-Antral Fistula

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Oro-antral Fistula Present

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Complications at Implant Placement• Pus• Sterile Serous Fluid• Non-conversion of Graft• Sinus Perforation

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Complications at Implant Placement

Swelling

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About Nine Months after Sinus Grafting

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Swelling Present

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Complications at Implant Placement• Sterile Serous Fluid• Non-conversion of Graft• Sinus Perforation

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Sinus Grafted

Case

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Sinus Floor drilled

through

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Sinus Floor perforated

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Collatape added to the Site

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Osteogen added

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A Shorter Implant placed

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Healed Result

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Late Complications after Implant Placement

• Infection• Loss of Graft• Bone Loss around Implants• Loss of Implants

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Complications at the Restorative Phase

• Loose Implants

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The Fish Bone ScenarioA Patient complained of a Swelling in

the Buccal SulcusOver a Sinus Grafted SiteA Small Sinus was Present

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A Flap was raisedThe Buccal Bones was intactwith No Signs of a Problem

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The Patient then reported that He had a Fishbone

stuck in his Gum Ten Days ago

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Causes of

Complications

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Pre-existing Infection• Periodontal Infection• Periapical Infection in the Area• Sinus Infection

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Surgical Field Contamination• Poor Surgical Technique• Contaminated Graft Material• Contaminated Implants

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Graft Non-conversion• Infected Graft• Material Failure• Systemic Problems• Calcium Metabolism Problems

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Graft Non-conversion• Kidney and Liver Disease• Osteoporosis• Malnutrition

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Patient Non-compliance• Smoking • Drugs• Alcohol• Poor Oral Hygiene

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Patient Non-compliance• Self Abuse• Not attending for appointments

when necessary

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Symptoms of Sinus Infection• Unilateral or Bilateral Headache• Throbbing Pain and Pressure• Pain over Upper Posterior Teeth

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Symptoms of Sinus Infection• Increased Pain on lowering Head• Reddening of Skin in Infra-orbital

Region

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The EndThe End