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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