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COMPLICATIONS AND SOLUTIONS TO SINUS SURGERIES

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Author: Dr Manesh Lahori , Dr Prerna Kaushik.
K.D. Dental College and Hospital, Mathura- U.P.

INTRODUCTION:
The lateral window sinus elevation procedure is a routine and highly successful preprosthetic procedure, used to increase bone volume in the posterior maxilla for the placement of dental implants. Many surgical techniques have been proposed that provide access to the maxillary sinus through the lateral wall to allow for elevation of the sinus membrane. Among these are the multiple variations of the hinge and complete osteotomy techniques, which may further lead to various intra or post operative complications.
Complications can be classified on the basis of probability of duration as:-

SHORT TERM COMPLICATIONS
  1. Bleeding
  2. Schneiderian Membrane Perforation
  3. Septa
  4. Incision line opening
  5. Infection
  6. Potential loss of implants

LONG TERM COMPLICATIONS
1.Cyst
SHORT TERM COMPLICATIONS
1. Bleeding
  • Small blood vessels are pushed toward the lateral aspects of the expanding sinus after tooth loss.
  • They may often be seen in transparence along the lateral aspect of the maxilla.

SOLUTION
Bleeding from a vessel within the thin lateral wall is rarely a concern. Bone wax or electrocautery can be used to contain the bleeding.
Crushing the vessel is not the first priority because further fracture of the thin bone or sinus membrane tearing

2. Schneiderian Membrane Perforation
The most common complication during sinus graft surgery is tearing or creation of an opening in the sinus membrane, with perforation rates of 14% to 56% reported in the literature.
  • This has several causes which include a preexisting condition, tearing during scoring of the lateral window, and attempting to elevate the membrane from the bony walls.
  • It occurs more in smokers.

SOLUTION
Once a tear or hole is identified, the sinus elevation procedure is modified. The regions distal to the tear are elevated first. The membrane elevation then approaches the tear from all sides, so the torn region may be elevated without increasing the opening size.

  1. A piece of resorbable collagen membrane (eg collatape) is placed over the opening to ensure continuity before the graft is placed.
  2. If the tear is larger and cannot be closed off with the circumelevation, a resorbable collagen membrane, but of a longer resorption cycle (Biomend) may be used to seal the opening.
A section of collagen matrix is cut to cover the sinus tear opening and overlap the margins more than 5mm. Once the opening is sealed, the graft procedure may be completed in routine fashion.
Additional antibiotic is added to the actual graft material.

  • When there is a perforation the implant placement should be delayed for at least two months in the simultaneous antroplasty to allow for healing of the membrane and the gingival tissues on the crest.
Risk of graft contamination increases with sinus perforation, and this waiting period permits assessment of post surgical complications before the implants are inserted.
This may increase both short and long term complications.
  • There is a greater bacterial penetration into the graft material through the torn membrane.
  • Mucous may invade the graft and affect the amount of bone formation.
  • Graft material may leak through the tear into the sinus proper, migrate to and through the ostium, and be eliminated through the nose or obstruct the ostium and prevent drainage.
  • It may also be lost through an opening in the medial wall caused by the surgery or by long term sinus infections.
  • Ostium obstruction is also possible from swelling of the membrane related to the surgery. These conditions increase the risk of infection.

3. Septa
  • Septa may be present in some cases. They divide the inferior portion of the antrum into sections.
  • A buttress or web formation may be present in the lateral wall of the maxilla. The lateral wall will not cause greenstick fracture as easily and rotate into its medial position.
  • The strut is also more likely to tear the membrane during the tapping process.

SOLUTION
The solution is to cut two windows on either side of the septa and elevate the membrane from both sides.

4. Incision line opening
It is uncommon because the crestal incision is in attached gingival and at least 5mm away from the lateral access window.

  • It occurs more commonly when lateral ridge augmentation is performed in the same surgery.
  • The consequence of incision line opening is delayed healing, leaking of the graft into the oral cavity, and increased risk of infection.

SOLUTION

  • Because the graft is more at risk with incision line opening reapproximating the tissue with additional surgery becomes a concern.
  • If the incision line failure is not related to an onlay graft and is only on the crest and away from the lateral access window, the area is allowed to granulate in, as is done in most implant incision line complications.

5. Infection
Acute post-operative sinusitis represents the most common short term complication and occurs in 3% of the sinus grafts.
  • The complications are more serious although not reported , like orbital cellulites, optic neuritis, cavernous sinus thrombosis, epidural and subdural infection, meningitis, cerebritis, blindness, osteomyelitis, and although rare, brain abscess and even death.
  • The most common postoperative complication of infection is intraoral swelling in the region of the access window.
    The swelling occurs 3 days or more after the surgery.
  • If the swelling is localized, incision and drainage are indicated, and a culture should be obtained as an aerobic bacteria is suspected.
  • Patients with clinical evidence of severe or persistent infection require a direct aspirate for grams stain and culture sensitivity.
  • Emergency consultation should be considered if the patient complains of severe headache, headache not relieved by mild analgesics, persistent or high fever, lethargy, visual impairment, or orbital swelling.
  • Vomiting, paresis, seizures, or altered mental status demand immediate hospitalization

SOLUTION
  • If infection occurs even after antibiotics are taken then antibiotics are prescribed again for at least 7 days since the vascular supply to the graft is compromised.
  • Saline rinses with a bulb syringe in the nostril are used to lavage the sinus through the ostium.
    The syringe should not seal the nasal opening, as this may force bacteria up toward the ethmoidal sinus. Instead a gentle lavage with sterile saline rinses the sinus and flushes out the mucous and exudates. The course of this therapy shall continue for at least 7 days.
  • If the infection continues to increase with swelling, pain, and/or fever, or if eye symptoms like diplopia or proptosis appear, the surgical site should be reentered. A curette is used to remove the infected tissue and material.
    The presence of any infection will resorb the graft tissue rapidly as a result of low pH and high macrophage involvement. The graft may be replaced once the infection has resolved.
  • Small oroantral fistulae may occur as a response to the infection and often close spontaneously following systemic antibiotics and daily rinses with chlorhexidine.
  • Larger fistulae require additional surgical management.

6. Potential loss of implants
  • Because of the poor quality and diminished quantity of bone found in the patient requiring antroplasty, the risk of implant loss tends to be higher than that of the patient with non-grafted posterior maxilla.
  • In a patient with sinus graft the use of 3-4 implants is recommended to endure the success of the reconstruction, even if one of the implants should fail.

SOLUTION
Use of short implants is not advisable. A minimum size of 12mm or longer is appropriate, exception is where wider implants can be used (>5mm).

LONG TERM COMPLICATIONS

1.CYST:
  • In 1927, Kubo reported a cyst arising in the maxilla as a delayed complication of radical surgical intervention in the maxillary sinus.
  • This lesion has been given several names including postoperative maxillary cyst, post operative buccal cyst, postoperative cheek cyst, mucocele, surgical ciliated cyst, and post operative paranasal cyst.
  • A history of previous Caldwell –Luc surgery is a common finding. The cyst is thought to arise from entrapment of epithelial remnants in the wound during closure.

SOLUTION

  • Recommended treatment is a Caldwell-Luc surgery completely removing the cyst wall. Enucleation and primary closure, or enucleation and open packing are effective when the cyst is small and unilocular lesions and areas of adhesion to adjacent structures.
  • The cyst cavity may be grafted with autologous bone in the event the patient elects to have another implant placed.

CONCLUSION:
However, Maxillary Antroplasty with sinus augmentation procedures have proven to be safe and effective and have permitted the placement of implants in sites that would have otherwise been impossible to treat.
The sinus floor, and to a smaller extent the elevated sinus membrane, offers an ideal environment for bone formation. Though it would seem intuitively counterproductive to bone graft healing, especially if the sinus membrane becomes perforated during the course of graft placement, this area is instead remarkably forgiving of complication, infection, resorption, or rejection.

REFERENCES:-
  1. TISSUE ENGINEERED BONE J Craniomaxillofacial Surg. 2007 Jun 18
  2. A new technique for the transcrestal sinus floor elevation and alveolar ridge augmentation with press-fit bone cylinders: A technical noteMINIMALLY INVASIVE TECH USING CYLINDRICAL BONE GRAFTSPublished in Clin Oral Implants Res. 2007 Feb;18(1):69-73.
  3. A histologic and histomorphometric evaluation of an organic bovine bone retrieved 9 years after a sinus augmentation procedure.J Periodontol. 2007 May;78(5):955-61
  4. Schneiderian membrane perforation rate during sinus elevation using piezosurgery: clinical results of 100 consecutive cases. Int J Periodontics Restorative Dentistry 2007 Oct,27(5):413-419

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