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Oral Surgery/Failed implant and sinus perforation

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QUESTION: Dear Dr. Teig,
Six plus months ago I had an implant placed on the upper right molar site.  Two weeks ago I had the healing cap put on.  After the Novocain wore off I had lots of pain.  This was done on  Friday 9/4 and I waited (hoping the pain would go away) until the following Thursday to go back to the oral surgeon.  He pushed on one side and I jumped with pain.  He wanted to test the implant pain by tightening the healing cap.  I jumped once again with pain.  He diagnosed that the implant would have to come out.  Everything looked great on the x-ray.  The next day when I went back to get the implant out, he unscrewed the healing cap and the implant came right out with it.  It never adhered to the bone.  Should an x-ray have shown this since I periodically went in to get it checked?  Shouldnít it have shown it was failing?
Next problem when the implant had been taken out I immediately had intense sinus pain/pressure.  I talked and it would vibrate into my sinuses.  I was dripping from my nose and my throat.  This was done on a Friday 9/11 so I was stuck until Monday.  I went in and I was given an antibiotic and told to take claritin.  After a few days I was still in intense pain.  He ordered a CT scan and today 9/17 after looking at the CD he saw a tear in the sinus membrane.  He put me on the steroid dosepack because of the inflammation and Iíll be watched in case I have to go to an ENT.
My question is, in all of 6 months, a failed implant canít be detected?
And, did the tear in the sinus membrane happen when he pulled the implant out?  Or did it tear when he put the implant in 6 months ago and I didnít get symptoms then?  And, how long does it take for the tear to repair.  Thank you so much for taking the time out to help me.

ANSWER: Sharon - I hate to tell you this, but it seems that the surgeon did not do enough testing prior to the implant placement to determine the exact location and anatomy of the sinus.  That is very important to determine.  The depth and location to plan on drilling needs to be completely known in advance or the placement could invade other anatomical places where the implants should not be placed or the surgeon could done a sinus lift surgery prior to implant placement to create more bone room for the implant.

Once the implant was placed and it perforated the sinus membrane, the chance that the implant healing would be successful would be much less, but there have been some cases where they heal if the membrane of the sinus is not perforated.  Most likely the membrane was perforated during the drilling or implant placement.  It could also be damaged during the removal, but if placed in normal bone the only way it could happen if the implant failed from the beginning and created enough inflammation to damage the bone.

Knowing if the implant failed is sometimes difficult to know if there are no symptoms.  There have been many implants placed over the years for many surgeon who discover a failure, even if the implant was placed in solid bone, some implants still fail for a number of different reasons and they are not discovered until the implant is expose and a healing cap is placed and found not solid.  


The tear can repair on is own, but may times it will not heal.  A knowledgeable oral and maxillofacial surgeon often needs to make a water tight seal from the mouth to not allow saliva or other contaminants to gain entrance to the healing membrane.  When a surgeon seals the wound the membrane can heal, but it can take a few months.  

So it is healable, but only if done by a skilled surgeon.  If you have any additional questions, feel free to contact me again.

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QUESTION: Dear Dr. Tieg,
Thank you so much for your prompt and very detailed answer.  After the oral surgeon visit, and since I was in agony, he wanted me to follow up with an ENT to get a second opinion.   The ENT said that after looking at the CT scan (which I had on 9/16) and then he put a scope up my nose (9/18) to check out whatís going on, he said in his opinion the inflammation was already going down and he did see pus/infection with the scope.  He also saw the tear and thought it would heal on its own.  I followed up today (9/21) with my oral surgeon to check out the gum closing and have a follow up in 2 weeks with the ENT to make sure everything is healing properly and the tear has hopefully healed on its own.

Iíd like to know how I can tactfully ask the oral surgeon, if there was a possibility this happened when he first put the implant in (wouldnít I have had lots of pain?).   Anything else I should ask him?

He did say heíd give me a refund, although I sort of missed out on most of that because I had it done in the beginning of the year when my insurance paid for half.  And I say I missed out because then I had to pay out of pocket for all future dental work.  Again Dr. Tieg thank you so much for your expertise.

Answer
Sharon -  It is a difficult question to answer.  I don't know your surgeon and how attentive he is to his preparations.  You would not know if there was an opening at the time of the implant insertion.  The insertion will create a tight seal to the opening and many patients would not be aware.  The question is if the doctor did know when he placed it.  If it occurred during his drilling then he would know, but if inserting the implant broke open the bone into the sinus, then it's possible that he didn't know.  He should have taken xrays immediately after the implant placement and that should have given an indication that the implant perforated into the sinus.

So, I guess he may not have known,  I don't know what else you can ask.  This is a situation that he should have  been aware of.  I'm so sorry I cannot help more.

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicing for over 20 years. Assistant Clincal Professor at State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA- University of Connecticut DMD-University of Pennsylvania School of Dental Medicine Oral and Maxillofacial Surgical Residency - Roosevelt Hospital, NYC

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