Next   Return to Sinus Graft, Posterior Immediate Provisional 10-Year-Comparison Course 2 Xin Wei, DDS, PhD, MS 1st edition 11/20/2015, last revision 06/03/2018

Hemorrhage Associated with Lateral Window

Mild to moderate hemorrhage is encountered as soon as incision is made for the lateral window.  It is a concern prior to bone graft and implant placement.  Hemorrhage appears to come from the sinus.  Bleeding may wash away the graft.  Therefore several pieces of Collagen Dressing are inserted into the sinus for hemostasis, followed by placement of Osteogen  (Fig.1 *) and implant (5x14 mm, tissue-level).  After placement of the 2nd implant, more Osteogen is placed buccal to the implants.  Insertion torque is ~ 35 Ncm.  Abutments (Fig. 2: 4x5 mm) are placed to hold perio dressing in place (no immediate provisional).  In fact, the patient returns within 20 minutes postop because hemorrhage from the incision.  Hemostasis is achieved with a few pieces of gauze in the buccal vestibule.  Ice pack is recommended.  By the evening, the patient reports minimal oozing.  When perio dressing is lost 10 days postop, the wound opens (Fig.3).  Later the wound heals. It appears that an immediate provisional provides the wound with temporary protection.  The abutments without provisional is irritating to the soft tissue (the cheek in this instance).   They have to be removed until the implants osteointegrate.  PA taken 4 months postop shows the bone in the sinus surrounding the implants (Fig.4 *).  The gingiva around the implants looks normal (Fig.5), although there is occasional and mild itching in the skin over the left sinus.

Approximately 2 months post cementation, the patient complains of looseness of one of the implants.  It is probably due to the fact that the sinus floor is too thin (2-3 mm), that the Tatum implant threads do not fully engage into the native bone (the rough portion) and that the implant is loaded too soon.  If the implant turns out to be minimally loose, remove the crown and the unipost and place a healing screw.  If the implant is fatally loose, remove it, explorer the osteotomy for wall integrity.  If it is solid, place 5.5 or 6.0 mm tap before placing an appropriate implant and healing abutment for more than 6 months (vs. 4 months previously).  In fact, the implant is quite loose with bone loss around the implant.