CLINICAL FINDINGS
  • Bilateral oro-antral fistulas
  • Large posterior maxillary defects
  • Scarred wound margins from previous surgeries
  • Deficient posterior maxillary alveolar bone
  • Peri-implant defects and soft-tissue compromise
  • Deep peri-implant probing depths with suppuration in peri-implantitis cases
  • CT scans demonstrated:
    • Large bilateral posterior maxillary osseous defects
    • Loss of sinus floor cortical plate
    • Severe posterior maxillary bone loss
    • Sinus communication defects
    • Peri-implant crestal bone loss around tilted implants
    • Sinus penetration and opacification in chronic rhinosinusitis cases
PP
Dr. Paul Petrungaro
Moderator · IML CaseRounds™
  • Complications associated with:
    • All-on-4 treatment
    • Excessive bone reduction
    • Poor wound closure
    • Sinus membrane perforation
    • Implant malposition
    Importance of:
    • Adequate keratinized tissue
    • Proper implant depth and angulation
    • Biofilm removal in peri-implantitis
    • Proper sinus management
    • CBCT-guided treatment planning
    Advanced reconstructive techniques:
    • Stem-cell enriched grafting
    • Titanium-reinforced membranes
    • PRP/A-PRF utilization
    • Soft-tissue flap advancement
    • MEMM (Modified Endoscopic Medial Maxillectomy)
    Zygomatic implant complications:
    • Chronic rhinosinusitis
    • Implant sinus penetration
    • Foreign-body reaction
    • Biofilm colonization
    Reported outcomes:
    • Successful closure of all oro-antral defects
    • 89.1% implant success in regenerated posterior maxilla
    • Significant postoperative sinus improvement
Treatment Planning

TOPIC E - ALL ON X ALL ON 4 COMPLICATIONS

Persistent oro-antral communications after implant treatment Chronic sinus complications Failed prior surgical closure attempts Posterior maxillary bone loss and discomfort
PATIENT SUMMARY
AGE / SEX
60
CHIEF COMPLAINT
Persistent oro-antral communications after implant treatment Chronic sinus complications Failed prior surgical closure attempts Posterior maxillary bone loss and discomfort
ASA CLASS
Class I
SMOKING
Non-smoker
KEY MEDICATIONS
Local anesthetic Sedation/general anesthesia Chlorhexidine mouth rinse Antibiotic regimen postoperatively Pain medication postoperatively
WORKING DIAGNOSIS
DR. PAUL'S TREATMENT PLAN
    1. Comprehensive CBCT evaluation
    2. Surgical flap elevation and fistula dissection
    3. Elevation of fistulous tissue into sinus cavity
    4. Placement of collagen membrane
    5. Stem-cell enriched cancellous grafting (Allostem®)
    6. Cortico-cancellous allogenic graft placement
    7. Titanium-reinforced ePTFE membrane fixation
    8. Amniotic/chorionic membrane placement
    9. Primary wound closure with ePTFE sutures
    10. Healing phase and membrane removal
    11. Implant placement into regenerated posterior maxilla where indicated
    12. Peri-implantitis debridement and detoxification:

    • Piezo scaling
    • Citric acid detoxification
    • Er,Cr:YSGG laser decontamination
    1. PRP application and graft reconstruction
    2. For refractory sinusitis:
    • Modified endoscopic medial maxillectomy (MEMM)
    • Ethmoidectomy
    • Culture-directed antibiotics and steroids