About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Sinus perforation from a dental implant – did the surgeon do it right?


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Hi Dr. Hall,

First, thank you for taking the time to answer questions. 🙂

My question is about the impact of a sinus perforation, removal of an implant, and antibiotics. I just had a dental implant (tooth #2) removed last Wednesday, six months after it was placed, he suspected bone loss and the gum was not filling in correctly. Also, when he placed the implant it punctured the sinus by a few mm.

After the removal, the OS said there was no infection and it was very easy to remove because it did not integrate at all, and there was no need to give me intravenous antibiotics during the process (I was sedated). He put me on sinus precaution of Flonase, no blowing nose, and no sneezing with mouth closed. He said he did not repair the perforation in my sinus, he just cleaned the area and stitched the gums. He said it would heal on its own and we should wait a year to see if the hole fills up with sinus tissue or bone and start again from there.

The following week I had continual congestion, especially at night, even though I was using the Flonase. I also had odd crackling in my ear when I moved my jaw (not jaw popping and no pain- just crackling like a blown speaker) I went back to him five days later and he said everything looked great. I did not agree and I requested antibiotics because I felt like it was getting infected. He reluctantly complied and since then my congestion has cleared significantly and air no longer escapes through the site. My question is, was it detrimental to not have been given antibiotics from the beginning and how do you know the sinus has healed correctly and the bone is not compromised with a lingering infection and congestion in the first week?

Thank you so much for sharing your knowledge!
– Kelly M.

Kelly,
First, answering your question directly, there is no harm in not starting the antibiotics right away. The indiscriminate prescribing of antibiotics, “just in case you have an infection,” is leading to a serious public health problem by helping cultivate antibiotic-resistant bacteria. Then, when you really need the antibiotic, it doesn’t work. So I like the idea that your surgeon waited to see signs of infection before prescribing the antibiotic. And Flonase seems a good choice also.

But there is another, more significant issue that you bring up that I want to address, and that is the failure of this dental implant. The implant perforated the sinus by a few millimeters??? That’s kind of a biggie. A few millimeters in dentistry is a lot. And the implant didn’t integrate with the bone at all. That’s another biggie. I hope your dentist has a good explanation for these two kind of serious errors.

To be clear here, the idea of the implant perforating the sinus is an issue with oral surgeons, with many maintaining that it isn’t a big deal. Others say that it is an indication of sloppy surgery that just increases the risk of implant failure. Many surgeons will say that they have perforated the sinus many times with implant placement and the site heals and everything is fine. But others will point to cases where this has allowed infection to get in around the implant from the sinus cavity. And then they also point to the issue of how much bone support the implant has. For however much the implant pokes into the sinus, that is that much less bone that is supporting the implant. I believe almost all surgeons will agree that while they may be able to get away with an implant sticking into the sinus one or two millimeters, “a few millimeters” is too far.

I don’t know what prompted the removal of the implant, but you’re lucky that this happened just six months from its placement, hopefully before anything was attached to the implant. Others who have had a sinus perforation from a dental implant haven’t been so fortunate. They have had persistent nasal problems for years after the implant restoration, only resolved by removal of the dental appliance that was attached to the implant and then possible bone grafting to repair the defect created followed by re-doing the implant surgery,

The standard of care for implant surgery requires the dentist to take whatever x-rays are necessary—preferably three-dimensional ones—to insure that there is enough bone present to stabilize the implant. So my question is, what is your surgeon going to do to insure that this doesn’t happen again? In other words, if your implant ended up so far into your sinus, there’s not enough bone there to support the implant. That would call for some bone grafting. In the area of the sinus, this is usually done in what is called a sinus lift procedure. Has your dentist suggested that?

I want to be careful here, because I have an incomplete picture of what is going on with you. But just from what you have told me, if I were getting an implant and my surgeon, in placing the implant, punctured my sinus and there was no osseointegration of the implant with the bone, I wouldn’t want this surgeon doing any more work on me. For you, as a minimum, I would get some answers about this, and maybe a second opinion.

– Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

A botched sinus perforation


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Hello Dr. Hall-
I had my right rear molar extracted because it felt sore when chewing and didn’t hit much on teeth below. The molar, I found out later, was in the sinus. Anyways, after the extraction, the dentist put a plasma plug into the socket and sewed that and something neon yellow into the tooth socket.

While recovering, about an hour after the extraction, I was feeling a lot of sensitivity in the right canine tooth. After carefully drinking a green smoothie, I noticed some of that liquid was in my nose with some blood. I went home to take it easy and did almost nothing and didn’t talk because certain words made me feel like air was going into the socket.

I called the dentist and went back. They did the exam and then they cut some of the tissue, scraped some bone and filled the area with collagen and sewed it in, this time with non dissolvable stitches and said come back in three weeks. I have been only drinking fluids, not bending, not looking down, just on bed rest eating healthy meals. Today is six days after surgery, and the packing has dissolved and most of my symptoms are back and my sinuses or ears are both aching. Yesterday the ear pain came and went. I am not talking because it feels sensitive speaking certain letters.

Do you think I should give this dull throb time to heal itself and keep taking it easy? Is this sounding like dry socket and a perforation? If I found food I drink in my nose – does this define a perforation? The dentist didn’t speak clear English so I am not sure what I have. I have been in so much pain from swelling and bruising. I took all 5 days of antibiotics and the sinus pills but the pressure and pain in my ears makes me think this is all causing a sinus infection? I also noted oral thrush as I have been taking antibiotics for a month. What should I do? I have no insurance. Is it definitely a sinus perforation if I saw my smoothy in my nose? Is it dry socket? Shall I give it a few more days? Yesterday I placed a small sterile gauze ball over the area. It was too uncomfortable and when I removed it, it had a bad odor. Thank you for this blog and for your help! What shall I do?
– Vanessa from California

Vanessa,
It certainly doesn’t sound to me like you are in good hands. I would find someplace to go for a second opinion.

With the pain and delayed healing, and you mention swelling, it sounds to me like, on top of the sinus perforation, you have an uncontrolled infection. If that is the case, you need a dentist who understands infection and knows how to pick the right antibiotic. I would tend to check with an oral surgeon, with that being the case. It also could be that you have a root tip or a bone fragment that went up into the sinus and that is what is causing the infection and complicating the healing.

And these sinus perforation repairs should not be falling out after a couple of days. I don’t understand that—if they sewed it closed, why is it coming out? Yes, when you have fluids or air passing between your mouth and your nose, that is a sinus perforation. Again, hopefully a dentist with a better command of the situation can get this fixed properly for you.
– Dr. Hall

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Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

The hundred thousand dollar smile makeover

Dear Dr. Hall,
I have had a terrible experience with my “smile-makeover.” It turned out horrible, so the dentist just refunded my money, and I am looking for a new dentist. I found your website while I was still his patient and was able to figure out that he had little to no knowledge of what you describe as a true cosmetic dentist.

So I made appointments with the first 3 cosmetic dentists on your list. I must say I was so disappointed with the 1st. While he rightly said my bite was off, I was there for a 2nd opinion of the 6 upper anterior crowns I had. He said I would first need to spend $300-400 with his hygienist, and then, to deal with my bite issues and everything the cost would range between $50,000 and $100,000. “About the price of a new car,” he said. I only wish I could replace my 6-yr-old car bought used, for 1/3 his idea of a new car. He never got to what type of smile I would end up with, as his idea was to build up my back teeth and have “an appliance” covering several teeth and add porcelain “where needed.”

My teeth and gums are pristine according to a general dentist I went to for opinion and a periodontist I also went to for opinion earlier. I don’t understand why I need all of this, and I can’t begin to afford this and want your opinion.
Thanks,
– Sally from Texas


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Sally,
There’s a great variation in what some expert cosmetic dentists charge, and the fees you’ve been quoted are definitely on the high side, even if you actually need all the work that has been quoted. I would keep going down the list and get another opinion. Meanwhile, let me give you a little insight into what I think is going on in your case.

You said that you know your bite is off, and it appears that you’re being quoted a fee for a full-mouth reconstruction to rebuild your bite. Do you actually need that? I don’t know that, but I can tell you that some dentists are very fussy perfectionists and they insist that every patient accept what they call “ideal treatment.” Other dentists are more pragmatic and will consider other options for patients who can’t afford the ideal. Fortunately, you’re in the Dallas-Fort Worth area where we have several recommended cosmetic dentists. Go ahead and shop around for second opinions.

I want to tell you a story about this cost issue and dentists’ fee levels. There is a city where we have two recommended cosmetic dentists—let’s call them Dr. Expensive and Dr. Budget. Dr. Expensive is famous and has patients flying in from far and wide to see him. He does absolutely exquisite work. Dr. Budget also does very beautiful work and has won awards for the beauty of his work. Dr. Expensive’s fees are about triple of what Dr. Budget charges. Is Dr. Budget an inferior dentist? I don’t think so. I’ve seen his work and it is world class. And guess what, Dr. Expensive goes to Dr. Budget for his dental work.

So get another opinion or two.

Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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