The following patient was referred for implant replacement of his first molar (#3). During the examination, a visible mass was noted on the left sternocleidomastoid muscle. The mass was examined and appeared to be a swollen lymph node. The patient reported that he was previously treated for testicular cancer many years ago. The patient was referred to an ENT and instructed not to return for implant placement until cleared by the physician.
The patient had a biopsy of the mass and was cleared by his physician for implant placement. He did not yet have a diagnosis. The decision was made to proceed with implant placement even though the diagnosis had not been made. If the diagnosis is favorable, then all is well. However, if the diagnosis is cancer, then the therapy could compromise his left occlusion, making his right occlusion all the more critical. Also, if treatment should involve radiation to the head and neck, his ability to have a sinus augmentation and implant might be contraindicated. Due to these factors, the decision was made to proceed with sinus augmentation and implant placement.
The patient was a 56-year-old male in otherwise good health. At the consult appointment, the patient’s blood pressure was 124/81. However, after his biopsy and while he was waiting for his diagnosis, he presented for surgery and his blood pressure was 179/83. This change in blood pressure was deemed stress-related and not related to cardiovascular disease. Therefore, the surgery proceeded as planned.
Sinus Augmentation and Head and Neck Cancer Therapy
A CT scan was taken before surgery and the decision was made to do a crestal osteotomy for access to the sinus membrane. However, the sinus membrane was torn when the membrane was exposed. An attempt to inject Sinus Graft under the membrane failed as shown on this radiograph with no graft material on the floor of the sinus. The decision was made to remove the membrane from the floor of the sinus and inject Sinus Graft™ without a membrane.
This radiograph shows what Sinus Graft™ looks like when injected onto the floor of the sinus without the pressure of the membrane compacting the graft material. The radiographs show the graft material in contact with the sinus wall with the membrane entirely removed.
This case shows what the graft looks like when it is under the sinus membrane. The arrows point to the sinus membrane and the graft material is dense and uniform in appearance.
2-week post-op. Even without a membrane covering the graft material, the graft material bonds to the implant and the sinus walls and sets in the sinus. The removal of a torn membrane and injection of the graft material onto the floor of the sinus is the treatment of choice.
At the post-op appointment, the patient reported his diagnosis was squamous cell carcinoma originating from the left posterior tongue. He was referred by his diagnosing ENT to a university hospital for robotic aided surgery.
After surgery to remove the cancer and the affected lymph nodes, the patient was allowed to heal before radiation therapy was initiated. Radiation therapy was initiated 3 months after sinus augmentation and implant placement. Radiation was followed by chemotherapy. The patient was instructed to return for healing abutment and restoration upon the recommendation of his physician. The patient was evaluated with a PET scan and determined to be free of cancer.
8 months after sinus augmentation and implant placement, the patient presented for his healing abutment. The following radiographs show successful sinus augmentation and implant integration during radiation and chemotherapy treatment.
A radiograph taken at the healing abutment 8 months after grafting and implant placement shows the sinus filled with newly regenerated bone with the floor of the sinus beyond the reach of periapical radiographs.
With the healing abutment in place, the implant is integrated with dense bone supporting the implant.
Radiation and chemotherapy is designed to kill rapidly growing cells. The proliferation of regenerative cells during bone regeneration could easily be compromised by cancer therapy. In this case, the grafting was done just prior to cancer surgery. After surgery, there is a healing period for the patient before radiation and chemotherapy is applied. This 3-month window provided adequate time for the regenerative cells to proliferate and form bone before radiation and chemotherapy could stop the regenerative process. Sinus Graft™ was successful in spite of loss of the sinus membrane and the initiation of radiation and chemotherapy. This successful outcome cannot not be extrapolated to other graft materials and more invasive surgical techniques.
MEMBER:
American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)