413
SCUBA AND PARRADQ 3. Meyer JE, Milford DS: “Solitary” myeloma of bone. A review
13. Bruce KW, Royer RQ: Multiple myeloma occurring in the jaws.
of 12 cases. Cancer 34:438, 1974 Mill WB, Griffith R: The role of radiation therapy in the management of plasma-cell tumors. Cancer 56:52 1, 1980 Woodruff RK, Whittle JM, Malpas JP: Solitary plasmacytoma. Cancer 43:2340, 1979 Woodruff RK, Malpas JS, White FE: Solitary plasmacytoma II: Solitary plasmacytoma of bone. Cancer 43:2344, 1979 Chak LY, Cox RS, Bostwick DG, et al: Solitary plasmacytoma of bone: Treatment, progression and survival. J Clin Oncol 5:1811, 1987 Fassica DS, Fassica FJ, Schray MF, et al: Solitary plasmacytoma of bone: Mavo Clinic exnerience. Int J Radiat Oncol Biol Phys 16:43, l-989 _ Bataille R, Sany J: Solitary myeloma: Clinical and prognostic features. A review of 114 cases. 48:845, 1981 Brinch L, Hannisdal E, Abrahamsen F, et al: Extramedullary plasmacytomas and solitary plasma cell turnouts of bone. Eur J Haemato144: 131, 1990 Bergsagel DE, Bailey AJ, Langley GR, et al: The chemotherapy of plasma-cell myeloma and the incidence of acute leukemia. N Engl J Med 301:743, 1979 Delauche-Cavallier MC, Laredo JD, Wybier M, et al: Solitary plasmacytoma of the spine. Long term clinical course. Cancer 61:1707. 1988
A study of 17 cases. oral Surg 6:729, 1953 14. Lewis RW, Cataldo E: Multiple myeloma discovered from oral manifestations: Report of case. J Oral Surg. 25:68, 1967
4. 5. 6. 7. 8. 9. 10.
11.
12.
J Oral Maxillofac 50:413-415.
15. Pepys MB: Amyloidosis, in Samter M et al (eds): Immunological Diseases. Boston/Toronto, Little, Brown, 1988, pp 631-674 16. Raubenheimer EJ, Routh J, de Coning JP, et al: Multiple myeloma presenting with extensive oral and general amyloidosis. Oral Surg Oral Med Oral Path01 6 1:492-497, 1986 17. Kyle RA, Greipp RR: Primary systemic amyloidosis: Comparison of mephalan and prednisone versus placebo. Blood 52:818, 1978 18. Brandt K, Cathcart ES, Cohen AS: A clinical analysis of the course and prognosis of forty-two patients with amyloidosis. Am J Med 44955, 1968 19. Limas C, Wright JR, Matsuzaki M, et al: Amyloidosis and multiple myeloma: A re-evaluation using a control population. Am J Med 54:166, 1973 20. Smith DB: Multiple myeloma involving the jaws: A study of 17 cases: review with report of an additional case. Oral Surg Oral Med Oral Path01 10:910, 1957 2 1. Murray RO, Watt I: Plasma cell diseases, in Sutton D (ed): Textbook of Radiology and Imaging (ed 4). London, UK Churchill Livingstone, 1987, pp 214-215
Surg
1992
Parapharyngeal Hemorrhage Secondary to Thrombolytic Therapy for Acute Myocardial Infarction LTC JOHN R. SCUBA, DC, USA, DDS,* AND MAJ CARLOS PARRADO, MC, USA, MDt
Thrombolytic therapy is a relatively new and dramatic mode of treatment of the evolving acute myocardial infarction secondary to coronary artery occlusion. The use of streptokinase, urokinase, and tissue plasminogen activator enable the emergency department physician and cardiologist to salvage the myocardium in evolving infarctions to a far greater degree than before these agents became available.’ However, Received from Brooke Army Medical Center, Fort Sam Houston, TX. * Assistant Chief, Oral and Maxillofacial Surgery Service. t Senior Resident, Internal Medicine Service. The opinions or assertions contained herein are the private views of the authors and are not to lx construed as official or as retIecting the views of the Department of the Army or the Department of Defense. Address correspondence and reprint requests to LTC Scuba: Oral and Maxillofacial Surgery Service, Beach Pavilion, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200. This is a US government work. There are no restrictions on its USe.
0278-2391/92/5004-0018$0.00/O
these agents are not without significant side effects and sequelae.2 This is a case presentation of a previously unreported complication following the use of a thrombolytic agent in the acute treatment of a coronary artery occlusion. Report of a Case The Oral and Maxillofacial Surgery Service was consulted to evaluate a 46-year-old man in the coronary care unit who had developed moderate midfacial swelling during the previous 12 hours. The patient had suffered an uncomplicated acute myocardial infarction earlier that day and had received effective thrombolytic therapy with tissue plasminogen activator (t-PA). On arrival in the coronary care unit, the patient began to feel discomfort and fullness in the right preauricular and mandibular regions, with a slowly developing swelling. He reported mild dysphagia and malaise, but no respiratory distress. Vital signs were stable and the patient was afebrile. The patient was receiving 1,000 U/h intravenous heparin for maintenance of coronary perfusion. The remainder of the history and systems review was typical for a patient with
414 acute myocardial infarction. Of significance was the fact that the patient had had a dental prophylaxis some 96 hours previous to the coronary event. On initial physical examination, the patient exhibited a mild to moderate, nonerythematous, firm, right midfacial and mandibular swelling. There was no protrusion of the tongue or respiratory difficulty, and the patient appeared to be in only mild distress. He was able to assume a supine position comfortably. He reported only mild malaise and denied chills, nausea, or emesis. Oral examination showed a tense swelling of the maxillary right buccal vestibule with extension into the cheek and mandibular vestibule. The patient had moderate to severe periodontal disease, although without exudate or marked inflammation. The maxillary right posterior den&ion was moderately tender to percussion. On further questioning, the patient, who was a good historian, gave a history of periodontal disease for which the dental prophylaxis had been performed. Consultation with the patient’s dentist revealed that the procedure involved local anesthetic injections in the right posterior maxilla during the procedure. For this reason, the possibility of an infmtemporal or masticator space abscess was considered, although the patient was afebrile. The patient was empirically started on aqueous penicillin G, 2 million U every 4 hours. On subsequent examination, the swelling became progressively larger, although the patient remained afebrile with stable vital signs. At approximately 24 hours after admission,
the appearance of ecchymosis in the neck strongly suggested the diagnosis of postthrombolytic hemorrhage (Fig 1). Although the swellingeventually became massive, as evidenced by the frontal and lateral soft-tissue films of the face (Fig 2), and the chest radiograph, the patient was at all times able to exchange air and vocalize without difficulty. Flexible fiberoptic nasopharyngolaryngoscopy revealed that the swelling involved the soft tissues of the larynx, vocal cords, and epiglottis, with displacement of the glottis. Emergent tracheostomy was considered at the time, but was deferred owing to the hazards of operating in an area with distorted anatomy, the potential for massivehemorrhage, and the possibility of losing a stable airway. Instead, the patient was managed with vigilant observation and by the discontinuance of the heparin anticoagulation.
FIGURE 1. Massive facial swelling with ecchymosis deep in anterior neck crossing the midline (arrow).
PARAPHARYNGEAL
HEMORRHAGE
FIGURE 2. Marked displacement of tracheal air shadow on anteroposterior skull film (arrow).
Discussion The dental procedure that this patient had was benign and noninvasive. There was minimal disruption of the gingival attachment and the vessels involved in the lamina propria of the gingiva were probably about 10 to 30 pm. Only the local anesthetic injection (made with a 27-gauge needle) could have involved the deeper tissues. This probably resulted in laceration of either one of the deep terminal branches of the maxillary artery and/or of the pterygoid plexus by the needle used for anesthesia, with subsequent hemorrhage into the anterosuperior lateral pharyngeal space. This complication, although unusual, is well recognized.5 In a patient without a coagulopathy, this occurrence is usually benign. However, as evidenced in this patient, potent thrombolytic agents may rapidly dissolve previously formed platelet plugs and lead to secondary bleeding, with extension into the parapharyngeal spaces. Once the bleeding developed in this patient, it presented a perplexing problem. The decision to discontinue anticoagulation in the face of a successfully reperfusing coronary vasculature was a difficult one. However, with progression of the facial swelling, and the potential for acute airway obstruction, the decision to discontinue heparin was made. With the increasing use of thrombolytic agents, various complications will occur.3 Most obvious are cases that would be predisposed to significant morbidity or mortality in the event of bleeding, such as patients having recent intracranial or spinal cord surgery,4 intraocular surgery, or recent major organ surgery. This case serves to show that any recent head and neck procedure, especially those requiring involvement of the deeper soft tissues, warrants close management to pre-
415
JENSEN. PERKINS, AND VAN DE WATER
serious complications, and may be a relative contraindication to the use of thrombolytic agents. vent
References I. Stewart JH. Olin JW. Graor RA: Thrombolytic therapy: A review. Cleveland Clin J Med 56:189, 1989
J Oral Maxillofac 50:415-418.
2. Stewart JH, Olin JW, Graor RA: Thrombolytic therapy: A review. Cleveland Clin J Med 56293, 1989 3. Shafer KE, Santoro SA, Sobel BE, et al: Monitoring activity of fibrinolvtic agents: A therapeutic challenge. Am J Med 76: 879, 19-84 4. Del Zoppo GJ, Zeumer H, Harker LA: Thrombolytic therapy in stroke: Possibilities and hazards. Stroke 17:595, 1986 5. Sicher H, DuBrul LE: Oral Anatomy (ed 5). Saint Louis, MO, Mosby, 1970
Surg
1992
Nasal Fossa and Maxillary Sinus Grafting of Implants From a Palatal Approach: Report of a Case OLE T. JENSEN, DDS, MS,* SCOTT PERKINS, DDS, MS,* AND FRANK W. VAN DE WATER, MD*
The treatment of the highly resorbed maxilla with dental implants can require both sinus and nasal floor augmentation bone grafting. Maxillary sinus grafts are most often done through a Caldwell-Luc approach, whereas nasal grafts are usually done through the nasal aperture. By using autogenous bone, both immediate and delayed implant placement have been successfully accomplished at both sites. l-3 Iliac bone is most often used for sinus grafts, but chin cortex, coronoid process, and alveolar process bone also have been used successfully. However, when bone is obtained from oral sites, delayed implant placement is advocated.4*’ Nasal fossa grafting has been done almost exclusively using iliac bone via a Le Fort I downgraft with delayed implant placement or implant-fixed onlay/inlay grafts6“ To obtain a suitable alternative to autogenous grafting in these regions, allografts and ceramic bone substitutes have been used in an attempt to provide a simple office procedure with minimal morbidity. However, the use of these materials to facilitate osseointegration is dubious because of their much-reduced capacity to stimulate bone formation in the sinus cavity or adjacent to a titanium implant when used either alone or in combination. ‘o-‘3 Various types of allogeneic bone preparations are currently being used in the sinus membrane lift pro* In private practice, Denver, CO. Address correspondence and reprint requests to Dr Jensen: Fillmore Medical Building, 303 Josephine St, Suite 303, Denver, CO 80206. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5004-0019$3.00/O
cedure, with varying results. Demineralized, freezedried, cancellous, allogeneic bone (ethylene oxide gassterilized) has been shown to have only fair osteogenic properties in the sinus or in augmentation applications because of attenuated inductivity, whereas mineralized, radiation-sterilized (2.5 Mrad), cancellous, allogeneic bone has been shown to induce dense bone formation after 6 months in the sinus provided a barrier membrane is used over the osteotomy site.5 When the use of an iliac autograft is precluded, and immediate implantation is done, the latter grafting technique is preferred because of its twofold greater bone inductivity.‘4-‘6 In the highly resorbed maxilla, marked lateral resorption of the alveolus occurs and the jaw decreases in size in all dimensions. A sinus membrane lift antroplasty in this situation exposes a narrow anterior antrum and midalveolar placement of implants will result in penetration directly into the nasal cavity (Fig 1C). Boyne has shown in a cadaver study of elderly edentulous individuals that in the first and second premolar regions up to 80% of the implants engage the lateral nasal wall or penetrate at least in part into the nasal cavity. ” In the first and second molar areas, 50% of the implants showed penetration through the lateral nasal wall. He concluded that in highly resorbed ridges, the transverse dimension of the maxilla is so reduced that the alveolar process tends to line up in the same vertical plane as the lateral wall of the nose. When the nasal cavity is penetrated in this type of situation, the nasal membrane can most oflen be dissected from the floor of the nose through the nasal aperture. However, when the implants are placed pos-
SCUBA AND PARRADQ 3. Meyer JE, Milford DS: “Solitary” myeloma of bone. A review
13. Bruce KW, Royer RQ: Multiple myeloma occurring in the jaws.
of 12 cases. Cancer 34:438, 1974 Mill WB, Griffith R: The role of radiation therapy in the management of plasma-cell tumors. Cancer 56:52 1, 1980 Woodruff RK, Whittle JM, Malpas JP: Solitary plasmacytoma. Cancer 43:2340, 1979 Woodruff RK, Malpas JS, White FE: Solitary plasmacytoma II: Solitary plasmacytoma of bone. Cancer 43:2344, 1979 Chak LY, Cox RS, Bostwick DG, et al: Solitary plasmacytoma of bone: Treatment, progression and survival. J Clin Oncol 5:1811, 1987 Fassica DS, Fassica FJ, Schray MF, et al: Solitary plasmacytoma of bone: Mavo Clinic exnerience. Int J Radiat Oncol Biol Phys 16:43, l-989 _ Bataille R, Sany J: Solitary myeloma: Clinical and prognostic features. A review of 114 cases. 48:845, 1981 Brinch L, Hannisdal E, Abrahamsen F, et al: Extramedullary plasmacytomas and solitary plasma cell turnouts of bone. Eur J Haemato144: 131, 1990 Bergsagel DE, Bailey AJ, Langley GR, et al: The chemotherapy of plasma-cell myeloma and the incidence of acute leukemia. N Engl J Med 301:743, 1979 Delauche-Cavallier MC, Laredo JD, Wybier M, et al: Solitary plasmacytoma of the spine. Long term clinical course. Cancer 61:1707. 1988
A study of 17 cases. oral Surg 6:729, 1953 14. Lewis RW, Cataldo E: Multiple myeloma discovered from oral manifestations: Report of case. J Oral Surg. 25:68, 1967
4. 5. 6. 7. 8. 9. 10.
11.
12.
J Oral Maxillofac 50:413-415.
15. Pepys MB: Amyloidosis, in Samter M et al (eds): Immunological Diseases. Boston/Toronto, Little, Brown, 1988, pp 631-674 16. Raubenheimer EJ, Routh J, de Coning JP, et al: Multiple myeloma presenting with extensive oral and general amyloidosis. Oral Surg Oral Med Oral Path01 6 1:492-497, 1986 17. Kyle RA, Greipp RR: Primary systemic amyloidosis: Comparison of mephalan and prednisone versus placebo. Blood 52:818, 1978 18. Brandt K, Cathcart ES, Cohen AS: A clinical analysis of the course and prognosis of forty-two patients with amyloidosis. Am J Med 44955, 1968 19. Limas C, Wright JR, Matsuzaki M, et al: Amyloidosis and multiple myeloma: A re-evaluation using a control population. Am J Med 54:166, 1973 20. Smith DB: Multiple myeloma involving the jaws: A study of 17 cases: review with report of an additional case. Oral Surg Oral Med Oral Path01 10:910, 1957 2 1. Murray RO, Watt I: Plasma cell diseases, in Sutton D (ed): Textbook of Radiology and Imaging (ed 4). London, UK Churchill Livingstone, 1987, pp 214-215
Surg
1992
Parapharyngeal Hemorrhage Secondary to Thrombolytic Therapy for Acute Myocardial Infarction LTC JOHN R. SCUBA, DC, USA, DDS,* AND MAJ CARLOS PARRADO, MC, USA, MDt
Thrombolytic therapy is a relatively new and dramatic mode of treatment of the evolving acute myocardial infarction secondary to coronary artery occlusion. The use of streptokinase, urokinase, and tissue plasminogen activator enable the emergency department physician and cardiologist to salvage the myocardium in evolving infarctions to a far greater degree than before these agents became available.’ However, Received from Brooke Army Medical Center, Fort Sam Houston, TX. * Assistant Chief, Oral and Maxillofacial Surgery Service. t Senior Resident, Internal Medicine Service. The opinions or assertions contained herein are the private views of the authors and are not to lx construed as official or as retIecting the views of the Department of the Army or the Department of Defense. Address correspondence and reprint requests to LTC Scuba: Oral and Maxillofacial Surgery Service, Beach Pavilion, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200. This is a US government work. There are no restrictions on its USe.
0278-2391/92/5004-0018$0.00/O
these agents are not without significant side effects and sequelae.2 This is a case presentation of a previously unreported complication following the use of a thrombolytic agent in the acute treatment of a coronary artery occlusion. Report of a Case The Oral and Maxillofacial Surgery Service was consulted to evaluate a 46-year-old man in the coronary care unit who had developed moderate midfacial swelling during the previous 12 hours. The patient had suffered an uncomplicated acute myocardial infarction earlier that day and had received effective thrombolytic therapy with tissue plasminogen activator (t-PA). On arrival in the coronary care unit, the patient began to feel discomfort and fullness in the right preauricular and mandibular regions, with a slowly developing swelling. He reported mild dysphagia and malaise, but no respiratory distress. Vital signs were stable and the patient was afebrile. The patient was receiving 1,000 U/h intravenous heparin for maintenance of coronary perfusion. The remainder of the history and systems review was typical for a patient with
414 acute myocardial infarction. Of significance was the fact that the patient had had a dental prophylaxis some 96 hours previous to the coronary event. On initial physical examination, the patient exhibited a mild to moderate, nonerythematous, firm, right midfacial and mandibular swelling. There was no protrusion of the tongue or respiratory difficulty, and the patient appeared to be in only mild distress. He was able to assume a supine position comfortably. He reported only mild malaise and denied chills, nausea, or emesis. Oral examination showed a tense swelling of the maxillary right buccal vestibule with extension into the cheek and mandibular vestibule. The patient had moderate to severe periodontal disease, although without exudate or marked inflammation. The maxillary right posterior den&ion was moderately tender to percussion. On further questioning, the patient, who was a good historian, gave a history of periodontal disease for which the dental prophylaxis had been performed. Consultation with the patient’s dentist revealed that the procedure involved local anesthetic injections in the right posterior maxilla during the procedure. For this reason, the possibility of an infmtemporal or masticator space abscess was considered, although the patient was afebrile. The patient was empirically started on aqueous penicillin G, 2 million U every 4 hours. On subsequent examination, the swelling became progressively larger, although the patient remained afebrile with stable vital signs. At approximately 24 hours after admission,
the appearance of ecchymosis in the neck strongly suggested the diagnosis of postthrombolytic hemorrhage (Fig 1). Although the swellingeventually became massive, as evidenced by the frontal and lateral soft-tissue films of the face (Fig 2), and the chest radiograph, the patient was at all times able to exchange air and vocalize without difficulty. Flexible fiberoptic nasopharyngolaryngoscopy revealed that the swelling involved the soft tissues of the larynx, vocal cords, and epiglottis, with displacement of the glottis. Emergent tracheostomy was considered at the time, but was deferred owing to the hazards of operating in an area with distorted anatomy, the potential for massivehemorrhage, and the possibility of losing a stable airway. Instead, the patient was managed with vigilant observation and by the discontinuance of the heparin anticoagulation.
FIGURE 1. Massive facial swelling with ecchymosis deep in anterior neck crossing the midline (arrow).
PARAPHARYNGEAL
HEMORRHAGE
FIGURE 2. Marked displacement of tracheal air shadow on anteroposterior skull film (arrow).
Discussion The dental procedure that this patient had was benign and noninvasive. There was minimal disruption of the gingival attachment and the vessels involved in the lamina propria of the gingiva were probably about 10 to 30 pm. Only the local anesthetic injection (made with a 27-gauge needle) could have involved the deeper tissues. This probably resulted in laceration of either one of the deep terminal branches of the maxillary artery and/or of the pterygoid plexus by the needle used for anesthesia, with subsequent hemorrhage into the anterosuperior lateral pharyngeal space. This complication, although unusual, is well recognized.5 In a patient without a coagulopathy, this occurrence is usually benign. However, as evidenced in this patient, potent thrombolytic agents may rapidly dissolve previously formed platelet plugs and lead to secondary bleeding, with extension into the parapharyngeal spaces. Once the bleeding developed in this patient, it presented a perplexing problem. The decision to discontinue anticoagulation in the face of a successfully reperfusing coronary vasculature was a difficult one. However, with progression of the facial swelling, and the potential for acute airway obstruction, the decision to discontinue heparin was made. With the increasing use of thrombolytic agents, various complications will occur.3 Most obvious are cases that would be predisposed to significant morbidity or mortality in the event of bleeding, such as patients having recent intracranial or spinal cord surgery,4 intraocular surgery, or recent major organ surgery. This case serves to show that any recent head and neck procedure, especially those requiring involvement of the deeper soft tissues, warrants close management to pre-
415
JENSEN. PERKINS, AND VAN DE WATER
serious complications, and may be a relative contraindication to the use of thrombolytic agents. vent
References I. Stewart JH. Olin JW. Graor RA: Thrombolytic therapy: A review. Cleveland Clin J Med 56:189, 1989
J Oral Maxillofac 50:415-418.
2. Stewart JH, Olin JW, Graor RA: Thrombolytic therapy: A review. Cleveland Clin J Med 56293, 1989 3. Shafer KE, Santoro SA, Sobel BE, et al: Monitoring activity of fibrinolvtic agents: A therapeutic challenge. Am J Med 76: 879, 19-84 4. Del Zoppo GJ, Zeumer H, Harker LA: Thrombolytic therapy in stroke: Possibilities and hazards. Stroke 17:595, 1986 5. Sicher H, DuBrul LE: Oral Anatomy (ed 5). Saint Louis, MO, Mosby, 1970
Surg
1992
Nasal Fossa and Maxillary Sinus Grafting of Implants From a Palatal Approach: Report of a Case OLE T. JENSEN, DDS, MS,* SCOTT PERKINS, DDS, MS,* AND FRANK W. VAN DE WATER, MD*
The treatment of the highly resorbed maxilla with dental implants can require both sinus and nasal floor augmentation bone grafting. Maxillary sinus grafts are most often done through a Caldwell-Luc approach, whereas nasal grafts are usually done through the nasal aperture. By using autogenous bone, both immediate and delayed implant placement have been successfully accomplished at both sites. l-3 Iliac bone is most often used for sinus grafts, but chin cortex, coronoid process, and alveolar process bone also have been used successfully. However, when bone is obtained from oral sites, delayed implant placement is advocated.4*’ Nasal fossa grafting has been done almost exclusively using iliac bone via a Le Fort I downgraft with delayed implant placement or implant-fixed onlay/inlay grafts6“ To obtain a suitable alternative to autogenous grafting in these regions, allografts and ceramic bone substitutes have been used in an attempt to provide a simple office procedure with minimal morbidity. However, the use of these materials to facilitate osseointegration is dubious because of their much-reduced capacity to stimulate bone formation in the sinus cavity or adjacent to a titanium implant when used either alone or in combination. ‘o-‘3 Various types of allogeneic bone preparations are currently being used in the sinus membrane lift pro* In private practice, Denver, CO. Address correspondence and reprint requests to Dr Jensen: Fillmore Medical Building, 303 Josephine St, Suite 303, Denver, CO 80206. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5004-0019$3.00/O
cedure, with varying results. Demineralized, freezedried, cancellous, allogeneic bone (ethylene oxide gassterilized) has been shown to have only fair osteogenic properties in the sinus or in augmentation applications because of attenuated inductivity, whereas mineralized, radiation-sterilized (2.5 Mrad), cancellous, allogeneic bone has been shown to induce dense bone formation after 6 months in the sinus provided a barrier membrane is used over the osteotomy site.5 When the use of an iliac autograft is precluded, and immediate implantation is done, the latter grafting technique is preferred because of its twofold greater bone inductivity.‘4-‘6 In the highly resorbed maxilla, marked lateral resorption of the alveolus occurs and the jaw decreases in size in all dimensions. A sinus membrane lift antroplasty in this situation exposes a narrow anterior antrum and midalveolar placement of implants will result in penetration directly into the nasal cavity (Fig 1C). Boyne has shown in a cadaver study of elderly edentulous individuals that in the first and second premolar regions up to 80% of the implants engage the lateral nasal wall or penetrate at least in part into the nasal cavity. ” In the first and second molar areas, 50% of the implants showed penetration through the lateral nasal wall. He concluded that in highly resorbed ridges, the transverse dimension of the maxilla is so reduced that the alveolar process tends to line up in the same vertical plane as the lateral wall of the nose. When the nasal cavity is penetrated in this type of situation, the nasal membrane can most oflen be dissected from the floor of the nose through the nasal aperture. However, when the implants are placed pos-
