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Chad Denomme Replied at Tue, Feb 13, 2018 4:54 AM

Can someone comment on the post above please.

Chad

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Chad Denomme Replied at Mon, Feb 5, 2018 6:42 AM

Thanks for the Reply guys.

Due to the combination of issues I am trying to overcome here I think I will refer this case.

If my GBR skills were at a higher level I think I would do GBR first and try to improve vertical and horizontal dimensions of the bone.

Doing both at the same time would increase my chances of having complications that could effect eachother. I.E infection of GBR and issues with sinus and vise versa.

Another concern here is the maxillary artery gives rise to the PSA artery, There is in intra and extraosseous branch sometimes detectable on CT.

In this case I believe on the PA we are seeing quite a large vessel which may represent the Intraosseous branch which  is running right through the window location that I would propose for lateral augmentation. If this vessel is damaged during the time the window is being made is it best to crush bone towards the posterior border of the window to stop bleeding.........or electrocautery? How often is this vessel an issue? Im sure many times it is not visible on even a CT but can you comment on complications in dealing with the intraosseous branch. Is it usually running on the surface of the Schneiderian membrane. Based on radiographs does it change the lateral approach planning?

One other comment on the steriods, obviously they help with swelling. I see that swelling is quite pronounced with these patients even the cases I refer. Do steroids make enough of a difference to give them to every patient so long as there medical history allows or is it like trying to take down an elephant with a BB gun.

Thanks

Chad

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Mark Kwon Replied at Fri, Feb 2, 2018 9:05 PM

Dr. Chung pretty much answered all q’s!

yes. Have a Helimend ready (Surgical Smart.com) in case a large tear occurs.

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Ho-Young Chung Replied at Fri, Feb 2, 2018 5:56 PM

Chad.  Thank you for posting this case for feedback from faculty.  You even uploaded a video of the cross section of proposed sites!  That's very helpful (and photos).  

Here's what I can see from your images and cbct.  Sinus augmentation in this case is pretty straight-forward although it becomes more difficult as you approach the posterior 6 area.  Also in the 6 area, the lateral wall becomes more slanted and thicker and the floor is uneven (both will make it more difficult for your sinus lift).  

More importantly, there is both a horizontal and vertical defect in Q2 and you may want to consider addressing this before your sinus augmentation.  Vertical GBR in this case will be most challenging.  Also, there is a soft tissue defect as well.  Answers to your questions can be found in your notes from Bites binder from sinus lift course that Dr. Kwon covered for you in Toronto.  I will briefly answer them here for your convenience.  

1. For any pre-op medications is it preferable to do a prophylactic dose of antibiotics or start her on a full course 3 days prior to surgery.

    clavulin start 1 day before

2.  What is the location of the window or windows and the size

    needs to be big enough for access both vertically and horizontally.  your case will have a bit of a dog bone shape as the floor is uneven

3. Is cortical cancellous bone the bone of choice

    any bone really works in the sinus.  it's a matter of how fast you want bone to turn-over and how long you want to last

4.  I will place PRF membrane and surederm after lifting the membrane before placing bone correct

    you should be prepared to repair any tear as well.  I don't normally use ADM in the sinus.  I like using a stiffer membrane like Helimend

5. Can you comment on flap design here 

    at least one vertical mesial of 24

6. Would perioperative steriods  help with the post op swelling these patient usually experience.

    yes but do not give for anyone diabetic or already on steroids

sinus augmentation is the easy part here.  addressing the horizontal/vertical bone defect as well as soft tissue defect will be much more challenging.

Ho-Young Chung