[Surgery]  Lateral Sinus

This is in response to the latest reply regarding SA4 Lateral Sinus Augmenation.

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.



by Chad Denomme at Fri, Feb 16, 2018 7:09 AM

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Ho-Young Chung Replied at Sun, Feb 18, 2018 9:28 AM

Good decision Chad.  Dr Jin answered everything.  I have seen and treated cases with larger intraosseous arteries (seen on cbct) but yours shows up on PA.  mind you I take cbct and Pano usually.  

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Bernard Jin Replied at Fri, Feb 16, 2018 9:10 AM

Hi Chad

Your observation is typical of the PSA.  It usually sits attached to the schneidarian membrane if you are able to dissect it from the bone.  Sometimes it can be embedded within the cortical plate itself.  Yes - often we encounter it when performing the osseous removal.

Bleeding management?  Pretty much all of the above.  However, the best practice is not to severe it to begin with.  Incidence of the bleeding varies on clinician's experience and approach; for me, the bleeding is an issue maybe <10% of the time.  If you perform very delicate window preparation, often you will notice the vessel move with the membrane as you lift it.

Steroids - well - that's controversial.  My IV sedation mentors were never proponents of it.  Oral surgeon mentors were.  I take it as a case-by-case basis - if the medical history permits it.  Steroids WILL minimize the inflammation for only a few days - but the inflammatory process still occurs... maybe distant enough for patient to blame you/the surgery.  LoL. 

Hope that answers your questions :)