Topic

[Surgery]  Closed Sinus Lift


 

This case was treatment-planned for a "closed"/internal sinus lift with a 10mm implant (3.5mm) as there was 8mm of bone height present. Particulate bone (Raptos) was packed in osteotomy site before implant placement.

 

I am not certain about the x-ray taken afterwards. Are you supposed to see the radiopacity of bone and lifted sinus?

 

Based on the radiograph, is it possible that the implant has perforated the sinus floor/membrane? What are the sequelae?

 

 What to do? Do you do an "external"/lateral approach sinus lift/graft? Do you perform the lateral approach immediately or delayed?


by Majid Sherkat at Thu, Apr 26, 2012 7:06 AM

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Mark Kwon Replied at Thu, May 3, 2012 5:10 PM

Hello guys! Sorry for the delay. I agree w dr.jin in regards to Dx and Txplanning. Here are my two cents: 1. In regards to remaining bone height being ~8mm; The appropriate method of elevation would have been SA2 technique (ie. conventionally the use of osteotomes); however, due to the lack of width , I see that you had to use NP implant (ie. 3.5 x 10mm implant) ; unfortunately, this forces you to use narrower osteotome to up-fracture for sinus floor. In my experience, whenever, i perform I like to use osteotome of 3.8mm diameter or wider to safely upfracture the sinus floor; Anything narrower increases the chance of membrane tear. In this situtation, you had no choice but to use narrower osteotome due to the pre-determined decision on using NP implant; As result, it may have resulted in membrane tear. 2. When I am faced in situtation such as this, I like to perform SA2 procedure using CASK technique : use of SAFE-cutting technology and Hydraulic lift of membrane; In my opinion this method is far safer in regards to prevention of membrane tear (You can find more information on video casting section) 3. I am also concerned of the thread design on the implant you have used; I suspect that you may loose bone to the level where the micro-thread meets the macro-threads on the fixture. I find this to be a common issue with ASTRA and Implant Direct fixtures. Hope this helps, sincerely, Mark f from Mexico 'Ola~~' ^^



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Bernard Jin Replied at Mon, Apr 30, 2012 2:20 AM

Hi Majid Good question: Yes & No. Yes - i would consider performing a lateral approach sinus lift if i happened to be certain of a perforation of the Schneiderian membrane DURING the crestal approach. At that point - i would perform a lateral window to see if the membrane can be repaired and graft placed around the implant. No - I would generally not find myself in this situation (i.e. switching from a crestal to a lateral midway during the treatment) because of the prep/work-up we would typically have done to determine if the case is actually a SA2 vs. a SA4 approach. If there was inadequate bone - I would proceed with a lateral window automatically. If you are asking if I'd perform a lateral window (as a salvage attempt) after i notice signs of a non-successful crestal appraoch (i.e. several days to several weeks later), the answer is "no, probably not." In that situation, I'd probably perform an explant, suture the site, place the patient on an antibiotic/decongestant regiment and wait it out till it all heals. Then I'd consider returning to perform a lateral window sinus graft.



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Majid Sherkat Replied at Sun, Apr 29, 2012 11:12 PM

Would you consider performing lateral approach sinus lift/graft at some point ?



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Bernard Jin Replied at Sat, Apr 28, 2012 8:32 PM

On a side note - bovine xenograft will generally always appear radiopaque. I personally prefer to use allo- and auto-grafts.



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Bernard Jin Replied at Sat, Apr 28, 2012 8:30 PM

Hi Majid, Thanks for your post. The radiopacity of the bone graft can also be determined by what type of graft material you used & how densely you packed it. Sometimes - it can be visible if you happen to be using much cortical bone as your graft material. If you happen to use mostly trabecular allograft - don't expect to see much opacity. Allografts generally don't appear radiographically immediately after placement. Nonetheless, I would not worry too much about it as you will likely see opacity developing around the apex of the implant over the next 4 - 6 months. Have the patient return at month 2, 4 and 6. You should be seeing gradual opacity in the image. As for you comment - the implant being 'perforating' into the floor of the sinus. Isn't that the objective of a crestal approach? Our objective is to up-fracture the sinus floor (while keeping the Schneiderian membrane intact). I suspect you may be asking: what to look for in case of a failure/problem. Typical symptoms to look for: sinus infection, congestion, pain, purulence, allograft/purulence being discharged through the nose, postural sinus pain/discomfort If you notice any of this - then you might need to take another film for re-evaluation of the site. If you are absolutely sure you perforated the membrane during the up-fracture of the floor, then you probably need to be looking out for these symptoms. Consider decongestants and antibiotics. If symptoms continue, consider aborting the case (explanting & revisiting the case another day). Hope that helps.