DDSGadget

OsseoNews Staff

In what circumstances do you prefer vertical mattress sutures?

<p>After sinus augmentation the tissues were open. Now there is not enough tissue to close this gap. Any ideas?</p>

How to close this gap after sinus augmentation?

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I understand that you did internal sinus lift and you perforated the sinus and the area not closing. What you need to do is to curet the area to cause bleeding then releasing incision this way you can obtain more than enough tissue to achieve primary closure. When you do this you need to apply mattress sutures. The number one goal is to achieve blood clot.

Another way is open the flap, place resorebabel membrane over perforation and follow with releasing incision, etc..

How can you start a surgery when you don’t know how to cope with complications, release a flap….. 
Have you been to a course? Participated to hands-on?
What would you answer if you were sued?
That you looked at a video on Vumedi or Utube with no scientific commitee Wheeler you can find some of the most ridicule us surgeries, neglecting all the litterature?
Extremely sad but very common nowadays 
P. Russe

It looks as though you have created an oro-antral communication (OAC).  Have you performed a Valsava manoeuvre to check for antro-oral air escape?  Does the patient report oro-nasal fluid escape?  If so it needs surgical closure as soon as possible.  There are various techniques but a standard buccal advancement flap - a so-called Rehrmann flap - would be the simplest approach.  If you don't know how to close an OAC please refer to an oral surgeon a.s.a.p.  Don't try to close it yourself and refer it to an OS when it all falls apart again.

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Plz ck uploaded image. Make an incision accordingly. Elevate the flap. Release the flap for primary closure. Place membrane over the exposed area. And close with appropriate suturing technique. Hope this helps.
Most of us learn with failures :-)

Oh boy! 

We all need to learn, but to be caught (in this very basic situation) unable to close a flap is concerning. Is the patient still in the chair waiting to find out what advice you got online?

You really do need a little more education prior to lifting that scalpel.

Cut periosteum or place dermal allograft or buccal fat pad graft

Hello everyone 
First of all this guy is seeking help over here and not be criticized or crucified,
The nerds who posted negative post never gave any advice on how to help with the situation, your presence in this platform is useless and unnecessary 

To go back to the main issue 
You have what we call OAC ( oro-antral communication) , two ways to approach it
1- advanced buccal flap , one doctor has illustrated it with a post previously 
2-palatal pediculated flap where you rotate a flap from the palate and cover the communication 
 Place the patient on antibiotics/ antihistamine accordingly and follow up

Good luck Doc

THOSE WHO NEVER MAKE MISTAKES, NEVER WORKS ENOUGH!

Consider this...surgical approach with advancing flap will work; however, this is much simpler....curette, establish significant bleeding, place mixture of Calcium sulfate and Tetracycline, and place cyanoacrylate on top of this and wound edges....almost guaranteed to work...the fibroblasts love the calcium sulfate and cyanoacrylate...should see rapid epithelialization and healing....good luck!

The gold standard for closing an OAC is to suture the Schneiderian membrane tear. All other solutions, while viable in some cases, are second-best. That's not to say they won't work, just that they can be unpredictable. IMHO, referral to an OS would best serve the patient's best interest long term, as well as yours. If you're in the US, you may have to answer to a lawsuit and, if you're a GP and did not refer to an OS, that's about the worst thing you can do. Mistakes and accidents happen to all. However, how you handle them is crucial. I don't know the extent of your general surgical training or expertise, but my instinct tells me that if you had to come on here to ask for advice, you don't have the experience to advance a palatal pedicle flap, or perform any of the other suggestions given -- all valid, but not always free of complications. Do the right thing and refer the patient to a good Oral Surgeon ASAP. An active, open OAC must be closed as soon as possible, or the infectious complications can take a long time to heal. Your patient will thank you, your peace of mind will thank you and, most of all, your career will thank you. We can all run into difficulty, but it's knowing when to back off and refer to the specialist that makes the ultimate difference. "Don't try to be a hero" are golden words.

Dr John M ,
I am doing this since 2005.The reason I upload this case is to get some ideas and not to be critisized by someone I do not even know.I have done all by the protocol but I stuck in this situation.Therefore I tried an advance flap or mattress sutures but I got this again.I think that the reason of this is the buccal loss of bone .

Colleague, from this description and from the picture, do not understand how the condition of the sinusitis is before and after the intervention. Whether the process is active before or now the solution is different. Show the x-ray!

Could you please give more detail of your case?  This is not a difficult situation to treat, but it would be helpful if you gave more information.  Thank you.

I actually had a very similar case referred to me recently and what I ultimately did which solved the problem was quite simple. Make a crestal incision to allow an elevator in to release the buccal and palatal tissue. Place a collagen wound dressing (Colla Cote/Colla Tape etc...) over the perforation to stabilize a clot and then cover that with a PTFE membrane. Suture with whatever material you desire and after 3-4 weeks you can simply remove the PTFE and you should discover a nice epithelial lining perfect for continued healing and maturation. Or you could refer...

I understand that you are seeking help but to assume that an OA communication is the result of "loss of buccal bone" is really concerning... I am not saying this to be critical. This should be a reminder to all of us on this forum, myself included, that it is ok to refer as we don't need to be "Super Dentist".

Also not meaning to be hyper critical....But I agree with Tim Carter....Being a "Super Dentist" is not the way to practice.  This is a classic Oro-Antral communication.  Sinus lift procedures are for Periodontists and OMFS.  This probably needs a Buccal fat pad graft to close and should be referred out to a specialist ASAP.  Being a specialist, I live by the words that a procedure should NOT be done if you are not able to handle the potential complications.  NONE of us are infallible, but knowing and realizing our limitations is not only a good thing, but it will keep you out of litigation and off the Radar of your State Board.

So much can be done with adequate flap design.  I’d use PRF also to close communication.

I would like to mention and get clarified a few things for educational purposes. 
1. Is it supposed to be an internal lift?
2. If so, I trust it is contraindicated since the crestal bone width is minimal, about 1mm. 
3. Still, assuming that you tried internal, did you place a membrane plug to protect the membrane and bone graft for the augmentation?
4. If yes, is the bone graft spread in the sinus cavity?
5. Why is the incision open at the distal part, far away from the communication?
6. is the patient medical free?

In my opinion, better approach would be:
1. Lateral window
2. Membrane elevation and if possible repair with stitches 
3. Whether no. 2 applies or not, cover of the Schneiderian membrane with collagen membrane and prf. 
4. bone substitute
5. one more membrane above the crestal bone 
6. periosteal release and stitches. 

Please correct me if I am missing something.

Your post sinus augmentation does look kind of strange. This doesn't look like any sinus lift i have done (i perform lateral/vertical sinus lift regularly).  you don't have any vertical release to access the buccal.  why is your osteotomy window towards the occlusal? were you attempting a vertical or lateral window sinus lift? If your sinus floor is <2mm, you should have done a lateral window.  Unless your very proficient with Desah burs to perform a vertical sinus lift with <4mm of sinus floor.  You don't have to be specialist to perform sinus lift. You just have to perform at specialist level.  

The correct term is OAF (oroantral fistula).  Please just flip through Atlas or Contemporary for reference.  to "REPAIR" OAF after extraction. diameter 0-2mm observation; 2-6mm collagen plug and stay suture; >6mm primary closure (some kind of flap).  

but i am assuming your plan is to place dental implant after sinus lift. You have basically 2 options. 1) no graft or 2) graft. 
1). vertical release buccal flap.  you can place a collagen membrane over the bony defect.  score the periosteum to achieve primary closure and let the membrane heal. return after 3-4 months to try lateral window sinus lift. by then the schneiderian membrane would have returned for you to try again.  can't really "suture" the sinus membrane.  just have to let it heal and regrow to cover the sinus walls. 
2) make an envelope buccal flap.  make the window bigger.  Use tacs to secure Mem-Lok and swing the membrane into the sinus cavity to create a new sinus floor.  place graft.  place another collagen membrane over the lateral window. then primary closure.  take Dr Pikos sinus lift course. he teaches this technique.  

With your complication and assuming pt's sinus floor <4mm, missing both molars and premolars (large span),  i would have done a lateral window sinus lift (easier and faster).  I am curious how you performed this sinus lift.  your incision looks like it was healed before and somehow you punctured into the sinus.  doesn't look like you performed a flap.  I don't see clean incisions of your flap. 

anyway hope this helps.  good luck.

1.  The correct term is oroantral communication - OAC.  The walls of the opening had not yet epithelialised when you took this photograph.  However,if it hasn't been repaired yet your patient may have developed an oroantral fistula (OAF) by now.
2. Do not try to suture the Schneiderian membrane tear.  The gap is too large and the membrane is too fragile.  It is simply not possible and you will merely make the defect larger
3. No need for a plug of buccal fat pad.  Moreover, there are large vessels in this area of the buccal sulcal reflection and you run the risk of a haematoma.
4. Avoid putting any foreign material - dermal/collagen allograft, bone substitute, calcium sulphate, PDF, etc - into the hole. It isn't necessary.
5. Avoid a palatal transposition flap.
6. At the end of the day this is a fairly small defect which can be simply and expeditiously closed with a standard Rehrmann pattern buccal advancement flap.
7. Finally and most importantly, please don't have a go if you don't have the practical experience.  It's much safer to refer to a specialist and I hope you will have already done so by now