Lateral window sinus graft: preferences?

I have been placing sinus grafts for a few years now. I am curious about preferences for graft materials short of PRP. I do not use PRP and have been having success with cortico-cancellous bone and sterile saline. I have also been incorporating clindamycin into the graft material for prophylactic reasons following the suggestion a few years back by someone I cannot presently recall. I would appreciate any suggestions that follow and am willing to try anything that has merit. I realize there is no standard “cocktail” but I’m always wanting to explore all options and why. I have a lateral window coming up next week and will post a CT if needed. I’m fairly conservative and have been successful with one major failure that probably stemmed from a medical issue and not the graft components themselves. Thank you kindly in advance.

25 Comments on Lateral window sinus graft: preferences?

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Joseph Kim, DDS, JD
2/15/2019
1st layer - PRF membrane against Schneiderian membrane; collagen foam or tape if PRF not available. PRF seals any tears, and provides a cushion for sharp and pointy particulate graft materials. Collagen foam does not seal tears, but does provide a cushion. 2nd layer - bovine xenograft, 0.25-1.00 mm diameter, hydrated in PRF liquid, if available, against PRF membrane or collagen foam. This provides a very stable long term floor of the elevated sinus, especially if implant placement needs to be delayed. 3rd layer - mineralized, 0.25-1.00 mm diameter cortical, hydrated in PRF liquid and mixed with any autogenous chips, if available, against medial wall, prior to implant placement. Then, backfilled to window after implant placed. Fast turnover, allows implant uncover in 4 months. 4th layer - cell occlusive collagen membrane against window, or over a GBR ridge augmentation. Prevents soft tissue invagination and results in a smooth bone surface. 5th layer - dense PTFE suture with deep apical mattress (horizontal mattress 10 mm from wound margin) to "smush" membrane against bone. Interrupted and/or continuous sutures to close wound, place close enough to prevent any blood from coming out of the site, ensuring saliva doesn't going in. * IV/IM clindamycin added to graft if any visible tears ** 2 gm amox or 600 mg clindamycin, 400 mg ibu, 1 hour preop dose *** amox or augmentin (tears), or clindamycin regimen, afrin/sudafed decongestant, norco 7.5 (12-20 depending on extent of flap) postop
Dr. David Morales
2/15/2019
I have been using Perioglas for eight years on all my lateral sinus elevations with great success. I do not use a membrane just the Perioglas. Even when the membrane tears I do not place a membrane, I place the Perioglas only. I have had great success with it. A maxillofacial surgeon introduced me to it. It is all I use. RX amoxicillin 500mg 3 x day for 7days. I save clindamycin for when there is an infection, not as a prophylactic tx.
Paul
2/15/2019
And what is the scientific foundation to the above stated protocols of sinus lifts?
Joseph Kim, DDS, JD
2/15/2019
The protocol I stated is what I currently do in my practice, in fact 4 sinuses in the past week. Is there something you can cite to contradict anything I’ve written? The literature supports my protocol. PRF used in sinus grafting has plenty of citations. Allograft and xenograft are also well documented. Wallace has multiple papers on the use of bovine xenograft, along with the suggestion for collagen membrane when using xenograft particulate to prevent soft tissue invagination. Personally, I see the same problem with allograft. Particle size is my personal preference for handling. PRF exudate may lack scientific basis, but is not harmful, and contains growth factors which can’t hurt. Adding IV antibiotic with anaerobic coverage is mentioned by Choukroun, et al. Deep apical mattress suture is a mechanical alternative to bone tacks. Hope this helps.
John Beckwith
2/15/2019
I follow Misch protocol as it sounds you do. Collagen membrane w .2ml clindamycin (150 mg/ml) and allograft w .8ml clindamycin. .Prf for a tear and Under flap closure No problem 10 yrs
Paul
2/15/2019
This look like a recipe from a cook book. Self proclaimed guru said and everybody listened. Very much like everything else in dentistry.
Joseph Kim, DDS, JD
2/15/2019
What’s wrong with cook books? Also, are you accusing me of proclaiming to be a guru?
Manosteel
2/16/2019
Cook Book? I was one of Carl Misch's grads. He might have not known it all but he was the worlds formost authority. His program was like post grad only without the daily insult and demeanor. By the way that method does work!
John Beckwith DMD DABOI
2/16/2019
Agree.. thank you. If it weren’t for dr Misch 90% of us would not be placing today and another 5% would be causing harm.
Paul
2/15/2019
Cooks books are good in the kitchen. We have to understand the basis of what we do because we are either pretending or we are professionals. I strongly encourage you to look up Dr. Martin Chin from San Francisco and his statements on the way we practice without understanding the biology behind it. Dr. Chin explains in his lecture series "Embryomimetic Regeneration." He is much more eloquent and knowledgable than I could claim about myself. With regard to "guru" i did no mean you but some names that were quoted. Sorry for the misunderstanding.
Joseph Kim, DDS, JD
2/16/2019
I agree with your general premise, however, most of our colleagues will always be better clinicians than scientists. While I would love to see doctors opening more books than flaps, this is just not the real world. As you know, no individual step of the procedures we do is particularly difficult, yet neglecting any one of them will significantly increase the odds of failure. Thus, I prefer to teach a cook book starting point, to encourage them to get in a checklist mindset. Over time, most begin to see the importance of reviewing the literature, or at least investing in a well edited book, but in the mean time, it helps them provide some semblance of predictability for their patients, who would otherwise suffer from their inexperience. Having said that, we should all view the claims of the experts in our field with some degree of skepticism, recognizing the inherent limitations of the art and science of this field, which is plagued by practical limitations such as tiny sample sizes, a dearth of prospective studies, short follow up periods, and significant corporate sponsorship. It is wise to ask ourselves if the information we are hearing is directly benefiting the person who is promoting it.
Dr. David Morales
2/16/2019
Dr. Kim thank you for your post. Fantastic responses! It is a great profession! We are blessed to be helping patients daily. I do have follow ups with my patients because I place and restore the implants. My first lateral sinus elevation utilizing perioglas was my mother! Eight years ago! She was 72 years old at the time. She is doing great with three implants #2,3 and 4 . We all have different protocols because we all have trained under different doctors in different countries! So I believe if you have had success with your technique then keep using it. Our education never stops, with new technology we must continue evolving and creating better treatments for our patients.
John Beckwith DABOI/FAAID
2/15/2019
Please be specific w “guru” . Big problem w Dentistry is everyone has an opinion rather than facts backed by clinical evidence. I prefer to base clinical decisions on documented clinical success.
Dr. Bill Woods
2/15/2019
I forgot to mention that I use a collagen membrane against the Sneiderian membrane as learned from Dr Pikos course and Dr Rutowski at his AAID course in Dayton. I also use another membrane against the lateral wall and suture periosteally before closing. The clindamycin is of the injectable form. I’m still interested in your graft components. Thank you all kindly for your input. Bill
Dr. Gerald Rudick
2/16/2019
The Schneiderian Membrane is a very fragile membrane, and must be respected as such. When possible, PRF is an ideal "patch" to repair a tear in the membrane, as it bonds directly with it, and is inexpensive...however, as experience shows us, it is not always possible to draw blood from the patient in a dental office, so a substitute a collagen membrane will suffice, and it is always better to have a "cushion" against the membrane to prevent sharp pieces of the particulate grafting material from doing further damage as it is packed into a defect.
Paul
2/16/2019
D. Kim, It looks like we both give some thought to our profession. I greatly appreciate your response because this was my intent in stimulating learning not looking for recipes. My feeling is that we need to strife to be true to the title we carry or otherwise we are merely technicians and that is why dental schools are separated from medical schools. In some countries dentistry is a specialty of medicine called stomatology while here it is a craft starting with dental schools and continuing throughout the years we "practice". I agree that a recipe is better than using Reader's Digest as a guide.
Dr. Moe
2/17/2019
Paul, I disagree with your impression of Dentistry especially, "here it is a craft starting with dental schools and continuing throughout the years". I DO believe Dentistry is a specialty in Medicine, specifically oral medicine whether it's classified here as such or not. I think Dentistry as a technician is more of a layman's impression of what dentistry actually is in this country. And I believe you do the profession a disservice if you don't clear that up with your patients, as I do on a daily basis. Would you consider surgeons/doctors in any other medical field, technicians? No? Do they have to account for patient's well being? Yes? Similarly, Do you not take a patient's medical status (meds, complications, possible med interactions before prescribing) into consideration before proposing surgical vs. non-surgical options? Because if you do not, and if you don't use medical science about healing, and don't provide pharmaceuticals for infection and analgesia basically manage the patient throughout, I guess you are a technician. In that case, anyone can take the tooth out. Since, I believe most of us do all that and then some more to help our patients' overall health, I Do Not consider Dentists to be technicians, only That's a very narrow worldview of the people who are not dentists. This comment is not written with an admonishing tone but just highlighting that We gotta stop looking at ourselves just as tooth docs, otherwise Yes, like other commentators have said in other blog post, we are just tooth jewelers. But we in practice actually know, it's a lot more than just white teeth.
Paul
2/17/2019
Everyone is entitled to their opinion. Everybody has different expectations of himself and the people who seek out our services are entitled to their as well. Oral surgeons spend as much time doing their training as general dentists do in their general dental education. One has to be honest with himself and accept that we received four and sometimes three years of education that could be condensed to a maximum of two (in my humble opinion). We are called doctors to make us look like the accepted term doctors for the sake of dealing with the general public. As a comparison, I suggest, there are many fields of study like engineering that in comparison to dental education graduates should be receiving Phd degrees after 4 years. Obviously some of us make up the deficiencies from dental school and continue to learn others dedicate themselves to earning a living or making money. It is mind boggling that in the United States someone comes out of dental school and is allowed to practice unsupervised. Does that system really work? We use to be able to administer sedation and killed a few people without any extra training. Doesn't that say something? Even today, the requirements are still very lenient and very dangerous.
Joseph Kim, DDS, JD
2/17/2019
While I agree that the rigor of engineering is in many ways greater than medical fields, their expertise is limited to a narrow focus. I would have to disagree with the suggestion that undergraduate coursework in engineering is equivalent to a PhD, from my experience with my in house laboratory technician, who holds a mechanical engineering degree, with honors. The short response to your observation that many dentists are underqualified, is that the US system allows for a range of quality, so long as it is clinically acceptable. Thus, C- work is legally acceptable, and should be associated with a lower fee, while A level work should command higher remuneration. Treatment that falls short of the standard of care can be dealt with through civil litigation. In my opinion, it takes approximately 5 years for most dentists to gain enough experience to provide high level dentistry. Prior to this time, I advise young doctors to find a mentor and be very critical of their own work. Having said all that, let's try to stay on this thread's topic of sinus grafting advice.
John Beckwith DMD DABOI
2/17/2019
I knew I should of been a barber and pulled teeth on the side... I think u should find another field of study and do not pull Dentistry down with you. Im embarrassed to share the DMD/DDS title with you. Maybe a Denturist is better suited for you. I personally worked hard for 32 years, took on mountains of debt and continue to distinguish myself through CE. You have done the opposite and have issues.
Paul
2/17/2019
Mr. Beckwith, This is a typical answer of someone I had in mind when I wrote the comment. All you can do is exhaust some steam. I have practiced dentistry longer than you have but that does not blind me to the problems of dentists and dentistry. I have no doubt that you have distinguished yourself in a way that only you know how.
John Beckwith DMD DABOI
2/17/2019
Mr Beckwith??? Excuse me paul but u are once again stepping on toes. Get with it or stay out of the conversation
Paul
2/17/2019
Mr. Beckwith, It is not the purpose of this forum to have some personal bickering go on. Out of respect for others, I will end my presence with regard to the subject.
John Beckwith DMD DABOI
2/17/2019
Ok MR PAUL Good luck
Dr Bill Woods
2/17/2019
My original request to gather opinions on grafting components has certainly taken a left turn. Please adhere to my original request and reserve your interactive opinions to each other in another venue. That is serving no purpose. Now, back to the topic, what are your thoughts on what you are using- recombinant BMPs, gems, xenografts, allografts, Puros vs mineralized and demineralized bone, TCP, antibiotics, and/or any combinations thereof that may be useful to consider. It is my understanding that the literature is replete with various outcomes and there is no real “ sinus graft cocktail” as stated earlier. I’m interested in what is used and why and the results of your professional endeavors in that regard. I love the exchange. That is what makes this sight great, in my book. Thank you, Bill

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