Packed in More Graft than Needed: What Should I Do?

Anon. asks:
This is my first case of using a lateral window for a sinus lift. The surgery went very well and I did not notice any perforations of the Schneiderian membrane after I elevated it. I packed 3.5 grams of bone graft material into the sinus. When I viewed the immediate post-op panoramic radiograph, I noticed that I had packed in a bit more graft than I really needed and this appears to have obliterated part of the maxillary sinus cavity. The graft is tent shape with the summit at the first molar area. Could this result in any complications? The patient reported some nose bleeding the day after the surgery and I wonder if this could be an indication of a perforated membrane due to excessive packing of the graft material? Is there anything I can do? Should I just observe at this point?

8 Comments on Packed in More Graft than Needed: What Should I Do?

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Nose Bleeding is not necessarely a sign of perforation but can be the cases should check for perforation during the surgery and as long as the sinus seems packed with no dispersion o0f the granules i don't think there is a perforation... overpacking won't cause a problem unless the graft blocked the ostium of the may know where the ostium is on a ct scan...if the nose of the patient is open, don't worry...At least that's what i can say based on your description
Dr tong xin
Don`t worry,perforation is sometimes happened when sinus lift.if you notice it and use a membrane to repair it,nothing will happened.but sometimes we don`t notice it ,nose bleeding and materials can be found in oral cavity.but it will be ok if there is no infection.some of my patients had nose bleeding after operation and nothing i think the most important thing you needed is antibiotic therapy,iv,at least for 7 days,untill the materials is covered by epithilium.
If you review the anatomy, the membrane contains very small vessels, and sometimes manipulating the membrane itself can cause slight hemorrhage. The patient will likely say there is blood clots or blood tinged mucous for 1-3 days. Afterwards, there should be no further bleeding. And its usually a small amount. Also reviewing the anatomy, you've lifted the floor, lateral and medial walls of the sinus. You should not be anywhere close to the ostium. Pinching off the ostium will not create any immediate symptoms, but when the sinus is full, then the patient will complain of pressure, pain sensation. Its like your sink getting clogged. It doesn't become a mess until the water overflows onto the floor. And I will stress, this type of procedure have significant complications which you should be aware of. Some that are benign some that are more serious. By gathering your question, I will assume you have taken a course in sinus grafting and am sure you are proficient in it. But you should also read and learn on potential complications of procedures as well. We tend to learn more from our mistakes rather than our successes.
Excellent advice from OMS. Is the patient on an antibiotic? (I prefer Augmentin for sinus lifts.) Dr. Sohn, an OMS and phd in pharm, has research showing new bone formation in the sinus with no graft material. (See for more info) Personally, I like to use a small amount of collagen foam. IMO, if the membrane is lifted with no perforation and the implant is immediately placed "tenting" the membrane (assuming the implant is stable, of course), no graft material is needed. If the implant is not immediately placed, a graft material (collagen or otherwise) should be used to tent the membrane. The graft material is simply holding the space for new bone formation...almost anything will work and, imo, the more benign/inert, the better. That's why I like collagen foam (collafoam) better than cadaver bone as I think cadaver bone may be more prone to cause infections, especially if the membrane is torn. Sinus infections are nothing to mess around with...if moderate to severe swelling occurs and does not seem to respond to the antibiotic, the graft should be removed ASAP. My .02.
kiran kumar
dr anon,a little amount of nasal bleeding on next day is nothing to long as u are sure of no perforations during surgery and u checked the integrity of the membrane by asking the patient to do a valsalva manouevre or just taking a deep breath, and u see the membrane moving without any bubbles emnating as far as the tenting issue goes it happens when the membrane is not sufficiently elevated from the mesial wall. if there are no symptoms of graft emerging from the nose and no foul smell of infection persistently,u neednt worry.with all the presentation u gave now ur worry is have u elevated the membrane wide enough to form enough bone width (mesio distally& bucco lingually)to place sufficient diameter of implants in sufficient number. a cat scan can help u before u place the implants to evaluate the width (bucco lingual) and length(mesio distal)bone formed in accordance to ur elevation. all the best.
satish joshi
My own observation is that many times a clinician doing sinus lift first few times, is very fearful of perforating membrane or some thing else and dose not elevate membrane MEDIALLY properly,many times dose not even touch the medial wall.So even if your PAN X ray shows too much graft vertically,most probably it may be in the vicinity of lateral wall only.CT scan will show you truth.Good luck.
Ziv Mazor
Nose bleeding after sinus augmentation is quite a common phenomena.Sometimes it correlates to membrane perforation.With patient careful instructions and avoiding sneezing with a closed mouth as well as correct posture these symptoms will vanish. There is no need for overpacking.Probably you raised too much.Usually 2-2.5cc are sufficient for a reg size sinus. The only concern is blocking the ostium. You should define it on the pre op CT scan and avoid geeting there.
dr shabbir
all the best i have similar case and the patient is driving me crazy but i am sure just cover him with good antibiotics