Sinus Membrane Perforation: What Else Can I Do?

Dr. R, a periodontist, asks:

I have done a lateral window sinus lift , during which I had a significant perforation towards the end of the procedure (I have already started packing bone graft). I decided to repair and proceed. I attempted a repair with a collagen membrane and tried to contain the bone graft. I was not very happy with the result as the graft didn’t seem very well contained, but decided to give it a chance. Patient healed without any complications, but I got very minimal bone (appx 5mm) and more distal than intended area.

I waited about 6mo. from initial surgery and re-attempted the sinus lift. When I opened, I realized that the membrane really never healed and window is still patent with some mushy bone. The sinus also has a septum, which is why the original sinus lift got complicated. I also tried using the piezo for the second one, but since there was already no membrane it was not very helpful.

have done several sinus lifts, but this is my first time to have such a big perforation where the whole membrane is gone and I attempted Pikos technique (both times). The containment was much better the second time, and PA revealed a decent looking sinus lift. However, at 3month post op, the area looks very hazy, with islands of denser appearing bone on PA. The was hoping to see a very radio opaque dome shaped area like we normally do with bio-oss. The bone graft and membrane used were bio-oss, biogide. I plan is to wait for anther 3m and send him for a CAT scan.

I am not sure if there is anything else I can do. Assuming it looks the same, is it worth do attmept another sinus lift. Pt is missing #14,15. Would it be better to get an Implant on #15 area, and attempt a bridge (I understand its not advisable to mix implants and teeth for a bridge). Is there a better way to contain the graft than tacking a membrane to the lateral wall?

7 Comments on Sinus Membrane Perforation: What Else Can I Do?

New comments are currently closed for this post.

sb oral surgeon

3/22/2010

A few thoughts: 1. All patients having sinus lifts in my office get pre-op scans, this way there are no "surprise" septa. 2. A peri-apical radiograph is really a poor way to evaluate a sinus graft result. Panoramic x-rays and scans are much more informative. 3. When membrane perfs occur, you should consider the anatomy of the region when attemtping a repair. It is easy to laterally fixate a membrane. It is the medial fixation (or lack there of) and containment of the graft that must be assured before closing. It sounds like your graft material leaked out medially. Your containment method must provide medial containment of the graft, in order to do this your membrane has to be resting against the medial wall of the sinus. Your membrane tore while you were packing your graft material BECAUSE your membrane lift did not go to the medial wall. The sinus septum can make this difficult. 4. The Pikos technique can work when the regenerative membrane goes all the way to the medial wall. If it doesn't, you will lose your graft containment and your result can suffer. 5. You have operated on this patient twice and still have not accomplished your goal. Do yourself a favor and refer to a friend who has experience with these types of cases. Operating a third time may be insanity. According to Einstein the definition of insanity is "doing the same thing over and over again and expecting different results" 6. If your sinus is not healthy (clogged with lose graft material,) you will not get regeneration of the sinus membrane in 4-6 months as the literature states. While your patient may be assymptomatic, your sinus may be "sick" SCan the patient and refer.

David Nelson DDS

3/24/2010

I totally agree with SB. As hindsite perhaps the Bio-Oss should have been treated with GEM21s. The researchers at osseohealth will tell you off the record that they prefer it over the beta calcium triphosphate in the "kit". I have had great healing in all types grafts but it does add cost. I don't have experiace with BMP (infuse by Medtronic) or PRP, but that may be your ticket. Good luck.

sb oral surgeon

3/24/2010

sorry david nelson, the answer here is not growth factors, it's experience, treatment planning, and anatomy. if your graft is not contained, your result will suffer, no matter what you put in the sinus. thanks for agreeing with me, though.

Reed

3/24/2010

Thank you for the comments. I did get the scan results now, and I have bone mesially and distally, but only about 5mm in the middle of the window. I should be able to do mesial implant with out a problem. I was surely going to refer the pt to another surgeon if it has to be done a 3rd time. I guess I am sane..after all.Its just I was not sure if its worth trying the same thing for the third time with out changing some thing else in addition to myself. The other problem is, I am not sure how to find someone who is experienced with this. In other words, I consider my self 'experienced' in sinus lifts (obviously not after this particular case).I do 2-3/month and have been doing for about 10yrs.I have never had a problem so far with or with out perf. So, I am just not sure how to find someone that can confidently fix this. I do not personally know anyone. Would referring to a University program be better option?

Reed

3/24/2010

Just wanted to add that I have gotten scans a couple of times for this case. While you are right that PAs dont give all the information, they are very good to get substantial information when you dont have a machine in office. And even the scan did not show me clearly that the window is not closed after the first sinus lift. When I go back and look at the scan after I know this fact, I can vaguely see one or two islands (

David Nelson DDS

3/25/2010

Dear SB, When I agree with you that means I think all your points are well taken and very important. Containing the graft IS of utmost importance as you say. I agree with your post! Follow all the steps outlined by you, SB - but is there something else going on? Undiagnosed Diabetic? Postmenapausal female? Growth factors don't compensate for poor technique, rather they enhance healing. I always enjoy your posts. And yes I have a tomographic unit in my office.

Jim Guthrie

4/22/2010

I DO MOST OF MY BONE GRAFTS BUT LEAVE THE SINUS LIFTS TO MY OS BUDDIES. HOWEVER, IN MANY GRAFT WHERE THE GRAFT SITE IS COVERED WITH A RESORBABLE MEMBRANCE I FIND OCCASSIONS WHERE PRIMARY CLOSURE IS DIFFCULT TO ACHIEVE. THOUGHT THE NON RESPRBABLE MEMBRANCE REQUIRE A MINOR SECOND ENTRY, IT APPEARS TO ME THIS COULD BE BENEFICIAL FOR THE GRAFT SUCCESS AND EASE OF SURGICIAL PROCEDURE. COULD SOMEONE GIVE ME THEIR TAKE ON THE NON RESPRBABLE MEMBRANNCE, ITS SUCCESS AND THE PREFERRED TYPE. THANKS JIM G

Sinus Membrane Perforation: What Else Can I Do?

7 Comments on Sinus Membrane Perforation: What Else Can I Do?

Featured Products

Featured Videos

New Posts