Crestal sinus lift complication: thoughts?

How did you visualize the perforation? Did you perform a lateral window? Lateral window would have provided you ample space to cover the perforation with a membrane and continue with your bone graft, implant placement (depending on the size of your perforation ). Thanks for sharing

Hi Dr. AZ I was able to visualize the perforation with high power magnification and light through the osteotomy. I could have performed a lateral window but at that point, I should have discussed this at consultation and gotten consent to go this route if I have complications. Good suggestion. I will mention at all my next consultations that this may be the route if indirect not successful. Thank you for your comments! Dr. J

Sounds like you did a great job - stopped and treated the perforation instead of moving forward and hoping for the best. Predictable with less risk of complications. When will you re enter to place the implant?

Good call... the perforation will heal within 30 some days... I fully agree with Dr. AZ, as I found out way early in my career you should always have included in your complication/ consent form that “certain circumstances may arise during the planned surgery in which an alternative approach may be needed in order to accomplish the planned end result”.. as well, you may have been a little over zealous with the pressure....the Schneiderien membrane, if the sinus is healthy, normally can’t be seen on a CAT scan... and is on average is from .5-.8mm thick.. I would allow 6weeks healing, go in and do a lateral wall approach if there is any uncertainty with doing the CAS- kit approach, and place the implant.

The sinus membrane will heal quickly without the need for PRF or Bio Oss in the osteotomy. In three weeks one can reopen the small crestal access and elevate the now healed membrane with ease and then place the implant. I think the advice to use a lateral approach for a case like this is invasive without benefit. Simply open and lift with saline and place the selected implant. You likely do not even need to place any allograft for a small lift (bump) like this before placing the implant. Keep it simple .

This is a typical complication related to the choice of surgical approach. Do we really need a crestal approach in such a case? Short implant was not preferable even penetrating 1 mm into the sinus?

You don’t need grafting material for a small Summer’s lift. It’s all propaganda by regen companies. Study after study after study have demonstrated that a stable blood clot is all that’s necessary for bone regeneration. Also, once there is a perf I would NEVER place xenograft. If it gets in the sinus, it’s going to likely result in longstanding sinusitis. If it was a small perf, a Collaplug probably would have been adequate. Your nemesis now is since you created an osteotomy, and a sinus perforation and foreign graft material, there is a real risk you will end up with a soft tissue defect tunnel from sinus to gingiva (even though there may not be a OA fistula). Oh, and despite your colleague’s “30 day” line answers; BioOss will hang around for 10+ years once placed. Why on earth would you put this in when you want rapid bone turnover? I use xenograft for the sinus lift when I want long-standing mechanical “lift” (synthetic materials also work well for this). Nobody places xenograft as a type of ridge preservation! You’ll end up with entering mush in 3 months, 6 months , one year. Don’t believe me; ask a reputable specialist that used it in the past - emphasis on used. Converting to a lateral approach from an already-present perforation is absolutely no treat to perform. You usually end up perpetuating the Schneiderian membrane tear and the the only thing to be gained would be the ability to seal the perforation with a collagen membrane from the sinus side without gaining any lift whatsoever. In the future, go back to a traditional Summer’s lift or lateral approach and tell the gimmicks and gags company reps to take a hike. By the way, usually a lateral approach is just as quick as a Summer’s lift plus you get wayyyyy more lift with direct visualization. But to each their own; I’m sure you’re only looking out for the patient’s best interests.

When you have 4mm or more of residual bone height and a minimum of 4mm bone width, you can use Dansah burs to prepare osteotomy and do sinus lift at the same time without the need for a separate hydraulic lift procedure. Check out versah.com for more info.

It is always a good idea to go the conservative route as you did. It does look like there is a piece of root or necrotic bone chip in the palatal root area. I can see what looks like bone loss where a palatal root used to be. The ridge width looks minimal too. I've found in these cases, internal lifts do not work as well with narrow ridges and buccal and lingual defects. I do think you will be successful with an internal lift next time though. If you put the PRF in the osteotomy ahead of the graft, small sinus defects can be repaired also if the membrane is not totally blown or largely perfed. Is the Bioss cadaver bone or equine/bovine? I think cadaver bone is much better. Also using a putty like material instead of a chip is better too. Just my 2 cents

I am a patient that can not find a dentist to help with implants OCO biomedical 5.0 Implants that are hitting my facial nerves and have been causing a lot of pain... They are "out of warranty" and so the  original dentist won't even help... I have been suffering a full-on toothache for a year now... Swollen face since January... I am begging for a dentist to please please please help me.!!!! We live in Florida but will travel ANYWHERE to get them fixed or removed... Please email me at: Email [email protected] Thank you in advance, CJ