How to close this gap after sinus augmentation?

Neil Zachs comments:

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.

Michael_T. DDS comments:

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.

CONAN TENG DDS comments:

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 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

John Townend comments:

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

WJ Starck, DDS comments:

This is easier to fix than you might think. Forget about all manner of advancement flaps and the like - a lot of times the will break down and dehisce and you'll find yourself in an even deeper hole.

The fix is a pedicled buccal fat pad graft. This is done by making a generous incision in the area of the posterior vestibule on that side. Enter the buccal fat pad space with a curved hemostat and spread. The buccal fat will start herniating up through the incision. Grasp it with the hemostat and gently tease it forward. If it won’t advance spread more in the space with the hemostat.

Then reflect a flap by making sulcular incisions on the side where your defect is. Reflect that flap and pull the pedicled buccal fat forward until it covers the defect. Suture it in place with horizontal or vertical mattress sutures. Pass the needle through the gingiva then through the fat pad, then back through the fat pad and back out through the gingiva.
About 2-3 mattress sutures should be sufficient. Then close your gingival flap. Tight primary closure is not necessary and best avoided so as not to restrict blood supply.

The graft can either be inlaid underneath the flap as I just described, or placed on the outside depending on the location and size of the original defect. If it’s outside it will look pretty funky for a few weeks as the body necroses the bulk and contour that the area doesn’t need. So let your patient know that this is expected.

Over the next several days and months, gingival epithelium will migrate over the fat pad and the entire bulk will remodel. It’s remarkable how good the body is at this, and I’m often surprised when I look -at these in a few month’s time - it looks like nothing ever happened.

I have used this technique many, many times to close very large to smaller dehiscences and sinus perforations. Because it is pedicled it mantains its blood supply which is everything in the world of wound defects.

Greg Kammeyer, DDS, MS comments:

I always find it amusing that some specialists never ask for help or do things by the book. My daughter had an OAC (that he created) that the OMFS left open for a year. To his credit, the hole closed substantially yet I had to close it which left some nasty PO symptoms. One of my local OMFS/MD's won't do ameloblastoma's yet will do face lifts. If we are not working together than how can we grow? esp when some one needs help.

Personally I like a rotated CT pedicle graft with a buccal release flap to have bilateral layered closure. Buccal fat pads work well yet it is connective tissue, keratinized tissue and bone that are missing. I prefer to replace what is missing.