I plan to place an implant with an external sinus lift in this region. The patient has mucosal thickening that has existed for 6 months. How would you proceed?
In all honesty I would proceed by referring this patient to someone with enough experience to handle it but beware because a lot of the folks with the skills and experience may no longer want to mess with it. I was on a call with a referring doc last week and we were discussing a complicated case which 5-10 years ago would have seemed like a fun challenge and I would have jumped right in. After years of dining on humble pie I have learned to stick with predictable procedures in which I can improve my craft. Without all of the details I really can’t speak on this case as it may actually be a simple sinus augmentation followed by a single implant in which case I believe that any experienced and capable clinician would just proceed. Since you are asking this question via an internet post I would suggest a referral to an experienced surgeon.
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I have been treating resorbed maxillae for 28 years via the lateral window (Caldwell Luc sinus graft approach-an SA$ in this case), and also received training at Loma Linda University, where Dr Phil Boyne claims to have discovered the procedure in 1955, which is before Tatum published on it. I note several things with your question that I’ll encourage you to consider:
- The Osteomeatal complex (OMC) doesn’t show in your radiograph. Standard of care includes that critical structure must be patent. It drains and allows the dead bacteria, cells and graft particles to exit and not cause/allow infection. You’ll want a full sinus CT and have someone that understands sinus anatomy to analyze it. It should be cleaned out before a graft. The sinus with minimal thickening is the most thickening you’d want to accept, yet OMC patency is critical.
- When doing this procedure, you are filling the bottom 1/3rd of the sinus with bone, and pushing the thickened lining caudally, which tends to block the OMC’s ability to drain.
- The whole sinus gets inflamed with this surgery, so the OMC gets more easily blocked that way too, especially when you have NO room for either to risk blocking it…which leads to sinus infection and graft failure and other nasty things. There are more steps to preventing blockage that are standard with this procedure that you’d learn in training.
- The simple answer has 2 parts:
a) refer the patient to an ENT. No matter what the OMC and sinus volume would show on the CT, this is too much tissue to risk blocking the sinus drainage.
b)
I could write a lot of basic principles of treating this area, but it’s evident you would benefit from more training. I recommend Dr Mike Pikos course in Florida. If you go somewhere else for training, be sure to get at least a 3-day course or preferably training at 2 locations and either way buy a book on sinus grafts as well. sadly, my advice also extends to SA2, Crestal Sinus Lift’s to a lesser extent, as well. I too have had my share of humble pie and with these cases, it is a matter of how much you know about what you are doing and how to manage complications.
If you feel you have done the above due diligence, and want to talk about the case, give me a call at 623-256-8686 after 4:30 MST M-Th.
Respectfully,
Greg Kammeyer, DDS, MS, DABOI
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SA 4 approach after ENT treatment, as the residual bone density is too low for an SA3 approach.
You have apparently attended some much better “hands on” training courses than I have as I would never recommend anyone introduce a new procedure into their practice based on a weekend with an expert. The courses I have attended (Chao PinHole, Ridge Splitting at the Meisinger High Altitude meeting, LANAP Training etc…) have all been just enough to convince an untrained observer to carry a hammer and see everything as a nail. They all have a tremendous bias and rarely concentrate on basic principals while focusing only on Dental Economics. While I have learned a great deal from all of these courses it is important to understand that I was already performing traditional soft tissue grafting prior to attending the Pin Hole, I was already doing ridge augmentation prior to attending the Ridge Split, and I was already performing conventional periodontal surgery prior to attending LANAP training. I agree with everything that you have suggested although I would caution anyone who attends a “hands on training” without an acceptable level of training prior to the course to hold off until you understand the principles of the anticipated end result prior to taking your new hammer out of your belt. Just a suggestion from an old conservative.
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You didn’t show the whole sinus CT view. Most likely just a retention cyst. you can remove it while doing the sinus lift. I’ve removed plenty of these. I would either go in after 2-3 months of healing. Or if the perforation is small i would just repair w/ collagen membrane and subsequently place allo/xeno graft mix and close it up. We all start with baby steps and escalate to more advance techniques. Unless you’ve gone through perio/OMS training you wouldn’t have had experience doing these surgical techniques and have to learn from a “hands-on” 3-7 day course. Then practice on your patients from easy cases to more complex cases. No one knows every procedure under the sun. we all have to learn from the bottom. But i do recommend if you don’t feel comfortable doing said procedure best to refer out to more experienced practitioner but doesn’t mean they are any more successful.
Having done more than 4000 implants in the last 15 years, this is one of the best pieces of advice I have seen on any board. Thank you Doctor.