JIACD
The Journal of Implant & Advanced Clinical Dentistry
Sinus Membrane perforation how could I repaired it?
Sat, 04/11/2009 - 14:07 — Dr. X
I had a large sinus membrane perforation and decided to aborted the procedure because I was worried about graft containment and membrane healing. How long should I wait before trying to re-lift and is there a technique that I could use to repair a large sinus tear without having to close and come back?
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Comments
Sinus membrane perf repair
There are a couple of ways to approach this:
1) Do a loma linda pouch technique using tacks and a collagen membrane to repair the tear
2) If perf is to large abort and cover the window with a membrane and wait 3 months and relift again.
Sinus perf
In case of large perfs you can do one of the following:
1)Create a pouch made of a collagen membrane-there are prefabricated collagen bags especially designed for that.
2) Use a titanium mesh to build the compartment and put a collagen membrane on it.
3)Close and wait for 3-4 months and come back again.Make sure to cover the window with a membrane.
Large Sinus Perf: A question for Ziv Mazor
Dear Dr. Mazor,
Thanks for your input. Your papers and research on sinus surgery are some of the best out there.
A couple of questions for you?
1) Who manufactures the Collagen bags as I haven't seen them for sale anywhere?
2) I assume the titanium mesh never gets removed since you are placing it within the sinus. In all cases of GBR with with titanium mesh you remove the mesh prior to implant placement for obvious reasons.
So that being said have you seen any long term complications leaving the mesh within the sinus compartment?
Thanks for your input
Large Sinus Perf: A question for Ziv Mazor
Great post Ziv.
I too would be interested in your opinion to periosurgeon questions?
Consider a Suture-Support technique for Perforated sinus membr
A noted speaker out there shows a unique technique for dealing with larger sinus perfs. Drill 2-4 small holes above your window. Then pass a suture thru the holes and suture it to the medial aspect of the perforated membrane. This creates a superior "stop" of suture for a collagen membrane. Place the membrane against the sutures and then backfill with your preferred graft. Close with an additional membrane over the window (lots of literature shows higher success when membrane placed over window).
Nick.
Large Sinus Perf:a question on Ziv Mazor's technique
Nicholas that technique works really great. I have done a couple of cases like that and has worked really well.
I to have the same questions as perioplastsurgeon on Ziv's technique.
Large Sinus Perf
Regarding your questions on the titanium mesh-it will of course stay there without attempting to take it out.There is no problem for the long term in leaving it untouched.
As for the "Collagen Condom" I have used pericardial membranes with great success pinned to the buccal aspect via titanium pins.OTA came out with a prefabricated collagen pouch for the same purpose. I try to push some of the industry manufacturers to fabricate pre filled tea bags with bone for these purposes...
BTW those of you who would like to have hands on live surgery experience on patients and experience sinus complications management are welcomed to join my course in belgrade Serbia.Details can be found in www.handsoncourse.com
ZIV Mazor Thanks for the Update on Sinus Perf recovery
Dr. Mazor thanks for the update. Sinus perforation can be a difficult scenario if you dont know what you are doing. I do find we tend to push the envelope on this and I notice people are trying all kinds of new techniques to repair large perfs rather then close up and come back a couple months later and relift. The old protocol on large sinus perfs was to stop the lift, cover the window with a membrane and come back 2 months later and relift. Now we tend to do all kinds of new approaches. I often wonder though are we more lucky then actually good. I wonder what the outcome or patient response is when we do one of these large repairs and the patient gets an infection or we subject the patient to chronic sinusitis problems due to interfering with the natural mechanism of the sinus's ability to clear bacteria with a large repair. What is your view of the above scenario? Thanks
Sinus membrane repair: My experience
I have much experience in sinus surgery, the best way to solve the problem, take a piece of gauze moistened with hydrogen peroxide for 2 minutes to pack, cut an oval membrane collagen resorption slowly, placing one of the surfaces with tissue acrylic paste on drilling immediately injected graft material, it gives fantastic results
Another way to do it is like
Another way to do it is like this: Use a large resorbable membrane and place it over the rupture, or if the rupture is so big that the large part of the sinus cavity is visible still remove all sinus membrane of the bone and push it towards the defect. This will also close more the defect after which you lay the membrane over it.
The Bio-oss granules in such an indication have an too big chance to migrate through the whole sinus, that's why I mix it also with Dynagraft DBM putty, in that case the augmentation will likely to stay on it's place.
Regards
Sinus Membrane Removal Post Perf: DON'T DO IT
First off you never remove the sinus membrane in its entirety. Even Dr. Pikos lecture has changed. He said in the past that he used to remove the entire sinus membrane now he refrains from that. Most ENT’s will tell you that when they used to treat sinus pathology it would be routine to get in there and remove all the membrane, now they refrain doing that.
The last thing you want to do is remove the sinus membrane entirely. The Sinus membrane is ciliated. It is well documented in the ENT literature that when you remove the sinus membrane as it heals the ciliated epithelium doesn’t come back. The function of the cilia is to move the bugs out of the sinus. If you remove the sinus membrane, you lose the cilia, so you would then be dooming a patient to Chronic Sinusitis for the rest of their life, which is also well documented.
The Dynagraft is a great idea to reduce particle spread within the perfed sinus.
Sinus Membrane repair: This is what works for me
I use Regenaform room temperature made by Exactech. It is a moldable allograft paste containing DFDBA, Cortical bone chips. This is sticky and holds in place. I mix it with autogenous bone and with PRPGF or blood. Excellent results.
I have used it as a sinus graft during sinus augmentation. The membrane was all torn. Placed the graft and layered with collatape. The graft stays in place. Patient was recalled every other day. Radiographs taken. After 4-5 months placed implants - worked great.
If you believe in god - you need to pray too :-)
Sinus Perf
I totally agree with the statement that he entire membrane should not be removed.Using Allograft putty is of great help- I personlly am a big fan of Regenaform which is an osseoinductive material with a gelatin carrier.
The most important part here is gaining experience and using the right armamantarium in our lifts.Do not use sharp curretes.It puzzels me seeing all those curretes which are sold by different companies...
And yes, being close to god in the holyland does help...
Sinus perforation repair my opinion
Sinus perforations can pre-exist prior to flap reflection. They can also occur with the dental assistant iatrogenically suctioning the thin sinus membrane, fibrous attachments with an irregular sinus floor topography, and surgical tools and technique variation, amongst others. I find extension of the osteotomy margin to be the simplest method for getting beyond the perforation without making it larger. The extension can provide for sound reflection (if it is not being aborted) with sinus curettes. I hope you find it helpful.
How did you get your membrane
How did you get your membrane perforated? I am interested in that because I think I have it too as I recently confronted a severe form of sinusitis. I am not completely recovered, I need to take the treatment until the end, this way I make sure the sinusitis doesn't come back.
Sinus membrane perforation: Wait 3-4 months and go back.
If you had to abort you should wait about 3-4 months then relift. The membrane should be thicker.
I usually never abort I usually repair. A sinus tear can usually be repaired using a collagen membrane. I usually use a pikos technique and tent in the membrane or tack it like the loma linda pouch.
Tom
Wow, 3-4 months is a long time.
Most people I know only wait 6-8 weeks. 3-4 months seems a bit long, but a little extra time is not going to hurt anything.
Remember, epithelium grows rapidly. Even if the tear is large, it should heal and mature quickly, espically in the closed environment of the maxillary sinus.
I do agree that most sinus perfs can be repaired.
3-4 months not long depening on how big the Sinus tear is.
The greater the perf the longer I wait for healing. If it is small Ill go back earlier.
Brooke
Misinterpreted
I read now that my statement of removing the sinus membrane is misenterpreted, sorry for the confusion.
I ment continue elevating the membrane and of course try to keep it intact as possible.
Misinterpreted
I read now that my statement of removing the sinus membrane is misenterpreted, sorry for the confusion.
I ment continue elevating the membrane and of course try to keep it intact as possible.