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rroque29 posted an update
Hey guys first time post. Ive bren trying to learn more about implants and doing my best to get better and better as a clinician.
The other day I placed an implant and tried to do a crestal sinus lift using the densah burs and allograft. The CBCT showed that i had about 6mm of bone till the sinus floor at site of the first molar. So I decided to place an 8mm implant. Unfortunately my angle was a bit off and my “dome” of bone isnt as clear. Did i perf the membrane? I dont have access to a cbct so i was unable to take one post op. Any thoughts or recommendations for the future?
Ill include 1) preop, 2)osteotomy with attempted sinus bump and 3)final photo.
Erick and Ivan11 Comments-
Hi @rroque29 great to see you on here!
What makes you think you perfd the membrane?
Did you feel when you broke the floor of the sinus?
Would love to hear what you guys think, @jostanger @mickyfrick
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@ivan-chicchon Hi! I can’t say for certain if you perforated the sinus or not (the PA’s aren’t clear to me), but implants can be placed up to 2 mm beyond the sinus floor, and the Schneiderian membrane typically heals well around the implant apex. Since you’re at 2 mm, you’re within range and I think your patient will heal uneventfully.
Perforations happen, and I’ve had my fair share of them, but it’s not the end of the world. Most of us aim to provide the best outcomes for our patients. Personally, I’ve found most perforations often occur during the initial breakthrough of the sinus floor or when over-condensing graft material without closely monitoring depth. I’ve also found that adding smaller pieces of collagen plug or collagen tape into the osteotomy during the breakthrough and initial lift has significantly reduced perforations in my hands. It seems to act like a cushion.
Signs I’ve had a macro perforation:
1. A lack of resistance when condensing the graft, as if the graft material just falls in.
2. Patients reporting fluid in their nose, indicating irrigation saline is passing through the perf.
3. Suctioning at the osteotomy and the patient feeling air in their nose.
4. A blown-out dome or overextended graft on a PA image.
5. heavy congestion. dome is gone and a complete lack of density at the 2 week follow up PA.
To manage patient expectations, I explain during the consult and informed consent:
“Have you ever cracked an egg and seen the membrane inside? Sometimes sinus membranes can be that thin, making them more prone to rupture. I won’t know until I go in, but if the membrane is too thin to hold bone, the best approach might be to let it heal and re-enter in two months. This allows scar tissue to thicken the membrane, creating a stronger foundation for the graft.” This has definitely saved me from some awkward conversations.Question for others in the community, What’s your tolerance for perforations? If you experience one do you attempt to clean the site out and reenter later? do you carry on and modify your approach?
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@mickyfrick dude…what an amazing quality reply brother. Thank you for sharing with us! 🙏🏼
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@mickyfrick Wow thank your for an amazing response. Lots to learn from that. I was doing my lift with the Densah burs. When you place collaplug or collatape before the initial breakthrough are the motor settings the same? Do you have irrigation on?
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@rroque29 I want to upvote @mickyfrick ‘s response —but our site doesnt have that function 😢 lol
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@rroque29 happy to help!
I’m usually going CCW, 800RPM, with irrigation. 2mm drill to the floor. You know when you hit the floor cuz it will suddenly feel very dense. that’s the cortical bone of the floor. In the posterior, I’m usually placing a 4.6mm or 5.2 mm implant. so I’ll expand the osteotomy 3.0mm, 4.0mm, and maybe 4.5mm. As I’m trying to break through the floor with 4.0mm (CCW @ 800RPM) you’ll feel the drill start to vibrate and bounce up and down. stop, suction the osteotomy, and look with a mirror/loupes. you can see that the floor is thinning and you’re about to break through. that’s when I’ll condense my small cut up pieces of collagen and continue CCW at 150 rpm. I do keep irrigation on at this point. it gives me feedback if patients feel it in their nose. the vibration will stop and now you’re through. I condense a few more collagen pieces, then start adding my graft.
I found this collagen is super helpful on sloped sinus floors. you’ll run into a situation where if you look inside your osteotomy, half of it is broken through and then other half there’s this ledge of bone. oh and when I condense graft irrigation is now off.
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@ivan-chicchon when examining the osteotomy I didn’t see black. The patient didn’t express any symptoms suggesting a perf. I was hoping to see the perfectly shaped dome above the implant apex but didn’t. So the novice that I am thought the worst
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@rroque29 when do you see the patient back. keep us posted. I know what you mean, we tend to assume the worst. Most of the time it turns out not to be worst case scenario–but instead medium case scenario lol
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@ivan-chicchon I see him in another will and will post again with follow up with a PAN and a new PA. again unfortunately no easy access to a CBCT where I am without the patient traveling far and paying a few hundred bucks
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When just getting Into Christal, sinus lifting, I’ve often found that it feels like you are going in blind Because, well, you are!
If the membrane was not punctured during the drilling protocol, the bone should stay localized.
However, the situation that you’re describing has happened to me many many times as well. Personally, it has not become an issue for me when this has happened.
Thoughts? @rodk
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Without a CBCT it’s impossible to know for sure— if you have a friend who has a CBCT you can ask if they can take one as a courtesy and send you the disc. How is the patient doing post op? (I find a lot of perforations have complications as listed above)
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