Can I perform lateral sinus lift for this case?
I have a 55 year old male, heavy smoker who had #3 [maxillary right first molar; 16] 2.5 years ago because of periodontal disease. He had a treatment plan to place 1 implant together with lateral sinus lift and bone graft. At that time, the CBVT showed the maxillary sinus with sinusitis with the sinus membrane thickness about 11mm. He took antibiotics during 2 weeks before the operation day to control the sinusitis. However, he didn’t come back the clinic to have implant surgery. Today, 2 years later, he comes back and asks for implant placement again. I take a new CBVT to check the sinus and the result is nearly the same as 2 years ago. The sinus membrane is very thick, about 11mm and he is still a heavy smoker. He has no symptoms of sinusitis. His general health is good and oral hygiene is not bad. In my opinion, this is a chronic sinusitis maybe because of smoking. I have no experience with doing at lateral sinus lift, especially with sinusitis like this case. Should I attempt to control the sinusitis with antibiotics? Which antibiotic would you recommend? In the past I have tried Augmentin 1 gram 2 tabs per day. Should I try an anti-inflammatory like Medrol 16mg per day for 1 week? Is this a case for a beginner?
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Panoramic View
27 Comments on Can I perform lateral sinus lift for this case?
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CRS
11/8/2013
If it were me, I get an ENT clearance since it is prudent to have a head and neck exam in a chronic smoker as a cancer risk factor. Then I would do a lateral lift with immediate placement, bury the implant four six months. The lift should not compromise the OMC since the thickening is limited. Good Luck.
sb oms
11/8/2013
Not a case for a beginner- but you are half way there if you know to ask!!
By the way, you should tweak the settings on your CBVT.
You should be able to get much clearer images, with better resolution, and the ability to magnify without blurring.
I have not found smoking alone as a risk factor for success with sinus grafting. In fact, the sinus membranes of most smokers are like leather, and they are easy to manupulate without tearing.
This guy has pretty significant pre-existing mucosal thickening in the exact area where you want to work. An ENT will get a medical CT scan of the patient and get a better idea of the soft tissues of the sinus. Your CBVT cannot differentiate between mucosal thickening, cysts, polyps, fluid etc... in the sinus. It just shows "stuff" where it shouldn't be.
Rand
11/12/2013
I have had a cone beam scanner for 5 years and get the same image quality as this doctor. How do you "tweak" it? What should be adjusted. I would like cleaner images. Any help is appreciated.
Paolo Rossetti
11/9/2013
Do it!
Tri
11/9/2013
Dear my colleagues,
Thank you very much for your comments.
Do you think lateral sinus lift is more difficult than crestal sinus lift in this case? Because the palatal wall is thinner and less alveolar bone than buccal wall. If I open the lateral window, I will get the more challenge to lift the membrane up, especially the middle wall. With crestal entrance, I feel more comfortable to lift the sinus floor membrane up, and then placing the implant through this entrance. I would like to hear your experience. Thank you very much for your help.
John T
11/9/2013
I'm always intrigued by the drug regimes quoted on this site.
(a) The normal antibiotics for an acute sinus infection are amoxicillin, doxycycline, clarithromycin or azithromycin - not co-amoxiclav
(b) The normal dose of co-amoxiclav for dental infections is 250/125 mg x 3 per day for 5 days. Why the double dose of amoxicillin and why the double dose of clavulanic acid?
(c) This man does not have an acute sinusitis, he just has localised chronic mucosal thickening (possibly smoking related) in the floor of one antrum, so what is the antibiotic going to achieve?
(d) On the last occasion you gave him an antibiotic (double dose co-amoxiclav?) for two weeks pre-operatively (!). What for?
(e) You are proposing to give him a high dose of methylprednisolone for one week postop. Why?
This is all pretty scary stuff.
Paolo Rossetti
11/9/2013
very good points.
Vipul G Shukla
11/13/2013
John T,
The usual adult dosage of Amoxicillin for a patient is 500 mg every 8 hours, not 250 mg. Adding clavulonic acid does not reduce the ideal adult dose. Moreover, for sinus infections, a regimen should last 7-10 days, not 5 days. And yes, Amoxicillin with clavulonic acid for 10 days is ideal treatment for maxillary sinus infections from susceptible bacteria. Jumping to higher antibiotics, when Amoxicillin usually works is unnecessary and leads to unwanted resistance in the community.
Only issue is this case it is more likely a thickened sinus lining in a chronic heavy smoker. Not necessarily an infection.
CRS
11/9/2013
Do what you are comfortable with but get the ENT consult, it is prudent for the thickened sinus chronic condition. I like the lateral approach since I can see what I'm doing. If I need more than a few mm of bone I use this approach. Debating about sinus antibiotics shoud be deferred to an ENT colleague get a good protocol from the right practitioner. Augmentin is used as a tertiary drug regimen for resistant infections you don't ' want to overmedicate prior to even starting the case. Antibiotics don't make the case work it is good surgical technique. An internal lift is fine depending on how much height you need. Since you seem to be vacillating just refer I since it is not a good beginners case. Unless you are trained and comfortable in sinus surgery as an OMS better to refer and happily restore, to be wiser. Steroids are indicated but are tapered you may get burned on this case especially with the poor advice posted so far.
E
11/10/2013
I have one similar case that has thickened sinus membrane because patient swims everyday and has some minor nose irritations. Would asking patient to stop swimming for a few months return things to a normal state?
CRS
11/10/2013
Probably not actually a thickened membrane is easier to lift. Just get an ENT consult if you are not comfortable. I would not let them swim 10-14 days post op to allow for wound healing.
Dr. Alex Zavyalov
11/11/2013
It is not a prosthetically driven treatment plan. The span of this defect is too large for a single restoration which cannot withstand a mastication loading from naturally powerful antagonists. Moreover, the patient definitely has a multiple enamel attrition problem
pickle
11/11/2013
It may be that the image distortion caused the enamel wear that you mentioned. Dear colleague Tri, could you provide us with the mesio-distal distance between teeth 17 and 15, even though it does not look that wide to me. Is an FPD 17-0-15 even in consideration for this case?
John Manuel, DDS
11/12/2013
There appears to be plenty of room for internal lift(s) from your panoramic film. Of course, the chronic sinus drainage should be addressed, but I don't think you'd have much risk of sinus membrane penetration if done correctly.
I would not place an implant as vertical as your slice shows, but would follow the palatal vault and the buccal plate angles a bit more.
There is probably room for two Bicon 5.0 x 6.0 , 4.5 x 6.0, 6.0 x 5.0 or best 6.0 x 5.7.
The ideal lift height should not exceed the implant width for prevention of membrane tear per research, and you appear to have enough room vertically for any of these 4 sizes.
To unnecessarily subject a patient to lateral sinus lift surgery, or excessive implant length sinus incursion should be considered and avoided.
John
Don Rothenberg
11/12/2013
I would encourage you to do it.
I would do an "internal sinus lift" and graft Synthograft mixed with the patients blood, into the osteotomy.
Then I would place a 4.5 or 5 mm by 6 or 8 mm Bicon implant.
I would use doxycycline 100mg for 10 days starting one day preop.
While there is no such thing as a "simple" case ...this is pretty straight forward.
Let us know how it turns out!
E Mellati
11/12/2013
I would reconsider doing this implant as patient has periodontitis to the extent that has lost a tooth from it (moderate-severe), is a heavy smoker and oral hygiene is less than good. He ticks all the boxes for future biological complications, especially in a site that is compromised to begin with. I suggest picking a better case as your first sinus lift experience.
Kevan Green
11/12/2013
I think a big issue in this case is the potential for blockage of the ostium. The ostia for drainage are located on superior aspect of the medial wall and open into the semilunar hiatus of the lateral nasal cavity. If you have an 11 or 12 mm thick membrane and you lift the sinus 12 mm, you may block the ostium. This would result in infection of the graft and failure.
As a point of reference: the ht. of the max. sinus has been reported as 24 to 45 mm and is smaller in women than in men ( Sahlstrand-Johnson, et al Computerized tomography measurements of different dimensions of maxillary and frontal sinuses BMC Medical Imaging 2011 11.8).
If the 3D study reveals sinus pathosis- such as a mucous retention cyst, fluid or a thickened membrane 10 mm or greater in size, we refer the patient to an ENT for evaluation and treatment prior to proceeding with a sinus augmentation procedure. The ENT physician will usually treat the patient with antibiotics, steroids, antihistamines, etc. The CT picture can change within a few weeks with treatment. It is also possible that the ENT may need to surgically treat the sinus and that might delay your plans for treatment.
The Misch text is a good reference for sinus anatomy and management.
Best regards- Kevan
Richard Hughes, DDS, FAAI
11/12/2013
Dr Manuel makes some valid points. Soboms also makes a good point about the quality of the scan. I doubt the membrane is 11 mm thick. I would obtain a medical quality scan. It possible that this is a mucoseal and an ENT consult is in order. If in doubt have a radiologist evaluate the scan!
I agree a Crestal approach is a valid option.
DR B L GUPTA
11/13/2013
YOU SHOULD DO SINUS LIFTWITHOUT FEAR OR OTHERWISE U GO FOR ZYGOMATIC IMPLANT
Tuss
11/13/2013
best to have an ENT remove and biopsy the tissue - everything else is guess work from the scan. Saw a similar patient 3 years ago and it turned out to be a carcinoma. With the history of untreated perio, poor attendance and a heavy smoker my next question would be is this patient an implant case.
CRS
11/13/2013
I don't get the trend of generalists, periodontists, endodontists, prostodontists, and implantologists stepping into cases which I'm cautious of and use consultations with other specialists dental and medical. I don't think it is in the best interests of th patient. Just because one thinks they can do something doesn't mean you should. Then the poor outcome is blamed on a technicality or the patient. I 'm considered arrogant since I point this out and th operator becomes defensive. Training and experience are obtainable but what is often needed is judgement and prudence. I'm seeing more of this in my practice, it is often avoidable if we work together. There is often very sage advice given from many sources, generalists and specialists which sometimes is refuted by other poster just to refute it seems. There is no shame in understanding limitations and getting consultation prior to deciding to start a case. Nobody is watching these dds and the patient trusts them. I know I will get flack for this post but I hope my comments are taken with humility, hindsite is always 20:20. And I am thankful for much of the advice posted here, I guess it is about filtering out the bravado.
Tri
11/14/2013
Dear my all lovely colleagues,
I'm so happy and so surprised about all the comments. I've studied a lots from all of you.
Thank you very much for your advice. I really appreciate them very much.
I decide to send the patient to ENT doctor for checking and consulting.
I also ask the patient stop smoking and try to control the oral hygiene well.
One more time, thank you very much for your help.
Best regards,
Dr. Tri Dung.
Peter Fairbairn
11/22/2013
Working an big city , most of my cases look like this , no real reason for ENT and they may not even know what a sinus augmentaion is strangely !
Lateral window always safer and you are more in control , use DASK ( since started using it nearly 4 years ago , I have not torn 1 lining ) and operate through a smaller window .
Thicker bone plate may require a post op dexa-methasone to relieve post op swellling.
But overall should be fine .
Generally if you are comfortable removing objects from the sinus then you are OK to place Implants there
Peter
Richard Hughes, DDS, FAAI
11/23/2013
If this is enamel abrasion (attrition) due to severe bruxing, then I strongly suggest not grafting the sinus and prepare and place a three unit FPD. Still have a medical grade Ct with radiologist interpretation and refer to ENT for evaluation and treatment.
On the other hand if this is a layering issue due to the CBCT and the patient does not visually present this way. Then obtain a higher quality medical CT with a radiologist interpretation. If a pathology is present, then make the appropriate referral for treatment. If no pathology then proceed with sinus augmentation. Perhaps a preop course of nasal steroids will shrink the membrane.
Tri Dung
11/24/2013
Dear my all colleagues,
I really appreciate all of your comments.
They help me a lots. I've sent my patient to ENT doctor and waiting for his answer.
Thank you very much for all of your advices.
Best regards,
Dr. Tri Dung.
zhen
3/15/2014
I am disgusted that a colleague would consider offering surgery on a patient that he is not competent to do. This is worse than operating without informed consent. I'm relieved you referred him to an ENT. Next refer him to an oral surgeon. Bring him into your practice for the portions of restoration that are your core competence.
Richard Bryant
8/9/2016
Periodontal disease, Possible sinus pathology,Smoking, Possible Bruxer, Compliance issues First time operator ......I would do nothing on this patient. Refer for Periodontal consult and consider conventional crown and bridge. This is a disaster waiting to happen.
Great that you asked. When things go wrong , scope of practice will be the first thing they go for , amongst other issues.
Regards
Dr Richard Bryant
