Controlling Bleeding During Sinus Lift with Lateral Window Approach: Recommendations?

You can use a rongeur to crush the bone where the blood vessel emerges or use bone wax.

I use, for this purpose, different way of solution: **steril gauge soaked in H2O2 12 vol. and inserted in cavity. **with radiobistoury i find the rising bleeding and i stop it. with this two ways i can face this specific problem.

dr steve wallace recommends; place the suction in the artery. by the time you are done , it ll stop bleeding. that was in is lecture, but i dont know personally since i have never tried it.

Try a few Hail Mary's

My experience has been that bleeding issues may be alarming but usually controlable. The problem is that I have had some bleeding issues that were very scary. I am a GP but have years of experience and thousands of surgeries for third molars, implant placement, sinus lifts, GBR, etc. I wish my experience never happens to any of you but if it does you should be prepared. I do 1 or 2 sinuses a week plus much other bone grafting. I find it remarkably unusual to have much bleeding from the sinus, luckily. My worst bleeding issues have come from the flap reflection and I mean these are good muco-periosteal reflections prior to periosteal scoring. In the sinus, the branch of the maxillary artery courses mid-sinus on the lateral side of the membrane. Because of this I always leave the window of bone that is released. I have heard that the sinus artery is more alarming than serious and that the artery retracts and closes after a few minutes. If you are a gp experiencing a lot of blood for the first time, it is scarry. Locate a product called Helistat by Xenax?, it is a collogen product but much more absorbant than any other collogen you will try. An oral surgeon told me to have it ready when doing any surgery. He was right! I would try to put the sponge on the area and then gauze pressure. Most of the rapid bleeding incidents will be from the flap accessory vessels. One surgery I must have weakend a vein during reflection under the zygoma, let me say that a true bleeder, you will not have time to think, blood comes so fast you wont believe it is possible. Pressure w/4x4 gauze is all that will start to control it. then you may isolate with a hemostat. I have my helistat and 4 x 4 sponges out at the start of an invasive surgery. A true bleeder, you have no time to think, you just react, when it slows down then you can apply the simple remedies. Just my opinion. Thanks Leonard

Thanks Leonard, my experiences seem to be close to yours as well. I have just recently learn since posting this questions, of a product called Hemcon by Zimmer. It is the same as the battle field dressing used in severe war wounds. It is derived from Chitosan a product derived from the exoskelton of the shrimp. Very pricy but nice to have when you need it I suppose.

Thanks Dr. N I will get some to try. That looks familiar and I will refer to chitosan... think I read it here somewhere. L.

The number one reason for bleeding from the internal maxillary artery is from removal of the window from the membrane. A signifcant number of cases have an intra-osseous branch of the artery rather than just being lateral to the membrane. This can be determined by a CBCT scan. The height of the artery from the residual crest can also be highly variable. We try to make all of our lateral windows inferior to this branch. If very low to the crest, we may elect to do a crestal approach (osteotome or trephine bone core). If a larger volume of graft is needed, multiple cores can be raised for protection of the membrane from perforation. RJM

RJM, thanks for the response. I have had my CBCT for 15 months now and in the case I asked about I could not see the PSA but then agian I was sectioning and looking into the osseous wall. I suspect that the bleeder I hit the other week was in the membrane itself so I went back to re-study my scan to see if I could change settings and pick up on more soft tissue perhaps in the membrane region but was not able to see anything. By the way my patient's post-op has been find to date and like Leonard said this was more alarming than actually a problem but one I certainly want to learn from. --Thanks Mark

Dear friends, an emostatic technique I use is the bone wax. I put the wax with pressure over the area and , after many seconds, i remouve the excess with a sterile gauze.It works!! Best regards and compliments to Dr Salama for the SIO conference the 11 Febr in Bologna. Carminerapani

Piezo surgery is a good preventive method. It cuts hard tissue, but not soft. You can cut around the artery with care.