Crestal vs Lateral Sinus Lift?

Just for the sake of completeness, what is your reason for anorganic bovine or TCP vs DMFDB ?

Both materials are completely free of any organic tissue. With anorganic bovine, it is heated high enough to turn any cells or tissues into ash, leaving just the minerals behind. Being synthetic, b-TCP contains zero living tissue, yet has an excellent resorption profile and long term data to justify it’s use. Both of these materials require FDA registration and have been shown to be safe in humans. For optimal results, it is best to pair a ptfe membrane with the b-TCP. I have used both 4+ month resolvable xenograft membranes and ptfe for bovine with excellent results. Allografts, by comparison, will heal differently than the grafts mentioned above, something that I didn’t notice until approximately 10 years after apparently successful grafts. In patients who were experiencing periimplantitis around implants in grafted bone, radiographs would show strange patterns of resorption in allograft sites. Upon surgical entry, it it notable that the the periimplantitis around allograft is markedly different than around sites that had no grafting (native bone), or bone grafted without allograft, which would appear as a traditional saucerization in an intraoral radiograph. Instead, the allograft bone would still be present, but in clumps and chunks. At last year’s AAID meeting (the first AAID conference I’ve attended), I happened to run into Greg Steiner, a periodontist who also runs SteinerBio. He graciously took the time to present his theory of why it seemed that this strange pattern of clumpy, necrotic bone was present in allograft sites. In short, the allograft seems to elicit a long term foreign body type of reaction which histologically shows as what appears to be sclerotic bone encapsulating allograft particles that appear to be unchanged, meaning they have not turned over. Instead, over he years, the bone around these particles turns relatively solid, with no vascularization to the deeper areas of the sclerotic bone. In fact, he showed me clinical and histological pictures of several cases where the pattern of clumpy bone was present, and only in sites where allograft was present. He explained that b-TCP and anorganic bovine do not result in the sclerotic bone, as evidenced in many citations, while the claims associated with allograft are not overseen by the FDA, since allografts qualify as human transplants, and are not subject to FDA approval. While his claims seem a bit conspiratorial, I have, so far, found no opposing research, and clinically, his theory of sclerotic bone is the only one that fits the pattern of destruction that I only see around sites that were grafted with allograft. Having said that, these were problem sites were all medium and large size grafts, which is why I never seem to see this phenomenon around sites with minor allograft use. Also, it is unclear is mixing the allograft with autogenous or bovine results in any different than allograft alone. Another interesting phenomenon, is that I don’t seem to see this problem in sites where irradiated cancellous bone was used, whether blocks or particulate, at least the material from Rocky Mountain Tissue Bank, which leads me to believe that not all allografts are biologically equivalent. In summary, currently, I only use allograft blocks (irradiated cancellous), and mostly anorganic bovine for GBR. Until more research becomes available to explain the phenomenon I described above, I am avoiding freeze dried allografts in all sites. Hope this helps.

Good advice, Tim.

Thank you. Can you please tell me how the patency of the ostium restricts you from making a decision. I appreciate your comments. LG

LG: with all due respect here, the question you ask should be known before performing any sinus lift surgery. If you honestly were about to perform this surgery and don't understand the risk of sinus lift complications including the knowledge of a patent ostium, then please do not attempt this case. This is the problem, everyone wants to be a surgeon but not everyone should be one. I feel so sorry for patients nowadays, have no idea what they're getting themselves into anymore.

No need to be snobby and unprofessional PerioG. The fact that he is asking these questions indicate he is honestly trying to do what’s best for his patient and improve his knowledge. Don't forget, you where in his position once and im sure your first few lifts left a lot to be desired. We need to support each other not try to scare others from evolving.

ST: I was waiting for someone to give me a reply like yours. This female is at risk, I don't really give a crap if I hurt someones feelings here. My interest is the patient. When I started performing a sinus lift surgery, I knew the risks. To ask about the significance of a patent ostium tells me this doctor is not ready to perform this surgery. Period.

For a large lift, I agree that imaging a patent osteum is preferable, but for a minor lift, as seen here, I don’t think it is necessary. Judging by the minor thickening of the membrane at the floor of the sinus, and the location of the proposed augmentation and implant length, it seems highly unlikely that any harm could be done. While I don’t want to encourage poor imaging technique, these straightforward cases were routine in my practice many years before we had a CBCT. Seeing the osteum in a panoramic radiograph was basically impossible, yet patients received predictable, safe care.

Dear PerioG: I hope your chairside manner with your patients is better than your obnoxious demeanor towoard colleagues on this forum. FYI - am a Board Certified Oral & Maxillofacial Surgeon AND a BOARD CERTIFIED OTOLARYNGOLOGIST. 35 years experience. I am well aware of the sinus anatomy including the ostium. I was asking, in a case like this where minimal grafting and no risk of ostium encroachment, how was that information pertinent in the question at hand - crestal vs lateral sinus lift. Thank you. Louis Gallia MD, DMD, FACS

ST: No the problem here is I am the only one that does give a crap here! Continue to remain diplomatic, that's fine. Give this doctor a sense of security that everything is going to be alright. And how's that helping him or the patients?

Your message may be harsh but I agree with your sentiment. The success of a surgeon lies within the knowledge of complication risks and anatomical understanding as much as the skillset.

This isn't about being Macho Man, this is about causing no harm to patients. If you want to perform a procedure then know the risks. If no one brought up patency of the ostium, this doctor would be going in oblivious, not even knowing that was a thing. So go ahead and think this is about ego, I personally don't care what you think of me. I care about what's happening to our industry. Doctors performing surgeries when they have no business doing so. This isn't about me not being busy either, I am busy taking care of the crap from doctors that don't understand the surgeries they are about to perform. And don't let the name fool you.... From PerioG