Detection of perforation of the Schneiderian Membrane when using the Crestal Approach?

Have patient pinch nostrils and breathe through his nose. If you see bubbles emanating from your osteotomy site then there has been a perforation of the membrane. DrT

You can't always be sure of a tear with the crestal approach. However, there are systems that minimise the risk such as DASK, Neobiotech's etc. Alternatively you can place membrane through the osteotomy such as autologous fibrin (PRGF technique)which can protect the membrane and also aid repair in case of a small tear.

When approaching the membrane, crystal or lateral approach, one has to slow down and take it easy. Respect the membrane. That said, the use of collagen or PRF is most beneficial for repairing a tear of the membrane or protecting the membrane. Fine tactile sense goes along way with these procedures!

This is why I am opposed to blind surgery . With one of the most important tenents of surgery being visualization and access, the open, traditional technique makes too much sense. Three minutes to create the bony window and as Richard says, about three times as long to lift the membrane, you know if the membrane is intact. If you must, I would reserve the "blind technique" for cases where you have 9-11 mm of bone and a perforation wouldn't really matter. Keep your shiny side up! Bv

Squirt some water into the osteotomy with a monoject. If it comes back out, the membrane is intact. If it disappears, the patient starts coughing, etc...the membrane is torn. Furthermore, with good lighting, you can usually see the membrane. If it looks like a black hole, you gotta perf.

Just had a small tear yesterday doing an internal ( I very rarely do them as I prefer the lateral through a small Dask window ) . I could see it and then lifted the lining further from the adjacent walls as to "bunch it up a bit . Then grafted and placed the Implant , as the graft material sets it shuld be no issue and the lining will heal over it. We have done many cases where the lining was removed ( Taking something out of the sinus ) an Implant placed and directly grafted onto through the lateral window , and it just healed as it would. But Wleed nice idea with PRGF. The best way to check though is as Paul said squirt saline in and hold the patients nose and aske them to blow and the saline will be forced back out through the osteotomy . If Torn they will sense the saline in the sinus . But as said above not sure tears are an issue if you dont use certain graft particulates . Peter

Correction the damaged lining was only removed in the are of the implant to allow for grafting

There's no need to hold their nose when you squirt the saline in with the monoject. If the membrane is intact, the water comes back out through the osteotomy. If it's perforated, the water drains through their nose to their throat and they cough. This assumes that the patient is in a supine position and a has a patent/open ostium. Any patient with a closed ostium should not be having a sinus augmentation until it's corrected. This is easily checked pre-op by asking the patient to breathe though their nose. Make sure and check both nostrils separately.

thanks for all for your comments special thanks goes for poul its realy good way for detection of perforation is by using normal saline injection by monoject but the problem is that we can not detect the size of the perforation not all perforation make us to stop augmentation, with tiny perforation like 1mm or less we can go ahead and complet our sinus lift but with a bigger perf we must stop because the particles may displaced to the sinus and cause areal problem by closing the osteoms(the openings of the sinus to the nose) and there is such a cases reported again thanks for all

This is more of a curiosity for most dentists I guess, but if available, a small diameter endoscope (rigid or flexible) with 0 degree optics placed directly in the osteotomy gives you a perfect caudal view of the sinus membrane. Change to a 30 or 70 degree if there is a perforation or further inspection of the sinus is indicated. And if you´re really nevrotic, another way to control your crestal approach is through a "bird´s eye view" of the sinus membrane; by placing an endoscope either transnasally through the ostium or transorally through a small puncture in the canine fossa. Just for fun, check out the work done by dr. Schleier et al: Simultaneous dental implant placement and endoscope-guided internal sinus floor elevation: 2-year post-loading outcomes. Clin Oral Implants Res. 2008 Nov;19(11):1163-70.

OMS resident, your comments are well received. I am a bit lower tech and use my mouth mirror and the Valsalva maneuver.

Richard, as you understood I posted it just for fun. Low tech maneuvers are working out great for most of us and in most cases... But on the other hand, endoscopes in the OMFS area are useful for others than just the ENT guys...:-)

Oms there is a video of a sinus procedure done with a balloon filmed through the Ostium with a scope done by Karl Hienze Heuckman on the Meisinger site I think . He let me use the footage a few years ago for teaching purposes. Peter

BV - thanks!