OMC Obstruction: contraindication for sinus lift?

Years ago when I went through Misch's course, my understanding was that an obstructed OMC was an absolute contraindication to any sinus lift. Given drainage is through the OMC, I do agree with the opinion that it is a contraindication. I often find that some ENT's or medical professionals really don't understand our procedures and what we really do. This could be the case.

It is mentioned that a thickened sinus mucosa is seen in the CT Scan.......has the patient recovered from a previous sinus infection, that has left a thickened Schneiderian membrane? If the ENT doc said that drainage has patency, I would not hesitate to do a lateral approach sinus lift. When doing your sinus lift, you are going to gently push the membrane out of the way, so that you can put in a PRF membrane to protect the lining, and biomaterials to leave some space to get bone to develop. In the event of some temporary blockage due to inflammation,you have to be assured that the maxilary sinus can be cannulated in vivo through the nostil. Hilt Tatum, forty years ago, did not have the information or technology we have today; and he proceeded to take on the sinus, and change the fact that bone can be developed in the maxilla in order to place dental implants and give the patients back their teeth. Be bold young man, have confidence and you will succeed...... when you see Hilt at the next AAID or ICOI meeting, take him aside and he will tell you about all the challenging things he did when no one else had the guts to do it.

Obstruction of the OMC means the maxillary sinus does not have the ability to effectively excrete mucosal secretions, allowing for the secretions to remain in the sinus and hence the accumulation noted on CT/CBCT. This significantly increases the risk of disease. Any disease process within the maxillary sinus can be intensified when the sinus is manipulated or it may have created a more frail schneiderian membrane that is more prone to tear.

Dr. Sadrameli, I respect your opinion, however my suggestion written above is based on the information provided by the writer who said that an ENT reviewed the information and confirmed that although there appears to be an obstruction and a thickening of the membrane, he was not concerned about the drainage ..... we certainly do not want to harm our patients, but obstructions and inflammation can be dealt with by medication.

Blocked OMC is a clear contradiction for sinus augmentation. I had similar case that I referrred to an ENT specialist. No sinus procedure was recommended for 2 months while the patient received treatment. There are people can suggest and do extra ordinary things let alone augmenting a sinus with OMC obstruction! The question to be answered is, what will happen if the Schneiderian membrane does not stay intact during the lifting procedure? Perforation of Schneider’s membrane occurs in approximately 56% of cases and determines a temporary impairment of ciliary function, predisposing to the penetration of bacterial agents (Kasabah 2003; Regev 1995). Let’s not forget that not having teeth is not life threatening but infected sinus in connection with grafting can seriously harm the patient and leave the surgeon suffering from sleepless nights!

How much does this patient want a prosthetic tooth replacement and why do they want an implant restoration? Have they been led to believe that they should replace the tooth with an implant restoration or terrible things will happen? Have all other options been discussed? I frequently see patients seeking a second or third opinion and they have been led to believe that a 3 unit fixed bridge is a very poor alternative. Sometimes this is what I recommend based on the long term success I have observed from my own treatments . How old is the patient and what tooth is missing?

All the above comments are helpful from a practical point of view but may I suggest or remind that we are proposing carrying out a procedure where mainstream opinion currently lies against carrying out this. As a result, if you have any form of negative outcome, short or long term, the finger of jurisprudence will always point to you. Any decent lawyer working for a patient in this case will win any argument of any type of failure (relevant or not) simply because the surgical site was deemed non ideal. I doubt if you could reasonably consent this away.

Thank you all for your comments, it was a great help especially when arguing the ENT about this case.

Thickened sinus mucosa is most probably a sign of chronic inflammation, by placing graft material there may activate and aggravate the condition thus causing the infection of the material that in case be of no use the other probability is the perforation of the membrane which in turn may causes oral antral fistula which is one of the most difficult cases unless a proper Caldwelluck operation is done.So considering these dangers sinus lifting in this case according to my opinion is contraindicated. Good Luck

I would coordinate treatment having the ENT dialate and enlarge the OMC then do the sinus lift with less risk of a complication. Thickened membranes are actually easier to lift, but a tuned up healthier sinus is preferred.

Thickened sinus membrane suggests infection - however membrane thickness can vary from between individuals - as long as there is a patent ostium you can proceed with a sinus lift but as a precaution I would prescribe Co-Amoxiclav for 1 week plus Otrivine Nasal Drops before proceeding with the sinus surgery

After 24 years of Sinus Augmentation I have fortunately never had an infection or any ill effect baring post op swelling . Now with Dask and other newer devices in the last 7 -8 years I have had only 3 tears of the lining ...... simply things have moved on . Did 5 cases last Tuesday some complex and again the protocols and equipment advances make it routine and predictable . Yes any Ostium Blockages can be dealt with easily by an ENT using fiberOptic surgery . As for thickened linings as I work in an urban environment it is a regular feature . It is interesting though that a number of ENT surgeons appear to still be oblivious of our work in the sinus . Regards

I agree with Peter, a FESS procedure performed by the ENT would assure patency. I use Nasonex and Afrin to keep the osteum open post op.