Sinus lift with partition management?

Take it one step at a time. You may have an oral-antral communication or fistula. Let the ENT treat and clear the infection and then take a new CT scan to verify that the infection is gone and to assess what you have at that time. If you end up with less than 3-4 mm of vertical bone, a lateral approach for the sinus graft is recommended.

This should be relatively simple to manage. The key is to remove the tooth atraumatically. By that I mean by separating the roots so they can be removed individually. Then the region has to be debrided thoroughly, removing all the granulation tissues and epithelial downgrowths. Then it gets a little more complex, if you allow the region to heal "naturally" the soft tissues will collapse down and relatively little bone fill in the socket will develop. It is relatively simple to place bone graft in the socket, to cover this with a membrane, and close with a suture. There are all sorts of material to use, a topic too large to discuss here. If this works then the socket will regenerate to a considerable extent. which will help in future therapy. Of course, this procedure should be carried out under antibiotic coverage, again too large a subject to discuss in this post. Some will have concern that this procedure may "bottle up" the infection and encourage it to spread. This does not happen in the vast majority of cases. The case should be followed carefully in the immediate past-operative period. If the infection seems to be progressing then it may be necessary to remove the grafting materials. That is rare. I hope this helps, best wishes.

In order to prevent any oro antra fistula the patency of the sinus ostium must be checked before the extraction .

Dear Wally, This case would be a definite contraindication for sinus bone graft some 30 years ago. Still, with the advance of modern ultrasonic equipment and the knowledge gathered, the task is not so impossible. I think it is a case of banal mucusitis. Does the patient smoke? If so - it adds to the risk of complications. I concur with the above replies. Take it one step at a time. First-remove the fractured tooth, wait for the soft tissue of the socket healing (40 days to two months). As the prosthetic plan dictates restoration of both upper right molars (since the patient HAS teeth till the lower right second molar), usually two wide implants should be placed in area 16 &17. The most predictable approach should be with two lateral windows. The thickened mucosa, should not be a problem, on the contrary. I would stay away from a crestal approach for the graft in the posterior portion, as frequently those connections are filled with thick tissue, difficult to be dissected from the sinus mucosa. Sometimes encapsulated or/and infected tissue might be present there. Lifting that mess up would be the last thing I would want on the top of my sinus bone graft. The alternative- through both lateral windows you would be able to check the healing, following the extractions, and if any soft tissue i present-remove it through careful debridement, folowed by grafting. Best of luck and please, keep us current on this beautiful and challenging case.

Paul reports above that he found BioOss and BioGide for socket regeneration gave problems with post-op infection and pain in some of his cases. We use BioOss Collagen instead of BioOss and Mucograft instead of Bio-Gide. Collagen in the bone mixture gels on mixing with saline and with the blood in the socket which tends to restrict early infiltration, contamination of the graft and infection. Bio-Oss acts as a scaffold for new bone development, the collagen jump starts the healing cascade. Perhaps the most useful aspect of this material is that it tends to minimize later ridge shrinkage, probably because it is very slow to resorb. Bio-Gide is too thin to cover effectively over a socket graft, it traditionally has been used to cover a bone graft under a soft tissue flap where it has proven effectiveness. Mucograft is a much thicker material. When used over a socket we stabilize the exposed Mucograft with a thin coating of Peri-Acryl Tissue Glue. Using this protocol we generally get good results with both socket regeneration and ridge maintenance. EthOss and Augma are both beta tricalcium phosphate, 35% calcium sulfate materials which fill out the socket defect. The materials then dissolve at differing rates which allows natural bone regeneration. I am not sure how well these materials restrict alveolar ridge shrinkage. I hope this helps : Good Luck

I agree Peter Hunt , EthOss and Bio-Os's are completely different materials , EthOss is true regenerative material , up regulating the host healing , turning over to host bone . Augma a great material , again is a completely different material (which looks similar) as it has no BTcP in it . Hence the difficulty in getting FDA approval for EthOss is the only comparatives are Orthopedic materials . Anyway there seem to be some interesting benefits with Ethoss in the sinus due to its properties , using it twice or more a week has been really predictable and we have been pushing our expectations . in over 25 years augmenting sinuses I have never had an infection , maybe just lucky . Regards

No matter how good bone you use, it is useless investment and effort if the patient's ostium is not patent. Check the CT preoperatively to see patency of it. If not patent, have informed consent to refer the patient to ENT when postextraction sinusitis is in doubt. Next step is extraction and medication. Extract it and cover the perforated membrane with gel foam, and pour in sinusitis medication to get it healed. When healing is good after 3 months(minimum time window for membrane to be healed), then you may consider operation strategy. When there is big wall like that, it is best to make separated sinus graft for each implant. I will probably try for Densah bur lift or crestal lift for the #3i and lateral approach for #2i. Dont think of some splendid novel OP technique and just make sure have longer appointment for the surgery.......