Suturing Technique: Best Protocol?

Typically, tears in the sinus membrane do not require suturing. A collagen membrane of your choice (long-term resorbable preferable) placed as a patch should do the trick every time. Large tears used to be sutured. When I did it, I used a simple interrupted with absorbable (C-3) suture. I focused more on preventing a larger tear than placement of knot. Today, I rarely get a perforation I can't deal with by using a membrane. Also, large tears mean delayed healing in most cases. Smaller tears do not.

I agree with SeaMentum completely. I did my first sinus graft in 1987 and I haven't sutured a membrane in years. BTW - Bioguide handles well in this situations as does RCM by Ace. Biomend is too stiff.

Suturing the sinus memb. is hardly done nowadays. It was once a well practiced procedure under the name of "Fikling-Inkwell procedure", but with the advent of resorbable collagen membranes you can use the double layer technique then why get into the hassels of suturing.

Trying to suture the sinus membrane will cause you frustration only.It will most likely enlarge the tear.Using a collagen membrane in small and medium tears will do. In large tears I would use a big collagen membrane like a teabag and than go on with the procedure.

Repairing the Schneiderian membrane is not a very easy task because the membrane is always very thin and friable. If a previous inflammatory condition has resulted in thickening or partial stiffness of the membrane, or in case of a large tearing, suturing the membrane is mandatory. Especially when discontinuation of the procedure is not on the agenda.I usually take advantage of a 5-0 vicryl suture on a 20mm tapered needle and a pair of magnification loupes plus cold light.I understand that a periodontist, for example, may find it a frustration or even a burden, but it is a simple and routine procedure for oral and maxillofacial surgeons, whom due to their range of training and scope of practice, are quite familiar with microsurgical techniques.

LOL Dr. Jafari Most Oral surgeons I know would never try and suture the sinus membrane as it routinely will tear as Dr. Mazor pointed out. I dont care what loops your wearing and please dont bore me with your level of training. Most Periodontist I know are more then well train, as a matter of fact most General Dentists have the training to handle such things. Please never try and Suture a Sinus tear you will only make it worse. Use a Membrane to repair a small tear its its to large dont be to brazzen close up and come back another day.

Sir,Thank you very much for your gracious and very benevolent advices and make sure that they all will be considered.Your level of politeness is an example to all of us.I really appreciate your concern.I never use loops,instead,I use loupes.In all those cases that suturing the membrane is not feasible,I will certainly use a collagen membrane patch.My respects.

Dr Jafari. I only got out of line when I felt your comments were demeaning to other specialties. "I understand that a periodontist, for example, may find it a frustration or even a burden, but it is a simple and routine procedure for oral and maxillofacial surgeons, whom due to their range of training and scope of practice, are quite familiar with microsurgical techniques." I think anyone would agree that your above comments were demeaning. You comments were demeaning to periodontists, as your saying a periodontist level of training isnt enough to handle what you do everyday as an OMFS. You do contribute alot to this website with your cut and paste answers and at time can be helpful in spreading knowledge. I would thank you very much if you could be a little more gracious and don't downgrade other specialties. Everyone has thier own level of training and the point of this site is to spread knowledge and not point out deficiencies based on level of training. By the way as a General Dentist I always where "loupes" and I never repair a sinus membrane by suturing, when the majority a research out there points one to use a membrane when repairing a sinus tear. My most humble respects.

Good information on this subject I find that with a repair the use of PRP coagulates the graft together very well and adheres to the membrane as well Im not sure if it actually makes a difference but it "feels"right in that graft material does not swim around the tears and layers of membranes it certainly creates a seal By the way PRP is routine as opposed to only for tears Easy stuff to do even for a mere general practitioner:-)

Suturing a sinus membrane is a mere urban legend: the whole scientific literature indicates that the use of a collagen membrane is the most effective way to solve this problem. Last but not least, i think that not only a great, perfectly-trained OMFS could suture tha schneiderians membrane, but also a modest, humble periodontist (as i am)...

Dear Dr. Ben, sir, This is what I call a reasonable and rational dialogue between two responsible colleagues within a friendly atmosphere and I hope that the whole world goes this way.First, I actually do not cut and paste my comments(honestly).I am sure that nobody believes that I own all the knowledge and information by myself.What I do is that I read the literature, keep some notes from its key points,translate them into our native language (which is Farsi), write them down somewhere in my personal library and keep them for good.When I need them (e.g. writing a comment), I go back to them,translate them back into English,let my word processor software to correct my grammatical and spelling errors and then submit them.I feel very proud and honored that you and the other colleagues have read my comments and opined about them.I feel really flattered if my English has impressed you so much that you think that I am copying the other people's texts. It is Plagiarism and it is absolutely immoral in any culture.Seondly, I never meant to demean or offend any other discipline.I just made an example and if I have not been able to use the proper words or they have elicited a misunderstanding, I deeply regret it.But, I vehemently believe that everybody should practice within the confines of his/her training background and the limits of his field.Third, I really believe that you should wear loupes rather than WHERE them (just kidding).

Dr Jafari, Do you still suture membrane tears? If so, do you have any literature that suggests suturing is more advantageous over placing a collagen membrane? I would like to say I have read your posts before and I don't believe you intended your first comment here to be as scathing as it came out. I am a periodontist who teaches at a local university as well and I constantly experience the whole turf war you elude to. Sinus elevation does not fall into the confines of a specialty (certainly not OUT of a surgical specialty like perio) and it is up to the surgeon (GP's are surgeons when they are cutting) to make the proper repairs when they can. So, if you tear a membrane during surgery you should be able to deal with it. BTW - I think this debate arises in any forum discussing complications. I find learning from other people's experiences is much more fulfilling than arguing who should be doing what procedures.

Most of the frustration regarding suturing small membrane tears is really related to accessability and visibility. We use surgical operating microscopes when performing sinus grafts at 6-10 power. The direct lighting through the lens allows us to visualize the medial sinus wall, where many perforations occur. If there is a minor perf, using resorbable sutures with a small circular needle and opthalmic forceps, we have found that suturing becomes a fairly easy procedure. We still use collagen membranes subsequently even in the absence of a visual tear. We do this to prevent any extravasation of the graft material when packing the sinus, and to prevent causing additional tears from graft material pressure at a point when perforations cannot be visualized. Utilizing these procedures has dramatically reduced our complication rate for lateral wall grafting procedures.

Dear SeaMentum, this would be the reference you were asking for.I am sure nobody can find a more reliable and knowledge-dependent reference than Dr. Miller's comments on this site. Now,I can feel relieved.

I agree with SeaMentum: in spite of Dr. Miller's post, in the whole scientific literature we couldn't find any consensus about the advantages in suturing over placing a collagen membrane.

Without involing myself in controversy of TO SUTURE-NOT TO SUTURE, I will just mention one fact. Our residents have one rule, large perf,close it. small perf, collagen membrane. We have pretty good success.

What I mean "close it",is without garfting.

Let's not get into a rhetorical debate over the wisdom of sutures vs membrane in sinus tears. The important thing is to minimize complications in lateral wall graft procedures. I have seen residents place a membrane over a small tear and then place a graft only to find that the pressure of graft placement caused the tear to enlarge. Both the membrane and graft material then extravasated into the sinus space causing a pan sinusitis and failure. Once you have occluded the new sinus space with graft material, you are unable to visualize where the graft material is traveling. Whenever possible, unless it is a pinpoint tear, we attempt to suture the membrane and also place a collagen membrane over the area prior to placing the graft material. Even in the presence of a substantial tear, our success rates are equal to those of non-perfed surgeries. While you may not be able to point to a study in the literature contrasting techniques, our statistics continue to guide us when making clinical decisions in this procedure. RJM

I agree with Ziv Mazor. Suturing the sinus membrane may result in a larger tear. Steve Wallace showed an interesting technique at the Boston AO meeting in which he uses a large collagen membrane to cover the perforation, it's tacked to bone outside the sinus for stability to ensure the membrane will not be displaced. He calls it the pouch technique. I thought it was an interesting way to cover the perf.

i see that the coments left here are quite old however i would like to share some of my experiences . i have had a few memberane tears in my practice and a few were notably large . as for the small ones we have used the membrane technique very sucessfully , for the large ones i recomend a suturing technique similar to a continuous suture but withour knots followed with cyanoacrylate glue . it works well .

I don't know if anyone has mentioned this yet, but with piezosurgery, my perforation rate is almost 0% (knock on wood) some have said that avoiding the tear is the key, it really is. I have yet to come accross a septum, adhesion, or anatomical anomoly that I could not work through with piezosurgery. This is the future of the lateral window technique, I can tell you my pulse used to race when I elevated the membrane. Now, with piezosurgery, there are no surprises, the atmosphere in my OR is calm, and it really makes the procedure enjoyable. As for the suture vs membrane repair argument, I have done both many times. Today, if it got so bad that I had to suture, I would close up and come back another day.

can anyone comment about the failed sinus graft causing oroantral fistula repeatadly inspite of all the abovesaid positive methods used ?