The Combination Case: Sinus graft and Khoury plate-Part 1

174 Rating(s).


Posted on By richard martin In Bio-modifiers: BMP-2 / PRGF

This case is that a a middle aged patient who wished to restore her dentition- I had placed an implant right maxillary 6 yrs ago- she returned having several teeth missing now with pneumatizaton of the sinus and width defect- I sent her for orthodontic alignment - restoration of vertical dimension - now at a point for staged reconstruction- width defect could have been managed in several ways but in this case I noted that I had a thick septum wall in sinus- thinking about what I have seen on XP- I was inspired by Mia and Snjezana to utilize the lateral sinus wall as a "modified Khoury plate" I will present what I encountered, what I learned and how I mangaged "in game"

Comments , critiques and questions welcome!

The Sinus lateral window plate
Ridge atrophy

Harvest started with Piezo blade - switched to round bur due to sinus anatomy
Perforation of membrane but delicately handled dissection no further tear


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24 Comments

Minor fracture of plate when placing screw


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Pre op CBCT - mild width defect


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Great case Richard. With the thick cortical plate and septum, I think the management was amazing that you only got a small perforation. I have also found that the membrane also tears where you have discovered, likely from my opinion due to the hinge axis and rotation to remove the window. When the thinner cortical plate pushes inward as you rotate the cortical plate up, the pressure can tear the membrane. What I usually do, is use the piezo blade to cut my window. Then where the hinge to rotate the window bends, I use the round diamond bur or piezo tip to remove more bone to expose more membrane and try to elevate the membrane off the surrounding bone to give more slack. Then I try to gently lift up the plate from anterior to posterior gently lifting with a tissue forcep or debaukey as I gently try to use a sinus curet to peel the membrane off the back part of the plate. This helps to reduce the perforation risk for me, however when harvesting the plate from the window the frequency of perforations does go up. I can't add much to your management, you did an awesome job! Ever consider using a diamond disk and spitting that thick window into two cortical plates to allow more bone plates for the reconstruction? Thank you for posting a great case.
Regards, Naheed


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Naheed,

Thank you for kind words- I 100% agree with tear location and i think if you look at my second post I mentioned that- I did start with piezo and switched to round diamond but no matter what I think you are on point with the hinge or garage door - in my traditional lift I do not remove wall but in fracture -I freed up the plate with a freer elevator and the special flat "trumpet" like tip that worked beautifully as I left the perf relase for last- I did not consider spliting plate as I wanted to use the septum thickness as wedge against the native maxilla however I ve put that in my "next play" plan- always room for improvement !!

Cheers,

Richard


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Awesome case Richard. I love the concept of same site harvest whether its in posterior maxilla as you show or anterior or posterior mandible. I still believe that autogenous bone is the gold standard, and management of cases like you show here is just SMART!
Congrats. my friend. Looking at your block, perhaps thinning or hollowing it from the sinus side would've allowed for a curved Khoury CAGE that would have fit well with morphology of your defect?

Thanks for sharing this innovative case !

Ehab


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Ehab;

We have Howie coming to Atlanta for a Hands-on on this technique on Jan. 20th. After seeing him LIVE in Brazil, it appears he does it as you suggested and harvests much autogenous chips via scaper during thinning of the bone .

regards Dr. S


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Ehab,

Great to hear from you my friend- After looking at cases from Mia and the complication that Snjezana showed and my and Armando's analysis of the plate I was a bit hesitant to use, but a setback is an opportunity for a comeback , so I must build from personal experience-

Ah my friend - read my Bomerang post and see where I reduced the septum tell me if its Khoury cage-As always your input is invaluable

Cheers,

Richard


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This forum is a great place to get motivation for every single day.
After I saw your post at dawn we finally started to collect our sinus window cases (some of them still in progress) to see which factors were decisive for failure or success.
You warned of lip pressure in anterior maxilla - the only one case without any bone resorption in anterior maxilla was one patient that hardly use to move her lips (very, very silent and quiet).
Thick cortical bone and septum in this case (very advanced, bravo!) make a difference, keep us posted!
Cheers
Snjezana



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Snjezana,

Kind words - thank you - In looking at this case I was hesitant to use window but when I studied the CBCT and saw the think wall and septum and felt - that the only way to truly understand the healing was to attempt. I took into consideration what Armando & Howie posted about resorptiveprocess and looked at Croatia cases- and then approached it from a biomechanical standpoint- in traditional khoury plate technique I see gaps 5mm and greater and distance from the native bone and bone chips packed in this gap well what I considered was the muscular forces of the muscles of mastication and facial expression play a role with the porous bone scaffold of the sinus? So what I thought was that if I had a thick bone although still porous and I decreased the gap from the native maxilla to the porous graft plate, say no more than 3 to 4 mm with the septum scaffold in the middle acting as what we call rebar ( placed before concrete is poured in road construction in Texas ) could this be of benefit? In the second case that I posted the Boomerang" I again had a septum, I reduced it a touch but not too much as to where it sat against on the maxilla Creating only a 2 to 3 mm gap with overlay of xeno --- I will watch this close case closely as Time will tell. I saw the patient for one week postop today and she is doing well. I will have her back in a couple weeks and submit photos- looking at what you discussed about lip pressure in the anterior maxilla, Ehab posted a great case with bone plates in the anterior maxilla - where I think his success lies is that he used mandibular bone and had a very nice cortical mandibular plate as support- last thought- success rate with tuberoseal grafts? High? Why - close proximity to native bone?

Cheers,

Richard

Look at that septum
Not a very big gap- could that be the key?


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Nice case richard, i like this approach!!
thanks for sharing
greetings
Vladimir García Lozada


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Vladimir,

Thank you- impressed by your talents also!

Cheers,

Richard


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Hi Richard, great job. When you say change from piezo to round bur...you mean Round Diamand Bur?
I think that this thick plate will make his job.
Congrats and keep us posted!
Regards
Jorge


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Jorge,

Yes round diamond- which is way I did before piezo- easy to round the corners- yes there is a round piezo- but I like cutting effiency of diamond.

Cheers,

Richard


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DeeeeaRichard!!!

Thank you for not giving up on sinus plate.
IMO we should not compare block from the sinus with a mandibular bone block,they do not behave the same,bone has not equal consistency, and under my fingers does not behave the same.
As far as sinus wall block-the thicker the better. And managing to use septum too (btw, very cool), it can't get any better. And scraping that curved block is not easy AT ALL..not enough space to do THE scrap, and u only thin the edges more and more,and they break sometimes,it gets smaller than it is..and so on...for that small amount of the chips I would not do it. And why scraping it from the inside and placing again the same bone (more traumatized) under the same side of the block..that bone from the inside part is not a pure cortical bone. Hmmmmmm..am I philosophizing to much:)
And I would not split it- rarely having a flat thick wall.
I would not use it for augmentation of mandibula, to much muscle activity. I think only screws survive :D
I am still waiting for the sinus blocks to come back. On one case I needed to do more augmentation when placing implants.
Nowdays :), if I would use sinus block I would scaffold it with xenograft on top of it to minimize resorption,and I would do the same for the tuberosal block. Mandibular bone is a story for itself.

Tell me more about the septum-was it on purpose done like that? If so, how would u manage to take it out if the septum was a long one, like a bridge connecting outside and inside wall of the sinus. I assume this septum was a short one?oder?

Thank you for your new variations.
Hope u will clear my thoughts and doubts.
Always happy to learn something new.

Mia


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Mia,

Thank you for the kind words and support I think that if you were going to scrape it is done prior to harvesting the sinus plate and you can also scrape in areas where you're not going to take the plate but I think that Thinning it out as you say could jeopardize the long-term success - if you are able to take a long window anterior posterior , you could split it in half either from anterior to posterior or superior to inferior and then stack them on top of each other like tiles but I would not split the actual plate inside like it's done similar to splitting a thick mandibular plate likeCristian eloquently showed. Call though the curve of the buttress can make harvest more difficult I think it turns out to be a plus if position against the lateral maxilla because it already creates the gap as I stated before I think the gap distance in my mind plays a huge role in revascularization of the graft and stability. Note granted I don't have as much experience as a team Croatia but I'm just looking at it from a bio mechanical standpoint as I previously noted

As far as the septum in this case in my mind either I think I've identified a decision tree as far as when to use the sinus play or not in looking at the preoperative CBCT we should look for cases where there is a nice septum because again this I think this can increase the stability with a thicker piece of bone and wedging the septum against the native maxilla and packing along either side of it as far as how did I get this septum out well once identified it and I hope in the end for your portion of the window I dissected off the membrane all the way to the medial wall and I had cut how about 2 mm in already and want to dissection was complete I was able to in fracture and remove the rest of the wall another key point I think is depending on the remaining vertical height of the maxilla you can plan to start inferior osteotomy slightly more inferior if you know what I mean so that you can catch a bit more of the thicker part of the septum

I hope this makes some sense and my apologies if I've created a new research monster

Cheers,

Richard


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Difference between mandibular and sinus window block. Exactly as described by Cristian Rotaru.
Cheers
Snjezana


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Snjezana,

I read your previous response to my other post and hopefully have not created too much work for the students please tell them I apologize yes you clearly show the difference tween mandibula and a sinus play however at the end of the day if you still had adequate going to place the implants and could additionally Veneer
at the time of placement the other thing that you know is that with that thick remaining piece of mandibular bone against the maxilla the body will continue to attempt to resorb this meaning increased osteoclast activity whereas with this sinus plate we could add some soft tissueand densah at the time of implant placement . Another thing that we could look at and you studying these cases are the preoperative CBCT's to see if there is a septum present although historically we do not like septums because it makes the dissection a bit more difficult actually these cases could lead to increased graftvstability and I also think the gap distance is huge factor. in your case that you posted on my other post you did not want to show the huge graftvdistance it worked out beautifully in this case but maybe we could make a decision tree that says if we're going to use a sinus plate, stick to the maxilla and no more than 3 to 4 mm anything greater than that we would have to go to a mandibular plate?

Cheers

Richard


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We just love extra-work before Christmas :)
See you in Vegas!
Ivana&Matko


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Ivana & Matko,

I must apologize for the extra work but.. I have also heard extra work over The holidays means extra time off after I'm sure you're reading this Dr. Pohl ....


On the other hand, A spark, an idea a thought - it is how all breakthroughs are born!


Happy Holidays!!

Richard


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Very good points,Richard. We are going to measure how the final gained volume depends on plate-bone distance.
Haha,I like your expression that “we historically don't like septum“
Cheers,see you soon
Snjezana


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Snjezana,

Please do not work the students to hard over the holidays but I appreciate you doing the research to see what you can come up with

So as one of my mentors once told me - it iscalled research because at first we search and find nothing but then when we research and research we will find something!

I have included a few photos have a little project I worked on last evening- gap distance - septum strut


Happy holidays

Richard


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Richard, but they just LOVE extra work:)! Without extra work there is only mediocracy and all of them are envelopes. BTW, how many dental doctors from Europe fly to DentalXP in LV in the very first year after university and already know the work of all DentalXP opinion leaders? And, don`t worry, they`ll prolong the trip:))
You are absolutely right - it would be pity to give up sinus window bone. I like your yesterday evening handicraft. Drawing on palate - palate bone plate?December is so full with pre - Christmas events and dinners that I truly miss evenings spent with dentistry.

Cheers, happy holidays
Snjezana


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Snjezana,

very true but don't them have them being mad at me!!yes the drawing on the palate is a modification of the technique that I am preparing to chat with Howie about prior to performing


Happy Holidays,

Cheers

Richard




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