Sinus Access Window Bone for Khoury technique

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Posted on By snjezana pohl In Failures

My colleagues and me have seen convincing results for lateral ridge augmentation with sinus window bone plates. Now I am alarmed because I`ve had three failures in a short time.
First case: I came to conclusion that a pressure from provisional bridge (and manipulations for fixing it, taking out..) has caused the bone resorption. Impression was taken prior to the ridge augmentation. All other cases worked very well out, but then…
Other two cases, both of them done with a very thin sinus window bone plates.
For mandibular cortical bone plates the thickness doesn`t play a crucial role. But it seems that a softer, more elastic posterior maxilla bone obviously requires a certain thickness. It doesn`t resist a pressure, so it doesn`t maintain a space.
We are going to evaluate all cases (some still healing), but since I praised high-spirited sinus window bone plates I feel responsible to warn you.
This post is not complete (yesterday I simply had not stuff to take intraoperative images) and one case I can not find, I`ll complete it this week.




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26 Comments

Snjezana. Good know this can happen, but let's not jump to any conclusions. Personally I am not convinced the cortical plate Khoury technique is superior in the long run. Perhaps it just takes longer to remodel to the same outcome eventually. I am not aware of any long term follow up studies using the Khoury technique. BTW Howie CBCT do not tell the whole story either. CBCT only determines radiopacity remains present nothing more. I am most interested in the presence of living tissue. The thickness of the dead cortical plate is probably not the key to success or failure in the long run. " LIVING BONE IS A COWARDLY TISSUE. DEAD BONE NO WORRIES". Warmly Chuck.


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It never happened to me with mandibula bone plates.
And 3 failures out of 10 cases...too much failures.
Friday`s poetry and Sunday evening depression.
Warmly, Snjezana.


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The less GBR and Khoury plates you do the less depression and better you will sleep.


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Like always I strongly agree with you.
It was by jogging today, I thought about posting some pretty Sunday`s poetry, but then I realized that it`s not fair if I not warn all of you. It`ll take 2-3 months till we collect all our sinus window cases.
Do you like my jogging route?
Warm regards
Snjezana


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Wow! Much better than mine. Coincidentally I just finished my jog and am sitting in my backyard catching up on cases. Not quite the view you have, but relaxing just the same.


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It is beautiful, your place. Lucky you, the whole Sunday in front of you.
This dead bone is supposed to be protective. It should protect the living bone from pressure and hold the space. If it doesn`t, the particulate bone disappears. And it seems that THIN AND MAXILLA bone plate is not strong enough to withdraw the pressure.
Enjoy your day!
Warm regards
Snjezana


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Chuck

. " LIVING BONE IS A COWARDLY TISSUE. DEAD BONE NO WORRIES"

I like that but what does it mean? Just a little more explanation could be helpful...

Thanks

Rocco


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Rocco. Living bone is a delicate tissue that resorbs quickly and coverts to a more protective tissue when subjected to any insult or infection. It is a protective mechanism to avoid osteomyelitis and protect the body from systemic infection. Dead bone has not the ability to do anything as it is dead.


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Snjezana,

As Howie would say -these are cases that we keep in the bottom draw- it takes courage to show these but like all cases on the post there is always a chance to learn - Couple ideas-thickness of bone from sinus vs Manible - membranous vs endochondral- Autogenous resorption rate- porous maxilla bone- with porous sinus graft- ( is allograft or mix with xenograft slow down resorptiveprocess ?) - How was stability of screws-(I know you are always concerned with screw size) All grafts appear to be anterior maxilla- - was tissue passive enough to offset lip pressure ?

Thats quite a bit but you asked for input- and although you lost some of grafts - still appears you gained some and can re- augment.


Cheers,

Richard


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Richard, OMS in you, used on hard events:) You are right, I could re-graft. In two cases I`ve done ridge splitting with augmentation.
The screws were the only stable things in the whole story. (The problem with screws was in August, I informed you in my root plates post that this problem is solved:)
Autogenous bone was harvested from mandibula with bone scraper. According to Khoury original protocol I don`t mix xenograft (allograft still not available in Cro, I`ll inform you when this problem is going to be solved:)
Sinus window plates I used only in maxilla. It reduces morbidity. When doing augmentations in mandibula I (fortunately) always take bone plates from mandibula.
Cheers
Snjezana


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Hi, Snjezana !
I also have seen a fast resorption pattern of the sinus plates. Especially when they were harvested from thin sinus walls. They were <1mm in thickness( in one case you could almost see through it) and after 4 months at re entering the plate was completely gone but it managed to maintain the augmented site and the end result was satisfacatory.
In my cases , i thought this happened because of the thin plate. When harvesting from mandible, i can not take a plate so thin than this from sinus. From mandible i always end up with a 1mm or >1 mm thick plate, so i never saw this in mandible cases. Probably has something to do with quality of bone also, more dense in the mandible
Thank you for sharing this observation !
I wish you all the best !


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Cristian, if just the plate get resorbed I wouldn`t worry. But in these three cases, the plate resorption must be occurred in the early stage of healing, so augmented bone was not maintained.
After thinning out with bone scraper, my mandibula bone plates have around 1mm thickness. In my experience I would say that the difference is in the bone quality.
Thank you for your input
Best regards
Snjezana


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btw, great jogging view.
Croatia is a very beautiful country, almost every year i want to come there in the summer time for vacation, but somehow i always end up in other destinations :)


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Cristian, you are always welcome. We are going to figure out something to connect dentistry with pleasure in Croatia.
Best regards
Snjezana


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Snjezana,

Stunning views- I can't match that except I won a little money on the golf course this morning-

I know that Khoury is strict autogenous but we know that it has a high resorptive rate and we must over graft to compensate as well as if we add PRGF or PRF it helps quality- Soo.. if you use thin sinus plates why not add some Xeno under sinus plate like a modified sausage and see what happens- even if sinus bone resorbs - ( membranous bone?) the Xeno could possibly maintain volume and structure as we see in Urban technique?


Cheers,

Richard


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Richard, be sure that it is the next thing that I am going to do. I was stubborn applying only autogenous bone. Thanks.
Today on my way to the office I made plans how to spend a few days in Cro with Chuck, you and other DentalXP family members. It`s going to be a great fun.
Cheers
Snjezana


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snjezana well done for showing this as it teaches us so much more. To few are prepared to show failures. From my experience the thin zygomatic bone is very poor and tends to resorb no matter what we do here and therefore I am not a big user of the bone. I do not think it has to do with the thickness as I have used both thick and thin with not great results. Obviously there may be other issues. But by the same token when you look at all the beautiful successes you have you need to question the patients biology as well. I often do blood tests and mostly Iron studies to assess the healing responses in these patients I have often found deficiencies in Iron folate or B12


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I like your input, Howie.
Cristian, me, you - all of us have experienced failures with posterior maxilla bone blocks.
Isn´t it amazing that De La Rosa shows so beautiful results using tuberositas bone for immediate dentoalveolar reconstruction?
Dr. Choukroun recommends to check Vitamin D and cholesterol.
These big bone augmentations are serious surgical interventions and probably we should do a proper preoperative preparation, inclusive blood tests.
If we look CBCT from the first patient - it is really 1 mm all along.
Best regards
Snjezana


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The difference with his bone is that it is tuberosity bone not cortical bone huge difference in the vascularity


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And it is inside of defect (socket),it must not resist that much lip pressure.


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Snjezana, I believe there is a lot to learn about physiopathology of bone. About your technique and Khoury one, a possible key, is bone density, as shown on picture below. Showing failure is always expression of great personality and generousity. My sincere appreciation for that. Armando


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Armando, I think that all together we figured out that poor bone quality, poor density played a crucial role. And that big surgeries require blood tests.
Thank you for the illustration. Back to the basic!
My orthodontics professor from Munich (professor Ingrid Rudzki) used to show almost only failures and to say:"Children, learn from my failures, why do you feel that you must repeat my failures and learn then from them?"
I have felt obliged to post failures since I praised sinus window bone blocks. And it is not easy, you are so right.
Thank you for your kind words.
Best regards
Snjezana


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Snjezana,


Croatia meeting would be great!!

It's interesting that we mention blood test for these cases I too routinely check values prior to my larger cases as well as my immediate loads- I agree w chokuron and vitamin D and cholesterol I remember sitting in a lecture he showed incredible numbers almost 50% of people being low - another thing I checked is the blood sugar and hemoglobin A-1c - and really questioning them about if they're taking aspirin some patients don't feel this is a medication and many times will not list-

BTW on my way to work I think about if I could really perfect the teleporter so that I could avoid all the traffic
Cheers,

Richard


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Richard and Howie. I couldn't agree more in regard to the systemic risk factors. Living and practicing in Pittsburgh, I see large percentage of patients with Vit-D deficiency, high cholesterol, over weight, smokers and Diabetics. Maybe that is why I am underwhelmed by my results with regeneration and maintenance of "new bone" long term. However, I find my long term results with autogenous soft tissue augmentation and preliminary results with PET protocols to be satisfactory.Cheers. Chuck


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Thanks for the honesty and integrity. We all benefit form this and we will wait to hear from you as you see more cases develop....Thanks Dr. Salama


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Thank you for your kind words. I`ll be back with an overview.
Best regards
Snjezana


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