Lateral Sinus Lift using SynthoGraft™

Welcome to the Bicon webcast on this Thursday the sixth of May. Today’s scheduled procedure is a lateral sinus lift for the left side. What we will be using is a combination of autogenous bone and SynthoGraft to perform a lateral approach to a sinus lift in the maxillary left again. Our approach is obviously will be intraoral And if you look closely, you will see that the floor of the sinus is within two three millimeters of the crest. The intended treatment plan calls for the placement of an additional two to three implants posterior to the existing teeth. Due to the variation in the anatomical definition of the soft tissue over the tuberosity, we will not include all of the tuberosity in our incision. Often we do include the tuberosity in the incision in order for us to harvest the bone of the tuberosity and include it with the bone graft. So without further ado, let’s get started. As you can see, the maxillary fibrous tuberosity is quite prominent. So incising it, okay, will create a larger or a deeper soft tissue flap. So we will actually incise right around it as our approach will be centered right in the area anterior to the zygomatic buttress, is right there. So the initial incision will go from the tuberosity or buccal to the tuberosity. And we’re gonna cross over onto the palate but only slightly in order for us to avoid any of those vessels that could be crossing the area. Okay. Okay. Now the tooth eminence is gonna create a bit of a difficulty for the flap. So we will bypass it and go right above it and then widen the incision a little bit more. Going right into this areolar tissue, hopefully between all of the muscles of the facial expression. Okay, we will open the flap slightly. We will collect some of the blood from the area to use for mixing with the SynthoGraft. So we just collect some of this blood that will allow us to moisten the graft. What is the recommended agent to mix with the SynthoGraft by the inventor and manufacturer. Okay, just a little bit of patience and you do not have to go to a venipuncture or anything like that to collect the blood. Okay, we’re almost there. So all you need is roughly about a cc. Okay? Now we complete our flap dissection. We will just retract the flap and that will allow us easier access and visibility by simply suturing it to the neighboring cheek mucosa and thereby allowing us the ability to just simply open the surgical site by opening the mouth. Suction in the back. That’s what we need to do. For the window osteotomy, we will use a fine acrylic lab bur. Okay? And then estimating roughly two to three millimeters of native bone will go another millimeter or two above them and the window will start at this point and there and go up. We don’t need to make it too big. Okay? So first we will outline it. So we’re going to collect some bone shavings from the back using this MX grafter which has a little reservoir behind a curved sharp blade. And upon tracing this blade, are able to shave some of the bone. Most of this bone is going to be cortical. Alrighty. K. K. It still hasn’t mobilized yet. Okay. Now it did. Alright. Okay. There’s just that one little corner in the anterosuperior. Bringing up the, the mucosa off of the bone. Quite a bit of coloring. Gonna go to the anterior portion. Okay. Good. Suction the back. Good. And more posteriorly. And surprisingly, the mucosa is quite adherent to the, tissue which to the bone which is quite surprising as a matter of fact. And I expect it to be adherent in the area where we have bleeding. There as well. Good. The right angle curette allows us to go toward the floor of the sinus which is the bottom of the crest, freeing that. Okay. Nicely there. Now we have the severe bend, and that will go toward the anterior portion. And once we free that up towards the slope, of the or the anterior slope of the sinus cavity. Okay. And there’s a little adhesion here that you can feel. And we’re gonna come at it from the posterior to free the adhesions again. Once the floor is freed up, then we have to start focusing on dissecting fully toward the palatal wall. And we have nice approach here and this will go right again against the floor and the corner. And we are starting to mobilize the actual sinus mucosa. Take a breath in, Take a breath in. Good. Good. Good. Good. So as you can see now, we have the sinus mucosa lining lifting up. You know, we wanna make sure it’s doing the same thing anteriorly, and we wanna make sure it’s freed up in this anterior superior corner. Again, we will use the broader side of the simple angled curette or the the nearly straight one. There’s some tethering here as well. You wanna make sure you don’t have any tears, perforations, etcetera. And you can feel when it’s bone, definitely can positively tell that with the tip of your instrument is against bone. And when it isn’t, obviously, you can tell that as well. Okay. One thing that I’m just not happy with yet is this line angle right here, this corner. It’s just and that is because actually, if you recall, that little vessel that’s crossing over, that’s embedded in the tissues. So you have to sort of carefully keep mobilizing it. Okay? So these are the Kerrison rongeurs. Okay. And don’t really overdo it, just taking a bite. This just gives me a little bit more access there. It’s pretty heavy bone as we are approaching the base of the zygomatic buttress and that’s much better. I have more access so I can see better. Okay. Right now, if you look closely as well, we are starting to get into the actual zygomatic process of the maxillary bone. I’m gonna pinch your nose and I want you to ever so slightly, ever so gently to blow your nose out just to verify that we have no perforation. Okay? As you saw, no bubbles came out and rather the mucosal lining just plumped out. And we will use a mixture of fine grit size and large grit size with a ratio of two to one, fine to coarse. So we will mix them together to homogenize the mixture. We will mix the bone graft that we obtained. We will also mix the collected cc of blood. And always start with the posterior. We pack it in some more. You have a significant extent in the anterior aspect. Always use a little curette to pack them. Make sure that you have some resistance. Okay? Now we go to the depth. I’m already seeing significant resistance or feeling resistance to my packing. This is not an amalgam. You don’t need to pack it till it’s screaming for mercy. But you want to have a reasonable expectation that you have not caused the perforation and the way you can get that assurance is by getting a little push back. A little resistance. So this is the fourth half syringe. So we’re almost at about two cc seeing that every cc, excuse me, every syringe is roughly one cc, one milliliter in volume. So we’re almost there. I’m going to give it a little bit of a packing and we’ll do a little backfill. But one of the important things that we tend to forget sometimes is to pack down because the way we created this window, we left a little bit of a ledge so that the graft has something to contain it crestally. Okay? So I’m almost there. Okay. And this should be the last backfill syringe now. And that will put us almost exactly at two cc’s. We do have roughly about three cc’s of graft altogether. Okay, that’s it. Now, I’m going to take a gut suture, four o gut on FS2 needle. First, we will take a suction and clean out around the window osteotomy. You don’t want to embed your… is this on? Okay, good. Just wanna clean it out. Okay. And now take the scissors. Okay. Tissue pickups please. Thank you. Remove the retraction suture. Okay. Let’s take that back. And the next, the first thing you wanna do when you have a releasing incision with a corner is to re approximate the corner and then everything else will fall into place. Okay, so we start with the corner. So the sequence goes, if you have a corner, sort of key it back together and then close the releasing incisions they will not tend to remain open if you don’t close them first. We will finish up. Okay. This is kind of pretty deep back there. I’ll I’ll take a figure of eight suture to start this running suture. That will start us off quickly. Okay, a couple more minutes. Doing fabulous, alright. Okay, you don’t want to make these very tight as they can cause incision breakdown. So all we want is to get them in and it’s very tempting to make them tight because it’s easy to do so. So we’ll just place our last knot and k. Good. Great. Couple more throws for good measure. Good. And that’s one. Okay. Fabulous. Good. So here is our final incision suture. Okay. So as you see, we have a significant height. You can compare, this is an eight millimeter long implant. These two are six millimeter long implants. So roughly we have about twelve millimeters total height, which gives us the latitude of placing an eight millimeters long implant even longer. And we should have no problem with that. And what you look for when you look at the postoperative radiograph after a lateral lift is you want to look at a nice curvature. That means that you don’t have any escaping graft particles. You want to see that your graft has reached this horizontal line, which is the shadow of the palatine bone. You want to see that you don’t have anything tufting up on one end or the other, and it’s nice and round and smooth. That means that your graft is contained, that your graft is as full as the actual depth or height of your alveolar process and that you’ve achieved your goal. Well, it’s a very good question. In this case, we probably would have been able to do the floor transport technique. As you noticed, the crest was pretty narrow. We would have been able to obtain primary stability from the palatal and buccal slope. In this case, for those of you who do not use the plateau designed implant, the Bicon implant, you will definitely need to go to a lateral sinus lift. And we wanted to show you the versatility of the techniques that we use. And one of them is the lateral sinus lift technique with the SynthoGraft. But it can be done with a floor transport. This case in particular could have been done with a floor transport. Yes, absolutely. That’s why you saw that we worked hard at getting the medial wall, the palatal slope, getting it completely freed up of the mucosal lining of the sinus. So definitely, that is really the mainstay of the sinus lift. Otherwise, you’d be doing just a buccal wall graft, not a sinus lift. You’ve got to free up the palatal wall. Very infrequently, certainly probably twenty or more fold less than we used to do the lateral sinus lifts when the ultra short, the six millimeter and five millimeter implants were available. We can obtain primary stability. We can do floor transport or even internal lift, where in the past we needed to go to a lateral lift because we needed an eleven millimeter or longer implant. With the plateau design Bicon implants and the ultra short implants, we not never, but very infrequently resort to lateral sinus lifting. Why would I use a membrane is more of the question. What would the membrane accomplish besides increasing the cost, adding another element that takes time to resorb, and isolating the graft from the beneficial effects of the periosteum. So placing a membrane against the window, had we had, let’s say, a tear of the periosteum, or had we had some pathology in the area, would have been justified, and in fact necessary. But because the periosteum was intact, the dissection as you saw was pretty uneventful in that area, a membrane was going to have little additional beneficial effect. And therefore, makes actually the surgery a little bit more complex. You’re trying to hold the membrane in the back or suture it or tack it and then suture the flap over it and so on with no real benefit. So we actually forgo it when the flap or the periosteum is intact. I would have considered placing implants at the same time in this case. And actually, I debated it. The patient was however quite uncomfortable. As you notice, he was struggling very much. And he’s hypertensive. And as you know with hypertensive patients using beta blockers, etc, the visibility was somewhat reduced. So I wanted to finish this step of the process with full visibility and just close it for his comfort and safety. But had this not been in a hypertensive kind of stressed out patient, it would have probably been an easy implant or two or three to place. The one added variable that I had mentioned early on in the case is relative to the second bicuspid location where the crest is thin. And that will be probably a future webcast where we would place an implant and perform a graft. So you have two choices. Depending on the patient’s tolerance and health, you may go back in and fix it if it’s a gigantic amount of graft. If it’s a small amount of graft, okay, we almost always, by nature of this procedure, we almost always over graft the sinus more than we need it. In this case, we have probably four extra millimeters of height more than we need them for a six or an eight millimeter implant to be placed acceptably. So we have a little bit of leeway. After the initial loss of the graft goes in, or the dehiscence of the graft goes into the sinus cavity, Okay? It will eventually taper off and seal off itself. Okay? What happens with those particles is a competent sinus lining will have the cilia beating out all of these lost pieces of bone, particles, out through the ostium and they get disposed of that way either by blowing the nose or just swallowing them. If, however, your tear is so gigantic, okay, that all of the graft is lost in the sinus, you just have cloudy sinus all over, then you unfortunately have no choice but to sort of go back in. You have to clean the sinus. You can’t have graft all over the sinus because A) you’ve really not done what we started off trying to do, which is a graft of the sinus. Right? And so you want to take it out because it can increase the rate or the risk of significant sinusitis. Plus, if you go back in right at the same time, the patient is still anesthetized, granted you have to redo your sutures, but it’s not a big deal. You may be able to just go in and irrigate the sinus with sterile saline, clean out all of these particles, and then put a containment membrane of some sort, either Surgicel, Vicryl mesh, or other type of wide sticky membrane that you will tack into place, and then place your graft again. But it will be the right thing to do for the patient. So, loss of graft, small tears, usually are self containing. The body will deal with them efficiently and effectively. Big tears, you have to go back in. And it’s your call. My advice to you is to go back in at the same time. Does that answer your question? Micro tears, you won’t see them. They’re micro. They’re too small. And they matter. You will know, what you will see if it’s a micro tear, what you will not see is if there’s any mucosa excuse me, mucus that gets in or any bacteria or anything infective that gets in, it will prevent the graft from coalescing. So it will look okay. It will look fine. But when you reenter to place an implant, it won’t be bone. It won’t be turning over into bone. It will be just white particles. And then that may lead you to having to do the sinus lift again. Only this time, you just have to remove all of the loose material, clean it out, and then pack new bone right through the implant osteotomy. So again, thank you all for your attention and see you later. Thanks.