Bone suture and lateral sinus lift surgery.

Bone suture in lateral sinus lift has four indications. Three of them depend on creating a hole in the lateral maxillary sinus wall above the antrostomy window for securing the elevated medial maxillary sinus membrane to manage perforated Schneiderian membrane. Covering the buccal antrostomy window with the buccal fat pad (BFP) for better nourishment of the inserted graft and as an alternative for bone tags in fixation of collagen membrane has been reported previously. A new indication for firmly anchoring the BFP to the medial maxillary sinus wall as the last resort for the management of perforated Schneiderian membrane is explained in this article.

INTRODUCTION

Sinus lift surgery is recommended in maxillary edentulous region when the remaining available bone is inadequate as consequence of maxillary sinus pneumatization.[1] It is a preprosthetic surgery that was popularized with the introduction of dental implants.[2] Other uses have been explained for this technique for outpatient posterior maxillary segmental orthognathic surgery and orthodontic purposes.[34]

Bone suture consists of creating a hole in the bone for the purpose of anchoring soft tissues to the bone. Creating bone holes in lateral maxillary sinus wall above the antrostomy window for fixing torn Schneiderian membrane is a known indication for bone suture technique [Figure 1].

Figure 1

Elevating Schneiderian membrane from the medial maxillary sinus wall and securing it to the bone hole above the antrostomy window

Securing the buccal fat pad (BFP) to the periphery of the antrostomy window for better nourishment of the grafted material in maxillary sinus and as an alternative to bone tags for fixation of collagen membrane are the other applications.[567] A new indication for firmly anchoring the BFP to the medial maxillary sinus wall as the last resort for the management of perforated Schneiderian membrane is explained in this article.

SURGICAL TECHNIQUE AND PATIENT

The patient was 62-year-old male who had decided to replace his lost teeth in the jaws with fixed dental implants. During the lateral sinus lift surgery, a large perforation occurred that was not amenable to local application of collagen membrane. The BFP was brought out through a 1-cm incision behind the maxillary buttress and was firmly attached to the medial wall with the aid of the bone suture. The biomaterial (DFDBA: Cenobone, Hamanand Saz Baft, Kish, Iran) was added beneath that, between BFP and maxillary sinus floor. Six months after lateral sinus lift surgery, two dental fixtures (Biohorizons: Birmengam, USA) were inserted. Prosthodontic treatment was uneventful [Figure 2].

Figure 2

(a) Buccal fat pad (*) is fixed to the palate by means of bone suture; (b) schematic representation; (c) cone-beam computed tomography taken 1-month after the operation shows the ability of the flap to retain the biomaterial between the flap and maxillary sinus floor; (d) postoperative photograph 1-year after prosthetic replacement

DISCUSSION

Using BFP as the last resort for managing perforated Schneiderian membrane is increasing today.[89] Suturing this flap to the remaining Schneiderian membrane is difficult and has the risk of suture release through the delicate thin Schneiderian membrane. Firmly securing the BFP to the medial maxillary sinus wall has the benefit of isolating the graft/biomaterial from maxillary sinus and participating in graft nourishment. We do every effort to complete the procedure in the first sinus lift surgery because stopping the procedure and re-entry to the surgical field in another session is associated with a great failure rate in our hands.

Lateral sinus lift is a modified form of caldwell-luc surgery in which the integrity of maxillary sinus membrane is preserved. When the schneiderian membrane is torn and the surgeon decide to stop the procedure and doing another attempt several month later, then the clinician is confronted with previously operated sinus with established increased risk of complications.[10]

CONCLUSION

Bone suture in the medial maxillary sinus wall is a useful aid in managing large perforated Schneiderian membrane, with the aid of the BFP. This technique should be considered when other simpler methods are not responsive.