How To Repair Hole In Sinus
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Several reports demonstrate successful utilise of the buccal fatty pad (BFP) every bit pedicled graft in reconstructing small to medium sized maxillary defects. BFP harvesting has so far been shown to exist an like shooting fish in a barrel, well-tolerated, and uncomplicated technique for oral reconstruction. This case report proposes the use of BFP for repairing of the perforated sinus membrane during sinus augmentation.
Introduction
Loss of maxillary molar teeth leads to rapid loss of bone in the alveolus and increases the size of the maxillary sinus. Os loss tin extend to the alveolar process, leaving simply a thin wall of bone betwixt the maxillary sinus and the rima oris.1 Augmentation of the maxillary sinus floor is a well-documented technique and is generally accepted as an implantology procedure to facilitate placement of dental implants in the posterior atrophic maxilla. The classic procedure for maxillary sinus floor augmentation entails preparation of a trap door including the Schneiderian membrane in the lateral sinus wall.ii Pikos3 reported that perforation of the Schneiderian membrane is the most common complication that occurs during the sinus elevation augmentation. Its prevalence is between twenty% and 60%.3 Perforation of the Schneiderian membrane is most likely to happen at sharp angle and ridge lines, septa, and spines.iii,–5 Information technology tin can as well happen when the membrane is being elevated off the junior and anterior bony aspect of the sinus and can occur due to irregularities of the sinus floor.iv,half dozen,seven Previous sinus surgery, which ofttimes results in a tissue scar, and absence of alveolar bone are besides possible risk factors.4 Many methods have been advocated for handling of perforation of the Schneiderian membrane during the sinus floor peak and augmentation.three,8,–xi
A pedicled graft of the buccal fatty pad (BFP), which enables the closure of oral defects even up to an surface area of lx × 50 mm12 and a thickness of 6 mm,13 has often been used for the reconstructions of intraoral defects.12,–17 The BFP is an encapsulated, rounded, biconvex fat structure located between the buccinator medially and the anterior margin of the masseter muscle and the mandibular ramus and zygomatic arch laterally.xviii Recently, Stajcic17 reported the successful use of the BFP for the closure of an oro-antral fistula in 56 cases. Wong19 found that by using the BFP for additional and immediate claret and nutrition supply and protection of the graft, the quality of bone could be improved for other parts likewise.19 Adult subcutaneous fatty tissue is an abundant source of multipotent cells. Recently, several publications have reported that adipose tissue contains a population of cells able to differentiate into different cell types, including adipocytes, osteoblasts, myoblasts, and chondroblasts.20 Previous studies take shown that adipose-derived adult stem cells express bone mark proteins, including alkaline phosphatase, type I collagen, osteopontin, and osteocalcin, and produce a mineralized matrix as shown by alizarin red staining.21 By placing the BFP between fast-growing fibrous tissue and the defect itself, slow-growing osseoprogenitor cells can drift into the bone defect and lead to the reossification of this area.22
Big perforations represented in the literature an accented contraindication to continuation of the surgery, especially if the graft cloth is in granules or fries. The presence of foreign bodies that are free to move within in the sinus appears to create the state of affairs for initial pathologies of the mucosa.ix
This article reports the use of a pedicled BFP graft for endmost a large perforated sinus membrane at the same time equally sinus augmentation with bone graft material.
Clinical Case
A 49-twelvemonth-one-time human being was referred to a prosthodontist with a complaint of discomfort with missing teeth. The posterior portions of maxilla were edentulous and lacked sufficient os for implant placement without sinus augmentation. The alveolar acme in the posterior maxillary area was less than 3 mm (Figure one). Oral examinations showed that his oral hygiene was appropriate, with no lesions noted. His past medical history included no remarkable disease. Because the patient strongly wished to have fixed prosthesis, placement of osseointegrated implants later on sinus augmentation was planned. Patients did non display signs and symptoms of sinus or intraoral diseases.
Figure 1.
Panoramic view of enlarged correct sinus
Figure i.
Panoramic view of enlarged correct sinus
Local anesthesia was performed with lidocaine hydrochloride (Ecocain ii%, Molteni Dental, Scandicci, Italy) with 1:50 000 epinephrine.
Vertical incisions were extended to the inductive and posterior vestibule. The trapezoidal buccal mucoperiosteal flap was then reflected from the alveolar procedure and the lateral wall of the maxilla. The lateral wall of maxillary sinus was fenestrated with a round diamond bar with saline solution irrigation to marking the limits of a rectangular surface area (15 × 10 mm), and a door in the lateral wall was prepared. The Schneiderian membrane was freed and separated from the lateral wall of the sinus using blunt instruments. Although care was taken to preserve the mucosal lining, the sinus membrane was torn. The BFP was exposed by a 2-cm, horizontal periosteal incision lateral to the maxillary butress extending backwards to a higher place the maxillary second molar tooth. Blunt dissection through the buccinator and loose surrounding fascia allowed the BFP to herniate into the mouth. The body of the BFP and the buccal extension were gently mobilized past blunt dissection, taking intendance non to disrupt the frail capsule and vascular plexus and to preserve equally wide a base as possible. Pressure on the cheek helped to express the fat into the mouth (Figure two). Subsequently the pad had been dissected gratuitous from the surrounding tissues, it was grasped with vascular forceps, gently teased out, advanced, and expanded over the defects. A pigsty was created with a fissure bur (702) through the window into the maxillary os transsinusally. An eighteen-gauge needle passed through the bur hole, and the penetration site in the palatal mucosa was marked. Then a suture needle was passed through the palatal mucosa and grasped with forceps when it appeared in the elevated sinus, and the BFP was pulled to the sinus flooring. Then the needle passed through the palatal os through the osteotomy site, and the suture was folded in the palatal gingiva (Figure 3). BFP covered the remaining role of the Schneiderian membrane and acted equally a barrier between the sinus antrum and the site of graft material placement. A 2:one mixture of autogenous os and bovine xenograft (Bio-Oss, Geistlich Pharm AG, Wolhausen, Switzerland) was used every bit the graft textile, and the sinus was then filled with graft mixture (Figure iv). The mucoperiosteal flap was repositioned and sutured (Figure 5). No surgical splint or dressings were used.
Figures two–4. Figure 2. Perforation of the Schneiderian membrane and releasing buccal fat pad. Figure iii. Rotation of pedicled buccal fat pad and use of it as a replacement for perforated Schneiderian membrane. Effigy iv. Placement of bone graft fabric under the buccal fat pad to augment the sinus
Figures 2–4. Figure 2. Perforation of the Schneiderian membrane and releasing buccal fat pad. Figure 3. Rotation of pedicled buccal fat pad and use of it as a replacement for perforated Schneiderian membrane. Effigy 4. Placement of os graft material under the buccal fat pad to augment the sinus
Figures v
and vi. Figure 5. Schematic presentation of the closing perforated Schneiderian membrane. Figure 6. Close radiographic view of augmented sinus after 4 months
Figures 5
and 6. Figure 5. Schematic presentation of the endmost perforated Schneiderian membrane. Figure 6. Shut radiographic view of augmented sinus later on 4 months
Postoperative antibiotic (amoxicillin, i.v gm for 10 days) and mouthwash (chlorhexidrine digluconate, 0.ii% for 6 weeks) were administered. Postoperatively, the decrease of the depth of the vestibular sulcus gradually improved and was restored most to the preoperative form about two months afterwards the functioning. The patient was followed for four months after augmentation (Figure 6). After that, posterior maxillary alveolar bone was enough for implant placement.
Discussion
Anatomically, the BFP consists of a primal body and four extended processes. It possesses favorable characteristics for the reconstruction of intraoral defects, especially in the posterior maxillary region. The blood supply to the BFP is derived from the buccal and deep temporal branches of the maxillary artery, the transverse facial branch of the superficial temporal artery, and from some minor branches of the facial artery.fourteen This rich claret supply of the pedicled BFP suggested that it could provide critical vascular support to the mucus membrane roofing and to the bone grafts compared to the bioresorbable membranes, which promote both calcified and soft-tissue healing.18
This flap is piece of cake to fix, modify, and relocate, demonstrates a strong ability to resist infection, can be associated with other pedicled flaps, has a minimal incidence of failure when properly performed, completes its epithelialization in a few weeks, needs no microvascular anastomosis, will not lead to perceivable deformity in the donor site (cheek), and causes minimal discomfort for patients.15,16
The limitations of BFP pedicled flap should not exist disregarded. This flap can only cover a soft-tissue defect of limited area. Reduction in oral opening, partial necrosis, infection, excessive scarring, and sulcus obliteration might also exist some complications. Since the size of the defect in sinus augmentation is not that big and its location is near the donor site, these problems are of little importance and were not seen in this case. As the cost is less than the traditional utilise of resorbable membranes, further studies could exist designed to compare the effect of the BFP with collagen membranes.
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Ali Hassani, DMD, MS, is an banana professor in the Department of Oral and Maxillofacial Surgery, Azad University of Medical Sciences, Tehran, Iran.
Arash Khojasteh, DMD, is chief resident, Department of Oral and Maxillofacial Surgery, Taleghani Hospital, Beheshti Academy of Medical Sciences, Tehran, Iran.
Marzieh Alikhasi, DDS, MS, is assistant professor, Department of Stock-still Prosthodontics, School of Dentistry, Medical Sciences/Academy of Tehran, Tehran, Iran. Accost correspondence to Dr Alikhasi at Department of Fixed Prosthodontics, School of Dentistry, Medical Sciences/University of Tehran, Ghods St, Enghelab St, Tehran, Iran. (electronic mail: m_alikhasi@yahoo.com)
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