Two surgeries in one: SA4 Sinus Augmentation and Horizontal Bone GBR.
At: GBR+CAS Live surgery mentorship course.
Each course has its own experiences, and this one brought a lot of learning, teamwork, and pride. On August 1st, 2019, our doctors explored and built their skills. The following study case shows how our Doctors worked with the latest materials and concepts during GBR + CAS Live Surgery Mentorship with Dr. Jim Yeganegi.
Past Medical history:
- History of well controlled hypertension for 25 years. BP prior to surgery: 132/76 mm Hg, HR: 76
- The patient has a history of diabetes for about 10 years, his latest HBA1c readings were recorded at 6.3.
- The patient has a history of hiatal hernia.
- The patient does not smoke.
- Linagliptin and amlodipine.
Past Dental History:
- The patient had a consultation with a periodontist in June and was referred to ENT for consultation due to the concern of radiopacity in the left sinus. Received clearance from ENT for Sinus grafting
- The patient had implants in Q4 in the last two years.
The patient wishes to have Q2 missing teeth replaced. Due to inadequate bone height and width, it was decided to plan a two-stage procedure with the first stage being sinus lift and GBR to gain bone dimensions. Sinus lift with lateral window approach was planned, then implant supported 3 units bridge is planned to replace the missing teeth as a secondary surgery.
Fig. 1 Pre-operative Panoramic Radiograph
Fig. 2 Intra oral soft tissue profile.
Fig. 3 CBCT workup showing ideal implant position and inadequate residual bone height and width.
- Cytoplast RTM 30 X 40 resorbable membrane
- OsteOss Powder 3.5 CC, cortico-cancellous allograft
- Profix tenting Screw Kit (1 Screw)
- 4-0 prolene and 5-0 Monocryl
After pre-op medications, antibiotics and corticosteroids were given starting the day before and the morning of surgery respectively, blood was drawn for PRF. Adequate anesthesia was achieved by using Lidocaine 1:100,000. A palatalized crestal incision was planned with an oblique releasing incision starting at the distal line angle of the tooth 24 and extended medially to provide a wide base to the flap.
Flap design was to allow for as minimal a reflection as possible and maximum access and visibility as necessary. After flap elevation, the site for a lateral sinus window was identified and marked with a surgical pencil. The outline was carefully drilled out with a small round surgical bur with copious sterile irrigation. once the window was created, the bone was teased away from the membrane which consequently allowed membrane release off the sinus floor. After achieving the desired release, PRF membranes were placed beneath the membrane as an added protection, before approximately 3.5 cc of 50/50 allogenic bone powder were prepared as sticky bone with PRF and compacted into space. Once the bony Wall was separated from the membrane instruments were introduced to allow careful separation of the Schneiderian membrane from the sinus walls. The membrane integrity was continuously checked via Valsalvas test, visual verification to ensure no perforations were detected. Once the membrane was positioned up superiorily then PRF membranes were added to the membrane. The empty sinus cavity was packed with “sticky bone” (Using Choukroun protocol) on the sinus floor and then particulate allograft (50/50 corticocancellous bone Osteoss) against the medial: anterior and posterior walls. The window was covered with the autogenous bone initially separated from the membrane. This was overlaid with Osteoss. The buccal bony defect in the 24 positions was previously debrided of soft tissue and decorticating with bleeding holes to initiate RAP. This region was grafted with Osteoss in an onlay manner. The buccal graft and lateral window complex were covered by a Long Lasting Resorbable Cytoplast Membrane secures with fixation screws (Profix membrane/bone fixation kit). PRF membranes were draped over the collagen membrane. Primary tension free flap closure was achieved with an initial periosteal releasing incision followed by periosteal brushing to allow tissue release to cover the graft and drape at least 4mm over the palatial tissue. Flap closure comprised of membrane and flap horizontal mattress sutures using 4-0 Prolene which was also used in a continuous interlocking manner across the ridge crest. The anterior and posterior oblique releasing incisions were sutured with single interrupted sutures using 5-0 Monocryl. The patient was given post-op and home care instructions
Post-Operatively, the patient was instructed to follow a post-surgical precautionary protocol and prescribed Ibuprofen 600mg q4-6 hrs prn pain, for 4 days as well as to take dexamethasone (8mg day 1 post-op, 4 mg day 2 post-op).
Fig. 4 Lat Sinus bony window removed. Schneiderian membrane visible.
Fig. 5 After graft placement and placing collagen membrane to secure the graft/bony window.
Fig. 6 Tissue Closure with 4/0 prolene and 5/0 PTFE
Fig.7 Post Op CBCT showing grafted bone inside the sinus and on buccal aspect
Suture removal after ensuring healing was progressing as desired. The site looked clean and healthy, so the patient was allowed to travel and return for second stage surgery after 4 to 6 months.
READ WHAT THE DOCTOR AND MENTOR HAVE TO SAY
ABOUT THEIR EXPERIENCE WITH THIS COURSE.
Dr. Tina He
“Dr. Yeganegi is not only an experienced implant practitioner, but also an excellent instructor. I really appreciate his thorough detailed instruction throughout the treatment plan and surgery process. The clinical knowledge and skills I learned from Dr. Yeganegi are very practical and can be utilized right away in my practice”
“A great learning experience for everyone involved in this complex surgery. Dr.He’s Careful Treatment planning and sequencing of the surgical steps for the lateral window approach Sinus Augmentation (SA4) and horizontal ridge development (GBR) enabled her to execute both surgeries in one. The post op Scan shows a uniform, well formed and confined graft which looks promising. It was a pleasure to work with Dr.He, her assistant as well as the entire Hiossen Team, our surgical assistants Irene and Heidi who’s care and preparation allowed for our Live Surgery doctors to have a positive learning experience. Every surgery and every doctor provides learning for myself and our team and we are grateful for these opportunities to continue our education live”
TAKE THE CHALLENGE. TAKE THE NEXT STEP.