TRANSCRIPT:

So let's discuss another scenario here. In this case, we've accessed the lateral sinus. We see our sinus window. When we went to elevate the sinus membrane, however, there was a small perforation created. Now this perforation is approximately 3 millimeters in size. So it's not incredibly large, but it's large enough to cause concern.

Any perforation in the membrane can be an avenue by which the graft can leak out and migrate to places we don't want it to migrate to, increasing the chance of infection and failure of the graft. With this particular perforation size, which is 3 millimeters or less, some authors advocate that at the 3-millimeter, 2-millimeter mark, that size is actually not significant and not likely to have a large negative impact on the graft.

One of the reasons they say that is as you elevate the membrane and you create laxity in the membrane, it sort of folds in on itself and can cover some of those small holes on its own. That being said, in my practice, any time I see a perforation at all, no matter what the size is, I cover it. I don't want to leave an opening that graft can migrate through. That's the biggest reason that we have complications with this procedure. And so if I can avoid that and I can close that perforation, that makes me sleep better at night.

So when I do have a small perforation from 0 to 3 millimeters, in my practice, I cover that with a PRF membrane. I flatten the PRF into a membrane. I lay that onto the perforation. It's got a suction against it or adhere to it, and it's going to create a barrier there. I'm then going to pack my graft against that barrier.

Now if you don't have PRF in your practice, what I would recommend is utilizing a small collagen membrane or a piece of collotape to go ahead and cover that perforation. And again, you're going to apply it. You're going to hope that it kind of suctions up against there. That's one reason I do like PRF. The collagen membrane can be a little finicky to work with, but you want to get it laid over in that perforation. And now we can go ahead.

In order to address that 3-millimeter perforation, we're going to go ahead and cover it with PRF before we place our graft. And I do also want to indicate that if you do notice a perforation, go ahead and continue elevating your membrane. You're going to want to have your elevation done before you start to place PRF or a collagen membrane. We've finished our elevation. We're ready for grafting.

Now we're going to go ahead and we're going to place our PRF membrane in and over that perforation. On a live patient, that membrane of the PRF and the sinus membrane is going to kind of suction up against each other. That's one reason I like PRF. It adheres really well to the membrane. At this point, we can go ahead and start packing our graft and we can pack it up against that membrane.

When you do place this, make sure that it's obviously a little larger than your perforation. You want it to extend beyond the perforation so that if it moves a little bit, you still have good blockage in your perforation. Now we'd be ready to go ahead and pack our graft around it.

Hey Matt, so how do you actually pack graft without disrupting your collagen membrane? That seems like a really tricky thing to do. The short answer is very carefully. The detailed answer would be the biggest thing that you can do is ensure that your membrane, the PRF and the collagen membrane that you have covering the perforation is large enough that there's some additional coverage beyond the perforation.

So that if that membrane does move slightly or get slightly dislodged, it's still covering the perforation. The key is to maintain that coverage. The other thing that I would recommend is to when you pack up against it, I would strategically pack and kind of stabilize that area first so that you know that you have some bone pushing up against where the perforation is and then pack around and fill it around versus trying to do that spot last when you have less direct visualization of it. And it's harder to tell what's going on in that area.

Lesson Summary

In this scenario, a small perforation (approximately 3 millimeters) is created while elevating the sinus membrane during a procedure. While some authors argue that this size of perforation may not have a significant negative impact on the graft due to the membrane folding in on itself, it is recommended to always cover any perforation to prevent graft leakage and migration. To cover the perforation, a PRF membrane can be flattened and placed over it, creating a barrier. If PRF is not available, a small collagen membrane or collotape can be used instead.

To pack the graft without disrupting the membrane, it is important to ensure that the membrane provides enough coverage beyond the perforation. This prevents the membrane from being dislodged or moved. Additionally, strategically packing and stabilizing the area around the perforation first, with bone pushing against it, can help maintain coverage and prevent disruption during the grafting process.