2. • INTRODUCTION
• DEVELOPMENT OF PARANASAL SINUSES
• ANATOMY OF PARANASAL SINUSES
• HISTOLOGY OF PARANASAL SINUSES
• PHYSIOLOGY OF PARANASAL SINUSES
• FUNCTIONS OF PARANASAL SINUSES
• EXAMINATION OF MAXILLARY SINUS
CONTENTS
2
3. • PATHOLOGY RELATED TO PARANASAL SINUSES
• MICROBIOLOGY OF THE PARANASAL SINUSES
• PHARMACOLOGICAL ASPECT OF TREATMENT
RELATED TO PARANASAL SINUSES
• PROSTHODONTIC CONSIDERATIONS IN
RELATION TO MAXILLARY SINUSES
• CONCLUSION
• REFERENCES
3
11. 11
Anterioposterior – 35.6 mm
Mediolateral - 27mm
Superoinferior - 37mm
Superior wall - floor of orbit
Inferior wall – alveolar process of maxilla
Base – lateral wall of nasal cavity
Anteriorly – anterior surface
of body of maxilla
Posteriorly – pierced
by alveolar canals
APEX – zygomatic
process of maxilla
12. The sinus is found to vary widely in shape and
accordingly classified into four types -
• Semi-ellipsoid - 15%
• Paraboloid - 30%
• Hyperbolic - 47%
• Cone shaped - 8%
12
Lauren N. Butaric, Laura T. Buck, Antoine Balzeau, Anton du Plessis, Frederick E. Grine,
The Paranasal Sinuses of the Hofmeyr Cranium, Hofmeyr, 10.1007/978-3-031-07426-
4_11, (179-211), (2023).
13. G R O W T H O F M A X I L L A R Y
S I N U S
13
Thiagarajan, Balasubramanian. (2012). Anatomy of Paranasal Sinuses. ENT SCHOLAR
14. SICHER (1949) stresses that the antrum continues to grow
throughout the life.
MATTILA & WESTERHOLM (1968) claim that after dental
extractions the maxillary sinus continues to widen at the
extraction site.
14
27. P H Y S I O L O G Y OF P A R A N A S A L
S I N U S E S
27
28. The functions of warming/humidification of air.
Assisting in regulation of intranasal pressure.
Contributing to immune defense.
Increasing mucosal surface area.
Lightening the skull.
Giving resonance to the voice.
Absorbing shock (dampening the forces of mastication), and
Contributing to facial growth.
FUNCTION OF PARANASAL SINUSES
28
29. 29
NEGUS V, NEIL E, FLOYD WF. The mechanism of phonation. Trans Am Laryngol Assoc.
1957;78:49-61; discussion 61-4. PMID: 13530011.
36. TRANSILLUMINATION
dull side - sinus mucosa thickened/
sinus contains fluid/mass.
opaque sinus - with active infection.
36
Christmas DA, Mirante JP, Yanagisawa E. Sinus transillumination, then and now. Ear Nose Throat J.
2014 Dec;93(12):490-1. doi: 10.1177/014556131409301201. PMID: 25531840.
37. D I A G N O S T I C I M A G I N G
O F
M A X I L L A R Y S I N U S
37
42. • CT scan – to investigate the mucosal surface & bony
framework of the sinus.
• 3D CT scan – greatest use in facial trauma when
evaluation of the degree of displacement of the
fracture segment has to be done.
• MR imaging – better soft tissue discrimination than CT
& useful in studying the spread of the disease.
42
43. Odontogenic sinusitis (acute/chronic)
Maxillary sinusitis (acute/chronic ;
suppurative/non suppurative )
Oro antral communication & fistula
Benign tumours (osteoma)
PATHOLOGY RELATED TO PARANASAL
SINUSES
43
44. ODONTOGENIC SINUSITIS
ACUTE MAXILLARY SINUSITIS
• CHRONIC MAXILLARY SINUSITIS
C L I N I C A L F I N D I N G S
44
48. ANTIMICROBIALS –
Erythromysin 250 – 500 mg qid for 5 days
(most suitable)
Amoxicillin 250 – 500mg tid for 5 days (broad
spectrum)
P H A R M A C O L O G I C A L A S P E C T
48
50. MUCOLYTIC AGENTS – (to reduce viscosity
of mucous secreted)
Steam inhalation, tinc. Benzoin, camphor,
menthol.
Inhalation of 2-3 tablespoon full of tinc.
Benzoin in a bowl of steaming water for 5 – 10
50
54. Factors in consideration are –
Implant diameter.
Implant surface area.
Number of implants to be placed.
Splinting of implants.
Implant surface coatings.
Implant design.
54
55. The treatment plan approach to providing
additional prosthodontic abutments in the
maxillary posterior edentulous region has
been organized by MISCH (1987) into
four alternative treatment options
dependent on the available bone height
T R E A T M E N T S E L E C T I O N
55
58. SA-1 – CONVENTIONAL IMPLANT PLACEMENT
Sufficient bone height permits the placement of endosteal
implants.
Patients with narrower bone volume (width) may be treated
with osteoplasty or augmentation.
58
59. SA-2 - SINUS LIFT
Elevation of the sinus floor from below.
An implant osteotomy 1- 2 mm below the floor
of the sinus is done. The flat end osteotome is
then inserted & firmly tapped into position 2 mm
beyond the prepared implant osteotomy.
A green stick fracture of the sinus floor usually
59
60. SA-3 - SINUS GRAFT & STAGED
ENDOSTEAL IMPLANT PLACEMENT
A lateral maxillary wall approach (TATUM) just
superior to the residual alveolar bone is
performed.
After rotating the lateral access window &
membrane in and upward to a superior
60
61. SA-4 - SINUS GRAFT HEALING & DELAYED IMPLANT SURGERY.
The Tatum lateral wall approach is used to gain access to the maxillary sinus,
then elevating the sinus membrane and allowing placement of autogeneous
bone alloplasts & allografts in the region similar to SA – 3.
However the healing period of the graft is prolonged to 6 – 10 months.
61
63. PROSTHODONTIC REHABILITATION OF THE
POSTERIOR ATROPHIC MAXILLA
Recent trends in sinus augmentation
TECHNIQUES
INDIRECT TECHNIQUE DIRECT TECHNIQUE
summers modified summers
63
64. garbacea, Antoanela & Lozada, Jaime & Church, Christopher A & Al-Ardah, Aladdin &
Seiberling, Kristen A & Naylor, W Patrick & Chen, Jung-Wei. (2012). The Incidence of
Maxillary Sinus Membrane Perforation During Endoscopically Assessed Crestal Sinus Floor
Elevation - A Pilot Study. Journal of Oral Implantology. 120416110635004. 10.1563/AAID-
JOI-D-12-00083.1.
65. SUMMERS METHOD
Permits immediate implant placement.
After incision, the established sites are reached using
smallest diameter first. Each site enlarged until its diameter is
equal to the size of the intended implant.
Small quantities of bone from the adjacent site is mixed
with the graft & placed into the previously tapped implant site.
Placement of implant & sutures.
65
70. 1. On first night after surgery, head should be
elevated on 2 or more pillows
2. Liquid diet for 2 days and then soft diet for 2
weeks
3. Some nasal bleeding may occur during first day
4. Medications – Amoxicillin with clavulanate
potassium 625mg BID for 10days; ibuprofen
600mg and acetaminophen 500 mg QID for 3
days; oxymetazoline nasal spray for 7 days; 1.2%
chlorhexidine mouth 30 cc BID for 14 days
5. Avoid chewing from the surgical site, blowing
the nose for 2 weeks, smoking, balloon blowing,
sucking liquid with straw, flying in pressured
aircraft or scuba diving, carbonated drinks
(minimum 3 days), heavy lifting of weights, and
playing musical instrument that require blowing.
Actions that create negative pressure (blowing of
nose or sucking through straw) must be avoided
by the patient during the first week after surgery.
70
78. Tumours of maxillary sinus sometimes require extensive
surgeries like maxillectomy or maxillary resection.
Violation of the hard palate creats an anatomic defect that
allows the oral cavity, maxillary sinus and nasal cavity to
become one confluent chamber.
Lack of anatomic boundaries create disabilities in speech &
deglutition. Nutrition is compromised along with possible
social communication.
Maxillofacial considerations
78
79. Prosthetic intervention, with a maxillary prosthesis, is
necessary to restore the contours of the resected
palate & to recreate the functional separation of the
oral cavity & sinus & the nasal cavity.
Prosthetic intervention should occur at the time of
surgical resection & is necessary for the remainder of
the patients life.
79
80. Surgical enhancements have been suggested to
prepare the defect for optimal prosthetic
rehabilitation.
1) Maintain as much hard palate as possible.
2) Skin graft the cheek flap.
3) Remove the inferior turbinate.
4) Skin graft the maxillary sinus walls.
80
82. The system of cavities, depressions, ostia, and processes is a
complex system of structures which must be understood before
surgical management of sinus disease can be safe and effective.
The physiology and function of the paranasal sinuses is a subject
that reflects the complexity of their anatomy.
Continued research may likely reveal that all of these functions are
part of a bigger, more involved picture than is now apparent.
C O N C L U S I O N
82
83. The maxillary sinus & its dental implications.
H.C. KILLEY & L.W. KAY
Dental implant prosthetics.
CARL E. MISCH
Textbook of oral & maxillofacial surgery.
NEELIMAANIL MALIK
Human anatomy. Vol. 3; 4th edition.
B D CHAURASIA
Gray’s Human anatomy . 39th Ed.
R E F E R E N C E S
83
84. Oral radiology – principles & interpretation. 5th Ed.
WHITE & PHARAOH
Clinical maxillofacial prosthetics.THOMAS D. TAYLOR
Prosthodontic rehabilitation of the posterior atrophic maxilla: Recent
trends in sinus augmentation. JIPS;2008;8(1);2-5
Diagnosis & treatment of diseases & disorders of the maxillary
sinus.ORAL & MAXILLOFACIAL SURGERY CLINICS OF NORTH
AMERICA;1999;11(1).
Systematic review of survival rates for implants placed in the grafted
maxillary sinus. Int J Periodontics Restorative Dent 2004;24:565-77.
84
85. Bathla SC, Fry RR, Majumdar K. Maxillary sinus augmentation. J Indian
Soc Periodontol. 2018 Nov-Dec;22(6):468-473. doi:
10.4103/jisp.jisp_236_18. PMID: 30631223; PMCID: PMC6305100
Abadzhiev, Metodi. “ALTERNATIVE SINUS LIFT TECHNIQUES
Literature review.” (2010).
Proussaefs P, Lozada J. The “Loma Linda pouch”: A technique for
repairing the perforated sinus membrane. Int J Periodontics Restorative
Dent 2003;23:593-7.
Regev E, Smith RA, Perrott DH, Pogrel MA. Maxillary sinus
complications related to endosseous implants. Int J Oral Maxillofac
Implants 1995;10:451-61.
Ziccardi VB, Betts NJ. Complications of maxillary sinus augmentation.
In: Jensen TO, editor. The Sinus Bone Graft. Chicago: Quintessence
Publication Co.; 1999. p. 201-8.
Chan HL, Wang HL. Sinus pathology and anatomy in relation to
complications in late
85
The complexity of the anatomy of paranasal sinuses , as well as their functions make these sinuses an interesting and rewarding topic of study.
There are a total of four paired sinuses. They include the frontal, ethmoid, maxillary and sphenoid sinuses.
These sinuses are essentially mucosa-lined air spaces within the bones of the face and skull.
Development of paranasal sinuses begins in the womb, but results in only two clinically relevant sinuses by birth - the maxillary and the ethmoid sinuses.
The development of paranasal sinuses begins as evaginations of the nasal mucous membrane during the 2nd and 4th month of pregnancy. Further development takes place after birth.
With the start of the 2nd teething, a further growth begins.
The maxillary sinus (antrum of Highmore) is the first to develop. These structures are usually fluid-filled at birth.
pneumatization takes place with the eruption of the teeth
Pneumatisation can be so extensive as to expose tooth roots with only a thin layer of soft tissue covering them.
As we read that the maxillary and the ethmoidal sinus is first to develop during birth,so ethmoidal sinus aapear during development as fluid filled sinuses.During fetal development the anterior cells form first, followed by the posterior cells. The cells grow gradually and are adult size by age 12. They are not usually seen on radiographs until age one. TEthmoid cells are the most variable and can often be found above the orbit, lateral to the sphenoid, into the roof of the maxillary sinus, and anteriorly above the frontal sinus
The frontal sinus is likely formed by the upward movement of the anterior-most ethmoid cells. True growth begins at age five and continues into the late teens.
undeveloped until age three. By age 18 the sinuses reach full size.
The maxillary sinus communicates with the posterior part of the hiatus in the middle meatus via an aperture – the maxillary ostium (3 -6 mm diameter).
In the adult, the floor of the sinus is approx. 1.0 – 1.25 cm below the level of floor of the nasal cavity.36-45 mm in height, 38-45 mm ap average volume 15 ml
In the adult, the floor of the sinus is approx. 1.0 – 1.25 cm below the level of floor of the nasal cavity.roots of II molar are closest to sinus(VON BONSDORFF,1925)
Proximity of root to the sinus – (PAATERO)
II M > I M > III M > II PM > I PM > Canine
The maxillary sinus is the first to develop (3 months I.U.)
AT BIRTH – shallow cavity 2cm (A-P); 1cm (M-L); 1cm (S-I); situated in the lateral wall of nose. (RITTER,1971).
PNEUMATIZATION – results in growth of antrum at the rate of 3 mm (A-P)/year; and lateral & vertical diameters at the rate of 2 mm/yr till nine years of age.
AT NINE YEARS – 25mm x 18mm x 18mm at this pneumatization phase, the sinus is more vulnerable to infection than any other sinus. BY 12 YEARS – floor of the sinus is at the level of the nasal floor.
Growth continues in concert with the eruption of permanent teeth till 15th to 18th year when the normal size is reached & secondary dentition is virtually complete
Shape of the sinus changes from tubular (birth) to ovoid (childhood) to pyramidal (adult).
Greater the pneumatization, thinner the bony walls of the sinus & larger is the size of the sinus.
Lies in the frontal bone deep to the superciliary arch.
It extends upwards above the medial end of the eyebrow, and backwards into the medial part of the root of the orbit.
It opens into the middle meatus of the nose.
The right & left sinuses are usually unequal in size and rarely one or both may be absent.
The average height , width & A-P depth is about 2.5 cm
Better developed in males than in females.
These are numerous small intercommunicating spaces lying within the ethmoid bone.
These sinuses are divided into anterior, middle & posterior groups.
ANTERIOR GROUP is made up of 1 – 11 air cells and opens into the anterior part of hiatus semilunaris.
MIDDLE GROUP is made up of 1 -7 air cells & opens into the middle meatus of the nose.
POSTERIOR GROUP is made up of 1 -7 air cells & opens into the superior meatus of the nose.
Endosseous anastomosis at lateral wall and sinus membrane –supplies lateral wall os sinus membrane –psa io
Extraosseous anastomosis-within periosteium –supplies sinus mucous membrane –psa io
Flap prepration-perforation –radiolucency in the buccal plate -
Risk of oro antral – fistula is less likely in children & teenagers.
Inadvertent displacement of teeth or root into the antrum is also less likely in such cases. (KILLEY & KEY,1972)
Patients having large antra have more chances of fracture of the floor of the sinus during extraction of any upper tooth from canine to 3rd molar.
The most probable site of fracture is the maxillary tuberosity region.
The most probable site of fracture is the maxillary tuberosity region.
Palatal root of max. 1st molar has maximum chances of being displaced to the antrum.
Presence of an unerrupted 3rd molar constitutes a potential line of weakness for extraction of adjacent 2nd molar.
Such tumours result in loosening of the tooth in the vicinity ( bone destruction) , pulpal necrosis( blood supply) & an acute apical abscess.
If the tumour erodes the posterior wall, then the PSA nerve can be damaged & patients initial complain is usually anaesthesia of maxillary teeth or gum.
If roof of the antrum is involved then areas supplied by IO nerve are anaesthetized initially. The tumour may escape from the ostium & present at the nasal cavity resulting in nasal blockade & acute sinusitis due to pus collection.
Crack fractures of the bony floor usually heal uneventfully - even when there is an accompanying tear of the sinus lining – unless the blood clot in the tooth socket breaks down.
(When antral irrigation is required in children, puncture into the sinus must be made through the middle meatus but for the same condition in adults, it’s the inferior meatus which is approached.)
For dependent drainage of the sinus usually the thinner wall of the canine fossa (sub labial antrostomy) is selected.
The sinuses are lined with pseudostratified ciliated columnar epithelium (respiratory type) which is in continuity with the mucosa of the nasal cavities. The epithelium of the sinuses is thinner than that of the nose.
There are four basic cell types. These include ciliated columnar epithelial cells, non cilliated columnar cells, basal cells, and goblet cells.
The ciliated cells have 50-200 cilia per cell which beat at about 700-800 times/minute, moving mucus at a rate of 9 mm/minute
Noncilliated cells serve to increase surface area (likely to facilitate humidification and warming of inspired air).
The basal cell's function is unknown. They vary in size, shape and number. Some have theorized that they serve as a stem cell which can differentiate as needed.
Goblet cells produce glycoproteins which are responsible for the viscosity and elasticity of mucus. They are innervated by the parasympathetic and sympathetic nervous system which control the consistency of mucous secretion.
The mucociliary mechanism provides the means for the removal of particulate matter and bacteria. The ciliated cells in each sinus beat in a specific direction. A resulting pattern of mucus flow in spiral tracts towards ostium results where it is then discharged into the middle meatus of the nose. Since many of the sinuses develop in an outward and inferiorly fashion, the ciliated mucosa often moves material against gravity to the sinus' exit.
The purpose to impart resonance to the voice has been postulated but many silent animals (rabbit, deer) have large well developed maxillary sinuses.
A more popular theory is that is that the purpose of the paranasal sinuses is to lighten the skull, which might be excessive if these spaces are filled with bone.
But LAST (1959), had suggested that if these sinuses were filled with bone, the additional increase in weight would merely amount to a pipe & a pair of spectacles.
BRAUNE & GLASEN (1877) calculated that no more than 1% weight would be added if all the paranasal sinuses be filled with spongy bone.
Whether these cavities fulfill a real purpose in mammalia is questionable – a point endorsed by NEGUS, NEIL & FLOYD (1958), whose careful research into the comparative anatomy of the paranasal sinuses appears to indicate that the antra in man merely represent an unwanted space.
Clinical examination includes both a focused history & a careful physical evaluation. burkitt
MEDICAL HISTORY -
Any H/O - Compromised condition / Upper airway or sinus infection / nasal or sinus surgery / Allergy (skin testing).
Factors associated with the sign & symptoms of the disease.
Bilateral involvement indicates systemic condition whereas unilateral findings are more common with space occupying lesions & bacterial sinusitis.
Pain that originates from the sinus is fairly localized & is made worse by bending over.
When numbness or severe pain is reported, tumour should be suspected.
Improvement of the condition with decongesants or intra nasal sprays indicate mucosal condition of inflammatory origin.
A H/O trauma may indicate blockage of sinus drainage.
PHYSICAL EXAMINATION
Inspection
Inspection of surrounding tissues, skin, mucosa for swelling, symmetry and coloration.
SINUS ENDOSCOPY
The endoscope is inserted through a inferior meatal puncture or a previously created antral window or the anterior maxillary wall via the buccal sulcus.
Apart from diagnosing, it also helps in removal of diseased tissues, lavage & obtaining specimens for culture.
ASPIRATION
Not routinely used as other reliable non – invasive techniques provide adequate results.
But may be used in conditions that are unresponsive to antibiotic doses or when there is severe unremitting pain.
Recovery of bacteria in a density of at least 104 CFU/mm is considered diagnostic of a true infection.
Performed in a darkened room by placing a lightened instrument into the oral cavity with the patient’s lips tightly closed.
Observations made as to how well the anterior wall of the sinus transilluminates.
Most commonly used as a screening tool or to monitor a resolving sinusitis for which repeated x- ray exposure is not justified.
Best demonstrated by 150 occipitomental radiograph, a view first described by WATERS & WALDRON (1915) nose chin view with nose and chin touching the film. Nest for maxillary sinus and open mouth to view sphenoidal sinus
Valuable in localizing a foreign body (root).
Pus produces a horizontal fluid level (only if there is air above it).
Caldwell view Also called occipitomental view or nose forehead position,best for frontal and ethmidal sinus
Submento vertex…Best for shenois sinus and posterior wall of maxillary sinus
Most important supplementary investigation to clinical examination.
Intra oral views significantly contribute to supplementary investigations
Orthopantomograph – for routine detection of odontogenic & mucosal cysts of maxillary sinus.
Opacities in sinus radiograph may be due to transudates, exudates, blood, mucosal thickening or mass of polyps.
Tomography – for solid masses(osteoma, antrolith, early erosion of wall of sinus).
Radiopaque dyes (50% Hytrast) can be introduced to investigate intra – antral cysts. (HARRISON;1972)
Dentascan – it’s a CT dental reformatting program that allows reconstruction of the mandibular/maxillary alveolar ridges in coronal & panormic planes. This software was developed as a more accurate & sophisticated method of evaluating the jaw for purpose of dental implant technology. The image displays predominantly the osseous anatomy of the jaws.
ODONTOGENIC SINUSITIS – involved tooth in oral cavity, throbbing pain, foul pus running down the nose.
ACUTE MAXILLARY SINUSITIS - tenderness & swelling over the sinus, anaesthesia over distribution of IO nerve, oro antral fistula, pus discharge, fetor oris, nasal blockage, heavy feeling of head, nasal discharge.
CHRONIC MAXILLARY SINUSITIS – may be asymptomatic, however the clinical symptoms, if present, will be same as that of acute maxillary sinusitis with decreased intensity or presenting only at acute exacerbations.
ORO ANTRAL COMMUNICATION –FRESH COMMUNICATION (5 E)
escape of fluid ; epistaxis ; escape of air ; enhanced column of air ;
excruciating pain.LATER STAGE (5 P)
pain (diminished) ; persistent foul nasal discharge ; postnasal drip ;
possible sequelae of general systemic conditions ; popping out of antral polyp.
NORMAL FLORA
Earlier studies had indicated that the sinuses were naturally sterile.
BROOKE (1981) reported that predominantly anaerobes are present naturally.
However the consensus remains that the para nasal sinuses are normally sterile.
ACUTE SINUSITIS
S. pneumoniae & H. influenzae (adults) Rhinoviruses , adenoviruses, Influenza type A, Parainfluenza viruses
Fungi from mucorale order, Aspergillus.
CHRONIC SINUSITIS
The degree to which bacteria are involved is not clear & its difficult to determine which bacteria dominate the condition.
Bacteria associated with those of acute sinusitis may be dominant along with anaerobic bacteria (Bacteroids fragalis group)
Respiratory syncitial viruses (RAMADAN et al)Aspergillus (granulomatous invasive fungal sinusitis), Mucorales
BED REST; PLENTY OF FLUIDS; MAINTENANCE OF ORAL HYGIENE
The presence of maxillary sinus presents many unique & challenging conditions in implant placement.
Most noteworthy is sinus graft to increase available bone height.
The available bone height is lost due to periodontal diseases, bone resorption after tooth loss, decreased vascularization of alveolar bone & absence of muscle stimulation.
The width of posterior maxilla decreases at a more rapid rate than in other regions of jaws. (PIETROKOVSKI).
The density of the bone of the region decreases dramatically in long term edentulous conditions.
Not only that, the pneumatization of the maxillary sinus after tooth loss adds to the compromise in initial implant stability at the time of implant insertion.
Its fortunate that because of initial width, even with a 60% decrease in width; the residual ridge is still adequate for implants.
The natural dentition in the posterior maxilla is provided with largest diameter teeth, the greatest no. of roots & the greatest amount of root surface area. These are biomechanical advantages to sustain greater forces in less dense bone. Implant treatment plans should attempt to simulate the conditions found in natural teeth.
Insertion of smaller surface area of implants as plate – form or smaller diameter root – form implants are not recommended.
Augmentation for width can be achieved with bone spreading or interpositional grafts. Onlay autogeneous bone graft is most predictable when bone width is less than 2.5 mm
“HALO FORMATION” (WORTH & STONEMAN ;1972) – natural elevation of the sinus membrane occasionally occuring around teeth due to periodontal diseases, resulting in formation of new bone below.
Indirect sinus lift –if the residual bone height is equal to or >6 mm.[28]
2mm initially then subsequentally widened the osteotomy site and kept 2mm short of sinus fllor
After the largest osteotome has expanded the implant site, bone mix are added to the osteotomy site as grafting material -25% autogeneous bone graft and 75% hydroxyapatite graft should be used . The graft is inserted before the fracture of the sinus floor….after that an osteotome of lesset diameter is inserted to the osteotomy site and tapped gently to fracture the floor of the sinus. When sinus floor fractures a different pitch sound can be heard . Sinus floor elevation is then done by reinserting the largest osteotome in the implant site with the gtraft material at place . The graft material in place exerts pressure and helps in sinus floor elevation . Excess of bone graft can be adde dti achieve the desired amount of sinus elevation.. An implant of slightly larger diameter than the prepared osteotomy site is the inserted.
2mm initially then subsequentally widened the osteotomy site and kept 2mm short of sinus fllor
After the largest osteotome has expanded the implant site, bone mix are added to the osteotomy site as grafting material -25% autogeneous bone graft and 75% hydroxyapatite graft should be used . The graft is inserted before the fracture of the sinus floor….after that an osteotome of lesset diameter is inserted to the osteotomy site and tapped gently to fracture the floor of the sinus. When sinus floor fractures a different pitch sound can be heard . Sinus floor elevation is then done by reinserting the largest osteotome in the implant site with the gtraft material at place . The graft material in place exerts pressure and helps in sinus floor elevation . Excess of bone graft can be adde dti achieve the desired amount of sinus elevation.. An implant of slightly larger diameter than the prepared osteotomy site is the inserted.
Modified summers technique –we do not fracture the floor of the sinus wall, the rounded osteptome permit safely comprimition of the bone after preparing the pilot hole expanding the hole and extrusion of the sinus graft cavity and placing the implant.
Given by sole et al in 2012, inflatable balloon to lidt the sinus. Zimmer sinus lift balloon was used(lifts gently and evenly ). Metal shaft is present which is connected to the tip of the balloon which has inflation capacity of 5 mm. osteotome is used to break the floor of the sinus by 5mm and after addition of the bone , the sleeve of the ballon is then inserted 1 mm beyond the sinus floor. The saline is then injected slowly from the balloon so that the ballon inflate progressively. The ballon is inflated and deflated until the desired sinus elevation is achieved. 1cm3 of saline=6mm of sinus floor raised.
Minimally invasive transalveolar sinus approach was given by khee et al in 2014. calcium phosphosilicate putty was used for hydraulic sinus membrane elevation .drilling done 1mm short osf sinus floor.concave 3mm osteotome used to fracture the sinus floor . Novabone cannula placed in the prepared osteotomy site and materaila is placed in the sinus. Due to consistency of the material the sinus membrane is lifted up.
Bleeding can occur while performing an osteotomy. Bleeding from the sinus membrane can be controlled by placing gauze soaked with anesthetic solution containing 1:80,000 epinephrine directly onto the membrane. Bleeding from the bone requires application of direct pressure with an artery forceps, or it can be managed with a cautery unit. Another method for containing an intraosseous arterial bleeder is to displace the membrane and compress the bone with a mosquito hemostat, thereby crushing the bone and obstructing the bleeding blood vessel.[
If membrane perforation occurs during the lifting of sinus membrane and is a small defect of less than 2mm it can be left to heal itself if more tha 2mm membtane can be patched with a piece of hydrated resorbable collagen barrier .
Residual alveolar bone 5 mm or below then this technique
Anterior vertical incision should be at least 10–15 mm anterior to the wall of sinus to ensure soft tissue over the bone. Next, a mid-crestal ridge/palatal incision with 15C blade is made connecting the vertical incision. It is desirable to make the horizontal incision in keratinized tissue to facilitate suturing. Full‑thickness flap is reflected to access canine fossa just below the infraorbital foramen, buttress of the zygomatic arch, and posterior lateral maxillary wall. While elevating full‑thickness flap, the elevator must be adherent to the bone surface, so that the periosteum remains unchanged
3. Lateral window/antrostomy – After flap elevation, a sterile number 2 pencil is used to demarcate the outline of the lateral wall window on the buccal plate of bone. Position of the antrostomy is determined by the size and location of maxillary sinus. t. High-speed handpiece with number 8 diamond bur is used to outline the window until bluish hue is visible with gentle brushing or paintbrush stroke. Sinus membrane elevation – Detach the sinus membrane with blunt instrument. Elevation should be preceded only when the membrane detaches.[21] Membrane should be elevated carefully starting on the sinus floor and then extending to the anterior and posterior walls with the help of sinus curettes [Figure 2]. The final elevation is up to the medial wall to the full height of the expected graft placement [Figure 3]. Sinus membrane integrity can be tested by asking the patient to breathe in deeply while observing the membrane lifting. 5. Preparation of implant site – If there is minimum of 3–4 mm of residual crestal bone of good quality, it is possible to place implants simultaneously or else place the implant after 4–6 months. Since the maxillary bone is a low-density bone, undersize the implant osteotomy site. Protect the sinus membrane with periosteal elevator to avoid damaging with drills 6. Graft placement – Sinus membrane should be protected with collagen membrane. Implants are placed in the prepared implant sites. Bone grafts are placed in the least accessible area first. Anterior and posterior recesses are filled first followed by the area along the medial sinus wall. Do not compact the bone graft too tightly as it prevents vascularization. But some authors showed that sinus lift can be performed using the lateral approach with whole blood as the sole filling material with promising results.[22,23] Thus, sinus augmentation with simultaneous implant placement can be done using platelet‑rich fibrin as a sole grafting[24] 7. Membrane placement – Resorbable membrane is placed over the window (collagen membrane adheres over the bone which does not require fixation screws and does not require removal) 8. Suturing/incision closure – Nonresorbable monofilament suture and horizontal mattress sutures are used to suture the flap (does not require any advancement.
In 2001, Vercellotti et al. introduced the piezoelectric technique.[25] The advantage of piezoelectric osteotomy lies in being able to cut the bony window with great simplicity and precision while ensuring the membrane’s integrity. This is due to the termination of the surgical action when the piezosurgery tips come in contact with nonmineralized tissue.[26,27]
7-10 days
2-6 months heat cure
2-4 months after surgery
