This document provides an overview of dental implant sinus lift procedures. It begins with brief anatomy of the maxillary sinus and defines a dental implant. It then discusses patient evaluation, including radiographic assessment and anatomical limitations for implantation. Classification systems for the posterior maxilla are presented. The document reviews indications, contraindications, and surgical techniques for sinus lift procedures, including direct and indirect methods. It also discusses graft materials, post-operative instructions, and potential complications.

2. Presented By
DR. Saima Gul
Postgraduate trainee OMFS

3. DENTAL IMPLANT
SINUS LIFT

4. Contents :
 Brief sinus anatomy
 Brief about implant
 Patient evaluation
 Posterior maxilla classification
 Indications , contraindications for sinus lift
 Different sinus lift procedures
 Post-op instructions
 Complications

5. Anatomy of maxillary sinus
 Maxillary sinus is the largest sinus in the head and neck region.
 SHAPE-Pyramidal with base towards the lateral wall of nose and apex
toward zygomatic process of maxilla.
 BOUNDRIES -
 Anterior wall-facial surface of maxilla
 Posterior wall- infratemporal surface of maxilla.
 Roof- Floor of orbit
 Floor – Alveolar process of maxilla.
 Opens into middle meatus

6.  The bony walls are thin, except for the anterior wall and
the alveolar ridge in the dentate patient.
 Is lined with a pseudostratified columnar epithelium –
“Schneiderian Membrane”
 Is approximately 15ml in volume
air space although the actual
size depends on the amount of
resorption that has taken place
 Formation begins in the second to
third year of life and is nearly
complete by 12 years of age

7. What is an Implant?
Dental implant is an artificial titanium fixture
which is placed surgically into the jaw bone to
substitute for a missing tooth.

8. Surgical procedure
STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC RESTORATION

9. Patient evaluation
 Medical evaluation
 Evaluation of Implant Site
 Bone Height, Bone Width and Anatomic
considerations

10. Patient evaluation
Radiographic evaluation
 Periapical radiographs
 Panoramic radiograph
 Occipitomental view
 CT scan (axial and coronal view)
 CBCT
 MRI
 Ultrasound

11. Anatomic limitations
 Buccal Plate 0.5mm
 Lingual Plate 1.0 mm
 Maxillary Sinus 1.0 mm
 Nasal Cavity 1.0mm
 Incisive canal Avoid
 Inter implant distance 3mm
 Inferior alveolar canal 2.0mm
 Mental nerve 5mm from foramen
 Adjacent to natural tooth 1.5mm

12. Etiology of decreased bone
height in posterior maxilla
The maxillary sinus grows by a bone remodeling
process named PNEUMATIZATION as age advances.
This physiological process accompanied with
increased tooth resorption due to tooth loss leads to
decrease in bone height in the posterior maxilla.

13. Limitations to Implant
placement in the Maxilla
 Ridge width
 Ridge height
 Bone quality

14. Misch classification of
posterior Maxilla
>12mm
10mm
5-10mm <5mm

15. Chiapasco Classification
(2003)
 Classification is based on 3 variables:
 Width
 Height of the residual alveolus
 Inter-ridge relation
 The variables are used to define 8 types of sinus-
posterior maxillary alveolar morphologies
according to their treatment needs

16.  Classes A to D address height and width, and the
remaining classes define crown height space.

17. Class A
 Residual alveolar ridge height of 4 to 8mm
 Residual alveolar ridge width of more than 5mm (i.e.
absence of significant horizontal resorption and
maintenance of acceptable horizontal intermaxillary
relationships)
 Absence of vertical resorption of the alveolar ridge
with maintenance of acceptable vertical intermaxillary
relationship

18. Class B
 Residual alveolar ridge height of 4 to 8mm
 Residual alveolar ridge width of 5mm(i.e. presence of
horizontal resorption and unfavorable horizontal
intermaxillary relationship)
 Absence of vertical resorption of the alveolar ridge
with maintenance of acceptable vertical interarch
distance

19. CLASS C
 Residual alveolar ridge height of less than 4mm
 Residual alveolar ridge width of at less than 5mm
 Absence of vertical resorption of the alveolar ridge
with maintenance of acceptable vertical interarch
distance

20. CLASS D
 Residual alveolar ridge height of less than 4mm
 Residual alveolar ridge width of less than 5mm(i.e.
presence of horizontal resorption and unfavorable
horizontal intermaxillary relationship)
 Absence of vertical resorption of the alveolar ridge
with maintenance of acceptable vertical interarch
distance

21. CLASS E
 Same characteristics as Class A except with
increased crown height space

22. CLASS F
 Same characteristics as Class B except with
increased vertical crown height space

24. CLASS G
Same characteristics of Class C
except with increased vertical
crown height space

25. CLASS H
Same characteristics as class D except
with increased vertical crown
height space

27. Indications for sinus lift
 Pneumatization of the sinus
 Poor bone density
 Strong occlusal forces

28. CONTRAINDICATIONS
 Local contraindications
 Intraoral contraindications
 General medical conditions of concern

29. Absolute contraindications
1. Severe (noncorrectable) deformities of the maxillary sinus
2. Scarred and hypofunctional sinus mucosa following trauma
of previous operation
3. Radiotherapy of the head and neck area (dose above 45Gy)
4. Acute or Chronic recurrent sinusitis with or without
polyposis, that disrupts mucociliary clearance and is
unresponsive to medical or surgical treatment
5. Local expression of a systemic granulomatous disease such as
Wegener Granulomatosis or midline idiopathic
granuloma
6. Benign but locally aggressive tumor (amelobastoma,
myxoma)
7. Malignant tumor, both primary and metastatic, deriving from
epithelial, connective, or odontogenic tissue (squamous cell
carcinoma, adenoid cystic carcinoma)

30. INTRAORAL
CONTRAINDICATIONS
1. Grossly inadequate oral hygiene or inability to
perform or maintain appropriate oral hygiene
2. Untreated periodontal disease of adjacent
dentition
3. Gross malocclusion and insufficient freeway space
for restoration
4. Severe pathologic parafunctional habit (clenching
or bruxism)
5. Fulminant mucosal disease (desquamative mucosal
disease, erosive lichen planus)
6. Severe Xerostomia

31. GENERAL MEDICAL C/I
 following conditions unless treated and under control with the
patient’s complete understanding of the risks, generally
contraindicate the sinus graft procedure:
1. Chronic renal disease
2. Chronic liver disease
3. Uncontrolled diabetes
4. Uncontrolled hypertension
5. Hemophilia or treatment with anticoagulant therapy
6. Metabolic bone disorders
7. Uncontrolled thyroid disorders
8. Uncontrolled adrenal disorders
9. Immunocompromised, including HIV
10. Steroid treatment at the time of the sinus graft procedure

32. Surgical Solutions to
Anatomical Limitations
 Onlay bone graft
 Sinus lift
1. Direct technique
2. Indirect techniques
 Summer’s method
 Hydropneumatic sinus lift
 Bone dilatation technique
 During extraction sinus lift
 Balloon sinus lift

33. Direct technique
Advantages:
 When more than 4-5mm of bone grafting is required
 Sinus membrane is directly visualized
 Easy access
Disadvantages:
 More pain
 More post operative discomfort
 Time consuming
 Needs highly efficient surgeon
 More susceptible for infection

34. Indirect techniques
Advantages:
 Minimally invasive surgical procedure.
 The osteotomy is minimal being 1-3 mm deep and wide.
 Minimal instrumentation with closed graft deliver permits
a sterile technique.
 Simplicity of the procedure requires less time and
expertise
Disadvantages:
 Immediate implant loading is recommended after 3
months.
 Blind procedure (the sinus isn’t exposed).
 More chance of errors to occur

35. Direct technique

36. Indirect technique

37. Floor dilatation technique

38. Summer’s technique

39. Balloon dilatation technique

41. During extraction

42. Hydropneumatic technique

44. AUTOGRAFT
 Maxillary Tuberosity
 Zygomaticomaxillary buttress
 Zygoma
 Mandibular symphysis
 Mandibular body
 Ramus of the mandible
 Tibial Bone Grafts
 Iliac Grafts
 Calvarial Grafts

45. Allografts
 Hydroxyapatite
 Bioactive Glass
 Beta-tricalcium Phosphate
 BMP

46. Postop instructions
 Do not disturb or touch the wound.
 Avoid rinsing or spitting for 2 days to allow blood clot
and graft material stabilization.
 Don’t blow your nose at least 4weeks after surgery
 Do not apply pressure with your tongue or fingers to
the grafted area, as the material is movable during the
initial healing.
 Do not lift or pull on the lip to look at the sutures.
 Do not smoke.
 Keep good oral hygiene

47. COMPLICATIONS

48. Complication Possible Cause
Intraoperative
Bleeding Osteomeatal complex obstruction
Buccal flap tear Inadequate graft fill
Infraorbital nerve injury Alveolar ridge fracture
Membrane perforation Damage to adjacent dentition
Early Post Operative
Incision line opening Acute infection
Bleeding Graft loss (partial or complete)
Barrier membrane exposure Implant failure
Infraorbital nerve parasthesia Oroantral fistula
Late Postoperative
Graft loss/failure Soft tissue invasion over access window
Implant failure Maxillary cyst
Oroantral fistula Chronic sinus disease
Implant migration Chronic infection
Inadequate graft fill sequelae Chronic painD.V.BHUVANESH KUMAR 48

49. Sinus membrane tear

50. Oxycellulose mesh placement over tear mucosa