10 SINUS LIFT PROCEDURES seminar 10.pptx
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This concise PowerPoint presentation provides a technical overview of the sinus lift procedure including surgical techniques, indications, patient assessment, and potential complications. Gain a comprehensive understanding of this crucial oral surgery that facilitates dental implant placement in the maxillary posterior region
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10 SINUS LIFT PROCEDURES seminar 10.pptx
- 1. SINUS LIFT PROCEDURES PRESENTED BY- DR.SNEHA RATHEE POST GRADUATE III DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
- 2. Contents • Introduction • History • Anatomy • Indications/contraindications • Classifications • Technique • Complications • References
- 3. Introduction • Lack of sufficient bone height along maxillary sinus poses significant difficulty for placement of implants in edentulous maxillary jaw • To increase the amount of bone in the posterior maxilla, the sinus lift procedure, or subantral augmentation has been developed in mid 1970’s • Maxillary sinus floor elevation was first described by Dr. Hilt Tatum at Alabama implant conference in 1976
- 4. History • The first sinus graft was performed by Tatum in February 1975 • Boyne and James authored the first publication on the technique in 1980 • Tatum, 1986- crestal approach using socket former • Summers, 1994- crestal approach using tapered osteotomes • Cosci F and Luccioli, 2000- use of trephine drill for atraumatic sinus lift
- 5. History • Lalo et al, - osteotome and drill with stopper • Tilotta et al, - osteotome equipped with a trephine bur and stopper • Soltan et al, - antral membrane balloon elevation • Vercellotti et al, 2001- piezoeectric system • Kher et al, 2014- minimally invasive transcrestal approach using CPS putty to elevate sinus membrane
- 6. Maxillary sinus anatomy • The maxillary sinus is a pyramid-shaped cavity with its base adjacent to the nasal wall and apex pointing to the zygoma. • The average dimensions of the adult sinus are 2.5–3.5 cm wide, 3.6–4.5 cm tall, and 3.8–4.5 cm deep. • Volume of approximately 12–15 cc. • Anteriorly, it extends to the canine and premolar area.
- 7. Maxillary sinus anatomy • The sinus floor usually has its most inferior point near the first molar region. • The size of the sinus increases with age if the area is edentulous. • The maxillary sinus bony cavity lined with the sinus membrane, is also known as the ‘schneiderian membrane.’
- 8. Maxillary sinus anatomy • This membrane consists of ciliated epithelium • It is continuous with, and connects to, the nasal epithelium through the ostium in the middle meatus. Size- 1-17mm, average- 2.4mm • The membrane has a thickness of approximately 0.8 mm. • Antral mucosa is thinner and less vascular than nasal mucosa
- 9. Maxillary sinus anatomy • Sensory innervation- maxillary division on the trigeminal nerve and its branches • Blood supply to the maxillary sinus is by branches of internal maxillary artery • Venous drainage runs anteriorly into the facial vein and posteriorly into the maxillary vein, jugular vein and dural sinus system
- 10. Functions of maxillary sinus • Humidifying and warming inspired air • Regulation of intranasal pressure • Increasing surface area for olfaction • Lightening of the skull mass • Resonance • Absorbing shock • Contributing to facial growth • Mucociliary propulsion of mucous and serous secretions towards ostium
- 11. Misch bone density classification Bone density Description Tactile analogue Location D1 Dense cortical Oak wood Anterior mandible D2 Porous cortical and coarse trabecular White pine or spruce wood Anterior mandible Posterior mandible Anterior maxilla D3 Porous cortical and fine trabecular Balsa wood Anterior maxilla Posterior maxilla Posterior mandible D4 Fine trabecular Styrofoam Posterior maxilla
- 12. Misch classification of posterior maxilla
- 13. Indications • Residual subantral bone is less than 10 mm in height. • Residual subantral bone is less than 5 mm in width • Maxillary sinus is free of any acute or chronic infection (sinusitis) or pathology (cyst).
- 15. Contraindication • Heavy smoking • Acute sinus infection • Significant recurrent history of chronic sinusitis • Uncontrolled diabetes • Maxillary sinus hypoplasia (MSH) • Cystic fibrosis (CF) • Maxillary sinus malignant tumours • Big nose variant – patients having inferior turbinate and/or meatus pneumatization
- 16. Pre- and post –medication for sinus graft procedure Antibiotics • Amoxicillin–clavulanic acid combination drug • If the patient is allergic to penicillin, then either cefuroxime or clindamycin • Antibiotics like clindamycin can also be added with the graft material used for filling the elevated sinus cavity. It significantly reduces the chances of postoperative infection complications.
- 17. Pre- and post –medication for sinus graft procedure Analgesics • Any analgesic combination which contains codeine can be prescribed, one tablet 1 h before surgery and one 1 TDS continued for 5 days after surgery. • Codeine is a potent antitussive and so it reduces coughing, which may exert additional pressure on the elevated sinus membrane and can cause its tear and the introduction of bacteria into the graft.
- 18. Pre- and post –medication for sinus graft procedure Anti anxiety/sedatives • Sedative like alprazolam should be given to the patient: 1. One tablet in the night before surgery to reduce anxiety, so that patient can sleep comfortably at night before the surgery. 2. One tablet in the morning before the surgery, which reduces the patient’s anxiety so that the patient remains calm and comfortable during the surgery. It also enhances the effect of the analgesia. 3. One tablet at night after the surgery; it reduces excessive movement of the patient, which may cause the complications.
- 19. Pre- and post –medication for sinus graft procedure Corticosteroids • A short-term dose of a steroid like dexamethasone 4mg can be prescribed 1. Steroids reduce the inflammation of soft tissue and so the chances of postoperative swelling, pain, and incision line opening are reduced. 2. Ensures the patency of the ostium and minimizes any inflammation in the sinus before surgery. • Two tablets (8 mg) in the morning, the day before surgery. • Two tablets (8 mg) in the morning, before the surgery. • One tablet (4 mg) on the next day, i.e. on the morning after the surgery. • One tablet (4 mg) on the third day morning, (48 h) after the surgery.
- 20. Pre- and post –medication for sinus graft procedure Multivitamins • Vitamin B complex + zinc + Lactobacillus combination for 5 days after the surgery. • It enhances postoperative healing process and maintains gastric flora during the intake of antibiotics. Antibacterial oral rinse • Chlorhexidine gluconate 0.12% should be used just before the surgery and twice a day for 2 weeks after the surgery. • It significantly reduces the microbial flora in the oral cavity and the chances of post-surgery complications.
- 21. Pre- and post –medication for sinus graft procedure Cryotherapy • Ice or cold dressings on the face and cold oral liquids should be used for 24–48 h after sinus graft surgery. It minimizes the postoperative inflammatory swelling. • Hot fomentations • Heat may be applied to the region 48 h after surgery, to increase blood and lymph flow; it clears the area of inflammatory consequences and also reduces any ecchymosis present.
- 22. ABC classification of sinus augmentation CLASS A
- 23. ABC classification of sinus augmentation CLASS B Sinus class B Sinus class B-V Sinus class B-H Sinus class B-c
- 24. ABC classification of sinus augmentation CLASS C Sinus class C Sinus class C-V Sinus class C-H Sinus class C-c
- 26. Classification of maxillary sinus septa and clinical recommendation on management
- 28. Conventional surgical techniques • There are two main conventional approaches to the maxillary sinus floor elevation procedure, which have been modified to a large extent with the invention of new armamentariums for safe and effective elevation of the schneiderian membrane. • Direct technique • Indirect technique
- 29. Armamentarium
- 30. Lateral approach for sinus grafting • This procedure was first performed by Tatum in February 1975.
- 36. Simultaneous or delayed implant placement • Depending on the residual subantral bone height to stabilize the implant- simultaneous or delayed implant insertion in sinus grafting. • Subantral bone height is 4 mm or less- (initial implant stability could be jeopardized) two-stage lateral antrostomy • Residual bone is sufficient in dimension and quality to adequately stabilize the implant- the implant can be inserted at the time of sinus grafting.
- 37. Graft Materials For The Sinus Grafting • Autogenous bone- Iliac crest, chin, anterior ramus, and tuberosity • Hydroxyapatite (HA), mixed with autogenous bone or used alone • The demineralized bone matrix (FDBM, Grafton), a viable alternative for autogenous bone if used with Bio-Oss or tricalcium phosphate (TCP). • Bio-Oss or HA + β-TCP • Platelet-rich growth factors like platelet rich plasma (PRP)/platelet-derived growth factor (PDGF)/plasma rich growth factor (PRGF)/platelet rich fibrin (PRF)
- 39. Case report 1- Sinus Grafting With Lateral Approach And Delayed Implant Insertion
- 42. Case Report 2 Bilateral Sinus Grafting With Simultaneous Implant Placements
- 46. Transcrestal technique (Indirect) • A crestal approach for sinus floor elevation with subsequent placement of implant was first suggested by tatum, 1986 • Summer, 1994- tapered osteotomes with increasing diameter • Indicated when implant stability can be achieved despite limited bone height • Can be done in the presence of 3mm or more of residual bone • Conventional transcrestal sinus lift require >6mm
- 47. Transcrestal technique (Indirect) • Crestal incision is made, implant drills are used to create osteotomy leaving 1mm of bone between site and sinus membrane • Sequential osteotomies are done to compact bone laterally and apically which will elevate the sinus membrane • Bone graft is placed • Implant is placed with a cover screw and primary closure
- 48. Transcrestal technique (Indirect) • Advantages- minimally invasive technique • Minimal instrumentation with closed graft delievery permits sterile technique • Disadvantage- • Immediate implant loading is recommended after 3 months • Blind procedure • More chances of sinus membrane tear
- 49. Modifications
- 50. Lateral approach of sinus lifting using piezosurgery • The ultrasonic piezosurgery unit has specifically been developed for cutting bony tissue with minimal damage to the soft tissue. • High-frequency oscillations between 24 and 29.500 Hz, modulated with a low frequency between 10 and 60 Hz, enable efficient and controlled use and improve healing of the tissue
- 52. Dask Technique • The DASK sinus elevation kit (from Dentium Co. Ltd., Seoul, Korea) contains specially designed tips, which are used with the rotary handpiece to score the osseous window to approach the sinus membrane. It also contains sinus curettes to elevate the sinus membrane
- 53. Technique
- 56. Antral membrane balloon technique • Introduced by Soltan et al • An inflatable balloon is used to elevate the sinus membrane. • Balloon-harboring device -stainless steel tube (3mm) connects on its proximal end to the dedicated inflation syringe, and its distal portion has an embedded single use silicone balloon. • The balloon is inflated with diluted contrast fluid that pushes up the Schneiderian membrane, creating the desired height for implant placement.
- 57. Antral membrane balloon technique
- 58. Antral membrane balloon technique
- 59. Antral membrane balloon technique Complications- membrane tear • If balloon inflated too fast or more than 4ml, may burst • Infection • Failure to expose the medial wall Advantages- • Minimal risk of membrane tear • Reduced post-operative tear, bleeding • Beneficial when access is limited • Presence of adjacent teeth Disadvantage- • Requires buccal fenestration
- 60. Hydraulic Sinus Lift (HySiLift) • In 2010, Andreasi Bassi and Lopez- advantage of hydraulic pressure on a graft material of pasty consistency to detach the antral mucosa and simultaneously fill the sub-antral space • Instrument- three components • Titanium syringe- equipped with micrometric control piston on which it is possible to assemble single-use plastic syringes of various volumes • Dispenser- threaded and surgical steel (conical or cylindrical) • Needle
- 61. Hydraulic sinus lift (HySiLift) • The volume injected is between 0.5 and 0.7 ml • The micrometric screw can be activated manually or, if desired, by contra angle hand piece geared down. • If the elevation insufficient it can be implemented by injecting other biomaterial • If the remaining ridge has a height of more than 4 mm, the implant can be inserted and possibly should have a diameter of 0.4–0.5 mm wider than that of the dosing device used
- 62. Hydraulic sinus lift (HySiLift) Advantages- • Can be used with both flap and flapless method • Conspicuous and harmonic increase in the three dimensional sub-antral space • Brief learning curve • Reduced operating time • Greater precision (micrometric control on the progression of the piston)
- 63. Controlled Hydraulic Sinus Lift • Kao et al • Hydraulic pressure in a closed system places equal pressure on all surfaces within the system, thereby eliminating “point sources” of pressure and gently elevating the Schneiderian membrane equally at all points of attachment. • This controlled hydrostatic sinus lift procedure is accomplished by using a calibrated, hand- controlled pump and in-line pressure sensor meter
- 65. Minimally invasive transalveolar sinus approach (MITSA) • Kher and co-workers, 2014 • Calcium phosphosilicate putty for hydraulic sinus membrane elevation • 0.2cm of CPS putty injected into osteotomy • Greenstick fracture of the sinus floor • 0.5cm of putty
- 66. Antral membrane elevation via post graft • Soltan et al in 2011 • Antral membrane lift by a post-shaped graft is a crestal approach technique that can be used in severely resorbed ridges. • This technique is advantageous in the presence of teeth adjacent to the edentulous spaces because of the limited accessibility to lifting the membrane via lateral window technique.
- 67. Antral membrane elevation via post graft
- 68. Antral membrane elevation via post graft Possible complications • Post-operative pain • Sinus membrane tear • Infection • Crestal bone height loss • Oro-antral communication • Bleeding • Dislodging of the graft • Loss of implant • Sloughing of the palatal flap and graft exposure
- 69. Indirect sinus elevation with osseodensifiction • The technique was introduced by Huwais in 2013. • They used specially designed bur called Densah bus in counter clockwise direction at a speed of 800-1500 rpm to achieve osseodensification. • The tip of these burs is designed to achieve apical condensation of bone enabling an indirect sinus elevation with reduced chances of perforation.
- 70. Endoscopically controlled osteotome sinus floor elevation • Osteotomes D1,D2,D3.8 for implants of 3.75, 3.8 or 4.1mm diameter • D4.5 for 4.5mm implant
- 71. Endoscopically controlled osteotome sinus floor elevation
- 72. Endoscopically controlled osteotome sinus floor elevation Advantages- • Risk of damaging the periosteum and the blood supply to lateral antral wall is decreased • Preserves the periosteal supply • Avoid membrane rupture • Direct inspection of perforation or antral pathology Disadvantages- • Special training required • Need for a second surgeon • Technically challenging • Time-consuming
- 73. Complications • Bleeding • Buccal flap tear • Infraorbital nerve injury • Membrane perforation Intraoperative • Incision line opening • Bleeding • Barrier membrane exposure • Infraorbital nerve paresthesia Early postoperative • Graft loss/failure • Implant failure • Oroantral fistula • Implant migration • Inadequate graft fill Late postoperative
- 76. References • A simplified classification and repair system for sinus membrane perforation- Paul et al, Innovation in periodontics • ABC sinus augmentation classification- Hom-laywang et al, International journal of periodontics and restorative dentistry • Antral membrane balloon elevation- muna soltan et al, Journal Of Oral Implantology
Editor's Notes
- Calcium phosphosilicate
- Calcium phosphosilicate
- Sensory innervation of the maxillary sinus is supplied by the maxillary division on the trigeminal nerve and its branches- posterior superior alveolar nerve, anterior superior alveolar nerve, infraorbital nerve and greater palatine nerve Middle superior alveolar nerve contributes to secondary mucosal innervation Blood supply to the maxillary sinus is by branches of internal maxillary artery The lateral branches of the sphenopalantine and greater palatine arteries, and the floor of the sinus, the posterior, middle and anterior superior alveolar arteries Venous drainage runs anteriorly into the facial vein and posteriorly into the maxillary vein, jugular vein and dural sinus system because the blood supplies to the maxillary sinus area are from terminal branches of peripheral vessels, significant haemorrhage during the sinus-lift procedure is rare
- 1. The anterior maxilla region (second premolar to second premolar), usually has D3 bone, but in few cases it may have D2 bone quality. 2. The posterior maxilla region (molar region) usually has D4 bone but in cases of sinus grafting it may have D3 bone 6 months after grafting. 3. The anterior mandible region (first premolar to first premolar) usually has D2 bone, but the resorbed anterior mandible may have D1 bone quality in approximately 25% of cases, more commonly in males. 4. The posterior mandible region (second premolar and molars) usually has D3 bone, but in some cases it can have D2 bone quality.
- Treatment categories ranged from subantral augmentation category 1 (SA1) to SA4 based on bone height A (>5 mm) and B (2.5-5 mm) based on ridge width. SA1: It has an adequate vertical bone for implants, that is, 12 mm. No manipulation of sinus is required. SA2: It has 0-2 mm less than the ideal height of bone and may require surgical correction. SA3: It has just 5-10 mm of bone below sinus. SA4: It has less than 5 mm of bone below sinus.
- Residual subantral bone is less than 10 mm in height. Residual subantral bone is less than 5 mm in width – sinus lifting and grafting can be performed to insert a narrow diameter but longest possible implant, to gain more implant bone contact area for optimal results in implant therapy. Maxillary sinus is free of any acute or chronic infection (sinusitis) or pathology (cyst).
- Smoking is a relative contraindication for sinus grafting as many studies have shown more failures of sinus grafting and implants in smokers. However, smokers can successfully be treated with sinus grafting and implant therapy but the patient should refrain from smoking at least 15 days before sinus graft surgery and for 4–6 weeks after surgery. Maxillary sinus hypoplasia (MSH) – in these patients, the sinus drainage system is chronically compromised and is associated with malformed uncinate process. Cystic fibrosis (CF) – cystic fibrosis is a genetic disease which represents 92–100% chronic sinusitis rate. Patients with cystic fibrosis exhibit significant rates of sinus polyp formation and fungal sinusitis.
- 1. Amoxicillin–clavulanic acid combination is the drug of choice for sinus procedures (e.g. tab. Augmentin, 1 g) – One tablet twice a day starting 1 day before surgery and continued 5 days after surgery. 2. If the patient is allergic to penicillin, then either cefuroxime axetil (1 tab. Ceftin, 500 mg b.i.d.) or clindamycin (1 tab. Dalacin C, 300 mg t.i.d.) can be prescribed for the patient. 3. Antibiotics like clindamycin (inj. Dalacin-C, 300 mg) can also be added with the graft material used for filling the elevated sinus cavity. It significantly reduces the chances of postoperative infection complications.
- Any analgesic combination which contains codeine (tab. Tylenol 3) can be prescribed, one tablet 1 h before surgery and one 1 t.i.d. continued for 5 days after surgery. Codeine is a potent antitussive and so it reduces coughing, which may exert additional pressure on the elevated sinus membrane and can cause its tear and the introduction of bacteria into the graft.
- Anti anxiety/sedatives Sinus grafting is a technique-sensitive and time-consuming procedure; thus a sedative like alprazolam (tab. Alprax, or Valium, 2 mg) should be given to the patient: 1. One tablet in the night before surgery to reduce anxiety, so that patient can sleep comfortably at night before the surgery. 2. One tablet in the morning before the surgery, which reduces the patient’s anxiety so that the patient remains calm and comfortable during the surgery. It also enhances the effect of the analgesia. 3. One tablet at night after the surgery; it reduces excessive movement of the patient, which may cause the complications.
- Class A represrents abundant bone with ≥10mm bone height below the sinus floor and ≥5mm bone width, allowing proper implant placement
- Class B represents barely sufficient bone with 6-9mm bone height below the sinus floor and further subdivided into division H (horizontal defect <5mm) and division V (vertical defect >3mm away from cementoenamel junction) and division C (combined horizontal and vertical defect) Class C indicates compromised bone with <5mm bone height below the sinus floor and this is further subdivided like class B
- Class C indicates compromised bone with <5mm bone height below the sinus floor and this is further subdivided like class B
- A Implant motor (physiodispensor) is also used for lateral sinus window preparation. B Either contra-angle or straight handpieces (1:1) C and D can be used with large round carbide or diamond bur to prepare the osteotomy in the lateral wall of the sinus. (E) A special set of sinus curettes/elevators is then used to carefully elevate the sinus membrane. (F and g) Special instruments can be required to carry the graft into the elevated sinus floor and to fill it adequately and effectively.
- A crestal incision is given along with two vertical extensions and a trapezoidal mucoperiosteal flap is elevated to expose the lateral aspect of the posterior maxilla. Then the osteotomy is completed by preparing a rectangular/oval window in the lateral bony wall of the maxillary sinus to expose the sinus membrane. The osteotomy can be prepared with the rotary handpiece using a large round carbide or diamond bur. The diamond bur should be preferred over the carbide bur because the carbide bur has more tendency to tear the delicate sinus membrane. The newer piezosurgery unit can also be used for the safe preparation of the window osteotomy and the elevation of the sinus membrane, as it does not cut the soft tissue and thus chances of the sinus membrane tearing are minimized. Once the osteotomy is completed to expose the sinus membrane, the bony window can gently be tapped with the back of the mouth mirror handle, to visualize the complete preparation and to break the small and thin bony bridges still left between the window bone and the surrounding lateral wall of sinus. The sinus membrane is then gently lifted up from the bony floor by using a special set of sinus curettes. Marx and Garg suggested that a cottonoid soaked with a carpule of 2% lidocaine with 1:100,000 epinephrine should be left in the space created for 5 min, to limit bleeding and allow better visualization for further dissection. It is important to free up the sinus membrane in all directions (anteriorly, posteriorly, and medially) before attempting to intrude the sinus elevators medially to elevate the sinus membrane from the sinus floor to the desired height. At the time of sinus membrane elevation, the sharp margins of the curette/sinus elevator should always be maintained on the bony floor to avoid inadvertent membrane tear. The curette should never be placed blindly into the access window. A space is created after the sinus membrane has been elevated by the intruded sinus elevators. This space is then grafted using various bone substitutes alone or mixed with autogenous bone. Care should be taken not to overfill the elevated sinus floor, because it may cause membrane necrosis. The medial part of the sinus is grafted first. The graft material used can be either an autograft, an allograft, a xenograft, an alloplast, a growth-factor infused collagen matrix, or combinations thereof. After the implants have been placed, the remaining lateral part of the sinus defect is grafted and the window can be covered with a collagen barrier membrane to prevent any soft tissue growth in the grafted sinus.
- (A) Lateral and (B) cross-sectional views of posterior maxilla showing sinus cavity (sinus antrum) and subantral residual bone, which is inadequate in height to insert adequately long implants. (A and b) A mid-crestal incision along with two facial vertical extensions are made and a trapezoidal mucoperiosteal flap is elevated to expose the lateral wall of the maxillary sinus.
- (A and b) A rectangular or oval osseous window is carefully prepared on the lateral wall of the sinus using a large round diamond bur to expose the sinus membrane without perforating it. (A and b) Once the osteotomy is completed to expose the sinus membrane, the bony window can gently be tapped with the back of the mouth mirror handle to visualize the complete preparation and to break the small and thin bony bridges still left between window bone and surrounding bone.
- (A and b) The schneiderian membrane is carefully elevated to the desired height using a special set of sinus curettes. (D) A parenteral antibiotic like clindamycin can also be mixed with the graft to prevent any postoperative infection. (A–c) The elevated sinus floor is grafted through the lateral window using bone substitutes mixed with autogenous bone. A resorbable collagen membrane can be placed under the elevated sinus membrane before filling it with the graft as it protects the sinus membrane from being torn by the graft particles.
- Once the elevated sinus floor has been loosely filled with the graft, the implant osteotomies are prepared in the usual fashion and implants are inserted. (A–d) The rest of the sinus is further grafted until it is all loosely packed with the graft. If subantral bone height is inadequate to stabilize the immediately inserted implants, the surgeon can only graft the sinus and choose to go for delayed implant placement when the new bone has regenerated in the grafted sinus floor after 6–8 months.
- (A and b) A resorbable collagen barrier membrane can be placed to cover the lateral window to prevent soft tissue ingression into the grafted sinus. (C and d) Flap is sutured back with a primary closure. Implants are uncovered and restored after new bone formation has occurred in the entire grafted sinus in 6–8 months.
- Depending on the residual subantral bone height to stabilize the implant- simultaneous or delayed implant insertion in sinus grafting. Implants are placed either simultaneously with the graft (one-stage lateral antrostomy) or after a delayed period of up to 6–12 months, to allow for graft maturation (two-stage lateral antrostomy). The initial bone thickness at the alveolar ridge seems to be a reliable indicator in deciding between these two methods. If the subantral bone height is 4 mm or less, initial implant stability could be jeopardized. Therefore, a two-stage lateral antrostomy should be carried out. If the residual bone present below the sinus floor is sufficient in dimension and quality to adequately stabilize the implant, the implant can be inserted at the time of sinus grafting.
- Autogenous bone remains the gold standard in bone grafting. Iliac crest, chin, anterior ramus, and tuberosity have all been mentioned as common autogenous donor sites in maxillary sinus lift. Hydroxyapatite (HA), mixed with autogenous bone or used alone, has also been shown to be a viable alternative. Based on past research and clinical trials, the demineralized bone matrix (FDBM, Grafton), which is osteogenic in nature, can be a viable alternative for autogenous bone if used with Bio-Oss or tricalcium phosphate (TCP). Bio-Oss or HA + β-TCP has shown remarkable results in sinus grafting even if used alone. Mixing platelet-rich growth factors like platelet rich plasma (PRP)/platelet-derived growth factor (PDGF)/plasma rich growth factor (PRGF)/platelet rich fibrin (PRF) to the sinus graft material increases the amount, quality, and pace of new bone formation in the grafted sinus
- (A and b) Autogenous bone can be harvested from the mandibular symphysis using trephines, crushed and mixed with demineralized bone matrix (C and d) any synthetic graft like HA or HA + β-TCP mixture and used to graft the sinus. (E) The other intraoral sources of autograft can be mandibular buccal shelf or (F) maxillary tuberosity. (G and h) The mixture of the HA (70%) and β-TCP (30%) has also been used to successfully graft the sinus cavity, with predictable success rate.
- A- Preoperative dental radiograph shows inadequate subantral bone height to insert implant; thus sinus grafting and delayed implant placement are planned to replace missing first molar. (B and c) The lateral and cross-sectional CT images with simulated implant placement show absolute need of sinus grafting procedure for adequately long implant placement. (A) A trapezoidal flap is elevated to expose the anterolateral wall of the sinus and an oval window is prepared using a large round diamond bur to expose the sinus membrane. (B) Further, the Schneiderian membrane is carefully elevated using a set of sinus elevators. (C) The PRGF (plasma rich in growth factors) is prepared from the patient’s venous blood.
- (A–d) Autogenous bone, which is harvested from the maxillary tuberosity of the same side, is mixed with PRGF and bone substitute (HA + β-TCP). Besides enhancing the bone regeneration potential of the bone graft, PRGF also binds the graft particles together and improves its handling properties. (A) Elevated maxillary sinus is grafted and (B) covered with a barrier collagen membrane. (C) Flap is sutured with primary closure. (D and e) CT cross-sectional images show new bone formation in the grafted sinus after 6 months, which seems sufficient for the insertion of an adequately long implant.
- A) The implant osteotomy is prepared after 6 months using only osteotomes to laterally condense the bone and (B) implant (5 × 13 mm) is inserted. (C) Inserted implant shows adequate primary stability evaluated with the torque ratchet (more than 35 Ncm (a) Clinical view of inserted implant and (b) postimplantation radiograph. (c and d) Implant uncovered and restored after 6 months. (e) Radiograph 1 year after loading shows stable bone around the implant.).
- (A and b) Long-time missing teeth numbers 15, 16 and 26 have resulted in lowering down of the sinus floor, which in turn leads to reduced subantral bone height insufficient to insert implants; thus, sinus grafting procedure and simultaneous implant insertion is planned. (A and b) A trapezoidal flap is elevated to expose the lateral wall of the sinus on the right side of maxilla.
- (A) The sinus lining path is approximately marked using sterile HB pencil using the radiograph as reference. This avoids the problem of window preparation at an incorrect position. (B) An oval window is prepared on the lateral wall of the sinus using a large round diamond bur to expose the membrane. A (C) greyish colour sinus membrane can be seen through the scored window. (A and b) The sinus membrane is carefully elevated using a set of sinus curettes and (C) the elevated sinus floor is grafted using a mixture of HA and β-TCP.
- (A) The implant osteotomies are prepared and implants are inserted in usual fashion. (B) Graft is further filled into the sinus over the implants and (C) the flap is sutured back. (A–c) Sinus grafting and implant insertion are performed in a similar fashion on the left side.
- Postoperative radiograph shows elevated and grafted sinuses with inserted implants.
- With advancements in technology and armamentariums, several modifications have been proposed in the conventional lateral sinus window technique, which was originally proposed by Tatum
- Application of the various piezo tips: SL1 Tip is a diamond-coated tip for vestibular bone window cut and for attenuation of sharp angles. (A and b) A rectangular window can easily be scored using this tip, without tearing the sinus membrane. SL2 Tip is a diamond-coated ball tip for smoothing the vestibular bone window; precise osteoplasty using this tip at the prepared osteotomy corners to remove the sharp bony edges, reduces the chances of membrane tear during elevation. (C and d) Ball diameter: 1.5 mm, laser marked every 2 mm. (E and f) SL3 Tip is a flat-ended noncutting tip used for detaching the Schneiderian membrane from the window edge. SL4 Tip is a noncutting spatula, oriented at 90°, used for detaching the Schneiderian membrane inside the sinus. SL5 Tip is a noncutting spatula, oriented at ±135°, used for detaching the Schneiderian membrane inside the sinus and for removing anatomical structures.
- Wall-off technique- After elevating the mucoperiosteal flap to expose the ridge and lateral wall of the sinus, a special DASK drill attached to a rotary handpiece is used to carefully score a circular osseous window at the lateral osseous wall of the sinus, without any tear to the underlying Schneiderian membrane. Once the drill has reached the membrane, the scored round bony wall is carefully removed (wall-off) from the underlying sinus membrane and the membrane is elevated using a special set of sinus curettes. (A and b) Grind-out technique- A special large coarse diamond DASK drill is used to grind the lateral wall of the sinus with a sweeping action to reach the underlying sinus membrane. Once the sinus membrane is exposed, it is elevated using a special set of sinus curettes.
- After exposing the sinus membrane either with wall-off or grind-out technique, a special DASK tip is used to detach the membrane from the prepared window margins. (B) Once the membrane has successfully been detached all around from the prepared osseous window, a special set of curettes (sinus elevators) is used to elevate the Schneiderian membrane to the desired height. A and b) After the sinus membrane has been elevated to the desired height, the osteotomy for the implant is prepared from the crestal approach using drills of the particular implant system.
- Sinus lining exposed after removal of bone from the lateral wall of the maxilla and some dissection (carried out with suction in place). Note that the lining is not elevated in this picture because there is no suction. Yankeur suction placed in nose with tip facing toward the maxillary ostium and the nostrils are pinched. This causes the sinus lining to be elevated due to mild negative pressure thus greatly helping the surgeon carry out the procedure under direct vision.
- Six millimeters of bone. Crestal and minimal vertical relaxing incisions. Buccal wall osteotomy. Balloon testing. Balloon insertion. (a) Balloon insertion along antral floor. (b) Balloon inflation.
- 7. Antral void. 8. Resorbable collagen membrane saturated with platelet-rich plasma (PRP). 9. Resorbable hydroxylapatite moistened with PRP. 10. Insertion of loosely compacted graft. 11. Graft in place. 12. Mucoperiosteal flap, repositioned and sutured. 13. Postoperative X ray
- The single-use syringes can be pre-loaded with a desired amount of graft material that was nanocrystalline hydroxyapatite in an aqueous medium or it is possible to directly use the syringe containing the graft material as provided by the manufacturer The semi-spherical tip of the ML Injector allows this instrument to penetrate barely 3 mm in the sub-schneiderian space without damaging the overlying mucosa while the lateral openings allow uniform distribution of the graft that, due to its paste-like consistency, forms a dome
- Implant tunnel preparation and sinus floor discontinuation immediately before ML Injector placement. ML Injector in place pre-loaded with the biomaterial. Implant placement.
- A, Initial pilot drill up to 1 mm before reaching the sinus floor membrane. B, Piezosurgical drill can be used to gently perforate the floor of the sinus floor. A, The Luer-Loc cannula with tapered plug-in end inserted into the osteotomy site and should insert 1 mm inferior to the sinus floor but not touch the sinus floor. B, Hydrostatic pressure was applied to detach the Schneiderian membrane. A, Pressure controlled meter with pump can provide suitable controlled force. B, Pressure meter with sensor to monitor the hydrostatic pressure.
- Preoperative xray The osteotomy is prepared to 4 to 5 mm diameter depending on the width of the existing ridge and the diameter of the implant that is going to be placed. A No. 8 round diamond bur is used to create an indentation in the crestal bone. Sequential StemVie osteotomes are used with a mallet to prepare the diameter of the osteotomy. Once the floor of the sinus is freed, the proper size StemVie Post graft, 4 or 5 mm in diameter and 13 mm in length is prepared, trimmed with a scalpel, and placed in the prepared osteotomy. The graft should fit passively through the prepared osteotomy. As it is gently pushed into the sinus, the core elevates the sinus membrane. The core is positioned to remain in contact with the crestal ridge to keep the graft stable. The implant graft allows the sinus membrane to reestablish higher in the antrum creating a tenting effect that induces bone formation. As an alternative, the graft core could be prepared by mixing 60% calcium sulfate and 40% StemVie Granules, or any resorbable graft with enough aqueous solution of metronidazole to form a thick paste. A 4- or 5-mm graft carrier is used to shape the graft and extrude it into a cylinder shape while the mixture is still soft. Once the composite graft is shaped, it should be allowed to set hard for 10 minutes on a sterile dish.
- When osteotome sinus floor elevation is applied without sinuscopic control, a direct inspection of the sinus membrane is not possible, and during reparation of the implant site a perforation may not be recognized With the use of endoscope, reduced invasivity and patient morbidity has been claimed. Procedure- Under local anesthesia, sinus was punctured without flap elevation in the middle of canine fossa with a trocar of 5mm diameter Sinuscope with view angle of 70,90 and 120 degree were used Prior to elevation the sinus was examined and the natural ostium was inspected Any pathological findings were noted After a crestal incision, a mucoperiosteal flap was raised A 2mm deep primary pilot drilling was done followed by preparation using osteotomes of increasing diameter (concave tip) Osteotome remained for 1min in contact before the next diameter as used With the final osteotome the cortical plate was punched out with the adherent membrane and a tent like formation was made Further dissection carried out using blunt elevator under direct scopic view At the end site were tested for perforation by the Valsalva maneuver
- 0.5cm3 of particulated autogenous bone from the retromolar region or 0.5cm3 of b-tricalcium phosphate were used Largest osteotome was reinserted to position the graft material in newly formed space between the membrane and the sinus floor Endoscopic examination 6 months postoperatively. The sinus membrane shows no signs of inflammation or perforation. 6 months post-operatively, implants uncovered and prosthesis installed Opg of Pre-op, immediate post op and follow up at 6 months
- Sinus membrane perforations occurred during TSFE in cadaver Intact sinus membrane Perforation provoked by a pilot drill Large laceration caused by an implant drill Perforations that occurred during membrane elevation with manual instruments Membrane collapse following an overfill of bone graft