The document provides information on the anatomy and surgical procedures related to maxillary sinus augmentation. It discusses the maxillary sinus anatomy, blood supply, drainage pathways, and membrane characteristics. It then describes various sinus lift surgical techniques categorized based on residual bone height (SA-1 to SA-4). For each category, it details the surgical steps, grafting materials used, healing timelines and risks. It also outlines post-operative care instructions and possible complications along with their management.

1. Dr. Firas Kassab

2. • Maxilla is 35 times more edentulous than
mandible
• Maxillary sinus continues pneumatization
throughout life.
• The available bone is lost from the inferior
expansion of the sinus after tooth loss,
involving the residual ridge region
• The bone density in this region is also
decreases rapidly an on average is the least
dense of any oral region
Dr. Firas Kassab

3. Blood supply is mainly derived from nose
• Sphenopalatine artery
• Anterior & posterior nasal artery
• Infraorbital artery
• Posterior & middle superior alveolar artery
• Facial artery
• Palatine artery
Dr. Firas Kassab

4. Venous drainage
• Anterior facial vein
• Pterygoid veinous plexus
Lymphatic drainage
• Submandibular lymphnode
Nerve supply
• Maxillary division of trigeminal nerve (V2)
Dr. Firas Kassab

5. • Pyramidal shape
• Roof : floor of orbit
• Floor : alveolar bone and
palatine process
• Anterior wall : facial surface
of maxilla
• Posterior wall : infratemporal
surface
• Medial wall : lateral wall of
nasal cavity
Dr. Firas Kassab

6. • Schneiderian membrane
• Mucoperiosteum cansists 3 layers
• 1.Epithelium lining : pseudostratified columnar ciliated
epithelium
• 2.Lamina propria can stripped easily from
• 3.periosteum underlying bone
• There are numerous goblet cell
• Most of the serous and mucous glands found in
the lining are located near the maxillary ostium
Dr. Firas Kassab

7. Dr. Firas Kassab

8. • The maxillary ostium opening
in the medial wall
and near the superior
aspect of the sinus
• The cilia beat toward the
ostium at 15 cycles/minute
• Adequate manipulation of
the membrane and placement
of graft material are
possible without impeding
the drainage of the sinus
Dr. Firas Kassab

9. Dr. Firas Kassab

10. • The SA-2 to SA-4 surgical procedures the
sinus should be free of infection
• In addition, a thorough history and clinical
evaluation of the maxillary sinus are
conducted.
• Potential infection in the region of the sinuses
may result in extremely severe complication
Dr. Firas Kassab

11. • Physical examination
• Radiography
• Conventional :OPG, water’s view
• CT
• MRI
• CT is currently the modality of choice
• Any sign of acute sinusitis, root tips, cysts or
tumors complicate the procedure and mandate
further evaluation
• Known diseases of the antrum should be
treated before sinus grafts
Dr. Firas Kassab

12. Dr. Firas Kassab

13. • Patient sedation, local anesthesia, and
preparation of an aseptic environment
• Antiseptic mouth rinse : Chlorhexidine scrub
and rinse may be used
• Iodophor compounds ( Betadine ) are a most
effective antiseptic, but inhibit the
osteoinduction of demineralized bone
Dr. Firas Kassab

14. Regional anesthesia
• Blocking maxillary nerve (v2 ) : 1.8 ml
• Hemimaxilla, side of nose, cheek, lip, sinus area
• Long-acting anesthetic : Bupivacaine 0.5 % or
Etidocaine 1.5 % with EPI 1:200,000
Local infiltration
• Labial mucosa and palatal region
• Complete hemostasis
• Lidocaine 2 % with EPI 1:100,000
Dr. Firas Kassab

15. • 1. dense compact (D-1) bone
• 2. dense to thick porous compact and coarse trabecular
(D-2) bone
• 3. porous compact and fine trabecular (D-3) bone
• 4. fine trabecular (D-4) bone
Dr. Firas Kassab

16. Dr. Firas Kassab

17. • Height > 12 mm.
• An improved compressive thread design
implant (4 mm. diameter) implants may
accommodate
• 11 mm. of bone height in D2,
• 12 mm. in D3,
• 13 mm. in D4
• In division A, root form implants are placed
for prosthetic support
• Division B bone, osteoplasty or augmentation
to increase the width to Division A
Dr. Firas Kassab

18. • Then reevaluated to determine the proper treatment
plan classification
• Endosteal implantation in the SA-1 category are left
to heal in a nonfunctional environment for
approximately 4 to 8 months before the abutment
posts are added for prosthodontic reconstruction
Dr. Firas Kassab

19. • Height 10 – 12 mm.
• When the available bone is 10 to 12 mm.
Insufficient in length for ideal implant length
Incision and Reflection
• A full thickness incision is made on the crest of
the ridge from the tuberosity to the distal of the
canine region and vertical incision 5 mm.
Dr. Firas Kassab

20. Osteotomy and Sinus lift ( SA-2 )
• The depth of the osteotomy is approximately
1 to 2 mm. short of the floor of the antrum
• Reduced speed of the hand piece ( slower
than 1000 rpm ) enhances the tactile sense
and feel the cortical plate of the antral floor
Dr. Firas Kassab

21. • The osteotome is inserted and tapped firmly
into final position up to 2 mm.
• The apical portion of the implant engages the
cortical floor, with bone over the apex, and an
intact sinus membrane
Dr. Firas Kassab

22. Dr. Firas Kassab

23. • The patient’s prosthodontic treatment is
similar to that in the SA-1 category
• The implant body should not have an apical
hole, which also may fill with mucous and be a
source of further sinus infections
Dr. Firas Kassab

24. • Height 5 – 10 mm.
Incision line and reflection
• Awareness of the greater palatal artery, in
the severe atrophic maxilla
• A relief incision enhance access and vision
• Aggressive reflection of the flap may cause
damage to infraorbital nerve
Dr. Firas Kassab

25. Access window
• #6 round diamond bur
• Copious sterile saline
• The outline is scored on the
bone with a rotary
instrument
Dr. Firas Kassab

26. • The corners of the access window are
usually round
• paintbrush stroke approach until a bluish
hue or hemorrhage from the site is
observed
• A flat-ended metal punch or mirror handle
and mallet are used to gently separate the
lateral window from the surrounding bone,
while still attached to the thin sinus
membrane
Dr. Firas Kassab

27. • A soft tissue curette is introduced along the
margin of the window
• The curette is never blindly placed into the
access window
• The periosteal elevators and curettes further
reflect the membrane off, to a height of at
least 16 mm from the crest of the ridge
Dr. Firas Kassab

28. Dr. Firas Kassab

29. Dr. Firas Kassab

30. Dr. Firas Kassab

31. Several graft materials have been studied
• Autogenous bone : any debris from implant
osteotomies, the tuberosity region, exostoses,
cores from the symphysis or ramus region
• Demineralized freeze-dried bone (DFDB)
• Beta tricalcium phosphate
• Xenograft hydroxyapatite
• Combinations
Dr. Firas Kassab

32. • 1. dense HA + antibiotic
• 2. cacium phosphate (usually
xenograft microporous HA such
as Osteograft N-300 or Bio-
Oss) + DFDB + PRP from whole blood
+ antibiotic
• 3. autogenous bone
Dr. Firas Kassab

33. • Graft materials not mixed with blood or anesthetic
solution
• The toxic byproducts of blood catabolism and the
acidic pH of anesthetic both may decrease bone
formation
• A resorbable membrane may be placed over the
lateral access window
Dr. Firas Kassab

34. • The 5 to 8 mm of initial bone height may
stabilize the implant and permit its rigid
fixation
• An endosteal implant may be inserted at this
appointment
Dr. Firas Kassab

35. • Several advantages tend toward the decision
to delay implant placement for approximately
4 months
• Disadvantage of delaying the implant
placement is the need for an additional
surgery
• The implant may be inserted after 2 months
yet reducing considerably the risk of infection
Dr. Firas Kassab

36. • Primary closure using interrupted horizontal
mattress or a continuous suture
• Sinus incision line opening may contribute to
infection, contamination, or loss of graft
materials
Dr. Firas Kassab

37. Healing for implants placed into sinus grafts
The main variables appear to be the time
healing
• The volume of the subantral graft
• The distance from the lateral to medial wall
• The amount of autologous bone
• The health status of the patient : Diabetics,
postmenopausal women
All of which relate to the amount of new bone
formation
Dr. Firas Kassab

38. • Autogenous bone (4-6 months)
• Autogenous bone + porous HA + DFDB (6-10
months)
• Alloplasts only as tricalcium phosphate (24
months)
Dr. Firas Kassab

39. • Height < 5 mm
• There for the fewer bony walls, less favorable
vascular bed, minimal local autologous bone,
and larger graft volume
• Sinus graft is performed as in the previous
SA-3 procedure
Dr. Firas Kassab

40. • Additional bone harvest site is usually
required : ascending ramus of mandible
• The implant does offer an advantage if coated
with HA
• The time interval for rigid osseous fixation is
dependent on the density of bone
Dr. Firas Kassab

41. • Do not
• blow your nose
• Tobacco use
• Drinking with straw
• lift or pull on lip to look at sutures
• Sneezing with closed mouth
• Take your medication as directed
• Aware of small granules in your mouth
Dr. Firas Kassab

42. Notify the office if :
• You feel granules in your nose
• Your medications do not relieve your discomfort
Dr. Firas Kassab

43. Window
• Bleeding – bone wax, electrocautery
• Septum – make two windows seperated by septum
• Perforation – repair after membrane elevation
Dr. Firas Kassab

44. Membrane
• Perforation – repair
Small – collagen membrane (Collatape)
Large – slow resorbable membrane (Biomend)
• Thick
Polyp – curette out
Mucocele – drain
• Delay sinus graft
Dr. Firas Kassab

45. Dr. Firas Kassab
Possible Complication - Small Perforation

46. Dr. Firas Kassab
Possible Complication - Large Perforation

47. Dr. Firas Kassab

48. • Incision line opening – assess need to restore
• Bleeding (from nose) – do not blow nose, do
not lower head
• Graft – escape through perforation, assess
amount swelling/infection
• Antibiotic – oral, IV
• Drain, remove graft
• Assess progression – culture and sensitivity test
anaerobes/aerobes
• Reassess antibiotic choice
• Refer
Dr. Firas Kassab

49. • Amoxicillin 2 g stat, 500 mg qid
+ Metronidazole 500 mg stat, 250 mg tid
or
Clindamycin 300 mg stat, 150 mg qid
Dr. Firas Kassab