MAXILLARY SINUS AUGMENTATION.pptx

MAXILLARY SINUS
AUGMENTATION
PRESENTED BY:
SHARMIKA SAVANTH
PG 3RD YEAR
GUIDED BY:
Dr. G . HIMA BINDU
READER

CONTENTS
• Introduction
• Anatomy of the maxillary sinus
• Sinus Augmentation
• Direct Sinus lift
• Indirect Sinus lift
• Recent Advances
• Complications and Management
• Alternatives to sinus lift
• Conclusion

INTRODUCTION
• A pre-requisite for successful implant therapy is the presence of an
adequate quantity and quality of bone.
• A common clinical finding when planning for implant placement in
the posterior maxilla is lack of adequate bone height either due to
low lying maxillary sinus or due to atrophy of the alveolus following
extraction.
• This ultimately results in the floor of the sinus lying close to the
alveolar bone making it difficult for placement of an implant.

• Maxillary sinus augmentation is a procedure that aims to increase
the vertical bone height of the alveolar bone to allow placement of
dental implants.
• For more than 30 years, the maxillary sinus augmentation
procedure has been performed for implant‐directed maxillary
reconstruction. There are various techniques, approaches, and
materials used in this procedure.
• However, a thorough knowledge of contemporary augmentation
procedures mitigated by proper patient selection can lead to
effective long-term solutions in the management of the deficient
posterior maxilla.

• The paranasal sinuses are air-filled extensions of the nasal
cavity. These are the spaces which communicates with the nasal
airway.
• Maxillary sinus is the biggest pyramidal-shaped paranasal sinus.
• There are 4 main paranasal sinuses:
Frontal
Maxillary
Sphenoid
Ethmoid

MAXILLARY SINUS
• “Maxillary sinus is the pneumatic space that is lodged inside the
body of maxilla and that communicates with the environment by
way of the middle meatus and nasal vestibule.”
• 1st described by Highmore in 1651- Hence also called “Antrum
of Highmore”
• Maxillary sinus is first of the PNS to develop.
• It starts as a shallow groove on
• the medial surface of maxilla
• during the 4th month IUL.
• largest sinus in the head and neck region.

ANATOMY
• It is pyramidal in shape.
• Measures 35mm x 32mm x 25mm
• With volume 15 to 30ml.
• Opening of the maxillary sinus is called ostium.
• It opens in middle meatus at the lower part of the hiatus semilunaris.
• Lies above the level of nasal floor.
• The ostium lies approximately 2/3rd up the medial wall of the sinus,
making drainage of the sinus inherently difficult.
• In 15% to 40% of cases a very small, accessory ostium is also found.
• Blockage of the ostium can easily occur when there is inflammation of
the mucosal lining of the ostium.

 ROOF : Thin orbital plate
 FLOOR: Alveolar process of maxilla carrying roots of premolars and molars
 ANTERIOR WALL: Facial surface of maxilla
 POSTERIOR WALL: Separates the sinus from infratemporal and pterygopalatine fossa
 BASE: Lateral wall of nose
 APEX: Zygoma

Antral Floor
Extends anteriorly to the premolar or canine region & posteriorly to the
maxillary tuberosity
In dentulous pts’: thickest wall and about same level of nasal floor.
In edentulous pt: 1 cm below nasal floor
MB root apex of 2nd molar closest to sinus wall (average distance of
0.83 mm), Most subject to exposure with extraction in molar area.
Palatal root apex of 1st premolar farthest.

MICROSCOPIC FEATURES
• Pseudostratified ciliated columnar or cuboidal epithelium –
SCHNEIDERIAN MEMBRANE
• Most numerous cells -Columnar ciliated cells
• Additional cells- Basal cells, Columnar non-ciliated cells and mucus
producing, secretory and Goblet cells
• Thickness: 0.13 to 0.5 mm (average 0.8 mm thick).

• Arterial supply:
Branch of third part of maxillary artery
Posterior superior alveolar artery
Infra-orbital artery
Greater palatine artery
• Venous drainage:
Anteriorly Facial vein which then drains into pterygoid venous
plexus.
• Nerve supply:
1.Anterior superior alveolar nerve
2.Middle superior alveolar nerve
3.Posterior superior alveolar nerve

Functions
• Imparts resonance to the voice
• Increases the surface area and lightens the skull
• Moistens and warms inspired air
• Filters the debris from the inspired air
• Absorbing shock, helping to lessen brain trauma
• Contributing to facial growth
• Mucociliary propulsion of mucous and serous secretions toward
the ostium
• Limit extent of facial injury from trauma
• Provides thermal insulation
• Serves as accessory olfactory organs.

MAXILLARY SINUS SEPTA
• First mentioned by Underwood in 1910,
• Made of cortical bone
• Maybe either horizontal or vertical
• Prevalence: 25% to 31.7%.
• Length: 2.5 - 12.7 mm
• More in edentulous or atrophic ridges than in partially edentulous or
non-atrophic arches
• Majority are located between the 2nd premolar & 1st molar area

• Based on their origin: Underwood, 1910.
1. Primary septa: formed during maxillary development and tooth growth
2. Secondary septa: which is acquired during pneumatization of sinus after tooth loss.
3. Small, irregularly positioned carrying vessels and nerves. Two basal septa
4. Complete septum,
5. Partial horizontal septum.
Applied Aspects
• Small septa can be avoided by inferior osteotomy at 3-4mm above sinus floor.
• If there is a full partition of the sinus by a septum Double window approach.

• The procedure of choice to restore the bone deficiency in posterior
maxillary edentulous region with a low lying sinus.
• Initially described by Tatum at an Alabama implant conference in 1976
• Subsequently published by Boyne and james in 1980 SINUS BONE
GRAFTING.
• One of the most common preprosthetic surgeries performed in dentistry
today.

BONE ATROPHY OF MAXILLA
• Accelerates in case of tooth extractions
• Accelerated bone loss is higher in females due to bone
density and hormonal balance of the body
• Severe atrophy maybe expected with extraction of molars
than the premolars
• Multiple extraction of teeth in the same quadrant
• Traumatic extractions
Mohammad A H. Maxillary Sinus Lifting: Review of the Two Main Approaches. Glob J Oto
2017; 8(4): 555745.

INDICATIONS
• Less than 10 mm alveolar
residual bone height
• Less than 4 mm residual
bone width
• No history of any
pathology
• Interpositional graft with
Le Fort I fractures
• Reconstruction of palate
clefts
CONTRAINDICATIONS
INTRAORAL
• The presence of an irregular
alveolar crest
• Alveolar scar possibility
• Cysts and tumours
LOCAL
• Odontogenic infections
• Allergic rhinitis, sinusitis
• Sepsis
SYSTEMIC:
• High doses of radiation in the head
and neck region
• Uncontrolled systemic disturbances
• Excessive smoking, alcohol or
substance consumption.

CLASSIFICATION OF SINUS
Misch(1987): The maxillary sinus maybe
classified based on the residual alveolar height into
4 categories:
 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.
10-12mm
 SA3: It has just 5-10 mm of bone below sinus.
 SA4: It has less than 5 mm of bone below
sinus

Davarpanah et al. 2001: based on volume of bone in subsinus area in 3
dimensions.
1. Vertical bone loss from within the sinus
2. Vertical bone loss (apicocoronal) of the alveolar ridge
3. Horizontal bone loss (buccopalatal) of the alveolar ridge
4. Combination subsinus bone loss

• Tavelli et al. 2017 proposed a new classification for sinus presurgical evaluation
Includes the following parameters:
○ (Favorable/ Normal/ Unfavorable)
1. Risk of perforations
• Membrane thickness
• Sinus septa
• Angle of buccolingual sinus wall
• Teeth presence
• Implants or teeth roots adjacent to sinus
2. Bone conditions:
• Buccal bone thickness
• Residual alveolar ridge height
• Residual alveolar ridge width
3. Other:
• Sinus width
• Alveolar- Antral Artery
• Visbility/ oral opening
Tavelli et al. Sinus presurgical evaluation: a literature review and a new classification proposal. Minerva
Stomatologica 2017 June;66(3):115-31

After doing the same for all parameters, the clinician has to add up all the
results and divide this sum by “25,” which is the sum of all the significances

Evaluation of maxillary sinus
• Interarch space. A minimum of 5 to 7 mm is required for prosthetic
restoration. If the distance is inadequate, it will have to be created by the
following (Misch, 1987):
• a. Alteration of the mandibular occlusal plane
• b. Vertical osteotomy of the maxillary alveolus
• c. Gingivectomy for removal of bulky tissue
• Periodontal disease:
• Causes thickening of the maxillary sinus mucosa (Engstrom and
colleagues, 1988; Moskow, 1992) and
• Implant failure, which is not affected by immediate or delayed
placement (Evian and colleagues, 2004).

RADIOGRAPHIC ANALYSIS
EXTRAORAL
• OPG
• Water’s view
• Lateral skull
• MRI SCAN
• CT
• 3D CT
INTRAORAL
• Periapical view
• Occlusion view
• Lateral occlusal view

• Currently, two main approaches to the maxillary sinus floor elevation procedure
are found in the literature. The first approach, lateral antrostomy (Direct sinus lift
procedure) , is the classic and the more commonly performed technique originally
described by Dr. Tatum.
• More recently advocated a second approach: the crestal approach, Dr. Robert B.
Summers (Indirect sinus lift procedure) , using osteotomes
• LATERAL WINDOW (Direct sinus lift procedure)
– With grafting
– without grafting
• TRANSALVEOLAR (Indirect sinus lift procedure)
– With grafting
– Without grafting
• ADVANCED SURGICAL TECHNIQUES
– Balloon lift
– Hydraulic pump

Decision tree for Sinus Elevation Procedures
Kim, D. M., & Ho, D. K. (2014). Decision Tree for Maxillary Sinus Elevation Options. Clinical Maxillary
Sinus Elevation Surgery

Kim, D. M., & Ho, D. K. (2014). Decision Tree for Maxillary Sinus Elevation Options. Clinical Maxillary
Sinus Elevation Surgery

Armamentarium
• Apart from the traditionally used surgical instruments, a variety of curettes
and osteotomes are required for sinus augmentation procedures

(a) Basic surgery instruments. (b) Lateral window sinus lift instruments.

Preclinical training on the hen’s egg shell step-by-
step
•Initial osteotomy can be prepared with a high-
speed round diamond bur. The corners of the
access are usually round. if they are too sharp,
membrane perforation may occur during
instrumentation.
• the osteotomy is done with a light touch,
paintbrush stroke approach until the membrane is
exposed and the window is free.
• detach the transparent membrane lying between
the egg shell and the egg white gently without
tearing, using the inverted cone bur.
• this reduces membrane tension, facilitating
further separation.
Chandra RV, Srikanth K, Kumar A, Naveen A. Bench surgery training for sinus lift procedures by
modeling the sinus lining with an eggshell membrane: A technical report. J Dent Implant 2015;5:31-8

PREOPERATIVE MEDICATION
Antibiotics
• Misch (1992): risk of infection of the implants and/or the
grafting materials.
• Prophylactic antibiotics are therefore recommended to prevent
the onset of infection

Anti-Inflammatory Agents (Misch and Moore, 1989)
• Dexamethasone 3 mg:
1. 9 mg on the morning of surgery
2. 6 mg on the morning after surgery (day 1)
3. 3 mg on the morning after (day 2) or
Medrol dose pack: a declining dosage taken over 6 days
Analgesics:
• Ibuprofen 400–800 mg three times daily/as needed for pain or
• Acetaminophen with codeine every 6 hours/as needed for pain

Decongestants
Systemic
○ Oxymetazoline (Afrin)
○ Pseudophedrine 1 tablet three times daily starting 1 day prior to
surgery
○ (Sudafed) and for 2 days after surgery
Topical Spray
○ Oxymetazoline 0.05% 1 hour prior to surgery or
○ Phenylephrine 1%
• Patients on Anticoagulant Therapy
• Requested to stop the use of any medications that increase their bleeding
time (aspirin or warfarin) 5 days prior to the surgery.
• Should check with their physician prior to stopping their medication

• Specifically, four different anatomic locations have been described for SA:
(Lazzara 1996, Zitzmann & Scharer 1998)
• superior lateral wall, or “Caldwell-Luc,” opening, which is located high
on the lateral wall of the maxilla just anterior to the zygomatic arch;
• middle lateral wall opening, which is located midway between the alveolar
ridge and the zygomatic arch;
• inferior lateral wall opening, which is located at the level of the alveolar
ridge;
• crestal osteotomy approach, which is an opening through the alveolar bone
crest superiorly toward the floor of the sinus.

DIRECT SINUS LIFT
• Also called the lateral window approach.
• Originally developed by Tatum. Later described by Boyne and James in
1980.
• This surgical intervention is still the most frequently used method to
enhance the vertical alveolar bone height of the posterior part of the
maxilla before or in conjunction with installation of implants

INCISION
• A bevel horizontal incision (at 1–2
mm palatal to the alveolar crest and
at least 4–6 mm away from the
estimated border of the hard tissue
outline “window”)
• Buccal vertical releasing incisions are
placed at the mesial and distal
extension of the horizontal incision.
• Full-thickness buccal flap is reflected
from the crestal side all the way to 4–
6 mm apically beyond the upper
portion of the bony window outline.

OUTLINE OF THE BONY WINDOW
• Size of the window is determined by the
area to be grafted in the lateral aspect of
the buccal alveolus.
• Osteotomy (window) can be oval or
rectangular.
• Inferior osteotomy is started in 1st or 2nd
molar region 3-5mm from ridge and 1
mm from sinus floor.
• Superior osteotomy is at 10-15mm
height from inferior osteotomy.
• Mesial border can be extended as far as
distal to canine(5mm beyond anterior
antral wall)
• Distal border - Tuberosity

PREPARATION OF THE BONY
WINDOW
• No. 4, 6, or 8 diamond round bur
or piezo with copious saline
irrigation is utilized to outline
window
• The osteotomy is deepened in
smooth, light sweeping motions
until the bone is thin and
translucent enough to visualize the
underlying gray/red color of the
sinus membrane.

Infracture
• 1st : the bone is pushed inward with the sinus
membrane. The height of this trapdoor should
not exceed the width of the sinus to allow for
a final horizontal position of the new floor.
The sinus membrane is then gently lifted from
the bony floor by means of an antral curette.
• 2nd -This space is then grafted with different
materials to provide the platform for implant
placement and sutured back .
• A 1-stage procedure is less time-consuming
for both the clinician and the patient.
However, it is more technique-sensitive and
its success relies heavily on the amount of
residual bone.

Modifications of the Direct
technique
• Double window approach- This was described by Betts et al in 1994
for sinus augmentation in cases with septate sinus.
• The presence of maxillary sinus septa can complicate both the luxation
of the window into the sinus and the lifting of the membrane

• Slot-like window technique for maxillary sinus floor elevation-
Given by Wang F et al in 2016.
• Was proposed to overcome the morbidities associated with extensive
window created during traditional lateral bony window preparation.
• The apico-coronal height of the bony window was only 1~2 mm
Wang F et al. Slot-like window technique for maxillary sinus floor elevation.Int J Clin Exp Med
2016;9(11):21690-21698

Small window approach-
• Given by Baldini et al 2017.
• A smaller window of 6x6 mm dimensions
was proposed to reduce post-op morbidity
Low window approach
Zaniol et al 2018.
• The rationale for creating a low window
at the most coronal and mesial possible
position is that the more apical and
distal the window is, the more difficult
the surgical access to the sinus will be.
• Placement of the lower horizontal
osteotomy flush with the sinus floor
eliminates any residual bone wall that
could hinder detachment of the sinus
membrane.

Yong, C. W., & Loh, F. C. (2020). Wire loop sinus membrane elevator: a novel instrument for lateral window sinus lift. International Journal of
Oral and Maxillofacial Surgery.
• A 0.4-mm wire was chosen because it is soft enough to allow the clinician
to bend it using finger pressure, but still stiff enough to maintain its shape
when light forces are applied.

ADVANTAGES
• Direct visualization of sinus
membrane
• Easy access
DISADVANTAGES
• More pain and post-op
discomfort
• Time consuming
• Steep learning curve
• More chances of infection

INDIRECT SINUS LIFT
• Also called as the Trans-crestal approach
• 1st advocated by Tatum in 1986. Later modified by Summers in
1994
• Most suitable for installation of a single implant, can be used for
multiple implants.

• TATUM’S TECHNIQUE(1986)-
A crestal incision is given in the edentulous area
↓
a “socket former” for the selected implant size was used to prepare
the implant site.
↓
A “green-stick fracture” of the sinus floor was accomplished by hand
tapping the “socket former” in a vertical direction.
↓
After preparation of the implant site, a root-formed implant was
placed and allowed to heal in a submerged way.

Indirect osteotome maxillary sinus floor
elevation (OMSFE)
• Advocated by Summers(1994)
• Generally employed when the residual bone height is equal to or greater than 6
mm
• Uses osteotome in increasing diameters through crestal approach
• No drilling- conserves bone
• Compresses adjacent bone by tap and push; augments upto 13mm (Nikenke
et al. 2002)

Bone-added osteotome sinus floor elevation
procedure (BAOSFE)
• The (BAOSFE) technique attempts to
reposition existing crestal bone under the
sinus, along with graft materials, thereby
elevating the sinus floor and increasing
osseous support for an implant.
• Employs a specific set of osteotomes.
• The tips of these instruments have a
concave nose and a sharpened edge,
which can be used to shave bone from
the side wall of the osteotomy.
• The shaved bone, added graft materials,
and trapped fluids create pressure as the
osteotomes are inserted, resulting in
elevation of the sinus floor.

Trephine drill mediated transcrestal
sinus floor elevation
• Cosci and Luccioli (2000) introduced a series of atraumatic lifting
drills of varying lengths to avoid perforation of the sinus barrier
during drilling of the implant site

• If RBH is: 6-7 mm,
• trephine drill of 3 mm diameter is initially used for the first 2-4 mm,
then 3 mm long and 2 mm diameter pilot drill is used, followed by the 3
mm long intermediate and 3.1 mm diameter drill, and by one or more
atraumatic lifting drills of the actual heights of the ridge as measured on
the radiograph.
• If RBH is 4-5 mm,
• trephine drill is not used and the site is initially prepared with the
dedicated 3 mm long and 2 mm diameter pilot drill, the rest of the
preparation procedure remaining identical.
• The site is probed with a blunt instrument to feel the presence of the
Schneider membrane, after using the first atraumatic lifting drill.
• If the presence of bone is felt, a 1 mm longer atraumatic lifting drill is used,
and so on, until the sinus lining is felt.
• Osteotomes are not used.
• The integrity of the maxillary sinus epithelium is carefully checked with a
blunt instrument, then it is gently lifted, and graft material placement followed
by implant placement is done.

• Lalo et al(2005) proposed a device for diminishing the sinus
membrane perforation by an osteotome and drilling with a
stopper, whereas Tilotta et al(2008) reported on a surgical
procedure using an osteotome equipped with a trephine bur
and stopper.

ADVANTAGES
• Minimally invasive surgical
procedure.
• osteotomy is 1-3 mm deep and
wide.
• Minimal instrumentation with
closed graft delivery permits a
sterile technique.
• Simplicity of procedure
requires less time and
expertise
DISADVANTAGES
• Blind procedure (the sinus isn’t
exposed).
• More chance of errors to occur

Comparison of Direct v/s Indirect
• Pal et al. compared the two different ways of SA:
• gain in bone height was significantly greater in direct procedure through
lateral antrostomy (mean 8.5 mm) than in indirect method through crestal
approach by osteotome technique (mean 4.4 mm).
• They concluded that osteotome technique can be recommended when
more than 6 mm of residual bone height is present and an increase of 3–
4 mm is expected.
• In case of more advanced resorption, direct method through lateral
antrostomy has to be performed.
• Both sinus elevation techniques did not seem to affect the implant
success rate.
• Esposito et al. found that if residual alveolar bone height is 3–6
mm, a crestal approach to lift the sinus lining and place 8-mm
implants may lead to fewer complications than a lateral window
approach to place implants at least 10 mm long.

Minimally Invasive Surgery
• Smaller incisions and with minimal surgical stress. There are some
obvious advantages with a less invasive surgical approach for the
patient, such as quicker recovery, less postoperative pain, and
economic gain due to shorter recuperation.
• Various minimally invasive sinus lift devices on the market can be
clustered according to the drilling speed.
High speed drilling
Sinus Crestal Approach (SCA) Kit
Dentium Advanced Sinus Kit
Sinus Lateral Approach (SLA) Kit
Samuel Lee's Internal Sinus Grafting
System
Santa System
Low speed drilling
Hatch Reamer
Bone Compression Kit
Cowellmedi Sinus Lift Kit
Sinu-Lift System
Disc-up Sinus Reamer

• Cho et al. 2010 and Kang and Lee 2007 reported that sinus
membrane elevation using the Hatch Reamer showed a very high
success rate with rapid sinus membrane elevation.
• Lee and Kim reported that quick and safe sinus membrane
elevation was possible even at the septum area by using the SCA
kit, which was a high-speed drill with a special blade, reducing the
risk of sinus membrane perforation.
LS reamer

BALLOON SINUS LIFT TECHNIQUE
• The zimmer inflated sinus balloon was designed to lift the schneiderian membrane
gently and uniformly.
• The balloon instrument can also be used to anticipate the required bone graft
material, such as 1 cc of saline, which is used to inflate the balloon, equal to 1 cc of
grafting material.
• On average, with 1 cc of saline the sinus lift balloon may elevate sinus membrane 6
mm.

Antral membrane balloon elevation
(AMBE) technique
• Introduced by Soltan et al. 2005
• An inflatable balloon is used to elevate the sinus membrane.
• The technique is especially beneficial when access is difficult
and when adjacent teeth are present next to the edentulous
area.
• LIMITATIONS:
• requires a buccal fenestration
• and a larger incision than others

Minimally Invasive Antral Membrane Balloon
Elevation (MIAMBE)
• Proposed by Kfir et al(2007)
• an upward-expanding balloon deployed via a 3 mm osteotomy.
• It is brief (less than 60 min), performed under local anesthesia,
and leaves the patient with very little operative and postoperative
discomfort.

Minimally Invasive Transcrestal (Mitsa) approach Using Cps Putty
to Elevate the Sinus Membrane
• Documented by Kher et al. 2014
• Osteotomy initiated at ridge crest and stopped 1mm short of
sinus floor.
• Widening of osteotomy site and delivery of 0.2cm of CPS putty.

• The hydrostatic pressure exerted by the putty results in an
atraumatic elevation of the sinus floor.
• The authors claim that the most significant benefit from the use of
this technique is that it can achieve a gain in bone height
comparable with that achieved with the use of the lateral window
approach, while maintaining the advantage of the less invasive
transalveolar approach.

Piezoelectric minimally invasive system
• Involves the use of piezoelectric tips to elevate
the sinus membrane, thereby completely
eliminating chances of sinus perforation
• Vercellotti et al. in 2001 introduced the
piezoelectric system.
• Torrella et al. proposed the use of
piezoelectric surgery for lateral osteotomies.
Adv:
• Precise cut ensuring membrane integrity
• due to the cessation of the surgical action
when the piezosurgery tips come in
contact with nonmineralized tissue.
• separation of the periosteum is also
achieved by the ultrasonic vibrations of
the piezoelectric elevator
• safer, aseptic.

Membrane perforation rate using
conventional rotating instruments and
piezoelectric device
• Atieh(2015) found no significant difference in perforation risk.
• Stacchi et al(2017) found a lower incidence of membrane
perforation during piezosurgery (10.9%) than during conventional
surgery (20.1%).
• Jordi et al(2018) conducted a meta-analysis and the results
showed Membrane perforations in MSA may be significantly
reduced applying piezoelectrical devices for MSA.

HYDRAULIC SINUS LIFT
• The sinus membrane is lifted through a crestal approach,
characterized by the hydraulic detachment of the mucosa through
injection of a liquid followed by its spontaneous expulsion or
aspiration, and simultaneous filling of the sub Schneiderian space,
with solid or semisolid grafting material.

SINU-LIFT SYSTEM
• This a minimally invasive two-staged indirect sinus lift procedure
called a “Sinu-Lift system” that utilizes beta-tricalcium phosphate in
conjunction with platelet-rich plasma
• The disposable kit consists of starter drill, curettes, and bone
packer.

• A 2mm twist drill advanced to 1-2mm
short of maxillary sinus membrane
• The starter Sinu drill (ø 3.2-mm)
makes osteotomy towards the sinus
membrane which disengages upon
contact with the sinus membrane to
avoid the rupture.

• The 3-mm yellow and 4.2mm
blue curettes are used to gently
separate and additional
elevation of the membrane
• The bone packer is used to fill
the space incrementally with
pure phase synthetic β-TCP
(Tricalcium phosphate) sized
500- 1000 μm mixed with PRP.

Hydrodynamic Ultrasonic Maxillary Sinus
Lift (INTRALIFT)
• Velázquez-Cayón et al. 2012: used ultrasonic tips (TKW1-5) for
sinus lift by ultrasound cavitation. Troedhan et al. introduced in
2010
• Adv:
 less trauma
 Conservative bone incisions
 Reduced bleeding
 Better visibility
 Less risk of membrane tear

Minimally Invasive Transcrestal Guided
Sinus lift
• Bone augmentation is performed using a template-assisted
surgical approach in combination with drills and expander-
condensing osteotomes.

• Materials used for sinus floor grafting include autogenous bone,
allogeneic bone, sintered xenograft, and recombinant bone
morphogenetic protein (BMP).
• The graft material chosen must provide adequate viable bone to
stabilize the implant initially and encourage osseointegration.

STUDIES SUPPORTING SAWITHOUT GRAFTING
STUDY APPROACH GRAFTING OUTCOME
Lundgren
2004
Lateral No Bone formation seen after SA
Thor 2007 Lateral No Bone formation seen after SA
Hatano
2007
Lateral No Bone formation seen after SA with
simultaneous implant placed
Pjetursson
2009
Osteotome With and
without
New bone seen with and without
grafting but more bone gain in grafted
sites
Nedir 2009 Osteotome No Osteotome without graft is sufficient to
create new bone

STUDIES SUPPORTING SA WITH GRAFTING
STUDY Graft OUTCOME
Szabo 2005 Autogenous vs
B-TCP
No significant difference btw 2 grafts
used
Nkenke
2009
Different
materials
Success of procedure and implant
survival does not depend on type of graft
used
Esposito
2010
Different
materials
No evidence in clinical outcomes btw
different grafts
Lindgreen
2012
B-TCP vs DBB Implant success rate was not dependent
on the material used

BARRIER MEMBRANES IN SINUS LIFT
• Non-resorbable: ePTFE,
titanium mesh,
• Bio-absorbable: collagen, freeze
dried lamellar bone sheets, PRP,
CaSo4 barriers
• Placement: should cover the
window by min. of 3-5mm. Can
secured with tacks or screws.
STUDY SURVIVAL RATE WITH
MEMBRANE
SURVIVAL RATE WITHOUT
MEMBRANE
Tarnow et al. 2000 100% 92.6%
Tawill & Mawla 2001 93.1% 78.%
Froum et al. 1998 99.2% 96.3%
Fugazzotto and Vlassis indicated that SMPs are not considered a reason to discontinue sinus lift procedures but should be addressed by properly
isolating and repairing the SMP. Repair could include folding of the sinus membrane itself, covering the SMP with an absorbable membrane, or
careful suturing. As an alternative, the use of fibrin adhesive (FA) for repair of perforations has been advocated

Use of PRP
• Arora et al. 2010: systematic rev.- no obvious positive effects of
PRP on bone graft healing in SA was seen, but it improves bone
handling.
Use of PRF
• Ali et al. 2015: systematic rev.- addition of PRF to DFDBA accelerates
graft maturation and decreases healing time. No effect when mixed with
deproteinized bovine bone. PRF membranes represent easy & successful
method to cover the sinus membrane or window.

Postoperative instructions
• On first night after surgery, head should be elevated on 2 or more
pillows
• Liquid diet for 2 days and then soft diet for 2 weeks
• Some nasal bleeding may occur during first day
• Medications –
• Amoxicillin with clavulanate potassium 625 mg BID for 10 days;
• ibuprofen 600 mg and acetaminophen 500 mg QID for 3 days;
• oxymetazoline nasal spray for 7 days;
• 1.2% chlorhexidine mouth 30 cc BID for 14 days
• Avoid chewing from the surgical site,
• Actions that create negative pressure must be avoided during the
first week after surgery: 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. Sneeze
with mouth open.

HEALING FOLLOWING
SINUS
AUGMENTATION

• Sinus is a type of contained-defect.
• Most biocompatible bone grafts can be used successfully.
• With time they may undergo resorption.
• Hatano et al. reported that in initial 2-3 years the material may
undergo pneumatization, to avoid this non-resorbable or only
slowly resorbed.
• Healing pattern in sinus bone grafting did not differ greatly
among a variety of grafting materials; autogenous, allogenic,
xenogenic or alloplastic could be safely used.
• Inclusion of autogenous bone graft can reduce the resorption
time owing to greater bone formation and osteoinduction.
• Sinus augmentation occurs as graft consolidates resulting in the
formation of new bone facilitating implant placement.

• No significant differences in the success rates and/or rate of
infection between simultaneous or staged implant placement
(Sinus Consensus Conference, 1996; Del Fabbro and
colleagues, 2004; Wallace and Froum, 2004).
• Simultaneous implant placement has the following
advantages:
 Fewer surgical procedures
 Less healing time
 Less morbidity
 Less financial expense
 Less patient anxiety

Pre-surgical checklist for prevention of
complications
• Maintain a checklist of diagnostic assessments.
• accurate and complete medical, dental, and social history is taken.
• thorough dental, prosthetic, periodontal, and radiographic examination.
• Obtain additional medical or dental consultations, if indicated.
• Thoroughly discuss procedures and their possible complications with the
patient.
• Review and explain the pre- and postoperative instructions & medications
• Be certain that all supplies and instruments are present and that the
equipment is working prior to the surgery. Have backup supplies and
equipment available.
• For example:
• anesthesia, lidocaine 2% 1:50,000 to control hemorrhage and
eliminate pain.

Complications in Sinus Lift
Surgery
• Bleeding
• Buccal flap tear
• Infraorbital nerve injury
• Membrane perforation.
Intra-
operative
• Incision line opening
• Bleeding
• Barrier membrane exposure
• Infra-orbital nerve paresthesia
Early post-
operative
• Graft loss/failure
• Implant failure
• Oroantral fistula
• Implant migration
• Inadequate graft fill.
Late post-
operative

Management
Bleeding:
• Cause: damage to anastomosis
• Prevent: by preop. Imaging of sinus to locate vessels. Use of less
invasive procedures like piezo or ballon elevation.
• Tx:
 Direct pressure on bleeding site
 Use of hemostatic agents
 Bone wax
 Electrocautery
 Suture the vessel proximal to the bleeding point

Perforations:
• Very small: self repair
• >5mm: bioresorbale membrane is used
• Suturing or patching
• collagen membrane,
• fibrin sealants,
• platelet concentrates
• freeze dried human lamellar bone sheets.
• “Loma Linda pouch”: a slow-resorbing collagen membrane with
external tack fixation, which results in complete coverage of all the
internal bony walls (for minimal or no membrane cases)

Postop. Graft or sinus infections
• 4 stages, with 7-10 days interval
1. Re-institution of antibiotics or change of antibiotics
(Augmentin/Levaquin and Metronidazole)
2. Insertion of drain with antibiotics
3. Partial Debridement graft material in case of its infection
4. Total debridement of graft and sinus cavity

Zygomatic Implants
• Patients with moderate to severe atrophy challenge the surgeon
to discover alternative ways to use existing bone or resort to
augmenting the patient with autogenous or alloplastic bone
materials.
• If sinus augmentation cannot be performed due to a pre-exisitng
condition, these come into play.

Tilted Implants
• Tilted implants were suggested to be useful in the treatment of
edentulous jaws avoiding the bone augmentation procedures and
the involvement of anatomical structures during surgery

Short Implants
• Short implants present a promising approach for patients with
advanced atrophy to avoid augmentative procedures.
• Mangano et al. considered short implants to have a length of
8 mm

CONCLUSION
• The most commonly used surgical intervention for obtaining appropriate
bone height prior to the placement of endosseous implants in the posterior
maxilla is grafting to the floor of the maxillary sinus.
• It is of utmost importance that the preoperative evaluations are done
perfectly and the most suitable technique is decided accordingly for that
particular situation, to improve the prognosis of that treatment.

REFERENCES
• Tiwana PS, Kushner GM, Haug RH. Maxillary sinus augmentation. Dent
Clin North Am. 2006 Jul;50(3):409-24
• Stern A, Green J. Sinus lift procedures: an overview of current techniques.
Dent Clin North Am. 2012 Jan;56(1):219-33,
• Pal US, Sharma NK, Singh RK, et al. Direct vs. indirect sinus lift procedure:
A comparison. Natl J Maxillofac Surg. 2012;3(1):31-37.
• Pozzi A, Moy PK. Minimally invasive transcrestal guided sinus lift (TGSL): A
clinical prospective proof-of-concept cohort study up to 52 months. Clin
Implant Dent Relat Res 2014;16:582-93
• Ali S, Bakry SA, Abd-Elhakam H. Platelet-Rich Fibrin in Maxillary Sinus
Augmentation: A Systematic Review. J Oral Implantol. 2015 Dec;41(6):746-
53.
• Tarun Kumar A B, Anand U. Maxillary sinus augmentation. J Int Clin Dent
Res Organ 2015;7, Suppl S1:81-93

• T P, B S, Kumar TS, Jain AR, P S. An alternative maxillary sinus
lift technique - sinu lift system. J Clin Diagn Res. 2015
Mar;9(3):ZC33-7
• Al-Dajani M. Recent Trends in Sinus Lift Surgery and Their Clinical
Implications. Clin Implant Dent Relat Res. 2016;18(1):204-12.
• Wang F et al. Slot-like window technique for maxillary sinus floor
elevation.Int J Clin Exp Med 2016;9(11):21690-21698
• Zaniol T, Zaniol A. A Rational Approach to Sinus Augmentation:
The Low Window Sinus Lift. Case Reports in Dentistry 2017;
Article ID 7610607
• Starch-Jensen T, Jensen JD. Maxillary Sinus Floor Augmentation:
a Review of Selected Treatment Modalities. J Oral Maxillofac Res
2017;8(3):e3
• Zhou X, Hu XL, Li JH, Lin Y. Minimally invasive crestal sinus lift
technique and simultaneous implant placement. Chin J Dent Res
2017;20:211-8

• Pawar et al. Maxillary Sinus Floor Elevation Techniques with
Recent Advances: A Literature Review Asian Pacific Journal Of
Health Sciences, 2017; 4(1):112-129
• Bathla SC, Fry RR, Majumdar K. Maxillary sinus augmentation. J
Indian Soc Periodontol. 2018;22(6):468-473.
• Devameena S, Dinesh D S, Lakshmi Devi G, Shanmugavadivel
G. Sinus lift procedures in dental implants: A literature review on
techniques, recommendations, and complications. Indian J Dent
Sci 2020;12:180-6
• George J, Gopal S, Huda F, Thomas N. Minimally Invasive
Transalveolar Sinus Augmentation: An Answer to Sinus
Conundrum. Dent Med Res 2020;8:4-9

MAXILLARY SINUS AUGMENTATION.pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to MAXILLARY SINUS AUGMENTATION.pptx

Similar to MAXILLARY SINUS AUGMENTATION.pptx (20)

Recently uploaded

Recently uploaded (20)

MAXILLARY SINUS AUGMENTATION.pptx