Maxillary ridge augmentation is a common procedure nowadays, This presentation is about the direct and indirect procedures for maxillary sinus lift for implant placement. with recent advancement in the procedures.

1. MAXILLARY SINUS LIFT
PRESENTED BY
DR. SIDDHARTH RAWAT
ASSISTANT PROFESSOR
ORAL AND MAXILLOFACIAL SURGERY
SCHOOL OF DENTAL SCIENCES

2. Content
1. Introduction
2. Indications and Contraindications for Sinus Lift Procedures
3. Radiographic Evaluation
4. Types of Sinus Lift Procedures
- Direct sinus augmentation technique
- Indirect sinus augmentation technique
5. Minimally Invasive Surgeries
6. Complications
7. Conclusion
8. 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 the mid 1970s.
Maxillary (Sinus Floor Elevation) SFE was first described by Dr. Hilt Tatum at an Alabama
implant conference in 1976

4. Indication for Sinus lift
No history of sinus pathosis.
Insufficient residual bone height (less than 10 mm of bone height).
Severely atrophic maxilla.
Poor bone quality and quantity in the posterior maxilla.

5. Containdication for Sinus lift
Recent radiation therapy in maxilla.
Uncontrolled systemic diseases such as diabetes mellitus.
Acute/chronic maxillary sinusitis.
Heavy smoker.
Alcohol abuse.
Psychosis.
Severe allergic rhinitis.
Tumour or large cyst in the maxillary sinus.
Oroantral fistula.

6. Radiographic Evaluation
In 1987, Misch developed a classification for the treatment of edentulous posterior maxilla
based on the amount of bone available below the antrum and the 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.

7. Classification of maxillary sinus based on residual bone
height
O
MS
AH
O – Orbit
MS – Maxillary Sinus
AH- Alveolar Height

8. Types of Sinus lift Procedures
Direct sinus augmentation technique (DSAT)
 Indirect sinus augmentation technique (ISAT)

9. Direct sinus augmentation technique (DSAT)
Tatum and Boyne and James were the first authors to publish studies on elevation of the
maxillary sinus floor in patients with large, pneumatized sinus cavities.
They described a two-stage procedure, where the maxillary sinus was grafted using
autogenous particulate iliac bone in the first stage of surgery. After approximately 3 months,
a second stage of surgery was performed in which blade implants were placed.
Hence, It’s also known as two-stage procedure.

10. Surgical Procedure for DSAT
Lateral window approach for sinus augmentation

11. Modification of Caldwell Luc technique
LA administration
PSA nerve block, ASA nerve block, Palatal infiltration
Crestal incision is given from maxillary tuberosity to the point just anterior to anterior border of
sinus along with vertical releasing incisions.
Mucoperiosteal flap reflected, lateral wall of maxilla exposed. Linear osteotomy performed using
#6 or #8 round bur.

12. Diagram demonstrating the ideal location of sinus window preparation of the lateral maxillary wall. The inferior ostectomy
should be approximately 1 mm superior to or level with the floor of the sinus. The posterior ostectomy should be at the corner
of the maxillary buttress. The anterior ostectomy should be adjacent to and parallel with the lateral wall of the nose, and the
superior ostectomy should be at the height of the intended graft.
(From Block MS. Color atlas of dental implant surgery. 2nd edition. Philadelphia:Saunders;2007. p. 129)

13. Once the window is created membrane is exposed, adherent bone is either removed or
rotated medially.
Schnederian membrane is elevated using a freer or currete.
Bone graft is placed under the membrane in anterior and inferior direction. Graft should
contact the medial wall of maxillary sinus.
Mucoperiosteal flap is repositioned and sutured.
After 3-6 months implant is placed.

14. Direct sinus lift with simultaneous implant placement with use of autogenous bone graft (a) In-fracturing and
lifting of lateral window of right maxillary sinus, (b) Autogenous bone harvested from donor site being placed in
newly created space, (c) Bone packed in the window, (d) Sinus floor augmented and implant placed

15. Line diagrams illustrating Direct sinus lift with
simultaneous implant placement,
(a) Atrophic posterior maxilla with residual bone height
between sinus floor and alveolar crest inadequate for
placement of dental implant,
(b) Lateral wall of sinus in-fractured and membrane is
elevated,
(c) Grafted bone is densely packed in space created
after lifting the membrane,
(d) Augmented maxillary sinus with implant placed

16. Indirect sinus augmentation technique (ISAT)
A crestal approach for sinus floor elevation with subsequent placement of implants was first
suggested by Tatum in 1986.
Summers (1994) later described another crestal approach, using tapered osteotomes with
increasing diameters.

17. Surgical Procedure for ISAT
A crestal approach for sinus floor elevation

18. Indicated when minimal bone height is needed.
Crestal incision is made and implant drills are used to create an osteotomy, leaving 1 mm of
bone between site and sinus membrane.
Sequential osteotomies are done to compact the bone laterally and apically, which will
elevate the sinus membrane.
Bone graft is placed.
Implant is placed with a cover screw and primary closure is done.

19. Figure a: Pre-operative orthopantomography
Figure b: Elevation of the sinus membrane using the
balloon technique
Figure c: Creation of a bony window in the mandibular
symphysis region for graft harvest
Figure d: Clinical picture showing the insertion of the graft
material
Figure e: Immediate post-operative
Figure f: One-year post-operative orthopantomograph
showing the implant with prosthesis
a b
c d
e f

20. a: Indirect sinus lift technique
using angulated sinus osteotome
b: Implant in situ and bone graft
imamate post-operative
c: Six months' post-operative
orthopantomograph showing the implant
d: Nine months' post-operative
orthopantomograph showing implant with
prosthesis
a b
c d

21. Minimally Invasive Surgery
 A minimally invasive surgical procedure has been defined in general surgery as a
procedure that is carried out with the least damage possible to the patient.
 The procedure is called “minimally invasive” when there is minimal damage to biological
tissues at the point of entrance of the instrument.

22. Various minimally invasive sinus lift
devices according to the drilling speed
1. Low Speed Drilling is recommended in
Hatch Reamer (Sinustech America, Calabasas, CA, USA)
 Bone Compression Kit (MIS, Tel Aviv, Israel)
 Cowellmedi Sinus Lift Kit (Cowellmedi Co., Busan, South Korea)
 Sinu-Lift System (Innovative Implant Technology, Aventura, FL, USA).
Disc-up Sinus Reamer (Dentimate Co., Seoul, South Korea).
Sinus Master (Mr. Curette Tech., Seongnam, South Korea)

23. 2. High-speed drilling is to be applied
Sinus Crestal Approach (SCA) Kit (NeoBiotech, Seoul, South Korea).
 Dentium Advanced Sinus Kit (Dentium, Suwon, South Korea).
 Sinus Lateral Approach (SLA) Kit (NeoBiotech, Seoul, South Korea) [Figure 4] and [Figure
5]
 Samuel Lee's Internal Sinus Grafting System (MegaGen, Daegu, South Korea)
 Santa System (Dentis, Daegu, South Korea).

24. 3. Devices that allow for both high- and low-speed drilling are
The Dr. Cosci drill (Dentech Co., Tokyo, Japan) and
Sinus Lift Drill (SSI, Seongnam, South Korea)

25. LS reamer for sinus lateral approach (SLA, NeoBiotech, Seoul, South
Korea)

26. Hydrodynamic ultrasonic cavitational sinus
lift

27. Trephine drill mediated transcrestal sinus floor elevation

28. Transcrestal sinus floor elevation using antral membrane mini
balloon

29. Piezoelectric System
Vercellotti et al. in 2001 introduced the piezoelectric system. The piezoelectric system, a
relatively newer technique.
Microvibration of 20-60 μm from 25-29 KHz with sterile water is safer, aseptic, and prevents
Schneiderian membrane perforations.
Torrella et al. proposed the use of piezoelectric surgery for lateral osteotomies.

30. Minimally Invasive Transcrestal (Mitsa)approach
Using Cps Putty to Elevate the Sinus Membrane
Another novel technique as documented by Kher et al. 2014
minimally invasive transalveolar sinus elevation technique utilizing calcium phosphosilicate
(CPS) putty for hydraulic sinus membrane elevation.
In this technique, transcrestal SFEs are performed using a modification of Summers'
technique.

31. MITSA hydrolic membrane elevation using CPS putty

32. Lateral sinus augmentation using LS reamer, neobiotec and augmentation using CPS putty

33. Complications
Intraoperative
Bleeding.
Buccal flap tear.
Infraorbital nerve injury.
Membrane perforation.
Early Postoperative
Incision line opening.
Bleeding.
Barrier membrane exposure.
Infraorbital nerve paresthesia.

34. Late Postoperative
Graft loss/failure.
Implant failure.
Oroantral fistula.
Implant migration.
Inadequate graft fill.

35. Conclusion
The present study identified that with a wider alveolus, shorter implant with greater diameter
can be used safely, probably owing to increased surface area causing more
osseointegration.
Result of sinus augmentation depends on surgeon's acumen and experience.
The goal of any dental implant surgeon is to use a cost-effective, short duration, less risky,
simple, and highly predictable outcome procedure.

36. 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.

37. References
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. doi:10.4103/0975-5950.102148.
Schwartz-Arad D, Herzberg R, Dolev E. The prevalence of surgical complications of the
sinus graft procedure and their impact on implant survival. J Periodontol 2004;75:511-16.
Misch, Carl E. Contemporary Implant Dentistry, 3rd ed. St Louis: Mosby, 934-6.

38. Boyne PJ and James RA. Grafting of the maxillary sinus floor with autogenous marrow and
bone. J Oral Surg 1980;38:613-16.
Tatum H Jr. Maxillary and sinus reconstructions. Dent Clin North Am 1986;30:207-29.
Tarun Kumar A B, Anand U. Maxillary sinus augmentation. J Int Clin Dent Res Organ
2015;7, Suppl S1:81-93

39.  Block MS. Color atlas of dental implant surgery. 2nd edition. Philadelphia:Saunders;2007. p. 129