Sinus lift procedures. final copy of presentation pptx

SINUS LIFT PROCEDURES
PRESENTED BY
NAMITHA,.AP
3 rd MDS
Leonardo Da Vinci in
Nathaniel
Highmore 1651
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health
Sciences; 2020 Jan 25. PAGE NO.987
Hilt tatum 1970
1

Contents
 Introduction
 Anatomy of maxillary sinus
 Bony walls
 Blood supply
 Schneiderian membrane
 Clinical Assessment of maxillary sinus
 Miscellaneous Factors That Affect the
Health of the Maxillary Sinus
 Relative and absolute
contraindications
 Reduction of sinus graft complications
 Armamentarium
 Misch’s classification
 Chiapasco’s classification
 Different techniques of sinus floor
elevation
 Intra operative complications
 Post operative complications
 Summary
 Related articles
 References
2

INTRODUCTION
Most challenging
and complex
intraoral regions that
confronts
the implant clinician
Most
predictable
intra oral
region to grow
bone height
Poor bone
density
requires
implants of a
larger size
including
length
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020 Jan 25.
PAGE NO.987
3

The maxillary sinus/
Antrum of Highmore
4

Bony walls
Surgical access
during caldwel luc
procedure Infections leads to
ocular symptoms
internal maxillary artery,
pterygoid plexus,
sphenopalatine
ganglion, and greater
palatine nerve
patency of the
ostium must be
maintained
The primary ostium is
located in the superior
aspect of the sinus
medial wall
intraosseous anastomosis of the
infraorbital and posterior superior
alveolar artery
Site for lateral wall sinus
graft
close
relationship
with the
apices of the
maxillary
molars and
premolars.
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020 Jan 25. PAGE NO.990
5

Blood supply
Vital part of the healing and regeneration
of bone after a sinus graft
Resnik R. Misch's Contemporary Implant Dentistry E-Book.
Elsevier Health Sciences; 2020 Jan 25. PAGE NO.993,994
6

Schneiderian membrane Line the inner walls of the sinus
Serum mucosa glands are located underneath – especially
next to ostium opening
Thickness 0.13 - 0.5 mm
Main carrier of bone reformation after sinus floor elevation
Mucosal thickening is the most frequently observed
abnormality – 66%
7

Maxillary sinus
membrane
Cilia beat toward the ostium at
approximately 15 cycles per minute, -
stiff stroke through the serous layer,
reaching into the mucoid layer
An alteration in the sinus ostium
patency or the quality
of secretions can lead to disruption
in ciliary action, which
may result in rhinosinusitis.
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier
Health Sciences; 2020 Jan 25. PAGE NO.995
8

Maxillary sinus – clinical assessment
A thorough preoperative evaluation is completed to rule out any
existing pathologic condition in the maxillary sinus
Helps in proper bone
formation
Reduce risk of possible
mucus or bacteria
contamination of the graft
Avoid formation of bacterial
smear layer on the implant
proximity of the maxillary
sinus to numerous vital
structures is identified
sinusitis
cavernous sinus
thrombosis
Orbital cellulitis
osteomyelitis meningitis
Complications of infections in this region
Elsevier Health Sciences; 2020 Jan 25. PAGE NO.996,997
9

The nasal fluids may be used to evaluate
the
medial wall of the sinus by asking the
patient to blow the nose in a
waxed paper.
• mucus should be clear and thin in nature
Normal
• A yellow or greenish tint or thickened
discharge
Infection
symptomatic - exudate
in the middle meatus and may be
inspected with a nasal speculum
and headlight (rhinoscopy) through the
naresResnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences;
2020 Jan 25. PAGE NO.997 10

Methods of examination
of the infected maxillary sinus
CBCT TRANSILLUMINATION NASOENDOSCOPY
MAGNETIC
RESONANCE IMAGING
[MRI]
NASOENDOSCOPY BACTERIOLOGY
CYTOLOGY
FIBREOPTIC
ANTROSCOPY
RADIOGRAPHY
best option
1.Water’s
projection
2.Panoramic
3.Peri apical
Differentiatio
n of soft
tissues within
the sinus
Resnik R. Misch's Contemporary
Implant Dentistry E-Book. Elsevier
Health Sciences; 2020 Jan 25. PAGE
NO.997
11

Unfavourable radiographic situations
following SFE
1. Spreading of particulate bone substitute in the sinus cavity
2. Sinus reaction after bone grafting
3. The implant is not covered by the grafting material
12

(A) Normal paranasal anatomy
(B) Paranasal pathology and anatomic
variants.
Maxillary Sinus: Anatomical Variants
pharmacologic
protocol may need to
be altered
implants may be
placed after the sinus
graft has matured
can predispose a
patient to
postsurgical
complications
13

consideration should be given
to not place the implant at the same time as the sinus
graft, and
the recommended preoperative and postoperative
pharmacologic
protocol is especially warranted.
NASAL SEPTUM
DEVIATION
MIDDILE
TURBINATE
VARIANTS
UNCINATE
PROCESS VARIENTS
SUPPLEMENTAL
OSTIA
MAXILLARY
HYPOPLASIA
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020 Jan 25. PAGE
NO.998.999
14

Maxillary hypoplasia
Inferior Turbinate and Meatus
Pneumatization
(Big-Nose Variant)
malformed and positioned uncinate
process is associated with this disorder, leading
to chronic sinus
drainage problems. Most often, these patients
have adequate bone
maxillary sinus is lateral to the edentulous
ridge. When inadequate bone height is present below
this structure, a sinus graft does not increase available
bone height for an implant.
15

SEPTA
 Increase the risk of sinus membrane perforation
 Complicate inversion of bone plate and elevation of sinus
membrane
 Modification of conventional surgical technique is required
first described by
the anatomist
Underwood13 in
1910 and are
thus also
referred to as
Underwood’s
septa
16

MAXILLARY SINUS PATHOLOGY
 Relative or absolute contraindication for many procedures that will alter
the sinus floor before or in conjunction with sinus grafting and/or implant
insertion.
 The risk of postoperative infection is elevated and may compromise the
health of the implant and the patient.
 pathologic conditions, either preoperative or postoperative, of a maxillary
sinus should be evaluated, diagnosed, and treated.
(1) inflammatory
lesions
(3) neoplasms (2) cystic lesions
(4) antroliths and
foreign bodies
NO.1000
17

INFLAMMATORY DISEASE
 Inflammatory conditions can affect the maxillary sinus from odontogenic
and nonodontogenic causes.
Odontogenic Rhinosinusitis
(Periapical Mucositis)
Mild mucosal thickening
(Non odontogenic)
Sciences; 2020 Jan 25. PAGE NO.1000,1001
18

Acute Rhinosinusitis
Chronic Rhinosinusitis
Allergic RhinosinusitisFungal Rhinosinusitis
purulent nasal Discharge, facial pain and tenderness,
nasal congestion, and possible
fever.
Treated before grafting procedure
Delay implant placement
Extended antibiotic coverage
Does not
resolve in 6
weeks
Irritating allergen in the upper respiratory tract
extensive history of
antibiotic use, chronic exposure
to mold or fungus in the
environment,
or history of
immunosuppression.
19

Cystic lesions
 Cystic type lesions are a common occurrence
 microscopic lesions to large, destructive, expansile pathologic conditions
The most common
cysts in the maxillary
sinus are mucous
retention
cysts
Psedocysts
Retention
cysts
Microscopic in
size - No
treatment
not a contraindication
greater than 8 mm -
drained and allowed to
heal before or in
conjunction with sinus
elevation surgery.
Slow growing lesion, mucosal and cortical integrity is
preserved
20

Primary Maxillary Sinus Mucocele
 Surgical removal of
this cyst is indicated
prior to any bone
augmentation
procedures
Cystic,expansile, low attenuation destructive lesion
Nasal
obstruction
painful swelling
of the cheek
Possible ocular
symptoms
Displacement
of teeth
Consequent to an obstruction
of the sinus ostia and
drainage pattern
Accumulation
of mucous
Expand from
pressure
Fate of sinus
walls
Remodelling/c
ompletely de
ossified /
eroded
NO.1004
21

Secondary Maxillary Sinus Mucocele
(Postoperative Maxillary Cyst)
 Surgical ciliated cysts
should be enucleated
before any bone
augmentation
procedures.
 If observed after the
sinus graft, then the
cysts should be
enucleated and
regrafted in the site
secondary to a
previous trauma or
surgical procedure in
the sinus cavity
well-defined
radiolucency
circumscribed by
sclerosis
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020 Jan 25. PAGE NO.1005.1006
22

Neoplasms
 Any signs or symptoms of
a lesion of this type
should be immediately
referred for medical
consultation.
 Sinus graft surgery is
absolutely
contraindicated while this
condition exists.
squamous cell carcinomas or
adenocarcinomas
swelling in the
cheek area, pain,
anesthesia or
paresthesia of
the infraorbital
nerve
(e.g., anterior
wall), and visual
disturbances
(e.g., superior
wall).
various-sized radiopaque masses
complete opacification, or bony wall changes
lack of a posterior wall on a panoramic radiograph
sign of possible neoplasm
NO.1005
23

Antroliths and Foreign Bodies
 Maxillary sinus antroliths
are the result of complete
or partial encrustation of a
foreign body.
 These masses found
within the maxillary sinus
originate from a central
nidus, which can be
endogenous or
exogenous If sinusitis exists -
should be allowed to heal completely before sinus augmentation
procedures.
A nonsymptomatic condition may have the
antrolith removed and sinus graft performed at the same surgery,
only if the sinus membrane is not compromised.
Before sinus
augmentation and
implant
placement, the
antrolith
should be
surgically
removed.
24

Miscellaneous Factors That Affect the
Health of the Maxillary Sinus
 Increased morbidity after sinus graft
procedures
 smoking is not an absolute
contraindication
 patients should be instructed to cease
smoking before and after sinus graft
procedures
 higher risk of wound dehiscence, graft
infection and/or resorption, and a
reduced probability of osseointegration.
 patients refrain from smoking at least 15
days before surgery (i.e., the time it takes
for nicotine to clear systemically) and 4 to
6 weeks after surgery
Detailed informed consent in which risks connected
to smoking are clearly defined and explained.
25

Relative and Absolute Contraindication to
Maxillary Sinus Graft Procedures
26

Reduction of sinus graft complications
strict aseptic technique
Intraoral and extraoral
scrubbing with
chlorhexidine
scrubbing and draping the
patient, and gowning the
doctor and assistant
Sterile gloves and sterile
instruments
Pre operative and post
operative pharmacological
regimen
NO.1008
27

Oral antimicrobial rinse
 Gentle oral rinses of chlorhexidine
gluconate 0.12% should be used
twice daily for 2 weeks after surgery
or until the incision line is completely
healed
 Both systemic and topical
decongestant medications are useful
in reopening a blocked sinus ostium
and facilitating drainage.
 Oxymetazoline 0.05% (Afrin or Vicks
Nasal Spray) and phenylephrine 1%
are useful topical decongestant
medications.
Glucocorticoid medications
 Decrease inflammation of the soft tissue and
minimize postoperative pain, swelling, and
incision line opening.
 clinical manifestations of surgery on the sinus
mucosa also can be decreased
Decongestant medications
PAGE NO.1009,1010
28

Instrumentation
• Most commonly used to create the osteotomy through which the sinus floor is accessed
Rotary instruments
• Used to carve into the anterior sinus wall to create an antrostomy for SFE in a simple and
very safe procedure
Bone scrapers
• Used to separate / reflect and elevate the Schniederian membrane from the maxillary
bone
Sinus lift curettes
Piezoelectric devices and corresponding tips
29

Bone scraper trimming the buccal plate in order to
reduce the thickness of the wall
Complete osteotomy using a piezoelectric round
tip, minimizing the risk of membrane perforation
https://pocketdentistry.com/the-maxillary-sinus-
lift/#:~:text=The%20sinus%20lift%20procedure%20is,for%20placement%20of%20dental%20implants.
31

• ADEQUATE VERTICAL BONE - > 12 mm
SA1
• 0-2 mm less than ideal height 10-12 mm
SA2
• 5-10 mm of bone below the antrum
SA3
• Less than 5mm of vertical bone below
maxillary sinus
SA4
MISCH’S CLASSIFICATION (1987)
32

CHIAPASCO CLASSIFICATION 2003
 Classification is based on 3 variables:
Width
Height of the residual alveolus
Inter-ridge relation
 The variables are used to define 8 types of sinus posterior maxillary
alveolar morphologies according to their treatment needs
 Classes A to D address height and width, and the remaining classes define
crown height space.
Chiapasco M, Zaniboni M, Rimondini L. Dental implants placed in grafted maxillary sinuses: a retrospective analysis of
clinical outcome according to the initial clinical situation and a proposal of defect classification. Clinical Oral Implants
Research. 2008 Apr;19(4):416-28.
33

Surgical Technique
Subantral Option One:
Conventional Implant Placement
 when sufficient bone height is
available to permit the placement of
endosteal implants following the
usual surgical protocol, with no
maxillary sinus involvement.
 D3 or D4 bone - bone compaction or
osseodensification to prepare the
implant site is common
 permits a more rigid initial insertion of
the implant and also increases the BIC
( bone to implant contact percentage)
Required bone dimensions
 minimum ideal bone height for the
SA-1 is related to the associated force
factors.
PAGE NO.1011,12
37

38

Resnik R. Misch's Contemporary Implant
Dentistry E-Book. Elsevier Health Sciences;
2020 Jan 25. PAGE NO.1011
Narrower bone volume patients (Division B)
osteoplasty or
augmentation
The insertion of
smaller surface
area implants
are not
suggested
forces are
greater & Bone
density is less
WIDTHAUGMENTATION
BONE SPREADING
MEMBRANE GRAFTING
AUTOGENOUS GRAFTS
most
common
approach
when the
bone density
is poor
< 2.5 mm of width (C–w)- increase width using
onlay autogenous bone grafts.
Progressive loading during the prosthetic
phases of the treatment is suggested in D3 or D4 bone
39

Subantral Option Two: Sinus Lift and
Simultaneous Implant Placement
 Intended implant
length is 1 to 2 mm
greater than the vertical
bone present-
SA-2 surgical approach modifies the floor of the maxillary sinus, a preexisting pathologic condition
of the sinus should not be present because it may affect the implant site by
retrograde infection.
40

Tatum -
1970
• developed
this technique
Misch -1987 • published
Summers -
1994
• Similar
procedure
implant is placed via an osteotome
technique - elevates the membrane
approximately 1 to 2 mm with the use
of no grafting.
Ideally, an 8-mm implant is used with
caution
reserved for 8 to 10 mm of host bone
below the sinus
Dentistry E-Book. Elsevier Health
41

INCISION AND REFLECTION
 A full-thickness incision is made on the crest of the edentulous ridge from the
tuberosity to the distal of the canine region.
 A vertical, lateral relief incision is made at its distal and anterior extension of the
crestal incision for approximately 5 mm.
 If minimal attached tissue exists on the crest of the ridge, which is more often
observed in the premolar region, then the primary incision is made more palatal to
place more keratinized tissue on the facial aspect
 When teeth are present in the region, the crestal incision extends at least one tooth
beyond the edentulous site.
 If one tooth is missing - a direct (flapless technique)
 Once the tissue is reflected, the width of the available bone is evaluated to ensure
that it is greater than 6-7 mm wide and allows the placement of Division A root-form
implants.
42

OSTEOTOMY AND SINUS
ELEVATION(SA 2)
 The depth of the osteotomy -1 to 2 mm short of
the floor of the antrum.
 The implant osteotomy is prepared to the
appropriate final diameter, short of the antral
floor, by approximately 1 mm.
D3 BONE
• Osteotome of the same diameter as the
final osteotomy
D4 BONE
• Osteotomy 1- 2 sizes smaller than the final
implant size - OSSEODENSIFICATION
43

 A flat-end or cupped-shape
osteotome is selected for the
infracture of the sinus floor.
 The osteotome is inserted and tapped
firmly in 0.5- to 1.0-mm increments
beyond the osteotomy until reaching
its final vertical position, up to 2 mm
beyond the prepared implant
osteotomy.
 A slow elevation of the sinus floor is
less likely to tear the sinus mucosa.
 compresses the bone below the
antrum - greenstick- type fracture in
the antral floor, and slowly elevates
the unprepared bone and sinus
membrane over the broad-based
osteotome.
Elsevier Health Sciences; 2020 Jan 25. PAGE NO.1013
44

Implant placement
 The implant is slowly threaded into position so the membrane is less likely
to tear as it is elevated.
 implant design should include a convex apex with no apical openings as
this design will be less likely to cause a membrane perforation.
 The apical portion of the implant engages the more dense bone on the
cortical floor, ideally with bone over the apex, and an intact sinus
membrane.
Implant extend
0 to 2 mm
beyond sinus
floor
Compressed
bone over
implant apex –
1mm
3 mm elevation
of sinus
mucosa
45

 even when membrane perforation occurs and/or no bone grows around
the apical end of the implant, the SA-2 technique is of benefit because the
apical end of the implant is surrounded by denser bone.
 This enhances rigid fixation during healing and increases BIC, leading to
improved loading conditions.
 If inadequate bone is formed around the apical portion of an implant, then
a progressive-loading protocol for D4 bone is suggested during prosthetic
reconstruction
If a sinus membrane perforation occurred
during the initial implant placement
procedure, then bone height growth is less
likely to occur.
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences;
2020 Jan 25. PAGE NO.1013
46

Modified Trephine/Osteotome
Approach (Simultaneous Implant
Placement) – Fugazzoto (2002)
 within approximately 1–2 mm of the sinus membrane at a reduced cutting speed.
 A calibrated osteotome corresponding to the diameter of the trephine preparation is used under gentle
malleting forces, to implode the trephine bone core to a depth approximately 1 mm less than that of the
prepared site
 This technique is indicated in the presence of 4–5 mm of RBH in order to avoid repeated traumatic
malleting of the osteotomes
A trephine with a 3.0 mm external
diameter is followed by an osteotome
to implode a core of residual alveolar
bone prior to simultaneous implant
placement.
https://pocketdentistry.com/crestal-sinus-floor-elevation-sfe-approach-overview-and-recent-developments/
47

Subantral Option Three: Sinus Graft with
Immediate Endosteal Implant Placement
 A residual height of 5 mm for the SA-3 category has been selected for two main
reasons:
(1) This height (in adequate bone width and quality) can be considered sufficient to
allow primary stability of implants placed at the same time as the sinus graft
procedure,
(2) because of the amount of residual bone (5mm), greater blood supply is present,
which allows for more predictable and faster healing
indicated when at least 5 mm of vertical bone and sufficient width are
present between the antral floor and the crest of the residual ridge in
the area of the intended prosthesis abutment
NO.1014
48

ANAESTESIA FOR SINUS GRAFT
SURGERIES
 Infiltration anesthesia has been used with success for sinus graft
surgeries in the past
 more profound regional anesthesia is achieved by blocking the
secondary division of the maxillary nerve (V2)
 The sinus graft surgery -reflection of the soft tissue extending to
the zygomatic process.
 V2 block is advantageous for patient comfort, and this achieves
anesthesia of the hemimaxilla, side of the nose, cheek, lip, and
sinus area.
INFILTRATION
anaesthesia
Posterior
superior
alveolar nerve
block
Palatal
infiltration
Middle
superior
alveolar nerve
block
49

Surgical approaches
Lateral wall approach
 A Tatum lateral maxillary wall approach is
performed by performing an osteotomy over
the lateral wall of the maxillary sinus,
infracturing the window, elevating the sinus
membrane and window, grafting to the medial
wall, and then placing the implant (SA-3).
Lateral wall approach
Crestal approach
50

Flap design
 Most commonly, the initial incision is
mid crestal extending well beyond
the planned extension of the
osteotomy
 Wound edges lacking bone support
may give rise to soft tissue collapse or
major dehiscences in the absence of
blood supply
 When a staged approach is indicated,
it would be recommended to place
the incision line slightly on the buccal
aspect (within the keratinized gingiva)
of the crest as this may offer easier
and quicker access for window
opening
PAGE NO.1016
51

Incision and reflection
 A crestal incision is made on the palatal aspect of the maxillary posterior
edentulous ridge from the tuberosity to one tooth anterior to the anterior
wall of the maxillary sinus, leaving at least 2 mm of attached tissue on the
facial aspect of the incision.
 Because ridge resorption occurs toward the midline at the expense of the
buccal dimension, the incision is made with awareness of the greater
palatal artery, which proceeds close to the crest of the ridge in the severely
atrophic maxilla
Incision line is designed to avoid the planned location of lateral window
52

 A vertical relief incision is made on the distal of the
incision to enhance surgical access to the maxillary
tuberosity.
 A broad-base anterior vertical relief incision is also
made at least 10 mm anterior to the anterior
vertical wall of the sinus.
 This may result in the incision being made over the
distal aspect of the first bicuspid or canine.
 The facial soft tissue flap is designed, following
general principles, with a base wider than the crest
to ensure proper blood supply.
 The palatal portion of the flap is first reflected,
followed by the facial crestal tissue, which is
reflected off the crest.
BLEEDINGFROMPALATALFLAP
HEMOSTAT
PRESSURE OVER GREATER PALATINE
FORAMEN WITH BLUNT INSTRUMENT
ELECTROCOAGULATION
NO.1016
53

Mucoperiosteal elevation
 The facial full-thickness mucoperiosteal
flap is reflected to expose the complete
lateral wall of the maxilla and a portion of
the zygoma. (to the anticipated height of
the lateral window - antral wall)
 The facial flap should be reflected to
provide complete vision and access to
the maxillary lateral wall.
 The superior aspect of the flap should
never approach the infraorbital foramen
because aggressive reflection of the facial
flap - neuropraxia type of nerve
impairment and damage to this nerve
structure.
Prominent zygoma
- flap reflection is
difficult
54

Sinus window osteotomy
 The crestal part of the window
(osteotomy) should be higher than the
sinus floor in order to contain the bone
substitute
Lower border of window
Residual ridge height from the crest
Crest of residual ridge
Shape of the window is generally pyramidal –
top of the pyramid is crestal
Rounded angles to avoid
membrane tearing
identified due to the lack of blood supply compared to the
surrounding cortical ( bluish in case of a thin cortical bony
wall)
NO.1015
55

Window mapping
5 mm distal to
the most posterior
planned implant site
approximately 2-3 mm above
the planned implant length
A soft tissue retractor - above the superior margin of the
lateral-access window (i.e., always maintained on bone, not
soft tissue) - retract the facial flap and prevents the retractor’s
inadvertent slip into the access window
56

The inferior score line of the rectangular access window on
the lateral maxilla is placed approximately 1 to 2 mm above
the level of the antral floor (i.e., which in an SA-3 is >5 mm
from the crest).
At or below the level of antral floor
• infracture of the lateral wall will be impossible
because the score line will be over host bone
too high (>4 mm) above the sinus floor
• ledge above the sinus floor will result in a blind
dissection of the membrane on the floor, which
may also lead to perforation.
The anterior vertical line of the access window
is scored
approximately 1 to 2 mm from the anterior
sinus border.
57

Top hinge
trapdoor
technique
Repositioned
bony window
trapdoor
Complete
osteotomy
The original modified Caldwell-Luc technique – Tatum 1977
opening a bony window inward using a top hinge in the
lateral maxillary sinus wall; the osteotomy is prepared in a
superior position just anterior to the zygomatic buttress.
Thick bony plate repositioned over the grafting material
Piezoelectric bony window preparation: note the PSAA artery
showing by transparency via the thin buccal plate
most commonly reported is the preparation of an access hole
by removing the entire buccal bone plate (thinning of the
buccal bone to a paper-thin bone lamella prior to the
elevation of the sinus membrane).
https://pocketdentistry.com/lateral-sinus-grafting-approach-overview-and-recent-developments/
58

Access window
 The overall design of the lateral-access window is determined after the
review of the CBCT scan
Thickness of the lateral
wall of the antrum
Position of the antral
floor from the crest of
the ridge
Posterior of the anterior
wall in relationship to the
teeth (if present)
Presence of septa on the
floor and/or walls of the
sinus
Any associated
pathology within the
maxillary sinus.
The outline of the Tatum lateral-access window is scored on the
bone with a rotary handpiece under copious cooled sterile saline
easier to perform this
step at 50,000 rpm (1:1
handpiece).
it is possible even at 2000
rpm, depending on the
lateral-wall
bone thickness
W shaped in short
septum/ 2 windows
surrounding septum
NO.1016
59

Zygomatic bone and buccal wall
influence on SFE
 Thick buccal wall
combined with a low
zygoma position – favour
of avoiding complete
osteotomy
 Repositioned window trap
Prominent zygoma buttress – serious
obstacle for upper position of the
window trap
Especially difficult in resorbed ridge
cases – limiting the height of
window
60

Complications
Endosseous anastomosis from the posterior superior alveolar and the
infraorbital artery
 largest blood vessel in the lateral wall
 when the lateral wall is very thin in the
edentulous patient, the anastomosis
will atrophy and become non-existent
 located approximately 15 to 20 mm
from the alveolar crest
 The horizontal lines of the access
window should ideally not be
positioned directly over this structure.
 The vertical lines of the access window
often cut through the artery( blood
supply may be from either direction,
both vertical access lines may have
bleeding.)
If intraosseous bleeding is
a problem!
High-speed diamond used
without irrigation and
polish the bleeding site
Electrocautery Hemostat
61

SINUS MEMRANE ELEVATION
A flat-ended metal punch (or mirror handle) and mallet - gently infracture the lateral-access
window (still attached to the thin sinus membrane)
punch is first positioned in the center of the window.
If light tapping does not greenstick fracture the bone - placed along the periphery of the
access window and tapped again.
Another light tap with the mallet - greenstick fracture of the bone along the scored line.
If this still does not free the window -further scoring of the bone with the handpiece and
diamond bur is indicated – Tapping repeated
NO.1016
62

 A short-bladed soft tissue curette designed with two
right-angle bends is introduced along the margin of
the window (i.e., Salvin Sinus Curette No. 1).
 The curved portion is placed against the window,
whereas the sharp edge is placed between the sinus
membrane and the margin of the inner wall of the
antrum for a depth of 2 to 4 mm.
 curette - always stay on the bone, used in a scraping
motion
 The curette is slide along the bone margin 360
degrees around the access window.
 This ensures the release of the membrane from the
surrounding walls of the sinus without tearing from
the sharp bony access margins.
Short and smooth sinus curette
initiating the membrane lifting
membrane lifted in all directions:
anteriorly, posteriorly, and medially
63

 The sinus membrane may be elevated from the antral walls easily because it has few elastic
fibers and is not attached to the cortical wall.
 A larger curved periosteal or sinus membrane elevator is then introduced through the lateral-
access window along the inferior border (i.e., Salvin Sinus Curette No. 2).
 Once again, the curved portion is placed against the window, and the sharp margin of the
curette is dragged along the floor of the antrum while elevating the sinus membrane.
 Once the mucosa on the antral floor is elevated, the lateral, distal, and medial wall of the
sinus is addressed
 curette is pushed against the bone that easily reflects the membrane
 The periosteal elevators and curettes further reflect the membrane off the anterior vertical
wall, floor, and medial vertical wall.
 A Kerrison rongeur or a second window similar to the initial score-and-fracture technique
may be used to expand the size of the access window.
64

 It is better to err on the high side to
ensure that ideal implant height may be
placed without compromise (i.e., always
maintaining a patent ostium).
 The lateral-access window is positioned
as part of the superior wall of the graft
site, once in final position.
original sinus floor - base
posterior antral wall, medial antral wall, and
anterior antral wall – sides
lateral-access window and elevated sinus
mucosa - superior wall
Membrane elevation should reach the medial wall
in order to optimize a tension-free grafting
material introduction for a 3D regeneration
(filling)
65

SEPTA INCIDENCE ON SFE
Panoramic radiograph showing a vertical
septum protruded in the sinus cavity
One-month postoperative radiography
after sinus grafting
The presence of septa in the region of the sinus floor (bucco-palatal or mesio-distal) can cause complications
during SFE procedures; while they can limit creation of a window in the lateral antral wall and elevation of a
hinge door, there is a risk of tearing the Schneiderian membrane of the maxillary sinus when elevating it from
an alveolar recess containing several septa.
66

 If the buccal wall is eliminated (complete antrostomy), the sinus membrane is
elevated directly with blunt instruments, broad-based freers, and curettes with
different angulations to access the different walls of the sinus.
 It is recommended to use smooth and large end curettes in order to reduce the
trauma.
 Dedicated piezoelectric inserts are also available.
 They are particularly useful to start the lifting procedure especially in the presence of
a septum
Bell-shaped” tip facilitating the lifting
procedure toward the knife-edge
septum
The presence of a septum
with a sharp edge
jeopardizing the integrity of
the Schneiderian membrane
Two distinct entries to reach the
sinus from each side of the
septum
67

Introduction of the Grafting Material into the Sinus
 pushed through the window in all directions: mesially and
distally with the help of instruments such as pluggers,
periosteal elevators, or even osteotomes
 It must reach the medial wall of the maxillary sinus.
 placed loosely, avoiding overpacking.
 add an additional 20 % of bone-grafting material to
counteract the loss of originally grafted volume.
 After the grafting material is placed into the sinus, the
mucoperiosteal flap is repositioned combined or not to
membrane placement over the lateral window
68
The resulting space created after
membrane-lifting inward is packed with
bone-graft material that is placed under
the membrane.

SINUS GRAFT – LAYERED APPROACH
1.carrier for the antibiotic
2. seals the opening
TOP LAYER
69

MIDDLE LAYER BOTTOM LAYER
 Osteogenic material is capable of
producing bone, even in the absence
of local undifferentiated mesenchymal
cells.
ideal particle size for predictable bone
regeneration to be
approximately 250 to 1000 ìm
AUTOGENOUS BONE
bone fragments from
implant osteotomy
sites
bone cores over the
roots of anterior teeth
sinus exostoses
cores from the
mandibular symphysis
or ramus regionResnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020 Jan 25. PAGE
NO.1021
70

 The autogenous bone is then placed on the
floor by making small spaces with a curette
within the allograft material.
 a space should be made to the medial wall
because it is advantageous for autograft chips
to be placed in approximation to the medial
wall.
 After placement of the autogenous bone, the
grafted area is veneered with the allograft
material to fill any voids that are present.
Dentistry E-Book. Elsevier Health Sciences;
2020 Jan 25. PAGE NO.1021
71

Implant insertion
 When preparing the osteotomy into
the grafted sinus, a finger rest
should be maintained -control of the
handpiece is maintained upon
perforation into the sinus.
 Care should be exercised to not
extend the osteotomy into the
grafted material.
 Dispersion of the graft material
 Penetration though the inferior floor
should only be approximately 1 mm,
as there will be no resistance from
the graft material when placing the
implant.
 In most cases, the osteotomy will be
underprepared to allow for
osseodensification (D4 bone).
72

DISADVANTAGES OF
SA3 TECHNIQUE
 The healing time for the implant is no longer arbitrary, but it is more patient specific
 postoperative sinus graft infections occur ( 3% to 5% )
 implant in the middle of the sinus graft does not provide a source of blood vessel (impair the vascular
supply)
 Bone width augmentation may be indicated in conjunction with sinus grafts
 The bone in the sinus graft is denser with the delayed implant placement.
 Underfilled sinusgraft results in an implant placed in the sinus proper, rather than the graft site.
 On reentry to a sinus graft, it is not unusual to observe a craterlike formation in the center of the
lateral-access window, with soft tissue invagination.
 If the implant is already in place, then it may be difficult to remove the soft tissue and assess its
precise extent
NO.1022
73

MEMBRANE PLACEMENT
Absorbable collagen
membrane protecting the
grafting material
 The membrane barrier is used to cover the osteotomy site
extending 2–3 mm beyond its borders, promoting hemostasis,
and preventing graft disruption at the time of suturing
 Depending on the authors, the membrane is stabilized (with tacks
or screw) or not.
 As in a GBR procedure, the membrane appears to exclude non-
osteogenic soft tissue invasion from the grafted sinus, with a
resultant increase in vital bone formation and an increased rate of
implant survival.
1. Vital bone formation in SFE is improved
2. Vital bone formation is similar with nonabsorbable and absorbable
membranes.
3. Implant survival rate is similar with nonabsorbable and absorbable
membranes.
After implant placement, a thin layer of graft material may be
veneered over the lateral access opening.
A resorbable membrane (e.g., Collatape) is then placed over the
lateral-access window
74

SUTURING TECHNIQUE
 insure proper flap closure without tension in order to
maintain hemostasis and to prevent bone exposure
through healing by primary intention.
 Uninterrupted sutures are used specifically on the top of
the ridge in case of delayed or submerged implant
placement
 removed 10 days to 2 weeks following the SFE procedure.
Proper flap closure using
uninterrupted sutures on the top
of the crest and single sutures
(5/0 or 4/0) for the releasing
incisions
75

 The piezoelectric osteotomy of the bony window easily
cuts mineralized tissue without damaging the soft
tissue
 sinus membrane elevation from the sinus floor is
performed using both piezoelectric elevators and the
force of a physiologic solution subjected to
piezoelectric cavitation without causing perforations. Light handpiece pressure
and an integrated saline
coolant spray keep the
temperature low and the
visibility of the surgical site
high.
CONTRIBUTION OF PIEZOELECTRIC
SURGERY IN SFE
76

 useful for the preparation of the bony window
(diamond-coated square or bell-shaped tips) and
in atraumatic dissection of the thin and delicate
sinus membrane with specially designed tips
(rounded, dull, bell-shaped, or curette-shaped tips)
 When the lateral wall is thin, it is advised to use the
diamond ball smoothing insert or the diamond
scalpel to outline the window.
 If the wall is thick, it is less time-consuming to first
reduce the thickness of the wall with the
osteoplasty insert and then refine the window with
the diamond-coated smoothing insert
 The initial release of the membrane from the
antrostomy edges - a dull, rounded, noncutting
elevator that works with saline cavitation to safely
create a small internal elevation - completed with
conventional sinus membrane curettes.
Bell-shaped” piezoelectric tip initiating the
dissection of the Schneiderian membrane
77

DENTIUM ADVANCED SINUS KIT (DASK)
http://dentium.com/data/CM/0LNFd6z0xik52.pdf
78

Crestal approach
 uses an osteotome to break through the floor and then graft below the
sinus membrane
Step 1 A conventional full-thickness flap with crestal incision
A pilot drill - initial osteotomy 1 to 2 mm short of the sinus floor.
Incrementally larger surgical drills or osteotomes - to widen the
osteotomy, at least one drill short of the final implant width
81

Step 2
Step 3
Step 4
A small diameter osteotome is inserted into the prepared
site to compress the sinus floor using a surgical mallet
Incremental wider osteotomes are inserted to expand and to obtain vertical expansion
of the bone height to accommodate the implant diameter
After the last osteotome is used, bone graft material is slowly
introduced into the osteotomy site.
1. a PRF coagulant maybe placed into the osteotomy site.
2. collagen is tapped into position to elevate the membrane.
A small piece of collagen
is placed into the osteotomy site, with the last osteotome.
The graft material is slowly introduced into the sinus osteotomy
with a bone graft spoon or an amalgam carrier. The sinus
floor is then elevated by repeated increments of bone graft
material and placed into position with an osteotome.
82

Once the osteotomy is widened and sinus membrane is
elevated to the desired height, the implant may be inserted.
Step 5
Disadvantages
1.unknown perforation of
sinus membrane
2. elevate the membrane
approximately 3 to 4 mm.
Advantages
surgical simplicity,
which decreases possible
surgical morbidity.
If greater height is required, the lateral-wall approach may be used
PAGE NO.1024
83

Subantral Option Four: Sinus Graft Healing and
Extended Delay of Implant Insertion
 less than 5 mm remains between the residual crest
of bone and the floor of the maxillary sinus
 SA-3 approach is warranted, but pathology is
present
 Larger antrum and minimal host bone on the
lateral, anterior, and distal regions of the graft -
antrum expanded more aggressively into these
regions.
 Fewer bony walls, less favorable vascular bed,
minimal local autologous bone, and larger graft
volume all mandate a longer healing period and
slightly altered surgical approach.
INDICATIONS
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020
Jan 25. PAGE NO.1024
84

 medial wall of the sinus
membrane is elevated
approximately12 mm from the
crest so that adequate height
is available for future
endosteal implant placement
 The width of the host site for
most edentulous posterior
maxillae is Division A.
 Division C–w to D -
membrane or onlay graft for
width
 When the graft cannot be
secured to the host bone, it is
often better to perform the
sinus graft 6 to 9 months prior
to the autogenous graft for
width.
 After the graft maturation, the
implants may be inserted Resnik R. Misch's Contemporary Implant Dentistry E-Book.
85

VASCULAR HEALING OF THE GRAFT
 Healing of the sinus graft takes place by several vascular routes
endosseous vascular anastomosis
and the vasculature of the sinus
membrane from the
sphenopalatine artery
Mildly resorbed ridges, from
both centromedullary and
mucoperiosteal vessels
as age and the resorption
process increases - totally
dependent on the
mucoperiosteum
periphery of the graft is mainly
supplied by
central portions of the graft
receive blood from collateral
branches of the endosseous
anastomosis
Extraosseous vascular anastomosis may
enter the graft from the lateral-access
window
Healing time
Volume of the SA
graft
Distance from the
lateral to medial
wall
Amount of
autologous bone
in the
multilayered
approach
86

Shrinkage of the graft
 Overall height of bone graft
decreased during first 2- 3 years
 Thereafter only minor changes
 Graft height upto 96 months after
augmentation – higher than in pre
operative level
 Implant loading promotes
osteogenesis over the long term
87

TYPE OF GRAFT MATERIAL USED
 Bone formation is fastest and most complete within the first 4 to 6 months
with autogenous bone, followed by the combination of autogenous bone,
porous HA, and DFDB (6–10 months); alloplasts only (i.e., TCP) may take 24
months to form bone.
 The time required before implant insertion for SA-4 or implant uncovery is
dependent on the volume of the sinus graft.
 Most healed sinus augmentations (i.e., especially SA-4) will be the D4 type
of bone; therefore osseodensification surgical approach and progressive
bone loading techniques should be strictly followed.
88

POST OPERATIVE INSTRUCTIONS
89

IMPLANT INSERTION

Previousaccesswindowmayappear
Completely healed with
bone
Soft and filled with loose
graft material
With cone shaped fibrous
tissue ingrowth
implant osteotomy and placement follow the
approach designated by the bone density
The periosteal flap on the lateral side is elevated to directly allow
inspection of the previous access window of the sinus graft
If soft tissue has proliferated into the access
window from the lateral-tissue region, then it is
curetted and removed.
The region is again packed to a firm consistency
with autologous bone from the previously
augmented tuberosity and mineralized freeze-
dried bone.
PAGE NO.1027
90

 The implant osteotomy may then be prepared and the implant placed a
the D4 bone protocol.
 Additional time (6 months or more) is allowed until the stage II implant
uncovery is performed and progressive bone loading is used during
prosthetic reconstruction. (dependent on the density of bone at the
reentry of implant placement)
 An SA-4 sinus graft has a recommended healing time at least 4 to 6
months for implant insertion and another 4 to 8 months for implant
uncovery.
91

Modifications of the “Original” Bone-Added Osteotome
Sinus Floor Elevation (BAOSFE)Technique (OSFE Summers
1994c)
Schematic drawings illustrating the BAOSFE technique. (a) Concave osteotome introduced 1–2 mm
beneath the sinus floor. (b) Bone particles filling the created space beneath the sinus membrane. (c)
Implants stabilized in the residual bone with their apical part surrounded by bone chips
92

Modified Osteotome Technique
(Drills + Osteotomes + BS)
 No instrument (osteotome, drill) should penetrate the
sinus cavity during any part of the procedure.
 The positioning of the implants is carried out with a
round bur, and the preparation of the site begins with a
2 mm twist drill (pilot drill) and maintained to a distance
of only 2–3 mm
 The 3 mm twist drill completes the preparation of the
implant site for a standard-diameter implant.
 The drilling must remain 1 mm below the floor of the
sinus.
 Radiographic control helps to confirm the integrity of
the sub-sinus floor.
 Grafting material is introduced into the surgical site
before using the first osteotome (Summers No. 3
osteotome).
 This material will serve as a shock absorber to gently
fracture the sinus floor.
Schematic drawings illustrating the modified
osteotome technique. (a) Pilot drill initiating the
SFE preparation avoiding the sinus floor. (b)
Concave osteotome kept beneath the sinus floor
while pushing up added bone substitutes mixed
with the residual fragmented autogenous bone. (c)
Implant surrounded by particulate bone substitute
mixed with autogenous bone; note the intact lifted
sinus membrane apically
93

Modified Trephine/Osteotome Sinus Augmentation
Technique (Post-extraction Molars and Premolars)
 Fugazzotto (1999) - localized SFE and guided bone
regeneration at the time of maxillary molar
extraction.
 Based on preoperative radiographs, measurement of
removed roots and residual ridge morphology as
guides, the clinician uses the trephine to prepare a
site to within approximately 1–2 mm of the sinus
membrane.
 If the bone core is retained inside the trephine after
its removal, it is gently pulled out and replaced in the
alveolar bone preparation. Atraumatic extraction of the molar - to preserve
interradicular bone, a calibrated trephine bur is placed
over the interradicular bone (to encompass both the
interradicular septum and approximately 50 % of the
extraction sockets)(each trephine bur is approximately
1 mm thick).
https://pocketdentistry.com/crestal-sinus-floor-elevation-sfe-approach-overview-and-recent-
developments/
94

 An osteotome is selected according to the diameter of the trephine
preparation: gentle malletting forces implode both the trephined
interradicular bone and the underlying sinus membrane to a depth at least
equal to the apico-occlusal dimension of the trephined bone core.
 The residual extraction socket is filled with bone substitutes.
 An appropriate membrane is secured with fixation tacks.
 Flaps are sutured so as to achieve passive primary closure.
 This technique combines SFE procedure with GBR at the time of molar
extraction in order to regenerate bone both buccolingually and apico-
occlusally for an optimal implant positioning (delayed).
95

BAOSFE method, originally described by Soltan and Smiler (2005),
in which antral membrane elevation is executed via the osteotomy
site using a dedicated balloon.
 After screw-tap removal and evaluation of sinus membrane
integrity, the metal sleeve of the balloon-harboring device is
inserted into the osteotomy 1 mm beyond the sinus floor.
 The balloon is inflated slowly with the barometric inflator up to 2
atm.
 Once the balloon emerged from the metal sleeve balloon is
inflated with progressively higher volume of contrast fluid.
 Then, the balloon is deflated and removed.
Minimally Invasive Antral Membrane Balloon Elevation
(MIAMBE)
96

Minimally invasive transcrestal (mitsa) approach using cps
putty to elevate the sinus membrane
 Modification of summers technique
 Hydraulic pressure excerted by the putty
results in an atruamitic elevation of the sinus
floor
 Operator skill and experience necessory for
success and a minimum of 3 mm of available
bone height is needed for achieving primary
stability for implants
98

Dentium advanced sinus kit
http://dentium.com/data/CM/0LNFd6z0xik52.pdf
99

Maxillary Sinus Autografting - Densah® Lift Protocol I
MINIMUM RESIDUAL BONE HEIGHT ≥ 6 mm MINIMUM
ALVEOLAR WIDTH NEEDED = 4
Measure the bone height to the
sinus floor
Pilot drill 1 mm below the sinus
floor
Densah® bur (2.0) OD mode to
sinus floor.When feeling the haptic
feedback of the bur reaching the
dense sinus floor, stop and confirm
the 1st bur vertical position with a
radiograph
http://versahindia.com/wp-content/uploads/2017/11/IFU-Watermark-REV010-copy.pdf
102

Use the sequential Densah® Burs in
Densifying Mode (Counterclockwise
drill speed
800-1500 rpm with copious irrigation)
with pumping motion to achieve
additional
vertical depth and maximum
membrane lift of 3 mm (in 1 mm
increments) and reach
final desired width for implant
placement.
Place the implant into the
osteotomy
http://versahindia.com/wp-content/uploads/2017/11/IFU-Watermark-
REV010-copy.pdf
103

Densah® Lift Protocol II
 Measure bone height to sinus floor, flap the soft
tissue using instruments and technique normally
used.
 Depending upon the implant type and diameter
selected for the site, begin with the narrowest
Densah® Bur (2.0). Avoid using pilot drill
 Use the next wider Densah® Bur (3.0) OD mode
upto 3 mm past the sinus floor
 When feeling the haptic feedback of the bur
reaching the dense sinus foor, modulate pressure
with a pumping motion to advance past the sinus
foor in 1 mm increments up to 3 mm
MINIMUM RESIDUAL BONE HEIGHT = 4-
5 mm MINIMUM ALVEOLAR WIDTH
NEEDED = 5 mm
104

 Use the sequential wider Densah® Burs (4.0), (5.0) in OD Mode upto 3 mm
(in 1 mm increments) and reach final desired width for implant placement.
 Propel allograft : Use the last Densah® Bur in Densifying Mode
(Counterclockwise)drill speed 150-200 rpm with no irrigation)
 The Densah® Bur must only facilitate the allograft material compaction to
lift the sinus membrane further, and not advance beyond the sinus floor.
 Place implant
105

Densah® Protocol III
 MINIMUM RESIDUAL BONE HEIGHT = 2-3 mm MINIMUM ALVEOLAR WIDTH
NEEDED = 7 mm
 No pilot drill
 No densah bur 2 OD mode to the sinus floor
1. Enter with Densah bur 3.0 OD mode to the sinus floor
2. Densah bur 4.0 OD mode 1 mm increment past sinus floor
3. Densah bur 5.0 OD mode 1 mm increment upto 3 mm past the sinus floor
4. Propel allograft – use the last Densah bur 5.0 OD mode countrtclockwise with
low speed 150 -200 rpm with no irrigation to propel the allograft into the
sinus
5. Place the implant
106

INTRAOPERATIVE COMPLICATIONS
RELATED TO SINUS GRAFT SURGERY
MEMBRANE
PERFORATIONS
ANTRAL SEPTA
BLEEDING
NO.1028-1030
107

SHORT TERM POST OPERATIVE
COMPLICATIONS
INCISION LINE OPENING NERVE IMPAIRMENT ECCHYMOSIS PAIN
OROANTRAL FISTULA
POST OPERATIVE
INFECTION
SPREAD OF INFECTION OVERFILLING THE SINUS
POSTOPERATIVE CBCT
MUCOSAL THICKENING
(FALSE POSITIVE FOR
INFECTION)
IMPLANT PENETRATION
INTO THE SINUS
MIGRATION OF IMPLANTS
POST OPERATIVE FUNGAL
INFECTION
occur within the first few months after surgery
NO.1030 -1045
108

Summary
 Sinus graft procedure is more than 97% effective.
 An organized approach needs to be completed with respect to patient selection, pathology
evaluation, pharmacologic management, and surgical and prosthetic protocol to increase
success and decrease potential morbidity of the procedures.
NO.1045
109

Related articles
 To test whether a reduction of bone
window dimension, in a split-mouth
randomized study design, focused on
lateral sinus floor elevations, can
achieve better results than a wider
window in terms of augmented bone
height and a reduction of patient
discomfort and surgical complications
110

A reduction of window dimensions did not affect the safety of the surgical procedure.
The two testing techniques showed no statistically significant differences in surgical intervention
duration. Patients’ opinion at 7-day and 14-day post-op showed a preference for test procedure.
111

 To compare the efficacy of 1-stage versus
2-stage lateral maxillary sinus lift
procedures.
112

RESULTS CONCLUSIONS
 No statistically significant differences
were observed between implants
placed according to 1- or 2-stage
sinus lift procedures.
 In patients having residual bone
height between 1 to 3 mm below the
maxillary sinus, there might be a
slightly higher risk for implant failures
when performing a 1-stage lateral
sinus lift procedure.
113

 The purpose of this study was to compare three different
methods for sinus elevation:
(1) Lateral antrostomy as a two-step procedure
(2) Lateral antrostomy as a one-step procedure
(3) Osteotome technique with a crestal approach.
 Indication criteria were defined, based on the residual bone
height measured from computed tomography scans, for the
sake of applying the appropriate technique.
114

In 30 patients designated for implant treatment in
the resorbed posterior maxilla, 79 implants were
placed in combination
with a bone-grafting material for sinus
augmentation.
115

 Success rate for the osteotome technique - 95% during the 30-
month study period; no failures occurred in any site treated
with a lateral antrostomy.
 The gain in bone height was comparable for the one-step
(median = 10 mm) and two-step (median = 12.7 mm) lateral
antrostomies.
 These sites exhibited a significantly greater increase in bone
height than did the sites in Which the osteotome technique
was applied.
 The histologic sections showed both bone apposition in
intimate contact with the bone-grafting material particles and
initial signs of its remodeling.
Osteotome technique
can be recommended
when more than 6 mm
of residual bone height
is present and an
increase of about 3 to 4
mm is expected.
CONCLUSIONS
In cases of more
advanced resorption a
one-step or two-step
lateral antrostomy has to
be performed.
116

 The purpose of this study was to compare the intraoperative and postoperative effects of
Piezosurgery and conventional rotative instruments in direct sinus lifting procedure.
 Twenty three patients requiring direct sinus lifting were enrolled.
 The osteotomy and sinus membrane elevation were performed either with Piezosurgery tips
or rotative diamond burs and manual membrane elevators.
Time elapsed between bony window
opening and completion of membrane
elevation (duration), incidence of
membrane perforation, visibility of the
operation site,as well as patient’s
expectation before and experience after
the operation were evaluated
117

significantly more pain and swelling in the conventional group compared with
the Piezosurgery group
Patients’ daily life
activities and experience
about the operation are
not affected from the
surgical technique
Piezosurgery causes less
pain and swelling
postoperatively
compared with
conventional technique
118

 The aim of this study was to determine
membrane elevation height and perforation
rate using the transcrestal balloon technique
(B) and a conventional osteotome approach,
as control (C)
 Ten fresh, completely edentulous cadaver
heads (seven male and three female)
 In a split-mouth design, each sinus was
randomly assigned to either the
experimental or the control technique.
119

 During the procedure, an endoscope
was used to monitor the elevation
procedure and the occurrence of sinus
perforation.
 The elevation continued until either
15 mm (measured from the alveolar
crest) was reached or a perforation
occurred.
 The residual ridge and the elevated
membrane height were measured and
compared with the paired Student’s t-
test.
 Presence of sinus perforation was
recorded at three cutoff points: 10, 12,
and 15 mm
120

Conclusion
 Based on the findings of this study, the balloon and the conventional
osteotome approach are comparable in terms of perforation rate as it
relates to the elevation height.
 Also, the amount of residual alveolar bone was not related to the incidence
of perforation and the height of sinus elevation.
122

REFERENCES
 Delilbasi C, Gurler G. Comparison of piezosurgery and conventional
rotative instruments in direct sinus lifting. Implant Dentistry. 2013 Dec
1;22(6):662-5.
 Baldini N, D'Elia C, Bianco A, Goracci C, De Sanctis M, Ferrari M. Lateral
approach for sinus floor elevation: large versus small bone window–a
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