Sinus lift procedures.pptx

SINUS LIFT PROCEDURES
PRESENTED BY
NAMITHA,.AP
3 rd MDS
Leonardo Da Vinci in 1489
Nathaniel
Highmore 1651

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
The maxillary sinus/
Antrum of Highmore

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.

Superior wall – floor of
orbit
Inferior wall – residual
alveolar bone
Apex – lateral
wall
Facial surface of
maxilla
Infra temporal
surface of maxilla
Lateral
wall of
nasal
cavity
Apex - Directed laterally towards
zygomatic process of maxilla

Blood supply
Vital part of the healing and
regeneration of bone after a sinus
graft

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%

Maxillary sinus
membrane
T
Cilia of the columnar epithelium
beat
toward the ostium at
approximately 15 cycles per
minute, with a
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.

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

•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 CLASSIFIACTION (1987)

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.

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 nares

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
Differentiation
of soft tissues
within the
sinus

Maxillary Sinus :Computerised Tomography
Radiographic Anatomy
Maxillary sinus membrane
Normal/healthy
•Completely
radiolucent
maxillary sinus (dark)
Abnormal/
pathologic
condition
•Any radiopaque or
whitish area
 The normal sinus membrane is
radiographically invisible, whereas
any inflammation or thickening of
this structure will be radiopaque.
 The density of the diseased tissue
or fluid accumulation will be
proportional to varying degrees of
gray values.
THE FIRST THING TO LOOK IS THE DENSITY OF THE SINUS.
NORMAL SINUS – LOW DENSITY HOMOGENOOUS CAVITY

(A) Normal paranasal anatomy (B) Paranasal pathology and anatomic variants.
Ostiomeatal complex

Maxillary Sinus: Anatomical Variants
 Numerous anatomic variants arise that can predispose a patient to
postsurgical complications.
 When these conditions are noted, a pharmacologic protocol may
need to be altered and/or implants may be placed after the sinus
graft has matured, rather than predisposing them to an increased
risk by inserting them at the same time as the sinus graft.

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

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.

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

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

INFLAMMATORY DISEASE
 Inflammatory conditions can affect the maxillary sinus from
odontogenic and nonodontogenic causes.
Odontogenic
Rhinosinusitis
(Periapical Mucositis)
Mild mucosal
thickening (Non
odontogenic)

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.

Cystic lesions
 Cystic type lesions are a common occurrence in the maxillary sinus.
They may vary from 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

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/
completely
de ossified /
eroded

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

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

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.

Bucco palatal distance
 Proportion of vital bone
formation after sinus
augmentation is inversely
proportional to the bucco
palatal distance of the maxillary
sinus
 Considered for the clinical
decision of the type of sinus floor
procedure and timing of implant
placement

RESIDUAL
BONE
HEIGHT
RESIDUAL
BONE
WIDTH
RESIDUAL
BONE
VOLUME
HELPS TO
SELECT
TECHNIQUE
AUGMENTATION IS RECOMMENDED IF LESS
THAN 4- 6 mm
Thinner sinus membrane
Increased risk of
perforation
Quality (density) and quantity of available bone
influence the clinical success of dental implants

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

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 impre
operative level
 Implant loading promotes
osteogenesis over the long term

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

Management of Rhinosinus Dysfunction
 Anatomical and functional
changes in the osteomeatal
complex are responsible for
anterior localised sinusitis
Concha bullosa
High and
posterior septal
deviation
Reverse
curvature of the
middle
turbinate
Large Haller cell
Anatomical
change in the
uncinate
Synechia of
middle
turbinate
Narrowing of the
infundibulum by
Haller’s cells from
the ethmoid on
the internal and
inferior wall of the
orbit

Concha bullosa by
pneumatisation of the middle
turbinate present in 30% of the
population
Reduces the middle meatus and
mucociliary clearance
Right middle
turbinate inverted
Septal deviation in
left nasal caity
Aspergillosis of maxillary sinus

Mucosal abnormalities of the sinus floor
 Non cystic polypoid
opacities ( usually
associated with
hypertrophy of the
endosinus mucosa)
are indolent and are
represented by
antrochoanal polys
in their incipient form,
and polypoid
opacities reacting to
submucosal forign
bodies or prior tooth
root diseases

 Cystic polypoid
opacities,or antral
pseudocyst or submucosal
polyp affect 12% of the
population and ggenerally
do not involve mucosal
hypertrophy
Left side - mucosal cyst
Right side pseudo polyp
PARAMETERS
TO CONSIDER
ESTIMATED
HEIGHT OF
ENHANCEMENT
VERTICAL
DIMENSION OF
OPACITY
POSITION OF
OSTIUM
COMPARED TO
FLOOR
• Allow crestal and lateral filling
• Margin of safety sufficient for
enhancements less than 14 mm
Height of opacity
does not exceed the
lower 1/3rd of
maxillary sinus
• Only allow crestal filling
• This type of filling enhances the neo
floor less than 4 mm
Opacity exceeds the
lower half of the
sinsus
• Do not allow any filling and prior
restoration of the maxillary sinus
through middle meatomy is
required
Opacity reches the
lower 2/3rd of sinus

Mucosal hypertrophies
 Not
contraindic
ation unless
they do not
destabilise
the sinus
function but
represent a
guarantee
of durability
of the
mucosa
when it is
lifted

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.

Relative and Absolute Contraindication
to Maxillary Sinus Graft Procedures

Absolute endosinusal
containdications
 There are infectious or inflammatory sinonasal diseases with or
without sinonasal polyposis with high potential for recurrence
• Cystic fibrosis, Kartagener’s syndrome, Young’s syndrome
Congenital mucociliary drainage disorders
• Sarcoidosis,Wegener and Churg Strauss syndrome
Systemic granulomatous rhinosinusitis and vascullitis
• Stage 3 and 4 in Rouviere classification
Sinonasal polyposis
Acquired or drug induced immune deficiency

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

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
 successfully decrease infectious
episodes and minimizes
postoperative complications from
the incision line
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
 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.
 vasoconstrictor action of oxymetazoline lasts
approximately 5 to 8 hours, which is preferred
compared with 1 hour for phenylephrine.
Topical decongestant drugs -
rebound phenomenon and the
development of rhinitis
medicamentosa
if used more than 3 to 4 days.
(effectiveness of the
topical decongestant is
enhanced by proper position of
the patient’s head during
administration of the drug )

Analgesic medications
 very minimal postoperative
analgesic coverage.
 If a narcotic is required, any
analgesic combination containing
codeine, such as Tylenol is
prescribed postoperatively
because ( potent antitussive, and
coughing may place additional
pressure on the sinus membrane
and introduce bacteria into the
graft)
 patient is instructed to cough (if
necessary) with the mouth open
so excessive air pressure does not
occur through the ostium.
Cryotherapy
 Application of cold dressings and cold
oral liquids, along with elevation of the
head and limited activity for 2 to 3
days, will help minimize the swelling
 Ice or cold dressings should only be
used for the first 24 to 48 hours.
 After 2 to 3 days, heat may be
applied to the region to increase
blood and lymph flow, which helps to
clear the area of the inflammatory
consequences

Surgical treatment of maxillary sinus
- History
1970
 Began to augment the posterior
maxilla with autogenous rib bone
to produce adequate vertical
bone for implant support.
 He found that onlay grafts below
the existing alveolar crest would
decrease the posterior intradental
height significantly, yet very little
bone for endosteal implants would
be gained.
1974
 Developed a modified Caldwell- Luc procedure
for sinus augmentation (SA) grafting.
 crest of the maxilla was infractured to elevate
the maxillary sinus membrane
 Autogenous bone was then added in the area
previously occupied by the inferior third of the
sinus.
Endosteal implants were inserted in this grafted bone
after approximately 6 months.
Implants were then loaded with final prostheses after
an additional 6 months.
Dr Hilt Tatum

1975
 A lateral-approach surgical
technique to elevate the sinus
membrane and place implants
simultaneously.
 The implant system used was a
one-piece ceramic implant, and a
permucosal post was required
during the healing period.
 Early ceramic implants were not
designed adequately for this
procedure, and results with the
technique were unpredictable
1981
 A submerged titanium implant for
use in the posterior maxilla and
achieved predictable results
 Expanded the application of the
SA augmentation technique with a
lateral maxillary approach and the
use of synthetic bone.
1980
From 1974 to 1979, the primary graft material
for sinus grafts was autologous bone

Lateral sinus grafting
approach
•Special instrument socket former for selected implant size was used to prepare the
implant site leading to green stick fracture of the sinus floor moving it in a more apical
direction
1.Osteotome mediated transcrestal SFE approach Tatum 1970
•Sub sinus residual bone is 5-6 mm and the bone is of low density
2.Osteotome sinus floor elevation Summers 1994
•Pressure on the graft material and trapped fluids exert hydroulic pressure on the sinus
membrane, creating a blunt force over an expanded area that is larger than the
osteotome tip
3.Bone added osteotome sinus floor elevation (BAOSFE)
Crestal sinus floor elevation
approach

Treatment classifications for the
posterior maxilla
Misch
•organized a treatment approach to the posterior maxilla based on the amount of bone below the
antrum
1984
•expanded the treatment approach to include the available bone width that was related to implant
design
1986
•Misch included the technique of the sinus floor elevation through the implant osteotomy before implant
placement
1987
•modified to include the lateral dimension of the sinus cavity; this dimension was used to modify the
healing period protocol
1995
He reported on 170 sinus graft cases, with two complications
and an uneventful resolution.

Formation of bone
Smaller width
sinuses (0-10
mm)
Larger width
sinuses < 15
mm
Resnik modification in 2017
 to include alternative treatment
options with short implants, crestal
grafting approaches, and
treatment plan modifications
based on force-related factors
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020
Jan 25. PAGE NO.1011

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.
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier Health Sciences; 2020
Jan 25. PAGE NO.1011,12

•minimum of 8 mm of bone is
required from the crest of the ridge
to the inferior floor of the sinus for
the placement of an 8-mm implant.
•If multiple implants are placed, then
ideally the implants should be
splinted for force distribution.
Favorable
conditions
•greater than 10 mm of bone is
required in height to allow for
placement of an implant so it does
not invade the maxillary sinus.
•Allow an implant of 10 mm in length
to be placed that will allow for a
greater insertion torque and BIC.
Unfavorable
conditions
Resnik R. Misch's Contemporary Implant Dentistry E-Book. Elsevier
Health Sciences; 2020 Jan 25. PAGE NO.1011

Resnik R. Misch's Contemporary Implant
Dentistry E-Book. Elsevier Health Sciences;
2020 Jan 25. PAGE NO.1011

 Narrower bone volume patients (Division B) in SA-1 may be treated
with osteoplasty or augmentation to increase the width of bone.
 The insertion of smaller surface area implants (as small-diameter
root-form implants) are not suggested because the forces are
greater in the posterior regions of the mouth, and the bone density is
less than in most regions.
 narrow ridge is often more medial than the central fossa of the
mandibular teeth and will result in an offset load on the restoration,
which will increase the strain to the bone.
 multiple narrow diameter implants may be placed to support one
tooth (i.e., two narrow diameter implants to support one molar).

WIDTHAUGMENTATION
BONE
SPREADING
MEMBRANE
GRAFTING
AUTOGENOUS
GRAFTS
most common
approach when
the bone density
is poor
less than 2.5 mm of width is available in the
posterior edentulous region (C–w) - most
predictable treatment option - increase width
using onlay autogenous bone grafts.
Endosteal implants - left to
heal in a
nonfunctional environment
for approximately 4 to 8
months
(depending on bone density
and force factors) before
the abutment
post(s) are added for
prosthodontic
reconstruction.
Progressive loading during the
prosthetic
phases of the treatment is
suggested in D3 or D4 bone

Subantral Option Two: Sinus Lift and
Simultaneous Implant Placement
 intended implant
length is 1 to 2 mm
greater than the
vertical bone present
 1 to 2 mm may be
achieved via
elevating the sinus
membrane without
bone grafting.
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.

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

Rationale
 In some situations, a longer implant may be
required for prosthetic support and initial
fixation.
 They observed the natural elevation of the
sinus membrane around teeth with periapical
disease.
 The elevation of the membrane resulted in new
bone formation once the tooth infection was
eliminated.
Worth and Stoneman
comparable phenomenon of bone
growth under an
elevated sinus membrane called a
“halo formation”
Palma and colleagues
Elevation of the sinus membrane in
implant insertion, with or without a
graft material below the mucosa,
gave similar results in primates
regarding implant stability or BIC
after healing.
Autologous bone present above the apical portion of
the implant with an SA-2 technique,
and the sinus floor fracture (which increases the
regional accelerated phenomenon of bone repair and
formation), new bone formation over the implant apex
is predictable.

INCISION AND REFLECTION
 In an edentulous posterior maxilla, 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, the reflection is similar to a single-tooth
replacement option, and even a direct (flapless technique) may be
used.
 A full-thickness palatal flap is first reflected because the palatal
dense cortical plate facilitates soft tissue reflection.
 Special attention is given to avoid the pathway of the greater
palatine artery or to remain completely subperiosteal so that this
structure remains within the soft tissue.

 The labial mucosa is reflected off the edentulous ridge, rather than
elevating the tissue from the bone.
 The crest should not be used to leverage the tissue because the
ridge may have minimal cortical bone and a perforation may result.
 This could result in damage to the residual ridge or possibly even
penetrate the sinus or nasal cavity.
 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.

OSTEOTOMY AND SINUS
ELEVATION(SA 2)
 The endosteal implant osteotomy is prepared
as determined by the density of bone
protocol, which is usually D3 or D4 bone.
 The depth of the osteotomy is approximately
1 to 2 mm short of the floor of the antrum.
 When in doubt of the height dimension, the
osteotomy should err on a shorter length.
 The implant osteotomy is prepared to the
appropriate final diameter, short of the antral
floor, by approximately 1 mm.

 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.
D3 BONE
• Osteotome of the
same diameter as the
final osteotomy
D4 BONE
• Osteotomy 1- 2 sizes
smaller than the final
implant size -
OSSEODENSIFICATION

 This surgical approach compresses the bone below the antrum, causes
a greenstick- type fracture in the antral floor, and slowly elevates the
unprepared bone and sinus membrane over the broad-based
osteotome.
 If the osteotome cannot proceed to the desired osteotomy depth after
tapping, then it is removed and the osteotomy is prepared again with
rotary drills an additional 1 mm in depth.
 The osteotome is then reinserted to attempt the greenstick fracture of
the antral floor.
 Care should be exercised when removing the osteotomes from the
osteotomy site.
 The osteotome should never be luxated because this will increase the
width of the final osteotomy, leading to less insertion torque

 Once the osteotome prepares the implant site, the implant may
then be threaded into the osteotomy and extended up to 2 mm
above the floor of the sinus.
 The implant is slowly threaded into position so the membrane is less
likely to tear as it is elevated.
 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.
 The implant may extend 0 to 2 mm beyond the sinus floor, and the 1
mm of compressed bone covering over the implant apex results in
as much as a 3-mm elevation of the sinus mucosa
 Ideally, the implant design should include a convex apex with no
apical openings as this design will be less likely to cause a
membrane perforation.

MODIFIED SA2 TECHNIQUES
 Rosen and associates developed a
modification --- To use at the time of an
extraction of a maxillary molar.
 maxillary molar is extracted, the
surrounding walls of bone are intact, and
no periapical pathologic condition is
present.
 The crest of the ridge to the antral floor
should be 7 mm or more in height.

 A 5- to 6-mm trephine bur is used in the center of the extraction site
and prepares the bone 1 to 2 mm below the antral floor.
 A 5- to 6-mm-diameter, flat-ended or cup-shaped osteotome and
mallet intrudes the core of bone 2 mm above the sinus floor,
creating 9 mm or more of vertical bone.
 A socket graft may be used within the extraction socket but is not
pushed into the surgical space of the sinus because it may perforate
the sinus mucosa.
 After 4 months, an implant may be inserted.

COMPLICATIONS
 If a sinus membrane perforation occurred during the initial implant
placement procedure, then bone height growth is less likely to
occur.
 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

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

 Infiltration anesthesia has been used with
success for sinus graft surgeries in the past;
however, more profound regional
anesthesia is achieved by blocking the
secondary division of the maxillary nerve
(V2).
 The sinus graft surgery often requires the
reflection of the soft tissue extending to the
zygomatic process.
 In addition, several branches of the
maxillary division of the fifth cranial nerve
innervate the sinus mucosa.
 V2 block is advantageous for patient
comfort, and this achieves anesthesia of the
hemimaxilla, side of the nose, cheek, lip,
and sinus area.
anaesthesia
Posterior
superior
alveolar
nerve block
Palatal
infiltration
Middle
superior
alveolar
nerve block

 high and within the pterygomaxillary
tissue behind the posterior wall of the
maxilla
 at the depth of approximately 1 inch
with a long-gauge needle within the
greater palatine foramen
Too deep an
administration with a greater palatine
approach may result in the
penetration of the orbit floor.
Periorbital
swelling
proptosis Dilated pupil
Optic nerve
block
Transcient
loss of vision
diplopia
Retrobulbar
hemorrhage
sequelae
easier to perform
may injure the pterygoid plexus or the
maxillary artery and result in hematoma, or it
may fail to reach the proper landmark
More difficult to locate the foramen and
negotiate up the canal.
may also injure the greater palatine artery or
nerve
V2 block
anesthesia:

Anasthesia within greater palatine
foramen
 success rate is greater, and the clinical risks appear minimal.
 first attempt for block anesthesia is within the greater palatine foramen; if
unsuccessful, then the high posterior approach is used.
 reduction of the needle depth measurement for smaller patients and the strict
application of the technique.
 Proper angulation during soft tissue penetration prevents possible entrance into
the nasal cavity through the medial wall of the pterygopalatal fossa.
 Infiltration anesthesia is first administered to the posterior and middle alveolar
nerve and greater palatine nerve.
 Scrubbing, gowning, and draping of the patient is next.
 Then after the infiltration is effective, the V2 block is administered.
 A long-acting anesthetic such as bupivacaine 0.5% (Marcaine) is preferred.
 Block anesthesia with these agents is longer acting than infiltration in the maxilla

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

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

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

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
 Sometimes, this incision is made
slightly palatal to the crest (2–4 mm)
to preserve a wider band of
keratinized attached gingiva for a
more solid wound closure and to
avoid wound dehiscence. However,
an incision made too far palatally
may result in soft tissue dehiscence
due to compromised blood supply

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

 If bleeding from the palatal flap occurs, then a hemostat may be used
to constrict the blood vessels distal to the bleeding, pressure may be
applied over the greater palatine foramen with a blunt instrument, or
electrocoagulation at the bleeding site may be used.
 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.

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 may cause a
neuropraxia type of nerve impairment and damage to this nerve
structure.
 The reflected labial tissue can be sutured to the cheek mucosa,
carefully avoiding the parotid duct.
 All fibrous and soft tissue should be removed from the lateral-wall
access site to avoid soft tissue contamination of the bone graft

 Entrapping soft tissue
within the sinus may
lead to formation of
a secondary
mucocele or surgical
ciliated cyst.
 A moist 4 x 4 gauze or
a 2-4 molt with a
scraping motion
easily removes this
tissue
Prominent zygoma
- flap reflection is difficult

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

The sinus cavity is identified due to
the lack of blood supply compared
to the surrounding cortical, and is
often bluish in case of a thin
cortical bony wall
The bony window is either completely removed while the sinus membrane is carefully
elevated to create a space for the grafting material or mobilized together with the
attached bone window and rotated medially while preserving the sinus membrane intact.

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).

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

Techniques to score the
sinus window
(1) carbide bur
(No. 6 or No. 8
(2) diamond
bur
(3) bone
removal burs
(e.g., Dask bur)
(4) Piezosurgery
units
first bur -
No. 8 round
carbide
bur
followed
with a No.
8 round
diamond “
scratches the
bone and
designs the
overall
window
dimension
polishes” away
the bone
within the
groove made
by the carbide
bur ( early
learning
curve).
“chatter
” more
and
may
tear the
sinus
membr
ane if
the bur
inadvert
ently
comes
in
contact
with it

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.

 The most superior aspect of the lateral-access window should be
approximately 2-3 mm above the planned implant length (i.e., 12-
mm implant would require the window to be 15 mm from the ridge
crest).
 A soft tissue retractor placed above the superior margin of the
lateral-access window (i.e., always maintained on bone, not soft
tissue) helps retract the facial flap and prevents the retractor’s
inadvertent slip into the access window, which may damage the
underlying membrane of the sinus.
distal vertical line should be made approximately 5 mm distal to
the most posterior planned implant site (i.e., this will allow for
adequate space if the implant position is changed more distally).
If the patient is fully edentulous, the distal vertical line should be
made approximately 5 mm distal to the first molar position

Larger access window
easier access
ease of additional
membrane
elevation with
instruments
direct access that
facilitates graft
placement
Less stress on
membrane during
initial elevation
 The corners of the access window
should always be rounded, not
right or acute angles.
 If the corner angles are too sharp,
then membrane perforation may
occur from the use of a surgical
curette at the corner or during the
infracture of the lateral wall.
Once the lateral-access window is delineated, the rotary bur continues to scratch the
outline with a paintbrush stroke approach under cooled sterile saline irrigation, until a
bluish hue is observed below the bur or hemorrhage from the site is observed

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.)
 This is rarely a concern for vision or
blood loss during the procedure

If intraosseous bleeding is a
problem!
 High-speed diamond used to score the window may be used
without irrigation and polish the bleeding site, which cauterizes the
vessel from the heat on the bony wall.
 Electrocautery
 Hemostat
 care should be exercised to avoid fracturing the lateral wall and/or
perforating the sinus mucosa.
 Elevating the head and a surgical sponge applied to the site for a
few minutes also aides in the control of hemorrhage.

SINUS MEMRANE ELEVATION
ensure that the lateral window is completely “free” from the
host bone
•A flat-ended metal punch (or mirror handle) and mallet
gently infracture the lateral-access window from the
surrounding bone while still attached to the thin sinus
membrane.
The flat-ended punch is first positioned in the center of the
window.
If light tapping does not greenstick fracture the bone, then the
flat-ended punch is placed along the periphery of the access
window and tapped again.

If the window does not separate easily, then the punch is
rotated so that only an edge comes in contact with the
scored line.
This decreases the surface area of the punch against the
score line of the window and increases stress against
bone
Another light tap with the mallet will most likely cause
greenstick fracture of the bone along the scored line.
If this still does not free the window, then further scoring of
the bone with the handpiece and diamond bur is
indicated
tapping procedure is repeated.

 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.
 The curette should always stay on the bone and be used in a
scraping motion.
 If any sharp edges of bone remain on the bone’s margin, then they
may be flicked off with the curette.
 The curette is slid 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.

 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.
 Specially designed and shaped curettes are available to facilitate this surgical
maneuver.
 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.
 The curette should always be maintained on the bony floor to avoid a membrane
perforation.
 The curette is never blindly placed into the access window

 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
 Inspected for perforations or openings into the antrum proper.
 It is easier to gain direct vision and access to the distal portions of
the antrum than the anterior portions when the sinus area expands
beyond the access window.
 Therefore whenever the periosteal elevator or curette cannot stay
against the bone with good access in the anterior area, the access
window should be increased in size toward the anterior.
 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.

 The periosteal elevators and curettes
further reflect the membrane off the
anterior vertical wall, floor, and
medial vertical wall.
 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.
 The SA space has the original sinus
floor as the base; the posterior antral
wall, medial antral wall, and anterior
antral wall as its sides; and the
lateral-access window and elevated
sinus mucosa as its superior wall

Lifting the schniederian membrane
Short and smooth sinus curette
initiating the membrane lifting
Schneiderian membrane
lifted in all directions:
anteriorly, posteriorly, and
medially
Membrane elevation should
reach the medial wall in order
to optimize a tension-free
grafting material introduction for
a 3D regeneration (filling)
Care must be taken to perform a 3D membrane elevation: it is important to free up the sinus membrane
in all directions (mesially, distally, and medially).
The membrane at the inferior aspect of the osteotomy is dissected from the floor of the maxillary sinus
and elevated upward to create a space in the floor of the sinus for the bone-graft material. This
procedure will be performed according to the technique used.

 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

 Usually, membrane elevation starts at the edges, using a short curette, increasing gradually the
amount of membrane elevation from the superior border of the osteotomy, proceeding
approximately 2–3 mm mesially, toward the mesio-superior line angle and along the mesial part of
the window, and effecting detachment of a portion of the sinus membrane from the alveolar
bone.
 We proceed to the next step only once we have released the membrane at least 2 mm along
the superior, mesial, and distal borders of the bony window, allowing the passive insertion of
longer curettes into the created space. Surgical curettes should be permanently in tight contact
with the underlying bony walls in order to minimize membrane tearing.
 Care should be taken to perform 3-dimensional membrane lifting in order to decrease incidence
of sinus membrane perforation.
 Excessive pressure in a specific area while reflecting the membrane may lead to a perforation.
 Moreover, the membrane must be elevated higher than the superior osteotomy to prevent
excessive pressure on the bone-graft material.
 It is also important to reflect the membrane up to the medial (palatal) wall (see Fig. 5.21) of the
maxillary sinus in order to avoid membrane overlapping, thus resulting in incomplete bone
regeneration at the palatal wall of the implant.
 The limits of the reflected area are strongly related to the desired area to be grafted and the
positions of the future implants (delayed or simultaneous).

 In case of “complete osteotomy” or “repositioned bony window”)
procedures, the reflected membrane becomes the superior (and
distal) wall of the compartment that will receive the osseous graft.
 In the trapdoor hinge technique, gentle tapping is continued until
complete movement of the bony plate is observed. The bone trap
that was fractured inward in combination with the elevation of the
sinus membrane and rotated upward will create the roof and
provide adequate space for grafting material. Care should be
taken not to perforate the sinus membrane at this step.

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.
These septa
were first
described by
the anatomist
Underwood13
in 1910 and are
thus also
referred to as
Underwood’s
septa

 If septa are encountered in the antral floor during
SFE procedures, Boyne and James (1980)
recommended cutting them with a narrow chisel (or
a piezoelectric device nowadays) and removing
them with a hemostat so that the bone graft can be
placed completely across the antral floor without
interruption. If septa are left in situ during SFE, the
Schneiderian membrane is at risk of being torn,
particularly at the cranial edge of the septum, when
being elevated. Moreover, septa can impede the
view of the sinus floor and may limit placement of
grafting material, thus preventing adequate filling of
the sinus floor.
 An interesting alternative would be to perform two
different osteotomies from each side of the septum,
as if we are in the presence of two side-by-side
sinuses
Two distinct entries to reach
the sinus from each side of
the septum

Introduction of the Grafting Material into the Sinus
 The resulting space created after membrane-lifting
inward is packed with bone-graft material that is
placed under the membrane. The grafting material
should be pushed through the window in all directions:
mesially and distally with the help of instruments such as
pluggers, periosteal elevators, or even osteotomes.
Most importantly, it must reach the medial wall of the
maxillary sinus. It should be placed in the cavity loosely,
avoiding overpacking.
 The surgeon should 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

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

MIDDLE LAYER
 These materials are mixed in a
surgical bowl and filled into a bone
grafting syringe or 1 cc hypodermic
syringe.
 insert the syringe into the sinus
proper in approximation to the
medial wall and material is extruded
as the syringe is removed.
 grafting material should be
deposited in an anterior and inferior
direction (ensure material raises the
lateral window instead of intrusion
toward the medial wall. )
 Intrusion will lead to lack of bone
formation near the medial wall and
may affect implant placement and
post-sinus mucociliary functionideal particle size for predictable bone
regeneration to be
approximately 250 to 1000 ìm

 By extruding the material in the anterior direction, bone graft
material will be placed into the anterior segment of the sinus
incorporating graft material in contact with the anterior wall and
increasing blood supply for healing.
 condensed with a serrated packer, and packing pressure should be
firm but not excessive
INADEQUATE PRESSURE
• Airspaces - predispose the graft to future infection.
EXCESSIVE CONDENSATION
• perforation of the membrane and extrusion of material
into the sinus proper

BOTTOM LAYER
REGIONAL ACCELERATORY PHENOMENON AUTOGENOUS BONE
 Osteogenic material is
capable of producing
bone, even in the
absence of local
undifferentiated
mesenchymal cells.
 Autogenous bone
predictably exhibits this
activity in the sinus
graft.
Multiple steps to enhance bone growth
If little bleeding is present from the sinus floor and the
anterior wall, a sharp instrument (e.g., scaler,
curette) is used to scratch the bone.
introduces more growth factors into the site and
starts the angiogenesis process
blood vessels allow migration of osteoclasts and
osteoblasts that resorb and replace the graft with
live, viable bone.
blood vessels provide blood supply to the
autologous bone portion of the graft, which is
required for initial osteogenesis.

 The last regions to form bone are usually the center of
the lateral-access window and the region under the
elevated sinus membrane.
 no new bone at time intervals up to 12 months was
found to grow immediately under the sinus membrane.
 The most common harvest site for the lateral-wall
approach is the maxillary tuberosity on the same side of
the patient that the sinus is being augmented ( an
additional surgical site is not required, which decreases
morbidity to the patient )
 The autogenous bone is placed on the original bony
floor in the area most indicated for implant insertion.
 A blood supply from the host bone can be established
earlier to this grafted bone and maintains the viability of
the transplanted bone cells and the osteogenic
potential of the transplanted bone growth factors.
bone fragments
from implant
osteotomy sites
bone cores
over the roots
of anterior
teeth
sinus exostoses
cores from the
mandibular
symphysis or
ramus region

 The harvest of the tuberosity bone is initiated with the exposure of
the tuberosity bone; however( not extend the incision to the
hamular notch area - potential bleeding episodes.
 Once there is full-thickness reflection of the tuberosity bone, double-
action rongeurs may remove small pieces of the mainly cancellous
bone.
 usually soft and therefore is compressed to form more cells per
volume.
 rotary burs or bone chisels are not recommended - reduces the
amount of bone grafted and increases the possibility of perforation
into the sinus proper.
 Additional autogenous bone may be harvested intraorally or
extraorally, as indicated on a case-by-case basis

 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.

Implant insertion
 when the conditions are ideal for
the SA-3 sinus graft, the implant
may be inserted at the same
appointment.
 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.
 This will result in 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).
 Implant placement is more accurate when inserted with a
handpiece

SA 3 TECHNIQUE DISADVANTAGES
 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

MEMBRANE PLACEMENT
Absorbable collagen
membrane protecting the
grafting material
 Conflicting results concerning the benefits of placing a membrane over
the lateral window have been reported.
 Many investigators claimed positive results with barrier membrane
placement over the lateral wall in SFE (Wallace et al. 2005; Small et al.
1993; Hürzeler et al. 1996; Peleg et al. 1999; Lorenzoni et al. 2000) and
revealed a tendency for better bone formation and less implant failures
(Tawil and Mawla 2001; Pjetursson et al. 2008). On the opposite, a
recent review (Klijn et al. 2012) with histomorphometric data following
SFE with autografts alone did not confirm any effect of a barrier
membrane on bone formation.
 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 (Avila et al. 2010).
 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.
 Fewer studies have compared the results achieved with and without
barrier membranes (Froum et al. 1998; Tarnow et al. 2000; Tawil and
Mawla 2001).

BENEFICIAL EFFECTS OF MEMBRANE
 1. Vital bone formation in SFE is improved when a membrane is
placed over the window.
 2. Vital bone formation is similar with nonabsorbable and
absorbable membranes.
 3. Implant survival rate is similar with nonabsorbable and absorbable
membranes.
 Overall, it is recommended to use a membrane over the lateral
window in clinical situations characterized by a limited osteogenic
potential of the patient or the bone substitute used.

Membranes
 A membrane will delay
the invasion of fibrous
tissue into the graft and
will enhance the repair
of the lateral bony wall.
 Rarely will a resorbable
membrane become
infected.
 PRF may be used as a
double membrane by
placement over the
lateral collagen
membrane
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

Soft tissue closure
 The soft tissues and periosteum should be reapproximated for primary
closure without tension, with care to eliminate graft particles in the
incision line.
 Because of the access window grafting, along with the double layer
membrane, it is often necessary to stretch the tissue to allow for tension-
free closure.
 facial flap must often be expanded, which usually can be completed
by periosteal release incisions.
 A tissue pickup holds the facial flap to the height of the mucogingival
tissues junction.
 The flap is then elevated, and a No. 15 blade is used to incise the tissue
1 mm deep through the periosteum above the mucoperiosteum.
 Tissue scissors are then introduced into the incision parallel to the facial
flap at a depth of 3 to 5 mm.
 blunt dissection under the flap releases the periosteum and muscle
attachments to the base of the facial flap.
 The flap may then be advanced over the graft site to the palatal tissues

 It should be noted that horizontal vascular anastomoses are located
lateral to the maxilla, within the soft tissue (extraosseous
anastomosis), and approximately 20 mm above the crest of the
ridge.
 A blunt dissection does not violate these vessels.
 No tension should exist on the facial flap with primary closure of the
site.
 Interrupted horizontal mattress or a continuous suture (3-0
polyglycolic acid [PGA]) may be placed..
 Incision line opening may contribute to infection, contamination, or
loss of graft materials.
 The borders and flange of an overlaying soft tissue–borne denture or
partial denture are aggressively relieved to eliminate pressure
against the lateral wall of the maxilla.

SUTURING TECHNIQUE
 Suturing technique should insure proper flap closure without tension in
order to maintain hemostasis and to prevent bone exposure through
healing by primary intention.
 Single interrupted sutures (5/0 or 4/0) are mainly used for the releasing
incisions.
 Uninterrupted sutures are used specifically on the top of the ridge in
case of delayed or submerged implant placement; the stitch is
commenced at one extremity of the wound (generally at the posterior
extremity) and after the needle is passed through the two lips. It is then
carried under the slack of the thread, so that the loop of each stitch
after being tightened shall be at right angles to the edge of the wound,
while the portion intervening between the stitches is parallel to it. This
kind of suturing technique provides adequate tension for wound
closure, but loose enough to prevent tissue ischemia and necrosis.
 Sutures should be 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 for the releasing
incisions

CONTRIBUTION OF PIEZOELECTRIC
SURGERY IN SFE
 Piezoelectric surgery is a hard tissue surgical application using multipurpose high-
end ultrasonic device that was originally developed for the atraumatic cutting
of bone by way of ultrasonic vibrations and as an alternative to the mechanical
instruments that are used in conventional oral surgery.
 A critical feature of a piezosurgery unit is the ability to vary the oscillation
frequency and the cutting energy resulting in the selective cutting of bone
without damaging the adjacent soft tissue (e.g., vessels, nerves or specifically
sinus membrane in SFE), providing a clear visibility in the operating field due to
pressurized irrigation and cavitation effect, and cutting with micron sensitivity
without the generation of heat. Specific inserts are some three times more
powerful than conventional ultrasonic units, which allow them to cut highly
mineralized cortical bone. The reduced range and the linearity of the vibrations
allow for precise control of cutting. The cutting characteristics of piezosurgery
are mainly depending upon the degree of bone mineralization, the design of
the insert, the applied pressure on the handpiece and the speed of movement
during usage

 All of the surgical techniques to elevate the maxillary sinus present
the possibility of perforating the Schneiderian membrane. This
complication can occur during the osteotomy, which is performed
with burs, or during the elevation of the membrane when using
surgical manual curettes. The piezoelectric osteotomy of the bony
window easily cuts mineralized tissue without damaging the soft
tissue; moreover, 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.
 Over the past two decades, an increasing amount of literature has
shown that piezoelectric devices are innovative tools in oral surgery
(Fig. 5.32). Numerous publications have also shown the benefits of
their use in SFE (Vercellotti et al. 2001, 2005; Wallace et al. 2007).

 Piezoelectric kit including various tips used in the
different steps of SFE
 Piezosurgery can be particularly useful for the
preparation of the bony window (diamond-coated
square or bell-shaped tips) (see Fig. 5.16) and in
atraumatic dissection of the thin and delicate sinus
membrane with specially designed tips (rounded, dull,
bell-shaped, or curette-shaped tips)
 Piezoelectric SFE surgery has been described by
Vercellotti et al. (2001) (Vercellotti et al. 2005) who
demonstrated its clinical effectiveness and a better
tissue response based on histologic and
histomorphometric evidence of wound healing and
bone formation; the tissue response is more favorable
to piezosurgery than to diamond or carbide rotary
instrumentation (Vercellotti et al. 2005).
 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
Bell-shaped” piezoelectric tip initiating the
dissection of the Schneiderian membrane

 The bone removed by osteoplasty can
be harvested and incorporated within
the sinus graft.
 The initial release of the membrane from
the antrostomy edges is performed with a
dull, rounded, noncutting elevator that
works with saline cavitation to safely
create a small internal elevation
(Vercellotti et al. 2001). The procedure is
often completed with conventional sinus
membrane curettes.
 While perforation of the sinus membrane
is the most common complication (14–56
%) in SFE when using rotary instruments
(Testori et al. 2008), Wallace et al. (2007)
reported that piezosurgery could
significantly minimize sinus perforation
rates (3–7 %). Consequently, piezosurgery
offers a 75 % reduction in the expected
perforation rate.

 Further, the occurrence of perforations appears to be equally
attributable to rotary instrumentation, initial release of the
membrane at the antrostomy margin with hand instruments, and
the continued elevation of the membrane from the internal sinus
walls.
 Various tips are specifically designed for SFE. Light handpiece
pressure and an integrated saline coolant spray keep the
temperature low and the visibility of the surgical site high. It is
claimed that inadvertent perforations of the sinus membrane are
unlikely when piezosurgical techniques are appropriately applied.
 Both hinge and complete antrostomies can be performed.
Repositioned bony window is a particularly interesting application of
piezoelectric surger

DENTIUM ADVANCED SINUS KIT
(DASK)

Crestal approach
 uses an osteotome to break through the floor and then graft below
the sinus membrane.
 The following are the five steps used in the procedure:
Step 1
A conventional full-thickness flap with crestal incision is
completed to gain access to the bony ridge. A pilot drill is used
to perform the initial osteotomy 1 to 2 mm short of the sinus
floor. The exact measurement of the available bone is completed
via CBCT images. Incrementally larger surgical drills or
osteotomes should be used to widen the osteotomy, at least one
drill short of the final implant width

Step 2
A small diameter osteotome is inserted into the prepared
site to compress the sinus floor using a surgical mallet. A slight“give” will occur
when the bone is breached. A periapical radiograph
may be taken to verify positioning. Incremental wider
osteotomes are inserted to expand and to obtain vertical expansion
of the bone height to accommodate the implant diameter
Step 3 After the last osteotome is used, bone graft material is slowly
introduced into the osteotomy site. First, a PRF coagulant
maybe placed into the osteotomy site. This will allow for enhanced
soft tissue healing via penetration through the collagen
membrane to increase bone growth. Second, collagen is tapped
into position to elevate the membrane. A small piece of collagen
(i.e., approximately 1½ larger than the osteotomy hole) is placed
into the osteotomy site, with the last osteotome. The collagen
will act as a buffer between the bone graft material and the sinus
membrane. The collagen is less likely to perforate the membrane

Step 4 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.
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

Subantral Option Four: Sinus Graft Healing and
Extended Delay of Implant Insertion
 indicated when less than 5 mm remains between the residual crest
of bone and the floor of the maxillary sinus
 SA-3 approach is warranted because only 5 mm of bone is present,
but pathology is present
 Larger antrum and minimal host bone on the lateral, anterior, and
distal regions of the graft because the antrum generally has
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.

 in Division D maxillae,
it is usually necessary
to expose the lateral
maxilla and the
zygomatic arch.
 The access window in
the severely atrophic
maxilla may even be
designed in the
zygomatic arch.
 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 Tatum lateral-wall approach for sinus graft is
performed as
in the previous SA-3 procedure without the implant
insertion (better surgical access than their
SA-3 counterparts because the antrum floor is closer to
the crest, compared with the SA-3 posterior maxilla).

 less autogenous bone is harvested from the tuberosity, an additional
harvest site may be required, most often above the roots of the
maxillary premolars or from the mandible (i.e., ascending ramus).
 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

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

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.

IMPLANT INSERTION
 The implant surgery at reentry after successful sinus grafts is similar to
SA-1, with a few exceptions
 The periosteal flap on the lateral side is elevated to directly allow
inspection of the previous access window of the sinus graft.
 The previous access window may appear completely healed with
bone, soft and filled with loose graft material, or with cone-shaped
fibrous tissue in-growth (with the base of the cone toward the lateral
wall).

 If the graft site on the lateral-access wall appears clinically as bone,
then the implant osteotomy and placement follow the approach
designated by the bone density.
 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.

 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.
 The time interval for stage II uncovery and prosthetic procedures
after implant insertion of a sinus graft is dependent on the density of
bone at the reentry of implant placement.
 The crest of the ridge and the original antral floor may be the only
cortical bone in the region for implant fixation.
 The most common bone density observed for a sinus graft reentry is
D3 or D4.

 Most often, mineralized bone graft (or xenograft) material in the sinus
graft has not converted to bone.
 The tactile sense and the CBCT evaluation interpret the mineralized
graft material as a denser bone type; therefore a tactile or
radiographic D3 bone may actually be D4-like bone.
 It is prudent to wait longer (rather than shorter) for implant uncovery.
 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.
 Therefore the overall graft maturity time is 4 to 10 months for SA-3, and
SA-4 healing time is 8 to 14 months before prosthetic reconstruction.
 Progressive loading after uncovery is most important when the bone is
particularly soft and less dense.
 Inadequate bone formation after the sinus graft healing period of SA-4
surgery is a possible, but uncommon, complication.

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

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

Modified Trephine/Osteotome Approach
(Simultaneous Implant Placement
 Fugazzotto (2002) presented a technique in which a trephine with a 3.0 mm external diameter is utilized instead of a
drill (or an osteotome) as a first step, followed by an osteotome to implode a core of residual alveolar bone prior to
simultaneous implant placement.
 This technique could be utilized either following a flap reflection or using a flapless approach.
 A calibrated trephine bur with 3.0 mm external diameter is used to prepare the site to within approximately 1–2 mm
of the sinus membrane at a reduced cutting speed.
 Following removal of the trephine bur, if the bone core is found to be inside the trephine, it’s gently removed from
the trephine and replaced in the alveolar bone preparation.
 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.
 The widest osteotome utilized will be one drill size narrower than the normal implant site preparation.
 Implant placement induces a lateral dispersion of the imploded alveolar core with gentle and controlled
displacement.
 This technique both lessen the patient’s trauma and preserve a maximum amount of alveolar bone at the precise
site of anticipated implant placement.
 This technique is indicated in the presence of 4–5 mm of RBH in order to avoid repeated traumatic malleting of the
osteotomes and is always combined to simultaneous implant placement

Modified Trephine/Osteotome Sinus Augmentation
Technique (Post-extraction Molars and Premolars)
 Fugazzotto (1999) described a technique for accomplishing both
localized SFE and guided bone regeneration at the time of maxillary
molar extraction.
 After the atraumatic extraction of the molar in a manner so as to
preserve interradicular bone, a calibrated trephine bur is placed over
the interradicular bone, which is of sufficient dimension to encompass
both the interradicular septum and approximately 50 % of the
extraction sockets (each trephine bur is approximately 1 mm thick).
 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.
 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).

Minimally Invasive Antral Membrane Balloon
Elevation (MIAMBE)
 The presence of septa in maxillary sinus requires modification of surgical technique and carries a higher complication rate.
Minimally invasive antral membrane balloon elevation (MIAMBE) is one of many modifications of the 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 drilling depth is determined according to measurements obtained from the CT scan:
 A pilot drill pilot (2 mm diameter) is introduced in the center of the alveolar crest up to 1–2 mm below the sinus floor.
 The osteotomy is enlarged with the dedicated osteotomes.
 Bone substitute (BS) is injected into the site, and subsequently, the sinus floor is gently fractured.
 The membrane integrity is assessed. BS is injected again and a screw tap is tapped into the prepared site 2 mm beyond the
sinus floor.
 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
underneath the sinus membrane, the pressure dropped down to 0.5 atm.
 Subsequently, the balloon is inflated with progressively higher volume of contrast fluid.
 Sequential periapical X-rays evaluate the balloon inflation and membrane elevation. Once the desired elevation (usually 10
mm) is obtained, the balloon should be left inflated 5 min to reduce the sinus membrane recoil.
 Then, the balloon is deflated and removed. The membrane integrity is assessed by direct visualization and examination with
the suction syringe and respiratory movement of blood within the osteotomy site.

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

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 thr bur
reaching the dense sinus floor,
stop and confirm the 1st bur
vertical position with a
radiograph

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
fnal desired width for implant placement. Densah® Burs
must not advance more than
3 mm past the sinus foor at all times regardless of the
Densah® bur diameter.
Place the implant into the
osteotomy. If using the drill
motor to tap the implant
into
place, the unit may stop
when reaching the
placement torque
maximum. Finish placing
the implant to depth with a
torque indicating wrench.

Maxillary Sinus Autografting -
Densah® Lift Protocol II
 MINIMUM RESIDUAL BONE HEIGHT = 4-5 mm
MINIMUM ALVEOLAR WIDTH NEEDED = 5 mm
 Depending upon the implant type and
diameter selected for the site, begin with the
narrowest Densah® Bur (2.0). Change the drill
 motor to reverse – Densifying Mode
(Counterclockwise drill speed 800-1500 rpm with
copious irrigation). Begin running the bur to
 create the osteotomy. Modulate pressure with a
pumping motion to reach the sinus foor. Stop
drilling once you feel the haptic feedback
 of the bur reaching the dense sinus foor. Confrm
Bur position with a radiograph

 A. Use the next wider Densah® Bur (3.0) and advance it into the previously created osteotomy
with modulating pressure and a
 pumping motion. 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. Maximum possible advancement
past the sinus foor at
 any stage must not exceed 3 mm. Confrm the frst Densah® Bur vertical position with a
radiograph. Bone will be pushed
 toward the apical end and will begin to gently lift the membrane and autograft compacted
bone.
 B. Use the sequential wider 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 fnal desired width for implant placement. Densah® Burs Must not advance more than 3
mm past the sinus
 foor at all times regardless of the Densah® Bur diameter.

 In cases where additional lift of the membrane (more
than 3 mm)
 is desired, an allograft material can be placed into the
fnal width
 osteotomy.
 4. Use the last Densah® Bur in Densifying Mode
 (Counterclockwise drill speed 150-200 rpm with no
 irrigation) to propel the allograft into the sinus. The
Densah®
 Bur must only facilitate the allograft material
compaction to lift
 the sinus membrane further, and not advance beyond
the sinus
 foor. *Repeat steps 3 & 4 to facilitate additional
membrane lift
 Place the implant into the osteotomy. If using the drill
motor to tap the implant into place, the unit may stop
 when reaching the placement torque maximum. Finish
placing the implant to depth with a torque indicating
wrench.

Maxillary Sinus Autografting -
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

INTRAOPERATIVE COMPLICATIONS
RELATED TO SINUS GRAFT SURGERY
MEMBRANE
PERFORATIONS
ANTRAL SEPTA
BLEEDING

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

Long term results
 Primary method – long term evaluation of sinus grafts – implant
survival
•HA coated implants higher 3 year survival rates than machined
non coated screw design
Implant design
•Autologous < Autograft + Bone subtitutes < bone substitute
mixture
Type of graft material
•Rough surface implants > smooth surface implants
Surface condition of implants
Factors

Summary
 In the past, implant treatment in the posterior maxilla was reported as
the least predictable region for implant survival.
 Causes cited include inadequate bone height, poor bone density,
and high occlusal forces.
 The maxillary sinus may be elevated and SA bone regenerated to
improve available bone height.
 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.

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

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.

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

RESULTS CONCLUSIONS
 No statistically significant
differences were observed
between implants placed
according
 to 1- or 2-stage sinus lift
procedures. However this study
may suggest that 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.

 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.

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. The final bone heights were
measured from panoramic radiographs or
postoperative computed tomography scans.

 The success rate for the osteotome technique was 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 (p < 0.001) than did the sites in Which
the osteotome technique was applied (mean = 3.5 mm). The histologic
sections showed both bone apposition in intimate contact with the
bone-grafting material particles and initial signs of its remodeling.
 Conclusions. The results indicate that the 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. In
cases of more advanced resorption a one-step or two-step lateral
antrostomy has to be performed.

 The purpose of this study was to compare the intraoperative and
postoperative effects of Piezosurgery and conventional rotative
instruments in direct sinus lifting procedure.
 Twentythree 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 P0the operation site, postoperative pain,
swelling, sleeping, eating, phonetics, daily routine, and missed work
as well as patient’s expectation before and experience after the
operation were evaluated

RESULTS
 There was no significant difference between Piezosurgery and
conventional groups regarding incidence of membrane
perforation, duration, and operation site visibility as well as patient’s
expectation before and experience after the operation (P . 0.05).
However, there were significantly more pain and swelling in the
conventional group compared with the Piezosurgery group (P #
0.05)

CONCLUSIONS
 Sinus lifting procedure performed with Piezosurgery causes less pain
and swelling postoperatively compared with conventional
technique.
 Patients’ daily life activities and experience about the operation are
not affected from the surgical technique

Sinus lift procedures.pptx

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Sinus lift procedures.pptx