sinus lift

The maxillary sinuses were first illustrated and described by Leonardo Da Vinci in 1489 and later documented by the English anatomist Nathaniel Highmore in 1651.
The maxillary sinus, or antrum of Highmore, lies within the body of the maxillary bone and is the largest and first to develop of the paranasal sinuses.
Shape- a pyramid-shaped cavity; base- adjacent to the nasal wall; apex- pointing to zygoma.
Size- insignificant until eruption of permanent dentition; average dimensions of adult sinus- 2.5–3.5 cm wide, 3.6–4.5 cm tall, and 3.8–4.5 cm deep; estimated volume of approximately 12–15 cm.
Extent- Anteriorly, extends to canine and premolar area. sinus floor usually has its most inferior point near the first molar region.

1. Nishu Priya III MDS Maxillary sinus lift procedures

2. Introduction The posterior maxilla has been described as one of the most challenging and complex intraoral regions that confronts the implant clinician. • Poor bone density • Compromised available bone • Increased pneumatization of the maxillary sinus • Increased crown height space • Ridge position shifts toward lingual (medial) • Difficult access because of anatomic location • Increased biting force • Requirement of wider diameter implants and increased number

3. The maxillary sinuses were first illustrated and described by Leonardo Da Vinci in 1489 and later documented by the English anatomist Nathaniel Highmore in 1651. The maxillary sinus, or antrum of Highmore, lies within the body of the maxillary bone and is the largest and first to develop of the paranasal sinuses. Shape- a pyramid-shaped cavity; base- adjacent to the nasal wall; apex- pointing to zygoma. Size- insignificant until eruption of permanent dentition; average dimensions of adult sinus- 2.5–3.5 cm wide, 3.6–4.5 cm tall, and 3.8–4.5 cm deep; estimated volume of approximately 12–15 cm. Extent- Anteriorly, extends to canine and premolar area. sinus floor usually has its most inferior point near the first molar region. Maxillary sinus anatomy/ Antrum of Highmore

4. https://www.healthline.com/human-body-maps/maxillary-sinus#1

5. Supply and innervation Endosseous anastomosis (within the lateral wall of sinus) -supplies lateral wall and sinus membrane 1. Posterior superior alveolar artery 2. Infraorbital artery • Extraosseous anastomosis (within periosteum) -supplies sinus mucous membranes 1. Posterior superior alveolar artery 2. Infraorbital artery • Posterior lateral nasal artery (medial and posterior wall) -supplies medial and posterior walls of maxillary sinus

6. Schneiderian membrane Mucosal lining of the sinus • Pseudo-stratified columnar ciliated respiratory epithelium covering a thin layer of connective tissue • 0.45 to 1.40mm in thickness • Considered normal if less than 4mm Increased thickness associated with • thick gingival biotype • chronic sinus inflammation • smoking

7. 6 Clinical assessment In 1987 Misch developed four different categories for the treatment of the posterior maxilla (termed subantral [SA]) as SA-1 through SA-4 and was later modified and updated by Resnik in 2017 SA1 SA3 SA2 SA4 implant placement that does not extend into the maxillary sinus proper. implant placement that elevates the sinus membrane approximately 1 to 2 mm without bone grafting. implant placement and simultaneous bone grafting by either a crestal or lateral-wall approach. lateral wall sinus augmentation with delayed implant placement. >12mm 10-12mm 15-10mm <5mm

8. Radiological Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg. Completely radiolucent maxillary sinus (dark) Any radiopaque or whitish area Normal/healthy Abnormal/ pathologic condition The first thing to look is the density of the sinus. Normal sinus –low density homogeneous cavity

9. 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. Anatomical variants Deviated nasal septum Increased risk of sinusitis after the graft. Delayed implant placement + pre-operative and postoperative pharmacologic protocol Middle Turbinate Variants A concha bullosa is a pneumatization within the middle turbinate and may occlude the ostiomeatal complex, compromising adequate drainage. -4% to 15% of the population. paradoxically curved middle turbinate, which presents a concavity toward the septum, decreasing the size of the meatus.

10. Antral septa (i.e., also termed buttresses, webs, and struts) are the most common osseous anatomic variants seen in the maxillary sinus. Krennmair and colleagues further classified these structures into two groups: primary structures, which are a result of the development of the maxilla, and secondary structures, which arise from the pneumatization of the sinus floor after tooth loss. Misch postulated that septa might be bone reinforcement pillars from parafunction when the teeth were present. Septa Maxillary septa can prevent adequate access and visualization to the sinus floor; therefore inadequate or incomplete sinus grafting is possible.

11. Maxillary Hypoplasia direct result from trauma, infection, surgical intervention, or irradiation to the maxilla during the development of the maxillary bone. These conditions interrupt the maxillary growth center, producing a smaller than normal maxilla. Most often, these patients have adequate bone height for endosteal implant placement, and a sinus graft is not required to gain vertical height Inferior Turbinate and Meatus Pneumatization (Big-Nose Variant) the inferior third of the nasal cavity pneumatizes within the maxilla and resides over the alveolar residual ridge. A sinus graft is contraindicated with this patient condition because the sinus is lateral to the position of the implants. in most cases an onlay graft is required to increase bone h eight.

12. Contraindications of maxillary sinus graft procedure Relative contraindications 1. Limited anatomic/structural impairments of the sinus or nasal walls that are correctable (i.e., deviated septum) 2. Inflammatory/infectious processes that are treatable 3. Foreign bodies 4. Oroantral fistulas Absolute contraindications 1. Anatomic/structural impairments of the sinus or nasal walls that are n on-correctable. 2. Inflammatory/infectious processes that cannot be resolved 3. Fungal or granulomatous diseases of the naso -sinus. 4. Benign/malignant neoplasms of the naso -sinus.

13. Systemic Antibiotic Prophylaxis Augmentin (amoxicillin-clavulanic acid) (825 mg/125 mg), one tablet bid starting 1 day before surgery and 5 days after surgery Non-anaphylactic allergy to penicillin 2. Ceftin (cefuroxime axetil ) (500 mg), , one tablet bid starting 1 day before surgery and 5 days after surgery Anaphylactic allergy to penicillin 3. Doxycycline (100 mg), one tablet bid starting 1 day before surgery and 5 days after surgery Local Antibiotic in Graft 1. Ancef (Cefazolin 1 gm): Dilute with 2 mL saline (500 mg/mL) a. 0.2 mL or 100 mg: add to collagen membrane b. 0.8 mL or 400 mg: add to graft material 2. Clindamycin 150 mg/1 mL a. 0.2 mL or 30 mg: add to collagen membrane b. 0.8 mL or 120 mg: add to graft material Recommended prophylactic antibiotic drugs for sinus grafting procedures

14. Sinus lift techniques LATERAL WINDOW TECHNIQUES Modified Caldwell-Luc approach (Tatum) Ultrasonic ostectomy ( Torella ) Piezoelectric bony window osteotomy ( Vercellotti et al) Trephine ( Emtiaz ) Antral membrane balloon elevation ( Soltan and Smiler) Other variations Hinge osteotomy Elevated osteotomy Crestal osteotomy TRANSCRESTAL APPROACH TECHNIQUES Osteotome technique (Summers) Modified osteotome technique ( Davarpanah et al 1996) Hydraulic pressure- saline ( Sotirakis and Gonshor )

15. Trephine Piezoelectric bony window osteotomy Antral membrane balloon elevation Hydraulic pressure- saline Hinge osteotomy

16. History 1980: Boyne and James reported on elevation of the maxillary sinus floor in patients with large, pneumatized sinus cavities as a preparation for the placement of blade implants. Boyne, P. J. & James, R. A. (1980) Grafting of the maxillary sinus floor with autogenous marrow and bone. Journal of Oral Surgery 38, 613–616. 1994: Summers described a crestal approach, using tapered osteotomes with increasing diameters. Summers, R. B. (1994) A new concept in maxillary implant surgery: the osteotome technique. Compendium 15, 152–154–156, 158 passim; quiz 162. 1 988: The original rotary techniques with either surgical hand pieces or high speed hand pieces were modified by Wood and Moore 2001: Vercellotti introduced the Piezoelectric technique in the United States Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, Stoupel J, Del Fabbro M, Testori T. Maxillary sinus elevation by lateral window approach: evolution of technology and technique. Journal of Evidence Based Dental Practice. 2012 Sep 1;12(3):161-71.

17. Direct sinus lift Indirect sinus lift Invasive/Traumatic Also called open method Simultaneous implant placement is possible only if the residual bone height is more than 3-4 mm Can be performed in all cases. Bone gain is more. Higher chance of membrane tear Treatment duration is long The patient might report of pain in the first week Gingival inflammation is relatively high in the first week Mild post-operative swelling present Minimally invasive Also called closed or Crestal method or osteotome or transalveolar approach Implant placement can be done simultaneously Can be performed if residual bone height is >6 mm. Fewer chances of membrane tear Treatment duration is short Comparatively, there is no pain no gingival inflammation is seen No post-operative swelling

18. Instruments Rotary instruments: Most commonly used to create the osteotomy through which the sinus floor is accessed Bone scrapers: Used to carve into the anterior sinus wall to create an antrostomy for sinus floor elevation in a simple and very safe procedure Sinus lift curettes: Used to separate/reflect and elevate the Schniederian membrane from the maxillary bone

19. Sub-antral Option One: Conventional Implant p lacement SA-1 Requirements Favorable conditions: >8 mm host bone (implant approximately 8 mm in length or greater) Unfavorable conditions: >10 mm host bone (implant approximately 10 mm in length or greater) Because the maxillary sinus proper is not invaded during an SA-1 approach, it is less critical if preexisting pathology in the sinus is present. Osteoplasty in the SA-1 posterior maxilla may change the SA category if the height of the remaining bone is sufficient to allow for adequate bone postosteoplasty .

20. SA-2 Requirements Favorable conditions: (>8 mm host bone, ideally 10-mm implant) Unfavorable conditions: (>10 mm host bone, ideally 12-mm implant ) Sub-antral Option Two: Sinus Lift and Simultaneous Implant Placement The second SA option in the Misch SA classification, SA-2, is selected when the intended implant length is 1 to 2 mm greater than the vertical bone present. In this technique, 1 to 2 mm may be achieved via elevating the sinus membrane without bone grafting. Tatum originally developed this technique in 1970, and Misch first published it in 1987. Because the 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.

21. 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. 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 that this structure remains within the soft tissue. Incision and reflection

22. Oste Osteotomy and Sinus Elevation otomy and Sinus Elevation (SA-2) The depth of the osteotomy is approximately 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. A flat-end or cupped-shape osteotome is selected for the infracture of the sinus floor. D3 bone, an osteotome of the same diameter as the final osteotomy is selected. D4 bone, an osteotomy one to two sizes smaller than the final implant size maybe used, performing an osseodensification technique. 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. 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.

23. 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. 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.

24. Modified SA2 Techniques Rosen and associates developed a modification to the SA-2 treatment approach for use at the time of extraction of a maxillary molar. 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. The technique is indicated when the maxillary molar is extracted, the surrounding walls of bone are intact, and no periapical pathologic condition is present.

25. Complications If a sinus membrane perforation occurred during the initial implant placement procedure, then bone height growth is less likely to occur. This is the primary reason why only 0 to 2 mm of additional bone height is attempted with this technique. However, 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.

26. Subantral Option Three: Sinus Graft with Immediate Endosteal Implant Placement 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 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. SA-3 Requirements • Favorable conditions: (>5 mm host bone, Implant size < 4mm greater than host bone) • Unfavorable conditions: (>8 mm host bone, Implant size < 4mm greater than host bone)

27. 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. The facial full-thickness mucoperiosteal flap is reflected to expose the complete lateral wall of the maxilla and a portion of the zygoma. 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 Lateral wall approach

28. Access Window The outline of the Tatum lateral-access window is scored on the bone with a rotary handpiece under copious cooled sterile saline. It is often easier to perform this step at 50,000 rpm (1:1 handpiece), but it is possible even at 2000 rpm, depending on the lateral-wall bone thickness. 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). 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). The anterior vertical line of the access window is scored approximately 1 to 2 mm from the anterior sinus border. The 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.

29. 2. Sinus Membrane Elevation The first step in elevating the window is to ensure that the lateral window is completely “free” from the host bone. A flat-ended metal punch (or mirror handle) and mallet may be used to gently infracture the lateral-access window from the surrounding bone while still attached to the thin sinus membrane. I n the center of the window - light tapping  does not greenstick fracture the bone  flat-ended punch is placed along the periphery of the access window and tapped again.

30. 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.

31. Sinus Graft: Layered Approach 1. Top layer (superior) a. Collagen membrane b. Local antibiotic (Ancef) 2. Middle layer (intermediate) a. 70% mineralized freeze-dried bone allograft b. 30% demineralized freeze-dried bone allograft c. Platelet-rich fibrin from 10 mL of whole blood d. Antibiotic (Ancef 500 mg/mL) 3. Bottom layer (inferior) a. Autogenous bone 1.carrier for the antibiotic 2. seals the opening grafting material should be deposited in an anterior and inferior direction Regional Acceleratory Phenomenon. Autogenous bone

32. 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  result in the 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 insertion

33. Soft Tissue Closure 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. Therefore the 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.

34. 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 sinus graft results in an implant placed in the sinus proper, rather than the graft site. On re-entry to a sinus graft, it is not unusual to observe a crater like 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.

35. Crestal approach Crestal approach Requirements Favorable conditions: (>5 mm host bone, Implant size < 4mm greater than host bone) • Unfavorable conditions: (>8 mm host bone, Implant size < 4mm greater than host bone)

36. Crestal approach

37. SA 4 Requirements Favorable or unfavorable conditions: <5 mm host bone Subantral Option four : Sinus Graft Healing and Extended Delay of Implant Insertion In the fourth option for implant treatment of the posterior maxilla, SA-4, the SA region for future endosteal implant insertion is first augmented, then after sufficient healing, implant placement is completed. The SA-4 corresponds to a 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. The inadequate vertical bone in these conditions decreases the predictable placement of an implant at the same time as the sinus graft, and less recipient bone exists to act as a vascular bed for the graft. Therefore the 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. The Tatum lateral-wall approach for sinus graft is performed as in the previous SA-3 procedure without the implant insertion . After the graft maturation, the implants may be inserted

38. Indirect video

39. Healing of the sinus graft takes place by several vascular routes, including the endosseous vascular anastomosis and the vasculature of the sinus membrane from the sphenopalatine artery. The periphery of the graft is mainly supplied by vessels of the sinus membrane and by intraosseous vascular bundles. The central portions of the graft receive blood from collateral branches of the endosseous anastomosis. The extraosseous vascular anastomosis may enter the graft from the lateral-access window. 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. Vascular Healing of Graft

40. Sinus Graft Postoperative Instructions 1. Do not blow your nose. 2. Do not smoke or use smokeless tobacco. 3. Do not take in liquids through a straw. 4. Do not lift or pull on lip to look at sutures (stitches). 5. If you must sneeze, then do so with your mouth open to avoid any unnecessary pressure on the sinus area. 6. Take your medication as directed. 7. You may be aware of small granules in your mouth for 2 to 3 days after surgery. 8. Bleeding from the nostril may be present for the first 24 hours after surgery.

41. Intraoperative Complications Related to Sinus Graft Surgery Membrane Perforations Causes  preexisting perforation, tearing during scoring of the lateral window, existing or previous pathologic condition, and elevation of the membrane from the bony walls. The surgical correction of a small perforation is initiated by elevating the sinus mucosal regions distal from the opening. The antral membrane elevation technique decreases the overall size of the antrum, thus “folding” the membrane over on itself and resulting in closure of the perforation. A piece of resorbable collagen membrane (e.g., Collatape ) is placed over the opening to ensure continuity of the sinus mucosa before the sinus bone graft is placed. The collagen will stick to the membrane and seal the SA space from the sinus proper. Small (<2 mm) fast-resorbing collagen (e.g., Collatape , Oratape ) • Medium (2–4 mm) regular collagen (e.g., OraMem ) • Large (>4 mm) longer acting collagen (e.g., Renovix , OraMem Extend)

42. Bleeding Bleeding from the lateral-approach sinus elevation surgery is rare; however, it has the potential to be troublesome. Three main arterial vessels should be of concern with the lateral-approach sinus augmentation. Because of the intraosseous and extraosseous anastomoses that are formed by the infraorbital and posterior superior alveolar arteries, intraoperative bleeding complications of the lateral wall may occur. The soft tissue vertical-release incisions of the facial flap in a resorbed maxilla may sever the extraosseous anastomoses. Significant pressure at the posterior border of the maxilla and elevation of the head to reduce the blood pressure to the vessels usually stops this bleeding. The elevation of the head may reduce nasal mucosal blood flow by 38%. Methods to limit this bleeding, which is far less of a risk, have been addressed and include cauterization by the handpiece and diamond bur without water, electrocautery, or pressure on a surgical sponge while the head is elevated.

43. Incision line opening Nerve impairment Ecchymosis Pain Oroantral fistula Post operative infection Spread of infection Overfilling the sinus Postoperative cbct mucosal thickening Implant penetration into the sinus Migration of implants Post operative fungal infection Short-Term Postoperative Complications

44. Conclusion Any dental surgeon aims to use a simple, minimally invasive, cost-effective procedure with high predictability. Advanced and invasive surgical techniques often prolong the treatment duration. The choice of various surgical techniques should correlate with the indications, patient expectations about the treatment, predictability of the treatment choice, and clinician’s experience.

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