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74
The change of maxillary sinus ostium in diameterfollowing Sinus floor elevation surgery using Cone
beam computered tomography
LivingWell Dental Hospital
LivingWell Institute of Dental Research
Ho-yeol Jang, seung-gul So, Jae-bong Park, Hyoun-chull Kim, Il-hae Park, Sang-chull Lee
Ⅰ. Introduction
The elevation of the floor of the maxillary
sinus with an autogenous bone graft in a severely
resorbed edentulous maxilla is a generally
accepted pre-implantology procedure to enable
successful placement of endosseous implants in
an optimal prosthetic position1). An often
mentioned drawback of this procedure is the
development of maxillary sinusitis after
augmentation2). The clinical diagnosis of sinusitis
is characterized by a typical triad of symptoms, i.e.
nasal congestion, pathological secretion or
obstruction, and headache3,4). When using general
accepted Ear Nose and Throat (ENT) criteria
for diagnosing sinusitis, however, development
of postoperative chronic maxillary sinusitis
has been reported to occur in 1.3% of the patients
that underwent such a procedure5).
Although not many patients develop maxillary
sinus pathology-related complaints after sinus
floor elevation surgery, this procedure carries the
inherent risk of compromising sinus physiology.
It is generally assumed that the maxillary sinus
physiology is affected by the altered anatomy
(i.e. the lifted sinus floor in combination with a
bulging or injured subsurface of the lifted sinus
mucosa). Displacement of grafts into the maxillary
sinus can result in a foreign-body reaction and
cause serious complications. Mucosal swelling
may also lead to reduction of the patency of the
ostio-meatal unit. This unit plays a key role in
the development of sinusitis, through impairment
of the mucociliar cleansing system6). If the
maxillary sinus is (partly) filled up by hematoma
or seroma and/or the patency of the maxillary
ostium is reduced, maxillary sinusitis might
develop, compromising the success of the
grafting procedure.
Therefore preoperative observation of the
ostio-meatal unit and the mucosal lining of the
maxillary sinus is of great importance to evaluate
of sinus clearance and to diagnose maxillary
sinusitis. The aim of this study was to evaluate
the change of maxillay sinus ostium and phy
siology after maxillary sinus floor elevation
surgery.
Ⅱ. Materials and Methods
A total of 35 patients(20 men and 15 women),
with a mean age of 50 years (range 19 to 76
years), were examined by cone beam computered
tomography (CBCT). The total of 40 sinuses
which are excluded by any sign of pathology had
been evaluated on the patients. Preoperative
75
CBCT scanning was done parallel to the floor of
the nosal cavity, and these images were recon
structed with i-CAT program (ISI, USA). Pre
operative diameters of the maxillary sinus ostium
which is bounded below by the uncinate process
(U) and above by the lower bony portion of the
ethmoid sinuses (E) was measured from the coro
nal view perpendicular to the hard palate (Fig. 1).
Implant placement was performed simultaneously
with the sinus elevation procedure using the lateral
window technique and autogenous bone graft.
In 5 cases, sinus elevation surgery were
complicated by large perforations of the sinus
membrane, which were treated with a pericar
dium membrane (Tutoplast, Tutogen, Germmany)
that acted as a barrier. And it were administered
decongestant (pseudoephedrine HCl, 60mg/1day,
orally) in addition to antibiotics and analgesics for
3days.
Next day, postoperative CT scanning was
performed and diameters of ostium were
remeasured on same position. Obstruction degrees
of maxillary sinus cause by
III. Results
Diameters of maxiilary sinus ostium were
significantly (t-test, p-value<0.05) decreased
from a mean 3.25 mm to a mean 1.52 mm (mean
of differences ; 1.73 mm) between preoperative
and postoperative measurement. In 19 sinuses
obstruction of ostium were showed in postoper
ative CT images. And obstruction degrees of
maxillary sinus were observed; Type 1 in 7 cases,
Type 2 in 24 cases , Type 3 in 7 cases and Type
4 in 2 cases(Table 1). But none of all patients
showed symptoms or clinical signs of sinus
pathology at 3 months postoperative evaluation.
Fig. 1. Anatomy of maxillary sinus in CT scan andclassification of sinus obstruction levelmucosal swelling, postoperative hematoma or seromawere distinguished into 4 types (Fig. 1); Type 1 : limited to sinus floor obstructionType 2 : limitied to sinus lateral wall obstructionType 3 : below ostium not complete obstructionType 4 : complete obstruction of maxillary sinus
Table 1. CHANGE OF OSTIUM DIAMETER, FREQUENCY OF SINUS MEMBRANE PERFORATION ANDPOSTOPERATIVE SINUS OBSTRUCTION TYPE
76
Fig. 2. Type 1 : limited to sinus floor obstruction
Fig. 3. Type 2 : limitied to sinus lateral wall obstruction
Fig. 4. Type 3 : below ostium not complete obstruction
77
Ⅳ. Discussions
This report is the prospective evaluation of
sinus physiology in patients that had no pathologic
signs of maxillary sinus. It became clear that
negligible mucosal reactions were seen after
elevation surgery of the maxillary sinus floor.
None of all patients developed purulent maxillary
sinusitis.
The normal physiology of the maxillary sinus is
highly dependent on the proper function of both
the maxillary sinus ostium and the mucosal
lining7,8). Augmentation of the maxillary sinus does
not affect the maxillary sinus ostium, which
is located far from the operative field in the upper
portion of the medial wall. However, elevation
of the mucosa and insertion of grafts or implants
might be disturbing to the lining mucosa and
a source of chronic inflammation and sinusitis9).
Diminished maxillary sinus drainage is closely
related to structural and mucosal factors
responsible for the size of the maxillary ostium.
Therefore, all factors that disturb sinus drainage,
such as septal deviation, nasal polyposis, allergy,
obstructive lung disease, and infundibular
pathology, have to be evaluated by preoperative
screening and treated accordingly before
augmentation. The risk of developing maxillary
sinusitis is increased in patients with disturbed
clearance of the sinus10-18).
A maxillary sinus floor elevation procedure
reduces the volume of the maxillary sinus. As
a result of the iatrogenic damage caused by raising
the maxillary membrane, a transient or persisting
effect on the ciliated antral mucosa can be
expected. Among other effects, when the
maxillary sinus is filled up with blood, structural
delay of the maxillary sinus clearance is thought
to occur. This could result in blocking of the ostio-
meatal unit, which is a potential risk on
development of sinusitis. However, the results
of this study show no clinical signs of sinusitis
development in all patients. This indicates that
a normal maxillary sinus at the time of surgery
seems to have a high potential for regaining
its function postsurgery and the maxillary
sinus mucosa is capable of adapting adequately to
the changes induced by elevation procedure19,20).
Fig. 5. Type 4 : complete obstruction of maxillary sinus
Mucosal injury and postoperative swelling as
can be expected after sinus floor elevation
surgery may influence the mucociliar barrier
function and effectiveness of the cleansing system,
resulting in divergent radiographic findings.
Specially in clearance compromised patients, this
balance system of aggressive and defensive
forces is expected to be vulnerable, as represen
ted by endoscopic findings grade 3 and 4. A proper
anamnestic assessment of preexisting sinus
clearance impairment may detect patients who are
at risk for an impaired recovery of the maxillary
sinus mucosa following elevation.
The occurrence of iatrogenic sinus membrane
perforations during surgery seems not to be
related to the development of postoperative
sinusitis in healthy patients. Small perforations
of the mucosa cannot induce serious damage to
the maxillary sinus and therefore are not a
contraindication to the continuation of surgery,
provided that they do not allow the passage of
graft material inside the maxillary sinus. While
large perforations of the maxillary sinus
membrane could result in the discharge of bony
fragments into the maxillary sinus and thus
cause maxillary sinusitis. It has been reported that
large sinus membrane perforations should be
repaired with collagen membrane21-23). The patient
under consideration did not develop maxillary
sinusitis after surgery, probably because of
adequate sealing of the large iatrogenic perfo
ration in the sinus membrane. And it is better to
recommend decongestant medical therapy for
the upper airways in these cases.
The increase in bacterial growth after sinus floor
elevation might possibly be the effect of
the surgical procedure, which affected the
maxillary mucosal lining and especially the
mucosal defense system. A mildly decreased
sinus clearance probably facilitates the temp
orary presence of microorganisms. Vascular injury
following surgery, mucosal swelling, the presence
of old blood and a decrease of the patency of the
ostio-meatal unit might reduce the oxygen
pressure in the sinus, resulting in an impaired
sinus clearance24). This environment possibly
favors growth of pathogenic bacteria in the
maxillary sinus. In contrast, after recovery of the
sinus, the environment might be comparable to the
preoperative situation.
If patients develop chronic maxillary disease after
maxillary augmentation procedures, special care
is needed to prevent loss of the bone graft.
Intervention is necessary to establish adequate
drainage of the maxillary sinus and to remove
sequestra that may be responsible for maintaining
this undesirable situation. In Table 2, guidelines
for the treatment and prevention of transient
and chronic sinusitis are given. In this study, the
cases of mucosal perforation and Type 4
obstruction were administered nasal decongestant
to prevent sinitis in addition to antibiotics and
analgesics.
78
TTrraannssiieenntt ssiinnuussiittiiss
1. Use of decongestants and antibiotics
2. Follow-up after 2 weeks
3. If no recovery, transient sinusitis has possibly
evolved into subacute sinusitis needing further
treatment: a. Continuation of decongestants and
antibiotics
Table 2. GENERAL GUIDELINES FOR THETREATMENT OF TRANSIENT AND CHRONICMAXILLARY SINUSITIS AFTER ELEVATION OF THEMAXILLARY SINUS FLOOR
Ⅴ. Conclusions
The placement of implants in the posterior
maxilla with the maxillary sinus floor elevation
with an autogenous bone graft is now generally
accepted as a successful and biologically sound
procedure with a reasonably good prognosis.
However the procedure is not always free of
complications. Therefore prior to sinus floor
elevation surgery, preoperative evaluation and
diagnosis through CT images should be performed.
If a normal, or mild mucosal inflammatory aspect
of the sinus mucosa is found, without any sign
of pathology in the infundibular area (containing
the ostiomeatal unit), sinus floor elevation
surgery can be performed. In this study Diameters
of maxiilary sinus ostium were significantly
decreased and sinus obstructions were observed
frequently in Type 3 after sinus floor elevation
surgey. But these siturations were transitionally,
the 3-month postoperative radiographic exami
nation revealed complete recovery of the
maxillary sinus physiology in all patients.
REFERENCES
1. Raghoebar GM, Timmenga NM, Reintsema H,
Stegenga B, Vissink A. Maxillary bone grafting for
insertion of endosseous implants: results after 12-
124 months. Clin Oral Impl Res 2001;12:279-286.
2. Timmenga NM, Raghoebar GM, Boering G, van
Weissenbruch R. Maxillary sinus clearing after
sinus lifts for the insertion of dental implants. J Oral
Maxillofac Surg 1997;55:936-939.
3. Williams, J. & Simel, D. (1993) Does this patient
have sinusitis? Journal of the American Medical
Association 270:1242-1246.
4. Yonkers, A. (1995) Sinusitis. Inspecting the
causes and treatment. Ear Nose and Throat
Journal 71:258-262.
5. Timmenga NM, Raghoebar GM, V.Weissenbruch
R, Vissink A. Maxillary sinusitis following
augmentation of the maxillary sinus floor. A report
of two cases. J Oral Maxillofac Surg 2001;59:
200-204.
6. Bertrand B, Eloy Ph. Relationship of chronic
ethmoidal sinusitis, maxillary sinusitis, and ostial
permeability controlled by sinomanometry. A
statistical study. Laryngoscope 1992;102:1281-
1284.
7. William E, Bolger M, Clifford A, et al: Paranasal
sinus bony anatomic variations and mucosal
abnormalities: CT analysis for endoscopic sinus
surgery. Laryngoscope 1991;101:56.
8. Amble FR, Lindberg SO, McCaffrey TV, et al:
Mucociliary function and endothelins 1, 2, and 3.
Otolaryngol Head Neck Surg 1993;109:634.
9. Westrin KM, Stierna P, Carlsoo B, et al: Mucosal
fine structure in experimental sinusitis. Ann Otol
Rhino1 Laryngol 1993;102:639.
b. Maxillary drains for sinus irrigation
c. CT scanning and consideration of functional
endoscopic sinus surgery if no recovery within 3
weeks
CChhrroonniicc ssiinnuussiittiiss
1. Use of decongestants and antibiotics
2. CT scanning and functional endoscopic sinus
surgery
NOTE. Table created from data from references 10-18.
79
80
10. Kennedy D: Prognostic factors, outcomes and
staging in ethmoid sinus surgery. Laryngoscope
1992;102:1.
11. Davis W, Templer J, Lamear W: Patency rate
of endoscopic middle meatus antrostomy.
Laryngoscope 1991;101:416.
12. Schaefer S, Manning S, Close L: Endoscopic
paranasal sinus surgery: Indications and
considerations. Laryngoscope 1989;99:1.
13. Stammberger H: Endoscopic endonasal
surgery: Concepts in treatment of recurring
rhinosinusitis. Otolaryngol Head Neck Surg
1986;94:147.
14. Kennedy D: Functional endoscopic sinus
surgery. Arch Otolaryngol 1985;111:576.
15. Hartog B: Diagnosis and treatment of chronic
maxillary sinusitis. Thesis. Nieuwkoop, The
Netherlands, De Boer, 1997.
16. Lanza D, Kennedy D: Adult rhinosinusitis
defined. Otol Head Neck Surg 1997;117:1.
17. Timmenga NM, Raghoebar GM, Boering G, et
al: Maxillary sinus clearance after sinuslifting for
the insertion of dental implants. J Oral Maxillofac
Surg 1997;55:936.
18. Buiter C: Endoscopy of the upper airways.
Thesis. Amsterdam, The Netherlands, Exerpta
Medica, 1976.
19. Stammberger H. Endoscopic endonasal
surgery: concepts in treatment of recurring
rhinosinusitis. Otolaryngol Head Neck Surg
1986;94:147-156.
20. Jensen OT, Shulman L, Block MS, Iacono VJ.
Report of the sinus consensus conference of 1996.
Int J Oral Maxillofac Impl 1998;13:11-41.
21. Raghoebar GM, Timmenga NM, Reintsema H,
Stegenga B, Vissink A. Maxillary bone grafting for
the insertion of endosseous implants: Results after
12-.124 months. Clin Oral Implants Res
2001;12:279-286.
22. Sullivan SM, Bulard RA, Meaders R, Patterson
MH. The use of fibrin adhesive in sinus lift
procedures. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1997;84:616-619.
23. Block MS, Kent JN. Bone maintenance 5 to 10
years after sinus grafting. J Oral Maxillofac Surg
1998;56:706-714.
24. Aust R, Drettner B. Oxygen tension in the
human maxillary sinus under normal and
pathological conditions. Arch Otolaryngol
1974;78:264-269.
81
Abstract
Cone beam computed tomography를 통해상악동 거상술 시행한 환자에서 상악동구 직경 변화에 한 연구
장호열, 소승걸, 박재봉, 김현철, 박일해, 이상철
리빙웰 치과 병원, 리빙웰 치의학 연구소
상악동은 관골 돌기부터 비강에 이르는 상악체 속에 존재하는 피라미드형의 빈 공간이다. 상악동은 비강
외벽의 전상방에 존재하는 상악동구를 통해 중비도로 개구된다. 퇴축된 상악 구치부의 무치악부에서
lateral window를 통해 상악동 거상술을 시행하고 임프란트를 식립하는 술식은 보편화된 방법이다. 하지
만 상악동 거상술 시 점막의 손상이나 술 후 부종으로 인해 상악동구의 개방성이 감소되거나 폐쇄될 수
있고 심할 경우 상악동염과 같은 술후 합병증을 유발할 수 있다. 본 연구에서는 술 전 술 후의 CBCT 상
의 분석을 통해 상악동 거상술을 시행한 환자의 상악동구의 직경의 변화를 측정한 결과 또한 임프란트
시술 전 술 후 상악동염의 발병율의 위험을 높이는 상악동 질환의 존재 여부에 한 확인의 중요성에
해 고찰하고자 한다.