Maxillary sinus floor elevation

Sinus Floor Elevation ProceduresRegistrar: Dr Rakesh Chandran

Supervisor: Dr Yusuf Jadwat

• ANATOMY OF THE MAXILLARY SINUS• MEDICATION• SINUS FLOOR ELEVATION PROCEDURES• POST SURGICAL INSTRUCTIONS• COMPLICATIONS• REVIEW OF THE LITERATURE

PRESENTATION OUTLINE

ANATOMY OF THE MAXILLARY SINUS

• Pyramidal in shape• Apex pointed towards the zygomatic bone• Volume in an adult ≈15ml (range 9ml to 20ml)

BASE- lateral wall of nose• (≈33mm X 33mm)• Base to apex ≈ 23mm• Sinus ostium is placed high and is in an

unfavourable position for gravity dependent drainage

ANATOMY OF THE MAXILLARY SINUS

SUPERIOR WALL- floor of the orbit• Infraorbital nerves and vessels

POSTERIOR WALL • internal maxillary artery, • pterygoid plexus, • sphenopalatine ganglion• greater palatine nerve

FLOOR- alveolar process of the maxilla

LATERAL WALL-facial surface of the maxilla• infraorbital foramen• thickness ranges from 0.5 to 2.5mm

• Also known as Underwood’s septa• Almost 30% of dentate maxilla have septa• 75% appearing in the premolar region. • Complete septa are very rare (1%)• Primary septa are developmental• Secondary septa are caused by irregular

pneumatisation following loss of posterior teeth

SEPTA

• 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

SCHNEIDERIAN MEMBRANE

VASCULAR SUPPLY

Anastomosis• Infraorbital• posterior superior alveolar artery.• posterior lateral nasal (medial aspect of the sinus).

The formation of the intraosseous and extraosseous anastomoses is termed the double arterial arcade.

Coronal sections

The intraosseous branch of the posterior superior alveolar artery most frequently runs through a bony groove inside the lateral wall of the maxillary sinus.

Rarely the artery may run within a bony canal.

Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg.

The courses of the intra osseous branch of the posterior superior alveolar artery

Straight (78.1%)

U-shaped (21.9%)


Mean and range values of the height of the IObr of the PSAA from the CEJ in mm.

The minimum mean height from the cervix to the IObr• 21.1mm in the first molar region• 26.9mm in the first premolar region

More precautions should be taken at the first molar region than the first premolar region.


VENOUS DRAINAGEAnterior facial veinPterygoid venous plexus

LYMPHATIC DRAINAGESubmandibular lymph node

NERVE SUPPLYMaxillary division of trigeminal nerve (V2)

ABSOLUTE LOCAL CONTRAINDICATIONS

• local aggressive benign tumours • malignant tumours • large maxillary cysts• acute sinusitis• allergic rhinitis

RATIONALE FOR ANTIBIOTIC PROPHYLAXIS

• Endoscopically normal sinuses were shown to be non sterile• Most common bacteria

• Streptococcus viridans• Staphylococcus epidermidis• Streptococcus pneumonia

• Sinus graft procedure often violate the sinus mucosa and bacteria may contaminate the graft site

RATIONALE FOR ANTIBIOTIC IN THE GRAFT• the bone graft is a dead space prone to infection• systemic antibiotic drugs do not enter the area until revascularization

Systemic antibiotic prophylaxis

No allergy to penicillinAugmentin 825mg/125mg.

One tablet twice daily starting 1 day before/ 5 days after

Non anaphylactic allergy to penicillinCefuroxime axetil 500mg. (Cephalosporin)

One tablet twice daily starting 1 day before/ 5 days after

Anaphylactic reaction to penicillinLevofloxacin 500mg. (Fluoroquinolone)

One tablet starting 1 day before/ 5 days after

Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008

Antibiotic in graft

Cefazolin (1gm) dilute with 2ml saline (cephalosporin)100mg add to collagen membrane400mg add to graft material

Clindamycin 150mg/1ml30mg add to collagen membrane120mg add to graft material

Capsules and tablets should not be used as they contain fillers that are not conducive to osteogenesis.


Glucocorticoid medicationDexamethazone (4mg)Two tablets in the morning the day before and day of surgeryOne tablets in the morning for 2 days after surgery

Decongestant medicationOxymetazoline 0.05% (Vicks)

Analgesic medicationAnalgesic containing codeine as codeine is a potent antitussive.

CryotherapyIce or cold dressings for the 24 to 48 hoursThen heat applied to increase blood and lymph flow


SINUS FLOOR ELEVATION TECHNIQUES

LATERAL WINDOW

TRANSCRESTAL APPROACH

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 autogenousmarrow 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 osteotometechnique. Compendium 15, 152–154–156, 158 passim; quiz 162.

ATROPHIC POSTERIOR MAXILLA

Favourable interarch relationship

Insufficient bone height for standard implant

Vertical bone height ≤6mm or oblique sinus

floor

Lateral window technique

Vertical bone height >6mm and horizontal

sinus floor

Transcrestal

TREATMENT GUIDELINES- INTERNATIONAL TEAM FOR IMPLANTOLOGY (ITI)

LATERAL WINDOW TECHNIQUESModified Caldwell-Luc approach (Tatum)Ultrasonic ostectomy (Torella)Piezoelectric bony window osteotomy (Vercellotti et al)Trephine (Emtiaz)Antral membrane balloon elevation ( Soltan and Smiler)

Other variationsHinge osteotomyElevated osteotomyCrestal osteotomy

TRANSCRESTAL APPROACH TECHNIQUESOsteotome technique (Summers)Modified osteotome technique (Davarpanah et al 1996)Hydraulic pressure- saline (Sotirakis and Gonshor)

SINUS FLOOR ELEVATION TECHNIQUES

LATERAL WINDOW APPROACH

Katsuyama H., Jensen SS. ITI Treatment Guide. Volume 5. 2011

Handling the cortical bone

1. fracture the cortical bony plate like a trap-door and use it as the new sinus floor, leaving it attached to the underlying mucosa.

2. removal of the cortical bone and use it as the new sinus floor- elevated osteotomy

3. removal of the bone by thinning it out.

4. remove the cortical bony plate and replace it on the lateral aspect of the graft at the end of the grafting procedure.

LATERAL WINDOW APPROACH

Pjetursson BE., Lang NP. Clinical Periodontology and implant Dentistry. 2008

Removal of cortical bone

1. Round bur2. Ultrasonic instruments3. Piezoelectric4. Trephine

LATERAL WINDOW APPROACH- ANTRAL MEMBRANE BALLOON ELEVATION

Soltan M., Smiler DG. Antral membrane balloon elevation. Journal of oral Implantology. 2005

TRANSCRESTAL APPROACH- SUMMERS TECHNIQUE

Pjetursson BE., Lang NP. Clinical Periodontology and implant Dentistry. 2008

X

Larger diameter osteotomes

TRANSCRESTAL APPROACH- MODIFIED SUMMERS TECHNIQUE

Davarpanah M et al., 2011. The Modified Osteotome Technique. Int J Periodont Rest Dent

TRANSCRESTAL APPROACH- HYDRAULIC PRESSURE- SALINE

Do not blow your noseDo not use tobacco Do not drink with a strawDo not lift or pull up the lip to look at the sutures Sneeze with the mouth open

Notify the office if • you feel granules in your nose

POSTOPERATIVE INSTRUCTIONS

INTRA-OPERATIVE COMPLICATIONS1. Sinus membrane perforation (10 to 20%)2. Excessive bleeding (bony window/ sinus membrane/wound dehiscences)3. Injury of the infraorbital neurovascular bundle4. Implant migration5. Hematoma6. Adjacent tooth sensitivity

POST-OPERATIVE COMPLICATIONS1. Infection of the grafted sinus (3-7 days post-op) (3%). 2. Sinusitis

COMPLICATIONS

Confounding factorsStudy designPatient factors (age, gender, health, SES, hygiene…..Operator factors (experience, techniques…..Regenerative material propertiesFollow up periodImplant properties

LITERATURE REVIEW

Up to 1996?? Currently used

4th ITI Consensus conference onSinus Floor Elevation Procedures, 2008

ITI Treatment Guide (Volume 5)Review published 2011 with updated literatureJensen SS.

LITERATURE REVIEW

LITERATURE REVIEW

Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011

Technique Study characteristics Implant survival


85 studies, 4807 patients, 14944 implants,after 12 to 107 months loading

Machined implant surfaces: 61.2% to 100%Rough surface implants: 88.6% to 100%

Transcrestal technique

18 studies, 1096 patients, 1744 implants,after 12 to 64 months loading

83% to 100%

LITERATURE REVIEW



Study characteristics Implant survival

Bone substitute only

19 studies,740 patients, 2481 implants,after 12 to 107 months loading

82% to 100%

Excluding smooth surface88.6% to 100%

Autograft only or combined with bone substitute

36 studies,1210 patients, 4218 implants,after 12 to 107 months of loading

61.2% to 100%

Excluding smooth surface96% to 100%

LITERATURE REVIEW


Lateral window technique Implant survival

Deproteinised bovine bone mineral (DBBM) 85% to 100%

Deproteinised bovine bone mineral (DBBM) and autograft 89% to 100%

Autologous block grafts (iliac crest)- simultaneous 61.2% to 92.2%

Autologous block grafts (iliac crest)- staged 76.9% to 94.4%

Hydroxyapatite (alloplast) 96% to 100%

Demineralized Freeze Dried Bone allograft and DBBM 82.1% to 96.8%

Without grafting material* 97.7% to 100%

* Three case series, implants acted as tent poles allowing the coagulum to occupy the space

LITERATURE REVIEW


Lateral window technique Implant survival Implant survivalExcluding smooth surface

Membrane over the lateral window 92% to 100% 92% to 100%

Without the use of a membrane 61.2% to 100% 93% to 100%

LITERATURE - TRANSCRESTAL TECHNIQUE


Transcrestal technique Study characteristics Implant survival

Without grafting material 8 studies, 249 patients, 443 implantsafter 12 to 36 months of loading

91.4% to 100%

Deproteinised bovine bone mineral (DBBM)

4 studies, 122 patients, 195 implantsafter 12 to 45 months of loading

95% to 100%

Autologous bone 2 studies?, 489 patients, 771 implantsafter 20 to 54 months of loading

93.8% to 97.8%

• Maxillary sinus elevation is a predictable technique.• Autogenous bone grafts were considered the gold standard – now allografts with

particulate autografts are associated with better implant survival rates (Esposito et al., 2006).

• Rough surface implants have more favourable clinical outcomes.• Simultaneous and delayed give equivalent results.

CONCLUSION

Jensen SS., Katsuyama H., 2011. ITI Treatment guide. Volume 5. Sinus floor elevation procedures.Testori T et al., 2009. maxillary sinus surgery and alternatives in treatment.

Thank you

Health & Medicine

Maxillary sinus floor elevation