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Maxillary sinus floor elevation

Maxillary sinus augmentation

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Maxillary sinus floor elevation

  1. 1. Sinus Floor Elevation Procedures Registrar: Dr Rakesh Chandran Supervisor: Dr Yusuf Jadwat
  2. 2. • ANATOMY OF THE MAXILLARY SINUS • MEDICATION • SINUS FLOOR ELEVATION PROCEDURES • POST SURGICAL INSTRUCTIONS • COMPLICATIONS • REVIEW OF THE LITERATURE PRESENTATION OUTLINE
  3. 3. 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
  4. 4. 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
  5. 5. • 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
  6. 6. • 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
  7. 7. 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.
  8. 8. 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.
  9. 9. The courses of the intra osseous branch of the posterior superior alveolar artery Straight (78.1%) U-shaped (21.9%) Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg.
  10. 10. 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. Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg.
  11. 11. VENOUS DRAINAGE Anterior facial vein Pterygoid venous plexus LYMPHATIC DRAINAGE Submandibular lymph node NERVE SUPPLY Maxillary division of trigeminal nerve (V2)
  12. 12. ABSOLUTE LOCAL CONTRAINDICATIONS • local aggressive benign tumours • malignant tumours • large maxillary cysts • acute sinusitis • allergic rhinitis
  13. 13. 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
  14. 14. Systemic antibiotic prophylaxis No allergy to penicillin Augmentin 825mg/125mg. One tablet twice daily starting 1 day before/ 5 days after Non anaphylactic allergy to penicillin Cefuroxime axetil 500mg. (Cephalosporin) One tablet twice daily starting 1 day before/ 5 days after Anaphylactic reaction to penicillin Levofloxacin 500mg. (Fluoroquinolone) One tablet starting 1 day before/ 5 days after Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008
  15. 15. Antibiotic in graft Cefazolin (1gm) dilute with 2ml saline (cephalosporin) 100mg add to collagen membrane 400mg add to graft material Clindamycin 150mg/1ml 30mg add to collagen membrane 120mg add to graft material Capsules and tablets should not be used as they contain fillers that are not conducive to osteogenesis. Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008
  16. 16. Glucocorticoid medication Dexamethazone (4mg) Two tablets in the morning the day before and day of surgery One tablets in the morning for 2 days after surgery Decongestant medication Oxymetazoline 0.05% (Vicks) Analgesic medication Analgesic containing codeine as codeine is a potent antitussive. Cryotherapy Ice or cold dressings for the 24 to 48 hours Then heat applied to increase blood and lymph flow Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008
  17. 17. SINUS FLOOR ELEVATION TECHNIQUES LATERAL WINDOW TRANSCRESTAL APPROACH
  18. 18. 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.
  19. 19. 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)
  20. 20. 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) SINUS FLOOR ELEVATION TECHNIQUES
  21. 21. 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.
  22. 22. LATERAL WINDOW APPROACH Pjetursson BE., Lang NP. Clinical Periodontology and implant Dentistry. 2008 Removal of cortical bone 1. Round bur 2. Ultrasonic instruments 3. Piezoelectric 4. Trephine
  23. 23. LATERAL WINDOW APPROACH- ANTRAL MEMBRANE BALLOON ELEVATION Soltan M., Smiler DG. Antral membrane balloon elevation. Journal of oral Implantology. 2005
  24. 24. TRANSCRESTAL APPROACH- SUMMERS TECHNIQUE Pjetursson BE., Lang NP. Clinical Periodontology and implant Dentistry. 2008 X Larger diameter osteotomes
  25. 25. TRANSCRESTAL APPROACH- MODIFIED SUMMERS TECHNIQUE Davarpanah M et al., 2011. The Modified Osteotome Technique. Int J Periodont Rest Dent
  26. 26. TRANSCRESTAL APPROACH- HYDRAULIC PRESSURE- SALINE
  27. 27. Do not blow your nose Do not use tobacco Do not drink with a straw Do 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
  28. 28. INTRA-OPERATIVE COMPLICATIONS 1. Sinus membrane perforation (10 to 20%) 2. Excessive bleeding (bony window/ sinus membrane/wound dehiscences) 3. Injury of the infraorbital neurovascular bundle 4. Implant migration 5. Hematoma 6. Adjacent tooth sensitivity POST-OPERATIVE COMPLICATIONS 1. Infection of the grafted sinus (3-7 days post-op) (3%). 2. Sinusitis COMPLICATIONS
  29. 29. Confounding factors Study design Patient factors (age, gender, health, SES, hygiene….. Operator factors (experience, techniques….. Regenerative material properties Follow up period Implant properties LITERATURE REVIEW Up to 1996?? Currently used
  30. 30. 4th ITI Consensus conference on Sinus Floor Elevation Procedures, 2008 ITI Treatment Guide (Volume 5) Review published 2011 with updated literature Jensen SS. LITERATURE REVIEW
  31. 31. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Technique Study characteristics Implant survival Lateral window technique 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%
  32. 32. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Lateral window technique Study characteristics Implant survival Bone substitute only 19 studies,740 patients, 2481 implants, after 12 to 107 months loading 82% to 100% Excluding smooth surface 88.6% 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 surface 96% to 100%
  33. 33. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 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
  34. 34. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Lateral window technique Implant survival Implant survival Excluding 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%
  35. 35. LITERATURE - TRANSCRESTAL TECHNIQUE Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Transcrestal technique Study characteristics Implant survival Without grafting material 8 studies, 249 patients, 443 implants after 12 to 36 months of loading 91.4% to 100% Deproteinised bovine bone mineral (DBBM) 4 studies, 122 patients, 195 implants after 12 to 45 months of loading 95% to 100% Autologous bone 2 studies?, 489 patients, 771 implants after 20 to 54 months of loading 93.8% to 97.8%
  36. 36. • 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.
  37. 37. Thank you

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