Subantral Option 1 : Conventional Implant Placement

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MAXILLARY SINUS AUGMENTATION
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• Maxilla is 35 times more edentulous than mandible
• Maxillary sinus continues pneumatization
  throughout life.
• The available bone is lost from the inferior
  expansion of the sinus after tooth loss,
  involving the residual ridge region
• The bone density in this region is also decreases
  rapidly an on average is the least dense of any
  oral region

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Neurovascular supply

• Blood supply is mainly derived from nose
• Sphenopalatine artery
• Anterior posterior nasal artery
• Infraorbital artery
• Posterior middle superior alveolar artery
• Facial artery
• Palatine artery

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• Venous drainage
• Anterior facial vein
• Pterygoid veinous plexus
• Lymphatic drainage
• Submandibular lymphnode
• Nerve supply
• Maxillary division of trigeminal nerve (V2)

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Maxillary Sinus Anatomy

• Pyramidal shape
• Roof floor of orbit
• Floor alveolar bone and
  palatine process
• Anterior wall facial surface of
  maxilla
• Posterior wall infratemporal
  surface
• Medial wall lateral wall of
  nasal cavity

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Sinus membrane

• Schneiderian membrane
• Mucoperiosteum cansists 3 layers
• 1.Epithelium lining pseudostratified columnar
  ciliated epithelium
• 2.Lamina propria can stripped easily
  from
• 3.periosteum underlying bone
• There are numerous globlet cell
• Most of the serous and mucous glands found in the
  lining are located near the maxillary ostium

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• The maxillary ostium
  opening in the medial wall
  and near the superior
  aspect of the sinus
• The cilia beat toward the
  ostium at 15 cycles/minute
• Adequate manipulation of the membrane and
  placement of graft material are possible without
  impeding the drainage of the sinus

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Treatment planning for edentulous posterior
maxilla
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Patient evaluation

• The SA-2 to SA-4 surgical procedures the sinus
  should be free of infection
• In addition, a thorough history and clinical
  evaluation of the maxillary sinus are conducted.
• Potential infection in the region of the sinuses
  may result in extremely severe complication

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• Physical examination
• Radiography
• Conventional OPG, waters view
• CT
• MRI
• CT is currently the modality of choice
• Any sign of acute sinusitis, root tips, cysts or
  tumors complicate the procedure and mandate
  further evaluation
• Known diseases of the antrum should be treated
  before sinus grafts

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Premedications
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Surgical technique

• Patient sedation, local anesthesia, and
  preparation of an aseptic environment
• Antiseptic mouth rinse Chlorhexidine scrub and
  rinse may be used
• Iodophor compounds ( Betadine ) are a most
  effective antiseptic, but inhibit the
  osteoinduction of demineralized bone

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• Regional anesthesia
• Blocking maxillary nerve (v2 ) 1.8 ml
• Hemimaxilla, side of nose, cheek, lip, sinus area
• Long-acting anesthetic Bupivacaine 0.5 or
  Etidocaine 1.5 with EPI 1200,000
• Local infiltration
• Labial mucosa and palatal region
• Complete hemostasis
• Lidocaine 2 with EPI 1100,000

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Bone density classification

• 1. dense compact (D-1) bone
• 2. dense to thick porous compact and coarse
  trabecular (D-2) bone
• 3. porous compact and fine trabecular
  (D-3) bone
• 4. fine trabecular (D-4) bone

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Division of available bone
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Subantral Option 1 Conventional Implant
Placement

• Height gt 12 mm.
• An improved compressive thread design implant (4
  mm. diameter) implants may accommodate
• 11 mm. of bone height in D2,
• 12 mm. in D3,
• 13 mm. in D4
• In division A, root form implants are placed for
  prosthetic support
• Division B bone, osteoplasty or augmentation to
  increase the width to Division A

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• Then reevaluated to determine the proper
  treatment plan classification
• Remain 1-2 mm. short of the sinus floor is not
  indicated in the posterior maxilla
• Endosteal implantation in the SA-1 category are
  left to heal in a nonfunctional environment for
  approximately 4 to 8 months before the abutment
  posts are added for prosthodontic reconstruction

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Subantral Option 2 Sinus lift and Simultaneous
Implant Placement

• Height 10 12 mm.
• When the available bone is 0 to 2 mm.
  Insufficient in length for ideal implant length
• Incision and Reflection
• A full thickness incision is made on the crest of
  the ridge from the tuberosity to the distal of
  the canine region and vertical incision 5 mm.

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• Osteotomy and Sinus lift ( SA-2 )
• The depth of the osteotomy is approximately 1 to
  2 mm. short of the floor of the antrum
• Reduced speed of the hand piece ( slower than
  1000 rpm ) enhances the tactile sense and feel
  the cortical plate of the antral floor

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• The osteotome is inserted and tapped firmly into
  final position up to 2 mm.
• The apical portion of the implant engages the
  cortical floor, with bone over the apex, and an
  intact sinus membrane

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• The patients prosthodontic treatment is similar
  to that in the SA-1 category
• The implant body should not have an apical hole,
  which also may fill with mucous and be a source
  of further sinus infections

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Subantral Option 3 Sinus graft with delayed
endosteal implant placement

• Height 5 10 mm.
• Incision line and reflection
• Awareness of the greater palatal artery, in the
  severe atrophic maxilla
• A relief incision enhance access and vision
• Aggressive reflection of the flap may cause
  damage to infraorbital nerve

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• Access window
• 6 round diamond bur
• Copious sterile saline
• The outline is scored on the bone with a rotary
  instrument

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• The corners of the access window are usually
  round
• paintbrush stroke approach until a bluish hue or
  hemorrhage from the site is observed
• A flat-ended metal punch or mirror handle and
  mallet are used to gently separate the lateral
  window from the surrounding bone, while still
  attached to the thin sinus membrane

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• A soft tissue curette is introduced along the
  margin of the window
• The curette is never blindly placed into the
  access window
• The periosteal elevators and curettes further
  reflect the membrane off, to a height of at least
  16 mm from the crest of the ridge

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Sinus graft materials

• Several graft materials have been studied
• Autogenous bone any debris from implant
  osteotomies, the tuberosity region, exostoses,
  cores from the symphysis or ramus region
• Demineralized freeze-dried bone (DFDB)
• Beta tricalcium phosphate
• Xenograft hydroxyapatite
• Combinations

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A layered-type graft

• 1. dense HA antibiotic
• 2. cacium phosphate (usually xenograft
  microporous HA such as Osteograft N-300 or
  Bio-Oss) DFDB PRP from whole blood
  antibiotic
• 3. autogenous bone

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• Graft materials not mixed with blood or
  anesthetic solution
• The toxic byproducts of blood catabolism and the
  acidic pH of anesthetic both may decrease bone
  formation
• A resorbable membrane may be placed over the
  lateral access window

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• The 5 to 8 mm of initial bone height may
  stabilize the implant and permit its rigid
  fixation
• An endosteal implant may be inserted at this
  appointment

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• Several advantages tend toward the decision to
  delay implant placement for approximately 4
  months
• Disadvantage of delaying the implant placement is
  the need for an additional surgery
• The implant may be inserted after 2 months yet
  reducing considerably the risk of infection

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• Primary closure using interrupted horizontal
  mattress or a continuous suture
• Sinus incision line opening may contribute to
  infection, contamination, or loss of graft
  materials

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• Healing for implants placed into sinus grafts
• The main variables appear to be the time healing
• The volume of the subantral graft
• The distance from the lateral to medial wall
• The amount of autologous bone
• The health status of the patient Diabetics,
  postmenopausal women
• All of which relate to the amount of new bone
  formation

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• Autogenous bone (4-6 months)
• Autogenous bone porous HA DFDB (6-10 months)
• Alloplasts only as tricalcium phosphate (24
  months)

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Subantral Option 4 Sinus graft and extended
delay of endosteal implant placement

• Height lt 5 mm
• There for the fewer bony walls, less favorable
  vascular bed, minimal local autologous bone, and
  larger graft volume
• Sinus graft is performed as in the previous SA-3
  procedure

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• Additional bone harvest site is usually required
  ascending ramus of mandible
• The implant does offer an advantage if coated
  with HA
• The time interval for rigid osseous fixation is
  dependent on the density of bone

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Postoperative instructions

• Do not
• blow your nose
• Tobacco use
• Drinking with straw
• lift or pull on lip to look at sutures
• Sneezing with closed mouth
• Take your medication as directed
• Aware of small granules in your mouth

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• Notify the office if
• You feel granules in your nose
• Your medications do not relieve your discomfort

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Perioperative complications

• Window
• Bleeding bone wax, electrocautery
• Septum make two windows seperated by septum
• Perforation repair after membrane elevation

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• Membrane
• Perforation repair
• Small collagen membrane (Collatape)
• Large slow resorbable membrane (Biomend)
• Thick
• Polyp curette out
• Mucocele drain
• Delay sinus graft

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Possible Complication - Small Perforation
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Possible Complication - Large Perforation
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Postoperative complicationShort-term
complications

• Incision line opening assess need to restore
• Bleeding (from nose) do not blow nose, do not
  lower head
• Graft escape through perforation, assess amount
  swelling/infection
• Antibiotic oral, IV
• Drain, remove graft
• Assess progression culture and sensitivity test
  anaerobes/aerobes
• Reassess antibiotic choice
• Refer

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Suggest pharmacologic protocal for sinus graft
infection

• Amoxicillin 2 g stat, 500 mg qid
• Metronidazole 500 mg stat, 250 mg tid
• or
• Clindamycin 300 mg stat, 150 mg qid

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Reference

1. Misch CE. Contemporary implant dentistry. Mosby
   1999.
2. Spiekermann H. Color atlas of dental medicine
   implantology, Thieme 1995.
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5. www.google.com

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Special thanks

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