Sinus floor augmentation

Dr Alon Schifter
Dr Kars Sivan

M.I.S - Romania

Implant insertion in the posterior region of the

maxilla is a challenging procedure. The reduced
bone quantity and low bone quality are limiting
factors. However, existing proven treatment
modalities make treatment in this region as
.predictable as in any other intraoral region

Bryant SR. The effects of age ,jaw site, and bone condition on oral
implant outcomes, Int J Prosthodont 1998 ; 11: 470-490
Truhlar RS, Orenstein IH, Morris HF, Ochi S. Distribution of bone
quality in patients receiving endosseous dental implants. J Oral
Maxillofac Surg 1997 ;
55: 38-45

Treatment planning for sinus graft

cases
Presurgical osseous bed and the appropriate
grafting mode assessment
Evaluation of the alveolar relation and correct
placement of implants
Correct treatment plan sufficient number of
implants , length & width of implants for a
correct rehabilitation

The maxillary sinus

Anatomical considerations expansion of the maxillary

sinus

The maxillary sinus

(1) is the largest of
the four paranasal
sinuses along with
the frontal (2),
ethmoid (3) and
sphenoid (4).

Anatomical considerations expansion

of the maxillary sinus
The initial maxillary
sinus formation
begins in the fetus
and completes at the
age of 16-18 y.

Anatomical considerations expansion

of the maxillary sinus
The fourth expansion
phenomenon of the
maxillary sinus
occurs with the loss
of the posterior
teeth .

Anatomical considerations evolution

of posterior maxilla with loss of teeth
The height of the
posterior maxilla is
reduced greatly as a
result of dual
resorption from the
crest of the ridge and
pneumatization of the
maxillary sinus after
tooth loss.

Anatomical considerations special

considerations for the posterior maxilla
1.
2.
3.

Natural dentition
The largest diameter teeth
The greatest number of roots
The greatest amount of root surface area

Anatomical considerations special

considerations for the posterior maxilla

Anatomical considerations special

considerations for the posterior maxilla
1.
2.
3.

Bone quality
Poorest bone quality
Reduced bone density
Reduced contact
surface between bone
and tooth/implant

Anatomical considerations evolution of

posterior maxilla with loss of teeth
The width of posterior
maxillary bone and
density decreases at a
more rapid rate than any
other region of the jaws

Special considerations for the

posterior maxillary region
1. Early loss of teeth
2. Rapid horizontal and vertical resorption of
3.
4.
5.

the edentulous ridge

Pneumatization of the maxillary sinus
Poor bone quality
Poor implant / crown ratio

Pneumatization of the maxillary sinus

Radiologic evaluation

C.T SCAN

Treatment options for

posterior maxilla

Treatment history of posterior maxilla

literature review
Avoid the sinus and place implants ant., med., post.
(Linkow 1980, Ashkinazy 1982)

Place implants and perforate sinus floor

(Geiger 1977, Branemark 1984)

Use subperiostal implants

(Linkow 1980, Cranin 1985)

Horizontal osteotomy, interpositional bone grafting and endosteal

implants (Keller 1987, Sailer 1989)
Elevate sinus during implant placement

(Tatum 1981/86, Misch 1987)

Lateral wall approach, sinus graft , and simultaneous implant

placement
(Lozada 1993, Whittaker 1989, Misch 1990/93/95)

Sinus floor elevation from a crestal approach

(Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compendium 1994; 15: 154-156)

Sinus floor augmentation options

Lateral wall approach (OSFE)
Sinus floor elevation from a crestal
approach (CSFE)

Lateral wall approach

0pen sinus floor elevation (OSFE)

Sinus grafting aims to restore

the resorbed posterior maxilla
to allow placement of stable
dental implants through the
dynamic process of
osseointegration

Treatment history of posterior maxilla

literature review
The lateral maxillary
approach was
developed by Tatum in
1974 using autogenous
bone and expanded in
1980 by using synthetic
bone

Treatment selection subantral

classification
In1984 Misch
presented four
subantral treatment
options based on the
amount of bone
bellow the maxillary
sinus

Treatment selection subantral

classification (Misch 1984)
Healing time
graft (m.)

Healing time
implant (m.)

Treatment

Height(mm)

Procedure

SA-1

>12

Implant
placement

4-6

10-12

Osteotome sinus
lift & implant
placement

6-8

5-10

Lateral wall sinus

graft & implant
placement

SA-2

SA-3

SA-4

<5

Lateral wall sinus

graft / implant
placement

2-4

4-8

6-10

4-10

Treatment selection subantral

classification (Misch 1984)

SA-1 sufficient
available bone height
permits standard
protocol implant
placement

Treatment selection subantral classification

(Misch 1984)

SA-2 bone height

between 10-12 mm ,
sinus floor lift with
osteotomes followed
by implant
placement

Treatment selection subantral

classification (Misch 1984)
SA-3 bone height
between 5-10 mm ,
Tatum lateral
maxillary wall
approach with or
without immediate
implant placement

Treatment selection subantral

classification (Misch 1984)
SA-4 bone height
less than 5 mm ,
Tatum lateral
maxillary wall
approach preferred
with delayed implant
placement

Surgical phase

Lateral window approach

Instruments for the lateral approach

Flap design for lateral approach

Lateral wall osteotomy

With a round bur until the dark inner lining of
the sinus is seen
Round or oval design is preferred
About 3mm of bone between the inferior
border and the crest of the ridge
The size of osteotomy should permit easy
access to the Schniderian membrane
Elevation of the membrane should be
2-3mm above the length of the implant

The lateral approach

The lateral approach

The lateral approach

The lateral approach

The lateral approach

The lateral approach

The lateral approach

Sinus septum

Sinus septum

Grafting materials
Autogenous bone oral origin, iliac crest,
calvaria, ribs
Allograft FDBA, DFDBA
Xenograft bovine bone ( Bio Oss)
BTCP + Hydroxyapatite 4Bone by MIS
Collagen membranes

Osseointegration graft
consolidation bone regeneration

Vital host vascular bed is mandatory for bone

regeneration and graft consolidation
Migration of osteogenic cells
Formation of graft woven bone complex
Remodeling into lamellar bone

Bone graft healing

1.
2.
3.
4.

Incorporation cellular proliferation, migration,

differentiation, gene expression and adhesion
Replacement basic multicellular unit (BMU)
remodeling begins to replace the graft-woven bone
complex with lamellar bone
Modeling the process that reshapes the graft
woven and lamellar bone internally and externally
to satisfy the functional needs
Regional acceleratory phenomenon (RAP) the
process begins at day of surgery and lasts 2 y, and
accelerates all phases of healing

Membrane placement over lateral

window
An effective barrier over the lateral window as to
exclude the connective tissue from the wound and
graft material
Nonresorbable , long and short term bioabsorbable
collagen membranes, synthetic , titanium mesh or
repositioned original lateral bony wall
The membrane should cover the window by 3-5 mm
and should avoid placement under the incision lines

Preparing the patient, the staff

and the operatory for surgery

Preoperative medications

Antibiotics ( broad spectrum)

Steroids ( 3 days postop. treatment)
Analgesics ( NSAIDs)
Antiseptic mouth wash
( 0.2% chlorhexidine gluconate )

Sinus elevation procedure and

implant placement

case #1

case #2

Sleeper one

Sleeper one

Well be back in 9 months!!

Post surgery instructions

Avoid eating and drinking for 2 h .
Avoid spitting and washout of the oral cavity
for 24 h.
Avoid hot drinks and meals for 24 h.
Avoid any physical effort for 24 h.
Medications should be taken promptly.
Sutures should be removed 10 - 14 days after
surgery.
Patient could experience nasal bleeding

Contraindications and
complications

Contraindications to sinus grafting

1.
2.
3.
4.
5.
6.
7.

Severe deformities of the maxillary sinus

Scarred or hypofunctional sinus mucosa following
trauma or previous operation
Radiotherapy of the head and neck
Chronic recurrent sinusitis ( relative )
Local expression of a systemic granulomatous
disease
Benign but locally aggressive tumor
Malignant tumor

Thickened sinus membrane

consistent with chronic sinusitis

Bacterial sinusitis (left) and mucus

retention cyst (right)

Mucus retention cyst

Pseudocysts

Intrasinusal osteoma

Intraoral contraindications
Inadequate oral hygiene
Untreated periodontal disease
Gross malocclusion and insufficient freeway
space for restoration
Parafunctions
Mucosal disease
Severe xerostomia

Complications

Blood supply to the buccal antral

wall

Graft infection

Purulent exudate

Graft infection and breakdown

Oroantral fistula

Other complications
Dehiscence of oral mucosa
Profuse bleeding during surgery
Implant migration
Hematoma
Suture abscess
Adjacent tooth sensitivity
Loss of bone graft

Schneiderian membrane
perforations treatment

Small perforations will generally close by

self folding of the membrane as it is being
raised
Larger perforations will not close and must
be treated

The lateral approach

Small membrane tear

Large membrane tear

Membrane perforation

Membranes for perforation repair

Perforation of the sinus membrane is a common
complication , 10-44% are reported
Repairing perforations technique include
suturing , patching with biomaterials the most
common is bioabsorbable collagen membrane
The purpose of the repair is the containment of
the particulate graft material

Implant migration

Implant migration

Crestal sinus floor elevation

( CSFE)

Summers presented in 1994 a less invasive procedure for

sinus floor elevation with immediate implant placement
characterized by the use of specific root analog instruments osteotomes

Summers RB. A new concept in maxillary implant surgery: The

osteotome technique. Compendium 1994; 15: 154-156

The osteotome technique was

developed to:

1. To compress soft maxillary bone

2. Improved initial fixation
3. Better primary stabilization
4. The key to osseointegration !!!

The Summers technique

Uses root analog instruments osteotomes
The Schneiderian membrane is elevated using these
osteotomes from a crestal approach
No preparation of lateral window
Auxiliary bone addition which can reduce the risk of
perforating the membrane during elevation
The bone of the alveolar crest is condensed and the
primary stability of implants can be improved

The biologic principle of bone

compression osteoplasty
Osseous deformation and trabecular
microfracture
Increased mineral density intra-alveolarly
The increased mineral density becomes
mechanically and biologically operative

Surgical bone compression

First presented in 1993
Uses a set of osteotome instruments with
tapered shape and concave tips
The intention is to conserve bone by
displacing it laterally to form a dense wall (in
contrast to drilling)

Osteotomes

Osteotomes

The ostetome technique

Osteotome bone condensation
Ridge expansion osteotomy
Osteotome sinus floor elevation
Bone added osteotome sinus floor elevation

Osteotome bone condensation

Osteotome sinus floor elevation

Bone added osteotome sinus floor

elevation
Bone particles and trapped fluid create a
hydraulic effect thus moving the sinus wall and
membrane upward
The technique ensures accurate control over the
height of the grafted space
With the osteotome technique the sinus floor can
be elevated from 3-7 mm with simultaneous
placement of implants
A minimum pretreatment bone height (4-5 mm) is
needed to ensure adequate fixation of the
implant in the residual bone ( tapered implants
preferred)

Osteotomes

Bone compression kit

Bone compression kit

Advantages of
Bone Compression Kit
Less traumatic to the patient compared to
osteotomes
Better controlled by the operating surgeon
Predictable results
Calibrated diameter with the dental
implants

Gold rules for OSFE

High success and survival rates could be found
for all implant types tapered implant shape
could be beneficial for primary stability
The pretreatment bone height should be at least
5mm ( 3mm ?) implant success is reduced
with lower bone quantity
Submerged or non submerged implants showed
the same healing conditions and long term
success

OSFE compared to CSFE

CSFE is performed when residual bone height is
5mm or more OSFE can be performed with
less than 3mm bone height
With CSFE only single implants are placed
with OSFE multiple implants can be placed
The different sinus elevation technique do not
seem to affect the implant success rate

The sinus consensus conference of

:1996 concluded
The sinus graft should be considered a highly
predictable and effective therapeutic modality
For the lateral window approach implant survival
rate was similar for different grafting materials
(autogenous, ha+autogenous, dfdb+ha, ha
alone)
Implants placed with the osteotome sinus lift
performed better than implants placed in type
III IV bone

Implant & surgical considerations

for the posterior maxillary region
1.
2.
3.
4.
5.
6.
7.

One implant for each missing tooth

At least 4mm diameter implants, 5mm implants are
recommended
Implant length recommended > 13mm
Threaded design implants 30% greater surface
area , surface treated
If primary stabilization achieved, use immediate
implantation
Multiple implants splinted by prosthetic rehabilitation
No prosthetic connection between implants and teeth

Implant & surgical considerations

for the posterior maxillary region
8. Prepare osteotomy smaller then implant
diameter
9. Condense bone with osteotomes or with
the
bone compression kit
10. Primary closure of the flap, tension free
sutures
11. Integration period between 10-12 m
12. Progressive loading rehabilitation

The sinus graft procedure is the

most predictable method to grow
bone height for implant
reconstruction of posterior maxilla

THANK
YOU
MIS - Romania