Advanced surgery I Anatomy Sinus lift techniques Complications - - PowerPoint PPT Presentation

Advanced surgery I

Anatomy Sinus lift techniques Complications Theodora Kompotiati 09/23/2014

Anatomy of the maxillary sinus

Development of the maxillary sinus

• Begins to form in the fetus
• By 5 months has the size of a

pea

• Reaches adult size by 12-14

years

• Roots of max premolars and

molars in close proximity to the sinus

• Roots of 2nd molar nearest to

the sinus cavity (then those of 1st and 3rd molars)

Maxillary sinus

• Laterally directed pyramid,

25-35mm width 36-45mm height 38-45mm length

• Average volume 15-20 ml
• Ostium- average diameter

2.4mm (1-17mm)

Surgical complications in oral implantology, Quintessence 2011, Van den Bergh 2000

Osteomeatal complex

• A channel that links

the frontal sinus, ethmoid sinuses and maxillary sinus to the middle meatus that allows air flow and drainage

• Obstruction=infection

Anterior wall

• Cortical bone extending from the orbital

rim to just above the apex of the cuspid

• Infraorbital foramen (6-7mm below the
• rbital rim)
• Be aware of the foramen when

retracting the flap, no need for very high window preparations

Posterior wall

• Corresponds to pterygomaxillary

region which separates the antrum from the infratemporalfossa

• Vital structures: internal maxillary

artery pterygoid plexus, sphenopalatineganglion and greater palatine nerve.

• Should always be identified in

radiograph

• !!! Lack of posterior wall, pathologic

condition should be suspected

Superior wall

• Shared with the thin orbital floor
• Bony bridge present that houses the

infraorbital canal ( infraorbital nerve and vessels) Dehiscence may be present resulting in direct contact between infraorbital structures and sinus mucosa Sinus infections or neoplasms Proptosis, diplopia

Inferior wall

• Floor of the maxillary sinus
• Close relationship with apices of premolars

and maxillary molars

• In dentate patients the floor is

approximately at the level of the nasal floor

• In edentulous posterior maxilla the sinus

floor is 1cm below the level of the nasal floor

Medial wall

• Coincides with lateral wall of the nasal cavity
• In the superior aspect the ostium is located
• Ostium diameter in health averages 2.4mm.

Pathology 1-17mm

Lateral wall

• Posterior maxilla and zygomatic process
• Thickness varies from several mm in a dentate

patient to less than 1mm in an edentulous patient

Blood supply

• Maxilla is densely vascularized in young and

dentate patients

• Blood supply to bone is permanently reduced

with age, progressing atrophy and decrease in number and diameter of blood vessels

Blood supply

• Branches of maxillary

artery ØInfraorbital artery (IOA) ØPosterior superior alveolar artery ( PSAA)

Solar,1999

• 18 max segments, human

cadavers

• Extraosseous anastomosis

v8/18 of the specimens (44.4%) v23-26mm from the alveolar margin

• Intraosseous anastomosis

v100% v18.9-19.6 from the alveolar margin

Schneiderian membrane Blood supply

• PSAA
• IAO
• Intraosseous anastomosis of PSAA and IAO
• Sphenopalatine artery

Vascularization of the graft material into the sinus

• Intraosseous anastomosis
• Extraosseous anastomosis
• Vessels of the Schneiderian membrane

Innervation of maxillary sinus

• Maxillary nerve V2 (sensory)

Sensation to skin of midface, nasal and palatal mucosa, upper teeth and gingiva, lower eyelid

Branches of maxillary nerve

• Posterior,

middle, anterior superior alveolar nerve

• Greater palatine

nerve

• Infraorbital nerve

Septa

• First described by the

anatomist Underwood in 1910

• Known as Underwood’s septa
• Presence of septa can cause

complications during sinus elevation procedures

Ulm et al, 1995

• 41 edentulous maxillae
• Only lamellae ≥2.5mm in height considered septa
• Sinus floor with at least 1 septum –
• 1 septum- 26.8%, 2 septa- 4.9%
• 73.7% in anterior region (premolar), 19.9% in middle (1st

molar)and 6.6% in posterior (2nd molar)

• Mean height 7.9mm (highest 17mm)
• No correlation with residual bone height and incidence of

septa

31.7%

Pommer et al, 2012

• Systematic review
• 33 studies
• Sinus septa prevalence-
• 17.2% had bilateral septa
• 2 septa in same sinus-3.7%

3 septa in same sinus-0.5%

• 54.6% located at 1st and 2nd molar region
• mean height 7.5mm
• 99.7% of septa were incomplete
• Orientation (buccopalatal87.6%, mesiodistal 11.1%, parallel to sinus floor

1.3%)

• septa prevalence significantly lower in Asian population
• Septa prevalence significantly higher in edentulous ridges
• !!!!Diagnosis of sinus septa in PAN –incorrect results is

28.4% 29%

Maxillary Sinus Septa: Prevalence, Height, Location, and Morphology. A Reformatted Computed Tomography Scan Analysis

v Prevalence of one or more septa per sinus § 26.5% in the overall study population § 31.76% in the atrophic/edentulous maxilla § 22.61% in the non-atrophic/dentate maxillary segments v Anatomic location: § 25.4% were located in the anterior region § 50.8% in the middle region § 23.7% in the posterior region v Height of the septa varied among the different areas § 1.63– 2.44mm lateral area § 3.55– 2.58mm middle area § 5.46– 3.09mm medial area

Kim et al 2006

Sinus membrane

• Epithelial cells are a continuation of

the nasal mucosa

• Pseudostratified, ciliated, columnar

epithelium

• 5 types of cells: 1)ciliated columnar

2)non ciliated columnar 3) basal cells 4) goblet cells and 5) seromucinous cell

• Ciliated cells contain 50 to 200 cilia

per cell- help clear mucus

• Goblet cells produce glycoproteins-

viscosity and elasticity of the mucus produced

• Thickness of membrane: 0.3-0.8mm

Maxillary sinus bacterial flora

• Normal sinuses- non sterile
• 62.3% exhibited bacterial colonization

² Strep viridans ² Staph epidermidis ² Strep pneumoniae

• Culture findings from secretions in acute sinusitis

² Strep pneumoniae ² Strep pyogenes ² Haemophilus influenza

Misch, 3rd edition

CT SCAN

• Air: black

(radiolucent)

• Bone: white

(radiopaque)

• Fluid: varying degrees
• f gray
• Sinus membrane:

Normal-invisible Inflamed- varying degrees of gray

CT SCAN

• First thing we look is if

the ostium is patent

Anatomical variants

• Skeletal and bony abnormalities may

compromise the patency of the ostium and cause post-operative complications

Nasal septum deviation

• 70% of the population
• ver 14 years old
• Extreme cases may
• bstruct the
• steomeatal unit and

increase the risk of sinusitis after graft

Middle turbinate variants

• Middle turbinate:

significant role in proper drainange of maxillary sinus

• Concha bullosa:

pneumatization within the middle turbinate, may

• cclude osteomeatal

complex (4-15% of the population)

• Paradoxically curved

middle turbinate: concavity towards the septum, decreasing the size of meatus

Deflected uncinate process

Big nose variant

• Inferior turbinate

and meatus pneumatization

• 3% incidence
• If unaware the

implants can be placed into the nasal cavity

• !!!Sinus graft is

contraindicated

Pre-operative sinus pathology

• Acute sinusitis
• Chronic sinusitis
• Fungal sinusitis
• Cystic stractures and mucoceles
• Neoplasms

Acute Sinusitis

• Haemophilus influenza, Moraxella catarhallis,

Streptococcus preumoniae

• Fever, foul rhinorrhea or postnasal drainage,

facial pain/swelling

• Dental pain is common (sinus proximity)

!!!! Sinus surgery is strongly contraindicated

Radiographic appearance

• Air-fluid level
• If patient is supine the

fluid will accumulate in posterior area

• Thickening of

membrane

• Severe conditions- sinus

appears completely

• pacified

Acute bacterial sinusitis Amoxicillin 500mg tid 10-14 days Acute bacterial sinusitis with allergy to pen Trimethoprim- sulfamethoxazole

• r

1 double-strength tablet(160/800mg) bid 10-14 days Azithromycin Clarithromycin 500mg once daily 7-10days 500mg bid 10-14 days Acute bacterial sinusitis with antibiotic use in the past 4-6 weeks (or failure of the above meds) Amoxicillin-clavulanate

• r

875 mg bid 14-21days Fluoroquinolone: Ciprofloxacin Levofloxacin Moxifloxacin 750mg bid 10-14 days 500mg once daily 10-14days 400mg once daily 10-14days Acute bacterial sinusitis with suspected odontogenic origin Clindamycin

• f

300mg qid 14-21 days Metronidazole 500mg bid 14-21 days Al-Faraje 2011

Chronic sinusitis

• Not infection, chronic inflammation
• Diagnosis: pt must have had symptoms for at

least 12 weeks

• Congestion, nasal obstruction, sinus pressure,

postnasal drainage, fatigue, decreased sense

• f smell
• CT: mucosal thickening or sinus opacification
• Anterior rhinoscopy: swelling, thick drainage,

polyps

• !!!sinus augmentation will not initiate chronic

sinusitis, it may exacerbate the condition

Recommended treatment

• Corticosteroids
• Antihistamines
• Decongestants
• Leukotriene blockers
• Antibiotics (when bacterial infection occurs)

If medical therapy fails, ESS (endoscopic sinus surgery) may be required.

Fungal sinusitis

• Fungal ball
• Allergic fungal

rhinosinusitis

• Invasive fungal

sinusitis

Fungal sinusitis

• Fully opacified sinus
• Endoscopic sinus surgery

required

• Recurrence is common
• In invasive fungal sinusitis,

aggressive sx and antifungals are required

Any immunocompromised patient with facial pain, fever, and evidence of loss of sensation in the face, lips or palate should be considered to have invasive fungal sinusitis until proven

• therwise and sent directly to the emergency

room

Cystic structures and mucoceles

• Asymptomatic dome shape opacities
• Floor of maxillary sinus
• Pseudocysts(subperiosteal accumulations)
• Mucus retention cysts
• Mucoceles

Pseudocyst Mucocele

Neoplasms

• Squamous cell carcinoma-

most common malignant tumor of the maxillary sinus

• Sinus fully opacified
• Bony destruction rather than

expansion

• Nerve numbness
• Mobile teeth

When to refer?

Diagnosis Acute sinusisitis Failure of antibiotic therapy

• r complications

Chronic sinusitis Pre-op for control of inflammatory disease Pseudocyst/retention cyst Only if large enough to become obstructive Mucocele Pre-op for ESS Fungal Ball Pre-op for ESS Allergic fungal sinusitis Pre-op for ESS Invasive fungal sinusitis Emergency referral

Sinus elevation: Techniques

• Summer’s (internal osteotome-indirect)
• Caldwell-Luc (lateral window technique-direct)

• Internal Osteotome Technique

(Osteotomy & Sinus lift)

Invented by Summer 1994

Advantages

• Minimally invasive surgical procedure
• It improves the density of the maxillary bone,

which allows greater initial stability of implants

Summers suggested the crestal incision to be extended distally to the tuberosity area where autogenous bone can be harvested.

Summers RB. J Esthet Dent. 1998; 10(3):164-71. Sinus floor elevation with osteotomes.

Disadvantages

• Blind procedure
• The chances of achieving a sufficiently high

elevation with the osteotometechnique is limited.

• Higher chance of misaligning the long axis of

the osteotomeduring the sequential

• steotomy

Implant Dent. 2004 Mar;13(1):28-32. Maxillary sinus floor elevation: review of anatomy and two techniques. Woo I, Le BT.

Indications

• Single implant
• A minimum of 5mm of bone beneath the sinus is

required

• Rosen et al
• Toffler

10-20% increase in failures when residual bone ≤4mm

• Flat sinus floor, angulation of sinus floor can

increase the risk of perforation

Procedure

• Pilot bur to mark the implant site
• 2mm twist drill prepares the osteotomy 1-

2mm short of the sinus floor

• Final osteotomy width is sequentially obtained

remaining short of the sinus floor

• A flat-ended osteotome, the same diameter of the final osteotomy site, is

used within the site

• A surgical mallet is used to gently and slowly tap the osteotome1-2mm

through the sinus floor.

• Osteotomeraises the floor and 1-2mm of bone with the sinus mucosa
• ver the implant site.
• The implant is inserted into the osteotomy and extends 0-2mm above the

sinus floor.

Dome

Complications

• Tan et al, 2008

Systematic review 1776 implants, Osteotometechnique sinus membrane perforation rate 3.8% most common post-op complication: infection rate 0.8%

• Ferrigno, 2006:
• Perforation rate :2.2%
• Reiser, 2001:
• Perforation rate: 24%

• 30 healthy patients, ≤20 cig/day
• 36 implants Straumann implants (4.8x8,

4.8x10)

• Bio-Oss +autogenous
• Bio-gide (membrane perf)
• Perforation rate 2.8%
• Mean height gain 6 months post-sx-

4.08±1.31mm

Int J Oral MaxIllofac Implants 2012

• Cavicchia et al, suggested placement of

collagen tape into the osteotomy to help cushion the graft being tapped, prevent membrane perforation

Management

• Infection: antibiotics (augmentin,amoxicillin,

levofloxacin)

• if infection persists, refer to ENT
• If there is concern that graft is infected,

removal may be necessary

Membrane perforation

• Reiser et al:

Classification: Class I: ≤2mm with exposure of the implant into the sinus cavity and loss of doming Class II: ≥2mm Class I: Repair with collagen tape, prescribe antibiotics, antihistamines, decongestants. If bigger perforation is suspected, repair with collagen tape, graft and primary closure. Lateral window approach may be required for repair. No implant placement is recommended

Penarrocha-Diago, 2008 Benign paroxysmal vertigo Surgical trauma induced by percussion along with hyperextension of the neck can displace otolithsand result in vertigo Triggered by certain head movements in the plane of the posterior semicircular canals Incidence <3%, resolves itself within a month Symptoms are unpleasant, refer to ENT

Refer to ENT

• Diagnosis: Dix-Hallpike test (induce a rapid change

from the sitting position to the left or right head- hanging position)

• Treatment:

²Epley maneuver ² antivertigo drugs

• benzodiazepines (diazepam, clonazepam)
• antihistamines (meclizine, diphenhydramine)

Lateral Window technique

• Presented by Tatum in 1976
• Published by Boyne and James in 1980
• Modification of Caldwell-Luc procedure used to treat

maxillary sinusitis A defect was created in the inferior aspect of the anterior maxillary wall via a canine fossa approach and removed diseased mucosa from the maxillary sinus

Lateral window

• Pre-sx evaluation- CT scan
• Flap entry

(midcrestal/palatocrestal incision, anterior and posterior releasing incisions, FTF)

• Clinical inspection. In many

patients the lateral wall is thin and grayish-blue showing the circumference of the sinus

• Window preparation

Ø Large window for better access Ø 3mm from sinus floor and 3mm from anterior wall Ø Superior osteotomy-15mm from the crest Wallace et al, 2012

• Rotary technique (high speed hand piece,

diamond round bur preferred to carbide)

• Piezoelectric technique

²Less likely to damage blood vessels ²Less likely for perforation to occur

• DASK technique ( 6 or 8x4mm, dome shaped

drill)

PIEZO

DASK technique

Lateral window technique

• Outline of the

lateral window

• Deepen outline

with diamond bur until bluish hue of membrane is

• bvious
• Metal punch
• ver the lateral

wall-greenstick fracture the lateral window

• Sinus membrane

elevation

• Back rounded portion
• f the curette is

placed against the lateral window

• Sharp blade of the

curette against the inner wall and scrapes the membrane of the bone

• Bone graft
• Collagen

membrane

• PRGF

Dr Owens

Intraoperative complications-Lateral window

• Bleeding
• Perforation of the Schneiderian mebrane

Bleeding

• PSA artery, infraorbital artery
• Extraosseous anastomosis-flap elevation
• Intraosseous anastomosis- lateral window

preparation

• Possibility of bleeding from medial wall if

posterior nasal artery is damaged

Prevention- treatment

• Obtain pre-op CT scan images to locate vessel
• Visualize the vessel clinically
• Avoid the vessel when preparing the window
• Use piezoelectric surgery to avoid trauma to vessel
• Have materials on hand to control bleeding (bone wax,

electrocautery, local 1:50.000epi)

Membrane perforation

– Schwartz-Arad 2004, 36/81 (44%) – Chanavaz 1990 48/241 (20%)

• Retrospective study
• 127 patients, 202 SLs, 364 implants
• Membrane perforation 25.7% of SLs
• Most frequent was 1-3mm tears (14.9%)
• Most frequent post-op complication
• wound infection 7.1% of pts
• post-op sinusitis 3.9% of pts
• 85.1% of the SLs evolved without incident
• 14.9% of the SLs post-op complications (wound infection, abscess or dehiscence

with drainage)

• Complication rate smokers- 20.4%

non-smokers - 19.2%

Complication Rate in 200 Consecutive Sinus Lift Procedures: Guidelines for Prevention and Treatment

Vasquez, 2014

Membrane perforation prevention

• Knowledge of 3D sinus anatomy

²Thickness of crest and lateral wall ²Slope of the anterior sinus wall ²Membrane thickness ²Presence, size and location of septa

Piezoelectric surgery

• Decrease membrane perforation rate
• Wallace et al - 7% perforation rate
• Toscano et al – 3.6% perforation rate

Influence of anatomy on Schneiderian membrane perforation Cho et al 2001,

• 49 sinus procedures
• Pre-op evaluation with CT scan
• Group 1 : angle A≤30 degrees
• Group 2: 31≤ angle A≤60 degrees
• Group 3: angle A≥61 degrees

Perforation rates 37.5% (Group 1), 28.6% (Group 2), 0% (Group3)

Does membrane perforation affects implant survival?

• 12 patients, bilatetal SLs
• 1 site accidentally perforated
• Repair with collagen resorbable membrane
• Implants placed 6-9 months after graft
• Non-perf sites significantly more bone formation

(33.58% vs 14.17%)

• Implant survival
• Non perf 100%
• Perf 69.56%

Froum 2013,

• 40 treated sinuses (15 with perf/ 25 non-perf)
• Vital bone
• 26.3% in the perf sinuses
• 19.1 % in the non perf sinuses
• SDD
• Implant survival
• 100% in the perf sinuses
• 95.5% in the non perf sinuses
• NSSD

Membrane Perforation Classification

Fugazzotto

Class I: apical area, apical displacement of the membrane allows it to fold over itself, if concern present place collatape Class II: mesial and distal aspect u IIA: sinus cavity extends 4-5mm beyond

• perforation. Window is extended, exposing

intact membrane. If after reflection <3mm residual perforation use collatape. If >3mm, resorbable collagen membrane is used u IIB: no area exists to extend osteotomy to uncover intact sinus membrane. Upon reflection, perf gets bigger, need for new

• membrane. Resorbable collagen membrane

is inserted into the sinus window, with its ends extruding out of the window and secured with fixation tacks Class III: treated like Class IIB

I II III II Fugazzotto/Vlassis 2003, J perio

How to deal with septa?

• Lengthen the window in anterior posterior dimension for

access

• Use the septum as the posterior border of the preparation

if there is no need of augmentation further back

• Make two separate windows

• 144 sinus elevation procedures
• 328 implants
• Mean follow-up 48.4months
• Survival rate 93% up to 5 years
• Membrane perforation 28%

!!!Smoking >15 cig/day and residual bone height<4mm were significantly associated with reduced implant survival

POST-OP COMPLICATIONS

• Incision line opening
• Nerve impairment
• Acute infection/sinusitis
• Early implant migration into the sinus cavity
• Oroantral fistula

Acute sinusitis

• Most common post-op complication
• Tasoulis, 2011
• Incidence :2.9%
• Most often begins more than one week after

sx

• Symptoms: headache, fever, pain, congestion,

rhinorrhea, purulence post nasal discharge, halitosis, hyposmia or anosmia

Treatment

• Antibiotics (amoxicillin, augmentin, levaquin)
• Decongestants (patency of ostium)
• Nasal rinses with saline
• Analgesics

If no response to treatment, refer to ENT!!! Emergency consultation if patient complains about headache not relieved with analgesics, persistent high fever, lethargy, visual impairment or orbital swelling

Oroantral fistula

• Small (<5mm) will close spontaneously,

antibiotics and rinses with CHX

• Large (>5mm) will require additional surgical

intervention- rotated flap

References

• Solar P

, et al. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res. 1999 Feb; 10 (1):34-44.

• Ulm CW, Solar P

, Krennmair G, Matejka M, WatzekG. Incidence and suggested surgical management of septa in sinus-lift procedures. Int J Oral Maxillofac Implants. 1995 Jul-Aug;10(4):462-5.

• Pommer B, Ulm C, Lorenzoni M, et al. Prevalence, location and morphology of maxillary sinus septa:

systematic review and meta-analysis. J Clin Periodontol. 2012 Aug;39(8):769-73.

• Technique
• Misch, Resnik, Misch-Dietsh. Maxillary Sinus Anatomy, Pathology and Graft Surgery. (CH 38) pp 1055-1072.

Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.

• Wallace SS, Tarnow DP

, Froum SJ, Cho SC, Zadeh HH, Stoupel J, Del Fabbro M, Testori T. Maxillary sinus elevation by lateral window approach: evolution of technology and technique. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):161-71.

• Zhen F, Fang W, Jing S, Zuolin W. The use of a piezoelectric ultrasonic osteotome for internal sinus

elevation: a retrospective analysis of clinical results. Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):920- 6.

• Part IV Complications Associated with Lateral Window Sinus Elevation. pp 135-169. Surgical complications

in oral implantology : etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.

• Wallace, S. Complications in lateral window sinus elevation surgery. (CH16) pp 284-309. Dental Implant

Complications: Etiology, Prevention, and Treatment. Froum, SJ. 2010. Wiley-Blackwell.

• Rosen P

. Complications with the bone-added osteotome sinus floor elevation: etiology, prevention, and

• treatment. (CH 17) pp 310-324/
• van den Bergh JP

, ten BruggenkateCM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000;11(3):256-265

• implants using the alveolar expansion technique with osteotomes: A study of 4 cases. Int J Oral

Maxillofac Implants 2008:23:129-132

• Proussafs Repair of the perforated sinus membrane with a resorbable collagen membrane: A

human study Int J Oral Maxillof 2004.

• FugazzottoPA, Vlassis J. A simplified classification and repair system for sinus membrane
• perforations. J Periodontol. 2003 Oct;74(10):1534-41.
• Froum SJ, Khouly I, Favero G, Cho SC. Effect of maxillary sinus membrane perforation on vital bone

formation and implant survival: a retrospective study. J Periodontol. 2013 Aug;84(8):1094-9.

• ProussaefsP, Lozada J, Kim J, Rohrer MD. Repair of the perforated sinus membrane with a

resorbable collagen membrane: a human study. Int J Oral Maxillofac Implants. 2004;19(3):413-420.

• Cho SC, Wallace SS, Froum SJ, Tarnow DP, Influence of anatomy of Schneiderian membrane

perforations during sinus elevation surgery: three-dimensional analysis. Pract Proced Aesthet Dent 2001; 13:160-163.

• Vlassis JM, FugazzottoPA. A classification system for sinus membrane perforations during

augmentation procedures with options for repair. J Periodontol 1999;70(6):692-699.

• Testori T

, Weinstein RL, Taschieri S, Del Fabbro M. Risk factor analysis following maxillary sinus augmentation: a retrospective multicenter study. Int J Oral Maxillofac Implants. 2012 Sep- Oct;27(5):1170-6.

• Moreno Vazquez JC, et al. Complication rate in 200 consecutive sinus lift procedures: guidelines for

prevention and treatment. J Oral Maxillofac Surg. 2014 May;72(5):892-901

Thank you