Sinus lift

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Xray showing a sinus lift in the left upper jaw Sinus lift.gif
Xray showing a sinus lift in the left upper jaw
Sinus lift surgery, 3D Illustration Sinus lift.jpg
Sinus lift surgery, 3D Illustration

Maxillary sinus floor augmentation [1] (also termed sinus lift, sinus graft, sinus augmentation or sinus procedure) is a surgical procedure which aims to increase the amount of bone in the posterior maxilla (upper jaw bone), in the area of the premolar and molar teeth, by lifting the lower Schneiderian membrane (sinus membrane) and placing a bone graft. [2]

Contents

When a tooth is lost, the alveolar process begins to remodel. The vacant tooth socket collapses as it heals leaving an edentulous (toothless) area, termed a ridge. This collapse causes a loss in both height and width of the surrounding bone. In addition, when a maxillary molar or premolar is lost, the maxillary sinus pneumatizes in this region which further diminishes the thickness of the underlying bone. [3] Overall, this leads to a loss in volume of bone that is available for implantation of dental implants, which rely on osseointegration (bone integration), to replace missing teeth. The goal of the sinus lift is to graft extra bone into the maxillary sinus, so more bone is available to support a dental implant. [4]

Indications

While there may be a number of reasons for wanting a greater volume of bone in the posterior maxilla, the most common reason in contemporary dental treatment planning is to prepare the site for the future placement of dental implants.

Sinus augmentation (sinus lift) is performed when the floor of the sinus is too close to an area where dental implants are to be placed. This procedure is performed to ensure a secure place for the implants while protecting the sinus. Lowering of the sinus can be caused by: Long-term tooth loss without the required treatment, periodontal disease, trauma.[ citation needed ]

Patients who have the following may be good candidates for sinus augmentation.[ citation needed ]

It is not known if using sinus lift techniques is more successful than using short implants for reducing the number of artificial teeth or dental implant failures up to a year after teeth/implant placement. [4]

Technique

1) Edentulous area of two missing teeth is being prepared for future placement of dental implants with a lateral window sinus lift; incisions into the soft tissue are shown here. 2) The soft tissue is flapped back to expose the underlying lateral wall of the left maxillary sinus. 3) The bone has been removed with a piezoelectric instrument, exposing the underlying Schneiderian membrane, which is the lining of the maxillary sinus cavity. 4) Through careful instrumentation, the membrane is carefully peeled from the inner aspect of the sinus cavity. 5) The membrane has been reflected from the internal aspect of the inferior portion of the sinus cavity; one can now visualize the bony floor of the sinus cavity without its lining membrane (note the triangular ridge of bone within the sinus, known as an Underwood's septum). 6) The newly formed space within the bony cavity of the sinus yet inferior to the intact membrane is grafted with human cadaver allograft bone. The floor of the sinus will now be roughly 10mm or so more superior than it was before, providing enough room to place dental implants into the edentulous site. Lateral window sinus lift.jpg
1) Edentulous area of two missing teeth is being prepared for future placement of dental implants with a lateral window sinus lift; incisions into the soft tissue are shown here.
2) The soft tissue is flapped back to expose the underlying lateral wall of the left maxillary sinus.
3) The bone has been removed with a piezoelectric instrument, exposing the underlying Schneiderian membrane, which is the lining of the maxillary sinus cavity.
4) Through careful instrumentation, the membrane is carefully peeled from the inner aspect of the sinus cavity.
5) The membrane has been reflected from the internal aspect of the inferior portion of the sinus cavity; one can now visualize the bony floor of the sinus cavity without its lining membrane (note the triangular ridge of bone within the sinus, known as an Underwood's septum).
6) The newly formed space within the bony cavity of the sinus yet inferior to the intact membrane is grafted with human cadaver allograft bone. The floor of the sinus will now be roughly 10mm or so more superior than it was before, providing enough room to place dental implants into the edentulous site.

Prior to undergoing sinus augmentation, diagnostics are run to determine the health of the patient's sinuses. Panoramic radiographs are taken to map out the patient's upper jaw and sinuses. In special instances, Cone beam computed tomography is preferable to measure the sinus's height and width, and to rule out any sinus disease or pathology. [5]

There are several variations of the sinus lift technique.

Traditional Sinus Augmentation or Lateral Window Technique

There are multiple ways to perform sinus augmentation. The procedure is performed from inside the patient's mouth where the surgeon makes an incision into the gum, or gingiva. Once the incision is made, the surgeon then pulls back the gum tissue, exposing the lateral boney wall of the sinus. The surgeon then cuts a "window" to the sinus, which is exposing the Schneiderian membrane. The membrane is separated from the bone, and bone graft material is placed into the newly created space. The gums are then sutured close and the graft is left to heal for 4–12 months. [6]

The graft material used can be either an autograft, an allograft, a xenograft, an alloplast (a growth-factor infused collagen matrix), synthetic variants, or combinations thereof. [7] Studies indicate that the mere lifting of the sinus membrane, creation of a void space and blood clot formation might result in new bone owing to the principles of guided bone regeneration. [8] The long-term prognosis for the technique is estimated to 94%. [9]

Osteotome Technique

As an alternative, sinus augmentation can be performed by a less invasive osteotome technique. There are several variations of this technique and all originate from the original technique of Dr. Tatum, first published by Dr.s Boyne and James in 1980.

Dr. Robert B. Summers [10] described a technique that is normally performed when the sinus floor that needs to be lifted is less than 4 mm. This technique is performed by flapping back gum tissue and making a socket in the bone within 1–2 mm short of the sinus membrane. The floor of the sinus is then lifted by tapping the sinus floor with the use of osteotomes. The amount of augmentation achieved with the osteotome technique is usually less than what can be achieved with the lateral window technique. A dental implant is normally placed in the socket formed at the time of the sinus lift procedure and left to integrate with bone. Bone integration normally lasts 4 to 8 months. The goal of this procedure is to stimulate bone growth and form a thicker sinus floor, in order to support dental implants for teeth replacement. Sinus dimensions and shape significantly influence new bone formation after transcrestal sinus floor elevation: with this technique, the regeneration of a substantial amount of new bone is a predictable outcome only in narrow sinus cavities. During presurgical planning, bucco- palatal sinus width should be regarded as a crucial parameter when choosing sinus floor elevation with transcrestal approach as a treatment option. [11]

Dr. Bruschi and Scipioni [12] [13] described a similar technique (Localized Management of Sinus Floor or L.M.S.F.) that is based on a partial thickness flap procedure. This technique increases the malleability of the crestal bone and uses not the bone directly below the sinus, but rather the bone on the medial wall, and thus can be used in more extreme cases of bone resorption that would normally need to be treated with the lateral wall technique. The healing period is reduced to 1.5 to 3 months. Recently an electrical mallet [14] has been introduced to simplify the application of this and similar techniques.

Complications

A major risk of a sinus augmentation is that the sinus membrane could be pierced or ripped. Remedies, should this occur, include stitching the tear or placing a patch over it; in some cases, the surgery is stopped altogether and the tear is given time to heal, usually three to six months. Often, the sinus membrane grows back thicker and stronger, making success more likely on the second operation.[ citation needed ] Although rarely reported, such secondary intervention can also be successful when the primary surgery is limited to elevation of the membrane without the insertion of additional material. [15]

Besides tearing of the sinus membrane, there are other risks involved in sinus augmentation surgery. Most notably, the close relationship of the augmentation site with the sinonasal complex can induce sinusitis, which may chronicize and cause severe symptoms. Sinusitis resulting from maxillary sinus augmentation is considered a Class 1 sinonasal complication according to Felisati classification and should be addressed surgically with a combined endoscopic endonasal and endoral approach. [16] Beside sinusitis, among other procedure related-risks include: infection, [4] inflammation, pain, itching, allergic reaction, tissue or nerve damage, [4] scar formation, hematoma, graft failure, oro-antral communication / oro-antral fistula, tilting or loosening of implants, or bleeding, [4]

Recovery

It takes about three to six months for the sinus augmentation bone to become part of the patient's natural sinus floor bone. Up to six months of healing is sometimes left before implants are attempted. However, some surgeons perform both the augmentation and dental implant simultaneously, to avoid the necessity of two surgeries.[ citation needed ] [17] [18]

History

The first maxillary sinus floor augmentation procedure was performed by Oscar Hilt Tatum, Jr. in 1974.

A sinus-lift procedure was first performed by Dr. Hilt Tatum Jr. in 1974 during his period of preparation to begin sinus grafting. The first sinus graft was done by Tatum in February, 1975 in Lee County Hospital in Opelika, Alabama. This was followed by the placement and successful restoration of two endosteal implants. Between 1975 and 1979, much of the sinus lining elevation was done using inflatable catheters. After this, suitable instruments had been developed to manage the lining elevation from the different anatomical surfaces encountered in sinuses. Tatum first presented the concept at The Alabama Implant Congress in Birmingham, Alabama in 1976 and presented the evolution of technique during multiple podium presentations each year until 1986 when he published an article describing the procedure. Dr. Philip Boyne was introduced to the procedure when he was invited, by Tatum, to be "The Discusser" of a presentation on sinus grafting given by Tatum at the annual meeting of The American Academy of Implant Dentistry in 1977 or 1978. Boyne and James authored the first publication on the technique in 1980 when they published case reports of autogenous grafts placed into the sinus and allowed to heal for 6 months, which was followed by the placement of blade implants. This sequence was confirmed by Boyne before the attendees at The Alabama Implant Congress in 1994.

Cost-effectiveness

The slightly higher effectiveness (implant survival) of the lateral sinus lift technique needs to be considered in relation to the substantially higher costs in comparison with the transalveolar sinus lift technique. From a patient perspective the higher invasiveness of the lateral technique will also be an important decision criterion. However, the transalveolar approach is unlikely to be effective in cases of advanced levels of bone reduction at the implant site. [19]

Related Research Articles

<span class="mw-page-title-main">Dental implant</span> Surgical component that interfaces with the bone of the jaw

A dental implant is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodontic anchor. The basis for modern dental implants is a biological process called osseointegration, in which materials such as titanium or zirconia form an intimate bond to the bone. The implant fixture is first placed so that it is likely to osseointegrate, then a dental prosthetic is added. A variable amount of healing time is required for osseointegration before either the dental prosthetic is attached to the implant or an abutment is placed which will hold a dental prosthetic/crown.

<span class="mw-page-title-main">Maxillary sinus</span> Largest of the paranasal sinuses, and drains into the middle meatus of the nose

The pyramid-shaped maxillary sinus is the largest of the paranasal sinuses, located in the maxilla. It drains into the middle meatus of the nose through the semilunar hiatus. It is located to the side of the nasal cavity, and below the orbit.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Palatal expansion</span> Orthodontics device to widen the upper jaw

A palatal expander is a device in the field of orthodontics which is used to widen the upper jaw (maxilla) so that the bottom and upper teeth will fit together better. This is a common orthodontic procedure. Although the use of an expander is most common in children and adolescents 8–18 years of age, it can also be used in adults, although expansion is slightly more uncomfortable and takes longer. A patient who would rather not wait several months for the end result by a palatal expander may be able to opt for a surgical separation of the maxilla. Use of a palatal expander is most often followed by braces to then straighten the teeth.

<span class="mw-page-title-main">Alveolar process</span> Bulge on jaws holding teeth

The alveolar process or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones. The structures are covered by gums as part of the oral cavity.

<span class="mw-page-title-main">Toothlessness</span> Lacking teeth

Toothlessness, or edentulism, is the condition of having no teeth. In organisms that naturally have teeth, it is the result of tooth loss. Organisms that never possessed teeth can also be described as edentulous. Examples are the members of the former zoological classification order of Edentata, which included anteaters and sloths, as they possess no anterior teeth and no or poorly developed posterior teeth.

<span class="mw-page-title-main">Dentin dysplasia</span> Medical condition

Dentin dysplasia (DD) is a rare genetic developmental disorder affecting dentine production of the teeth, commonly exhibiting an autosomal dominant inheritance that causes malformation of the root. It affects both primary and permanent dentitions in approximately 1 in every 100,000 patients. It is characterized by the presence of normal enamel but atypical dentin with abnormal pulpal morphology. Witkop in 1972 classified DD into two types which are Type I (DD-1) is the radicular type, and type II (DD-2) is the coronal type. DD-1 has been further divided into 4 different subtypes (DD-1a,1b,1c,1d) based on the radiographic features.

Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration. Guided bone regeneration typically refers to ridge augmentation or bone regenerative procedures; guided tissue regeneration typically refers to regeneration of periodontal attachment.

Socket preservation or alveolar ridge preservation is a procedure to reduce bone loss after tooth extraction. After tooth extraction, the jaw bone has a natural tendency to become narrow, and lose its original shape because the bone quickly resorbs, resulting in 30–60% loss in bone volume in the first six months. Bone loss, can compromise the ability to place a dental implant, or its aesthetics and functional ability.

<span class="mw-page-title-main">Underwood's septa</span>

In anatomy, Underwood's septa are fin-shaped projections of bone that may exist in the maxillary sinus, first described in 1910 by Arthur S. Underwood, an anatomist at King's College in London. The presence of septa at or near the floor of the sinus are of interest to the dental clinician when proposing or performing sinus floor elevation procedures because of an increased likelihood of surgical complications, such as tearing of the Schneiderian membrane.

<span class="mw-page-title-main">All-on-4</span>

The term All-on-4, also known as All‐on‐Four and All‐in‐Four, refers to 'all' teeth being supported 'on four' dental implants, a prosthodontics procedure for total rehabilitation of the edentulous (toothless) patient, or for patients with badly broken down teeth, decayed teeth, or compromised teeth due to gum disease. It consists of the rehabilitation of either edentulous or dentate maxilla and / or mandible with fixed prosthesis by placing four implants in the anterior maxilla, where bone density is higher. The four implants support a fixed prosthesis with 10 to 14 teeth, and it is placed immediately, typically within 24 hours of surgery.

<span class="mw-page-title-main">Sinus implant</span>

A Sinus implant is a medical device that is inserted into the sinus cavity. Implants can be in conjunction with sinus surgery to treat chronic sinusitis and also in sinus augmentation to increase bone structure for placement of dental implants.

Platelet-rich fibrin (PRF) or leukocyte- and platelet-rich fibrin (L-PRF) is a derivative of PRP where autologous platelets and leukocytes are present in a complex fibrin matrix to accelerate the healing of soft and hard tissue and is used as a tissue-engineering scaffold for endodontics. PRF falls under FDA Product Code KST, labeling it as a blood draw/Hematology product classifying it as 510(k) exempt.

Zygoma implants are different from conventional dental implants in that they anchor in to the zygomatic bone rather than the maxilla. They may be used when maxillary bone quality or quantity is inadequate for the placement of regular dental implants. Inadequate maxillary bone volume may be due to bone resorption as well as to pneumatization of the maxillary sinus or to a combination of both. The minimal bone height for a standard implant placement in the posterior region of the upper jaw should be about 10 mm to ensure acceptable implant survival. When there is inadequate bone available, bone grafting procedures and sinus lift procedures may be carried out to increase the volume of bone. Bone grafting procedures in the jaws have the disadvantage of prolonged treatment time, restriction of denture wear, morbidity of the donor surgical site and graft rejection.

Surgically assisted rapid palatal expansion (SARPE), also known as surgically assisted rapid maxillary expansion(SARME), is a technique in the field of orthodontics which is used to expand the maxillary arch. This technique is a combination of both Oral and Maxillofacial Surgery and Orthodontics. This procedure is primarily done in adult patients whose maxillary sutures are fused and cannot be expanded via other techniques.

<span class="mw-page-title-main">Oroantral fistula</span> Medical condition

Oroantral fistula (OAF) is an epithelialised oroantral communication (OAC). OAC refers to an abnormal connection between the oral cavity and antrum. The creation of an OAC is most commonly due to the extraction of a maxillary (upper) tooth closely related to the antral floor. A small OAC may heal spontaneously but a larger OAC would require surgical closure to prevent the development of persistent OAF and chronic sinusitis.

Alveoloplasty is a surgical pre-prosthetic procedure performed to facilitate removal of teeth, and smoothen or reshape the jawbone for prosthetic and cosmetic purposes. In this procedure, the bony edges of the alveolar ridge and its surrounding structures is made smooth, redesigned or recontoured so that a well-fitting, comfortable, and esthetic prosthesis may be fabricated or implants may be surgically inserted. This pre-prosthetic surgery which may include bone grafting prepares the mouth to receive a prosthesis or implants by improving the condition and quality of the supporting structures so they can provide support, better retention and stability to the prosthesis.

Hector L. Sarmiento is an American periodontist involved in dental implant complications research.

<span class="mw-page-title-main">Alveolar cleft grafting</span>

Alveolar cleft grafting is a surgical procedure, used to repair the defect in the upper jaw that is associated with cleft lip and palate, where the bone defect is filled with bone or bone substitute, and any holes between the mouth and the nose are closed.

<span class="mw-page-title-main">Gingival grafting</span>

Gingival grafting, also called gum grafting or periodontal plastic surgery, is a generic term for the performance of any of a number of periodontal surgical procedures in which the gum tissue is grafted. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.

References

  1. ↑ Boyne, PJ. De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation. J Oral Maxillofac Surg 2005;63:1693-1707
  2. ↑ "Sinus Lift Surgery - Sinus Augmentation | Colgate". www.colgate.com. Archived from the original on 2015-07-01.
  3. ↑ Wagner, F; Dvorak, G; Nemec, S; Pietschmann, P; Figl, M; Seemann, R (January 2017). "A principal components analysis: how pneumatization and edentulism contribute to maxillary atrophy". Oral Diseases. 23 (1): 55–61. doi:10.1111/odi.12571. PMID   27537271.
  4. 1 2 3 4 5 Esposito, Marco; Felice, Pietro; Worthington, Helen V. (2014-05-13). "Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus". The Cochrane Database of Systematic Reviews (5): CD008397. doi: 10.1002/14651858.CD008397.pub2 . ISSN   1469-493X. PMID   24825543.
  5. ↑ Baciut, Mihaela; Hedesiu, Mihaela; Bran, Simion; Jacobs, Reinhilde; Nackaerts, Olivia; Baciut, Grigore (May 2013). "Pre- and postoperative assessment of sinus grafting procedures using cone-beam computed tomography compared with panoramic radiographs". Clinical Oral Implants Research. 24 (5): 512–516. doi:10.1111/j.1600-0501.2011.02408.x. PMID   22220751.
  6. ↑ "Sinus Lift Surgery | Perio.org". www.perio.org. Retrieved 2015-11-04.
  7. ↑ Kumar, Prasanna; Vinitha, Belliappa; Fathima, Ghousia (2013-06-01). "Bone grafts in dentistry". Journal of Pharmacy & Bioallied Sciences. 5 (Suppl 1): S125–S127. doi: 10.4103/0975-7406.113312 . ISSN   0976-4879. PMC   3722694 . PMID   23946565.
  8. ↑ Hurley LA, Stinchfield FE, Bassett AL, Lyon WH (October 1959). "The role of soft tissues in osteogenesis. An experimental study of canine spine fusions". J Bone Joint Surg Am. 41-A: 1243–54. doi:10.2106/00004623-195941070-00007. PMID   13852565.
  9. ↑ Riben C, Thor A (2016). "Maxillary Sinus Implants without the Use of Graft Material". Clinical Implant Dentistry and Related Research. 18 (5): 895–905. doi:10.1111/cid.12360. PMID   26482214.
  10. ↑ SUMMERS, ROBERT B. (May 1998). "Sinus Floor Elevation with Osteotomes". Journal of Esthetic and Restorative Dentistry. 10 (3): 164–171. doi:10.1111/j.1708-8240.1998.tb00352.x. ISSN   1496-4155. PMID   9759033.
  11. ↑ Stacchi, Claudio; Lombardi, Teresa; Ottonelli, Roberto; Berton, Federico; Perinetti, Giuseppe; Traini, Tonino (2018-03-23). "New bone formation after transcrestal sinus floor elevation was influenced by sinus cavity dimensions: A prospective histologic and histomorphometric study". Clinical Oral Implants Research. 29 (5): 465–479. doi: 10.1111/clr.13144 . ISSN   1600-0501. PMID   29569763. S2CID   4168825.
  12. ↑ Bruschi, G. B.; Scipioni, A.; Calesini, G.; Bruschi, E. (March 1998). "Localized management of sinus floor with simultaneous implant placement: a clinical report". The International Journal of Oral & Maxillofacial Implants. 13 (2): 219–226. ISSN   0882-2786. PMID   9581408.
  13. ↑ Bruschi, Giovanni B.; Crespi, Roberto; Capparè, Paolo; Bravi, Fabrizio; Bruschi, Ernesto; Gherlone, Enrico (April 2013). "Localized management of sinus floor technique for implant placement in fresh molar sockets". Clinical Implant Dentistry and Related Research. 15 (2): 243–250. doi:10.1111/j.1708-8208.2011.00348.x. ISSN   1708-8208. PMID   21599829.
  14. ↑ Crespi, Roberto; Capparè, Paolo; Gherlone, Enrico Felice (2013-01-18). "Electrical mallet provides essential advantages in split-crest and immediate implant placement". Oral and Maxillofacial Surgery. 18 (1): 59–64. doi:10.1007/s10006-013-0389-2. ISSN   1865-1550. PMID   23329162. S2CID   207045255.
  15. ↑ Kharazmi M, Hallberg P. "Secondary sinus lift: viable technique for when a membrane is raised without a graft, and fails". Br J Oral Maxillofac Surg.
  16. ↑ Felisati, Giovanni, Chiapasco, Matteo, Lozza, Paolo, Saibene, Alberto Maria, Pipolo, Carlotta, Zaniboni, Matteo, Biglioli, Federico & Borloni, Roberto (July 2013). "Sinonasal complications resulting from dental treatment: outcome-oriented proposal of classification and surgical protocol". American Journal of Rhinology and Allergy. 27 (4): e101–6. doi:10.2500/ajra.2013.27.3936. PMID   23883801. S2CID   207396181.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ↑ Riben, C.; Thor, A. (2012). "PMC Pub Med". International Journal of Dentistry. 2012: 105483. doi: 10.1155/2012/105483 . PMC   3383004 . PMID   22754569.
  18. ↑ Riben, C.; Thor, A. (2012). "PMC PUB MED". International Journal of Dentistry. 2012: 105483. doi: 10.1155/2012/105483 . PMC   3383004 . PMID   22754569.
  19. ↑ Listl S, Faggion CM (Aug 2010). "An economic evaluation of different sinus lift techniques". J Clin Periodontol. 37 (8): 777–87. doi:10.1111/j.1600-051X.2010.01577.x. PMID   20546083.

Chen, Leon; Cha, Jennifer (2005). "Journal of Periodontology March 2005". Journal of Periodontology. 76 (3): 482–491. CiteSeerX   10.1.1.611.3142 . doi:10.1902/jop.2005.76.3.482. PMID   15857085.

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