Transcript Subantral Option 1 : Conventional Implant Placement

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
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
Venous drainage
 Anterior facial vein
 Pterygoid veinous plexus
Lymphatic drainage
 Submandibular lymphnode
Nerve supply
 Maxillary division of trigeminal nerve (V2)
Maxillary Sinus Anatomy
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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
Sinus membrane
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Schneiderian membrane
Mucoperiosteum cansists 3 layers
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1.Epithelium lining : pseudostratified columnar ciliated
epithelium
2.Lamina propria
can stripped easily from
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3.periosteum
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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
Treatment planning for edentulous posterior maxilla
Patient evaluation
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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
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Conventional :OPG, water’s 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
Premedications
Surgical technique
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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
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 1:200,000
Local infiltration
 Labial mucosa and palatal region
 Complete hemostasis
 Lidocaine 2 % with EPI 1:100,000
Bone density classification
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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
Division of available bone
Subantral Option 1 :
Conventional Implant Placement
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Height > 12 mm.
An improved compressive thread design
implant (4 mm. diameter) implants may
accommodate
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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
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Remain 1-2 mm. short of the sinus floor is not
indicated in the posterior maxilla
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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
Subantral Option 2 : Sinus lift and
Simultaneous Implant Placement
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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.
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 patient’s 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
Subantral Option 3 : Sinus graft
with delayed endosteal implant
placement
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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
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Aggressive reflection of the flap may cause
damage to infraorbital nerve
Access window
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#6 round diamond bur
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Copious sterile saline
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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
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
A layered-type graft
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1. dense HA + antibiotic
2. cacium phosphate (usually
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whole blood + antibiotic
3. autogenous bone
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xenograft microporous HA such
as Osteograft N-300 or BioOss) + DFDB + PRP from
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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
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)
Subantral Option 4 : Sinus graft
and extended delay of endosteal
implant placement
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Height < 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
Postoperative instructions
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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
Notify the office if :
 You feel granules in your nose
 Your medications do not relieve your
discomfort
Perioperative complications
Window
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Bleeding – bone wax, electrocautery
Septum – make two windows seperated
by septum
Perforation – repair after membrane
elevation
Membrane
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Perforation – repair
Small – collagen membrane (Collatape)
Large – slow resorbable membrane (Biomend)
Thick
Polyp – curette out
Mucocele – drain
Delay sinus graft
Possible Complication - Small Perforation
Possible Complication - Large Perforation
Postoperative complication
Short-term complications
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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
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Antibiotic – oral, IV
Drain, remove graft
Assess progression – culture and sensitivity test
anaerobes/aerobes
Reassess antibiotic choice
Refer
Suggest pharmacologic protocal
for sinus graft infection
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Amoxicillin 2 g stat, 500 mg qid
+ Metronidazole 500 mg stat, 250 mg tid
or
Clindamycin 300 mg stat, 150 mg qid
Reference
1. Misch CE. : Contemporary implant
dentistry. Mosby : 1999.
2. Spiekermann H. : Color atlas of dental
medicine implantology, Thieme : 1995.
3. เอกสารประกอบการเรี ยนเรื่ อง ทันตกรรมรากเทียม โดย ผูช้ ่วย
ศาสตราจารย์ ดร. สุ มิตรา พงษ์ศิริ
4. เอกสารประกอบการเรี ยนเรื่ อง Diagnosis and
management of maxillary sinus โดย อ.ทพ.
สุ รศักดิ์ เยาว์เจริ ญสุ ข
5. www.google.com
Special thanks
ผูช้ ่วยศาสตราจารย์ ดร. สุ มิตรา พงษ์ศิริ