Closed sinus lift surgery Techniques and Criteria References: Linde - Clinical Periodontology and Implant Dentistry Newman and Carranza Clinical Periodontology 13th Edition 2019

2.  Boyne (1960)
 Boyne & James (1980) : Bladed Implant
• two‐stage :
1. Autogenous particulate iliac bone
2. Blade implants were placed (after 3month)
 Tatum (1986)
• TransAlveolar Tech (A) :
 Socket Former -- Green Stick F -- Root for Implant
 Summer (1994)
• TransAlveolar Tech (B) :
 Using tapered Osteotomes : conservative Tech
 Drilling was not performed

3. Two‐stage technique using the lateral
window approach
One‐stage technique using a lateral or a
transalveolar approach
How to decision?
Amount of residual bone available
Possibility of achieving primary stability

4. the most important of which is the
availability of bone
removable prostheses, short implants,
cantilevered restorations (Carranza)

5. Placement of short implants :
• most canservative : at least 6 mm of residual
bone
Tilted Implant
Extra‐long zygomatic implants
Minor augmentation – TransAlveolar Tech
Lateral approach (one or two satge):
• Most Invasive
Shortened Dental Arch

6. distal aspect of the implant is more apical than
at the time of implant placement

7. Patients maintained adequate (51–80%) chewing capacity
with a premolar occlusion

8. Implant success rates are equal to or
better than that of implants placed in
nongrafted maxillary bone
Interocclusal dimension is normal or only
moderately increased

10. Advantage : more conservative and less
invasive approach
Disadvantage : possibility of perforation
Elevated by up to 5 mm without perforating
the membrane

11. Flat sinus floor
Residual bone height of at least 5 mm
Adequate crestal bone width

12. less than 7 mm of existing vertical bone
height

13. Intraoral contraindications
Medical conditions
Local contraindications

14.  Chemotherapy or radiotherapy of the head and neck
area
 Immunocompromised patients
 Medical conditions affecting Bone metabolism
 Uncontrolled diabetes
 Drug or alcohol abuse
 Patient non‐compliance
 Psychiatric conditions

15. Mayfield (2001)
Petursson (2008)

16. Viral, bacterial, and mycotic rhinosinusitis
Allergic sinusitis
Sinusitis caused by intrasinus foreign
bodies
Odontogenic sinusitis resulting from
necrotic pulp tissue
All odontogenic, periapical, and radicular
cysts of the maxillary sinus

17. Acute sinusitis
Allergic rhinitis
Chronic recurrent sinusitis
Scarred and hypofunctional mucosae
Local aggressive benign tumors
Malignant tumors

18. patients with a history of inner ear
complications
positional vertigo
oblique sinus floor (>45° inclination) :
• high risk perforating

19. sloped sinus floor
presence of septa

21. The goal of sinus elevation and bone
augmentation is to lift the schneiderian
membrane from the floor of the sinus
originally used as a preprosthetic surgical
procedure

22. 5 mm of existing native bone
1 mm of remaining bone
Ability to achieve implant stability

23. 1. Presurgical patient preparation
2. Local anesthesia (buccal and palatal)
3. Mid‐crestal incision with or without
releasing
4. Implant positions are marked
5. Crestal floor to the floor of the maxillary
sinus, measured

24. Exact position of the implant site
is first marked with a small round bur

25. 6. Pilot drills
7. The first Tapered
Osteotome:
• Greenstick fracture
an osteotome is chosen to minimize the
force needed to fracture the compact bone.

26. 8. The seccond Tapered Osteotome:
• Increase the fracture area
diameter slightly larger then the first one

27. 9. The third Osteotome used is straight
diameter about 1–1.5 mm smaller than that
of the implant to be placed

29. Advantage:
• Reduce the risk of membrane perforation
• Reduce the risk of benign paroxysmal positional
vertigo
Disadvantage :
• More time consuming

30. 1. the straight osteotome
penetrates the sinus floor
2. Form and diameter that are
suitable for the implant
3. Final step before placing the
implant is to check that the
preparation is patent to the
planned insertion depth

31. 1. osteotomes are not supposed to enter the
sinus cavity
2. sinus membrane must by tested for any
perforations

32. 3. preparation is filled with grafting material

33. Preparation is checked for patency by
repeating the Valsalva maneuver.

34. Antiseptic rinsing 0.1–0.2% CHX:
• Twice daily - 3 weeks
Antibiotic prophylaxis:
• for 1 week in cases where bone substitutes are
used

35. There is still controversy with regards to
the necessity of using grafting material to
maintain the space for new bone formation
after elevating the sinus
• Rosen 1999
• Nedir 2010
• Schmidlin 2008
• Petursson 2009
• Bragger 2004

36.  Radiograph taken at the 5‐year follow‐up visit of an implant placed in
the first quadrant utilizing the osteotome technique without grafting
material. A new cortical bony plate at the inferior border of the
maxillary sinus is clearly visible, but no bony structure can be
detected apical to the implant

37.  Radiograph (same patient) taken after 5 years in function of an
implant placed in the second quadrant utilizing the osteotome
technique with xenograft grafting material. A dome‐shaped structure
is clearly visible, documenting a definite increase in bone volume
compared to the initial situation. The “dome” is surrounded by a new
cortical bony plate.

38.  (a) Radiograph taken immediately after implant insertion with
the osteotome technique and grafting material, showing a
cloudy dome‐shaped structure extending 2–3 mm apical to
the implant. (b) Radiograph of the same implant taken 1 year
later showing significant reduction of the size of the
“dome”, but the new bony structure is clearly visible apical to
the implant

39. Autogenous bone is often referred to as
the gold standard
Anorganic bovine bone-derived mineral
(ABBM)
demineralized freeze-dried bone allograft
(shrinkage)

42. Increased bone height from 2 to 7 mm
(average, 3.8 mm)
If more vertical bone height is needed, the
lateral wall osteotomy approach may be
more advantageous.

43. the implant survival rate was 96% when
residual bone height was 5 mm or more,
but dropped to 85.7% when residual bone
height was 4 mm or less

44. Transalveolar sinus floor elevation
technique was most predictable when the
residual alveolar bone height was ≥5 mm
and with implants of ≥8 mm.

45.  Indications:
Filling material for the sinus:
(either alone or in combination with a bone substitute)
Membrane to seal the lateral window
for protection of the schneiderian membrane after
detachment from the underlying bone
Close a membrane rupture.

46.  L-PRF can be used successfully as the sole filling
material during sinus augmentation, but only if it is used
simultaneously with the placement of implants

47. when L-PRF as the sole filler material,
natural bone regeneration occurred around
the implants
• 10 mm vertical bone gain with the Window technique
• 3.5 to 4 mm with the Transalveolar approach
All gain in radio opaque areas in the sinus,
observed on (CBCT), is “Vital” bone, with
0% substitute remnants.

48.  When implants have to be placed in a second
stage L-PRF can also be used, but it should
be mixed with a bone substitute to delay its
resorption.
 Lambert:
• use of pure autologous bone resulted in greater loss of
the augmented volume after 5 weeks
 A mixture (DBBM) and L-PRF resulted in
more new bone formation than when DBBM
was used exclusively.

49.  Fibrin glue : newly formed epithelium
 L-PRF for the treatment of perforations of the schneiderian membrane
1. L-PRF membranes are resilient
2. Pliable
3. easy to manipulate
4. have an adhesive nature
 They have the capacity to seal the connection to
the sinus in minutes

54. Rotary drill systems
Piezoelectric bone surgery

55. 1. Outlining the bony window directly
2. Lateral wall erosion (0% perforation)

56. Tapping can be bother some patients with
dense cortical bone and for those with
loose trabecular bone
benign paroxysmal positional vertigo
(BPPV)
patients must be able to open wide enough

57. benign paroxysmal positional vertigo

58. the most common intraoperative
complication is perforation of the sinus
membrane.
• Smaller perforations : using Tissue Fibrin Glue
• Larger perforations : achieved through a Lateral
Window
• Perforations before any grafting material
 procedure should be aborted or
 shorter implants used

59. Postoperative infections after transalveolar
sinus lift are rare complications
Postoperative hemorrhage
Nasal bleeding
Hematomas
Loosening of cover screws resulting in:
• Suppuration
• (BPPV)

60. In the posterior maxilla:
• High initial stability
• Rough surface geometry.
Implants with
• Slightly conical morphometry or
• implants with a Wider implant neck
tend to give better primary stability

61. Residual bone height of ≥8 mm and a flat
sinus floor:
• standard implant placement

62. Residual bone height of ≥8 mm and an
oblique sinus floor:
• standard implant placement using a short implant
• elevation of the maxillary sinus floor using the
osteotome technique without grafting material

63. Residual bone height of 5–7 mm and a
relatively flat sinus floor:
• elevation of the maxillary sinus floor using the
osteotome technique with grafting material that is
resistant to resorption

64. Residual bone height of 5–7 mm and an
oblique sinus floor:
• elevation of the maxillary sinus floor using the
lateral approach with grafting material, and
simultaneous implant placement (one‐stage)

65. Residual bone height of 3–4 mm and a flat
or oblique sinus floor:
• elevation of the maxillary sinus floor using the
lateral approach with grafting material, and
simultaneous implant placement (one‐stage)

66. Residual bone height of 1–2 mm and a flat
or oblique sinus floor:
• elevation of the maxillary sinus floor using the
lateral approach with grafting material and
delayed implant placement
4–8 months later (two‐stage)