Sinus Augmentation

Question 1

Maxillary Sinus Augmentation: History

Answer 1

• Boyne & James: 1980
  
  • first published technique
• Tatum: 1986
  
  • crestal approach
• Summers: 1994
  
  • Osteotome technique
• Sinus Consensus: 1996
  
  • predictable & effective

Question 2

Alternatives to Sinus Augmentation

Answer 2

• RPD
• Fixed Bridges
• Cantilevers
• Implants:
  
  • Short
  • Zygomatic
  • Tilted

Question 3

Maxillary Sinus Anatomy:

Answer 3

• Shape:
  
  • Pyramidal
• Membrane:
  
  • Lined by Pseudostratified columnar epithelium
    
    • • periosteum→ Schneiderin Membrane (0.3-0.8m)
• Size: 12-15 mL
• Dimensions:
  
  • Length: 38-45 mm
  • Height: 26-45 mm
  • Width: 25-35 mm
• Septa:
  
  • Normally In premolar Area
• Ostium
  
  • 40 mm from floor
• 6 walls:
  
  • Anterior
  • Posterior
  • Superior
  • Inferior
  • Medial
  • Lateral

Question 4

What Blood Vessels Innervate the maxillary sinus?

Answer 4

• Posterior Superior Alveolar A.
• Infraorbital A.
• Posterior Lateral Nasal A.

Question 5

What nerves innervate the maxillary sinus

Answer 5

• Superior Alveolar N
• Infraorbital N.

Question 6

Maxillary Sinus Function

Answer 6

• Warm Air
• Lighten Head
• Voice Resonance
• Dissipate Heat

Question 7

Sinus Anatomy Classification

Answer 7

Height from alveolar crest

• SA-1
  
  • > 12 mm
• SA-2
  
  • 10-12 mm
• SA-3
  
  • 5-10 mm
• SA-4
  
  • <5 mm

Question 8

Sinus Augmentation: Indications vs Contraindications

Answer 8

• Indications:
  
  • Posterior Maxilla Lacks vertical dimension
    
    • alveolar ridge resorption
    • sinus pneumatization
• Contraindications:
  
  • Relative:
    
    • Treatable sinus pathology
    • Smoking
  • Absolute:
    
    • Treated Sinus pathology that left irreversible dysfxn

Question 9

Pre-Op Sinus Evaluation

Answer 9

• Medical Contra-indication
• CBCT Scan
• ENT Consult
  
  • sinus problems
  • Destructive sinus surgery
• Delay Sinus Surgery due to:
  
  • nasal congestion
  • sinusitis
  • Respiratory Tract Infection
• Sinus pathology 30%
  
  • Thickend mucosa (65%)

Question 10

Pre-Op Sinus Medicines

Answer 10

• Antibiotics:
  
  • Amoxicillin
  • Clindamycin
  • Can be mixed in graft
    
    • 1:4 (Antibiotic:Graft)
• Decongestants
  
  • maintain patent ostium
  • Oxymetazoline (Afrin)
  • Pseudoephedrine
• Anti-inflammatory
  
  • Decreased edema & post-op pain
  • Medrol dose pack
  • Ibuprofen 800 mg
• Analgesics
  
  • Hydrocodone w/acetaminophen (Vicoden)
  • Codeine w/Acetaminophen (Tylenol #3)

Question 11

Amoxicillin

Answer 11

• Pre-op med
• 1g 1hr before surgery
• 500 mg qid 5-7 days

Question 12

Clindamycin

Answer 12

• Pre-op Med
• 300 mg 1 hr before surgery
• 150 mg tid 5-7 days

Question 13

Oxymetazoline

Answer 13

• aka Afrin
• Decongestant
• 1 hour before surgery until
  
  • 2 days after surgery

Question 14

Pseudoephedrine

Answer 14

• decongestant
• 1 tablet tid on day of surgery
• 2 days after surgery if perforation

Question 15

Ibuprofen

Answer 15

• Anti-inflammatory
• 800 mg
• 1 tablet tid 7 days after surgery

Question 16

Surgical Technique

Answer 16

• Osteotome (transcrestal)
  
  • SA-2 and SA-3
• Lateral Approach (Window)
  
  • SA-3 and SA-4

Question 17

Osteotome Technique

Answer 17

• Aka Transcrestal
• SA-2 and SA-3
• Instrument: OSteotomes
  
  • Curved tip
    
    • straight or angled
• Implant Survival Rate:
  
  • Bone Height:
    
    • ≥ 5mm = 96%
    • < 4 mm = 86%
• Advantages:
  
  • less
    
    • invasive
    • painful
    • risk of infection
• Disadvantages:
  
  • Blind
  • perforation
  • Lack Control

Question 18

Osteotome Technique: Advantages vs Disadvantages

Answer 18

• Advantages:
  
  • Less
    
    • Invasive
    • risk of infeciton
    • painful
    • overhead
• Disadvantages:
  
  • Lack control
  • Blind
  • Membrane perforation

Question 19

Osteotome Technique: Research studies

Answer 19

• Implant Survival Rate:
  
  • Bone Height ≥ 5mm → 96%
  • Bone Height < 4 mm → 86%

Question 20

Lateral Approach

Answer 20

• Aka Window
• S3-S4
• More invasive
• direct vision of sinus
• Instruments:
  
  • Pizoelectric surgery
  • Sinus Elevators
  • Kerrison Rongeur

Question 21

Osteotome vs Lateral Approach:

Bone Height Gain

Success Rate

Answer 21

• Osteotome:
  
  • Bone Height Gain: 3.5 mm
  • Success Rate: 95%
• Lateral Approach:
  
  • Bone Height Gain: 12.7 mm
  • Success Rate: 100%

Question 22

Pizoelectric Sinus Elevation

Answer 22

• Reduced perforation risk
• Ultrasonic Vibrations
• Hydropneumatic pressure

Question 23

Sinus Augmentation: Risks and Complications

During Surgery

Early Post Op

Late Post op

Answer 23

• During Surgery:
  
  • Sinus mucosa perforation
    
    • Schneiderin Membrane perforation (most common)
  • Fracture residual alveolar ridge
  • Obstruct Maxillary Ostium
  • Inadequate Fill
  • Bleeding
  • Damage adjacent dentition
• Early Post-op
  
  • Wound Dehiscence
  • Acute Sinusitis
  • Exposed barrier membrane
  • Lose implant or graft
• Late Post-op
  
  • insufficient quality or quantity of bone forming in sinus graft
  • oro-antral fistula
  • Chronic bone pain
    
    • remove implant
  • Chronic Sinus Disease

Question 24

Sinus Perforation

Answer 24

• Incidence: 10-30%
  
  • Pizo reduces to 7%
• Causes:
  
  • Tear membrane during prep
  • Fracture window
  • Elevate membrane
  • Septa or pathologic conditions
  • Very thin membrane
• Increase risk of infection
  
  • delay implant placement
• contaminated mucosa in graft

Question 25

What can cause a Sinus perforation

Answer 25

* Tear membrane during prep * Fracture window * Elevate membrane * Septa or pathologic conditions * Very thin membrane