Introduction

Many individuals with edentulous posterior maxilla present inadequate bone volume and vertical height between the floor of the sinus and the edentulous ridge, rendering it inadequate to accept a dental implant and achieve the degree of primary stability necessary for long-term success. The maxillary sinus, with all its variations, configurations, anomalies, and potential pathologies, has been a concern to dental implant surgeons. Over the past 30 years, creative surgeons have devised many different methods and protocols for entering the sinus cavity, elevating the Schneiderian membrane, and placing various grafting materials, with or without the addition of blood components, recombinant growth factors, and so forth. All efforts along these lines are, of course, aimed at inducing new bone formation in the space created between the bony walls of the sinus cavity and the elevated Schneiderian membrane, so that dental implants can be placed after adequate osteogenesis to allow for implant-supported restorations to be constructed.

The two main surgical approaches of sinus floor elevation are (Figure I.1): the external lateral window approach1,2 and the internal transalveolar approach.3–6 The environment of the lifted sinus membrane space inside the sinus cavity is beneficial for the bone formation. The elevation of the Schneiderian membrane for augmentation of the maxillary sinus was first presented by Tatum (1977) using autogenous bone from the iliac crest.1 However, to harvest bone graft from the second surgical site may affect the length of the surgical procedure, postsurgical morbidity, and patient comfort, although several bone replacement graft materials such as allografts, xenografts, alloplasts, and tissue engineering materials have been utilized.7–13 The lateral window surgical procedure is still relatively technique sensitive (Figures I.2 and I.3).

Figure I.1 Sinus elevation procedures. (a) Area for sinus elevation. (b) External approach. (c) Internal approach.

Figure I.2 (a–d) Sinus augmentation—lateral window approach.

Figure I.3 Sinus augmentation—lateral window approach. (a) Day 0: sinus graft. (b) Wait 6–9 months for bone graft to heal, then place implant. (c) Wait another 6–9 months for osseointegration and implant restoration.

The internal approach is considered more conservative and less invasive than the external lateral window approach. The original concept of the internal transalveolar technique used a set of osteotomes of various diameters to create a “green-stick fracture” by hand tapping force in the vertical direction4 (Figure I.4). The following intrusion osteotomy procedure elevates the sinus membrane by a tapping motion to create a “tent.” Bone grafting materials, blood clot, and the dental implant may be inserted into the tented space through the osteotomy opening. The osteotome technique is effective in certain cases, but the most sensitive aspect is the tapping force, which should be sufficient enough to infracture the sinus floor cortical bone but restrained enough to prevent the osteotome tip from traumatizing the Schneiderian membrane.14,15 Several surgical techniques have been proposed to minimize the sinus membrane perforation rate by using a piezosurgical device, balloon, and hydrostatic pressure.16–19

Figure I.4 (a–d) Internal approach—osteotome technique.

As treatment options of edentulous maxillary today may include dental implants, the practitioner must be familiar with various sinus lift surgical techniques in order to choose an ideal treatment option for the patient. The success of therapy is not only dependent on the success of the sinus elevation and the integration of an implant but also the position and utilization of the implant(s) for function, health, and aesthetics.20 With widespread use of dental implants, evaluating alveolar bony ridge volume and dimensions should also incorporate the interarch relationship to achieve a successful surgical, restorative, and aesthetic outcome (Figures I.5 and I.6 and Table I.1).21

Figure I.5 (a) and (b) Unfavorable crown-implant ratio.

Figure I.6 The interarch relationship should be considered in order to achieve a successful surgical, restorative, and aesthetic outcome.

Table I.1 Surgical and restorative treatment options for vertical interarch discrepancy.

This book attempts to describe and elucidate the sinus-related subjects and to offer some developing consensus as to state-of-the-art thinking and practice. With the step-by-step clinical procedures, readers may use this book as a clinical manual for sinus elevation procedures.

References

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