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This problem is especially magnified in the posterior maxilla, where progressive ridge resorption in an apical direction is combined to the progressive sinus pneumatization Garg as a consequence of intrasinus positive pressure Smiler et al. Moreover, poor bone quality is also often encountered.

Following tooth extraction, an initial R. Younes et al. As a result, the sinus floor is closer to the alveolar ridge. Based on the Cawood and Howell classification of bone loss, the residual bone crest may be classified in gradations of I dentate to VI paper thin Cawood and Howell The resulting alveolar bone atrophy may affect the ability to place implants of adequate size and length.

Accordingly, decision-making challenge vastly depends on valid clinical evidence to assess the most favorable treatment modalities. Thus, several attempts have been made in the past years to develop new surgical procedures for the augmentation of the resorbed posterior maxilla to be convenient support for long-term predicable implants.


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Maxillary sinus floor elevation SFE procedure is nowadays the most frequently used bone augmentation technique prior to implant placement, in more of half of the cases Seong et al. Conventional lateral SFE has been developed over three decades ago, initially developed by Tatum a at the end of the s , and was first published in a clinical study in by Boyne and James Boyne and James Since, numerous successful techniques have been described to restore maxillary bone height Smiler Most publications feature a lateral approach to the sinus cavity.

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According to the original technique, a horizontal incision is made in the mucosa at the top of the alveolar crest or slightly palatally to raise a full-thickness flap that is deflected to expose the lateral antral wall of the maxillary sinus where an antrostomy is performed modification of the Caldwell-Luc technique ; access to the maxillary sinus is obtained by drilling a bone window in the lateral sinus wall using round burs, while ensuring that the Schneiderian membrane remains intact.

The sinus membrane is then carefully elevated using sinus curettes, mobilized together with the attached bone window, and rotated medially.

While rotary instruments are still used for window preparation, the recent development of piezoelectric ultrasonic devices may contribute to reduce intraoperative complications such as membrane perforation Wallace et al. Three variations of the basic SFE were described by Smiler : the hinge osteotomy, the elevated osteotomy, and the complete osteotomy.

After a careful elevation of the sinus membrane from the walls of the sinus cavity, the resulting created space is ready for bone augmentation. The grafting material is steadily inserted in the cavity and subsequently the deflected gingival flap closes the sinus window.

Several approaches involve classifications and treatments of membrane tearing as well as adaptations to the closure of the sinus Vlassis and Fugazzotto ; Ardekian et al. Following SFE, a bone graft maturation time is required from 5 to 10 months depending on the grafting material.

Nowadays, the lateral SFE presents a clinically successful technique that offers good insight into the sinus cavity and leads to subsequent modifications in bone height Chiapasco and Ronchi However, these advantages involve a secondary surgery site when placing dental implants and thus hold several drawbacks such. To address these drawbacks, Summers a described a modification of the original SFE technique, which is a codified transalveolar crestal approach, namely, the osteotome sinus floor elevation OSFE , which was a called new method of placing implants into the maxillary bone without drilling.

In this technique, the use of the tapered osteotomes with increasing diameter aims to preserve the residual bone tissue instead of loosing it while drilling through a conventional procedure. Moreover, they improve bone density around the implant in case of low bone density, which is often the case in the posterior maxilla. The author Summers a concluded that the osteotome technique is superior to drilling for many applications in soft maxillary bone, capable to expand the bone.

The basic procedure involves a crestal incision at the planned implant site and a full-thickness flap that is prepared to expose the alveolar crest. After a preoperative careful measurement of the subsinus residual bone height, the initial osteotomy could be either created manually with osteotomes or by the use of a drill. The subsequent osteotomes are inserted into the implant socket by hand pressure or gentle malleting until the residual bone height RBH beneath the maxillary sinus floor is limited to about 2 mm.

Then, osteotomes of increasing diameters are placed sequentially until the planned implant diameter is reached. Tapping on the last osteotome results in a greenstick fracture of the sinus floor and lifts the Schneiderian membrane without violating it. Finally, an implant is placed in the prepared site. In fact, osteotome-mediated transcrestal SFE approach was first proposed by Tatum in the late s who used at that time a crestal approach.

His results using this transalveolar technique for SFE with simultaneous placement of implants were later published in Tatum In his original publication, a special instrument known as socket former was used to prepare the implant site leading to a controlled greenstick fracture of the sinus floor, moving it in a more apical direction. Root-formed implants were then simultaneously placed and allowed to heal in a submerged manner. At the time, the author did not use any grafting material to increase and maintain the volume of the elevated area. The space underneath the elevated floor is filled with particulate graft material via the implant bed to support the elevated membrane.

Later, to minimize the risk of membrane perforation, some clinicians used an inflatable device or fill the void with augmentation material prior fracturing the sinus wall Stelzle and Benner ; Soltan and Smiler Nowadays, several modifications of the original SFE technique have been described Chen and Cha either through a lateral or a crestal approach. In both procedures, when it is possible, implant insertion is performed simultaneously after.

Most authors make their decision whether to use a simultaneous or staged approach according to the amount of residual bone height RBH Zitzmann and Schrer ; Del Fabbro et al. The consensus for selecting a simultaneous implant placement is applicable with a RBH of at least 45 mm. However, recent studies indicated successful one-stage approaches with only 1 mm RBH Peleg et al. Taken together, the osteotome technique may provide lower morbidity and operational time but requires greater RBH. Nevertheless, in SFE, membrane integrity is a primary condition for and measure of success.

Furthermore, despite its predictability, the osteotome blind technique is associated with a higher possibility of membrane tearing, limited elevation of the sinus mucosa, and fewer control of the operation field. Apart from the different surgical approaches providing adequate structure for primary implant stability, several additional parameters such as simultaneously or delayed implant placement, time of unloaded healing as well as the use of grafting materials or membranes significantly affect implant survival.

The ideal graft material is described as a substance that will change into regular bone under functional loading without resorption and offers either osteoconductive or osteoinductive properties to promote new bone formation, able to support dental implants Block and Kent A broad variety of different grafting materials have been successfully applied in sinus augmentation, including autogenous bone AB , allografts, xenografts, and alloplasts.

AB has long been considered the gold standard for atrophic ridge regeneration because of its unique osteogenic, osteoinductive, and osteoconductive properties Del Fabbro et al. AB can be harvested from various donor sites i. In the first publications Boyne and James , the grafting material was initially AB harvested from the iliac crest. Nevertheless, it was shown that AB is subject to high resorption Wallace and Froum , with up to Additionally, the use of AB usually involves a second surgery site with the potential of donor site morbidity Block and Kent ; Smiler and Holmes Therefore, in order to avoid the drawbacks related to the use of AB, the development of alternative bone substitutes with osteoconductive properties can represent a valid alternative to AB, providing a scaffold for bone regeneration thus eliminating the need to harvest AB.

Allografts such as demineralized freeze-dried bone allograft DFDBA avoid a second surgical site and exhibit osteoinductive and osteoconductive properties Block and Kent ; Hallman et al.


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However, it was stated that DFDBA generates unpredictable bone formation with newly-formed bone of low quality and quantity Block and Kent The use of xenografts such as bovine bone mineral Sauerbier et al. Alloplastic materials are synthetic BS made of biocompatible, inorganic, or organic materials, not derived from a human or animal source. Their main advantage is that they have no potential for disease transmission.

What is a Sinus?

Suchlike bone substitute materials vary in porosity and structure particular pieces or blocks. Supplementary, some clinicians apply resorbable or nonresorbable membranes to protect the augmented area and prevent soft tissue encleftation in the grafted area. Thus, membranes may promote guided bone regeneration GBR and increase the amount of newly-formed bone Tarnow et al. Nevertheless, membranes may result in lower vascular supply to the graft, increased risk of infection, and additional cost.

It was stated that particulate grafting material that includes AB heals faster and therefore implants can be placed earlier Peleg et al. However, other authors Hallman et al. On the other hand, the predictability of SFE has been extensively reported and frequently measured through implant survival rate ISR criteria in order to evaluate the bone augmentation success.

Numerous systematic evidence-based reviews from to were published relative to implant outcomes following SFE Aghaloo and Moy ; Wallace and Froum ; Del Fabbro et al.

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The use of implants with a textured surface and the placement of a membrane over the antrostomy are associated with increased implant survival rates Pjetursson et al. At present, it is difficult to provide an unbiased quantitative estimate of the impact of sinus augmentation on implant survival.

Crestal Sinus graft and implant placement

This has been underlined by the Sinus Consensus Conference and is because of the almost complete absence of prospective comparative studies Jensen et al. Attempts have been made to conduct meta-analysis of the available literature Esposito et al. However, since survival rates in the posterior maxillae are different from other sites in the mouth, it would be sensible to compare implant survival after SFE to the survival in conventional implant placement in this particular area.

Although SFE has become a frequently used and clinically successful technique, the review of clinical investigations on sinus augmentation is inconsistent and often confounding Javed and Romanos Overall, variations in the selection of patients, the surgical procedures as well as the surgeons skill level account for the low clinical evidence Aghaloo and Moy The predictability of SFE procedure relies on several parameters in addition to the impact of the various SFE treatment modalities.

Particular attention was given to the influence of the surgical approach, the residual bone height, the type of implant, its surface and placement, the grafting material, and the use of membranes to provide clinical evidence for prospective treatment regimes. Since its introduction into clinical practice, the SFE surgical protocol has evolved through the years: harvesting sites, new graft materials, implant surface characteristics, timing of implant placement, and surgical techniques have been introduced in order to simplify the treatment and reduce the morbidity.

Nowadays, maxillary SFE became one of the preferred and better-documented techniques for the management of the atrophic posterior maxilla. The clinician should keep in mind that SFEs goal is to rehabilitate the resorbed posterior maxilla in order to allow a proper implant placement intended to heal following the basic principle of osseointegration.

Therefore, sinus graft consolidation is a fundamental for implant integration. It is important to know that the healing of the sinus graft is a dynamic process occurring several years after SFE. References Aghaloo TL, Moy PK Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? J Oral Maxillofac Surg J Oral Implantol Anatomical considerations. Int J Oral Maxillofac Surg Chen L, Cha J An 8-year retrospective study: 1, patients receiving 1, implants using the minimally invasive hydraulic sinus condensing technique.

J Periodontol Eur J Oral Sci CD Garg AK Augmentation grafting of the maxillary sinus for placement of dental implants: anatomy, physiology, and procedures. Implant Dent Graziani F, Donos N, Needleman I, Gabriele M, Tonetti M Comparison of implant survival following sinus floor augmentation procedures with implants placed in pristine posterior maxillary bone: a systematic review.

Clin Oral Implants Res Int J Oral Maxillofac Implants Hallman M, Sennerby L, Zetterqvist L, Lundgren S A 3-year prospective follow-up study of implant-supported fixed prostheses in patients subjected to maxillary sinus floor augmentation with a mixture of deproteinized bovine bone and autogenous bone Clinical, radiographic and resonance frequency analysis.

Int J Oral Maxillofac Surg A literature review. J Dent Tissue Eng Part B Rev Int J Oral Maxillofac Implants Nkenke E, Stelzle F Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review.

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Clin Oral Implants Res 20 Suppl 4 J Clin Periodontol Tissue Eng Part A Treatment of the atrophic posterior maxilla. Clin Implant Dent Relat Res Compendium Newtown Pa , , passim; quiz Summers RB c The osteotome technique: part 3Less invasive methods of elevating the sinus floor.

Int J Oral Maxillofac Implants Valentini P, Abensur D Maxillary sinus floor elevation for implant placement with demineralized freeze-dried bone and bovine bone Bio-Oss : a clinical study of 20 patients. A systematic review. Ann Periodontol J Am Geriatr Soc Comparison of the crestal and lateral approaches. Maxillary Sinus Gross Anatomy Sinus Vascularization Sinus Innervation Anatomical Variations The maxillary sinus sinus maxillaris is the largest of the paranasal sinuses air cavities.

It is located laterally in the face in both parts of the nasal cavity. This cavity is related to three other cavities: the orbit roof of the sinus , the oral cavity floor of the sinus , and the nasal cavity by the medial wall of the sinus. Since the s, odontologists and maxillofacial surgeons have used this natural cavity to compensate for maxillary posterior crestal atrophy and enable prosthodontic fixed solutions using dental implants after sinus floor elevation SFE procedures.

Before invading this new territory, we should be aware of the anatomical basis, anatomical variations e. These data are critical to ensure safe surgery and to avoid anesthetic failure, hemorrhage, or neuropathic injury. Furthermore, a variant of the normal nasal cavity anatomy and middle meatus variants condition the permeability of the maxillary sinus and increase the risk of maxillary sinusitis after surgery by restriction of the sinus ostium.

Sinus Augmentation

The process and patterns of skull pneumatization are not fully understood. The development of the paranasal sinuses begins in the third week of gestation. It continues throughout early adulthood.