|Year : 2020 | Volume
| Issue : 3 | Page : 180-186
Sinus lift procedures in dental implants: A literature review on techniques, recommendations, and complications
S Devameena1, DS Dinesh2, G LakshmiDevi1, G Shanmugavadivel3
1 Department of Prosthodontics and Crown and Bridge, Sri Venkateshwaraa Dental College, Ariyur, Puducherry, India
2 Department of Conservative Dentistry and Endodontics, Sri Venkateshwaraa Dental College, Ariyur, Puducherry, India
3 Department of Pedodontics and Preventive Dentistry, Sri Venkateshwaraa Dental College, Ariyur, Puducherry, India
|Date of Submission||14-Nov-2019|
|Date of Decision||11-Feb-2020|
|Date of Acceptance||05-Jul-2020|
|Date of Web Publication||14-Aug-2020|
Senior Lecturer, Sri Venketeshwaraa Dental College, Puducherry - 605 001
Source of Support: None, Conflict of Interest: None
Posterior atrophic maxilla with pneumatized sinus often challenges dental implant surgery. Sinus lift in order to augment the residual alveolar ridge height resulted in various sinus lift surgical techniques. Sinus augmentation in atrophic maxilla transforms the atrophic posterior maxilla to a favorable place for implant placement. Additional surgery of sinus lift during implant placement becomes a difficult decision for both dentist and patient. This literature search focuses on many valuable articles that support evidence on the treatment options and predictable increase in bone height after sinus lift procedure. This literature review explains on the classification of posterior atropic maxilla and its treatment options, sinus lift techniques, recommendations, complications, and a precise discussion that supports this procedure.
Keywords: Alveolar ridge resorption, atrophic posterior maxilla, dental implants, maxillary sinus, sinus lift technique
|How to cite this article:|
Devameena S, Dinesh D S, LakshmiDevi G, Shanmugavadivel G. Sinus lift procedures in dental implants: A literature review on techniques, recommendations, and complications. Indian J Dent Sci 2020;12:180-6
|How to cite this URL:|
Devameena S, Dinesh D S, LakshmiDevi G, Shanmugavadivel G. Sinus lift procedures in dental implants: A literature review on techniques, recommendations, and complications. Indian J Dent Sci [serial online] 2020 [cited 2020 Sep 23];12:180-6. Available from: http://www.ijds.in/text.asp?2020/12/3/180/292268
| Introduction|| |
Dental implants have revolutionized oral rehabilitation in edentulous posterior maxilla with fixed prosthesis. Posterior maxilla frequently presents with insufficient alveolar ridge with proximity to maxillary sinus. When teeth are extracted in the posterior maxilla, alveolar bone resorbs with inferior expansion of the sinus involving the residual ridge area. This process is known as pneumatization of the maxillary sinus. The pneumatized sinus with thin wall is difficult to manage during implant placement lead to the development of technique called “Sinus lift Procedure.” This technique was proposed by Tatum in 1977. Boyne and James were the first to publish an article and described this technique in 1980.,, This article reviews on various clinical presentations and its classifications, clinical procedures, and postoperative instructions to be followed after the surgery. This review was done by literature search on various databases focusing on clinical trials, systematic reviews, and meta-analysis to overcome the dilemma in planning sinus lift procedure for dental implants.
| Anatomy of Maxillary Sinus|| |
Maxillary sinus also called antrum of highmore is usually the largest of paranasal sinuses. The maxillary sinus is four-sided pneumatic space that is lodged inside the body of the maxilla. The base of the sinus is facing medially toward the nasal cavity, and the apex is pointed laterally toward the body of zygomatic bone [Figure 1]. The floor of the maxillary sinus is usually above three posterior maxillary molars and sometimes extends to the apices of premolars. The maxillary sinus provides drainage through the opening called ostium which opens in to middle meatus of the nasal cavity.
Two radiographic methods that are in the use for sinus evaluation are:
- Panoramic radiograph
- Computerized tomography scans.
Even though water's view (face down or modified) is routinely indicated for sinus detection, cyst such as densities are better illustrated in orthopantomogram (OPG) or computed tomography (CT) scan. The important criterion for selecting OPG or CT scan than waters view is for assessing remaining alveolar bone from the floor of sinus to the crest as it cannot be illustrated in waters view. Magnetic resonance imaging is sensitive in the diagnosis of pathologic conditions in the maxillary sinus mucosa. It can be considered as good adjunct for additional information for definitive diagnosis.
In general, three anatomic locations are utilized to enter the antrum.
- The classic superior position of the Caldwell-Luc opening just anterior to zygomatic buttress
- A mid maxillary entrance between the level of the crest of the alveolar ridge and the level of the zygomatic buttress
- A low position along the anterior surface of the maxilla, at the level of existing alveolar ridge.
Subantral classification and treatment options
Misch organized treatment options depending on available bone height between the floor of the antrum and crest of the residual ridge in the region of the ideal implant location [Figure 2] and [Table 1].
Surgical approach for sinus augmentation
The simplest form to treat maxillary atropy is Lefort I osteotomy which is an aggressive procedure. Maxilla is fractured down through the intraoral approach. Autocancellous large volume of graft is usually used at this time and grafted in the floor of sinus and lateral walls. Implants also can be planned at this time of the surgery. The risk of general anesthesia, age, and medical condition of patient is the limiting factor for this procedure. Atrophied posterior maxilla can be managed by indirect or direct sinus augmentation techniques.
Indirect sinus augmentation technique
Cases with residual alveolar bone (RAB) height of 6–8 mm are usually taken for indirect sinus augmentation. The implant site is exposed under local anesthesia and perforated with a pilot or initial drill to establish an axis for implant. Following initial drill, subsequent drills of increased diameter are used to enlarge implant recipient site corresponding to the diameter of implant. The height of drill is maintained 2 mm short of sinus floor. The indirect sinus lift is done by insertion of correct caliber osteotome and working up through successive greater instrument diameters, until the sinus floor get fractured and elevated up [Figure 3] and [Figure 4]. The sinus floor is lifted carefully by fracture of floor, separated from the Schneiderian membrane without damage to the membrane using a surgical mallet with controlled force. If required, autogenous graft material is inserted within the socket. The material is gradually displaced apically with the help of larger-diameter instruments, thereby lifting the membrane and condensing graft material below the elevated sinus floor. This sinus floor can also be lifted by green stick fracture using with flat top osteotomes which help to carry and push the floor along with graft material. Modified osteotomes are instruments that help to lift the sinus membrane without perforation. The implant can be placed immediately in the prepared site. 3–0 Vicryl sutures are used to close the surgical wound. Antibiotics, anti-inflammatory, and nasal decongestants are prescribed for 5 days. The patients are monitored on a periodic basis both clinically and radiologically.
Direct sinus augmentation technique (residual alveolar bone(RAB)5mm or below)
RAB 5 mm or below are considered for this technique. Autogenous bone grafts are harvested by shaving the mandibular bone from external oblique ridge area or parasymphysis region. A bone mill is used to grind the bone shaving into the fine particles. After adequate local anesthesia and preparation, a surgical incision is placed on the crest of residual bone at most appropriate area, with vertical releasing curvilinear incisions flaring into the vestibule. Full-thickness, subperiosteal labial, and palatal flaps are raised and reflected. After elevation, the anterolateral wall of maxillary sinus is visualized. Care must be taken to identify and protect infraorbital nerve, if encountered. The dimension of osteotomy is determined based on the clinical and radiographic examinations as well as the extent of edentulous span. The lateral access antrostomy is opened by scoring the outline created by round bur. The antrostomy is prepared resembling the shape of the rectangle with rounded corners. Once lateral access window is delineated, continue rotary to remove bone using paint brush stroke with copius irrigation until bluish hue is observed. Bluish hue indicates close approximation to the sinus membrane. Gentle tapping of the bone helps to separate the bone to create window. A buccal bone window in the exposed wall of maxillary sinus is done using a postage stamp method. The bony wall is gently manipulated with sinus membrane elevation without damaging Schneiderian membrane [Figure 5]. The previously obtained graft material is then placed and packed. The implant can be placed on same sitting with the help of a stent for appropriate faciolingual and mesiodistal positioning. The drills are used in a standard reduction gear hand piece along with a physiodispenser, enabling copious saline irrigation to prevent the excessive heat generation. The drills are used at the speed of 800–1000 rpm. After sequential drilling with reference to implant size, the implants are placed into the prepared site using a torque wrench. Sutures and medications are same as indirect sinus lift.
The patient who have very little or no available height for implant placement are treated using the two-stage approach. Here, graft materials are placed after sinus lift and allowed to heal for approximately 6–8 months before the second-stage surgery. After healing period, implant is placed and allowed to heal for additional 6 months and loaded with prosthodontic restorations.
Variation of surgical techniques
Apart from direct and indirect sinus lift, other variations of surgical techniques are also practiced. Modified osteotomes with rounded tip that do not fracture the sinus floor fragment instead comprimition of bone gently lift the floor along with graft. Other technique is balloon sinus lift where an elastic catheter is swollen by injecting saline which, in turn, push the sinus membrane without the risk of perforation.
Grafts used for sinus graft surgery
Alloplastic grafting materials have surged in recent years, these materials can be used alone or in combination with autogenous bone, demineralised bone, blood, or other substances. These materials reduce the second surgical donor site morbidity. Various materials used include hydroxyapatite, calcium phosphate ceramics, beta-tricalcium phosphate, calcium sulfate (Gypsum), bioactive glasses, and polymethylmetha acrylate.
Allogenic bone is derived from living and cadaver donors.
Allogenic materials are of two different types:
Demineralized bone is commonly used. They have inherent prone morphogenetic protein from an osteoinductive graft that stimulates adjacent undifferentiated cells to form the bone. These materials are available from the tissue banks. These grafts are combined with autogenous graft to expand their volume and can also be used alone with relative success. Bonemorphogenetic proteins were isolated in 1960's by Marshal Urist. He discovered these proteins are responsible for inducing bone formation when implanted in the animal tissue. These proteins are separated by aminoacid sequencing and recombination DNA techniques. Out of 15 different bone morphogenetic protein's (BMP's), BMP-2 and BMP-7 are heavily researched. Recombinant MP-2 was concluded as effective alternative for autologous iliac crest graft as there is no difference in effect and radiologic outcome.
Autogenous bone is the gold standard of all bone graft materials. It has the advantage of osteogenic potential, unquestioned biocompatibility, and no possibility of disease transmission. The commonly preferred sites for maxillary sinus graft include posterior iliac, the tibia, and various intraoral sites such as maxillary tuberosity, mandibular ramus, and mandibular symphysis.
Ali et al., in 2015, has done a systematic review on the effect of platelet-rich fibrin (PRF) in sinus augmentation. They concluded that PRF placed as sole-filling material had promising results. PRF seemed to accelerate the maturation of demineralized freezed dried allograft. PRF is suggested as an easy and successful method to cover the sinus membrane or osteotomy window.
The complications of sinus graft procedures are usually rare if promptly diagnosed. Postoperative infections rates are reported as 2% and 5.6% with no distinction between true sinus and sinus graft infections.
Intraoperative complications of sinus lift procedure
Apart from swelling, hematoma, infection which would occur postoperatively, an important intraoperative complication in direct sinus lift procedures is as follows:
- Perforation of Schinederian membrane
- Displacement of dental implant into sinus
- Presence of septal partition in the sinus cavity.
Perforation of schinederian membrane
The perforation of schneiderian membrane is one of the most common sinus lift complications as it compromises the bone graft survival. The management of perforated schneiderian membrane is performed intraoperatively depending primarily on the location and size of perforation. Once the perforation had occurred, implantologist should avoid applying any unnecessary pressure that could increase the size of perforation. In minor perforations, folding the membrane on itself can be sufficient or can be managed using a small collagen tape and a bioabsorbable membrane. In large perforations, after careful suturing, fibrin adhesive is applied, and bioabsorbable membrane is placed only on the surface of sutured schneiderian membrane. The walls of the sinus are not covered to maintain the continuous blood supply to the bone graft. Vlassis and Fugazzotto had given a classification of sinus membrane perforation and various treatment options. A technique “Loma Linda pouch” was introduced for repairing the perforated maxillary sinus membrane during the sinus grafting procedures. Collagen membrane is placed against the perforated site and subsequently adapted to the internal surface of the maxillary sinus with the curette. The collagen membrane is then folded along the lateral access window to form a pouch that isolates the graft material. This technique avoids the entry of graft material into the sinus cavity when treated for perforation. Then, the buccal and palatal flaps are sutured. This technique is formulated for superior protection and graft isolation. However, further clinical study and histological evaluation are recommended.
Displacement of implant into maxillary sinus
Displacement of implant may occur in following circumstances like.
- Placement of dental implant in posterior maxilla without sinus lift
- Surgical inexperience with anatomical landmarks of the maxillary sinus
- Existence of untreated perforation of antral base after drilling sequence
- Excessive tapping of dental implant during internal sinus osteotomy.
The displaced objects into the sinus can be retrieved in 1 of 3 methods.
- Suction from the extraction socket or drill site
- Classical cald-well Luc operation
- Endoscopic sinus surgery.
Modern sinus endoscopy was described by Messerklinger in 1960 and introduced in the US in 1985. It helps in minimal tissue manipulation and preserves mucociliary function. A deep partsch incision has to be given in anterior fornix and mucoperiosteal flap elevated. An osseous bony window created in the middle of canine fossa to avoid unnecessary enlargement of bone access. The endoscope has to be pushed into sinus to identify the displaced implant location. Under direct visualization, the implant has to be removed with curved clamp. A 3–4 mm straight (angled 0 degree) Hopkins Endoscope (Karl Storz Endoscope Tuttlingen, Germany) and Xenon light are used in this cases.
Maxillary sinus septa
Maxillary sinus septa was first mentioned by underwood 1910. Majority of septa are located between the second premolar and first molar. The presence of septa complicates sinus lift surgery. Complete partition of sinus by septa is managed by more than one lateral window created to circumvent the septa.
Infection usually does not occur within the sinus but in the grafted area below the sinus membrane. Sometime infection extends into sinus and present as pan-sinusitis. Testori Tziano had formulated suggestions based on clinical questions answered by the panel of experts (periodontitis, implantologist, maxillofacial surgeons, ear, nose, throat, and microbiology specialist).
The clinical consensus explained the common postoperative symptoms could be swelling, echymosis, mild-to-moderate discomfort, and minor nose bleed. The symptom usually resolves in 3 weeks. They suggested prophylaxis and postoperative regimen based on clinical experience and indirect evidence [Table 2].
The persistence of symptoms more than 3 weeks with associated pus discharge, fistulation, discharges from throat and nose, flapdehiscence, and suppuration has to be managed by multidisciplinary approach. Functional endoscopy sinus surgery can be suggested along with the removal of bone graft and implant through the oral approach. Microbial assays are recommended usually few days after pharmacological therapy.
Appropriate clinical recommendations
Careful assessment of the medical history, patient selection with healthy maxillary sinus, proper investigations, preoperative elimination of endodontic, and periodontic diseases are recommended. Smoking cessation protocol is a must, in case of heavy smokers who smoke more than 15 cigarettes per day. Full mouth plaque score and full mouth bleeding score < 15% are recommended. Proper sterilization protocols are to be followed. Preplanned patient reviews weekly for the 1st month and monthly for the following 3 months is recommended.
The patient advised to bite gauze with pressure in surgical site for at least a minimum of 20 min and preferably for 3–4 h. Patients are advised to follow prescribed medications and instructions.
Bleeding in the mouth or nose may be present. In case of excessive bleeding, call your dental office.
- The presence of small white particles in the mouth or nose. Maybe due to escape of the bone material through the nose or between stitches
- Swelling in the entire side of the face which would subside in 2 weeks
- Bruising on the cheeks, neck, and even near the shoulders may appear for some patients which would disappear gradually
- The patient advised to take liquid diet for 2 days and soft diet for 2 weeks. Stay upright as possible, rinse mouth with chlorhexidine 1.2% for 3–4 times per day, take calcium supplements, and also advised to take rest as much as possible. Prescribed medications are to be followed [Table 2].
Smoking restricted for at least 2 weeks, preferably for 6 weeks after the surgery.
Avoid the following-alcohol for 48 h, blowing nose, sneezing, bending forward, sucking withstraw, spitting or rinsing vigorously, playing musical instruments, removable dentures, and night guards.,
| Discussion|| |
In case of atrophic maxilla, the placement of implant was hardly done without invasive procedures that include bone augmentation or sinus lift procedure or both. Several complications include Schneiderian membrane perforation, nose bleeding, postoperative pain, and swelling may occur, even though it was not described as the important negative effect on implant success rates. The patient may be under psychological stress, fear of extra surgery, and increased cost if enough bone is not available for implant placement. Various studies carried out regarding the success rate of angulated implants which could be a possible alternative instead of sinus lift procedure. The crestal bone loss was found to be same or less for sinus lift when compared to axial implants. Some studies have advocated that single angulated implant placed to replace single missing tooth is not a good option, since prosthesis fabricated over it would be of fixed type and would create off axis loading. In one meta-analysis, the author found that there was no difference in success rate between tilted and axial implant. These studies support the placement of tilted implants that can be placed with high success rate as axial implant. However, a systematic review on angulated implants which is an alternative to bone augmentation and sinus lift procedure by Asawa et al. stated that this technique is extremely technique sensitive, useful in patients with resorbed ridges, but long-term studies are required to evaluate its success rate in terms of load distribution, marginal bone loss around implant, and prosthesis survival. However, currently, many practitioners are treating patients with this modality with great success. Smoking is one of a contraindication for implants with lot of controversies in implant success. It is also referred as a risk factor after sinus lift procedure. A retrospective study evaluated the effect of smoking and the amount of cigarette consumption on the success of implants placed in grafted maxillary sinuses. Sixty patients (16 smokers and 44 nonsmokers) were evaluated. Eighty-four maxillary sinuses were grafted, and a total of 228 endosseous root form implants were placed. Seventy implants were placed in 26 maxillary sinus lift smoker patients, and 158 implants were placed in 58 sinus lifted nonsmokers. After a mean follow-up period of 42 months (range of 2–60 months), there was a significantly higher cumulative implant success rate in nonsmokers (82.7%) than in smokers (65.3%) (P = 0.027). There was no correlation between implant failures and the amount of cigarette consumption (P > 0.99). Balaji had done a study on the patient who required direct and indirect sinus lift procedure. The mean postoperative bone height was evaluated on patients who had undergone these procedures. He identified increased RAB height in direct sinus lift procedure. However, the results were not statistically significant. Esposito et al. in 2010 done a Cochrane systematic review stated that short implants of 5 mm would be successful when residual bone height is 4–6 mm, but their long-term prognosis was unpredictable. He suggested that crestal approach is sufficient in bone height of 3–6 mm and 8 mm implant placement. Saraperaz-martenz in 2015 had done a systematic review and concluded sinus lift procedure as a valid surgical procedure to gain crestal height of 5–9 mm.
| Conclusion|| |
The primary method of long-term evaluation of sinus grafts has been evaluated based on the implant survival. Implants placed with sinus lift grafts had shown superior results than those placed without grafts. Literature search on the decision of sinus lift procedure suggests that angulated or short implant success rates are unpredictable and recommends sinus lift technique as a valid procedure to increase RAB height up to 5–9 mm. The procedure of direct or indirect sinus lift technique needs sound knowledge of sinus anatomy, proper preoperative evaluation, diagnosis, proper surgical techniques, regular recalls, and review.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]