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- Maxillary sinus augmentation
- Clinical Maxillary Sinus Elevation Surgery.PDF
- Reasons for Failure in Endoscopic Sinus Surgery
- Clinical Maxillary Sinus Elevation Surgery.PDF
Maxillary sinus augmentation
Int J Oral Dent Health This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Maxillary sinus membrane perforation or tear is the most common complication of the sinus grafting procedure. Repair of the sinus membrane is usually accomplished at the time of the sinus graft procedure and often results in uneventful postoperative complications.
However, complications may still arise, especially with large sinus membrane perforations or complete tears that could lead to an infection of the maxillary sinus and other anatomic areas of the maxillofacial complex that could result in bone graft and dental implant failure.
An alternative strategy and method to repair the Scheiderian membrane that results in a newly formed fibrotic sinus membrane is described that permits completion of dental implant treatment.
The maxillary sinus lift elevation procedure with bone graft augmentation is the most frequently performed surgical procedure to increase the vertical bone height of the posterior maxilla in preparation for dental implant placement. The procedure was first described by Tatum in [ 1 - 3 ] and later published by Boyne and James in [ 4 ].
However, this surgical procedure to correct the atrophic posterior maxilla is not without complications. Boyne [ 10 ] hypothesized that the size of the sinus membrane perforation may affect the success of the sinus bone graft augmentation procedure. The most common intraoperative complication reported with grafting of the maxillary sinus is a perforation of the Schneiderian membrane Figure 1 that is often managed at the time the perforation is observed [ 10 - 18 ].
A meta-analysis by Jensen and Terheyden [ 19 ] revealed that infections occur as high as 4. If the sinus infection is not identified and managed early in the course of treatment, such a complication can lead to the development of acute and chronic sinusitis, displacement of the graft material into the sinus cavity, loss of the graft material and oroantral communication [ 19 - 22 ]. Perforation of the sinus membrane may also effect homeostasis of the maxillary sinus and bacterial colonization into the maxillary sinus [ 12 , 16 - 18 , 20 - 22 ].
In more severe cases, the infection may progress to involve other anatomic structures of the maxillofacial region, such as the other paranasal sinuses, orbit and anterior and middle cranial fossae [ 24 - 26 ]. Figure 1: Intraoperative view of large perforation of the sinus membrane that occurred during the sinus lift elevation procedure.
Figure 1. The integrity of the Schneiderian membrane to prevent infection of the sinus cavity, loss of graft material and successful implant osseointegration cannot be under estimated.
Several studies have shown a correlation between infection of the sinus and bone graft and implant failures with perforation of the sinus membrane at the time of sinus grafting [ 12 , 18 , 22 - 33 ].
A literature review regarding re-entry to manage a large perforation, or even complete sinus membrane tear associated with sinus augmentation procedures revealed only one article by Mardinger, et al. The goal of this article is to describe the clinical and histological changes of the buccal gingival tissues and the Schneiderian membrane that allow re-entry into the maxillary sinus to continue grafting of the maxillary sinus and dental implant placement.
Such an alternative staged surgical strategy may avoid the postoperative complications associated with grafting the sinus cavity in the presence of a large perforation or complete tear of the sinus membrane. Like all sinuses, the maxillary sinus and nasal cavity are lined by a three-layered mucous membrane similar to that of the respiratory tract [ 34 ].
The sinus membrane varies in thickness from 0. It is continuous with the nasal epithelium, but thinner and not as vascular. The epithelial layer consists of pseudostratified ciliated columnar cells, basal cells and mucous secreting goblet cells.
The subepithelial layer consists of collagen bundles and elastic fibers that are moderately vascularized. The periosteum is intimately attached to the subepithelial layer and is attached to the osseous walls of the sinus membrane. There are many methods and techniques that have been published regarding management of the sinus membrane perforation, as this is the most frequent complication with the sinus elevation procedure with bone grafting [ 10 - 33 ].
A critical objective of sinus membrane repair is to prevent extravasation of the graft material into the sinus cavity. Schneiderian membrane perforations can be repaired with use of a bioresorbable collagen membrane Figure 2A autologous fibrin glue, demineralized freeze-dried human lamellar bone sheet, oxidized regenerated cellulose, sutures and with platelet rich plasma [ 9 , 11 - 15 , 17 , 18 , 23 , 30 , 31 , 35 - 37 ].
Figure 2A: Collagen membrane that will be trimmed and placed on the perforated sinus membrane. Figure 2A. With large sinus perforations greater than 15 mm, Pikos described the use of a slow bioresorbable collagen membrane and platelet rich plasma Figure 2B that acts as an adhesive to repair both partial and complete sinus membrane tears [ 12 , 36 ].
However, with large sinus membrane perforations, some authors recommend aborting the sinus augmentation procedure due to the higher percentage of implant failures associated with such large perforations [ 6 , 7 , 9 , 16 , 29 , 38 - 40 ].
An alternative strategy is to repair the large sinus membrane tear or perforation using a bioresorbable collagen membrane and platelet rich plasma, but without adding the bone graft material. Twelve weeks or later after the sinus membrane has healed, the maxillary sinus can be re-entered and the bone graft material added to the floor with or without simultaneous implant placement. Figure 2B: Intraoperative view of collagen membrane and platelet rich plasma PRP to repair and close off the perforated sinus membrane.
Figure 2B. When the clinician encounters a large perforation or tear Figure 1 during the sinus lift procedure or cannot control the membrane from tearing further, the clinician may elect to defer placing the graft material into the sinus cavity and focus on preparing the floor and walls to receive the graft material during the re-entry procedure that may occur 12 weeks or later.
After the edges of the torn sinus membrane are elevated from the floor and walls of the sinus cavity and positioned medially, a bioresorbable collagen membrane can be directly placed over the sinus membrane. The clinician must make sure that the collagen membrane is not in contact with the floor and walls anterior, medial and posterior of the sinus cavity.
Platelet rich plasma serves as a natural adhesive and barrier to the exposed sinus when applied to the bioresorbable collagen membrane and walls of the sinus cavity. Such biologic growth mediators have been shown to stimulate bone regeneration and soft tissue healing by promoting angiogenesis and increased levels of vascular endothelial growth factor [ 41 , 42 ]. Twelve weeks or later after the sinus membrane has been repaired, re-entry into the maxillary sinus can be accomplished to add the graft material and place the implants.
The newly formed fibrous buccal flap is continuous with the fibrotic Schneiderian membrane due to adhesions Figure 3A and Figure 3B and may be difficult to elevate the newly formed sinus membrane superiorly. Tearing of the sinus membrane when elevating in a medial direction is less likely due to the reparative process that results in a thick and fibrous sinus membrane Figure 4A that allows graft placement Figure 4B.
Figure 3A. Figure 3B. Figure 4A: Intraoperative view of thick fibrotic Schneiderian membrane arrows that develops 12 weeks after placement of the collagen membrane and platelet rich plasma on the perforated sinus membrane.
Fibrotic membrane is elevated superiorly and medially to create a space to allow placement of graft material into the sinus cavity. Figure 4A. Figure 4B. Many authors have reported on various techniques to repair the perforated and torn sinus membrane to complete the sinus elevation procedure, including grafting of the sinus [ 10 - 38 ]. Placing the graft material into the sinus cavity with a large perforation greater than In such clinical scenarios, the graft material may need to be removed and the sinus cavity drained and irrigated to resolve the infection [ 22 - 32 ].
Furthermore, studies by Proussaefs, et al. The study by Prossaefs and colleagues [ 18 ] also observed significant differences in formation of vital bone formation between non-perforated sinus membranes and perforated sinus membranes Both authors hypothesize that the poor results associated with a repaired sinus membrane were due to colonization of bacteria into the bone graft material and bioresorbable collagen membrane used to repair the Schneiderian membrane and displacement of the graft material into the sinus Cavity [ 18 , 29 ].
In their series of 17 patients that involved 21 reentered maxillary sinuses, they observed adhesions that limited mobility of the newly formed sinus membrane. Such adhesions and limited mobility still resulted in perforations or tears while attempting to elevate the sinus membrane in preparation for grafting the sinus.
This was due to the reparative process of the sinus membrane that results in a nonflexible membrane that cannot fold on itself compared to a health sinus membrane that has the ability to do so. Such perforations had to be covered by bioresorbable collagen membranes to complete the sinus graft procedure.
Higher implant failure rates in the re-entered maxillary sinus were also observed [ 33 ]. Mardinger and colleagues hypothesize that the modified environment of the maxillary sinus may result in less formation of new bone and the ability of the dental implant to successfully osseointegrate [ 33 ]. In an animal study, Haas, et al. Staged re-entry of the maxillary sinus to complete the grafting procedure may prevent microbial pathogens from invading into and displacement of the graft material into the sinus cavity that is responsible for initiating an acute sinusitis and infection observed with immediately repaired sinus membrane perforations [ 18 , 29 ].
This article describes an alternative surgical strategy and technique to assist the clinician in management of a large perforation or complete tear of the sinus membrane that avoids the postoperative complications associated with this surgical procedure.
Staged re-entry of the maxillary sinus to graft the sinus cavity is predictable and increases graft material and implant survival. The author declares no potential conflicts of interest with respect to financial funding, research, authorship and publication. Abstract Maxillary sinus membrane perforation or tear is the most common complication of the sinus grafting procedure.
Keywords Re-entry, Maxillary sinus, Infection, Sinusitis, Histology, Fibrotic Scheiderian membrane, Bioresorbable collagen membrane, Platelet rich plasma Introduction The maxillary sinus lift elevation procedure with bone graft augmentation is the most frequently performed surgical procedure to increase the vertical bone height of the posterior maxilla in preparation for dental implant placement.
Clinical Maxillary Sinus Elevation Surgery.PDF
B, Postoperative endoscopic findings of ESS show intractably diseased mucosa persisting in the maxillary sinuses even after making patent the maxillary orifice and restoring the ethmoid at 5 months. D, Postoperative endoscopic findings show rapid restoration of the intractable disease in the maxillary sinus at 5 months after the HPWJ procedure. Physiologic isotonic sodium chloride solution at a static pressure of 3 MPa in the tank is transmitted to the cannula and spout with a dynamic pressure of 1 MPa at the tip of the cannula. A, Preoperative persistent diffuse disease filled the sinus. B, Physiologic isotonic sodium chloride solution shot from the cannula.
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Reasons for Failure in Endoscopic Sinus Surgery
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J Oral Implantol 1 October ; 46 5 : — Xenograft bone substitutes are commonly used to increase bone volume and height in the deficient posterior maxilla. The addition of enamel matrix derivate Emdogain could increase the efficiency of the bone healing process. The aim of this prospective randomized, controlled split-mouth design study was to compare the percentage of newly formed bone in sinus floor augmentation with deproteinized bovine bone mineral with or without the addition of enamel matrix derivative after 6 months of healing.
The impact of failed surgery, whether economic, emotional or health-related, is considerable. Technical factors continue to play an important role in failed surgery. In others, poor patient selection is a key issue, particularly in the difficult area of facial pain.
Clinical Maxillary Sinus Elevation Surgery.PDF
The Art Of Choosing. Les Terrines. Nuovo Corso Di Diritto Civile. Bible Du Triathlon 2me Dition.
Int J Oral Dent Health This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Maxillary sinus membrane perforation or tear is the most common complication of the sinus grafting procedure. Repair of the sinus membrane is usually accomplished at the time of the sinus graft procedure and often results in uneventful postoperative complications. However, complications may still arise, especially with large sinus membrane perforations or complete tears that could lead to an infection of the maxillary sinus and other anatomic areas of the maxillofacial complex that could result in bone graft and dental implant failure.
Sinusitis , also known as rhinosinusitis , is inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include thick nasal mucus , a plugged nose , and facial pain. Sinusitis can be caused by infection , allergies , air pollution , or structural problems in the nose. Some cases may be prevented by hand washing, avoiding smoking, and immunization. Sinusitis is a common condition. Headache, facial pain, or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis.
This goal is achieved primarily by the endoscopic removal of disease from key areas of the anterior ethmoid and middle meatus. In addition, the technique also offers the possibility of performing sphenoethmoidectomy with preservation of the middle turbinate. Localized irreversible disease in the maxillary sinus may be removed endoscopically with minimal trauma. The technique allows excellent visualization, and results in minimal morbidity and bleeding. Nasal packing is not required, and surgery can usually be performed on an outpatient basis using local anesthesia. Kennedy DW. Functional Endoscopic Sinus Surgery : Technique.
The placement of endosseous implants in posterior edentulous maxilla is normally a challenging task in implant dentistry due to maxillary sinus pneumatization. Various sinus augmentation techniques have been used with impressive success rates aimed at developing these sites for implant placement. Knowledge of anatomy of maxillary sinus guides us not only in proper preoperative treatment planning but also helps us to avoid the possible complications that may arise during sinus augmentation procedure.
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