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SINUS LIFT NOTES FOR SEMINAR Flashcards

1
Q

shape of sinus

A

Pyramid shaped
Base: lateral nasal wall
Apex: zygoma
Roof: orbital floor
Floor: maxilla
Posterior: pterygomaxillary region
Anterior: bone from orbital rim to apex of cuspid

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2
Q

size of sinus

A

40 height x 30 width x 40 length
Volume 15 cc
5mm lift requires 0.70 cc
1cm below nasal floor

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3
Q

septa incidence

A

Septa: incidence is 33%. 1 is 27%, 2 septa is 5%

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4
Q

arteries supplying sinus

A

PSA (anastomoses), IOA, posterior lateral nasal a

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5
Q

nerves innervating sinus

A

Nerve: ASA, MSA, PSA n, IO, GP

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6
Q

sinus membrane - type of epi

A

pseudostratified, ciliated columnar epithelium

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7
Q

sinus membrane - mucous movement

A

Mucous moves 6mm/min

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8
Q

sinus drainage

A

ostium - semilunar hiatus - middle meatus

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9
Q

sinus membrane thickness

A

Usually 0.3-0.8mm thick

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10
Q

what happens if ostium is obstructed

A

Poor drainage and retention of secretions due to decreased mucociliary action of the sinus
rhinosinusitis, infection, and morbidity of the graft or implant

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11
Q

Does the dimension of residual ridge height affect NBF

A

No, according to avila-ortiz 2012

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12
Q

how would you manage a perforation

A

-try to place a membrane, then bone graft
-try to place implant (1-2mm through perf)
-direct approach
-abort procedure

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13
Q

How do u decide between direct and indirect?

A

Indirect: at least 5mm of bone, Favourable anatomy (sinus shape and slope and septa)

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14
Q

What is the effect of residual ridge height on implant survival?

A

96% if you have at least 5mm
86% if you have 4mm or less
Rosen 1999

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15
Q

What is the stability of the grafted bone height

A

Chen 2017
Reduction of 2.4mm in height
Worse if the sinus floor is flat

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16
Q

Describe Summers technique

A

Drill up to 1-2mm from sinus floor, enlarge implant site with drills of increasing diameter, use the last diameter osteotome to fracture the sinus, place implant.

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17
Q

What techniques are there for sinus floor elevation

A

-hydraulics
-OSFE (osteotome sinus floor elevation)
-BAOSFE (bone added OSFE)
-balloon method
-short implant
-densah burs

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18
Q

What is the effect of a perforation on your outcomes

A

still have good implant success, mainly if the perforation is managed appropriately (Diaz-Olivares 2021)
-higher risk of sinusitis

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19
Q

How do u decide on 1-stage or 2-stage

A

Determine if conditions are favorable or unfavorable
In favourable conditions (good quality of bone and minimal occlusal forces), 1-stage approaches can be performed with ≥ 5mm bone height and 2-stage approach should be used with < 5mm bone height
In unfavourable conditions, 1-stage approaches can be performed with ≥ 8mm bone height and 2-stage approach should be used with < 8mm bone height

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20
Q

Is there a difference in bone graft materials in the sinus

A

Deproteinized bovine bone

Del Fabbro 2004 – systematic review, NSSD
-100% autogenous
-95% auto + bone graft
-96% bone graft only
-higher survival for rough (96%) vs smooth (86%)

Wallace 2003:
-block graft is SSD lower (83%) than particulate (92%)

Aghaloo and Moy 2007:
-autogenous 92%
-allograft 93%
-xenograft 96%
-alloplast 81%

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21
Q

Do u need a bone graft material

A

(Shi 2016 – systematic review)
- survival rate of implants after sinus floor elevation
-without grafting: 97.3%
-with graft: 95.89%

Fouad et al 2018: compared a xenograft group with the graftless technique with lateral approach
- Bone gain in the xenograft group: 8.59 mm
- graftless group: 4.85 mm
- better bone height gain, bone density, and implant stability

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22
Q

How come you don’t need a graft material?

A

Lundgren 2004 described how you can get bone formation if there is space maintenance with the tenting effect of the implant (or if the membrane is sutured) as the space is filled with blood clot and then colonized by osteoblasts from the adjacent bony walls of the maxillary sinus and from the sinus membrane.

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23
Q

What is the overall survival rate of implants in the sinus

A

Del Fabbro 2004 – 92%

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24
Q

What is the survival of placing immediate or delayed implants

A

Fabbro 2004: NSSD, both roughly 92%

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25
What factors affect the outcomes
-smoking -residual bone height
26
What is the effect of implant size and length on outcomes
Del Fabbro 2012: no difference in implant survival with implant length Pjetursson 2009: with osteotome technique, there is a difference in survival: >12mm – 100% 10 – 99% 8mm – 99% 6mm – 48% Meta analysis shows NSSD in implant survival for narrow implants compared to conventional implants (Klein 2009)
27
How much bone gain do you get
Urban 2017: 5mm vertical
28
Who first described the sinus lift technique
-Tatum first suggested the indirect approach, then Summers did it
29
What about the use of bone growth factors?
L-PRF as the sole graft material showed bone formation 3mm vertical (Molemans 2019) Suarez-Lopez del Amo 2022: There was one study that reported L-PRF was associated with statistically significant 14% increase in bone formation and 10% decrease in residual bone graft compared to controls
30
Side effect of osteotome technique
Benign paroxysmal positional vertigo
31
Occlusion and angled screw access?
Swamidass 2021: Compared conventional and ASA, they both performed well after cyclic loading with comparable torque values Di Fiore 2023: -ASA did NOT affect crestal bone loss or mechanical complications
32
Would you splint your implants
De Souza Batista 2019: -higher implant survival with splinted, but no difference in MBL or prosthetic complications Might be a good option if there are high masticatory forces
33
Short implants versus long implants?
Short implants 8.5mm or less have a high survival rate of 94%, higher failure rate in smooth vs rough implants (Testori; Kotsovillis) Extra short implants 6mm or less have high survival rate of 97% for both short and long >10mm implants. No difference in MBL (Ravida 2019) Cruz 2018: short implants versus long implants with sinus lifts; found NSSD in survival or MBL; higher biological complications for long implants (perforations, sinus infections, pain, swelling) and prosthetic complications for short implants (screw fractures, ceramic fractures, abutment fractures, screw loosening)
34
What is the effect of penetrating the implant into the sinus cavity
Boyne 1993: 2-3mm in the sinus is ok and you get spontaneous bone formation around the apex If you have 5mm or more penetration you only get partial bone growth (50%) Ragucci 2019: if it was more or less than 4mm, implant survival rates were high and both groups had complications including nosebleeds and thickening of membrane. Zhong 2013: dog study that found if you have 2mm or less penetration you get membrane coverage and bone formation but if you have more than 3mm there isn’t. Again, both groups had NSSD in implant osseointegration and sinus health.
35
Where do you place implants from each other and from teeth? What happens if they are too close together
(Tarnow et al., 2000) * Implants placed greater than 3mm apart had 0.45mm crestal bone loss while implants placed less than 3mm apart had twice as much crestal bone loss of 1.04mm * increased crestal bone loss → decreases the likelihood of papilla fill Based on these findings, the distance between two adjacent implants should be 3.0mm and the distance between a tooth and implant should be 1.5mm (Vela et al., 2012) Authors reported that platform switched implants can be placed 1mm away from adjacent teeth if required (Rivara et al., 2020) The authors suggest that platform switched implants can be placed 2mm away from adjacent implants if required
36
Papilla fill
Kan 2003: Papilla fill is related to the interproximal bone level next to the adjacent teeth Souza 2019: papilla fill is related to morphology of the embrasure, better papilla fill with narrow and short interproximal spaces
37
How much bone do you need apical to the implant
2-3mm, so do 4mm overfill Rosen 1999: you need 50% of the implant in bone and at least 4mm of the implant in bone
38
How much bone height gain do you get with the indirect approach
3-4mm according to the Summers technique with osteotomes
39
What is the incidence of perforation
Tan et al 2008 for transcrestal technique – 0-21.4% mean of 3.8% (many visual limitations for detecting)
40
How will you check for perforation
-feel with depth gauge -check for bubbles -radiographically -breathing and fluid movement Ask if liquid in throat
41
Risk factors for perforation
-thickness of membrane (<1mm or >2mm) ideally between 1-1.5mm -steep sinus wall -septa -pathology -smoking
42
management of infection
clavulin, nasal saline rinses, ent referral
43
Adv and disadv septa?
Most common in the 2nd PM to 1st M region Adv: more bone for osteogenesis, wall for holding bone material, provides stability for implant Dis: higher prob of perforation, osteotome is difficult, makes lateral window challenging
44
How do you manage bleeding
position upright -pressure with gauze, can soak it in 1:50k epi -cautery (can lead to perf or necrosis) -make another window to access artery -cut bone with a high speed diamond bur
45
What is the effect of membrane perforation on sinus lift
According to Ferreira 2017, having a perforation does NOT affect implant survival rates. Having good management of the perforation is important though (97.7% in non perf, versus 97.1% in perf). Size of the perforation did not matter. Managed with collagen membrane with tacks to contain the graft. You can still get bone formation after a perforation, Ferreira found 24% NBF in large perforations which is comparable to non perf NBF in the literature. Higher prevalence of sinusitis has been reported with perforations (Hernandez Alfaro 2008)
46
What is enough stability for you
25-45 Ncm Although there isn’t a defined torque and it is mostly about limiting micromotion 35 Ncm is required for immediate loading
47
How much micromotion is okay
50-150 microns
48
What factors affect primary stability
-quantity and quality of bone -implant design -implant surgical technique
49
define osseointegration
Branemark (1977) originally described osseointegration as direct contact between an implant and living bone at the light microscope level - Branemark (1985) later specifies that there must be direct bone-to-implant contact under load - Zarb & Albrektsson (1991) definition is based on clinical criteria - “a process whereby clinically asymptomatic rigid fixation of alloplastic materials is achieved and maintained in bone during functional loading” - Glossary of Prosthodontic Terms (9th edition, 2017): - “the process and resultant apparent direct connection of an exogenous material’s surface and the host bone tissues, without intervening fibrous connective tissue present”
50
How will you check for osseointegration/ stability
-torque -RFA -Periotest -percussion testing (tapping and basing it off sound, not recommended) -reverse torque (not recommended)
51
When do you need to do a referral to ENT?
Referral recommended to ENT 1. Acute sinusitis (symptoms + air fluid level) tx by MD 2. Chronic sinusitis 3. Allergic sinusitis 4. Fungal sinusitis 5. Opacified sinus 6. Polyps 7. Cyst (>8 mm) 8. Primary/secondary mucocele 9. Tumors 10. Foreign bodies 11. Previous trauma
52
Contraindications for sinus lifts
Tumors -pathology (polyps -Sinusitis (acute can be tx, chronic is absolute, fungal is absolute) -smoking (relative)
53
sinusitis symptoms
nasal discharge -nasal congestion -facial pain -fever -radiograph shows air-fluid level
54
Describe the process of osseointegration
Bleeding in osteotomy site bathes implant in blood cells, clotting factors, proteins - Platelets aggregate, Clot formation begins, fibrin matrix is formed - Chemotactic signaling from blood cells to attract osteogenic cells which migrate through fibrin matrix (osteoconduction) - Osteogenic cells adhere to implant surface, proliferate, differentiate (osteoinduction) - Secretion of collagen-free organic matrix which will subsequently initiate collagen fiber assembly and mineralization (de novo bone synthesis) - Formation of woven bone which will later be remodeled and substituted by lamellar bone
55
How does roughness help with implant osseointegration
improving adsorption of fibrin and platelets, which helps with recruitment and attachment of osteogenic cells - increases BIC to enhance primary stability -optimal range is Sa = 1-2 microns
56
How do you determine primary stability
insertion torque (which is the rotational force during insertion), mainly influenced by the macro structure -RFA value, which applies a bending load and gives an ISQ value (implant stability quotient) which is the lateral stability of the implant which gives information of the changes in stability overtime
57
Describe the Straumann BLT implant surface
Grade 4 titanium with Roxolid (alloy of 85% titanium and 15% zirconium) SLActive surface: sandblasted acid etched. Crossfit connection with 15 deg internal core Tapered
58
What if the implant is spinning
Balshi 2007 – you can still have survival rate of 82% and osseointegration
59
What are the dimensional changes following tooth extraction?
Schropp 2003: 50% bone loss in the BL dimension 2/3 resorption occurs in the first 3m Bone level at extraction dictates healing (not adjacent teeth) Van der Weijden 2009 systematic review: Buccal Height 1.67 Lingual Height 2.03 Width 3.87, most of which is from the buccal bc the cortical plate is thin and mainly composed of bundle bone
60
What is the benefit of ridge preservation?
X2 loss in width without grafting 30-40% loss without graft 15-30% loss with graft More favourable ridge preservation if the buccal bone >1mm
61

Treatment Planning Notes (15 decks)

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