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Open Sinus Lift by Drs. W. Stephen Barnes and Michael J. Hoffman

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In our office, we frequently are called upon to replace missing posterior maxillary teeth using dental implants. The sinus cavity can often be a limiting factor in the ability to place implants in the posterior maxilla. When teeth are removed, the sinus will often pneumatize or enlarge, decreasing the available bone to support dental implants. When the available height is less than the length of our required implant length, additional surgery must be done to “re-establish” lost alveolar height.

Classically there have been two well-accepted methods of performing sinus lift grafts for posterior maxillary implants. An external sinus lift involves a lateral maxillary osteotomy, followed by gentle elevation of the Schneiderian membrane. This allows entrance into the created space below the antrum and subsequent graft placement. The alternative approach is an internal (Sommers) sinus lift. This involves in-fracture of the bone at the apex of the implant osteotomy in a superior direction to “push” the sinus lining superiorly. This is followed by graft placement and the implant is placed thereafter. In our experience, the Sommers lift is highly predictable and can accommodate a 4mm superior lift predictably and sometimes up to 6mm. Any implant requiring more than 4-6mm of lift, in our hands, is best accomplished with an open sinus lift. The open sinus lift is a procedure that we perform regularly and predictably in our office.

Case Report:

Diagnosis and Treatment Planning

EB is an otherwise healthy male who reported as a referral from his general dentist for the replacement of the right maxillary teeth. The restorative treatment plan called for implants in #4, #6 and #8 and fabrication of a fixed five-unit bridge. His panoramic radiograph (Fig. 1)—which we now calibrate electronically with our digital software, but classically was done with acetate paper using known magnifications—showed only 4mm of bone height for the implant in the #4 position.

In our office, we now have the capability to accurately measure the bone below the sinus cavity using a digitally calibrated panorex. This is done using a radiographic marker (5mm ball bearing) and calibrated measuring system built into the software. When we have at least 4mm of native alveolar bone, it usually affords us the instance to achieve primary implant stability at the time of placement. In this case, 10mm length implants are planned, especially to withstand the occlusal demands of the proposed restoration.

As an adjunctive treatment-planning tool, we also regularly use cone beam CT scanning to ensure a healthy, well-aerated sinus cavity and verify the patency of the osteomeatal complex. The osteomeatal complex is the natural drainage of the maxillary sinus into the middle meatus of the nose and its patency is imperative for healthy sinus drainage and a good surgical outcome. Our pre-operative surgical consultation also includes a discussion with the patient regarding the risks and alternatives to the surgery.

Procedure

After the administration of a local anesthetic with vasoconstrictor into the maxillary soft tissues, we draw blood from the antecubital fossa to harvest plasma rich in growth factors (PRGF) (Fig. 2). This has been well documented to accelerate the healing response and provides autogenous growth factors to our graft. The blood is taken to a centrifuge where it is spun and the platelet layer is isolated and collected (Fig. 3). While our PRGF is being prepared, we expose the lateral maxilla using a crestal incision with bilateral vertical releasing incisions (Fig. 4).

An osteotomy is carefully made in the lateral maxillary wall using rotary instrumentation and the sinus membrane is exposed (Fig. 5). The lateral sinus wall is gently infractured and lifted superiorly. In some patients, the Schneiderian membrane can be very thin and it’s not uncommon to encounter a membrane perforation (Fig. 6). In this particular case, we show the use of a resorbable collagen membrane to close a perforation in the thin sinus membrane after it is lifted (Fig. 7).

Once the sinus membrane is lifted superiorly, the implants are placed in their appropriate positions based on the restorative treatment plan and surgical guide (Fig. 8). In this case, there remains enough alveolar bone to achieve primary stability of the implant. If there are less than 3mm of alveolar bone height, it is usually difficult to achieve primary implant stability and therefore the grafting is done and implant placement is delayed until the graft has consolidated. Cover screws are placed over the implants to allow for primary closure when the surgery is finished.

A 50:50 mixture of freeze-dried mineralized bone (DCI Donor Services Tissue Bank) and irradiated bone (Rocky Mountain Tissue Bank) is mixed with the activated PRGF. Calcium chloride is added to the PRGF to “activate” the graft. The calcium chloride induces activation of the endogenous thrombin and the transformation of fibrinogen into fibrin. This process forms a coagulum of graft and PRGF, which has excellent handling properties (Fig. 9). The grafting is placed around the implants and into the newly created space (Fig. 10). A second resorbable collage membrane is placed over the lateral maxillary osteotomy to prevent epithelialization of the graft prior to closure. The wound is then closed in a tension-free manner with 4- 0 Vicryl (Fig. 11). A post-operative panorex is taken, showing good implant position and good graft consolidation (Fig. 12).

Post-operative instructions include basic sinus surgery instructions, a course of broad-spectrum antibiotics and analgesics. In cases where we encounter a sinus membrane perforation, Metronidazole is also prescribed post-operatively as secondary antibiotic coverage.

The implants are allowed to integrate for four months, after which they are uncovered, and tested for appropriate torque strength. Healing caps and later, impression posts are placed and the restorative phase is allowed to begin (Figs. 13-15).

In this particular case, the patient’s final restorative case was carried out with very nice cosmetic and functional results. This patient is now more than 10 years removed from surgery and continues to function well and good aesthetics have been maintained.


Drs. W. Stephen Barnes and Michael J. Hoffman are Diplomates of the American Board of Oral and Maxillofacial Surgery. Their practice, Falls Oral Surgery and Dental Implant Center, is located in Cuyahoga Falls, Ohio. Dr. Barnes graduated from Case Western Reserve University School of Dental Medicine and completed his surgery training at MetroHealth Medical Center and The Cleveland Clinic in Cleveland, Ohio. Dr. Hoffman completed his dental school education at Ohio State University School of Dentistry and his surgery training at MetroHealth Medical Center. The doctors at Falls Oral Surgery pride themselves on exceptional implant and oral surgical care.
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