Open Sinus Lift

Open Sinus Lifting
By:
Sarah Yusri
Dalia Sanaa
Contents:
 Introduction
 Indications and contraindications.
 Techniques
 Advantages
 Disadvantages
 Complications
 Conclusion
Introduction
 Missing upper back teeth are among the most difficult to
restore. When the back teeth in the upper jaw are missing the
sinus cavity becomes larger as the natural bone deteriorates
over time. A sinus lift, also called sinus augmentation or sinus
elevation, is a bone-augmentation procedure for patients who
have insufficient natural bone in this area for dental implant
placement. The procedure involves adding bone below the
sinus so that one or more implants can be placed
 Open sinus lift surgery is a form of pre-prosthetic surgery for
increasing the quality and quantity of bone in the posterior
region of the maxilla. Pre-operative assessment of the maxillary
sinus is essential for the success of this surgery. Rahpeyma and
Khajehahmadi.2015
 The literature has indicated the maxillary sinus lift procedure as
an excellent treatment option for posterior maxillary edentulism
and, when performed well, sinus graft procedures produce a
significant amount of bone, allowing the installation of implants in
an anatomical and proteic position proper. The variation of the
technique to be used is defined by the quantity of bone remaining,
its quality and surgical knowledge, and it is possible to use
combinations of these in certain cases. In order to improve the
bone height it is possible, besides the sinusal survey, to perform
onlay grafts; However, this type of procedure usually does not
offer noticeable changes
Indications for sinus augmentation:
 No history of sinus pathosis.
 Insufficient residual bone height (less than 10 mm of bone
 height).
 Severely atrophic maxilla.
 Poor bone quality and quantity in the posterior maxilla.
Contraindications for sinus
augmentation:
 Recent radiation therapy in maxilla.
 Uncontrolled systemic diseases such as diabetes mellitus.
 Acute/chronic maxillary sinusitis.
 Heavy smoker.
 Alcohol abuse.
 Psychosis.
 Severe allergic rhinitis.
 Tumor or large cyst in the maxillary sinus.
 Oroantral fistula.
Techniques
The two main techniques of SFE for dental implant placement are
A two-stage technique with a lateral window approach,
followed by implant placement after a healing period; and a one-
stage technique using either a lateral or a transalveolar
approach. The decision to use one- or two-stage techniques is
based on the amount of residual bone available and the
possibility of achieving primary stability for the inserted implants.
Lateral approach with bone grafting materials
(Open Sinus Lifting)
Surgical Technique:
 Administration of the local anesthesia.
 The maxillary sinus is exposed by a full-thickness
mucoperiosteal flap. The first incision is usually crestal, and it
should be longer than the future osteotomy in the
anteroposterior dimension. Mesial and distal releasing incisions
can be made to facilitate visibility.
 the dimensions of the osteotomy are determined based on the
clinical and radiographic examinations. The lower border of the
osteotomy should be approximately 3 mm above the sinus
floor.
 The osteotomy should be oval or rectangular, and corners and
sharp edges should be obtained using a round diamond or a
 The bony wall can now be carefully removed and retained for later
incorporation into the graft material or tapped into the sinus hinging
on its superior margin while still attached to the membrane.
 The sinus membrane is gently reflected and elevated using special
curettes to create space for the graft material.
 Sinus membrane reflection should be to the medial wall of the sinus
and superior enough to prevent pressure on the graft and prevent
membrane tearing during graft placement.
 The graft material of choice is then packed into the space created. A
synthetic membrane can be used to cover the window or the lateral
wall of the graft. Finally, the mucoperiosteal flap is repositioned and
sutured
One-stage versus two-stage lateral sinus lift
procedures:
 The advantages of a single stage procedure are reduced healing

time by 50% due to reduction of one operation; however, the
main potential disadvantage with the one- stage procedure is
the possibility of being unable to stabilize implants in minimal
bone heights, with the additional risk of implants falling inside
the sinus. Therefore, if an implant is unstable or it is suspected
that it would be difficult to stabilize, it is always possible to
postpone implant placement to wait for graft healing and opt
for a two-stage procedure.
Felice et.al concluded that :
No statistically significant differences were observed between
implants placed according to 1- or 2-stage sinus lift procedures.
However this study may suggest that in patients having residual
bone height between 1 to 3 mm below the maxillary sinus, there
might be a slightly higher risk for implant failures when
performing a 1-stage lateral sinus lift procedure.
Advantages:
 In most cases, it is the best available solution for
insufficient quantity of the alveolar bone during the
implantation into the dorsal parts of the maxilla
 Its role in current dental implantology is non-
replaceable
 Used when more than 4-5mm of bone grafting is
required
 Sinus membrane is directly visualized
 Easy access
Disadvantages:
 Invasive surgical procedure
 More pain and postoperative discomfort
 Time consuming
 More susceptible for infection
 More risk of complications
 Longer healing period
 Requires experienced surgeon
Complications:
Complications associated with maxillary sinus augmentation can
be categorized into:
 Intraoperative complications
 Acute postoperative complications
 Chronic postoperative complications
Serious complications are very rare, while the occurrence of the
other complications corresponds to the character of the procedure
and is acceptable for both the patient and the surgeon.
Perforation of the Schneiderian
membrane
 It is the most common complication of
maxillary sinus graft and it is reported to
occur in 10% to 34% of patients.
 Presence of sinus septa and a residual
bone height less than 3.5 mm increases
the risk for a sinus membrane
perforation.
 The incidence rate is higher in smokers
than nonsmokers because the maxillary
sinus membrane becomes thinner in
cigarette smoke.
 If not closed spontaneously, we should
use oxycellulose mesh for coverage.
 In emergency, the mesh can be used
to reconstruct the entire ceiling of the
augmented space.
 If the perforation of the maxillary
sinus membrane is smaller than 5
mm, the survival rate of implants has
been reported to be 97.14%.
 Perforation of the Schneiderian
membrane seems not to influence the
final treatment outcome, but it is
associated with a higher prevalence
for sinusitis.
Bleeding
 The infraorbital artery and posterior superior alveolar artery run in
and out of the lateral wall of the maxillary sinus, forming an
extraosseous anastomosis and intraosseous anastomosis.
 As for the intraosseous branch, it has been reported that straight-
type branches compose 75% of total cases, while U-shaped ones
make up 25%.
 If a small window is formed and positioned as low as possible, there
is a reduced chance of encountering the intraosseous branch.
 If excessive bleeding occurs during surgery, it has to be controlled.
Acute sinusitis
 Acute sinusitis is the most serious complication.
 It is most frequently caused by infection of the augmentation material
during the surgery.
 It has dramatic manifestations and requires revision surgery of the
maxillary sinus under general anesthesia with the removal of all foreign
bodies.
 It is a quite rarely occurring episode.
 The typical symptoms of sinusitis include foul odor, headache
(migraine), midfacial discomfort while running, pressure with head
position change, nasal obstruction, and tenderness.
Other complications
 Mild purulent exudate from a dehiscent mucosal wound accompanied
by swelling, pain and sub-febrile conditions, is not a big threat. It can
be usually managed by irrigations and antibiotic therapy.
 Second intention healing is observed sometimes, which represents no
big risk for the effectiveness of the procedure. If the bone window is
situated too close to the mucosal incision, or if the augmentation
material is too much compressed, the augmentation material can be
liberated from the wound. In this case, it is recommended to use
antibiotic treatment and try to apply a secondary suture
Other complications
 Postoperative hematoma is observed mostly in older females. It
has annoying effects in esthetic terms but usually resorbs
within two weeks.
 Primary failure (non-osseointegration) of the implant remains a
very rare event in hydroxyapatite-coated fixture. Long-term
success is not significantly different from that of usual
implantations.
Conclusion
 Lateral sinus lift, despite having some disadvantages, such as in
particular high demands on both surgeon and the patient and
longer healing period, is in most cases the best available
solution for insufficient quantity of the alveolar bone during the
implantation into the dorsal parts of the maxilla.
 Its role in current dental implantology is still non-replaceable.
 The invasiveness of the procedure can be substantially reduced
when performed by an experienced surgeon using the presented
surgical protocol. The risk of complications remains low.
Thank You

Open Sinus Lift

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 The advantages of a single stage procedure are reduced healing

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