Sinus lift

Sinus lift information including research and step but step protocols.

ADA dental codes for sinus lifts

What graft materials can you use in the sinus lift?

You can place almost anything into the sinus because it has excellent bone regeneration ability. Things as simple as collagen sponges have shown success. Some show good results with nothing at all, for samples of that check references 8-13  Rajkumar 2013.

ß-tricalcium phosphate (ß-TCP) and PRF slugs are some of the more common materials to use for sinus lifts. ß-TCP works as well as bovine. Kraus JOMI 2020

Technique to add 2-3mm 4mm max (Bill’s thoughts) more go lateral. If 3mm or less he goes lateral.

Follow these 3 rules create = success rates older study. I think all 3 are too conservative now

1. If 6mm or more of bone go crestal and place implant (maybe less) some say down to 3-4mm
2. 4-6mm lateral and place implant
3. <4mm lateral 2 step 1

Lateral exclusions 1

• Long term Abs >2weeks within last 3 months
• Bone metabolism drugs
• 10 or more cigarettes a day
• Alcoholic/drugs
• Pregnant or trying to get pregnant
• Mucocutaneous disease
• Severe acute or chronic sinus pathology (sarcoidosis, osteomas, carcinomas)
• History cancer or radiation to head or neck in last 18 months
• Chemo in past 12 months

Risk factors of failure of graft 1

• Smoking 15 cigarettes a day
• < 4mm bone
• age 1
• alcohol intake
• residual ridge
• hx periodontitis

Sinus pre-op medications

• 1-2 gm amoxicillin 1 hour prior or 1-2 grams Ceftin (Cefuroxime) 1 hour before.
• 400-600 mg ibuprofen

7 day Augmentin starting with loading dose 1 hour before.
Metronidazole 10mg once daily 7 day
3x3x3Rule
CHX and Sinus precautions for 2 weeks
Medrol pack

Sinus post-op medications

If no perforation

• Amoxicillin 500 mg  21 tabs tid or Ceftin (Cefuroxime) 500mg bid 20 tabs bid

If perforation

• Augmentin 875/125 20 tabs 1 tab bid or levaquin 750mg 5 tabs 1 tab qd
• Pain meds as feel appropriate

Sinus complications

Infection, swelling, and bruising are all complications. For the swelling and bruising just use ice packs and ibuprofen and maybe steroids. For infection use metronidazole and if does not get better in 3 days then remove graft.

Osteotome-mediated sinus floor elevation

1. Prep to 2mm floor
2. Up fracture with flat end osteotome
3. Pack graft material in with osteotome

Hydrodynamic piezoelectric internal sinus elevation

1. Prep close
2. Ultrasonic breaks floor
3. Valsalva to eval
4. Sinus membrane elevation with hydraulic pressure
5. Inject metronidazole infusion (1/20 of common 200mg tab)
6. Valsalva to eject fluid Bensaha 2012
7. Graft with fibrin rich CGF Kim 2014  Sohn 2011
   

Sinus bump

Bill Schaeffer

1. Drill to almost last drill size just below sinus floor. Makes punching in easier cause can see more. Bill tip
2. Albert’s BSB Hammerless crestal lift kit to get into the sinus – just breaching the bony floor.
3. Take some PRF “slug” and cut it into about 4 pieces.
4. Take some fine tweezers (non-toothed forceps) and bring a piece of slug up to the osteotomy.
5. Use YOUR plugger, with the depth stop (one size shorter than the drill stop last used) attached, and use that to push the the piece of slug into the hole.
6. Repeat until you’ve rammed at least one full slug (more if it’s a big lift) into the hole.
7. Take your final implant drill and set it for 50 rpm or less (my Bicon background!) and drill through the sinus floor without irrigation, knowing that the sinus lining has already been lifted up out of your way.
8. Add more PRF into the osteotomy, pushing it in again with the plugger.
9. Insert your implant.

PRF plug

Lateral or vertical get CBCT to find PSSA (posterior superior alveolar artery) lateral wall sinus

• Present 53% time
• Common to find during lateral approach of 1st molar
• Keep bony window under 15mm from alveolar crest
• Electrocauterize any bleed
• Terminate bleeding with Surgicel, digital pressure, and bone wax  usually unsuccessful.
• Injection of local anesthetic with vasoconstrictor and electrocautery may be avoided due to the close proximity of the Schneiderian membrane
• Topical bovine Thrombin (King Pharmaceuticals, Bristol, TN) were applied to the surgical
• Within 5 minutes of thrombin hemostasis can be achieved.1

Lateral video on FOR

Lateral technique I like by Ioannis Vergoullis

Literature review

Lit review
Conclusions are based on few small trials, with short follow-up, and judged to be at high risk of bias. Therefore conclusions should be viewed as preliminary and interpreted with great caution. It is still unclear when sinus lift procedures are needed. 5 mm short implants can be successfully loaded in maxillary bone with a residual height of 4 to 6 mm but their long-term prognosis is unknown. Elevating the sinus lining in presence of 1 to 5 mm of residual bone height without the addition of a bone graft may be sufficient to regenerate new bone to allow rehabilitation with implant-supported prostheses. Bone substitutes might be successfully used as replacements for autogenous bone. If the residual alveolar bone height is 3 to 6 mm a crestal approach to lift the sinus lining, to place 8 mm implants may lead to fewer complications than a lateral window approach, to place implants at least 10 mm long. There is no evidence that PRP treatment improves the clinical outcome of sinus lift procedures with autogenous bone or bone substitutes.

Short implants (5 to 8 mm) may be as effective and cause fewer complications than longer implants placed using a more complex technique. A second meta-analysis from Vetromilla JPD 2021 finds this to be the case.  It is not clear that bone graft materials are needed or whether some bone graft materials are more effective than others.  Biomaterials might be used in place of autogenous bone. There is no evidence to suggest factors extracted from the patients blood improve bone healing.

Lateral

1. Collagen membrane, BioXclude, epi-guide against membrane if tear (bad tear no implant)
2. B-tricalcium phosphate
3. Collagen or epi-guide over acess
4. Suture
5. Ice packs to reduce swelling
6. Nasal precautions 2 weeks
7. Medrol dose pack

Nanobone protocol

1. Lateral window Docs like mectron and cube about same.
2. Reflection Schneiderian membrane
3. Collagen membrane over Schneiderian membrane
4. Fill with nanobone mixed with blood
5. Membrane over access
6. Suture
7. Wait 15 months!!  Graft shrinkage of 9%

Bio-Oss or Bone Cermaic or PepGen P-15 1

1. Lateral window (make as small area as possible 1)
2. 6 months prior implant (common time period is 6 months for FDBA too?)

Calcium sulfate or calcium phosphate with gelfoam 1

1. Crestal raise membrane
2. Gel-foam as the base and then squirt Steiner calcium phosphate.
3. Restore 6 months

PepGen P-15 putty

1. Lateral and place after only 2 months! 1

Risk factors 

• Mucosal thickening >5mm (risk development severe infections)
• Polypoidal mucosal thickening
• Partial opacification and/or air/fluid level
• Complete opacification
• Previous issues of sinusitis Timmenga  Manor

Complications Kantranji

1. Infection – try 300mg clindamycin tid for 5 days and hydrogen peroxide rinse
2. Acute sinusitis – Augmentin and  Sinus care
3. Sinus perf – squirt saline or local anaesthetic into the osteotomy and see if it comes back out or disappears or “Trampoline Test” or check 4 bubbles= Collagen membrane
   • I place a bioXclude membrane then bone then implant.
   • If the tear is a huge, gaping, black hole then the process changes.  😉
   • In the situation described I most likely would have placed the implant and informed the patient of the increased risk of bleeding through their nose.  Most of the time it will heal up just fine.
   • if u suspect a torn membrane….would u just place some collagen product….dip it in gentamycin….and then still place ur implant?!   no particulate grafts DT post
4. Bleeding = electrocauterize, firm pressure, check above
5. Post op bleeding = decongestant and AB
6. Dehiscence = CHX 3times day and AB

Sinus perf lateral risk factors 1

1. Bony septa (make 2 smaller windows)
2. Narrow sinus antrum
3. Very thin sinus bone wall
4. Very thin sinus membrane
5. Scar from previous procedure (extraction??)

Infected about 5% time  Signs=severe pain, fistulous tract, recurrent facial swelling at 2-3 weeks, abscess, elevated body temp, loss of graft material through fistulous tract or borders of flap 1

1. CT any abnormal CT results = ENT consult
2. ENT endoscopic sinus surgery if communication between infected graft and sinus
3. Open window
4. Remove all infected graft
5. Irrigate sterile water
6. 100-200mg doxycycline with .1-.2mL saline to form putty
7. Placed on bone graft remaining for 2 minutes
8. Washed out with sterile saline
9. Bleeding re-established with light currette
10. AB Augmentin 5 days and 3x3x3 rule
11. If sinus problems then sinus recommendation for 4 days
12. At 6 months implants and graft any defect area still present

Suspected internal fistulous tract and sinusitis

If patient asymptomatic Augmentin 500 tid for 3 weeks then repeat CBCT 2 months later. If sinus remains cloudy or if symptoms occur at any time, refer to ENT.

Normal response

• Max swelling at 48 hours decreasing and disappearing at 10 days
• Minor pain from tension of swelling

Short 5 mm implants can be loaded in maxillary bone with a height of 4 to 6 mm, but the long-term prognosis is unknown. Sinus elevation alone may be successful in bone regeneration and crestal grafting may result in fewer complications than when using the lateral window approach. Bone substitutes may be possible to substitute for autogenous bone. The authors did agree that PRP treatment does not seem to improve the clinical outcome of sinus lift procedures with either autogenous bone or bone substitutes. = Oct 11

Lateral
takes longer and causes more postop complications than classical
crestal greenstick fracture of sinus floor with osteotome. 

Sinus lift hands on courses

The Brighter way with Dr. Joe,