Sinus Lift &Dental Implant Placement. With Clinical photographs

Dr. Amit T. SuryawanshiOral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

Bilateral Maxillary Sinus Lift

• Right side is planned as a staged sinus lift procedure with the surgical removal of the second bicuspid

• Left side planned for sectioning of fixed bridge, removal of fractured premolar, left antral graft and immediate placement of three osseointegrated tapered screw vent implants

First Surgical Procedure: Right Side

• This is a 40 year old patient scheduled for prosthetic reconstruction of maxillary arch

• Opposing fixed mandibular bridge work

• No posterior maxillary dentition• Our goal was to place 2, long,

tapered screw vent implants on the right side (13mm)

• Implant length is important in younger patients to insure long term, proper function against opposing fixed bridgework

Staged Sinus Lift

• The right side was staged

due to the lack of bone and

the desire to augment the

right antrum with 8-10mm

of bone

• As with all of our bone

grafting procedures, the

grafts are augmented using

platelet concentrate

Second Surgery: bilateral procedure

• 2 tapered screw vent implants are placed into the right antral graft

• On the left side we sectioned the fixed bridge distil to the maxillary left canine

• The left first bicuspid was surgically removed

• 3 tapered screw vent implants were placed in the left quadrant

• The anterior implant was immediately placed in the extraction site of the first bicuspid

• An antral sinus lift was performed on the left side for the posterior implant

• 11.5mm implant placed immediately into left antral graft

Surgical Notes

• Notice complete osseous healing of buccal window 4 months after staged antral graft on the right side

• The right sinus lift graft enabled the placement of a 4.7, 13mm & 3.7, 13mm implants into the second bicuspid and first molar sites

Surgical Notes• Note buccal defect associated

with anterior implant placed immediately into the first bicuspid extraction site

• Sinus window and schneiderian membrane visible with parallel pin in distil implant site

• Graft applied to left antrum as well as buccal defect

• Note the neat isolation and containment of graft material due to the use of platelet rich plasma

Final Notes

• Note radiopaque areas in the right and left sinus cavities indicating organization and ossification of sinus grafts

• This patient was treated in 2 efficiently planned surgical procedures with the aid of general anesthesia

Basic Surgical Techniques for Endosseous Implant Placement

Dental implant is an artificial titanium

fixture which is placed surgically into the

jaw bone to substitute for a missing

tooth and its root(s).

WHAT IS A DENTAL IMPLANT?

In 1952, Professor Per-Ingvar Branemark, a Swedish surgeon, while conducting research

into the healing patterns of bone tissue, accidentally discovered that when pure titanium comes into

direct contact with the living bone tissue, the two literally grow together to form a permanent

biological adhesion. He named this phenomenon "osseointegration".

History of Dental Implants

 

All current implant designs are

modifications of this initial design

First Implant Design by Branemark

STEP 1: INITIAL SURGERY

STEP 2: OSSEOINTEGRATION PERIOD STEP 3: ABUTMENT CONNECTION STEP 4: FINAL PROSTHETIC

RESTORATION

Surgical Procedure

Fibro-osseous integration

• Fibroosseous integration– “tissue to implant contact with dense collagenous tissue between the implant and bone”

• Seen in earlier implant systems.• Initially good success rates but extremely poor long term success.• Considered a “failure” by todays standards

Osseointegration• Success Rates >90%• Histologic definition

– “direct connection between living bone and load-bearing endosseous implants at the light microscopic level.”

• 4 factors that influence:Biocompatible material

Implant adapted to prepared site

Atraumatic surgery

Undisturbed healing phase

Soft-tissue to implant interface• Successful implants have an

– Unbroken, perimucosal seal between the soft tissue and the implant abutment surface.

• Connect similarly to natural teeth-some differences.– Epithelium attaches to surface of titanium much

like a natural tooth through a basal lamina and the formation of hemidesmosomes.

Soft-tissue to implant interface

• Connection differs at the connective tissue level.

• Natural tooth Sharpies fibers extent from the bundle bone of the lamina dura and insert into the cementum of the tooth root surface

• Implant: No Cementum or Fiber insertion.

Hence the Epithelial surface attachment is IMPORTANT

Subperiosteal

Transmandibular Implant

Blade Implant

Endosteal Implants

The “Parts”

• Implant body-fixture• Abutment (gingival/temporary healing vs.

final)• Prosthetics

Clinical Components

abutment

Team Approach

• A surgical – prosthodontic consultation is done prior to implant placement to address: – soft-tissue management– surgical sequence – healing time– need for ridge and soft-tissue augmentation

Clinical Assessment

• Assess the CC and Expectations• Review all restorative options:

– Risks and Benefits

• Select option that meets functional and esthetic requirements

Patient Evaluation

• Medical history– vascular disease– immunodeficiency– diabetes mellitus– tobacco use– bisphosphonate use

History of Implant Site

• Factors regarding loss of tooth being replaced

– When?

– How?

– Why?

• Factors that may affect hard and soft tissues:

– Traumatic injuries

– Failed endodontic procedures

– Periodontal disease

• Clinical exam may identify ridge deficiencies

Surgical Phase- Treatment Planning

• Evaluation of Implant Site• Radiographic Evaluation• Bone Height, Bone Width and Anatomic

considerations

Basic Principles

• Soft/ hard tissue graft bed• Existing occlusion/ dentition• Simultaneous vs. delayed reconstruction

Smile Line

• One of the most influencing factors of any prosthodontic restoration

• If no gingival shows then the soft tissue quality, quantity and contours are less important

• Patient counseling on treatment expectations is critical

Anatomic Considerations

• Ridge relationship• Attached tissue• Interarch clearance• Inferior alveolar nerve• Maxillary sinus• Floor of nose

Radiological/Imaging Studies

• Periapical radiographs• Panoramic radiograph• Site specific tomograms• CAT scan (Denta-scan, cone beam CT)

Width of Space and Diameter of Implant

Attention must be paid to both the coronal and interradicular spaces

A case against routine CT

• Expense• Time consuming process• Use of radiographic template/proper fit

requires DDS present• Contemporary panoramic units have

tomographic capabilities• Usually adds no additional data over

standard database

Image Distortion

Anatomic Limitations Buccal Plate 0.5mm

Lingual Plate 1.0 mm

Maxillary Sinus 1.0 mm

Nasal Cavity 1.0mm

Incisive canal Avoid

Interimplant distance 1-1.5mm

Inferior alveolar canal 2.0mm

Mental nerve 5mm from foramen

Inferior border 1 mm

Adjacent to natural tooth 0.5mm

Dental Implant Surgery Phase I

• Aseptic technique• Minimal heat generation

– slow sharp drills– internal irrigation?– external cooling

Dental Implant Surgery Phase I

• Adequate time for integration• Adequate recipient site

– soft tissue– bone

• Kind & Gentle technique

1. Chlorhexidine

2. Analgesics

+/- antibiotics

Disposition

Implant placement 3 months after menton bone grafting

Exposure of Implant during Placement

Summer’s Osteotomes

Limitations to Implant placement in the Maxilla

• Ridge width

• Ridge height

• Bone quality

Surgical Solutions to Anatomical Limitations

Onlay Bone Graft Sinus Lift

Summers, RB. A New concept in Maxillary Implant Surgery: The Osteotome technique.

Compendium. 15(2): 152, 154-6

• Ridge expansion technique– 3-4 mm of crestal alveolar width

required

• Sinus floor elevation technique– 8-9 mm of alveolar bone height

required in order to place a 13 mm implant

(4-5 mm sinus floor elevation)

IntroductionRidge expansion technique

• 1.6 mm pilot hole• Summers osteotome # 1-4

– sequenced tapered osteotomes.– ridge expansion (displacement) versus

bone removal.

• Final drill coincident with the final implant size (sometimes not necessary)

IntroductionSinus floor elevation technique

• 1.6 mm pilot hole • Summers osteotome # 1-4

– Sinus floor microfractured superiorly– Sinus floor can be elevated 4-5 mm – May backfill with bone allograft/alloplast

• Final drill coincident with final implant size

Surgical Technique

A. Rake, K. Andreasen, S. Rake, J. Swift A Retrospective

Analysis of Osteointegration in the Maxilla Utilizing an

Osteotome Technique versus a Sequential Drilling

Technique, 1999 AAOMS Abstract

• 155 maxillary implants in 84 patients restored for at least 6 months– 57 were placed utilizing the osteotome technique– 98 were placed utilizing the drilling technique

• One implant failed of the 98 in the drill group• None of the implants had failed of the 57 in the

osteotome group

Stage II Surgery Preoperative Considerations

• 3-6 months after stage I

Stage II Surgery Preoperative Considerations

• Done under local anesthesia• Pre-op medications

– Chlorhexidine rinse

Placement of healing abutment

• The failing implant is very difficult to treat• Traumatic surgical manipulation with

initial instability of implant increases risk of failure

• Implant success is only as good as the prosthodontic reconstruction

conclusions