9 780470 960738

kao_9780470960738_OL.indd 1 3/4/14 10:08 AM

PG3628File Attachment9780470960738.jpg

Clinical Maxillary Sinus Elevation Surgery

Clinical Maxillary Sinus Elevation SurgeryEditEd by

Daniel W.K. KaoCEO Washington dental GroupClinical Assistant Professor of PeriodonticsSchool of dental MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

this edition first published 2014 2014 by John Wiley & Sons, inc.

Editorial Offices1606 Golden Aspen drive, Suites 103 and 104, Ames, iowa 50010, USAthe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK9600 Garsington Road, Oxford, OX4 2dQ, UK

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood drive, danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. the fee codes for users of the transactional Reporting Service are iSbN-13: 978-0-4709-6073-8/2014.

designations used by companies to distinguish their products are often claimed as trademarks. Allbrand names and product names used in this book are trade names, service marks, trademarks orregistered trademarks of their respective owners. the publisher is not associated with any product orvendor mentioned in this book.

the contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting aspecific method, diagnosis, or treatment by health science practitioners for any particular patient. thepublisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. in view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. the fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that internet Websites listed in thiswork may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Clinical maxillary sinus elevation surgery / edited by daniel W. Kao. p. ; cm. includes bibliographical references and index. iSbN 978-0-470-96073-8 (pbk.) i. Kao, daniel W., editior of compilation. [dNLM: 1. Maxillary Sinussurgery. 2. dental implants. 3. Maxillary Sinuspathology. 4. Oral Surgical Procedures, Preprostheticmethods. 5. Osteotomemethods. 6. Sinus Floor Augmentationmethods. WV 345] RF425 617.523dc23

2014001172

A catalogue record for this book is available from the british Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print maynot be available in electronic books.

Cover design by Matt Kuhns

Set in 9.5/12pt Palatino by SPi Publisher Services, Pondicherry, india

1 2014

v

Contents

Contributors viiAcknowledgments ixintroduction xi

Chapter 1 Anatomy and Physiology of the Maxillary Sinus 1Harold A. DeHaven, Jr.

Chapter 2 the Applications and Limitations of Conventional Radiographic imaging techniques 9Hua-Hong Chien and Curtis S.K. Chen

Chapter 3 the Applications and Limitations of Advanced (3-dimensional) Radiographic imaging techniques 31Chih-Jaan Tai, Dimitris N. Tatakis, and Hua-Hong Chien

Chapter 4 Conventional instruments Preparation and Preclinical training of the Lateral Window technique 57Daniel W.K. Kao

Chapter 5 Clinical Procedures of the Lateral Window technique 67Daniel W.K. Kao

Chapter 6 Avoiding and Managing Complications for the Lateral Window technique 79Paul A. Levi and Eduardo Marcuschamer

Chapter 7 Advanced techniques of the Lateral Window technique 105Daniel W.K. Kao and Mana K. Nejadi

Chapter 8 basic instruments and Materials of the transalveolar Approach: Osteotome technique 113Daniel W.K. Kao and Elana E. Walker

vi Contents

Chapter 9 Clinical Procedures of the transalveolar Osteotome Approach 117Daniel W.K. Kao

Chapter 10 Postoperation Management of the transalveolar Osteotome Approach 127Gail G. Childers

Chapter 11 Advanced techniques of the transalveolar Approach 135Daniel W.K. Kao

Chapter 12 decision tree for Maxillary Sinus Elevation Options 149David Minjoon Kim and Daniel Kuan-te Ho

Chapter 13 Choices of bone Graft Materials 157David Minjoon Kim and Daniel Kuan-te Ho

Chapter 14 Review of dental implant Success and Survival Rates 165Wai S. Cheung

index 179

vii

Contributors

Curtis S.K. Chen, DDS, MSD, PhDProfessor and director of Oral Radiologydirector of Advanced Specialty Program in OMF Radiologydepartment of Oral Medicine School of dentistryUniversity of WashingtonSeattle, Washington

Wai S. Cheung, DMD, MSAssociate Professordepartment of PeriodontologySchool of dental Medicinetufts Universityboston, Massachusetts

Hua-Hong Chien, DDS, PhDClinical Associate Professor and Predoctoral Program directordivision of PeriodontologyCollege of dentistryOhio State UniversityColumbus, Ohio

Gail G. Childers, DMDClinical Assistant ProfessorSchool of dental MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

Harold A. DeHaven, Jr., DDSClinical Professordepartment of PeriodonticsSchool of dental MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

Daniel Kuan-te Ho, DMD, DMSc, MScAssistant Professordepartment of PeriodonticsSchool of dentistry University of texas Health Science Center at Houston Houston, texas

Daniel W.K. Kao, DDS, MS, DMD, DABPCEO Washington dental GroupClinical Assistant Professor of PeriodonticsSchool of dental MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

David Minjoon Kim, DDS, DMScAssociate Professor director of the Advanced Graduate EducationProgramdepartment of Oral Medicine, infection, and immunitydivision of PeriodontologyHarvard School of dental Medicineboston, Massachusetts

Paul A. Levi, DMDAssociate Clinical ProfessorSchool of dental Medicinetufts Universityboston, Massachusetts

Eduardo Marcuschamer, DMDPrivate practicedenver, ColoradoVisiting Assistant Professortufts Universityboston, Massachusetts

viii Contributors

Mana K. Nejadi, DMDClinical Assistant ProfessorSchool of dental MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

Chih-Jaan Tai, MD, MScAssociate Professordepartment of OtorhinolaryngologyChina Medical University and Hospital, taiwantaichung, taiwan

Dimitris N. Tatakis, DDS, PhDProfessor and director of Postdoctoral Programdivision of Periodontology College of dentistryOhio State UniversityColumbus, Ohio

Elana E. Walker, DMDClinical Assistant ProfessorSchool of dental MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

ix

Acknowledgments

i would like to express special gratitude for my boss, dr. Joseph Fiorellini, Chairperson at University of Pennsylvania Periodontal department. dr. Fiorellini is not merely a boss. He is a mentor and a friend who has supported me in writing this book from the very beginning concept through to its completion. in fact, hes been my solid sounding board whom ive bounced many new research ideas off him through out my career. From my very first published paper when i was a resident, to now, my first text book, i consider myself extremely lucky to be able to grow professionally and personally by working for such an exceptional leader.

in addition, this book could not have been completed without the help of the following key contributors. dr. Paul Levis encouragement in sharing his expertise and experience derived from his long and outstanding career. irelied on dr. Levis expertise in periodontal and implant surgery, along with dr. Eduardo Marcuschamer. those 2 brilliant minds helped produced an excellent chapter titled avoiding and managing complications for the lateral window technique. i believe my readers will enjoy such a wealth of knowledge from such experts, as i have. dr. Harold A. deHaven and dr. Gail Childers have also gracefully written anatomy and physiology of the maxillary sinus and postoperation managements of the transalveolar osteotome approach chapters. i know my readers will benefit greatly from their contributions. theyve cheered me on and believed in me even before i made my own marks in dentistry. to experience such kindness and support, im forever moved and humbled.

i would also like to thank the people at Wiley blackwell for making this book a reality - Rick blanchette, Nancy turner, and Sarah brown. they kept this book on schedule, answered questions, corrected errors, and took care of innumerable details to ensure this book is a success.

My sincere thanks go to my friend Al Canela for his kind assistance.

Finally, my deepest appreciation goes to:

My Lord, who guided me to recognize my passion and talent in dentistry.

x Acknowledgments

My loving wife, Anita, whom i am especially indebted to her unwavering encouragement. Her understanding throughout my demanding career and this seemly never ending project made this book possible.

My grandmother, parents, and sister, Gloria. Without their support and prayers, i could not have achieved my dream.

My kids, Elizabeth, Christopher and Josephina. they have had to endure my absence during my long work hours. this book could never been com-pleted without their unlimited love.

xi

Many individuals with edentulous posterior maxilla present inadequate bone volume and vertical height between the floor of the sinus and the edentulous ridge, rendering it inadequate to accept a dental implant and achieve the degree of primary stability necessary for long-term success. the maxillary sinus, with all its variations, configurations, anomalies, and potential pathol-ogies, has been a concern to dental implant surgeons. Over the past 30 years, creative surgeons have devised many different methods and protocols for entering the sinus cavity, elevating the Schneiderian membrane, and placing various grafting materials, with or without the addition of blood components, recombinant growth factors, and so forth. All efforts along these lines are, of course, aimed at inducing new bone formation in the space created between the bony walls of the sinus cavity and the elevated Schneiderian membrane, so that dental implants can be placed after adequate osteogenesis to allow for implant-supported restorations to be constructed.

the two main surgical approaches of sinus floor elevation are (Figure i.1): the external lateral window approach1,2 and the internal transalveolar approach.36 the environment of the lifted sinus membrane space inside the sinus cavity is beneficial for the bone formation. the elevation of the Schneiderian membrane for augmentation of the maxillary sinus was first presented by tatum (1977) using autogenous bone from the iliac crest.1 However, to harvest bone graft from the second surgical site may affect the length of the surgical procedure, postsurgical morbidity, and patient comfort, although several bone replacement graft materials such as allografts, xenografts, alloplasts, and tissue engineering materials have been utilized.713 the lateral window surgical procedure is still relatively technique sensitive (Figures i.2 and i.3).

the internal approach is considered more conservative and less invasive than the external lateral window approach. the original concept of the internal transal-veolar technique used a set of osteotomes of various diameters to create a green-stick fracture by hand tapping force in the vertical direction4 (Figure i.4). thefollowing intrusion osteotomy procedure elevates the sinus membrane by a tapping motion to create a tent. bone grafting materials, blood clot, and the dental implant may be inserted into the tented space through the osteotomy

Introduction

(a) (b)

Figure I.1 Sinus elevation procedures. (a)Area for sinus elevation. (b) External approach. (c) Internal approach.

(c)

(a) (b)

(c) (d)

Figure I.2 (ad) Sinus augmentationlateral window approach.

Introduction xiii

opening. the osteotome technique is effective in certain cases, but the most sensitive aspect is the tapping force, which should be sufficient enough to infrac-ture the sinus floor cortical bone but restrained enough to prevent the osteo-tome tip from traumatizing the Schneiderian membrane.14,15 Several surgical

Day 0sinus graft

Wait 69 months forbone graft to heal and

then implant placement

Wait another 69months for

osseointegration andimplant restoration

(a) (b) (c)

Figure I.3 Sinus augmentationlateral window approach. (a) Day 0: sinus graft. (b) Wait 69 months for bone graft to heal, then place implant. (c) Wait another 69 months forosseointegration and implant restoration.

(a) (b)

(c) (d)

Figure I.4 (ad) Internal approachosteotome technique.

xiv Introduction

techniques have been proposed to minimize the sinus membrane perforation rate by using a piezosurgical device, balloon, and hydrostatic pressure.1619

As treatment options of edentulous maxillary today may include dental implants, the practitioner must be familiar with various sinus lift surgical techniques in order to choose an ideal treatment option for the patient. thesuccess of therapy is not only dependent on the success of the sinus

Figure I.5 (a) and (b) Unfavorable crown-implant ratio.

(a) (b)

Figure I.6 The interarch relationship should be considered in order to achieve a successful surgical, restorative, and aesthetic outcome.

Table I.1 Surgical and restorative treatment options for vertical interarch discrepancy.

Treatment Options for Each Classification

Class II Interarch Discrepancy (vertical discrepancy)

Surgical treatment options Hard tissue augmentation xSoft tissue augmentation xOrthognathic surgery x

Restorative treatment options Pink porcelain/pink materials xAlter the vertical dimension x

Introduction xv

elevation and the integration of an implant but also the position and utili-zation of the implant(s) for function, health, and aesthetics.20 With wide-spread use of dental implants, evaluating alveolar bony ridge volume and dimensions should also incorporate the interarch relationship to achieve a successful surgical, restorative, and aesthetic outcome (Figures i.5 and i.6 and table i.1).21

this book attempts to describe and elucidate the sinus-related subjects andto offer some developing consensus as to state-of-the-art thinking and practice. With the step-by-step clinical procedures, readers may use this book as a clinical manual for sinus elevation procedures.

References

1 tatum H, Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 30 (1986):207229.

2 boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 38 (1980):613616.

3 Fugazzotto PA. the modified trephine/osteotome sinus augmentation technique: technical considerations and discussion of indications. Implant Dent 10 (2001):259264.

4 Summers Rb. A new concept in maxillary implant surgery: the osteotome technique. Compendium 15 (1994):152, 154156, 158 passim; quiz 162.

5 tatum H. Maxillary implants. Florida Dent J 60 (1989):2327.6 davarpanah M, Martinez H, tecucianu JF, Hage G, Lazzara R. the modified osteotome

technique. Int J Periodontics Restorative Dent 21 (2001):599607.7 Valentini P, Abensur dJ. Maxillary sinus grafting with anorganic bovine bone: a clinical

report of long-term results. Int J Oral Maxillofac Implants 18 (2003):556560.8 Gapski R, Neiva R, Oh tJ, Wang HL. Histologic analyses of human mineralized bone

grafting material in sinus elevation procedures: a case series. Int J Periodontics Restorative Dent 26 (2006):5969.

9 Froum SJ, Wallace SS, Elian N, Cho SC, tarnow dP. Comparison of mineralized cancel-lous bone allograft (Puros) and anorganic bovine bone matrix (bio-Oss) for sinus augmentation: histomorphometry at 26 to 32 weeks after grafting. Int J Periodontics Restorative Dent 26 (2006):543551.

10 Wagner JR. A 3 1/2-year clinical evaluation of resorbable hydroxylapatite OsteoGen (HAResorb) used for sinus lift augmentations in conjunction with the insertion of endosse-ous implants. J Oral Implantol 17 (1991):152164.

11 Wheeler SL. Sinus augmentation for dental implants: the use of alloplastic materials. JOral Maxillofac Surg 55 (1997):12871293.

12 Stacchi C, Orsini G, di iorio d, breschi L, di Lenarda R. Clinical, histologic, and histomor-phometric analyses of regenerated bone in maxillary sinus augmentation using fresh frozen human bone allografts. J Periodontol 79 (2008):17891796.

13 Froum SJ, Wallace SS, Cho SC, Elian N, tarnow dP. Histomorphometric comparison of a biphasic bone ceramic to anorganic bovine bone for sinus augmentation: 6- to 8-month postsurgical assessment of vital bone formation. A pilot study. Int J Periodontics Restorative Dent 28 (2008):273281.

14 Vitkov L, Gellrich NC, Hannig M. Sinus floor elevation via hydraulic detachment and elevation of the Schneiderian membrane. Clin Oral Implants Res 16 (2005):615621.

xvi Introduction

15 tan WC, Lang NP, Zwahlen M, Pjetursson bE. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor eleva-tion. Part ii: transalveolar technique. J Clin Periodontol 35 (2008):241254.

16 Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J Periodontol 76(2005):482491.

17 Sotirakis EG, Gonshor A. Elevation of the maxillary sinus floor with hydraulic pressure. J Oral Implantol 31 (2005):197204.

18 Sohn dS, Lee JS, An KM, Choi bJ. Piezoelectric internal sinus elevation (PiSE) technique: a new method for internal sinus elevation. Implant Dent 18 (2009):458463.

19 Kao dW, dehaven HA, Jr. Controlled hydrostatic sinus elevation: a novel method of elevating the sinus membrane. Implant Dent 20 (2011):425429.

20 Greenstein G, Cavallaro J, Romanos G, tarnow d. Clinical recommendations for avoidingand managing surgical complications associated with implant dentistry: a review. JPeriodontol 79 (2008):13171329.

21 Kao dW, Fiorellini JP. An interarch alveolar ridge relationship classification. IntJPeriodontics Restorative Dent 30 (2010):523529.

Clinical Maxillary Sinus Elevation Surgery, First Edition. Edited by Daniel W.K. Kao. 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc.

1

1 Anatomy and Physiology of the Maxillary Sinus

Harold A. DeHaven, Jr.

CHAPTER 1

Anatomy of the maxillary sinus

the maxillary sinus is the largest of the four bilateral air-filled cavities in the skull. it is located in the body of the maxilla and is a pyramidal-shaped struc-ture having as its base the medial wall (the lateral nasal wall). this important complex structure will be discussed later in greater detail. the pyramid has three main processes or projections: (1) the alveolar process inferiorly (bounded by the alveolar ridge), (2) the zygomatic recess (bounded by the zygomatic bone), and (3) the infraorbital process pointing superiorly (bounded by the bony floor of the orbit, and below it, the canine fossa). the alveolar and palatine processes form the floor of the maxillary sinus, which after the age of 16 usually lies 11.2 cm below the floor of the nasal cavity (Figure1.1).13

Usually the maxillary sinus is separated from the roots of the molar denti-tion by a layer of cancellous bone, although occasionally significant bone volume is absent, allowing the apices of the molar teeth to be very near or project into the floor of the sinus cavity. this can provide a direct pathway for odontogenic infection to spread into the maxillary sinus (Figure1.2). in such cases, tooth extraction may cause oro-antral fistula formation, with or without infection.

the zygomatic process or projection is largely unremarkable. Occasionally the maxillary sinus may be divided into two or even three separate compart-ments by bony septa.4 these can usually be seen clearly on radiographic

in this chapter, the reader will review anatomy landmarks of the maxillary sinus. in order to avoid/reduce some surgical compli-cations, it is essential to understand the blood supply, nerve innervations, function, and physiology of the maxillary sinus.

2 Clinical Maxillary Sinus Elevation Surgery

Figure 1.1 Sinus anatomy. The maxillary sinus is the largest air-filled cavity in the skull.

Figure 1.2 Odontogenic infection may create a pathway to spread infection into the maxillary sinus.

Anatomy and Physiology of the Maxillary Sinus 3

examination, as well as by other diagnostic media. the four sinus cavities are all lined with pseudostratified, ciliated, columnar epithelium overlying a layer of periosteum in contact with the bony sinus walls. this bilaminar struc-ture is known as the Schneiderian membrane, and its inner specialized epithe-lial lining is contiguous with the lining of the nasal cavity through an opening known as the natural ostium. the sinus linings, although similar in structure, are somewhat thinner than the lining of the nasal cavity.5, 6

Ostiumthe natural ostium is located in an anteromedial position in the superior aspect of the medial sinus wall (lateral nasal wall), and its location makes sinus drain-age by gravity impossible. it opens into the semilunar hiatus of the nasal cavity and is usually located in the posterior half of the ethmoid infundibulum behind the lower one-third of the uncinate process. the ostium size can vary from 1 to 17 mm and averages 2.4 mm. because the superior location makes natural drainage impossible, drainage is dependent upon the wave-like motion or beating of the hair-like cilia. the ostium is much smaller than the actual bony opening, and mucosa fills most of the space and defines the ostium.7 On the nasal aspect of the lateral nasal wall, the ostium is hidden behind the uncinate process in 88% of cases. Often there are accessory ostia present, usually located distal to the natural ostium in the area of the posterior fontanelle (Figure1.3).8

the medial sinus wall (lateral nasal wall) is a most significant structure, because the lateral wall presents a series of furrows and projections that can either facilitate maxillary sinus drainage through the ostium or, under certain circumstances, alter or impede sinus drainage. Small swellings of the path-ways or the projections resulting from inflammation can be caused by infec-tion, allergic rhinitis, or trauma, leading to impaired sinus drainage. When

Figure 1.3 The maxillary ostium (MO) enters the infundibulum, which is the space between the uncinate process (U) and the ethmoid bulla (*).