Maxillary sinus augmentation

By yasmine gamal
Aim :
To increase bone volume at the site of implant.
Indication :
1- Reduced bone height
2- Sinus pnuomatization
To increase residual bone
height either by :
Coronal approach or
Apical approach
Apical approach
1- Osteotome
2- Modified caldwell luk approach (lateral approach)
Osteotomy

It is performed by the use of osteotomes to create a

controlled fracture of the floor of the maxillary sinus.
This method creates space by elevating the sinus
membrane and provides room for the dental implant
and bone grafting material . It is used when residual
bone height from 4 to 6 mm .
Advantage:
1- Less invasive
2- Reduced surgical time
3- Lower morbidity compared to other
sinus lift techniques.
Lateral approach :
Bone over the sinus removed either by :
1- Trephine bur
2- Piezoelectic
3- Balloon
4- Disc
Lateral approach :
Trap door fracture
Balloon
 Sinus Lift Balloon allows for improved vertical sinus
elevation results and gives clinicians added security
when performing a traditional sinus lift procedure —
protecting the Schneiderian membrane from tearing,
which can significantly disrupt an implant case. The
balloon instrument is also well-suited for effectively
measuring the required bone grafting material. For
example, 1cc of saline, which is used to inflate the
balloon, is equal to 1cc of grafting material.
 There are three manners of use : 1-straight-angled,
2-micro-mini tip and
3- angled tip.
You inject the latex balloon slowly with saline to lift
the sinus.
Distraction osteogensis
Distraction osteogenesis
Definition : It is process trigger a series of biological
events, similar to that found in bone regeneration and
healing. Several adaptive changes occur at tissue in
response to an applied tension force.
To be successful
1- Atraumatic osteotomies.
2- Activation rate 1mm/day .
3- Stability of distraction device .
Phases
First phase : Latency phase
The time between the osteotomies to the start of
activation of distraction device.
Last for 5-7 days differ in children and old age .
Characterize by formation of fibrous callus, capillary
reorganization, periosteal formation and formation of
immature bone callus .
Distraction phase :
At this period the osteotomized segment is being
dislocated under tension force to form new bone .
It lasts for 1-2 weeks .
Dynamic micro movement are generated with
tissue formation parallel to tension vector .
New vessels, collagen and distraction fibroblast
are formed
The vascular growth observed is 10 time greater than
in the convectional healing .
The distracted fibrous area has more blood nutrient
and undifferentiated mesenchymal cells .
Controlled tension will convert them to condroblasts
and osteoblast , and favor production of osteogenic
proteins .
Consolidation phase :
The regenerated bone matures at this period
before removal of distraction device .
There is a reparative callus, regeneration of soft
tissue, periosteum, blood vessels and proliferation
of osteogenic cells .
Intramembranous ossification in mineralization
zone
Consolidation phase :
Ossification occurs when a primary ossification front
comes from both sites of central fibrous zone, forming
an immature bone bridge through the distraction
area .
Bone remodeling begins during consolidation phase
and continues up to a 1-2 year period, and creates
mature bone similar to the adjacent area .
Soft tissue volume increase due to a process called
distraction histiogenesis
Types :
1- Intra osseous .
2- Extra osseous .
3- Implant distractor .
Intra osseouse
Extra osseouse
Implant distractor
Factor affecting success :
Osseous factor : 1- Vascularity decrease vascularity
leads to ischemic fibrinogenesis result in loose
irregular collagen .
Osteotomies must take place under abundant
irrigation to avoid trauma for soft tissue and vascular
bed .
Distraction factor
Frequency (number of time that the distractor
activated within 24 hours) and rate(mm/day) .
Rate >2mm leads to fibrous union.
<0.5 premature bone union interfere with desired
displacement .
Types :
1- Horizontal to increase bone width .
2- Vertical to increase bone height
Horizontal distraction :
Traumatic tooth avulsion with loss of the buccal bone
plate is a typical example of a situation leading to a
horizontal defect .
First reported by Aparicio and Jensen
Horizontal distraction
By using laster crest widener which consists of 4
sharp arms, 2 of each side connected with guid pins
and activating screw .
Osteotomy done either by :
 1-Sagital micro saw.
 2-Reciprocating scalped saw .
 3-Piezoelectrice ultra sound bone cutter .
Surgical technique :
Result
 1-The bone width increase from 4mm to 6mm .
2- Attached mucosa also increase due to increased
bone mass ( histiogenesis ).
But the clinical utility of horizontal
distraction is limited due to the
distractor mechanism and annoying to
the patient .
Vertical distraction
Video
Computer-simulated bi-directional
alveolar distraction osteogenesis
Computer-based surgical planning allows surgeons to
evaluate bone morphology in three dimensions and to
perform accurate virtual surgery preoperatively.
Advantage :
It allowed precise 3-D simulation of the
morphologically complicated atrophic alveolar ridge
showing the atrophy and loss of healthy labial-buccal
alveoli .
The software also allowed visualization of the implant-
anchored fixed prostheses, based on the actual tooth
simulation modules or mirror techniques used for
missing teeth when the opposite teeth are present .
Soft tissue modification
Causes of recession
Anatomical - bulbous roots/ enamel pearls
 Tooth positioning/crowding
 Thin labial bone / bony dehiscence
 Thin biotype gingival tissue
 Toothbrush trauma
 Periodontal disease
 Traumatic occlusion
 Habitual – nail biting / pen chewing / piercing
 Orthodontic tooth movements
Soft tissue modification
Soft tissue defects : gingival recession
Classification of recession
 Several classification schemes have been used to help
diagnose gingival recession:
 Sullivan & Atkins 1968
 Mlinek et al. 1973
Miller 1985 a
 Smith 1997
 Mahajan 2010
The most commonly used is the Miller’s classification
Miller’s classification

Divided gingival recession defects into 4 categories

 Evaluated both soft and hard tissue loss
 Determined the level of root coverage achievable with
a free gingival graft
 It was therefore diagnostic and prognostic
Miller’s classification
Class I
 Marginal tissue recession which does not extend to
the mucogingival junction (MGJ).
 There is no alveolar bone loss or soft tissue loss in the
inter-dental area .
Complete root coverage obtainable .
Class ii
 Marginal tissue recession which extends to or beyond
the MGJ
 There is no alveolar bone loss or soft tissue loss in the
interdental area
Complete root coverage obtainable
Class iii
Marginal tissue recession which extends to or beyond
the MGJ.
Bone or soft tissue loss in the interdental area is present
Partial root coverage related to level of papilla height
Class iv
Marginal tissue recession which extends to or beyond
the MGJ.
 The bone or soft tissue loss in the interdental area is
present with gross flattening
 No root coverage
Attachment loss =
Probing depth measurement
(gingival margin to base of pocket)

Recession measurement
(CEJ to the gingival margin)
Attached gingiva provides protection to the mucosa
during function
Some studies have suggested recession is more likely if
there is less than 1mm of attached gingiva (keratinised
gingiva) Lang & Loe 1972
Others show that sites with a width of attached gingiva
less than 2mm can remain stable Dorfman et al 1982
Treatment modalities
Removal of the cause .
Grafts (free gingival graft – connective tissue graft )
Free gingival graft
Roll technique
The best as it has good blood supply .
Thank you