Sinus Lifting in Implantology

Maxillary Sinus
Anatomy, Pathology,
and Graft Surgery
ANATOMICAL CONSIDERATIONS OF THE
POSTERIOR MAXILLA
•the trabecular bone in the posterior maxilla is finer than other dentate regions.
•The width of the posterior maxilla decreases at a more rapid rate than in any other
region of the jaws.
•The resorption phenomenon is accelerated by the loss of vascularization of the

alveolar bone and the existing fine trabecular bone type.
•The posterior maxilla continues to progressively remodel toward the midline as the
bone resorption process continues.
•This results in the buccal cusp of the final restoration often being cantilevered
facially to satisfy esthetic requirements at the expense of biomechanics in the
moderate to severe atrophic ridges.
DENTAL CONTRAINDICATIONS
FOR IMPLANT TREATMENT OF THE
POSTERIOR MAXILLA
•A minimum of a healthy natural canine tooth or an implant abutment in the canine

region is required before posterior implants are considered in the quadrant.
•These contraindications are similar to those reported for standard implant treatment
of edentulous patients and may be summarized as follows:
•Inadequate oral hygiene.
•Untreated periodontal disease of the residual.
•dentition .
•Severe malocclusion.
•Severe bruxism with loss of incisal guidance.
•Active infection .
Decreased Crown
Height Space
POSTERIOR MAXILLA
•Once the occlusal plane is properly restored or modified, the CHS should be greater
than 8 mm (Figure 38-1).
• A gingivectomy is first considered because it is not uncommon for excess tissue

thickness to be present in this region.
• However, if tissue reduction cannot correct the CHS problem, then osteoplasty
and/or vertical osteotomy of the maxillary posterior alveolar process are indicated to
improve the vertical ridge orientation before implant surgery.
Decreased Crown
Height Space
POSTERIOR MAXILLA
Poor Bone
Density
POSTERIOR MAXILLA
•The poor-density bone of this region is often five to 10 times weaker compared with
bone found in the anterior mandible.
•The stress patterns in this bone migrate farther toward the apex of the implant
(Figure 38-2).
•As a result, bone loss is more pronounced and occurs also along the implant body,
rather than only crestally as in other denser bone conditions.
•In the posterior maxilla, the deficient osseous structures and an absence of cortical
plate on the crest of the ridge is often observed, which further compromises
•the initial implant stability at the time of insertion.
•Implant surgery more often uses bone compression rather than bone extraction to
create the implant osteotomy to compensate for these deficiencies.
• As a consequence, initial healing of an implant in D4 bone is often compromised.

Implant Size
POSTERIOR MAXILLA
•Implant success after loading is reduced in implants shorter than 10 mm, it is logical
to treatment plan longer implants in the region.
•Therefore the implant most often should be 12 to 16 mm long in this region of the
mouth.
Maxillary Sinus MAXILLARY SINUS
Development
Development
•A primary pneumatization of the maxillary sinus occurs at about 3 months of fetal

development by an out-pouching of the nasal mucosa within the ethmoid
infundibulum.
• At this time the maxillary sinus is a bud situated at the infralateral surface of the
ethmoid infundibulum between the upper and middle meatus.
•Prenatally, a secondary pneumatization occurs.
•At birth, the sinuses are filled with fluid and the maxillary sinus is still an oblong
groove on the mesial side of the maxilla, just above the germ of the first deciduous
molar.
Development
•Postnatally and until the child is 3 months of age, the growth of the maxillary sinus is
closely related to the pressure exerted by the eye on the orbit floor, the tension of the
superficial musculature on the maxilla, and the forming dentition.
•At 5 months, the sinus appears as a triangular area medial to the infraorbital
foramen.
•During the child’s first year, the maxillary sinus expands laterally underneath the
infraorbital canal, which is protected by a thin bony ridge.
• The antrum grows apically and progressively replaces the space formerly occupied
by the developing dentition.
Development
•The main development of the antrum occurs as the permanent dentition erupts and
pneumatization extends throughout the body of the maxilla and the maxillary
process of the zygomatic bone.
• Extension into the alveolar process lowers the floor of the sinus about 5 mm (Figure
38-4).
•In the adult, the sinus appears as a pyramid of five thin, bony walls. The base of this
pyramid faces the lateral nasal wall and often measures 33 X 33 mm.
•Its apex extends approximately 23 mm toward the zygomatic bone.
• The dentate adult maxillary sinus has an average volume of 15 mL, although the
range is 9.5 to 20 mL.
Development
Development
•The floor of the maxillary sinus cavity is reinforced by bony or membranous septa
joining obliquely or transversely from the medial and/or lateral walls with buttresslike
webs.
• They may be genetic or develop as a result of stress transfer within the bone over
the roots of teeth.
•These have the appearance of reinforcement webs in a wooden boat and rarely
divide the antrum into separate compartments.
•These elements are present from the canine to the molar region, and Misch has
observed they tend to disappear in the maxilla of the long-term edentulous patient
when stresses to the bone are reduced.
Development
•The most common oblique septum is located in the superior anterior corner of the
sinus or infraorbital recess (which may expand anteriorly to the nasolacrimal duct).
•The medial wall is juxtaposed with the middle and inferior meatus of the nose.
•In fact, even with the loss of a single molar, the sinus expands between the adjacent
tooth roots.
•In the edentulous maxilla, the antrum expands in both inferior and lateral
dimensions and may even invade the canine eminence region and proceed to the
lateral piriform rim of the nose.
•This limited dimension is compounded by the problem of bone of reduced quality

and the resultant medial posterior position of the ridge after resorption of bone
width.
Anatomy
•Infections of the maxillary sinus are common and may not only cause implant failure
but also may be life-threatening to the patient.
Anterior Wall
•The anterior wall of the maxillary sinus consists of thin, compact bone extending
from the orbital rim to just above the apex of the cuspid.
•Within the anterior wall and approximately 6 to 7 mm below the orbital rim, with
anatomic variants as far as 14 mm from the orbital rim, is the infraorbital foramen
(Figure 38-5).
Anatomy
Anterior Wall
Anatomy
Anterior Wall
•The infraorbial nerve runs along the roof of the sinus and exits through the foramen.
•The infraorbital blood vessels and nerves lie directly on the superior wall of the
interior and within the sinus mucosa.
•Tenderness to pressure over the infraorbital foramen or redness of the overlying skin
may indicate inflammation of the sinus membrane from infection or trauma.
• The anterior wall of the maxillary sinus may serve as surgical access during Caldwell-
Luc procedures to treat a preexisting or post–sinus graft, pathologic condition.
Anatomy
Superior Wall
Anatomy
Superior Wall
•A bony ridge is usually present in this wall that houses the infraorbital canal
containing the infraorbital nerve and associated blood vessels.
•Dehiscence of the bony chamber may be present, resulting in direct contact

between the infraorbital structures and the sinus mucosa.
• Ocular symptoms may result from infections or tumors in the superior aspects of the
sinus region and may include proptosis (bulging of the eye) and diplopia (double
vision).
•Superior spreading infections may lead to a brain abscess and death.
•Overpacking the maxillary sinus with bone graft material during a sinus graft may
result in pressure against the superior wall if a sinus infection develops.
Anatomy
Posterior Wall
•The posterior wall of the maxillary sinus corresponds to the pterygomaxillary region,
which separates the antrum from the infratemporal fossa.
•The posterior wall usually has several vital structures in the region of the
pterygomaxillary fossa, including:
• the internal maxillary artery.

• pterygoid plexus.
• sphenopalatine ganglion.
•greater palatine nerve.
• The posterior wall should always be identified on the radiograph.
• When lack of a posterior wall is present, a pathologic condition (including

neoplasms) is to be suspected.
Anatomy
Posterior Wall
•It should be noted that pterygoid implants placed through the posterior sinus wall
and into this region might approach vital structures, including the maxillary artery.
•Therefore a blind surgical technique to place a pterygoid implant through the

posterior wall may have increased surgical risk.
• Because pterygoid implants are often positioned in the third or fourth molar region,
they are of benefit primarily when third or fourth molars are needed for prosthetic
reconstruction or sinus grafts are contraindicated and available bone posterior to the
antrum is present.
Anatomy
Medial Wall
•On the nasal aspect, the lower section of the medial wall corresponds to the lower
meatus and floor of the nasal fossa; the upper aspect corresponds to the middle
meatus. The medial wall is vertical and smooth on the antral side.
•Located in the superior aspect of the medial wall is the maxillary or primary ostium.
• This structure is the main opening through which the maxillary sinus drains its
secretions via the ethmoid infundibulum through the hiatus semilunaris into the
middle meatus of the nasal cavity.
• The infundibulum is approximately 5 to 10 mm long and drains via ciliary action in a

superior and medial direction.
Anatomy
Medial Wall
•The ostium diameter averages 2.4 mm in health; however, pathologic conditions

may alter the size to vary from 1 to 17 mm.
•These additional ostia are usually the result of chronic sinus inflammation and
mucous membrane breakdown.
•Fontanelles are usually classified either as anterior fontanelles (AFs) or posterior

fontanelles (PFs).
•Primary and secondary ostia may, on occasion, combine and form a large ostium
within the infundibulum.
Anatomy
Lateral Wall
•The lateral wall of the maxillary sinus forms the posterior maxilla and the zygomatic
process (see Figure 38-6).
•This wall varies greatly in thickness from several millimeters in a dentate patient to
less than 1 mm in an edentulous patient.
•The lateral wall houses an endosseous anastamosis of the infraorbital and posterior
superior alveolar artery.
•The Tatum lateral wall approach sinus graft procedure uses this area for entrance
into the maxillary sinus (Figure 38-7).
Anatomy
Lateral Wall
Anatomy
Inferior Wall
•The first molar has the most common dehiscent tooth root, occurring approximately
2.2% of the time.
•the sinus floor is often 1 cm below the level of the nasal floor.
Maxillary Sinus: Vascular MAXILLARY SINUS
Supply and
Innervation
•The blood supply to the maxillary sinus comes directly from the maxillary artery.
•Branches of the maxillary artery, which most often include the posterior superior
alveolar artery and infraorbital artery, form endosseous and extraosseous
anastomoses that encompass the maxillary sinus.
• The endosseous anastomosis is found within the lateral wall of the sinus and
supplies this structure and the lateral aspect of the sinus membrane.
• A posterior lateral nasal artery (a branch of the sphenopalatine artery that also rises
from the maxillary artery) also supplies this region from the medial aspect of the
sinus.
Supply and
Innervation
•The formation of the endosseous and extraosseous anastomoses in the maxillary

sinus is termed the double arterial arcade.
• The extraosseous anastomosis is less common (present in 44% of the population)

and is found near the periosteum of the lateral wall.
• The extraosseous anastomosis is superior to the endosseous unit, which is

approximately 15 to 20 mm from the dentate alveolar crest.
• In addition to the double arterial arcade, a blood supply from the sphenopalatine
artery supplies the central and medial parts of the sinus membrane.
Supply and
Innervation
Supply and
Innervation
•In an edentulous maxilla with posterior vertical bone loss, the endosseous
anastamosis may be 5 to 10 mm from the edentulous ridge.
• The endosseous artery was able to be observed on computed tomography (CT)

scans in approximately one half of the patients requiring a sinus graft.
•In a long-term edentulous patient with a thin lateral wall, the artery may be
atrophied and almost nonexistent.
• On rare occasions, this anatomical structure may be a concern for arterial bleeding
complications during lateral-approach sinus elevation surgery.
Supply and
Innervation
•Because the endosseous anastomosis is often present and ranges from 5 to 20 mm

from the residual crest of the ridge, the lateral-access window for the sinus graft
procedure often violates this arterial supply.
• However, this is usually of little concern during the surgical procedure and may even
be of benefit postsurgery to provide a blood supply to the graft.
•The size of the lateral-wall arterial anastomoses usually approximates 1.5 mm in a

dentate patient and has little arterial pressure.
Supply and
Innervation
• Although the artery is often in the pathway of surgery for the Tatum lateralwall
approach to sinus grafting, endosseous bleeding is rarely observed as a pulsating
rhythm and may be easily arrested by the following:
• (1) cutting the bone and vessel with a high-speed diamond and no irrigation (which
cauterizes the vessel).
• (2) using electrosurgery on the vessel.
• (3) elevating the head and using a surgical sponge (gauze) and slight pressure over
the region for a few minutes.
Supply and
Innervation
•A hemostat may also be used to clamp the vessel, because it is readily observed;
however, fracture of the lateral wall may occur.
•The medial and posterior aspects of the maxillary sinus mucosa receive their blood
supply from the posterior lateral nasal artery.
• The sphenopalatine artery is the third or fourth branch of the maxillary artery and
enters the nasal cavity through the sphenopalatine foramen, which is near the
posterior portion of the superior meatus of the nose.
• Once through the foramen, the sphenopalatine artery branches into the posterior
lateral nasal artery and the posterior septal artery.
• The posterior lateral nasal artery supplies the medial and posterior walls of the
antrum (nasal cavity).
Supply and
Innervation
•Different factors can alter the vascularization in this area.
• With increasing age, the number and size of blood vessels in the maxilla decrease.
•As bone resorption increases, the cortical bone becomes thin, resulting in less
vascularization.
•As the lateral wall becomes thinner, the blood supply to the lateral wall and lateral
aspect of the bone graft comes primarily from the periosteum, resulting in a
compromised vascularization to the region (Figure 38-8).
• After surgery the arterial supply in the lateral outer wall (in spite of being severed
during the procedure) may help vascularize the sinus graft, because the anastomoses
may vascularize the graft from both the posterior region and anterior region.
Supply and
Innervation
Supply and
Innervation
•The venous drainage of the maxillary sinus originates from a vascular plexus near the
maxillary ostium that drains anteriorly into the facial vein and posteriorly into the
maxillary and jugular veins.
•The nerve supply to the maxillary sinus is via numerous branches of the second
division of the trigeminal nerve, including the posterior alveolar nerves, anterior
palatine, and infraorbital nerves.
• The infraorbital nerve is of concern in sinus elevation surgery because of its

anatomical position.
• This nerve enters the orbit via the inferior orbital fissure and continues anteriorly;
the nerve lies in a groove in the orbital floor (which is also the maxillary sinus superior
wall) before exiting the infraorbital foramen.
Maxillary Sinus Mucosa: MAXILLARY SINUS
Microscopic
Anatomy
•The microscopic primary epithelial cells of the maxillary sinus are a continuation of
the nasal mucosa and classified as : a pseudostratifi ed, ciliated columnar epithelium.
•However, the epithelial lining of the maxillary sinus is much thinner and contains
fewer blood vessels compared with the nasal epithelium.
Microscopic
Anatomy
•Five primary cell types exist in this tissue:
• (1) ciliated columnar epithelial cells
• (2) nonciliated columnar cells
• (3) basal cells
• (4) goblet cells
• (5) seromucinous cells.

Microscopic
Anatomy
•The ciliated cells contain approximately 50 to 200 cilia per cell.
• In a healthy patient, they help to clear mucus from the sinus and into the nose.
• The nonciliated cells comprise the apical aspect of the membrane, contain microvilli,
and serve to increase surface area.
•These cells have been theorized to facilitate humidification and warming of inspired
air.
•The basal cell’s function serves most likely as a stem cell that can differentiate as
needed.
•The goblet cells produce glycoproteins that are responsible for the viscosity and
elasticity of the mucus produced.
Microscopic
Anatomy
• The maxillary sinus has the highest concentration of goblet cells in comparison with
the other paranasal sinuses.
•Although the sinus mucosa has been called a mucoperiosteum.
•The very minimal and usual absence of osteoblasts in this tissue and, instead, the
presence of osteoclasts, may account for the enlargement of the antrum after tooth
loss.
•The maxillary sinus membrane also exhibits few elastic fibers attached to the bone,
which simplifies elevation of this tissue from the bone.
•The thickness of the sinus mucosa varies, but is generally 0.3 to 0.8 mm.60 In
smokers, it varies from very thin and almost nonexistent to very thick, with a
squamous type of epithelium.
MAXILLARY SINUS
Maxillary Sinus Mucosa:
Microscopic Anatomy
Maxillary Sinus Mucous MAXILLARY SINUS
Clearance
•The mucus of the maxillary sinuses is produced from serous and goblet cells, which
produce 1 L of mucus each day in healthy conditions.
•A blanket of mucus is propelled toward the ostium by the beating motion of the
ciliated lining cells.
• The mucous material of the sinus in health has two layers:
•(1) a top mucoid layer
• (2) a bottom serous layer (Figure 38-10).

Clearance
Clearance
• The top layer is sticky and collects bacteria and other debris, whereas the serous
layer is thin and acts as a lubricant.
•The cilia of the columnar epithelium beat toward the ostium at 15 cycles per minute,
with a stiff stroke through the serous layer, reaching into the mucoid layer.
• The cilia recover with a limp reverse stroke within the serous layer.
• This mechanism slowly propels the mucoid layer toward the ostium at a rate of 9
mm per minute and into the middle meatus of the nose.
•Various elements may decrease the number of cilia and slow their beating efficiency.
Viral infections, pollution, allergic reactions, and certain medications may affect the
cilia in this way.
Clearance
•Genetic disorders (e.g., dyskinetic cilia syndrome) and factors such as long-standing
dehydration, anticholinergic medications and antihistamines, cigarette smoke, and
chemical toxins also can affect ciliary action.
• Certain pathogens (Haemophilus influenzae, Streptococcus pneumoniae,

Pseudomonas aeruginosa) associated with sinusitis have been shown to release a
compound that slows and disorganizes ciliary beating along with affecting mucous
transport.
• Various medications have also been shown to affect ciliary action.
•Decongestant medications may alter the various layers of the sinus membranes,
thus interrupting normal ciliary activity.
• On the other hand, long-term antibiotic medications have been shown to have a
significant increase in ciliary beat frequency.
Clearance
•These cilia work to move contaminants toward the natural ostium and then to the
nasopharynx.
• The flow of mucus is toward the ostium, which leads to the infundibulum, through
the hiatus semilunaris, into the middle meatus of the nose, and ultimately into the
nasopharynx (Figure 38-11).
•An alteration in the sinus ostium patency or the quality of secretions can lead to
disruption in ciliary action resulting in sinusitis.
Clearance
Clearance
•The maxillary ostium and infundibulum are part of the anterior ethmoid middle
meatal complex, the region through which the frontal and maxillary sinuses drain.
•The amount of oxygen absorbed from the blood is not adequate to maintain this
drainage system.
• Additional oxygen has to be absorbed from the air in the sinus.
•The quantitative loss of cilia is reversed except when severe empyema with scarring
occurs, which results in the ciliated epithelium being replaced by squamous
epithelium.
Maxillary Sinus Bacterial MAXILLARY SINUS
Flora
•Maxillary sinuses have been considered to be sterile in health; however, bacteria can
colonize within them without producing symptoms.
•The production of nitrous oxide within the sinus cavity.
• In a study of patients who underwent surgical repositioning of the maxilla, Cook and
Haber reported that 80% of the patients showed no bacterial growth.
•The remaining 20% had some bacterial growth but in negligible numbers.
•They concluded that the asymptomatic adult maxillary sinus is usually sterile, but a
few transient bacteria may exist in a clinically asymptomatic antrum.
Maxillary Sinus Bacterial MAXILLARY SINUS
Flora
•Haemophilus influenzae was recovered from the purulent exudates with lower
numbers of staphylococci.
• In fact, the macroscopic appearance of the secretion should not be used to screen
samples, because several cases with H. influenzae grew also from nonpurulent
samples.
•Other reports have indicated the bacterial flora of the maxillary sinus consists of
nonhemolytic and a-hemolytic streptococci, as well as Neisseria spp.
•Additional microorganisms identifiable in various quantities belong to the

staphylococci, Haemophilus spp., pneumococci, Mycoplasma spp., and Bacteroides
spp.
•This is important to note because the sinus graft procedure often violates the sinus
mucosa, and bacteria may contaminate the graft site.
Maxillary Sinus: MAXILLARY SINUS
Clinical Assessment
•To establish an adequate osseous morphologic condition for the placement of

endosteal implants in the resorbed maxillary posterior region, various grafting
techniques have been developed to increase bone volume.
•In 1987, Misch developed four different categories for the treatment of the posterior
maxilla (termed subantral [SA]), as SA-1 through SA-4 (Figure 38-12).
• The SA-1 posterior maxilla allows implant placement inferior to the sinus cavity
without sinus manipulation, thus not altering the sinus floor or membrane.
• As such, if the patient has a preexisting maxillary sinus condition or develops a sinus
infection after implant placement, then implants are not at risk of becoming
contaminated.
Clinical Assessment
Clinical Assessment
•Preoperative evaluation is completed to rule out existing pathologic condition in the

maxillary sinus.
•In this way, the risk of mucus and bacteria contaminating the graft and creating a
bacterial smear layer on the implant, which results in impaired bone formation during
healing, is reduced.
• In addition, because of the proximity of the maxillary sinus to numerous vital

structures, postoperative complications can be very severe and even life threatening.
•Infections in this area have been reported to result in sinusitis, orbital cellulitis,
meningitis, osteomyelitis, and cavernous sinus thrombosis.
Clinical Assessment
•A physical examination of the maxillary sinus evaluates the middle third of the face
for the presence of asymmetry, deformity, swelling, erythema, ecchymosis,
hematoma, or facial tenderness (Table 38-1).
• Nasal congestion or obstruction, prevalent nasal discharge, epistaxis (bleeding from

the nose), anosmia (the loss of the sense of smell), and/or halitosis (bad breath) are
noted.
•The clinical examination for maxillary sinusitis concerns the regions surrounding the
maxillary antrum.
•The examination is conducted to assess each wall surrounding the maxillary sinus
separately.
Clinical Assessment
Clinical Assessment
•The infraorbital foramen on the facial wall of the antrum is palpated through the soft
tissue of the cheeks or intraorally to determine whether tenderness or discomfort is
present.
•The intraoral examination assesses the floor of the antrum by alveolar ulceration,
expansion, tenderness, paresthesia, and oroantral fistulae.
• The eyes are examined to evaluate the superior wall of the sinus for proptosis,
pupillary level, lack of eye movement, and diplopia.
• The nasal fluids may be used to evaluate the medial wall of the sinus by asking the
patient to blow the nose in a waxed paper.
• The mucus should be clear and thin in nature.

Clinical Assessment
•A yellow or greenish tint or thickened discharge indicates infection.
• Infected maxillary sinuses typically are symptomatic, which can exhibit exudate in
the middle meatus and may be inspected with a nasal speculum and headlight
(rhinoscopy) through the nares.
•Other methods of examination of the infected maxillary sinus may include

transillumination, naso endoscopy, bacteriology, cytology, fiber optic antroscopy, and
radiography (conventional, CT, or magnetic resonance imaging [MRI]).
Radiographic Evaluation
Waters’ Projection Radiographs
•The most common medical plain-film radiograph used for the evaluation of the
maxillary sinus is the occipitomental projection, also termed the Waters’ projection.
• This film is taken with the patient’s head tilted upwards approximately 40 degrees,
allowing a clear evaluation of the superior, lateral, and medial aspects of the maxillary
sinus.
•The Waters’ projection is often complimented with similar plain films such as the
Caldwell (frontal view), lateral view, and submentovertical (base view).
Waters’ Projection Radiographs
•The posterior teeth and/or alveolar residual bony process frequently obscure the
posteroinferior part of the sinus cavity.
•Because the sinus floor is a critical portion of the sinus for implant treatment, a
Waters’ projection radiograph has little use for diagnosis or treatment planning in
implant dentistry.
•It has been reported that 75% of these plain films are inaccurate in evaluating the
pathologic condition of the sinuses.
Panoramic Radiographs
•The panoramic radiograph is often used as a preliminary diagnostic radiograph in

implant dentistry.
•This radiograph can provide direct visualization of the anterior, lateral, and inferior
regions of the maxillary sinus.
• It is often sufficient to evaluate the amount of bone present below the maxillary
sinus (Figure 38-13).
•This available bone height may place the patient in a category of SA-1 (obviously
enough bone below the antrum for implants) or SA-4 (obviously not enough bone for
implants).
•The SA-2 and SA-3 categories are less obvious, because the specific bone height
range of 5 or 10 mm of bone may be influenced by film magnification.
•The hard palate appears as two radiopaque lines on the panoramic radiograph: one
line represents the structure on that side, and a second, lighter and fuzzier line
represents the ghost image from the other side.
•When these lines are observed several millimeters above the floor of the antrum, the
posterior maxilla has good surgical access for a lateral-wall approach for an SA-3 or
SA-4 sinus graft option.
• When the palate line is near the crest of the edentulous ridge, surgical access is
more difficult and the surgical lateral-access wall may even be within the zygomatic
process.
•The panoramic radiograph is useful for preliminary evaluation of the posterior

maxilla.
• However, it is not the standard radiograph used to evaluate the maxillary sinus for
abnormalities or pathologic conditions.
•Ghost and overlapping images will often obscure or distort the anatomy of the
maxillary sinus.
• If the patient is positioned upward with respect to the Frankfort horizontal plane,
then the hard palate and the shadow of the occipital bone will obscure the sinus.
•Another common positioning mistake is not placing the tongue in the roof of the
mouth.
• This will result in radiolucency over the maxilla that represents the palatoglossal air
space, as well as a radiopaque region from the tongue.
•This radiopaque region may be misinterpreted as a pathologic condition.
• The posterior wall of the maxillary sinus is often misinterpreted as the panoramic
innominate line.
• This artifact is a thin, vertical radiopaque line in the posterior one third of the
maxillary sinus that corresponds to the superimposition of the zygomatic process of
the maxilla and the frontal process of the zygoma.
•The posterior region behind

this innominate line is often
more radiopaque and may be
misinterpreted as available
bone “behind the sinus” for
endosteal implants (Figure 38-
14).
•The panoramic radiograph may be used as the only radiographic tool in an SA-1
treatment option.
• Because the sinus and/or floor is not manipulated during the surgery, the condition
of the sinus proper is much less relevant to implant insertion.
• Because the SA-3 or SA-4 sinus graft procedure augments the posterior maxilla, it
transforms the region to an SA-1 condition after graft maturity.
•Therefore after a sinus graft has positively modified the existing bone volume, a
panoramic radiograph is often the only radiographic modality used before implant
surgery.
Periapical Radiographs
•Periapical (PA) radiographs are of little value in the posterior maxilla, because the
observed area is small and inadequate.
• Cysts and inflammation of the membrane can sometimes be seen in association

with the apex of the tooth.
•In addition, certain cases of odontogenic sinusitis may be clearly seen on PA

radiographs.
•Although the PA radiograph can indicate a pathologic condition in the sinuses, it

usually does not provide enough information for reliable diagnosis.
• In general, plain-film PA radiographs of the sinuses are of little value in precise

osseous measurements and evaluation of pathologic conditions in the maxillary
sinuses.
Computerized Tomography
•This type of radiography provides much more detailed information about the
anatomy and pathologic condition of the sinuses compared with plain films.
• CT is the best option for viewing the surrounding osseous structures and pathologic
condition in the maxillary sinuses.
•In medical evaluation of the sinus cavity, images are taken in the coronal plane.
• For dental reformatted images, scans are usually taken in numerous transaxial slices
(Figure 38-15).
Computerized Tomography
Magnetic Resonance Imaging
•MRI is an imaging technique that allows for better differentiation of the soft tissues
within the sinuses.
•MRI has advantages over CT scanning for the evaluation of neoplasms, tumor
mapping, and evaluation of fungal sinusitis.
Ultrasound Evaluation
•Mode ultrasound may be used to evaluate for fluid in the maxillary sinus and for
mucosal thickening or soft tissue masses in the sinus.
• Therefore ultrasound can be used for diagnosing acute maxillary sinusitis.

Computed Tomography
Radiographic Anatomy
Maxillary Sinus Membrane
•A CT scan of normal, healthy paranasal sinuses reveal a completely radiolucent

(dark) maxillary sinus.
• Any radiopaque (whitish) area within the sinus cavity is abnormal, and a pathologic
condition should be suspected.
•The normal sinus membrane is radiographically invisible, whereas any inflammation

or thickening of this structure will be radiopaque.
• The density of the diseased tissue or fluid accumulation will be proportional to

varying degrees of gray values.
Computed Tomography
Ostiomeatal Complex
•The ostiomeatal unit is composed of the maxillary ostium, ethmoid infundibulum,

anterior ethmoid cells, and the frontal recess.
• The main drainage avenue of the maxillary sinus is through the ostium.
• The maxillary ostium is bounded superiorly by the ethmoid sinuses and inferiorly by
the uncinate process.
• The uncinate process is a bony knifelike projection that is attached inferiorly to the
inferior turbinate and posteriorly has a free margin.
•Drainage continues through the ostium into the infundibulum, which is a narrow
passageway leading into the middle meatus.
Computed Tomography
Ostiomeatal Complex
•The middle meatus is the radiolucent space bounded by the middle and inferior
turbinates.
•The nasal septum is the bony partition that creates a barrier between the right and
left sides of the nasal cavity (see Figure 38-11, A).
• Obstructions within any aspect of the nasal system predispose the area to
pathologic conditions (see Figure 38-11, B).
Anatomical Variants
•A pharmacologic discipline may be altered and/or implants may be placed after the
sinus graft has matured, rather than predisposing them to an increased risk by
inserting them at the same time as the sinus graft.
•As stated previously, patency of the ostium is paramount to maintain drainage.

Anatomical Variants
Nasal Septum Deviation
•A nasal septum deviation is a very common anatomical variant, occurring in as much

as 70% of the population older than 14 years.
•This bony variant in extremes may cause obstruction of the ostiomeatal unit, which
results in inflammation from air turbulence, causing increased mucosal drying and
particle deposition.
•If the deviation is long standing, then atrophy of the middle turbinate may occur,
resulting in narrowing of the ostiomeatal complex (Figure 38-16).
Anatomical Variants
•Of the 45 patients, five were found to have sinusitis postsurgery; all five of those
patients had a nasal deviation or oversized turbinate.
• Therefore when these conditions are observed, the implant should not be placed at
the same time as the sinus graft, and the recommended preoperative and
postoperative pharmacologic protocol is especially warranted.
Anatomical Variants

Anatomical Variants
Middle Turbinate Variants
•A concha bullosa is a pneumatization within the middle turbinate and may occlude
the osteomeatal complex, thus compromising adequate drainage.
•Another variant in this anatomical structure is a paradoxically curved middle

turbinate, which presents a concavity toward the septum, thus decreasing the size of
the meatus.
• This also predisposes the patient to sinus disease.

Anatomical Variants
Uncinate Process Variants
•A deflected uncinate process (either laterally or medially) can narrow the ethmoid
infundibulum, thus affecting the osteomeatal complex.
• Perforations may also be present within the uncinate process, leading to

communication between the nasal cavity and ethmoid infundibulum.
• In addition, the uncinate process may be pneumatized.
• Although this is rare, it may compromise adequate clearance and drainage.

Anatomical Variants
Supplemental Ostia
•A supplemental ostium or secondary ostia may occur between the maxillary sinus
and the middle meatus, which is often found in the posterior fontanelles (PFs).
•This may be found in approximately 18% to 30% of individuals.
• Because these secondary openings are usually located posterior and inferior to the
natural ostium, they may predispose the patient to sinusitis by the recirculation of
infected secretions from the primary meatus back into the sinus cavity.
• On occasion, these secondary ostia may be encountered during the elevation of the
medial wall of the antrum, before placement of the sinus graft.
• When observed, a piece of collagen is placed over the site to prevent graft material
from entering the nasal cavity.
Anatomical Variants
Maxillary Hypoplasia
•Hypoplasia of the maxillary sinus may be a direct result from trauma, infection,
surgical intervention, or irradia tion to the maxilla during the development of the
maxillary bone.
•These conditions interrupt the maxillary growth center, thus producing a smaller-
than normal maxilla.
• A malformed and positioned uncinate process is associated with this disorder,

leading to chronic sinus drainage problems.
• Most often, these patients have adequate bone height for endosteal implant
placement, and a sinus graft is not required to gain vertical height.
Anatomical Variants
Inferior Turbinate and
Meatus Pneumatization
(Big-Nose Variant)
•Misch has observed, on rare occasion, the inferior third of the nasal cavity
pneumatizes within the maxilla and resides over the alveolar residual ridge.
•When the patient has this condition, the maxillary sinus is lateral to the edentulous
ridge.
• When inadequate bone height is present below this structure, a sinus graft does not
increase available bone height for an implant.
•This condition is difficult to observe on a panoramic radiograph.

Anatomical Variants
Inferior Turbinate and
Meatus Pneumatization
(Big-Nose Variant)
•If unaware, then the implant can be placed into the nasal cavity above the residual
ridge and even penetrate the inferior turbinate.
• A sinus graft is contraindicated with this patient condition, because the sinus is
lateral to the position of the implants. Instead, an onlay graft is required to increase
bone height.
MAXILLARY SINUS PATHOLOGY
•A preexisting, pathologic, maxillary sinus condition is a contraindication for many

procedures that alter the sinus floor before or in conjunction with sinus grafting
and/or implant insertion.
• The risk of postoperative infection is elevated and may compromise the health of
the implant and the patient.
•Pathologic conditions of the maxillary sinus may be divided into four categories:
•(1) inflammation.
•(2) cystic conditions.
•(3) neoplasms.
•(4) antroliths and foreign bodies.

INFLAMMATION
•Inflammatory conditions can affect the maxillary sinus from odontogenic and
nonodontogenic causes.
•Odontogenic Sinusitis (Periapical Mucositis)
•The close proximity of the roots of the maxillary posterior teeth to the floor of the
sinus means that any inflammatory changes in the periodontium or surrounding
alveolar bone may cause pathologic conditions in the maxillary sinus.
Odontogenic Sinusitis (Periapical Mucositis) INFLAMMATION
Etiology
•Odontogenic sinusitis is caused by a periapical abscess, cyst, granuloma, or

periodontal disease that causes an expansile lesion within the floor of the sinus.
• Other causes include sinus perforations during extractions and foreign bodies (e.g.,
gutta-percha, root tips, amalgam).
Radiographic Appearance
•Periodontitis may produce generalized sinus mucosal hyperplasia, which is seen as a

radiopaque band that follows the contours of the sinus floor.
• A localized periapical mucositis reveals a thickening of the mucosal membrane

adjacent to the offending tooth and, on occasion, that perforates the floor of the
sinus.
• This radiographic appearance has been termed a halo effect.
•In the author’s opinion, smoking may be the influencing factor, causing an increased
risk of periodontitis, a decrease in immune response, and a decrease in the healthy
flow of the mucus within the antrum.
Differential Diagnosis
•This condition may be confused with acute sinusitis or mild mucosal thickening.
•However, in odontogenic sinusitis, the patient has teeth in the posterior maxilla and
will usually exhibit symptoms related to the teeth (i.e., pain from a posterior tooth or
a recent extraction, exudate around the existing natural posterior teeth).
Treatment
•Before sinus augmentation or implant placement, the tooth or teeth involved should
be treated periodontally, endodontically, or extracted.
• After intraoral soft tissue healing and resolution of the pathologic condition, the
sinus graft procedure may be performed with little risk of postoperative
complications.
Acute Rhinosinusitis INFLAMMATION
•A nonodontogenic pathologic condition may also result in inflammation in the form

of sinusitis.
•The most common type of sinusitis is acute rhinosinusitis.
• The signs and symptoms of acute rhinosinusitis are rather nonspecific, making it
difficult to differentiate from the common cold, influenza type of symptoms, and
allergic rhinitis.
•However, the most common symptoms include purulent nasal discharge, facial pain
and tenderness, nasal congestion, and possible fever.
Etiology
•An inflammatory process that extends from the nasal cavity after a viral upper
respiratory infection often causes acute maxillary sinusitis.
•The most important factor in the pathogenesis of acute rhinosinusitis is the patency
of the ostium.
•Local predisposing causes of sinusitis include inflammation and edema associated

with a viral upper respiratory tract infection or allergic rhinitis.
• As a consequence, mucous production within the sinus may be abnormal in quality

or quantity, along with a compromised mucociliary transport.
Etiology
• In an occluded sinus, an accumulation of inflammatory cells, bacteria, and mucus

exists.
•Phagocytosis of the bacteria is impaired with immunoglobulin (Ig)-dependent

activities decreased by the low concentration of IgA, IgG, and IgM found in infected
secretions.
•The oxygen tension inside the maxillary sinus has significant effects on pathologic
conditions.
Etiology
•Growth of anaerobic and facultative organisms proliferate in this environment.
•A direct correlation exists between the ostium size and the oxygen tension in the
sinus.
•As a consequence, a history of recurrent acute rhinosinusitis is relevant to determine

whether an implant may be at increased risk when inserted at the same time as the
sinus graft.
•The radiographic hallmark in acute rhinosinusitis is the appearance of an air-fluid

level.
• A line of demarcation will be present between the fluid and the air within the
maxillary sinus.
•If the patient is supine, then the fluid will accumulate in the posterior area; if the
patient is upright during the imaging, the fluid will be seen on the floor and horizontal
in nature.
•Additional radiographic signs include smooth, thickened mucosa of the sinus, with
possible opacification.
•In severe cases the sinus may fill completely with supportive exudates, which gives
the appearance of a completely opacifi ed sinus.
•With these characteristics, the terms pyocele and empyema have been applied.
Treatment
•a sinus graft is performed and allowed to mature several months before the
placement of the implant.
•In addition, the suggested antibiotic coverage may be altered and extended, both
before and after the sinus graft procedure.
Chronic Rhinosinusitis INFLAMMATION
•Chronic rhinosinusitis is a term used for a sinusitis that does not resolve in 6 weeks
and also has recurrent episodes.
•Symptoms of chronic sinusitis are associated with periodic episodes of purulent

nasal discharge, nasal congestion, and facial pain.
Chronic Rhinosinusitis INFLAMMATION
Etiology
•As maxillary rhinosinusitis progresses from acute to chronic, anaerobic bacteria

become the predominant pathogens.
•Chronic rhinosinusitis may appear radiographically as thickened sinus mucosa,

complete opacifi cation of the antrum, and/or sclerotic changes in the sinus walls
(which give the appearance of denser cortical bone in the lateral walls).
Treatment
•significant bacterial resistance and fungal growth is highly probable.
• Fungal infections may be difficult to treat and control, and serious complications
may result in postoperative sinus graft patients.
Allergic Sinusitis INFLAMMATION
Etiology
•Allergic sinusitis is a local response within the sinus caused by an irritating allergen in
the upper respiratory tract.
•The sinus mucosa becomes irregular or lobulated, with resultant polyp formation.
•Polyp formation related to allergic sinusitis is usually characterized by multiple,

smooth, rounded, radiopaque shadows on the walls of the maxillary sinus.
•Easily observed on a CT scan. In advanced cases, ostium occlusion, along with

displacement or destruction of the sinus walls, may be present, with a radiographic
image of a completely opacifi ed sinus.
Allergic Sinusitis INFLAMMATION
Treatment
•The polyp, if enlarged, may be removed before the sinus graft.
• This may be performed through an anterior Caldwell-Luc approach or by an

endoscopic procedure through the ostium.
•Allergic sinusitis patients often have a greater risk of complications related to an

increase in allergen production.
• Because sinus grafting is an elective procedure, the time of year for the surgery may
be altered to decrease the postoperative infection risk.
• For example, if hay fever or a grass allergy is related to the patient’s sinusitis, then
the sinus graft surgery should be performe in the season or seasons that have least
risk to aggravate the sinus mucosa (i.e., winter or fall).
Fungal Sinusitis INFLAMMATION
(Eosinophilic FungalRhinosinusitis)
•Granulomatous sinusitis is a very serious (and often overlooked) disorder within the
maxillary sinus.
•Patients who have fungal sinusitis are thought to have had an extensive history of
antibiotic use, chronic exposure to mold or fungus in the environment, or being
immunocompromised.
Etiology
•Fungal infections are usually caused by aspergillosis,mucormycosis, or
histoplasmosis.
•Chronic sinusitis patients should always be evaluated for granulomatous conditions,

because a high percentage of fungal growth exists in this patient population.
•Three possible clinical signs may differentiate fungal sinusitis from acute or chronic
sinusitis; however, a positive diagnosis require mycological and histological studies.
•1. No response to antibiotic therapy
•2. Soft tissue changes in sinus associated with thickened reactive bone, with
localized areas of osteomyelitis
•3. Association of inflammatory sinus disease that involves the nasal fossa and facial
soft tissue
•Granulomatous sinusitis may appear radiographically as mild thickening to complete
opacification of the sinus.
Treatment
•Patients with a history or current knowledge of fungal sinusitis should be referred to
their physician or otolaryngologist for treatment and surgical clearance.
•Treatment usually involves debridement and therapy with an antifungal agent, such
as amphotericin B.
CYSTIC LESIONS
•Cystic lesions are a common occurrence in the maxillary sinus, and studies have
reported a prevalence range of 2.6% to 20%.
• They may vary from microscopic lesions to large, destructive, expansile pathologic
conditions.
•They include pseudocysts, retention cysts, primary mucoceles, and postoperative

maxillary cysts.
Pseudocysts (Mucous Retention Cyst) CYSTIC LESIONS
•The most common cysts in the maxillary sinus are mucous retention cysts.
• After much controversy, in 1984, Gardner89 distinguished these cysts into two
categories:
•(1) pseudocysts
•(2) retention cysts.
•Pseudocysts are more common and of much greater concern during sinus graft
surgery, compared with retention cysts.
• Pseudocysts reoccur in approximately 30% of patients and are often unassociated

with sinus symptoms.
•As a consequence, many physicians do not treat this condition.
• However, when their size is larger than 10 mm in diameter, pseudocysts may

occlude the maxillary ostium during a sinus graft procedure and increase the risk of
postoperative infections.
Etiology
•A pseudocyst is caused by an accumulation of fluid beneath the periosteum of the
sinus mucosa.
•This elevates the mucosa away from the floor of the sinus, giving rise to a dome-
shaped lesion.
•Pseudocysts have also been termed mucosal cysts, serous cysts, and nonsecreting
cysts.
• Pseudocysts are not true cysts because they lack an epithelial lining.
• The cause of the fluid is from bacterial toxins from the sinus mucosa or from
odontogenic causes (see Figure 38-16).
•Pseudocysts are depicted radiographically as smooth, homogenous, dome-shaped,

round to ovoid, well defined radiopacities.
• Pseudocysts do not have a corticated (radiopaque) marginal perimeter and are

usually on the floor of the sinus cavity.
Treatment
•Pseudocysts are not a contraindication for sinus graft surgery, unless their
approximate size is greater than 10 mm in diameter.
• However, when in doubt, an evaluation of even smaller “cysts” by an

otorhinolaryngologist or ear, nose, and throat (ENT) physician may still be to confirm
the diagnosis.
•If a large pseudocyst is present, then the elevation of the membrane during a sinus
graft may raise the cyst to occlude the ostium.
•In addition, on elevation or placement of the grafting material, the cyst may be
perforated, allowing fluid within the cyst to contaminate the graft.
Treatment
• Large cysts of this nature should be drained and allowed to heal before or in
conjunction with sinus elevation surgery.
• Most often, an otolaryngologist or ENT physician should evaluate and treat this
condition before the sinus graft.
•If a pseudocyst is less than 10 mm, then less concern is needed and the fluid may be
drained in conjunction with sinus grafting, depending on the surgeon’s experience in
the treatment of this condition.
Retention Cysts CYSTIC LESIONS
•Retention cysts may be located on the sinus floor, near the ostium, or within antral
polyps.
•Because they contain an epithelial lining, researchers consider them to be mucous

secretory cysts and “true” cysts.
•Retention cysts are often microscopic in size.

Etiology
• Large cysts of this nature should be drained and allowed to heal before or in
conjunction with sinus elevation surgery.
• Most often, an otolaryngologist or ENT physician should evaluate and treat this
condition before the sinus graft.
•If a pseudocyst is less than 10 mm, then less concern is needed and the fluid may be
drained in conjunction with sinus grafting, depending on the surgeon’s experience in
the treatment of this condition.
Etiology
•Retention cysts result from partial blockage of seromucinou gland ducts located
within the connective tissue underlying the sinus epithelium.
•As the secretions collect, they expand the duct, producing a cyst that is
encompassed by respiratory or cuboidal epithelium.
•They may be caused by sinus infections, allergies, or odontogenic reasons.

•Retention cysts are usually very small and not seen clinically or radiographically.
• In rare instances, they may achieve adequate size to be seen in a CT image and may
resemble the appearance of a small pseudocyst.
Treatment
•No treatment for retention cysts exist before or in conjunction with a sinus graft
and/or implant insertion.
Primary Maxillary Sinus Mucocele CYSTIC LESIONS
•A primary mucocele is a cystic, expansile, destructive lesion that may include painful
swelling of the cheek, displacement of teeth, nasal obstruction, and possible ocular
symptoms.
Etiology
•The primary mucocele arises from blockage of the maxillary ostium by fibrous
connective tissue.
• Because of the compromised drainage, the mucosa expands and herniates through
the antral walls.
•This mucocele is classified as a cyst because it is lined by antral epithelium, which

contains mucin.
Primary Maxillary Sinus Mucocele CYSTIC LESIONS
•In the early stages, the primary mucocele involves the entire sinus and appears as an
opacified sinus.
• As the cyst enlarges, the walls become thin and eventually perforate.
• In the late stages, destruction of one or more surrounding sinus walls is evident.
Treatment
•Surgical removal of this cyst is indicated before any bone augmentation procedures.
Postoperative Maxillary Cyst CYSTIC LESIONS
•A postoperative maxillary cyst of the maxillary sinus is a cystic lesion that usually
develops secondary to a previous trauma or surgical procedure in the sinus cavity.
• It has also been termed a surgical ciliated cyst, postoperative maxillary sinus
mucocele, or a secondary mucocele.
Etiology
•The cyst is derived from the antral epithelium and mucosal remnants that previously
were entrapped within the prior surgical site.
• This separated mucosa results in an epithelium-lined cavity in which mucin is

secreted.
Etiology
• The antrum becomes divided by a fibrous septum in which one part drains normally,
whereas the other part is composed of the mucocele.
• It is relatively rare in the United States; however, it constitutes approximately 24%

of all cysts in Japan.
•At least three reported cases exist of a postoperative maxillary cyst forming after a
sinus graft procedure, including one by the author of this chapter.
•The cyst radiographically presents as a well-defined radiolucency circumscribed by

sclerosis.
• The lesion is usually spherical in the early stages, with no bone destruction.
• As it progresses, the sinus wall becomes thin and eventually perforates.
• In later stages, it will appear as two separated anatomical compartments.
Treatment
•Surgical ciliated cysts should be enucleated before any bone augmentation

procedures.
•If observed after the sinus graft, then they should be enucleated and regrafted in the
site.
NEOPLASMS
Etiology
•Primary malignant tumors within the maxillary sinus are usually caused by squamous
cell carcinomas or adenocarcinomas.
• Signs and symptoms of malignant disease are related to the surrounding sinus wall
that the tumor invades and includes swelling in the cheek area, pain, anesthesia or
paresthesia of the infraorbital nerve (e.g., anterior wall), and visual disturbances (e.g.,
superior wall).
• These tumors in the sinus are usually nonspecific and give a variety of
consequences, including opacified sinuses, soft tissue masses in the sinus, as well as
sclerosis, erosion, or destruction of the walls of the sinus.
• Sixty percent of squamous cell carcinomas of the paranasal sinuses are located in
the maxillary sinus, usually in the lower one half of the antrum.
NEOPLASMS
Etiology
•Clinical signs in the oral cavity reflect the expansion of the tumor and an increased
mobility of the involved teeth.
•Invasion of the infratemporal fossa is also possible.
•Radiographic signs of neoplasms may include varioussized radiopaque masses,

complete opacifi cation, or bony wall changes.
• A lack of a posterior wall on a panoramic radiograph should be a sign of possible

neoplasm (Figure 38-17).
NEOPLASMS
Treatment
•Any signs or symptoms of a lesion of this type should be immediately referred for
medical consultation.
•Of course, sinus grafts are contraindicated while this condition exists.
NEOPLASMS
ANTROLITHS AND FOREIGN BODIES
•Maxillary sinus antroliths are the result of complete or partial encrustation of a

foreign body.
•These masses found within the maxillary sinus originate from a central nidus, which
can be endogenous or exogenous.
Etiology
•The majority of endogenous sources are from dental origin, including retained roots,
root canal sealer, fractured dental instruments, and dental implants.
•Additionally, bone spicules, blood, and mucus have been reported to cause
antroliths.
• Reports in the literature of exogenous sources include paper, cigarettes, snuff, and
glue.
•The radiographic appearance of a maxillary antrolith resembles either the central

nidus (retained root) or appears as a radiopaque, calcified mass within the maxillary
sinus (Figure 38-18).
Differential Diagnosis
•Because the calcified antrolith is composed of calcium phosphate (CaPO4), calcium

carbonate salts, water, and organic material, it will be considerably more radiopaque
than an inflammatory or cystic lesion.
•The central nidus of the antrolith is similar to its usual radiographic appearance.
Treatment
•Before sinus augmentation and implant placement, the antrolith should be surgically
removed.
•If sinusitis exists, then the sinus cavity should be allowed to heal completely before
sinus augmentation procedures.
•A nonsymptomatic condition may have the antrolith removed, sinus membrane

opening sealed, and sinus graft performed at the same surgery.
CONSIDERATIONS SPECIFIC
TO SINUS GRAFTS
•Several conditions related to the maxillary sinus are a concern but are not necessarily
contraindications to the sinus graft procedure.
• However, they should be treated before or during the sinus graft surgery.
• For example, root tips in the antrum, pseudocysts, an oral antral opening, extraction
of hopeless teeth in the surgical site, and unerupted teeth all may be conditions that
may be performed in conjunction with the sinus graft.
•relative contraindications include patients with a narrowing of the osteomeatal

complex (e.g., deviated septum, abnormal large size of middle turbinate [concha
bullosa], enlargement of an air cell in the roof of the sinus [Haller cell]).
Smoking CONSIDERATIONS SPECIFIC
TO SINUS GRAFTS
•Overall, smokers have a 7% greater failure rate in the posterior maxilla than
nonsmokers.
• Smoking is known to be associated with an increased susceptibility to allergy and

infections, because it interferes with ciliary function and secretory immunity of the
nasorespiratory tract.
• In the maxillary sinus, this may have effects on both immune exclusion and
suppression, because IgA and IgM responses are reduced, whereas IgE responses are
increased.
TO SINUS GRAFTS
•Smoking is believed to disturb bone graft healing because it reduces local blood flow
by increasing peripheral resistance and causing an increased platelet aggregation.
•By-product chemicals of smoking, such as hydrogen cyanide and carbon

monoxide,have been shown to inhibit wound healing, as does nicotine, which inhibits
cellular proliferation.
• Tobacco may interfere directly with osteoblastic function, and strong evidence
exists of decreased bone formation in smokers.
TO SINUS GRAFTS
• In addition, smokers have a significant reduction of bone mineral content.
• Bone mineral density can be reduced two to six times in a chronic smoker.
• Overall, smoking may contribute to poor available bone quality and poor healing
capacity resulting from vascular and osteoblastic dysfunction.
•The sinus graft procedures observed one perforation of sinus mucosa in nonsmokers
and three perforations in smokers.
• Postoperative infections were zero for non smokers, and two sinuses became
infected within 2 months of the sinus graft in smokers.
TO SINUS GRAFTS
•Therefore it appears cigarette smoking is not a strict contraindication to sinus

grafting.
•However, this is not to say smokers have no risk.
•Smoking may represent a relative contraindication because of the risk of wound

dehiscence, graft infection and/or resorption, and a reduced probability of
osseointegration.
•It is recommended, however, that if a decision to proceed with surgery has been
made, then patients refrain from smoking at least 15 days before surgery (the time it
takes for nicotine to clear systemically) and 4 to 6 weeks after surgery.
Chronic Maxillary Rhinosinusitis CONSIDERATIONS SPECIFIC
TO SINUS GRAFTS
•These patients have altered sinus flora and are at greater risk of containing fungi
that can lead to severe fungal-related infections.
•Patients at a higher risk should have a thorough preoperative examination with a CT

evaluation and possible medical clearance.
•Furthermore, the sinus graft procedure should be performed before and separate
from the implant placement surgery.
TO SINUS GRAFTS
• In addition, when a patient is more at risk of a sinus infection during a specific time
period (e.g., grass allergy in the spring), it is prudent to perform the sinus graft
procedure at the time of the year with the least risk.
• In addition, pre- and postoperative antibiotic drugs may be extended to cover these
patients around the sinus graft procedure.
TO SINUS GRAFTS
•Absolute local contraindications to sinus grafting include the following (Box 38-2):
•1. The patient has an active sinus infection on the day of surgery. (The patient should
blow the nose, and the physician should evaluate the sample for color and thickness
of mucus.)
•2. The patient has a significant recurrent history of chronic sinusitis despite a history
of maxillary sinus corrective surgery.
•3. The patient has a significant recurrent history of fungal sinusitis.

TO SINUS GRAFTS
•4. The patient has uncontrolled, late-stage diabetes. (These patients are very
susceptible to fungal infections.)
•5. The patient has cystic fibrosis (CF), a genetic disease with a 92% to 100% chronic
sinusitis rate. (In addition, patients with CF exhibit significant rates of polyp formation
and fungal infections.)
•6. The patient has maxillary sinus hypoplasia (MSH).
•(The sinus drainage system is chronically compromised and is associated with a

malformed uncinate process.
• If implants are to be placed in patients with MSH, then the sinus cavity should not be
used and SA-1 procedures are recommended.
TO SINUS GRAFTS
•7. The patient has neoplasms (i.e., primary or secondary malignant tumors within the
maxillary sinus).
•8. The patient has inferior turbinate and/or meatus pneumatization (i.e., big nose
variant).
TO SINUS GRAFTS
SURGICAL ENVIRONMENT
•Although studies have reported little (if any) difference between the two approaches
for the placement of implants in existing bone volumes, care should be taken related
to the surgical environment for a sinus graft.
•A sinus graft surgery has a higher risk of infection than implant insertion surgery,
because the maxillary sinus is often predisposed to this complication.
• In fact, a patient may obtain a sinus infection after the surgery that is unrelated to
the sinus graft operation.
SURGICAL ENVIRONMENT
• However, the surgical manipulation of the antral mucosa causes an increased

release of histamine, which increases the thickness of the sinus mucosa and therefore
increases the risk that the osteomeatal unit will become compromised.
•As such, a surgical environment that includes intraoral and extraoral scrubbing with
chlorhexidine, scrubbing and draping the patient, as well as gowning the doctor and
assistant should be considered in addition to sterile gloves and sterile instruments.
• In addition, a filter to circulate and clean the air of the operating room may be
advantageous to decrease the risk of allergens.
Antimicrobial Medications PREMEDICATIONS
•The pharmacologic regimen includes an antibiotic drug, anti-inflammatory

medications, antimicrobial rinse, and analgesic medications.
•Bacterial invasion may originate from different sources:
•(1) transoral surgery.
•(2) bone graft material.
•(3) bacteria from the sinus cavity.
• Additionally, it has been documented that the inclusion of foreign bodies (e.g.,
implants, alloplasts, allografts) increases infection rates.
•Antibiotic medications have been shown to significantly reduce the number of sinus
graft or implant failures caused by infection.
•Anaerobic gram-positive cocci, and anaerobic gram-negative rods.
•Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are

the three most common pathogens found with acute sinus infections.
•Staphylococcus aureus along with anaerobic bacteria have a significant role in

causing chronic rhinosinusitis disease.
•The antibiotic class of choice is the b-lactam antibiotic drugs.
• However, bacterial resistance has become a significant problem in the treatment of

these pathogens.
•With the wide range of possible routes of bacterial invasion and types of bacteria,
the antibiotic drug must be broad spectrum to account for all these possibilities.
•Bacterial resistance is initiated by two common mechanisms:
• (1) production of antibiotic-inactivating enzymes (S. aureus, H. influenzae, and M.

catarrhalis)
• (2) alteration in target site (S. pneumoniae).

•Amoxicillin (the drug of choice for many years) is no longer used for antibiotic
prophylaxis for the sinus graft surgery.
• Instead, amoxicillin-clavulanate (Augmentin) is used, because the addition of

clavulanic acid enhances amoxicillin’s activity against the b-lactamase–producing
strains of bacteria.
•Maximum effectiveness of prophylactic antibiotic drugs occurs when the antibiotic is

in adequate concentrations in the tissue before bacterial invasion.
• Because the sinus mucosa has limited blood supply to combat possible bacterial
invasion from the sinus surgery, antibiotic medications should be administered at
least 1 full day before surgery and extended for 5 days after surgery.
• Recommended systemic antibiotic drugs are shown in Box 38-3.

Local Antibiotic Medications PREMEDICATIONS
•The antibiotic concentration within a blood clot of the sinus graft depends on the
systemic blood titer.
•After the clot stabilizes, further antibiotic drugs do not enter the area until
revascularization.
• The bone graft is a dead space with minimum blood supply and absence of
protection by the host’s cellular defense mechanisms.
•This leaves the graft prone to infections that would normally be eliminated by either
the host defenses or the antibiotic.
• The osteogenic induction of autografts and allografts is greatly retarded when

contaminated with infectious bacteria.
•To ensure adequate antibiotic levels in a SA graft, it is recommended to add

antibiotic to the graft mixture.
•This local antibiotic may protect the graft from early contamination and infection.
•Numerous studies have shown that an antibiotic added to graft material has no
deleterious effects on bone growth.
•Antibiotic drugs such as penicillin, cephalosporin, and clindamycin, even in high

concentrations, have not been found to be destructive to bone-inductive proteins.
•The locally delivered antibiotic should have efficacy against the most likely
organisms encountered.
•Because the incidence of allergy is so high with blactam antibiotic drugs, the
parenteral form of cefazolin (Ancef) or clindamycin is selected.
•Orally administered capsules and tablets should not be used within the graft,
because they contain fillers that are not conducive to osteogenesis.
• When the parenteral form of antibiotic is a liquid, the volume of liquid added to the
graft should be minimized to allow adequate handling of the graft mixture.
• (See Box 38-3 for the recommended amount of antibiotic that should be added to
sinus graft material).
•Clinical experience indicates that less risk of infection exists when preoperative and
postoperative antibiotic drugs are used both orally and in the graft.
•Because infection considerably impairs bone formation for patients undergoing sinus
graft procedures, oral antibiotic coverage is continued for 5 days after the surgery.
Oral Antimicrobial Rinse PREMEDICATIONS
•An additional antimicrobial medication is chlorhexidine gluconate.
• This category of mouth rinse has been shown to successfully decrease infectious
episodes and minimizes postoperative complications from the incision line.
•Gentle oral rinses of chlorhexidine gluconate 0.12% should be used twice daily for 2
weeks after surgery.
Glucocorticoid Medications PREMEDICATIONS
•The decrease in inflammation of the soft tissue decreases postoperative pain,

swelling, and incision line opening.
• In addition, the clinical manifestations of surgery on the sinus mucosa can also be
decreased by use of a steroid.
•Therefore the usual surgical protocol for most implant surgeries, including sinus
grafts, includes a short-term dose of dexamethasone (Decadron) (Box 38-4).
• To ensure patency of the ostium and minimize inflammation in the sinus before
surgery, steroid medications are initiated 1 full day before surgery.
•This medication should also be extended 2 days postoperatively because edema

peaks at 2 days.
Glucocorticoid Medications PREMEDICATIONS
Decongestant Medications PREMEDICATIONS
•Sympathomimetic drugs that influence a-adrenergic receptors have been used as

therapeutic agents for the decongestion of mucous membranes.
•Both systemic and topical decongestant medications are useful in reopening a

blocked sinus ostium and facilitating drainage.
•Oxymetazoline 0.05% (Afrin or Vicks Nasal Spray) and phenylephrine 1% are useful
topical decongestant medications.
•The vasoconstrictor action of oxymetazoline lasts approximately 5 to 8 hours, which

is preferred in comparison with 1 hour for phenylephrine.
• However, decongestant drugs have many disadvantages.
• Topical decongestant drugs can cause a rebound phenomenon and the

development of rhinitis medicamentosa if used more than 3 to 4 days.
• The effectiveness of the topical decongestant is markedly enhanced by proper

position of the patient’s head during administration of the drug.
• It should also be noted that the pulse amplitude and blood flow in the sinus mucosa
is reduced with decongestant drugs, such as oxymetazoline.
•This may, in turn, decrease the defense mechanism of the tissues.

•Caution is advised in pseudoephedrine administration to patients with high blood

pressure, heart disease, diabetes, thyroid disease, and/or prostatic enlargement.
•The use of this decongestant should be avoided in patients taking antihypertension

or antidepressant drugs containing a monoamine oxidase inhibitor because of a
potentiation of the action of the sympathomimetic amine.
• Patients receiving digitalis may experience an increase in ectopic pacemaker

activity.
• Side effects of this systemic decongestant also include nervousness, dizziness, or

sleeplessness.
Analgesic Medications PREMEDICATIONS
•Any analgesic combination containing codeine, such as Tylenol 3, is prescribed

postoperatively because codeine is a potent antitussive, and coughing may place
additional pressure on the sinus membrane and introduce bacteria into the graft.
• The patient is instructed to cough (if necessary) with the mouth open so that no air
pressure through the ostium occurs.
Cryotherapy PREMEDICATIONS
•With sinus elevation procedures, postoperative inflammation in the posterior maxilla

is very common.
•Because postoperative swelling can adversely affect the incision line, measures
should be taken to minimize this condition.
• Application of cold dressings and cold oral liquids, along with elevation of the head
and limited activity for 2 to 3 days, will help minimize the swelling.
• The applied cold dressing and liquids will cause vasoconstriction of the capillary
vessels, thus reducing the flow of blood and lymph, resulting in a lower degree of
swelling.
Cryotherapy PREMEDICATIONS
• Ice or cold dressings should only be used for the first 24 to 48 hours.
• After 2 to 3 days, heat may be applied to the region to increase blood and lymph
flow, to help clear the area of the inflammatory consequences.
• This also helps reduce any ecchymosis that may have occurred from the tissue
reflection.
Preparation and Antisepsis SURGICAL TECHNIQUE
•Sedation and adequate infiltration anesthesia (i.e., posterior and middle alveolar
nerve, greater palatine nerve) are obtained.
•The mouth cannot become a sterile environment for surgery.
•However, intraoral preparation before surgery may significantly reduce the bacterial
count in the mouth.
•Iodophor compounds (Betadine) are a most effective antiseptic.
• However, because the iodine is complexed with organic surface-active agents, it has
been shown to inhibit the osteoinduction of demineralized bone.
Preparation and Antisepsis SURGICAL TECHNIQUE
•Therefore care is taken to avoid contamination of the graft.
• As a consequence, intraoral preparation of the surgical site requiring a bone graft, a

0.12% chlorhexidine gluconate (Peridex) scrub, and rinse is most often used.
• Extraoral presurgical scrubbing of the skin should also be performed with

chlorhexidine antiseptics.
SINUS SURGERY: HISTORY
•In the early 1970s, Tatum began to augment the posterior maxilla with autogenous
rib bone to produce adequate vertical bone for implant support.
• He found that onlay grafts below the existing alveolar crest would decrease the
posterior intradental height significantly, yet very little bone for endosteal implants
would be gained.
•Therefore in 1974, Tatum developed a modified Caldwell-Luc procedure for SA

grafting.
• The crest of the maxilla was infractured to elevate the maxillary sinus membrane.
• Autogenous bone was then added in the area previously occupied by the inferior
third of the sinus.
SINUS SURGERY: HISTORY
TREATMENT CLASSIFICATIONS
FOR THE POSTERIOR MAXILLA
•In 1995, Misch41 modified his 1987 classifications to include the lateral dimension of
the sinus cavity; this dimension was used to modify the healing period protocol,
because smaller-width sinuses (0 to 10 mm) form bone faster than larger-width (>15
mm) sinuses.
Subantral Option One:
SURGICAL TECHNIQUE
Conventional ImplantPlacement
•Because the quality of bone in the posterior maxilla often is D3 or D4 bone, bone
compaction to prepare the implant site is common.
•This permits a more rigid initial insertion of the implant and also increases the BIC
after initial healing.
•The minimum ideal bone height is related to implant design and bone density;
however, at least a 12-mm implant in height is suggested for a 4-mm-diameter
threaded implant (Figure 38-20).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•Therefore after successful sinus grafts, the patient is placed in the SA-1 category and
surgical approach.
•Often the softer bone type after sinus graft indicates bone compression rather than
bone extraction techniques (Figure 38-21).
•Although a common axiom in implant dentistry is to remain 2 mm or more from an

opposing landmark, this is not necessary in the SA region.
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•The insertion of smaller surface area implants (as small-diameter root form implants)
is not suggested because the forces are greater in the posterior regions of the mouth,
and the bone density is less than in most regions.
• In addition, the narrow ridge is often more medial than the central fossa of the
mandibular teeth and will result in an offset load on the restoration, which will
increase the strain to the bone.
SURGICAL TECHNIQUE
•If less than 2.5 mm of width is available in the posterior edentulous region (C–w),
then the most predictable treatment option is to increase width using onlay
autogenous bone grafts.
•After graft maturation the area is reevaluated to determine the proper treatment
plan classification.
•Endosteal implants in the SA-1 category are left to heal in a nonfunctional

environment for approximately 4 to 8 months (depending on bone density) before
the abutment post or posts are added for prosthodontic reconstruction.
•Care is taken to ensure that the implants are not traumatized during the initial
healing period.
•Progressive loading during the prosthetic phases of the treatment is suggested in D3

or D4 bone.
Subantral Option Two:
SURGICAL TECHNIQUE
Sinus Lift and Simultaneous
Implant Placement
•The second SA option in the Misch SA classifi cation,
•SA-2, is selected when 10 to 12 mm of vertical bone is present (2 mm less than the

minimum height in SA-1) (Figure 38-22).
• To obtain the 12 mm of vertical bone necessary for improved implant survival in

ridges of adequate width (Division A), the antral floor is elevated through the implant
osteotomy 0 to 2 mm.
•Therefore a preexisting pathologic condition of the sinus should not be present,

because it may affect the implant site by retrograde infection.
SURGICAL TECHNIQUE
Implant Placement
SURGICAL TECHNIQUE
Implant Placement
Incision and Reflection
•The second SA option in the Misch SA classifi cation,
•SA-2, is selected when 10 to 12 mm of vertical bone is present (2 mm less than the

minimum height in SA-1) (Figure 38-22).
• To obtain the 12 mm of vertical bone necessary for improved implant survival in

ridges of adequate width (Division A), the antral floor is elevated through the implant
osteotomy 0 to 2 mm.
•Therefore a preexisting pathologic condition of the sinus should not be present,

because it may affect the implant site by retrograde infection.
SURGICAL TECHNIQUE
Implant Placement
Incision and Reflection
• When teeth are present in the region, the crestal incision extends at least one tooth
beyond the edentulous site.
•A full-thickness palatal flap is first reflected because the palatal dense cortical plate
facilitates soft tissue reflection.
•The labial mucosa is pulled off the edentulous ridge, rather than elevating the tissue
from the bone.
•The crest is not used to leverage the tissue, because the ridge may have minimal
cortical bone.
•This could result in damage to the residual ridge or possibly even penetrate the sinus
cavity.
Osteotomy and Sinus Lift (SA-2)
SURGICAL TECHNIQUE
•When in doubt of the height dimension, the osteotomy should err on a shorter
length.
•The implant osteotomy is prepared to the appropriate final diameter, short of the
antral floor, following the established protocol for bone density.
•A flat-end or cupped-shape osteotome of the same diameter as the final osteotomy

is selected.
•It is of a different end shape than osteotomes used for bone spreading.
•The osteotome is inserted and tapped firmly in 0.5- to 1.0-mm increments beyond
the osteotomy until reaching its final vertical position, up to 2 mm beyond the
prepared implant osteotomy (Figure 38-24).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•A slow elevation of the sinus floor is less likely to tear the sinus mucosa.
•This surgical approach compresses the bone below the antrum, causes a greenstick-
type fracture in the antral floor, and slowly elevates the unprepared bone and sinus
membrane over the broad-based osteotome.
• If the osteotome cannot proceed to the desired osteotomy depth after tapping,
then it is removed and the osteotomy is prepared again with rotary drills an
additional 1 mm in depth.
•The osteotome is then reinserted to attempt the greenstick fracture of the antral
floor.
SURGICAL TECHNIQUE
• Extraction forceps may be used to rotate and remove the osteotome from the
osteotomy.
•The osteotome is not luxated, because this will increase the width of the final
osteotomy.
•Once the osteotome prepares the implant site, the implant may then be threaded
into the osteotomy and extend up to 2 mm above the floor of the sinus.
•The apical portion of the implant engages the more dense bone on the cortical floor,
ideally with bone over the apex, and an intact sinus membrane.
•The implant may extend 0 to 2 mm beyond the sinus floor, and the 1 mm of
compressed bone covering over the implant apex results in as much as a 3-mm
elevation of the sinus mucosa (Figure 38-25).
SURGICAL TECHNIQUE
• Extraction forceps may be used to rotate and remove the osteotome from the
osteotomy.
•The osteotome is not luxated, because this will increase the width of the final
osteotomy.
•Once the osteotome prepares the implant site, the implant may then be threaded
into the osteotomy and extend up to 2 mm above the floor of the sinus.
•The apical portion of the implant engages the more dense bone on the cortical floor,
ideally with bone over the apex, and an intact sinus membrane.
•The implant may extend 0 to 2 mm beyond the sinus floor, and the 1 mm of
compressed bone covering over the implant apex results in as much as a 3-mm
elevation of the sinus mucosa (Figure 38-25).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•Some authors have used the SA-2 sinus lift procedure to gain more than 2 mm of
implant vertical height and/or place bone graft materials in the osteotomy site before
implant insertion.
•These blind surgical techniques increase the risk of sinus membrane perforation.
•When the sinus mucosa is perforated, the graft material may extrude into the atrum
and increase the risk of postoperative infection, because it may occlude the ostium
and alter the environment of the sinus proper.
•If a sinus infection occurs, then a bacterial smear layer may accumulate on the
implant apex.
•This prevents future BIC and may contribute to future sinus infections.
SURGICAL TECHNIQUE
•Attempts to feel the elevation of the membrane from within an 8-mm-deep implant
osteotomy that is approximately 3 mm in diameter may easily cause tearing of the
sinus lining.
•Four to 6 months after the surgical procedure, a radiograph that demonstrates bone
over the implant apex may be used to indicate the success of the 0- to 2-mm
increased vertical height.
•It is not unusual for the maxillary sinus to drape over the apices of a maxillary molar.
• When the tooth is extracted, the sinus often resides too close to the crest for
implant insertion, without grafting the sinus floor.
•Rosen developed a modification to the SA-2 treatment approach for use at the time
of an extraction of a maxillary molar.
SURGICAL TECHNIQUE
•The crest of the ridge to the antral floor should be 7 mm or more in height.
• Once the tooth is extracted and the surrounding boney walls confirmed, a
modification of the SA-2 technique is in order.
• A 5- to 6-mm trephine bur is used in the center of the extraction site and prepares
the bone 1 to 2 mm below the antral floor.
• A 5- to 6-mm-diameter, flat-ended or cup-shaped osteotome and mallet intrudes

the core of bone 2 mm above the sinus floor, creating 9 mm or more of vertical bone.
• A socket graft may be used within the extraction socket but is not pushed into the
surgical space of the sinus, because it may perforate the sinus mucosa.
•After 4 months, an implant may be inserted, often with a SA-1 or SA-2 approach.
SURGICAL TECHNIQUE
•If sinus membrane perforation occurred during the initial implant placement
procedure, then increased bone height is not likely.
•This is the primary reason why only 0 to 2 mm of additional bone height is

attempted with this technique.
• However, even when membrane perforation occurs and/or no bone grows around
the apical end of the implant, the SA-2 technique is of benefit, because the apical end
of the implant is surrounded by denser bone.
•This enhances rigid fixation during healing and increases BIC, leading to improved
loading conditions.
SURGICAL TECHNIQUE
•If inadequate bone is formed around the apical portion of a implant, then a
progressive-loading protocol for D4 bone is suggested during prosthetic
reconstruction.
•Worth and Stoneman have reported a comparable phenomenon of bone growth

under an elevated sinus membrane called halo formation.
•Natural elevation of the sinus membrane around teeth with periapical disease.
• The elevation of the membrane resulted in new bone formation once the tooth
infection was eliminated.
SURGICAL TECHNIQUE
•As a result of the autologous bone present above the apical portion of the implant
with an SA-2 technique, and the sinus floor fracture (which increases the regional
accelerated phenomenon of bone repair and formation), new bone formation over
the implant apex is predictable.
•When more than 2 mm of bone is desired above the sinus floor, a lateral-access
opening to the antrum, with direct vision and access to elevate the sinus mucosa on
the floor, is suggested.
•Because the lateral-access opening to the sinus is often 10 X 10 mm or larger and the
lateral maxilla over the sinus is only 1 mm thick, the sinus mucosa is more readily
elevated.
• If the mucosa is torn, then it may also be sealed with collagen before the sinus floor
augmentation.
SURGICAL TECHNIQUE
• Attempting to elevate the sinus mucosa more than 2 mm through an implant

osteotomy 3 to 4 mm wide and 8 mm deep is not predictable.
• Reiser reported that when the sinus elevation was 4 to 8 mm in cadavers, almost
25% resulted in sinus perforation.
• The implant osteotomy sinus floor augmentation technique is often attempted

because of the perceived ease of surgery of an SA-2 technique versus an SA-3 lateral-
access procedure.
•However, the few extra minutes needed to gain access from the maxillary lateral wall
and direct vision to the antral floor present obvious benefits
Subantral Option Three:
SURGICAL TECHNIQUE
Sinus Graft with Immediate or
Delayed Endosteal Implant Placement
•The third approach to the maxillary posterior edentulous region, SA-3, is indicated
when at least 5 mm of vertical bone and sufficient width are present between the
antral floor and the crest of the residual ridge in the area of a needed prosthodontic
abutment (Figure 38-26).
•When the original ridge is greater than 5 mm in width, the implant may be inserted
at the same time as the sinus augmentation or delayed 2 or more months before
implant insertion.
•The short delay between graft placement and implant insertion ensures the graft is
more stable and is healing without compromise related to postoperative sinus
infection.
•When the original ridge width is Division B or C–w, an onlay graft in conjunction with
the sinus augmentation is a possible treatment option (Table 38-2).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•The author has chosen a residual height of 5 mm for the SA-3 category for two main
reasons:
•(1) this height (in adequate bone width and quality) can be considered sufficient to
allow primary stability of implants placed at the same time of the sinus graft
procedure.
• (2) this height may allow the use of alloplastic materials, because adequate amounts
of bone may be harvested from the tuberosity to augment the alloplastic component
of the graft.
Anesthesia
SURGICAL TECHNIQUE
•Infiltration anesthesia has been used with success for sinus graft surgeries in the
past; however, more profound regional anesthesia is achieved by blocking the
secondary division of the maxillary nerve (V2).
•The sinus graft surgery often requires the reflection of the soft tissue to the
zygomatic process.
• In addition, several branches of the maxillary branch of the fifth cranial nerve
innervate the sinus mucosa.
•As such, a V2 block is advantageous for patient comfort, and this achieves
anesthesia of the hemimaxilla, side of the nose, cheek, lip, and sinus area.
Anesthesia
SURGICAL TECHNIQUE
•Two options exist for V2 block anesthesia:
•(1) high and within the pterygomaxillary tissue behind the posterior wall of the
maxilla (Figure 38-27)
• (2) at the depth of approximately 1 inch with a long-gauge needle within the greater
palatine foramen (Figure 38-28).
• The first method is easier to perform but may injure the pterygoid plexus or the
maxillary artery and result in hematoma, or it may fail to reach the proper landmark.
•With the second option, it is more difficult to find the foramen and negotiate up the
canal.
•It may also injure the greater palatine artery or nerve.

Anesthesia
SURGICAL TECHNIQUE
Anesthesia
SURGICAL TECHNIQUE
• Too deep an administration with a greater palatine approach may result in the
penetration of the orbit floor.
•Possible sequelae include periorbital swelling and proptosis, diplopia, retrobulbar

block with dilated pupil, corneal anesthesia, motionless eye, retrobulbar hemorrhage,
and optic nerve block with transient loss of vision.
•However, the success rate is greater, and the clinical risks appear minimal. Therefore
most often, the first attempt for block anesthesia is within the greater palatine
foramen; if unsuccessful, then the high posterior approach is used.
• Prevention of these complications is ensured by reduction of the needle depth

measurement for smaller patients and the strict application of the technique.
•Proper angulation during penetration pre vents the penetration into the nasal cavity
through the medial wall of the pterygopalatal fossa.
Anesthesia
SURGICAL TECHNIQUE
•Infiltration anesthesia is first administered to the posterior and middle alveolar nerve
and greater palatine nerve.
• Scrubbing, gowning, and draping of the patient is next.
•Of benefit to find the greater palatine foramen is an open-bore instrument, (i.e., the
handle of a mouthmirror with the mirror portion removed).
•Pressure is applied with this instrument along the palatal tissue, at the union of the
residual ridge and hard palate, in the region of the second molar (Figure 38-29).
•The open-bore handle will feel and recede into the foramen.
• Slight pressure for a few seconds then marks the tissue over the opening of the
foramen.
•A long, 11/2- inch needle is introduced into the foramen from the opposite side of
the mouth and negotiates the canal for approximately 1 inch.
Anesthesia
SURGICAL TECHNIQUE
Incision Line and Reflection
SURGICAL TECHNIQUE
•A crestal incision is made on the palatal aspect of the maxillary posterior edentulous
ridge from the tuberosity to one tooth anterior to the anterior wall of the maxillary
sinus, leaving at least 3 mm of attached tissue on the facial aspect of the incision.
• Because ridge resorption occurs toward the midline at the expense of the buccal
dimension, the incision is made with awareness of the greater palatal artery, which
proceeds close to the crest of the ridge in the severely atrophic maxilla.
SURGICAL TECHNIQUE
• If bleeding from the palatal flap occurs, a hemostat may be used to constrict the
blood vessels distal to the bleeding, pressure may be applied over the greater
palatine foramen with a blunt instrument, or electrocoagulation at the bleeding site
may be used.
•A vertical relief incision is made on the distal of the incision to enhance surgical
access to the maxillary tuberosity.
• A broad-base anterior vertical relief incision is also made at least 10 mm anterior to

the anterior vertical wall of the antrum.
SURGICAL TECHNIQUE
•The reflection is usually excessive if the infraorbital nerve (fan-shaped appearance)

emerging from the infraorbital foramen is visualized.
•The reflected labial tissue can be tied to the cheek mucosa with 2-0 silk sutures,
carefully avoiding the parotid duct.
•All fibrous tissue should be removed from the future lateral wall access site to avoid
soft tissue contamination of the bone graft. A wet surgical sponge can be used for
this purpose (Figure 38-30).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
Access Window
SURGICAL TECHNIQUE
•The overall design of the lateral-access window is determined after the review of the
CT scan, which helps determine the thickness of the lateral wall of the antrum, the
position of the antral floor from the crest of the ridge, the posterior of the anterior
wall in relationship to the teeth (if present), and the presence of septa on the fl oor
and/or walls of the sinus.
•The outline of the Tatum lateral-access window is scored on the bone with a rotary
hand piece under copious cooled sterile saline.
• It is often easier to perform this step at 50,000 rpm, but it is possible even at 2000
rpm, depending on the lateral-wall bone thickness.
•With experience, the first bur is usually a No. 6 round carbide, which scratches the
bone and designs the overall window dimension.
Access Window
SURGICAL TECHNIQUE
• This bur is followed with a No. 4 round diamond, which “polishes” away the bone
within the groove made by the carbide bur.
•A No. 6 round diamond bur for the entire process is of benefit for an early learning
curve, because carbide burs more readily tear the sinus membrane if the bur
inadvertently comes in contact with it.
• The inferior score line of the rectangular access window on the lateral maxilla is
placed approximately 2 to 5 mm above the level of the antral floor (which is 5 to 10
mm from the crest).
•If the inferior score line is made at or below the level of the antral floor, then
infracture of the lateral wall will be very difficult, leading to possible membrane
perforation.
• If the inferior score line is made too high (>5 mm) above the sinus floor, then a ledge
above the sinus floor will result in a blind dissection of the membrane on the floor.
Access Window
SURGICAL TECHNIQUE
• When available bone height is almost 10 mm, the sinus graft requires only 5 to 6 mm
of additional bone.
• Under these conditions, the lateral access is more limited, and the inferior score line
may be 1 to 2 mm above the antral floor.
•The most superior aspect of the lateral-access window should be approximately 8 to

10 mm above the inferior score line.
• A soft tissue retractor placed above the superior margin of the lateral-access
window helps retract the facial flap and prevents the retractor’s inadvertent slip into
the access window, which may damage the underlying membrane of the sinus.
Access Window
SURGICAL TECHNIQUE
•The anterior vertical line of the access window is scored approximately 5 mm distal
to the anterior vertical wall of the antrum.
•If the sinus access window outline is difficult to determine in relation to the sinus
cavity, then it should err over the antrum rather than over the bone around this
structure.
•The distal vertical line on the lateral maxilla is approximately 15 mm in the

edentulous posterior maxilla from the anterior limit of the window and is usually in
the region of the first molar, which is within direct vision of the operator.
•A larger access window offers many advantages, including less stress on the
membrane during initial elevation and ease of additional membrane elevation with
instruments because of the direct access that facilitates graft placement.
• Excessive size of the lateral-access window is not indicated, because the outer bony
wall of the maxilla helps bone grow into the sinus graft material.
Access Window
SURGICAL TECHNIQUE
•The corners of the access window are usually round, rather than at right or acute
angles.
•If the corner angles are too sharp, then membrane perforation may occur from the
use of a surgical curette at the corner or during the infracture of the lateral wall.
• Once the lateral-access window is delineated, the rotary bur continues to scratch
the outline with a paintbrush stroke approach under cooled sterile saline irrigation,
until a bluish hue is observed below the bur or hemorrhage from the site is observed.
• The expansion of the maxillary sinus after tooth loss pushes the arteries of the
membrane to the outside of the structure and just below the surrounding bone.
•Therefore either the bluish hue of the membrane or bleeding in the area are signs of
approaching the sinus membrane.
Access Window
SURGICAL TECHNIQUE
• This observation should be achieved circumferentially around the access window.
•The access window should not be overprepared in depth, because touching the
membrane with rotary burs may cause it to tear (see Figure 38-30, C, D).
•It should be noted that the largest blood vessel in the lateral wall is from an
endosseous anastomosis from the posterior superior alveolar and the infraorbital
artery that is approximately 1.5 mm in diameter.
•However, when the lateral wall is very thin in the edentulous patient, this blood
vessel atrophies and often is not present.
• Thus excessive bleeding is rare. This vessel proceeds in the lateral wall of the maxilla
15 to 20 mm from the dentate crest.
Access Window
SURGICAL TECHNIQUE
• The horizontal lines of the access window should not be positioned directly over this
structure.
•The vertical lines of the access window often cut through the artery.
• Because the blood supply may be from either direction, both vertical access lines
may have bleeding.
• This is rarely a concern for vision or blood loss during the procedure.
• If intraosseous bleeding is a problem, the high-speed diamond used to score the

window may be used without irrigation and polish the bleeding site, which cauterizes
the vessel Elevating the head and a surgical sponge applied to the site for a few
minutes is also sufficient to control this hemorrhage in many cases.
Sinus Membrane Elevation
SURGICAL TECHNIQUE
•A flat-ended metal punch (or mirror handle) and mallet are used to gently infracture
the lateral-access window from the surrounding bone, while still attached to the thin
sinus membrane.
• The flat-ended punch is first positioned in the center of the window.
• If light tapping does not greenstick fracture the bone, the flat-ended punch is placed
along the periphery of the access window and tapped again.
• If the window does not separate easily, the punch is rotated so that only an edge
comes in contact with the scored line.
• This decreases the surface area of the punch against the score line of the window
and increases the stress against the bone.
SURGICAL TECHNIQUE
•Another light tap with the mallet will most likely cause greenstick fracture of the
bone along the scored line.
•If this still does not free the window, then further scoring of the bone with the hand
piece and diamond bur is indicated, and the tapping procedure is repeated (see Figure
38-30, E).
•A short-bladed soft tissue curette designed with two right-angle bends is introduced
along the margin of the window (i.e., BioHorizons Sinus Currette No. 1).
• The curved portion is placed against the window, whereas the sharp edge is placed
between the sinus membrane and the margin of the inner wall of the antrum for a
depth of 2 to 4 mm.
•If any sharp edges of bone remain on the bone’s margin, then they may be flicked off
with the curette.
•The curette is slid along the bone margin, 360 degrees around the access window.
SURGICAL TECHNIQUE
• This ensures the release of the membrane from the surrounding walls of the sinus
without tearing from the sharp bony access margins.
• The sinus membrane may be elevated from the antral walls easily, because it has
few elastic fibers and is not attached to the cortical wall.
• Specially designed and shaped curettes are available to facilitate this maneuver (see
Figure 38-30, F).
•A larger curved periosteal or sinus membrane elevator is then introduced through

the lateral-access window along the inferior border (i.e., BioHorizons Sinus Currette
No. 2).
•Once again, the curved portion is placed against the window, and the sharp margin
of the curette is dragged along the floor of the atrum, while elevating the sinus
membrane.
SURGICAL TECHNIQUE
• The curette should always be maintained on the bony floor to avoid a membrane
perforation.
•The curette is never blindly placed into the access window.
•The surgeon should see and/or feel the curette against the antral floor or sinus walls
at all times.
•Once the mucosa on the antral floor is elevated, the lateral, distal, and medial wall of
the sinus is addressed.
•The curette is pushed against the bone that easily reflects the membrane.
• The sinus membrane is inspected for perforations or openings into the antrum
proper (see Figure 38-30, G to J).
SURGICAL TECHNIQUE
•It is easier to gain direct vision and access to the distal portions of the antrum than
the anterior portions when the sinus area expands beyond the access window.
•The access window should be increased in size toward the anterior.
• A Kerrison rongeur or a preparation similar to the initial score-and-fracture

technique may be used to expand the size of the access window.
•The periosteal elevators and curettes further reflect the membrane off the anterior
vertical wall, floor, and medial vertical wall to a height of at least 16 mm from the
crest of the ridge, or approximately 8 to 11 mm in an SA-3 procedure.
SURGICAL TECHNIQUE
• It is better to err on the high side to ensure that ideal implant height may be placed
without compromise (always making sure the ostium remains unobstructed).
• The lateral-access window is positioned as part of the superior wall of the graft site,
once in final position.
• The SA space has the original sinus floor as the base; the posterior antral wall,
medial antral wall, and anterior antral wall as its sides; and the lateral-access window
and elevated sinus mucosa as its superior wall.
•Sinus Graft: Layered Approach

•The Top Layer: Collagen and Antibiotic.
• A resorbable collagen membrane (CollaTape) soaked with a parental form of

antibiotic (Ancef 0.2 mL or Cleocin 0.2 mL) is then prepared.
SURGICAL TECHNIQUE
•The collagen is a carrier for the antibiotic to decrease the risk of postoperative
infection.
•In addition, in case of membrane tearing or separation of the sinus mucosa (with or
without the awareness of the surgeon) the collagen membrane seals the opening (see
Figure 38-30, Box 38-5).
•Several graft materials have been proposed in single use or mixes of different
combinations, which include autogenous bone,* demineralized freeze-dried bone
(DFDB) powder or cortical fibers.
•Recently, additional research has been focusing on combining “traditional” bone

substitutes with bone growth factors.
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
• Each graft material presents a similar, yet distinct, biological approach to the sinus
graft.
•DFDB has minute amounts of osteoinductive material capable of inducing some

undifferentiated mesenchymal cells to form osteoblasts.
•The mechanism for this process appears to relate to the bone morphogenic protein
found primarily in cortical bone.
•The ideal size and shape appears to be fibers of cortical bone (Grafton).
• In animal and human studies, demineralized freeze-dried bone allograft (DFDBA)

powder used alone in sinus grafts did not provide a satisfactory result, and the author
does not use it currently.
SURGICAL TECHNIQUE
• Bone was present, but not in as much volume as the graft material originally placed.
•Speculation exists that the material resorbes more rapidly than the bone formation
process, resulting in lesser volume of bone. In addition, when DFDB is placed into an
area of low-oxygen tension (hypoxic or hypocellular tissue), the material results in
fibrous or cartilage tissue rather than bone.
•Other authors have observed similar conclusions on the poor performance of DFDB
used alone in animal and human studies.
•At the Sinus Graft Consensus Conference, high success rates were reported for all
materials and combinations, with the exception of DFDB when used alone.
SURGICAL TECHNIQUE
•The DFDB portion of the graft appears primarily to be a source of type I collagen and
a small secondary response of BMP for undifferentiated cells.
• It may resorb and permit blood vessels to invade the graft.
•Its combination with autogenous bone allows bone formation from phase I or phase
II simultaneously.
•Researchers have postulated that this may produce more bone than when either
material is used alone.
SURGICAL TECHNIQUE
•In the graft technique the author uses, the DFDB cortical fibers are mixed with
another graft material (e.g., microporous HA or a mineralized bone allograft) and
platelet-rich plasma (PRP) (not with whole blood or anesthetic solution).
• The toxic by-products of blood catabolism181 and the acidic pH of anesthetic may
decrease bone formation.
• Whole blood is drawn (10 to 20 mL) from the patient and placed into a centrifuge for
approximately 10 minutes at 3400 to 5600 rpm.
•The blood is separated into three layers:
•(1) red blood cells,
•(2) a buffy coat of platelets and white blood cells.
• (3) serum.
SURGICAL TECHNIQUE
•The buffy coat and serum is then centrifuged again to increase the concentration of
platelets.
•Platelets contain platelet-derived growth factors (PDGFs), which are involved in the
cascade of bone mineralization.
• The PRP is added to the DFDB cortical fibers and osteoconductive ceramic graft
material in the intermediate layer of the sinus graft.
•An antibiotic is also added to the graft material when used for sinus grafts.
•Osteoconduction describes the ability of a material to permit bone to grow in its

presence.
•An osteoconductive material does not grow bone in the absence of bone or
differentiated mesenchymal cells.
SURGICAL TECHNIQUE
• Therefore these materials act more as fillers and may help form a future bone matrix
or maintain volume and consistency for surgical placement.
• Microporous HA may include mixtures of calcified or mineralized cortical or

trabecular bone, b-TCP, CaPO4, and xenographic bone and are all osteoconductive
bone graft materials.
•when a layered approach to sinus grafting includes autogenous bone at the most
inferior layer, a greater vital bone percent is obtained.
•The osteoconductive portion of the graft is mixed with an antibiotic for sinus grafts,
because the risk of infection is greater than for most bone-grafting procedures.
•A parental form of antibiotic is used rather than a tablet form, because oral antibiotic
drugs often have fillers in the product that are not osteoconductive.
•The most common antibiotic is Ancef 500 mg/mL, and 0.8 mL of solution is added to
the graft.
SURGICAL TECHNIQUE
•In sinus grafts the second layer of the graft consists of either microporous HA,
inorganic bovine bone, or mineralized FDBA (70%) mixed with 30% DFDB (cortical
fibers), the PRP obtained from 10 cc of whole blood, and a parental form of antibiotic.
•The mixture forms the intermediate layer of the sinus graft, and it is placed below
the collagen and antibiotic (which is on the top) and the autogenous bone on the
original sinus floor on the bottom.
• These materials are mixed together, placed in an open 3-mL syringe that has its end
removed, and placed in the sinus graft site with a forward and inferior packing
motion.
•Because the membrane has been elevated, the sinus graft mixture can be introduced
below it and condensed into position.
•Packing is firm but not excessive, because perforation of the medial wall is possible
and spaces for blood vessels must be present to grow to form new bone (see Figure
38-30, N and O).
SURGICAL TECHNIQUE
•The Bottom Layer: Regional Acceleratory Phenomenon.
•Once the sinus membrane has been elevated and collagen membrane plus antibiotic
has been inserted into the superior aspect of the graft site, the original antral floor
and anterior wall are scratched with a sharp hand instrument.
• This trauma sets up a regional acceleratory phenomenon (RAP) that introduces

more growth factors into the site and helps blood vessels from the bony walls to grow
into the graft.
•These vessels allow migration of osteoclasts and osteoblasts that resorb and replace
the graft with living bone.
•In addition, the blood vessels provide blood supply to the autologous bone portion of
the graft, required for initial osteogenesis.
SURGICAL TECHNIQUE
•The medial wall and posterior wall are not aggressively scratched; because they are
so thin, perforation may occur (see Figure 38-30, L).
•The size of the antrum in the lower one third is evaluated once the membrane has
been elevated.
•The lateral wall to medial nasal wall may be less than 10 mm (small), 10 to 20 mm
(average), or greater than 20 mm (large) and noted in the surgical report.
• This can be correlated with the rate of graft transformation because the new bone
forms from the surrounding walls of bone around the graft site.
• In general, the bone graft maturation time varies from 4 to 10 months, depending
on type of graft material and size of the graft site mediolateral and anteroposterior
(A-P) dimension.
SURGICAL TECHNIQUE
•Autologous Bone.
• An osteogenic material is capable of producing bone, even in the absence of local

undifferentiated mesenchymal cells.
• Autologous bone predictably exhibits this activity in the sinus graft.
• Tatum first developed and reported the use of autogenous bone for sinus grafts in
the 1970s, and Boyne and James5 first published the information in 1980.
• In primates (Macaca fascicularis), Misch found the use of iliac crest or tail bone in
sinus grafts produced bone slightly denser than typical in the region.
SURGICAL TECHNIQUE
•It is interesting to note that sinus grafts in the literature that have used all
autogenous bone have lower success rates than sinus grafts with synthetic
substitutes (e.g., Del Fabbro et al.29 reported 87.70% versus 95.98%).
• However, these reports are misleading.
• The sinus graft success is linked to the success rate of the implants inserted.
• Those articles that used autologous bone as the sinus graft material most often
used a machine surface condition implant, whereas those articles with only bone
substitutes most often used a rough implant surface condition.
• When success rates of implants in a sinus graft relative to implant surface condition
are evaluated, smooth-surface implants were 85.64% successful versus rough
surfaces at 95.98%.
•Therefore autogenous bone is no worse than bone substitutes as a graft material in

the sinus; however, it cannot be said to be better.
SURGICAL TECHNIQUE
•The Tatum surgical approach, using a portion of the lateral maxilla attached to the
sinus membrane to gain access to the graft region, results in at least some
autogenous cortical bone in the graft.
• Whether the lateral-wall cortical bone is an actual medium for bone growth has not
been determined, but this is a reasonable speculation.
• In addition, an autograft is harvested and placed on the original sinus floor.
•In other words, the bone growth came from the surrounding walls of bone, similar
to an extraction socket.
•The last regions to form bone are usually the center of the lateralaccess window and
the region under the elevated sinus membrane.
•In fact, no new bone at time intervals up to 12 months was found to grow
immediately under the sinus membrane.
SURGICAL TECHNIQUE
•As a result of these observations, Misch altered the surgical approach and alloplastic
and/or autologous graft placement position after 1987.
• Since then, the sinus membrane of the medial wall of the antrum isconsistently
elevated to the height of the SA augmentation.
•This provides an additional wall for host bone to help new bone formation.
•The sinus membrane of the anterior wall, and usually the posterior wall, are also
elevated to the expected height of the sinus graft.
•In addition to the lateral-access window, as much autogenous bone as practical is

harvested and used in the graft.
• The most common harvest site for the SA-3 approach is the tuberosity on the same
side of the patient that the sinus is being augmented.
SURGICAL TECHNIQUE
• In this way, an additional surgical site is not required.
•Additional sources of bone to be added to the graft site may be any debris from
implant osteotomies, bone cores over the roots of anterior teeth, sinus exostoses,
and cores from the mandibular symphysis or ramus region.
•The autogenous bone is placed on the original bony floor in the area most indicated
for implant insertion.
•A blood supply from the host bone can be established earlier to this grafted bone
and maintains the viability of the transplanted bone cells and the osteogenic
potential of the transplanted bone growth factors.
• Cancellous bone is best used after compaction of the graft to increase the cell
volume.
• Autogenous bone represents an important component of the sinus graft, and

harvesting of at least some autogenous bone is highly encouraged.
SURGICAL TECHNIQUE
•It should be noted that the autograft layer is not mixed with any bone substitute
material.
•When mixed with other materials, it is isolated farther from any initial source of
blood vessels; as a consequence, it may not remain vital.
• Although the release of growth factors, space maintenance, and a calcium source
are still of bene fit, the primary advantage of osteogenesis is lost when the
autogenous bone is mixed with other graft materials.
•A rotary bur separates the tuberosity from the palatine process and sections the
crestal bone distal to the second molar.
• A curved osteotome and mallet then separate the intact tuberosity.

SURGICAL TECHNIQUE
•The tuberosity bone is usually soft and therefore is compressed to form more cells
per volume.
•Then it is used in the most inferior portion of the sinus graft, on top of the original
antral floor. Additional autogenous bone may be harvested intra- or extraorally as
indicated on a case-by-case basis (see Figure 38-30, P).
•The first material intro-duced is a collagen membrane and antibiotic, which forms
the superior layer of the graft.
•The next layer (and often the largest) is a 70% mixture of CaPO4 (usually cortical
FDBA (MinerOss) or a xenograft microporous HA (OsteoGraft N-300 or Bio-Oss), a
30% volume of DFDB cortical fiber (Grafton), PRP from 10 to 20 cc of whole blood,
and antibiotic (Ancef 500 mg/ mL, 0.8 mL, or Cleocin 150 mg/mL, 0.8 mL), which acts
to form bone through a combination of osteoinduction and osteoconduction
pathways.
SURGICAL TECHNIQUE
•The last material introduced into the antrum in its most inferior position is
autogenous bone, usually harvested from the tube rosity. This osteogenic portion of
the graft is typically placed in the more anterior regions or in critical future implant
sites.
•Access Window.
•A resorbable membrane may be placed over the lateral-access window (see Figure
38-30,R).
• This delays the invasion of fibrous tissue into the graft and enhances the repair of
the lateral bony wall.
•A nonresorbable membrane is not used because it may complicate the treatment of

a postoperative sinus infection.
•
SURGICAL TECHNIQUE
•A bacterial smear layer may accumulate in the nonresorbable material and

contribute to the infection process.
•An infection with a resorbable membrane is less of an issue, because the lower pH of
the infection resorbs the membrane rapidly.
• PRP is placed over the lateral collagen membrane to increase the amount of growth
factors for bone formation and to increase the growth factors for tissue healing.
• If inadequate PRP is available because it was used in the second layer of the graft,
then PPP may be used.
SURGICAL TECHNIQUE
•All sinus graft combinations in the study demonstrated higher vital bone percent on
the cores when a barrier membrane was used.
•Misch observed a higher vital bone percent even when collagen was used over the
lateral-access site compared with no collagen.
•The 5 to 10 mm of initial bone height in a SA-3 posterior maxilla, the cortical bone
on the residual crest, and the cortical-like bone on the original antral floor may
stabilize an implant that is inserted at the time of the graft and permit its rigid
fixation.
•when the conditions are ideal for the SA-3 sinus graft, the implant may be inserted
(see Figure 38-30, S; Box 38-6).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•The ideal conditions for implant insertion at the same time as the sinus graft include
the following:
•(1) greater than 5 mm of bone below the antrum,
•(2) greater than 6 mm width of crestal bone.
• (3) D2 or D3 bone in the region.
•(4) no pathologic condition of the sinus is present.
•(5) no history of recurrent sinusitis is given by the patient.
• (6) no relative contraindications exist (e.g., smoking, ASA 3 patients with lowered
immune responses)
•(7) no or only a small tear in the sinus membrane during the procedure.
•(8) no para function on an overlying soft tissue–borne prosthesis.

SURGICAL TECHNIQUE
•Although the implant may be inserted at the same time as the sinus graft, several
advantages exist to delaying implant placement for approximately 2 to 4 months:
•1. The individual rate of healing of the graft may be assessed after 2 to 4 months
while the implant osteotomy is being prepared and the implant inserted.
• The healing time for the implant is no longer arbitrary, but it is more patient specific.
•2. Under ideal conditions, postoperative sinus graft infections occur in approximately
3% to 5% of patients, which is greater than the percentage for implant placement
surgery or intraoral onlay bone grafts.
SURGICAL TECHNIQUE
•If the sinus graft becomes infected with an implant in place, then a bacterial smear
layer may develop on the implant and make future bone contact with the implant less
predictable.
•The infection is also more difficult to treat when the implants are in place and may
result in greater resorption of the graft as a consequence.
• If the infection cannot be adequately treated, then the graft and implant must be
removed.
•Therefore a decreased risk of losing the graft and implant exists if a postoperative
infection occurs with a delayed implant insertion.
• Some reports in the literature indicate a slightly higher failure rate of implants when
inserted simultaneously compared with a delayed approach.
SURGICAL TECHNIQUE
•3. Blood vessels within the graft are required to form and remodel bone.
• An implant in the middle of the sinus graft does not provide a source of blood
vessels.
• It may even impair the vascular supply.
•4. Bone width augmentation may be indicated in conjunction with sinus grafts to
restore proper maxillomandibular ridge relationships and/or increase the implant
diameter in the molar region.
•Augmentation may be performed simultaneously with the sinus graft. As a result,

larger-diameter implants may be placed with the delayed technique.
SURGICAL TECHNIQUE
•5. The bone in the sinus graft is denser with the delayed implant placement.
• As such, implant angulation and position may be improved because it is not dictated
by existing anatomical limitations at the time of the sinus graft.
•6. The surgeon may access the sinus graft before implant insertion.
• On occasion, the sinus graft underfills a region, and the lack of awareness of the
condition during implant insertion at the same time results in an implant placed in the
sinus proper, rather than the graft site.
SURGICAL TECHNIQUE
•7. On reentry to a sinus graft, it is not unusual to observe a craterlike formation in the
center of the lateral access window, with soft tissue invagination.
• If the implant is already in place, then it may be difficult to remove the soft tissue
and assess its precise extent.
•When soft tissue is present at a delayed implant insertion, the region is curetted and
replaced with a bone graft before implant placement.
• The healing time for the implant is related to the developing bone assessed at the
delayed surgery, not an arbitrary period that may be, on occasion, too brief.
SURGICAL TECHNIQUE
•Soft Tissue Closure.
•The soft tissues and periosteum should be reapproximated for primary closure
without tension, with care to eliminate graft particles in the incision line.
• However, because a collagen membrane is placed over the lateral-access window,

the tissues often will not reapproximate without tension.
• Therefore the facial flap must often be expanded.
•A tissue pickup holds the facial flap to the height of the mucogingival tissues
junction.
•The flap is then elevated, and a No. 15 blade is used to incise the tissue 1 mm deep
through the periosteum above the mucoperiosteum.
SURGICAL TECHNIQUE
• Tissue scissors are then introduced into the incision parallel to the facial flap at a
depth of 3 to 5 mm.
•A blunt dissection under the flap releases the periosteum and muscle attachments to
the base of the facial flap.
•The flap may then be advanced over the graft site to the palatal tissues.
•It should be noted that horizontal vascular anastomoses occur lateral to the maxilla,
within the soft tissue, and approximately 20 mm above the crest of the ridge.
•A blunt dissection does not violate these vessels.
• No tension should exist on the facial flap with primary closure of the site.
SURGICAL TECHNIQUE
• Interrupted horizontal mattress or a continuous suture (3-0 polyglycolic acid [PGA])

may be placed.
• Suturing is more critical with this procedure than with many other implant
placements.
•Incision line opening may contribute to infection, contamination, or loss of graft

materials.
•The borders and flange of an overlaying soft tissue–borne denture or partial denture
are aggressively relieved to eliminate pressure against the lateral wall of the maxilla.
Subantral Option Four: Sinus Graft Healing
SURGICAL TECHNIQUE
and Extended Delay of Implant Insertion
• This option is indicated when less than 5 mm remains between the residual crest of
bone and the floor of the maxillary sinus (Figure 38-31).
• The SA-4 corresponds to a larger antrum and minimal host bone on the lateral,
anterior, and distal regions of the graft, because the antrum generally has expanded
more aggressively into these regions.
•The inadequate vertical bone in these conditions decreases the predictable

placement of an implant at the same time as the sinus graft, and less recipient bone
exists to act as a vascular bed for the graft (see Figure 30-8).
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
•In addition, less autologous bone exists in the tuberosityfor harvesting, and fewer
septa or webs usually exist in the sinus (and typically exhibit longer mediodistal and
wider lateromedial dimensions).
•Therefore the fewer bony walls, less favorable vascular bed, minimal local
autologous bone, and larger graft volume all mandate a longer healing period and
slightly altered surgical approach.
SURGICAL TECHNIQUE
•The Tatum lateral-wall approach for sinus graft is performed as in the previous SA-3
procedure (Figure 38-32).
•Most SA-4 regions provide better surgical access than the SA-3 counterparts because
the antrum floor is closer to the crest, compared with the SA-3 maxilla.
• However, in Division D maxillae it is usually necessary to expose the lateral maxilla

and the zygomatic arch.
•The access window in the severely atrophic maxilla may even be designed in the
zygomatic arch.
•The medial wall of the sinus membrane is elevated at least 16 mm from the crest so
that adequate height is available for future endosteal implant placement.
•This means the elevation is 11 to 16 mm from the sinus floor.

SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
• The combination of graft materials used and their placement are similar to those for
the SA-3 technique.
• However, because less autogenous bone is often harvested from the tuberosity, an
additional harvest site may be required, most often above the roots of the maxillary
premolars or from the mandible (i.e., from the ascending ramus).
•The width of the host site for most edentulous posterior maxillae is Division A.
• However, when Division C–w to B exists, an onlay graft for width is indicated.
•When the graft cannot be secured to the host bone, it is often better to perform the
sinus graft 6 to 9 months before the autogenous graft for width.
• Then after the onlay graft maturation, the implants may be inserted.
VASCULAR HEALING OF
THE GRAFT
•Healing of the sinus graft takes place by several vascular routes, including the
endosseous vascular anastamosis and the vasculature of the sinus membrane from
the sphenopalatine artery.
•In mildly resorbed ridges, the host bone receives its blood supply from both
centromedullary and mucoperisosteal vessels.
•However, as age and the resorption process increases, the bone gradually becomes
totally dependant on the mucoperiosteum for the blood supply.
• The periphery of the graft is mainly supplied by vessels of the sinus membrane and
by intraosseous vascular bundles.
VASCULAR HEALING OF
THE GRAFT
•The central portions of the graft receive blood from collateral branches of the
endosseous anastomosis.
•The extraosseous vascular anastomosis may enter the graft from the lateral-access
window.
•Many local variables are related to sinus graft maturation, including healing time,
the volume of the SA graft, the distance from the lateral to medial wall (small,
average, or large), and the amount of autologous bone in the multilayered approach,
all of which relate to the speed and amount of new bone formation.
•When the sinus graft is reentered at 2 months, the amount of new bone is minimal.
•At 4 to 6 months, more new bone in the sinus graft is observed; at 8 to 10 months,
more vital bone is evident.
VASCULAR HEALING OF
THE GRAFT
•The materials in the sinus graft affect the rate of bone formation.
•Bone formation is fastest and most complete within the first 4 to 6 months with
autogenous bone, followed by the combination of autogenous bone, porous HA, and
DFDB (6 to 10 months).
•A sinus graft site, which is the inferior third of the maxillary sinus, may be 5 to 30 mm
in mediolateral depth and 5 to 40 mm in mesiodistal length.
• The time required to form new bone in this region is related to the volume of the
graft.
•Therefore the time required before implant insertion for SA-4 or implant uncovery in
SA-3 is dependent on the volume of the sinus graft.
VASCULAR HEALING OF
THE GRAFT
•Delayed implant placement for 4 months or more in a small sinus permits the
evaluation of the graft and indicates the further time required for direct bone fixation
of the implant.
•If the sinus graft volume is moderate in size, then 6 months before reentry is
suggested.
•A large antrum (>20 mm wide and >30 mm A-P) may require 8 months before the
implant insertion or uncovery.
•If the bone density was D4 at implant placement, the graft site was large, and/or
little autologous bone was used in the graft, then the time before uncovery or
placement of the implants may be as long as 10 months.
POSTOPERATIVE INSTRUCTIONS
•Although smoking is not an absolute contraindication for sinus grafting, smoking

during the days immediately after the procedure is contraindicated because it may
compromise the healing from both the intraoral and SA graft region.
•A similar report by Peleg also found no statistical difference in implant failure rates
in sinus grafts between smokers and nonsmokers up to a 9-year postoperative period.
• This is not to say smoking is not a concern.
•For the health of the patient and the potential risk of sinus infection, the patient is
encouraged to cease smoking before, during, and after the sinus graft and implant
insertion.
•Blowing the nose and/or creating negative pressure while sucking through a straw or
cigarette should also be eliminated for the week after surgery.
•Block and Kentreported on a patient who lost the entire sinus graft 2 days after
surgery from blowing the nose.
•Sneezing, if it occurs, should be done with the mouth open to relieve pressure within
the sinus.
•Swelling of the region is common, but pain is usually less severe than after anterior
implants in an edentulous mandible.
•The patient should be notified that small bone particles or synthetic bone found in
the mouth or expelled from the nose with bleeding is not unusual (see Box 38-7).
IMPLANT INSERTION
•The periosteal flap on the lateral side is elevated to directly allow inspection of the
previous access window of the sinus graft.
•The previous access window may appear completely healed with bone, soft and
filled with loose graft material, or with cone-shaped fibrous tissue ingrowth (with the
base of the cone toward the lateral wall).
•If soft tissue has proliferated into the access window from the lateral-tissue region,
then it is curetted and removed.
•The region is again packed to a firm consistency with autologous bone from the
previously augmented tuberosity, with DFDB cortical fibers (Grafton), and with
resorbable HA (similar to the original graft).
IMPLANT INSERTION
•The implant osteotomy may then be prepared and the implant placed following the
D4 bone protocol.
• An HA-coated, threaded implant offers an advantage when the bone density is D4

at implant insertion.
•Additional time (6 months or more) is allowed until the stage II implant uncovery is
performed and progressive bone loading is used during prosthetic reconstruction.
IMPLANT INSERTION
•The most common bone density observed for a sinus graft reentry is D3 or D4.
• Most often, mineralized bone graft material in the sinus graft has not converted to
bone.
•The tactile sense and the CT evaluation interprets the mineralized graft material as a
more dense bone type.
•Therefore a tactile or radiographic D3 bone may actually be D4-like bone.
• Therefore it is prudent to wait longer (rather than shorter) for implant uncovery.
• As a result, the total time for SA-3 is 0 to 4 months before implant insertion and 4 to
6 months for uncovery, and an SA-4 sinus graft waits 4 to 6 months for implant
insertion and another 4 to 8 for implant uncovery.
IMPLANT INSERTION
• Therefore the overall graft maturity time is 4 to 10 months for SA-3, and SA-4
healing time is 8 to 14 months before prosthetic reconstruction.
• Progressive loading after uncovery is most important when the bone is particularly
soft and less dense.
•Inadequate bone for mation after the sinus graft healing period of SA-4 surgery is a
possible, but uncommon, complication.
• When observed, the SA-3 technique may be used to place additional SA graft before
the implant placement surgery 4 months later.
Membrane Perforations INTRAOPERATIVE COMPLICATIONS
RELATED TO SURGERY
•This has several causes, which include a preexisting perforation, tearing during
scoring of the lateral window, existing or previous pathologic condition, and elevation
of the membrane from the bony walls.
•This complication occurs about 10% to 34% of the time.
• It has been reported with a higher frequency in smokers.
• If membrane perforation occurs more often than this, then the surgeon should give
consideration to alter or reevaluate the surgical technique used in sinus grafting.
•Sinus membrane perforation usually does not affect the sinus graft.
•Macrolaceration of the sinus membrane resulted in a typical sinusitis appearance,

even when clinical conditions of infection were not present.
RELATED TO SURGERY
RELATED TO SURGERY
•Once the tear or perforation is identified, the continuation of the sinus elevation
procedure is modified.
• The sinus membrane should be elevated off the bony walls of the antrum, despite
the mucosal tear.
• If a portion of the membrane is not elevated away from a sinus wall, then the graft
material will be placed on top of the membrane, thus preventing the bone graft from
incorporating with the bony wall.
•The perforation of the sinus membrane should be sealed to prevent contamination

of the graft from the mucus and contents of the sinus proper and to prevent the graft
material from extruding into the sinus proper.
•When graft materials enter the sinus proper, they may become sources for infection
or may migrate and close off the ostium to the nose and create an environment for an
infection.
RELATED TO SURGERY
•Jensen reported that graft maturation occurred and no sinus infections were
observed despite a 35% incidence of sinus perforation during the procedure in 98
patients.
•The surgical correction of a perforation is initiated by elevating the sinus mucosal

regions distal from the opening.
• Once the tissues are elevated away from the opening, the membrane elevation with
a sinus curette should approach the tear from all sides so that the torn region may be
elevated without increasing the opening size.
• The antral membrane elevation technique decreases the overall size of the antrum,
thus “folding” the membrane over on itself and resulting in closure of the perforation.
RELATED TO SURGERY
• A piece of resorbable collagen membrane (e.g., CollaTape) is placed over the

opening to ensure continuity of the sinus mucosa before the sinus bone graft is
placed.
•The collagen sticks to the membrane and seals the SA space from the sinus proper
(Figure 38-33).
RELATED TO SURGERY
RELATED TO SURGERY
•If the sinus membrane tear is larger than 6 mm and cannot be closed off with the
circumelevation approach, then a resorbable collagen membrane, but of a longer
resorption cycle (BioMend), may be used to seal the opening.
•The remaining sinus mucosa is first elevated as described previously.
• A piece of collagen matrix is cut to cover the sinus tear opening and overlap the
margins more than 5 mm.
•It should be noted that when a sinus tear occurs, it is sealed with a dry collagen
membrane so that it may be rotated into the lateral-access opening, gently lifted to
the mucosal tissue around the opening, and allowed to stick to the mucosa.
RELATED TO SURGERY
•Because no antibiotic is used on the collagen to make this procedure easier to

perform, additional antibiotic is added to the graft material.
• Therefore 1 mL of Ancef 500 mg/mL or Cleocin 150 mg/mL is added to the graft
material.
•Once the opening is sealed, the sinus graft procedure may be completed in routine
fashion.
•However, care should be taken when packing the sinus with graft material.
• After a perforation, the graft is easily pushed through the collagen-sealed opening
and into the sinus proper, and a periosteal elevator may be placed at the top of the
graft site and under the perforation.
•The graft material is then gently inserted and pushed toward the sinus fl oor and
sides but not toward the top of the graft (Figure 38-34).
RELATED TO SURGERY
RELATED TO SURGERY
•A greater bacterial penetration risk exists into the graft material through the torn
membrane.
•Therefore additional antibiotic is added to the particulate graft material.
• In addition, mucus may invade the graft and affect the amount of bone formation.
•Graft material may leak through the tear into the sinus proper, migrate to and
through the ostium, and be eliminated through the nose or obstruct the ostium and
prevent the normal sinus drainage.
•Ostium obstruction is also possible from swelling of the membrane related to the
surgery.
•These conditions increase the risk of infection.

RELATED TO SURGERY
•When a larger sinus membrane perforation has occurred during a SA-3 approach, it is
prudent to delay implant insertion.
• Placement of implants is deferred for at least 2 months (in a SA-3 option) to allow
for healing of the membrane and the gingival tissues on the edentulous crest.
• Risks of the sinus graft entering the sinus proper increase when implants are pushed
into the grafted site.
• Therefore the waiting period before implant insertion permits assessment of

postsurgical complications and graft consolidation before the implants are inserted.
Antral Septa INTRAOPERATIVE COMPLICATIONS
RELATED TO SURGERY
•Antral septa (of buttresses, webs, and struts) are the most common osseous
anatomical variant seen in the maxillary sinus.
• Underwood, an anatomist, first described maxillary sinus septa in 1910.
• He postulated that the cause of these bony projections derived from three different
periods of tooth development and eruption.
• Krennmair further classified these structures into two groups: primary, which are a
result of the development of the maxilla, and secondary, which arise from the
pneumatization of the sinus floor after tooth loss.
RELATED TO SURGERY
•Misch postulated that septa might be bone reinforcement pillars from parafunction
when the teeth were present.
• He noticed these structures occur more often in SA-3 sinuses and after a shorter
history of tooth loss.
• Long-term edentulous sites and SA-4 sinuses have fewer septa.
• The prevalence of septa has been reported to be in the range of 33% of the maxillary
sinuses in the dentate patient and as high as 22% in the edentulous patient.
•The septa may be complete or incomplete on the floor, depending on whether they
divide the bottom of the sinus into compartments.
• The septa may also be incomplete from the lateral wall or, the medial wall, or it
should extend from the floor.
RELATED TO SURGERY
•The shape of an incomplete maxillary sinus septum often resembles an inverted

gothic arch that arises from the inferior or lateral walls of the sinus.
• In rare instances, they may divide the sinus into two compartments that radiate
from the medial wall toward the lateral wall (Figure 38-35).
•The most common location of septa in the maxillary sinus has been reported to be in
the middle (second bicuspid–fi rst molar) region of the sinus cavity.
• CT scan studies have shown that 41% of septa are seen in the middle region,
followed by the posterior region (35%) and the anterior region (24%).
• For diagnosis and evaluation of septa, CT scans are the most accurate method of
radiographic evaluation.
•Panoramic radiography has been shown to be very inaccurate with a high incidence
of faulty diagnoses.
RELATED TO SURGERY
RELATED TO SURGERY
•the lateral-access window may not greenstick fracture and rotate into its medial
position.
•The strut reinforcement is also more likely to tear the membrane during the
releasing of the access window.
•The sinus membrane is often torn at the apex of the buttress during sinus membrane
manipulation, because difficulty exists in elevating the membrane over the sharp
edge of the web, and the curette easily tears the membrane at this position.
•However, because septa are mainly composed of cortical bone, immediate implant
placement may engage this dense bone, allowing for strong intermediate fixation.
•Moreover, septa allow for faster bone formation because they act as an additional
wall of bone for blood vessels to grow into the graft.
RELATED TO SURGERY
Management of Septa Based on Location
•The use of CT radiographs before sinus graft surgery permits the surgeon to observe
and plan the necessary modifications to the sinus graft procedure as a result of the
septa.
•The modification to the surgery is variable depending on its location.
• The septa may be in the anterior, middle, or distal compartment of the antrum.
•When the septum is found in the anterior section, the lateral-access window is
divided into sections: one in front of the septa and another distal to the structure.
•This permits the release of each section of the lateral wall after tapping with a blunt
instrument.
•The elevation of each released section permits investigation into the exact location
of the septa and to continue the mucosal elevation.
RELATED TO SURGERY
•The mucosal tissue may often be elevated from the lateral walls above the septa.
•The curette may then slide down the side walls and release the mucosa from the
bottom half of the septum on each side.
•The sinus curette should then approach the crest of the buttress from both
directions, up to its sharp apex.
•This permits elevation of the tissue over the web region without tearing the
membrane (Figure 38-36).
•When the strut is located in the middle region of the sinus, it is more difficult to
make two separate access windows within the direct vision of the surgeon.
RELATED TO SURGERY

RELATED TO SURGERY
• As a result, one access window is made in front of the septa.
• The sinus curette then proceeds up the anterior aspect of the web, toward its apex.
•The curette then slides toward the lateral wall and above the septa apex.
•The curette may then slide over the crest of the septum approximately 1 to 2 mm.
• A firm, pulling action fractures the apex of the septum.
•Repeated similar curette actions can fracture the web off the floor.
• Once the septum is separated off the floor, the curette may proceed more distal
along the floor and walls (Figure 38-37).
RELATED TO SURGERY

Bleeding INTRAOPERATIVE COMPLICATIONS
RELATED TO SURGERY
•Three main arterial vessels should be of concern with the lateral-approach sinus
augmentation.
•Because of the intra- and extraosseous anastomoses that are formed by the
infraorbital and posterior superior alveolar arteries, intraoperative bleeding
complications of the lateral wall may occur.
• The soft tissue verticalrelease incisions of the facial flap in a resorbed maxilla may
sever the extraosseous anastomoses.
•The extraosseous anastomosis on average is located 23 mm from the crest of the

dentate ridge; however, in the resorbed maxilla, it may be within 10 mm of the crest.
•When this artery is severed, significant bleeding has been observed.
•These vessels originate from the maxillary artery and have no bony landmark to
compress the vessel.
RELATED TO SURGERY
• Therefore vertical release incisions in the soft tissue should be kept to a minimum
height with delicate reflection of the periosteum.
• Hemostats are usually difficult to place on the facial flap to arrest the bleeding.
•Significant pressure at the posterior border of the maxilla and elevation of the head
to reduce the blood pressure to the vessels usually stops this bleeding.
• The elevation of the head may reduce nasal mucosal blood flow by 38%.
•When this is not effective, pressure against the fourth cervical vertebra (C4) in the
neck to reduce blood flow to the external carotid and collagen sponges in the
posterior region can be used to reduce and arrest the hemorrhage.
•Microfibrillar purifi ed sheep collagen (Avitene) may adhere to a wet surface and
promote clot formation and stabilization.
RELATED TO SURGERY
•The vertical component of the lateral-access wall for the sinus graft often severs the
intraosseous anastomoses of the posterior alveolar artery and infraorbital artery,
which is on average approximately 15 to 20 mm from the crest of a dentate ridge.
•The third artery of which the implant surgeon should be cautious is the posterior
lateral nasal artery.
•This artery is a branch of the sphenopalatine artery that is located within the medial
wall of the antrum.
•As it courses anteriorly, it anastomoses with terminal branches of the facial artery
and ethmoidal arteries.
•A significant bleeding complication may arise if this vessel is severed during

elevation of the membrane off the thin medial wall.
RELATED TO SURGERY
•Once the bleeding is arrested, the sponges are removed, the layered graft materials
may be inserted, and the procedure is completed.
•Epistaxis (active bleeding from the nose) is a common disorder; however, it has been
reported that 6% of patients who experience this in the general population require
medical treatment to control and stop the hemorrhage because it lasts longer than 1
hour.
•Of these patients, 15% are on anticoagulant therapy.
• Treatment options to treat epitasis include nasal packing, electrocautery, and the
use of vasoconstrictive drugs.
•Vessel ligation and/or endoscopic surgery are necessary on rare occasion.

RELATED TO SURGERY
•The most common site (90%) of nasal bleeding is from a plexus of vessels at the
anteroinferior aspect of the nasal septum and the anterior nasal cavity (which is
anterior to the sinus cavity and within the anterior projection of the nose).
•If the orbital wall of the sinus is perforated, or if an opening into the nares is already
present from a previous event, then the sinus curette may enter the nares and cause
bleeding.
•The arteries involved in this site are composed of branches of the sphenopalatine
and descending palliative arteries, which are branches of the internal maxillary artery.
•The posterior half of the inferior turbinate has a venous network, the Woodruff
plexus.
RELATED TO SURGERY
• Lavage of the nares with warm saline and oxymetazoline decongestant sprays
provides excellent vasoconstritive activity to treat the condition.
• A cotton roll with silver nitrate or lidocaine with 1:50,000 epinephrine is also
effective.
•Bleeding from the nose may also be observed after sinus graft surgery.
•Placing a cotton roll, coated with petroleum jelly with dental floss tied to one end,
within the nares may obtund nose bleeding after the surgery.
•After 5 minutes the dental floss is gently pulled and removes the cotton roll.
• The head is also elevated, and ice is applied to the bridge of the nose.
•If bleeding cannot be controlled, then reentry into the graft site and endoscopic
ligation by an ENT surgeon may be required.
Incision Line Opening SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•Incision line opening is uncommon for this procedure because the crestal incision is
in attached gingiva and at least 5 mm away from the lateral-access window.
•Incision line opening occurs more commonly when lateral-ridge augmentation is

performed at the same time as sinus graft surgery, or when implants are placed
above the residual crest and covered with the soft tissue.
• It may also occur when a soft tissue–supported prosthesis compresses the surgical
area during function before suture removal.
Incision Line Opening SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•The consequences of incision line opening are delayed healing, leaking of the graft
into the oral cavity, and increased risk of infection.
• However, if the incision line failure is not related to a lateral onlay graft and is only
on the crest of the ridge and away from the sinus access window, then the posterior
crestal area is allowed to heal by secondary intention.
•The membrane should be cleaned at least twice daily with an abrasive devise and
oral rinses of chlorhexidine.
• If the incision line is not closed after 2 months, then a surgical procedure should
reenter the site, expand the tissues, remove the bone regeneration membrane, and
reapproximate the tissue.
Nerve Impairment SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•the infraorbital nerve lies within the orbital floor and exits the foramen
approximately 6.1 to 7.2 mm from the orbital rim.
• However, anatomical variants have been reported to be as far as 14 mm from the

orbital rim in some individuals.
• In the severely atrophic maxilla, the infraorbital neurovascular structures exiting the
foramen may be close to the intraoral residual ridge and should be avoided when
performing sinus graft procedures to minimize possible nerve impairment.
•This is of particular concern on soft tissue reflection and the bone preparation of the
superior aspect of the window.
•Because the infraorbital nerve is responsible for sensory innervations to the skin of
the molar region between the inferior border of the orbit and the upper lip, iatrogenic
injury to this vital structure can result in significant neurosensory deficits of this
anatomical area.
Nerve Impairment SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•Most often, the nerve is not severed, and a neurotmesis is present.
• This paresthesia usually resolves within 1 month after the surgery.

Acute Maxillary Rhinosinusitis SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•mild inflammatory mucosal changes do occur immediately postoperatively.
• This is a temporary reaction to the normal physiologic activity of the mucosal airway
defense mechanism.
•According to the literature, acute postoperative sinusitis occurs as a complication in

approximately 3% to 20% of sinus graft procedures,and it represents the most
common short-term complication.
• Most often, the infection begins more than 1 week after surgery, although it may
begin as soon as 3 days later.
• Because the surgical field is close to several vital structures, postoperative infections
may arise and spread very rapidly with possible lifethreatening complications.
COMPLICATIONS
•This disorder should be considered if the patient postoperatively complains of any of

the following symptoms: headache, pain or tenderness in the area of the maxillary
sinus, and rhinorrhea.
•Studies have supported the fact that patients who had predisposing factors for
sinusitis were more at risk of developing postoperative transient sinusitis.
• The wide range of reported percentages (3% to 20%) may be the result of different
methods used for diagnosis (i.e., clinical, radiographic, endoscopic) (Figures 38-38 and
38-39).
COMPLICATIONS
COMPLICATIONS
Sinus Physiology
•Elevation of the sinus mucosa and bone grafting does alter the overall maxillary
sinus environment by reducing the size of the sinus and repositioning the mucociliary
transport system.
•In spite of this, only short-term clearance impairment exists, resulting in only
subclinical effects on the sinus physiology.
•Resolution of these conditions has been accomplished with the use of antibiotic
drugs and/or Caldwell-Luc procedures.
•No long-term chronic sinusitis cases have been reported or documented.
•Prophylactic antibiotic medications and sound surgical principles minimize

postoperative infections and complications.
COMPLICATIONS
Sinus Physiology
• However, autogenous bone, allografts, and alloplasts in the sinus graft may be
subject to infection.
• The resistance to contamination is low and may be increased if contaminated by

intraoral or sinus pathogens.
•Cases of maxillary sinusitis after dental implant surgery have rarely been reported in
the dental literature.
•However, recently in the medical literature, numerous cases of minor to severe

complications after sinus surgery have been documented.
• Although very infrequent, severe infections may lead to more severe complications,
such as orbital cellulitis, optic neuritis, cavernous sinus thrombosis, epidural and
subdural infection, meningitis, cerebritis, blindness, osteomyelitis, and, although
rare, brain abscess and death.
COMPLICATIONS
Sinus Physiology
•Therefore it is recommended to develop a professional relationship with an
otolaryngologist before the dental surgeon’s first sinus graft is performed.
• After infections are eliminated, oroantral fi stulas are possible that may be difficult
to correct, possibly requiring numerous surgical procedures that include soft tissue
and bone grafts.
•In addition, prosthetic obturators may be required until the oral antral fistula is
corrected.
COMPLICATIONS
Sinus Physiology
•Although the incidence of infection after the procedure is usually low, the damaging
consequences on osteogenesis and the possibility of serious complications require
that any infection be aggressively treated.
•In case of postoperative infection, it is recommended that the clinician perform a

thorough examination of the area by palpation, percussion, and visual inspection to
identify the area primarily affected.
•Infection follows the path of least resistance and is observed by changes in specific
anatomical sites to which it spreads66 (see Table 38-1).
Clinical Evaluation SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•Radiographic evaluation of acute rhinosinusitis is both expensive and often

inaccurate (Figure 38-40).
•As such, a patient history for acute sinusitis is a benefit and is diagnostic when two or
more of the following factors are present:
•(1) facial congestion or fullness,
•(2) nasal obstruction or blockage,
•(3) nasal discharge,
•(4) purulence or discolored postnasal discharge,
•(5) facial pain or pressure,
•(6) hyposomia or anosmia (decrease or no ability to detect an odor),

•
COMPLICATIONS
•(7) purulence in the nares on physical examination,
•(8) fever,
•(9) headache,
•(10) halitosis,
• (11) dental pain,
• (12) cough,
• (13) ear pain.

COMPLICATIONS
•When multiple symptoms are evident, antibiotic drugs for acute rhinosinusitis are in
order.
•In addition, when associated with unresolved symptoms after a sinus graft, a CT scan
may be necessary.
COMPLICATIONS
Therapeutic Treatment of Postoperative Infections
•If infection occurs postoperatively, then treatment must be aggressive because of
the possible complications and morbidity of the graft material.
• Antibiotic therapy is the first line of treatment for these related symptoms.
•These include the most common type of pathogens involved, antimicrobial

resistance, pharmacokinetic and pharmacodynamic properties, and the sinus tissue
penetration of the various antibiotic drugs.
COMPLICATIONS
•Two such factors are used when evaluating sinus antibiotic medications:
• (1) the minimum inhibitory concentration (MIC)
• (2) the concentration of antibiotic drugs penetrating inflamed diseased sinus tissue.
•The MIC is the lowest concentration of the antimicrobial agent that results in the
inhibition of growth of a microorganism.
•The MIC is usually expressed by MIC 50 or MIC 90,meaning that 50% or 90% of the
microbial isolates are inhibited, respectively.
COMPLICATIONS
•Antimicrobial Classes
•b-Lactam Medications.
•its effectiveness has been questioned recently because of the high percentage of
blactamase– producing bacteria and penicillin-resistant
•S. pneumoniae. Augmentin (amoxicillin-clavulanate) has the added advantage of

activity against b-lactamase bacteria.
• It has been associated with a high incidence of gastrointestinal side effects;

however, with a new dosing regimen (twice a day [bid]), these complications have
been significantly decreased.
COMPLICATIONS
•Fluoroquinolone Medications.
•Fluoroquinolone drugs are bactericidal antibiotic medications that are classified into
four different generations.
• The third-generation quinolone drugs are well-suited, broad-spectrum antibiotic

medications and have been labeled by the U.S.
•Food and Drug Administration (FDA) for use against sinus pathogens.
•They exhibit excellent absorption and achieve very significant sinus blood levels,
even in pathologic conditions.
COMPLICATIONS
•Fluoroquinolone Medications.
•Quinolone drugs are distributed extensively throughout the sinus, with high levels
being found in inflamed tissue and maxillary sinus cysts.
•The tissue/blood ratio is approximately 4:1, making it extremely potent within the
diseased sinus.
•The three most common quinolone medications used for sinus treatment include
levofl oxacin (Levaquin), gatifl oxacin (Tequin), and moxifl oxacin (Avelox).
COMPLICATIONS
•Macrolide Medications.
• Macrolide drugs are bacteriostatic agents that include erythromycin, clarithromycin

(Biaxin), and azithromycin (Zithromax).
•These antibiotic drugs are very active against M. catarrhalis, although their activity
on H. infl uenzae is questionable.
COMPLICATIONS
•Lincosamide Medications.
•Clindamycin (Cleocin) is the primary lincosamide drug used in clinical practice today
that is considered to be bacteriostatic.
• However, in high concentrations, bactericidal activity may be present.
• Clindamycin is mainly used for the treatment of gram-positive aerobes and

anaerobes.
•With acute sinusitis disease, clindamycin is usually not indicatedbecause it exhibits

no activity against H. infl uenzae and M. catarrhalis.
• This drug may be used in chronic sinus conditions because anaerobic organisms play
a much larger role in the disease process.
COMPLICATIONS
•Tetracycline Medications.
•Doxycycline (Vibramycin) is a bacteriostatic agent with adequate activity against

penicillin-susceptible pneumococci and M. catarrhalis.
•This drug does not exhibit any activity against penicillin-resistant bacteria and is not
effective against H. infl uenzae.
• Severe side effects of this medication are photosensitivity and esophageal caustic
burns.
•As a consequence, tetracycline drugs are not used to treat postoperative sinus
infections.
COMPLICATIONS
•Sulfonamide Medications.
• The most common sulfonamide drug, trimethoprim-sulfamethoxazole (Bactrim), is

bacteriostatic.
• Recently, a high rate of resistance to these drugs has been seen with S. pneumoniae,
H.
•influenzae, M. catarrhalis, and other sinus pathogens.
•Therefore this drug is not considered to treat postoperative infections, unless a

culture and sensitivity test has been performed.
COMPLICATIONS
•Nitroimidazole Medications.
• Metronidazole is the most important member of the nitroimidazole group.
•It is bactericidal and is effective against gram-positive and gram-negative anaerobic

bacteria.
•Its main use would be in the treatment of chronic sinus conditions; however, it
should be used with another antibiotic drug to be effective against aerobic bacteria.
•In the evaluation of different antibiotic drugs used for the treatment of pathologic
conditions of the sinus, meticulous analysis of the activity against the most common
pathogens must be evaluated.
• With all the antibiotic medications evaluated, amoxicillinclavulanate, cefuroxime

axetil, levofloxacin, and moxifloxacin showed significant sinonasal and MIC 90 blood
levels against the most common pathogens associatedwith sinus infections.
COMPLICATIONS
•Nitroimidazole Medications.
•Moxifloxacin, a third-generation fluoroquinolone drug, has been shown to have

superior qualities compared with many other antibiotic medications.
•It shows extensive distribution throughout the sinuses in both inflamed and
noninflamed sinus tissue, with significantly high concentration within maxillary sinus
cysts.
•The tissue/blood ratio is 4:1, with blood levels occurring 3 to 4 hours after
administration.
•Because of the potency and expense of this medication, it is used only in the
treatment for severe infections.
COMPLICATIONS
•Decongestant Medications.
• If acute sinusitis symptoms are present, then a nasal decongestant may be used to
maintain the patency of the ostium.
•These sympathomimetic drugs infl uence a-adrenergic receptors to reopen a

blocked ostium and facilitate drainage.
•Oxymetazoline 0.05% (Afrin or Vicks Nasal Spray) is the most effective over-the-
counter topical decongestant.
•The vasoconstrictor action of this medication will last for approximately 5 to 8 hours.
COMPLICATIONS
•Decongestant Medications.
•However, proper administration positioning must be adhered to, which includes the
patient lying down with the head down.
•The antimicrobial solution is then directly applied to drain into the sinus ostium area.
The use of this medication is limited to 3 to 4 days to prevent a rebound phenomenon
and the development of rhinitis medicamentosa.
COMPLICATIONS
•No Response to Antibiotic and Decongestant Medications
•If symptoms are not alleviated with anti biotic and decongestant medications, then
possible referral to the patient’s physician or otolaryngologist is warranted.
•Emergency consultation should be considered if the patient complains of severe

headache that is not relieved by mild analgesics, as well as persistent or high fever,
lethargy, visual impairment, or orbital swelling.
COMPLICATIONS
Saline Rinses
•An important procedure for the patient with the presence of a sinus graft infection is
saline rinses with a bulb syringe or a squeeze bottle in the nostril used to lavage the
sinus through the ostium.
•The nasal saline rinse has a long history for treatment of sinonasal disease.
•Hypertonic and isotonic saline rinses have proven efficiency against chronic sinusitis.
•These techniques of nasal irrigation have been evaluated, with the best option of a
positive-pressure irrigation using a squeeze bottle that delivers a gentle stream of
saline to the nasal cavity (NeilMed, Santa Rosa, Calif.).
COMPLICATIONS
Saline Rinses
•The syringe or squeeze bottle should not seal the nasal opening, because this may
force bacteria up toward the ethmoidal sinus.
• Instead, a gentle lavage with sterile saline rinses the sinus and flushes out the mucus
and exudate.
•Ideally the head is placed down and forward so that the saline can reach the ostium
in the superior and anterior portion of the sinus.
• The course of therapy should continue for at least 7 days.

COMPLICATIONS
Saline Rinses
•Mild Infection:
•Symptoms:
•Purulent and nonpurulent nasal drip
•Nasal blockage
•Facial pain and pressure
•Intraoral and extraoral swelling
•Cough
COMPLICATIONS
Saline Rinses
•Mild Infection:
•Treatment:
•1. Amoxicillin-clavulanate (Augmentin) 825 mg/125 mg (1 tablet bid for 10 days)
•a. If nonanaphylactic allergy to amoxicillin, cefuroxime axetil (500 mg) 1 tablet bid
for 10 days
•b. If anaphylactic allergy to amoxicillin, levofloxacin (500 mg) 1 tablet bid for 7 days
•2. Over-the-counter decongestant (oxymetazoline 0.05% for 3 days)
•3. Nasal saline rinses

COMPLICATIONS
Saline Rinses
•A patient still symptomatic after 3 days of moxifloxacin treatment should have a
medical referral for evaluation and treatment.
• Removal of the graft is often indicated in those cases.
•Moderate to Severe Infection
•Symptoms from mild infection
•Severe headache
•High persistent fever (>102.5° F)
•Periorbital swelling
•Ocular symptoms (diplopia, proptosis)
•Altered mental status
•Infraorbital hyperesthesia
COMPLICATIONS
Saline Rinses
•Moderate to Severe Infection
•Treatment
•1. Moxifl oxacin (400 mg) 1 tablet bid for 10 days
•2. Medrol dosepak (4 mg), as directed
•3. Nasal saline rinses

COMPLICATIONS
Spread of Infection
•Because of the seriousness of ocular infections, early diagnosis and aggressive
treatment is paramount.
•Various routes may predispose this area to infection from the maxillary sinus and
include the following:
•1. The venous plexus of the maxillary sinus drains through the posterior wall into the
deep facial vein, through the pterygoid plexus, and finally into the cavernous sinus.
•2. Veins also perforate the osseous roof of the maxillary sinus, entering the orbit
through the superior and inferior ophthalmic vein.
• These veins also are connected to the pterygoid plexus and cavernous sinus.
COMPLICATIONS
Spread of Infection
•3. Additionally, numerous veins perforate the anterior wall that drain into the
superior ophthalmic vein and into the cavernous sinus.
• From the cavernous sinus, drainage through the deep middle cerebralvein
communicates with the white substance of the brain’s superficial venous system.
•Because of the elaborate maxillocerebral venous anastomoses, spread of infection

from the maxillary sinus may result in possible sequelae such as brain abscesses,
intraorbital abscesses, orbital cellulitis, cavernous sinus thrombosis, and
osteomyelitis.
Implant Penetration SHORT-TERM POSTOPERATIVE
into the Sinus COMPLICATIONS
•Brånemark reported on animal histologic studies and 44 clinical cases of implants

penetrating the maxillary sinus.
•They reported success rates comparable to other maxillary implants, and no

postoperative signs or symptoms were found with these implants.
• An animal study by Boyne led to the same conclusion.
• The assumption was that direct connection between hard and soft tissues to the
integrated implant created a barrier to the migration of microorganisms.
Implant Penetration SHORT-TERM POSTOPERATIVE
into the Sinus COMPLICATIONS
•However, it should be noted these animals do not have the same incidence of
maxillary sinusitis comparable to humans.
•It is possible that an implant that penetrates the sinus floor may contribute to a
source of periodic sinusitis, because a bacterial smear layer would be difficult to
remove through regular phagocytic activity.
• When this is suspected, an apicoectomy of the implant apex, from a lateral-access

window, may be of benefit.
Oroantral Fistula SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•Oroantral fistulae may develop postoperatively, especially if the patient has a history
of infection.
•Small oroantral fistulae (<5 mm) usually will close spontaneously after treatment
with systemic antibiotic drugs and daily rinses with chlorhexidine.
• However, larger fistulae (>5 mm) will normally require additional surgical
intervention.
•Larger fistulae are associated with an epithelialized tract, which is the result of the
fusion of the sinus membrane mucosa to the oral epithelium.
•When this occurs, patients will usually complain of fluids entering the nasal cavity
upon eating or drinking.
•Closure of oroantral fistulae can be achieved by using broad-based lingual or facial

rotated flaps.
COMPLICATIONS
•Buccal flaps to close the fistula may be more difficult after sinus graft because of the
location of the graft site.
• In addition, the buccal tissue is very thin, and rotated or expanded buccal flaps
usually result in loss of vestibular depth.
•Before the initiation of the flap design, the soft tissue around the fi stula is excised
and the sinus floor curetted to ensure direct bone contact.
• A tension-free rotated flap is then made for complete covering of th

communication.
• For oroartral closure after sinus graft procedures, a lingual flap is recommended
because of the abundance of keratinized mucosa with an adequate blood supply.
•Flap designs include island flaps, “tongue-shaped” fl aps, or rotational and advanced
flaps, depending on the size of the exposure.
COMPLICATIONS
•A key to close the oroartral opening is the dissection of the buccal flap lateral to the
fistula.
• An incision that extends 15 mm anterior and posterior to the fistula is of benefit.
• The fi stula then has an elliptical incision on each side of the opening.
• The core of tissue and the fistulous tract is excised.
• The facial flap is underminded and expanded well into the tissues of the cheek.
• The palatal aspect of the incision is adjacent to the tongueshaped flap.

COMPLICATIONS
• Placement of the incision for the pedicle flap should be split thickness and take into
account the location and depth of the greater palatine artery.
•Once the attached palatal pedicle graft is rotated to the lateral and attached to the
facial flap, horizontal mattress sutures are placed to invert the flap to achieve a
watertight seal.
•Sutures with high tensile strength should be used and allowed to remain in place for
at least 2 weeks (Figure 38-41).
COMPLICATIONS
Overfilling of the Sinus SHORT-TERM POSTOPERATIVE
COMPLICATIONS
•The goal of the sinus graft is to obtain enough vertical height of bone to place
endosteal implants with longterm success.
• The maximum length requirement of an implant with adequate surface of design is

rarely more than 15 mm, and as a result, the goal of the initial sinus graft is to obtain
at least 16 mm of vertical bone from the crest of the ridge.
• This usually means the bottom one half of the sinus is filled with graft material,
because most sinuses approximate 35 mm in height.
Overfilling of the Sinus SHORT-TERM POSTOPERATIVE
COMPLICATIONS
• A CT scan of the sinus before surgery may be used to estimate the amount of graft
material required for the ideal volume of sinus graft material.
•Care should be given to the amount of graft material placed into the sinus.
• Overfilling the sinus can result in blockage of the ostium, especially if membrane
inflammation or the presence of a thickened sinus mucosa exists.
•The majority of sinus graft overfills do not have postoperative complications.
•If, however, a postoperative sinus infection occurs without initial resolution, reentry
and removal of a portion of the graft and changing the antibiotic protocol may be
appropriate.
Postoperative Maxillary SHORT-TERM POSTOPERATIVE
Surgical Cysts COMPLICATIONS
•Incidence of a maxillary surgical cyst associated with a past sinus graft and blade
implant.
•Complete enucleation was accomplished, and healing was uneventful.

LONG-TERM RESULTS
•The most important factor for implant survival was the implant design, with HA-
coated implants having a higher 3-year survival rate than the machined, noncoated
screw design implants.

Sinus Lifting in Implantology

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Maxillary Sinus

•The resorption phenomenon is accelerated by the loss of vascularization of the

•A minimum of a healthy natural canine tooth or an implant abutment in the canine

•Inadequate oral hygiene.

•Untreated periodontal disease of the residual.

•Severe bruxism with loss of incisal guidance.

• A gingivectomy is first considered because it is not uncommon for excess tissue

• As a consequence, initial healing of an implant in D4 bone is often compromised.

•A primary pneumatization of the maxillary sinus occurs at about 3 months of fetal

•Prenatally, a secondary pneumatization occurs.

•Its apex extends approximately 23 mm toward the zygomatic bone.

•This limited dimension is compounded by the problem of bone of reduced quality

•Dehiscence of the bony chamber may be present, resulting in direct contact

•Superior spreading infections may lead to a brain abscess and death.

• the internal maxillary artery.

• The posterior wall should always be identified on the radiograph.

• When lack of a posterior wall is present, a pathologic condition (including

•Therefore a blind surgical technique to place a pterygoid implant through the

• The infundibulum is approximately 5 to 10 mm long and drains via ciliary action in a

•The ostium diameter averages 2.4 mm in health; however, pathologic conditions

•Fontanelles are usually classified either as anterior fontanelles (AFs) or posterior

•The formation of the endosseous and extraosseous anastomoses in the maxillary

• The extraosseous anastomosis is less common (present in 44% of the population)

• The extraosseous anastomosis is superior to the endosseous unit, which is

• The endosseous artery was able to be observed on computed tomography (CT)

•Because the endosseous anastomosis is often present and ranges from 5 to 20 mm

•The size of the lateral-wall arterial anastomoses usually approximates 1.5 mm in a

• (2) using electrosurgery on the vessel.

•Different factors can alter the vascularization in this area.

• The infraorbital nerve is of concern in sinus elevation surgery because of its

•Five primary cell types exist in this tissue:

• (1) ciliated columnar epithelial cells

• (2) nonciliated columnar cells

• (3) basal cells

• (4) goblet cells

• (5) seromucinous cells.

•The ciliated cells contain approximately 50 to 200 cilia per cell.

•Although the sinus mucosa has been called a mucoperiosteum.

• The mucous material of the sinus in health has two layers:

•(1) a top mucoid layer

• (2) a bottom serous layer (Figure 38-10).

• Certain pathogens (Haemophilus influenzae, Streptococcus pneumoniae,

• Various medications have also been shown to affect ciliary action.

• Additional oxygen has to be absorbed from the air in the sinus.

•The production of nitrous oxide within the sinus cavity.

•Additional microorganisms identifiable in various quantities belong to the

•To establish an adequate osseous morphologic condition for the placement of

•Preoperative evaluation is completed to rule out existing pathologic condition in the

• In addition, because of the proximity of the maxillary sinus to numerous vital

• Nasal congestion or obstruction, prevalent nasal discharge, epistaxis (bleeding from

• The mucus should be clear and thin in nature.

•A yellow or greenish tint or thickened discharge indicates infection.

•Other methods of examination of the infected maxillary sinus may include

Waters’ Projection Radiographs

Waters’ Projection Radiographs

•The panoramic radiograph is often used as a preliminary diagnostic radiograph in

•The panoramic radiograph is useful for preliminary evaluation of the posterior

•This radiopaque region may be misinterpreted as a pathologic condition.

•The posterior region behind

• Cysts and inflammation of the membrane can sometimes be seen in association

•In addition, certain cases of odontogenic sinusitis may be clearly seen on PA

•Although the PA radiograph can indicate a pathologic condition in the sinuses, it

• In general, plain-film PA radiographs of the sinuses are of little value in precise