Maxillary Sinus

37
Maxillary Sinus Anatomy,

Pathology, and Graft
Surgery
RANDOLPH R. RESNIK AND CARL E. MISCH
T
he posterior maxilla has been described as one of the most the ethmoid infundibulum. At that time, the maxillary sinus is a
challenging and complex intraoral regions that confronts bud situated at the infralateral surface of the ethmoid infundibu-
the implant clinician. There exist many treatment planning lum between the upper and middle meatus. Prenatally, a second-
and patient factors that contribute to these problems in this area, ary pneumatization occurs. At birth, the sinus is still an oblong
which in many cases require the clinician to have additional train- groove on the mesial side of the maxilla just above the germ of the
ing and an increased skill set: first deciduous molar.2
• Poor bone density At birth, the sinus cavities are filled with fluid. Postnatally and
• Compromised available bone until the child is 3 months old the growth of the maxillary sinus is
• Increased pneumatization of the maxillary sinus closely related to the pressure exerted by the eye on the orbit floor,
• Increased crown height space the tension of the superficial musculature on the maxilla, and
• Ridge position shifts toward lingual (medial) the forming dentition. As the skull matures, these three elements
• Difficult access because of anatomic location influence its three-dimensional (3D) development. At 5 months,
• Increased biting force the sinus appears as a triangular area medial to the infraorbital
• Requirement of wider diameter implants and increased number foramen.3
Before discussing the various treatment options of the pos- During the child’s first year, the maxillary sinus expands lat-
terior maxilla, it is imperative that the implant clinician have a erally underneath the infraorbital canal, which is protected by
strong foundation for maxillary sinus anatomy, anatomic variants, a thin bony ridge. The antrum grows apically and progressively
pathology, and a comprehensive understanding of the various replaces the space formerly occupied by the developing dentition.
treatment approaches. The growth in height is best reflected by the relative position of
the sinus floor. At 12 years of age, pneumatization extends to the
Maxillary Sinus Anatomy plane of the lateral orbital wall, and the sinus floor is level with
the floor of the nose. During later years, pneumatization spreads
The maxillary sinuses were first illustrated and described by Leonardo inferiorly as the permanent teeth erupt. The adult sinus has a vol-
Da Vinci in 1489 and later documented by the English anatomist ume of approximately 15 mL (34 mm height x 33 length x 23 mm
Nathaniel Highmore in 1651.1 The maxillary sinus, or antrum of width). The main development of the antrum occurs as the per-
Highmore, lies within the body of the maxillary bone and is the larg- manent dentition erupts and pneumatization extends throughout
est and first to develop of the paranasal sinuses (Fig. 37.1). Adult max- the body of the maxilla and the maxillary process of the zygomatic
illary sinuses are pyramid-shaped, air-filled cavities that are bordered bone. Extension into the alveolar process lowers the floor of the
by the nasal cavity. There is much debate about the actual function sinus approximately 5 mm. Anteroposteriorly, the sinus expansion
of the maxillary sinus. Possible theorized roles of the sinus include corresponds to the growth of the midface and is completed only
weight reduction of the skull, phonetic resonance, participation of with the eruption of the third permanent molars when the young
warming humidification of inspired air, and olfaction. A biomechani- person is about 16 to 18 years of age.4
cal adaptation of the maxillary sinus directs forces away from the orbit In the adult, the sinus is pyramid shaped with consisting of four
and cranial cavity when a force is delivered to the midface. bony walls, the base of which faces the lateral nasal wall and the
apex of which extends toward the zygomatic bone (Fig. 37.2). The
Development and Expansion of the Maxillary floor of the maxillary sinus cavity is reinforced by bony or mem-
branous septa, joining the medial or lateral walls with oblique or
Sinus transverse buttress-like webs. They develop as a result of genetics
A primary pneumatization occurs at approximately 3 months of and stress transfer within the bone over the roots of teeth. These
fetal development by an outpouching of the nasal mucosa within have the appearance of reinforcement webs in a wooden boat and
987
988 PART VI I Soft and Hard Tissue Rehabilitation
rarely divide the antrum into separate compartments. These ele-

ments are present from the canine to the molar region and tend to
2 disappear in the maxilla of the long-term edentulous patient when
stresses to the bone are reduced. Karmody found that the most
common oblique septum is located in the superior anterior corner
3 of the sinus or infraorbital recess (which may expand anteriorly to
the nasolacrimal duct).5 The medial wall is juxtaposed with the
4
middle and inferior meatus.
1 1 Although the maxillary sinus maintains its overall size while
the teeth are present, an expansion phenomenon of the maxil-
lary sinus occurs with the loss of posterior teeth.6 The antrum
expands in both inferior and lateral dimensions. This expansion
may even invade the canine eminence region and proceed to the
lateral piriform rim of the nose. The dimension of available bone
height of the posterior maxilla is greatly reduced as a result of dual
resorption from the crest of the ridge and pneumatization of the
sinus after the loss of teeth. The sinus expansion is more rapid than
the crestal bone height changes. As a result of the inferior sinus
• Fig. 37.1 Maxillary sinus (1) is the largest of the four paranasal sinuses. expansion, the amount of available bone in the posterior maxilla
The initial maxillary sinus formation is completed at age 16 to 18 years. 2, greatly decreases in height (Fig. 37.3). The maxillary sinus tends
Frontal sinus; 3, ethmoid sinus; 4, sphenoid sinus. to enlarge with age, as well as with edentulism, which further
Crista Frontal
galli sinus
Sphenoethmoidal sinus
Middle
meatus
Superior
meatus
Orbit
Frontonasal Maxillary
dura sinus
at birth
Nasal
septum Maxillary
sinus
evolution
Nasal
fossa
Inferior
meatus
Tooth
• Fig. 37.2 Maxillary sinus begins to form in the fetus and by 5 months is the size of a pea, under the
eye, and close to the ostium for drainage. By 16 years of age, the maxillary sinus has four thin, bony walls
around it. The superior wall separates it from the floor of the orbit. The medial wall contains the ostium to
drain the sinus and separates it from the nasal fossa. The lateral wall forms the maxillary bone below the
zygomatic arch. The floor of the antrum rests above the roots of the teeth.
CHAPTER 37 Maxillary Sinus Anatomy, Pathology, and Graft Surgery 989
3
3
4 3
A B
• Fig. 37.3 (A) The fourth expansion phenomenon of the maxillary sinus occurs with the loss of the poste-
rior teeth. The anterior portion of the sinus may expand to the piriform rim of the nose. The inferior expan-
sion may approach the crest of the ridge. 1, Maxillary sinus; 2, frontal sinus; 3, ethmoid sinus; 4, sphenoid
sinus. (B) Coronal section of the posterior region of the edentulous human maxilla. Note expansion of
the sinus floor inferiorly far below the level of the floor of the nose. The alveolar ridge bone is markedly
atrophied, whereas the ridge submucosa has become fibrotic. Stained with Rescorcin Fuchsin stain and
counterstained with Ban Gieson. (Courtesy Mohamed Sharawy, Augusta, Georgia.)
decreases the amount of available bone. In addition to the dimin- of the prosthesis is usually in the form of a ridge lap pontic area,
ished quantity, bone in the posterior maxilla often is softer and of which in most cases results in hygiene difficulties.␣
poorer quality. Radiographs typically reveal sparse trabeculations,
and the tactile experience of drilling in this bone resembles a Sty- Resultant Poor Bone Density
rofoam type of material (D4 Bone).
After normal sinus expansion, with periodontal disease and tooth In general, the bone quality is poorest in the posterior max-
loss increasing the bone loss, inadequate bone will result between illa, compared with any other intraoral region.9 A literature
the alveolar ridge crest and the floor of the maxillary sinus. In most review of clinical studies reveals that the poorest bone density
cases, bone quantity will be compromised for implant placement. may decrease implant loading survival by an average of 16%,
The limited available bone is compounded by a decrease in bone and it has been reported as low as 40%.10 The cause of these
density and the shifting of the residual ridge in a medial direction. failures is related to several factors. Bone strength is directly
Therefore this area of the maxilla is often reported with an increased related to its density, and the poor-density bone of this region
incidence of implant malpositioning and morbidity.␣ is often 5 to 10 times weaker, compared with bone found in the
anterior mandible. Bone densities directly influence the bone-
to-implant contact percentage (BIC), which accounts for the
Bone Resorption Process force transmission to the bone. The BIC is least in D4 bone,
The maxilla generally has a thinner cortical plate facially compared and the stress patterns in this bone migrate farther toward the
with any region of the mandible, and very minimal cortical bone is apex of the implant (Fig. 37.4). As a result, bone loss is more
present on the ridge. In addition, the trabecular bone in the posterior pronounced and also occurs along the implant body, rather
maxilla is finer (less dense) than other dentate regions. When maxil- than only crestally, as in other denser bone conditions. D4
lary posterior teeth are lost, an initial decrease in bone width at the bone also exhibits the greatest biomechanical elastic modulus
expense of the labial bony plate results. The width of the posterior difference compared with titanium under load.11 Earlier stud-
maxilla has been shown to decrease at a more rapid rate than in any ies and surgical protocols did not take into consideration the
other region of the jaws.7 The resorption phenomenon is accelerated poor BIC in this area.
by the loss of vascularization of the alveolar bone and the existing In the posterior maxilla, the deficient osseous structures and
fine trabecular bone type. However, because the initial residual ridge an absence of cortical plate on the crest of the ridge is often
is inherently wide in the posterior maxilla, even with a significant observed, which further compromises the initial implant stabil-
decrease in the width of the ridge, adequate-diameter root-form ity at the time of insertion. The labial cortical plate is thin, and
implants (∼5mm) usually can be placed. However, as the resorp- the ridge is often wide. As a result, the lateral cortical BIC to sta-
tion process continues, the residual ridge continues to progressively bilize the implant is often insignificant. The implant placement
shift toward the palate until the ridge is significantly resorbed into a protocol often uses bone compression (osseodensification) rather
medially positioned narrower bone volume.8 This results in the buc- than bone extraction (removal) to create the implant osteotomy
cal cusp and central fossa of the final restoration being cantilevered to compensate for these deficiencies. If the surgical protocol is
facially to satisfy esthetic requirements at the expense of biomechan- not modified, the initial healing of an implant in D4 bone will
ics in the moderate to severe atrophic ridges. This cantilevered part be compromised.␣
rim, with anatomic variants as far as 14 mm from the orbital rim,

is the infraorbital foramen (Fig. 37.6A). The infraorbital nerve
runs along the roof of the sinus and exits through the foramen.
The infraorbital blood vessels and nerves lie directly on the supe-
rior wall of the maxillary sinus and within the sinus mucosa.
Tenderness to pressure over the infraorbital foramen or redness
of the overlying skin may indicate inflammation of the sinus mem-
brane from infection or trauma, which may contraindicate graft
surgery until resolution. In patients exhibiting anatomic variants
of the infraorbital foramen, neurosensory impairment may occur
during retraction of this area, leading to neurapraxia type injuries.
The use of worn, sharp-edged retractors should be avoided when
reflecting tissue superiorly in this area to avoid potential injuries.
Within the anterior wall of the sinus, the thinnest part is the
canine fossa, which is directly above the canine tooth. The anterior
wall of the maxillary sinus may also serve as surgical access during
Caldwell-Luc procedures to treat a preexisting or post–sinus graft,
pathologic condition.␣
Superior Wall
The superior wall of the maxillary sinus coincides with the thin
• Fig. 37.4 Bone–implant contact percent is often reduced in the posterior inferior orbital floor. The orbital floor slants inferiorly in a medio-
maxilla because the quality of bone is poorer than other regions of the lateral direction and is convex into the sinus cavity.
mouth. This histologic slide depicts the numerous areas of no bone con- A bony ridge is usually present in this wall that houses the infra-
tact at the implant interface. orbital canal, which contains 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). When these
problems occur, the patient is closely supervised, and a medical
consult is advised to decrease the risk of severe complications that
may result from the spread of infection in a superior direction.
Superior-spreading infections may lead to significant ocular prob-
lems or brain abscesses. As a result, when ocular or cerebral symp-
toms appear, aggressive therapy to decrease the spread of infection
is indicated. 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 (see Fig. 37.6B).␣
Posterior Wall
The posterior wall of the maxillary sinus corresponds to the
• Fig. 37.5 Maxillary sinus is comprised of six walls that contain significant pterygomaxillary region, which separates the antrum from the
anatomic and vital structures, which are important in the placement of infratemporal fossa. The posterior wall usually has several vital
implants. 1, Lateral, 2, anterior, 3, medial, 4, posterior, 5, inferior, 6, superior. structures in the region of the pterygomaxillary fossa, including
the internal maxillary artery, pterygoid plexus, sphenopalatine
Bony Walls ganglion, and greater palatine nerve. The posterior wall should
always be identified radiographically because when the wall is not
The maxillary sinus features six bony walls, each of which contain present, a pathologic condition (including neoplasms) is to be sus-
important anatomic structures that play a significant role in the pected (see Fig. 37.6C).
treatment of the maxillary posterior region. The implant clinician Common donor sites to obtain autogenous bone for sinus aug-
must have a strong understanding and foundation of the bony mentation procedures include the tuberosity area. Special consid-
walls associated with the posterior maxilla in the preoperative eration should be taken for the posterior extent of the tuberosity
assessment before surgical procedures (Fig. 37.5) removal. Aggressive tuberosity removal may lead to bleeding in
the infratemporal fossa (pterygoid plexus), resulting in life-threat-
Anterior Wall ening situations.
The anterior wall of the maxillary sinus consists of thin, compact It should be noted that pterygoid implants placed through
bone extending from the orbital rim to just above the apex of the posterior sinus wall and into this region may approach vital
the cuspid. With the loss of the canine, the anterior wall of the structures, including the maxillary artery. A blind surgical tech-
antrum may approximate the crest of the residual ridge. Within nique to place a pterygoid implant through the posterior wall may
the anterior wall and approximately 6 to 7 mm below the orbital have increased surgical risk. However, they are of benefit primarily
A B
C D
E F
• Fig. 37.6 Six bony walls of the maxillary sinus. (A) Anterior. (B) Superior. (C) Posterior. (D) Medial. (E)
Lateral. (F) Inferior.
when third or fourth molars are needed for prosthetic reconstruc- The main drainage avenue of the maxillary sinus is through the
tion or sinus grafts are contraindicated and available bone poste- maxillary ostium. The primary ostium is located in the superior
rior to the antrum is present.␣ aspect of the sinus medial wall and drains its secretions via the
ethmoid infundibulum through the hiatus semilunaris into the
Medial Wall middle meatus of the nasal cavity. The infundibulum is approxi-
The medial wall of the antrum coincides with the lateral wall of mately 5 to 10 mm long and drains via ciliary action in a superior
the nasal cavity and is the most complex of the various walls of the and medial direction. The ostium diameter averages 2.4 mm in
sinus. On the nasal aspect, the lower section of the medial wall health; however, pathologic conditions may alter the size to vary
parallels the lower meatus and floor of the nasal fossa; the upper from 1 to 17 mm.12
aspect corresponds to the middle meatus. The medial wall is usu- The maxillary ostium and infundibulum are part of the ante-
ally vertical and smooth on the antral side (see Fig. 37.6D). rior ethmoid middle meatal complex, the region through which
the frontal and maxillary sinuses drain, which is primarily respon- the nasal floor. In the edentulous posterior maxilla the sinus floor
sible for mucociliary clearance of the sinuses to the nasopharynx. is often 1 cm below the level of the nasal floor (see Fig. 37.6F).
As a result, obstruction in one or more areas of the complex will Radiographically, the sinus inferior floor morphology is easily
usually result in rhinosinusitis or lead to morbidity of the graft or seen via 3D imaging. The floor is rarely flat and smooth; the pres-
implant. Patency of the maxillary ostium is most crucial preop- ence of irregularities and septa should be determined and their
eratively and postoperatively during maxillary graft sinus surgery exact locations noted. Irregular floors are most often seen after
to prevent infection and morbidity of the graft. Evaluating the teeth are extracted, leaving residual bony crests that increase risk
patency of the ostium via cone beam computerized tomography of perforation because of the difficulty in membrane reflection.
(CBCT) is easily accomplished with evaluation of serial cross- In some cases, the bony crests are not even seen on the CBCT
sectional images. The patency of the ostium must be ascertained evaluation.
before surgery to prevent or minimize postoperative complica- Complete or incomplete bony septa may exist on the floor
tions. This is easily verified via coronal or cross-sectional images in a vertical or horizontal plane. Approximately 30% of dentate
on CBCT surveys. Of utmost importance when performing maxillae have septa, with three-fourths appearing in the premo-
any procedure involving the maxillary sinus, the patency of the lar region. Complete septa separating the sinus into compart-
ostium must be maintained throughout the postoperative period. ments are very rare, occurring in only 1.0% to 2.5% of maxillary
If ostium patency is compromised, increased morbidity of the sinuses.15 The presence of septa complicate lateral wall sinus graft
implant or graft will occur because the mucociliary action of the procedures, which leads to an increased likelihood of membrane
maxillary sinus will be compromised. perforation.␣
Smaller, accessory or secondary ostia may be present that are
usually located in the middle meatus posterior to the main ostium. Ostiomeatal Complex
These additional ostia are most likely the result of chronic sinus
inflammation and mucous membrane breakdown. They are pres- The ostiomeatal unit is composed of the maxillary ostium, eth-
ent in approximately 30% of patients, ranging from a fraction moid infundibulum, anterior ethmoid cells, hiatus semilunaris,
of a millimeter to 0.5 cm, and are commonly found within the and the frontal recess, which encompasses the area of the middle
membranous fontanelles of the lateral nasal wall.13 Fontanelles are meatus. This common channel allows for air flow and mucociliary
usually classified either as anterior fontanelles (AFs) or posterior drainage of the frontal, maxillary, and anterior ethmoid sinuses.
fontanelles (PFs) and are termed by their relation to the uncinated Blockage in this area leads to impaired drainage of the maxil-
process. These weak areas in the sinus wall are sometimes used to lary, frontal, and ethmoid sinuses, which may result in rhinosi-
create additional openings into the sinus for treatment of chronic nusitis and postoperative complications after implant or grafting
sinus infections. Primary and secondary ostia may, on occasion, procedures.
combine and form a large ostium within the infundibulum.␣ Radiographic identification of the ostiomeatal complex and
related structures must be evaluated to prevent potential postopera-
Lateral Wall tive complications. Pathology or variations within the ostiomeatal
The lateral wall of the maxillary sinus forms the posterior max- complex may lead to postoperative sinus graft morbidity or implant
illa and the zygomatic process. This wall varies greatly in thick- complications caused by compromised mucociliary drainage (alter-
ness from several millimeters in dentate patients to less than 1 ation of normal sinus physiology) of the maxillary sinus.␣
mm in an edentulous patient. A CBCT examination will reveal
the osseous thickness of the lateral wall, which is crucial in defin- Blood Supply and Sensory Innervation
ing the osteotomy location and preparation technique. Patients
exhibiting increased parafunction forces will have thicker lateral The vascular supply in the maxillary sinus is a vital part of the
walls (see Fig. 37.6E). The lateral wall thickness of the maxilla healing and regeneration of bone after a sinus graft and healing
has been noted to be extremely variable, with some cases being of a dental implant. The blood supply to the maxillary sinus is
nonexistent. This will lead to an increased possibility of membrane derived from the maxillary artery, which emanates from the exter-
perforation, even occurring on reflection. In contrast, the lateral nal carotid artery. The maxillary artery supplies the bone sur-
wall may be very thick, which is usually seen with patients that rounding the sinus cavity and also the sinus membrane. Branches
exhibit parafunction and have just recently lost the posterior teeth. of the maxillary artery, which most often include the posterior
In these situations, lateral wall sinus grafting becomes very dif- superior alveolar artery and infraorbital artery, form endosseous
ficult because of the cortical thickness. The lateral wall houses the and extraosseous anastomoses that encompass the maxillary sinus.
intraosseous anastomosis of the infraorbital and posterior superior The formation of the endosseous and extraosseous anastomoses in
alveolar artery, which may lead to a bleeding complication because the maxillary sinus is termed the double arterial arcade. Studies
this area is the site for osteotomy preparation of the lateral wall have shown vascularization of postgraft material to depend on the
sinus graft procedure.␣ intraosseous and extraosseous anastomoses, along with the blood
vessels of the Schneiderian membrane, which is supplied by the
Inferior Wall posterior superior alveolar artery and the infraorbital artery along
The inferior wall or floor of the maxillary sinus is in close relation- the lateral wall.16
ship with the apices of the maxillary molars and premolars. The There exist different factors that alter the vascularization in this
teeth usually are separated from the sinus mucosa by a thin layer area. With increasing age, the number and size of blood vessels
of bone; however, on occasion, teeth may perforate the floor of the in the maxilla decrease. As bone resorption increases, the cortical
sinus and be in direct contact with the sinus lining. Studies have bone becomes thin, resulting in less vascularization. As the lateral
shown that the first molar has the most common dehiscent tooth wall becomes thinner, the blood supply to the lateral wall and lat-
root, occurring up to approximately 30% to 40% of the time.14 eral aspect of the bone graft comes primarily from the periosteum,
In dentate patients the sinus floor is approximately at the level of resulting in a compromised vascularization to the region.
Maxillary artery
Infraorbital
artery
Posterior
superior artery
Intraosseous
branch of PSA
A
C D
• Fig. 37.7 Blood supply of the maxillary sinus. (A) Extraosseous and intraosseous anastomosis, which
is made up of the infraorbital and posterior superior artery. (B) Cross-sectional cone beam computerized
tomography image depicting intraosseous anastomosis (arrow). (C) Intraosseous notch (arrow) containing
the intraosseous anastomosis, which comprises the posterior superior artery and infraorbital artery. (D) Pos-
terior lateral nasal artery location in the medial wall of the maxillary sinus. PSA, Posterior Superior Artery.
Extraosseous Anastomosis an edentulous maxilla with posterior vertical bone loss, the endos-
The extraosseous anastomosis is found in approximately 44% of seous anastomosis may be 5 to 10 mm from the edentulous ridge.
the population and is usually in close approximation to the peri- The endosseous artery has been shown to be observed on CBCT
osteum of the lateral wall. scans in approximately one-half of the patients requiring a sinus
The extraosseous anastomosis is superior to the endosseous graft.17 However, anatomic cadaver studies have shown the preva-
unit, which is approximately 15 to 20 mm from the dentate alveo- lence to be 100%.17 In 82% of cases, the most common anatomic
lar crest. To minimize vascular trauma to the extraosseous anasto- location was observed between the canine and second premolar
mosis, surgical and anatomic considerations should be addressed. region.18 However, with a long-term edentulous patient with a thin
Ideally, vertical incisions should be made as short as possible to lateral wall, the artery may be atrophied and almost nonexistent.
decrease the possibility of blood vessel damage. It is crucial to gain Surgical, radiographic, and anatomic considerations should be
adequate access to the lateral aspect of the maxilla, and the perios- addressed to minimize trauma to these blood vessels. The CBCT
teum should be reflected full thickness with great care. Haphazard radiographic identification is extremely important in identifying
reflection may lead to severing or damage to the anastomosis, with these blood vessels before surgery so preparation may be made.
resultant postoperative edema. Severing of the extraosseous anas- Radiographically, smaller anastomoses will not be seen if the pixel
tomosis may result in significant increased bleeding during the size (∼1.0 mm) is less than one-half the size of the anastomosis
surgical procedure. This intraoperative complication may give rise vessel. Studies have shown that the use of a 0.3 or 0.4 CBCT pixel
to impaired visibility for the clinician, along with increased sur- size for radiographic evaluation will most likely show the smaller
gery duration. Additionally, postoperative complications such as anastomoses.19
pain, edema, and ecchymosis may result from the severing of these Studies have shown that in 20% of lateral wall osteoto-
blood vessels. If trauma to these vessels occurs, direct pressure or mies significant bleeding complications may occur,20 mainly
the use of electrocautery may be used. However, electrocautery may because the anastomosis is greater than 1.0 mm in diameter.
potentially cause membrane damage or necrosis. If severe bleed- It has been shown that vessels larger than 1.0 mm are more
ing occurs, curved Kelly hemostats are used to clamp the bleeding problematic and associated with significant bleeding, whereas
vessel, followed by ligature placement. A slowly resorbable suture smaller vessels (<1.0 mm) are usually insignificant and easily
with high tensile strength such as Vicryl is recommended.␣ managed (Fig. 37.7; Box 37.1).
In most cases, bleeding is a minor complication and of short
Intraosseous Anastomosis duration; however, in some instances it may be significant and
The intraosseous anastomosis is found within the lateral wall of the difficult to manage. To control bleeding, there are many possible
sinus, which supplies the lateral wall and the sinus membrane. In treatments: (1) the patient should be repositioned into an upright
• BOX 37.1 Arterial Supply to Posterior Maxilla The epithelial lining of the maxillary sinus is much thinner
(Double Arterial Arcade) and contains fewer blood vessels than the nasal epithelium. This
accounts for the membrane’s pale color and bluish hue. Five pri-
• Endosseous anastomosis (within the lateral wall of sinus) mary cell types exist in this tissue: (1) ciliated columnar epithelial
-supplies lateral wall and sinus membrane cells, (2) nonciliated columnar cells, (3) basal cells, (4) goblet cells,
1. Posterior superior alveolar artery and (5) seromucinous cells. The ciliated cells contain approxi-
2. Infraorbital artery mately 50 to 200 cilia per cell. In a healthy maxillary sinus the
• Extraosseous anastomosis (within periosteum) cilia cells assist in clearing mucus from the sinus and into the naso-
-supplies sinus mucous membranes pharynx. The nonciliated cells compose the apical aspect of the
1. Posterior superior alveolar artery
2. Infraorbital artery
membrane, contain microvilli, and serve to increase surface area.
• Posterior lateral nasal artery (medial and posterior wall) These cells have been theorized to facilitate humidification and
-supplies medial and posterior walls of maxillary sinus warming of inspired air. The basal cell’s function is similar to that
of a stem cell that can differentiate as needed. The goblet cells in
the maxillary sinus produce glycoproteins that are responsible for
the viscosity and elasticity of the mucus produced. The maxillary
position and pressure applied with a surgical gauze; (2) electrocau- sinus contains the highest concentration of goblet cells compared
tery may be used, although this may lead to membrane necrosis and with the other paranasal sinuses. The maxillary sinus membrane
perforation, with possible migration of graft material; (3) a second also exhibits few elastic fibers attached to the bone (no tenacious
window may be made proximal to the bleeding source to gain access attachment is usually present), which simplifies elevation of this
to the bleeding vessel, especially if location cannot be obtained from tissue from the bone during grafting procedures. The thickness
the original window; and (4) cutting the bone and vessel with a of the sinus mucosa in health varies, but it is generally 0.3 to 0.8
high-speed diamond with no irrigation (which cauterizes the vessel).␣ mm.22 In smokers, it varies from very thin and almost nonexistent
to very thick, with a squamous type of epithelium.
Posterior Lateral Nasal Artery Radiographically, normal, healthy paranasal sinuses reveal a
A posterior lateral nasal artery (branch of the sphenopalatine completely radiolucent (dark) maxillary sinus. Any radiopaque
artery that also rises from the maxillary artery) supplies the medial (whitish) area within the sinus cavity is abnormal, and a patho-
aspect of the sinus cavity. The medial and posterior walls of the logic condition should be suspected. The normal sinus membrane
maxillary sinus mucosa receive their blood supply from the poste- is radiographically invisible, whereas any inflammation or thick-
rior lateral nasal artery. ening of this structure will be radiopaque. The density of the dis-
During sinus graft surgery the clinician may be in close eased tissue or fluid accumulation will be proportional to varying
approximation to this artery when elevating the membrane off the degrees of gray values.
medial wall. Care should be exercised to minimize trauma to this Maintaining the integrity of the sinus membrane is crucial in
area because aggressive reflection of the membrane may result in decreasing postoperative complications, including loss of graft
trauma to the blood vessel or perforation into the nasal cavity. material and the possibility of infection.
Trauma to this artery may cause significant bleeding in the Many factors may alter the physiology of the sinus mucosa,
sinus proper and also within the nasal cavity. Because the medial such as viruses, bacteria, and foreign bodies (implants). Care
sinus wall is very thin (usually one-half the thickness of the lateral should be taken to minimize membrane perforations during sur-
wall), aggressive membrane reflection may result in trauma, lead- gery. If perforations occur, appropriate repair treatment protocols
ing to bleeding issues.␣ should be followed.␣
Sphenopalatine/Infraorbital Arteries
Maxillary Sinus Mucociliary Clearance
The sphenopalatine artery is also a branch of the maxillary artery and
enters the nasal cavity through the sphenopalatine foramen, which is Normal mucociliary flow is crucial to maintaining the healthy
near the posterior portion of the superior meatus of the nose. physiology of the maxillary sinus. In a healthy sinus an adequate
As the sphenopalatine artery exits the foramen, it branches into system of mucus production, clearance, and drainage is maintained.
the posterior lateral nasal artery and the posterior septal artery.21 The key to normal sinus physiology is the proper function of the
Additionally, the infraorbital artery enters the maxillary sinus via the cilia, which is the main component of the mucociliary transport
infraorbital fissure in the roof of the sinus and ascends cranially into system. The cilia move contaminants toward the natural ostium and
the orbital cavity. Because of the anatomic locations of these blood then to the nasopharynx. The cilia of the columnar epithelium beat
vessels, it is rarely a concern with respect to sinus graft surgery. toward the ostium at approximately 15 cycles per minute, with a
The sphenopalatine and infraorbital blood vessels are usually stiff stroke through the serous layer, reaching into the mucoid layer.
not problematic for bleeding complications during lateral-approach They recover with a limp reverse stroke within the serous layer. This
sinus elevation surgery because of their anatomic locations. How- mechanism slowly propels the mucoid layer toward the ostium at a
ever, incorrect incision locations and aggressive reflection may rate of 9 mm per minute and into the middle meatus of the nose.22
damage the blood vessels. If bleeding does occur, it is usually easily In health, mucoid fluid is transported toward the ostium of
controlled with pressure and local hemostatic agents.␣ the maxillary sinus and drains into the nasal cavity, eliminating
inhaled small particles and microorganisms. This mucociliary
transport system is an active transport system that relies heavily
Maxillary Sinus Mucosa on oxygen. The amount of oxygen absorbed from the blood is not
The epithelial lining of the maxillary sinus is a continuation of the adequate to maintain this drainage system; additional oxygen has
nasal mucosa and is classified as a pseudostratified, ciliated colum- to be absorbed from the air in the sinus. This is why the patency of
nar epithelium, which is also called the respiratory epithelium. the ostium is crucial in maintaining the normal transport system.
Organisms trapped on mucus Mucus movement

Ostium
Outer layer
of mucus
Cilia Periciliary
serous fluid
Pseudostratified
Goblet cell
columnar
Basal cell epithelial cell
Air
Gel phase Mucous gland
Propulsion
Aqueous phase
Recovery
A Epithelium B
C D
• Fig. 37.8 Maxillary sinus membrane (Schneiderian Membrane). (A) The pseudostratified columnar epi-
thelium cells have 50 to 200 cilia per cell that beat toward the ostium to help clear 1 L of mucus from
goblet and mucous glands each day from the sinus. In health, the mucous has two layers: a bottom serous
layer and top mucoid layer. The cilia beat with a stiff stroke in the mucoid layer toward the ostium and a
relaxed recovery stroke within the serous layer. (B) Cross-sectional image depicting an inflamed Schnei-
derian membrane. If the sinus membrane is of normal thickness, it will not be visible on a radiograph. (C)
Clinical image depicting the thinness of the lateral wall and show through (dark blue) of the Schneiderian
membrane. (D) Bluish hue of the membrane after lateral wall window preparation.
Various elements may decrease the number of cilia and slow the patency of the maxillary ostium and the ostiomeatal com-
their beating efficiency. Viral infections, pollution, allergic reac- plex in the postoperative period to minimize the possibility of
tions, and certain medications may affect the cilia in this way. complications.
Genetic disorders (e.g., dyskinetic cilia syndrome) and factors The physiologic mucociliary transport system may be com-
such as long-standing dehydration, anticholinergic medications promised by abnormalities in the cilia, which include a decrease
and antihistamines, cigarette smoke, and chemical toxins also can in overall ciliary number and poor coordination of their move-
affect ciliary action23 (Fig. 37.8). ment. This altered physiology may result in an increased mor-
An alteration in the sinus ostium patency or the quality bidity of implant placement or bone graft healing. Therefore it
of secretions can lead to disruption in ciliary action, which is crucial that the mucociliary drainage mechanism be main-
may result in rhinosinusitis. For clearance to be maintained, tained throughout the postoperative treatment period. This
adequate ventilation is necessary. Ventilation and drainage are is most likely accomplished with good surgical technique,
dependent on the ostiomeatal unit, which is the main sinus evaluation and treatment of prior drainage issues, and strict
opening. Ciliary movements of ciliated epithelial cells dictate adherence to the use of pharmacologic agents (e.g., antibiotics,
clearance of the maxillary sinus. It is important to maintain corticosteroids).␣
A B
C D
• Fig. 37.9 Subantral augmentation classification. (A) SA-1: implant placement that does not extend into
the maxillary sinus proper. (B) SA-2: implant placement that elevates the sinus membrane approximately
1 to 2 mm without bone grafting. (C) SA-3: implant placement and simultaneous bone grafting by either a
crestal or lateral-wall approach. (D) SA-4: lateral wall sinus augmentation with delayed implant placement.
Maxillary Sinus Bacterial Flora infections in the maxillary sinus. A strict aseptic technique should be
There is much debate on the bacterial flora of the maxillary sinus. adhered to during any surgical procedures that invade the maxillary
Maxillary sinuses have been considered to be generally sterile in sinus proper. This will minimize the possibility of bacterial coloniza-
health; however, bacteria can colonize within the sinus without tion within the graft, which may lead to increased morbidity. The
producing symptoms. In theory, the mechanism by which a ster- type of bacteria inhabiting the sinus is very important because it
ile environment is maintained includes the mucociliary clearance dictates what antibiotic is prescribed preoperatively, postoperatively,
system, immune system, and the production of nitric oxide within and therapeutically in case of infection. The most common bacteria
the sinus cavity. In recent endoscopic studies, normal sinuses were present in the sinus must be susceptible to the specific antibiotic to
shown to be nonsterile, with 62.3% exhibiting bacterial coloniza- prevent infection and decrease the morbidity of the graft. The antibi-
tion. The most common bacteria cultured were Streptococcus viri- otic selected should not be the clinician’s “favorite”; instead it should
dans, Staphylococcus epidermidis, and S. pneumoniae.24 The culture be the most ideal antibiotic, which is specific for the involved bac-
findings for secretions in acute maxillary sinusitis yielded high teria. Ideally, Augmentin (875/125 mg) has been shown to be most
numbers of leukocytes, S. pneumoniae, or S. pyogenes, with Hae- effective antibiotic for bacterial infections in the maxillary sinus.␣
mophilus influenzae being recovered from the purulent exudates
with lower numbers of staphylococci. Other reports have indicated Maxillary Sinus: Clinical Assessment
the bacterial flora of the maxillary sinus consists of nonhemolytic
and alpha hemolytic streptococci, as well as Neisseria spp. Addi- To establish adequate osseous morphology for the placement of
tional microorganisms identifiable in various quantities belong to endosteal implants in the resorbed maxillary posterior region,
staphylococci, Haemophilus spp., pneumococci, Mycoplasma spp., various grafting techniques have been developed to increase bone
and Bacteroides spp. This is important to note because the sinus volume. In 1987 Misch25 developed four different categories for
graft procedure often violates the sinus mucosa, and bacteria may the treatment of the posterior maxilla (termed subantral [SA]) as
contaminate the graft site, leading to postoperative complications. SA-1 through SA-4 and was later modified and updated by Resnik
The implant clinician must understand the importance of reduc- in 2017 (Fig. 37.9). The SA-1 posterior maxilla allows implant
ing the bacterial count and possible microorganisms that may initiate placement inferior to the sinus cavity, without penetration into
TABLE Preoperative and Postoperative Physical the superior wall of the sinus for proptosis, pupillary level, lack of eye
37.1 Examination 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
Site Signs of Infection waxed paper. The mucus should be clear and thin in nature. A yellow
Inferior wall Bulge in hard palate, ill-fitting den- or greenish tint or thickened discharge indicates infection. Infected
ture, loose teeth, hypesthesia or maxillary sinuses typically are symptomatic, which can exhibit exudate
nonvital teeth, bleeding, palatal in the middle meatus and may be inspected with a nasal speculum
erosion, oroantral fistula and headlight (rhinoscopy) through the nares. The methods of exami-
nation of the infected maxillary sinus may include transillumination,
Medial wall Nasal obstruction, nasal discharge,
epistaxis, cacosmia, visible mass
nasoendoscopy, bacteriology, cytology, fiberoptic antroscopy, and radi-
in nostril ography CBCT, or magnetic resonance imaging [MRI]).␣
Anterior wall Swelling, pain, skin changes
Maxillary Sinus Radiographic Evaluation
Posterior wall Midface pain, hypesthesia of one-
half of face, loss of function of Various radiographic techniques have been used in implant dentistry
lower cranial nerves to evaluate the maxillary posterior region. In the early days of oral
implantology, evaluation of this area was limited to 2-dimensional
Superior wall Diplopia (double vision), proptosis
(2D) radiographs. However, these types of radiographs have inher-
(eye bulging out), chemosis, pain
or hypesthesia, decreased visual ent disadvantages that are affected by magnification and distortion,
acuity which leads to errors in diagnosis and treatment planning. Currently,
this anatomic area is evaluated mainly by the use of 3D radiographic
techniques (CBCT) or medical CT because they have become more
accurate and efficient, with a significant reduced radiation.
the sinus proper. Because the sinus floor is not altered, a preexist-
ing sinus pathology or anatomic variant will be less likely to affect Cone Beam Computerized Tomography
the healing process. As such, if the patient has a preexisting maxil-
lary sinus condition or develops a sinus infection after implant CBCT surveys have allowed the implant clinician to evaluate
placement, then implants are not at risk of becoming contami- anatomic structures, anatomic variants, and pathologies more
nated. However, the SA-2 to SA-4 surgical procedures do alter the accurately. Many software programs are available that allow
sinus membrane and sinus floor. With these treatment options, combining 3D images with computer software and allow an
a thorough preoperative evaluation is completed to rule out any accurate assessment of the maxillary sinus. Because visualization
existing pathologic condition in the maxillary sinus. In this way, of the maxillary sinus and surrounding structures are crucial for
the risk of possible mucus or bacteria contaminating the graft and the proper diagnosis and treatment planning, it is highly sug-
creating a bacterial smear layer on the implant is reduced. There- gested the implant clinician utilize CBCT anytime procedures
fore the possibility of impaired bone formation during healing is involve the maxillary sinus.
reduced. In addition, because of the proximity of the maxillary Presently, no radiographic modality provides more information
sinus to numerous vital structures, postoperative complications about the paranasal sinuses than CBCT. This type of radiography
can be very severe and even life-threatening. provides much more detailed information about the anatomy and
Pathologic conditions associated with the paranasal sinuses are pathologic condition of the sinuses compared with 2D radiog-
common ailments and afflict more than 31 million people each raphy. Studies have concluded that CBCT is the best option for
year. Approximately 16 million people will seek medical assistance viewing the surrounding osseous structures and pathologic condi-
related to sinusitis; yet sinusitis is one of the most commonly tion in the maxillary sinuses.27,28
overlooked diseases in clinical practice. Potential infection in the The maxillary sinus can be evaluated with most CBCT images,
region of the sinuses may result in severe complications. Infections including reformatted axial, panoramic, cross-sectional, sagittal, and
in this area have been reported to result in sinusitis, orbital celluli- 3D images. Most physicians use the coronal radiographs to evaluate the
tis, meningitis, osteomyelitis, and cavernous sinus thrombosis. In paranasal sinuses. The implant clinician must have a clear understand-
fact, paranasal sinus infection accounts for approximately 5% to ing of the CBCT radiographic anatomy and the pathologic conditions
10% of all brain abscesses reported each year.26 associated with the posterior maxilla and maxillary sinus regions.␣
A physical examination of the maxillary sinus evaluates the
middle third of the face for the presence of asymmetry, deformity, Normal Anatomy
swelling, erythema, ecchymosis, hematoma, or facial tenderness
(Table 37.1). Nasal congestion or obstruction, prevalent nasal dis- Maxillary Sinus Membrane (Schneiderian
charge, epistaxis (bleeding from the nose), anosmia (the loss of the Membrane)
sense of smell), and/or halitosis (bad breath) are noted.
The clinical examination for maxillary rhinosinusitis concerns the A CBCT scan of normal, healthy paranasal sinuses reveals a com-
regions surrounding the maxillary antrum. The examination is con- pletely radiolucent (dark) maxillary sinus. Any radiopaque (whit-
ducted to assess each wall surrounding the maxillary sinus separately. ish) area within the sinus cavity is abnormal, and a pathologic
The infraorbital foramen on the facial wall of the antrum is palpated condition should be suspected. The normal sinus membrane is
through the soft tissue of the cheeks or intraorally to determine whether radiographically invisible, whereas any inflammation or thicken-
tenderness or discomfort is present. The intraoral examination assesses ing of this structure will be radiopaque. The density of the dis-
the floor of the antrum by alveolar ulceration, expansion, tenderness, eased tissue or fluid accumulation will be proportional to varying
paresthesia, and oroantral fistulae. The eyes are examined to evaluate degrees of gray values.␣
Frontal Ethmoid Osteomeatal

sinus sinus complex
Eye
Ethmoid
bulla
Hiatus Uncinate
Semilunaris process
Infundibulum
Middle
Ostium
meatus
Maxillary Maxillary
sinus sinus
A
Inferior turbinate Middle turbinate Nasal septum Inferior meatus
Deflected
ucinate
process
Concha
Non-patent bullosa
ostium
Big nose
Polyps variant
Mucous Deviated
retention cyst septum
B Paradoxical middle turbinate
• Fig. 37.10 (A) Normal paranasal anatomy. (B) Paranasal pathology and anatomic variants.
Ostiomeatal Complex meatus and warms, moistens, and cleans the air that is respirated
into the lungs.
The ostiomeatal unit is composed of the maxillary ostium, eth- The nasal septum is the bony partition that creates a barrier
moid infundibulum, anterior ethmoid cells, and the frontal recess. between the right and left sides of the nasal cavity. Obstructions
The main drainage avenue of the maxillary sinus is through the within any aspect of the nasal system predispose the area to patho-
ostium. The maxillary ostium is bounded superiorly by the eth- logic conditions (Fig. 37.10).␣
moid 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 Maxillary Sinus: Anatomical Variants
continues through the ostium into the infundibulum, which is a
narrow passageway leading into the middle meatus. The middle Numerous anatomic variants arise that can predispose a patient
meatus is the radiolucent space bounded by the middle and infe- to postsurgical complications. When these conditions are noted,
rior turbinates.␣ a pharmacologic protocol may need to be altered and/or implants
may be placed after the sinus graft has matured, rather than pre-
Nasal Cavity disposing them to an increased risk by inserting them at the same
time as the sinus graft. As stated previously, patency of the ostium
Within the nasal cavity, three nasal turbinates or conchae (supe- is paramount to maintain drainage. Preexisting skeletal and bony
rior, middle, and inferior) exist and are small downward projec- abnormalities of the ostiomeatal complex may compromise the
tions of bone. Between the turbinates is a space or recess termed patency of the maxillary ostium, thereby, predisposing patients to
a meatus. The respiratory epithelium covers the turbinates and maxillary rhinosinusitis.
MT
IT
• Fig. 37.11 Nasal septum deviation is a common variant. Extreme cases

may obstruct the ostiomeatal unit and increase the risk of sinusitis after a
sinus graft.
Nasal Septum Deviation

A nasal septum deviation is a very common anatomic variant, occur-
ring in as much as 70% of the population older than 14 years. This A
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 (Fig. 37.11).29
Timmenga and colleagues30 evaluated 45 patients who received
85 sinus grafts with endoscopy postsurgery. 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, consideration should be given
to not place the implant at the same time as the sinus graft, and
the recommended preoperative and postoperative pharmacologic
protocol is especially warranted.␣
Middle Turbinate Variants

The middle turbinate plays a significant role in proper drainage of B
the maxillary sinus. A concha bullosa is a pneumatization within
• Fig. 37.12 (A) Nasal cavity anatomy: inferior turbinate (IT), middle turbi-
the middle turbinate and may occlude the ostiomeatal complex, nate (MT), inferior meatus (red arrow), middle meatus (yellow arrow). Note
compromising adequate drainage. This variant is seen in approxi- the paradoxical middle turbinate. (B) Coronal image depicting concha bul-
mately 4% to 15% of the population (Fig. 37.12).31 Another vari- losa (arrow) and deviated septum.
ant in this anatomic structure is a paradoxically curved middle
turbinate, which presents a concavity toward the septum, decreas-
ing the size of the meatus. This also predisposes the patient to a the posterior fontanelles (PF). This may be found in approximately
higher incidence of sinus disease.␣ 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
Uncinate Process Variants infected secretions from the primary meatus back into the sinus cav-
The uncinate process is a projection of the ethmoid bone which is ity. On occasion, these secondary ostia may be encountered during
located in the wall of the lateral nasal cavity. This bony process is an the elevation of the medial wall of the antrum before placement of
important anatomic structure in the patency of the ostium. A deflected the sinus graft. When observed, a piece of collagen is placed over the
uncinate process (either laterally or medially) can narrow the ethmoid site to prevent graft material from entering the nasal cavity.␣
infundibulum, affecting the ostiomeatal complex. Perforations may
also be present within the uncinate process, leading to communication Maxillary Hypoplasia
between the nasal cavity and ethmoid infundibulum. In addition, the
uncinate process may be pneumatized. Although this is rare, it may Hypoplasia of the maxillary sinus may be a direct result from
compromise adequate clearance and drainage of the maxillary sinus.␣ trauma, infection, surgical intervention, or irradiation to the max-
illa during the development of the maxillary bone. These condi-
tions interrupt the maxillary growth center, producing a smaller
Supplemental Ostia than normal maxilla. A malformed and positioned uncinate
A supplemental ostium or secondary ostia may occur between the process is associated with this disorder, leading to chronic sinus
maxillary sinus and the middle meatus, which is often found in drainage problems. Most often, these patients have adequate bone
Maxillary Sinus Pathology

A pre-existing, pathologic, maxillary sinus condition may be a rela-
tive or absolute contraindication for many procedures that will 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. There-
fore pathologic conditions, either preoperative or postoperative, of a
maxillary sinus should be evaluated, diagnosed, and treated.
Pathologic conditions of the maxillary sinus may be divided
into four categories: (1) inflammatory lesions, (2) cystic lesions,
(3) neoplasms, and (4) antroliths and foreign bodies. Studies have
shown that 20% to 45% of the asymptomatic population has a sub-
clinical pathologic condition in the maxillary sinus. The author has
evaluated approximately 2000 prospective candidates for maxillary
sinus augmentation procedures at the Misch International Implant
Institute for signs of pathology. The results concluded 38.7% of
asymptomatic patients had maxillary sinus pathologic conditions
on CBCT scan evaluation. Manji and colleagues evaluated 275
• Fig. 37.13 Maxillary hypoplasia. Coronal cone beam computerized patients and concluded that 45.1% were classified as exhibiting
tomographic view of an abnormally small sized maxillary sinus sinus pathology (i.e., 56.5% had mucosal thickening (≥5 mm),
28.2% with polypoidal thickening, 8.9% partial opacification and/
or air/fluid level, and 6.5% complete opacification).32 Because of
this increased incidence, it is highly recommended that a thorough
radiographic evaluation be completed on all prospective sinus eleva-
tion patients.
Inflammatory Disease
Inflammatory conditions can affect the maxillary sinus from
odontogenic and nonodontogenic causes.
Odontogenic Rhinosinusitis (Periapical Mucositis)

Odontogenic sinusitis describes a type of sinus disease in which
radiographic, microbiologic, and/or clinical evidence indicates it is of
a dental origin (i.e., from a tooth). The close proximity of the roots
of the maxillary posterior teeth to the floor of the sinus suggest any
• Fig. 37.14 Inferior meatus pneumatization (big nose variant). Cone beam
inflammatory changes in the periodontium or surrounding alveolar
computerized tomographic panoramic image depicting the abnormally
large nasal cavity extending into the molar area. bone may result in pathologic conditions in the maxillary sinus.
Etiology. Odontogenic sinusitis is usually the result of an
infected tooth (e.g., periapical abscess, cyst, granuloma, periodontal
disease) that causes an expansile lesion within the floor of the sinus.
height for endosteal implant placement, and a sinus graft is not Periapical inflammation has been shown to be capable of affect-
required to gain vertical height (Fig. 37.13) ing the sinus mucosa, with and without perforation of the cortical
bone of the sinus floor. Infection and inflammatory mediators are
Inferior Turbinate and Meatus Pneumatization capable of spreading directly or via bone marrow, blood vessels,
(Big-Nose Variant) and lymphatics to the maxillary sinus, causing an inflammatory
Misch had observed, on rare occasion, that the inferior third of response.33 Additional etiologic factors include sinus perforations
the nasal cavity pneumatizes within the maxilla and resides over during extractions and foreign bodies (e.g., gutta-percha, root tips,
the alveolar residual ridge. An evaluation of 550 computerized amalgam). Odontogenic rhinosinusitis is often polymicrobial, with
tomography (CT) scans of complete or partially edentulous maxil- anaerobic streptococci, Bacteroides spp., Proteus spp., and coliform
lae found this condition in 18 patients (3% incidence). When the bacilli involved. Studies have shown 10% to 40% of all rhinosinus-
patient has this condition, the maxillary sinus is lateral to the eden- itis sinusitis cases may have an underlying dental pathology.34,35␣
tulous ridge. When inadequate bone height is present below this Radiographic Appearance. The radiographic evaluation of
structure, a sinus graft does not increase available bone height for an patients with odontogenic sinusitis will most commonly dem-
implant. This condition is difficult to observe on a two-dimensional onstrate a unilateral maxillary sinusitis. A unilateral maxillary
panoramic radiograph. If unaware, then the implant can be placed odontogenic sinusitis is often overlooked on CBCT scans because
into the nasal cavity above the residual ridge and even penetrate the they are frequently asymptomatic. Involvement of the ostiome-
inferior turbinate. A sinus graft is contraindicated with this patient atal complex may result in extension to adjacent paranasal sinuses
condition because the sinus is lateral to the position of the implants. (e.g., ethmoid, frontal, sphenoid), ranging from 27% to 60%
Instead, in most cases an onlay graft is required to increase bone among patients with odontogenic sinusitis.36 Odontogenic sinus-
height (Fig. 37.14).␣ itis has been shown to exhibit bilateral involvement in 20% of
• Fig. 37.15 Odontogenic rhinosinusitis. Cone beam computerized tomo-

graphic panoramic view showing molar roots extending into the maxillary
sinus, resulting in inflammation of the sinus membrane. Note the com-
• Fig. 37.16 Mild mucosal thickening. Three-dimensional axial view show-
munication between the maxillary molar roots and the maxillary sinuses. ing bilateral mucosal thickening (gray area surrounding the bony walls of
the maxillary sinus).
patients. In some cases, a slight thickening of the sinus membrane
may be present adjacent to the offending tooth.37 Usually the
radiographic appearance will be a radiopaque band that follows Radiographic Appearance. On a CBCT image, usually thick-
the contours of the sinus floor.␣ ened mucosa will appear as a radiopaque widened membrane.
Differential Diagnosis. Odontogenic sinusitis may be confused Thickened mucosa can easily be seen when evaluating axial images.␣
with acute rhinosinusitis sinusitis; however, acute rhinosinusitis is Treatment. Usually no treatment is necessary because mild
almost always symptomatic. Mild mucosal thickening from a non- mucosal thickening is asymptomatic. Studies have shown that
odontogenic origin (e.g., smoking, allergy) may also show similar slight mucosal thickening allows for sinus grafting procedures to
radiographic signs. However, the nonodontogenic origin may be be completed with a decreased incidence of membrane perfora-
confirmed from lack of radiographic evidence of a diseased or pain- tion (Fig. 37.16).␣
ful tooth.␣
Treatment. Before any type of sinus augmentation or implant Acute Rhinosinusitis
placement into the sinus, the tooth or teeth involved should be A nonodontogenic pathologic condition may also result in inflam-
treated periodontally, endodontically, or extracted. After intraoral mation in the form of sinusitis. The most common type of sinus-
soft tissue healing and resolution of the pathologic condition (i.e., itis is acute rhinosinusitis (i.e., sinusitis symptoms of less than
a minimum of 6 weeks), the bone graft and/or implant may be 3 months). The signs and symptoms of acute rhinosinusitis are
performed with minimal morbidity. The removal of unhealthy rather nonspecific, making it difficult to differentiate from the
teeth decreases sinus membrane thickening, but most of the time common cold, influenza type of symptoms, and allergic rhinitis.
it does not completely resolve it. In addition, epithelial metaplasia However, the most common symptoms include purulent nasal
with the ciliated mucosa changing to simple cuboidal and strati- discharge, facial pain and tenderness, nasal congestion, and pos-
fied squamous keratinized tissue may result. Therefore, depend- sible fever.
ing on the severity, in some cases the mucosal thickness may Acute maxillary rhinosinusitis results in 22 to 25 million
remain because of the change in epithelia structure and metaplasia patient visits to a physician in the United States each year, with
changes6 (Fig. 37.15).␣ a direct or indirect cost of $6 billion. Although four paranasal
sinuses exist in the skull, the most common involved in rhinosi-
Mild Mucosal Thickening (Nonodontogenic) nusitis are the maxillary and frontal sinuses.45
Sinus membrane thickening has been shown to be present in Etiology. An inflammatory process that extends from the
approximately 46.7% of patients, with equal distribution between nasal cavity after a viral upper respiratory infection often causes
healthy and unhealthy natural teeth.38 The most common area for acute maxillary sinusitis. Microbiological cultures have shown the
the mucosal thickening has been shown to be in the midsagittal most common pathogens causing acute rhinosinusitis are S. pneu-
sinus region, which is adjacent to the first and second molars. In moniae, H. influenzae, and Moraxella catarrhalis. These pathogens
the literature, it is accepted that mucosal thickening greater than 2 include approximately 20% to 27% β-lactamase–resistant bacte-
mm is considered a pathologic sinus membrane.39-42 ria. S. aureus has also been cited, with the microbiology of acute
Etiology. Local odontogenic issues, such as periapical pathol- rhinosinusitis. However, this pathogen is usually only seen in nos-
ogy, periodontal disease, and the health of the adjacent dentition, ocomial (hospital-induced) sinusitis and is unlikely to be seen in
have been shown to be the etiologic factor in the inflammatory an elective sinus graft patient.
response to the sinus membrane in approximately 50% of cases.43 The most important factor in the pathogenesis of acute rhinosi-
However, nonodontogenic factors such as smoking,44 allergies, nusitis is the patency of the maxillary ostium.46,47 Local predispos-
sinus congestion, mold, and air pollution may aggravate the sinus ing causes of sinusitis include inflammation and edema associated
mucosa, resulting in mild thickening. Chronic inflammatory con- with a viral upper respiratory tract infection or allergic rhinitis.
ditions may result in altered bacterial flora, along with mucociliary As a consequence, mucous production within the sinus may
clearance and cilia changes.␣ be abnormal in quality or quantity, along with a compromised
A B
• Fig. 37.17Acute rhinosinusitis. (A and B) Flat radiopaque (gray) line within the maxillary sinus, which is
termed an air-fluid level and consistent with acute rhinosinusitis.
mucociliary transport. In an occluded ostium, an accumulation of Etiology. As maxillary rhinosinusitis progresses from the acute
inflammatory cells, bacteria, and mucus exists. Phagocytosis of the phase to the chronic phase, anaerobic bacteria become the predomi-
bacteria is impaired with immunoglobulin (Ig)-dependent activi- nant pathogens. The microbiology of chronic rhinosinusitis is very
ties decreased by the low concentration of IgA, IgG, and IgM difficult to determine because of the inability to acquire accurate
found in infected secretions. cultures. Studies have shown that possible bacteria include Bacte-
The oxygen tension inside the maxillary sinus has significant roides spp., anaerobic gram-positive cocci, Fusobacterium spp., and
effects on pathologic conditions. When the oxygen tension in the aerobic organisms (Streptococcus spp., Haemophilus spp., Staphylo-
sinus is altered, resultant sinusitis occurs. Growth of anaerobic and coccus spp.).49 A Mayo Clinic study showed that in 96% of patients
facultative organisms proliferate in this environment.48 Many fac- with chronic rhinosinusitis, active fungal growth was present.50␣
tors may alter the normal oxygen tension within the sinuses. A Radiographic Appearance. Chronic rhinosinusitis may
direct correlation exists between the ostium size and the oxygen appear radiographically as thickened sinus mucosa, complete
tension in the sinus. In patients with recurrent episodes of sinus- opacification of the antrum, and/or sclerotic changes in the sinus
itis, oxygen tension is often reduced, even when infection is not walls (which give the appearance of denser cortical bone in the
present. As a consequence, a history of recurrent acute rhinosinus- lateral walls).␣
itis is relevant to determine whether a bone graft or dental implant Treatment. Medical evaluation and clearance by an experi-
may be at increased risk of morbidity.␣ enced physician in sinus pathology (e.g., otolaryngologist [ENT])
Radiographic Appearance. The radiographic hallmark in is highly recommended for patients with chronic maxillary rhi-
acute rhinosinusitis is the appearance of an air-fluid level. A line of nosinusitis before any sinus grafting, because significant bacterial
demarcation will be present between the fluid and the air within resistance and fungal growth is highly probable. Fungal infections
the maxillary sinus. If the patient is radiographically positioned are often difficult to treat and control, and serious complications
supine, then the fluid will accumulate in the posterior area; if the may result in postoperative sinus graft patients. In many chronic
patient is upright during the imaging survey, the fluid will be seen rhinosinusitis patients, a sterile and nonpathologic sinus is dif-
on the floor and horizontal in nature. Additional radiographic ficult to obtain, contraindicating (absolute) sinus grafting and/or
signs include smooth, thickened mucosa of the sinus, with pos- implants.␣
sible opacification. In severe cases, the sinus cavity may fill com-
pletely with supportive exudates, which gives the appearance of a Allergic Rhinosinusitis
completely opacified sinus. With these characteristics, the terms Etiology. Allergic sinusitis is a local response within the maxil-
pyocele and empyema have been applied.␣ lary sinus caused by an irritating allergen in the upper respiratory
Treatment. Because acute rhinosinusitis is one of the most tract. Therefore allergens may be a cause of acute or chronic rhi-
common health problems today, patients having sinus grafting nosinusitis. This category of sinusitis may be the most common
procedures should be well screened for a past history and cur- form, with 15% to 56% of patients undergoing endoscopy for
rent symptoms. Even though acute rhinosinusitis is a self-limiting sinusitis showing evidence of allergy. Allergic rhinosinusitis often
disease, a symptomatic patient should be treated and cleared by leads to chronic sinusitis in 15% to 60% of patients.51 The sinus
their physician before any grafting procedures. These patients are mucosa frequently becomes irregular or lobulated, with resultant
also more prone to postoperative rhinosinusitis. As a result, a sinus polyp formation.␣
graft is performed and given a longer healing period before place- Radiographic Appearance. Polyp formation related to allergic
ment of an implant. In addition, the suggested antibiotic coverage sinusitis is usually characterized by multiple, smooth, rounded,
may be altered and extended, both before and after the sinus graft radiopaque shadows on the walls of the maxillary sinus. Most
procedure (Fig. 37.17).␣ commonly, polyps initially are located near the ostium and are
easily observed on a CBCT scan. In advanced cases, ostium occlu-
Chronic Rhinosinusitis sion, along with displacement or destruction of the sinus walls,
Chronic rhinosinusitis is a term used for a sinusitis that does not may be present with a radiographic image of a completely opaci-
resolve in 3 months and also has recurrent episodes. It is the most fied sinus.␣
common chronic disease in the United States, affecting approxi- Treatment. When patients have a history of allergic rhinosinus-
mately 37 million people. Symptoms of chronic rhinosinusitis itis, special attention must be given to a patent ostium, bacterial
are associated with periodic episodes of purulent nasal discharge, resistance, and close postoperative supervision. Polyps, if enlarged
nasal congestion, and facial pain. or too numerous, may be required to be removed before the sinus
A B
• Fig. 37.18 Allergic rhinosinusitis. (A) Bilateral polypoid inflammation consistent with allergic rhinosinusitis. (B) Polyp removal on a patient
with chronic allergic rhinosinusitis. Unfortunately the polyps have a high incidence of recurrence, and in many cases this contradicts implant
treatment.
graft. This may be performed through an anterior Caldwell-Luc

approach or by an endoscopic procedure via the maxillary ostium.
Allergic sinusitis patients often have a greater risk of complica-
tions 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 performed in the
season or seasons that have least risk to aggravate the sinus mucosa
(i.e., winter or fall). In severe cases of polyposis, any procedure
violating the sinus proper may be an absolute contraindication
(Fig. 37.18).␣
Fungal Rhinosinusitis (Eosinophilic Fungal Rhinosinusitis)

Granulomatous rhinosinusitis is a very serious (and often over- • Fig. 37.19 Fungal rhinosinusitis. Coronal cone beam computerized
looked) disorder within the maxillary sinus. Patients who exhibit tomographic image of fungal rhinosinusitis, which has the radiographic
signs of fungal rhinosinusitis may indicate an extensive history of appearance of an opacified sinus with localized highly densified areas.
antibiotic use, chronic exposure to mold or fungus in the envi-
ronment, or history of immunosuppression. Fungal rhinosinusitis thickening (less common) to complete opacification (more com-
has been categorized into five types: acute necrotizing (fulmi- mon) of the sinus. The majority of sinuses show complete opaci-
nant), chronic invasive, chronic granulomatous invasive, fungal fication with hyperdense areas.54 Extension beyond the maxillary
hall (sinus mycetoma), and allergic. The first three types are clas- sinus to other sinuses is common and expansion and erosion of a
sified as tissue-invasive and the last two are noninvasive fungal sinus wall may be present.␣
rhinosinusitis.52 Treatment. Patients with a history or current knowledge of
Etiology. Fungal infections are usually caused by aspergillosis, fungal rhinosinusitis should be referred to their physician or an
mucormycosis, or histoplasmosis. Chronic rhinosinusitis patients ENT for treatment and surgical clearance (i.e., in most cases clear-
should always be evaluated for granulomatous conditions because ance will not be given because fungal rhinosinusitis is rarely cur-
a high percentage of fungal growth exists in this patient popula- able). Treatment usually involves debridement and therapy with
tion. Of concern in these patients is eosinophils are activated that an antifungal agent, such as amphotericin B (Fig. 37.19).␣
release major basic protein (MBP) into the mucus, which attacks
and destroys the fungus. However, this may result in the mem- Cystic Lesions
brane being irritated and possibly irreversibly damaged, which
allows bacteria to proliferate. Three possible clinical signs may Cystic type lesions are a common occurrence in the maxillary
differentiate fungal rhinosinusitis from acute or chronic rhinosinus. They may vary from microscopic lesions to large, destruc-
sinusitis; however, a positive diagnosis requires mycological and tive, expansile pathologic conditions. Cystic lesions may include
histologic studies.53 pseudocysts, retention cysts, primary mucoceles, and postopera-
1. No response to antibiotic therapy tive maxillary cysts.
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
Pseudocysts (Mucous Retention Cyst)
nasal fossa and facial soft tissue␣ The most common cysts in the maxillary sinus are mucous reten-
Radiographic Appearance. Granulomatous rhinosinusitis tion cysts. After much controversy, in 1984, Gardner55 distin-
is extremely variable and may appear radiographically as mild guished these cysts into two categories: (1) pseudocysts and (2)
Fluid
B
• Fig. 37.20
Pseudocyst. (A) Diagram showing fluid accumulation underneath the membrane. (B) Radio-
graph showing the dome-shaped characteristics of a pseudocyst.
retention cysts. Pseudocysts are more common and of much or placement of the grafting material, the cyst may be perforated,
greater concern during sinus graft surgery, compared with reten- allowing fluid within the cyst to contaminate the graft. Large cysts
tion cysts. Pseudocysts recur in approximately 30% of patients of this nature should be drained and allowed to heal before or in
and are often unassociated with sinus symptoms. As a conse- conjunction with sinus elevation surgery. Most often, an ENT phy-
quence, many physicians do not treat this condition. However, sician should evaluate to determine any intervention. If a pseudo-
when their size is larger (approximately >10 mm in diameter), cyst is less than 8 mm, then less concern is needed and the fluid
pseudocysts may occlude the maxillary ostium during a sinus graft may be drained in conjunction with sinus grafting, depending on
procedure and increase the risk of postoperative infections. Stud- the surgeon’s experience in the treatment of this condition. Caution
ies have shown successful bone graft and implant placement in should be exercised to prevent membrane perforation. A strict recall
maxillary sinuses with pseudocysts.56 evaluation of this area during the follow-up period of the sinus graft
surgery is in order because reoccurrence of pseudocysts is common.␣
Etiology
A pseudocyst is caused by an accumulation of fluid beneath the peri- Retention Cysts
osteum of the sinus mucosa. This elevates the mucosa away from the
floor of the sinus, giving rise to a dome-shaped lesion. Pseudocysts Retention cysts may be located on the sinus floor, near the ostium,
have also been termed mucosal cysts, serous cysts, and nonsecreting or within antral polyps. Because they contain an epithelial lining,
cysts. Pseudocysts are not true cysts because they lack an epithelial researchers consider them to be mucous secretory cysts and “true”
lining; however, they are surrounded by fibrous connective tissue.57 cysts. Retention cysts are often microscopic in size.
The cause of the fluid is thought to result from sinus mucosa bacte-
rial toxins or from odontogenic causes (Fig. 37.20).␣ Etiology
Retention cysts result from partial blockage of seromucinous
Radiographic Appearance gland ducts located within the connective tissue underlying the
Pseudocysts are depicted radiographically as smooth, homog- sinus epithelium. As the secretions collect, they expand the duct,
enous, dome-shaped, round to ovoid, well-defined radiopaci- producing a cyst that is encompassed by respiratory or cuboidal
ties. Pseudocysts do not have a corticated (radiopaque) marginal epithelium. They may be caused by sinus infections, allergies, or
perimeter and almost always located on the floor of the sinus cav- odontogenic reasons.␣
ity. In some cases, pseudocysts may encompass the entire maxillary
sinus, making diagnosis difficult because it may be radiographi- Radiographic Appearance
cally similar to rhinosinusitis.␣ Retention cysts are usually very small and not seen clinically or
radiographically. In rare instances, they may achieve adequate size
Treatment to be seen in a CT image and may resemble the appearance of a
Pseudocysts are not a contraindication for sinus graft surgery, unless small pseudocyst.␣
their approximate size increases the possibility of occluding the
maxillary ostium. If a large pseudocyst (i.e., greater than 8 mm) is Treatment
present, then the elevation of the membrane during a sinus graft No treatment for retention cysts exist before or in conjunction
may raise the cyst to occlude the ostium. In addition, on elevation with a sinus graft and/or implant insertion.␣
Fluid
A
B
• Fig. 37.21Primary maxillary sinus mucocele. (A) Diagram showing expansive nature of a primary maxil-
lary sinus mucocele. (B) Radiograph showing the initial stage of complete opacification and later stages
including expansion of the bony plates.
Primary Maxillary Sinus Mucocele Etiology

A primary mucocele is a cystic, expansile, destructive lesion that A postoperative maxillary cyst is a direct result of trauma or past
may include painful swelling of the cheek, displacement of teeth, history of surgery within the maxillary sinus. The cyst is derived
nasal obstruction, and possible ocular symptoms.58 The primary from the antral epithelium and mucosal remnants that previ-
mucocele is more commonly found in the ethmoid sinus (45.5%) ously were entrapped within the prior surgical site. This separated
versus the maxillary sinus (18.3%).59 mucosa results in an epithelium-lined cavity in which mucin is
secreted. The antrum becomes divided by a fibrous septum in
Etiology which one part drains normally, whereas the other part is com-
The primary mucocele arises from blockage of the maxillary posed of the mucocele. It is relatively rare in the United States;
ostium by fibrous connective tissue. Because of the compromised however, it constitutes approximately 24% of all cysts in Japan.
drainage, the mucosa expands and herniates through the antral At least three reported cases exist of a postoperative maxillary cyst
walls. This mucocele is classified as a cyst because it is lined by forming after a sinus graft procedure, including one by the author
antral epithelium, which contains mucin.␣ of this chapter.63␣
Radiographic Appearance
Radiographic Appearance The cyst radiographically presents as a well-defined radiolucency
In the early stages, the primary mucocele involves the entire sinus circumscribed by sclerosis. The lesion is usually spherical in the
and appears as an opacified sinus. As the cyst enlarges, the walls early stages, with no bone destruction. As it progresses, the sinus
become thin and eventually perforate. In the late stages, destruc- wall becomes thin and eventually perforates. In later stages, it will
tion of one or more surrounding sinus walls is evident.␣ appear as two separated anatomic compartments.␣
Treatment Treatment
Surgical removal of this cyst is indicated prior to any bone aug- Surgical ciliated cysts should be enucleated before any bone aug-
mentation procedures (Fig. 37.21).␣ mentation procedures. If observed after the sinus graft, then the
cysts should be enucleated and regrafted in the site (Fig. 37.22)␣
Secondary Maxillary Sinus Mucocele Neoplasms

(Postoperative Maxillary Cyst) Etiology
A postoperative maxillary cyst of the maxillary sinus is a cystic Primary malignant tumors within the maxillary sinus are usually
lesion that usually develops secondary to a previous trauma or caused by squamous cell carcinomas or adenocarcinomas. Signs
surgical procedure in the sinus cavity. It also has been termed a and symptoms of malignant disease are related to the surround-
surgical ciliated cyst, postoperative maxillary sinus mucocele, ing sinus wall that the tumor invades and includes swelling in the
or a secondary mucocele.60-62 Secondary mucoceles occur most cheek area, pain, anesthesia or paresthesia of the infraorbital nerve
commonly in the maxillary sinus (86%) versus the ethmoid sinus (e.g., anterior wall), and visual disturbances (e.g., superior wall).
(7.1%).59 These tumors in the sinus are usually nonspecific and give a variety
Fluid
A B
C D
• Fig. 37.22 Secondary maxillary sinus mucocele. (A) Diagram showing cystic nature of a secondary
mucocele, which divides the sinus into two compartments. (B) Radiograph of blade implant with well-
defined radiolucency around the implant. (C) Blade implant removed with associated pathology. (D) Histol-
ogy revealing a secondary maxillary sinus mucocele.
of consequences, including opacified sinuses; soft tissue masses in maxillary sinus originate from a central nidus, which can be
the sinus; and sclerosis, erosion, or destruction of the walls of the endogenous or exogenous.64
sinus. Sixty percent of squamous cell carcinomas of the parana-
sal sinuses are located in the maxillary sinus, usually in the lower Etiology
one-half of the antrum. Clinical signs in the oral cavity reflect the The majority of endogenous sources are from dental origin,
expansion of the tumor and an increased mobility of the involved including retained roots, root canal sealer, fractured dental instru-
teeth. Invasion of the infratemporal fossa is also possible.1␣ ments, and dental implants. Additionally, bone spicules, blood,
and mucus have been reported to cause antroliths.65 Reports in
Radiographic Appearance the literature of exogenous sources include paper, cigarettes, snuff,
Radiographic signs of neoplasms may include various-sized radi- and glue.66 Although most antroliths are asymptomatic, they
opaque masses, complete opacification, or bony wall changes. A often are associated with sinusitis.␣
lack of a posterior wall on a panoramic radiograph should be a
sign of possible neoplasm (Fig. 37.23).␣ Radiographic Appearance
The radiographic appearance of a maxillary antrolith resembles
Treatment either the central nidus (e.g., retained root) or appears as a radi-
Any signs or symptoms of a lesion of this type should be immedi- opaque, calcified mass within the maxillary sinus (Fig. 37.24).␣
ately referred for medical consultation. Sinus graft surgery is abso-
lutely contraindicated while this condition exists.␣
Differential Diagnosis
Because the calcified antrolith is composed of calcium phosphate
(CaPO4), calcium carbonate salts, water, and organic material, it
Antroliths and Foreign Bodies will be considerably more radiopaque than an inflammatory or
Maxillary sinus antroliths are the result of complete or partial cystic lesion.67 The central nidus of the antrolith is similar to its
encrustation of a foreign body. These masses found within the usual radiographic appearance.␣
known to be associated with an increased susceptibility to aller-

gies and infections because it interferes with ciliary function and
secretory immunity of the nasorespiratory tract. In the maxillary
sinus, this may have direct effects on both immune exclusion and
suppression because IgA and IgM responses are reduced, whereas
IgE responses are increased. Smoking is believed to interfere
with 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.
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.68
There exist many clinical studies with smoking and sinus
graft procedures. Klokkevold evaluated the success rate of dental
implants placed in the posterior maxilla; it showed a 7% greater
failure rate compared with nonsmokers.69 Lindquist showed that
• Fig. 37.23 Axial contrast-enhanced computerized tomography (bone smokers can also suffer detrimental effects around successfully
window) shows almost complete radiopacification of the right maxillary integrated maxillary implants, with a significantly greater bleed-
sinus by squamous cell carcinoma. There is destruction of the walls of ing index, greater mean peri-implant pocket depth, more frequent
the sinus and an air-fluid interface in the left sinus. (From Koenig LJ, et al. peri-implant inflammation, and radiographically greater mesial
Diagnostic Imaging: Oral and Maxillofacial. 2nd ed. Philadelphia, PA: Else- and distal bone loss.70 Olson and colleagues found an association
vier; 2017.) between dental implants placed in augmented maxillary sinuses
and history of smoking.71 Widmark reported a higher failure rate
in smokers after rehabilitation of severely resorbed maxillae with
and without bone graft.72 Schwartz-Arad and colleagues evaluated
212 implants in the posterior maxilla, resulting in a 95.5% success
rate with nine failures. Of the nine failures, five were in patients
that smoked.73
In summary, smoking is not an absolute contraindication for
sinus graft procedures. However, patients should be instructed to
cease smoking before and after sinus graft procedures because of
the literature-based studies showing a higher risk of wound dehis-
cence, 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 (i.e., the time it takes for
nicotine to clear systemically) and 4 to 6 weeks after surgery. More-
• Fig. 37.24 Antroliths. Any object left in the sinus will calcify and is termed over, smokers should sign a detailed informed consent in which
an antrolith. Antroliths usually will result in mucociliary clearance issues. risks connected to smoking are clearly defined and explained.␣
Treatment
Before sinus augmentation and implant placement, the antrolith Relative and Absolute Contraindication to
should be surgically removed. If sinusitis exists, then the sinus cav- Maxillary Sinus Graft Procedures
ity should be allowed to heal completely before sinus augmen-
tation procedures. A nonsymptomatic condition may have the In general contraindications for implant surgery also apply to
antrolith removed and sinus graft performed at the same surgery, sinus graft procedures. However, additional specific and local
only if the sinus membrane is not compromised.␣ conditions may exist that increase morbidity. Several conditions
related to the maxillary sinus are a concern, but they are not neces-
sarily contraindications to the sinus graft procedure. The implant
Miscellaneous Factors That Affect the Health clinician, after evaluation of the CBCT scan and evaluation of the
maxillary sinus, will in some cases need further medical evalua-
of the Maxillary Sinus tion before proceeding with procedures that may invade the sinus
Smoking proper. There exists a wide variation in the severity of the possible
pathologic conditions that may be present in the maxillary sinus.
The use of tobacco is one of the main factors that may lead to For example, a patient may have a mild deviated septum. Because
an increased morbidity after sinus graft procedures. Smoking is it does not affect the mucociliary clearance of the maxillary sinus
• BOX 37.2 Absolute versus Relative • BOX 37.3 Medical Consultation: Otolaryngologist
Contraindications (ENT)
Relative contraindications: No referral
1. Limited anatomic/structural impairments of the sinus or nasal walls that 1. Mild mucosal thickening
are correctable (i.e., deviated septum) 2. Small cyst (<8 mm)
2. Inflammatory/infectious processes that are treatable 3. History of mild Sinusitis with no radiographic evidence of pathology
3. Foreign bodies Referral recommendation
4. Oroantral fistulas 1. Air-fluid Level
Absolute contraindications: 2. Cyst (~ >8 mm)
1. Anatomic/structural impairments of the sinus or nasal walls that are 3. Primary/secondary mucocele
noncorrectable. 4. Polyps
2. Inflammatory/infectious processes that cannot be resolved (i.e., chronic 5. Opacified sinus
rhinosinusitis) 6. Chronic sinusitis (MRSA, fungal)
3. Fungal or granulomatous diseases of the nasosinus. 7. Bony wall expansion /destruction
4. Benign/malignant neoplasms of the nasosinus. 8. Previous trauma
8. Foreign body in sinus
10. Early learning curve
ENT, Ear, nose, and throat (otolaryngologist); MRSA, methicillin-resistant Staphylococcus aureus.
and there is no associated pathology, no medical consultation
by an ENT is warranted. However, if a deviated septum is pres-
ent and severe, resulting in a nonpatent ostium, an ENT referral
would be highly recommended. Following the principles of prophylactic antibiotic administra-
A list of relative and absolute contraindications is listed in tion, the antibiotic should be effective against the bacteria most
Boxes 37.2 and 37.3.␣ likely to cause infection. The most likely contaminating organisms
after intraoral surgery are primarily streptococci, anaerobic gram-
Reduction of Sinus Graft Complications positive cocci, and anaerobic gram-negative rods. S. pneumoniae, H.
influenzae, and M. catarrhalis are the three most common patho-
Even though sinus graft procedures have high success rates, these gens found within the maxillary sinus that may lead to acute sinus
procedures tend to have a higher risk of infection than implant infections.78 S. aureus is not common with acute episodes; however,
placement surgery because the patient is predisposed to infec- it has been shown to have a significant role in causing chronic rhi-
tions originating from the oral surgical procedure (i.e., intraoral nosinusitis disease, along with anaerobic bacteria. The organisms
infection originating from the surgical site) or from the sinus associated with infection in general oral surgical procedures include
graft procedure (i.e., infection within the sinus proper). There- α-hemolytic streptococci and S. viridans.79 Therefore a pharmaco-
fore a surgical environment that includes a strict aseptic technique logic protocol should be effective against these organisms.
including intraoral and extraoral scrubbing with chlorhexidine, When evaluating various classes of antibiotic medications used
scrubbing and draping the patient, and gowning the doctor and for treatment of maxillary sinus infections, the antibiotic class
assistant should be considered in addition to sterile gloves and of choice is the β-lactam antibiotic drugs. With the wide range
sterile instruments. The risk of postoperative sinus infection is of possible routes of bacterial invasion and types of bacteria, the
generally less than 5% when these procedures and a preoperative antibiotic drug must be broad spectrum to account for all these
and postoperative pharmacologic regimen are used.73,74 possibilities. However, bacterial resistance has become a signifi-
cant problem in the treatment of these pathogens. Bacterial resis-
Prophylactic Medications tance is initiated by two common mechanisms: (1) production of
antibiotic-inactivating enzymes (S. aureus, H. influenzae, and M.
Systemic Antimicrobial Medications catarrhalis) and (2) alteration in target site (S. pneumoniae). Stud-
The risks of bacterial contamination before and after sinus graft ies have shown the following resistance (i.e., β-lactamase produc-
procedures are much different than routine implant surgical pro- tion) results80:
cedures. Therefore the pharmacologic protocol for sinus graft pro-
H.influenzae: 36.8%
cedures should be effective against the organisms in this surgical
M.catarrhalis: 98%
site. The recommended pharmacologic regimen includes a pro-
S.pneumoniae: 28.6%
phylactic antibiotic, anti-inflammatory medications, and antimi-
crobial rinses. Because of the high rate of bacterial resistance, amoxicillin (the
Compared with routine dental implant surgery, sinus augmen- drug of choice for many years) is no longer recommended for anti-
tation has a greater chance of morbidity because of the possible biotic prophylaxis for the sinus graft surgery. Instead, amoxicillin-
additional routes of infection. Bacterial invasion may originate clavulanate (Augmentin) is used because the addition of clavulanic
from different sources such as (1) intraoral surgery, (2) bone graft acid enhances amoxicillin’s activity against the β-lactamase–pro-
material, and (3) bacteria from the sinus cavity. Additionally, it ducing strains of bacteria.
has been well documented that the inclusion of foreign bodies The patient with a history of nonanaphylactic allergic reaction
(e.g., implants, autografts, allografts) increases infection rates.75,76 to penicillin may take cefuroxime axetil (Ceftin) as an alterna-
Because a greater chance of infection and morbidity exists with this tive.81 Ceftin is a second-generation cephalosporin that possesses
type of surgical procedure, a strict antibiotic protocol is of benefit. good potency, efficiency, and strong activity against resistant S.
Antibiotic medications have been shown to significantly reduce the pneumoniae and H. influenzae. If a patient has a true history of
number of sinus graft or implant failures caused by infection.77 anaphylactic reaction to penicillin, recurrent sinus infections, or
a recent history of antibiotic use, then doxycycline may be used. • BOX 37.4 Recommended Prophylactic Antibiotic
In the past, the quinolone class of antibiotics (e.g., Levaquin, Drugs for Sinus Grafting Procedures
Avelox) have been used with excellent success because they exhibit
superior activity against most types of involved bacteria. However, Systemic Antibiotic Prophylaxis
recently the Food and Drug Administration (FDA) has recom- 1. Augmentin (amoxicillin-clavulanic acid) (825 mg/125 mg), one tablet bid
mended the adverse effect of tendon damage does not warrant its starting 1 day before surgery and 5 days after surgery␣
routine use anymore.
Maximum effectiveness of prophylactic antibiotic drugs occurs Non-anaphylactic allergy to penicillin
2. Ceftin (cefuroxime axetil) (500 mg), , one tablet bid starting 1 day before
when the antibiotic is in adequate concentrations in the tissue surgery and 5 days after surgery␣
before bacterial invasion is initiated. Because the sinus mucosa has
limited blood supply when infection and inflammation is pres- Anaphylactic allergy to penicillin
ent, poor antibiotic blood levels are achieved. Therefore to combat 3. Doxycycline (100 mg), one tablet bid starting 1 day before surgery and 5
days after surgery␣
possible bacterial invasion from the sinus surgery, antibiotic medi-
cations should be administered at least 1 full day (24 hours) before Local Antibiotic in Graft
surgery and extended for approximately 5 days after surgery.␣ 1. Ancef (Cefazolin 1 gm): Dilute with 2 mL saline (500 mg/mL)
a. 0.2 mL or 100 mg: add to collagen membrane
Local Antibiotic Medications b. 0.8 mL or 400 mg: add to graft material
The antibiotic concentration within a blood clot of the sinus 2. Clindamycin 150 mg/1 mL
graft depends on the systemic blood titer. After the clot stabilizes, a. 0.2 mL or 30 mg: add to collagen membrane
further antibiotic drugs do not enter the area until revasculariza- b. 0.8 mL or 120 mg: add to graft material
tion.82 The bone graft is a dead space with minimum blood supply bid, Twice a day.
and absence of protection by the host’s cellular defense mecha-
nisms. This leaves the graft prone to infections that would nor-
mally be eliminated by either the host defenses or the antibiotic.
The osteogenic induction of autografts and allografts is greatly • BOX 37.5 Glucocorticoid Protocol
retarded when contaminated with infectious bacteria.83 To ensure
adequate antibiotic levels in an SA graft, it is recommended to add Dexamethasone (4 mg) × 6 tablets
antibiotic to the graft mixture.84,85 This local antibiotic may pro- • Two tablets (8 mg) in the morning, the day before surgery
tect the graft from early contamination and infection. Numerous • Two tablets (8 mg) in the morning of surgery
• One tablet (4 mg) in the morning, the day after surgery
studies have shown that an antibiotic added to graft material has
• One tablet (4 mg) in the morning, the second day after surgery
no deleterious effects on bone growth. Antibiotic drugs such as
penicillin, cephalosporin, and clindamycin, even in high concen-
trations, have not been found to be destructive to bone-inductive
proteins.86 is recommended to decrease postoperative edema. Glucocor-
The locally delivered antibiotic should have efficacy against ticoids have been well documented to decrease inflammation
the most likely organisms encountered. Because the incidence of of the soft tissue and minimize postoperative pain, swelling,
allergy is so high with β-lactam antibiotic drugs, the parenteral and incision line opening. In addition, the clinical manifesta-
form of cefazolin (Ancef ) is recommended. If there exists a true tions of surgery on the sinus mucosa also can be decreased by
allergy to penicillin (i.e., anaphylactic), then Cleocin may be used use of a glucocorticoid medication.89 Therefore the usual surgi-
as an alternative. Orally administered capsules and tablets should cal protocol for most implant surgeries, including sinus grafts,
not be used within the graft because they contain fillers that inter- includes a short-term dose of dexamethasone (Decadron) (Box
fere with bone regeneration. 37.5). To ensure patency of the ostium and minimize inflam-
Clinical experience indicates that less risk of infection exists mation in the sinus before surgery, steroid medications are ini-
when preoperative and postoperative antibiotic drugs are used tiated 1 full day before surgery. This medication should also be
both orally and in the graft. Because infection considerably extended 2 days postoperatively because edema peaks at 2 to 3
impairs bone formation for patients undergoing sinus graft pro- days postsurgery.␣
cedures, oral antibiotic coverage is continued for approximately 5
days after the surgery. Recommended antibiotic drugs are shown Decongestant Medications
in Box 37.4.␣ Sympathomimetic drugs that influence α-adrenergic receptors
have been used as therapeutic agents for the decongestion of
Oral Antimicrobial Rinse mucous membranes. Both systemic and topical decongestant
An additional antimicrobial medication used with respect to sinus medications are useful in reopening a blocked sinus ostium and
augmentation surgery is chlorhexidine gluconate. This category of facilitating drainage. Oxymetazoline 0.05% (Afrin or Vicks
antimicrobial rinse has been shown to successfully decrease infec- Nasal Spray) and phenylephrine 1% are useful topical deconges-
tious episodes and minimizes postoperative complications from tant medications. The vasoconstrictor action of oxymetazoline
the incision line.87 Gentle oral rinses of chlorhexidine gluconate lasts approximately 5 to 8 hours, which is preferred compared
0.12% should be used twice daily for 2 weeks after surgery or until with 1 hour for phenylephrine. However, decongestant drugs
the incision line is completely healed.88␣ have many disadvantages. Topical decongestant drugs can cause
a rebound phenomenon and the development of rhinitis medi-
Glucocorticoid Medications camentosa if used more than 3 to 4 days. The effectiveness of the
Sinus augmentation surgery usually results in increased post- topical decongestant is markedly enhanced by proper position of
operative inflammation. Therefore a pharmacologic regimen the patient’s head during administration of the drug. It should
also be noted that the pulse amplitude and blood flow in the Surgical Treatment of the Maxillary Sinus:
sinus mucosa is reduced with decongestant drugs, such as oxy- History
metazoline. This may, in turn, decrease the defense mechanism
within the tissues.90 In the early 1970s, Tatum began to augment the posterior maxilla
As a consequence of the medical and local risks of deconges- with autogenous rib bone to produce adequate vertical bone for
tant medications, the modified sinus graft pharmacologic proto- implant support.91,92 He found that onlay grafts below the exist-
col no longer recommends the prophylactic use of decongestant ing alveolar crest would decrease the posterior intradental height
medications.␣ significantly, yet very little bone for endosteal implants would be
gained. Therefore in 1974 Tatum developed a modified Caldwell-
Analgesic Medications Luc procedure for sinus augmentation (SA) grafting. The crest of
In most cases, sinus graft procedures usually require very mini- the maxilla was infractured to elevate the maxillary sinus mem-
mal postoperative analgesic coverage. If a narcotic is required, brane. Autogenous bone was then added in the area previously
any analgesic combination containing codeine, such as Tyle- occupied by the inferior third of the sinus. Endosteal implants
nol 3, is prescribed postoperatively because codeine is a potent were inserted in this grafted bone after approximately 6 months.
antitussive, and coughing may place additional pressure on Implants were then loaded with final prostheses after an additional
the sinus membrane and introduce bacteria into the graft. The 6 months.
patient is instructed to cough (if necessary) with the mouth In 1975 Tatum developed a lateral-approach surgical technique
open so excessive air pressure does not occur through the to elevate the sinus membrane and place implants simultaneously.
ostium.␣ The implant system used was a one-piece ceramic implant, and
a permucosal post was required during the healing period. Early
ceramic implants were not designed adequately for this procedure,
Cryotherapy and results with the technique were unpredictable. In 1981 Tatum
With sinus elevation procedures, postoperative inflammation in developed a submerged titanium implant for use in the posterior
the posterior maxilla is very common because of the extent of tis- maxilla and achieved predictable results.
sue reflection. Because postoperative swelling can adversely affect From 1974 to 1979, the primary graft material for sinus
the incision line, measures should be taken to minimize this con- grafts was autologous bone. In 1980 Tatum55,93 further
dition. Application of cold dressings and cold oral liquids, along expanded the application of the SA augmentation technique
with elevation of the head and limited activity for 2 to 3 days, with a lateral maxillary approach and the use of synthetic bone.
will help minimize the swelling. The applied cold dressing and The same year, Boyne and James first reported on the sinus
liquids will cause vasoconstriction of the capillary vessels, reduc- graft technique using autogenous bone for SA grafts.60 Most of
ing the flow of blood and lymph, resulting in a lower degree of the publications in the 1980s were anecdotal or based on very
swelling. Ice or cold dressings should only be used for the first 24 small sample sizes.␣
to 48 hours. After 2 to 3 days, heat may be applied to the region
to increase blood and lymph flow, which helps to clear the area
of the inflammatory consequences. This also assists in the reduc-
tion of ecchymosis that may have occurred from the bleeding Treatment Classifications for the Posterior
and tissue reflection.␣ Maxilla
In 1984, Misch61 organized a treatment approach to the posterior
Aseptic Technique maxilla based on the amount of bone below the antrum, and in
Because of the extent of tissue reflection, technique sensitivity 1986 he expanded the treatment approach to include the available
of sinus surgery, and need for asepsis, oral or conscious seda- bone width that was related to implant design. In 1987 Misch
tion is usually recommended for sinus graft procedures. After included the technique of the sinus floor elevation through the
sedation and adequate infiltration anesthesia (i.e., posterior implant osteotomy before implant placement.62 He reported on
and middle alveolar nerve, greater palatine nerve) are obtained, 170 sinus graft cases, with two complications and an uneventful
the patient is prepared for surgery. Preparation of the surgi- resolution.
cal site is important in sinus manipulation surgery to reduce In the Misch SA classification, the treatment modality is
contamination by the patient’s own normal flora. The oral cav- dependent on the available bone height between the floor of the
ity cannot become a sterile environment for surgery. However, antrum and the crest of the residual ridge in the region of the
intraoral preparation before surgery may significantly reduce ideal implant locations. The SA protocol also suggested a surgi-
the bacterial count in the mouth. Studies reveal a significant cal approach, bone graft material, and a time table for healing
reduction in bacteremia during extractions and implant sur- before prosthetic reconstruction. In 1995 Misch94 modified his
gery complications after preparation with antiseptic mouth 1987 classifications to include the lateral dimension of the sinus
rinse.89,90 cavity; this dimension was used to modify the healing period pro-
Iodophor compounds (Betadine) are a most effective anti- tocol because smaller width sinuses (0–10 mm) form bone faster
septic. However, because the iodine is complexed with organic than larger width (>15 mm) sinuses. The Division A–width ridge
surface-active agents, it has been shown to inhibit the osteoinduc- was also increased to 6 mm to permit more bone to encompass
tion of allograft bone. Therefore the use of 0.12% chlorhexidine the implant on each side. In 2017 Resnik modified the Misch
gluconate (Peridex) scrub and rinse is most often used as intraoral classification to include alternative treatment options with short
preparation of the surgical site requiring a bone graft. Extraoral implants, crestal grafting approaches, and treatment plan modi-
presurgical scrubbing of the skin should also be performed with fications based on force-related factors, which are detailed in Box
chlorhexidine antiseptics prior to surgery.␣ 37.6 (Figs. 37.25–37.28).␣
Surgical Technique cause micromovement during the healing phase and poorer
healing (Fig. 37.29).
Subantral Option One: Conventional Implant Because the maxillary sinus proper is not invaded during an
Placement SA-1 approach, it is less critical if preexisting pathology in the
sinus is present. However, if pathology is present that warrants
The first Misch SA treatment option, SA-1, occurs when suffi- medical referral, then this should be completed before any implant
cient bone height is available to permit the placement of endosteal placement. Therefore in general the sinus pathologic contraindi-
implants following the usual surgical protocol, with no maxillary cations for sinus graft surgery do not apply for implant insertion
sinus involvement. Because the quality of bone in the posterior max- when adequate bone is present below the sinus for implants of
illa often is D3 or D4 bone, bone compaction or osseodensification adequate size to support the load of the prosthesis. Although a
to prepare the implant site is common. This technique permits a common axiom in implant dentistry is to remain 2 mm or more
more rigid initial insertion of the implant and also increases the BIC. from an opposing landmark, this is not necessary in the SA region.
Narrower bone volume patients (Division B) in SA-1 may
Required Bone Dimensions be treated with osteoplasty or augmentation to increase the
In the abundant bone volume (Division A),the minimum ideal width of bone. The insertion of smaller surface area implants (as
bone height for the SA-1 is related to the associated force fac- small-diameter root-form implants) are not suggested because
tors. Under favorable conditions, a minimum of 8 mm of bone the forces are greater in the posterior regions of the mouth, and
is required from the crest of the ridge to the inferior floor of the bone density is less than in most regions. In addition, the
the sinus for the placement of an 8-mm implant. The literature narrow ridge is often more medial than the central fossa of the
has concluded that short implants (8 mm) have been shown mandibular teeth and will result in an offset load on the res-
to be successful in the posterior maxilla. If multiple implants toration, which will increase the strain to the bone. However,
are placed, then ideally the implants should be splinted for multiple narrow diameter implants may be placed to support
force distribution. For unfavorable conditions, greater than one tooth (i.e., two narrow diameter implants to support one
10 mm of bone is required in height to allow for placement molar).
of an implant so it does not invade the maxillary sinus. This Osteoplasty in the SA-1 posterior maxilla may change the SA
will allow an implant of 10 mm in length to be placed that category if the height of the remaining bone is sufficient to allow
will allow for a greater insertion torque and BIC. Therefore the for adequate bone postosteoplasty. Augmentation for width may
implant will be less likely to have force-related effects that may be accomplished with bone spreading, membrane grafting, or
autogenous grafts. Larger diameter implants are often required in
the molar region, and bone spreading to place wider implants is
• BOX 37.6 Force-Related Factors the most common approach when the bone density is poor. If
less than 2.5 mm of width is available in the posterior edentu-
Favorable Conditions lous region (C–w), then the most predictable treatment option is
• Good quality of bone (D2/D3 bone) with the presence of cortical bone to increase width using onlay autogenous bone grafts. After graft
present
• Minimal occlusal force factors
maturation the area is reevaluated to determine the proper treat-
• No parafunction ment plan classification.
• Ideal crown/implant ratio␣ Endosteal implants in the SA-1 category are left to heal in a
nonfunctional environment for approximately 4 to 8 months
Unfavorable Conditions (depending on bone density and force factors) before the abut-
• Poor quality of bone (D3/D4 bone) with no cortical bone present ment post(s) are added for prosthodontic reconstruction. Care
• Increased occlusal force factors is taken to ensure that the implants are not traumatized during
• Parafunctional forces present the initial healing period. Progressive loading during the pros-
• Poor crown/implant ratio thetic phases of the treatment is suggested in D3 or D4 bone
(Box 37.7).␣
A B
• Fig. 37.25Bone quality. (A) Thick cortical bone and a dense cancellous bone, which is consistent with a
D2 type of bone, (B) No cortical bone present, with very fine trabecular bone, which is usually consistent
with D4 bone and mainly found in the posterior maxilla.
Subantral Option Two: Sinus Lift and published a similar procedure in 1994, 24 years after Tatum’s
Simultaneous Implant Placement first presentation.
Because the SA-2 surgical approach modifies the floor of the
The second SA option in the Misch SA classification, SA-2, is maxillary sinus, a preexisting pathologic condition of the sinus
selected when the intended implant length is 1 to 2 mm greater should not be present because it may affect the implant site by
than the vertical bone present (Fig. 37.30). In this technique, 1 retrograde infection.
to 2 mm may be achieved via elevating the sinus membrane with- This technique is reserved for 8 to 10 mm of host bone below
out bone grafting. Tatum95 originally developed this technique the sinus in which an implant is placed via an osteotome tech-
in 1970, and Misch96 first published it in 1987. Summers97 nique that elevates the membrane approximately 1 to 2 mm with
the use of no grafting. Ideally, an 8-mm implant is used with cau-
tion in these cases.
Rationale
In some situations, a longer implant may be required for pros-
thetic support and initial fixation. Worth and Stoneman98 have
reported a comparable phenomenon of bone growth under an
elevated sinus membrane called a “halo formation”. They observed
the 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. In an
article by Palma and colleagues99 the elevation of the sinus mem-
brane in implant insertion, with or without a graft material below
the mucosa, gave similar results in primates regarding implant
stability or BIC after healing. As a result of the autologous bone
present above the apical portion of the implant with an SA-2 tech-
nique, 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.␣
• Fig. 37.26 Force factors. The posterior maxilla is very susceptible to
force-related issues because of strong muscles such as the temporalis Incision and Reflection
(green) and masseter (red). In an edentulous posterior maxilla, a full-thickness incision is made
on the crest of the edentulous ridge from the tuberosity to the distal
of the canine region. A vertical, lateral relief incision is made at its
distal and anterior extension of the crestal incision for approximately
5 mm. If minimal attached tissue exists on the crest of the ridge,
which is more often observed in the premolar region, then the pri-
mary incision is made more palatal to place more keratinized tissue
on the facial aspect. When teeth are present in the region, the crestal
incision extends at least one tooth beyond the edentulous site. If one
tooth is missing, the reflection is similar to a single-tooth replace-
ment option, and even a direct (flapless technique) may be used.
A full-thickness palatal flap is first reflected because the palatal
• Fig. 37.27 Parafunction. Forces are significantly increased in patients dense cortical plate facilitates soft tissue reflection. Special atten-
who exhibit parafunction. In this radiograph, the prominent antegonial tion is given to avoid the pathway of the greater palatine artery or
notch is consistent with parafunctional forces and masseter hypertrophy. to remain completely subperiosteal so that this structure remains
A B
• Fig. 37.28 Crown/implant ratio. The maxillary posterior region often is confronted with a an increased
interocclusal space because of the vertical and horizontal bone resorption. (A) Three-dimensional image
showing the apical positioning of implants caused by vertical bone resorption. (B) Cone beam computer-
ized tomography interactive treatment planning evaluating the increased crown height space.
A B
• Fig. 37.29 SA-1 (A and B) Treatment plan which includes implant placement below the maxillary sinus proper.
• BOX 37.7 SA-1 Requirements because this will increase the width of the final osteotomy, leading
to less insertion torque. Once the osteotome prepares the implant
• Favorable conditions: >8 mm host bone (implant approximately 8 mm site, the implant may then be threaded into the osteotomy and
in length or greater) extended up to 2 mm above the floor of the sinus. The implant
• Unfavorable conditions: >10 mm host bone (implant approximately 10 is slowly threaded into position so the membrane is less likely to
mm in length or greater) tear as it is elevated. 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
within the soft tissue. The labial mucosa is reflected off the eden- 0 to 2 mm beyond the sinus floor, and the 1 mm of compressed
tulous ridge, rather than elevating the tissue from the bone. The bone covering over the implant apex results in as much as a 3-mm
crest should not be used to leverage the tissue because the ridge may elevation of the sinus mucosa (Fig. 37.31). Ideally, the implant
have minimal cortical bone and a perforation may result. This could design should include a convex apex with no apical openings as
result in damage to the residual ridge or possibly even penetrate the this design will be less likely to cause a membrane perforation.␣
sinus or nasal cavity. Once the tissue is reflected, the width of the
available bone is evaluated to ensure that it is greater than 6-7 mm Modified SA2 Techniques
wide and allows the placement of Division A root-form implants.␣ Rosen and associates100,101 developed a modification to the SA-2
treatment approach for use at the time of an extraction of a maxil-
Osteotomy and Sinus Elevation (SA-2) lary molar. The technique is indicated when the maxillary molar is
The endosteal implant osteotomy is prepared as determined by the extracted, the surrounding walls of bone are intact, and no periapi-
density of bone protocol, which is usually D3 or D4 bone. The cal pathologic condition is present. The crest of the ridge to the
depth of the osteotomy is approximately 1 to 2 mm short of the antral floor should be 7 mm or more in height. Once the tooth is
floor of the antrum. When in doubt of the height dimension, the extracted and the surrounding bony walls confirmed, a modifica-
osteotomy should err on a shorter length. The implant osteotomy tion of the SA-2 technique is in order. A 5- to 6-mm trephine bur
is prepared to the appropriate final diameter, short of the antral is used in the center of the extraction site and prepares the bone 1
floor, by approximately 1 mm. to 2 mm below the antral floor. A 5- to 6-mm-diameter, flat-ended
A flat-end or cupped-shape osteotome is selected for the infrac- or cup-shaped osteotome and mallet intrudes the core of bone 2
ture of the sinus floor. Usually in D3 bone, an osteotome of the mm above the sinus floor, creating 9 mm or more of vertical bone.
same diameter as the final osteotomy is selected. In D4 bone, an A socket graft may be used within the extraction socket but is not
osteotomy one to two sizes smaller than the final implant size maybe pushed into the surgical space of the sinus because it may perforate
used, performing an osseodensification technique. The osteotome is the sinus mucosa. After 4 months, an implant may be inserted.
inserted and tapped firmly in 0.5- to 1.0-mm increments beyond Some authors have used the SA-2 sinus lift procedure to gain
the osteotomy until reaching its final vertical position, up to 2 more than 2 mm of implant vertical height. However, these
mm beyond the prepared implant osteotomy. A slow elevation of blind surgical techniques increase the risk of sinus membrane
the sinus floor is less likely to tear the sinus mucosa. This surgical perforation.
approach compresses the bone below the antrum, causes a green- The success of the intact sinus membrane lift cannot be con-
stick-type fracture in the antral floor, and slowly elevates the unpre- firmed before or at the time of implant placement. Attempts to
pared bone and sinus membrane over the broad-based osteotome. If “feel” the elevation of the membrane from within an 8-mm-deep
the osteotome cannot proceed to the desired osteotomy depth after implant osteotomy may cause tearing of the sinus lining.
tapping, then it is removed and the osteotomy is prepared again Attempting to elevate the sinus mucosa more than 2 mm
with rotary drills an additional 1 mm in depth. The osteotome is through an implant osteotomy 3 to 4 mm wide and 8 mm deep
then reinserted to attempt the greenstick fracture of the antral floor. is not predictable. Reiser and colleagues102 reported that when
Care should be exercised when removing the osteotomes the sinus elevation was 4 to 8 mm in cadavers, almost 25%
from the osteotomy site. The osteotome should never be luxated resulted in sinus perforation. The implant osteotomy sinus floor
A B
• Fig. 37.30 SA-2. (A) Radiograph depicting an SA-2 (maxillary second premolar) and SA-1 (maxillary first
molar). (B) SA-2 implant that includes implant insertion with penetration into the maxillary sinus proper 1
to 2 mm without bone grafting.
A B
• Fig. 37.31 (A) SA-3 crestal. Treatment plan that includes implant insertion with bone grafting via the
crestal (osteotomy) approach gaining approximately 3 to 4 mm of height. (B) Lateral wall. Treatment plan
that includes implant insertion with bone grafting via the lateral-wall approach gaining more than 4 mm of
height (i.e., amount of height is determined by size of lateral wall).
technique is often attempted because of the perceived ease of

surgery of an SA-2 technique versus a lateral-wall or transcrestal • BOX 37.8 SA-2 Requirements
approach.␣ • Favorable conditions: (>8 mm host bone, ideally 10-mm implant)
• Unfavorable conditions: (>10 mm host bone, ideally 12-mm implant)
Complications
If a sinus membrane perforation occurred during the initial
implant placement procedure, then bone height growth is less
likely to occur. This is the primary reason why only 0 to 2 mm Subantral Option Three: Sinus Graft with
of additional bone height is attempted with this technique. How-
ever, even when membrane perforation occurs and/or no bone
Immediate Endosteal Implant Placement
grows around the apical end of the implant, the SA-2 technique The third approach to the maxillary posterior edentulous region,
is of benefit because the apical end of the implant is surrounded SA-3, is indicated when at least 5 mm of vertical bone and suf-
by denser bone. This enhances rigid fixation during healing and ficient width are present between the antral floor and the crest of
increases BIC, leading to improved loading conditions. If inad- the residual ridge in the area of the intended prosthesis abutment
equate bone is formed around the apical portion of an implant, (Fig. 37.32).
then a progressive-loading protocol for D4 bone is suggested dur- A residual height of 5 mm for the SA-3 category has been
ing prosthetic reconstruction (Box 37.8).␣ selected for two main reasons: (1) this height (in adequate bone
width and quality) can be considered sufficient to allow primary Two options exist for V2 block anesthesia: (1) high and within
stability of implants placed at the same time as the sinus graft pro- the pterygomaxillary tissue behind the posterior wall of the max-
cedure, and (2) because of the amount of residual bone (5mm), illa or (2) at the depth of approximately 1 inch with a long-gauge
greater blood supply is present, which allows for more predictable needle within the greater palatine foramen (Fig. 37.33). The first
and faster healing. method is easier to perform but may injure the pterygoid plexus
or the maxillary artery and result in hematoma, or it may fail to
Anesthesia reach the proper landmark. With the second option, it is more
Infiltration anesthesia has been used with success for sinus graft difficult to locate the foramen and negotiate up the canal. It
surgeries in the past; however, more profound regional anesthesia may also injure the greater palatine artery or nerve. Too deep an
is achieved by blocking the secondary division of the maxillary administration with a greater palatine approach may result in the
nerve (V2). The sinus graft surgery often requires the reflection penetration of the orbit floor. Possible sequelae include periorbital
of the soft tissue extending to the zygomatic process. In addition, swelling and proptosis, diplopia, retrobulbar block with dilated
several branches of the maxillary division of the fifth cranial nerve pupil, corneal anesthesia, motionless eye, retrobulbar hemorrhage,
innervate the sinus mucosa. As such, a V2 block is advantageous and optic nerve block with transient loss of vision. However, the
for patient comfort, and this achieves anesthesia of the hemimax- success rate is greater, and the clinical risks appear minimal. There-
illa, side of the nose, cheek, lip, and sinus area. fore 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 soft tissue penetration prevents possible entrance into the
nasal cavity through the medial wall of the pterygopalatal fossa.
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. Then after the infil-
tration is effective, the V2 block is administered. A long-acting
anesthetic such as bupivacaine 0.5% (Marcaine) is preferred.
Block anesthesia with these agents is longer acting than infiltra-
tion in the maxilla.103
The greater palatine foramen is found using an open-bore
instrument (i.e., the handle of a mouth mirror with the mirror
portion removed). Pressure is applied with this instrument along
the palatal tissue, at the union of the residual ridge and hard pal-
ate, in the region of the second molar. Most often, 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 fora-
men. A long, 1.5 inch needle is introduced into the foramen
from the opposite side of the mouth and negotiates the canal for
approximately 1 inch.␣
Surgical Approaches
• Fig. 37.32 SA-4. Treatment plan that includes bone grafting via the
lateral-wall approach with no implant placement. Implant placement is There exist two options for grafting the sinus along with simulta-
delayed according to the healing of the sinus graft sites. neous implant placement.
A B
• Fig. 37.33 Anesthesia, V2 block. (A) Greater palatine foramen approach through the greater palatine
foramen located 1 cm medial and adjacent to the second molar teeth. (B) Cotton swab may be pressed at
the junction of the hard palate and the maxillary alveolar process until it falls into the foramen depression.
The needle is advanced perpendicular until bone is contacted slowly at an angle of 45 degrees to the long
axis of the hard palate.
A B
• Fig. 37.34 Incision/reflection. Full-thickness reflection is necessary to expose the lateral wall. (A) For a
single-tooth sinus augmentation, usually the incision extends one tooth on each side of the edentulous
site. (B) For a large SA4 edentulous area, the anterior incision must extend 5-10 mm anterior to the anterior
wall (approximately distal of cuspid) and posteriorly to the tuberosity.
Lateral Wall. A Tatum lateral maxillary wall approach is per- Access Window. The overall design of the lateral-access window
formed by performing an osteotomy over the lateral wall of the is determined after the review of the CBCT scan, which helps
maxillary sinus, infracturing the window, elevating the sinus determine the thickness of the lateral wall of the antrum, the posi-
membrane and window, grafting to the medial wall, and then tion of the antral floor from the crest of the ridge, the posterior
placing the implant (SA-3). of the anterior wall in relationship to the teeth (if present), the
Incision and Reflection. A crestal incision is made on the pal- presence of septa on the floor and/or walls of the sinus, and any
atal aspect of the maxillary posterior edentulous ridge from the associated pathology within the maxillary sinus.
tuberosity to one tooth anterior to the anterior wall of the maxil- The outline of the Tatum lateral-access window is scored on the
lary sinus, leaving at least 2 mm of attached tissue on the facial bone with a rotary handpiece under copious cooled sterile saline. It
aspect of the incision. Because ridge resorption occurs toward the is often easier to perform this step at 50,000 rpm (1:1 handpiece),
midline at the expense of the buccal dimension, the incision is but it is possible even at 2000 rpm, depending on the lateral-wall
made with awareness of the greater palatal artery, which proceeds bone thickness. There exist multiple techniques to score the sinus
close to the crest of the ridge in the severely atrophic maxilla. If window: (1) carbide bur (No. 6 or No. 8), (2) diamond bur, (3)
bleeding from the palatal flap occurs, then a hemostat may be used bone removal burs (e.g., Dask bur), or (4) Piezosurgery units. With
to constrict the blood vessels distal to the bleeding, pressure may experience, the first bur is usually a No. 8 round carbide, which
be applied over the greater palatine foramen with a blunt instru- scratches the bone and designs the overall window dimension. This
ment, or electrocoagulation at the bleeding site may be used. bur is followed with a No. 8 round diamond, which “polishes” away
A vertical relief incision is made on the distal of the incision to the bone within the groove made by the carbide bur. A No. 8 round
enhance surgical access to the maxillary tuberosity. A broad-base diamond bur for the entire process is of benefit for an early learning
anterior vertical relief incision is also made at least 10 mm anterior curve because carbide burs “chatter” more and may tear the sinus
to the anterior vertical wall of the sinus. This may result in the membrane if the bur inadvertently comes in contact with it.
incision being made over the distal aspect of the first bicuspid or The inferior score line of the rectangular access window on the
canine. The facial soft tissue flap is designed, following general lateral maxilla is placed approximately 1 to 2 mm above the level
principles, with a base wider than the crest to ensure proper blood of the antral floor (i.e., which in an SA-3 is >5 mm from the crest).
supply. The palatal portion of the flap is first reflected, followed by If the inferior score line is made at or below the level of the antral
the facial crestal tissue, which is reflected off the crest. floor, then infracture of the lateral wall will be impossible because
The facial full-thickness mucoperiosteal flap is reflected to the score line will be over host bone. If the inferior score line is
expose the complete lateral wall of the maxilla and a portion of made too high (>4 mm) above the sinus floor, then a ledge above
the zygoma. The facial flap should be reflected to provide com- the sinus floor will result in a blind dissection of the membrane on
plete vision and access to the maxillary lateral wall. The superior the floor, which may also lead to perforation.
aspect of the flap should never approach the infraorbital fora- The most superior aspect of the lateral-access window should
men because aggressive reflection of the facial flap may cause a be approximately 2-3 mm above the planned implant length (i.e.,
neuropraxia type of nerve impairment and damage to this nerve 12-mm implant would require the window to be 15 mm from the
structure. The reflected labial tissue can be sutured to the cheek ridge crest). A soft tissue retractor placed above the superior mar-
mucosa, carefully avoiding the parotid duct. All fibrous and soft gin of the lateral-access window (i.e., always maintained on bone,
tissue should be removed from the lateral-wall access site to avoid not soft tissue) helps retract the facial flap and prevents the retrac-
soft tissue contamination of the bone graft. Entrapping soft tissue tor’s inadvertent slip into the access window, which may damage
within the sinus may lead to formation of a secondary mucocele the underlying membrane of the sinus.
or surgical ciliated cyst. A moist 4 x 4 gauze or a 2-4 molt with a The anterior vertical line of the access window is scored
scraping motion easily removes this tissue (Fig. 37.34).␣ approximately 1 to 2 mm from the anterior sinus border. The
A B C
D E
• Fig. 37.35 Window preparation. (A) Window osteotomy should be made just through the cortical bone.
(B) Initially, an outline form should be completed with a round carbide (No. 8), (C) Final preparation should
be completed through the cortical bone with a round diamond (No. 8). (D and E) Osteotomy is complete
when the window is free 360°.
distal vertical line should be made approximately 5 mm distal to the posterior superior alveolar and the infraorbital artery. How-
the most posterior planned implant site (i.e., this will allow for ever, when the lateral wall is very thin in the edentulous patient,
adequate space if the implant position is changed more distally). the anastomosis will atrophy and become nonexistent. The anas-
If the patient is fully edentulous, the distal vertical line should be tomosis has been shown to be located approximately 15 to 20 mm
made approximately 5 mm distal to the first molar position. If the from the alveolar crest.
sinus access window outline is difficult to determine in relation The horizontal lines of the access window should ideally not be
to the sinus cavity, then it should err over the antrum rather than positioned directly over this structure. The vertical lines of the access
over the bone around this structure. window often cut through the artery. Because the blood supply may
In general, a larger access window offers many advantages, includ- be from either direction, both vertical access lines may have bleeding.
ing easier access, less stress on the membrane during initial elevation, This is rarely a concern for vision or blood loss during the procedure.
and ease of additional membrane elevation with instruments because If intraosseous bleeding is a problem, then the high-speed diamond
of the direct access that facilitates graft placement. The corners of the used to score the window may be used without irrigation and polish
access window should always be rounded, not right or acute angles. the bleeding site, which cauterizes the vessel from the heat on the
If the corner angles are too sharp, then membrane perforation may bony wall. Electrocautery may also be used on this vessel, if neces-
occur from the use of a surgical curette at the corner or during the sary. A hemostat maybe used; however, care should be exercised to
infracture of the lateral wall. Once the lateral-access window is delin- avoid fracturing the lateral wall and/or perforating the sinus mucosa.
eated, the rotary bur continues to scratch the outline with a paint- Elevating the head and a surgical sponge applied to the site for a few
brush stroke approach under cooled sterile saline irrigation, until a minutes also aides in the control of hemorrhage.␣
bluish hue is observed below the bur or hemorrhage from the site Sinus Membrane Elevation. The first step in elevating the win-
is observed. The expansion of the maxillary sinus after tooth loss dow is to ensure that the lateral window is completely “free” from
pushes the arteries of the membrane to the outside of the structure the host bone. A flat-ended metal punch (or mirror handle) and
and just below the surrounding bone. Therefore either the bluish hue mallet may be used to gently infracture the lateral-access window
of the membrane or bleeding in the area are signs of approaching the from the surrounding bone while still attached to the thin sinus
sinus membrane. This observation should be achieved circumferen- membrane. The flat-ended punch is first positioned in the center
tially around the access window. The access window should not be of the window. If light tapping does not greenstick fracture the
overprepared in depth because direct contact with the membrane bone, then the flat-ended punch is placed along the periphery of
with rotary burs may cause a perforation (Fig. 37.35). the access window and tapped again. If the window does not sepa-
Complications rate easily, then the punch is rotated so that only an edge comes
Endosseous Anastomosis. It should be noted that the largest blood in contact with the scored line. This decreases the surface area of
vessel in the lateral wall is from an endosseous anastomosis from the punch against the score line of the window and increases the
A B
C D
• Fig. 37.36 Sinus membrane reflection. (A) Membrane reflection starts on the floor, (B) is extended to the
anterior wall, (C) extended to the posterior, (D) and then to the superior. Curette should always be main-
tained on the bone to prevent perforation.
stress against the bone. Another light tap with the mallet will most curette is pushed against the bone that easily reflects the mem-
likely cause greenstick fracture of the bone along the scored line. brane. The sinus membrane is inspected for perforations or open-
If this still does not free the window, then further scoring of the ings into the antrum proper.
bone with the handpiece and diamond bur is indicated, and the It is easier to gain direct vision and access to the distal por-
tapping procedure is repeated. tions of the antrum than the anterior portions when the sinus area
A short-bladed soft tissue curette designed with two right-angle expands beyond the access window. Therefore whenever the peri-
bends is introduced along the margin of the window (i.e., Sal- osteal elevator or curette cannot stay against the bone with good
vin Sinus Curette No. 1). The curved portion is placed against access in the anterior area, the access window should be increased
the window, whereas the sharp edge is placed between the sinus in size toward the anterior. A Kerrison rongeur or a second win-
membrane and the margin of the inner wall of the antrum for dow similar to the initial score-and-fracture technique may be
a depth of 2 to 4 mm. The curette should always stay on the used to expand the size of the access window.
bone and be used in a scraping motion. If any sharp edges of bone The periosteal elevators and curettes further reflect the membrane
remain on the bone’s margin, then they may be flicked off with off the anterior vertical wall, floor, and medial vertical wall. It is bet-
the curette. The curette is slid along the bone margin 360 degrees ter to err on the high side to ensure that ideal implant height may
around the access window. This ensures the release of the mem- be placed without compromise (i.e., always maintaining a patent
brane from the surrounding walls of the sinus without tearing ostium). The lateral-access window is positioned as part of the supe-
from the sharp bony access margins. The sinus membrane may rior wall of the graft site, once in final position. The SA space has the
be elevated from the antral walls easily because it has few elastic original sinus floor as the base; the posterior antral wall, medial antral
fibers and is not attached to the cortical wall. Specially designed wall, and anterior antral wall as its sides; and the lateral-access window
and shaped curettes are available to facilitate this surgical maneu- and elevated sinus mucosa as its superior wall (Figs. 37.36 and 37.37).␣
ver. A larger curved periosteal or sinus membrane elevator is then Sinus Graft: Layered Approach.
introduced through the lateral-access window along the inferior Top Layer: Collagen and Antibiotic. A resorbable collagen
border (i.e., Salvin Sinus Curette No. 2). Once again, the curved membrane (Oratape) soaked with a parental form of antibiotic
portion is placed against the window, and the sharp margin of the (Ancef 0.2 mL) is then prepared (Box 37.9). The collagen and
curette is dragged along the floor of the antrum while elevating antibiotic are placed onto the elevated antral floor region and
the sinus membrane. The curette should always be maintained on attach to the sinus mucosa on the superior part of the graft site.
the bony floor to avoid a membrane perforation. The curette is The collagen is a carrier for the antibiotic to decrease the risk of
never blindly placed into the access window. The implant clinician postoperative infection. In addition, in case of membrane tearing
should see and/or feel the curette against the antral floor or sinus or separation of the sinus mucosa (with or without the awareness
walls at all times. Once the mucosa on the antral floor is elevated, of the clinician), the collagen membrane seals the opening (Fig.
the lateral, distal, and medial wall of the sinus is addressed. The 37.38). It is imperative that a portion of the membrane be left
A B
• Fig. 37.37 Window elevation. (A and B) The window should not be “intruded” but elevated. When com-
plete, the lateral wall will be at 90 degrees and the medial bone exposed (green arrow).
• BOX 37.9 Sinus Graft Layered Technique bone formation that a composite type of graft. Hallman and col-
leagues showed that sinuses grafted with 100% xenograft com-
1. Top layer (superior) pared with 100% autogenous exhibited greater healing and higher
a. Collagen membrane implant survival rates.116 Froum and colleagues reported that if
b. Local antibiotic (Ancef)
20% autogenous bone was added to other bone substitutes, a
2. Middle layer (intermediate)
a. 70% mineralized freeze-dried bone allograft greater mean vital bone formation was found.117
b. 30% demineralized freeze-dried bone allograft Demineralized freeze-dried bone (DFDB) has been shown
c. Platelet-rich fibrin from 10 mL of whole blood to be osteoinductive, which is capable of inducing undifferenti-
d. Antibiotic (Ancef 500 mg/mL) ated mesenchymal cells to form osteoblasts. The mechanism for
3. Bottom layer (inferior) this process appears to relate to the bone morphogenic protein
a. Autogenous bone, tuberosity* (BMP) found primarily in cortical bone. In animal and human
*Dependent on the amount of host bone present studies, DFDB allograft (DFDBA) powder used alone in sinus
grafts did not provide satisfactory results. Bone was present but
not in sufficient volume as the graft material originally placed.
Speculation exists that the material resorbs more rapidly than
outside of the sinus, preventing “intrusion” of the entire mem- the bone formation process, resulting in less bone formation.
brane into the sinus during bone placement. In addition, studies have shown that DFDB, when placed into
Second Layer: Sinus Graft Materials. The second layer of an area of low-oxygen tension (hypoxic or hypocellular tissue),
the sinus graft layered approach is the most abundant and con- results in fibrous or cartilage tissue rather than bone.118 Other
sists of the allograft bone grafting material. Many materials have authors have observed similar conclusions on the poor perfor-
been proposed in single or combination mixes, including min- mance of DFDB used alone in animal and human studies.119At
eralized and demineralized freeze-dried bone,104,105 β-tricalcium the Sinus Graft Consensus Conference,14 high success rates were
phosphate (β-TCP),106 xenograft hydroxyapatite (HA) (bovine reported for all materials and combinations, with the exception
anorganic bone), and calcium carbonates (bioactive glass).107 In of DFDB when used alone.
addition, more recent research has focused on combining “tradi- Mineralized freeze-dried bone allografts (FDBAs) are an allo-
tional” bone substitutes with bone growth factors.108 Each graft genic bone that does not undergo the demineralization process.
material used in the sinus graft technique presents a similar, yet FDBA has the same BMP content in its organic matrix; however,
distinct, biological approach to the healing process. it does not have the same osteoinductive capability as DFDBA.
What Type of Graft Material? Autogenous bone for years has been FDBA has been shown to be a better scaffold (osteoconduction)
considered the gold standard of grafting material. Tatum first de- than DFDBA, which allows for superior space maintenance.120
veloped and reported the use of autogenous bone for sinus grafts Eventually, osteoclasts breakdown the mineral content of FDBA
in the 1970s, and Boyne109,110 and James first published the in- until demineralization occurs, inducing new bone formation and
formation in 1980. In primates (Macaca fascicularis), Misch111,112 a prolonged protein release.
found the use of iliac crest or tail bone in sinus grafts produced Cammack and colleagues examined mineralized and deminer-
bone slightly denser than typical in the region, as evidenced from alized freeze dried allograft used in sinus augmentation procedures
histology sections harvested at the reentry procedure. Similar find- and found no statistical significance between the two bone sub-
ings have been observed during case series studies, with patients stitutes. A histomorphometric study by Froum and colleagues121
undergoing sinus grafts with autologous bone from the iliac crest at 26 to 32 weeks after grafting evaluated mineralized cancel-
or intraoral donor sites.113 lous bone allograft (MCBA) and anorganic bovine bone material
It is interesting to note that sinus grafts in the literature that (ABBM) for sinus augmentation. Bilateral sinus grafts, one filled
have used 100% autogenous bone have lower success rates than with MCBA and the other with ABBM, were compared. The aver-
sinus grafts with synthetic substitutes (e.g., Del Fabbro and col- age vital bone content of the MCBA was 28.25%, compared with
leagues114 reported 87.70% versus 95.98%).115 Many additional the ABBM of only 12.44%. Therefore mineralized corticocancel-
studies have concluded that 100% autogenous bone results in less lous bone of approximately 250 to 1000 µm is advantageous for
A B
• Fig. 37.38 Top layer. (A and B) Fast-resorbing collagen (e.g., Collatape) is used with antibiotic as the top
layer. The collagen membrane should be positioned to the medial wall and with a small segment exposed
outside the superior aspect of the window. A longer acting collagen may be used if a known membrane
perforation is present.
A B
• Fig. 37.39 Middle layer. The middle layer consists of allograft (i.e., 70% mineralized, 30% demineralized)
plus antibiotic. (A) Allograft syringed into the sinus proper. (B) Packing of the sinus with a packer.
bone graft material because it fulfills space maintenance require- shown an ideal particle size for predictable bone regeneration to be
ments and allows for cell migration.122 approximately 250 to 1000 µm.123
Allograft bone material is available in three particle forms: In addition to the mineralized bone, bone graft factors in the
cortical, cancellous, and corticocancellous. Cortical allografts are form of platelet-rich fibrin may be used. Whole blood is drawn
associated with an increased density and greater space maintenance (approximately 10 ml) from the patient and placed into a cen-
properties, which allow for slower resorption. Cancellous chips are trifuge for 10 to 15 minutes at 3000 rpm. The blood is sepa-
advantageous because they allow for osteoconductive scaffolding rated by the centrifuge into three layers: (1) red blood cells, (2)
and deposition of osteoblasts while being faster resorbing. Ideally, platelet-rich fibrin (PRF), and (3) platelet-poor plasma (PPM).
the use of corticocancellous bone is advantageous because it allows The PRF layer contains many growth factors that are involved in
for both the benefits of cancellous and cortical bone to be used in the cascade of bone mineralization.124 The PRF is added to the
the grafting process. bone substitutes, along with a local antibiotic to be added into
The ideal particle size of the allograft material is very important the sinus proper. A parenteral form of antibiotic is used rather
in the bone regeneration process because too small (<125 µm) than a tablet form because oral antibiotic drugs often have fillers
particle size leads to fast resorption, with an inconsistent bone in the product that are not osteoconductive. The most common
formation. A larger particle size (>1000 µm) restricts resorption antibiotic is Ancef 500 mg/mL, and 0.8 mL of solution is added
and may be sequestered or result in delayed healing. Studies have to the graft (Fig. 37.39).␣
Summary: 2nd Layer. The second layer of the lateral-wall sinus symphysis or ramus region. The autogenous bone is placed on the
graft will consist of the following: original bony floor in the area most indicated for implant insertion.
1. a. 70% mineralized FDBA, 30% demineralized DFDBA A blood supply from the host bone can be established earlier to this
OR grafted bone and maintains the viability of the transplanted bone
b. Mineralized FDBA: (Corticocancellous) cells and the osteogenic potential of the transplanted bone growth
• Particle Size = 250–100 µm factors. Autogenous bone represents an important component of the
• Approximately 250–1000 µm sinus graft, and is of more importance in an SA-4 approach com-
2. PRF pared with an SA-3, which has more host bone present (Fig. 37.40).
3. Local antibiotic (Ancef ) The harvest of the tuberosity bone is initiated with the expo-
These materials are mixed in a surgical bowl and filled into a bone sure of the tuberosity bone; however, care should be exercised to
grafting syringe or 1 cc hypodermic syringe. When placing the graft not extend the incision to the hamular notch area because this
material, insert the syringe into the sinus proper in approximation to may result in potential bleeding episodes. Once there is full-thick-
the medial wall and material is extruded as the syringe is removed. ness reflection of the tuberosity bone, double-action rongeurs may
The grafting material should be deposited in an anterior and inferior remove small pieces of the mainly cancellous bone. The tuberos-
direction. This will ensure material raises the lateral window instead of ity bone is usually soft and therefore is compressed to form more
intrusion toward the medial wall. Intrusion will lead to lack of bone cells per volume. Usually, rotary burs or bone chisels are not
formation near the medial wall and may affect implant placement recommended because this reduces the amount of bone grafted
and post-sinus mucociliary function. By extruding the material in the and increases the possibility of perforation into the sinus proper.
anterior direction, bone graft material will be placed into the anterior Additional autogenous bone may be harvested intraorally or extra-
segment of the sinus incorporating graft material in contact with the orally, as indicated on a case-by-case basis (Fig. 37.41).
anterior wall and increasing blood supply for healing. The material The autogenous bone is then placed on the floor by making
should be condensed with a serrated packer, and packing pressure small spaces with a curette within the allograft material. Ideally,
should be firm but not excessive. Inadequate pressure will result in air- a space should be made to the medial wall because it is advanta-
spaces, which may predispose the graft to future infection. Excessive geous for autograft chips to be placed in approximation to the
condensation may lead to perforation of the membrane and extrusion medial wall. After placement of the autogenous bone, the grafted
of material into the sinus proper. area is veneered with the allograft material to fill any voids that
Bottom Layer␣ are present.␣
Regional Acceleratory Phenomenon. The third or bottom layer will Implant Insertion. A review of the literature by Del Fabbro
consist of multiple steps to enhance bone growth. First, especially and colleages126 notes success rates of implants placed at the same
if little bleeding is present from the sinus floor and the anterior time as the graft have a survival rate of 92.17%, whereas a delayed
wall, a sharp instrument (e.g., scaler, curette) is used to scratch implant insertion has a survival rate of 92.93%. The 5 to 10 mm
the bone. This trauma will initiate the regional acceleratory phe- of initial bone height in an SA-3 posterior maxilla, the cortical
nomenon (RAP), which introduces more growth factors into the bone on the residual crest, and the cortical-like bone on the origi-
site and starts the angiogenesis process. The blood vessels allow nal antral floor may stabilize an implant that is inserted at the
migration of osteoclasts and osteoblasts that resorb and replace the time of the graft and permit its rigid fixation. Therefore when the
graft with live, viable bone. In addition, the blood vessels provide conditions are ideal for the SA-3 sinus graft, the implant may be
blood supply to the autologous bone portion of the graft, which inserted at the same appointment. When inserting implants into
is required for initial osteogenesis. The medial wall should not be an SA-3 sinus graft, the sinus should always be completely filled
scratched because it is very thin and perforation may occur.␣ prior to implant placement. Attempting to graft after implant
Autogenous Bone. The second part of the third layer is the use insertion is very difficult and will lead to voids. When preparing
of autogenous bone. Osteogenic material is capable of producing the osteotomy into the grafted sinus, a finger rest should be main-
bone, even in the absence of local undifferentiated mesenchymal tained so that control of the handpiece is maintained upon perfo-
cells. Autogenous bone predictably exhibits this activity in the si- ration into the sinus. Care should be exercised to not extend the
nus graft. Misch has performed reentry of more than 1500 sinus osteotomy into the grafted material. This will result in dispersion
grafts (at implant placement) accompanied by more than 50 hu- of the graft material. Penetration though the inferior floor should
man histologic sections and 18 primate sinus grafts and histology. only be approximately 1 mm, as there will be no resistance from
A consistent histologic and clinical finding is that bone grows into the graft material when placing the implant. In most cases, the
the augmentation region from the surrounding walls of the max- osteotomy will be underprepared to allow for osseodensification
illary antrum in which the sinus membrane was elevated.125 In (D4 bone). Implant placement is more accurate when inserted
other words, the bone growth came from the surrounding walls with a handpiece (Figs. 37.42 and 37.44).
of bone, similar to an extraction socket. The last regions to form The advantage of the SA-3 technique is the decreased treat-
bone are usually the center of the lateral-access window and the ment time because the implant and sinus graft are completed at
region under the elevated sinus membrane. In fact, no new bone the same time. In addition, there exist several disadvantages of
at time intervals up to 12 months was found to grow immediately immediate implant placement compared with delaying implant
under the sinus membrane. placement (i.e., SA-4 approach):
The most common harvest site for the lateral-wall approach is 1. The individual rate of healing of the graft may be assessed dur-
the maxillary tuberosity on the same side of the patient that the ing the healing period, while the implant osteotomy is being
sinus is being augmented. In this way, an additional surgical site prepared and the implant inserted. The healing time for the
is not required, which decreases morbidity to the patient. Addi- implant is no longer arbitrary, but it is more patient specific.
tional sources of bone to be added to the graft site may be any bone 2. Under ideal conditions, postoperative sinus graft infections occur
fragments from implant osteotomy sites, bone cores over the roots in approximately 3% to 5% of patients, which is greater than
of anterior teeth, sinus exostoses, and cores from the mandibular the percentage for implant placement surgery or intraoral onlay
A B
C
• Fig. 37.40 Autogenous bone harvest. (A) Usually because of access, the maxillary tuberosity is the most
ideal location for autogenous harvest. (B) Harvest can be completed with a double-action rongeur. (C) Usu-
ally large autogenous pieces may be obtained without penetration into the maxillary sinus.
A B
• Fig. 37.41 Bottom layer. The bottom layer consists of any autogenous bone obtained because the
importance of autogenous bone is inversely proportional to the amount of host bone present. (A) harvested
bone placed into window. (B) Final bone packing of autogenous bone.
A B C
• Fig. 37.42 SA-3 implant placement. (A) After lateral-wall sinus grafting, the osteotomy is completed, usu-
ally after the initial surgical drill, osteotomes are used to widen the osteotomy. (B) Implant placement into
graft material. (C) Final veneer grafting over implant site.
A B
• Fig. 37.43 Membrane. (A) Collagen membrane positioning over the lateral window (i.e., may use platelet-
rich fibrin over collagen). (B) Final suturing of surgical site.
A B
• Fig. 37.44 SA-3 lateral wall. (A) The sinus should always be grafted before implant placement (B) because
grafting is difficult to complete after implant is placed (i.e., cannot graft on medial aspect of implant).
bone grafts. If the sinus graft becomes infected with an implant 6. The clinician may access the sinus graft before implant inser-
in place, then a bacterial smear layer may develop on the implant tion. On occasion, the sinus graft underfills a region, and the
and make future bone contact with the implant less predictable. lack of awareness of the condition during implant insertion at
The infection is also more difficult to treat when the implants the same time results in an implant placed in the sinus proper,
are in place and may result in greater resorption of the graft as a rather than the graft site.
consequence. If the infection cannot be adequately treated, then 7. On reentry to a sinus graft, it is not unusual to observe a crater-
the graft and implant must be removed. Therefore a decreased like formation in the center of the lateral-access window, with
risk of losing the graft and implant exists if a postoperative infec- soft tissue invagination. If the implant is already in place, then
tion occurs with a delayed implant insertion. Some reports in the it may be difficult to remove the soft tissue and assess its pre-
literature indicate a slightly higher failure rate of implants when cise extent. When soft tissue is present at a delayed implant
inserted simultaneously compared with a delayed approach. insertion, the region is curetted and replaced with a bone graft
3. Blood vessels within the graft are required to form and remodel before implant placement. The healing time for the implant is
bone. An implant in the middle of the sinus graft does not provide related to the developing bone assessed at the delayed surgery,
a source of blood vessels. It may even impair the vascular supply. not an arbitrary period that may be, on occasion, too brief.␣
4. Bone width augmentation may be indicated in conjunction Membranes. After implant placement, a thin layer of graft mate-
with sinus grafts to restore proper maxillomandibular ridge rial may be veneered over teh lateral access opening. A resorbable
relationships and/or increase the implant diameter in the molar membrane (e.g., Collatape) is then placed over the lateral-access
region. Augmentation may be performed simultaneously with window (Fig. 37.43). A membrane will delay the invasion of fibrous
the sinus graft. As a result, larger diameter implants may be tissue into the graft and will enhance the repair of the lateral bony
placed with the delayed technique. wall. A nonresorbable membrane should not be used because reen-
5. The bone in the sinus graft is denser with the delayed implant try would be required and the possibility of postoperative sinus
placement. As such, implant angulation and position may be infection will increase. A bacterial smear layer may accumulate in
improved because it is not dictated by existing anatomic limita- the nonresorbable material and contribute to the infection process.
tions at the time of the sinus graft. Rarely will a resorbable membrane become infected.
PRF may be used as a double membrane by placement over “give” will occur when the bone is breached. A periapical radio-
the lateral collagen membrane to increase the amount of growth graph may be taken to verify positioning. Incremental wider
factors for bone formation and to increase the growth factors osteotomes are inserted to expand and to obtain vertical expan-
for tissue healing. If inadequate PRF is available because it was sion of the bone height to accommodate the implant diameter.
used in the second layer of the graft, then PPP may be used Step 3: After the last osteotome is used, bone graft material is slow-
because platelets are present but in lower quantities. Froum ly introduced into the osteotomy site. First, a PRF coagulant
and colleagues127 evaluated sinus grafts with barrier mem- maybe placed into the osteotomy site. This will allow for en-
branes over the lateral-access wall compared with no barrier hanced soft tissue healing via penetration through the collagen
membrane. All sinus graft combinations in the study demon- membrane to increase bone growth. Second, collagen is tapped
strated higher vital bone percentage on the cores when a bar- into position to elevate the membrane. A small piece of collagen
rier membrane was used. Misch observed a higher vital bone (i.e., approximately 1½ larger than the osteotomy hole) is placed
percentage even when collagen was used over the lateral-access into the osteotomy site, with the last osteotome. The collagen
site compared with no collagen. Tarnow and colleagues com- will act as a buffer between the bone graft material and the sinus
pleted a split-mouth design study with bilateral sinus grafts, membrane. The collagen is less likely to perforate the membrane.
with or without covering the lateral window with a membrane. Step 4: The graft material is slowly introduced into the sinus oste-
Histologic samples revealed a higher percentage of bone with a otomy with a bone graft spoon or an amalgam carrier. The si-
membrane (25.5%) compared with no membrane (19.9%).128␣ nus floor is then elevated by repeated increments of bone graft
Soft Tissue Closure. The soft tissues and periosteum should be material and placed into position with an osteotome.
reapproximated for primary closure without tension, with care Step 5: Once the osteotomy is widened and sinus membrane is
to eliminate graft particles in the incision line. Because of the elevated to the desired height, the implant may be inserted.
access window grafting, along with the double layer membrane,
it is often necessary to stretch the tissue to allow for tension-free This SA-3 crestal technique has the advantage of surgical sim-
closure. Therefore the facial flap must often be expanded, which plicity, which decreases possible surgical morbidity. The main
usually can be completed by periosteal release incisions. A tissue disadvantage of this technique is the unknown perforation of the
pickup holds the facial flap to the height of the mucogingival tis- sinus membrane. Ideally, the sinus membrane integrity should be
sues junction. The flap is then elevated, and a No. 15 blade is maintained during the procedure. The limitations of this technique
used to incise the tissue 1 mm deep through the periosteum above include elevating the membrane approximately 3 to 4 mm. If greater
the mucoperiosteum. Tissue scissors are then introduced into the height is required, the lateral-wall approach may be used (Figs. 37.45
incision parallel to the facial flap at a depth of 3 to 5 mm. A and 37.46; Box 37.10).␣
blunt dissection under the flap releases the periosteum and muscle
attachments to the base of the facial flap. The flap may then be Subantral Option Four: Sinus Graft Healing and
advanced over the graft site to the palatal tissues.
It should be noted that horizontal vascular anastomoses are Extended Delay of Implant Insertion
located lateral to the maxilla, within the soft tissue (extraosse- In the fourth option for implant treatment of the posterior max-
ous anastomosis), and approximately 20 mm above the crest of illa, SA-4, the SA region for future endosteal implant insertion is
the ridge. A blunt dissection does not violate these vessels. No first augmented, then after sufficient healing, implant placement is
tension should exist on the facial flap with primary closure of completed. This option is indicated when less than 5 mm remains
the site. Interrupted horizontal mattress or a continuous suture between the residual crest of bone and the floor of the maxillary
(3-0 polyglycolic acid [PGA]) may be placed. Suturing is more sinus (Fig. 37.47). In addition, if an SA-3 approach is warranted
critical with this procedure than with many other implant place- because only 5 mm of bone is present, but pathology is present, it is
ments. Incision line opening may contribute to infection, con- often advantageous to complete an SA-4 technique. The SA-4 cor-
tamination, or loss of graft materials. The borders and flange of responds to a larger antrum and minimal host bone on the lateral,
an overlaying soft tissue–borne denture or partial denture are anterior, and distal regions of the graft because the antrum gener-
aggressively relieved to eliminate pressure against the lateral wall ally has expanded more aggressively into these regions. The inad-
of the maxilla. equate vertical bone in these conditions decreases the predictable
Crestal Approach. The second option for an SA-3 sinus placement of an implant at the same time as the sinus graft, and
augmentation and implant placement is the use of the crestal less recipient bone exists to act as a vascular bed for the graft. In
approach. This approach has become more popular for reducing addition, in most cases, less autologous bone exists in the tuberosity
complications from lateral-wall sinus augmentation procedures. for harvesting, and fewer septa or webs will exist in the sinus (and
The crestal approach sinus augmentation uses an osteotome to typically exhibit longer mediodistal and wider lateromedial dimen-
break through the floor and then graft below the sinus membrane. sions). Therefore the fewer bony walls, less favorable vascular bed,
The following are the five steps used in the procedure: minimal local autologous bone, and larger graft volume all mandate
a longer healing period and slightly altered surgical approach.
Step 1: A conventional full-thickness flap with crestal incision is The Tatum lateral-wall approach for sinus graft is performed as
completed to gain access to the bony ridge. A pilot drill is used in the previous SA-3 procedure without the implant insertion (Fig.
to perform the initial osteotomy 1 to 2 mm short of the sinus 37.48). Most SA-4 regions provide better surgical access than their
floor. The exact measurement of the available bone is com- SA-3 counterparts because the antrum floor is closer to the crest,
pleted via CBCT images. Incrementally larger surgical drills or compared with the SA-3 posterior maxilla. However, in Division
osteotomes should be used to widen the osteotomy, at least one D maxillae, it is usually necessary to expose the lateral maxilla and
drill short of the final implant width. the zygomatic arch. The access window in the severely atrophic
Step 2: A small diameter osteotome is inserted into the prepared maxilla may even be designed in the zygomatic arch. In general,
site to compress the sinus floor using a surgical mallet. A slight the medial wall of the sinus membrane is elevated approximately
A B
Collagen PRF Collagen PRF Bone graft
C D
Collagen PRF Bone graft
E
• Fig. 37.45 Crestal approach. (A) Step 1: Initial osteotomy short of sinus floor. (B) Osteotome used to widen
osteotomy. (C) Platelet-rich fibrin and collagen membrane placement. (D) Allograft material placement.
(E) implant placement.
12 mm from the crest so that adequate height is available for future membrane and by intraosseous vascular bundles. The central por-
endosteal implant placement. The combination of graft materi- tions of the graft receive blood from collateral branches of the
als used and their placement are identical to the SA-3 technique endosseous anastomosis. The extraosseous vascular anastomosis
lateral-wall approach. However, because less autogenous bone is may enter the graft from the lateral-access window.
often harvested from the tuberosity, an additional harvest site may Many local variables are related to sinus graft maturation,
be required, most often above the roots of the maxillary premolars including healing time, the volume of the SA graft, the distance
or from the mandible (i.e., ascending ramus). from the lateral to medial wall (small, average, or large), and the
The width of the host site for most edentulous posterior maxillae amount of autologous bone in the multilayered approach, all of
is Division A. However, when Division C–w to D exists, a mem- which relate to the speed and amount of new bone formation.
brane or onlay graft for width is indicated. When the graft cannot The time of evaluation of the sinus graft is perhaps the great-
be secured to the host bone, it is often better to perform the sinus est variable of all. Froum and colleagues129,130 evaluated a sinus
graft 6 to 9 months prior to the autogenous graft for width. After graft from the same patient at 4 months, 6 months, 12 months,
the graft maturation, the implants may be inserted (Box 37.11). and 20 months. The amount of new bone continuously increased,
compared with the amount of graft material in the antrum. In
Vascular Healing of Graft addition, the additional time allowed the graft to mature into a
Healing of the sinus graft takes place by several vascular routes, load bearing type of bone. In summary, the more time that elapsed
including the endosseous vascular anastomosis and the vasculature from sinus graft to implant loading, the more vital bone was avail-
of the sinus membrane from the sphenopalatine artery. In mildly able to support the occlusal load.
resorbed ridges, the host bone receives its blood supply from both The type of bone graft material used in the sinus graft may affect
centromedullary and mucoperiosteal vessels. However, as age the rate of bone formation. Bone formation is fastest and most com-
and the resorption process increases, the bone gradually becomes plete within the first 4 to 6 months with autogenous bone, followed
totally dependent on the mucoperiosteum for the blood supply. by the combination of autogenous bone, porous HA, and DFDB
The periphery of the graft is mainly supplied by vessels of the sinus (6–10 months); alloplasts only (i.e., TCP) may take 24 months to
A B C
D E F
G H I
• Fig. 37.46 Crestal approach. (A) Initial osteotomy completed via fully guided template 1 mm short of the
sinus floor, (B) Sequential osteotomes are used to infracture sinus floor, (C) Placement of PRF plug, (D)
Collagen membrane placed over osteotomy site, (E) Osteotome used to elevate collagen membrane, (F)
Bone allograft placed into osteotomy site in increments, (G) Osteotomes elevate graft material, (H) Implant
placement, (I) Final implant with graft material.
Postoperative Instructions
• BOX 37.10 SA-3 (Crestal Approach) Requirements The postoperative instructions are similar to those for most oral
• Favorable conditions: (>5 mm host bone, Implant size < 4mm greater surgical procedures. Rest, ice, pressure, and elevation of the head
than host bone) are particularly important. Strict adherence to the pharmaco-
• Unfavorable conditions: (>8 mm host bone, Implant size < 4mm logic protocol as mentioned previously is vital to decrease postop
greater than host bone) morbidity is of major importance. Although smoking is not an
absolute contraindication for sinus grafting, smoking during the
healing period may negatively affect the healing and increase the
form bone. The time required before implant insertion for SA-4 or possibility of postoperative infections.
implant uncovery is dependent on the volume of the sinus graft. Blowing the nose and/or creating negative pressure while
Most healed sinus augmentations (i.e., especially SA-4) will be the sucking through a straw or cigarettes should also be eliminated
D4 type of bone; therefore osseodensification surgical approach and for the 2 weeks after surgery. Block and Kent131 reported on a
progressive bone loading techniques should be strictly followed.␣ patient who lost the entire sinus graft 2 days after surgery from
A B C
D E F
• Fig. 37.47 SA-4. (A) Membrane elevation starting on the floor of the sinus. (B and C) Membrane is
reflected to the medial wall. (D) First layer (superior) is collagen with antibiotic. (E) Second layer (middle)
allograft bone. (F) Third layer (floor), which is comprised of autogenous bone.
A B
• Fig. 37.48 SA-4. Bone placement (A) placement with a 1-cc syringe. (B) Bone packer is used until “push-
back” is obtained.
risk of incision line opening. The patient should be notified that

• BOX 37.11 SA-4 Requirements small bone particles or synthetic bone found in the mouth or
• Favorable or unfavorable conditions: <5 mm host bone expelled from the nose with bleeding is not unusual (Box 37.12).␣
Implant Insertion
The implant surgery at reentry after successful sinus grafts is simi-
blowing the nose. Sneezing, if it occurs, should be done with the lar to SA-1, with a few exceptions. The periosteal flap on the lat-
mouth open to relieve pressure within the sinus. Swelling of the eral side is elevated to directly allow inspection of the previous
region is common, but pain is usually less severe than after ante- access window of the sinus graft. The previous access window may
rior implants in an edentulous mandible. In addition, the patient appear completely healed with bone, soft and filled with loose
should be warned against lifting and pulling on the lip to observe graft material, or with cone-shaped fibrous tissue in-growth (with
the surgical site or during oral hygiene procedures to reduce the the base of the cone toward the lateral wall).
• BOX 37.12 Sinus Graft Postoperative Instructions • BOX 37.13 Membrane Perforations
1. Do not blow your nose. • Small (<2 mm) fast-resorbing collagen (e.g., Collatape, Oratape)
2. Do not smoke or use smokeless tobacco. • Medium (2–4 mm) regular collagen (e.g., OraMem)
3. Do not take in liquids through a straw. • Large (>4 mm) longer acting collagen (e.g., Renovix, OraMem Extend)
4. Do not lift or pull on lip to look at sutures (stitches).
5. If you must sneeze, then do so with your mouth open to avoid any
unnecessary pressure on the sinus area.
6. Take your medication as directed.
7. You may be aware of small granules in your mouth for 2 to 3 days after
analysis of failed sinus grafts found 48% (79 of 164 failures) were
surgery. attributed to sinus membrane perforations.130 In an endoscopic
8. Bleeding from the nostril may be present for the first 24 hours after surgery. evaluation after sinus grafts, macrolaceration of the sinus mem-
brane resulted in a typical sinusitis appearance, even when clini-
cal conditions of infection were not present.132 Once the tear or
perforation is identified, the continuation of the sinus elevation
If the graft site on the lateral-access wall appears clinically as bone, procedure is modified. The sinus membrane should be elevated
then the implant osteotomy and placement follow the approach des- off the bony walls of the antrum, despite the mucosal tear. If a
ignated by the bone density. If soft tissue has proliferated into the portion of the membrane is not elevated away from a sinus wall,
access window from the lateral-tissue region, then it is curetted and then the graft material will be placed on top of the membrane,
removed. The region is again packed to a firm consistency with autol- preventing the bone graft from incorporating with the bony wall.
ogous bone from the previously augmented tuberosity and mineral- The perforation of the sinus membrane should be sealed to pre-
ized freeze-dried bone. The implant osteotomy may then be prepared vent contamination of the graft from the mucus and contents of
and the implant placed a the D4 bone protocol. Additional time (6 the sinus proper and to prevent the graft material from extruding
months or more) is allowed until the stage II implant uncovery is into the sinus proper. When graft materials enter the sinus proper,
performed and progressive bone loading is used during prosthetic they may become sources for infection or may migrate and close
reconstruction. The time interval for stage II uncovery and prosthetic off the ostium to the nasal cavity and create an environment for
procedures after implant insertion of a sinus graft is dependent on an infection.
the density of bone at the reentry of implant placement. The crest of Numerous studies have shown a very low probability of sinus
the ridge and the original antral floor may be the only cortical bone infections after perforations in the sinus membrane. Jensen and
in the region for implant fixation. The most common bone density colleagues133 reported that graft maturation occurred and no sinus
observed for a sinus graft reentry is D3 or D4. Most often, mineral- infections were observed despite a 35% incidence of sinus perfora-
ized bone graft (or xenograft) material in the sinus graft has not con- tion during the procedure in 98 patients.
verted to bone. The tactile sense and the CBCT evaluation interpret The surgical correction of a small perforation is initiated by
the mineralized graft material as a denser bone type; therefore a tactile elevating the sinus mucosal regions distal from the opening. Once
or radiographic D3 bone may actually be D4-like bone. It is prudent the tissues are elevated away from the opening, the membrane ele-
to wait longer (rather than shorter) for implant uncovery. An SA-4 vation with a sinus curette should approach the tear from all sides
sinus graft has a recommended healing time at least 4 to 6 months for so that the torn region may be elevated without increasing the
implant insertion and another 4 to 8 months for implant uncovery. opening size. The antral membrane elevation technique decreases
Therefore the overall graft maturity time is 4 to 10 months for SA-3, the overall size of the antrum, thus “folding” the membrane over
and SA-4 healing time is 8 to 14 months before prosthetic reconstruc- on itself and resulting in closure of the perforation. A piece of
tion. Progressive loading after uncovery is most important when the resorbable collagen membrane (e.g., Collatape) is placed over the
bone is particularly soft and less dense. Inadequate bone formation opening to ensure continuity of the sinus mucosa before the sinus
after the sinus graft healing period of SA-4 surgery is a possible, but bone graft is placed. The collagen will stick to the membrane and
uncommon, complication.␣ seal the SA space from the sinus proper.
If the sinus membrane tear is larger than 6 mm and cannot be
closed off with the circumelevation approach, then a resorbable
Intraoperative Complications Related to collagen membrane with a longer resorption cycle (e.g., Renovix,
BioMend), may be used to seal the opening.
Sinus Graft Surgery The remaining sinus mucosa is first elevated as described pre-
viously. A piece of collagen matrix is cut to cover the sinus tear
Membrane Perforations opening and overlap the margins more than 5 mm. It should be
The most common complication during sinus graft surgery is tear- noted that when a sinus tear occurs, it is sealed with a dry col-
ing or creation of an opening in the sinus membrane (Box 37.13). lagen membrane so that it may be rotated into the lateral-access
This has several causes, which include a preexisting perforation, opening, gently lifted to the mucosal tissue around the opening,
tearing during scoring of the lateral window, existing or previous and allowed to stick to the mucosa. Once the opening is sealed,
pathologic condition, and elevation of the membrane from the the sinus graft procedure may be completed in routine fashion.
bony walls. According to studies, membrane perforations occur However, care should be taken when packing the sinus with graft
about 10% to 34% of the time. It has been reported with a higher material. After a perforation, the graft is easily pushed through
frequency in smokers. If membrane perforation occurs more often the collagen-sealed opening and into the sinus proper. The graft
than this, then the clinician should give consideration to alter or material is then gently inserted and pushed toward the sinus floor
reevaluate the surgical technique used in sinus grafting. and sides but not toward the top of the graft. A sinus perforation
Sinus membrane perforation usually does not affect the sinus may cause an increased risk of short-term complications. A greater
graft. However, in a report of the Sinus Consensus Conference, bacterial penetration risk exists into the graft material through
the torn membrane. In addition, mucus may invade the graft and Sinus septa may create added difficulty at the time of surgery.
affect the amount of bone formation. Graft material may leak Maxillary septa can prevent adequate access and visualization to
through the tear into the sinus proper, migrate to and through the sinus floor; therefore inadequate or incomplete sinus graft-
the ostium, and be eliminated through the nose or obstruct the ing is possible. These dense projections complicate the surgery in
ostium and prevent the normal sinus drainage. Ostium obstruc- several ways. After scoring the lateral-access window in the usual
tion is also possible from swelling of the membrane related to the fashion, the lateral-access window may not greenstick fracture
surgery. These conditions increase the risk of infection. However, and rotate into its medial position. The strut reinforcement is also
despite these potential complications, the risk of the infection is more likely to tear the membrane during the releasing of the access
low (less than 5%); therefore the sinus graft surgery should con- window. The sinus membrane is often torn at the apex of the but-
tinue, and the patient should be monitored postoperatively for tress during sinus membrane manipulation because difficulty
appropriate treatment (Figs. 37.49 and 37.50).␣ exists in elevating the membrane over the sharp edge of the web,
and the curette easily tears the membrane at this position. How-
ever, because septa are mainly composed of cortical bone, immedi-
Antral Septa ate implant placement may engage this dense bone, allowing for
Antral septa (i.e., also termed buttresses, webs, and struts) are strong intermediate fixation. Moreover, septa allow for faster bone
the most common osseous anatomic variants seen in the maxil- formation because they act as an additional wall of bone for blood
lary sinus. Underwood,134 an anatomist, first described maxillary vessels to grow into the graft.
sinus septa in 1910. He postulated that the cause of these bony
projections derived from three different periods of tooth develop- Management of Septa Based on Location
ment and eruption. Krennmair and colleagues135 further classified The use of CBCT radiographs before sinus graft surgery permits the
these structures into two groups: primary structures, which are a surgeon to observe and plan the necessary modifications to the sinus
result of the development of the maxilla, and secondary struc- graft procedure as a result of the septa. The modification to the sur-
tures, which arise from the pneumatization of the sinus floor after gery is variable depending on its location. The septa may be in the
tooth loss. anterior, middle, or distal compartment of the antrum. When the
Misch136 postulated that septa might be bone reinforcement septum is found in the anterior section, the lateral-access window is
pillars from parafunction when the teeth were present. He noticed divided into sections: one in front of the septa and another distal to
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 den-
tate patient and as high as 22% in the edentulous patient.137 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.
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.
The most common location of septa in the maxillary sinus has
been reported to be in the middle (second bicuspid–first molar)
region of the sinus cavity. CBCT 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, CBCT scans are the most accurate method of
radiographic evaluation.138 Panoramic radiography has been shown
to be very inaccurate, with a high incidence of faulty diagnoses. • Fig. 37.49 Maxillary sinus perforation from window outline osteotomy.
A B
• Fig. 37.50 Perforation repair. (A and B) Extended collagen membrane fixated on the superior aspect of
the sinus cavity.
the structure. This permits the release of each section of the lateral the antrum. As it courses anteriorly, it anastomoses with terminal
wall after tapping with a blunt instrument. The elevation of each branches of the facial artery and ethmoidal arteries. A significant
released section permits investigation into the exact location of the bleeding complication may arise if this vessel is severed during
septa and to continue the mucosal elevation. elevation of the membrane off the thin medial wall.
The mucosal tissue may often be elevated from the lateral Epistaxis (active bleeding from the nose) is a common disorder;
walls above the septa. The curette may then slide down the side however, it has been reported that 6% of patients who experience
walls and release the mucosa from the bottom half of the sep- this in the general population require medical treatment to con-
tum on each side. The sinus curette should then approach the trol and stop the hemorrhage because it lasts longer than 1 hour.
crest of the buttress from both directions, up to its sharp apex. Treatment options to treat epitasis include nasal packing, electro-
This permits elevation of the tissue over the web region without cautery, and the use of vasoconstrictive drugs. Vessel ligation and/
tearing the membrane. When the strut is located in the middle or endoscopic surgery are necessary on rare occasions.
region of the sinus, it is more difficult to make two separate The most common site (90%) of nasal bleeding is from a
access windows within the direct vision of the clinician. As a plexus of vessels at the anteroinferior aspect of the nasal septum
result, one access window is made in front of the septa. The sinus and the anterior nasal cavity (which is anterior to the sinus cav-
curette then proceeds up the anterior aspect of the web, toward ity and within the anterior projection of the nose). The posterior
its apex. The curette then slides toward the lateral wall and above nasal cavity accounts for 5% to 10% of epitasis events and is
the septal apex. The curette may then slide over the crest of the in the region of the sinus graft. If the orbital wall of the sinus
septum approximately 1 to 2 mm. A firm, pulling action frac- is perforated, or if an opening into the nares is already present
tures the apex of the septum. Repeated similar curette actions from a previous event, then the sinus curette may enter the nares
can fracture the web off the floor. Once the septum is separated and cause bleeding. The arteries involved in this site are com-
off the floor, the curette may proceed more distal along the floor posed of branches of the sphenopalatine and descending pallia-
and walls. When the septum is in the posterior compartment tive arteries, which are branches of the internal maxillary artery.
of the sinus, it is often distal to the last implant site. When this The posterior half of the inferior turbinate has a venous network
occurs, the posterior septum is treated as the posterior wall of called the Woodruff plexus. Lavage of the nares with warm saline
the sinus. The sinus membrane manipulation and sinus graft are and oxymetazoline decongestant sprays provides excellent vaso-
placed up against and anterior to the posterior septum (Figs. constrictive activity to treat the condition. A cotton roll with
37.51–37.53).␣ silver nitrate or lidocaine with 1:50,000 epinephrine may also
be effective.
Bleeding from the nose may also be observed after sinus graft
Bleeding surgery. Placing a cotton roll, coated with petroleum jelly with
Bleeding from the lateral-approach sinus elevation surgery is rare; dental floss tied to one end, within the nares may obtund nose
however, it has the potential to be troublesome. Three main arte- bleeding after the surgery. After 5 minutes the dental floss is gently
rial vessels should be of concern with the lateral-approach sinus pulled and removes the cotton roll. The head is also elevated, and
augmentation. Because of the intraosseous and extraosseous anas- ice is applied to the bridge of the nose. If bleeding cannot be con-
tomoses that are formed by the infraorbital and posterior superior trolled, then reentry into the graft site and endoscopic ligation by
alveolar arteries, intraoperative bleeding complications of the lat- an ENT surgeon may be required (Figs. 37.55 and 37.56).␣
eral wall may occur. The soft tissue vertical-release incisions of the
facial flap in a resorbed maxilla may sever the extraosseous anas- Short-Term Postoperative Complications
tomoses. The extraosseous anastomosis on average is located 23
mm from the crest of the dentate ridge; however, in the resorbed Short-term complications are defined as those that occur within
maxilla, it may be within 10 mm of the crest. When this artery the first few months after surgery.
is severed, significant bleeding has been observed. These vessels
originate from the maxillary artery and have no bony landmark to Incision Line Opening
compress the vessel. Therefore vertical release incisions in the soft
tissue should be kept to a minimum height with delicate reflec- Incision line opening is uncommon for this procedure because
tion of the periosteum. Hemostats are usually difficult to place the crestal incision is in attached gingiva and usually is at least
on the facial flap to arrest the bleeding. Significant pressure at the 5 mm away from the lateral-access window. Routinely, the soft
posterior border of the maxilla and elevation of the head to reduce tissue requires release before primary approximation and sutur-
the blood pressure to the vessels usually stops this bleeding. The ing. Because a collagen membrane is placed over the window, the
elevation of the head may reduce nasal mucosal blood flow by soft tissue will usually not approximate without tension unless the
38%.139,140 surgeon expands the facial flap by releasing the periosteum above
The vertical component of the lateral-access wall for the sinus the mucogingival junction (where the tissue becomes thicker).
graft often severs the intraosseous anastomoses of the posterior Incision line opening occurs more commonly when lateral-ridge
alveolar artery and infraorbital artery, which is on average approxi- augmentation is performed at the same time as sinus graft surgery,
mately 15 to 20 mm from the crest of a dentate ridge. Methods to or when implants are placed above the residual crest and covered
limit this bleeding, which is far less of a risk, have been addressed with the soft tissue. It may also occur when a soft tissue–supported
and include cauterization by the handpiece and diamond bur prosthesis compresses the surgical area during function before
without water, electrocautery, or pressure on a surgical sponge suture removal.
while the head is elevated (Fig. 37.54). The consequences of incision line opening are delayed healing,
The third artery of which the implant surgeon should be cau- leaking of the graft into the oral cavity, and increased risk of infec-
tious is the posterior lateral nasal artery. This artery is a branch of tion. However, if the incision line failure is not related to a lateral
the sphenopalatine artery that is located within the medial wall of onlay graft and is only on the crest of the ridge and away from the
1031
A B C
D E F
G H I
J K L
• Fig. 37.51 Large septum in center of sinus. (a) Septum. (B) Window made anterior to septum. (C) Membrane
is elevated off of floor. (D–G) Membrane is exposed anteriorly, posteriorly and to the medial wall. (H) Posterior
window is outlined. (I–L) Membrane exposed on second window allowing for grafting around the septum.
sinus access window, then the posterior crestal area is allowed to augmentation), then the membrane should be cleaned at least
heal by secondary intention. During this time, a soft tissue–borne twice daily with an oral rinses of chlorhexidine.␣
prosthesis should be aggressively relieved, with no reline mate-
rial in contact with the ridge. If incision line opening includes Nerve Impairment
a portion of a nonresorbable membrane (i.e., for lateral-ridge
The infraorbital nerve is of concern in sinus elevation surgery
because of its anatomic position. This nerve enters the orbit via the
inferior orbital fissure and continues anteriorly. It lies in a groove
in the orbital floor (which is also the maxillary sinus superior wall)
before exiting the infraorbital foramen. The infraorbital nerve
exits the foramen approximately 6.1 to 7.2 mm from the orbital
rim. Note that anatomic variants have been reported to include
dehiscence and malpositioned infraorbital foramina, along with
the nerve transversing the lumen of the maxillary sinus rather
than coursing through the bone within the sinus ceiling (orbital
floor). Malpositioned nerves have been reported as far as 14 mm
from the orbital rim in some individuals. In the severely atrophic
maxilla, the infraorbital neurovascular structures exiting the fora-
men may be close to the intraoral residual ridge and should be
avoided when performing sinus graft procedures to minimize pos-
sible nerve impairment. This is of particular concern on soft tissue
reflection and the bone preparation of the superior aspect of the
window. Special considerations should be taken during reflection
A of the superior flap, and sharp-ended retractors should be avoided.
Usually, those most at risk have a small cranial base (i.e., elderly
females).
Complication
Because the infraorbital nerve is responsible for sensory innerva-
tions to the skin of the molar region between the inferior bor-
der of the orbit and the upper lip, iatrogenic injury to this vital
structure can result in significant neurosensory deficits of this ana-
tomic area. Most often the nerve is not severed, and a neuropraxia
results. Even though this injury is sensory and there is no motor
deficit, patients usually have a difficult time adapting to this neu-
rosensory impairment (Fig. 37.57).␣
B
Management
If an infraorbital nerve impairment occurs, the implant clinician
• Fig. 37.52 Clinical image of septum. (A) Two windows bisecting the sep- should immediately follow the clinical and pharmacologic neuro-
tum. (B) Both windows reflected exposing the septum. sensory impairment protocol.␣
A B
• Fig. 37.53 Septum in posterior part of sinus. (A) Maxillary septum found on the floor in the posterior of
the sinus. (B) An access window and curette elevates the mucosa anterior to the septum. The posterior
septa is used as a posterior wall to contain the graft material.
Revision Surgery Treatment Implications

When failure or compromise of the sinus graft occurs, reentry Because of access issues, along with the higher perforation rate and
procedures are sometimes required to correct deficits. Failed or fibrotic changes in the Schneiderian membrane, patients need to
compromised sinus grafts result in altered soft and hard tissue be informed of a higher postoperative complication rate involving
characteristics, mainly the formation of adhesions of the Schnei- questionable reentry bone growth and implant success. If reentry
derian membrane to the buccal flap. This results in difficulty with is necessary, usually bony adhesions and bony fenestrations of the
reflecting the buccal flap during the reentry procedure. Stud- lateral walls will be present.
ies have shown that separation of the adhesions from the sinus The combination of fibrotic changes of the Schneiderian
mucosa led to a 47% perforation rate. In addition, it has been membrane, increased chance of perforation, and altered sinus
shown that altered characteristics of the Schneiderian membrane physiology lead to a high complication rate. The continuation
result in a nonflexible thick fibrotic membrane. In some cases, in of the sinus mucosa and oral mucosa make reentry revision sur-
which voids are present but have difficult access, regrafting proce- gery problematic and difficult. This will require the separation
dures may need to be accomplished via a closed approach through of the oral and sinus mucosa to gain access to the sinus proper
the osteotomy site.101 (Fig. 37.58).␣
A B
• Fig. 37.54 Intraosseous anastomosis. (A) Significant bleed from anastomosis (B) controlled by crushing
bony area in which bleeding originated.
A B
• Fig. 37.55Nasal bleeding. (A) Nasal bleeding immediately postop (B) usually may be controlled by gauze
pressure packs.
Edema The greater the surgery duration, the greater is the chance of
edema. Caution should be used to decrease the amount of surgical
Because of the extent of tissue reflection and manipulation, sinus duration and should not exceed the patient’s tolerance. To mini-
graft surgery often results in significant edema. The resultant post- mize edema, corticosteroid use is used 1 day before and 2 days
operative swelling can adversely affect the incision line, leading to after surgery. This short-term prophylactic steroid use will allow
greater morbidity. for adequate blood levels to combat edema, which usually will
peak at 48 to 72 hours. Dexamethasone is the ideal drug of choice
Prevention because of its high antiinflammatory potency.␣
The use of good surgical technique that involves careful reflection

and retraction will decrease the amount of postoperative edema.
Cryotherapy
Application of an ice pack, along with elevation of the head and
limited activity for 2 to 3 days, will help minimize the post-
operative swelling. This cryotherapy will cause vasoconstriction
of the capillary vessels, reducing the flow of blood and lymph
and resulting in a lower degree of swelling. Ice or cold dressings
should only be used for the first 24 to 48 hours. After 2 to 3
days, heat (moist) may be applied to the region to increase blood
and lymph flow to help clear the area of the inflammatory conse-
quences. This will also help reduce the possibility of ecchymosis
that may result.␣
Ecchymosis
Sinus graft surgery also increases the possibility of bruising or
• Fig. 37.56 Bleeding control. Bleeding may be controlled by electrocautery. ecchymosis. Because of the extent of reflection, bone preparation,
V2 V2
16.02mm
A B
C
• Fig. 37.57 Nerve impairment. (A) Infraorbital foramen anatomic variants that are close to the residual
ridge. (B) V2 sensory impairment. (C) Special broad-based retractor which minimizes trauma to the infra-
orbital nerve.
and the highly vascular surgical area, ecchymosis will occur more may place additional pressure on the sinus membrane and intro-
often with this procedure compared with other implant related duce bacteria into the graft. The patient is instructed to cough (if
surgeries. necessary) with the mouth open to minimize possible air pressure
changes within the sinus cavity.␣
Etiology
Oroantral Fistulae
The etiology of ecchymosis includes the following: blood vessels
rupture → red blood cells die and release hemoglobin → macro- Oroantral fistulae may develop postoperatively, especially if the
phages degrade hemoglobin via phagocytosis → production of patient has a history of past sinus pathology or infection. Small
bilirubin (bluish-red) → bilirubin is broken down to hemosiderin oroantral fistulae (<5 mm) usually will close spontaneously after
(golden-brown).␣ treatment with systemic antibiotic drugs and daily rinses with
chlorhexidine. However, larger fistulae (>5 mm) will normally
require additional surgical intervention (Fig. 37.60). Larger
Prevention fistulae are associated with an epithelialized tract, which is the
In most cases, ecchymosis will not be able to be completely pre- result of the fusion of the sinus membrane mucosa to the oral
vented; however, the goal should be to minimize the extent of epithelium. When this occurs, patients will most likely complain
bruising. Additionally, good surgical technique, shorter surgical of fluids entering the nasal cavity on eating or drinking. Caution
duration, the avoidance of anticoagulant analgesics, and postop- should be exercised in using the Valsalva maneuver (i.e., nose
erative cryotherapy all aid in the control of this phenomenon. blowing test) to confirm the presence of an oroantral fistula at
Patients should always be informed of the possibility of ecchymo- the time of surgery. The patient is asked to pinch their nostrils
sis. This is easily accomplished by having it be part of the postop- together to occlude the nose. The patient blows gently to see if
erative instructions (Fig. 37.59).␣ air escapes into the oral cavity via the sinus. This is not recom-
mended because this test may create an opening or make a small
Pain opening larger. The Valsalva maneuver may be used postopera-
tively to diagnose a suspected communication.
Minimal discomfort and pain is usually associated with sinus graft
surgery. However, if narcotics are indicated, any analgesic combi- Management
nation containing codeine, such as Tylenol 3, is prescribed post-
operatively because codeine is a potent antitussive, and coughing Closure of oroantral fistulae can be accomplished by using broad-
based lingual or facially rotated flaps (Figs. 37.61 and 37.62). Buc-
cal flaps to close the fistula may be more difficult after a 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 fistula is excised and the sinus
floor curetted to ensure direct bone contact. A tension-free rotated
B
• Fig. 37.58 Revision surgery. (A) Postoperative infections often result in • Fig. 37.59 Postoperative edema and ecchymosis. One of the most
the sinus and nasal epithelium being continuous, (B) Reentry into sinus common postoperative complications is edema and ecchymosis, which
requires incising the tissue to separate the oral and nasal epithelium. often may extend into the mandible and neck area.
(approximately 0%–27%) on the incidence of infection leading

to acute rhinosinusitis.141 Postoperative infections after sinus graft
surgery may result from the following:
• Acute rhinosinusitis: infection within the sinus proper
• Graft site: infection within the graft area
• Combination infection: from acute rhinosinusitis and graft
site
Graft Site Infections

Etiology of Graft Site Infection
The graft site may become infected from many sources: (1) preex-
isting site bacteria, (2) bacterial contamination of the surgical site,
A (3) graft material, (4) surgical technique, (5) bacterial contami-
nation from acute rhinosinusitis, (6) lack of systemic and local
prophylactic antibiotics, and (7) systemic, mediation, or lifestyle
factors (Fig. 37.64).
Additionally, studies have shown a direct correlation between
an increased infection rate with simultaneous implant placement
and with simultaneous ridge augmentation.
One such study showed that simultaneous ridge grafting
increased the infection rate significantly (15.3%) versus sinus graft-
ing alone (3%).142 Most often, the infection begins more than 1
week after surgery, although it may begin as soon as 3 days later.␣
Diagnosis
B The most common sign of graft site infection is swelling, pain,
dehiscence, or exudate near or including the grafting surgical
• Fig. 37.60 Oroantral fistula: (A) Postoperative fistula resulting from poor site. Patients may complain of poor taste and loss of graft par-
wound healing. (B) Radiograph showing communication between the ticles in their mouth. Incision line opening is a common sequa-
sinus and oral cavity. lae with exudate discharge. Graft site infections usually occur
within days to weeks of the surgery and are less common as a late
flap is then made for complete covering of the communication. infection. Initially, the infection may start as a graft site infection
For oroantral closure after sinus graft procedures, a lingual flap is (localized to the graft), which then leads to an acute maxillary
recommended because of the abundance of keratinized mucosa rhinosinusitis (Fig. 37.65).␣
with an adequate blood supply. Flap designs include island flaps,
“tongue-shaped” flaps, or rotational and advanced flaps, depend- Treatment
ing on the size of the exposure. A key to closing the oroantral Although the incidence of infection after the procedure is usu-
opening is the dissection of the buccal flap lateral to the fistula. An ally low, the damaging consequences on osteogenesis and the
incision that extends 15 mm anterior and posterior to the fistula possibility of serious complications require that any infection be
is of benefit. The fistula then has an elliptical incision on each aggressively treated. In case of postoperative infection, it is recom-
side of the opening. The core of tissue and the fistulous tract are mended that the clinician perform a thorough examination of the
excised. The facial flap is undermined and expanded well into the area by palpation, percussion, and visual inspection to identify
tissues of the cheek. The palatal aspect of the incision is adjacent to the area primarily affected. Infection will usually follow the path
the tongue-shaped flap. Placement of the incision for the pedicle of least resistance and is observed by changes in specific anatomic
flap should be split thickness and take into account the location sites to which it spreads.143
and depth of the greater palatine artery. Once the attached palatal Early, aggressive treatment is crucial for graft site infections
pedicle graft is rotated to the lateral and attached to the facial to prevent the loss of graft or extension of the infection into the
flap, horizontal mattress sutures are placed to invert the flap to sinus proper, causing an acute rhinosinusitis or spread of infec-
achieve a watertight seal. Sutures with high tensile strength (Vic- tion to other vital areas. Initially, systemic antibiotics along with
ryl) should be used and allowed to remain in place for at least 2 antimicrobial rinses should be used. If infection persists, debride-
weeks (Fig. 37.63).␣ ment and drainage should be completed, along with the use of
sterile saline and chlorhexidine. A Penrose drain may also be
Post-Operative Infection used in cases that do not respond to systemic antibiotics. In some
instances, oroantral fistulae result after infection cessation (see the
When evaluating postsurgical infectious complications after sinus section “Oroantral Fistulae”).
graft procedures, the implant clinician must differentiate the Antibiotic treatment in the maxillary sinus, both prophylacti-
type, location, and etiology of the infectious episode. The infec- cally and therapeutically, is much different than for most oral sur-
tion may originate within the graft site or may originate in the gical procedures. When selecting antibiotic medications for sinus
maxillary sinus proper. It could also be a combination of both infections, a variety of factors must be evaluated. These include
(Table 37.2). Very few studies have evaluated these different pro- the most common type of pathogens involved, antimicrobial resis-
cesses. Postsurgically, there exist many reports with varying results tance, pharmacokinetic and pharmacodynamic properties, and
A B
D E
• Fig. 37.61 Oroantral fistula repair. (A) oroantral fistula, (B) flap extension for tension-free closure, (C)
Extended collagen membrane, (D) Membrane positioned, (E) Lateral sliding flap to obtain primary closure.
A B
• Fig. 37.62 Membrane-assisted closure of oroantral communications. (A) Oroantral fistula in the right
maxillary alveolar process in the region of the missing first molar, which is to be closed with subperiosteal
placement of alloplastic material such as gold or titanium foil or a resorbable collagen membrane. Facial
and palatal mucoperiosteal flaps are developed. Extension of the flaps along the gingival sulcus one or
two teeth anterior and posterior allows some stretching of the flap to facilitate advancement for closure
over the defect. The fistulous tract is excised. Osseous margins must be exposed 360 degrees around
the bony defect to allow placement of the membrane beneath the mucoperiosteal flaps. The flap is sup-
ported on all sides by underlying bone. (B) Closure. Ideally, the flaps can be approximated over the defect.
In some cases, a small gap between the flaps will heal over the membrane by secondary intention. Even if
the intraoral mucosa does not heal primarily, the sinus lining usually heals and closes, and the membrane
is then exfoliated or resorbed, and mucosal healing progresses. (C) Cross-section of membrane closure
technique. Buccal and palatal mucoperiosteal flaps are elevated to expose osseous defect and large area
of underlying alveolar bone around the oroantral communication. The membrane overlaps all the margins
of the defect, and the facial and palatal flaps are sutured over the membrane. (From Hupp JR, et al. Con-
temporary Oral and Maxillofacial Surgery. 5th ed. St Louis, MO: Elsevier; 2009.)
the tissue (sinus) penetration of the various antibiotic drugs. The associated with a high incidence of gastrointestinal side effects.
antibiotic medication of choice should be effective against respira- However, with the dosing regimen (twice a day [bid]), these com-
tory and oral pathogens while exhibiting known activity against plications have been significantly decreased. Two recommended
resistant strains of the common pathogens. Two such factors are cephalosporin medications have also been suggested to treat rhi-
used when evaluating sinus antibiotic medications: (1) the mini- nosinusitis: cefuroxime axetil (Ceftin) and cefpodoxime proxetil
mum inhibitory concentration (MIC) and (2) the concentration (Vantin). Other cephalosporin drugs fail to achieve adequate sinus
of antibiotic drugs penetrating inflamed diseased sinus tissue. The fluid levels against the causative pathogens. Ceftin and Vantin
MIC is the lowest concentration of the antimicrobial agent that have good potency and efficacy, while exhibiting strong activity
results in the inhibition of growth of a microorganism. The MIC against resistant S. pneumoniae and H. influenzae.␣
is usually expressed by MIC 50 or MIC 90, meaning that 50% Macrolide Medications. Macrolide drugs are bacteriostatic
or 90% of the microbial isolates are inhibited, respectively. Previ- agents that include erythromycin, clarithromycin (Biaxin), and
ous studies and treatment modalities used amoxicillin as the first azithromycin (Zithromax). Macrolide medications have good
drug of choice. However, with the increasing prevalence of peni- activity against susceptible pneumococci; however, with the
cillinase- and β-lactamase–producing strains of H. influenzae and increasing rate of macrolide resistance, their use in combating
M. catarrhalis, along with penicillin-resistant strains of S. pneu- sinus pathogens is becoming associated with a high likelihood of
moniae, other alternative antibiotic drugs should be selected. clinical failure. These antibiotic drugs are very active against M.
β-Lactam Medications. The most common β-lactam antibi- catarrhalis, although their activity on H. influenzae is question-
otic drugs used in the treatment of rhinosinusitis and graft site able. These antibiotic medications are not suggested to treat post-
infections are penicillin (amoxicillin, Augmentin) and cephalo- operative sinus infections.␣
sporin (Ceftin, Vantin). Amoxicillin has been the drug of choice Lincosamide Medications. Clindamycin (Cleocin) is the
for years to combat the bacterial strains associated with rhinosi- primary lincosamide drug used in clinical practice today that
nusitis and infections in the oral cavity. However, its effectiveness is considered to be bacteriostatic. However, in high concen-
has been questioned recently because of the high percentage of trations, bactericidal activity may be present. Clindamycin
β-lactamase–producing bacteria and penicillin-resistant S. pneu- is mainly used for the treatment of gram-positive aerobes
moniae. Augmentin (amoxicillin-clavulanate) has the added and anaerobes. With acute sinus disease, clindamycin is
advantage of activity against β-lactamase bacteria. It has been usually not indicated because it exhibits no activity against
A B
C
• Fig. 37.63Postsinus graft infection. (A) Preoperative radiograph. (B) Postoperative sinus augmentation.
(C) 4-week postop with graft site infection and acute rhinosinusitis.
H. influenzae and M. catarrhalis. This drug may be used in pathogens. This drug should not be considered to treat postopera-
chronic sinus conditions because anaerobic organisms play a tive infections unless a culture and sensitivity test has been per-
much larger role in the disease process.␣ formed and susceptibility is shown.␣
Tetracycline-Derived Medications. Doxycycline (Vibramy- Metronidazole Medication. Metronidazole is the most impor-
cin) is a bacteriostatic agent with adequate activity against peni- tant member of the nitroimidazole group. It is bactericidal and is
cillin-susceptible pneumococci and M. catarrhalis. This drug does effective against gram-positive and gram-negative anaerobic bac-
not exhibit any activity against penicillin-resistant bacteria and is teria. Its main use would be in the treatment of chronic sinus (not
not effective against H. influenzae. However, doxycycline may be acute) conditions. The medication should be used with another
used as an alternative antibiotic for the treatment of acute rhino- antibiotic drug to be effective against aerobic bacteria.
sinusitis infections.␣ Antibiotic Conclusion. In the evaluation of different antibi-
Sulfonamide Medications. The most common sulfonamide otic drugs used for the treatment of pathologic conditions of the
drug, trimethoprim-sulfamethoxazole (Bactrim) is bacteriostatic. sinus, meticulous analysis of the activity against the most com-
Recently a high rate of resistance to these drugs has been seen mon pathogens must be evaluated. With all of the antibiotic med-
with S. pneumoniae, H. influenzae, M. catarrhalis, and other sinus ications evaluated, amoxicillin-clavulanate, and cefuroxime axetil
TABLE
37.2 Types of Postoperative Sinus Infections
Acute Rhinosinusitis Graft Site Infection Combination

Etiology • Preexisting pathology • Preexisting pathology Primary site could
• Nonpatent ostium • Oral pathogen contamination be sinus proper or
• Anatomic variants • Untreated periodontitis graft site
• Graft overfill • Perforation
• Postsurgery physiologic alteration • Lack of asepsis
• Spread of infection from graft site • Long duration surgery
• History of chronic rhinosinusitis • Simultaneous ridge augmentation
• Preexisting odontogenic or allergic rhinosinusitis • Simultaneous implant placement
• Lack of prophylactic medication
• Lack of local graft antibiotics
• Systemic diseases, smoking/alcohol
Bacteria Aerobic gram-positive cocci (Streptococcus pneumoniae) Aerobic gram-positive cocci (S. viridans) Any combination of
Aerobic gram-negative rods (Haemophilus influenzae) Aerobic gram-positive cocci (Staphylococcus pathogens
(Staphylococcus epidermidis, Streptococcus viridans, aureus)
Branhamella catarrhalis) Aerobic gram-negative rods (Bacteroides)
Aerobic gram-positive cocci (peptostreptococcus)
Prevention CBCT: Prophylactic medication Any combination of
Confirmation of ostium patency Good surgical technique preventive mea-
Confirmation of no pathology or anatomic variants Aseptic technique sures
Prophylactic medications Short surgical duration
No membrane perforation
Symptoms Mild: Site pain/edema Any combination of
Facial pain/edema Incision line opening symptoms
Congestion Exudate
Nasal drip/blockage Bad taste
Cough Bleeding
Severe: Intraoral swelling
Significant facial pain/edema
Fever
Headache
Proptosis/diplopia
Malaise
Ideal antibi- β-Lactam β-Lactam β-Lactam
otic Lincosamide
Initial treat- Antibiotic: Antibiotic: Antibiotic:
ment 1. Augmentin 1. Augmentin 1. Augmentin
2. Ceftin 2. Clindamycin 2. Ceftin
Nasal saline Chlorhexidine Nasal saline/rinse
Secondary Referral, especially if cerebral/ocular symptoms Debridement/irrigation Debridement
treatment Possible culture Possible culture
Referral, especially
if cerebral/ocular
symptoms
CBCT, Cone beam computerized tomography.
show excellent MIC 90 blood levels against the most common Saline Rinses. An important treatment for the patient with the
pathogens associated with sinus infections.␣ presence of acute rhinosinusitis and graft infections is the use of
Decongestant Medications. Recent recommendations in the saline rinses with a bulb syringe or a squeeze bottle in the nos-
medical literature state that nasal decongestants (sympathomimetic tril used to lavage the sinus through the ostium. The nasal saline
drugs) should not be used except in severe cases of congestion and rinse has a long history for treatment of sinonasal disease. Hyper-
infection. Nasal decongestants have been shown to impair blood tonic and isotonic saline rinses have proven to be effective against
flow, decreasing antibiotic levels to the site. Additionally, it may chronic rhinosinusitis. These techniques of nasal irrigation have
cause a rebound phenomenon and the development of rhinitis been evaluated, with the best option of a positive-pressure irriga-
medicamentosa. This rebound phenomenon has been theorized to tion using a squeeze bottle that delivers a gentle stream of saline
occur as a negative feedback vasodilation after repeated introduc- to the nasal cavity (NeilMed’s Sinus Rinse; NeilMed Pharmaceu-
tions of the sympathomimetic (vasoconstricting) drug.␣ ticals Inc.). The syringe or squeeze bottle should not seal the nasal
delivery and also have a high degree of rebound effect (rhinitis

medicamentosa).
If symptoms are not alleviated with antibiotic and deconges-
tant medications, possible referral to the patient’s physician or
ENT is warranted. Emergency consultation should be considered
if the patient complains of a severe headache that is not relieved by
mild analgesics, as well as persistent or high fever, lethargy, visual
impairment, or orbital swelling.
The authors highly recommend that a professional association
with an ENT be obtained. Because the possible morbidity of these
infections and causative pathogen is not easily determined, referral
is sometimes needed. Additionally, if mild sinus symptoms per-
sist or signs of severe infection are present, immediate referral is
• Fig. 37.64 Graft site infection showing exudate and incision line opening. recommended. Resolution of these conditions has been accom-
plished with the use of antibiotic drugs, endoscopic treatment, or
Caldwell- Luc procedures (Fig. 37.68).␣
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 Combination (Graft Site Infections/Acute
down and forward so that the saline can reach the ostium in the Rhinosinusitis)
superior and anterior portion of the sinus. The course of therapy
should continue for at least 7 days.144 Another option is the Neti Etiology
Pot, which is very common among chronic rhinosinusitis patients The etiology of a combination infection can either be initiated
(Fig. 37.66).␣ from the graft site or the sinus proper.␣
Acute Rhinosinusitis Infections Diagnosis

The diagnosis for a combination type infection can parallel a com-
Etiology of Acute Rhinosinusitis bination of graft site symptoms and/or acute rhinosinusitis.␣
There are two causes of acute maxillary rhinosinusitis after sinus
graft surgery: (1) preexisting maxillary sinus pathology or (2) Treatment
progression of sinus graft surgery to involve the maxillary sinus The treatment of a combination type infection should include the
proper (Fig. 37.67).␣ use of a β-lactam antibiotic (e.g., Augmentin) followed by the use
of debridement and nasal saline rinses. If ocular or cerebral symp-
toms persist, or the patient does not respond to antibiotic treat-
Diagnosis ment, referral is recommended.
Maxillary rhinosinusitis is a complication that arises when the The most current, comprehensive study on the treatment
patient postoperatively complains of any of the following symp- of sinus disease involves guidelines established by the Sinus
toms: (mild) headache, pain, or tenderness in the area of the and Allergy Health Partnership, Centers for Disease Control
maxillary sinus; rhinorrhea; or (severe) fever, headache, or ocular and Prevention, and the FDA in 2000. With this information
symptoms. Studies have supported the fact that patients who had as a guide, the following recommendations for antibiotic use
predisposing factors for rhinosinusitis were more at risk of devel- in the treatment of infections after sinus graft are suggested
oping postoperative transient rhinosinusitis. (Box 37.14).␣
The wide range of reported percentages (3%–20%) may be
the result of different methods used for diagnosis (i.e., clinical,
radiographic, endoscopic). Cases of maxillary sinusitis after dental Spread of Infection
implant surgery have rarely been reported in the dental literature.
However, recently in the medical literature, numerous cases of Because of the anatomic and topographic location of the maxillary
minor to severe complications after sinus surgery have been docu- sinus, infections from oral or sinus pathogens may spread quickly
mented. Although very infrequent, severe infections may lead to to adjacent sites.
more severe complications, such as orbital cellulitis, optic neuri- Sinus-related pathologic conditions are the most common
tis, cavernous sinus thrombosis, epidural and subdural infection, cause of orbital infection, accounting for 60% to 84% of cases.
meningitis, cerebritis, blindness, osteomyelitis, and, although Because of the seriousness of ocular infections, early diagnosis and
rare, brain abscess and death.145␣ aggressive treatment is paramount.
Various routes may predispose this area to infection from the
Treatment maxillary sinus and include the following:
If infection occurs postoperatively, treatment must be aggres- 1. The venous plexus of the maxillary sinus drains through the
sive because of the possible complications that may arise to close posterior wall into the deep facial vein, through the pterygoid
anatomic structures. Systemic antibiotic therapy is the first line plexus, and finally into the cavernous sinus.
of treatment, along with close observation of symptoms. Recent 2. Veins also perforate the osseous roof of the maxillary sinus,
medical literature discourages the use of systemic decongestants entering the orbit through the superior and inferior ophthal-
and highly recommends the use of saline lavage and rinses. Sys- mic vein. These veins also are connected to the pterygoid plexus
temic decongestants have been shown to impair site antibiotic and cavernous sinus.
A B
D E
• Fig. 37.65 Postgraft infection. (A) Cone beam computerized tomographic (CBCT) coronal image show-
ing implant with associated infection. (B) Axial CBCT image showing a completely opacified sinus. (C)
Intraoral view of draining fistula tracts (green arrows). (D) Incision and drainage. (E) Exudate and infected
tissue removal.
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 cerebral vein communicates with the white substance
of the brain’s superficial venous system.
Because of the elaborate maxillocerebral venous anastomo-
ses, 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 Into the Sinus

Bränemark and colleagues146 reported on animal histologic stud-
ies and 44 clinical cases of implants penetrating the maxillary
sinus. They reported success rates comparable to other maxillary
• Fig. 37.66Neti Pot. Used for nasal irrigation resulting in flushing out the implants, and no postoperative signs or symptoms were found
nasal passages. with these implants. An animal study by Boyne147 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. 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
B
• Fig. 37.67 Culture and sensitivity. In some cases of rhinosinusitis, a cul- B
ture and sensitivity test may be administered. (A) Swab sealed and sent to
laboratory for culture and sensitivity testing.(B) Culture swab placed into • Fig. 37.68 Functional endoscopic sinus surgery (FESS). (A) FESS scope.
the infected site. (B) Surgical placement of FESS.
• BOX 37.14 Infection Treatment Summary

(Combination)
Mild Infection
Symptoms
• Purulent and nonpurulent nasal drip
• Nasal blockage
• Facial pain and pressure
• Intraoral and extraoral swelling
• Cough␣
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. True anaphylactic allergy to amoxicillin:
doxycycline (100 mg) 1 tablet bid for 10 days
2. Nasal saline rinses␣
Moderate to Severe Infection

Symptoms
• Mild infections symptoms
• Severe headache
• High persistent fever (>102.5°F) • Fig. 37.69 Implant penetration into sinus. Coronal image showing
• Periorbital swelling implant placement into maxillary sinus leading to a completely opacified
• Ocular symptoms (diplopia, proptosis) maxillary sinus.
• Altered mental status
• Infraorbital hyperesthesia␣
Treatment Postoperative Cone Beam Computerized
1. Immediate physician referral (emergency room or ENT Physician)
Tomographic Mucosal Thickening (False
Bid, Twice daily; ENT, ear, nose, and throat (physician).
Positive for Infection)
Immediate postoperative radiographs may reveal significant muco-
sal thickening within the sinus. The clinician should not determine
this to be infection unless the previously mentioned signs of infec-
smear layer would be difficult to remove through regular phago- tion are noted. Normally, elevation of the sinus mucosa and bone
cytic activity. When this is suspected, removal of the implant or grafting does alter the overall maxillary sinus environment by reduc-
an apicoectomy of the implant apex, from a lateral-access window, ing the size of the sinus and repositioning the mucociliary transport
may be of benefit (Fig. 37.69).␣ system. In spite of this, only short-term clearance impairment exists,
resulting in only subclinical effects on the sinus physiology. How-
ever, in cases of preoperative sinusitis histories, elevation surgery
Overfilling of the Sinus may predispose a patient to sinus-related complications. It has been
shown that these procedures do alter the microbial environment.
The goal of the sinus graft is to obtain sufficient vertical height Studies reveal at 3 months after surgery, positive sinus cultures were
of bone to place endosteal implants with long-term success. The present compared with cultures taken for the same patients pre-
maximum length requirement of an implant with adequate sur- operatively. However, after 9 months the cultures were similar to
face of design is rarely more than 15 mm, and as a result, the goal the preelevation results. The key is maintenance of the ostiomeatal
of the initial sinus graft is to obtain at least 16 mm of vertical opening between the maxillary sinus and the nasal cavity.␣
bone from the crest of the ridge. This usually means the bot-
tom one-half of the sinus is filled with graft material because Migration of Implants
most sinuses approximate 35 mm in height. A CBCT scan of
the sinus before surgery may be used to estimate the amount of In 1995 the first case of a displaced (migrated) implant into the
graft material required for the ideal volume of sinus graft mate- maxillary sinus was documented. Since then, an increased number
rial. Care should be given to the amount of graft material placed of reports are coming to light, documenting an ever-increasing
into the sinus. Overfilling the sinus can result in blockage of the problem. Reports have shown that implants migrating from the
ostium, especially if membrane inflammation or the presence of maxillary sinus have been found in the sphenoid sinus, ethmoid
a thickened sinus mucosa exists. sinus, orbit, nasal cavity, and anterior cranial base.
The majority of sinus graft overfills do not have postopera-
tive complications. If, however, a postoperative sinus infection Etiology
occurs without initial resolution, reentry and removal of a por-
tion of the graft and changing the antibiotic protocol may be The etiology of implant displacement or migration from the
appropriate (Fig. 37.70).␣ maxillary sinus includes many possibilities. The timing of
A B
• Fig. 37.70 Overfilling of the sinus. (A) Cone beam computerized tomographic coronal scan image depict-
ing excess graft material occluding the maxillary ostium. (B) Significant overfill of maxillary sinus leading to
an acute rhinosinusitis.
implants ending up in the maxillary sinus proper varies from TABLE

intraoperative displacement to migration years later. Many etio- 37.3 Migration of Dental Implants
logic factors have been suggested, according to the timing (early
versus late) (Table 37.3).␣ Early Late
• Poor initial stability • Too early loading
Prevention • Overpreparation of osteotomy • Changes in intranasal or
site intrasinus pressure
For early migration/displacement complications, most likely the • Poor quality of bone • Peri-implantitis
cause is surgical error or incorrect treatment planning. When • No crestal cortical bone • Autoimmune reaction
evaluating late migration/placement complications, the majority • Implant placement into sinus
of issues are a direct result of postoperative prosthetic errors (too without bone graft
early loading) or factors that are precipitated by lack of integration • Incorrect treatment planning
or minimal bone at the implant interface.␣ • Surgical inexperience
• Untreated antral preparation
• Postoperative sinus infection
Management • Immediate placement implants
The management of displaced or migrated implants into the max-

illary sinus should be treated with urgency. Leaving implants in
the maxillary sinus may lead to acute rhinosinusitis complications. termed fungus balls or aspergilloma and is associated with immu-
Additionally, implants left in the maxillary may become calcified nocompetent patients.
(antrolith) or become displaced into other anatomic areas (e.g.,
sinuses, orbit, nasal cavity, brain).
The patients should be referred as soon as possible for removal
Diagnosis
via a Caldwell-Luc approach or endoscopy (functional endoscopic Usually, the patient will present with clinical symptoms of frontal
sinus surgery [FESS]) (Figs. 37.71–37.77).␣ headache, orbicular pain, nasal congestion, and bleeding, with signs
of chronic rhinosinusitis. Radiographically, a distinctly increased
Postoperative Fungal Infection soft tissue density mass (radiopacity) is seen on CBCT scans.␣
Fungal infection after sinus bone grafting is rarely reported; how-

ever, with the increased number of sinus graft procedures being
Management
performed, inevitably more will be reported in the literature. Fun- Referral to an ENT for evaluation and confirmation of diagnosis.
gal sinusitis is a destructive, invasive disease that is mostly caused Usually, treatment involves surgical removal via Caldwell-Luc or
by Aspergillus. Aspergillus spp. is a fungus of the Ascomycetes class, FESS techniques because systemic antimycotic drugs are ineffective.␣
which is one of the most commonly encountered in the human
environment. In the diagnosis of fungal sinusitis, there exist two Summary
forms: noninvasive and invasive. The invasive form is rare and
is almost always associated with immunocompromised patients. In the past, implant treatment in the posterior maxilla was reported
Erosion and osseous destruction occurs that may be fatal. How- as the least predictable region for implant survival. Causes cited
ever, this form has not been associated with dental implants or include inadequate bone height, poor bone density, and high
sinus graft surgery. occlusal forces. Past implant modalities attempted to avoid this
Case studies have shown postoperative complications after region, with procedures such as excessive cantilevers from anterior
sinus graft surgery148 and overextension of root canal filling implants or excess numbers of pontics when implants are placed
involving the noninvasive form. This type of fungus growth is also anterior and posterior to the antrum.
B C
• Fig. 37.71Migrated implants into maxillary sinus. (A and B) Implants displaced into maxillary sinus. (C)
Implant obstructing the maxillary ostium.
The maxillary sinus may be elevated and SA bone regener-

ated to improve available bone height. Tatum began to develop
these techniques as early as the mid-1970s.3 Misch149 developed
four options for treatment of the posterior maxilla in 1984 based
on the height of bone between the floor of the antrum and the
crest of the residual bone. These options were further modified
to reflect the width of available bone, once adequate height was
obtained. Root-form implants of adequate size are indicated in
the posterior maxilla. The higher forces and less dense bone often
require larger diameter implants.
It is the observation of the authors, using the sinus graft pro-
cedures described in this chapter for more than 30 years, in clini-
cal practice, universities, and private implant institutes, that the
sinus graft procedure is more than 97% effective. This region
of the mouth predictably grows more bone in height than any
other intraoral region. However, an organized approach needs to
be completed with respect to patient selection, pathology evalu-
ation, pharmacologic management, and surgical and prosthetic
protocol to increase success and decrease potential morbidity of
the procedures.
• Fig. 37.72 Migrated implant into nasal cavity. Implant that was displaced
into the maxillary sinus and eventually eroded through the medial wall of
sinus into the nasal cavity.
B
• Fig. 37.73 Migrated implants. (A) Ethmoid sinus. (B–D) Migrated implant into sphenoid sinus. (A, From
Haben M, Balys R, Frenkiel S. Dental implant migration into the ethmoid sinus. J Otolaryngol. 2003;32:342–
344, 2003; B–D, From Felisati G, Lozza P, Chiapasco M, et al. Endoscopic removal of an unusual foreign
body in the sphenoid sinus: an oral implant. Clin Oral Implants Res. 2007;18:776–780.)
B
• Fig. 37.74(A and B) Migrated implants into the orbital area. (From Griffa A, Viterbo S, Boffano P. Endoscopic-
assisted removal of an intraorbital dislocated dental implant. Clin Oral Implants Res. 2010;21:778–780.)
• Fig. 37.75 Migrated implants anterior cranial base. (From Cascone P, et al. A dental implant in the anterior
cranial fossae. Int J Oral Maxillofac Surg. 2010;39:92–93.)
A B
• Fig. 37.76 Etiology of displaced/migrated implants. (A) Implant placement into maxillary sinus without
bone grafting. (B) Implant placement into sites with poor bone density, therefore compromised primary
stability.
A B
C D
• Fig. 37.77 (A) Panoramic radiograph depicting migrated dental implant in the right sinus. (B) Coronal
image showing implant in the maxillary ostium area. (C) Functional endoscopic sinus surgery (FESS)
approach to retrieve implant. (D) Removal of implant from sinus cavity. (From Chiapasco M, Felisati G,
Maccari A, et al. The management of complications following displacement of oral implants in the para-
nasal sinuses: a multicenter clinical report and proposed treatment protocols. Int J Oral Maxillofac Surg.
2009;38(12):1273–1278.)
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Maxillary Sinus

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37

Maxillary Sinus Anatomy,

rarely divide the antrum into separate compartments. These ele-

rim, with anatomic variants as far as 14 mm from the orbital rim,

Organisms trapped on mucus Mucus movement

Gel phase Mucous gland

Frontal Ethmoid Osteomeatal

B Paradoxical middle turbinate

• Fig. 37.11 Nasal septum deviation is a common variant. Extreme cases

Nasal Septum Deviation

Middle Turbinate Variants

Maxillary Sinus Pathology

Odontogenic Rhinosinusitis (Periapical Mucositis)

• Fig. 37.15 Odontogenic rhinosinusitis. Cone beam computerized tomo-

graft. This may be performed through an anterior Caldwell-Luc

Fungal Rhinosinusitis (Eosinophilic Fungal Rhinosinusitis)

Primary Maxillary Sinus Mucocele Etiology

Secondary Maxillary Sinus Mucocele Neoplasms

known to be associated with an increased susceptibility to aller-

technique is often attempted because of the perceived ease of

Collagen PRF Collagen PRF Bone graft

Collagen PRF Bone graft

risk of incision line opening. The patient should be notified that

Revision Surgery Treatment Implications

The use of good surgical technique that involves careful reflection

(approximately 0%–27%) on the incidence of infection leading

Graft Site Infections

Acute Rhinosinusitis Graft Site Infection Combination

CBCT, Cone beam computerized tomography.

delivery and also have a high degree of rebound effect (rhinitis

Acute Rhinosinusitis Infections Diagnosis

3. Additionally, numerous veins perforate the anterior wall that

Implant Penetration Into the Sinus

• BOX 37.14 Infection Treatment Summary

Moderate to Severe Infection

implants ending up in the maxillary sinus proper varies from TABLE

The management of displaced or migrated implants into the max-

Fungal infection after sinus bone grafting is rarely reported; how-

The maxillary sinus may be elevated and SA bone regener-

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