We have created a protocol for open sinus lifting. This textbook has gathered the practical experience of the surgical team of the Refformat clinic. It was developed by the scientific department of the clinic under the leadership of Maxim Vladimirovich Khyshov.

We have prepared a training manual for young doctors who are beginning to master surgical dentistry. The tutorial will tell you in detail about the operation of open sinus lifting. We have described the entire process of surgical treatment: from the initial consultation and the algorithm of surgical manipulations to the postoperative management of the patient.

Indications and contraindications

1/7.

Indications

Bone Height

More than 6 mm

One-step operation Implantation with closed sinus lifting

Staging

Closed Sinus-lifting Implantation

Manipulation

Bone Height

2– 5 mm

Manipulation

Open sinus lifting Implantation

Staging

One-step operation Implantation with open sinus lifting

Bone Height

Less than 2 mm

Manipulation

Open sinus lifting Delayed implantation

Staging

Two-stage operation Implantation 4−6 months after open sinus lifting

Absolute contraindications

Heart attack or stroke

Diseases of the cardiovascular system

Obtaining the conclusion of a cardiologist 6 months after the onset of the disease

Conditions for implantation

We are waiting for 6 months from the beginning of the disease

Our recommendations

Diseases of the endocrine system

Our recommendations

Consultation and treatment with an endocrinologist.
Conclusion and control tests after stabilization of the condition

Conditions for implantation

А. Daily glucose fluctuations are less than 3 mmol/ml. At the same time, the glucose value is less than 8 mmol/ml, glycated hemoglobin is less than 7.5 mmol/ml
Б. Normalization of calcitonin levels

Radiation/chemotherapy in the anamnesis

Oncological diseases

Our recommendations

If the maxillofacial area is irradiated, implantation is not possible In other cases, we are waiting 6 months

Conditions for implantation

Obtaining an oncologist’s opinion 6 months after the onset of the disease

Reception of bisphosphonates

Osteoporosis

Our recommendations

Consultation of the attending physician about substitution therapy for a long time, more than 6 months

Conditions for implantation

Cancellation of bisphosphonates 6 months before implantation. The conclusion of the attending physician. Stabilization of biochemical parameters

A. Diabetes mellitus:
glucose more than 10, glycated hemoglobin more than 8 mmol/ml Daily fluctuations in glucose levels more than 2 mmol/ml;
Б. Diseases of the thyroid gland

Relative contraindications

Pregnancy

Lactation

Age before 18

Herpetic rashes

We are planning implantation after pregnancy.
In case of acute inflammatory pathology, we remove the tooth at any stage of pregnancy.

The antibiotic amoxicillin is compatible with breastfeeding. During lactation, bone resorption prevails over osteogenesis. In our practice, no significant differences were found during implantation.

In the acute stage, we do not perform implantation.

The candidate’s age is determined by skeletal maturation, not passport age. The closure of the main growth zones is determined by the X-ray of the hand. We perform implantation after the closure of growth zones.

Acute infectious processes in the oral cavity

Specific diseases

During the period of deterioration of the general condition of the body

Infectious diseases

2-3 days before the operation, we perform oral sanitation and prescribe rational anti-inflammatory and antibiotic therapy.

Implantation is carried out in consultation with the attending physician.

Implantation is carried out in consultation with the attending physician. Rational antibiotic therapy is important.

Implantation is performed after stabilization of the condition. With arterial hypertension, in consultation with the attending physician, under sedation and under the supervision of an anesthesiologist-resuscitator.

Example: cold, flu, high blood pressure.

Example: with viral liver damage, fluoroquinolones are allowed: Levofloxacin, Clinafloxacin, Ofloxacin, – and penicillin group antibiotics: Ampicillin, Ampisid, Ampic, Azlocillin.

Example: syphilis, actinomycosis.

The first days of the women’s cycle

Cosmetic injections

The pain threshold and blood clotting are reduced. We recommend postponing surgical procedures for a few days.

We recommend postponing the operation for 7−10 days, the formation of hematomas is possible.

Polypous changes in the sinus mucosa (photo 1).

Exacerbation of chronic sinusitis.

Relative local contraindications

Multiple caries, poor oral hygiene is a source of infection. We’ll talk about this later.

Obstruction of the natural anastomosis – the ostiomeatal complex (photo 2).

Anomalies and underdevelopment of the facial skeleton, flattening of the middle third of the face and underdevelopment of the maxillary sinuses.

Allergic rhinitis, pollinosis.

We refer the patient to an ENT doctor, then proceed to surgery.

An artery running along the anterior wall of the maxillary sinus.

On the CBCT, when planning surgery, we note the position of the artery. When performing an open sinus lift, we bypass it to avoid profuse bleeding.

Artery in the wall

Osteomeatal complex — this is a natural fistula between the nasal passages and the maxillary sinus. Its permeability affects healing.

Osteomeatal complex

Choosing the optimal position of the implant in the bone

Upper jaw

Preoperative preparation and planning

3/7.

We find out the patient's complaints and expectations. It is important to discuss the duration and stages of treatment, inform about possible complications.

We collect information about the bad habits and chronic diseases of the patient.

The orthopedic doctor makes a comprehensive treatment plan. The implantologist surgeon plans implantation.

Collecting anamnesis and talking with the patient

16:45

Сбор анамнеза, обсуждение ожиданий пациента, знакомство

11:06

Данные внешнего осмотра челюстно-лицевой области

02:34

Диагностика патологий ВНЧС, особенности открывания рта

Biotype and condition of soft tissues

Dental formula

The required amount of oral cavity sanitation before implantation

Examination of the oral cavity

04:53

Осмотр слизистой оболочки полости рта и красной каймы губ

Sufficient interalveolar height in the implantation area

02:29

Прикус, его патологии, зубная формула

03:05

План лечения, этапность хирургии, ортопедии, терапии

01:06

Заключение

Bone height in the implantation area

Proximity of the maxillary sinus

Proximity of the mandibular nerve

Snapshot Analysis

The presence of inflammation, cysts, fractures of the tooth

The presence of several chambers, sept in the sinus

Bone height in the implantation area

Proximity of the maxillary sinus

The presence of inflammation, cysts, fractures of the tooth

Analysis of a three-dimensional image of a cone-beam tomography

The presence of several chambers, sept in the sinus

Thickness of the cortical layer

Spongy bone density (a tool in the viewer)

Resorption of the cortical plate

Thickness of the vestibular bone

Discussion of the need for treatment under sedation

Indications for treatment under sedation are

A large volume of surgical intervention

Burdened allergoanamnesis

Pathologies of the cardiovascular system, stomatophobia

The operation time is more than 90 minutes

90 minutes is the average time of infiltration anesthesia, after which blood circulation is well restored

Necessary analyses

Electrocardiogram (ECG)

Detailed biochemical blood analysis

General blood test

The analysis for hospitalization is an analysis for HIV, syphilis and hepatitis B and C.

How not to conduct an initial appointment

00:18

How not to conduct an initial appointment

Occlusal and side mirror

Soft tissue retractors

ISO 100

Photo protocol

Aperture F22-29

Shutter speed 1/160

You will need:

Camera Settings for Canon:

20:24

Why conduct a photo protocol

Front photo with retractors. You are not bending over the patient, but asking him to turn around.

You take side photos without removing the retractors, but only loosening the tension on the opposite side. Focus on premolars.

Camera angles of the photo protocol

How to cover the operating table

00:55

How to process a patient

01:13

Aseptics and antiseptics
Hand Preparation

01:27

How to set up the operating table

Instruments for the operating table

Optragate

Sterile gauze wipes

Antiseptic preparation for the treatment of the patient’s hands and face

We also use:

Aqueous solution of chlorhexidine bigluconate 0.2%

Bone-plastic material Bio-Oss or other osteoconductive dispersed material

Implantology Kit

Equipment for the operation

Liston centrifuge, model C 2204. We use it in the 3000 rpm mode, 20 minutes to make a PRF membrane.

Physiodispenser

This centrifuge is a matter of pride of Russian production.

Spherical boron. The tip. We choose a speed of 900−1000 revolutions per minute, irrigation. Select the reverse mode so as not to injure the sinus mucosa.

Tools for creating a bone window

It is important — the revolutions can reach 1300 if the thickness of the vestibular bone is more than 2 mm, before the mucosa begins to shine through. We choose up to 1300 revolutions per minute if the thickness of the vestibular bone is more than 2 mm.

For novice doctors, we recommend starting at 700 revolutions per minute. Alternatively, we use a bone scraper to gain access to the sinus and collect bone tissue. If you are performing an open sinus lifting operation for the first time, start with 700 revolutions per minute.

Tools for peeling the Schneider membrane

Blunt Sinus-Lift Elevator (9560) working part

Kohler 3604
working part

Sinus lift curette (black line) working part

Blunt Sinus-Lift Elevator (9560)

Protocol for step-by-step creation of access to the sinus

4/7.

The anesthetic capsule is divided into 5−7 injections in order to avoid hydraulic fracturing of the underlying tissues.

Conducting anesthesia

1−1.5 carpules are injected from the vestibular side according to the type of infiltration anesthesia. We conduct conducting anesthesia in the area of the large palatine opening. 1/3 of the capsule is injected from the palatine side.

PRF/ Platelet Rich Fibrin is a fibrin clot enriched with platelets.

After anesthesia, we take 8 ml of venous blood to make PRF, use a 9 ml Vacuum tube with filler. Under the influence of adrenaline, the membrane turns out to be of better quality than when taking blood before anesthesia.

Manufacturing of PRF membrane

According to the personal practice of the anesthesiologists of the clinic Refformat.

Blood is centrifuged at a speed of 3000 rpm for 10 minutes.

Accelerates healing and improves regeneration.

The durable fibrin matrix contains: High platelet concentration — 90%, High-concentration platelet growth factors (PDGF), Vascular Endothelial (VEGF) Transforming (TGF) fibronectin, vitronectin and thrombospondin.

L-PRF is a fibrin rich in leukocytes and platelets

For open sinus lifting, 1 membrane is needed. If you install implants in the wells of the removed teeth, then 1−3 membranes are needed for each well.

We recommend squeezing the membrane of excess fluid and removing the erythrocyte residue. Before placing the membrane into the wound surface, we prepare it. Cut off the erythrocyte residue and squeeze out the excess fluid.

The horizontal incision shifted to the palate by 1−2 mm relative to the middle of the alveolar process for better regeneration of soft tissues in the postoperative period. Vertical laxative incision upwards. To the hillock of the upper jaw or through the gingival groove of the molar, without damaging the peak of the papilla.
In the medial direction, it passes into an intracerebral incision in the premolar region (if present) or canine.

Incision

Small spherical boron up to 1.5 mm in diameter. Rotation speed 1000 rpm, reverse for atraumatic work. The window size is from 8−9 mm, BUT NOT MORE THAN 1.5 cm. With a large volume, it is better to make two windows at a distance from each other than one large one.

Access

The darker the Schneider membrane in the preparation area, the thinner the membrane and the increased risk of perforation. If it is light, we suspect polyposis and check with the CBCT. With a sickle-shaped ironer, we remove the prepared bone fragment, after completing the open sinus, we will return it to its place.

00:23

Access

Full-layer flap.

Chips from a scraper the chips are placed in a cup on a sterile table filled with saline.

DO NOT use a bone scraper with a thin cortical plate.

Alternative access

00:31

Alternative access

There are no sharp and rough movements - we delicately collect bone chips.

Peel off the full-layer flap

With a sickle-shaped ironer, we remove the prepared bone fragment, after completing the open sinus, we will return it to its place.

Alternative access: piezosurgery

00:38

Alternative access with a golden pine forest

With piezo nozzles (must have a spherical working part) carefully dissect the bone tissue

Peeling of the membrane

The dark color of the membrane indicates its small thickness and the risk of perforation

Grey membrane color - denser, low risk of perforation

With the first movement, we gently start the instrument in the lower part of the bone window, with smooth movements we disconnect the membrane from the bone from the inside of the sinus

We are moving simultaneously in three directions, that is, the first movement forward, the second in the medial direction, the third — in the distal

The detached membrane represents the upper boundary for the installation of the implant, the location of the bone plastic material

We conduct a nasal-oral test.

We introduce bone-plastic material, install the implant and insert a collagen sponge soaked in physical solution.

The working part of the tool always rests on the bone when peeling. It is impossible to move the tool without fixing it on the bone!

00:10

Naso-oral test

00:54

Peeling of the membrane