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

The sponge should be moistened with saline or liquid from L-prf.
When applying, we hold it with tweezers, we start it inside the sinuses with a spoon.

The introduction of a collagen sponge to hold the sinus membrane at the desired level

If it is necessary to remove teeth, then it is carried out before sinus lifting.
In this protocol, we analyze implantation in the adentia zone. If you are going to be implanted in the wells of removed teeth, please refer to our protocol of immediate implantation.

Formation of the bed for implant placement

We collect the autobone from the drill turns and when using a bone scraper.

In a metal bowl, mix with bone-plastic material, 1:1.

Collecting of the autobone during the formation of the bed

Moisten the bone material with saline or liquids with a fraction of PRF.

With a large amount of work (bilateral extensive sinus lifting), additionally, using bone traps, we take the bone from the outer oblique line on the lower jaw.

We pass with a forming cutter for the entire length of the implant, mode 500-700 rpm.

Basic drilling: 250 rpm, no irrigation for bone collection.

The scheme of the formation of the bed for the implant

It is important to check the position of the implant with a parallelism pin at each stage of drilling.

Прецизионное сверло Precision Drill (дополнительно)

Пилотное сверло
Drill with tip Tapered, Ø 2,0 мм

Индикатор направления
Direction indicator

Корневидное сверло
Tapered Drill, Ø 3,5 мм

Корневидное сверло Tapered Drill, Ø 4,3 мм

We do not use a finishing drill.

Parallelism check and relationships with teeth antagonists.

Collecting of bones.

Application of material

We introduce a mixture of autologous bone with Bio Oss in the proportion of 60% to 40% (if the height of the alveolar ridge is less than 3 mm).

We use granules of osteoplastic material no larger than 2 mm, since large granules are prone to exposure.

We check the absence of contact of the implant with the membrane, the top of the implant should be at the level with the osteoplastic material. We take this into account when choosing the length of the implant.

We observe how the material is saturated with blood before suturing.

We introduce a mixture of autologous bone and Bio-oss into the sinus area BEFORE installing an implant for the framework support of the sinus mucosa.

Surgical stage

5/7.

We use a ratchet key (ratchet) for the final positioning of the implant.

Deepen the implant into the bone. An implant with a polished neck requires minimal penetration.

Installation of the implant

An implant with a rough neck is deepened by 1.5-2.5 mm.

The implant with a polished neck is deepened. 0.5-1 mm below the level of the bone.

Determination of the depth of penetration

Greater implant depth with a polished neck is possible to increase the biological width.

When conducting an open sinus lift, we work in the area of chewing teeth, this area is not aesthetically significant. We do not install temporary orthopedic constructions at once until osseointegration occurs. •The shaper is installed at a torque of more than 30 n/cm and in the absence of antagonists.

<15 H/cm2

Low

20

Stability value

Cover screw

Possible suprastructure

25-30 H/cm2

Short gum former, minimum chewing load

Stability value

Possible suprastructure

Medium

35

<35 H/cm2

It is possible to make a crown (aesthetically significant area). The temporary crown is NOT involved in the bite

Stability value

Possible suprastructure

High

70

<70 H/cm2

Avoid such values, perform bone decompression

H/cm2

Stability value

Possible suprastructure

Concept of biological width

We introduce the PRF membrane into the window area, slightly moving it beyond the edges of the window to fix it.

Distribute PRF one tube per window.

PRF

We squeeze the membrane that closes the window. It impregnates the bone-plastic material.

Suturing with interrupted sutures without tension synthetic monofilament thread of medium or long term resorption based on glyconate (e.g. Monosyn 5/0).

Suture

We sutured with vertical mattress sutures in the region of the papillae.

If the clinic does not have a tomograph, a standard OPTG. This is the minimum you need to do.

CBCT after surgery

Postoperative management

6/7.

Amoxiclav 875 mg.

Omez 1 tab.

Dexamethasone 2 tab.

1 tab 2 times a day for 7 days OR sumamed for 3−5 days. With perforation or inflammation in the sinus, a penicillin series for 10 days, sumamed for 5 days.

1 time per day for 3 days from tomorrow.

30 minutes in the morning Before meals for the duration of the antibiotic.

Ibuprofen 400 mg.

For the first 48 hours

Quitting smoking

Oral baths

For pain - 1 tab.

Apply ice every 2 hours for 20 minutes in the area of ​​the operation.

With an aqueous solution of Chlorhexidine 0.02% (Paradontax) from tomorrow 3-4 times a day after meals for 5 seconds. until the sutures are completely removed.

Within 2 weeks.

Brush the teeth

Do not blow your nose

In the area of ​​the operation only with a surgical soft toothbrush from tomorrow for 10 days.

But blot your nose.

Sneeze with your mouth open

Do not go to the sauna for 10-14 days

Do not fly on an airplane and do not dive for 2 weeks (so that the pressure in the sinus does not increase). Do not dive until fully healed or cleared by your doctor - usually about 3-4 months; It is important to avoid physical activity for 2-3 days to reduce the risk of high blood pressure. It rises in all vessels at the same time and a high value can lead to bleeding.

Do not lie in a hot bath, do not consume very hot food and drinks - we avoid local and general heat loads. From overheating, vasodilation will occur, which can provoke bleeding, and it is easy to burn the surgical wound with hot food.

Coordination with an ENT specialist

Topical steroids

(beclomethasone, mometasone, fluticasone) 2 doses 2 times a day for the duration of the antibiotic for swelling (Nasonex).

An antibiotic

is prescribed a few hours before surgery — with a polypous process 36 hours before (3 tablets before surgery). If not, in the morning on the day of the operation, 1 tablet of amoxiclav 875 mg.

Vasoconstrictor drugs

(Xylometazoline, Naphthyzin, Otrivin) are not recommended, because due to local vasospasm, the concentration of the antibiotic in the surgical area is reduced.

Taking antibiotics

for at least 7 days with standard surgery protocol (open sinus lift, with closed sinus lift 5 days), 10-14 days in the presence of perforation.

Removal of sutures after 14 days

Follow-up examination 5-6 weeks after suture removal

Follow-up examination + OPTG or CT scan after 3 months with a stability of more than 30 n/cm

Postoperative management of the patient

Follow-up examination + OPTG or CT scan after 5-6 months with stability less than 30 n/cm, native bone height less than 2 mm, then implant opening. After 10 days, the removal of sutures and the orthopedic stage

Even with a primary stability of more than 30 n/cm, the orthopedic stage is not earlier than 4 months after the operation!

Complications

7/7.

The most common complication during surgery is perforation of the membrane of the maxillary sinus.

During the operation

00:53

Perforation of the membrane

Action algorithm and the principle of perforation closure depends on the size of the defect:

We use a hemostatic sponge and a PRP membrane ((using a membrane (collagen or demineralized laminae) or fibrin glue)

Perforation up to 5 mm

First, peel off the Schneiderian membrane as much as possible, if necessary, expand the window towards the perforation in the bone up to 1cm2 or make an additional window.

Perforation f from 5mm to 10mm

Peel off the membrane as much as possible, fill the defect with a hemostatic sponge and sutured hermetically, the implant is not installed, re-call after 2.5 months, fresh CT scan and implant.

Perforation more than 10 mm

Perforation more than 10 mm

With proper management of perforation, its presence does not affect the success of the operation!

We plug the sinus with a collagen sponge to a negative nasal test.

We do not use osteoplastic material to avoid its spread through the sinus.

Sinus Conservation Algorithm

Signs: complaints of swelling, pain that increases when the head is tilted, possibly fever, weakness.

On examination: the lymph nodes are enlarged on the side of the performed manipulations, painful on palpation, swelling along the transitional fold in the area of ​​the previously performed sinus lifting.

Early infection: we check the safety of the sutures, determine the purulent discharge in the area of ​​the sutures.

After surgery: Sinusitis

We carry out a puncture in the window area, so we determine the pathological discharge in the sinus. We expand with a small incision in the presence of a discharge. We wash the wound with chlorhexidine solution 0.05% or metronidazole.

We extend the course of the antibiotic Amoxiclav 875 mg for 3 days.

Late infection: we carry out a puncture in the window area, we determine the discharge in the sinus. In the presence of discharge: expand with a small incision, wash the wound with 0.05% chlorhexidine or metronidazole.

We prescribe Sumamed 500 mg, take 1 tablet a day for 6 days.

We prescribe droppers with anti-inflammatory and anti-edematous components - once, with abundant discharge once a day for 3 days.

In case of extension of the process, attachment of the mobility of the implants, we recommend sinus debridement and removal of the implants. In case of a sluggish process and the occurrence of chronic rhinosinusitis without the involvement of implants, we do not remove the implants. We refer the patient to an ENT doctor for endoscopic sinus debridement.

At the stage of suture removal or at the second stage of a two-stage implantation: We remove the gum shaper, tighten the implant and tightly suture the wound. We prescribe Sumamed 500 mg for 3 days, 1 tablet per day.

Manipulation is advisable when mobility occurs in the first two weeks after surgery and when the patient needs help during the day.

In other situations, we remove the implant.

After surgery: Mobility of implants

After surgery: Bleeding

After surgery: Bleeding

Blood pressure control

Contraindications

After stabilization

Locally: cold, cauterize the wound surface in case of capillary bleeding (for example, Kaprofer) or bandage the vessel in case of injury.

If bleeding continues after stabilization of blood pressure parameters, use Dicinon: 2 tablets per day, course up to 3 days.

History of thrombophlebitis, heart attack, stroke.

We perform CBCT and assess the location of the implant. If it lies close to the osteomeatal complex, we refer the patient to an ENT doctor.

After surgery: Implant migration

If the implant is located in the hole or next to it, we remove the implant by intraoral access. In case of any doubts, we send the patient to an ENT doctor.

Algorithm of doctor’s actions in case of complications of implant treatment.

Inspection

We unscrew the plug

Photo protocol

During the inspection, we carry out probing. We place the probe in the hole of the plug or shaper and shake it, assessing the mobility of the implant. Before probing, check that the plug or shaper is securely screwed to the implant.

We carry out a photo protocol in the frontal, lateral and occlusal projections.

Unscrew the plug, install the Osstell (Penguin) sensor and measure the implant mobility. We enter data into the patient’s card. On average, the stability value of implants is about 70 ISQ units (ISQ).

Mobility

Implant

Anesthesia

In other cases

Mobility was determined at the stage of installation of formers (two-stage implantation): we save the implant.

The implant is mobile and the one-stage operation was less than 14 days ago. If the patient applied immediately (24 hours) in case of discomfort, then we keep the implant.

In other cases, we perform the removal of the implant. It is necessary to invite a nurse to take blood and make a prf membrane.

When saving the implant

When removing the implant

Remove the gingiva former, tighten the implant with low torque values, install the plug, freshen the wound edges and sutured tightly.

Unscrew the implant, perform curettage, insert PRF, sutured if necessary. We fix the data in the map.

Assign sumamed 500 mg

1 tab 1 time per day for 3 days, Omez 1 tab in the morning 3 minutes before meals for 3 days.

Patient's message

When a patient complains of pain or mobility of the implant in the area of ​​the intervention, we examine the patient, draw up a photo protocol and perform CBCT.