Understanding of sinus surgery

1. Basic Course Understanding of sinus surgery Slides: 33 Duration: 50 min www.befrest.com

2. Concepts Purpose of training Goal of training Key Point • To master relevant notion and steps of sinus surgery - To raise understanding of sinus surgery • Maxillary Sinus • Sinus Lift • Crestal Approach, Lateral Approach www.befrest.com

3. Contents Part 1. Sinus Part 2. Maxillary Sinus Part 3. Schneiderian Membrane Part 4. Sinus Lift Part 5. Precaution related to sinus lift surgery Part 6. Steps of Sinus Lift Part 7. Ordinary type of sinus lift surgery : Osteotome Part 8. Requisition for Sinus Lift KIT Part 9. Quiz Part 10. Glossary www.befrest.com

4. Part 1. Sinus Paranasal Sinus  a group of four paired air-filled spaces that surround the A group of four paired air-filled spaces that surround the nasal cavity. Frontal Sinus Ethmoid Sinus SphenoidalSinus Maxillary Sinus • Function of Maxillary Sinus: • Humidifies, warms and filtrates the inspired air. • Resonation of voice. • Lightening the skull to maintain proper head balance. www.befrest.com

5. Part 1. Sinus • Healthy Sinus • Healthy mucosa surrounds inner wall of paranasal sinus. • Mucus drains out from mucosa to nose. • Sinus infection: • In case that ostium of sinuses clogs mucosa will bloat from infection. • Mucosdrainging from mucosa clogs the nose not running down, which ends up resulting in inflammation of sinus. www.befrest.com

6. Part 2. Maxillary Sinus • Maxillary Sinus • The biggest hollow space of Paranasal sinus. • It is lodged inside of the body of Maxilla, and lies above maxillary premolars and morals (#4 - #7). Maxillary Sinus Maxillary Sinus www.befrest.com

7. Part 2. Maxillary Sinus Shape of Maxillary Sinus Shape of sinus varies as below A, B, C and D types. B type is the most general. www.befrest.com

8. Part 2. Maxillary Sinus • Shape of Maxillary Sinus Floor • According to the shape Maxillary sinus floor anatomy varies: • Flat • Inclined • Septum Flat Inclined Septum www.befrest.com

9. Part 3. Schneiderian Membrane Schneiderian Membrane Filmy membrane akin to membrane of egg surrounds inside of maxillary sinus cavity . Schneiderian Membrane • Thickness: 0.13~0.5 mm. • Membrane appears opaque, sinus is inferred as thick. • Membrane appears black, is inferred as thin. • Feature: Inelastic, self-recovering, sticky to bone • and easily separated from bone. www.befrest.com

10. Part 4. Sinus Lift Sinus Lift: A surgery to lift sinus membrane to secure required alveolar bone height. Sinus Membrane Membrane Sinus Alveolar Bone Alveolar Bone Alveolar Bone is high enough for implantation. Alveolar bone is not enough for implantation, therefore, in such cases is needed sinus lift surgery with GBR. www.befrest.com

11. Part 4. Sinus Lift • Indications of sinus lift surgery: • In cases of implantation on premolar, molar under maxilla. • After lifting the sinus membrane, bone graft materials augment the sinus floor. Lifted Membrane Membrane Sinus Fixture Alveolar Bone Alveolar bone augmentation with bone graft www.befrest.com

12. Part 4. Sinus Lift • Clinical case of sinus Lift • Red-highlighted show thickness of alveolar bone. • Sinus Lift • Bone graft • Implant placement Delayed implantation due to limited height of alveolar bone. www.befrest.com

13. Part 4. Sinus Lift • Sinus lift surgery consists on complicated surgical procedures, therefore it requires skill and expertise. • Nowadays, sinus lift surgery as a part of implant surgery, is becoming even more common and frequent amongst implantologists . www.befrest.com

14. Part 5. Precaution related to sinus lift surgery Precaution of membrane perforation: Membrane perforation could result in losing grafted bone material into sinus cavity and sinus inflammation Countermeasure for membrane perforation: - Natural healing (one week). - Overlapping mucosa in case the perforated extent is tiny. - Applying collagen membrane (Atelocare). - Suturing. - Stanching and plugging perforated membrane with tissue glue. Inflammation or edema caused from Membrane Perforation www.befrest.com Applying absorbable collagen membrane Membrane perforation

15. Part 6. Sinus Lift Steps Approaching techniques of sinus lift: According to the approaching directions, there are two kinds of sinus augmentation surgery, 1) Crestal Approach and 2) Lateral Approach. www.befrest.com

16. Part 6. Sinus Lift Steps Crestal Approach Lateral Approach • A way to lift sinus membrane making a path from bottom to top. Making an approach from lateral wall of Sinus cavity. www.befrest.com

17. Part 6. Sinus Lift Steps Guidance of choosing sinus lift approach type: Theoretical perspective criterion is based on remaining bone depth. Crestal Approach Lateral Approach Remaining bone depth ranges5-6 mm Remaining bone depth ranges1-4 mm 5-6mm 1-4mm ◈ CrestalApproach : • Success rate of implantation on the condition of bone depth over 5 mm 94.6% Success rate of implantation on the condition of bone depth over 4 mm 73.3% www.befrest.com

18. Part 6. Sinus Lift Steps Guidance of choosing sinus lift approach type: Clinical perspective criterion is subject to competency of clinician Crestal Approach Lateral Approach In case that membrane perforation occurs in the operation of Crestal Approach, Switching to lateral approach is required to counteract membrane perforation. - Crestal approach type is preferred by the reasons that the surgery is easier and more resilient than lateral approach. - Artery lies on the site where lateral approach applies to, therefore practitioner tends to avoid lateral approach. Artery Vessel Incision Line Membrane perforation halfway through Crestal Approach Switching to lateral approach www.befrest.com

19. Part 6. Sinus Lift Steps • Pros and cons of each approach type www.befrest.com

20. Part 6. Sinus Lift Steps Clinicians prefer crestal approach to lateral approach in reluctance to complication and potential risk of lateral approach > Korean. Korean. Crestal Approach Lateral Approach www.befrest.com

21. Part 7. Ordinary sinus lift surgery: Osteotome • Bone graft through sinus lift of Crestal approach is generalized since birth of Osteotome made by Robert Summers. • -Osteotome Techinque • Drilling up to leaving 1-2mm remaining bone is performed and then Osteotomeis inserted and malleted to move up remaining bone and sinus membrane. www.befrest.com

22. Part 7. Ordinary sinus lift surgery: Osteotome • Disadvantage of Osteotome: Surgery result is unsteady being influenced from clinician’s skill. • - Difficulty in penetrating remaining bone • Probability of membrane perforation due to error in gauging thickness of remaining bone. • In case of hard bone, penetrating remaining bone is tough and requires alert to perform. • - Causing uncomfortness to patient • Malleting performed to move up remaining bone causes uncomfortness and dizziness to patient. • - Switching to drilling • In case that remaining bone is hard, the path that Osteotome is malleted, is deflected and does not penetrates. www.befrest.com

23. Part 7. Ordinary sinus lift surgery: Osteotome • Disadvantage of Osteotome Is sinus membrane lifted enough? Sinus membrane extent lifted through osteotome is not enough for bone graft rather narrow, which weakens bone regeneration. Conversion from grafted bone materials to new human bone happens by the effect of osseoconduction, so that contact between grafted bone material and remaining bone should augment as much as possible to prompt bone regeneration. Osteoconduction : a phenomenon that osteoblasts migrate and attaché to other site. Blood www.befrest.com

24. Part 7. Ordinary sinus lift surgery: Osteotome • Disadvantage of Osteotome Difficult to graft bone material: - Drilled and created path is not wide enough to push up bone material. - Part of grafted bone material is prone to falling and coming apart. www.befrest.com

25. Part 7. Ordinary sinus lift surgery: Osteotome More safe and convenient surgery instruments which provides more predictable surgery results compared to osteotome, are on development globally. www.befrest.com

26. Part 8. Requisition for sinus lift kit 1. A specialized drill which penetrates sinus floor easily not causing membrane perforation, has to compose the KIT. 2. A stopper component which control drilling depth has to compose the KIT. 3. A tool, which lifts sinus membrane safely and sufficiently wide after penetration of sinus floor, has to compose the KIT. 4. Set of tools, used to extract autologous bone or ease bone graft, brings convenience. 5. Price of the KIT has to be affordable and tools in the kit have to be durable and simplify surgery steps. www.befrest.com

27. Part 8. Requisition for sinus lift kit • Ideal sinus lift kit : CAS KIT • The optimized surgery kit for sinus membrane lift through Crestal approach featuring CAS drill with stopper to prevent membrane perforation in application of hydraulic lift. Ø3.0 Filling bone material Implant placement Drilling Hydraulic lift www.befrest.com

28. Part 9. Quiz No1) What is the biggest hollow space of Paranasal sinus which situates underneath cheek bone? Maxillary Sinus • No2) Please, select correct statement of Maxillary Sinus. • ① Hollow space which situates underneath cheek bone. • ② It is positioned underneath Maxillary molar & premolar (#4 to #7 or #8). • ③ Normal shape of maxillary sinus is round. • ④ Sinus floor is always flat-shaped. • ⑤Filmy membrane akin to membrane of egg surrounds inside of Schneiderian membrane. √ √ www.befrest.com

29. Part 9. Quiz No3) What is the filmy membrane akin to membrane of egg which surrounds inside of Sinus Cavity?  Schneiderian Membrane • No4) Please, select correct statement of sinus membrane • ① It is filmy membrane which surrounds inside of Sinus cavity. • ② If sinus appears black, then the membrane is thick. • ③ It is elastic. • ④ It is not sticky to bone and easily separated from bone. • ⑤ It has nature of self-recovery in case of impairment. √ √ √ • No5) What is the surgery applied to secure required alveolar bone height for placing implant by lifting sinus membrane and grafting bone material ? •  Sinus Lifting surgery www.befrest.com

30. Part 9. Quiz No6) Please, fill the box with sinus surgery approach type Lateral Approach • No7) Please, select correct statement of Crestal Approach • ① It is a type of surgery which makes path from bottom to top with drilling. • ② It is a type of surgery which makes window from flank securing sight to sinus. • ③ Crestal Approach surgery is more resilient than lateral approach. • ④ Risk of membrane perforation is high as sight to sinus is not secured. • ⑤ Bone graft is doable securing sight to sinus membrane. √ √ √ Crestal Approach www.befrest.com

31. Part 9. Quiz • No8) Please, select correct statement of Lateral Approach. • ① It is a type of surgery which makes path from bottom to top with drilling. • ② It is a type of surgery which makes window from flank securing sight to sinus. • ③ The part where surgery is performed is more resilient than lateral approach. • ④ Counteracting membrane perforation is easy. • ⑤ Bone graft is doable securing sight to sinus membrane. √ √ √ • No9) Please, select critical factors that ideal sinus lift Kit should have. • ① Capability of penetrating sinus floor and lift the membrane must be easy. • ② Membrane separation has to be performed safely. • ③ Extent of lifted membrane has to be narrow and convex. • ④ Surgical sequence has to be time-consuming and complicated. • ⑤ Bone graft has to be processed readily and rapidly not causing inflammation. √ √ √ www.befrest.com

32. Part 10. Glossary • Maxillary Sinus: The biggest hollow space of Paranasal sinus which situates underneath cheek bone. • Schneiderian Membrane:A filmy membrane akin to membrane of egg which surrounds inside of Schneiderian membrane. • Sinus Lift • A surgery applied to secure required alveolar bone height for placing implant by lifting sinus membrane and grafting bone material. • Crestal Approach • A surgery which makes path from bottom to top with drilling to lift sinus membrane for bone graft. • Lateral Approach • A surgery which makes window from flank securing sight toward sinus, lifting sinus membrane for bone graft. www.befrest.com