Maxillary sinus vascular anatomy and its relation to sinus lift surgery

More documents

Recommendations

Info

Rosano et al Haemorrhage risk during sinus surgery Fig. 5. Macro-anatomical dissection of the sinus lateral wall: the alveolar antral artery is close to the Schneiderian membrane and no bony layer between such vessel and the membrane is visible after antrostomy. could often be completely adherent to the sinus membrane (that means not radiographically visible) instead of being located inside the buccal wall cortex. This would justify the contradiction between a 100% prevalence of this artery found by dissection and an only 47% prevalence detected by CT scan in the present study. The authors’ opinion is that such contradiction may not depend on the AAA small diameter, which makes it radiographically undetectable in some cases, as suggested by Elian et al. (2005) and Mardinger et al. (2007), but on an entirely intra-sinusal location of the vessel. The course of the AAA, as identified in this study, is in agreement with the CT study by Ella et al. (2008) where intra-osseous, intra-sinusal and sub-periosteal courses of this artery were detected. As stated by Ella et al. (2008), a ‘‘superficial’’ location of such anastomosis, which is under the periosteum of the sinus lateral wall should also be considered. In the present study, such sub-periosteal course was identified by means of both CT scan analysis and anatomical dissection in the maxillary tuberosity area but never in the area usually selected for sinus antrostomy. When carrying out sinus lift surgery, the bony window height should be almost 13 mm from the ridge if the purpose is to place 11–13 mm dental implants. Thus, in patients with severely atrophic posterior maxillae (classes V, VI), the possibility of lacerating the AAA must be considered, especially when the residual ridge is o3mmhigh. The diameter of the anastomosis was 2 mm in a very few cases (3.3% by dissection and 2% by CT scan); anyway, this eventuality, even if infrequent, is worthy to be taken into serious consideration. As a matter of fact, if the damage of a bony vessel o2 mm can be barely relevant under a clinical point of view, the transection of an AAA with a diameter over 2 mm is likely to produce bleeding and impairment of vision, which may lead to a potential membrane perforation, thus prolonging the overall operation time, interfering with the placement of bone graft and constituting atruesurgicalcomplication. In addition, the haemorrage from this artery (a) may displace the grafting material due to a ‘‘washing’’ effect caused by the blood pressure, thus reducing or compromising the filling of the space below the Schneiderian membrane after sinus floor elevation, and (b) may produce relevant haematomas of the cheek area causing discomfort to patients and creating an ideal ‘‘pabulum’’ for bacteria growth and consequent infection. It is the authors’ opinion that the excision of a large diameter AAA in combination with the inadvertent tearing of the sinus membrane has the potential to induce sinus mucosa swelling, extrusion of blood into the sinus cavity as well as a postoperative sinusitis as a major drawback. In fact, if the maxillary sinus is, even partly, filled up by mucosal oedema, haematoma or seroma, a delay of maxillary sinus clearance may occur because of the reduction of maxillary ostium patency, and maxillary sinusitis may develop as well, compromising the success of the grafting procedure (Timmenga et al. 2003). Thepreservationofsuchanastomosisisimportant not only to avoid bleeding complications but also to support bone graft neoangiogenesis (Taschieri & Rosano 2010); in this perspective, its concomitant reflection with the Schneiderian membrane during sinus augmentation procedures, if possible and especially when its diameter is consistent, should be seriously considered. In conclusion, the authors recommend to rely upon CT scan imaging, which has been proved to be the most appropriate radiographic method for detecting any anatomical variation within the sinus (Schwarz et al. 1987; Quirynen et al. 1990; Alder et al. 1995; Dula et al. 2001), before sinus lift surgery is performed, in order to presurgically evaluate the location, size and thus the clinical relevance of this anastomotic vessel. Extreme caution should be taken when the residual ridge height is o3mm. References Aghaloo, T.L. & Moy, P.K. (2007) Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? The International Journal of Oral & Maxillofacial Implants 22 (Suppl.): 49–70. Alder, M.E., Deahl, S.T. & Matteson, S.R. (1995) Clinical usefulness of two dimensional reformatted and three dimensionally rendered computerized tomographic images: literature review and a survey of surgeons’opinions. Journal of Oral and Maxillofacial Surgery 53: 375–386. Cawood, J.I. & Howell, R.A. (1988) A classification of the edentulous jaws. The International Journal of Oral and Maxillofacial Surgery 17: 232–236. Chanavaz, M. (1996) Sinus grafting related to implantology. Statistical analysis of 15 years of surgical experience (1979–1994). Journal of Oral Implantology 22: 119–130. Del Fabbro, M., Rosano, G. & Taschieri, S. (2008) Implant survival rates after maxillary sinus augmentation. European Journal of Oral Sciences 116: 497–506. Dula, K., Mini, R., Van der Stelt, P.F. & Buser, D. (2001) The radiographic assessment of implant patients: decision making criteria. The International Journal of Oral & Maxillofacial Implants 16: 80–89. Elian, N., Wallace, S., Cho, S.C., Jalbout, Z.N. & Froum, S. (2005) Distribution of the maxillary artery as it relates to sinus floor augmentation. The International Journal of Oral & Maxillofacial Implants 20: 784–787. Ella, B., Sédarat, C., Da Costa Noble, R., Normand, E., Lauverjat, Y., Siberchicot, F., Caix, P. & Zwetyenga, 4 | Clin. Oral Impl. Res. 10.1111/j.1600-0501.2010.02045.x c 2010 John Wiley & Sons A/S
Rosano et al Haemorrhage risk during sinus surgery N. (2008) Vascular connections of the lateral wall of the sinus: surgical effect in sinus augmentation. The International Journal of Oral & Maxillofacial Implants 23: 1047–1052. Gaudy, J.-F. (2003) Anatomie Clinique. Rueil-Malmaison Cedex: Groupe Liaisons, Editions CdP, 11pp. Lekholm, U. & Zarb, G.A. (1985) Patient selection. In: Brånemark, P.-I., Zarb, G.A. & Albrektsson, T., eds. Tissue Integrated Prosthesis. Osseointegration in Clinical Dentistry, 199–209. Chicago: Quintessence. Mardinger, O., Abba, M., Hirshberg, A. & Schwartz- Arad, D. (2007) Prevalence, diameter and course of the maxillary intraosseous vascular canal with relation to sinus augmentation procedure: a radiographic study. The International Journal of Oral and Maxillofacial Surgery 36: 735–738. Pjetursson, B.E., Tan, W.C., Zwahlen, M. & Lang, N.P. (2008) A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Journal of Clinical Periodontology 35: 216–240. Quirynen, M., Lamoral, Y., Dekeyser, C., Peene, P., van Steenberghe, D., Bonte, J. & Baert, AL. (1990) The CT scan standard reconstruction technique for reliable jaw bone volume determination. The International Journal of Oral & Maxillofacial Implants 5: 384–389. Rosano, G., Taschieri, S., Gaudy, J.-F. & Del Fabbro, M. (2009) Maxillary sinus vascularization: a cadaveric study. Journal of Craniofacial Surgery 20: 940–943. Schwarz, M.S., Rothman, S.L.G., Rhodes, M.L. & Chafetz, N. (1987) Computed tomography: part II. Preoperative assessment of the maxilla for endosseous implant surgery. Journal of Oral & Maxillofacial Implants 2: 143–148. Solar, P., Geyerhofer, U., Traxler, H., Windisch, A., Ulm, C. & Watzek, G. (1999) Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clinical Oral Implants Research 10: 34–44. Taschieri, S. & Rosano, G. (2010) Management of the alveolar antral artery during sinus floor augmentation procedures. The International Journal of Oral and Maxillofacial Surgery 68: 230. Timmenga, N.M., Raghoebar, G.M., Liem, R.S.B., van Weissenbruch, R., Manson, W.L. & Vissink, A. (2003) Effects of maxillary sinus floor elevation surgery on maxillary sinus physiology. European Journal of Oral Sciences 111: 189–197. Traxler, H., Windisch, A., Geyerhofer, U., Surd, R., Solar, P. & Firbas, W. (1999) Arterial blood supply of the maxillary sinus. Clinical Anatomy 12: 417– 421. Wallace, S.S. & Froum, S.J. (2003) Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Annals of Periodontology 8: 328–343. c 2010 John Wiley & Sons A/S 5 | Clin. Oral Impl. Res. 10.1111/j.1600-0501.2010.02045.x
Page 1 and 2: Gabriele Rosano Silvio Taschieri Je
Page 3: Rosano et al Haemorrhage risk duri

Maxillary sinus vascular anatomy and its relation to sinus lift surgery

Create successful ePaper yourself

Delete template?

Save as template?