Cuốn sách này mô tả rất chi tiết hầu hết các kỹ thuật hiện đang được sử dụng để thực hiện các thủ thuật nâng xoang và được bổ sung bởi nhiều hình ảnh minh họa và hình vẽ hữu ích. Cuốn sách cũng có một chương giá trị về các biến chứng có thể xảy ra và cách điều trị chúng. Tất cả các phần thông tin rất hữu ích cho các bác sĩ lâm sàng muốn tìm hiểu thêm về chủ đề này. Điều thú vị hơn nữa đối với con mắt phê bình của tôi là chương về viễn cảnh tương lai, nơi các tác giả nhận thức rõ ràng rằng lượng kiến thức mà chúng ta có ngày nay vẫn chưa đủ để đưa ra các khuyến nghị đáng tin cậy về quy trình có thể là quy trình hiệu quả nhất cần tuân theo khi phục hồi hàm sau teo . Chúng tôi biết cách thực hiện nhiều quy trình phức tạp và sáng tạo, mặc dù chúng tôi vẫn chưa biết, khi nào và nếu chúng tôi nên thực hiện chúng và cách nào là hiệu quả nhất. Chúng tôi vẫn chưa biết liệu chúng tôi có cần sử dụng mảnh ghép hay không vào xoang và đâu có thể là vật liệu ghép tốt nhất. Do đó, tôi sẽ nhân cơ hội nhấn mạnh thêm một lần nữa nhu cầu của chúng tôi về nghiên cứu lâm sàng đáng tin cậy để cung cấp các lựa chọn điều trị tốt nhất cho bệnh nhân của chúng tôi. Cuốn sách này chỉ ra bao nhiêu giải pháp khả thi mà chúng ta có, điều này là tốt để biết, nhưng bây giờ chúng ta có những ưu tiên mới: chúng ta cần biết những thủ tục nào trong số các thủ tục được mô tả có liên quan đến tỷ lệ thành công cao hơn, ít biến chứng hơn, thời gian phục hồi ngắn hơn, v.v. Cuốn sách này do đó có thể là một động lực để cộng đồng nghiên cứu quốc tế ưu tiên một số lĩnh vực nghiên cứu nhằm tìm ra những câu trả lời lâm sàng mà chúng tôi thực sự cần. Chúng ta biết cách thực hiện các thủ thuật nâng xoang theo nhiều cách khác nhau, nhưng bây giờ chúng ta cũng cần biết tại sao chúng ta làm chúng, khi nào chúng ta nên làm và thủ thuật nào được sử dụng là hiệu quả nhất.
Embryology
The mechanisms and patterns of skull pneumatization remain largely unclear, with the development of paranasal sinuses commencing in the third week of gestation and continuing into early adulthood By 12 weeks, the turbinate structures in the nasal cavity are formed, and palatal fusion takes place An embryological channel leading to the maxillary sinus develops between 11 to 12 weeks, located laterally to the cartilaginous uncinate process and originating from the middle meatal groove This ectodermal invagination from the nasopharynx initiates and expands laterally within the maxillary bone.
At birth, the maxillary sinus is a small groove measuring 7 × 4 × 4 mm, located on both sides of the nasal cavity It is initially filled with fluid and begins to pneumatize shortly after birth By 9 months, the sinus develops into a small bean-shaped cavity, which progressively takes on a pyramidal shape by the age of 5 years (Ogle et al 2012).
Growth of the sinus after the birth is biphasic, with rapid growth during the fi rst
Between the ages of 3 and 7, growth occurs at a slower pace, with a subsequent growth spurt from 7 to 12 years old, followed by a slowdown into early adulthood (Lawson et al 2008) During the ages of 9 to 12, the floor of the sinus typically aligns with the floor of the nose After this stage, as permanent teeth begin to erupt, the floor of the sinus descends, leading to significant pneumatization that can expose tooth roots, which may only have a thin layer of soft tissue covering them within the sinus (Wang et al 1994).
The functional roles of the maxillary or paranasal sinuses remain unclear, with ongoing debates regarding their biological significance Historically, since Galen in 130 AD, various functions have been proposed for the paranasal sinuses These include mechanical roles such as reducing the weight of the skull and facial bones, providing protection against facial impacts, and serving as pillars for dispersing masticatory forces Additionally, the sinuses are thought to play a role in air conditioning and filtering, warming inspired air, regulating intranasal and sinus gas pressures, and enhancing voice resonance.
Gross Anatomy
The maxillary sinus, a pyramid-shaped cavity within the maxilla, has its apex reaching the zygomatic process and its base contributing to the medial wall of the sinus and the lateral wall of the nasal cavity.
The maxilla bone features a medial wall with a large triangular opening known as the hiatus maxillaris Over time, the lateral wall of the nasal cavity becomes enveloped by surrounding bony structures, including the lacrimal bone at the front, the inferior turbinate below, the uncinate process of the ethmoid above, and the vertical part of the palatine bone at the back Connective tissue and mucosa gradually reduce the hiatus to one or two small openings, referred to as ostia, situated beneath a shelf-like structure of the middle turbinate Additionally, the frontal sinus and anterosuperior cells of the ethmoid also open into the middle meatus.
The posterior wall of the maxillary sinus (tuberosity) is bound by the pterygoid space (fossa) form the fi rst method of vascular and nervous supply
The anterolateral wall acts as a barrier between the cheek's soft tissues and the sinus, serving as the primary approach for sinus floor elevation via the canine fossa This technique is named after the levator labii anguli muscle, often referred to as the canine muscle due to its resemblance to a dog's appearance when contracted.
The superior wall of the sinus is a crucial component of the orbital floor In instances of traumatic injury to the eyeball, this floor may sustain fractures or disruptions, allowing pressure to dissipate downward to safeguard the ocular globe.
In the superior wall of the maxillary sinus we found the infraorbitalis canal for nervous fi bers of the anterosuperior teeth descending into the anterolateral wall
Fig 2.1 Lateral view of the maxillary bone with the external walls of the maxillary sinus: orbital fl oor
( pink ), anterior wall ( yellow ), posterior wall ( purple )
Finally, the infraorbitaris foramen permits the passing of sensitive nervous fi bers and vascular bundles to the cheek tissues (Fig 2.6 )
The posterior wall of the maxillary sinus is comprised of the alveolar process of the maxillary bone, which exhibits significant variability concerning the roots and apices of the teeth In some cases, the sinus can even extend between the teeth and their roots, a condition known as a procident sinus.
Fig 2.2 Medial view of the isolated maxillary bone with the large triangular opening of sinus ( asterisk ): the hiatus of the maxillary bone
Fig 2.3 Lateral wall of the nasal fossa with three turbinates (superior, middle, and inferior) and under the middle turbinate the ostium of the maxillary sinus ( arrow )
Fig 2.4 Horizontal section of the maxillary sinus
See the thinness of the anterior wall of the sinus
( asterisk indicates the canine fossa)
Fig 2.5 Eye-ball traumatism with fracture ( arrow ) of the orbital fl oor in the direction of the maxillary sinus
The area beneath the middle turbinate comprises an anatomical complex that includes the uncinate process, infundibulum, and ethmoid bulla, arranged from anterior to posterior Notably, the maxillary sinus ostium, which is oval-shaped, is located at the lower end of the infundibulum Additionally, research indicates that accessory ostia may be present in approximately 10% of cases (Jog and McGarry, 2003).
The middle meatus is located between the middle and inferior conchae, featuring an upper and anterior section that connects to a funnel-shaped passage known as the infundibulum This infundibulum serves as the communication channel between the frontal sinus and the nasal cavity, facilitating drainage and airflow.
The hiatus semilunaris is a deep curved groove located on the lateral wall of the middle meatus, beginning at the infundibulum and extending downward and posteriorly This groove serves as the opening for the anterior ethmoid cells and the maxillary sinus, with the maxillary sinus's slit-like opening positioned in the posterior section of the hiatus semilunaris The upper boundary of this groove, known as the bulla ethmoidalis, is prominent and bulging, and above it lies the aperture of the middle ethmoidal cells.
Fig 2.6 Infraorbital canal on a coronal CT and its endpoint in the infraorbital foramen in the skull
The orifice connecting the great sinus to the middle meatus is located in the medial wall of the sinus, closer to the roof than the floor, which makes it difficult for fluids to drain from the cavity Occasionally, a second circular orifice may be present, positioned lower and opening into the middle meatus just above the midpoint of the inferior concha's attached margin.
Sinus Vascularization
The maxillary sinus receives its blood supply from a network of arterial anastomoses, primarily through the superior alveolar arteries, which enter via the tuberosity, and the greater palatine artery, which supplies the posterior and medial walls of the sinus.
Figs 2.7 and 2.8 Lateral view of the ostiomeatal complex under the middle concha (sectioned along the dotted line ) Uncinate process
( blue line ), and two ostia of the maxillary sinus
( light blue ) sphenopalatine artery, the pterygopalatine, the infraorbital artery in the anterior wall and posterior lateral nasal artery in the medial wall
Understanding the anatomical path of the anterior maxillary wall and the alveolar process arteries is crucial for successful sinus lift procedures During these surgeries, there is a risk of cutting intraosseous vessels, which can lead to bleeding complications in about 20% of osteotomies (Elian et al 2005).
Since the publication of the study by Solar et al (1999), it has been well established that the lateral maxilla receives its blood supply from the branches of the posterior superior alveolar artery and the infraorbital artery These arteries form two types of anastomoses in the lateral wall, with intraosseous connections observed in 66% of patients according to Rodella et al (2010) and in 100% of cases as reported by Traxler et al (1999).
Fig 2.9 External vascular- ization of the lateral walls of the maxillary sinus (arteries injected with green latex)
Anastomosis ( thin arrow ) between the alveolar posterosuperior artery ( black arrowhead ) and infraorbitalis artery ( white arrowhead )
Fig 2.10 Vascularization of the lateral walls of the maxillary sinus (arteries injected with green latex)
( thin arrow ) between the alveolar posterosuperior artery ( black arrowhead ) and infraorbitalis artery ( white arrowhead )
In a study by Rodella et al (2010), variations such as two parallel arteries were identified in 10% of anatomical subjects, while Traxler et al (1999) observed an extraosseous anastomosis in 44% of cases.
Arteries had a mean diameter of 1.6 mm and the mean distance between the intraos- seous anastomosis and the alveolar ridge was 19 mm in anatomical studies versus
16 mm from the alveolar ridge in CT studies (Mardinger et al 2007 ; Elian et al 2005 ) Only intraosseous arteries can be identifi ed on CT in 53 % of cases (Elian et al
2005 ) to 55 % (Mardinger et al 2007 ) versus 100 % in cadaveric anatomical stud- ies CBCT studies give the same data with 52.8 % anastomosis observed by Jung et al ( 2011 ) on CBCT of 250 patients
Fig 2.11 CBCT axial section of the maxillary sinus with intraosseous artery in the canine fossa ( white arrows )
Fig 2.12 Two intraosseous arteries in the same lateral wall of the maxillary sinus
Geha and Carpentier ( 2006 ) observed that intraosseous anastomosis sometimes occurs at the interface of the sinus membrane and the internal side of the sinus wall
Chronic sinusitis can lead to osseous sclerosis, resulting in anatomical variations that may become intraosseous and clearly defined on CBCT or CT scans.
The venous system is primarily drained by a single trunk, which extends from the sphenopalatine vein, or through three venous plexuses: the anterior pterygoid plexus, the posterior pterygoid plexus, and the alveolar plexus The anterior and posterior pterygoid plexuses converge near the lateral pterygoid muscle and connect with the alveolar plexus, which drains partially into the maxillary vein and partially into the facial vein (Dargaud et al 2001).
Sinus Innervation
The posterior superior alveolar nerve, a branch of the infraorbital nerve, splits into two branches: one that innervates the tuberosity and sinus antrum, and another that extends to the apices of the molar teeth.
Fig 2.13 Double intraosse- ous artery in the lateral wall of the maxillary sinus ( white arrows )
Fig 2.14 Large intraosseous artery in the sclerotic sinus wall ( white arrows )
The infraorbital canal, located at the roof of the sinus, allows the passage of sensitive infraorbital nerves and branches off two additional nerves: the variable middle superior alveolar nerve, which travels along the postero- or anterolateral wall of the sinus to the premolar apices, and the anterior superior alveolar nerve.
The incisal and canine apices are located 15 mm before the infraorbital foramen, and during sinus lift procedures, the nerves in the canine fossa may intersect with the surgical pathway This can lead to neuropathic pain due to nerve sectioning and abnormal healing following the surgery (Hillerup 2007).
Anatomical Variations
Maxillary Sinus Size and Volume
The maxillary sinus exhibits significant variations, sometimes confined to the maxillary area or communicating with other facial bones, with an average volume in humans of approximately 15 cm³ CT studies reveal a wide range of sinus volumes; for instance, Uchida et al (1998) reported an average volume of 13.6 ± 6.4 cm³ among 38 sinus CTs, ranging from 3.3 to 31.8 cm³ Additionally, Sahlstrand-Johnson et al (2011) found that maxillary sinuses are generally larger in males (18 cm³) compared to females (14.1 cm³), with a mean volume of 15.7 ± 5.3 cm³ and a range of 5 to 34 cm³ Despite the considerable size variations, no statistical correlation was found between sinus volume and age, although sinus pneumatization was noted to increase with tooth loss Literature indicates that the dimensions of the maxillary sinus vary, measuring between 22.7 to 35 mm in mesiodistal width, 36 to 45 mm in vertical height, and 38 to 45 mm in anteroposterior depth.
In some rare cases, we have found an hypoplasia of the maxillary sinus sometimes misdiagnosed as chronic sinusitis on panoramic radiographs (Figs 2.17 and 2.18 )
Fig 2.15 Coronal CT view of the anatomical variation of the infraorbitalis canal
( white arrow ) detached from the orbital fl oor through the maxillary sinus
Fig 2.16 Anatomical view of the canine fossa in the anterior lateral wall of the maxillary sinus with the passage of anterior and middle superior alveolar nerves ( arrows )
Fig 2.17 Coronal CT view of the right microsinus
Studies indicate that the prevalence of unilateral hypoplasia ranges from 7% to 10.4%, as observed in CT scans (Kantarci et al 2004; Bolger et al 1990) This condition may be associated with the abnormal anatomy of the uncinate process.
Computed tomography, specifically Cone Beam Computed Tomography (CBCT), is essential for assessing the distance between the medial and lateral walls of the maxillary sinus prior to surgical procedures This evaluation helps to prevent perforation of the sinus membrane and allows for accurate estimation of grafting material volume Radiological studies indicate that the minimal width of the maxillary sinus varies, with measurements ranging from 12 mm (Sahlstrand-Johnson et al 2011) to 13.4 mm at half-height (Uthman et al 2011) Understanding these dimensions is crucial for successful surgical outcomes.
Fig 2.18 Axial CT image of the right microsinus
Fig 2.19 Close proximity of the internal and external walls of the left maxillary sinus (coronal
According to Cho et al (2001), a CT scan analysis revealed that the angle between two walls significantly increases the risk of membrane perforation, particularly when the angle is 30° or less, which was observed in 37.5% of perforation cases.
Sinus Walls
Extreme pneumatization of the maxillary sinus can lead to an increase in volume and a thinning of the sinus wall According to Kawarai et al (1999), the bone thickness at the canine fossa during sinus surgery using the Caldwell–Luc method was measured at 1.1 mm ± 0.4 mm.
Chronic sinusitis often leads to significant inflammation of the soft tissue, resulting in wall thickening in approximately 97.3% of cases, with an average thickness of 2.6 mm in affected sinuses In comparison, the control group shows an average wall thickness of 0.98 ± 0.2 mm, highlighting the severity of the condition (Joshua et al 2013; Deeb et al 2011).
Septa
Septa on the inner surface of the maxillary cavity often lead to perforation of the Schneiderian membrane during sinus lift surgery, complicating the lateral window luxation process.
Preoperative evaluation by CBCT or CT of septa led to modifi cations of the sur- gical approach (Krennmair et al 1997 ; Betts and Miloro 1994 )
In some cases high septa lead to partial or complete division of the sinus cavity (Fig 2.21 )
We can found numerous anatomical, radiological or surgical studies on the prev- alence, location, and size of the maxillary sinus septa
Fig 2.20 Axial CBCT image of the sclerotic walls of the left maxillary sinus in this case of chronic sinusitis
According to Ogle et al (2012), a strut of bone is defined as a septum measuring at least 2.5 mm in height They categorize septa into primary septa, located between the roots of the second premolar and first molar, between the first and second molar, or distal to the roots of the third molar, and secondary septa, which result from pneumatization after dental extractions.
Since the study by Underwood ( 1910 ), the prevalence of septa observed in anatomi- cal studies has varied from 18.5 % (Krennmair et al 1997 ) to 39 % (Ella et al 2008 )
Fig 2.21 Complete bilateral septa in the maxillary sinus with mucosal hyperplasia only in the anterior compartment
Fig 2.22 Axial CT image of multiple septa inside the maxillary sinuses
Surgical and clinical observation studies indicate a prevalence of septa ranging from 27.7% (Krennmair et al., 1997) to 57.6% (Jensen and Greer, 1992) among a limited sample of 26 patients However, CT imaging has proven essential for evaluating septa prior to surgery A review of the literature reveals over 20 radiological studies utilizing both 2D and 3D imaging techniques, including panoramic radiographs, CT, and CBCT, which report varying prevalence rates across different populations Notably, Lugmayr et al (1996) identified a 13% prevalence of septa in a study of 200 CT scans, while Orhan et al (2013) reported a significantly higher prevalence of 58% in CBCT assessments of 554 sinuses.
Maestre–Ferrin et al ( 2011 ) showed in a comparative study that panoramic radiographs vs CTs than 2D images (conventional radiographs) led to an erroneous diagnosis in 46.5 %
According to Neugebauer et al (2010), septa are commonly found in only one sinus, occurring in 24.6% of cases, while 13.7% of patients have septa in two sinuses In a study involving 1,029 patients, 8.7% exhibited up to three septa per sinus Conversely, van Zyl and van Heerden (2009) reported that 64% of patients demonstrated multiple septa in their anatomical configuration.
Results from the literature indicate variability in the identification and determination of the minimum height of bony structures, influenced by the methods employed, image resolution—particularly the comparison between CBCT and CT—and the criteria used for defining septa According to Neugebauer et al (2010), the average septal height measured with CBCT was 7.3 ± 5.08 mm in 74.7% of cases, with a maximum height recorded at 36 mm.
The middle and posterior areas of the sinus are the most common sites for septa formation, with Neugebauer et al (2010) reporting that 76.9% of septa occur in the molar region, while Koymen et al (2009) found this figure to be 66.6%.
The majority of septa orientation is predominantly transversal in a buccopalatal direction, with a prevalence of 74.7% according to Neugebauer et al (2010) However, sagittal orientation is also observed, ranging from 3.7% as reported by Park et al (2011) to 25.3% in cases studied by Neugebauer et al (2010).
A recent review of the literature by Wen et al ( 2013 ) led to the proposal of a fi rst
Fig 2.23 Axial CT image of the posteriorly oriented maxillary sinus septa location of septa, number, size (greater or smaller than 6 mm), and orientation (mediolateral or anteroposterior; Figs 2.25 , 2.26 , and 2.27 )
Anatomical variations in the nasal cavity and ostiomeatal complex can elevate the risk of sinusitis following surgery It is essential to assess these variations using CBCT or CT scans prior to any intervention, focusing not only on the permeability of the maxillary sinus ostia but also on all anatomical factors that may contribute to their narrowing.
• Narrowing of the infundibulum by Haller’s cells from the ethmoid on the internal and inferior wall of the orbit (Fig 2.28 )
• Laterally deviated uncinate process, sometimes pneumatized (rare variation 1–2 % by extension of anterior ethmoid cells into the uncinate process)
CT of the anteroposterior septa of the left maxillary sinus ( white arrow ) forming a barrier inside the sinus
Fig 2.25 Axial CT of a patient with a sinus septum behind the canine fossa, the surgical method for sinus lift
• Concha bullosa by pneumatization of the middle turbinate present in 30 % of the population This variation reduces the middle meatus and mucociliary clearance (Fig 2.29 )
• Paradoxal (i.e., inverted) convexity or rotation of the middle turbinate in 11 % of the population (Fig 2.30 )
• Septal deviation in the nasal cavity and bony spicules (Fig 2.31 )
Fig 2.26 Panoramic CT of a patient with a sinus septum behind the canine fossa, the surgical method for sinus lift
Fig 2.27 Coronal CT of a patient with a sinus septum behind the canine fossa, surgical method for sinus lift
Fig 2.28 Coronal CBCT view of the procidence of the anterior ethmoidal cells
( asterisk ) above the maxillary sinus ostia
Fig 2.29 Coronal CBCT view of concha bullosa
( asterisk ) of the right middle turbinate
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Fig 2.30 CT, coronal view of the patient with the right middle turbinate inverted
Fig 2.31 Septal deviation in left nasal cavity
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