MAXILLARY SINUS SURGERY and alternatives in treatment

London, Berlin, Chicago, Tokyo, Barcelona, Istanbul, Milan, Moscow,New Delhi, Paris, Beijing, Prague, São Paulo, Seoul and Warsaw

TIZIANO TESTORI MASSIMO DEL FABBRO ROBERTO WEINSTEIN STEPHEN WALLACE

iv — Maxillary sinus surgery and alternatives in treatment

authors

TIZIANO TESTORI MD, DDS, FICD received his MD degree (1981), DDS degree (1984), and Speciality inOrthodontics (1986) from the University of Milan, Italy. He is Head of the Section ofImplant Dentistry and Oral Rehabilitation, Galeazzi Institute (Chairman: Prof. R.L.Weinstein), University of Milan, Italy. He had a Fellowship at the Department of OralMaxillo-Facial Surgery, School of Dentistry, Loma Linda University, Loma Linda CA (Head:Philip J. Boyne, DMD, MS, DSc) (1991), and a Fellowship at the Division of Oral Maxillo-Facial Surgery, School of Medicine, University of Miami, Miami FL (Head: Robert E. Marx,DDS) (2000). He is a Visiting Professor at New York University, College of Dentistry, USA,and Fellow of the “International College of Dentists” (FICD). He is President of the ItalianSociety of Oral Surgery and Implantology (SICOI). He is a member of the Periodontology/Implantology Editorial Board for Practical Procedures & Aesthetic Dentistry (PPAD) (aMontage Media publication), and a member of the Editorial Board of the European Journalof Oral Implantology (Quintessence Publishing Co. Ltd). He acts as referee for Oral Surgeryand Implant Dentistry for the National Committee of the Health Ministry for CE programs.He is a reviewer for the Cochrane collaboration, Oral Health Group, and founding member ofthe Italian Section of the ICOI (International College of Oral Implantologists). He is an activemember of the European Board of Oral Surgery (EFOSS), and active member and lecturerfor the Academy of Osseointegration (AO), American Academy of Periodontology (AAP) andAmerican Association of Oral and Maxillofacial Surgeons (AAOMFS). He is author of over200 scientific and clinical papers for professional journals.

MASSIMO DEL FABBRO Born in Milano, Italy in 1964. Degree in Biology (1989) at the University of Milan. Ph.D.in Human Physiology (1994) at the University of Milan. Post-doctoral fellowship (1995-1997) at the Institute of Physiology, University of Milan. In 1999-2002 he obtained agrant for the project “Physiopathology of Periodontal and Peri-implant soft tissues” at theDepartment of Medicine, Surgery and Dentistry, University of Milan. Since 2002 he hasbeen a Researcher in Dentistry, Oral Surgery & Medicine at the faculty of Medicine of theUniversity of Milan. His scientific interests are in the fields of physiopathology ofperiodontal and peri-implant tissues, biology of osseointegration, regenerative techniques,tissue engineering, biomedical statistics, and methodology of research. He is Head of theSection of Oral Physiology at the Department of Health Technologies (Chair: Prof. R.Weinstein), IRCCS Istituto Ortopedico Galeazzi, University of Milan. He is author and co-author of over 80 papers in the fields of periodontology, implant dentistry, endodonticsand physiology.

ROBERTO WEINSTEIN Born in Varese in 1948, graduated in Medicine in 1972 and specialized in ClinicalDentistry in 1974 at the University of Milan, Italy. A student of Giorgio Vogel, in 1981 hebecame a University Researcher, in 1988 he became an Associate Professor at theUniversity of Modena, and in 1990 he became a Tenured Professor at the University ofMilan. He has been Head of the Dental Clinic at the Orthopaedic Institute Galeazzi inMilan since 2002, where he is also the Scientific Director. He has also been the Head ofthe Odontostomatology School of Specialization and has held the Chair for theUndergraduate course in Dentistry and Dental Prosthesis Work. He is Past President andFounder of the SIOH (Società Italiana di Odontostomatologia per Handicappati) and PastPresident of the Italian Society of Periodontology.

STEPHEN WALLACE Graduated in Dental Medicine in 1967 from New York University, College of Dentistry,certificate in Periodontology in 1971 at Boston University. He is an Associate Professorat the Department of Oral Implantology, New York University, Periodontics and ImplantDentistry, and divides his time between teaching and clinical research. He is a fellow ofthe International Congress of Oral Implantologists (ICOI) and the American Academy ofPeriodontology (AAP) and the Academy of Osseointegration (AO). He is the author ofover 50 scientific papers on grafting biomaterials and on surgical procedures formaxillary sinus lifting. An internationally renowned speaker, he practises in Waterbury,Connecticut, focusing his work in the areas of periodontology and implantology.

v

the following have contributed to the creation of this book:

ALESSANDRO BAJ MD, Specialist in Maxillofacial Surgery, Visiting Professor at the Postgraduate Programin Maxillofacial Surgery the University of Parma, Visiting Professor at theUndergraduate Program School of Dentistry at the University of Milan, Department ofClinical Maxillofacial Surgery, Chairman Prof. A.B. Giannì, Istituto Galeazzi, Milan,Italy.

GIANMARCO BELLONI MD, Specialist in Radiology, First-level Executive at the Diagnostic RadiologyImaging Department, ARS Medical Clinic Group Lugano, Ticino, CH, Italy.

FRANCESCA BIANCHI Doctor of Dental Surgery (DDS), Tutor at the Implantology and Oral RehabilitationDepartment, Head Dr T. Testori. School of Dentistry, Chairman Prof. R.L.Weinstein. Department of Health Technologies Istituto Ortopedico Galeazzi IRCCS,University of Milan, Italy.

MATTEO CAPELLI Doctor of Dental Surgery (DDS), Tutor at the Implantology and Oral RehabilitationDepartment, Head Dr T. Testori. School of Dentistry, Chairman Prof. R.L.Weinstein. Department of Health Technologies Istituto Ortopedico Galeazzi IRCCS,University of Milan, Italy.

FRANCO CARLINO MD, Specialist in Maxillofacial Surgery, Fellow at the Clinical Maxillofacial SurgeryDepartment, Chair Prof. A.B. Giannì, Istituto Ortopedico Galeazzi IRCCS, Milan,Italy.

GIORGIO CASTELLAZZI MD, Specialist in Radiology, Department of Diagnostic & Interventional Radiology,Istituto Ortopedico Galeazzi IRCCS, Milan, Italy.

GIAMPIERO CORDIOLI MD, Specialist in General Surgery, Specialist in Dental Medicine and DentalProstheses, Director of the Dental Clinic, University of Padua, Italy.

LUCA FRANCETTI Associate Professor, Head of the Periodontology Department, School of Dentistry,Chairman Prof. R.L. Weinstein. Department of Health Technologies, IstitutoOrtopedico Galeazzi IRCCS, University of Milan, Italy.

LUCA FUMAGALLI Doctor of Dental Surgery (DDS), Tutor at the Implantology and Oral RehabilitationDepartment, Head Dr T. Testori. School of Dentistry, Chairman Prof. R.L.Weinstein. Department of Health Technologies, Istituto Ortopedico Galeazzi IRCCS,University of Milan, Italy.

FABIO GALLI MD, Head of the section of Implant Prosthetic Dentistry. Implantology and OralRehabilitation Department, Head Dr T. Testori. School of Dentistry, Chairman Prof.R.L. Weinstein. Department of Health Technologies, Istituto Ortopedico GaleazziIRCCS, University of Milan, Italy.

ALDO BRUNO GIANNÌ MD, Specialist in Maxillofacial Surgery, University of Milan, Director of thePostgraduate Program in Maxillofacial Surgery, University of Milan, Italy. Director ofDepartment of Maxillofacial Surgery, Department of Health Technologies IstitutoOrtopedico Galeazzi IRCCS, University of Milan, Italy.

ZEINA MAJZOUB MD, Specialist in Odontostomatology and in Periodontology, Boston University,USA. Director of the Clinical Research Department, Lebanese University, Beirut,Lebanon.

vi — Maxillary sinus surgery and alternatives in treatment

MARIO MANTOVANI MD, Visiting Professor at University of Milan, Italy, Specialist in Otorhinolaryngologyand Cervical-facial Pathologies, Specialist in Plastic Surgery, Specialist inMaxillofacial Surgery. Otorhinolaryngology Clinic at the University of Milan,Ospedale Maggiore Policlinico IRCCS, Milan.

GIANPIERO MASSEI MD, Specialist in Maxillofacial Surgery, Specialist in Plastic Surgery, Chairman ofthe Biocra Society, private practice in Turin, Italy.

RICCARDO MONTEVERDI MD, Specialist in Maxillofacial Surgery. Visiting Professor at the UndergraduateProgram School of Dentistry at the University of Milan, Department of ClinicalMaxillofacial Surgery, Chairman Prof. A.B. Giannì, Istituto Galeazzi, Milan, Italy.

ANDREA PARENTI Doctor of Dental Surgery (DDS), Tutor at the Implantology and Oral RehabilitationDepartment, Head Dr T. Testori. School of Dentistry, Chairman Prof. R.L.Weinstein. Department of Health Technologies, Istituto Ortopedico Galeazzi IRCCS,University of Milan, Italy.

FRANCO PERONA Medical Doctor MD, Specialist in Radiology, Director Department of Diagnostic &Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.Professor at the School of Radiology, Faculty of Medicine, University of Milan.

PIETRO SALVATORI Medical Doctor MD, Specialist in Maxillofacial Surgery, Specialist inOtorhinolaryngology, Head of the Cervical-Maxillofacial Surgery Unit, IstitutoOrtopedico Galeazzi, Milan, Italy.

FRANCESCO SANTORO Medical Doctor MD, Specialist in Otorhinolaryngology, OtorhinolaryngologyDepartment, at S. Anna Hospital, Como, Italy, Director Prof. R. Spinelli.

SILVIO TASCHIERI Medical Doctor MD, Specialty in Dentistry (DDS), Visiting Professor and Head ofthe Department of Endodontics and Endodontic Surgery, School of Dentistry,Chairman Prof. R.L. Weinstein. Department of Health Technologies, IstitutoOrtopedico Galeazzi IRCCS, University of Milan, Italy.

OLIVEIRA TOMIC Medical Doctor MD, Specialist in Plastic Surgery, Department of ClinicalMaxillofacial Surgery, Chairman Prof. A.B. Giannì, Department of HealthTechnologies, Istituto Ortopedico Galeazzi IRCCS, University of Milan, Italy.

CONCEZIONE TOMMASINO Associate Professor of Anesthesia and Intensive Care, University of Milan, Italy.Head of the Anesthesiology Department for Dental Medicine. San RaffaeleHospital, Milano, Italy.

PAOLO TRISI Doctor of Dental Surgery (DDS), Scientific Director of the BioCra (BiomaterialClinical Research Association, Pescara). Head of the Biomaterials Department,School of Dentistry, Chairman Prof. R.L. Weinstein. Department of HealthTechnologies, Istituto Ortopedico Galeazzi IRCCS, University of Milan, Italy.

PASCAL VALENTINI Doctor of Dental Surgery (DDS). Head of Post-graduate Program in Implantology,Department of Health Science and Human Biology, University of Corsica, PasqualePaoli Corte, France. Associate Clinical Professor Loma Linda University, LomaLinda, CA, USA.

TOMASO VERCELLOTTI Medical Doctor MD, Specialty in Dentistry (DDS), Visiting Professor inMaxillofacial Surgery, University of Genoa, Italy, Otorhinolaryngology Clinic, ChairProf. A. Salami.

FRANCESCO ZUFFETTI Medical Doctor MD, Specialty in Dentistry (DDS), Tutor at the Implantology andOral Rehabilitation Department, Head Dr T. Testori. School of Dentistry, ChairmanProf. R.L. Weinstein. Department of Health Technologies Istituto OrtopedicoGaleazzi IRCCS, University of Milan, Italy.

vii

viii — Maxillary sinus surgery and alternatives in treatment

contents

page chapter

x foreword

xii preface

xiii acknowledgements

1 01 Introduction and background

M. DEL FABBRO

7 02 Anatomy of the maxillary sinus

M. DEL FABBRO, T. TESTORI

23 03 Otorhinolaryngological contraindications in augmentation of the maxillary sinus

M. MANTOVANI

35 04 The role of endoscopy in maxillary sinus augmentation.

Indications for endoscopic surgery to optimize sinus functions

F. SANTORO, P. SALVATORI, S. TASCHIERI, T. TESTORI

45 05 Biologic and biomechanical basis of bone healing

and osseointegration of implants in sinus grafts

P. TRISI, G. MASSEI

81 06 The role of CT scans in maxillary sinus augmentation surgery

G. BELLONI

91 07 Maxillary atrophy: classification and surgical protocols

A.B. GIANNÌ, R. MONTEVERDI, A. BAJ, F. CARLINO, O. TOMIC

133 08 Anesthesia techniques for sinus augmentation surgery.

Conscious sedation using midazolam

C. TOMMASINO

145 09 Clinical indications for different types of graft material

S.S. WALLACE

167 10 Histologic and clinical results of sinus floor augmentation

with bone substitutes

P. VALENTINI

179 11 Bioglass in oral surgery

G. CORDIOLI, Z. MAJZOUB

Contents ix

191 12 Surgical procedures: lateral window approach

T. TESTORI, S.S. WALLACE

217 13 Alternatives to sinus floor augmentation

T. TESTORI, F. GALLI, L. FUMAGALLI, A. PARENTI, S.S. WALLACE

229 14 Piezoelectric surgery.

Maxillary sinus floor augmentation techniques

T. VERCELLOTTI

239 15 Maxillary sinus augmentation crestal techniques

G. CORDIOLI, Z. MAJZOUB

259 16 Autogenous bone harvesting techniques from intraoral sites

M. CAPELLI, T. TESTORI

273 17 Autogenous bone harvesting techniques from extraoral sites:

iliac crest, calvaria, fibula and tibia

A. BAJ, A.B. GIANNÌ, R. MONTEVERDI, T. TESTORI

295 18 The use of platelet rich plasma in maxillary sinus augmentation.

Biologic principles and clinical studies

M. DEL FABBRO, F. ZUFFETTI

311 19 Complications: diagnosis and management

T. TESTORI, S.S. WALLACE, R. MONTEVERDI, A. BAJ, A.B. GIANNÌ

325 20 Systematic review of the literature on maxillary sinus augmentation

associated with implantation procedures

M. DEL FABBRO, L. FRANCETTI, S. TASCHIERI, T. TESTORI

343 21 Future developments in maxillary sinus surgery

S.S. WALLACE, M. DEL FABBRO, T. TESTORI

349 22 Advanced imaging techniques in sinus surgery

F. PERONA, G. CASTELLAZZI

359 23 Appendix: collection of clinical records, files, patient monitoring and data reporting

M. DEL FABBRO, F. BIANCHI, F. GALLI, T. TESTORI

371 Index

foreword

In recent years, the focus has shifted to new aspects of implantology. The 1980s wasthe decade of osseointegration, the 90s were the years of guided boneregeneration and the current decade is that of esthetic techniques, load-bearing, and the simplification of operational procedures. These variousaspects often overlap, and it is usually in the decade that follows that thekey problems are finally resolved and new protocols are drawn up.

Maxillary sinus elevation techniques have played an important part inclinical research since the reference publication by Philip Boyne in1980. Today, after 25 years of studies by doctors and researchers, morethan 1000 scientific articles are available that deal exclusively with thesubject of maxillary sinus augmentation.

The idea for this book originated at the Consensus Conference onMaxillary Sinus Surgery of the Italian Society of Oral Surgery, which washeld in Montecatini in November 2001. Taking their idea from the confer-ence, the authors of this book began to work together closely, creating anew, up-to-date text that brings together the most recent scientific discov-eries and the most innovative clinical protocols, together with the possiblealternatives to maxillary sinus augmentation techniques. This book seeksto present the various approaches used for maxillary sinus augmentation,as presented at the Consensus Conference in Montecatini, together with athorough analysis of all the protocols, based on the evidence.

‘Maxillary Sinus Surgery and Alternatives in Treatment’ reports the clini-cal experience and the efforts of research carried out by a prestigiousgroup of clinicians and researchers who analyze maxillary sinus elevationfrom every possible angle. The surgical procedures are presented with thesupport of basic scientific knowledge and other medical specialities,thanks to the large number of multi-disciplinary research contributions.No aspect related to maxillary sinus surgery has been neglected: endo-scopic, radiological, anesthesia and conscious sedation techniques areall presented in the form of operational protocols.

The rational basis and specific clinical indications for each graft materialare shown, in addition to relative histologic data.

Both traditional and innovative techniques for maxillary sinus surgery arediscussed, together with the clinical criteria that support them. Thechapters on alternative therapies, piezoelectric surgery and the applica-tion of PRP in maxillary sinus surgery are particularly innovative. Thechapters on short-term and long-term complications and the review of lit-erature are also extremely interesting.

x — Maxillary sinus surgery and alternatives in treatment

xiForeword

The book begins with anatomy, otorhinolaryngological implications andbone healing, and goes on to cover diagnosis, surgery and patient-moni-toring. This allows students and experts to enter the world of modernimplantology via a consistent training path.

This publication thus manages to combine the goals of a student textbook with a valid tool for the development of professional clinicalexperts.

Finally, my appreciation goes to all the authors who, thanks to theirefforts, have created a book that will contribute to improving ourpatients’ health, the ultimate goal for which all doctors must strive.

Dennis Tarnow

C H A I R M A N O F D E PA R T M E N T O F P E R I O D O N T I C S A N D I M P L A N T D E N T I S T R Y

N E W Y O R K U N I V E R S I T Y

preface

Writing a scientific book is always an exciting, unforgettable journey for the authors, forseveral reasons.

The first is connected to the tool used to divulge their thoughts: printedmatter. It may seem obsolete to use this means of communication in theage of the Internet, but using printing, the greatest invention of all time,to communicate scientific knowledge is one of the greatest adventuresthat Man can face.

The second reason is an inherent part of the profession of lecturer that weauthors practice: the possibility of communicating the subject of ourresearch is a decisive moment in our professional life.

Last, but not least, is the possibility of offering the scientific community afurther chance for debate and comparison which, we hope, this book mayencourage.

We hope that the readers can share our journey and our belief in scientificprogress.

Roberto L. Weinstein

Stephen S. Wallace

Massimo Del Fabbro

Tiziano Testori

xii — Maxillary sinus surgery and alternatives in treatment

xiiiAcknowledgements

acknowledgements

My sincere thanks go to Giovanna, my lifelong companion and esteemed colleague, andto Veronica, my beloved daughter who, through their silent strength, havesupported me, accepting my lack of attention and company.My thanks must also go to my teachers, who taught me that one can onlytruly treat the patients who come to us to cure their health through knowl-edge, dedication, discipline, professional ethics and the humility to feellike a student for life.My deepest esteem and gratitude go to the masters who welcomed me totheir professional surgeries and their university institutes. Ennio Giannìand Antonino Salvato taught me a multidisciplinary and dental medicalapproach. Melvyn H. Harris, Philip J. Boyne and Robert E. Marx, from theoral surgery field, have been milestones in my professional life, togetherwith Myron Nevins, Richard J. Lazzara, Dennis P. Tarnow and Arun K.Garg, with their teachings on periodontal and implantology fields. My gratitude also goes to all the authors who have allowed this book to bepublished, thanks to their scientific contribution, to Massimo Del Fabbrofor his dedication and willingness while the book was being created, inaddition to his contribution as the author of important chapters.Special thanks go to Roberto L. Weinstein, a friend, expert and modernmaster who, with his volcanic mind, inspired, coordinated and led thewriting of this volume.I would also like to thank Paolo Bellizzomi and his editorial team for theirexcellent revision work that allowed us to create a modern, easy-to-consulttext.Last, but not least, my thanks to all the colleagues who have believed inus, buying the book in the hope that it will aid the better care of theirpatients.

Tiziano Testori

xiv — Maxillary sinus surgery and alternatives in treatment

01

1

Introduction and background

M . D E L FA B B R O

BA SI C A NATO M Y

The maxillary sinus begins to developbetween the second and third month of preg-nancy, with an evagination of the nasal pas-sage lateral wall mucosa. At birth, it is about0.1 to 0.2 cm3 in size and remains small untileruption of the permanent teeth (Van denBergh et al. 2000). Development, in terms ofpneumatization (the increase of the volume ofair contained in it), is completed by adoles-cence, although its volume may increase fur-ther after tooth loss in the posterior maxilla.

The maxillary sinus is the largest of theparanasal cavities, which include the eth-moidal, frontal and sphenoidal sinuses andwhich usually occupies a large part of themaxillary bone. It is an air cavity with a quad-rangular pyramidal shape with various walls: amedial wall facing the nasal cavity, a posteriorwall facing the maxillary tuberosity, a mesio-vestibular wall for the presence of the caninefossae, an upper wall which is the orbit floor,and finally, a lower wall that is next to thealveolar process and which is the bottom of themaxillary sinus itself (McGowan et al. 1993).The maxillary sinus communicates with thehomolateral nasal fossa by means of a naturalostium located antero-superiorly on the medialsurface, which drains into the middle meatus

(May et al. 1990). All paranasal sinuses com-municate with the nasal fossae and thereforealso, indirectly, with each other FIG. 1A-B, 2A-C.They serve mainly to humidify and heat the airwe breathe in. They also contribute to reduc-ing the weight of our facial bones, protect thebase of the skull against trauma, thermallyinsulate the upper nerve centers and influ-ence phonation by acting as an indirect reso-nance box (Blanton & Biggs 1969; Ritter &Lee 1978).

The two bone walls most often involved inmaxillary sinus surgery are the mesio-vestibularwall and the medial wall.

The mesio-vestibular wall is usuallymade up of a thin cortex (thickened bonewalls are occasionally found) containing theneurovascular bundle: the arterial anasto-mosis between the upper, infra-orbital pos-terior-alveolar artery and the infra-orbitalnerve that permeates and innervates the ante-rior teeth, if present, and related periodontaltissues FIG. 3A-C. In some cases it may be 2 mmthick, especially in brachytype patients withan increased cross-facial diameter. A varia-tion in thickness or an interruption cannotnormally be detected in an orthopantograph.Pre-existing thicknesses can be evaluatedprior to surgery only by means of a CT scan.Lack of bone cortex areas can be found, witha consequent direct contact between vestibu-lar mucosa and sinus mucosa FIG. 4A-C. Theposterior teeth are innervated by neurovascu-lar branches coming from the maxillarytuberosity (de Mol Van Otterloo 1994). Thisanatomic aspect has consequences due tothe narrow space available for antrostomysurgery. An apical surgical approach to anyviable teeth may cause a high risk of toothnecrosis (Van den Bergh et al. 2000).

The medial wall is rectangular and formsthe bone septum that separates the maxillarysinus from the nasal cavity. The lower portioncorresponds to the lower meatus of the nasalcavity (Chanavaz 1990).

8 — Maxillary sinus surgery and alternatives in treatment

02

9Anatomy of the maxillary sinus

1 A > ANTERIOR SECTION OF THE

MAXILLARY SINUSES.

HYPERPNEUMATIZATION OF THE

LEFT SINUS AND ATROPHY OF

THE ALVEOLAR RIDGE FURTHER

TO THE LOSS OF TEETH CAN BE

NOTED.

1 B > CT ANTERIOR SECTION OF

MAXILLARY SINUSES. THE

OSTEOMEATAL COMPLEX CAN BE

SEEN.

2 A-B > RATIO OF THE

MAXILLARY SINUS. THE PROBE

ENTERS FROM THE PYRIFORM

OPENING AND REACHES THE

MEDIAL WALL OF THE SINUS

(LATERAL WALL OF THE NASAL

CAVITY).

2 C > CLOSE-UP OF OSTIUM.

THIS FORAMEN IS NORMALLY A

6 MM BY 3.5 MM OVAL.

1 A

2 A

2 B

2 C

1 B

5 ) E X T R E M E AT R O P H I E S

With extremely severe atrophy affectingthe basal bone, complex bone reconstructionsusing microvascular bone flaps, mainly fibulaflap, may be advisable FIG. 100-101. During thesecomplex bony reconstructions, it is important touse articulated study casts, in order to planprecisely the surgical phase. As already stated,the biology of a revascularized flap is very dif-ferent from a bone graft, as the bone in amicrovascular flap is already vital by definition,and therefore the healing mechanism is compa-rable to that of fractures, without any resorp-tion linked to creeping substitution. After a fewweeks, it is theoretically possible to placeimplants, although it is advisable to wait atleast 3 months.

When the implants are placed, it will benecessary to reshape the fibula graft and assess the need to augment the peri-implantsoft tissue FIG. 102-120.

L I P O S C U L P T U R E

As previously mentioned, especially incases with anterior maxillary bone atrophies, itis often not possible to correct in a satisfactoryway the aging aspect of perioral and labial softtissue. Plastic esthetic surgery techniques,such as liposculpture, may therefore be usedfor these patients.

I N T R O D U CT I O N

Liposculpture is a technique that usesautogenous adipose tissue to correct depres-sions and increase volume of the cervical-facialarea with the final goal of improving the har-mony and esthetics.

This technique has been used successfullyfor over a century; fat grafts in scar areas weredescribed for the first time by Neuber (Neuber1893).

122 — Maxillary sinus surgery and alternatives in treatment

87 > PATIENT WITH SKELETAL CLASS II RELATIONSHIP. 88 > THE COUNTERCLOCKWISE MANDIBULAR ROTATION,

DUE TO LOSS OF MAXILLARY VERTICAL DIMENSION, HIDES

THE SKELETAL CLASS II RELATIONSHIP.

89 > SURGICAL CORRECTION OF MAXILLARY BONE

ATROPHY WITH LE FORT I OSTEOTOMY TO VERTICALLY

LOWER MAXILLA, AND INTERPOSITION BONE GRAFT,

TOGETHER WITH MANDIBULAR OSTEOTOMY TO RESTORE

CORRECT SKELETAL RELATIONSHIP ON SAGITTAL PLANE.

123Maxillary atrophy: classification and surgical protocols

90 91

92 93

969594

999897

90 > INTRAORAL

MAXILLARY VIEW OF

VERTICAL BONE

ATROPHY.

91 > INTRAOPERATIVE

VIEW OF ILIAC BONE

GRAFTS, ON NASAL

FOSSAE AND MAXILLARY

SINUSES AFTER

MAXILLARY OSTEOTOMY.

92 > RIGID

STABILIZATION OF

MAXILLA.

93 > POSTOPERATIVE

ORTHOPANTOGRAPH

SHOWING MAXILLARY

BONE RECONSTRUCTION

AND MANDIBULAR

OSTEOTOMY.

94-95-96 > LATERAL

CEPHALOMETRIC

RADIOGRAPH, ANTERIOR

AND SAGITTAL VIEW

WITH MAXILLARY BONE

ATROPHY AND SKELETAL

CLASS II RELATIONSHIP

(MANDIBULAR UNDER-

DEVELOPMENT), HIDDEN

BY COUNTERCLOCKWISE

MANDIBULAR ROTATION.

97-98-99 >

POSTOPERATIVE

LATERAL CEPHALO-

METRIC RADIOGRAPH,

ANTERIOR AND SAGITTAL

VIEW ON COMPLETION

OF IMPLANT PROS-

THESIS TREATMENT.

MANDIBULAR OSTE-

OTOMY FOR BRINGING

FORWARD BONE

ALLOWED PRESER-

VATION OF CORRECT

SAGITTAL PROJECTION

OF CHIN, AFTER

RESTORATION OF

ANTERIOR FACIAL

HEIGHT.