Treatment of sinusitis associate with filling material of the maxillary sinus by endonasal endoscopic sinus surgery simultaneous sinus-lifting and dental implantation

A total of 23 sinus lifting procedures were performed, using a mixture of bovine bone, autogenous bone and PRP. According to our surgical procedure we performed in our patients 1 a 2 stage sinus lifting, 46 implants were inserted.Dental prosthetic rehabilitation was undertaken 5 months after implants insertion and submerged healing. Implant success was assessed clinically and radiographically. The height of the graft and bone density was measured 6th and 9th month after surgery using serial CT. The following parameters were assessed: failure of the augmentation procedure, implant failure, and vertical bone height.


Introduction
At present, dental implants are the best solution for the rehabilitation of patients with various forms of toothless [1].
However, atrophy of the edentulous ridges make diffi cult for implant placement diffi cult.
Numerous procedures and materials are used to repair bone defects. The bone graft procedures used in oral implantology include autograft reconstruction, GBR, maxillary sinus fl oor elevation, and alveolar distraction osteogenesis [2][3][4][5][6][7][8]. The decision to choose any option depends on clinical factors and ultimately on the skill of the clinician.
The sinus lift procedure is one of the primary surgical options allowing placement of dental implants in the posterior maxilla. The traditional technique consists in a modifi ed Caldwell-Luc approach, where access to maxillary sinus is obtained by drilling abone window in lateral sinus wall; then, Schneiderian membrane is carefully detached and elevated from sinus fl oor in order to insert grafting materials, including autogenous bone, allografts, xenografts, or alloplasts. Implants can be inserted simultaneously, or in a second stage if residual bone is not suffi cient to obtain an adequate primary stability [9][10][11][12][13].
If the residual bone is 6-7 mm, use the closed sinus lift method with access from the chewing surface of edentulous ridges using osteomas [14].
Sinus fl oor augmentation with autogenus bone grafts or with biomaterials has since long been the predominant, welldocumented procedure in the literature [15,16]. However, the procedure may be complicated in patients with chronic maxillary sinusitis [17,18]. Sinus membrane pathology can potentially complicate the post procedural course of sinus lift.
In clinical practice, chronic maxillary sinusitis is often observed due to the hit of fi lling material from the tooth canal into the sinus cavity [19]. To remove the fi lling material from the sinus cavity, the traditional Caldwell-Luc method was used. Modern tendencies of оral surgery are aimed at minimizing surgical trauma and reducing the time for rehabilitation of patients.
In this connection, new technologies without perforation violating the vestibular sinus wall which allow to reduce the volume surgical intervention and shorten the time of treatment.
Revision sinus surgery for infl ammatory diseases of maxillary sinus has been revolutionized by endoscopic techniques used in maxillary sinus surgery [20,21].
Recent technological advances in the fi eld of endoscopy have resulted in substantial improvements in endoscopecontrolled surgery of paranasal sinuses. Endoscopically technique involves endonasal approach by endoscop and is a minimally invasive procedure [22][23][24][25][26].
Тhe most important factor in sinus lift surgery is atraumatic detachment of the periosteum of the maxillary sinus membrane from the bony antrum-fl oor to the preparation of a mucoperiosteal fl ap to provide a reliable osseointegration of and bone regeneration around the grafting material, which can only take place with a fully intact periosteum Treating maxillary sinus pathology by endoscopic approaches, prior to implant insertion and/or sinus augmentation, is crucial for a better outcome of the dental procedure. In patients with pathologies sinus due to hit of fi lling material from the tooth canal into the sinus cavity needing a sinus lift procedures, optimal solution using endoscopic technology [26,27].

Objectives
Optimization of the sinus-lifting in patients with fi lling material in maxillary sinus cavity by a one-stage endonasal endoscopic elimination of the sinus pathology and carrying out a sinus-lifting.

Materials and methods
A total of 14 patients (8 males and 6 females, the age was 31 to 64 years, from 2016 to 2020) with ridge defects in age group were selected for the study. All patients had a partially or totally edentulous atrophied posterior maxilla. All patients underwent a thorough clinical examination according to a generally accepted scheme.
Preoperative planning includes a careful history and physical exam, in addition to preoperative radiologic investigation, which include computed tomography scan to to determine the existing osseos structure and to evaluate any pathology of the sinuses (Figure 1). Treatment initiates with the administration of a single preoperative dose of systemic antibiotic (Amoxicillin, clindamycin or levaquin) and Chlorhexidine 0.12 percent rinse.
A total of 18 sinus lifting procedures were performed, using a mixture of bovine bone, autogenous bone and PRP. bone around and above the implants. The implants appeared to be well integrated with no peri-implant bone loss. At 5 years follow up, excellent integration of grafted tissue, steady levels of bone around the implants and healthy peri-implant tissues were reported. Implants placed in the reconstructed areas were demonstrated to integrate normally, postoperative occlusal function and esthetics have been favorable.

Conclusion:
The method of simultaneous endonasal sanitation of the maxillary sinus, sinus-lifting, dental implantation, allows to reduce the probability of perforation of the membrane, signifi cantly shortening the rehabilitation period of patients with insuffi cient bone tissue in the maxillary sinus. These methods led to simpler, more comfortable, lower risks of morbidity, more predictable compared to more invasive maxillary sinus augmentation.
The fi rst procedure was always the endoscopic endonasal sinus surgery. This was performed in all the patients through an enlarged natural sinus ostium in the middle nasal meatus.
All operations were carried out under general anesthesia.
The ostium was enlarged to a size that allowed access to the sinus with appropriate instruments. The fungal material, and hypertrophic mucosa within the maxillary sinus were removed and sent for pathological analysis. Sinus lifting procedures were performed using a lateral window approach. Osteotomy was performed on the lateral surface of the sinus wall using a round drill. After the elevation of the sinus membrane, the dental implant sites were prepared using low-speed calibrated burrs, specifi c to the implant system used. The cavity between the sinus membrane and the sinus fl oor was fi lled in with a mixture of particulate bovine bone graft (Bio-Osss, Geistlich Pharma, Wolhusen, Switzerland), autologous bone, and plateletrich plasma (PRP), and the dental implants were inserted with a good primary stability. According to our surgical procedure we performed in our patients 1 a 2 stage sinus lifting, 46 implants were inserted.
The delayed establishment of dental implants was carried out in 4 patients after 5 months after operation. Immediate implant placement (one-stage sinus lifting protocol) was performed when a mean bone height of at least 4 mm was present on CT examination. For the one-stage protocol the implant site was prepared and the implant inserted in the residual subantral bone. Тhe osteotomy window was covered with the PRP membrane before fl ap closure. The mucoperiostal fl ap was sutured using 3.0 silk suture. Hospitalization after surgery varied from 1 to 2 days. The sutures were removed 10e14 days postoperatively.
The height of the graft and bone density was measured 6th and 9th month after surgery using serial CT scan ( Figure 2).
Dental prosthetic rehabilitation was undertaken 5 months after implants insertion and submerged healing. Implant success was assessed clinically and radiographically. As a result of the introduction of these innovative technologies, surgical technologies for managing patients with sinus pathology have been optimized, using minimally invasive endoscopic technique, simultaneous endonasal sanation of the maxillary sinus with endoscopic assisted sinus lifting before dental implantation.

Conclusion
The method of simultaneous endonasal sanitation of the maxillary sinus, sinus-lifting, dental implantation, allows