上颌窦提升PPT演示课件

,YOUR SITE HERE,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,LOGO,上颌窦提升术,1,1.,定义,2.,起源,3.分类,4.,Contents,4.手术流程,2,上颌窦底提升术：,当上颌后牙缺失后，上颌窦的底壁就会下降到缺失牙原来的牙根的位置，加之牙槽嵴萎缩、上颌窦气腔化，导致上颌窦底到牙槽嵴顶的高度不足,此时一旦种植就有可能穿透上颌窦壁，为了植入种植体，经常需要将上颌窦底黏膜抬高并补骨，使其创造足够的骨量，提供牙科植体的种植。,上颌窦提升术,就是指提升上颌窦底的位置后,将骨移植材料放置于新形成的窦底与原上颌窦底之间,使得上颌窦底至牙槽骨嵴顶高度增加。,3,上颌窦底提升术的起源：,19世纪初，欧洲人利用熟石膏注入的方式治疗上颌窦疾病。,70年代中期，Tatum提出开放式上颌窦底提升术，使用自体骨将上颌窦底提升并同时植入植体，Boyne和James是第一位正式将上颌窦底提升术在文献上记录下的学者。,Tatum于80年代中期为上颌窦底提升术设立了一连串的规则，之后的研究者即根据这些初步的工作延续改进上颌窦底提升术。,Summers在1994年发表osteotome technique作为上颌窦底提升术的方法。,1998年，林野在国内率先报告上颌窦提升术，使该区种植成功率大大提高，成为常规种植修复的安全区域。,4,分类,上颌窦提升术,开放式上颌窦底提升术,（外提升）,闭合式上颌窦底提升术,（内提升）,内窥镜辅助下窦底提升术,（属于内提升的特殊方式）,5,开放式上颌窦底提升术,开放式上颌窦底提升术,是在上颌窦前壁处开窗,通过特制的提升工具将上颌窦底黏膜提升,在提升的上颌窦底处可放置移植骨块或人工骨粉,可同期或分期植入种植体。,6,开放式上颌窦底提升术,优点：,该术可在直视下进行,能形成充足的骨量,窦膜损伤易处理,提升的上颌窦底高度较高、易控制,多用于上颌后份植入区骨质高度,5mm,的病例。,7,开放式上颌窦底提升术,缺点：,手术范围较广、损伤较大,术后反应较重、费用高,患者不易接受,由于上颌前磨牙及磨牙的天然牙根在上颌窦区域常位于上颌窦腔内，上颌窦粘膜包绕该牙根，走行不规则，加之上颌窦本身凹凸不平，单个牙缺失或间隔牙缺失行上颌窦底提升术时，受其近远中相邻牙根的影响，要完整无损的剥离上颌窦粘膜相当困难。,8,开放式上颌窦底提升术,外提升一般分为:,(1)infracture osteotomy technique；,(2)antrostomy ostrotomy technique；,(3)grinding technique,目前常采用,infracture osteotomy technique,，将开窗骨片内推当做基底骨，但常因纵隔嵴的关系，易造成撑膜不易或撑膜破损，手术者尝试修正手术方法以减少手术风险，各种撑膜器械与方法应运而生。,9,开放式上颌窦底提升术,外提升一般操作步骤：,1)麻醉,2)切口翻瓣,3)骨窗制备,4)分离上颌窦粘膜,5)制备种植窝,6)填塞骨移植材料,7)植入种植体,8)缝合及手术后处理,10,开放式上颌窦底提升术,常规方法,切口翻瓣：,常规于牙槽嵴顶偏腭侧做粘骨膜切口，切口距开窗边际应2毫米以上，近中切口向颊侧前庭沟方向延伸，并越过前庭沟，远中切口可延至上颌结节区，沿牙槽嵴切口向颊侧上方剥离骨粘膜瓣，暴露上颌窦前外侧壁。,11,开放式上颌窦底提升术,常规方法,骨窗制备：,用球钻在缺牙间隙上方上颌窦前壁确定开窗线，开窗范围直径约1.5厘米，窗层距牙槽嵴顶35毫米。顶线做半层骨截除，形状有圆形、矩形、椭圆，一般以为椭圆较佳。,12,开放式上颌窦底提升术,常规方法,分离上颌窦粘膜：,轻叩顶线青枝骨折，用特制器械细心剥离窦底、内、外、前、后壁之下份窦粘膜，连同开窗骨板向内上方旋转成为上领窦内植骨区的顶，选择合适的窦膜剥离器，细致完整地剥离上颌窦底粘膜，并向上推起，逐步达到要求提升高度。,13,开放式上颌窦底提升术,改良方法一,骨窗制备：,根据三维CT 重建后的数据，确定上颌窦外侧壁的开窗位置。骨窗面积尽量要小(约1.3 cm 0.8 cm 即可)，金刚砂球钻和压电超声骨刀联合应用，先使用金刚砂球钻快速磨除上颌窦外侧骨壁部分皮质骨，深度控制在1.5 mm 左右(根据CT 扫描后的测量数据决定相应的初步磨除骨质厚度)。然后再用超声骨刀切割开窗部位的骨质，以分离上颌窦黏膜及骨窗骨质。将剩余骨质取出后，利用具有转角的上颌窦黏膜剥离器仔细谨慎剥离上颌窦黏膜和窦底的粘连。,14,分离上颌窦粘膜：,将纱布蘸生理盐水至全湿,从开窗处先垂直下压,造成初步黏膜剥离内凹。,将纱布往骨窗下缘内推,反复撑松后,再往外扩(上下左右各方位)创造足够的植牙空间,将纱布先留至窗口内作为阻挡器械钻孔伤及黏膜的屏障。纱布于种植窝预备后取出。,开放式上颌窦底提升术,改良方法一,15,开放式上颌窦底提升术,改良方法二,(a),Initial preparation of the osteotomy.,(b),The sinus membrane is dissected away from the margins of the fenestration with a sinus membrane elevator .,(c),A,haemostatic nasal balloon,is used to push the membrane gently inwards .,(d),The sinus membrane is lifted away from the bottom of the sinus with the dilated haemostatic nasal balloon .,(e),The sinus floor is filled with material for grafting .,16,开放式上颌窦底提升术,改良方法二,1. Six millimeters of bone. 2. Crestal and minimal vertical relaxing incisions. 3. Buccal wall osteotomy. 4. Balloon testing. 5. Balloon insertion. 6. (a) Balloon insertion along antral floor. (b) Balloon inflation.,气球充水撑膜法其骨窗至少要开到,6mm,，然后置入泄气状态的气球一只，其宽度为,3mm,，以注射筒注入生理盐水于气球，注入,1ml,时，可撑高,6mm,，注入,2ml,时，可撑高,13mm,，将所撑出的空间植入骨粉补骨。,17,开放式上颌窦底提升术,改良方法三,Fig.,1. Use of negative air pressure by nasal suction through the nostril during sinus lift.,Use of negative air pressure by nasal suction,during,maxillary sinus floor lift,18,开放式上颌窦底提升术,改良方法三,Fig. 2. After raising the sinus lining a membrane (Bio-Gide, Geistlich Biomaterials),was placed internally to prevent damage to the lining when packing with the graft material (Bio-Oss, Geistlich Biomaterials).,19,开放式上颌窦底提升术,改良方法四,Figs 1a and 1b A flap was superiorly raised to expose the anterolateral wall of the maxilla. A bony window was prepared by rectangular,osteotomy to enable visualization of the maxillary sinus mucosa. An opening was created with a 702 bur superiorly and distally to the window,through the wall of the maxilla and the sinus mucosa.,20,开放式上颌窦底提升术,改良方法四,Figs 2a and 2b A suction tube was positioned and kept functioning over the created opening to establish negative pressure inside the maxillary sinus.,21,开放式上颌窦底提升术,改良方法四,Figs 3a and 3b The articulated bony window in position to accommodate the graft inside the sinus cavity.,22,开放式上颌窦底提升术,改良方法四,Fig 4 Graft inside the sinus cavity.,23,闭合式上颌窦底提升术,闭合式上颌窦底提升术于1994年由Summers发明，当骨高度不足时在牙槽嵴顶以特殊设计的骨凿扩孔或以钻针钻至离上颌窦底约1-2mm，再以槌子敲击骨凿冲压提升上颌窦底，植骨后植入种植体。,24,闭合式上颌窦底提升术,优点：,局部上颌窦底的提升，手术范围小,创伤小,术后反应轻微,治疗时间缩短,一般不需植骨，或仅需植入少量人工骨，费用低, 减轻了患者的经济负担，患者易于接受,缺点：,不能在直接视野下进行手术,窦膜损伤不易发现,上颌窦提升高度有限。,25,闭合式上颌窦底提升术,()骨凿式上颌窦底提升术（osteotomesinus floor elevation，OSFE）,()液压窦挤压技术(hydraulic sinus Condensing technique),()超声骨刀IM系统,(),水压上颌窦提升术,()内,窥镜辅助下窦底提升术,26,()骨凿式上颌窦底提升术（osteotome sinus floor elevation，OSFE）,特色是骨凿功能性尖端为内凹端,除具有骨挤压作用外,亦有骨片提升作用,OSFE技术是先使用先锋钻在植牙区钻到距离上颌窦底约12 mm的高度,然后逐级扩大到种植体植入所需的大小,最后再使用锤子敲击骨凿凿穿窦底,使皮质骨破裂,造成“帐篷架高效应”,将窦膜往上提升,可加或不加补骨材料。折断的皮质骨可诱导种植体根尖周围骨的再生，种植体植入后骨结合与骨再生同时进行。,27,()骨凿式上颌窦底提升术（osteotome sinus floor elevation，OSFE）,1）颜面消毒及局部麻醉，采腭侧切口，必要时于切线两端往颊侧加垂直切线，全层翻起黏骨膜瓣。,2）小球钻定位，再以直径2 mm先锋钻预备种植窝至距离上颌窦底约12 mm。必要时可进行根尖片摄影，以检查所钻深度。确定深度无误后，逐级备洞至如上深度至拟用种植体相应直径。若先锋钻预备时发现骨质疏松可以用系统配套的骨挤压器,逐级挤压来增强骨质密度并达离上颌窦底相应距离。,28,()骨凿式上颌窦底提升术（osteotome sinus floor elevation，OSFE）,3）使用骨凿及槌子将上颌窦底部皮质骨板敲破，敲入前先以所要填充的移植骨垫底，再以骨凿敲入原来钻骨深度，尽量避免骨凿进入鼻窦内以减少上颌窦粘膜受创的机会。,4）充填的移植骨可以单独为自体移植骨或混合使用同种异体骨、异种骨、人工合成材料等。依据研究显示，使用不同种的移植骨，对于植体成功率并不会造成明显差异。为了便于判断，可考虑使用具放射线不透性之移植骨。,29,()骨凿式上颌窦底提升术（osteotome sinus floor elevation，OSFE）,5）重复以骨凿将移植骨充填进上颚窦内，骨凿敲入深度应始终维持不要超过上颚窦底部。上颌窦充填的移植骨高度视需植入的植体长度而定，一般建议垫完后的骨嵴高度应比植入植体长度多2毫米。依Reiser等人的研究建议，使用银汞充填器充填移植骨两次，约可增高上颌窦膜1毫米，可藉此衡量所必需填入的骨量。为慎重起见可在送入植体之前再次以根尖摄影确认充填高度。,30,()骨凿式上颌窦底提升术（osteotome sinus floor elevation，OSFE）,6）最后放入植体，检查初期稳定度后，关闭窗口。,7）术后给予患者抗生素、止痛药及漱口水，合并给予抗组织安类药物以减少上颌窦分泌物。此外要特别叮咛患者避免用力擤鼻涕及打喷嚏，减少出入公共场所以减低上呼吸道感染机会。,31,(),液压窦挤压技术,(hydraulic sinus Condensing technique),Leon Chen,所提出液压窦挤压技术,(hydraulic sinus Condensing technique),。该技术不用骨凿而改用牙科用的气动高速手机，先使用直径,3mm,圆钻针钻至轻触皮质骨层，再使用直径,2mm,的圆钻针，继续钻穿皮质骨层，并打转,20,至,30,秒，藉由手机的水压与气压把黏膜充气撑离，然后再使用,1.8mm,圆形端黏膜探针，去测量至窦底的真正长度，并使用骨粉输送器,(bone carrier),置入骨粉，使用骨粉挤压器,(condenser),去推骨粉撑膜，将膜撑至所需高度，便开始制备窝洞，植入种植体。,32,()液压窦挤压技术(hydraulic sinus Condensing technique),A sinus condensing kit* was developed especially for this procedure. It consists of round diamond sinus burs with 1, 2, and 3 mm diameters. Titanium-coated sinus graft condensers are supplied in 2, 3, 5, and 6mm diameters.The sinus condensers are marked at depths of 3,5, 8, and 10 mm. Using these tools in combination with hydraulic pressure supplied by a surgical handpiece,clinicianscan safely separate the Schneiderian membrane from the sinus floor and prepare the area for immediate implant placement in a fashion that takes advantage of anatomical features normally viewed as restrictive.,33,()液压窦挤压技术(hydraulic sinus Condensing technique),With 5 mm (A) of sinus floor thickness, use a 3 mm round diamond,bur (B) to start the osteotomy.,34,()液压窦挤压技术(hydraulic sinus Condensing technique),Tapping pinhole access to the sinus. The 2 mm round bur (A) forms a conical shape (B) at the end of the osteotomy. Consistent hydraulic pressure from the handpiece (C) through the pinhole inflates the,Schneiderian membrane.,35,()液压窦挤压技术(hydraulic sinus Condensing technique),Gently push the material (A) through the pinhole with a 3 mm condenser (B) to initially loosen the membrane. The conical end of the osteotomy,prevents the condenser from entering the cavity.,36,()液压窦挤压技术(hydraulic sinus Condensing technique),Widen the osteotomy with a 3 mm implant drill (A).The bone graft,mixture will insulate the drill bit from the membrane,37,()液压窦挤压技术(hydraulic sinus Condensing technique),Use a combination of mineralized bone with at least 50% peptide-coated particulate (A) for the secondary graft. Pack the material in with a wider,condenser (B).,38,()液压窦挤压技术(hydraulic sinus Condensing technique),Use an appropriately sized drill (A) to widen the osteotomy for implant placement.,39,()液压窦挤压技术(hydraulic sinus Condensing technique),Use implants (A) with closely spaced threads.,40,(),超声骨刀,IM,系统,超声骨刀有很强的硬组织识别能力，只切割骨组织，无损伤软组织的危险，在获得最大的骨切割精度的同时，可以降低上颌窦黏膜的损伤。藉超声骨刀的特性，有效磨穿骨组织却不易磨破软组织，更可利用内冲水压的方式，在磨穿窦底骨质同时，藉由水压冲膜，与Leon Chen的液压窦挤压技术方式雷同。,41,()超声骨刀,应用一,Piezosurgery system 为意大利Mectron 公司生产。频率2529 Hz，振幅60200 m。有金钢砂喷涂的刀头OP4（图1）或OT4，及银色剥离器EL1。,42,()超声骨刀,应用一,1）颜面消毒及局部麻醉，采腭侧切口，必要时于切线两端往颊侧加垂直切线，全层翻起黏骨膜瓣。,2）小球钻定位，再以直径2 mm先锋钻预备种植窝至距离上颌窦底约12 mm。必要时可进行根尖片摄影，以检查所钻深度。确定深度无误后，逐级备洞至如上深度至拟用种植体相应直径。,43,()超声骨刀,应用一,3）以Piezosurgery 超声骨刀机接OP4 或OT4 刀头向上颌窦底方向磨切（图2）,，去除残余窦底皮质骨。进入上颌窦时会感觉阻力突然减小，此时停止修磨。采用EL1 钻头以划圈方式小心剥离上颌窦黏膜，同时嘱患者用鼻吸气，辅助上颌窦底黏膜提升。采用捏鼻鼓气法检查是否有窦膜破孔。若有穿孔，采用Bio-Guide 胶原膜修补，并嘱患者鼻呼气，使窦底膜下降与胶原膜更好贴合。之后将骨移植材料送入窦底黏膜下提升处。,4）最后放入植体，检查初期稳定度后，关闭窗口。,44,()超声骨刀,应用二,(a) Initial situation. (b) Flap elevation. (c and d) In the initial phase,the IM2 insert was used.(e) OT4 was used to prepare the osteotomy up to the Schneiderian membrane.,45,()超声骨刀,应用二,(f) The osteotomy site completed. (g) BioOss1 mixed with autologous bone inserted.,(h and i) The implant has been installed.,46,(),球囊上颌窦提升术,1)麻醉，切口翻瓣，小球钻定位，再以直径2 mm先锋钻预备,种植窝至距离上颌窦底约12 mm。,2）The osteotomy was enlarged by osteotome of 2.8 mm to 3.15 mm (Figure 1C), and the sinus floor was gently broken.,After examining the integrity of the sinus membrane (by Valsalva maneuver and direct visualization), Fisiograft gel (GHIMAS, Casalecchio di Reno, Italy) was injected to enhance lubrication.,An 8F sleeve (2.6-mm internal diameter) was screwed in up to 0.5mmsuperior to the sinus floor. A dedicated inflatable balloon(7F external diameter, inflated volume _2.5 mL) was advanced 1 mm to 2 mm beyond the tip of the metal sleeve and anchored by a locking mechanism at the proximal part of the sleeve (Figure 1DI). The balloon was slowly inflated with the dedicated inflator syringe using diluted contrast media (50% Ultravist 370 diluted with normal saline), with inflating pressure not exceeding 2 atmospheres. The balloon inflation and sinus-floor elevation were evaluated by sequential periapical X rays (Figure 1DII). Once the desired elevation (usually .10 mm) was obtained, the balloon was deflated and removed with the sleeve. A second test of membrane integrity was done as previously mentioned.,47,(),球囊上颌窦提升术,(AI) Bone thickness under sinus membrane and septum.,(AII) Maxillary sinus.,(B) Pilot drill.,(C) Expanding osteotomy (2.8 mm) and breaking the sinus floor.,(DI) Balloon setup.,(DII) Antral membrane elevation by balloon.,(E) Following bone transplantation.,(FI) Implant fixation and septal drilling.,(FII) Second implant fixation,(FIII) Postprocedural follow up (3 weeks).,48,(),水压上颌窦提升术,A water lift system consists of two different components. The first is an intraosseous small titanium screw used for bone anchorage with hermetic infiltration of the sinus floor (the length/diameter of the titanium screws used for bone anchorage were 5/3.5 5/4 8.5/3.5 and 8.5/4 mm) (Fig. 1).,Fig. 1. Sinus infiltration device for the crestal approach.,49,The second part is a hermetic connector, which injects liquid through the intraosseous element.,(),水压上颌窦提升术,Fig. 2. Sinus elevation with the infiltration device (surgical view).,50,(,),内窥镜辅助下窦底提升术,为一种在内窥镜监视下的上颌窦内提升术。经上颌窦鼻侧面的尖牙窝插入鼻窦内窥镜。在内窥镜监视下提升窦底、植入移植材料和植入种植体。内窥镜下窦底提升术造成的手术创伤小,能有效降低窦底黏膜穿孔率,能监视提升的高度和移植骨的位置。但手术设备昂贵,因此不能被当作标准的手术程序推广应用。,51,(,),内窥镜辅助下窦底提升术,A cortical plate is punched out of the sinus floor and elevated with the adherent sinus membrane by an osteotome (left,schematic drawing; right, sinuscopic view).,52,(,),内窥镜辅助下窦底提升术,Dissection of the sinus membrane from the sinus floor with a blunt elevator (left, schematic drawing; right, sinuscopic view).,53,(,),内窥镜辅助下窦底提升术,Reinsertion of the osteotome with grafting material (left, schematic drawing; right, sinuscopic view).,54,(,),内窥镜辅助下窦底提升术,Endoscopic examination 6 months postoperatively. The,sinus membrane shows no signs of inflammation or perforation.,55,Thank you!,56,