Clinical

Maxillary sinus surgery: Anatomy

and advanced diagnostic imaging
Tiziano Testori1

Abstract
No treatment plan for the posterior maxilla can fail to consider the status of the maxillary sinus. If pneumatization of the sinus
or alveolar bone resorption has occurred, then bone grafting or sinus elevation may be necessary to enable implant-supported
rehabilitation. Anatomic features including the Schneiderian membrane, the major arteries and nerves, and any bony septa
optimally should be three-dimensionally rendered with advanced diagnostic imaging technologies such as computed
tomography (CT). A determination can then be made as to whether alternatives to sinus elevation may be considered. If sinus
elevation is inevitable, it is essential to have an excellent understanding of the sinus anatomy, which is briefly outlined in this
article.

Key words: sinus anatomy, maxilla, diagnostic imagery

Introduction Clinicians initially tried to solve the problem of insufficient

In developing any treatment plan for the maxilla that posterior bone support by using prostheses with distal
includes the posterior regions, the status of the maxillary extensions supported by implants placed anteriorly or by
sinus must be carefully considered. Pneumatization of the combining long implants in the anterior with short posterior
sinus may limit the amount of residual bone. Given the implants. However, by the late 1970s, Tatum1 and Boyne2
tendency of the alveolar ridge to progressively resorb after were reporting on an alternative: elevation of the maxillary
tooth loss and the typically poorer quality of posterior sinus in order to better accommodate placement of
maxillary bone, rehabilitation of this area with endosseous implants. Since then, numerous approaches to
implant-supported fixed prostheses has traditionally been maxillary sinus elevation have developed, and a substantial
challenging. body of research has demonstrated the procedure to be
predictably successful.3 At the same time, other alternatives
have also developed, including the use of reduced-length
1Tiziano Testori, MD, DDS implants with roughened surfaces or tilted implants
Assistant Clinical Professor and Head of the Section of Implant inserted in a variety of ways.
Dentistry and Oral Rehabilitation, Department of Odontology, at the This article briefly reviews the role of computed
University of Milan, Milan, Italy.
Private Practice, Como, Italy. tomography (CT) when sinus-augmentation surgery is
www.implantologiaitalia.it. being considered.

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The Role of CT in Sinus Augmentation

When the alveolar process has resorbed significantly and
sufficient bone to accommodate implants appears to be
unavailable, diagnostic imaging plays a vital role, providing
reliable and necessary information.4,5 CT offers considerable
advantages compared with traditional diagnostics
(orthopantography, intraoral radiographs). For complex
dental operations, CT must be considered an essential
presurgical diagnostic method (Figures 1-3).6-8
With three-dimensional reconstructions based on CT
scan data, morpho-volumetric analysis of the planned
surgical site becomes relatively simple, and the available
densitometric information ensures much higher diagnostic
confidence compared with conventional radiologic
investigation. Electronic reconstructions are now available Figure 1: High definition 3D reconstruction of the maxillary bone.
in various rendering modes that synthesize an enormous
amount of information, contained in hundreds of axial
images. In addition to being immediate and diagnostically
exhaustive, these images can be easily interpreted by
operators.
Combining the scan data with a computer-guided
surgical system such as the Tapered Navigator® Kit (BIOMET
3i) for CT guided surgery may make it possible to place
implants despite the anatomical limitations. CT guidance
technology allows clinicians to measure with great precision
the locations of anatomic structures and the dimensions of
underlying bone. Bone densities can also be easily
identified, and an accurate surgical guide with precise
surgical instrumentation can be fabricated. The use of these
combined tools sometimes enables placement of implants
when the bone under the maxillary sinus is minimal. Figure 2: Virtual endoscopy with VRT superimposition of soft tissues
can be used to check patency.
If a sinus elevation is unavoidable, a variety of anatomical
factors may influence the design of the lateral window and
the choice of graft material. Information on bone density,
bone cortical walls, and bone resorption in the alveolar
processes is important for planning functionally and
aesthetically optimal prosthetic treatment. Information on
associated orosinus pathologies is also important.
Determining the position and patency of the maxillary
sinus ostium is essential when planning sinus-elevation
procedures. Of particular importance is the integrity of the
ostio-meatal complex, the morpho-functional unit used for
drainage and aeration of the anterior ethmoidal cells, the
maxillary sinuses, and the frontal sinuses. CT scanning
allows for precise evaluation of its numerous components,
revealing any irregularities in development (e.g. bulla
conche, septum deviation, or inflammation involving the
maxillary sinus ostium). Respecting the structure of the Figure 3: Virtual endoscopy used to analyze the tooth positions with
respect to the maxillary sinus floor.
ostium is essential for a successful operation.

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Figure 4: Frontal section of the maxillary sinuses. Hyperpneumatization Figure 5: Relationship between the nasal cavity and the maxillary sinus.
of the left sinus and atrophy of the alveolar ridge subsequent to tooth
loss is evident.

Figure 6: The instrument enters from the pyriform opening and Figure 7: The foramen of the sinus ostium is normally a 6mm by 3.5mm
reaches the medial wall of the sinus (the lateral wall of the nasal oval.
cavity).

Overview of the Sinus Anatomy The maxillary sinus communicates with the homolateral
All the paranasal sinuses occupying the maxillary bone nasal fossa by means of a natural ostium located postero-
humidify and warm the inhaled air. They also thermally superiorly on the medial surface (Figures 6 and 7). In adults
insulate the upper nerve centers, protect the skull base from with a full set of teeth, the maxillary sinus floor is the
trauma, influence phonation by acting as an indirect strongest of the bone walls surrounding the cavity. However,
resonance box, and contribute to reducing the weight of the as aging occurs, the sinus floor tends to resorb and form
facial bones.9,10 The largest of the paranasal air cavities, the dehiscences around the roots. The root ends may jut into
maxillary sinus includes a medial wall that separates the the cavity, covered only by the Schneiderian membrane and
maxillary sinus from the nasal cavity, a posterior wall facing a small bone cortex flap (which in turn may be missing).
the maxillary tuberosity, a mesio-vestibular wall containing Extreme care must be taken to avoid tearing the membrane
the neurovascular bundle, an upper wall constituting the when separating it from such exposed apices.
orbit floor, and a lower wall next to the alveolar process that The mesio-vestibular and medial bone walls are the ones
is the bottom of the maxillary sinus itself (Figures 4 and 5).11 most often involved in maxillary sinus surgery. An accessory

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ostium may sometimes be found on the medial wall. When

this occurs, it should be identified before any
maxillary sinus-elevation procedure is performed, to avoid
detaching the mucosa up to this point.

The Sinus Membrane

The Schneiderian (mucous) membrane lines the inner walls
of the sinus and in turn is covered by pseudo-stratified
columnar ciliated epithelium (Figures 8-10). Serum-mucosa
glands are located in the lamina directly underneath,
especially next to the ostium opening. Normally the thickness
of the Schneiderian membrane varies from 0.13mm to
0.5mm. However, inflammation or allergic phenomena may
cause it to thicken, either generally or locally (in streaks). In
Figure 8: Diagram of the Schneiderian mucosa with various cellular
components.
such cases, it may be necessary for an otolaryngologist to
restore the sinus to a physiologic state before a sinus-lift
operation can be carried out.

Progressive Change, Edentulism, and Bone

Resorption
In cases of maxillary edentulism, progressive resorption of
the alveolar ridge may reduce the bone to a thickness of less
than 1mm. Several causes may contribute to this
phenomenon. Teeth and the masticatory loads they apply
stimulate the alveolar bone and limit its resorption.
Immediately after the avulsion of a tooth, significant bone-
modeling typically occurs. Vertical bone loss later tends to
stabilize, averaging about 0.1mm/year, though large
variations can be found among individuals. However,
hormonal imbalances, metabolic factors, inflammation, and
certain systemic pathologies can cause the bone resorption
Figure 9: Diagram of the ciliated epithelium, propellant for sinus
secretions. to accelerate again. Age and gender may also influence
bone loss.
The sinus floor tends to lower craniocaudally as the
alveolar ridge is resorbed in the opposed direction. It is the
lack of vertical posterior maxillary bone that often
necessitates the use of bone grafts or sinus-lifting
procedures prior to implant rehabilitation.
Progressive resorption of the posterior maxillary
edentulous ridge follows a well-defined path that differs
from that of the anterior regions and includes repeatable,
predictable morphologic changes. Cawood and Howell’s
system for classifying the degrees of atrophy based on the
morphologic differences in the residual ridge12 is extremely
useful for presurgical diagnostic assessment, as the ridge
appearance is connected to the horizontal and vertical size
of bone available for implants.

Figure 10: A thin sinus membrane.

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Figure 11: Underwood septa inside the maxillary sinus. Figure 12: Another view of the Underwood septa.

Figure 13: Vascular system of the maxillary sinus. Figure 14: The diameter of this alveolar antral artery, detected during
left sinus-floor augmentation, was nearly 3mm.

Bony Septa masticatory loads optimally. After the complete loss of

Inside the maxillary sinus, bony septa originating in the sinus teeth, the septa sometimes gradually disappear.18
floor are often found (Figures 11 and 12). Called Underwood A tridimensional x-ray diagnosis of septa presence is
septa, they may divide the back part of the sinus into important for planning the size, shape, and position of the
multiple compartments known as posterior recesses. They antrostomy in maxillary sinus elevation and later separating
may even occasionally reach from the base to the upper the sinus membrane from the septa.
sinus wall, creating two sinuses.13 Estimates of the
prevalence of such septa have ranged from 16 to 58%.14-17 Vascularization
The formation of Underwood septa may be linked to the Three arteries supply blood to the maxillary sinus: the
fact that teeth are lost at different times. The edentulous infraorbital artery, the posterior lateral nasal artery, and the
areas may resorb in a manner that results in a difference in posterior superior alveolar artery (Figures 13 and 14). While
level between the two adjacent portions of the sinus floor. their presence should be investigated to avoid hemorrhages
It is thought that a bony septum may form in the area during sinus-grafting surgery, severe hemorrhages tend to be
between the two regressing areas in order to transfer rare, as the main arteries do not run inside the surgical area.19

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Figure 15: After emerging from the infraorbital foramen, the infraorbital nerve seen in this
cadaver dissection splits into smaller branches.

If small vessels located in the exposed Schneiderian patient’s bone and other significant structures, making it
membrane are broken, it is better to allow hemostasis to easier to choose among treatments including sinus-floor
occur naturally. Applying light pressure with a gauze may elevation.
be effective, however, whereas an electrocoagulator may
cause membrane necrosis. Disclosure
The contributing clinician has a financial relationship with
Innervation BIOMET 3i LLC resulting from speaking engagements,
Innervation of the maxillary sinus originates directly from the consulting engagements, and other retained services.
maxillary nerve, the second branch of the fifth cranial nerve. Reprinted with permission from JOURNAL OF IMPLANT AND
With its posterior middle and superior alveolar branches, it RECONSTRUCTIVE DENTISTRY® Vol. 3 No. 1
innervates the posterior sinus floor together with the molar
and premolar teeth. The anterior superior alveolar branch References
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