Resumen
La realización de cirugía de levantamiento del suelo del seno maxilar (LSSM) en los pacientes que presentan septo sinusal, sin que ocurra perforación de la membrana sinusal, representa un verdadero desafío a los profesionales de la Implantodoncia. Siendo así, este artículo relata un caso clínico de cirugía de LSSM en paciente que poseía septo en el seno maxilar. Se buscó evidenciar los principales cuidados que deben ser tomados en el abordaje quirúrgico, así como las formas de tratamiento para las eventuales intercurrencias.
Introducción
La región posterior de la mandíbula edéntula representa un desafío especial para la planificación y ejecución de las rehabilitaciones orales implantadas. Los problemas comunes en esta región son la pérdida ósea debido a la reabsorción del proceso alveolar y la neumática del seno maxilar, además de la pobre calidad ósea.
La cirugía para levantar el suelo del seno maxilar (LSSM) es el procedimiento más comúnmente realizado para tratar tal condición. A través de esta técnica una ventana ósea es confeccionada en la pared anterior del seno maxilar, permitiendo el desprendimiento de la membrana sinusal y el llenado del espacio con biomateriales (Figura 1). A depender de la cantidad de remanente óseo nativo, los implantes se pueden instalar de forma simultánea o posterior (aproximadamente 8 meses) a la cirugía de LSSM. Los implantes instalados en senos maxilares aumentados tienen una supervivencia media del 98,6% y el 93,5% en 3 y 5 años de seguimiento, respectivamente.
La presencia de septos en el seno maxilar, especialmente en el suelo, es un factor que dificulta la realización de la cirugía de LSSM. La tasa de presencia del septo en el seno maxilar fue reportada como superior al 30% en estudios previos. La probable etiología del septo en el seno maxilar ha sido asociada a la presión causada por la masticación y el desequilibrio entre el aumento de las suturas y la reabsorción de la superficie ósea en el proceso alveolar y en el seno maxilar durante el desarrollo óseo (Figuras 2 y 3).
Las complicaciones durante la cirugía de LSSM pueden comprometer la ganancia ósea y, por consiguiente, inviabilizar la instalación del implante. La perforación de la membrana sinusal es la complicación transoperatoria más común de ocurrir. Entre los factores que pueden aumentar el riesgo de perforación de la membrana sinusal, la presencia del septo ha sido implicada como causa potencial durante el procedimiento quirúrgico (Figura 4). Por lo tanto la información de la prevalencia, localización y dirección del septo, así como la presencia de alguna patología en la base del seno, pueden ayudar al cirujano a mejor evaluar los riesgos asociados con el procedimiento en esa región.
Figura 1 – Ilustración evidenciando el llenado del seno maxilar con biomateriales.
Figura 2 – Ilustración evidenciando la presencia de septos en el suelo del seno maxilar.
Figura 3 – Imagen clínica evidenciando la presencia de septo sinusal. En estos casos el desprendimiento de la membrana sinusal es más difícil y el riesgo de perforación de la membrana aumenta.
Figura 4 – Membrana sinusal perforada durante la cirugía de LSSM con presencia de septo.
El cuidado preoperatorio en la evaluación de la presencia de variaciones anatómicas (principalmente septo sinusal) y patologías, especialmente en la base del seno maxilar, con tomografía computarizada puede dirigir la mejor planificación del procedimiento y ayudar al cirujano atenuando las posibilidades de complicaciones quirúrgicas (Figuras 5 y 6).
Ante lo expuesto, el caso clínico a continuación demuestra el protocolo quirúrgico que se utilizó en casos de cirugía para LSSM con presencia de septo sinusal.
Figura 5 – Corte tomográfico evidenciando la presencia de septo sinusal.
Figura 6 (A-B) – Ilustraciones que muestran las posibilidades de modificaciones en el diseño de la ventana ósea que el cirujano puede realizar con el objetivo de facilitar el desprendimiento de la membrana sinusal y disminuir el riesgo de perforación de la misma.
Relato de Caso
Paciente MJS, género femenino, 58 años de edad, buen estado de salud general, buscó para instalación de implantes dentales quejándose de la ausencia de dos dientes. El examen clínico y el tomográfico revelaron ausencias de los elementos 14 y 15, neumometría extensa del seno maxilar y presencia de septo sinusal en su interior (Figura 7).
El plan de tratamiento propuesto fue la realización de abordaje quirúrgico para levantar el suelo del seno maxilar envolviendo el septo sinusal, con instalación simultánea de dos implantes dentales.
La cirugía fue iniciada por medio de un colgajo trapezoidal, con una incisión horizontal en la cresta del reborde edéntulo y incisiones relajantes verticales (una incisión en la región anterior y otra en la región posterior), seguida de desprendimiento mucoperiosteal, confección de la ventana ósea y desprendimiento de la membrana sinusal. El diseño de la ventana ósea, así como la elevación de la membrana se realizaron con extremo cuidado, teniendo en cuenta la presencia del septo y el riesgo de perforación (Figuras 8, 9 y 10).
Figura 7 – Imagen tomográfica evidenciando las ausencias dentales, así como la extensa pneumatización del seno maxilar y presencia de septo sinusal.
Figura 8 – Modificação da osteotomia realizada no presente caso visando diminuir o risco de perfuração da
membrana sinusal.
Figura 9 – Juego de curetas específicas para levantamiento del piso del seno maxilar (Supremo, Sao Paulo-Brasil).
Figura 10 – Aspecto clínico después de la confección de la ventana ósea y elevación de la membrana sinusal. Se observa la presencia del septo, así como ausencia de perforación de la membrana.
Después de elevación de la membrana, se realizó el fresado e instalación de dos implantes cono morse 3.8x10mm (SIN, São Paulo-Brasil) con estabilidad inicial de 20 Ncm. El fresado e instalación de los implantes se hizo de acuerdo con las recomendaciones del fabricante (Figuras 11 y 12).
En la secuencia, todos los gaps y espacios vacíos de la región implantada recibieron relleno con injerto óseo bovino medular (Lumina-Porous, Criteria, São Carlos-Brasil). Inicialmente, el biomaterial fue acomodado para llenar toda la región posterior del seno maxilar y luego se llenó todo lo demás (Figuras 13 y 14). En el biomaterial se añadió membrana de colágeno reabsorbible (Lumina-Coat, Criteria, São Carlos-Brasil) con el objetivo de impedir la invasión de los tejidos blandos hacia el interior del injerto y la cavidad sinusal (Figura 15). El procedimiento quirúrgico fue finalizado con la realización de sutura utilizando hilo de nylon 4-0 (Figura 16).
Figura 11 – Después del fresado los implantes fueron instalados y anclados en el remanente óseo cervical.
Figura 12 – Implantes instalados. Se observa el paralelismo entre los mismos, así como la necesidad de relleno con biomaterial.
Figura 13 – Relleno del seno maxilar con biomateriales. Se observa que el mismo se acompaña en la región posterior del seno maxilar de forma cuidadosa.
Figura 14 – Aspecto después de relleno total. Obsérvese que se utilizó un biomaterial medular con gránulos mayores, lo que de acuerdo con la literatura actual favorece la neoformación ósea.
Figura 15 – Membrana de colágeno recubriendo todo el biomaterial. De este modo se disminuye la invasión de tejidos blandos hacia el interior del injerto.
Figura 16 – Realización de sutura con hilo de nylon.
La paciente fue acompañada periódicamente durante el período de cicatrización. Después de 6 meses del postoperatorio, la paciente regresó a la cirugía de reapertura, en la que se observó un aspecto de normalidad y salud de los tejidos involucrados. En consecuencia, se realizaron los procedimientos de moldeo, confección e instalación de las coronas protéticas sobre los implantes (Figuras 17, 18 y 19). Doce meses después de la instalación de las coronas, se realizó un examen radiográfico periapical que evidenció la estabilidad de los resultados alcanzados (Figura 20).
Figura 17 – Cicatrizadores instalados. Se observa el aspecto de salud de los tejidos blandos involucrados.
Figura 18 – Vista oclusal de las coronas protéticas atornilladas en el modelo de yeso. Se observa el adecuado posicionamiento de los implantes de acuerdo con la emergencia de los tornillos.
Figura 19 – Coronas protéticas atornilladas en la boca de la paciente. Se observa el resultado satisfactorio alcanzado.
Figura 20 – Examen radiográfico periapical con un año de seguimiento después de la colocación de las coronas dentales. Se observa la homogeneidad del injerto, así como la ausencia de remodelación ósea periimplantada.
Conclusión
La presencia de septo sinusal dificulta la realización de cirugía de LSSM, lo que viene a requerir del cirujano modificaciones en la realización de la osteotomía, así como conocimiento y habilidad para eludir las eventuales intercurrencias.
81 Comments
Awesome post! Keep up the great work! 🙂
Good day! This is kind of off topic but I need some advice from an established blog. Neala Ivan Gagnon
Just wanna state that this is extremely helpful, Thanks for taking your time to write this. Layne Tammy Trumaine
The comparison using the tiger as an example was great!God bless You for reaching out to us. Melinde Justinian Holli
This paragraph is truly a good one it helps new web people, who are wishing in favor of blogging. Rosanna Moishe Analise
I am actually thankful to the owner of this web site who has shared this fantastic post at at this time. Kordula Huberto Phip
I cannot thank you enough for the post. Much thanks again. Kay Shalom Balthazar
I really liked your article post. Much thanks again. Awesome. Aggie Ryun Coady
Wonderful article! We will be linking to this great post on our website. Keep up the great writing. Missie Morry Jacki
I was very pleased to find this website on bing, just what I was searching for : D as well saved to my bookmarks . Roze Riobard Jonina
You made some nice points there. I did a search on the issue and found most individuals will consent with your blog. Sarine Wilburt Sadira
I like this website because so much useful stuff on here :D. Gianina Curtice Cotter
A big thank you for your blog article. Much thanks again. Cool. Brandais Wildon Wolfy
If you want to obtain a great deal from this paragraph then you have to apply these techniques to your won webpage. Nanete Garey Georg
Marvelous, what a website it is! This blog provides useful facts to us, keep it up. Ira Weidar Graybill
Wow! At last I got a weblog from where I be able to really obtain helpful data regarding my study and knowledge. Krystal Jed Mufinella
Only wanna comment on few general things, The website pattern is perfect, the written content is real great : D. Gusty Wallis D’Arcy
I really like and appreciate your article. Awesome. Mella Tybalt Formica
Simply wanna say that this is extremely helpful, Thanks for taking your time to write this. Frank Maddie Lorenzo
Pretty! This was an extremely wonderful post. Thank you for supplying this info. Annissa Earl Pugh
Absolutely composed written content, Really enjoyed looking at. Linn Jayson Jemie
For the reason that the admin of this web page is working, no doubt very quickly it will be well-known, due to its feature contents. Marys Wayne Iddo
You made some good points there. I did a search on the subject and found most persons will agree with your blog. Brenda Darn Sherlock
Hi there! I just wish to offer you a huge thumbs up for the excellent info you have here on this post. I will be returning to your site for more soon. Melanie Saunders Melissa
Thanks-a-mundo for the article. Much thanks again. Fantastic. Bertine Minor Seda
After looking at a few of the blog posts on your web site, I really like your technique of writing a blog. Ellen Hussein Toomay
Now I am going to do my breakfast, later than having my breakfast coming over again to read additional news. Devin Samuele Meara
Major thankies for the article post. Really thank you! Really Great. Caresa Percy Spiros
I do not even know how I ended up here, but I thought this post was good. Amara Howard Gona
I all the time emailed this webpage post page to all my associates, since if like to read it next my contacts will too. Ardath Hadleigh Teryl
Hey there, I think your website might be having browser compatibility issues. When I look at your blog in Opera, it looks fine but when opening in Internet Explorer, it has some overlapping. I just wanted to give you a quick heads up! Other then that, excellent blog! Gertie Benn Partan
I rattling happy to find this web site on bing, just what I was looking for : D besides bookmarked. Lin Stern Valerio
Hi there colleagues, good piece of writing and nice urging commented here, I am genuinely enjoying by these. Analiese Crichton Malka
You should take part in a contest for one of the best blogs on the web. I will suggest this site! Moria Johnathon Ephram
Excelente nota, muy buena manera de abrir los ojos a los que lo necesitamos Ray Page Uria
Hi to all, how is all, I think every one is getting more from this site, and your views are nice in support of new people. Revkah Stearne Donaugh
I was gunna subscribe but you support Biden so see ya Casey! I was gunna binge watch all your videos as I have just found your channel but not anymore Carola Sheff Guenevere
whoah this blog is fantastic i like studying your articles. Keep up the great work! You know, lots of individuals are looking around for this info, you can help them greatly. Melisenda Gard Odom
Thanks in favor of sharing such a good opinion, piece of writing is nice, thats why i have read it entirely| Kerrill Bondie Bearce
May I simply just say what a comfort to discover an individual who truly understands what they
are talking about on the net. You actually understand how to bring an issue to light and make it important.
A lot more people must read this and understand this side of
the story. I can’t believe you’re not more popular since you most certainly have
the gift.
Hi, i think that i noticed you visited my blog so i came to return the
want?.I am attempting to to find things to improve my web
site!I guess its adequate to make use of some of
your ideas!!
my web site … CBD oil for anxiety
I know this if off topic but I’m looking into starting my own weblog and
was wondering what all is required to get setup?
I’m assuming having a blog like yours would cost a pretty penny?
I’m not very internet savvy so I’m not 100% positive.
Any suggestions or advice would be greatly appreciated.
Many thanks
As I web-site possessor I believe the content material here is rattling magnificent , appreciate it for your hard work. You should keep it up forever! Good Luck. Ollie Boigie Francis
Hi Dear, are you truly visiting this website daily, if so after that you will absolutely get fastidious knowledge.
my web-site: best CBD oil for dogs
Hi Dear, are you in fact visiting this website on a regular basis,
if so after that you will without doubt obtain pleasant know-how.
Everything is very open with a really clear explanation of the issues.
It was definitely informative. Your site is very helpful. Thank you for sharing!
Milk ristretto grounds to go shop aftertaste grinder barista froth medium, robust, dark black doppio decaffeinated half and half. Farand Brant Higinbotham
You made some decent points there. I looked on the internet for the topic and found most guys will agree with your website. Marge Pietrek Finny
I was very happy to discover this website. I need to to thank you for ones time due to this fantastic read!! I definitely loved every bit of it and I have you saved as a favorite to see new stuff in your site. Karilynn Craggie Madalena
Hey there! This is my 1st comment here so I just wanted to give a quick shout out and say I truly enjoy reading through your articles. Doreen Cristobal Barri Lorianna Salmon Ruthanne
How do you take your pictures for instagram? Or who takes them? Binny Darby Cho
It’s not my first time to visit this web site, i am visiting this web site dailly and obtain pleasant facts from here every day.
Check out my web-site area 52 delta 8 THC products
Thanks for your personal marvelous posting! I really enjoyed reading it, you
could be a great author.I will be sure to bookmark your
blog and definitely will come back down the road.
I want to encourage you to continue your great job, have a nice day!
Area 52 delta 8 carts – Area 52 delta 8 carts
Area 52 delta 8 carts – delta 8 THC area 52
Area 52 delta 8 carts – delta 8 THC area 52
area 52 delta 8 THC products – delta 8 THC for sale area 52
Area 52 delta 8 carts – Area 52 delta 8 carts
Thankfulness to my father who informed me about this web site,
this webpage is actually amazing.
P.S. If you have a minute, would love your feedback on my new website
re-design. You can find it by searching for «royal cbd»
— no sweat if you can’t.
Keep up the good work!
Review my blog post: buy instagram followers
I couldn’t resist commenting. Well written!
delta 8 THC area 52 – delta 8 THC area 52
delta 8 THC area 52 – delta 8 THC for sale area 52
delta 8 THC for sale area 52 – buy delta 8 THC area 52
Area 52 Delta 8 THC – buy delta 8 THC area 52
delta 8 THC area 52 – Area 52 Delta 8 THC
QUE INCREIBLE
Somebody necessarily help to make seriously articles I might state.
That is the first time I frequented your web page and thus
far? I surprised with the research you made to make this particular publish amazing.
Magnificent task!
Here is my blog post; delta 8 THC gummies [http://www.thedailyworld.com]
When someone writes an piece of writing he/she retains the image of
a user in his/her mind that how a user can be aware of
it. So that’s why this piece of writing is great.
Thanks!
If you are going for finest contents like myself, simply pay a visit this
website daily for the reason that it gives feature contents, thanks
I am regular visitor, how are you everybody? This paragraph posted at
this site is really fastidious.
Hi there would you mind stating which blog platform you’re using?
I’m planning to start my own blog soon but I’m having a tough time deciding between BlogEngine/Wordpress/B2evolution and Drupal.
The reason I ask is because your design and style
seems different then most blogs and I’m looking for something completely unique.
P.S My apologies for getting off-topic but I had to
ask!
Does your website have a contact page? I’m having problems locating it but,
I’d like to send you an e-mail. I’ve got some ideas for your blog you might be interested in hearing.
Either way, great website and I look forward to seeing it expand over time.
It’s going to be ending of mine day, however before finish I am
reading this fantastic paragraph to increase my experience.
Your style is unique compared to other people I have
read stuff from. Many thanks for posting when you’ve got the opportunity, Guess
I will just bookmark this web site.
I believe that is among the so much important info for me.
And i am glad studying your article. But should remark on some common things,
The website style is perfect, the articles is truly excellent : D.
Good process, cheers
Highly descriptive blog, I enjoyed that bit. Will there be a part 2?
Its like you read my mind! You appear to know a lot about this, like you wrote the book in it
or something. I think that you could do with some pics to drive the message home
a bit, but other than that, this is excellent blog.
A fantastic read. I will certainly be back.
Hey there, You have done a fantastic job. I’ll definitely digg
it and personally recommend to my friends. I am confident
they will be benefited from this site.
If some one needs to be updated with hottest technologies then he must be visit this site and be up to date daily.
Nice weblog here! Also your site so much up fast! What web host are you the use of?
Can I get your affiliate hyperlink in your host? I desire my website
loaded up as fast as yours lol
It’s an awesome piece of writing in support of
all the online visitors; they will get advantage from it
I am sure.
Look at my website; area52
Your style is very unique in comparison to other
folks I’ve read stuff from. Thanks for posting when you’ve got the opportunity,
Guess I’ll just book mark this site.
you’re truly a just right webmaster. The website loading speed is amazing.
It kind of feels that you’re doing any distinctive trick.
In addition, The contents are masterwork. you have done a
magnificent activity on this topic!
WONDERFUL Post.thanks for share..extra wait .. …
Magnificent site. Lots of helpful information here.
I am sending it to some friends ans additionally sharing in delicious.
And certainly, thanks for your effort!
It’s awesome to pay a visit this site and reading the views
of all mates about this paragraph, while I am also keen of getting know-how.
What’s up, just wanted to mention, I liked this post.
It was inspiring. Keep on posting!
Admiring the time and effort you put into your site and in depth information you present.
It’s awesome to come across a blog every once in a while that
isn’t the same old rehashed information. Wonderful read! I’ve bookmarked your site and I’m including your RSS feeds to
my Google account.
Undeniably consider that that you stated. Your favourite reason seemed to
be on the web the simplest factor to have in mind of. I say to you, I certainly get annoyed while folks think about
worries that they just do not recognise about. You managed to hit the nail upon the top
and outlined out the entire thing without having side effect , folks could take a
signal. Will likely be again to get more. Thanks
wow, awesome blog post.Thanks Again. Awesome.
Hi there, of course this piece of writing is truly nice and
I have learned lot of things from it regarding blogging.
thanks.