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Maxillary sinus lift

Sinus Lift Procedure of the Maxilla in Patients with Inadequate Bone for Dental Implants National Taiwan University Hospital
Dr. Chen-Ying Wang
2010, Dec 8th
Outlines
Maxillary atrophy: classification and surgical protocols Anatomy of the maxillary sinus
In average:
- 2.5 cm in width, 3.75 cm in height, 3.0 cm in anterior-posterior depth
- pyramidal shape
- Mean: 15 cm3
• Sinus pneumatization increases size:
- Advancing age
- Tooth loss
• Ostium
located at cranial side, 25-35 mm above the antral floor
provides drainage into the nasal cavity
impossible for mechanical blockage during sinus lift procedure
• Schneiderian membrane:
- 0.13-0.5 mm thick

- Tseng et al., J Taiwan Periodontol(2010) examined 226 sinuses through reformatted - 47.8% of sinus floors at least one septum, 39% in male, 55% in female - locaton of the septa: anterior region-20.8%, middle region-14.6%, posterior region-27% - Sinus pathology: prevalence 15%, in total edentulous patient 6.6%, in partially edentulous patient 18.2% - The prevalence of sinus septa and pathology are not significant in both male and The main blood supply to the maxillary sinus: - Posterior superior alveolar artery(PSAA) (Intraossoeus anastomosis with IAr at 18.9 to 19.6mm away from sinus base)(Solar 1999, Elian 2005) - Posterior lateral nasal artery The main innervation to the maxil ary sinus: - Superior alveolar branch of maxil ary nerve - Anterior superior alveolar branch of infraorbital nerve
Indication/ contraindication

Indication:
- Native bone height less than 8mm(Jenson OT,1998) - sinus pathology - former sequelae sinus surgery(Caldwell Luc op)
Maxillary atrophy: classification and surgical protocols

Posterior bone atrophy
Type A: Hyperpneumatization – Sinus lift with surgery
Type B: Horizontal deficiency – Sinus lift with bone graft
Type C: Vertical deficiency – Vertical onlay bone graft +/- sinus lift
Type D: Combined deficiency – Vertical and transverse onlay bone graft +/- sinus lift,
vestibular plastic surgery
Surgical Techniques
- Boyne, 1980: first publication - Tatum, 1986: Top-hinge-trap-door technique - Summer, 1994: Trans-alveolar technique~ by osteotomes • Simultaneous or in second phase implant surgery - Less than 5mm native bone height is available, should for two stage procedure ( Misch 1992, Ulm 1995, Lazzara 1996) Bone graft material - Particulate bone grafts have higher success rates than block grafts ( Jensen - Histological data: NTUH data - Graft healing time: Most suggested~ 6months(Misch 1993), Demineralized graft~ 9 to 12 months(Wheeler 1996, Chanavaz 1990), Mainly autograft~ 3 to 4 months(Jensen OT 1998) Alternative materials for maxillary sinus augmentation? BMPs (Cochran, 1997): ideal carrier material for BMPs~ Medication before and after sinus surgery - prophylactic: amoxicil in, 7 days (Chanavaz,1990 / Misch,1992) - Augmentin: 8~10days
Complications: Diagnosis and management

Systemic disease and medications related
Uncontrolled diabetes
Osteoporosis with Bisphosphonate medication
Immunocompromised patients (AIDS, cyclic neutropenia)
Cigarette smoking(-/+)
Anatomy and surgical procedure related
Perforation of Schneiderian membrane (Raghoebar, 1997):
most common, occurrence 16%~58%
Irregularities, sinus septa, root configuration
Bleeding
Implants into sinus
Obliteration of sinus cavity

Sinus pathology related
Pseudocysts, retention cysts, mucoceles (Gardner,1984)

Infection related
Infection: Swelling/pus/purulent/hematoma
Wound dehiscence
Bone sequestrum
Post-operative sinusitis (nasal congestion, purulent discharge, headaches): 10%
Oroantral fistula: in very few cases
Long-term results
- Overall implant success: 83%~100% - Rough surface is better than smooth surface - Delay implant surgery is better than simultaneously approach - Implant failure rates were relatively high in cases with pre-surgical bone height of Future development

Conclusion
Sinus bone grafting for gaining bone mass in the atrophic edentulous maxilla has been demonstrated to be both safe and predictable. CT image is important for sinus surgery pre-op evaluation, diagnosis, treatment planning. To know the complication during sinus lifting procedure, and always respect the anatomic limitation. New technology, new adventure and better success rate.

Source: http://www.tcoi.org.tw/max/ezcatfiles/tcoi/img/img/346/107022864.pdf

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