|Year : 2020 | Volume
| Issue : 3 | Page : 449-456
|Direct maxillary sinus floor augmentation and simultaneous implant placement for rehabilitation of the severely resorbed posterior maxilla: A prospective clinical study
Pulkit Khandelwal1, Vikas Dhupar2, Francis Akkara2, Neha Hajira3
1 Department of Oral and Maxillofacial Surgery, Rural Dental College, Loni, Ahmadnagar, Maharashtra, India
2 Deptartment of Oral and Maxillofacial Surgery, Goa Dental College and Hospital, Goa, India
3 Department of Prosthodontics, Rural Dental College, Loni, Ahmadnagar, Maharashtra, India
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|Date of Submission||20-Nov-2018|
|Date of Decision||03-Aug-2019|
|Date of Acceptance||29-Oct-2019|
|Date of Web Publication||06-Aug-2020|
| Abstract|| |
Aims and Objectives: The aim of this prospective clinical study was to evaluate the success of one-stage direct (lateral) sinus lift procedure in severely atrophic posterior maxilla. Materials and Methods: One-stage direct (lateral) sinus lift procedure was carried out at 15 sites in 13 patients. All patients included in the study presented with partially edentulous posterior maxilla with one or more missing teeth and residual bone height less than 5 mm. Three months after surgery, patients were evaluated to access increase in residual bone height, density of new bone formed and implant stability. Patients were also evaluated after 3 months of prosthetic placement for the success of implant-supported prosthesis. Results: At 3 months post-operatively, increase in residual bone height was 8.31 ± 1.63 mm and the mean density of the newly formed bone around the implants was 417 ± 66.61 HU. All implants were stable and successfully osseointegrated, except one implant that was lost. The success rate of implant stability was 96.3% during the study period. Conclusion: Single-stage direct (lateral) maxillary sinus floor augmentation is a good treatment option with predictable outcome for patients with deficient alveolar bone in posterior maxilla.
Keywords: Edentulism, implant, pneumatisation, posterior maxilla, sinus lift
|How to cite this article:|
Khandelwal P, Dhupar V, Akkara F, Hajira N. Direct maxillary sinus floor augmentation and simultaneous implant placement for rehabilitation of the severely resorbed posterior maxilla: A prospective clinical study. Indian J Dent Res 2020;31:449-56
|How to cite this URL:|
Khandelwal P, Dhupar V, Akkara F, Hajira N. Direct maxillary sinus floor augmentation and simultaneous implant placement for rehabilitation of the severely resorbed posterior maxilla: A prospective clinical study. Indian J Dent Res [serial online] 2020 [cited 2022 Jan 22];31:449-56. Available from: https://www.ijdr.in/text.asp?2020/31/3/449/291501
| Introduction|| |
Following extraction, pneumatisation of the maxillary sinus, poor quality of remaining alveolar bone and higher occlusal forces make implant placement in posterior maxilla a challenging task., Post-extraction expansion of maxillary sinus in inferior direction is 2.18 ± 2.89 mm for dentate v/s contralateral sites, and 1.83 ± 2.46 mm for same site pre- and post- extraction. Maxillary sinus pneumatises by 1.52 ± 2.15 mm after extraction of a molar. Reduction in residual ridge height is about 2–3 mm for maxilla during first year after extraction. This is due to the increased osteoclastic activity of periosteum, increase in positive intra-antral pressure and absence of stimulation for bone remodelling.
Vertical alveolar ridge augmentation is often required for implant placement in posterior maxilla. Maxillary sinus floor augmentation increases the amount of bone in the posterior maxilla by elevating sinus membrane from underlying bone and placement of bone graft beneath it. Implants can be placed at the same time as sinus floor augmentation surgery (simultaneous placement) or after a healing period (delayed placement). Sinus-lift procedure was first performed by Tatum (1975) and first published by Boyne and James (1980)., Thereafter, many techniques have been developed such as Summers's crestal approach, use of piezoelectric surgery, piezoelectric bony window osteotomy with sinus membrane elevation, sub-antroscopic latero-basal sinus augmentation, antral membrane balloon elevation, trephine osteotomy, negative pressure technique and water lift system.
Two main techniques of sinus floor elevation are as follows:
- Lateral window (direct) sinus augmentation technique
- Transcrestal (indirect) sinus augmentation technique.
When residual vertical alveolar bone height of more than 5 mm is present, osteotome-mediated sinus floor elevation (indirect technique) and simultaneous placement of implants with or without the use of a graft material are usually indicated. When the residual bone height is 5 mm or less, lateral window technique with a grafting material is indicated. The lateral approach provides direct manipulation of the Schneiderian membrane, offers better control and is considered more predictable when extensive implantations are needed., Kher et al. found an implant survival rate of 96.67% during a mean follow-up of 15.74 months post-loading.
The aim of this study was to evaluate the success of one-stage direct (lateral) sinus lift procedure in severely atrophic posterior maxilla.
| Methodology|| |
Patients presenting with edentulous, atrophic posterior maxillary ridges either unilaterally or bilaterally were included in the study. Ethical approval was obtained from Institutional Review Board. Informed consent was taken from all patients. Patients were included in the study based on inclusion and exclusion criteria mentioned below:
- Partially or completely edentulous posterior maxilla with residual bone height less than 5 mm
- Six months gap between tooth extraction and implant placement
- Presence of healthy or restored adjacent teeth
- Patients with controlled systemic condition (ASA physical status: Category 1 and 2)
- Excellent oral hygiene.
- Uncontrolled metabolic diseases, compromised immune system, haematologic disorders, pregnancy, prior radiotherapy of the maxillofacial region, chemotherapy, bone disease, medication or any other systemic illness which may affect prognosis of the treatment
- Radiographic evidence of maxillary sinus pathology
- History of sinusitis or maxillary sinus surgery
- Inadequate mouth opening
- Patients with habits of smoking, tobacco chewing, alcoholism, etc.
Systemic conditions like uncontrolled metabolic disorders, compromised immunity or prior radio-chemotherapy of maxillofacial region interfere with physiological wound healing and osseointegration. Peri-implant inflammation is common in diabetic patients. Bone grafting procedure, if performed on an unhealthy sinus, will lead to fluid stagnation, mucus stasis, bacterial overgrowth, leading to supra-infection and exacerbated sinusitis. It is very difficult to lift the sinus membrane in the presence of any pathology such as polyps or hyperplastic mucosa and fibrosis from the previous sinus surgery. Smoking reduces local blood flow and disturbs graft healing.,,,
- At 3 months follow-up after surgery, the following parameters were assessed by Cone Beam Computed Tomographic scan (C.B.C.T):-
- Gain in bone height achieved
- Any pathological changes in maxillary sinus post-surgery
- Local bone density of new bone formed at dental implant recipient sites.
- At 3 months following prosthesis placement (9 months after surgery), implant stability was evaluated using the following criteria:
- Absence of clinically detectable implant mobility
- Absence of pain or any subjective sensation
- Absence of recurrent peri-implant infection
- Absence of continuous radiolucency around the implant
Pre-surgical evaluation included detailed case history, clinical examination, blood investigations, photographs and radiographic analysis. Radiological analysis used was a combination of intra-oral periapical radiograph (IOPAR)/Orthopantamogram and C.B.C.T. scan of the maxilla [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
|Figure 1: Pre-operative photographs. a) Intra-oral photograph showing missing left maxillary first molar. b) Intra-oral periapical radiograph (IOPAR) showing deficient bone height. c) Cross-sectional view of CBCT showing residual ridge height = 3.90 mm. d) Panoramic view of CBCT|
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Under local anaesthesia, incisions were placed, mucoperiosteal flap was raised and the anterolateral wall of maxillary sinus was visualised. Piezoelectric surgical unit with ultrasonic tip no. 679 was used for window preparation [Figure 2]a. The osteotomy wall was fractured, removed and kept in saline [Figure 2]b. The underlying sinus membrane was separated and elevated using the mechanical action of the sinus lift instruments [Figure 2]c. Valsalva manoeuvre was performed to diagnose the integrity of the membrane, in case of perforation of Schneiderian membrane. It was deemed unnecessary in the other cases as it was quickly ascertained that the membrane had remained intact because the sinus membrane was moving with the respiratory rhythm (bellows effect). In cases of Schneiderian membrane perforation, a bioabsorbable collagen membrane was placed under the perforation to create a temporary interface between the sinus cavity and the bone graft. Drill hole for implant site was prepared using surgical stent and the space created after the sinus membrane elevation was grafted using bioactive synthetic calcium-phosphosilicate bone graft material [Figure 2]d. Implants were placed and initial stability of the implants placed was confirmed clinically [Figure 2]e. The grafted site was closed with the bony window plate which was harvested at the time of window preparation. In all cases, primary soft tissue closure was achieved with 3-0 silk or 3-0 vicryl suture [Figure 2]f. Immediate radiograph was taken to confirm correct positioning of implant and graft material [Figure 3]a. Medicines and post-operative instructions were given to the patients. All patients were evaluated during the first week, first month, 3 months [Figure 3]b, [Figure 3]c and 6 months post-operatively. Surgical exposure of the implant and placement of the healing abutment were done after 6 months of implant placement. After 15 days, prosthesis was fabricated. All the patients were followed up regularly [Figure 3]d, [Figure 3]e, [Figure 3]f.
|Figure 2: Surgical technique. a) Window preparation. b) Intact Schneiderian membrane visible. c) Elevation of Sinus membrane with sinus lift curette. d) Bone graft material packed for sinus floor augmentation. e) Implant placement. f) Primary closure|
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|Figure 3: Post-operative photographs. a) Immediate IOPAR. b) CBCT (03 months post-surgery): cross-sectional view. c) CBCT: Panoramic view. d) Final prosthesis: Occlusal view (03 months post-prosthetic). e) Final prosthesis: Lateral view. f) IOPAR: Final Prosthesis|
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| Observation and Results|| |
A total of 15 sinus floor augmentation procedures were performed in 13 patients (Nine females and four males with mean age of 46.93, varying from 36 to 64 years). Eleven patients were treated with unilateral procedure while two patients had bilateral involvement [Table 1]. The mean residual bone height pre-operatively was found to be 3.12 ± 0.91 mm (range 1.00 mm to 4.2 mm). The pre-operative mean bone density was 618 HU ± 128.07 (range 397 HU to 806 HU) [Table 2]. No abnormalities were noted in the sinuses in C.B.C.T. pre-operatively except at two sites (13.34%), where transverse complete septa were present. The mean surgical time taken for piezoelectric bony window preparation was 4.8 ± 2.21 min (ranging from 2–9 min). There were no significant intra operative complications. Only one case had perforation of sinus membrane which was repaired by the placement of collagen membrane [Figure 4]a, [Figure 4]b, [Figure 4]c. There was no incidence of bleeding complications or displacement of implant into maxillary sinus. Post-operatively, swelling was observed in five cases which subsequently subsided within 3 to 5 days; one patient experienced pain post-operatively. Rest of the cases were comfortable during post-operative follow-up periods. There was no incidence of sinusitis, hematoma formation, epistaxis, ecchymosis, nasal obstruction, purulent discharge from nose/throat or flap dehiscence [Table 2].
|Figure 4: Management of perforation of sinus membrane. a) Perforated sinus membrane. b) Perforation repaired by the placement of collagen membrane. c) Guided tissue regeneration (GTR) membrane secured over osteotomy site before flap closure|
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Total 27 implants were placed in these 13 patients/15 sites [Figure 5]. At the end of 3 months follow up, there was a significant increase in residual bone height, ranging from 5.8 mm to 12.06 mm (average of 8.31 ± 1.63 mm). The mean density of the newly gained bone around the implants was 417 ± 66.61 HU (range, 323-585 HU) [Table 2]. The mean value of bone height was 11.57 ± 1.45 mm along the mesial aspect of implant and 11.22 ± 1.39 mm along the distal aspect of implant below sinus lining at 3 months post-operatively. The post-operative bone height was measured by calculating mean of bone height present below sinus lining along mesial and distal aspect of implants and was found to be 11.42 ± 1.29 mm (range 10–15 mm) below sinus lining at 3 months post-operatively.
|Figure 5: 27 Implants placed at 15 sites in 13 patients (Immediate post-operative X-rays). (a – n) (Except b, g, h): Unilateral procedure. b) Bilateral procedure in a 37-year-old female. g) and h) Bilateral procedure in a 52-year-old female|
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Implant success (Nine months follow-up)
Out of 27 implants placed, one implant was lost from grafted side at 5 months follow-up. Rest of the implants were stable and no implant mobility was detected at 9 months follow-up. No subjective symptoms or any sign of peri-implant infection was present.
All cases showed evidence of increased radiopacity of alveolar bone around the implants with absence of any radiolucency between the implants and the alveolar bone. All implants were stable and successfully osseointegrated, except one implant that was lost. The success rate of implant stability was 96.3% during the study period.
Pearson correlation coefficient was applied to find a statistical relationship between:
- Age of patient and pre-operative bone height
- Period of edentulism and pre-operative bone height
- Age of patient and gain in bone height achieved.
Co-relation between period of edentulism and pre-operative bone height was found to be statistically highly significant (P-value = 0.000). However, co-relation between age of patient and pre-operative bone height as well as co-relation between age of patient and gain in bone height was found to be statistically non-significant (P-value = 0.202 and P value = 0.847, respectively) [Table 3].
| Discussion|| |
Loss of teeth causes accentuated bone deficiency, both in height and width as well as density, due to significant resorption of alveolar bone. Cases with less than 5 mm bone height are indicated for two-stage direct augmentation technique. However, augmentation of maxillary sinus with simultaneous placement of dental implants is a feasible option for patients with as little as 3 mm of alveolar bone height prior to augmentation grafting. Daelemans et al. and Khoury reported a success rate of 93.4% and 94%, respectively, for the single-stage procedure, wherein pre-treatment alveolar bone height was less than 5 mm., In our study, pre-operative mean bone height was 3.12 ± 0.91 mm (range 1.00–4.2 mm) and single-stage surgery was considered as the number of steps did not appear to critically influence the outcome of primary and secondary stability of implant. At the end of 3 months, the mean post-operative bone height gained following the sinus augmentation was 8.31 ± 1.63 mm (ranging from 5.8–12.06 mm). Zitzmann and Scharer reported similar findings with gain in bone height by 10 mm. Al-Dajani found that the lateral window approach can increase the vertical bone height greater than 9 mm.
The most common type of bone in the edentulous posterior maxilla consists of D3/D4 type. Bone density less than 400HU is associated with a higher risk of implant failure, whereas bone density ranging from 400–1000HU represents a safe zone. It was noted that the sites selected for implant placement had mean bone density of 618 HU ± 128.07 (ranging 397 to 806 HU), which correlated with D3 bone [Figure 6]a. During follow-up period of 3 months, the mean density of new bone formed around the implants below sinus lining was 417 ± 66.61 HU (range: 323 to 585 HU) [Figure 6]b. Reactive-bone formation below the sinus floor occurs due to physiologic stimulation of the alveolar bone that is largely driven by local cytokines and growth factors. Tajima et al. found out that the mean density of newly formed bone around the implants was 323 ± 156.2 HU (range: 185 to 713 HU). Huang et al. reported that bone density of native bone was higher than bone mineral density of grafted bone at the follow-up period of 4 to 5 months after bone grafting.
|Figure 6: Local bone density at dental implant recipient site. a) Pre-operative. b) Post-operative (new bone formed)|
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Perforation of Schneiderian membrane, uncontrolled haemorrhage or displacement of implant into the maxillary sinus may occur during the sinus augmentation procedure. The prevalence of sinus membrane perforation is 20% to 60% and occurs mostly at sharp ridge lines, septa, and spines. Collagen membrane should be used to close small tears (5 to 10 mm) in the Schneiderian membrane and a cross-linked type I collagen membrane for predictable repair of large perforations (10 mm). In a review, Vina-Alumina andPenarrocha-Diago reported 88.6% implant survival rate in maxillary sinus lift procedures with membrane perforation, and in maxillary sinus lifts with intact membranes, the survival rate rose to 98%. However, Oh and Kraut concluded that perforation of the Schneiderian membrane does not cause negative long-term effects on bone grafts and implants.
The implant may also get displaced into the maxillary sinus if the implant does not have enough primary stability. Any change in intrasinal and nasal pressures, autoimmune reaction to the implant causing peri-implant bone destruction, and improper distribution of occlusal forces may lead to migration of implant into the maxillary sinus. The displacement of implants or graft materials into the maxillary sinus results in a foreign-body reaction and causes serious complications such as maxillary sinusitis. The displaced implants must be immediately retrieved surgically. Caldwell-Luc approach should be used when implant cannot be retrieved by means of endoscopy. Incidence of development of post-operative maxillary sinusitis after augmentation of the sinus floor ranges from 0% to 20%. Maxillary sinusitis develops due to reduced drainage of the sinus. Use of appropriate antibiotics before and after the surgical procedure reduces infection risk. Transient maxillary sinusitis should be treated with decongestants and antibiotics. If no recovery occurs within 3 months, functional endoscopic sinus surgery is required.
The survival rate of implants placed in sinuses augmented with the lateral window technique varied from 61.7% to 100%, with an average survival rate of 91.8% in the literature [Table 4]. The success rate of implant stability in the present study was 96.3%. In 15 direct sinus augmentation sites, 27 implants were placed in the augmented sites. One implant failed to osseointegrate. This case occurred at the site where pre-operative residual alveolar bone height was 1 mm. Although primary stability was achieved at a time of implant placement, implant was lost from the grafted site at 5 months follow-up. A strong negative significant correlation was found between period of edentulism and residual alveolar bone height (P < 0.05).
One-stage direct sinus floor augmentation technique should be the treatment of choice when the height of residual bone is less than 5 mm in the posterior maxilla. This procedure can provide significant increase in bone height (8.31 ± 1.63 mm) with implant success rate of 96.3%.
| Conclusion|| |
Single-stage direct (lateral) maxillary sinus floor augmentation is a good treatment option for patients with deficient alveolar bone in posterior maxilla (residual bone height <5 mm).
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Conflicts of interest
There are no conflicts of interest.
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Dr. Pulkit Khandelwal
Department of Oral and Maxillofacial Surgery, Rural Dental College, Loni, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]
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