1. 30/01/15 1
MAXILLARY SINUS FLOOR ELEVATION WITH
IMMEDIATE IMPLANT PLACEMENT.
CLINICAL AND RADIOLOGICAL FINDINGS
Uzunov NG
Department of Maxillofacial Surgery, Faculty of Dental Medicine Plovdiv
2. 30/01/15 2
Introduction
The edentulous or partially edentulous resorbed maxilla is recognized as the most
difficult area for rehabilitation in dental implantology.(1-3)
Advanced maxillary
resorption may reduce the dimensions of the alveolar process under the
critical level for accommodation of dental implants. In addition, primary
implant stability is often compromised by the poor bone quality (abundant
cancellous and scanty cortical bone) in this region.(4-6)
Many different
techniques have been proposed to address this clinical problem,(3, 4, 7)
but only
three of them are considered to be the most predictable and well
documented: (1) total or segmental(11-13)
onlay maxillary grafts; (2) Le Fort I
interpositional bone grafts;(14-16)
and (3) maxillary sinus augmentation.
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The lateral maxillary sinus
augmentation (LMSA) procedure
The lateral maxillary sinus augmentation (LMSA) procedure was
first suggested in 1974 by Dr. Hilt Tatum(17, 18)
and then published
by Boyne and James in 1980.(19)
They described a 2-stage
procedure with a healing phase of 4 to 6 months to allow
biologic integration of the graft. The method was used by other
workers(7)
and in 1996 The Sinus Consensus Conference raised
by the Academy of Osseointegration came to the conclusion
that the sinus lift is highly predictable and effective treatment
modality.(20)
Since then maxillary sinus augmentation became a
routine technique to improve the unfavorable conditions in the
posterior maxilla for dental implants placement.
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Purpose
The aim of this study was to evaluate
the results after sinus floor elevation
with simultaneous implant
placement
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Materials and methods
Patients
Thirty six adults (24 females and 12 males), ranging in age from 27 to 74
years in age (mean 50,28 ± 12,83) presented for dental implant
treatment for missing maxillary molars and premolars. In all cases the
natural teeth had been lost many years earlier resulting in extensive
alveolar ridge resorption. After thorough examination LMSA with
simultaneous implant placement was offered. The benefits and draw-
backs of the proposed method were meticulously explained and
signed informed consent was obtained before treatment. Patient and
defect distribution is shown on Table 1. Three patients were tobacco
users; all had developed some masticatory parafunctions.
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Table 1. Patient distribution
Number of
implants
Paragon Anthogyr Bruxism Bruxomania
Chewing hard
things
Consistency
of food
1 f 36 2 2 40 yes yes no Hard mainly
2 m 38 4 4 0 no yes yes Soft mainly
3 m 45 2 2 30 yes yes no General
4 f 50 4 3 1 12 yes yes no Hard mainly
5 f 72 2 2 0 no yes no General
6 f 41 2 2 0 yes yes yes Hard mainly
7 f 62 2 2 0 yes yes no General
49 18 11 7 5 7 2
Implants Parafunctions
Patients
Gender
Tobacco
usage
(cigarettes per
day)
Age
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Materials and methods
• Transplantation materials
• Enzyme-processed partially dematerialized freeze-dried bone allograft (ep-
DFDBA)[1]
was used as a bone substitute and enzyme-processed freeze-dried
dura mater allograft (e-FDDMA)[2]
was applied as a barrier membrane.
• Implants
• A total of 11 Taper-Lock[3]
and 7 Anthogyr[4]
screw type implants were mounted
into the resorbed distal maxillae. All implants were placed simultaneously with
the LMSA procedure. Two of them were mounted in fresh extraction sockets.
[1] Demineralized bone tissue, Institute of Cryobiology and Food Technologies, Sofia
• [2] Dura Implant, Institute of Cryobiology and Food Technologies, Sofia
• [3] Paragon Implant Company, Encino, Ca; consequently Centerpulse Dental
• [4] Anthogyr, Salanches, France
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Surgical technique
The operations were made under local or general anesthesia
following the Caldwell-Luc approach. A bony window was
outlined, fractured and pushed into the sinus. The
Schneiderian membrane was elevated from the margins of
the window and the sinus floor (Fig. 2). The space between
the sinus floor and the elevated membrane was packed with
blocks of ep-DFDBA filling the gaps with particulate ep-
DFDBA (Fig. 2 and 3). The implants were mounted and an
e-FDDMA membrane was placed over the window and fixed
with sutures or Anthogyr membrane fixing screws. (Fig. 4).
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Surgical technique
Figure 2. Technique of LMSA. Left: The bony window is outlined, the window plate is
fractures and pushed into the sinus (white arrow), the Schneiderian membrane is
elevated and the space between the sinus membrane and floor is packed with ep-
DFDBA. Right: Three implants are mounted. With the exception of the cervical third
the rest part of the implant freely penetrates into the maxillary sinus.
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Surgical technique
Figure 3. Technique of LMSA. Left: Nearly the whole implant stem is free standing in the sinus
cavity. Blocks of ep-DFDBA over the implant apex. Note the insufficient alveolar width and
exposed implant threads (arrow). Right: After extraction of tooth 28 a large alveolar defect was
produced (blue arrow), through which a block of ep-DFDBA is seen (yellow arrow). The walls of
the defect are very thin and fragile.
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Postoperative follow-up
During the first two weeks patients were examined clinically on a daily basis
and on a monthly basis following the uncovering procedure until the final
restoration was placed, and every 6 months thereafter. Several clinical
parameters were measured (Table 2). Clinical parameters measured
included: 1) Implant mobility (IM); 2) Probing depth (PD); 3) Clinical
attachment level (CAL) Radiographic examinations were following one and
the same schedule for all patients Table 2.
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Table 2. Postoperative follow-
up schedule
-3 -2 -1
At
surgery 1 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Surgery
Implantuncovery
Gingivalhealing
Prothesizing
IM y y y y y y y
PD y y y y y y y
CAL y y y y y y y
Panoramic
radiographs y y y y y y y y y y
Periapical
radiographs y y y y y y y
y
y
Weeks
Osseintegration Function
yearly
25 -
36
Months
on 6 months
Radiographic
examination
Examination
Parameter/Technique
on 3 monthsdaily
Preparationforsurgery
monthly
Clinical
examination
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Results: Wound healing
In all patients the healing period was uneventful.
One membrane dehiscence was observed during
the second week postoperatively. This was daily
treated with local hygienic measures and covered
with mixture of Indextol™ and iodoformium. The
dehiscence closed by second intention for two
weeks.
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Results: Implant uncovery
Seventeen implants were uncovered after 10 months
and 1 after 4 months because one patient asked
for additional implant in the same site. The second
surgical procedure in this case was done after
radiological visualization of new bone formation
around the first three implants.
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Results: Implant uncovery and
re-entry
At the re-entry operation in all cases we found bone
apposition around and even over the implants.
The e-FDDMA membrane was still visible in the
case with the implant added 6 months after the
first procedure.
In all other individuals we could not trace the
membrane.
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Results: Two-year follow-up
Soft tissue changes within the 2-year period as verified by
clinical measurements are minimal with no signs of
periimplantitis, implant dehiscence or fenestration.
Radiographic examinations revealed extensive bone resorption
of the regenerate during the first year which slowed down in
the next months.
All implants serve now successfully as supports for cemented
bridges.
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Case report
Figure 5. A 45 year old woman presented for implant treatment. Left: Preoperative
orthopantomogram revealed heavy maxillary atrophy and pneumatization. Tooth 28 is
to be extracted. Right: Same orthopantomogram. Red – sinus floor; Yellow –
alveolar ridge. The thickness of the alveolar ridge in positions 25, 26, and 27 is less
than 3 mm
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Figure 6. First surgical
operation consisted of
extraction of tooth 28,
LMSA and immediate
implant placement.
Implants placed in
positions 24, 25, 26.
The last two implants
freely penetrate into
the maxillary sinus
cavity. Healing was
uneventful.
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Case report
Figure 7. Six months after the first LMSA the patient wished another implant in position
27. Left: Re-entry at 6 months. LMSA via back placed window, already packed with
ep-DFDBA (dark yellow arrow). The new implant is in place (white arrow). Note the
excellent healing after the first LMSA. The narrow alveolar ridge in position 24-25 is
vertically and laterally augmented (black arrow) and implants are covered with new
bone (blue arrow). The e-FDDMA is partially resorbed but still visible (red arrow)
Right: Healing after the second LMSA procedure
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Case report
Figure 8. Second re-entry 10 months after the first operation and 4 months after the
second one. Left: The e-FDDMA from the first operation is fully resorbed (yellow
arrow). The alveolar ridge is augmented with new bone with rough surface (white
arrow). The second membrane (black arrow) is visible over the implant in position 27
(green arrow) Right: Note the good contour of the laterally and vertically augmented
alveolar ridge.
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Case report
Figure 9. At taking the impression for the final restoration. Impression copings in place.
Left: Adequate alveolar bone height and width. Right: Alignment of implants
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Case report
Figure 10. Final restoration. Left: After one year of function. Right: After two years of
function. Some resorption has taken place within well accepted limits. No signs of
periimplantitis.
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Case report
Figure 12. Postoperative panoramic radiographs. Red – bottom of maxillary sinus; Yellow
– alveolar ridge. Left: Six months after the first LMSA and before placement of the
additional implant. Bone regeneration is clearly seen. Right: Before second re-entry
for exposure of implants. The difference in bone regeneration and maturization is
illustrated by the differences in the radiolucency of the two regenerates. The
regenerated bone after the second LMSA procedure is outlined because it is not well
mineralized.
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Case report
Figure 13. Postoperative panoramic radiographs. Red – bottom of maxillary sinus; Yellow
– alveolar ridge. Left: After fixation of the final bridge. Right: After two years of
function. Resorption has taken place within accepted rates
27. 30/01/15 27
Discussion
To deal with problems resulting from the atrophied and
pneumatized posterior maxilla a number of approaches
have been proposed. Three major surgical procedures are
considered to be the most effective and well documented;(5, 12,
13, 20-23)
1) Total maxillary sandwich onlay bone grafts for
alveolar ridge augmentation;(22-27)
2) Le Fort I osteotomy with
simultaneous interpositional bone grafting;(4, 10, 28-30)
and 3) Sinus
floor lift procedures with inlay autogenous or allogenous
graft.
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Discussion
Grafting to the alveolar ridge may reduce the posterior
interocclusal space so significantly as to cause prosthetic
restorative problems.(5, 10)
Le Fort I osteotomies with
simultaneous bone grafting must be performed under
general anesthesia in hospital environment and there is
potential for skeletal relapse of the moved maxillary
segment.(5, 10)
With the sinus lift approach the floor of the
maxillary sinus is augmented preserving the existing
maxillo-mandibular occlusal relationship.(5, 10, 25-30)
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Discussion
In all grafting procedures infection and resorption of the
regenerate bone are the most important complications. Soft
tissue changes we found within the 2 year period are within
accepted ranges and does not show sings of periimplant
inflammation. Variations in resorption activity as visualized
by radiographic examinations showed extensive resorption
during the first year which gradually slowed down to
acceptable rates.
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Table 3. Publications on the use of allogenous
dura mater as a GTR membrane for alveolar
ridge augmentation
Author Year Journal Defect type
Marx and Carlson 1991 J Oral Maxillofac Surg BA +DI
Fontana, Trisi and Piatelli 1994 J Periodontol BA +DI
Remagen and Prezmecky 1995 Implant Dent BA +DI
Piattelli, Scarano and Piattelli 1996 J Periodontol BA +DI
Piattelli, Scarano and Piattelli 1996 Biomaterials BA +DI
Peleg et al 1999 J Periodontol BA +DI
Borissov et al 2004 Bulg J Vet Med E
Positive results
As in any GTR or GBR procedure the membrane material can play crucial
role for the final outcome of the therapy.
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Discussion
Fontana, Trisi and Piatelli(31)
implanted 85 dura mater
membranes around dental implants and reported excellent
osseointegration with partial dehiscence of only 4%. During
a re-entry full substitution of the defect with both cancellous
and cortical bone was found. Remagen and Prezmecky(32)
demonstrated new bone formation after alveolar ridge
augmentation with dura mater in more than 600 cases.
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Discussion
Piattelli, Scarano and Piattelli(33)
observed new lamellar bone
after alveolar ridge augmentation with FDDMA and
demineralized bone. Piattelli, Scarano and Piattelli(34)
and
Peleg et al(5)
published histological results after GTR with
dura mater for treatment of peri-implant dehiscencies and
fenestrations proving its effectiveness. More recently Shah
and Jathal(35)
and Borissov et al(36)
documented the clinically
and histologically the biocompatibility of FDDMA in
experimental studies, pointing out that human FDDMA(36)
is a
xenogenous material for the experimental animals.
33. 30/01/15 33
Conclusions
• The LMSA procedure is technically demanding.
• It depends on many factors that might affect implant survival
such as:
• The type of graft used for augmentation;
• Membrane type;
• The surgical technique: and
• The type of implants.
• In our series e-FDDMA served well as a GTR membrane.
• The combined technique we used is in consistency with
other techniques and can widen the indications for
immediate implant placement.
• In the light of changing realities allogenous dura mater has
physical strength, insusceptibility to infections, slow
resorption and manageability and may serve is a good
model for the development of new resorbable GTR
membranes.
34. 30/01/15 34
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