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MAXILLARY SINUS FLOOR ELEVATION WITH IMMEDIATE IMPLANT PLACEMENT.

CLINICAL AND RADIOLOGICAL FINDINGS

Uzunov NG

Department of Maxillofacial Surgery, Faculty of Dental Medicine Plovdiv

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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

PatientsThirty 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 BruxomaniaChewing 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

Gen

der 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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Surgical technique

Figure 4. Technique of LMSA. Left: Membrane fixation Right: After 30 days of healing

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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 -1At

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

Impl

ant un

cove

ry

Gin

giva

l hea

ling

Pro

thes

izin

g

IM y y y y y y y

PD y y y y y y y

CAL y y y y y y yPanoramic radiographs y y y y y y y y y yPeriapical

radiographs y y y y y y y

y

y

Weeks

Osseintegration Function

yearly

25 - 36

Months

on 6 months

Radiographic examination

Exa

min

atio

n

Par

amet

er / T

echn

ique

on 3 monthsdaily

Pre

para

tion

for su

rger

y monthly

Clin

ical

exam

inat

ion

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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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Radiological follow-up

Figure 11. Before surgery

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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

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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 +DIFontana, Trisi and Piatelli 1994 J Periodontol BA +DIRemagen and Prezmecky 1995 Implant Dent BA +DIPiattelli, Scarano and Piattelli 1996 J Periodontol BA +DIPiattelli, Scarano and Piattelli 1996 Biomaterials BA +DIPeleg et al 1999 J Periodontol BA +DIBorissov 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.

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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.

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