For citation purposes: El Haddad E, Lauritano D, Giovine G, Carinci F. Lateral window for major sinus lift bone grafting: Technical note. Annals of Oral & Maxillofacial Surgery 2014 Jul 10;2(2):13.

Case report

 
Implantology

Lateral window for major sinus lift bone grafting: Technical note.

E El Haddad1, D Lauritano2*, G Giovine1, F Carinci3
 

Authors affiliations

(1) Private practice, Turin

(2) University of Milan-Bicocca

(3) University of Ferrara

* Corresponding author Email: dorina.lauritano@unimib.it

Abstract

Introduction

After the loss of teeth in the posterior maxilla, the thickness or vertical height between the alveolar crest and maxillary sinus may be insufficient to place dental implants. At present, maxillary sinus lifting has become a widely used technique for augmenting bone tissue volume in the maxilla. Various surgical techniques can be applied to achieve a sufficient bone volume in order to place implants. Among the techniques used for lateral surgical access to the antral cavity, the technique of complete removal of the bony window through rotary instruments, and the technique of partial conservation of the window with the overturning inside the sinus (trap door) are widely known. In this article the authors present an alternative to surgical access, using a technique with a minor invasive approach with a high biological value. This method provides a lateral access to the maxillary sinus with a minimally invasive osteotomy. The osteotomic incision, of very reduced dimensions, must be performed with perfectly regular lines to delimit a rectangular shape, and convergent incisions in the cavity direction, realizing a true chamfer and preserving the integrity of the Schneiderian membrane.

Case report

A 54-year-old female presented in our dental clinic to replace the right superior premolars.

Implants were placed after performing a anthrostomy and maxillary sinus lift with a new technique. In order to guarantee greater stability to bone plug a membrane of PRF (Platelet Rich Fibrin) was placed according to the Choukroun Technique and the flap was sutured. Finally prosthetic rehabilitation was completed after six month.

Conclusion

The technique of sinus lift with side access, with purposes of implant prosthetic rehabilitation, is characterized by high predictability of success. Among the techniques of lateral surgical access to the antral cavity, the technique of complete removal of the bony window through rotary instruments and the technique of partial conservation of the window with the overturning inside the sinus (trap door) are widely known. In this paper we have described a new surgical technique less invasive, infact, in any case it is essential, irrespective of the technique used, preserving the integrity of the Schneiderian membrane.

Introduction

After the loss of teeth in the posterior maxilla, the thickness or vertical height between the alveolar crest and maxillary sinus may be insufficient to place dental implants[1,2]. In the immediate period after maxillary posterior tooth extraction, initial decrease in alveolar width is due to resorption and/or loss of buccal bone. Continuous bone remodelling, absence of stimulation, loss of bone height and density, can lead to an increase in antral pneumatization. The maxillary sinus pneumatization is caused both by progressive resorption of alveolar processes, and by increase of intra-antral pressure. In such a situation, the residual vertical bone height progressively decreases, and standard implant placement becomes more and more difficult[3,4]. In these patients, grafting techniques before placing implants in the posterior edentulous area are required. At present, maxillary sinus lifting has become a widely used technique for augmenting bone tissue volume in the maxilla. Various surgical techniques can be applied to achieve a sufficient bone volume in order to apply implants. The lateral approach, first described by Tatum in 1976, provides surgical access through the zygomatic lateral wall of the maxilla, followed by elevation of the sinus membrane and placement of grafting material[5].

This surgery creates an antrotomy access to the sinus, detaching Schneider’s membrane from the sinus floor, and placing a grafting material into the sinus cavity to promote vertical bone augmentation[6]. The long-term success of this technique has been reported even with the use of different types of grafting materials and implants[7]. Sinus augmentation has a high percentage of success, but presents a number complications: intraoperative complication, such as membrane perforation, fracture of the residual alveolar ridge, obstruction of the maxillary ostium, haemorrhage, damage to adjacent dentition; early post-operative complications such as haemorrhage, wound dehiscences, acute infection, exposure of barrier membrane, graft infection, graft loss and dental implants failure, and late post-operative complications such as graft loss, implant loss or failure, implant migration, oroantral fistula, chronic pain, chronic sinus disease, chronic infection[8,9]. The most frequent complication is surely the Schneiderian membrane perforation. Anatomic irregularities of the sinus floor, or residual sinus septa, and above all the window design, can increase the risk of perforation. Nowadays the use of piezoelectric osteotomy provides a good tactile sense, does not damage non mineralized structures, and prevents membrane perforation[10,11].

Technical note

In this article the authors present an alternative to surgical access, using a technique with a minor invasive approach with a high biological value. This method provides a lateral access to the maxillary sinus with a minimally invasive osteotomy. The osteotomic incision, of very reduced dimensions, must be performed with perfectly regular lines to delimit a rectangular shape, and convergent incisions in the cavity direction, realizing a true chamfer.

Case report

A 54-year-old female presented in our dental clinic to replace the right superior premolars (Figure 1). An x-ray panoramic was performed and, due to a lack of bone (Figure 2), we underwent the patient to a maxillary sinus lift. An x-ray study was performed with a tridimensional method (TC, Cone Beam, Siemens, Medical Sistem, Italy) (Figure 3 and Figure 4), to define sinus anatomy details:

- height of the residual bone ridge

- location of seven cavities (seven of Underwood), present in at least 30% of cases

- vertical and mesio-distal extension of the maxillary sinus

- health conditions of the Schneiderian membrane

- thickness of the lateral bone wall

The height of the residual bone ridge allows us to establish two important parameters:

- lower limit of osteotomy

- planning the immediate or delayed insertion of the implants

Loss of right superior premolars

Panoramic X-ray (particular)

TC, Come Beam imaging

TC, Come Beam imaging

It’s important, during surgical planning, to identify the presence of a septum that could hamper the correct detachment of the membrane. The septum, originating from the floor, sometimes develops considerably in a vertical sense. In this case, the solution is to create two independent windows, one mesial and the other distal to the septum. The greater the thickness of the lateral wall, the more difficult both osteotomic access and membrane detachment. In any case, our new technique proposes an anthrostomic access of limited dimensions, with the maximum conservation of the lateral wall of the sinus (Figure 5). The risk of membrane perforation is related to the angle between the vestibular wall of the sinus and the medial one: the more acute the angle, the more difficult the membrane detachment. An angle greater than 60 degrees presents no risk of perforation; when the angle is between 30 and 60 degrees, the risk of perforation increases approximately 30%. If the angle is less than 30 degrees, the risk increases to 60% (Figure 6). After x-ray study the gingival flap is designed (Figure 7). Osteotomy is performed with the use of sonic instruments (Airson®, TeKne Dental srl, Calenzano (FI), Italy). This technique allows to perform thin, very precise osteotomies, between 0.18 and 0.25 millimetres, greatly reducing the risk of damaging soft tissues and with an increased saving of bone tissue. The bone plug resulting from the above-mentioned osteotomy is delicately detached from the membrane, removed and conserved in a physiological solution (Figure 8). Once anthrostomic window is performed, we proceed to membrane detachment from the apical part to mesial portion, then distal, finishing with the most coronal (Figure 9). This surgery must be performed always maintaining the sharp part of the detacher constantly on the bone floor, verifying membrane integrity with Valsava manoeuvre (Figure 10). Implants (Megagen srl, Como, Italy) are placed before filling the cavity with grafting material (Figure 11). Finally anthrostomy is closed repositioning the bone plug (Figure 12). In order to guarantee greater stability to bone plug a membrane of PRF (Platelet Rich Fibrin) is placed according to the Choukroun Technique (Figure 13). Then the flap is sutured and an x-ray is performed to control implants position (Figure 14 and Figure 15). Finally prosthetic rehabilitation is completed after six month (Figure 16).

Anthrostomic access

Sinus angles. Risk of membrane perforation is related to the angle between the vestibular wall of the sinus and the medial one: the more acute the angle, the more difficult the membrane detachment. An angle greater than sixty degrees presents no risk of perforation; when the angle is between 30 and 60 degrees, the risk of perforation increases to approximately 30%. If the angle is less than 30 degrees, the risk increases to 60%.

Flap design

Bone plug put in a physiological solution

Membrane detachment from the apical part to mesial portion, then distal, finishing with the most coronal

Valsalva manoeuvre

Implant placing and filling cavity with grafting material

Repositioning of bone plug and closing anthrostomy

PRF (Platelet Rich Fibrin) membrane according to the Choukroun Technique

Suturing of the flap

X-ray to control implants position

Prosthetic rehabilitation after six months

Discussion

Dental implant placement is often restricted by sinus enlargement in the posterior maxilla. Various sinus augmentation techniques have been introduced so far to overcome the problem. The conventional method for sinus augmentation is the lateral window technique. Membranes prevent graft migration and soft tissue invasion of the sinus[12], favouring a greater amount of bone regeneration in the sinus[13]. Several studies assessed survival rates of implants with sinus floor lifting[14], however, very few controlled clinical trials have evaluated the need of placing a membrane over the antrostomy defect in terms of implant survival, and most of them have conflicting results. Therefore, the debate on the necessity of barrier membranes in sinus augmentation still persists. However, because of limitations in bone regeneration, attention has focused on biological mediators to enhance the clinical benefits of bone grafts and improve wound healing[15]. Purified and recombinant growth factors, including platelet-derived growth factor (PDGF) and insulin-like growth factor I (IGF1), have demonstrated significant therapeutic potential in preclinical and clinical studies[16]. Platelets produce and release multiple growth and differentiation factors critical for regulation of wound healing. Refinements in haematological instrumentation now enable the efficient collection of platelets in high concentrations, such as platelet-rich plasma (PRP)[17]. In other medical specialties, platelet-rich plasma (PRP) is known to support wound healing in the therapy of sulcus-cruris, and in ophthalmology PRP has been applied in the treatment of macular defects[18]. An in vitro study has shown that proliferation of human osteoblast-like cells can be stimulated by concentration dependent platelet concentrates and supports the assumption that the clinical use of PRP might increase bone regeneration. In addition to single case reports about the topical use of PRP in oral surgery, other studies have investigated its effects in animal experiments. Furthermore, some reports have discussed different combinations of autologus bone or bovine collagen with PRP[19,20]. Lenharo and Cosso[21] claimed that using the technique of obtaining platelet-rich plasma, in order to produce a high concentration of growth factors derived from platelets, appears to be a significant addition to surgical techniques for tissue regeneration. They mentioned that bone regeneration is predictable when considering viable cells (osteocompetents), growth factors and organic or synthetic matrices. They also concluded that the regeneration in bone areas treated with growth factors seems to have better epithelial repair compared with control areas, as well as bone regeneration is improved. In contrast Gürbüzer et al.[22] concluded that the application of PRP alone into soft tissue impacted mandibular third molar extraction sockets failed to increase the osteoblastic activity in postsurgical weeks. They investigated the early effect of platelet-rich plasma (PRP) on osteoblastic activity during the healing process of soft tissue impacted mandibular third molar extraction sockets by means of bone scintigraphy. Scintigraphic findings did not show significantly increased osteoblastic activity.

Conclusion

The technique of sinus lift with side access, with purposes of implant prosthetic rehabilitation, is characterized by high predictability of success. Numerous studies have shown that the method of filling the antral cavity with autologous bone or allograft, does not influence on outcome in terms of successful implant surgery, tissue healing and complications. Instead, the use of a barrier on the access window, compared to no use of any barrier, really influences the implant success, limiting any complications. A systematic review, published by Tarnow in 2000, showed a 91.5% implant success especially when the bone window is closed with the placement of a membrane of resorbable material[23]. Among the techniques of lateral surgical access to the antral cavity, the technique of complete removal of the bony window through rotary instruments and the technique of partial conservation of the window with the overturning inside the sinus (trap door) are widely known. In this paper we have described a new surgical technique less invasive, infact, in any case it is essential, irrespective of the technique used, preserving the integrity of the Schneiderian membrane.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Conflict of interests

None declared.

Competing interests

None declared

References

1. Misch CE. Maxillary sinus augmentation for endosteal implants: organized alternative treatment plans. Int J Oral Implantol.1987;4:49-58.

2. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg. 1988;17:232-6.

3. Raja SV. Management of the posterior maxilla with sinus lift: Review of techniques. J Oral Maxillofac Surg. 2009;67:1730–4.

4. Toffler M. Minimally invasive sinus floor elevation procedures for simultaneous and staged implant placement. N Y State Dent J. 2004;70:38.

5.Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986;30: 207-29.

6. Hirsch J & Ericsson I. Maxillary sinus augmentation using mandibular bone grafts and simultaneous installation of implants. A surgical technique. Clinical oral implants research. 2002; 2, 91–96.

7. Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotome: a systematic review and meta-analysis. J Periodontol. 2005 Aug;76(8):1237-51.

8. Zijderveld SA, Van den Bergh JP, Schulten EA, Ten Bruggenkate CM. Anatomical and surgical findings and complications in 100 consecutive maxillary sinus floor elevation procedures. J Oral Maxillofac Surg. 2008;66:1426-38.

9. Raghoebar GM, Batenburg RH, Timmenga NM, Vissink A, Reintsema H. Morbidity and complications of bone grafting of the floor of the maxillary sinus for the placement of endosseous implants. Mund Kiefer Gesichtschir. 1999;3Suppl 1:S65-9.

10. Saker M, Ogle O. Benign paroxysmal positional vertigo subsequent to sinus lift via closed technique. J Oral Maxillofac Surg. 2005;63:1385-7.

11. Vernamonte S, Mauro V, Messina AM. An unusual complication of osteotome sinus floor elevation: benign paroxysmal positional vertigo. Int J Oral Maxillofac Surg. 2011;40:216-8.

12. Buser D, Bragger U, Lang N & Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clinical oral implants research. 2002; 1, 22–32.

13. Schenk R, Buser D, Hardwick WR & Dahlin C. Healing pattern of bone regeneration in membrane-protected defects: a histologic study in the canine mandible. The International Journal of Oral & Maxillofacial Implants. 1994; 9, 13.

14. Pjetursson BE, Tan WC, Zwahlen M & Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Journal of Clinical Periodontology. 2008; 35, 216–240.

15. Hanisch O, Lozada JL, Holmes RE, Calhoun CJ, Kan JY, Spiekermann H. Maxillary sinus augmentation prior to placement of endosseous implants: a histomorphometric analysis. Int J Oral Maxillofac Implants. 1999;14:329-36.

16. Yildirim M, Spiekermann H, Biesterfeld S, Edelhoff D. Maxillary sinus augmentation using xenogenic bone substitute material Bio-Oss in combination with venous blood. A histologic and histomorphometric study in humans. Clin Oral Implants Res. 2000;11:217-29.

17. Josifova D, Gatt G, Aquilina A, Serafimov V, Vella A, Felice A. Treatment of leg ulcers with platelet-derived wound healing factor (PDWHFS) in a patient with beta thalassaemia intermedia. Br J Haematol. 2001;112:527-9.

18. Gehring S, Hoerauf H, Laqua H, Kirchner H, Kluter H. Preparation of autologous platelets for the ophthalmologic treatment of macular holes. Transfusion. 1999;39:144-8.

19. Thorwarth M, Rupprecht S, Falk S, Felszeghy E, Wiltfang J, Schlegel KA. Expression of bone matrix proteins during de novo bone formation using a bovine collagen and platelet-rich plasma (PRP)—an immunohistochemical analysis. Biomaterials. 2005; 26:2575-84.

20. Schlegel KA, Donath K, Rupprecht S, Falk S, Zimmermann R, Felszeghy E, et al. De novo bone formation using bovine collagen and platelet-rich plasma. Biomaterials. 2004;25:5387-93

21. Lenharo A, Cosso F. Utilização de plasma autógeno rico em plaquetas em alveolus dentários pós-extração: avaliações radiográficas e histológica. In: Gomes LA (ed.), Implantes ósseo integrados, vol. 16; 2002, 237e259, 2002.

22. Gürbüzer B, Pikdöken L, Urhan M, Süer BT, Narin Y. Scintigraphic evaluation of early osteoblastic activity in extraction sockets treated with platelet-rich plasma. J Oral Maxillofac Surg. 2008; 66: 2454-2460.

23. Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC. Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study. Int J Periodontics Restorative Dent. 2000 Apr;20(2):117-25.

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