|Year : 2011 | Volume
| Issue : 1 | Page : 29-33
Direct sinus elevation and composite bone grafting for immediate implant placement in the posterior maxillary region
Nettemu Sunil Kumar1, R Sowmya2
1 Department of Periodontology and Oral Implantology, S. B. Patil Dental College, Bidar, Karnataka, India
2 Department of Periodontology and Oral Implantology, Amrita School of Dentistry, AIMS, Amrita Lane, Ponekkara P.O., Edapally, Kochi, Kerala, India
|Date of Web Publication||2-Feb-2011|
Department of Periodontology and Oral Implantology, Amrita School of Dentistry, AIMS, Amrita Lane, Ponekkara P.O., Edapally, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An atrophied posterior maxilla is the most challenging intraoral area confronting the implantologists, requiring utmost skill for the achievement of successful results. This case report exemplifies the use of a lateral wall osteotomy approach for sinus floor elevation, combined with the composite grafting to provide the ideal milieu for placement of a dental implant.
Keywords: Composite bone graft, direct sinus elevation, implant placement
|How to cite this article:|
Kumar NS, Sowmya R. Direct sinus elevation and composite bone grafting for immediate implant placement in the posterior maxillary region. J Dent Implant 2011;1:29-33
|How to cite this URL:|
Kumar NS, Sowmya R. Direct sinus elevation and composite bone grafting for immediate implant placement in the posterior maxillary region. J Dent Implant [serial online] 2011 [cited 2020 Sep 22];1:29-33. Available from: http://www.jdionline.org/text.asp?2011/1/1/29/76430
| Introduction|| |
The posterior maxilla has been described as the most difficult intraoral area confronting the implant practitioner, requiring utmost ingenuity to achieve successful results. , Both anatomic features and mastication dynamics contribute to the challenge of placing titanium implants in this region. 
Although management of the posterior maxilla presents many challenges, use of different procedures make it possible to create successful bone-anchored restorations in this region predictably. 
One such procedure, the sinus floor elevation technique, to facilitate implant placement in atrophic posterior maxillae was first presented in the late 1970s  and the first article on this subject was published in 1980. 
The technique of sinus elevation and simultaneous implant placement, in particular, offers the benefit of fewer surgical procedures, shorter treatment time and reduced expense. It was considered generally that at least 5 mm of bone must be present to ensure rigid fixation of the implant at the time of placement. 
However, there is evidence to show that it may be possible to successfully use the one-stage approach even when the residual crestal bone height is as little as 1 mm. ,
When a mature bone graft is employed for both mechanical and biologic implant stability, the use of a composite graft with an autogenous component is considered.  The increased volume of the mineralized bone that results from such a graft may ultimately lead to a more stable graft with greater implant-bone contact and therefore provide a more favorable prognosis for implant survival. ,
This case report presents the use of a lateral wall osteotomy approach for sinus floor elevation and the use of a composite grafting to allow placement of a dental implant in the posterior maxilla with an insufficient volume of residual alveolar bone.
| Case Report|| |
A 30-year-old male patient presented with a chief complaint of difficulty in chewing food due to absence of a molar tooth in the upper right region. The patient had undergone extraction of the right upper first molar, 5 years back, due to dental caries and the medical history was non-contributory. The patient did not give information regarding any deleterious habits. Radiographic examination including orthopantomogram revealed a flat sinus floor with 4.2 mm of residual alveolar bone height which was insufficient for placement of an implant supported prosthesis [Figure 1].
A lateral wall approach of sinus floor elevation and simultaneous implant placement was decided upon as the final treatment plan. Informed consent was obtained from the patient.
The surgical site was anesthetized by local administration of 2% lignocaine hydrochloride (LOX, Neon Laboratories Ltd., Mumbai, India) with 1:200,000 adrenaline [Figure 2].
A modified crestal incision, with the incision placed toward the palatal aspect of the edentulous area, was performed to achieve complete flap coverage over the site after implant placement. This incision was then continued as the crevicular incision around the teeth adjacent to the edentulous site. Vertical releasing incisions were made along the mesial line angles of the second premolar and second molar and extended beyond the muco-gingival junction to help achieve a tension-free flap with a broad base. The muco-periosteal flap was reflected and elevated to obtain direct access and visibility to the sub-periosteal surgical site.
Sinus membrane elevation using the direct technique
Osteotomy was initiated on the lateral wall of the maxillary sinus with 023-029 round steel burs (Hager and Meisinger GmbH, Dusseldorf, Germany) under cooling with sterile isotonic saline solution and a bony window was prepared with extreme caution to avoid perforation of the sinus mucosa. The sinus mucosa was then gently elevated using a sinus elevation kit (Friatech AG, Mannheim, Germany), dissected carefully and the bony wall was pushed inside carefully [Figure 3]. The space for bone grafting was thus prepared. The integrity of the sinus membrane was confirmed by observing the "in" and "out" movements of the membrane during inhalation and exhalation.
Autogenous block bone graft harvesting using "minimum button-hole" technique
Autogenous bone grafts are considered as the gold standard for bone reconstruction; the use of autogenous bone can be considered when the reconstructed segment is expected to be loaded with oral implants. It has been shown that in the facial skeleton, membranous bone, such as that grafted from the mandible, undergoes less resorption than endochondral bone, such as the iliac crest. , Also, if the graft volume is sufficient for the planned reconstruction, mandibular bone is the ideal choice. ,
In the region just apical to the roots of the mandibular right incisors and canine, a minimal vestibular incision was made to create a button hole. An 11 mm diameter cylindrical autogenous block bone was harvested using a round trephine bur [Figure 4]. The block bone graft was subsequently crushed and reduced into chips and blended with bovine hydroxyapatite synthetic graft material (Bio-Oss, Geistlich Pharmaceuticals, Wolhausen, Switzerland). This composite bone graft can serve as a blend of osteogenic bone and osteo-conductive graft particles.
The composite bone graft was placed in the prepared space beneath the elevated bony wall of the sinus [Figure 5].
|Figure 5 :The composite bone graft placed under the elevated sinus mucosa|
Click here to view
The implant drilling was performed under copious irrigation. An initial marking of the site was done using a round bur and subsequent osteotomies were carried out with a 2 mm drill to establish the depth and direction, and finally a 3.65 mm drill was used. A self-threaded titanium implant (4.2 mm Χ 10 mm) was inserted and covered with a titanium cover screw [Figure 6]. Adequate primary stability was accomplished by the residual host bone.
The use of barrier membranes in combination with particulate grafts and implants is reported to be an effective procedure in both humans and experimental animals. ,,
A sterile, bio-resorbable collagen membrane (Healiguide, Advanced Biotech Products, Chennai, India) was adapted over the sinus buccal window as well as the implant, and particular care was taken to ensure that the membrane extended 2 mm all around to completely cover the sinus bony window and the implant [Figure 7].
Periosteal releasing incisions were finally made to ensure tension-free primary closure of the muco-periosteal flap over the membrane. The recipient and the donor sites were consequently sutured using an absorbable suture material (4-0 Vicryl, Ethicon, Inc., Johnson and Johnson, Somerville, NJ, USA)
A prescription of 8 mg of betamethasone was given jointly with 2 g/day of amoxicillin for 10 days. The patient was asked to rinse with warm saltwater rinses for the first 2 weeks to promote normal flap healing without disturbing the wound. The patient was instructed to use chlorhexidine gluconate 0.12% (Peridex, Zila Pharmaceuticals, Phoenix, AZ, USA) to facilitate plaque control. 
The surgical site was checked every 2 weeks for a period of 2 months. After 6 months of healing, the second surgery was performed to uncover the implant for abutment connection, and subsequently, the crown was placed [Figure 8].
The success criteria used were: the implant was immobile, no signs of pain or suppuration were present, direct implant-to-bone contact was visible on radiographs, and vertical bone resorption was less than 1.0 mm in the first year after prosthetic loading.  For the benefit of proper visual comparison of the preoperative and postoperative bone height in the sinus augmented region, 1 year postoperatively, the postoperative radiograph was taken after temporary removal of the crown, prior to X-ray exposure.
| Discussion|| |
Studies of the long-term success of osseo-integrated implants placed in the posterior maxilla have painted a mixed picture. Implants used in the posterior maxilla showed a higher failure rate related to Type IV bone. , However, other investigators have shown significantly higher success rates. ,,
A systematic review proved that the overall implant survival rate of implants placed after sinus grafting technique was 91.49%.  The review also supported the statement that bone-substitute materials used in combination with autogenous bone may be extremely effective compared to the use of autogenous bone alone. Bone substitutes also help to reduce the volume of autogenous bone that needs to be harvested. Finally, autogenous bone in particulate form seemed to provide better outcomes compared to block grafts, and therefore, may be the preferred choice. ,
Also, excessive resorption of autografts may be overcome by using bone substitutes that are known for their slow resorption rates and which can increase the stability of the graft during the consolidation phase. 
Thus, in this case report, a composite particulate graft was used to utilize the osteogenic, osteo-inductive and osteo-conductive properties of the graft particles.
The clinical findings after 1 year of implant placement showed the implant to be healthy. The radiograph confirmed this by showing very negligible amount of bone loss [Figure 9].
| Conclusion|| |
Dental implant placement in the posterior maxilla remains a challenge. Insufficient bone volume due to alveolar bone resorption in the edentulous maxillae and the pnuematization of the maxillary sinus makes it extremely difficult to place implants in this region.
This problem can be overcome by performing a maxillary sinus floor elevation and augmentation using various bone graft materials between the sinus mucosa and the bony floor of the sinus.
This case report highlights the use of a lateral wall osteotomy for sinus floor elevation along with the use of composite graft to allow implant placement in the posterior maxilla.
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