|Year : 2019 | Volume
| Issue : 2 | Page : 60-65
Outcomes of intentional perforation of the maxillary sinus floor during implant placement: A single-center, prospective study in 57 subjects
Vallabhdas Santosh1, Parushuram Bhukya2, Bhagyasri Medisetty1, Viswa Chandra Rampalli1, P Anuup Kumaar1
1 Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India
2 Department of Prosthodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India
|Date of Web Publication||13-Jan-2020|
Dr. Vallabhdas Santosh
Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: An essential precondition for successful implant therapy is the presence of an adequate quantity and quality of bone.
Aims: The purpose of this study was to radiographically evaluate the bone formation around the dental implants which were placed at different depths into the maxillary sinus by intentional perforation of maxillary sinus floor during implant placement and its effect on implant survival rate.
Settings and Design: A total of 86 implants of varying dimensions were placed in maxillary premolar and molar region by intentional perforation of the maxillary sinus floor during implant placement in 57 patients.
Subjects and Methods: They were divided into three groups G1, G2, and G3 based on the depth of penetration into the maxillary sinus (region by [IS] compartment) (IS-G1-1 mm; G2-2 mm; G3-3 mm). The following parameters were evaluated-torque, bone density, and bone fill after 6 months of implant placement.
Statistical Analysis Used: The comparison among groups for repeated measures data was made by ANOVA repeated measures test. The correlation between two parameters, i.e., torque and bone fill was done by Karl Pearson's correlation test
Results: No significant differences were observed among the three groups for torque, bone fill, and bone density from baseline to 6 months. The correlation between torque and bone fill revealed R = 0.198, P = 0.293 which was statistically insignificant
Conclusions: There were minimal failure rates and complications observed at the end of the study period. The survival rate of implants was not influenced either by torque or by the depth of penetration of implant into the maxillary sinus.
Keywords: Perforations, periodontology, sinus lift
|How to cite this article:|
Santosh V, Bhukya P, Medisetty B, Rampalli VC, Kumaar P A. Outcomes of intentional perforation of the maxillary sinus floor during implant placement: A single-center, prospective study in 57 subjects. J Dent Implant 2019;9:60-5
|How to cite this URL:|
Santosh V, Bhukya P, Medisetty B, Rampalli VC, Kumaar P A. Outcomes of intentional perforation of the maxillary sinus floor during implant placement: A single-center, prospective study in 57 subjects. J Dent Implant [serial online] 2019 [cited 2020 Jul 13];9:60-5. Available from: http://www.jdionline.org/text.asp?2019/9/2/60/275699
| Introduction|| |
The posterior edentulous maxilla, which is mostly often made up of spongy bone, challenges the dentist for the normal placement of the implant when compared with other areas mainly due to the presence of the maxillary sinus.,,, To overcome these challenges several treatment options such as the use of short implants,, zygomatic implants, tilted implants, ridge augmentation with various grafting materials had been proposed by various authors, which have their own limitations. Placement of short implants in the region of inadequate bone height and in the area with poor bone quality often leads to the failure of implants.,,
Some investigators claim that intentional perforation of the Schneiderian membrane during implant placement has shown that the success rate of penetrated implants in the maxillary sinus is high, without any kind of complications, especially in the cases where the sinus intrusion is <3 mm.,,,,,
The aim of this prospective study was to radiographically evaluate the bone formation around the dental implants, which were placed at different depths into the maxillary sinus by intentional perforation of the maxillary sinus floor during implant placement and its effect on implant survival rate.
| Subjects and Methods|| |
This was a single-center, prospective observational study done in 57 patients, who had one or more edentulous areas in the maxillary posterior region and were willing for the replacement by endosseous implants. All the surgeries were performed by a single designated operator, whereas the relevant readings were recorded by calibrated operators, who were blinded to the nature of the group.
Systemically healthy male and female patients within the age group of 57–50 years with one or more edentulous areas in the maxillary posterior tooth region; having a residual bone height of 5–7 mm and a minimum thickness of about 6 mm were included in this study.
The presence of maxillary sinus pathologies, medically compromised patients, patients who underwent maxillary sinus lift procedure in prior or who underwent radiotherapy or chemotherapy in the past 12 months, patients with uncontrolled periodontal disease, pregnant or lactating females, and smokers were excluded from the study.
In a total of 57 patients, 86 implants were placed with intentional perforation of the maxillary sinus floor. Twenty patients received single implants, whereas five patients received two implants. All patients were explained regarding the study, signed a written informed consent form before enrolment and were subjected to professionally delivered oral hygiene, as required before implant placement procedures. All patients were given preoperative loading dose of antibiotics. Patients rinsed with 0.2% chlorhexidine mouthwash for 1 min prior to the implant placement procedure. All patients were treated under local anesthesia using 2% lignocaine with adrenaline (1:80,000). A crestal incision was made to expose the alveolar ridge and mucoperiosteal flap was elevated and surgical stent to facilitate the optimal implant positioning were used. Osteotomy preparation was carried out, and implants (Adin Implant systems) of varying dimensions were placed by intentional perforation of maxillary sinus floor during implant placement in all subjects. Diagnosis of sinus penetration was confirmed during implant bed preparation (after osteotome use), and the membrane perforation was confirmed with a gauge. All implants were placed, achieving good primary stability. The radiograph was taken to evaluate the final position of implant. This was followed by the placement of cover screw and primary closure was obtained over the implant.
On the radiograph, in the area of implant placement, two horizontal lines were drawn one at the crest of alveolar ridge and other at floor of maxillary sinus. Joining these two lines a vertical line was drawn along the long axis of implant. The two ends of this vertical line were represented as point A and point B and the implant apex is represented as Point C. The distance from Point A to Point B represents intraosseous (IO) compartment and distance from point B to point C represents intrasinus (IS) compartment. Based on the ratio of IO and IS compartment these 86 implants were divided into 3 groups. Group 1 (G1): IO: IS is 5:1, Group 2 (G2): IO: IS is 4:2, and Group 3 (G3): IO: IS is 3:3 [Figure 1]. The following parameters were evaluated at baseline and after 6 months: Torque (using torque gauge incorporated with manual ratchets), bone fill (using digital subtraction technique and morphometric area analysis) and bone density (using ImageJ software) [Figure 2].
|Figure 1: The distance from Point A to Point B represents intraosseous compartment and distance from Point B to Point C represents intrasinus compartment. Based on the ratio of intraosseous and intrasinus compartment these 86 implants were divided into 3 groups. Group 1 (G1): intraosseous: intrasinus is 5:1, Group 2 (G2): intraosseous: intrasinus is 4:2 and Group 3 (G3): intraosseous: intrasinus is 3:3|
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|Figure 2: The evaluation of bone fill was assessed using the digital subtraction technique and morphometric area analysis at the baseline and postoperatively at an interval of 3 and 6 months, using two kinds of image processing software|
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Follow-up assessments and postsurgical care
Postoperative instructions were given, and routine antibiotics and analgesics were prescribed for 5 days. Patients were recalled 1 week after surgery. Sutures were removed, and patients were instructed to gently brush the area with a soft-bristled toothbrush. Patients were then monitored for any complications at the end of 1 week, 2 weeks, 1 month, 3 months, and 6 months. At each of the recall visits, oral hygiene was assessed, and oral hygiene instructions were reinforced. After a period of 6 months prosthetic rehabilitation was initiated.
A standardized intraoral periapical radiograph was taken on the day of implant placement (baseline) and after 6 months postoperatively to evaluate the bone formation around the implant apex.
The evaluation of bone fill was performed by a single operator using the digital subtraction technique and morphometric area analysis by using specific tools in two kinds of image processing software.
Digital subtraction technique and morphometric area analysis
The radiographs obtained at 3 and 6 months were subtracted from the radiograph taken at the baseline by using commercially available image processing software (Adobe Photoshop® 6.0, Adobe Systems, San Jose, USA). To reduce brightness and contrast variations, both images were adjusted based on the levels and curves in the software. Before digital subtraction, both radiographs were moved inappropriate directions as needed, to reduce geometric distortion. These images were then superimposed and subtracted by selecting the image > calculation > exclusion > new channel tools. The excluded residual bone height was outlined by using the polygonal lasso tool, and the layer was copied and saved as a separate joint photographic expert group document at low compression.
After digital subtraction, the digitized and excluded residual bone height was transferred to open source software for area calculation (ImageJ, Research Services Branch, National Institutes of Health). The layer was converted into a grayscale image, and the measurement scale was set to account for any magnification/reduction of the radiograph because of the radiovisiography. The area of the layer was calculated (in mm2) by initially enclosing the entire area with the rectangular selection tool and then by using Analyze > Analyze Particles tool.
To calibrate Image J, a scale bar was placed on one image for each magnification. The file was opened with an image containing a scale bar inserted by the microscope or camera software that acquired the image. The length measured for the scale bar was entered as distance in pixels. The length of the scale bar as labeled by the microscope is entered as known distance and subsequent analysis was measured on this scale.
The comparison among groups for repeated measures data was made using ANOVA repeated measures test. The correlation between two parameters, i.e., torque and bone fill was done by Karl Pearson's correlation test.
| Results|| |
The mean age of the subject pool (n = 57) was 34.5 ± 7.26 years. The surgical procedure (placement of implant by intentional perforation of maxillary sinus floor) was well tolerated by all the subjects. No losses in follow-up were reported. Of 86 implants placed in 57 patients radiographic follow-up verified an ordinary bone healing in all the subjects except for one implant, which failed to osseointegrate.
No statistically significant differences were observed between the three groups for torque at the end of 6 months (P = 0.761). The mean torque values (N/cm) for three groups were: 39.58 ± 15.29, 34.44 ± 14.02, and 38.89 ± 19.97, respectively [Table 1].
|Table 1: Intergroup comparison between the groups Group 1, Group 2, Group 3 for the parameters Torque and bone fill|
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No statistically significant differences were observed between the three groups for bone fill at the end of 6 months (P = 0.503). The mean marginal bone formation (bone fill) from baseline to 6 months around penetrated implant apex was 1.76 mm, 2 which was statistically insignificant [Table 2].
|Table 2: The comparison between Group 1, Group 2, Group 3 for the parameter bone fill (mm2)|
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No statistically significant differences were observed between the three groups for bone density at the end of 6 months. The mean bone density values (HU) at baseline (0 days) for three groups were: 170.80 ± 129.50, 146.80 ± 101.80 and 186.80 ± 124.40 (P = 0.779) and at 6 months were 476.00 ± 120.10, 395.40 ± 152.00, and 460.10 ± 165.50 (P = 0.437) [Table 3] and [Table 4].
|Table 3: The comparison between Group 1, Group 2, Group 3 for the parameter HU (0 days)|
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|Table 4: The comparison between Group 1, Group 2, Group 3 for the parameter HU (180 days)|
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Correlation between torque and bone fill
The correlation between torque and bone fill revealed: R = 0.198, P = 0.293 which was statistically insignificant.
| Discussion|| |
Rehabilitation of posterior maxilla using dental implants often remains as a challenge to the dentist because following tooth extraction there is an initial decrease in the bone width due to the resorption of buccal bone plate, followed by the continuing loss of bone height and density. Moreover, there is an increase in antral pneumatization due to increased osteoclastic activity of the periosteum and an increase in intra-antral pressure because of which the sinus floor is present closer to the alveolar crest. Sinus augmentation procedures are widely performed to correct vertical deficiencies encountered in the posterior maxillary region to enable optimal implant placement.
Some authors recommend engaging the apex of the implant into the sinus floor to obtain increased implant stability because the sinus floor is composed of dense cortical bone., Bicortical fixation is a novel approach intended to increase implant stability in the maxillary posterior region by engaging two layers of cortical bone, i.e.,,, alveolar crest cortical bone and apically into the sinus floor. Hsu et al., concluded that the use of bicortical fixation is simpler and economical when compared to indirect sinus elevation and allows for the placement of longer implants when compared to unicortical fixation. Similarly, in the present study, implants were placed by intentionally perforating the maxillary sinus floor in a bicortical fixation manner to assess the amount of new bone formation around the dental implant and its effect on implant survival rate.
In a study done by Zhong et al.,, on the effects of dental implant penetration into the maxillary sinus cavity in different depths on osseointegration and sinus health in a canine model concluded that despite the protrusion extents, penetration of dental implant into the maxillary sinus with membrane perforation does not compromise the sinus health and the implant osseointegration. The implants that were placed with a depth of 1 mm and 2 mm were fully covered with newly formed membrane and partially with new bone but implants with 3 mm penetrating depth showed no membrane or bone coverage. In case of the present study, no significant differences were found among groups as the mean marginal bone formation (bone fill) around penetrated implant apex recorded was 1.76 mm2 at the end of the follow-up period of 6 months.
In a review by Maria Ragucci et al., on implant survival and complication rates of implants intruding into the sinus cavity concluded that, the estimated survival rates were 99.5% in implant penetrating ≤4 mm and 98.5% in implant penetrating >4 mm. in the present study as well, there were no statistically significant differences in survival rates according to the degree of penetration in the three groups (P = 0.403).
Jung et al. reported that implants which penetrated <2 mm into the sinus floor was covered by the sinus mucosa in mongrel dogs., CT scans showed that implant protrusion of >4 mm in the maxillary sinus can cause thickening of the sinus mucosa around the implants. However, these sinuses remained asymptomatic. In the case of this study, no complications regarding sinus membrane perforation were observed in the study period of 6 months.
Kim et al. evaluated clinical outcomes of implants placed into maxillary sinus with a perforated sinus membrane. The average residual bone height obtained was 3.4 ± 2.0 mm in cases of simultaneous implant placement and 0.6 ± 0.9 mm in cases of delayed placement, whereas, the mean marginal bone formation (bone fill) around the penetrated implant apex recorded in the present study was 1.76 mm2.
Despite the different penetrating depths, the osseointegration in the interface between the sinus floor and implant interface was achieved and no inflammatory reaction was observed in the surrounding sinus membrane, suggesting that the exposed implants do not make the maxillary sinus membrane vulnerable to complications and has no effect on the survival rate of the implants either. Further long-term studies with larger sample size are required to thoroughly assess the efficacy of this procedure.
| Conclusion|| |
To conclude, There were minimal failure rates and complications observed at the end of the study period. The survival rate of implants was not influenced either by torque or by the depth of penetration of implant into the maxillary sinus.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hürzeler MB, Kirsch A, Ackermann KL, Quiñones CR. Reconstruction of the severely resorbed maxilla with dental implants in the augmented maxillary sinus: A 5-year clinical investigation. Int J Oral Maxillofac Implants 1996;11:466-75.
Deporter D, Todescan R, Caudry S. Simplifying management of the posterior maxilla using short, porous-surfaced dental implants and simultaneous indirect sinus elevation. Int J Periodontics Restorative Dent 2000;20:476-85.
Garg AK. Augmentation grafting of the maxillary sinus for placement of dental implants: Anatomy, physiology, and procedures. Implant Dent 1999;8:36-46.
Sharan A, Madjar D. Maxillary sinus pneumatization following extractions: A radiographic study. Int J Oral Maxillofac Implants 2008;23:48-56.
ten Bruggenkate CM, Asikainen P, Foitzik C, Krekeler G, Sutter F. Short (6-mm) nonsubmerged dental implants: Results of a multicenter clinical trial of 1 to 7 years. Int J Oral Maxillofac Implants 1998;13:791-8.
Fugazzotto PA. Shorter implants in clinical practice: Rationale and treatment results. Int J Oral Maxillofac Implants 2008;23:487-96.
Galán Gil S, Peñarrocha Diago M, Balaguer Martínez J, Marti Bowen E. Rehabilitation of severely resorbed maxillae with zygomatic implants: An update. Med Oral Patol Oral Cir Bucal 2007;12:E216-20.
Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Relat Res 2001;3:39-49.
Chiapasco M, Zaniboni M. Methods to treat the edentulous posterior maxilla: Implants with sinus grafting. J Oral Maxillofac Surg 2009;67:867-71.
Papaspyridakos P, De Souza A, Vazouras K, Gholami H, Pagni S, Weber HP. Survival rates of short dental implants (≤6 mm) compared with implants longer than 6 mm in posterior jaw areas: A meta-analysis. Clin Oral Implants Res 2018;29 Suppl 16:8-20.
Tzerbos F, Bountaniotis F, Theologie-Lygidakis N, Fakitsas D, Fakitsas I. Complications of zygomatic implants: Our clinical experience with 4 Cases. Acta Stomatol Croat 2016;50:251-7.
Irinakis T, Dabuleanu V, Aldahlawi S. Complications during maxillary sinus augmentation associated with interfering septa: A new classification of septa. Open Dent J 2017;11:140-50.
Lifshey FM, Kang BB. A simple method of barrier membrane fixation for large sinus membrane tears. J Oral Maxillofac Surg 2009;67:1937-40.
Brånemark PI, Adell R, Albrektsson T, Lekholm U, Lindström J, Rockler B. An experimental and clinical study of osseointegrated implants penetrating the nasal cavity and maxillary sinus. J Oral Maxillofac Surg 1984;42:497-505.
Oh E, Kraut RA. Effect of sinus membrane perforation on dental implant integration: A retrospective study on 128 patients. Implant Dent 2011;20:13-9.
Nooh N. Effect of schneiderian membrane perforation on posterior maxillary implant survival. J Int Oral Health 2013;5:28-34.
Shahzad KM, Madson AQ, Shipp EM, Ellis AW. Success rate of dental implants placed in the atrophic posterior maxilla with intentional sinus floor perforation in lieu of indirect sinus augmentation: A retrospective report of 26 consecutive patients and literature review. Open J Stomatol 2017;7:113-20.
Abi Najm S, Malis D, El Hage M, Rahban S, Carrel JP, Bernard JP. Potential adverse events of endosseous dental implants penetrating the maxillary sinus: long-term clinical evaluation. Laryngoscope 2013;123:2958-61.
Yellarthi PK, Rampalli VC, Anumala N, Devaraju RR. Assessment of bone-fill following regenerative periodontal therapy by image subtraction using commercially available software. J Indian Acad Oral Med Radiol 2014;26:13-8. [Full text]
Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH. Implant-retained mandibular overdentures with immediate loading. A retrospective multicenter study on 226 consecutive cases. Clin Oral Implants Res 1997;8:48-57.
Schnitman PA, Wöhrle PS, Rubenstein JE, DaSilva JD, Wang NH. Ten-year results for Brånemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12:495-503.
Crismani AG, Bernhart T, Schwarz K, Celar AG, Bantleon HP, Watzek G. Ninety percent success in palatal implants loaded 1 week after placement: A clinical evaluation by resonance frequency analysis. Clin Oral Implants Res 2006;17:445-50.
Valderrama P, Oates TW, Jones AA, Simpson J, Schoolfield JD, Cochran DL. Evaluation of two different resonance frequency devices to detect implant stability: A clinical trial. J Periodontol 2007;78:262-72.
Huwiler MA, Pjetursson BE, Bosshardt DD, Salvi GE, Lang NP. Resonance frequency analysis in relation to jawbone characteristics and during early healing of implant installation. Clin Oral Implants Res 2007;18:275-80.
Hsu A, Seong WJ, Wolff R, Zhang L, Hodges J, Olin PS, et al
. Comparison of initial implant stability of implants placed using bicortical fixation, indirect sinus elevation, and unicortical fixation. Int J Oral Maxillofac Implants 2016;31:459-68.
Zhong W, Chen B, Liang X, Ma G. Experimental study on penetration of dental implants into the maxillary sinus in different depths. J Appl Oral Sci 2013;21:560-6.
Ellegaard B, Baelum V, Kølsen-Petersen J. Non-grafted sinus implants in periodontally compromised patients: A time-to-event analysis. Clin Oral Implants Res 2006;17:156-64.
Ragucci GM, Elnayef B, Suárez-López Del Amo F, Wang HL, Hernández-Alfaro F, Gargallo-Albiol J. Influence of exposing dental implants into the sinus cavity on survival and complications rate: A systematic review. Int J Implant Dent 2019;5:6.
Jung JH, Choi BH, Jeong SM, Li J, Lee SH, Lee HJ. A retrospective study of the effects on sinus complications of exposing dental implants to the maxillary sinus cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:623-5.
Jung JH, Choi BH, Zhu SJ, Lee SH, Huh JY, You TM, et al
. The effects of exposing dental implants to the maxillary sinus cavity on sinus complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:602-5.
Lambert F, Léonard A, Drion P, Sourice S, Layrolle P, Rompen E. Influence of space-filling materials in subantral bone augmentation: Blood clot vs. autogenous bone chips vs. bovine hydroxyapatite. Clin Oral Implants Res 2011;22:538-45.
Kim GS, Lee JW, Chong JH, Han JJ, Jung S, Kook MS, et al
. Evaluation of clinical outcomes of implants placed into the maxillary sinus with a perforated sinus membrane: A retrospective study. Maxillofac Plast Reconstr Surg 2016;38:50.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]