Indirect Maxillary Sinus Lift for Single Tooth Implant: A Clinical Study

Original Article DOI: 10.17354/ijss/2015/53 Indirect Maxillary Sinus Lift for Single Tooth Implant: A Clinical Study Ramanuj C Tandel 1, Devashri Parikh 2, Babu Parmar 3 1 Post-graduate Student, Department of Oral & Maxillofacial Surgery, Government Dental College & Hospital, Ahmedabad, Gujarat, India, 2 Student, Department of Prosthodontia Crown & Bridge & Implantology, College of Dental Science & Research Center, Ahmedabad, Gujarat, India, 3 Head, Department of Oral & Maxillofacial Surgery, Government Dental College & Hospital, Ahmedabad, Gujarat, India Abstract Purpose: Tooth replacement with dental implant has been most challenging in maxillary posterior region due to pneumatization of maxillary sinus. Indirect maxillary sinus floor augmentation is one of the methods to overcome this problem so a clinical study was performed in institute and patients treated with indirect maxillary sinus lift and simultaneous implant placement. Aim: The aim of this study is to evaluate clinically and radiographically the long -term success of one-stage indirect (crestal approach) sinus lift procedure using alloplastic bone graft material and bioabsorbable membrane in conjunction with two-stage implant placement in atrophic partially edentulous posterior maxilla. Materials and Methods: One-stage indirect maxillary sinus lift in conjunction with two-stage implant placement was carried out in six patients at six sites. All the patients were partially edentulous with posterior maxillary alveolar ridge height of >5 mm and were in the age group of 20-50 years. Bioactive glass putty, bioabsorbable collagen membrane and 3.75 mm 11.5 mm implants were used. Patients were evaluated clinically and radiographically for 18 months after placement of implants at intervals of 6 months to assess increase in residual ridge height, peri-implant condition (marginal bone loss, plaque and gingival index) and implant stability. Results: Maxillary first molar was the most common site (71.42%) for sinus lift and implant placement. Caries was the most common cause (83.33%) for loss of tooth. Increase in residual ridge height ranged from 71.43% to 133.33%) as measured by denta-scan. Implant survival rate was 100%. Marginal bone loss ranged from 0.6 to 1.2 mm. Implant stability was measured by periotest (2-6). Only one patient had perforation of the sinus membrane, but it was sealed satisfactorily by bioabsorable membrane. Conclusion: One-stage crestal approach sinus lift procedure with alloplastic bone graft material in combination with two-stage implant placement has a predictable outcome in patients with severe resorption of the posterior maxilla. Key words: Alloplastic bone graft, Maxillary sinus floor augmentation, Single tooth dental implant INTRODUCTION The most commonly used augmentation method for the sinus reconstruction was presented by Tatum in 1976 at Alabama implant conference and published by Boyne and James in 1980. 1-3 It intended to increase the vertical bone dimension in the posterior maxilla where access to the www.ijss-sn.com Access this article online Month of Submission : 12-2014 Month of Peer Review : 01-2015 Month of Acceptance : 01-2015 Month of Publishing : 02-2015 maxillary sinus is obtained by drilling a bony window in the lateral sinus wall while ensuring that the sinus membrane remains intact. Sinus elevation using the lateral window approach required extensive surgical manipulation and extended waiting period before uncovering for implant placement. To overcome this disadvantage and to augment the bone for implant placement in a simpler less invasive manner Summers (1994) proposed the osteotome technique or the indirect sinus lifting. 4 In contrast to more invasive lateral approach, this method is a conservative surgical entry, more localized augmentation of the sinus with less degree of post-operative morbidity, and an ability to load the implants in a shorter time period. Corresponding Author: Dr. Ramanuj C Tandel, Department of Oral & Maxillofacial Surgery, Government Dental College & Hospital, Ahmedabad, Gujarat, India. Phone: +91-9429277574. E-mail: drramanujtandel@gmail.com International Journal of Scientific Study February 2015 Vol 2 Issue 11 60

Summers 4 suggested that the bone added osteotome sinus floor elevation (BAOSFE) technique should be considered for patients with (remaining bone height) residual bone heights (RBH) of 5 mm or more. According to Romero- Millán et al., indirect osteotome mediated sinus floor elevation (OMSFE) is indicated for a bone height of 6-8 mm. More bone height was gained when graft material was used. MATERIAL AND METHODS The study consisted of sample of six patient and six implant sites, who visited the Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Ahmedabad. The patients were selected randomly irrespective of the sex and socioeconomic status. Inclusion and Exclusion Criteria Inclusion criteria Age between 20 and 50 years, residual alveolar bone height above 5 mm at the edentulous posterior maxillary region, buccolingual and mesiodistal bone dimension should be >5 mm, quality of bone D3 and D4, a delay of at least 6 months between tooth extraction and an implant placement, absence of maxillary sinusitis, presence of normal healthy adjacent teeth or restored teeth. Exclusion criteria Uncontrolled systemic illness, presence of periapical pathology, heterotopic _ossification radiotherapy in maxillofacial region, oral destructive habit, debilitating temporomandibular joint pathosis, inadequate mouth opening, which cannot allow placement of instruments necessary for implant insertion. Preoperative Evaluation of Implant Site Pre-operatively, each patient was subjected to a detailed clinical and radiographic examination of the soft and hard tissue which provided necessary diagnostic information for proceeding with implant therapy. Implant, Bone Graft and Membrane Used In our study, we have used self-threaded, tapering, double thread, acid etched and sand-blasted, selective integrated surfaced implants, sinus lift kit, alloplastic bone graft (bioactive glass putty), resorbable collagen membrane. Pre-operative Preparation of Patient Tablet augmentin (625 mg tds) and non-steroidal antiinflammatory drugs were administered 24 h before surgery to achieve adequate blood concentrations. Nasal decongestant in the form of tablet was started twice a day, a day before surgery, nasal decongestant drops (otrivin) was started as two drops twice a day, a day before surgery. All patients were told to rinse with 0.2% chlorhexidine gluconate mouthwash pre-operatively. Surgical Technique Posterior superior alveolar nerve, infraorbital nerve and greater palatine nerve blocks were given with sensorcaine, and local infiltration was done with 2% lignocaine HCL with 1:100,000 adrenaline concentration An incision 2-3 mm on the palatal side of the crest of the ridge with two releasing incisions given (Figure 1) A full-thickness mucoperiosteal flap was reflected and retracted (Figure 2) Surgical stent inserted over site. Using round bur marking of implant position done on the bone by handpiece 1:20 reduction gear at the low speed (800 1200 rpm) high torque (35 ncm) along with copious irrigation (external and internal) of normal saline to prevent thermal injury to the bone Pilot drill was used to prepare an implant bed 1-2 mm short of the sinus floor Consecutive drills till planned size implant diameter were used to prepare the implant site 2 mm away from the sinus floor boundary according to the dentascan The sinus floor was broken with osteotome (of the It includes the following: The gingival health was assessed for color, consistency, texture, bleeding on probing and pocket depth Presence of sufficient inter-occlusal space The bone topography was evaluated with ridge mapping technique Pre-surgical measurement of the alveolar height to the sinus floor, bucco-lingual and mesio-distal width of edentulous space was measured using standard intra oral peri-apical (IOPA), orthopantamogram (OPG) and computed tomography (CT) scan/dentascans Pre-operative, intra-operative and post-operative photographs were taken for record maintenance and documentation. Figure 1: Incision 2-3 mm on the palatal side of the crest of the ridge 61 International Journal of Scientific Study February 2015 Vol 2 Issue 11

Tandel, et al.: Indirect Maxillary Sinus Lift same diameter as the last drill used to prepare the osteotomy site) by tapping light strokes with a mallet (Figure 3)5 Alloplastic bone graft granules are mixed with patient s blood and obtain a putty consistency, which is condensed at sinus floor below the membrane with osteotomes (Figure 4) Figure 2: Flap reflected and retracted exposing crestal bone The mobilized bone at the sinus floor along with the membrane is raised with osteotome (of same diameter as the last drill used to prepare the osteotomy site was selected) and mallet to the final implant length (Figure 5) When the sinus membrane is intact, a bellows effect may be observed as the patient breathes. If a tear occurs in the membrane, place a small piece of resorbable collagen membrane (PerioCol - GTR) against the tear, where it should easily adhere. Check again for the bellows effect. If a larger perforation occurs in the membrane, laminar bone (membrane like sheets of demineralized freezed-dried bone) can be used to easily repair it A self-tapping implant was inserted in the prepared site A titanium cover screw supplied with the implant was inserted on the implant (to protect internal threads and close the dead space) with the use of implant screw driver (Figure 6) The mucoperiosteal flap was repositioned and sutured with the help of (3-0) black silk. Figure 3: Stopper of osteotome is adjusted according to implant length Figure 5: Prepared final osteotomy Figure 4: Alloplastic bone graft placement at sinus floor Figure 6: Implant in proper position International Journal of Scientific Study February 2015 Vol 2 Issue 11 62

Two Stage Surgical Exposure of the Implant Surgical exposure of the implant and placement of the healing cap was done 6 months after placement of the implant. After 15 days of two-stage, an abutment was attached to the implant and prosthesis was fabricated (Figures 7 and 8). All the patients were kept on regular follow-up. RESULTS The present study was conducted in the Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Ahmedabad. It was conducted on 6 patients with 6 implant sites, to evaluate clinically and radio graphically; the self-threaded, tapered, double thread; EZ selective integrated surfaced implants placed using direct sinus lift technique (lateral approach) with alloplastic bone graft (a bio-active glass) as the graft material and resorbable collagen membrane as the barrier membrane followed by simultaneous placement of the implant. Follow-up was done 6 month after sinus lift and simultaneous implant placement (time allowed for graft maturation and implant healing) and at the interval of 1 year and 2 years after final prosthesis. Standardized IOPA, digital OPG and CT scan/dentascan were taken pre-operatively and at 6 months follow-up intervals. In our study of six patients, height of the residual alveolar bone was in the range of 5-7 mm, on an average 6.0 mm (Table 1). Summers 4 suggested that the BAOSFE technique should be considered for patients with RBH of 5 mm or more. Some have suggested pre-operative RBH from 8 to 10 mm 3 ; others have recommended 4 mm. 3 There is a lack of conclusive evidence relating pre-operative RBH to implant survival. However, Rosen et al. 6 Demonstrated implant success was reduced to 85.7% for implants placed in pre-operative RBH of 3-4 mm compared to 96% for implants put in pre-operative bone of >5 mm. DISCUSSION Del Fabbro et al. 7 found implant survival after osteotome mediated sinus floor augmentation 92.7% for 331 implants placed in <5 mm ridge height and 96.9% for 2525 implants inserted in >5 mm ridge height. Hence, treatment plan selected was osteotome mediated maxillary sinus floor augmentation along with simultaneous implant placement. Figure 7: Clinical view of abutment and healing of surrounding gingival tissue Pjetursson et al. 8 evaluated the pattern of tissue remodeling after maxillary floor elevation using transalveolar osteotome technique with or without using grafting materials the mean RBH for implants placed with grafting material 6.4 mm mean bone gain of 4.1 mm. All these coincide with our study where average residual alveolar bone height was 6.0 mm pre-operatively (Figures 9 and 10) in the sample of 6 patients (Table 2) and after sinus floor augmentation, the residual alveolar bone height was in the range of 9.0 11.0 mm, on an average 10.2 mm (Table 2) suggest that the final bone gain was very significant in the range of 4-5 mm (Figures 11 and 12), on an average 4.25 mm Figure 8: Occlusal view of maxilla showing prosthesis at left first molar Figure 9: Pre-operative panoramic computed tomography view - showing inadequate residual alveolar bone height 5.0 mm for an implant insertion at maxillary left first molar region 63 International Journal of Scientific Study February 2015 Vol 2 Issue 11

Table 1: Maxillary alveolar ridge height, clinical evaluation after sinus lift and implant placement Site of sinus lift with implant placement Pre operative radiographic bone height Follow up after one stage surgery Local Pain Soft tissue Maxillary swelling/ dehiscence sinusitis infection Post operative radiographic bone height Bone height achieved after sinus floor augmentation Radiographic evaluation Crestal/ Peri implant vertical radio lucency bone loss Maxillary right first molar 6.0 mm A A A A 10.0 mm 4.0 mm A A Maxillary left first molar 5.0 mm A P A P 9.0 mm 4.0 mm A A Maxillary left second molar 7.0 mm A A A A 11.0 mm 4.0 mm A A Maxillary right first molar 6.0 mm A A A A 11.0 mm 5.0 mm 11 mm A (6 months) Maxillary left first molar 6.5 mm A A A A 11.0 mm 4.5 mm A A Maxillary right second molar 5.5 mm A A A A 9.5 mm 4.0 mm A A Table 2: Statistics evaluation of bone heightpreoperative and postoperative Statistical analysis Pre operative bone height Bone height 6 months after sinus lifting surgery Bone gain following sinus lift surgery Mean 6.0 10.25 4.25 Median 6.0 10.5 4 Mode 6.0 11 4 Standard deviation 0.70711 0.88034 0.41833 Figure 12: Post-operative dentascan cut showing the bone height 9.0 mm 6 months after surgery after sinus floor augmentation over the period of 6 months following surgery. Hence, 71.51% bone gain was noted on an average after sinus floor augmentation with alloplastic bone graft. Figure 10: Pre-operative dentascan cut showing residual alveolar bone height 5.0 mm where implant has to be placed Figure 11: Post-operative panaromic computed tomography view at 6 months - showing raise in bone level above the initial sinus floor and implant covered with bone. Bone height 9.0 mm Indirect OMSFE is indicated for a bone height of 6-8 mm and more bone height was gained when graft material was used stated by Romero-Millán et al. (2012). 9 Though the autografts are widely considered the gold standard for osseous reconstruction, there are some practical difficulties in clinical use such as secondary surgery, morbidity of the donor site, surgery under general anesthesia etc. In this study, an alloplastic bone graft material was used for the sinus floor augmentation; graft is made of natural low crystalline hydroxy apatite with collagen. It is available in form of granules, has graft retentive properties, easy manipulation during surgery, no risk of immunogenic response and infection transmission and very low chances of graft infection because antibiotics readily penetrates into it due to its hydrophilic nature. Also there is formation of bony tissues noted in the bone graft. International Journal of Scientific Study February 2015 Vol 2 Issue 11 64

Romero-Millán et al. 9 analyzed studies published on OMSFE between 1999 and 2010 on patients with a minimum of 1 year of follow-up and found that most frequent complication was perforation of the Schneiderian membrane; this was present in almost all of the articles with a range of 2.2:21.4%. Similarly, in 1 out of 6 patients (16.66%), Schneiderian membrane perforation occurred which was successfully repaired by sealing the perforation with resorbable collagen membrane (Periocol - GTR). Although the patient had experienced pain and mild attack of maxillary sinusitis after 2 months, the next follow-up visits were absolutely normal. It had not adversely affected the outcome during the followup and the post-operative healing was uneventful. The maxillary sinusitis was treated conservatively with the help of antibiotics, analgesics, and decongestants. In all the rest of patients (83.33%), there was the absence of local inflammation/infection, pain, a soft tissue dehiscence after surgery (Table 1). In this study, osteotomes with stoppers are used which can be adjusted at required length which reduced the risk of invading the sinus cavity and made it possible to lift the membrane gently without perforating the membrane same method is described by Tilotta et al. 10 The success criteria suggested by Schmitt and Zarb 11 for edentulous patients were utilized and applied to the six implant sites, which were examined during the last recall visit. Each implant was examined and found to be asymptomatic without any clinical evidence of mobility. Radiographically, all the implants showed absence of periimplant radiolucency. Bleeding on probing was present at one implant site (16.66%) and probing depth was 3 mm mesially and distally at one implant site (16.66%) (Table 1). Table 1 shows that soft tissue complications such as moderate inflammation, redness edema, and glazing, bleeding on probing (gingival index 2) were observed at one site (16.66), which easily resolved with good oral hygiene practice and without any compromise in osseointegration. Result was consistent with the study of Rebaudi et al. 12 According to Table 1 neither prosthesis loosening nor prosthesis fracture was encountered in any patient. Patient s response to rehabilitation with single tooth restoration using indirect sinus lifting and simultaneous implant placement were good to very good, both from esthetic and functional aspects, which was similar to the findings of Ekfeldt and Carlsson. 13 The major criterion for evaluating implant success is change in bone level around the implants. During follow-up period of 6 months of implant loading only one implant site (16.66%) at maxillary right first molar had bone loss of 1 mm. This value coincide with the study of Friberg et al. 14 but long-term follow-up is needed to know the mean annual bone loss of 0.2 mm/year for success of implant (Table 1). Sinus floor augmentation by indirect technique along with simultaneous implant placement can be an excellent method for restoring the partial edentulism, if performed by the experienced hand. Preventing complications requires an understanding of the biomechanical principles involved in surgical management of Schneiderian membrane during sinus lift, perfect attention to the many details involved in the diagnosis and treatment planning and encouraging the patient toward maintaining strict oral hygiene to increase the longevity of the implant. CONCLUSION With RBH between 5 and 10 mm this technique allows for localized maxillary sinus elevation. It is a conservative surgical entry, more localized augmentation of the sinus with less degree of post-operative morbidity, and an ability to load the implants in a shorter time period than conventional Caldwell Luc approach to sinus augmentation. It should be noted that bone grafts are placed blindly in to the space below the sinus membrane. Hence, the main disadvantage of this technique is uncertainty of a possible perforation of the Schneiderian membrane and loss of graft in to the sinus. The drawback of the procedure can be substantially reduced when performed by an experienced surgeon using the presented surgical protocol. The risk of complications remains low. It can be concluded that sinus floor augmentation by indirect technique improves both the residual alveolar ridge dimension and the osseointegration of implants. REFERENCES 1. Misch CE. Book of Contemporary Implant Dentistry. 2 nd ed. St. Louis: Mosby; 1999. 2. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (II). Etiopathogenesis. Eur J Oral Sci 1998;106:721-64. 3. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613-6. 4. Summers RB. The osteotome technique: Part 2 The ridge expansion osteotomy (REO) procedure. Compendium 1994;15:422, 424, 426. 5. Sforza NM, Marzadori M, Zucchelli G. Simplified osteotome sinus augmentation technique with simultaneous implant placement: A clinical study. Int J Periodontics Restorative Dent 2008;28:291-9. 6. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH, et al. The bone-added osteotome sinus floor elevation technique: Multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants 1999;14:853-8. 7. Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S. Implant 65 International Journal of Scientific Study February 2015 Vol 2 Issue 11

survival rates after osteotome-mediated maxillary sinus augmentation: A systematic review. Clin Implant Dent Relat Res 2012;14 Suppl 1:e159 68. 8. Pjetursson BE, Rast C, Brägger U, Schmidlin K, Zwahlen M, Lang NP. Maxillary sinus floor elevation using the (transalveolar) osteotome technique with or without grafting material. Part I: Implant survival and patients perception. Clin Oral Implants Res 2009;20:667-76. 9. Romero-Millán J, Martorell-Calatayud L, Peñarrocha M, García-Mira B. Indirect osteotome maxillary sinus floor elevation: An update. J Oral Implantol 2012;38:799-804. 10. Tilotta F, Lazaroo B, Gaudy JF. Gradual and safe technique for sinus floor elevation using trephines and osteotomes with stops: A cadaveric anatomic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:210-6. 11. Schmitt A, Zarb GA. The longitudinal clinical effectiveness of osseointegrated dental implants for single-tooth replacement. Int J Prosthodont 1993;6:197-202. 12. Rebaudi A, Koller B, Laib A, Trisi P. Microcomputed tomographic analysis of the peri-implant bone. Int J Periodontics Restorative Dent 2004;24:316 25. 13. Ekfeldt A, Carlsson GE. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implant 1994;9:179-83. 14. Friberg B, Grondahl K, Lekholm U. A new self-tapping Brånemark implant: Clinical and radiographic evaluation. Int J Oral Maxillofac Implants 1992;7:80-5. How to cite this article: Tandel RC, Parikh D, Parmar B. Indirect Maxillary Sinus Lift for Single Tooth Implant: A Clinical Study. Int J Sci Stud 2015;2(11):60-66. Source of Support: Nil, Conflict of Interest: None declared. International Journal of Scientific Study February 2015 Vol 2 Issue 11 66