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YJCMS1862_proof ■ 6 September 2014 ■ 1/6 Contents lists available at Journal of Cranio-Maxillo-Facial Surgery A clinical and radiographic case series of implants placed with the simpliﬁed minimally invasive antral membrane elevation technique in the posterior maxilla Kher , Andreas L. Ioannou *, Tarun Kumar Kostantinos Siormpas Miltiades E. Mitsias , Ziv Mazor Georgios A. Kotsakis Private Practice, Mumbai, India b Advanced Education Program in Periodontology, University of Minnesota, United States Division of Periodontology, Bapuji Dental College & Hospital, Davangere, India Private Practice, Larissa, Greece e Department of Periodontology & Implant Dentistry, New University College of Dentistry, NY, United States Private Practice, Ra'anana, Israel The aim of the present case series was to evaluate a simpli ﬁed minimally invasive transalveolar sinus Paper received 2 March 2014 elevation technique utilizing calcium phosphosilicate (CPS) putty for hydraulic sinus membrane eleva- Accepted 15 August 2014 tion. The simpliﬁed minimally invasive antral membrane elevation technique is based on the application Available online xxx of hydraulic pressure via a viscous bone graft that acts as an incompressible ﬂuid.
In this retrospective study, 21 patients (mean age: 48.5 ± 12 years) consecutively treated with the simpliﬁed minimally invasive transalveolar sinus elevation technique were evaluated. 28 tapered im- plants were placed in posterior maxillary sites with less than 6 mm of residual bone height as deter- Maxillary sinus/surgery mined radiographically on cone beam volumetric tomographs. No sinus membrane perforations were Surgical procedures noted and none of the patients complained of symptoms of sinusitis post-operatively (0%). The mean Minimally invasive gain in bone height post-operatively was 10.31 ± 2.46 mm (p < 0.001). All implants successfully inte- Putty bone substitute grated (100% success rate) and were loaded with cement-retained prostheses.
The proposed technique is a simple, efﬁcacious, minimally invasive approach for sinus elevation that can be recommended for sites with at least 3 mm of residual height.
2014 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
extraction, but is unrealistic for sites where anatomic limitations require more involved procedures (). One such Dental implant therapy has revolutionized the rehabilitation of case is the edentulous posterior maxilla.
both the form and the function of missing teeth. In contemporary Following extraction of teeth in the maxillary posterior region, dental practice, implant dentistry is recognized as the pneumatization of the maxillary sinus frequently occurs ( " for the rehabilitation of edentulous sites ). Depending on the degree of ). Patients' demands frequently dictate minimally invasive pneumatization in conjunction with the amount of coexisting surgery and timely delivery of restoration ( ridge resorption in an apical-coronal direction, different surgical ). This dual goal can be readily delivered by methods are employed for sinus lift surgery concepts such as immediate implant placement, or non-submerged implant placement in sites with adequate bone volume post- tionally, indirect, or transalveolar sinus ﬂoor elevation techniques are utilized when less than 5 mm of gain in bone height are sought, while more aggressive direct, or lateral-window ap- proaches are utilized in more advanced cases * Corresponding author. Advanced Education Program in Periodontology, University of Minnesota, 515 Delaware Street SE, Minneapolis, MN 55455, United Direct sinus augmentation techniques have been shown to yield States. Tel.: þ1 651 395 9200.
E-mail address: (A.L. Ioannou).
very favorable outcomes in regards to bone regeneration in the 1010-5182/ 2014 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
Please cite this article in press as: Kher U, et al., A clinical and radiographic case series of implants placed with the simpliﬁed minimally invasive antral membrane elevation technique in the posterior maxilla, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.08.005 YJCMS1862_proof ■ 6 September 2014 ■ 2/6 U. Kher et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 sinus as well as very good success rates for implants placed in placement were included in this study. A minimum of 2 mm of bone height from the crest of the ridge to the ﬂoor of the sinus, of the major drawbacks associated with this type of technique is and 5 mm of minimum bone width were set as inclusion criteria.
patient satisfaction. Not only do patients undergo a more involved In addition, patients had to be healthy, non-smokers, with no procedure that has greater morbidity than conventional implant history of acute sinusitis or sinus pathology. Patients with placement, but they usually have to wait for several months prior to asymptomatic mild thickening of the sinus mucosa were included.
having their chief concern addressed, restoration of their functional Exclusion criteria included history of previous maxillary sinus surgery, chronic intake of any medication that affects bone heal- In a hypothetical case of ridge atrophy with coexisting pneu- ing (chronic steroid regimen, oral or IV bisphosphonates, etc.), matization of the sinus it is not infrequent for less than 5 mm of active periodontal disease, or periapical pathology of the adjacent residual bone height to remain in the posterior maxilla. In such a case a patient would routinely undergo direct sinus augmentation All patients were evaluated preoperatively for the need for sinus followed by implant placement approximately 6e9 months later, augmentation via cone beam tomography scans (CBCTs). The in- they would ﬁnally have the implant restored after 3e4 months of dications for the procedure and possible complications were healing, giving a total treatment time of approximately 1 year. It is reviewed with the patients and all patients agreed to proceed and only reasonable that this estimated waiting time would seem signed a consent form.
protracted to the majority of patients. In order to address this concern there are recent reports in the literature showing that the 2.2. Surgical technique and follow-up controlled elevation of the sinus ﬂoor using hydraulic pressure may extend the indications for transalveolar sinus augmentation tech- Patients were treated under local anesthesia and were pre- niques and reduce treatment time for patients medicated with a loading dose of amoxicillin/clavulanate potas- Utilizing the minimally invasive antral membrane sium administered 1 h prior to the surgical appointment elevation technique, were successful in achieving (875 mg/125 mg). Transcrestal sinus ﬂoor elevations were per- up to, or even beyond, 10 mm of gain in vertical bone height in a formed using a modiﬁcation of the Summer's technique series of published reports (The ). The pre-operative height of the residual ridge rationale behind the use of a balloon is the even distribution of was assessed radiographically by an experienced implant surgeon hydraulic pressure at the membraneebone interface that results in . Local anesthesia was administered using 2% lidocaine atraumatic and safe elevation of the schneiderian membrane.
with 1:100,000 epinephrine to aid hemostasis of the area. Full Although efﬁcacious, this technique has not become the standard thickness mucoperiosteal ﬂaps were elevated in the posterior method for sinus elevation surgical procedures, possibly because of maxilla in order to gain access to the alveolar crest (A). An the need to purchase specialized equipment and for speciﬁc osteotomy was initiated at the ridge crest using a 2.0 mm pilot drill. The drill was stopped 1 mm short of the estimated height of The number of different surgical techniques for sinus the sinus ﬂoor. A periapical X-ray was obtained to verify the exact augmentation is only surpassed by the number of biomaterials position of the drill in proximity to the sinus ﬂoor. The osteotomy that have been used to overcome the challenge of insufﬁcient was further widened using the drilling sequence recommended vertical bone height in the posterior maxilla by the implant manufacturer (Tapered Internal, BioHorizons, ). Various bone-grafting Birmingham, AL, USA). A small quantity of approximately 0.2 cm3 materials are frequently used in sinus lift procedures, including of CPS putty (NovaBone Dental Putty, NovaBone Products, Ala- autogenous bone, allografts, xenogeneic bone, and alloplastic bone chua, FL, USA) was delivered in the osteotomy via a narrow- tipped cartridge delivery system to act as a cushion prior to ). Recent data have tapping the sinus ﬂoor, and a 3 mm concave osteotome with shown that bone substitutes displaying a putty-like consistency depth markings and a mallet were used to carefully fracture the can present a valuable alternative in bone-grafting procedures ﬂoor of the sinus ,C). Care was taken not to push the osteotome into the sinus cavity to avoid inadvertent perforation The handling characteristics of putty bone substitutes of the sinus lining. Following the green-stick fracture of the ﬂoor have expanded the available array of treatment options for bone of the sinus, the bone substitute was directly injected into the grafting in narrow spaces, and their viscoelastic properties may be prepared sinus cavity via the cartridge delivery system. The car- exploited to increase the safety and predictability of sinus lift tridge tip ﬁtted tightly in the osteotomy and allowed the insertion pressure due to injection of the graft to be delivered directly to The aim of the present case series was to evaluate a minimally the fractured inferior border of the sinus ﬂoor. 0.5 cm3 of CPS invasive transalveolar sinus elevation technique utilizing calcium putty was carefully injected into the osteotomy (). The hy- phosphosilicate (CPS) putty for hydraulic sinus membrane drostatic pressure exerted by the putty resulted in an atraumatic elevation of the sinus ﬂoor. CPS putty was added in increments until adequate elevation of the schneiderian membrane was seen 2. Materials and methods on intra-operative radiographs. An appropriately sized implant was placed at the level of the osseous crest using a manual torque 2.1. Patient selection wrench for enhanced tactile sensation (,E). The implants were initially engaged into the remaining native bone at the crest In this retrospective study, 21 patients consecutively treated in of the ridge and then slowly twisted in to engage in the viscous a dental clinic with a simpliﬁed, minimally invasive technique for CPS putty at the apical aspect of the osteotomy. Cover screws transalveolar sinus elevation were evaluated. Data related to age, were placed and primary ﬂap closure was achieved utilizing a sex, implant location, intra-operative or post-operative compli- single interrupted suturing technique.
cations, implant stability, implant success and radiographic bone Postoperative instructions included oral administration of changes were recorded for all patients. Patients with treatment amoxicillin/clavulanate potassium (500 mg/125 mg three times a plans for sinus elevation surgery with simultaneous implant day) and ibuprofen (400 mg four times a day) for the ﬁrst week Please cite this article in press as: Kher U, et al., A clinical and radiographic case series of implants placed with the simpliﬁed minimally invasive antral membrane elevation technique in the posterior maxilla, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.08.005
YJCMS1862_proof ■ 6 September 2014 ■ 3/6 U. Kher et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 Fig. 1. Pre-operative assessment of the cross-sectional radiographic image revealed less than 6 mm of preoperative height on the edentulous site.
post-operatively. Chlorhexidine rinses were prescribed twice daily for the above measurements (Image J, National Institutes of Health, for 2 weeks. The patients were instructed to limit themselves to a Bethesda, Maryland, USA).
soft diet for the ﬁrst 2 weeks after surgery.
All patients were followed-up and assessed for implant survival Patients were followed-up at 24 h, 10 days and 3 months after and sinus complications on an individualized recall basis. Patients the surgery for post-surgical evaluation. Second stage surgery was were urged to contact the implant surgeon if any complication scheduled at 3e5 months post-sinus lift. During the implant arose between the recall appointments. Implant success was eval- uncovery appointment a periapical radiograph was taken to eval- uated clinically according to the criteria of .
uate the amount of vertical bone height gain and assess radio- Brieﬂy, the examination consisted of clinical detection of implant graphic signs of implant integration (Radiographic mobility with the application of horizontal jiggling forces with the measurements of bone height from the crest to the ﬂoor of the rear end of two periodontal probes. Assessment of the peri-implant sinus where calculated twice by the same examiner at two different tissues was performed visually for signs of erythema and/or edema time intervals and the means of both measurements were reported.
and by palpation of the tissues surrounding the implant area.
The measurements included the scaling of the measured gain in Additionally, periapical radiographs were obtained to ascertain the vertical bone height based on the radiographic magniﬁcation of the absence of a continuous radiolucency around the implant. Patients implant to reduce any bias associated with possible elongation of were also interviewed for subjective symptoms and evaluation of the periapical radiographs. Specialized imaging software was used Fig. 2. (A) Intraoperative view of the residual ridge prior to initation of the osteotomy; (B) the tip of the cartridge inserted into the osteotomy site; (C) application of the osteotome to produce the required elevation of the sinus ﬂoor; (D) implant placement; (E) implants placed at the level of the osseous crest; (F) postoperative radiograph showing signiﬁcant elevation of the sinus ﬂoor. Note the even ﬁll of the sinus antrum by the ﬂow of the viscous putty.
Please cite this article in press as: Kher U, et al., A clinical and radiographic case series of implants placed with the simpliﬁed minimally invasive antral membrane elevation technique in the posterior maxilla, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.08.005
YJCMS1862_proof ■ 6 September 2014 ■ 4/6 U. Kher et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 version 3.0.1, 2013 (2013-05-16, The R Foundation for Statistical Computing, Vienna, Austria).
A total of 29 implants (Tapered Internal, BioHorizons, Birming- ham, AL, USA) were placed in 21 consecutively treated patients with the simpliﬁed minimally invasive transalveolar sinus eleva- tion technique. The average patient age was 48.5 ± 12 years, and 9 patients were female. None of the patients were smokers. The re- cord of adverse events included mild to moderate postoperative edema for the ﬁrst two or three postoperative days in most pa- Fig. 3. Note the narrow tip of the delivery system that allows intimate contact of the tients, and ﬂap dehiscence in one patient that was caused by cartridge with the walls of the osteotomy.
trauma during mastication. No reports of hematoma, severe pain, or paroxysmal vertigo were noted in the present case series. The sinus elevation was combined with CPS putty in all cases. No sinus 2.3. Statistical analysis membrane perforations were noted and none of the patients complained of symptoms of sinusitis post-operatively (0%). The Patient characteristics and implant success were presented mean preoperative bone height was 4.34 ± 1.16 mm, while a sig- descriptively. The gain in bone height post-sinus surgery was niﬁcant gain of 10.31 ± 2.46 mm was noted post-operatively assessed with a Wilcoxon signed-rank test. The alpha level was set ¼ 0.05. Calculations were performed with statistical software, R Of the 29 implants placed, ﬁve were placed in 2nd premolar sites, 19 in 1st molar sites and ﬁve in 2nd molar sites. 28 of the 29 implants were placed simultaneously with the transalveolar sinus elevation with good to optimal primary implant stability in sites with residual bone height ranging from 2.8 mm to 6.5 mm. The remaining implant was placed after 6 months of healing due to the poor bone quality at the site. The residual bone height during the sinus augmentation surgery was 2.5 mm and the bone quality was deemed as poor (class IV) during implant site preparation, thus implant placement was aborted and the osteotomy was ﬁlled with CPS putty after elevation of the sinus to 13.5 mm. After 6 months of healing the site was re-entered and the implant was successfully placed with adequate primary stability. The implant was func- tionally loaded after 4 months of healing and remained successful throughout the follow-up period. Due to delayed implant place- ment this ﬁxture was excluded from the analysis. All implants placed in this case series were left to heal for 4e5 months after implant placement and were then loaded with cement-retained prostheses. All of the simultaneously placed implants (28/28) were clinically stable and had no signs of peri-implant disease Fig. 4. Description of the radiographic assessment technique utilizing the known during a follow-up period of at least 1 year post-placement (min- implant length as reference for accuracy of measurements.
imum of 9 months post-loading) (100% success rate).
Fig. 5. (A) Clinical photo prior to treatment; (B) preoperative radiograph; (C) utilizing the osteotomy approach; (D) postoperative radiograph; (E) implant placed at the level of the osseous crest; (F) postoperative radiograph showing ﬁnal prostheses.
Please cite this article in press as: Kher U, et al., A clinical and radiographic case series of implants placed with the simpliﬁed minimally invasive antral membrane elevation technique in the posterior maxilla, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.08.005 YJCMS1862_proof ■ 6 September 2014 ■ 5/6 U. Kher et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 membrane or a platelet-rich-ﬁbrin membrane Increase in vertical bone height post-surgery.
Pre-operative bone height The consistency of the putty helps minimize membrane per- Post-operative bone height forations and associated adverse events during percussion with osteotomes. The technique also attempts to overcome the need to *Highly statistically signiﬁcant (p < 0.001).
purchase the specialized equipment required to apply hydraulic pressure for the elevation of the schneiderian membrane, while simultaneously placing an adequate volume of the graft material in the site to allow for placement of the implants. Additional ad- vantages of this technique are its atraumatic nature, reduced The use of the minimally invasive antral membrane elevation chair-side times, reduced overall treatment duration, improved technique has a well-documented history of success in achieving patient comfort and minimal graft wastage. The alloplastic signiﬁcant elevation of the sinus ﬂoor while sparing the need for biomaterial utilized has been shown to exhibit timely resorption more invasive direct sinus augmentation approaches and subsequent replacement with new vital bone in histological ). Implant placement simultaneously studies with residual graft fractions ranging from 4.3% to 11.5%, with this technique is highly predictable and yields success rates after 6 months of healing ranging from 95.2% to 100% for 6e18 months of follow-up ( The prompt bone turnover rate observed with CPS putty These results are compara- may provide a clinical beneﬁt in terms of primary and secondary ble, yet slightly better than those reported in a large-scale survival implant stability that increases its suitability in implant surgery analysis of implants placed with the osteotome technique for in- direct sinus lift (). When comparing these re- Limitations of the technique proposed, are the necessary oper- sults it should be noted that the latter study reports survival rates of ator skill and experience needed for success, and the minimum up to 12 years of function, which may partially explain the differ- 3 mm of available bone height needed for achieving primary sta- ence in outcomes ().
bility for the implant. In one case where treatment was planned Results from the work of Kﬁr et al. (), and Mazor with the recommended technique and a baseline bone height of et al. ) are also well within the range of 92.7e96.9% 2.5 mm, adequate primary stability was not attainable due to the survival reported by a systematic review for sinus lift using the poor bone quality of the site and thus treatment was performed in a transalveolar approach In this review it staged manner. Therefore, when considering the loosely packed was concluded that implants placed in sites with remaining bone medullary bone frequently encountered in the posterior maxilla, height less than 5 mm have a reduced overall survival rate the simpliﬁed minimally invasive antral membrane elevation ). Even though in most published cases, the technique should be recommended for sites with at least 3 mm of minimally invasive antral membrane elevation technique has been residual bone height. The application of this technique should al- utilized in cases with less than 5 mm of residual bone height, ways be performed simultaneously with the placement of the survival of implants placed with this technique is very high, appropriate biomaterials in the osteotomy, as the use of a blood clot reaching up to 100% for 18 months of follow-up ).
or platelet concentrates alone may lead to unpredictable results The most signiﬁcant beneﬁt from the use of this technique is (). On the other hand, bone substitutes such as that it can achieve a gain in bone height comparable with that freeze-dried allografts, xenografts and mineralized alloplastic achieved with the use of the lateral window approach, while substitutes have all shown to be efﬁcacious in sinus augmentation maintaining the advantage of the less invasive transalveolar procedures with results comparable to those observed with par- approach (The procedure is effective even in ticulated or block grafts of autogenous bone ( highly resorbed residual ridges, as signiﬁcant quantities of grafting material can be rapidly introduced at the site with minimum risk of ). The use of bone morphogenetic protein 2 107 perforation. In general, the transalveolar sinus lift approach is has also shown very promising results in sinus augmentation sur- employed for sites with more than 6 mm of bone height pre- gery and if the currently available information is supported by operatively, while lateral window approaches are reserved for longitudinal studies, their clinical use may surpass that of bone cases with diminished baseline dimensions substitutes ).
). The currently proposed technique extends the application The presented technique may offer a more conservative proce- of the transalveolar approach to cases with signiﬁcantly less bone dure with less postoperative morbidity, than the direct sinus height (3e6 mm).
augmentation approach. This technique can be successfully used In this prospective study, a simpliﬁed minimally invasive for sinus augmentation with simultaneous implant placement, as it transalveolar technique for sinus augmentation was utilized by may offer increased primary stability to the implant due to the exploiting the viscous consistency and ﬂow characteristics of a new viscous nature of the utilized bone graft. These advantages make generation putty graft. The presented technique serves a dual this simpliﬁed approach a viable option for transalveolar sinus purpose: to minimize adverse events associated with the use of augmentation. A possible limitation of the present study is the osteotomes, and to provide an inexpensive technique for predict- relatively short-term follow-up observed, with a minimum obser- able elevation of the sinus membrane. A key determinant of success vation time of 9 months when loading was considered the baseline in the present study was careful case selection. On a patient level, and 12 months when placement was set as the baseline. None- only healthy individuals that were non-smokers were admitted to theless, it is well established that the vast majority of early and this study in order to avoid poor responders to treatment. On a site- medium-term implant failures occur at the time of second stage level, none of the cases had sinus septa in the selected implantation surgery rather than manifesting as failure to maintain osseointe- regions that may increase the risk of membrane perforation, or gration post-loading ). Yet, controlled technique failure. In such an unfortunate instance, a conventional clinical studies are required to longitudinally assess the efﬁcacy of lateral-window sinus augmentation approach should be utilized to this surgical improvisation in comparison to direct sinus augmen- allow for increased visibility, isolation of the membrane perforation tation approaches and to unequivocally prove the proposed supe- and coverage of the perforation with an absorbable collagen riority of the presented technique on patient-related outcomes.
Please cite this article in press as: Kher U, et al., A clinical and radiographic case series of implants placed with the simpliﬁed minimally invasive antral membrane elevation technique in the posterior maxilla, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.08.005 YJCMS1862_proof ■ 6 September 2014 ■ 6/6 U. Kher et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 Kﬁr E, Kﬁr V, Goldstein M, Mazor Z, Kaluski E: Minimally invasive subnasal eleva- tion and antral membrane balloon elevation along with bone augmentation and implants placement. J Oral Implantol 38: 365e376, 2012 The simpliﬁed minimally invasive antral membrane elevation ﬁr E, Kﬁr V, Kaluski E, Mazor Z, Goldstein M: Minimally invasive antral membrane technique is based on the application of hydraulic pressure by a balloon elevation for single-tooth implant placement. Quintessence Int 42: viscous bone graft that acts as an incompressible ﬂuid. Therefore, simultaneously with the atraumatic elevation of the schneiderian ﬁr E, Kﬁr V, Mijiritsky E, Rafaeloff R, Kaluski E: Minimally invasive antral mem- brane balloon elevation followed by maxillary bone augmentation and implant membrane, grafting of the maxillary sinus is achieved resulting in ﬁxation. J Oral Implantol 32: 26e33, 2006 promotion of intrasinus bone formation, increased implant stability Kher U, Mazor Z, Stanitsas P, Kotsakis GA: Implants placed simultaneously with due to the viscoelastic nature of CPS putty, and a shorter operative lateral window sinus augmentation using a putty alloplastic bone substitute forincreased primary implant stability: a retrospective study. Implant Dent 23: time owing to the simultaneous elevation and grafting approach.
The proposed technique is a simple, efﬁcacious, minimally invasive Kotsakis G, Chrepa V, Marcou N, Prasad H, Hinrichs J: Flapless alveolar ridge approach for sinus elevation that can be recommended for sites preservation utilizing the ‘socket-plug' technique: clinical technique and review of the literature. J Oral Implantol, 2012 (in press) with at least 3 mm of residual height.
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