A clinical and radiographic case series of implants placed with the simplified minimally invasive antral membrane elevation technique in the posterior maxilla
Introduction
Dental implant therapy has revolutionized the rehabilitation of both the form and the function of missing teeth. In contemporary dental practice, implant dentistry is recognized as the “golden standard” for the rehabilitation of edentulous sites (Scheuber et al., 2012). Patients' demands frequently dictate minimally invasive surgery and timely delivery of restoration (Hartlev et al., 2013, Nickenig et al., 2014). This dual goal can be readily delivered by concepts such as immediate implant placement, or non-submerged implant placement in sites with adequate bone volume post-extraction, but is unrealistic for sites where anatomic limitations require more involved procedures (Hartlev et al., 2013). One such case is the edentulous posterior maxilla.
Following extraction of teeth in the maxillary posterior region, pneumatization of the maxillary sinus frequently occurs (Mazor et al., 1999, Rothamel et al., 2007). Depending on the degree of pneumatization in conjunction with the amount of coexisting ridge resorption in an apical-coronal direction, different surgical methods are employed for sinus lift surgery (Summers, 1994, Mazor et al., 1999, Nkenke et al., 2002, Kfir et al., 2006). Traditionally, 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 approaches are utilized in more advanced cases (Engelke and Deckwer, 1997).
Direct sinus augmentation techniques have been shown to yield very favorable outcomes in regards to bone regeneration in the sinus as well as very good success rates for implants placed in grafted bone (Mazor et al., 1999, Galindo-Moreno et al., 2008). One of the major drawbacks associated with this type of technique is patient satisfaction. Not only do patients undergo a more involved procedure that has greater morbidity than conventional implant placement, but they usually have to wait for several months prior to having their chief concern addressed, restoration of their functional ability.
In a hypothetical case of ridge atrophy with coexisting pneumatization of the sinus it is not infrequent for less than 5 mm of residual bone height to remain in the posterior maxilla. In such a case a patient would routinely undergo direct sinus augmentation followed by implant placement approximately 6–9 months later, they would finally have the implant restored after 3–4 months of healing, giving a total treatment time of approximately 1 year. It is only reasonable that this estimated waiting time would seem protracted to the majority of patients. In order to address this concern there are recent reports in the literature showing that the controlled elevation of the sinus floor using hydraulic pressure may extend the indications for transalveolar sinus augmentation techniques and reduce treatment time for patients (Kfir et al., 2007, Kfir et al., 2009a, Kfir et al., 2011). Utilizing the minimally invasive antral membrane elevation technique, Kfir et al. (2006) were successful in achieving up to, or even beyond, 10 mm of gain in vertical bone height in a series of published reports (Kfir et al., 2007, Kfir et al., 2009a, Kfir et al., 2011, Kfir et al., 2012). The rationale behind the use of a balloon is the even distribution of hydraulic pressure at the membrane–bone interface that results in atraumatic and safe elevation of the schneiderian membrane. Although efficacious, this technique has not become the standard method for sinus elevation surgical procedures, possibly because of the need to purchase specialized equipment and for specific training.
The number of different surgical techniques for sinus augmentation is only surpassed by the number of biomaterials that have been used to overcome the challenge of insufficient vertical bone height in the posterior maxilla (Galindo-Moreno et al., 2008, Dahlin and Johansson, 2011). Various bone-grafting materials are frequently used in sinus lift procedures, including autogenous bone, allografts, xenogeneic bone, and alloplastic bone substitutes (Del Fabbro et al., 2004, Galindo-Moreno et al., 2008, Sununliganon et al., 2014, Xuan et al., 2014). Recent data have shown that bone substitutes displaying a putty-like consistency can present a valuable alternative in bone-grafting procedures (Vance et al., 2004, Mahesh et al., 2012, Kotsakis et al., 2012, Kotsakis et al., 2014a). The handling characteristics of putty bone substitutes have expanded the available array of treatment options for bone grafting in narrow spaces, and their viscoelastic properties may be exploited to increase the safety and predictability of sinus lift procedures.
The aim of the present case series was to evaluate a minimally invasive transalveolar sinus elevation technique utilizing calcium phosphosilicate (CPS) putty for hydraulic sinus membrane elevation.
Section snippets
Patient selection
In this retrospective study, 21 patients consecutively treated in a dental clinic with a simplified, minimally invasive technique for transalveolar sinus elevation were evaluated. Data related to age, sex, implant location, intra-operative or post-operative complications, implant stability, implant success and radiographic bone changes were recorded for all patients. Patients with treatment plans for sinus elevation surgery with simultaneous implant placement were included in this study. A
Results
A total of 29 implants (Tapered Internal, BioHorizons, Birmingham, AL, USA) were placed in 21 consecutively treated patients with the simplified minimally invasive transalveolar sinus elevation technique. The average patient age was 48.5 ± 12 years, and 9 patients were female. None of the patients were smokers. The record of adverse events included mild to moderate postoperative edema for the first two or three postoperative days in most patients, and flap dehiscence in one patient that was
Discussion
The use of the minimally invasive antral membrane elevation technique has a well-documented history of success in achieving significant elevation of the sinus floor while sparing the need for more invasive direct sinus augmentation approaches (Kfir et al., 2006, Kfir et al., 2007, Kfir et al., 2009a, Kfir et al., 2009b). Implant placement simultaneously with this technique is highly predictable and yields success rates ranging from 95.2% to 100% for 6–18 months of follow-up (Kfir et al., 2009b,
Conclusions
The simplified minimally invasive antral membrane elevation technique is based on the application of hydraulic pressure by a viscous bone graft that acts as an incompressible fluid. Therefore, simultaneously with the atraumatic elevation of the schneiderian membrane, grafting of the maxillary sinus is achieved resulting in promotion of intrasinus bone formation, increased implant stability due to the viscoelastic nature of CPS putty, and a shorter operative time owing to the simultaneous
Conflict of interest
None of the authors has any conflicts of interest to this study.
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