Direct sinus lift using composite bone graft in implant dentistry: a pictorial case report

Introduction

Implant dentistry has become an excellent treatment modality in the modern era of dentistry. It not only allows for a conservative and esthetic alternative to treating partial edentulism, but also provides a stable foundation for treating complete edentulism. Dental implants are a viable treatment option when there is sufficient quantity and quality of bone. This problem is especially magnified in the posterior maxilla where ridge resorption and sinus pneumatization, compounded with a poor quality of bone, are often encountered. The procedure of choice to restore this anatomic deficiency is maxillary sinus floor elevation (sinus lift).

What is sinus lift?

Maxillary sinus augmentation (also known as sinus floor elevation) procedures have become increasingly popular before placement of dental implants in posterior maxillae that have suffered severe bone loss due to:

In 1970s, Hilt Tatum used maxillary sinus cavity to increase available bone using graft material, which allowed greater implant to bone contact area once the bone graft matured.

All about the maxillary sinus!

A) ANATOMIC CONSIDERATIONS

Maxillary sinus is the biggest pyramidal-shaped paranasal sinus.

Average dimensions of the maxillary sinus

• Height :36–45 mm
• Width :23–25 mm
• Length: 38–45 mm (anteroposterior axis).
• The average volume of the maxillary sinus is 15 ml.

B) BOUNDARIES OF MAXILLARY SINUS

C) DIAGNOSTIC IMAGING

It provides information about maxillary sinus membrane, arterial passages in the lateral sinus wall, pathologies of maxillary sinus, and presence of septa.

It is an essential component of treatment planning in oral rehabilitation in posterior maxillary region.

D) VASCULARISATION

Blood supply occurs by the branches of maxillary artery,

• Infraorbital artery
• Posterior lateral nasal artery
• Posterior superior alveolar artery

Indications of sinus lift procedure

Contraindications of sinus lift procedure

Technique for maxillary sinus lift procedure

There are four main approaches for maxillary sinus floor elevation:

In this case report we shall be discussing about “Direct Sinus lift technique”. Sinus membrane is directly visualized and instrumented through the window created in the lateral wall of maxillary sinus.

Pictorial case report

Pre-operative photographs

Radiographic examination

The bone height was around 4.5mm, and thus inadequate.

Treatment – Sinus lift procedure by Direct Sinus lift technique/Lateral window technique

1) Incision & flap reflection

Full thickness mucoperiosteal flap is reflected.

2) Preparation of lateral wall

3) Elevation of Schneiderian membrane

4) Placement of resorbable collagen membrane beneath sinus membrane

5) Harvesting autogenous bone graft from mandibular symphysis region

6) Autogenous bone graft + resorbable collagen membrane + alloplast bone graft

7) Placement of graft

8) Placement of resorbable collagen membrane on lateral window

7) Sutures placed

Postoperative sutures removal

Postoperative RVG: 6 months

Preoperative & Postoperative

Post-op instructions

Treatment guidelines

Here are the treatment guidelines for enhancement of the vertical alveolar bone height and oral rehabilitation of the atrophic posterior maxilla with implants

Conclusion

References

1. 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 Jul;20(7):667-76. [PubMed] [CrossRef]
2. Shi JY, Gu YX, Zhuang LF, Lai HC. Survival of Implants Using the Osteotome Technique With or Without Grafting in the Posterior Maxilla: A Systematic Review. Int J Oral Maxillofac Implants. 2016 Sep-Oct;31(5):1077-88.
3. Chen MH BE, Shi JY. Clinical and Radiological Outcomes of Implants in Osteotome Sinus Floor Elevation with and without Grafting: A Systematic Review and a Meta-Analysis. J Prosthodont. 2017 Jan 12.
4. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, Schmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83.
5. Nedir R, Nurdin N, Vazquez L, Abi Najm S, Bischof M. Osteotome Sinus Floor Elevation without Grafting: A 10-Year Prospective Study. Clin Implant Dent Relat Res. 2016 Jun;18(3):609-17.
6. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Part II: transalveolar technique. J Clin Periodontol. 2008 Sep.