Direct v/s Indirect sinus lift in maxillary dental implants

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1 Originl Clinicl Studies - Comprtive Study: Implnts Direct v/s Indirect sinus lift in mxillry dentl implnts Access this rticle online Wesite: DOI: / Quick Response Code: S. M. Blji Director, Blji Dentl nd Crniofcil Hospitl, Teynmpet, Chenni, Tmil Ndu, Indi Address for correspondence: Dr. S. M. Blji, Blji Dentl nd Crniofcil Hospitl, 30, KB Dsn Rod, Teynmpet, Chenni , Tmil Ndu, Indi. E-mil: smlji@gmil.com ABSTRACT Introduction: Lck of sufficient one height long mxillry sinus poses significnt difficulty for plcement of implnts in edentulous mxillry jw. Minimlly invsive sinus ugmenttion is n effective solution for this prolem. The mnuscript intends to present long period results of such ugmenttion using direct (DSAT) nd indirect (ISAT) minimlly invsive sinus ugmenttion technique (SAT) from single center. Mterils nd Methods: Records of ptients who required minimlly invsive sinus ugmenttion to increse residul one height for implnt plcement fulfilling predetermined exclusion nd inclusion criteri. Only ptients with follow-up records for t lest yer were considered. Both DSAT nd ISAT were employed for sinus ugmenttion. The ge, gender, period of edentulousness, lveolus thickness t crestl level during the pre- nd postopertive ssessment, implnt length, nd dimeter of implnts were collected from cse histories. Descriptive sttistics, Chi-squre, pired test, nd one wy nlysis of vrince (ANOVA) ws used ppropritely. P 0.05 ws considered s significnt. Results: There were 197 implnts plced nd men ge of the group ws 40.2 ± 10.7 yers. There ws slight mle predilection (54.3%). The gin in one height s expressed in percentge fter yer ws 134.6%. On compring the length of residul lveolr one (RAB) t strt nd end of study, ISAT hd men preopertive height of 7.88 mm while postopertive height ws mm. For DSAT, the men height t strt of tretment ws 3.94 mm while t the end it ws mm. The men increse in height ws 6.19 mm. For oth cses, P ws Discussion: Age, gender, nd period of edentulism did not influence the outcome. The lveolr width ppers to differ nd influence the outcome. When lveolr width increses, wider dimeter implnts cn e plced y compromising height. Thus it is clinicl cumen tht would e extremely helpful to guge the outcome of the condition. Keywords: Alveolr one height, dentl implnts, minimlly invsive sinus ugmenttion, sinus surgery INTRODUCTION Successful dentl implnt plcement in non-dentte re of mxillry posterior region requires sufficient trining. They pose ll chllenges tht re inherent to this region. The mxill is mde up of spongy one nd hs one of the lest dense ones in orl cvity. [1] Periodontl disese stimulted teeth loss cuses ccentuted one deficiency, oth in height nd width y significnt resorption of lveolr one. Time period of tooth loss leds to sence of continuous one stimultion tht ws erlier provided y dentition. Bone remodeling in the region is further complicted y post extrction one resorption, pneumtiztion of mxillry sinuses, nd poor qulity of residul lveolr one. [2] In the immedite time period fter mxillry posterior tooth extrction, initil decrese in lveolr width is y resorption nd/or loss of uccl one. With continuous one remodeling, sence of stimultion, loss of one height, nd density leds to n increse in ntrl pneumtiztion. The mxillry sinus pneumtiztion is cused y progressive hllowing out of lveolr process of picl spect medited y osteoclsts nd y increse in positive intr-ntrl pressure. In such sitution, the residul 148 Annls of Mxillofcil Surgery July - Decemer 2013 Volume 3 Issue 2

2 verticl one height is decresed mking stndrd implnt plcement difficult. [1,2] To dpt, circumvent, nd tret this locl physiologicl s well s ntomicl limittion; mxillry sinus floor elevtion hs ecome n importnt preplcement procedure in dentl implnt tretment plnning. Vrious methodologies hve evolved to increse the thickness of mxillry sinus floor. The tretment gol of ll such procedures is to increse residul one height. Few of the technique involve simple, miniml elevtion of mxillry sinus memrne, Schneiderin memrne, while other include plcement of vrious type of grfts including llogrfts, utogrfts, one morphogenetic proteins, nd hydroxyptite crystls. [3-5] The success of minimlly invsive sinus ugmenttion nd dentl implnt plcement relies on selection of technique of plcement, grft mteril, if necessry nd dequte preopertive plnning esides the skill of opertor. There re two min wys of reching sinus memrne; direct one nd n indirect method of sinus ugmenttion. The direct sinus ugmenttion technique (DSAT) involves direct visuliztion nd mnipultion of Schneiderin memrne while the other method indirectly (ISAT) mnipultes the memrne. Both these method hve delineted indiction nd contrindiction. The fctors tht contriute to survivl rte of sinus ugmenttion nd dentl implnt plcement re still the suject of discussion. [5] This im of present study is to present 1-yer outcome of mxillry sinus ugmenttion procedure performed in single center using the stndrd technique. Comprison of one grft, the technique nd gin in one height t the end of yer is lso presented. MATERIALS AND METHODS This retrospective study included records of ll consecutive ptients seeking dentl implnt who required mxillry sinus ugmenttion. The study period ws June 2008-My In these ptients FDA pproved, self-threded titnium implnts hd een plced in single stge nd followed-up for t lest yer ±4 weeks. These ptients initilly presented with edentulous; trophic mxillry rch either due to physiologicl ging, trum, or periodontl conditions nd ptients presenting with one or more missing teeth in posterior mxillry rch, either unilterlly or ilterlly. In ll 182 ptients, 197 implnts were plced long the ugmented sinus. Ptients with systemic illness/systemic drugs tht would ffect postopertive heling; ptients with poor orl hygiene, chronic smokers, psychitric illness, nd preexisting sinus prolem were excluded from the study. The ge, gender, period of edentulousness, lveolus thickness t crestl level t the pre-opertive ssessment, implnt length, nd dimeter of implnt were collected from cse history. Direct sinus ugmenttion technique (DSAT) After identifying the residul lveolr one (RAB) height in imging studies, only those cses tht hs RAB height 5 mm or elow ws considered for this technique. Autogenous one grfts ws hrvested y shving the mndiulr one from externl olique ridge re or chin re. A one mill ws used to grind the one shving into fine prticles. After dequte locl nesthesi nd preprtion, surgicl incision ws plced on the crest of RAB t most pproprite re, with verticl relesing curviliner incisions flring into the vestiule. Full-thickness, superiostel lil, nd pltl flps were rised, reflected. Cre ws tken to keep the se of flp rod s well s dequte uccl nd pltl tissue for closure. After elevtion, the nterolterl wll of mxillry sinus ws visulized. Cre ws tken to identify nd protect infroritl nerve, if encountered. The dimension of osteotomy ws determined sed on clinicl nd rdiogrphic exmintions s well s the extent of edentulous spn. A uccl one window ws mde on exposed wll of mxillry sinus using postge stmp method. The ony wll ws gently mnipulted with sinus memrne elevtors without dmging Schneiderin memrne. The previously otined grft mteril ws then plced nd pcked. The implnt ws plced on sme sitting with help of stent which ws positioned, then removed, nd the site ws checked for pproprite fciolingul nd mesiodistl positioning [Figures 1 nd 2]. Any ovious norml crestl defects required slight modifiction of the position. A pilot drill of 2 mm in dimeter ws then drilled in mrked implnt site on RAB to estlish depth nd xis of implnt recipient site. The implnt ws plced with its xis prllel to occlusl forces. Prlleling pins were employed s necessry to check prllelism of drill holes. The drills were used in stndrd reduction ger hnd piece long with physiodispenser enling copious sline irrigtion to prevent excessive het genertion. The drill ws used t the speed of 800-1,000 rpm. Drills with grdully incresing dimeters were used to enlrge implnt recipient site till the desired dimeter corresponding to implnt s dimeter ws reched. Implnts were then plced into the prepred site using torque wrench. 3-0 Vicryl sutures were used to close the surgicl wound. Antiiotic coverge, pin killers, nd nsl decongestnts were prescried for 5 dys. The ptients were monitored on periodic sis, oth cliniclly nd rdiologiclly. Indirect sinus ugmenttion technique (ISAT) Cses with RAB height of 6-8 mm were tken for indirect sinus ugmenttion. The RAB to receive the implnt ws exposed under locl nesthesi nd perforted using smll rounded drill. A pilot drill ws plced in mrked implnt site to estlish the xis of implnt recipient site. Following the pilot drill, susequently incresing dimeter of drills were used to enlrge implnt recipient site till the desired dimeter corresponding to implnt dimeter ws reched. The height of drill ws mintined 2 mm short of sinus floor. The indirect sinus lift ws done y insertion of correct clier osteotome nd working up through successively greter instrument dimeters, until the sinus floor ws frctured nd elevted up. The sinus floor ws crefully frctured, seprted from the Schneiderin memrne voiding dmge to memrne using surgicl mllet with controlled force. If required, utogenous grft mteril ws inserted within the socket. The mteril ws displced piclly with help of lrger-dimeter instruments, therey lifting the memrne nd condensing grft mteril etween the ltter nd sinus floor. The implnt ws then plced immeditely in the prepred site [Figures 3-5]. 3-0 Vicryl sutures were used to close the surgicl wound. Antiiotic coverge, pin killers, nd nsl decongestnts were prescried for 5 dys. The ptients were monitored on periodic sis oth cliniclly nd rdiologiclly. Annls of Mxillofcil Surgery July - Decemer 2013 Volume 3 Issue 2 149

3 Mesurements Digitl pnormic rdiogrphs nd rdiovisiogrphy records (ccounted for distortion/mgnifiction) tken using repetedly clirted mchines were used for screening exmintions nd tretment plnning. In rdiogrphs, height of the residul one ws mesured in imging records three times nd verge tken s preopertive height. The height of one ws estimted in the sme region of implnt fter yer nd tken s 1 yer postopertive one height. The gin in one height ws expressed s percentge of increse in one height (new height - old height) divided y the old one height. All the dt thus collected were entered nd nlyzed using Sttisticl Pckge for Socil Service, version 17.0 (SPSS Inc, IBM, IL, USA). Descriptive dt re presented. Chi-squre test nd pired t-test ws used to compre the difference etween direct nd indirect technique. One wy nlysis of vrince (ANOVA) ws employed to identify the men etween continuous outcome vriles. P 0.05 ws tken s significnt. RESULTS c Figure 1: Direct sinus lift with simultneous implnt plcement with use of utogenous one grft () In-frcturing nd lifting of lterl window of right mxillry sinus, () Autogenous one hrvested from donor site eing plced in newly creted spce, (c) Bone pcked in the window, (d) Sinus floor ugmented nd implnt plced d Of the 197 instnces of implnt plcement through ISAT nd DSAT, the men ge of the group ws 40.2 ± 10.7 yers. There ws slight mle predilection (54.3%). Bsed on ge group, 23.4% elonged to ge elow 30 yers, 26.4% in yers, nd 33.55% in yers. Of ll, 112 cses (56.9%) required grfts. The most common cuse of tooth loss ws dentl cries, periodontl diseses ccounting for 88% of cses. The men period of edentulism ws 4.6 ± 2.8 yers. The overll RAB ws 4.6 mm, while lveolus width ws 8.5 mm. Among the study group, verge length of implnt used ws 12 mm with dimeter of 3.8 mm. This differed with the technique. The gin in one height s mesured in percentge fter yer ws 134.6% [Tle 1]. On compring ISAT (n = 108) nd DSAT (n = 89), the gender nd ge distriution in study popultion ws not significnt. The plcement of grft ws significnt etween ISAT nd DSAT [Tle 2]. On compring the men ge etween ISAT nd DSAT, difference ws not sttisticlly significnt (P = 0.271). The men period of edentulous lso did not pper to infl uence (P = 0.87). The difference in lveolr width ws significnt etween ISAT nd DSAT cses (P = 0.01). The men length nd dimeter of implnt used ws lso sttisticlly significnt (P = nd 0.007, respectively). The gin in one height expressed s percentge of originl RAB height t end of 1 yer for ISAT ws 99.52% while for DSAT it ws %. This difference ws sttisticlly significnt. [Tle 3]. In the indirect sinus lift (ISL) method, when grft ws used, the men gin percentge ws ± 6.04%; while when no grfts were used, the gin in height ws 95.2 ± 11.36%. On compring length of the RAB t strt nd end of study, ISAT hd men preopertive height of 7.88 mm while postopertive height ws mm. The men increse in height ws 5.34 mm. This difference ws sttisticlly significnt. Similrly for DSAT, men height t strt of tretment ws 3.94 mm; while t the end it ws mm. The men increse in height ws 6.19 mm. For oth cses, P ws [Tle 4]. c Figure 2: Line digrms illustrting direct sinus lift with simultneous implnt plcement, () Atrophic posterior mxill with residul one height etween sinus floor nd lveolr crest indequte for plcement of dentl implnt, () Lterl wll of sinus in-frctured nd memrne is elevted, (c) Grfted one is densely pcked in spce creted fter lifting the memrne, (d) Augmented mxillry sinus with implnt plced d DISCUSSION Edentulous mxillry segment hs severl ntomicl nd physiologicl limittions such s deficiency of spongy mxillry lveolr one, incresed pneumtiztion of the mxillry sinuses, nd fster negtive remodeling in sence of continuous pressure on periodontium. These fctors render rehilittion of the region very chllenging. Owing to limited RAB, sinus floor elevtion is 150 Annls of Mxillofcil Surgery July - Decemer 2013 Volume 3 Issue 2

4 seen s prerequisite for dentl implnt plcement. [3] The sinus elevtion procedure hs n integrl invsive surgicl procedure tht could pose surgicl moridity s well s increse cost of tretment. The ISAT procedure performed with 5-8 mm thick RAB Figure 3: Pre- nd postopertive orthopntomogrph (OPG) in cse treted with indirect sinus lift nd one grft for implnt plcement, () Insufficient residul one, () After prosthetic rehilittion following indirect sinus lift, one grfting, nd implnt plcement is less invsive nd less costly for predictle implnt plcement. [2] For ridges with 3-5 mm thick RAB, surgicl modlities s those proposed y Summers, [6] Fugzzotto, [7] nd Toffler [8] provides less trumtic nd less costlier lterntives especilly in compromised single molr sites. In the present study, sinus ugmenttion is done either y stndrd DSAT or ISAT s single step procedure. During nd fter plcements of dentl implnts, no significnt complictions were reported. These results were consistent with the findings of Grzini F et l. [9] They compred implnt survivl following sinus floor ugmenttion nd estimted the survivl rte etween 75 nd 100% oth for nonugmented nd ugmented res. Similrly, Miln Jurisic et l., nd Din nd Ro estimted high success rte in their immedite nd delyed implnt plcements on 61 ptients nd 11 ptients, respectively. [3,10] The numer of steps in surgery did not pper to influence outcome of the study s reported y Wtzek. [11] Hence, in the present study only single stge surgery ws considered s the c Figure 4: () Implnt recipient site prepred using drills, () Implnt plced in prepred site, (c) After rehilittion with prosthesis Figure 5: Sequentil steps in indirect sinus ugmenttion technique; implnt site prepred strting from smll dimeter to lrge dimeter drills, sinus floor frctured, elevted, nd one grft plced in the resultnt spce nd immedite implnt plcement Tle 1: Demogrphic nd clinicl fetures of study popultion Minimum Mximum Men Stndrd devition Age (yers) Period of edentulous (yers) Preopertive residul one height (mm) Preopertive lveolr one width (mm) Implnt length (mm) Implnt dimeter (mm) Postopertive one height t 14 weeks (mm) Gin in height (%) Annls of Mxillofcil Surgery July - Decemer 2013 Volume 3 Issue 2 151

5 Tle 2: Comprison of gender, ge, nd grft use mong techniques for minimlly invsive sinus ugmenttion Technique Indirect; n (%) Direct; n (%) P vlue Gender Mle 58 (54.2) 49 (45.8) Femle 50 (55.6) 40 (44.4) Age group (yers) (47.8) 24 (52.2) (46.2) 28 (53.8) (66.7) 22 (33.3) 51 nd ove 18 (54.5) 15 (45.5) Grfts Yes 23 (20.5) 89 (79.5) 0.000* No 85 (100) - *P 0.05 is considered s sttisticlly significnt Tle 3: One wy nlysis of vrince (ANOVA) for comprison mong techniques for minimlly invsive sinus ugmenttion n Men SD 95% CI men P vlue Lower Upper Age (yers) Indirect Direct Period of edentulism (yers) Indirect Direct Alveolr width (mm) Indirect * Direct Implnt length (mm) Indirect * Direct Implnt dimeter (mm) Indirect * Direct Gin in one height t end of 12 months (%) Indirect * Direct *P 0.05 is considered s sttisticlly significnt, SD = Stndrd devition, CI = Confidence intervl Tle 4: Comprison of pre- nd postopertive one height for minimlly invsive sinus ugmenttion Technique Preopertive Postopertive P vlue Men SD Men SD Indirect * Direct * *P is considered s highly significnt, SD = Stndrd devition numer of steps did not pper to criticlly influence outcome of primry nd secondry stility of implnt. The single most importnt criteri for selecting n ISAT re the RAB eing 6 mm or more. When RAB ws ove 12 mm, sinus ugmenttion ws not required. When RAB is 5 mm nd less, DSAT is preferred s the grft needs to e plced. Minimum thickness requires incresed RAB for implnt plcement. Hence, grfts were lwys plced in DSAT cses. In the grey zone of 5-6 mm, depending on other fctors such s period of edentulism, lveolr width, nd ge of ptients; the technique ws chosen. It ws oserved tht shorter implnts with wide dimeters were pt for ptients who hd thicker lveolr ridges. This ensured oth primry nd secondry stility of implnts during the erly nd lte phses. The im of this study ws to descrie outcome of the ISAT nd DSAT t end of yer. It is oserved tht the height is gined much with DSAT. This difference proly comes from two fctors; the plcement of grft in ll cses of DSAT, nd the second fctor is the RAB height itself. As the gin in one height is smll, percentge chnge is oscured y this mthemticl clcultion. Age, gender, nd period of edentulism did not influence the outcome [Tle 2]. The lveolr width ppers to differ nd influence the outcome. When height of RAB is reduced, lveolr width will increse [Tle 3]. When the width increses, wider dimeter implnts cn e plced compromising height. This could e relted to increse in surfce re with incresing dimeter. Thus, it is clinicl cumen tht would e extremely helpful to guge outcome of the condition. Irrespective of the technique, there ws significnt difference etween preopertive nd t the end of the tretment with significnt vlue [Tle 4]. The DSAT gve etter increse in height thn ISAT. This could e ttriuted to use of grfts. The outcome of sinus ugmenttion procedure for implnt plcement hs een presented from single center. It ppers from the study tht cse selection nd grft plcement plys n importnt role in determining outcome of ugmenttion procedure. Owing to plcement of grft, RAB height regined through DSAT is higher. CONCLUSION The present study identified tht with wider lveolus, shorter implnt with greter dimeter cn e used sfely, proly owing to incresed surfce re cusing more osseointegrtion. The study lso identified tht result of sinus ugmenttion depends on surgeon's cumen nd experience. The gol of ny dentl implnt surgeon is to use cost-effective, short durtion, less risky, simple, nd highly predictle outcome procedure. Advnced nd extensive surgicl techniques often increse tretment durtion nd costs with no solute prediction of result. Use of minimlly invsive technique such s DSAT nd ISAT provides cost ffordle, less risky, nd predictle results s compred to invsive procedures. The techniques employed in this mnuscript hs fcilitted implnt plcement in res of limited one height, improved primry stility, high implnt success in posterior mxill, simple, nd minimlly invsive surgery with incresed success nd cse cceptnce. REFERENCES 1. Rj SV. Mngement of the posterior mxill with sinus lift: Review of techniques. J Orl Mxillofc Surg 2009:67; Toffler M. Minimlly invsive sinus floor elevtion procedures for simultneous nd stged implnt plcement. N Y Stte Dent J 152 Annls of Mxillofcil Surgery July - Decemer 2013 Volume 3 Issue 2

6 2004;70: Dniel D, Ro SG. Evlution of increse in one height following mxillry sinus ugmenttion using direct nd indirect technique. J Dent Implnt 2012;2: Wllce SS, Froum SJ. Effect of mxillry sinus ugmenttion on the survivl of endosseous dentl implnts. A systemtic review. Ann Periodontol 2003;1: Pl US, Shrm NK, Singh RK, Mhmmd S, Mehrotr D, Singh N, et l. Direct vs. indirect sinus lift procedure: A comprison. Ntl J Mxillofc Surg 2012;3: Summers RB. The osteotome technique: Prt 3-less invsive methods for elevtion of the sinus flow. Compend Contin Educ Dent 1994;15: Fugzzotto PA. The modified trephine/osteotome sinus ugmenttion technique: Technicl considertions nd discussion of indictions. Implnt Dent 2001;10: Toffler M. Stged sinus ugmenttion using crestl core elevtion procedure nd modified osteotomes to minimize memrne perfortion. Prct Proced Aesthet Dent 2002;14: Grzini F, Donos N, Needlemn I, Griele M, Tonetti M. Comprison of implnt survivl following sinus floor ugmenttion procedures with implnts plced in pristine posterior mxillry one: systemtic review. Clin Orl Implnts Res 2004;15: Jurisic M, Mrkovic A, Rdulovic M, Brkovic BM, Sándor GK. Mxillry sinus floor ugmenttion: compring osteotome with lterl window immedite nd delyed implnt plcements: An interim report. Orl Surg Orl Med Orl Pthol Orl Rdiol Endod 2008; 106: Wtzek G, Weer R, Bernhrt T, Ulm C, Hs R. Tretment of ptients with extreme mxillry trophy using sinus floor ugmenttion nd implnts: Preliminry results. Int J Orl Mxillofc Surg 1998;27: Cite this rticle s: Blji SM. Direct v/s Indirect sinus lift in mxillry dentl implnts. Ann Mxillofc Surg 2013;3: Source of Support: Nil, Conflict of Interest: None declred. Clender of Events Octoer 3-6, th Annul Conference of the Indin Society for Dentl Reserch-IADR Indi Division Dentl Reserch Forging hed Venue: New Delhi, Indi Emil: isdr2013@gmil.com We: Octoer 21-22, st Interntionl Conference on Orl nd Mxillofcil Surgery (ICOMS) Venue: Brcelon, Spin Emil: icoms2013@rcelocongresos.com We: Novemer 25-28, th World Cleft Congress of the Interntionl Cleft Lip nd Plte Foundtion Creting Smiles Chnging Lives Venue: Hnoi, Vietnm We: Mrch 13-15, th Pn Africn Congress of Orl & Mxillofcil Surgeons PnAfCOMS Venue: Niroi, Keny We: Mrch 24-29, st Annul Meeting of Americn Cleft Plte- Crniofcil Assocition Venue: Indinpolis, Indin, USA We: June 17-19, th Asi Pcific Dentl Congress (APDC) Venue: Dui, United Ar Emirtes Emil: info@pdentlcongress.org June 25-28, nd Generl Session & Exhiition of the IADR Venue: Cpe Town, South Afric August 22-25, 2014, 11 th Asin Congress on Orl nd Mxillofcil Surgery (ACOMS) Venue: Xi n QuJing Interntionl Convention Centre, Chin Emil: kqcszx@fmmu.edu.cn We: Septemer 11-14, 2014 FDI Annul World Dentl Congress 2014 Venue: New Delhi, Indi We: Septemer 23-26, 2014 XXII Congress of the Europen Assocition for Crnio- Mxillo-Fcil Surgery Venue: Prgue Congress Centre, Prgue, Czech Repulic Emil: ecmfs2014@gurnt.cz We: My 5-9, th Interntionl Congress on Crniofcil Osteoiology & Distrction Venue: The Bndos Islnd Resorts, Repulic of mldives Emil : info@distrction2014.com We: Annls of Mxillofcil Surgery July - Decemer 2013 Volume 3 Issue 2 153