Lozada et al. Professor and Director, Advanced Education Program in Implant Dentistry, School of Dentistry. b

Transcription

1 Lateral and crestal bone planing antrostomy: A simplified surgical procedure to reduce the incidence of membrane perforation during maxillary sinus augmentation procedures Jaime L. Lozada, DMD, a Charles Goodacre DDS, MSD, b Aladdin J. Al-Ardah, DDS, MS, c and Antoanela Garbacea, DDS d School of Dentistry, Loma Linda University, Loma Linda, Calif This clinical report presents a simplified surgical procedure for accessing the maxillary sinus antrum via lateral and crestal approaches, which reduces the potential for sinus membrane perforation and subsequent complications when graft materials and dental implants are placed into the sinus. Due to visual limitations, perforations and associated complications can jeopardize the success rate of the graft and the implants. While there is a lack of clinical data, clinical observations suggest that the procedure, described by the authors as lateral/crestal bone planing antrostomy, can reduce the possibility of perforation of the maxillary sinus membrane during the lateral and crestal approaches to the grafting of the maxillary sinus floor. The technique involves the use of specially designed rotary instruments that plane away the bone in thinner layers, with less chance of excess bone removal and membrane perforation. (J Prosthet Dent 2011;105: ) Maxillary sinus floor elevation is a reconstructive procedure that augments a deficient posterior maxilla when pneumatizaton of the maxillary sinus is present, allowing dental implants to be placed that support single crowns or a fixed prosthesis. The conventional technique for maxillary sinus elevation involves surgical access through the lateral wall of the zygomatic buttress of the maxilla, followed by elevation of the sinus membrane and placement of a bone graft material. This technique, first described by Tatum in 1976, and first published by Boyne and James in 1980, 1,2 is also referred to as the lateral approach to the maxillary sinus floor. This surgical procedure, which uses various graft materials, has been evaluated by several authors. 3-8 In a recent systematic review of published randomized controlled trials of different maxillary sinus augmentation techniques and materials, the authors concluded that bone substitutes were as effective as autogenous bone for augmenting the maxillary sinus. 4 While sinus grafting is considered to be a relatively invasive technique, a low incidence of surgical and postsurgical complications has been reported. 9,10 The most common surgical complication is perforation of the sinus membrane, 9-14 which occurs in 7 to 10% of the procedures, but has been reported to occur in as many as 35% of procedures. 10,13,15-17 Membrane perforations, as described in the literature, are associated with postoperative complications, which include acute or chronic sinus infection, bacterial invasion, swelling, bleeding, wound dehiscence, loss of the graft material, and a disruption of normal physiologic sinus function. 10,13,16,18-20 Various surgical modalities have been used to reduce trauma and membrane perforation when performing maxillary sinus graft procedures. Barone et al 21 analyzed the surgical access to the maxillary sinus, osteotomy, and sinus membrane elevation by comparing 2 treatment procedures, one involving the use of a piezoelectric device and the other using conventional instruments. No significant differences were recorded between the 2 treatments in any of the investigated clinical parameters. Interestingly, some authors have not reported any correlation between membrane perforations and implant survival, 9,10,13,16,22-24 while others have reported a correlation between implant failure and sinus membrane perforation. A less invasive procedure for sinus membrane elevation along with immediate dental implant placement was introduced by Summers. 25 This procedure is indicated when the residual amount of alveolar bone is between 4 and 8 mm below the sinus floor. The sinus membrane is elevated with osteotomes from a crestal approach through the osteotomy prepared for dental implant placement, without the need for a lateral window. 7 A recent systematic review 4 concluded that a 3- to 6-mm residual alveolar bone height combined with a crestal lift approach and placement of 8-mm implants may result in fewer a Professor and Director, Advanced Education Program in Implant Dentistry, School of Dentistry. b Professor, Restorative Dentistry, and Dean, School of Dentistry. c Assistant Professor and Internship Coordinator, Advanced Education Program in Implant Dentistry. d Graduate student, Advanced Education Program in Implant Dentistry.

2 148 Volume 105 Issue 3 complications than a lateral window approach to place 10-mm implants. However, the authors cautioned that these conclusions were based on a small number of trials with short follow-up periods and a high risk of bias. Furthermore, the ostetome/crestal sinus membrane elevation (OCSME) is a visually restrictive procedure used to access the maxillary sinus floor and, therefore, is a technique-sensitive procedure with inherent difficulty, especially when direct visual examination of the maxillary sinus membrane is required. Despite widespread clinical application of this procedure, and the advent of multiple surgical variations of the technique, 22,25-28 few studies have reported incidence of sinus membrane perforations when the OCSME technique is used. Grafting the cavity and subsequent placement of implants is an alternative to the conventional approach of accessing the maxillary sinus, and is described by the authors as lateral bone planing antrostomy. The technique gradually eliminates the bone from the lateral aspect of the maxillary sinus during the lateral approach to the antrum, and in a single implant osteotomy site during the crestal approach to the sinus. This technique has the potential of minimizing the rate of sinus membrane perforation during surgery. This clinical report describes the use of specially designed surgical drills and curettes to access the maxillary sinus cavity via lateral and crestal approaches for maxillary sinus grafting in the treatment of 2 patients. CLINICAL REPORTS Patient 1 A 68-year-old, healthy, nonsmoking woman presented to the Center for Implant Dentistry at the Loma Linda University School of Dentistry for the treatment of a completely edentulous maxilla with dental implants. Following clinical examination, the patient was presented with a The Journal of Prosthetic Dentistry 1 Pre-operative CBCT cross-section image right pneumatized maxillary sinus. 2 Six mm diameter dome shaped drill used to perform lateral bone planing. treatment plan that included bilateral grafting of both maxillary sinuses via a lateral approach and the placement of dental implants. The implants were to be placed 8 months after grafting to support and retain a fixed maxillary complete denture. After thorough discussion of the treatment plan, the patient consented to have the maxillary sinuses grafted as proposed. The patient was presented with both the option of a fixed maxillary complete denture and a maxillary implant-retained overdenture. The patient selected the fixed option. A careful analysis of cone-beam computerized tomography (CBCT) images was performed to determine the precise location in which to execute the lateral approach to the maxillary sinus cavity (Fig. 1). After local anesthesia was administered bilaterally in the maxilla, the patient was prepared for a full-thickness flap reflection and exposure of the lateral aspect of the maxillary sinus bilaterally. A series of specially designed surgical drills and curettes (DASK Advanced Sinus Kit; Dentium, Seoul, Korea) that can be used to displace the maxillary sinus floor from the lateral and crestal approaches was used to prepare the area for maxillary sinus grafting. For the lateral approach to the maxillary sinus, a dome-shaped drill (6 mm in diameter x 4 mm in height) was used to prepare the lateral wall of the maxillary sinus. The drill uses internal and external irrigation for cooling at a speed of rpm (Fig. 2). Bone thinning was accomplished using light pressure and rotating strokes under copious irrigation on the lateral aspect of the sinus wall to gradually eliminate the bony thickness until the maxillary sinus

3 March Drill used to plane bone until thin enough to become flexible. 4 Maxillary sinus membrane exposed to initiate separation from inner walls of sinus. 5 Dome shaped curettes displacing sinus membrane from floor of maxillary sinus. 6 Placement of graft material against sinus floor after intact membrane elevation. 7 Post-operative CBCT showing volume of bone in grafted maxillary sinus cavity. membrane was identified by a bluish hue appearing through the thin bone (Fig. 3). This phase of the maxillary sinus graft surgical procedure is described by the authors as lateral bone planing antrostomy (LBPA). The area where access to the maxillary sinus cavity was to occur was expanded to reach a dimension of approximately 20 mm in length and 10 mm in height. The bone was thinned and made flexible by a gradual planing process, so that it could be easily displaced inward along with the membrane (Fig. 4). The sinus membrane was then carefully elevated from the sinus floor using the specially designed curettes (DASK Advanced Sinus Kit; Dentium). The curettes were used to detach the membrane from the anterior, inferior, and medial walls of the maxillary sinus cavity (Fig. 5). Upon confirmation of an intact sinus membrane and sufficient superior displacement, the sinus cavity was then grafted with 2 cc of 1.0- to 2.0-mm particles of hydroxyapatite (HA) coated with beta-

4 150 Volume 105 Issue 3 tricalcium phosphate (TCP) (Osteon; Dentium) (Fig. 6). The mucoperiosteal flap was then repositioned and sutured with continuous horizontal mattress sutures and single interrupted ties (GORE-TEX suture; W.L. Gore & Associates, Inc, Flagstaff, Ariz). The same procedure was accomplished for the opposite side, maintaining the integrity of the maxillary sinus membrane. A postoperative CBCT was made to evaluate the volume of graft material placed in the sinus floor (Fig. 7). Postoperative medications consisting of 500 mg amoxicillin 3 times per day for 1 week, or 300 mg clindamycin 4 times per day for 1 week, were prescribed for the patient. The patient was seen 2 weeks after the surgery for suture removal, and no complications were noted. The patient indicated that there was minimal discomfort and swelling after the surgery. 8 Pre-operative cross-section CBCT radiograph depicting sinus floor level in relation to crest of ridge. Patient 2 A healthy, 52-year-old nonsmoking man presented for treatment of a single edentulous area of the left maxillary first molar. The clinical and radiographic examination showed partial pneumatization of the maxillary sinus in that area. Based on measurements made from digital periapical radiographs and a CBCT analysis, 7 mm of bone was present below the maxillary sinus floor (Fig. 8). The patient was presented with a treatment plan that included a crestal approach to the maxillary sinus floor and lifting of the membrane for the simultaneous placement of graft material and a dental implant. The site would then be allowed to heal for 6 months after surgery. The patient consented to the treatment as presented. Local anesthesia was administered and the site was prepared for a crestal approach to the sinus cavity. Using a midcrestal incision, a mucoperiosteal flap was elevated, exposing the crest of the ridge. In anticipation of the surgery, the radiographic images were evaluated, and a decision was made The Journal of Prosthetic Dentistry 9 Dask drill (3.3 mm diameter) for crestal bone planing antrostomy. to place a dental implant with dimensions of 5 mm in diameter by 12 mm in length (Dentium, Seoul, Korea); this procedure would be performed simultaneously with an osteotome sinus membrane elevation. Following the recommended drilling sequence, the site was prepared 1 mm short of the existing floor of the maxillary sinus. A 3.3-mm-diameter, dome-shaped crestal approach drill (Dentium) was used to eliminate the remaining bone below the sinus floor (Fig. 9). The drill was used at a speed of 800 rpm with a copious amount of internal irrigation (Fig. 10). Using minimal pressure to guide the drill apically, the sinus floor was accessed, thus permitting the use of specially designed crestal sinus curettes (Dentium) to complete the displacement of the maxillary sinus membrane through the osteotomy site (Fig. 11). The Valsalva maneuver confirmed the intact condition of the maxillary sinus membrane. As part of the protocol currently in use at the Loma Linda University Center for Implant Dentistry, 0.25 cc of graft material consisting of 0.3- to 0.5-mm hydroxyapatite particles (HA) coated with beta-tricalcium phosphate (TCP) (Osteon; Dentium) was introduced through the osteotomy and carefully displaced using a dome-tipped curette (Dentium). An intraoperative digital periapical radiograph was made to ensure sufficient graft material was present below the sinus floor. The previously selected implant was placed at a torque of 35 Ncm, the mucoperiostal flap was repositioned over the implant, and suturing was completed. A postoperative CBCT and a periapical radiograph were made to evaluate the volume of graft material placed apical to the implant in the

5 March Crestal bone planing antrostomy drill with depth control cylinder to prevent perforation of maxillary sinus membrane. 11 Crestal bone planning antrostomy drill advancing to reach the maxillary sinus floor. 12 Post-operative cross-section CBCT radiograph depicting grafted sinus floor with simultaneous implant placement. maxillary sinus floor (Fig. 12). Amoxicillin (500 mg, 1 capsule every 8 hours for 7 days) and ibuprofen (800 mg, 1 tablet every 8 hours as needed for pain) were prescribed. Instructions for postoperative care were given to the patient. The patient was seen 2 weeks after the surgery for suture removal and stated that there had been no discomfort or swelling after the surgery. DISCUSSION This clinical report of 2 patients presents a modification to conventional surgical procedures for accessing the maxillary sinus antrum via lateral and crestal approaches. The procedure described by the authors as lateral/crestal bone planing antrostomy has the potential to reduce the perforation rate of the maxillary sinus membrane during the lateral and crestal approach to the grafting of the maxillary sinus floor. Conventional methods to access the maxillary sinus cavity for grafting procedures consist of using rotary instrumentation, a piezoelectric handpiece, and osteotomes. 1,2,25,27,29 Some authors have indicated that more time is required to perform the osteotomy and to complete the sinus membrane elevation with the piezoelectric device than with conventional rotary instruments. 29 Vercelloti et al 29 described the advantage of piezosurgery as being the ability to cut the bone window while avoiding the risk of membrane perforation. Additionally, piezoelectric elevators can then be used to lift the sinus membrane without any increased risk of perforation. The major limitation of piezosur-

6 152 Volume 105 Issue 3 gery seems to be the time factor. Cutting procedures are substantially more time consuming due to the low cutting efficacy of the surgical tips compared with conventional osteotomy devices. According to other studies 30,31 depending on the bone structure and thickness, the duration of the osteotomy procedure can be increased by up to fivefold or more. In the authors experience, the proposed procedure, described as lateral/crestal bone planing antrostomy (LBPA, CBPA), has the potential to reduce the time required surgically to access the maxillary sinus cavity, as well as to reduce the incidence of maxillary sinus membrane perforation. One comparative study evaluated the use of the piezoelectric device versus rotary instruments during maxillary sinus antrostomy in 13 patients. Membrane perforation occurred in 30% of the maxillary sinuses in the piezoelectric group and in 23% of maxillary sinuses in the rotary instrumentation group. 21 In contrast, the reduction in surgical time with this technique is based on the exclusive use of a single drill for LBPA and CBPA; there is no need to use additional instruments such as piezo tips, chisels, mallets, and other instruments used with conventional techniques. The diameter of the drill aids in the immediate outlining of the antrostomy during its use. Direct access to the paper-thin bone immediately adjacent to the maxillary sinus membrane, or to the membrane itself, facilitates and simplifies the detachment of the Schneiderian membrane from the inner walls of the maxillary sinus cavity. Seventeen patients were treated using the described lateral bone planing antrostomy (LBPA) procedure; only one patient (5.8%) had a perforated maxillary sinus membrane. Fourteen additional patients were treated using the CBPA procedure with simultaneous implant placement. Two patients exhibited signs of a perforation when the Valsalva maneuver was performed, but the small perforation could not be visibly detected. In both of these perforations, The Journal of Prosthetic Dentistry dental implants were placed and the patients remained asymptomatic. The patients were free of complications during the initial 2 weeks, and at the 1-, 3-, and 6-month postoperative appointments. SUMMARY The clinical report describes 2 techniques and the application of specifically designed surgical instruments that may decrease the incidence of maxillary sinus membrane perforation and decrease surgical time, thus lessening complications during and after maxillary sinus graft procedures. Controlled clinical studies with randomized designs are needed before definitive conclusions can be drawn. REFERENCES 1. Tatum H Jr. Maxillary and sinus implant reconstruction. Dent Clin North Am 1986;30: Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38: Chiapasco M, Romeo E, Vogel G. Tridimensional reconstruction of knife-edge edentulous maxillae by sinus elevation, onlay grafts, and sagital osteotomy of the anterior maxilla: preliminary surgical and phrostetic results. Int J Oral Maxillofac Implants 1998;13: Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, et al. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus. Cochrane Database Syst Rev 2010;3:CD Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus Conference of Int J Oral Maxillofac Implants 1998;13 Suppl 1: James RA, Lozada JL, Whittaker JM, Cordova C, GaRey DJ. Histological response and clinical evaluation of heterograft and allograft materials in the elevation of the maxillary sinus in the preparation of endosteal implants sites. Simultaneous sinus elevation and root form implantation: an eight-month autopsy report. J Oral Implantol 1989;15: Smiler DG, Holmes RE. Sinus lift procedure using porous hydroxyapatite: a preliminary clinical report. J Oral Implantol 1987;13: Wheeler SL, Holmes RE, Calhoun CJ. Sixyear clinical and histologic study of sinuslift grafts. Int J Oral Maxillofac Implants 1996;11: Cho SC, Wallace SS, Froum SJ, Tarnow DP. Influence of anatomy on Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis. Pract Proced Aesthet Dent 2001;13: Schwartz-Arad D, Herzberg R, Dolev E. The prevalence of surgical complications of the sinus graft procedure and their impact on implant survival. J Periodontol 2004;75: Levin B, Al-Maseeh J, Symeonides E. The osteotome technique: a classification for technique approach and clinical case reports. Compend Contin Educ Dent 2005;26: Proussaefs P, Olivier HS, Lozada J. Histologic evaluation of a 12-year old threaded hydroxyapatite-coated implant placed in conjunction with subantral augmentation procedure: a clinical report. J Prosthet Dent 2004;92: Shlomi B, Horowitz I, Kahn A, Dobriyan A, Chaushu G. The effect of sinus membrane perforation and repair with Lambone on the outcome of the maxillary sinus floor augmentation: aradiographic assessment. Int J Oral Maxillofac Implants 2004;19: Sorní M, Guarinos J, Peñarrocha M. Implants in anatomical buttresses of the upper jaw. Med Oral Patol Oral Circ Bucal 2005;10: Buchmann R, Khoury F, Faust C, Lange DE. Peri-implant conditions in periodontally compromised patients following maxillary sinus augmentation. A long term post therapy trial. Clin Oral Implants Res 1999;10: Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteome sinus floor elevation: a preliminary prospective study. Int J Oral Maxillofac Implants 2002;17: Stricker A, Voss PJ, Gutwald R, Schramm A, Schmelzeisen R. Maxillary sinus floor augmentation with autogenous bone grafts to enable placement of SLA-surfaced implants: preliminary results after months. Clin Oral Implants Res 2003;14: Chanavaz M. Maxillary sinus: anatomy, physiology, surgery, and bone grafting related to implantology--eleven years of surgical experience ( ). J Oral Implantol 1990;16: Aimetti M, Romagnoli R, Ricci G, Massei G. Maxillary sinus elevation: macrolaceration and microlacerations of the sinus membrane as determined by endoscopy. Int J Periodontics Restorative Dent 2001;21: Cordioli G, Mazzocco C, Schepers E, Brugnolo E, Majzoub Z. Maxillary sinus floor augmentation using bioactive glass granules and autogenous bone with simultaneous implant placement. Clinical and histological findings. Clin Oral Implants Res 2001;12: Barone A, Santini S, Marconcini S, Giacomelli L, Gherlone E, Covani U. Osteotomy and membrane elevation during the maxillary sinus augmentation procedure: A comparative study: piezoelectric device vs. conventional rotative instruments. Clin Oral Implants Res 2008;19: Fugazzotto PA, Vlassis J. A simplified classification and repair system for sinus membrane perforations. J Periodontol 2003;74:

7 March Rosen PS, Summers R, Mellado JR, Salkin et al. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treatment patients. Int J Oral Maxillofac Implants 1999;14: Fermergård R, Astrand P. Osteotome sinus floor elevation and simultaneous placement of implants: a 1-year retrospective study with Astra Tech implants. Clin Implant Dent Relat Res 2008;10: Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium 1994;15: Summers RB. The osteotome technique: Part 2--The ridge expansion osteotomy (REO) procedure. Compendium1994;15: Summers RB. The osteotome technique: Part 3--The less invasive methods of elevating the sinus floor. Compendium 1994;15: Fugazzotto PA. Sinus floor augmentation at the time of maxillary molar extraction: technique and report of preliminary results. Int J Oral Maxillofac Impants 1999;14: Vercellotti T, De Paoli S, NevinsM. The piezoelectric bony window osteotomy and sinus membrane elevation: introduction of a new technique for simplification of the sinus augmentation procedure. Int J Periodontics Restorative Dent 2001;21: Hoigne DJ, Stübinger S, Von Kaenel O, Shamdasani S, Hasenboehler P. Piezoelectric osteotomy in hand surgery: first experience with a new technique. BMC Musculoskelet Disord 2006;7: Kramer FJ, Ludwig HC, Materna T, Gruber R, Merten HA, Schliephake H. Piezoelectric osteotomies in craniofacial procedures: a series of 15 pediatric patients. Technical note. J Neurosurg 2006;104: Corresponding author: Dr Jaime L. Lozada Center for Implant Dentistry Loma Linda University Anderson St, Room 4411 Loma Linda, CA Fax: jlozada@llu.edu Copyright 2011 by the Editorial Council for The Journal of Prosthetic Dentistry. Access to The Journal of Prosthetic Dentistry Online is reserved for print subscribers! Full-text access to The Journal of Prosthetic Dentistry Online is available for all print subscribers. To activate your individual online subscription, please visit The Journal of Prosthetic Dentistry Online. Point your browser to elsevierhealth.com/periodicals/ympr/home, follow the prompts to activate online access here, and follow the instructions. To activate your account, you will need your subscriber account number, which you can find on your mailing label (note: the number of digits in your subscriber account number varies from 6 to 10). See the example below in which the subscriber account number has been circled. Sample mailing label This is your subscription account number *********AUTO**SCH 3-DIGIT V97-3 J J. H. DOE 531 MAIN ST CENTER CITY, NY