Annals of Dental Research

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P a g e 1 ADR 7 (1), 1-6, 2017 Journal Homepage: www.hgpub.com/ojs2/index.

*Department of Oral and Maxillofacial Surgery, S.G.

1 P a g e 1 ADR 7 (1), 1-6, 2017 Journal Homepage: Direct Sinus Lift with Putty Alloplastic Bone Substitute for Simultaneous Implant Placement A Case Report Chander Prakash*, Rao Dayashankar*, Sheorain Anil K*,Arya Varun*, Singh Vikram* *Department of Oral and Maxillofacial Surgery, S.G.T Dental College, Hospital and Research Institute, Sri Guru Gobind Singh Tricentenary University, Gurgaon, Haryana, India Corresponding author, chander.prakash321@gmail.com, phone: Article History Received: 10 March 2017 Accepted: 25 April 2017 Available Online: 15 May 2017 Keywords Sinus, Implant, Bone. Annals of Dental Research (ISSN: ) Abstract The sinus lift procedure aims to create the bone volume for the placement of implant of requisite length. Very few studies have shown the immediate implant placement in severe atrophic ridges (less than 5 mm bone height). In this case report a 52 year old female patient with a chief complaint of missing left posterior premolar-molar region wished fixed rehabilitation. Since the CBCT showed only 3.06 mm of the residual bone height below the sinus in relation to 26 region, lateral sinus augmentation with putty alloplastic bone substitute was done with simultaneous implant placement. Putty alloplastic bone substitute was used effectively to augment the maxillary sinus region and also to stimulate the bone regeneration. A more viscous consistency of the biomaterials used for sinus augmentation could positively affect the primary stability of an implant placed simultaneously with a sinus lift procedure. HATAM : Publishers. All rights reserved. Introduction An adequate amount of residual bone both in width and height, is required for successful implant placement and the success rate depends to a great extent on the volume and quality of the surrounding bone. 1-4 Primary Implant

2 P a g e 2 stability of the implant is one of the fundamental criteria for obtaining osseointegration and one of the most desirable factors for simultaneous implant placement. The lateral window approach described by Boyne and James 5 and developed by Tatum 6 is very predictable, safe, and one of the most frequently performed treatment modalities. It is a well-documented technique; however, there is no consensus on the ideal grafting material for sinus augmentation surgery. The aim of this clinical report is to analyze the possibility of simultaneous implant placement in sinus augmentation with putty alloplastic bone substitute in bare minimum residual bone height. Simultaneous implant placement is closely related to the achievement of primary stability upon implant insertion, and the absence of micro-movements during the healing period. 7-8 Osstell device was used to measure the resonance frequency analysis values in this case study to assess the primary stability. Resonance Frequency Analysis (RFA) is a non-invasive intraoral method designed to assess boneimplant interface and may therefore provide clinical evidence of implant stability. 9 Case Report A 52 year old patient came to the outpatient department of SGT dental college, Gurgaon in 2016 with a chief complaint of missing left upper posteriors. On clinical examination tooth no # 25,26,27 was missing (Fig 1). A thorough case history of the patient revealed that the teeth were extracted 6 years back after fracture of the complete crown with an old history of bridge irt 25 and 27. All blood investigations were done to rule out any systemic abnormalities. Radiographic assessment of residual bone was done on CBCT and Intra Oral Periapical Radiographs. The exact measurement of residual bone height on CBCT was recorded as 3.06 mm and width of 5.89 mm in relation to 26 region (Fig 2.a, b). Blood investigations were done and revealed no systemic abnormalities. After giving all other alternative treatment plans with pros and cons of each treatment options patient was planned for 2 implant placement in relation to 25 and 26 region. Implant in 26 region was planned simultaneously after direct sinus lift with PABS. Inclusion and exclusion criterion taken for this case report were:a healthy male or female patients with inadequate bone height in the deficient posterior maxilla who requiredrehabilitation with dental implant placement, Patient who was willing for simultaneous implant placement with graft and was available for follow-up visits up to 6 months with a good general health status. Patient with poor oral hygiene, chronic smoker, systemic illness/systemic drugs that would affect postoperative healing, acute and chronic sinus infections were excluded. Surgical phase After the administration of local anaesthesia an incision was made over the crest of ridge slightly 2 3 mm on the palatal side of the crest of the ridge with a vertical releasing incision at least 15 mm mesial to the antral opening. With the help of Sinus Lateral approach kit 5 mm

3 P a g e 3 diameter of lateral window was prepared in relation to 26 region (Fig 3). The bellow effect was observed as the patient breathed to confirm patency of the intact sinus membrane. With a surgical curette, the underlying membrane was lifted from the inside wall of the sinus and 1cc of CPS putty was filled in the space created after lifting the sinus (Fig 4). The osteotomy preparation for implant was done as per sequencing drilling and the implants were placed in relation to 25 and 26 regions and the fixture used were Adin Touareg-S tapered implant of diameter 4.0mm and length 10 mm (4x10).Direct sinus lift procedure was performed irt 26 region using alloplastic bone graft material, putty alloplastic bone substitute (NovaBone Dental Putty; NovaBone Products, Alachua, FL).Primary stability was recorded as the maximum insertion torque (MIT) achieved using a torque wrench and RFA values within the ISQ scale (Osstell TM device, Integration Diagnostic AB, Sweden) 10. After placing the cover screw the Primary flap closure was achieved using a single interrupted suturing technique (Fig 5). All relevant Post-operative instructions were given. Systemic antibiotics (amoxicillin and clavulanic acid ), analgesics were prescribed for 5 days along with maintainence of good oral hygiene with 0.2% chlorhexidine gluconate rinses after every meals. No intraoperative and post-operative complications were recorded. Second stage surgery: After a healing period of 6 months of implant placement the RFA values were taken again and there was a significant increase in Resonance frequency analysis buccolingually from 54 to 67 and Mesiodistally from 55 to 69 at the time of implant placement (0 months) and after 6 months in implant placed in relation to 26 region. Periapical X ray was taken which showed good bone growth, and the sinus cavity around the implant was filled with dense bone like tissue (Fig 6).The healing abutment was placed after considering consolidation and maturation of the graft. Discussion Severe atrophy of the edentulous maxilla (Cawood classv and VI) 11 and progressive pneumatisation of the maxillary sinus may limit or prevent the dental rehabilitation with implants and augmentation of the maxilla is necessary. The use of sinus lift procedures is well documented, and it can provide adequate bone support for dental implants in patients that present a loss of bone height in the posterior maxillary regions. Sinus augmentation grafting and implant placement are accomplished as either a 1-step or a 2-step surgical procedure. In the 1-step procedure, the maxillary sinus is augmented and dental implants are placed simultaneously into the grafted site. Whereas In 2-step procedure, implant placement is delayed until there is evidence that the graft material has provided adequate bone in the posterior maxilla. The general consensus, based on empirical observations, has been that the 1-step procedure should be reserved for patients who have at least 5 mm of alveolar bone in the posterior maxilla to

4 P a g e 4 Figure 1: Edentulous site in relation to 26, 27 Figure 4: Implant and graft placement (a) (b) Figure 5: Primary flap closure Figure 2: Pre-operative CBCT depicting edentulous site Figure 3: Lateral window preparation Figure 6: Post-operative radiograph

5 P a g e 5 stabilize the implants else 2-step surgical procedure in less than 5mm of residual bone height. 12,13 The factors that contribute to the survival rate of sinus augmentation and dental implant placement are still the subject of discussion. Nevertheless, very few studies were carried out to understand if the bone grafted during a sinus lift is able to assure a good primary stability during implant insertion and if it is able to maintain this stability after 6 or 12 months. 14 The aim of our case report was to observe the clinical outcomes of putty alloplastic bone substitute in enhancing the primary implant stability. In this clinical case we have done the direct sinus lift with PABS along with simultaneous implant placement in less than 5 mm of residual bone height i.e 3.06 mm and found optimal primary stability with a torque of 25 N cm2. Hence, if the initial stability can be improved despite a lack of residual bone height, successful osseointegration of implants can be expected. Putty alloplastic bone substitute (PABS) is a premixed composite of bioactive calcium phosphosilicate particulate and a synthetic absorbable binder in a putty form. This graft material has the ability to adhere to normal bone, aid its remodeling, and enable hemostasis. 15 In our case report we have found a significant increase in Resonance frequency analysis (ISQ value) mean from 0 month (55) to 6 months (66). Therefore the increased RFA values showed the positive outcome towards success of implants in less residual bone height increased with PABS. The augmentation of the Maxillary sinus induces the bone formation by promoting osteoconduction from surrounding parent bone and is dependent on the rates of revascularization and osteoblast recruitment. 16,17 Conclusion The Putty Alloplastic Bone Substitute can be used as a good alloplastic material as a substitute of autogenous bone graft for enhancing the primary stability of the simultaneously placed implant and can save time for prosthetic rehabilitation and avoidance of second surgery. Therefore with the changing trends in implant loading, from delayed to early and now immediate, the faster rates of healing and osseointegration can be achieved with the use of this technique. References 1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10: Albrektsson T, Branemark PI, Hansson HA, Lindstro m J. Osseointegrated titanium implants. Requirements for ensuring a longlasting, direct bone-toimplant anchorage in man. Acta Orthop Scand. 1981;52: Engquist B, Bergendal T, Kallus T, Linden U. A retrospective multicenter evaluation of osseointegrated implants supporting overdentures. Int J Oral Maxillofac Implants. 1988;3: Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental

6 P a g e 6 implants: the Toronto study. Part I: surgical results. J Prosthet Dent. 1990;63: Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg. 1980;38: Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986; 30(2): Friberg B, Sennerby L, Linden B, Gröndal K, Lekholm U. Stability measurements of one-stage Bränemark implants during healing in mandibles. A clinical resonante frequency análisis study. Int J Oral Maxillofac Surg. 1999;28: Ivanoff CJ, Sennerby L, Lekholm U. Influence of inicial implant mobility on the integration of titanium implants. An experimental study in rabbits. Clin Oral Implants Res. 1996;7: Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont. 1998;11: Meredith N, Alleyne D, Cawley P. Quantitative determination of the stability of the implant-tissue interface using resonance frequency analysis. Clin Oral Implants Res. 1996;7: Cawood JL, Howell RA. A classification of the edentulous jaw. Int J Oral Maxillofac Surg 1988; 17: Smiler DG, Johnson PW, Lozada JL, Misch C, Rosenlicht JL, Tatum OH Jr, Wagner JR. Sinus lift grafts and endosseous implants: Treatment of the atrophic posterior maxilla. Dent Clin North Am 1992;36: Wheeler SL, Holmes RE, Calhoun CJ. Sixyear clinical and histologic study of sinus-lift grafts. Int J Oral Maxillofac Implants 1996;11: Degidi M, Daprile G, Piattelli A, Carinci F. Evaluation of factors influencing RFA values, at insertion surgery, of implants placed in sinus augmented and non grafted sites. Clinical Implant Dentistry and Related Research. 2007; 9(3): Histomorphic Evaluation of a Calcium- Phosphosilicate Putty Bone Substitute in Extraction Sockets. Kotsakis G, Joachim F, Saroff S, Mahesh L, Prasad H, Rohrer M. Int J Periodontics Restorative Dent Mar-Apr; 34(2) Avera, SP, Stampley WA & McAllister BS. Histologic and clinical observations of resorbable and non resorbable barrier membranes used in maxillary sinus graft containment. International Journal of Oral and Maxillofacial Implants. 1997;12: Block MS, Kent JN. Sinus augmentation for dental implants: the use of autogenous bone. Journal of Oral and Maxillofacial Surgery.1997;55:

PALATAL POSITIONING OF IMPLANTS IN SEVERELY RESORBED POSTERIOR MAXILLAE F. Atamni, M.Atamni, M.Atamna, Private Practice Tel-aviv Israel

PALATAL POSITIONING OF IMPLANTS IN SEVERELY RESORBED POSTERIOR MAXILLAE F. Atamni, M.Atamni, M.Atamna, Private Practice Tel-aviv Israel Abstract: Objectives: To evaluate an alternative treatment for rehabilitation