Reconstruction and rehabilitation

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1 CLINICAL Minimally Invasive Subnasal Elevation and Antral Membrane Balloon Elevation Along With Bone Augmentation and Implants Placement Efraim Kfir, DMD 1 Vered Kfir, DMD 2 Moshe Goldstein, DMD 3 Ziv Mazor, DMD 4 Edo Kaluski, MD 5 * Atrophic edentulous anterior maxilla is a challenging site for implant placement and has been successfully treated surgically by anterior maxillary osteoplasty. This procedure is associated with considerable discomfort, morbidity, and cost and consequently reduced patient acceptance. The efficacy and safety of minimally invasive bone augmentation of the posterior maxilla has not been extended thus far to the anterior subnasal maxilla. We present 2 representative cases in which minimally invasive subnasal floor elevation was performed along with minimally invasive antral membrane balloon elevation. Both segments underwent bone grafting and implant placement during the same sitting. Minimally invasive anterior maxilla bone augmentation appears to be feasible. Designated instruments for alveolar ridge splitting and nasal mucosa elevation are likely to further enhance this initial favorable experience. Key Words: subnasal, nasal floor, antral membrane, bone augmentation, minimally invasive, maxilla, sinus, implants INTRODUCTION 1 Dental clinic, Petah-Tikvah, Israel. 2 Dental clinic, Kupat Holim Clalit (Remez), Rehovot, Israel. 3 The Hebrew University and Hadassah Ein-Karem Medical Center Jerusalem, and periodontal clinic, Tel- Aviv, Israel. 4 Periodontal clinic, Raánana, Israel. 5 Department of Cardiology, University Hospital, University of Medicine and Dentistry, Newark, New Jersey. * Corresponding author, ekaluski@gmail.com DOI: /AAID-JOI-D Reconstruction and rehabilitation of the atrophic edentulous anterior maxilla present a considerable challenge to dental implant therapy. Anterior maxillary osteoplasty has emerged over the years as the best strategy to address this problem. Implants were traditionally placed in a second procedure. 1 Recently, minimally invasive antral membrane balloon elevation (MIAMBE) 2 was successfully Journal of Oral Implantology 365

2 Minimally Invasive Subnasal Elevation introduced to perform posterior maxilla bone augmentation even in the most challenging subset of patients 3 (eg, those in which there are multiple septa or extremely atrophic eggshell maxilla). However, the subnasal maxilla remained a condition in which open surgery was the only therapeutic option. We present 2 cases in which subnasal elevation and MIAMBE were simultaneously performed and followed by bone grafting and implant placement. CASE 1 A 57-year-old man was referred for rehabilitation edentulous left anterior maxillary segment (missing teeth 12, 13, and 14). Tooth 12 was previously extracted because of vertical fracture, and tooth 14 was extracted because of periodontal disease. The patient s medical history was insignificant (including absence of sinusitis or allergies), and he has never smoked. The treatment plan was implant placement in sites of teeth 12, 13, and 14. The preoperative computed tomography (CT) analysis (Figure 1) demonstrated that the bone height/width measurements in these sites were 8.8/4.18 mm, 5.57/2.53 mm, and 5.0/5.0 mm in teeth 12, 13, and 14, respectively. A polypoid mass was incidentally noted in the posterior compartment of the septated maxillary sinus. Surgical procedure Initially, 3 mm posterior to an existing implant (tooth 11), a full-thickness incision was made from the palatal to the buccal border of the alveolar ridge. A horizontal full-thickness incision was then performed in the middle of the alveolar crest to expose it. On the buccal aspect of the flap, a partial-thickness flap was performed beyond the mucogingival junction (by doing so the periost is still attached to the bone, and its blood supply is preserved). After alveolar crest exposure at sites 12 and 13, a horizontal bone incision was made at the center of the alveolar ridge with a diamond disc (0.25 mm thick, 8 mm diameter, Microsaw, Dentsply Friadent, Mannheim, Germany). The initial bone split incision was deepened using Piezosurgery with an OT7S tip (Mectron, Carasco, Italy) to a depth of 1 mm below the nasal floor (based on CT measurements). A D-shaped SplitMax chisel (Meta, Italy, reference number ) was used to further widen the space between 2 plates (palatal and buccal). The ridge was carefully split while ensuring that the buccal and palatal cortical plates did not detach. Drilling with a pilot drill (2 mm diameter) at the future implant site up to 1 mm underneath the nasal floor (as measured by CT) was followed by osteotomy widening (Figure 2) from 2 to 3.3 mm with the SplitMax 3.3 mm diameter chisel (Meta, Italy, reference number ) up to the nasal floor. Bone graft material (0.25 ml Mineross, BioHorizons, Birmingham, Ala) was injected with a dedicated MIAMBE bone graft injector (MIAMBE, Natanyah, Israel), and the nasal floor was subsequently fractured with a SplitMax 3.3 mm chisel (Figure 3). Bone graft material was injected again (an additional 0.25 ml Mineross, BioHorizons) into the osteotomy with subsequent placement of 3.3/13 mm and 3.3/11 mm implants (NTI Implants Hi-Tech, Herzlia, Israel) at sites 12 and 13, respectively (Figures 4 and 5). At site 14, sinus floor elevation was accomplished using the MIAMBE technique, 2,3 initially drilling (2 mm in diameter) at the center of the alveolar crest up to 1 mm underneath the sinus floor and, subsequently, widening the osteotomy from 2 mm to 2.9 mm with the MIAMBE osteotom. Bone substitute material (0.1 ml Mineross, BioHorizons) was injected with the MIAMBE bone graft injector, and the sinus floor was subsequently fractured with the MIAMBE osteotom (Figure 6). The antral membrane integrity was assessed by the Valsalva maneuver. The MIAMBE screw-tap working length was adjusted according to sinus floor depth (sinus floor depth þ Vol. XXXVIII / No. Four / 2012

Kfir et al FIGURE 1. Preoperative computed tomography reveals a narrow and low anterior maxilla ridge (underneath the nasal floor). Underneath the maxillary sinus the bone height is ;4 mm.

3 Kfir et al FIGURE 1. Preoperative computed tomography reveals a narrow and low anterior maxilla ridge (underneath the nasal floor). Underneath the maxillary sinus the bone height is ;4 mm. A polyp and septa are noted in the maxillary sinus. mm) and tapped into the osteotomy. The antral membrane integrity was reassessed. Subsequently, the metal sleeve of the MIAMBE balloon-harboring device was advanced 1 mm beyond the sinus floor. The MIAMBE balloon was inflated with contrast material with the dedicated MIAMBE indeflator. Balloon inflation and antral membrane elevation were assessed by serial periapical radiographs (Figure 7). Once the desired elevation was obtained the balloon was removed, membrane integrity was reassessed (by direct visualization using the dedicated suction syringe and the inward and outward movement of blood within the osteotomy during inspirationexpiration). Bone substitute (1 ml Mineross, BioHorizons) was injected through the osteotomy into the sinus underneath the antral membrane, and implant placement was performed (4.2/13 mm TFR, Hi-Tech Implants). The gap between the implants was filled with bone graft material (Mineross, BioHorizons). The alveolar ridge was covered with a platelet-rich fibrin membrane (obtained by centrifugation of 10 ml autologous venous blood at 2700 rpm for Journal of Oral Implantology 367

$Use of a SplitMax chisel (C) to widen the osteotomy and fracture the nasal floor (F). Note the piriform rim (P) and nasal septum (S). Various SplitMax tips are displayed. FIGURE 4.$

4 Minimally Invasive Subnasal Elevation FIGURES 2 7. FIGURE 2. Enlarging the osteotomy from 2 mm to 3.25 mm using a SplitMax chisel (C). The nasal floor is marked (F). FIGURE 3. Use of a SplitMax chisel (C) to widen the osteotomy and fracture the nasal floor (F). Note the piriform rim (P) and nasal septum (S). Various SplitMax tips are displayed. FIGURE 4. The first osteotomy (tooth 12) received bone substitute (B) and implant (I-12). The second osteotomy (tooth 13) was done using a SplitMax chisel (C) to lift the nasal floor (F) 4 mm. Note the anterior wall of the maxillary sinus (A) and the sinus septum (SS). FIGURE 5. Note the implants in area 12 (I-12) and area 13 (I-13). The implant tip extends 3 4 mm beyond the line of the original sinus floor and is surrounded by bone substitute (B). FIGURE 6. Sinus floor (SF) fractured with the minimally invasive antral membrane balloon elevation osteotom (O). FIGURE 7. Minimally invasive antral membrane balloon (M) elevation is done. Note the nasal floor (F), anterior wall of the maxillary sinus (A), and sinus septum (SS). 10 minutes) followed by coronally positioned flap and primary closure by sutures (Vycril 4/0 and Silk 4/0). Periapical radiographs obtained at 3 months (Figure 8) and CT scans obtained at 8 months (Figures 9 through 11) confirmed that a new nasal floor had been created with considerable gains in bone height. Of note, the polypoid mass had not changed in size through the entire follow-up period. 368 Vol. XXXVIII / No. Four / 2012

Kfir et al FIGURES 8 11. FIGURE 8. At 3 months after the procedure a new nasal floor (F) has formed. FIGURE 9. (a) Baseline panoramic view. (b) Panoramic view 8 months later. FIGURE 10.

5 Kfir et al FIGURES FIGURE 8. At 3 months after the procedure a new nasal floor (F) has formed. FIGURE 9. (a) Baseline panoramic view. (b) Panoramic view 8 months later. FIGURE 10. Computed tomography 8 months after the procedure. Note the implants at sites 12 (I-12), 13 (I-13), and 14 (I-14); the new nasal floor (NF); the inferior turbinate (IT); and the nasal lateral wall (LW), which is also the medial wall of the sinus (S). FIGURE 11. (a) Sagittal view of site 14. (b) Coronal view of site 14. Note the sinus (S) and the inferior turbinate (IT). CASE 2 A 51-year-old woman was referred for esthetic and functional reconstruction of an edentulous maxilla. Her medical history was insignificant except for a history of cigarette smoking (1 pack per day for 30 years). The treatment plan was to restore the maxilla with a fixed complete denture from sites 2 through 15 (5 implants on the right side starting from tooth 6 distally and 5 implants on the left side starting from tooth 11 and progressing posteriorly). The implants were placed in 2 separate surgical sessions starting with the left side. The maxilla reconstruction included minimally invasive subnasal elevation, bone augmentation, and placement of implants using the osteotom technique in the subnasal segment and the MIAMBE method more posteriorly. Anatomic-morphologic evaluation and measurements were obtained from a panoramic view radiograph (Figure 12) and CT (coronal plane shown in Figure 13 and sagittal plane shown in Figure 14). The radiologic analysis revealed 3 septa and 4 compartments in the left maxillary sinus. In the anterior maxilla, the residual ridge was narrow and shallow and not amenable for implant fixation. Surgical procedure A full-thickness buccopalatal incision posterior to the incisive papilla was followed by a horizontal full thickness incision in the middle of the alveolar crest. On the buccal Journal of Oral Implantology 369

6 Minimally Invasive Subnasal Elevation FIGURE 12. Preoperative panoramic radiograph. Note the sinus septa (SS). aspect of the flap a partial thickness flap was performed beyond the mucogingival junction. At sites 11 and 12, the Microsaw disc was used for initial cutting and then the Piezosurgery with an OT7S tip was used to deepen the osteotomy. This was followed by widening the space between the plates using the D-shaped SplitMax chisel, drilling with a 2 mm drill up to 1 mm underneath the nasal floor and fracturing the nasal floor (Figure 15) using the SplitMax chisel (3.3 mm, reference ). After nasal floor fracturing, bone substitute (0.25 ml Mineross, BioHazard) was injected into the osteotomy, and the first 3.3/13 mm NTI implant was inserted at site 11. A similar protocol was used for the 3.3/ 13 mm NTI implant at site 12 (Figure 16). In sites 13 and 14, subsequent to bone augmentation of the maxillary sinus floor by the MIAMBE technique, two TFR 4.2/13 mm implants were placed (Figures 17 through 20). The 12-month CT follow-up is shown in Figures 21 through 23. DISCUSSION The approach to the atrophic anterior edentulous maxilla has evolved over the past 20 years. Surgical reconstruction for bone mass restoration has been rendered highly effective, resulting in good procedural success and excellent implant survival rates (of 80% 95%). 4,5 However, these surgical procedures, which usually involve autologous bone harvesting (from the iliac crest, calvarium, tibia, mandible symphysis, maxillary tuberosity), were associated with donor-site related morbidity. Moreover, these procedures mandated general anesthesia, hospitalization, and high costs and required exceptional cognitive and surgical skills. These surgical procedures are associated with considerable disability, discomfort, and serious complications (eg, hemorrhage, graft resorption, graft exposure, wound dehiscence, fistula, infection, sinus membrane perforation [26% 6 ], and acute sinusitis). Surgical reconstruction of the edentulous maxilla may carry some other considerable benefits beyond enhancing the support and integration of dental implants. 7 These additional benefits include restoring facial morphology and soft tissue support and improving impaired phonetics, esthetics, and airway function. However, only a minority of edentulous patients require these incremental attributes and benefits. Because surgery creates a more radical 370 Vol. XXXVIII / No. Four / 2012

Kfir et al FIGURES 13 14. FIGURE 13. Preoperative computed tomography of the coronal plane. FIGURE 14.

7 Kfir et al FIGURES FIGURE 13. Preoperative computed tomography of the coronal plane. FIGURE 14. Preoperative computed tomography of the sagittal plane reveals 3 septa and 4 compartments in the left maxillary sinus. Journal of Oral Implantology 371

Minimally Invasive Subnasal Elevation FIGURES 15 16. FIGURE 15. Osteotomy enlargement using a SplitMax chisel (C), while splitting the nasal floor (F). FIGURE 16.

8 Minimally Invasive Subnasal Elevation FIGURES FIGURE 15. Osteotomy enlargement using a SplitMax chisel (C), while splitting the nasal floor (F). FIGURE 16. While the first implant is placed (I-1) at area 11, the SplitMax chisel (C) is widening the osteotomy and splitting the nasal floor (F) for the second implant at area 12. Note the anterior wall (A) of the maxillary sinus and the sinus septum (SS). 372 Vol. XXXVIII / No. Four / 2012

Kfir et al FIGURES 17 20. FIGURE 17. Minimally invasive antral membrane balloon elevation (MIAMBE) performed in a maxillary sinus with 3 sinus septa (SS) and 4 compartments.

9 Kfir et al FIGURES FIGURE 17. Minimally invasive antral membrane balloon elevation (MIAMBE) performed in a maxillary sinus with 3 sinus septa (SS) and 4 compartments. The MIAMBE balloon (M) occupies the first compartment. The second implant (I-2) occupies the nasal floor (F) at area 12. FIGURE 18. While compartment 1 of the maxillary sinus undergoes bone grafting (B) and implant fixation (I-3), the minimally invasive antral membrane balloon (M) is inflated in compartment 2 of the maxillary sinus with 4 compartments and 3 sinus septa (SS). FIGURE 19. Minimally invasive antral membrane balloon (M) inflated in the third compartment (C3), while the first (C1) and second (C2) compartments undergo bone grafting and implant placement (I3 and I4). FIGURE 20. The 4 implants after minimally invasive antral membrane balloon elevation. Note the nasal floor (F). alteration in the relationship between the mandible and the maxilla, it is logical (although not universally acceptable 8,9 )to plan implant placement only after the morphologic changes associated with surgery have settled and not during the reconstructive surgery. 10,11 This recommendation for deferred implant placement appears to be applicable even to less extensive surgical reconstructions, such as sandwich osteotomies. 12 There is a need for a minimally invasive method that will allow bone augmentation of the subnasal (anterior) maxilla. Such a procedure can result in higher patient acceptance and may overcome the treatment barriers associated with current open surgical methods. After introducing the osteotom method and subsequently MIAMBE 13 for noninvasive bone augmentation of the atrophic posterior maxilla, the subnasal segment of the maxilla remained the only maxillary segment in which minimally invasive bone augmentation and implant placement was not feasible. 14 We describe 2 of 11 cases in which subnasal elevation and MIAMBE were performed side by side at our clinic. The procedure is done during a single sitting under local anesthesia, with basic periodontal instrumentation and without any short- or long-term discomfort. MIAMBE has formerly demonstrated wider applicability (no exclusions), similar efficacy, and superior safety compared with open sinus lift. The MIAMBE procedure resulted in fewer infections (0.8% versus 5%) and membrane tears (5% versus 20% 55%); absence of vascular, Journal of Oral Implantology 373

Minimally Invasive Subnasal Elevation FIGURES 21 23. FIGURE 21. Panoramic axial view 13 months after the initial procedure. FIGURE 22.

10 Minimally Invasive Subnasal Elevation FIGURES FIGURE 21. Panoramic axial view 13 months after the initial procedure. FIGURE 22. Coronal section of the right side at 13 months: Note the new sinus floor (SF), sinus (S), lateral wall of the nasal cavity (LW), and inferior turbinate (IT). FIGURE 23. Coronal section of the left side at 13 months. Note the new sinus floor (SF), sinus (S), lateral wall of the nasal cavity (LW), and inferior turbinate (IT). 374 Vol. XXXVIII / No. Four / 2012

11 Kfir et al nerve, or bone injuries (occasionally reported with open sinus lift); and absence of prolonged swelling, hematoma, sinus dysfunction or pain 2 (which are seen very frequently in open sinus lift and result in low patient acceptance rates). It should be noted that the nasal cavity floor is considerably different from the floor of the maxillary sinus. The nasal floor lining is much thicker and more amenable to mild osteotom elevation without tearing than the antral membrane lining of the maxillary sinus. Based on our initial experience, the nasal floor lining can be raised only 2 3 mm by using the osteotom alone. However with hydraulic pressure exerted by bone graft material injection, a 5 mm elevation underneath the inferior turbinate can potentially be accomplished. One of the major issues in planning nasal floor elevation is the decision regarding the optimal or desirable elevation. Essentially, any penetration of the nasal floor considerably enhances implant support in view of the exceptional density and quality of the nasal floor bone. The desired elevation should be individualized based on the depth of the impression behind the piriform rim. Although the desired elevation could ideally be 2 5 mm, the elevation should not encroach or come in close vicinity (,1 3 mm) to the inferior turbinate (inferior concha) as that may compromise nasal air flow. If excessive elevation encroaches on the inferior turbinate, resulting in functional impairment of the nasal flow, the inferior turbinate (concha) may have to be modified or removed surgically to secure nasal air flow. Although in theory more than modest elevation of the nasal floor can result in nasal airway modification and even obstruction, this did not present as a clinical problem in any of our patients to date. Although the procedure is in its infancy, the authors are confident that with experience and evolution of dedicated instrumentation this procedure can be streamlined and become a more commonly used technique applicable to most patient types. On the patient end this procedure is associated with less pain and discomfort, brief recovery, and a shorter time to implant loading. From the doctors standpoint it is a shorter procedure, which can be accomplished in an outpatient settings; requires less surgical skills, time, and equipment; and is free from any meaningful complications. The authors are convinced that once this procedure is refined it will likely generate a higher patient and practitioner acceptance rate than current open procedures. STUDY LIMITATIONS We have described just 2 cases representing an evolving method that will require confirmation regarding procedural success and failure rates, the quality and volume of bone augmentation, and implant survival. CONCLUSION Minimally invasive subnasal floor elevation accompanied by bone augmentation and implant placement appears feasible. Dedicated instrumentation and method refinement are likely to further enhance the efficacy and safety of this procedure first reported here. REFERENCES 1. Laverick S, Summerwill A, Cawood JI. Ten years of experience with the anterior maxillary and mandibular osteoplasty (class IV ridges): a retrospective analysis of implant survival rates. Int J Oral Maxillofac Surg. 2008;37: Kfir E, Goldstein M, Yerushalmi I, et al. Minimally invasive antral membrane balloon elevation results of a multicenter registry. Clin Implant Dent Relat Res. 2009;11 (suppl 1):e83 e Kfir E, Goldstein M, Rafaelov R, et al. Minimally invasive antral membrane balloon elevation in the presence of antral septa: a report of 26 procedures. J Oral Implantol. 2009;35: Lundgren S, Nyström E, Nilson H, Gunne J, Lindhagen O. Bone grafting to the maxillary sinuses, nasal floor and anterior maxilla in the atrophic edentulous maxilla. A two-stage technique. Int J Oral Maxillofac Surg. 1997;6: Journal of Oral Implantology 375

12 Minimally Invasive Subnasal Elevation 5. Li KK, Stephens WL, Gliklich R. Reconstruction of the severely atrophic edentulous maxilla using Le Fort I osteotomy with simultaneous bone graft and implant placement. J Oral Maxillofac Surg. 1996;54: Raghoebar GM, Timmenga NM, Reintsema H, Stegenga B, Vissink A. Maxillary bone grafting for insertion of endosseous implants: results after months. Clin Oral Implants Res. 2001;12: Lundgren S, Sjöström M, Nyström E, Sennerby L. Strategies in reconstruction of the atrophic maxilla with autogenous bone grafts and endosseous implants. Periodontol ;47: Isaksson S, Ekfeldt A, Alberius P, Blomqvist JE. Early results from reconstruction of severely atrophic (Class VI) maxillas by immediate endosseous implants in conjunction with bone grafting and Le Fort I osteotomy. Int J Oral Maxillofac Surg. 1993;22: Sailer HF. A new method of inserting endosseous implants in totally atrophic maxillae. J Craniomaxillofac Surg. 1989;17: Nyström E, Lundgren S, Gunne J, Nilson H. Interpositional bone grafting and Le Fort I osteotomy for reconstruction of the atrophic edentulous maxilla. A two-stage technique. Int J Oral Maxillofac Surg. 1997;26: Nyström E, Nilson H, Gunne J, Lundgren S. Reconstruction of the atrophic maxilla with interpositional bone grafting/le Fort I osteotomy and endosteal implants: a year follow-up. Int J Oral Maxillofac Surg. 2009;38: Jensen OT, Kuhlke L, Bedard JF, White D. Alveolar segmental sandwich osteotomy for anterior maxillary vertical augmentation prior to implant placement. J Oral Maxillofac Surg. 2006;64: Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol. 2007;78: Garg AK. Subnasal elevation and bone augmentation in dental implantology. Dent Implantol Update. 2008;19: Vol. XXXVIII / No. Four / 2012

Minimally Invasive Antral Membrane Balloon Elevation Results of a Multicenter Registrycid_

Minimally Invasive Antral Membrane Balloon Elevation Results of a Multicenter Registrycid_213 83..91 Efraim Kfir, DMD;* Moshe Goldstein, DMD; Israel Yerushalmi, DMD; Ronen Rafaelov, DMD; Ziv Mazor, DMD;