|Year : 2018 | Volume
| Issue : 1 | Page : 27-33
Management of maxillary posterior inadequate ridge height for prosthetic rehabilitation
Diganta Manohar Thube, Nihal Dattatray Devkar, Akshay Ramesh Vibhute, Divya Sanjay Agarwal, Praful Dhiraj Walke
Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||11-Jun-2018|
Dr. Diganta Manohar Thube
Department of Periodontology, Sinhgad Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
The rehabilitation of patients affected by posterior maxillary atrophy by the aid of implant-supported fixed prosthesis presents a challenge in many cases. The available residual alveolar ridge is insufficient for the placement of dental implants because of alveolar bone resorption, pneumatization of the maxillary sinus, or their combination. Maxillary sinus floor augmentation is the treatment of choice in such cases. Sinus lift procedure can be carried with or without simultaneous implant placement. Recently, various newer techniques have been introduced for sinus floor elevation such as antral membrane balloon elevation, water lift technique, and piezosurgery. Furthermore, short implants and zygomatic implants can also be done in severe posterior atrophied maxilla.
Keywords: Implants, maxillary sinus, maxillary sinus floor augmentation, piezosurgery
|How to cite this article:|
Thube DM, Devkar ND, Vibhute AR, Agarwal DS, Walke PD. Management of maxillary posterior inadequate ridge height for prosthetic rehabilitation. J Dent Allied Sci 2018;7:27-33
|How to cite this URL:|
Thube DM, Devkar ND, Vibhute AR, Agarwal DS, Walke PD. Management of maxillary posterior inadequate ridge height for prosthetic rehabilitation. J Dent Allied Sci [serial online] 2018 [cited 2019 Oct 21];7:27-33. Available from: http://www.jdas.in/text.asp?2018/7/1/27/234182
| Introduction|| |
The rehabilitation of patients affected by posterior maxillary atrophy by the aid of implant-supported fixed prosthesis presents a challenge in many cases. Frequently, the available residual alveolar ridge is insufficient for the placement of dental implants because of alveolar bone resorption, pneumatization of the maxillary sinus, or their combination.
Maxillary sinus floor augmentation is the treatment of choice when insufficient alveolar bone height prevents placement of dental implants in the posterior edentulous maxilla.
There are two types of sinus lift procedures, direct and indirect. Direct type again is of two types:
- Sinus lift with simultaneous implant placement and
- Sinus lift with delayed implant placement.
Direct procedure involves creating an antrostomy defect to access the sinus, detaching Schneiderian membrane from the sinus floor, and placing a graft material into the sinus cavity to promote vertical bone augmentation. Many clinicians use membranes to cover the antrostomy defects in sinus augmentation to enclose the graft material in the sinus cavity until progressive wound healing can stabilize the graft.
The utilization of different filling materials has been reported after augmentation. The autologous graft is the gold standard, given its osteogenic, osteoinductive, and osteoconductive properties. It can be obtained from different areas, including retromolar trigone, chin, or iliac crest. Other options, such as allografts, xenografts, and alloplastic materials, have also been widely reported in the literature.
Surgical techniques for sinus floor elevations using the indirect transcrestal approach are mainly based on the fracture or perforation of the sinus floor by means of osteotomes or burs.
| Indications for Sinus Lift Procedures|| |
- Sinus lift procedures are indicated in free-end situations in the maxilla, where insufficient bone height is available for dental implants, or in totally edentulous maxillae with insufficient bone height 
- Indications for direct versus indirect technique [Table 1].
- Direct sinus lift technique – simultaneous versus delayed implant placement [Table 2].
|Table 2: Direct sinus lift technique - simultaneous versus delayed implant placement|
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| Contraindications for Sinus Lift Procedures|| |
- Tumors or pathologic growth in the sinus 
- Maxillary sinus infection 
- Severe chronic sinusitis (bacterial, viral, mycotic rhinosinusitis, allergic sinusitis, sinusitis caused by intrasinus foreign bodies, and odontogenic sinusitis resulting from necrotic pulp tissue)
- Surgical scar/deformity of sinus cavity
- Dental infection involving or in proximity to sinus
- Severe allergic rhinitis/sinusitis 
- Chronic topical steroid use.
- Radiation therapy involving the maxillary sinus
- Metabolic disease, for example, uncontrolled diabetes
- Excessive tobacco use
- Drug/alcohol use
- Psychological/mental impairment.
Lateral window technique
The most widely used techniques for maxillary sinus floor elevation are the classical lateral antrostomy introduced by TATUM in 1976. Lateral antrostomy may be performed using a one-or two-step approach. Implants are installed simultaneously with the bone graft (1-stage lateral antrostomy) or after a delay to allow for bone healing (two-stage lateral antrostomy). Residual bone thickness (whether it is greater or less than 5 mm) is the deciding factor between the two methods., Lateral sinus augmentation with bone harvested from an intraoral site was reported by Wood and Moore. The one-stage procedure is less time-consuming for the clinician and patient, but its success depends on the amount of residual bone.
Local anesthesia is administered and crestal incision is placed on the alveolar ridge and vertical incisions are placed one tooth anterior and one tooth posterior to the area of interest. A mucoperiosteal buccal flap is elevated exposing the lateral bony wall of the sinus antrum at the edentulous region distal to the first premolar. A round diamond bur (No. 2 and No. 4), 2 mm in diameter, is used to outline the lateral window, which is completely removed to expose the Schneiderian membrane. Using sinus elevators, the membrane is gently separated from the housing bone and pushed away to achieve a tension-free reflection exposing the sinus walls. Sinus cavity is filled with the grafting material and the flaps are repositioned and sutured. The amount of grafting material placed into each sinus varied depending on the amount of augmentation needed to accommodate the implant/s [Figure 1].
|Figure 1: (a) Lateral window is cut at the periphery of the access window (b) The bony window then pushed inwards to become the superior wall of the grafted maxillary sinus space (c) Flap is sutured back (d) Lateral window is cut completely away (including the bone at the center of the window) (e) Schneiderian membrane is elevated inward and upward to become the superior containment of the grafted maxillary sinus space without a superior bony wall (f) Flap is sutured back|
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This technique utilizes a crestal approach, proposed by SUMMERS in 1994. In 2002, Fugazzotto  suggested that the pristine bone at sites of implant placement could be drilled up to the sinus floor with a trephine bur and used to fracture the sinus floor by hydraulic pressure through osteotomes.
Local anesthesia is administered and crestal incision is given; a full-thickness flap is then raised to expose the alveolar ridge. Next, an osteotomy is performed, starting with an osteotome of the smallest size, which is tapped in place in the bone with a mallet or drill. More osteotomes of gradually increasing size are then used to expand the alveolus and compress the bone. Once the largest osteotome has been placed, prepared bone grafting material is added to the osteotomy so that it presses on the sinus membrane. This additional pressure causes the elevation of the membrane. Additional grafting material may be used to achieve the desired amount of elevation. An implant – slightly larger in diameter than the osteotomy – is then inserted in the site [Figure 2].,
|Figure 2: (a) Osteotomy site is prepared using osteotomes (b-g) Schneiderian membrane is progressively elevated by using graft material and osteotomes (h) and (i) Implane placement done|
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When performing sinus floor elevation, the risk of complications must be considered and the appropriate treatment foreseen. The most common intraoperative complication is perforation of the sinus membrane [Figure 3].
The presence of maxillary sinus septa and root apices penetrating into the sinus may increase the risk of membrane perforation. The risk of perforation has been reported to be between 10% and 40% during surgery (Block and Kent, 1997; Timmenga et al., 1997; Pikos, 1999). In the event of a membrane perforation, it is recommended to elevate the membrane in the opposite direction to prevent further enlargement of the perforation. Smaller perforations (<5 mm) may be closed using tissue fibrin glue, suturing, or by covering them with a resorbable barrier membrane [Figure 4].
In cases of larger perforations, larger barrier membranes, lamellar bone plates, or suturing may be used either alone or in combination with tissue fibrin glue to provide a superior border for the grafting material. In instances of larger perforations, where a stable superior border cannot be achieved, the grafting of the maxillary sinus must by aborted and a second attempt at sinus floor elevation may be performed 6–9 months later (Tatum et al., 1993; van den Bergh and ten Bruggenkate, 2000).
Other complications that were reported during surgery included excessive bleeding from the bony window or the sinus membrane and wound dehiscences. Iatrogenic complications include the injury of the infraorbital neurovascular bundle from deep dissection to free the flap from tension or blunt trauma due to the compression of the neurovascular bundle during retraction. Implant migration, hematoma, and adjacent tooth sensitivity have also been reported.
Infection of the grafted sinuses is a rare complication. However, the risk for infection increases with a membrane perforation. Hence, it is recommended to avoid sinus grafting and simultaneous implant placement in situ ations of membrane perforation (Jensen and Katsuyama, 1996). Infection of the grafted sinuses is usually seen 3–7 days postsurgically and may lead to a failure of the graft. Possible complication secondary to infection may involve a parasinusitis with the spread of the infection to the orbital or even to the brain. For these reasons, infected sinus grafts must be treated immediately and aggressively. Surgical removal of the entire graft from the sinus cavity and administration of high doses of antibiotics are essential.
| Nongrafting Alternatives to Sinus Lift|| |
While the survival rates of single-tooth replacements were found to be reduced if supported by implants <10 mm in length, interest in these short designs has been growing with the introduction of rough-surfaced implants. Survival rates of rough-surfaced short implants for single-tooth replacement have been reported to approach those of implants >10 mm.
However, this finding was predominantly obtained in the posterior mandible, where the bone is usually of higher density. Therefore, it should be expected that an implant <10 mm placed in the posterior maxilla carries an increased risk of failure. Due to crestal bone loss and/or sinus pneumatization, vertical bone height will often fall short of 10 mm in the posterior maxilla. Implants <10 mm may be considered when two or more implants are to be placed, and provided that the implant-supported crowns are rigidly splinted [Figure 5].
Angled or Tilted Implants
To avoid sinus grafting, angled implants may be anchored in the anterior or posterior sinus wall or in the pterygoid plate. This approach will potentially reduce the overall duration of treatment and enable the use of longer implants, thus adding to the primary stability of implants placed in the posterior maxilla.
Any tilted implant will need to be rigidly connected to axially loaded implants in the anterior segment. Angled posterior implants combined with at least two anterior implants in native bone by way of cross-arch stabilization have been demonstrated to offer short-term success rates on a par with rough-surfaced implants placed in bone augmented sinus lift procedures [Figure 6].
Another alternative to sinus lift procedures in completely edentulous patients would be to place zygomatic implants. One or two implants can be anchored bilaterally in the zygomatic bodies.
With regard to splinting, the same requirement applies as for posterior tilted implants; enough bone needs to be present to anchor two to four conventional implants in the anterior segment, thus obtaining cross-arch stabilization through rigid splinting of all implants. Unlike tilted implants, zygomatic implants need to be placed under general anesthesia. Another advantage of zygomatic implants over staged grafting procedures is that they reduce the overall treatment time. A final prosthesis can be usually delivered within 6 months. Disadvantages include their highly operator-sensitive placement, palatal bulkiness of the final prosthesis due to their palatal emergence platforms, and more serious complications than those reported after regular sinus grafting procedures. Combined with two or more anterior implants, zygomatic implants offer a survival rate similar to implants placed in grafted sites of the posterior maxilla [Figure 7].
Newer techniques in sinus lift
Antral membrane balloon elevation
The antral membrane balloon elevation (AMBE) technique has been proposed by Soltan and Smiler.
In this technique, a mucoperiosteal flap is elevated at the site, and an osteotomy of the buccal bone is performed by copious irrigation. The resulting bony fenestration is pressed inward, carrying the underlying membrane along with it. The dissection of the membrane for the sinus wall should be carried up to the medial wall. At this point, a balloon made out of latex is used. It should be inflated with 3–4 mL of sterile saline solution to check for leaks. The balloon is then emptied and placed against the sinus floor midway between the lateral and medial walls. The balloon is gently inflated with 2–4 mL of sterile saline solution, and as it expands, the membrane is elevated. After the required amount of elevation of the membrane, the balloon is deflated and removed. The space created by the balloon is grafted with a bone graft material. The mucoperiosteal flap is repositioned and sutured [Figure 8].
|Figure 8: (1) 6mm of bone (2) Crestal and minimal vertical relaxing incision (3) Buccal wall osteotomy (4) Balloon Testing (5) Balloon Elevation (6) (a) Balloon insertion along antral floor (b) Balloon inflation (7) Antral void (8) Resorbable collagen membrane saturated with platelet rich plasma (9) Hydroxyapatite moistened with PRP (10) Insertion of loosely compacted graft (11) Graft in place (12) Mucoperiosteal flap repositioned and sutured (13) Post-operative x-ray|
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Advantages of the antral membrane balloon elevation technique:
- Minimal risk of tearing and with a conservative, tissue-sparing surgical approach
- Reduces postoperative pain, bleeding, possibilities of infection, and the other morbid symptoms often associated with sinus lift procedures
- The technique is often completed within 30 min
- It is especially beneficial when access is difficult and when adjacent teeth are present next to the edentulous area.
Disadvantages of the antral membrane balloon elevation technique
- Unlike some of the currently used techniques, which are performed from a crestal approach, AMBE requires a buccal fenestration and a larger incision than do other alternative operations.
- On occasion, the membrane will tear either when preparing the osteotomy or reflecting the window. In such instances, the collagen resorbable membrane placed before grafting can be used to repair the defect.
- If the balloon is inflated too fast or if >4 mL of fluid is used to expand it, it may burst. This could rupture the antral lining. At this juncture, judgment should dictate whether to abort the operation or to repair the damage with a guided regenerative membrane.
- Depending on the overall health of the patient, as with any surgical procedure, infection is possible. The graft is most often lost under these circumstances. For this reason, the patient should be premedicated with 2 g of augmentin or 600 mg of clindamycin 2 h before surgery. Antibiotic coverage is continued for 5–7 days.
- Another possible complication may be caused by failure to expose the medial wall of the sinus. This wall must be exposed because the viability of the graft will depend on its intimate relationship to the adjacent bone. The postoperative X-ray will verify if the balloon-created antral space is filled and properly condensed.
Water lift system
The water lift system is a recently introduced sinus surgical instrument. According to the manufacturer's instructions, the water lift system is specifically designed for the safe operation of sinus lifting and includes the following sinus surgical set: an artificially intelligent (AI) drill, which is a resistance-sensitive drill, and an aqua system, which is a sinus membrane elevation instrument capable of providing evenly distributed hydraulic pressure on the Schneiderian membrane during sinus membrane elevation. The AI drill was designed to stop drilling on contact of the drill bit with the Schneiderian membrane [Figure 9].
|Figure 9: (a) Prepare osteotomy site using an artificial intelligent drill (b) and (c) Placing the aqua filter into the prepared door (d) (e) and (f) Lifting the Schneiderian membrane with a radiographic contrast medium using aqua system (g) Membrane elevation done (h) Filling the bone replacement material through the osteotomy prepared (i) Implant placement done|
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Vercellotti et al., in 2001, successfully used the piezoelectric technique to enable window access with a greatly decreased chance of membrane perforation [Figure 10].
|Figure 10: (a) Initial situation (b) Flap elevation (c) and (d) IM-2 insert was used (e) OT-4 insert was used to prepare osteotomy upto Schneiderian membrane (f) Osteotomy completed (g) Graft inserted (h) and (i) The implant has been installed (j) Prosthetic phase (k) Definitive treatment|
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The piezoelectric osteotomy procedure involves cutting a window in the alveolar bone. This can be done with great simplicity and precision – avoiding the risk of perforating the membrane – because of the shape of the bone scalpels, which work with ultrasonic modulating vibrations. The piezoelectric device has the ability to automatically cease surgical action when the scalpel comes into contact with nonmineralized tissue. Separation of the membrane is achieved by the ultrasonic vibrations of the piezoelectric device and by the hydropneumatic pressure of the physiologic solution used in a piezoelectric cavitation.
This technique has greatly reduced the risk of membrane perforation (approximately 5%–7%). Wallace et al. reported the perforation rate was reduced from the average of 30% with rotary instrumentation to only 7% with piezosurgery.,
| Conclusion|| |
Restoring edentulism with dental implants requires careful treatment planning. This is especially true with the posterior maxilla when pneumatized maxillary sinuses could limit the amount of alveolar bone for implant placement. Maxillary sinus floor elevation offers one of the most common preprosthetic procedures to solve this problem. Various techniques are available for maxillary sinus floor elevation, of which lateral window approach and crestal or osteotome approach are the most commonly used. The use of osteotomes for the transcrestal sinus floor elevation is a less invasive procedure than the lateral window approach in implant surgery. The long-term clinical outcome for the procedure is good and complications are few. Recently, newer techniques have been introduced to overcome the disadvantages of lateral window approach and transcrestal approach. Piezosurgery has been gaining wide acceptance as it prevents tearing of Schneiderian membrane.
The clinician should, however, understand that for a predictable outcome, a flat sinus floor without bone septa, an intact Schneiderian membrane is essential and membrane elevation must be performed with great care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]