LONGITUDINAL
EVALUATION OF THE LATERAL SINUS LIFT TECHNIQUE AND SIMULTANEOUS IMPLANT
PLACEMENT
AVALIAÇÃO LONGITUDINAL DA TÉCNICA DE LEVANTAMENTO LATERAL DE
SEIO MAXILAR E COLOCAÇÃO SIMULTANEA DE IMPLANTES
Andrade PC*, Brito Jr RB**, Smanio H***, Gomes França FM****
ABSTRACT: The aim of the present study
was to evaluate the clinical and radiographic results of maxillary sinus floor
lifting, performed by a lateral approach, with simultaneous implant placement. Thirty-seven patients
participated in the study, they were treated with lateral sinus lifting
procedure and simultaneous placement of 80 implants. Implants were evaluated
clinically and radiographically, and were followed up for six months. The
criteria used to assess the success of this technique were: Radiographic aspect suggesting implant
osseointegration with the bone tissue (absence of radiolucent alveolar areas);
absence of pain on percussion and torque on implants; implant immobility
checked by torquemeter. The
descriptive data analysis showed no presence of painful symptoms or mobility in
any of the evaluated implants. Nevertheless, 1
or 2 mm of bone loss was observed around the alveolar bone crest in 9 implants
(11.3%). The results demonstrated that the maxillary sinus floor lifting,
performed by a lateral approach, with simultaneous implant placement technique
was possible and sucessful.
KEYWORDS: Maxillary sinus. Autologous
transplantation. Dental implants.
RESUMO:
O objetivo deste
estudo foi avaliar a elevação do assoalho do seio maxilar, pela técnica de
abertura de janela lateral, e instalação simultânea de implantes. Participaram
desta pesquisa 37 indivíduos homens e mulheres com idade acima de 40 anos, não
fumantes, leucodermas, com presença de área doadora de enxerto intraoral à
cirurgia de levantamento de seio maxilar e foram submetidos a um total de 80
implantes. Os implantes foram avaliados clínica e radiograficamente após seis
meses. Os critérios clínicos verificados foram dor e mobilidade, por meio de
percussão e torquímetro (20N) respectivamente; e critérios radiográficos,
avaliados através da presença ou ausência de radiolucidez entre o ombro do
implante e a crista óssea alveolar, como um indicativo de perda óssea,
avaliadas por meio de radiografias periapicais. A análise descritiva dos dados
demonstrou que não houve presença de sintomatologia dolorosa e mobilidade em
nenhum dos implantes avaliados, no entanto, observou-se presença de
radiolucidez na região de crista óssea alveolar em 9 implantes (11,25%), sendo
que 7 implantes (8,75%) evidenciaram perda óssea de 1 mm e 2 implantes (2,5%)
mostraram perda óssea de 2 mm. Por meio dos resultados, foi possível concluir
que 88,75% dos implantes instalados simultaneamente à elevação do seio maxilar
pela técnica de abertura de janela lateral, obtiveram ausência de dor, de
mobilidade e de perda óssea na altura da crista óssea alveolar.
PALAVRAS-CHAVE:
Seio Maxilar. Transplante
Autólogo. Implantes dentários.
INTRODUCTION
The posterior maxillary is a region in the oral cavity that presents
difficulties to surgically place and maintain implants. After loss of the
posterior maxillary teeth, the alveolar process undergoes gradual resorption,
aggravated even further by pneumatization of the maxillary sinus1.
In addition, there are other aspects of implant placement to be
considered, such as the difficulty of surgical and reconstructive access, great
demand of occlusal forces, low bone density at the site and the region being
difficult for the patient to clean, as these cause quantitative and qualitative
bone and morphological alterations in the region2. These are some of the eventualities that could limit
or make it difficult to plan surgical prosthetic implants3.
An alternative treatment for these cases is the augmentation of the posterior maxillar by
sinus lifting augmentation, performed by
a lateral approach allowing osseointegrated implants to be installed
simultaneously, and prosthetic rehabilitation to be done later. The use of
autogenous, allogenous and alloplastic materials have improved the results of
this surgical technique and made them more predictable.3,4,5 The surgical sinus floor elevation
technique5,6 through a lateral access window, enables one to place
implants with a vertical height gain of up to 12mm6.
Whereas the maxillary sinus inferior wall lifting technique is more
conservative and enables implants to be placed with a maximum gain of 4mm
height, simplifying the lifting technique and reducing the costs7.
To place implants simultaneously with the two above-mentioned
techniques, there must be a minimum of 5mm of remaining alveolar bone1,4,6-11.
Simultaneous implant placement in extremely pneumatized maxillary
sinuses is advantageous in patients’ treatment by reducing their morbidity with fewer surgical interventions and the
implants are more safely stabilized12.
Autogenous bone is deal in comparison with other materials, because it
is highly osteogenic, osteoinductive and osteoconductive. Autogenous bone may
be collected from the iliac bone anterior crest, cranial cap, tibia, ribs or
intraoral regions, such as the mandibular symphysis, mandibular ramus and
maxillary tuberosity3-5.
However, several complications during and after conclusion of a sinus
graft procedure have been demonstrated in the literature. The commonest
complication is perforation of the maxillary sinus membrane, classified by
researchers as being commonly treatable with the use of collagen membrane. The
formation of mucocele, chronic sinusitis, infection, loss of graft material and
implant non-osseointegration are other complications reported1,9-11,13,14.
Therefore, the aim of this study was to verify the clinical and
radiographic success of the maxillary sinus lift technique with lateral window
opening and simultaneous implant placement.
METHODS AND
MATERIALS
A sample of unrelated, healthy, non-smoking subjects, over the age of 40
years, leucoderms, with presence of intraoral graft donor area and need of
sinus augmentation
to implant placement, were recruited for this study. The patients signed
consent forms approved by the ethical committee in Research at São Leopoldo
Mandic Dental School (#1256). These patients were submitted to implants
surgeries, with the intention of clinically and radiographically evaluation of
the maxillary sinus lift technique, with lateral window opening and
simultaneous implant placement.
After six months
post-surgery, the criteria used to assess the success of the maxillary sinus
lifting technique with lateral window opening and simultaneous implant
placement were as follows: Radiographic aspect suggesting implant
osseointegration with the bone tissue (absence of radiolucent alveolar areas,
by periapical radiographic measurements of the implant shoulder up to the
alveolar bone crest comparing with the initial radiograph); absence of pain on
percussion and torque on implants; implant immobility checked by torquemeter
(3i Implant Innovations, Inc).
Panoramic and periapical radiographs were used to diagnose sinus
pneumatization and alveolar bone loss.
Pre-operatively, the following drugs were prescribed: Dexamethasone
(Decadron®) injectable, 2mg, intramuscular: 1h before
surgery (anti-inflammatory); Azytromicine 500mg: two tablets 1h before surgery
(antibiotic); Alprazolan (Frontal®) 2mg: half an hour
before surgery (anxiolytic); assepsia of the face and intraoral regions with 2%
Chlorhexidine Digluconate.
The incisions consisted of a mid-crestal incision and two beveled
vertical incisions to the height of the vestibule. After completely exposing
the maxilla lateral wall, either U-shaped, rectangular, circular or oval
osteotomy was performed (Figure 1A). While using the diamond burr, it was
delicately “painted” over the bone, thus preserving the integrity of the
Schneider membrane, and abundant irrigated with sterile saline solution.
During osteotomy, the buccal plate was green-stick fractured and the
sinusal membrane was displaced.
Care was taken not to perforate the sinusal membrane, which was
carefully displaced with special curettes. The periosteal elevator was used to
withdraw the membrane from the vertical anterior wall, floor and middle
vertical wall to a height of 8 to 11 mm from the edge of the crest.
An autogenous graft was chosen from the mento region or the retromolar
area, depending on the case, together with freeze-dried bone. The implant was
introduced into the previously made surgical alveolus, halfway up to the
implant length. This material was mixed and condensed against the anterior and
posterior maxilla (Figure 1B) in order to mold the graft against and over the
implant to a height of 10 to 12 mm. During this procedure the implant was kept
in a position that would not compromise the subsequent prosthetic restoration.
Figure 1
– A: “U”-shaped lateral surgical
window; B: Graft material filling the space formed by sinusal membrane
elevation and
simultaneous implant placement.
A collagen membrane was placed over the sinusal membrane as a
prophylactic measure against possible micro-perforation and a reabsorbable
membrane was placed to cover the access window and implants; the tissues were brought
together so that the periosteum on each side of the primary incision could
establish contact, without intervening graft material or tissue tension.
Interrupted suture was used. Panoramic and periapical radiographs were taken 6
months after surgery.
As post-operative medication, the following drugs were prescribed:
Azytromicine 500mg: 1 tablet per day, for 15 days (antibiotic); Etoricoxib
(Arcoxia®) 120mg: 1 tablet per day, for
4 days (anti-inflammatory); Paracetamol 750mg: 1 to 2 tablets every 6 hours, in
case of pain (analgesic); Fexofenadine chloride 60mg plus Pseudoephedrine
Chloride 120 mg (Allegra D®): 1 tablet
every 12 hours, for 7 days (decongestant); Complex B 5000 units (Citoneurim®): 2 tablets per day, for 15 days; 0.12%
Chlorhexidine Digluconate applied to the region twice a day for 1 minute, for 5
days, afterwards use mouthwash twice a day for another 10 days. The data were
submitted to statistical exploratory analysis.
RESULTS
A total of 80 implants were installed in 37 patients (17 men and 20
women) ranging in age from 41 to 87 (mean age 57.4 years). The results, after 6
months evaluation, showed absence of painful symptoms and mobility in any of
the assessed implants, however, radiolucence was observed in the alveolar bone
crest region in nine implants (11.3%), as described in Table 1.
Bone loss of 1 and 2 mm was observed between the implant shoulder and
the alveolar bone crest, assessed by measurements in periapical radiographs. As
described in Table 2, seven implants (8.7%) presented 1 mm of bone loss and two
implants (2.5%) showed 2 mm of bone loss.
Table 1
– Absence or presence of the assessed criteria
Criteria Assessed |
Absence |
Presence |
Total |
||
|
n |
% |
n |
% |
|
Pain |
80 |
100 |
0 |
0 |
80 |
Mobility |
80 |
100 |
0 |
0 |
80 |
Radiolucence |
71 |
88.7 |
9 |
11.3 |
80 |
Table 2 – Frequence of bone
loss, assessed radiographically, between the implant shoulder and the alveolar
bone crest.
Loss (mm) |
Comparison with implants that had bone loss |
Comparison with total implants |
||||
|
n |
% |
total |
n |
% |
total |
1 |
7 |
77.8 |
9 |
7 |
8.7 |
80 |
2 |
2 |
22.2 |
9 |
2 |
2.5 |
80 |
DISCUSSION
The commonest complication associated with sinus lifting is sinusal
membrane perforation1,4,13.
Moreover, it was related a case of
excessive Schneider member elevation during the bone graft procedure, causing
the maxillary sinus to be partially obliterated. In this study, no perforation
of the Schneider membrane, or any other complication occurred14.
A sufficient amount
of pre-existent bone in the maxilla is required for a single stage maxillary
sinus lifting with simultaneous implant placement. The height between the
remaining bone crest up to the maxillary sinus must be at least 5 mm; and the
minimum bone thickness between 6 and 7 mm15.
If there is insufficient remaining bone to stabilize the implant, two-stage
surgery is recommended, with the bone graft being done first and then the
implants.
Autogenous bone grafting is used to create and maintain a space between
the sinusal membrane surface and the exposed implant surface, and thus keep the
integrity of the membrane. Clinical and histological evidences indicate that
the use of autogenous bone graft is favorable during maxillary sinus lift
procedures, as it demonstrates good osteogenic, osteoinductive and
osteoconductive properties3,4.
Among the most requested bone donor areas the mento and ascendant
mandible ramus can be used.5 The use of
mandibular bone as graft in maxillary sinus lifting has grown. Of particular
importance, intraoral grafts are associated with less bone reabsorption as
compared to grafts of extraoral origin, such as the iliac crest8. Other advantages associated with intraoral
grafts include the use of local instead of general anesthetic, shorter
operating time without the need to hospitalization, less morbidity at the donor
site and lower costs.4 Based on these
findings autogenous bone graft from the mandibular ramus and mandibular
symphysis or mento, associated with freeze-dried bone were chosen for this
research.
In the present study, no pain on percussion and torque on implants was
detected, nor implant mobility checked by torquemeter (20N), in six months,
resulting in clinical success up to the present time.
Radiographically, the results indicated 88.7% success as regards bone
loss, evidenced by measurements of periapical radiographs performed six months
after maxillary sinus lifting surgery with immediate implant placement. It was
found that 11.3% of the cases presented bone loss, assessed from the implant
shoulder to the alveolar bone crest, and seven implants (8.7%) evidenced bone
loss of 1 mm and two implants (2.5%) showed bone loss of 2 mm.
Bone graft of the maxillary sinus floor with autogenous bone for implant
insertion was considered a safe treatment modality with good long term results9,10,
however, infection during healing of the grafted site reduced the success
and subsequent osseointegration of the implant9.
In another study the authors11 assessed 38 implants by
measuring the distance between the top of the implant shoulder and the first
implant contact and radiographically visible bone on the mesial and distal
sides. The last exam showed a mean bone loss of 1.65 mm on the mesial and 1.68
mm on the distal side. The implant success rate was 76.3%, as three implants
(7.9%) were lost. The implant loss was associated with surgical membrane
exposure.
The Maxillary Sinus Consensus Conference report of 1996, stated that the
various materials commonly used for grafts in the maxillary sinus all aim for
an acceptable performance of around 90% success, if used alone or in
combination16. In this study
freeze-dried bone was used in association with autogenous bone. Freeze-dried
bone has been shown to possess slower revascularization and a greater
reabsorption rate than autogenous bone, which may probably have caused alveolar
bone loss around the implants, particularly when the tooth elements were
extracted in the same session as the implant, autogenous and freeze-dried bone
graft placements.
Adequate bone volume and quality at the surgical site is a prerequisite
for a favorable long-term prognosis in osseointegrated implants. As shown by
the results of the present study (no implant with mobility), correct bone
increase is essential for good endosseous implant stability. Without this bone
increase, implantodontic treatment may be compromised and lead to loss of the
implant.
CONCLUSIONS
According
to the results obtained in this study, it was possible to conclude that:
·
In all the cases there was absence of pain and
mobility after 6 months.
·
Radiographic observation showed alveolar bone
loss of 1 or 2 mm in 11.3% of the implants after the same period of
observation.
·
Lateral sinus lift in conjunction with implant
placement allowed prosthetic rehabilitation in patients with severe posterior
maxilla atrophy.
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* Paulo Coelho Andrade, DDS. MS research assistent, São Leopoldo Mandic Dental School, Campinas/SP. e-mail: implantodontia@terra.com.br
** Rui Barbosa Brito Jr., DDS, MS, PhD, professor, São Leopoldo Mandic Dental School, Campinas/SP e-mail: rui_barbosa@hotmail.com
*** Henrique Smanio, DDS, MS, professor, São Leopoldo Mandic Dental School, Campinas/SP, email: henriquesmanio@hotmail.com
**** Fabiana M. Gomes França, DDS, MS, PhD, professor, São Leopoldo Mandic Dental School, Campinas/SP - Rua José Rocha Junqueira, 13 - Ponte Preta - Campinas/SP - Brazil. Zip Code: CEP 13045-610. e-mail: biagomes@yahoo.com
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