A Hybrid Technique for Sinus Floor Elevation in the Severely Resorbed Posterior Maxilla

8/3/2019 A Hybrid Technique for Sinus Floor Elevation in the Severely Resorbed Posterior Maxilla

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Journal o Periodontal&Implant ScienceJPIS

pISSN 2093-2278

eISSN 2093-2286

Copyright 2010 Korean Academy of Periodontology

This is an Open Access article distributed under the terms of the Creative Commons AttributionNon-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).

A hybrid technique or sinus foor elevation in the

severely resorbed posterior maxilla

Ui-Won Jung, Ji-Youn Hong, Jung-Seok Lee, Chang-Sung Kim, Kyoo-Sung Cho, Seong-Ho Choi*

Department o Periodontology, Research Institute or Periodontal Regeneration, College o Dentistry, Yonsei University , Seoul, Korea

Purpose: This study aimed to evaluate the eectiveness o the modied sinus oor elevation technique described hereateras a hybrid technique, in 11 patients with severely resorbed posterior maxillae.Methods: Eleven patients who received 22 implants in the maxillary premolar and molar areas by the hybrid technique wereenrolled in this study. A slot-shaped osteotomy or access was prepared on the lateral wall along the lower border o the sinusoor. The Schneiderian membrane was ully reected through the lateral slot. Following drilling with the membrane protect-ed by a periosteal elevator, the bone was grated. All implants were placed simultaneously with sinus augmentation. The cu-mulative success rate was calculated and clinical parameters were recorded. Radiographic measurements were perormed.Results: All implants were well maintained at last ollow up (cumulative success rate=100%). The mean residual bone height,augmented bone height, crown-to-implant ratio, and marginal bone loss were 4.11.64 mm, 8.761.77 mm, 1.210.33 mm, and0.340.72 mm, respectively.Conclusions: Simultaneous implant placement with sinus augmentation by hybrid technique showed successul clinical re-sults over a 2-year observation period and may be a reliable modality or reconstruction o a severely resorbed posterior max-illa.

Keywords: Bone substitutes, Dental implants, Maxillary sinus.

J Periodontal Implant Sci 2010;40:76-85 doi: 10.5051/jpis.2010.40.2.76

Research Article

INTRODUCTION

It can be challenging to place implants in the posterior max-illa because various anatomical limitations can jeopardize the

long-term success o implant rehabilitation [1]. In particular,reduced vertical alveolar bone height resulting rom pneuma-

tization o the maxillary sinus [2,3] and resorption o the ridgeollowing tooth extraction [4] oten hamper placement o the

implant with a proper length.Since it was rst introduced by Boyne in 1969, maxillary si-

nus oor elevation utilizing the Caldwell-Luc technique hasbeen associated with clinical success [5-11]. This technique

provides an easier approach to the sinus membrane with

good visibility through the lateral opening. However, disad-vantages, like invasiveness o the surgical procedure, bleed-

ing, postoperative swelling, and pain, do exist. This techniqueis also associated with high risks or various biological com-

plications including membrane peroration, exposure o theopening site, inection, and stula ormation.

In order to simpliy the lateral window technique, Sum-mers introduced the crestal approach, called bone-added os-

teotome sinus oor elevation (BAOSFE) [12]. This procedureis relatively more conservative and less invasive; however,

some problems or common use remain, the most prominento which are limited accessibility and visibility or elevating

the sinus membrane. The Schneiderian membrane is elevat-

Received: Feb. 10, 2010; Accepted: Mar. 25, 2010*Correspondence: Seong-Ho Choi

Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 134 Shinchon-dong, Seodaemun-gu,

Seoul 120-752, Korea

E-mail: shchoi726 @yuhs.ac, Tel: +82-2-2228-3189, Fax: +82-2-392-0398


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Journal o Periodontal&Implant ScienceJPIS Ui-Won Jung et al. 77

ed only by hydraulic pressure rom the plug o bone grat ma-

terials with luid reserved inside and using a set o osteot-omes (Implant Innovations, Palm Beach Gardens, USA) or

compaction rather than direct surgical undermining. Thus,the extent o reection varies according to the elasticity o the

membrane and the attachment to the underlying bone [13].Excessive distension can lead to peroration o the mem-

brane, the requency o which is approximately 3.8% (range,0-21.4%).

Opinions about the eect o membrane peroration duringBAOSFE on the success rate o implantation are controver-

sial. Some reports suggest that the inuence is insignicant[14-17], while others have reported associated reductions in

survival rates [18,19]. Still, the integrity o the sinus membrane

is important or containing grat materials, and or BAOSFE,the augmentation is generally limited to 3-5 mm in height.The height o the remaining bone can be correlated with

the success rate o the implant placed using the BAOSFEtechnique. The general recommendation is to use this tech-

nique when there is 5-7 mm o remaining bone [20]. When 4mm or less o the bone is available, the success rate is 85.7%,as compared to 96% when the minimum height is 5 mm [21].

It can be assumed that 6 mm or more o preexisting bonewould be required to accommodate an implant at least 10

mm in length since the achievable bone gain with theBAOSFE technique is limited to 3-5 mm [12,22]. Furthermore,

a sufcient amount o bone is needed to provide appropriateinitial stability or the implant.

In brie, the lateral window approach allows substantial ele-vation o the sinus oor and provides a good visual approach

to the Schneiderian membrane. On the other hand, the cr-estal approach is less invasive, shows reduced postoperative

complications, and improves initial stability with osteotomecondensation. Thereore, i greater bone augmentation and

sufcient initial stability are achieved without peroration othe sinus membrane when using the BAOSFE technique, the

5-mm limitation could be overcome.

This study aimed to evaluate the eectiveness o the modi-ed sinus oor elevation technique described here as a hy-brid technique, which is a BAOSFE-based technique com-

bined with a minimal-sized lateral access slot or direct sur-gical undermining o the Schneiderian membrane, in 11 pa-

tients with severely resorbed posterior maxillae.

MATERIALS AND METHODS

Patient and site description

This study was carried out at the Department o Periodon-

tology o the Dental Hospital o Yonsei University, Seoul,

South Korea and included 11 patients who visited between

December 2006 and August 2007 or xed type implant re-

habilitation in maxillary posterior areas with limited boneheight. Systemic health and extraoral and intraoral condi-

tions were evaluated. Medically compromised patients werereerred to a physician. Prior to sinus augmentation, internal

disease o the maxillary sinus, the remaining depth o the al-veolar ridge, and the position o septum were determined

precisely using panoramic radiographs and computerizedtomography (CT). Three-dimensional reconstructions o the

pre-operative CT scans (OnDemand 3D program, CyberMed,Seoul, Korea) were prepared or treatment planning, deter-

mining the insertion path, and simulation o the surgery. Pa-tients were selected according to the ollowing inclusion cri-

teria: 1) A remaining posterior maxillary edentulous ridge

with insuicient vertical bone height, 2-7 mm, 2) Healingtime since tooth extraction longer than 3 months.Exclusion criteria included: 1) an uncontrolled medical con-

dition: a psychological disorder, diabetes mellitus, immunesuppression, bisphosphonate medication, chemotherapy, or

radiotherapy, 2) a pathologic lesion in the sinus: benign/ma-lignant tumor, mucocele, or active sinusitis, 3) paraunctionalhabits like bruxism or clenching, 4) untreated active perio-

dontitis in neighboring teeth.The general procedures or implantation and the possible

complications were thoroughly explained to the patients.The treatment option was chosen ater discussing the bene-

its and risks o the surgery with each patient. Written in-ormed consent, which was in accordance with the institu-

tional review board (IRB) at Yonsei Dental Hospital (2-2008-0011), was obtained rom each patient.

Eleven patients were included: eight men and three wom-en, with an average age o 49.4 years (range, 35-69 years). All

patients were determined to have intact and healthy maxil-lary sinuses. None o the patients smoked and patients with

active periodontal lesions were treated beore implant sur-gery.

All o the patients, except one with severe dental caries, had

undergone tooth extraction due to periodontal problems,and one patient (patient no. 6) was diagnosed with general-ized aggressive periodontitis (GAP). Twenty-two dental im-

plants (Straumann SLA, Institute Straumann AG, Walden-burg, Switzerland) were placed in the maxillary premolar and

molar areas using the hybrid technique: 10 on the right and13 on the let. All o the implants were placed with the length

o at least 10 mm and 95.5% were wider than 4.8 mm in di-ameter. Detailed inormation about the patients and im-

plants placed are listed in Table 1.

Surgical procedures

Pre-surgical CT (GE Medical System, Milwaukee, USA)


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Journal o Periodontal&Implant ScienceJPISHybrid technique ensured successul sinus augmentation78

scans were perormed to evaluate the pathologic lesion and

identiy the size and shape o the maxillary sinus (Fig. 1). Sur-gical procedures were perormed using antibiotic prophylax-

is (Augmentin, Il-Sung Drug Company, Seoul, Korea). Local

anesthesia was achieved with lidocaine 2% with 1:100,000epinephrine (Yuhan, Seoul, Korea). Horizontal midcrestal and

vertical releasing incisions were made and a ull thicknessap was reected. A slot-shaped ostectomy was prepared on

the lateral bony wall using a piezoelectric device (Piezosur-gery, Mectron, Carasco, Italy) (Fig. 2). The position o the slot

opening was just above the sinus loor, running along thelower border. The mesiodistal width o the slot was extended

just enough to include the placement sites. The apicocoronalheight was about 3-5 mm to allow proper access o the eleva-

tion instruments to the sinus oor. Schneiderian membranereection was ully extended mesiodistally and medially over

the uture drilling site using a sinus membrane elevator in-

serted through the access slot. Drilling was perormed in se-rial sequence while the membrane was protected by a pe-riosteal elevator (Fig. 3). Bone grat material (MBCP, Biomat-

lante, Vigneux de Bretagne, France; Osteon, Dentium, Seoul,Korea) was added rom both directions through the lateral

slot and drilled sites. Final site preparation was perormednot with drills but with osteotomes (Institut Straumann AG,Waldenburg, Switzerland), using the nal diameter or one

step smaller to condense the bone available (Fig. 4). Implantswere placed simultaneously with sinus augmentation (Fig. 5),

and insertion torque was recorded.Simple interrupted and mattress sutures were made using

4-0 Monosyn (gluconate monolament, B. Braun, Melsun-gen, Germany). The sutures were removed ater 10-14 days

and the patients were prescribed 2% chlorhexidine 3 timesper day over 2 weeks. Temporary dentures were not allowed

until overall swelling had subsided, at which time the den-ture could be relined.

Table 1. Details o the individual implants placed.

Patient

number

Missing

tooth

Implant diameter/

length (mm)

Amount of

bone graft

material (g)

Follow-up

period

(months)

1 #26 S 4.1RN / 10 MBCP 0.5 + Auto 33

#27 TE 4.1RN / 10 33

2 #27 TE 4.8WN / 12 MBCP 0.5 + Auto 32

3 #17 S 4.8WN / 10 MBCP 1.5 + Auto 28

#16 TE 4.1RN / 10 28

#26 TE 4.1RN / 10 28

#27 S 4.8WN / 10 28

4 #16 S 4.8WN / 10 MBCP 0.5 + Auto 295 #15 TE 4.1RN / 10 MBCP 0.25 + Auto 26

6 #17 TE 4.8WN / 10 MBCP 3 + Auto 25

#16 TE 4.8WN / 10 25

#25 TE 4.1RN / 10 25

#26 S 4.8WN / 10 25

#27 S 4.8WN / 10 25

7 #16 TE 4.1RN / 10 MBCP 0.5 28

8 #26 TE 4.8WN / 10 MBCP 1.0 + Auto 27

#27 TE 4.8WN / 10 27

9 #17 S 4.8WN / 10 MBCP 0.5 + Oragraft 27

#16 S 4.8WN / 10 27

10 #26 S 4.8RN / 10 Osteon 0.5 + Oragraft 25

#27 S 4.8RN / 10 25

11 #27 S 4.8RN / 10 Osteon 0.5 + Auto 25

DiameterS: standard, TE: tapered effect, RN: regular neck, WN: wide neck.

Bone graft materialMBCP: macroporous biphasic calcium phosphate, Osteon,

Oragraft, Auto: autogenous bone.

Figure 1. Pre-operative computed tomography. (A) Panoramic view. (B) Three-dimensional reconstructed image. Note that there was a sep-tum at the second molar area in the let maxillary sinus.

A B


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Figure 2. Preparation o the access slot and drilling o the implant site.

Figure 3. Ater reection o the ap, the access slot was prepared along the lower borderline o the sinus with the piezoelectric device. Drill-ing was perormed while the Schneiderian membrane was protected by the periosteal elevator.

Figure 4. Bone grating through lateral slot and drilled sites.


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Prosthetic treatment and maintenance

The prosthetic treatments and unctional loadings were in-corporated ater a healing period o 5-10 months (average, 7.5

months). All patients had been provided with screw-retained

type prosthetics using a SynOcta

abutment (Institute Strau-mann AG, Waldenburg, Switzerland). Ater the nal settingo the crown, patients received ollow-up care every 3 months.

Examination included evaluation o sot tissue and oral hy-giene states, particularly around the implants.

Evaluation and analysis

All patients were ollowed until August 2009. Clinical pa-rameters including the plaque index (Lo_e & Silness), gingival

index (Silness & Lo_e), probing depth, and peri-implant kerati-nized tissue were evaluated at the nal ollow-up appoint-

ment. Radiographic parameters including preoperative re-

maining bone height, postoperative augmented bone height,

crown-to-implant ratio, and marginal bone loss were evalu-

ated just ater implant surgery, one year ater placement, andat the nal ollow-up visits, and were compared to the base-

line measurements (Figs. 6-8). All measurements were per-

ormed twice by dierent investigators.At the nal visit, cone beam volumetric tomography wasperormed or radiographic evaluation o the grated sinus in

6 patients (Fig. 9). Panoramic and peri-apical standard radio-graphs were taken or the remainder. The presence o any

complications was recorded. The categories were: 1) opera-tive complications: excessive bleeding, peroration o mem-

brane, and benign paroxysmal vertigo, 2) postoperative com-plications: swelling, ecchymosis, pain, loss o grat materials,

and nasal bleeding, 3) prosthetic complication: decementa-tion, screw loosening, racture o porcelain, and racture o

xture.

Figure 5. Simultaneously placed implants at the second molar area.

Figure 6. Radiographs on the day o surgery (A) and 27 months ater surgery (B). Arrowheads: augmented bone area.

A B


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Statistical analysis

The cumulative success rate (CSR) o the implants placedusing the hybrid technique was calculated by lie-table analy-

sis [23]. The criteria or success were those proposed by Co-chran et al. [24] 1) absence o clinically detectable implant mo-

bility, 2) absence o pain or subjective sensation, 3) absence o

recurrent peri-implant inection, and 4) absence o continu-

ous radiolucency around the implant. For the radiographicmeasurements, the correlation between the evaluations o

the two examiners was determined.

RESULTS

All patients were ollowed or an average o 27.3 months(range, 25-33 months). There were no ailures or removal o

the xtures, and 22 implants were maintained until the nalrecall.

Details about implant placements and clinical observations

Using the hybrid technique by slot access, an average o0.45 g o bone substitute was used or each implant. In some

cases, a minimal amount o autogenous bone was added. In-sertion torque ater implant installation was 29.57 Ncm

(range, 0-50 Ncm).

Table 2 shows the plaque and gingival index values mea-sured at last ollow-up examination. All patients except onemaintained good or acceptable oral hygiene. The normal

range o probing depth was present in all patients (Table 3).The width o keratinized tissue around the implant was

4.641.56 mm. The patient who was diagnosed with GAP re-ceived ve implants in the severely resorbed posterior maxil-

la; all implants were well maintained (Fig. 7).

Radiographic analysis

The measurements o the two dierent examiners were

well correlated (correlation coefcient=0.99, P


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Radiographic analysis showed that the augmented bonegrat ormed a dome with a clear round margin under the el-

evated Schneiderian membrane. This grated area surround-ed the xture, and the implant apex was not exposed out o

the dome or the membrane. The means and standard devia-tions o radiographic parameters are shown in Table 4.

Cumulative success rateNo patients withdrew rom the study; the CSR was 100%.

ComplicationsThere were no perorations o the sinus membranes, even

or patients who had an irregularly shaped oor or specicseptum involved. Benign paroxysmal vertigo, which can

sometimes occur ater severe osteotome preparation, did notoccur in any patient. Bleeding and/or acial swelling that oc-

curred ater the surgery was relatively mild as compared tothat ollowing the conventional lateral window approach.

Postoperative complications like ecchymosis, loss o gratmaterials, or nasal bleeding did not occur. Ater unctional

loading, no specic prosthetic complications were observed.

DISCUSSION

Many treatment modalities have been proposed to over-

come an inadequate volume o bone in atrophic ridges andpneumatized maxillary sinuses. Tooth-implant connected

bridges, zygoma implants, and short or tilted implants arethe alternatives or gratless reconstruction, whether or not

the distraction osteogenesis, sinus oor, or inlay/onlay gratscompensated or the vertical loss o bone with hard tissue

augmentation [25]. Despite evidence o clinical utility, ew othese techniques are appropriate or routine use by practitio-

ners. In this study, we proposed a hybrid technique as a sim-

pler and saer alternative or placing dental implants simul-taneously with sinus elevation in severely resorbed posteriormaxilla and evaluated the clinical outcomes in 11 patients

over 2 years o ollow up.The hybrid technique used in this study was based on

BAOSFE and was modied to have a lateral access slot, whichwas derived in part rom the lateral window concept. BAOS-

FE is a less traumatic technique that decreases patient mor-bidity. Specially designed osteotomes with concave tips are

inserted just short o the membrane so as not to penetratethe oor, and the membrane is elevated by a hydraulic plug

composed o bone particles and uids trapped in the tips o

instruments [12]. This blood cushion helps to avoid direct

Table 4. Radiographic analysis.

Number of implants MeanSD

Remaining bone height 2-4 mm 11 4.11.64

4-6 mm 8

6-8 mm 3

Augmented bone height 5-7 mm 6 8.761.77

7-9 mm 69 mm 10

Crown to implant ratio 0.5-1.0 6 1.210.33

1.0-1.5 12

1.5-2.0 4

Marginal bone loss


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contact between the sinus membrane and the hard objects

like bone substitutes, particles, and instruments [26]. Howev-er, in several studies, in which avorable clinical results and no

specic signs o perorations were detected during BAOSFE,disrupted membrane integrity around the augmented area

was ound upon endoscopic evaluation [16,17]. In most o thecases, microlaceration and small-sized peroration were in-

volved with vertically excessive, but laterally limited, disten-sion o the elevated membrane, which could cause displace-

ment and loss o the grat materials. Transient or chronic si-nusitis, local inammation, and resorption o the bone grat

by extravasation o the grat materials have been reported,stressing the importance o maintaining membrane integri-

ty to guide bone regeneration underneath [27,28].

The primary purpose or modiying BAOSFE with lateralslot ostectomy was to provide good visual access or reect-ing the Schneiderian membrane at the inerior border o the

sinus loor. The apico-coronal dimension o the slot is 3-4mm, and the mesiodistal extension included the implanta-

tion site (ideally to within 2 mm above the lower border othe sinus oor). Limiting these dimensions provided a pas-sageway or instrumentation without causing any difculties

to the membrane at the inerior sinus border. The slot maydecrease the risk o tearing and peroration during surgery

and overcome the limitations associated with the blind tech-nique or the conventional lateral window technique.

In the blind technique, the Schneiderian membrane mightbe at high risk or peroration due to the restricted reection

pattern [13,16]. In the hybrid technique, drilling was perormedand osteotomes were used under the protection o the mem-

brane with the periosteal elevator inserted through the slot.Drilling with direct vision and the protection o the mem-

brane reduced the number o tappings on the sinus loor,which also decreased the chance o peroration related to the

tapping sequence [17,21]. In addition, minimizing tappingmight reduce patient discomort and the chance o paroxys-

mal positional vertigo that can be induced by head trauma

with vibratory and percussive pressures on the upper maxilla[29-31].A thin sinus membrane, an irregularly sloped inerior bor-

der, and specic anatomic structures like the sinus septa arealso involved with membrane peroration [7,32,33]. The prev-

alence o sinus septa is about 25% and sinus septa are signi-cantly more common in the atrophic edentulous maxillary

segments than in the non-atrophic dentate areas [34,35]. Inthe lateral window technique, membrane peroration rates

during bone grating have been reported at 10-40% [7,36-38].Hinge-type openings might make tearing more likely when

associated with septa [33] or an anatomically narrow-shaped

sinus (in the sagittal section), which preclude window dis-

placement inward and upward [33,39]. In our study, some pa-

tients showed septa or moderately inclined slopes that couldhave experienced perorations i the elevations were per-

ormed by conventional crestal or lateral approaches. How-ever, with the help o visual access and minimal reection o

the Schneiderian membrane, there was no excessive tensionto cause rupture when the grat materials were pushed up-

wards and no specic complications were observed.In the conventional lateral window approach, too much

bone substitute tends to be used. Direct application o thegrat materials through the drilling site ensured the even

distribution in all directions and created a dome-shaped ele-vation around the implant apex. The average volume o the

grated material was approximately 0.45 mg per implant.

Most o the grated material surrounded the implant closely.The survival rate o sinus augmentations is signiicantlyhigher when the barrier membrane is placed on the lateral

window than when no barrier is placed [8,40]. Sealing by bar-rier membrane can isolate the grated material rom connec-

tive tissue invasion and results in a better quality o bone. De-spite the act that no barrier membrane coverage was used inthis study, there were no signs o grat material loss, and di-

mensional changes o the augmented bone were minimal.In the hybrid technique, the sizes o the incision and reec-

tion o the periosteal ap are minimized with respect to theconventional lateral window technique, which might reduce

postoperative complications like swelling and pain. Becauseo the limited-sized preparations, the chance o intruding

into several intraosseous anastomoses in the lateral sinuswall is reduced.

I sufcient primary stability is provided, a one-stage ap-proach is preerred, even in minimal residual alveolar bone.

Primary stability, which protects the implants rom micro-movement, is an important actor or successul implantation.

In this study, better initial stability was achieved because thesot bone was compressed by the osteotome during the nal

preparation o the implant bed. In addition, the coronal ta-

pered design o the xture improved initial stability. Hence,i the initial stability can be controlled despite a lack o resid-ual bone height, successul osseointegration o implants can

be expected. In this study, the mean insertion torque repre-senting primary stability o the implant was approximately

30 Ncm, and there was no spinning o the implants whentightened manually.

Within the limitations o the small number o patients andthe relatively short ollow-up period, our results indicate that

simultaneous implant placement with sinus augmentationby hybrid technique resulted in clinically successul out-

comes over a 2-year observation period and suggest that this

technique is a predictable treatment modality in severely re-


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sorbed posterior maxillae with a low prevalence o complica-

tions.

CONFLICT OF INTEREST

No potential conict o interest relevant to this article wasreported.

ACKNOWLEDGMENTS

This study was supported by a aculty research grant rom

Yonsei University College o Dentistry or 2009 (6-2009-0041).

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A Hybrid Technique for Sinus Floor Elevation in the Severely Resorbed Posterior Maxilla

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