sinus elevation ; grafts

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Sinus Elevation and Bone Grafting in

Implantology

Dr. Bhuvanesh Kumar.D.V

D.V.BHUVANESH KUMAR

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Contents• Introduction• Anatomy of the maxillary sinus• Classification of Bone

• Amount of Available Bone• Misch Classification on Bone Density• CT Classification

• Classifications of the Posterior Maxilla• Misch Classification• Chiaspasco Classification

• Indications and Contraindications• Sources of Graft material• Techniques

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•Prosthetic Management of the Sinus Graft Patient•1st Stage Provisional Prosthesis•2nd Stage Provisional Prosthesis•Definitive Prosthesis

•Complications•Review of Literature

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IntroductionA common problem

encountered while placing implant fixtures in the posterior maxilla region is the lack of bone required for successful implant therapy

This problem led to the development of the sinus elevation procedure by Tatum, James and Boyd in the 1950s.

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• Grafting of the sinus floor increases the vertical height of the posterior maxillary bone prior to implant placement

• The reports of implant survival under functional loading vary from 36% to 61.7% and the overall success rate is 91.6% for implants with a rough surface and 92.3% for particulate bone grafts.

The 1996 Sinus Consensus Conference deemed this therapeutic modality highly predictable and effective

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Anatomy of the maxillary sinus

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• Is approximately 15ml in volume air space although the actual size depends on the amount of resorption that has taken place

• Formation begins in the second to third year of life and is nearly complete by 8 years of age

• It has a non-physiologic drainage port high on the medial wall that drains into the middle meatus of the nose.D.V.BHUVANESH KUMAR

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•The bony walls are thin, except for the anterior wall and the alveolar ridge in the dentate patient.

•Is lined with a pseudostratified columnar epithelium – “Schneiderian Membrane”

•Beneath the surface epithelium , is a highly vascular thin tissue which Is followed by periosteum D.V.BHUVANESH KUMAR

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• Area of sinus surgery is mainly supplied by branches from the internal maxillary artery.

• Other arteries supplying the sinus are:• Infraorbital artery• Superior labial artery• Anterior ethmoidal artery

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Classification of Bone

Division A Bone (Abundant Bone)Division B Bone (Barely Sufficient Bone)Division C Bone (Compromised Bone)Division D Bone (Deficient Bone)

Bone Density

D1 Dense Cortical Bone

D2 Thick dense to porous cortical bone on crest and coarse trabecular bone within

D3 Thin porous cortical bone on crest and fine trabecular bone within

D4 Fine trabecular bone

D5 Immature, non-mineralized bone

D1: >1250 Hounsfield unitsD2: 850-1250 Hounsfield unitsD3: 350-850 Hounsfield unitsD4: 150-250 Hounsfield unitsD5: <150 Hounsfield units

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Classifications of the Posterior

Maxilla

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•Misch Classification•Chiapasco Classification

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Misch Classification (1999)Treatment

OptionResidual

Bone Height (mm)

Treatment Procedures Healing Time

1 >12 Division A implant placement Implant Osseointegration: 4-6

2 10-12 Sinus graft; simultaneous division A implant placement

Implant Osseointegration: 6-8

3 5-10 Lateral wall approach sinus graft; delayed division A implant placement

Graft consolidation: 2-4Implant Osseointegration: 4-8

4 >5 Lateral Wall approach sinus graft; delayed division A implant placement

Graft consolidation: 6-10Implant osseointegration: 4-10

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Option 1 Option 2

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Option 3 Option 4

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Chiapasco Classification (2003)• Modification of the existing classifications with the aim

of correlating morphology with current surgical reconstructive protocols.

• Classification is based on 3 variables:• Width• Height of the residual alveolus• Inter-ridge relation

• The variables are used to define 9 types of sinus-posterior maxillary alveolar morphologies according to their treatment needs

• Classes A to D address height and width, and the remaining classes define crown height space.

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Class A•Residual alveolar ridge height of 4 to 8mm•Residual alveolar ridge width of at least 5mm (i.e. absence of significant horizontal resorption and maintenance of acceptable horizontal intermaxillary relationships)

•Absence of vertical resorption of the alveolar ridge with maintenance of acceptable vertical intermaxillary relationship

•Suggested Surgical Protocol:A. Sinus Elevation with osteotome

techniqueB. Sinus Elevation via lateral approach

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Class B•Residual alveolar ridge height of 4 to 8mm•Residual alveolar ridge width of 5mm(i.e. presence of horizontal resorption and unfavorable horizontal intermaxillary relationship)

•Absence of vertical resorption of the alveolar ridge with maintenance of acceptable vertical interarch distance

•Suggested Surgical Protocol:A. Sinus Elevation and lateral bone graftingB. Sinus Elevation and guided bone

regenerationD.V.BHUVANESH KUMAR

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Class C•Residual alveolar ridge height of less than 4mm•Residual alveolar ridge width of at least 5mm (i.e. absence of significant horizontal resorption with maintenance of acceptable horizontal intermaxillary relationship)


•Suggested Surgical Protocol:• Sinus Elevation via lateral approach

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Class D•Residual alveolar ridge height of less than 4mm•Residual alveolar ridge width of less than 5mm(i.e. presence of horizontal resorption and unfavorable horizontal intermaxillary relationship)


•Suggested Surgical Protocol:A. Sinus elevation via lateral approach with

lateral bone graftingB. Sinus Elevation and guided bone

regenerationD.V.BHUVANESH KUMAR

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Class E• Same characteristics as Class A except with increased

crown height space

• Suggested Surgical Protocol:A. Vertical onlay grafts with autogenous bone blockB. Interpositional alveolar bone graftC. Vertical guided bone regenerationD. Vertical distraction osteogenesis

• The sinus graft is associated with one of these procedures but only if correction of the vertical intermaxillary discrepancy is insufficient to obtain adequate bone volume for implant placement

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Class F•Same characteristics as Class B except with increased vertical crown height space

•Suggested Surgical Protocol:A. Simultaneous vertical and horizontal onlay grafts

with autogenous bone blocksB. Interpositional bone graft without sinus graftingC. Simultaneous vertical and horizontal bone

regeneration

•Vertical distraction osteogenesis is not indicated because the technique does not correct the horizontal defect

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Class G

•Same characteristics of Class C except with increased vertical crown height space

•Suggested Surgical Protocol:A. Sinus graft via a lateral approach

combined with vertical autogenous block onlay graft

B. Sinus graft with vertical guided bone regeneration D.V.BHUVANESH KUMAR

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Class H•Same characteristics as class D except with increased vertical crown height space

•Suggested Surgical Protocol:A. Sinus graft via a lateral approach with

simultaneous vertical and horizontal onlay block grafts

B. Sinus graft with simultaneous vertical and horizontal guided bone regeneration

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Indications and Contraindications

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Indications•Pneumatization of the sinus•Poor bone density•Strong occlusal forces

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Pneumatization of the Sinus

• The maxillary sinus retains its overall size when teeth remain in function, but it expands when posterior teeth are lost.

• The antrum expands both inferiorly and laterally potentially invading the canine and lateral piriform regions.

• After the loss of teeth, the amount of teeth in the posterior maxilla is greatly reduced. D.V.BHUVANESH KUMAR

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• A major criterion for successful implant treatment is the amount of available bone. Height of the bone is a consideration for predictability of implant treatment

• Because of periodontal disease, tooth loss, and sinus expansion, there is often less than 10mm of bone between the maxillary sinus floor and the alveolar crest ridge.

• Removal of teeth in patients with “pneumatic trifurcation” can leave only 4 to 5mm of bone remaining

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Poor Bone Density

•Bone mineral density is critically important for implant survival under a load. Implants are at the greatest risk of failure under conditions of poor mineralization.

•The bone density of the maxilla is often 5 to 10 times lower than that of the anterior mandible and the quality of bone in the posterior maxilla is poorer than in any other intraoral region

•Deficient osseous structure jeopardizes not only the initial implant stability but also load bearing capacity.

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Strong Occlusal Forces

•The bite force in the molar region for a dentate individual ranges from 1,378 to 1,723 Pa.

•Natural molars have a 200% more surface area than premolars and a significantly wider diameter. Both these factors reduce bone strain.

•Following this natural model, implant support should be greater in the posterior molar region than in any other area of the mouth.

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•In addition, the posterior maxilla opposes natural teeth or implant supported restorations contributing greater force to soft tissue-borne restorations.

•Therefore decreased bone quality and quantity as well as increased bite force should be considered in the treatment of this region of the mouth.

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Contraindications

•A grafting procedure generally does not interfere with sinus function when performed on a healthy sinus. However when performed on an unhealthy sinus, the same procedure will contribute to fluid stagnation and bacterial overgrowth, leading to exacerbated sinusitis

•The presence of space occupying masses such as polyps, tumors and hyperplastic mucosa represent obstacles to the elevation of the sinus mucosa.

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Contraindications•Local contraindications

• Potentially Irreversible (relative) contraindications• Irreversible (absolute) contraindications

•Intraoral contraindications•General medical conditions of concern

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Potentially Irreversible, Relative Contraindications

• Some anatomic and/or structural alterations of the nasomaxillary complex may interfere with the normal ventilation and mucociliary clearance of the maxillary sinus

• Compensation may occur over time, leaving such conditions clinically silent or with only mild to moderate, sometimes intermittent symptoms

• Sinus grafting in these settings decompensate a compromised sinus, causing mucus stasis, suprainfection and subacute sinusitis.

• Elevation of the sinus floor and/or modification of the sinus anatomy may on occasion lead to better sinus drainage in the presence of mild sinus membrane dysfunction D.V.BHUVANESH KUMAR

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Irreversible, Absolute Contraindications1. Severe (noncorrectable) deformities of the maxillary sinus2. Scarred and hypofunctional sinus mucosa following

trauma of previous operation3. Radiotherapy of the head and neck area (dose above

45Gy)4. Chronic recurrent sinusitis with or without polyposis, that

disrupts mucociliary clearance and is unresponsive to medical or surgical treatment

5. Local expression of a systemic granulomatous disease such as Wegener Granulomatosis or midline idiopathic granuloma

6. Sarcoidosis7. Benign but locally aggressive tumor (amelobastoma,

myxoma)8. Malignant tumor, both primary and metastatic, deriving

from epithelial, connective, or odontogenic tissue (squamous cell carcinoma, adenoid cystic carcinoma)

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Intraoral Contraindications

1. Grossly inadequate oral hygiene or inability to perform or maintain appropriate oral hygiene

2. Untreated periodontal disease of adjacent dentition

3. Gross malocclusion and insufficient freeway space for restoration

4. Severe pathologic parafunctional habit (clenching or bruxism)

5. Fulminant mucosal disease (desquamative mucosal disease, erosive lichen planus)

6. Severe Xerostomia

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Sources of graft material

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Terms • Autograft / autologous graft: a graft of tissue derived from

another site in or on the body of the organism receiving it.

• Allograft: graft taken from one human and transplanted into another

• Alloplastic graft: a graft consisting of an inert material

• Xenograft: a graft taken from a donor of another species

-Glossary of Prosthodontic Terms 8

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Autografts

•The advantage of using autologous bone in sinus grafts offers the following advantages:

1. Increased bone formation2. Shorter healing time requirements than

for bone substitutes3. Possibilities for simultaneous lateral

augmentation4. Low operator costs5. No risk of disease transmission

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Disadvantages

•Need for a second operative site•Difficulty in obtaining a sufficient amount of graft material in some cases (especially in intra-oral sites)

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Maxillofacial Donor Sites

•Maxillary Tuberosity•Zygomaticomaxillary buttress•Zygoma•Mandibular symphysis•Mandibular body•Ramus of the mandible

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Other Sites…•Tibial Bone Grafts•Iliac Grafts•Calvarial Grafts

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Graft form & Maximum volume available from

autogenous bone donor sitesDonor Site Form Available Maximum Volume (ml)ExtraoralPosterior Iliac Crest Block / particulate 140Anterior Iliac Crest Block / Particulate 70Tibia Particulate 20 to 40Cranium Dense cortical Bone 40IntraoralAscending Ramus Block 5 to 10Anterior Mandible Block / particulate 5Tuberosity Particulate 2-4Misc (suction traps) Particulate Varies

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Maxillary Tuberosity and Buttress

•Approximate Resorption time: 3-6 months

•Can be used for small reconstructions with low or moderate osteogenic potential •hyperpneumatized unilateral maxillary sinuses or

•bilateral sinuses in conjunction with other graft materials

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Maxillary Tuberosity and Buttress

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Mandibular Symphysis

•Approximate Resorption time: 4-8 months

•Can be used for small reconstructions with low or moderate osteogenic potential •hyperpneumatized unilateral maxillary sinuses or


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Mandibular Symphysis

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Mandibular Ramus and Bone Shavings from Adjacent Areas of Surgical Site

•Approximate Resorption time: 3-7 months•Can be used for small reconstructions with low or moderate osteogenic potential •hyperpneumatized unilateral maxillary sinuses or


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Mandibular Ramus

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Bone Suctioned while Drilling Osteotomies

•Approximate Resorption Time: 1-3 months

•Very small defects such as exposed implant threads

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Alloplasts for Grafting

•Hydroxyapatite•Bioactive Glass•Beta-tricalcium Phosphate

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Advantages•Ready availability•Elimination of the need for a patient donor site

•Reduced anesthesia and surgical time•Decreased blood loss•Fewer complications

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Hydroxyapatite• Hydroxyapatite in its various permutations has

demonstrated excellent osteoconductive capacity.• Marorana et al compared the degree of marginal

bone resorption and implant longevity when HA or xenograft was used in sinus augmentation and found no significant difference in terms of bone resorption around implants or osseointegration success rates in a 4-year follow-up study.

• They reported a 97% success rate for treatment of 34 patients with 26 sinus grafts and 37 implants placed, with 1 implant lost.

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•Silva et al used HA in the form of solid bioceramic discs to treat critical-sized defects in rat craniums that were allowed to heal primarily. They found that the ceramic achieved better results than autogenous grafts alone.

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Bioactive Glass

•Bioglass is a silicon dioxide material that contains calcium, phosphate and sodium ions (45% SiO2, 24.5% CaO, 24.5% Na2O and 6% P2O5) in particle sizes ranging from 90 to 710µm

•When bioglass particles come into contact with tissue fluid, hydroxycarbonate (HCA) forms on their surface, making them highly conducive to osteoblast attachment via chondroitin sulfate and glycosamine protein bonds.

•Mineralization progresses rapidly under these conditions, resulting in dense bone formation.

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•Bioactive glass bonds directly to bone.•Through osteoconduction, glass becomes wholly incorporated and is then resorbed and replaced by bone.

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Beta-tricalcium Phosphate

• β-TCP is a highly biocompatible, resorbable, osteoconductive grafting material that has been tested in many animal studies and used extensively for repair of bone defects and to expand autograft for sinus grafting.

• Artzi et al placed β-TCP and bovine bone in critical sized defects in dog mandibles. Both showed excellent bone bridging, but the β-TCP had entirely resorbed by 24 months and was completely replaced by lamellar bone.

• Engelke et al used β-TCP to place sinus-directed implants and reported that 200 implants osseointegrated for a 95% success rate.

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• 100% synthetic and fully Resorbable.• It is composed of calcium phosphosilicate (CPS) particles in a

bimodal size distribution combined with• polyethylene glycol and glycerine binder.

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• Upon implantation, the water soluble binder is• absorbed within 24 to 72 hours, creating a 3-

dimensional porous scaffold that facilitates diffusion of blood and tissue fluids through the matrix

• After implantation, surface reactions result in absorption of the graft material, a controlled release of Si, Ca, and P ions, and concurrent new bone formation.

• These surface reactions result in an osteostimulative effect, defined as the stimulation of osteoblast proliferation in vitro as evidenced by increased DNA content and elevated osteocalcin and alkaline phosphatase levels

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Techniques

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Sinus Allograft Procedures

•Allogenic bone is placed using any of the three generally accepted procedures:•The osteotome technique•The simultaneous sinus elevation and implant placement technique

•A two stage lateral approach to sinus elevation and implant placement

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Osteotome Technique

• Was developed to compress soft maxillary bone

• Improved initial fixation obtained from bone compression of the osteotomy walls leads to better primary stabilization.

• Healing is rapid and uneventful

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• Requires a two-person team• Involves inserting a series of osteotomes of successful

larger diameter until full depth is reached, if possible.

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•Surgeon positions and guides the instrument with both hands – one hand creates a rest and maintains stability while the other hand gently rotates and applies pressure with the osteotome

•The assistant will apply gentle malleting technique to the osteotome.

•Osteotome is roated after every stroke to prevent binding to the bone.

•Osteotomes are to be kept lubricated but irrigation is not required.

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•To form a round osteotomy, side to side movement of the instrument is to be avoided.

•Each strike of the mallet is applied to the osteotome in exactly the same path that it is held. Off-angled malleting causes the osteotome to migrate and creates an elliptical osteotomy, which comprimises initial fixation

•The surgeon places restraining pressure on the osteotome to prevent it from advancing more than 1mm with each impact of the mallet

•A drill can be used at any step to increase the diameter of the osteotomy or deepen the preparation as needed.

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Bone Added Osteotome Sinus Floor Elevation

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Staged Sinus Floor Elevation•A technique for sinus floor augmentation with delayed implant placement

•Introduced by Tatum in 1977•Large sized osteotome is used to infracture the crest after limited use of drills or trephines

•Grafting is done without disturbing the sinus membrane. A collagen membrane is used to close the sinus membrane

•The crestal entry creates a “socket” that heals rapidly.

•Implant fixture is placed 6 months laterD.V.BHUVANESH KUMAR

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Lateral Wall Approach for Sinus Elevation

•Is used for both delayed and simultaneous implant placement

•Autogenous bone is harvested from the lateral wall of the antrum for use in conjunction with the allograft

•The full extent of the sinus wall is made visible by thinning out of the lateral wall

•Osteotomy is performed using a multifluted finishing bur.

•Infracture and membrane elevation are accomplished and the graft procedure is performed. D.V.BHUVANESH KUMAR

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a. Delayed sinus elevation with 1 to 4mm of residual bone. A partial thickness Flap is bevelled to the palate

b. Elevation of Buccal and Palatal flaps & osteotomy made in the lateral wall of sinus D.V.BHUVANESH KUMAR

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Simultaneous Sinus Elevation and Implant Placement

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Prosthetic Management of the Sinus Lift Patient

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Diagnosis and Treatment Planning

•Verify the maxillomandibular relationship using mounted casts

•Duplicate the casts and fabricate a wax mockup to determine the prospective occlusal plane, occlusal scheme and esthetics

•Make impression of the mockup to create surgical template and a provisional prosthesis and to aid in the creation of both the second stage screw-retained provisional restoration and the definitive prosthesis.

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First Stage Provisional Prosthesis•Removable Partial Denture

•Used to replace teeth distal to the canine•Must have maximum stability and cross arch transmission of occlusal forces

• Retaining system should include shallow occlusal or incisal rests as well as retaining and bracing arms

• A combination clasp system provides stress relief and also permits easy adaptation and subsequent adjustment of the retainer system to the abutment teeth

• Provide relief over the edentulous areas

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•Pressure from the transitional CPD may cause micromovement of the implants – the patient should be instructed not to wear the prosthesis for 3 weeks following implant surgery. At the time of insertion, the denture flange must be kept away from the graft area

•The prosthesis will be worn for at least 9 months. Following 1st stage surgery, it will be refitted and the tissue treatment material will be replaced weekly until the surgical site has healed.

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Second Stage Provisional Prosthesis

•Following implant uncovering and abutment installation, a screw-retained fixed-detachable prosthesis is fabricated.

•The prosthesis is fabricated as soon as it is feasible following installation of the preselected abutments

•It permits loading of the grafting material and surrounding alveolar bone without going directly to the final restoration

•Provisional loading allows the graft and native alveolar bone to remodel in response to bone strains transmitted to through loading

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•The provisional prosthesis is worn for at least 6 months

•When anterior implant(s) are in ungrafted alveolar bone and posterior implants are in the sinus graft, the definitive prosthesis is constructed approximately 6 months after placement of the second-stage provisional prosthesis.

•If the prosthesis is supported only by implants placed in a graft material, the provisional is worn for 1 year prior to the fabrication of the definitive prosthesis to allow for maturation of the graft.

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Advantages•The advantages of using a second-stage single screw-retained provisional prosthesis are:• Acts a template for the definitive prosthesis• Allows the patient to wear a fixed prosthesis after

second-stage surgery• Allows the patient to learn how to function with

and maintain a screw-retained fixed detachable prosthesis

• Is retained by the patient after completion of the definitive prosthesis, and may be used if alterations to the final prosthesis are ever required

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Definitive Prosthesis• Is a fixed-detachable screw retained restoration

constructed from type IV gold alloy with a heat-cured acylic resin veneer

• For shock absorption, acrylic resin occlusal surfaces may be employed to reduce forces on the underlying graft and implants.

• When < 5mm of residual bone remained beneath the sinus before grafting use acrylic resin occlusal surfaces

• When > 5mm residual bone was present beneath the sinus, gold occlusal surfaces are used.

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Complications

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Complication Possible Cause

Intraoperative

Bleeding Osteomeatal complex obstruction

Buccal flap tear Inadequate graft fill

Infraorbital nerve injury Alveolar ridge fracture

Membrane perforation Damage to adjacent dentition

Early Post Operative

Incision line opening Acute infection

Bleeding Graft loss (partial or complete)

Barrier membrane exposure Implant failure

Infraorbital nerve parasthesia Oroantral fistula

Late Postoperative

Graft loss/failure Soft tissue invasion over access window

Implant failure Maxillary cyst

Oroantral fistula Chronic sinus disease

Implant migration Chronic infection

Inadequate graft fill sequelae Chronic painD.V.BHUVANESH KUMAR

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Membrane Perforations and Tears

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Dehiscense of Graft Site

Epithelial Cyst

Oro-Antral Fistula in Smoker

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Review of Literature

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Tarnow DP, Wallace SS, Froum SJ. Histologic and clinical comparision of bilateral sinus floor elevations with or without barrier membrane Int J. Periodontics Restorative Dent 2000

A controlled trial by Tarnow et al, Tawil and Mawla and Froum et al showed that there is a higher implant survival rate with membrane use.

Study Survival Rate with Survival Rate without

Tarnow et al (2001)

100%; n =28 implants

92.6%; n = 27 implants

Tawil et al (2001) 93.1%; n = 29 implants

78.1%; n=32 implants

Froum at al (1998) 99.2%; n= 133 implants

96.3%; n=82 implants

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Tepper G. et al: Effects of sinus lifting on voice quality: a prospective study and risk assessment. Clin. Oral Impl. Res. 14, 2003; 767–774

• No changes were detected in any of the commonly evaluated parameters.

• These were rated subjectively by patients and their friends or relatives and objectively with instrumental tools under isolated phoniatric lab conditions.

• They concluded that, sinus lift surgery appears to be a safe, predictable evidence-based method for regenerating the highly atrophic posterior maxilla, which does not jeopardize the individual characteristic voice pattern of high-profile patients critically dependent on their voices for their livelihood

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Dec-2013

There were 197 implants placed and mean age of the group was 40.2 ± 10.7 years. There was a slight male predilection (54.3%).

The gain in bone height as expressed in percentage after a year was 134.6%. On comparing the length of residual alveolar bone (RAB) at start and end of study, ISAT had a mean preoperative height of 7.88 mm while postoperativeheight was 13.22 mm.

For DSAT, the mean height at start of treatment was 3.94 mm while at the end it was 10.13 mm. Themean increase in height was 6.19 mm

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•Age, gender, and period of edentulism did not influence the outcome.

• The alveolar width appears to differ and influence the outcome.

•When alveolar width increases, wider diameter implants can be placed by compromising height.

•Thus it is a clinical experience that would be extremely helpful to gauge the outcome of the condition.

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• Jenson OT: The Sinus Lift Procedures. 2° Edition, Mosby Co. 2007• Misch CE: Contemporary Implant Dentistry. Mosby Co. 1997• Garg A: Bone: Harvesting Biology and Grafting. • Babbush CA: Implant dentistry – the art and science.

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Thank You

D.V.BHUVANESH KUMAR

sinus elevation ; grafts

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