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Lateral Sinus Augmentation: A Simplified Safer Approach

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International Journal of Oral Implantology and Clinical Research, May-August 2013;4(2):83-89
83
Lateral Sinus Augmentation: A Simplified Safer Approach
IJOICR
CASE REPORT
Lateral Sinus Augmentation: A Simplified Safer Approach
Douglas F Dompkowski, Gregori M Kurtzman
10.5005/JP-Journals-10012-1098
ABSTRACT
Enlargement of the maxillary sinus often precludes implant
placement in the posterior quadrant without augmentation to
create increased bone height to stabilize the implant fixtures
and provide load handling following restoration. Maxillary sinus
augmentation has been a technical challenge due to the potential
for tearing of the Schneiderian membrane during lateral window
formation. This article will discuss and review unique
instrumentation for a safer simpler approach to lateral window
maxillary sinus augmentation.
Keywords: Maxillary sinus, Sinus lift, Sinus augmentation,
Dental implant.
How to cite this article: Dompkowski DF, Kurtzman GM. Lateral
Sinus Augmentation: A Simplified Safer Approach. Int J Oral
Implantol Clin Res 2013;4(2):83-89.
Source of support: Nil
Conflict of interest: Dr. Domkowski has lectured for Hiossen
and received honoraria.
INTRODUCTION
A common clinical problem when implants are to be placed
into the posterior maxilla when teeth have been extracted
at a prior date is loss of osseous height sufficient to place
implants. Some patients show resorptive patterns along with
sinus enlargement that leave minimal bone height that can
accommodate implant usage. Maxillary sinus augmentation
with various bone graft material have become routine
treatment over the past 18 years. Numerous studies have
reported highly successful implant survival rates when
placed into an augmented sinus.1-3 Transalveolar sinus
floor elevation also referred to as subantral augmentation,
was first described by Tatum4 and later modified by
Summers,5-7 uses a series of osteotomes with a mallet to
create an osteotomy and in-fracturing the sinus floor while
elevating the Schneiderian membrane into the sinus cavity.
Following manipulation, the membrane is then lifted and
the space created in the sinus is augmented with bone
particulate graft material increasing the volume and height
of bone available for implant placement.
Numerous studies show that when >5 mm of residual
alveolar bone is present, simultaneous implant placement
can be achieving preformed adequate primary stability.6,8,9
Yet, when there is less than 5 mm of residual alveolar bone
height, a delayed 2-stage approach has been recommended
for improved implant success.10,11 The most common
complication of the lateral sinus elevation approach is
tearing of the Schneiderian membrane which could allow
for bacterial contamination or loose particles gaining access
to the sinus cavity. A safer, lateral window approach to sinus
augmentation procedure will be discussed using safe end
specialized drills with vertical stoppers for osseous window
formation and subsequent membrane elevation (Lateral
Approach Sinus Kit, Hiossen, Philadelphia, PA, USA/
Osstem, Seoul, South Korea).
MATERIALS AND METHODS
The Lateral Approach Sinus Kit (LAS-Kit) provides ‘dome’
drills, ‘core’ drills, metal stoppers, side wall drill and a bone
separator tool (Fig. 1).
The dome drill is a unique osseous drill allowing removal
of the lateral wall of the maxillary sinus while collecting
autogenous bone to be added to the material to be placed
into the sinus. Macro- and micro blades provide excellent
cutting of the lateral wall without tearing of the sinus
membrane. These dome drills available in both 5.0 and
7.0 mm diameter are run at 1,200 to 1,500 rpm with
irrigation in an implant surgical handpiece. Metal depth
control stoppers are provided that fit on the dome drills
limiting depth of penetration (0.5, 1.0, 1.5, 2.0, 2.5 and 3.0
mm) and are used sequentially to safely expose the sinus
membrane.
The core drill, also available in 5.0 and 7.0 mm diameter
differs from the dome drill in that the center does not cut,
with bone removal resulting in a core of bone being left
over the sinus. This boney lid is removed due to its small
size and can be ground to be added to the graft material
being placed into the sinus. This particular drill follows the
same design of the crestal augmentation sinus (CAS) drills
and are utilized at 1,200 to 1,500 rpm as are the dome drills.
The metal drill stoppers also fit these drills allowing
controlled sequential depth preparation. The bone separator
tool is utilized to separate the osseous core created from
the core drill.
The side wall drill may be used to enlarge the osseous
window created by the dome drill if desired. The tip of this
drill is smooth and designed to safely push the sinus
membrane away from the cutting portion of the drill, which
starts 1 mm from the safe end. Osseous cutting is performed
at 1,500 rpm using the side of the rotating drill to enlarge
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Douglas F Dompkowski, Gregori M Kurtzman
the osseous window. The metal drill stoppers from the CAS-
Kit may be utilized on these side wall drills to limit
accidental penetration too far into the sinus and tearing of
the membrane during this drills use. As with the other drills
in this kit, irrigation is used during its use.
CASE REPORT
A male aged 65, presented with the desire for rehabilitation
of the maxillary arch implant placement with the posterior
maxillary left quadrant which had been missing teeth for
an extended period of time. Radiographically, enlargement
of the maxillary sinus was noted with insufficient height in
the molar region for implant placement (Fig. 2). Sinus
augmentation was discussed to assist in achieving the
patients desired treatment goal. As less than 5 mm of crestal
height was available, implant placement would not be
possible at the time of sinus augmentation as primary
stability would not be achievable.
Following administration of local anesthetic, a crestal
incision with a vertical releasing incision was made and a
full thickness flap was elevated (Fig. 2). Elevation of the
flap extended superiorly to expose the lateral wall of the
maxillary sinus up to the inferior aspect of the zygoma
(Fig. 3). Endosseous implants were placed in the posterior
right and anterior segments which had sufficient bone height
and width for fixture placement.
A 5 mm wide dome drill was placed onto the surgical
handpiece with a 0.5 mm drill stopper (Fig. 4). This would
allow initiation of the window without the possibility of
excessive penetration and subsequent damage to the sinus
membrane. The dome drill with stopper was placed on the
lateral sinus wall at a height more superior then the current
height of the available bone as measured radiographically
(Fig. 5). This is done to ensure that the window created has
elevatable membrane circumferentially. When maximum
depth has been achieved with the 0.5 mm drill stopper
present, the drill stopper is changed to a 1.0 mm stopper
and drilling is continued (Fig. 6). The drill stopper is
sequentially increased checking for membrane exposure
Fig. 1: Lateral approach sinus kit (LAS-Kit)
Fig. 2: CBCT pretreatment radiographs demonstrating insufficient
osseous height for implant placement without sinus augmentation
in the molar region
Fig. 3: Lateral aspect of the maxillary posterior following
elevation of a full thickness flap
Fig. 4: Dome drill with 0.5 mm stopper placed on the
surgical handpiece
Fig. 5: Lateral sinus approach initiated with the dome drill and a
0.5 mm drill stopper
International Journal of Oral Implantology and Clinical Research, May-August 2013;4(2):83-89
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Lateral Sinus Augmentation: A Simplified Safer Approach
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show clinically at the window (Fig. 9). The osseous grinding
from the dome drill is periodically removed from the drill
to be used with the osseous graft to be placed (Fig. 10).
Fig. 6: Lateral sinus approach continued with the dome drill
and a 1.0 mm drill stopper
Fig. 7: Lateral sinus approach continued with the dome drill and
a 1.5 mm drill stopper
Fig. 8: Lateral sinus approach continued with the dome drill and
a 2.0 mm drill stopper
(Figs 7 and 8). As bone is removed over the sinus membrane,
the area changes in color from the light color of the bone
(ivory) to a darker gray as the sinus membrane begins to
Fig. 9: Lateral wall of the maxillary sinus following sequential use
of the dome drill with decreasing stopper depth demonstrating no
damage to the sinus membrane after bone removal
Fig. 10: Patient’s bone collected in the dome drill that will be
added to the osseous graft to be placed into the maxillary sinus
Fig. 11: Final dome drill with a 2.5 mm stopper utilized to fully
expose the sinus membrane
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Douglas F Dompkowski, Gregori M Kurtzman
Final window creation is made with the dome drill, in
this particular case with a 2.5 mm drill stopper (Fig. 11).
Some patients may require deeper drilling which is
dependant on thickness of the lateral maxillary sinus wall.
The intact sinus membrane is noted with no bone over the
membrane at the window that has been created on the lateral
wall (Fig. 12). An osseous septum is noted running vertically
at the middle of the window created. The presence of the
septum would preclude use of the core drill as it would be
very difficult to remove the widow core created without
tearing the sinus membrane.
Sinus curettes are utilized to start the sinus membrane
elevation at the inferior aspect, teasing the membrane from
the osseous wall of the sinus interiorly (Fig. 13). As this
case has a septum the anterior and posterior aspects of the
sinus in relation to the septum are elevated separately, with
attention to teasing the membrane from the septum as part
Fig. 12: Lateral window completed demonstrating the intact sinus
membrane following use of the dome drills and stoppers. A bone
septa is noted vertically in the window
Fig. 13: Curettes utilized to tease the membrane from the bone
wall and elevate the membrane in preparation for sinus grafting
Fig. 14: Sinus membrane has been elevated and the bone septa
is clearly noted
Fig. 15: Resorbable collagen tape an absorbable membrane (Ace
surgical) is placed into the sinus to line the elevated membrane
and assist in containing the osseous graft that will be placed
of the elevation process. It is important that the elevation
also include the medial wall of the sinus so that fills a volume
great enough that the implant when placed will be
surrounded by bone (Fig. 14). Failure to elevate the medial
wall aspect may result in the implant when placed having
no osseous contact which may decrease implant success
following loading. Additionally, the authors advise elevation
to a greater height than the implant length to be placed when
a delayed fixture placement is to be performed. This will
allow for possible graft resorption during healing that may
yield less height then was planned.
An absorbable collagen membrane (Resorbable
Collagen Tape, Ace Surgical, Brockton, MA) is inserted
into the sinus to act as a membrane to thicken the sinus
membrane and seal any micro tears that might be present
(Fig. 15). The Resorbable Collagen Tape is cut to size and
placed into the sinus dry using the patient’s blood in the
International Journal of Oral Implantology and Clinical Research, May-August 2013;4(2):83-89
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Fig. 16: Regenaform cortical cancellous bone chips (Exactech) is
gently packed into the cavity created with sinus membrane elevation
Fig. 17: Maxillary sinus has been filled with the Regenaform cortical
cancellous bone chips (Exactech) to a level flush with the exterior
lateral wall
Fig. 18: Guidor, a resorbable membrane (Sunstar) is placed over
the lateral window to prevent soft tissue in growth during
graft organization
Fig. 19: Cytoplast PTFE suture (Osteogenics Biomedical) placed
in a horizontal mattress technique is placed to close the flap with
primary closure the goal
Fig. 20: Radiograph immediately after sinus augmentation
demonstrating the new osseous height achieved with sinus elevation
and grafting
Fig. 21: Six months following sinus grafting the soft tissue shows
no inflammation and is ready for implant placement into the
grafted sinus
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Douglas F Dompkowski, Gregori M Kurtzman
site to wet it as it is placed. Once wetted with blood the
Resorbable Collagen Tape becomes sticky attaching itself
to the sinus membrane.
Autogenous bone collected from the dome drill was
mixed with Regenaform cortical cancellous bone chips
(Exactech, Gainesville, FL) in a sterile dappen dish and
mixed. The osseous graft mixture was carried to the oral
cavity and introduced into the elevated sinus and gently
condensed with a large plugger, pushing the mixture to the
medial and filling in a lateral direction until the entire cavity
was filled (Fig. 16). The process was repeated in the cavity
anterior to the septa. Sufficient osseous graft was placed
till the sinus was augmented to be flush with the outer aspect
of the lateral sinus wall at the window that had been created
(Fig. 17).
A long-term resorbable membrane (Guidor, Sunstar,
Chicago, IL) was cut to extend beyond the outline of the
lateral window and placed over the osseous graft that had
been placed into the sinus (Fig. 18). The flap was
repositioned and initially closed with a horizontal mattress
suture using Cytoplast ePTFE, (Osteogenics Biomedical,
Lubbock, Texas) to achieve primary closure at the crest
(Fig. 19). This suture serves to resist soft tissue tension that
may result due to inflammation and the resulting swelling
following surgery. Additional sutures are placed to close
the incision line using a simple interrupted technique. The
radiograph shows initial graft placement and the elevation
achieved to create a site that can accommodate implant
placement at a later date (Fig. 20).
The patient returned 6 months following sinus
augmentation for implant placement. Soft tissue in the site
on the lateral aspect demonstrated no inflammation and
incision lines were not discernable on the gingiva (Fig. 21).
A radiograph was taken to check and verify the organization
of the osseous graft that had been placed into the sinus and
determine if the site was ready for re-entry for implant fixture
placement (Fig. 22). A full thickness flap was made and the
lateral aspect of the maxillary sinus where the window had
been created demonstrating good integration of the graft
with the surrounding native bone of the patient (Fig. 23).
CONCLUSION
Emphasis has moved to the use of a crestal approach to
sinus elevation when additional osseous height is required
for implant placement. This approach works well when at
least 5 mm of osseous height is present for immediate
implant placement. Yet when less bone height is present a
lateral window approach may be a more prudent technique
to increase crestal height so that implant fixtures may be
placed.
The lateral sinus augmentation approach can be
challenging as tearing of the sinus membrane often
necessitates abandoning the procedure and re-entry at a later
date after the membrane has healed. Previous techniques
involved use of diamonds or carbides in a high speed
handpiece to use of piezo surgical units. These approaches
had potential for membrane damage (burs in a high speed)
or were very slow (piezo). The LAS-Kit, from Hiossen/
Osstem utilizes special designed drills that greatly minimize
tearing of the membrane and improve the safety of the
procedure.
REFERENCES
1. Blomqvist JE, Alberius P, Isaksson S. Two maxillary sinus
reconstruction with endosseous implants: a prospective study.
Int J Oral Maxillofac implants 1998 Nov-Dec;13(6):758-766.
2. Valentini P, Abensur DJ. Maxillary sinus grafting with anorganic
bovine bone: a clinical report of long-term results. Int J Oral
Maxillofac Implants 2003 Jul-Aug;18(4):556-560.
3. Tong DC, Drangsholt M, Beirne OR. A review of survival rates
for implants placed in grafted maxillary sinuses using meta-
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4. Tatum OH Jr. Maxillary and sinus implant reconstructions. Dent
Clin North Am 1986 Apr;30(2):207-229.
5. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH,
Marks MH, Fugazzotto PA. The bone-added osteotome sinus
Fig. 22: Radiograph 6 months after sinus augmentation demons-
trating the new osseous height achieved with sinus elevation and
grafting
Fig. 23: The grafted site 6 months following sinus augmentation
after full thickness flap elevation in preparation for implant placement
International Journal of Oral Implantology and Clinical Research, May-August 2013;4(2):83-89
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Lateral Sinus Augmentation: A Simplified Safer Approach
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floor elevation technique: multicenter retrospective report of
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6. Summers RB. A new concept in maxillary implant surgery: the
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7. Summers RB. The osteotome technique: part 3-less invasive
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8. Emmerich D, Att W, Stappert C. Sinus floor elevation using
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10. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor
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11. Peleg M, Mazor Z, Garg AK. Augmentation grafting of the
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Maxillofac Implants 1999 Jul-Aug;14(4):549-556.
ABOUT THE AUTHORS
Douglas F Dompkowski (Corresponding Author)
Private Practitioner, Periodontology and Implant Dentistry, Bethesda
Maryland; Faculty, Department of Periodontology, University of
Maryland, Maryland, USA, e-mail: dompkowskidds@verizon.net
Gregori M Kurtzman
Private General Practice, Silver Spring, Maryland, USA
... Enough space was created for bone graft placement for the implant to be surrounded by bone later. [6] d. The sharp part of the detacher was constantly maintained on the bone floor and membrane integrity was checked with Valsalva maneuver. ...
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