|Ahead of print publication
Indirect sinus lift in maxillary posterior region using BAOSFE technique
Niveditha Varmudy, Sapna Chengappa Kambiranda, Syed Ghouse Ahmed, Nitesh Shetty
Department of Prosthodontics, Srinivas Institute of Dental Sciences, Mangalore, Karnataka, India
|Date of Submission||10-Mar-2022|
|Date of Decision||04-Jun-2022|
|Date of Acceptance||20-Jun-2022|
Department of Prosthodontics, Srinivas Institute of Dental Sciences, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Implant placement in edentulous posterior maxilla along the maxillary sinuses poses difficulties following tooth extraction due to ridge resorption and pneumatization of sinuses resulting in inadequate vertical bone height. The maxillary sinus lying close to the posterior maxillary edentulous ridge can be augmented by various methods such as lateral window sinus floor elevation, crestal approach, and grafting procedures. Summers introduced the less invasive approach for the sinus floor elevation known as osteotome sinus floor elevation technique in which the vertical bone height was attained by retaining and relocating existing bone using different graded osteotomes. He further modified this technique by addition of bone graft to the osteotomy site before sinus elevation known as bone added osteotome mediated sinus floor elevation (BAOSFE). This case report shows placement of implant in atrophic maxillary region using BAOSFE technique.
Keywords: BAOSFE, implants, indirect sinus lift, posterior maxilla
|How to cite this URL:|
Varmudy N, Kambiranda SC, Ahmed SG, Shetty N. Indirect sinus lift in maxillary posterior region using BAOSFE technique. Indian J Dent Sci [Epub ahead of print] [cited 2022 Dec 9]. Available from: http://www.ijds.in/preprintarticle.asp?id=359868
| Introduction|| |
Dental implants are a continuously evolving fixed treatment modality used to replace missing teeth. The restoration of complete and partial edentulous arches with dental implants has shown favorable long-term survival and high success rate., However, type IV bone has less favorable or poor implant success rate, and this is usually seen in the posterior regions of the maxilla (4.4%) compared to type II and type III bone seen in anterior jaw segments (4.2%).,,, The placement of implants and its success is influenced by the bone quality and quantity. In maxillary posterior edentulous arches, the survival rate is comparatively lower due to the pneumatization of the maxillary sinus and the bone resorption seen following extraction. In 1994, Summers proposed the technique of osteotome-mediated internal sinus-lift procedure and implant placement in the posterior maxilla with type IV bone.,, Later, he modified this method by addition of bone graft into the osteotomy site followed by sinus elevation and named it as bone-added osteotome-mediated sinus floor elevation (BAOSFE). This approach works by repositioning the existing crestal bone under the sinus and adding bone graft materials, thereby elevating the sinus floor and increasing osseous support for an implant.,,
This case report shows placement of implant in atrophic maxillary region using BAOSFE technique.
| Case Report|| |
A 25-year-old male patient with good general health condition reported to our clinic in Dubai with the chief complaint of ill-fitting removable partial denture in the maxillary arch and desired a fixed treatment solution. On intraoral examination, missing tooth in relation to 24 was observed [Figure 1]a and [Figure 1]b. The soft tissue on the edentulous ridge was healthy, devoid of any inflammation with a thin gingival tissue biotype of 4-mm attached gingiva. The ridge was well rounded with adequate mesiodistal and buccolingual width and an interocclusal space of 8 mm [Figure 1]c.
|Figure 1: (a) Preoperative photograph maxillary arch – 24 missing. (b) Preoperative photograph mandibular arch. (c) Interocclusal space – 8 mm. (d) Preoperative radiograph|
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On radiographic examination, the edentulous region showed no periodontal pathology or retained root. D3-D4 bone quality with coarse trabecular bone pattern was observed. The height of the bone from the crest to the maxillary sinus floor showed 7 mm which was insufficient for an ideal implant to be placed [Figure 1]d. Therefore, single implant placement by performing indirect sinus lift procedure using BAOSFE technique was planned in relation to 24.
The surgery was performed under standard sterilization protocol. Prior to the surgery, the patient was given 1-g amoxicillin (antibiotic) and ponstan forte (analgesic). Local anesthesia (buccal and lingual infiltration) lidocaine 2% (1:80 000) was used.
MYRIAD implant system was chosen for the surgery. A crestal incision from 23 to 25 region was made [Figure 2]a and [Figure 2]b followed by a full-thickness mucoperiosteal flap elevation. The bone was drilled to a depth of 7 mm using an initial pilot drill of 2.0-mm diameter. The orientation of the drill, angulation, and its proximity to the maxillary sinus was checked using a periapical X-ray [Figure 2]c. The second drill of 2.5-mm diameter followed by [Figure 2]d 3.2-mm twist drill was used up to a height of 8 mm. The proximity with the maxillary sinus was again checked with a periapical X-ray which showed that the twist drill was 2–3 mm beneath the Schneiderian membrane of the maxillary sinus.
|Figure 2: (a and b) Implant surgery: Crestal incision from 23 to 25 region. (c) Periapical X-ray to check the proximity to maxillary sinus. (d) Implant osteotomy surgical drills. (e) Summers osteotome kit. (f) Indirect sinus lift done with different caliber osteotomes|
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Osteotomes were used and inserted to perform the indirect sinus lift procedure [Figure 2]e. This was followed by the usage of successively greater diameter osteotomes until the sinus floor was fractured and elevated [Figure 2]f. A surgical mallet with controlled force was used to fracture the sinus floor carefully and separated from the Schneiderian membrane avoiding any kind of damage. The Valsalva test to assess the patency of the Schneiderian membrane was negative throughout the procedure. The final height obtained with sinus lift was 12 mm. BioHorizons MinerOss cortical-cancellous allograft bone graft material was placed in the osteotomy site [Figure 3]a. The implant size of the 11 mm × 3.8 mm implant (MYRIAD) was placed immediately in the osteotomy site [Figure 3]b. Later, it was hand tightened using a torque wrench. The initial primary stability obtained was around 35N [Figure 3]c. Following this, resorbable collagen membrane (Remotis) was inserted within the osteotomy site [Figure 3]d. Healing abutment was placed on the implant to help in the formation of gingival emergence profile for the final restoration, followed by suturing (sterile synthetic absorbable braided polyglycolic acid suture) [Figure 3]e, and postoperative X-ray was made [Figure 4]a.
|Figure 3: (a) BioHorizons MinerOss bone graft. (b) MYRIAD implant placement – 11 mm × 3.8 mm. (c) Implant placed in osteotomy site. (d) Remotis collagen membrane placed in osteotomy site. (e) Healing abutment, suture in place|
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|Figure 4: (a) Opg showing implant with healing abutment in 24 region. (b) Uncovery and impression coping attached. (c) Closed tray impression of maxillary arch, mandibular alginate impression, and bite registration|
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Postsurgical instructions and antibiotic medications were prescribed for 1 week to control postoperative pain and infection. The patient was recalled for a follow-up after 2 days. No extraoral swelling was observed. Removal of the sutures was performed 7 days postsurgery. The healing was found to be satisfactory. The patient was recalled after 2 months. The healing abutment was removed and a smooth healthy gingival cuff around the healing abutment was formed and the final impression was made. The impression coping was attached to the implant, and X-ray was taken to check the close adaptation of the abutment to implant collar. Closed tray impression procedure was used and sent to the laboratory with the selected shade [Figure 4]b and [Figure 4]c and bite registration record. The patient was recalled after 1 week for final restoration. The abutment was screwed to the implant platform in 24 region; periapical X-ray was taken to check the fit after which the abutment screw was torqued to 30 Ncm [Figure 5]a, [Figure 5]b, [Figure 5]c. Porcelain fused to metal crown was cemented using zinc oxide eugenol cement, and X-ray was made with the restoration in place [Figure 5]d. The patient was recalled after 2 weeks; the final prosthesis had good esthetic and functional results.
|Figure 5: (a) Abutment screwed to implant platform. (b) Cement-retained porcelain fused to metal implant restoration. (c) Implant restoration in occlusion. (d) Opg showing final implant restoration with relation to 24|
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| Discussion|| |
Determining residual bone height (RBH) is crucial in deciding the right technique for sinus elevation. According to the Sinus Consensus report in 1996, the surgical requirement for implant surgery is classified into 4 categories based on the RBH.
- Class A: >10 mm – Classic implant protocol could be followed
- Class B: 7 mm to 9 mm – BAOSFE could be performed with simultaneous implant placement
- Class C: 4 mm to 6 mm – Lateral approach could be performed with delayed or immediate implant placement
- Class D: 1 mm to 3 mm – Lateral approach could be performed with delayed implant placement.,
Summers BAOSFE technique is mainly used for patients with RBH of 5 mm or more. Bone added osteotome-mediated sinus floor elevation (BAOSFE uses a combination of osteotome sinus floor elevation (OSFE) technique and a bone graft material. The volume of the prepared bone and the graft material acts as a hydraulic plug which helps in upward push of the osteotome to elevate the sinus floor. This is followed by implant placement, thus facilitating the elevation of the sinus membrane by tenting it with its apical end. The allograft used in this case is MinerOss from BioHorizons, a mixture of allograft mineralized cortical and cancellous bone particles. The cortical part contributes for the structural integrity and has the capacity to maintain space. The cancellous part has a porous architecture which helps in osteoconduction and rapid revascularization. This was followed by placement of Remotis, a xenograft of porcine origin, a natural, fully resorbable collagen membrane. In this case, we followed a similar technique wherein the implant was placed using a combination of OSFE technique along with bone graft. We had a RBH of 7 mm in maxilla 24 region which was ideal for BAOSFE technique, and following the surgical protocol, we had gained 5-mm bone height, there was no membrane tear, and an adequate primary stability was achieved.
This BAOSFE technique favors successful surgical and prosthetic treatment outcome enhancing survival rate. It has an added advantage of reduced postoperative complications and improved initial stability due to osteotome condensation with bone graft placement resulting in limited pneumatization of maxillary sinus. This method is more conservative than the conventional lateral approach which is an invasive surgical procedure and might involve complications such as membrane perforation, postoperative swelling, and fistula formation. Thereby, BAOSFE technique followed in this case report reduced the operation time and postoperative morbidity. However, the limitation of this case report is placement of implant on a single patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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