Efficacy of Sinus Balloon Technique in Transcrestal Sinus

ASSESSMENT OF THE EFFICACY OF SINUS BALLOON TECHNIQUE IN TRANSCRESTAL SINUS FLOOR ELEVATION SURGERY

Introduction

The new advances and devices simplified the original techniques used in sinus floor elevation surgery. The sinus membrane elevation conventionally established through two main approaches the modified (Caldwell-Luc) approach (Tatum 1976), or by a more conservative approach transcrestal osteotome (summer technique, 1994). Lateral window technique can be applied when the subantral bone height is less than 5 mm (1). It is predictable and allow for greater amount of bone augmentation but it need larger surgical access (2), with high risk of Schneiderian membrane perforation and possible trauma to intraosseous arterial supply (3-4).

On the other hand the osteotome technique is less invasive (5), and associated with less post-operative morbidity (6). However, this technique has several limitations included (restricted indications and allow for only minimal amount of bone gain which is 2-3 mm.

Later, many modifications established to facilitate and optimize the results achieved with original approaches, among these modifications AMBE (antral membrane balloon elevation via crestal approach) has been introduced which can achieve the maximum results obtained with lateral approach in a less invasive manner.

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Materials and Methods

This study was conducted from December 2013 to December 2014 in college of dentistry / university of Baghdad / Oral and Maxillofacial department. It based on clinical and radiographical data.

The sample included patients with single or multiple missing teeth in the sinus zone of atrophied maxilla in which the subantral bone height was ≤ 4 mm for the two stage sinus floor elevation surgery and > 4 mm for one-stage sinus floor elevation surgery.

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A total of (13) adult Iraqi patients aged (28-57) years, (4) males & (9) females were participated in this study. The total performed sinus lift cases were (17) with a total of (27) sinus lift sites.

Inclusion criteria

1. The patient age ranged from 20 – 70 years.
2. Missing tooth (teeth) in the sinus zone of atrophied maxilla in which the subantral distance < 8 mm.
3. Good oral hygiene.
4. Insufficient subantral bone height to perform dental implantology when it is < 8mm and the implant will be placed in a single or a two-stage surgery depending on the patient residual alveolar ridge height (RAR).
5. Healed planned implant site at least 6 months after extraction.
6. Healthy person with no history of specific systemic diseases that may affect on the bone healing , dental implant osseointegration and the maxillary sinus health such as (osteoporosis, diabetic, bleeding disorders , head and neck neoplasia , other factors) .

Exclusion criteria

1. Any local or systemic disease that may affect on the bone healing potential , dental implant osseointegration and maxillary sinus condition such as (diabetes, osteoporosis, etc…..)

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2. Presence of periodontal disease on intra oral examination (bleeding on probing and probing pocket depth >4mm.

3. Presence of infection as detected by clinical and radiographical examination of the planned surgical site.

4. Sinus disease (sinusitis, mucormycosis, retention cyst, mucocele, tumor, polyp, etc…..).

(The presence or absence of maxillary sinus disease confirmed by preoperative CBCT scan).

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5. History of previous sinus surgery.

6. Presence of septa in the planned site for maxillary sinus floor elevation as confirmed by preoperative radiograph (CBCT scan).

7. Head and neck radiotherapy

Surgical procedure

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The drilling site & depth were determined regarding the measurements obtained from the preoperative CBCT or medical CT scan.

In the completely edentulous patients a surgical stent was fabricated in order to precisely determine the planned implants sites.

All the patients rinsed with chlorohexidine 0.2% for 1 min preoperatively.

Surgery was performed under local anesthesia (2% lidocaine with 1:100,000 adrenalin as vasoconstrictor, 2.2 ml). Infiltration of the posterior superior alveolar nerve, greater palatine nerve & infraorbital nerve block were done.

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A crestal incision is made slightly with palatal bias & a full thickness flap (extensive flap design) was raised.

In case of completely edentulous or long span edentulous maxilla, the drilling site was marked with pilot drill through a clear acrylic surgical guide prior to the raising of the flap.

The drilling site was marked initially by the pilot bur (2.2mm & 2.6 mm in diameter) in the center of the alveolar crest & stopped 1 mm below the sinus floor.

Drilling was done using the Dentium (korea) implant system or Nucleoss (Turkey) implant system “according to the availability.

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The dental implant bed site was enlarged to at least 4.2 mm to allow entry of balloon & the bed was then enlarged until reaching to the final drill determined diameter. Counter sink was ignored due to the poor bone density (Type III or IV) in the sinus zone of maxilla and in order to obtain good implant stability.

An osteotome tip was inserted NO D2.0 mm, No D3.0 mm and / or NO D3.8 mm, and gentle tapping applied by mallet to al­low for controlled green-stick fracture of the sinus cortical layer (sinus floor). Entrance in to the SMS (sinus membrane space) was manifested by changing in the voice resonance and tactile sense of the surgeon.

Depending on the residual alveolar bone height, the integrity of the Schneider’s membrane can be assessed clinically either by direct vision or by using hydraulic pressure test to elevate and detect the sinus membrane patency.

When the sub-antral bone height is less than 4 mm the movement of Schneiderian membrane can be assessed by direct vision as it elevated with patient inspiration and dropping upon expiration.

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Hydraulic pressure test was performed by using 20cc normal saline syringe then by introducing the normal saline irrigation in each bed, no coughing reflex or aspiration of saline through the nose should be occur, this will confirm the integrity of the membrane clinically.

Following the manufacturer instructions the MEDALLION sinus Lift Balloon was checked for patency by inflation and deflation 3-4 times prior to its application. The balloon was detached from the syringe & the syringe was filled with the 0.5cc of sterile normal saline initially, then increased to 1cc later if needed to achieve gradual elevation of sinus membrane. The utilized amount of normal saline depend on the required amount of sinus membrane elevation and correspond to the amount of bone substitute that placed in the created sinus membrane space.

Balloon expansion of 1.0cc saline equals 6 mm of membrane elevation and 1 cc of bone graft material needed to fill the void.

The balloon inserted in the subantral space “beneath the sinus membrane” and then inflated. This procedure was repeated several times. After the desired sinus membrane elevation achieved, the GBR membrane is inserted in the bed and pushed apically with an osteotome beneath the elevated schneiderian membrane.

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The Particulate bone grafts {B Tricalcium phosphate sterile resorbable bone substitute} was then injected in the prepared bed & guided gently beyond the fractured sinus floor beneath the schneiderian membrane with osteotome .

Then suturing the flap & giving instructions to the patient. The minimum follow-up period after treatment was 6 months.

The following points were assessed in this study

• Schneider’s membrane perforation assessed clinically and by post-operative radiograph (CBCT scan).
• Pain (Degree of pain severity) was assessed according to the visual analogue scale.
• The amount of gained bone was assessed by post-operative CBCT scan measurements.
• Implant survival rate 6 months after placement was recorded.
• Post-operative complications including nasal bleeding, ecchymosis, leakage of bone graft in to oral cavity, infection, oro-antral communications and Wound dehiscence were recorded.

Results

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The total performed sinus floor elevation cases were (17) with a total of (27) sinus floor elevation sites. 15 cases were performed in a single stage surgery (simultaneous sinus floor elevation and dental implant placement) and two cases were performed in a two stage surgery (sinus floor elevation and delayed dental implant placement 6 months later .

9 patients underwent unilateral sinus floor elevation surgery and 4 patients underwent bilateral sinus floor elevation surgery.

The mean bone gain in this study was (6.70) mm and the mean utilized non autogenous bone graft material was (0.74) cc. The maximum of gained bone with sinus balloon technique was (10.6) mm and the minimum of gained bone was (4.9) mm. 23 dental implants placed in augmented maxillary sinus, two implants early failed (8.70 %) and the survival rate of the dental implants inside sinus was (91.30 %).

28 dental implants were placed outside the sinus in the same patients, 1 implant early failed 3.57% and 27 dental implants with a survival rate of 96.42%

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The cumulative survival rate of dental implants inside and outside sinus was 94.12%. Schneider’s membrane perforation didn’t occur in any case of this study (0%). Minor post-operative complications were registered involving mild nasal bleeding in one patient and infraorbital ecchymosis in another patient which resolve spontaneously and need no intervention.

Conclusion

 The utilization of hydraulic pressure in combination with sinus balloon technique is of great value in both sinus membrane elevation and as a diagnostic tool of Schneiderian membrane perforation.

The (AMBE) antral membrane balloon elevation via crestal approach solve the limitations of osteotome technique (original summer technique) for cases even when the subantral bone height is less than 3 mm .It also reduces the risk of sinus membrane perforation and reduces the postoperative pain, infection, and other symptoms usually occurred with sinus lift procedures.

References

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Toscano N,Holtzclaw D,Rosen P. (2010) The effect of piezoelectric use on open sinus lift perforation: a retrospective evaluation of 56 consecutively treated cases from private practices. J Periodontol. 81(1):167-71.

Woo I,Le BT. (2004) Maxillary sinusfloorelevation:reviewofanatomyandtwotechniques. Implant Dent. 13(1):28-32.

Solar P, Geyerhofer U, Traxler H, Windisch A, Ulm C, Watzek G. (1999) Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res .10(1):34-44. (Abstract)

Vercellotti T. (2004) Technological characteristics and clinical indications of piezoelectric bone surgery. Minerva Stomatol .53(5):207-214. (Abstract)

Kim Y,Cho Y,Yun P. (2013) Assessmentof dentists’subjectivesatisfactionwithanewlydevelopeddeviceformaxillarysinusmembraneelevationby thecrestalapproach. J Periodontal Implant Sci .43(6):308-14.

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Baumann A, Ewers R. (1999) Minimally invasive sinus lift. Limits and possibilities in the atrophic maxilla. Mund Kiefer Gesichtschir. 3(1):70–73.

 

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