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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 786-789
Osteotome sinus floor elevation without bone grafting and simultaneous implant placement in the atrophic maxilla: A pilot study


1 Department of Prosthodontics, Private Practice, ADA Dental Clinic, Atatürk Bulvari, Yat Sitesi, B Bloc, No. 4 Kusadasi, Aydin, Turkey
2 Department of Oral and Maxillofacial Surgery, Konak Dental Hospital, Konak, Izmir, Turkey

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Date of Submission23-Nov-2010
Date of Decision14-Feb-2011
Date of Acceptance04-Aug-2011
Date of Web Publication5-Apr-2012
 

   Abstract 

Aims: This study evaluated the clinical and radiographic outcome of implants placed in the posterior maxilla with the osteotome sinus floor elevation (OSFE) technique without graft material.
Materials and Methods: Twenty-seven 4.1-mm-diameter dental implants (Straumann AG, Basel, Switzerland) were placed to 17 sinuses with residual bone height of ≤10 mm and ≥5 mm to rehabilitate 23 molar and 4 premolar sites. Implants were simultaneously placed with the OSFE procedure without graft material.
Results: All implants were successfully integrated after 8-12 weeks healing time. At the 2-year follow-up, all the implants presented the survival criteria proposed by Buser et al. and Cochran et al.
Conclusion: The OSFE technique without grafting material may be predictable because the success rate was 100% in this study. Implants gained endo-sinus bone despite the lack of graft material. More patients and longer follow-up are needed to validate the results of this pilot study.

Keywords: Dental implants, maxillary sinus, osteotome technique, sinus floor elevation

How to cite this article:
Senyilmaz D P, Kasaboglu O. Osteotome sinus floor elevation without bone grafting and simultaneous implant placement in the atrophic maxilla: A pilot study. Indian J Dent Res 2011;22:786-9

How to cite this URL:
Senyilmaz D P, Kasaboglu O. Osteotome sinus floor elevation without bone grafting and simultaneous implant placement in the atrophic maxilla: A pilot study. Indian J Dent Res [serial online] 2011 [cited 2019 Jul 18];22:786-9. Available from: http://www.ijdr.in/text.asp?2011/22/6/786/94669
The prerequisite for dental implant treatment is the presence of adequate residual bone volume and quality for implant placement. [1],[2] However, the edentulous posterior maxilla frequently represents a challenge because of the lack of bone due to alveolar ridge resorption and maxillary sinus pneumatization. [1],[3] Efforts such as the application of tilting implants, zygoma implants, short implants, sinus floor elevation with lateral approach, etc. have been made to allow successful implant placement in the posterior maxilla subject to limited bone height under sinus. [4],[5],[6],[7],[8],[9],[10] When there is severe atrophy of the bone crest, owing to long-standing edentulism or chronic peri-radicular pathology, it may be necessary to restore the bone volume. [1] The lateral window technique for the maxillary sinus elevation is one of the most commonly used bone augmentation procedures. [4],[5] The lateral approach technique involves the use of a grafting material in conjunction with immediate or delayed implant placement. [5] However, because this surgical procedure is complex, invasive and time consuming, alternative methods have been developed to avoid it, whenever possible. [4],[5],[6],[7],[8],[11]

The osteotome sinus floor elevation (OSFE) procedure, introduced by Summers may be less invasive, less time-consuming, cost-effective, and reduces postoperative discomfort to the patient. [5],[8],[9],[11],[12],[13] The procedure consists of elevating the Schneiderian membrane with osteotomes through a crestal approach, placing simultaneously the bone grafting material and the implant. [12],[13] However, recently, the necessity of placing a filling material for sinus lifting procedures has been questioned and it has been demonstrated that when a space is maintained between the sinus membrane and the sinus floor, bone forms and fills the graft free volume. [3],[4],[5],[9] In the present study, the 2-year clinical results of implants placed with the OSFE procedure but without grafting material have been evaluated.


   Materials and Methods Top


Patient criteria

The patients were selected according to the following criteria:

  • Patients needed implant treatment in the posterior maxilla.
  • The OSFE technique was used without graft material.
  • 8-10-mm-long implants planned.
  • Residual bone height (RBH) was ≤10 mm and ≥5 mm.
  • Implant had to penetrate at least 2 mm into the sinus on at least one side.
  • Implant primary stability had to be achieved.
Surgical procedures

Seventeen patients (nine women, eight men) with a mean age of 55 years, at a private practice setting were consecutively included from May 2007 to 2008 with the latest follow-up in April 2010. All patients were healthy. One patient was smoker.

The patients received a total of 27 dental implants (Straumann AG, Basel, Switzerland) (23 molar area and 4 in the premolar). All implants were placed with OSFE procedure without graft material. From the 27 implants inserted, 19 were 10 mm long and 8 were 8 mm long. The diameter of the implants was 4.1 mm. Prophylactic antibiotics (Augmentin; Amoxicillin/Clavulanic acid, GlaxoSmithKline, Fako, Istanbul, Turkey; 1000 mg, 2 times daily) were given to the patients the day before surgery and for 5 days after surgery. Midcrestal incisions were performed for flap elevations. The implant position was marked on the alveolar crest with a small round bur (Ø 1.4 mm). After locating the implant position, the opening of the preparation was widened with two sizes of round burs (Ø 2.3 mm and Ø 3.1 mm). Minimal pilot drilling (Ø 2.2 mm) was performed to a depth approximately 1 mm away from the sinus floor boundary according to the panoramic radiograph. The cortical part of the implant bed was further widened to Ø 3.5 mm. The sinus floors were broken by slight strokes with a mallet and carefully pushed into the sinus cavities. The sites were enlarged by the 3.5-mm diameter osteotomes and raised to a maximal height of 3 mm [Figure 1]. No grafting material was used. The 4.1 mm implants were inserted to prepared osteotome sites. All the implants achieved primary stability. The flap sites were then sutured around the healing abutments allowing for non-submerged healing. The healings were uneventful and lasted for 8-12 weeks.
Figure 1: Osteotomy instruments (Straumann AG, Basel, Switzerland)

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Prosthetic procedures

The implants were allowed to heal 2-3 months. A panoramic and a periapical radiograph were taken to examine whether there was radiolucency around the implant body. When implants were stable, solid abutments (Straumann, Basel, Switzerland) were tightened with a torque of 35 Ncm. Impression copings with the correct color code were placed and polyether impressions (Impregum, 3M ESPE, Seefeld, Germany) were made with customized acrylic resin trays (LeadDent, Germany). The analogs (Straumann, Basel, Switzerland) were placed over the impressions. The final soft tissue casts (Sheraalpin, Shera Werkstoff-Technologie GmbH Co., Lemförder, Germany) were articulated on a semi-adjustable articulator. The zirconium frameworks of the implants were fabricated using CAD/CAM technology. The cast models were scanned with a three-dimensional-image-scanner (Dental Wings, Montreal, Canada) and the frameworks were milled from zirconium-oxide blanks (Copran, White Peaks Dental GmbH Co., Essen, Germany). The frameworks' contours and passivity were controlled intraorally and considered satisfactory. The frameworks were then veneered with feldspathic ceramic (Vita VM9, Vita Zanhfabrik, Bad Sackingen, Germany). Finally, the zirconium-oxide suprastructures were cemented to the implant abutments intraorally using self-adhesive resin cement (Rely X U100, 3M ESPE, Seefeld, Germany). The patients were instructed on the maintenance of interproximal gingival health with the aid of dental floss (Super Floss, Oral B, Frankfurt am Main, Germany).

Clinical evaluation

The survival criteria proposed by Buser et al. and Cochran et al. were applied: [14],[15] (i) absence of clinically detectable implant mobility, (ii) absence of pain or any subjective sensation, (iii) absence of recurrent periimplant infection, (iv) absence of continuous radiolucency around the implant.

Radiographic evaluation

Panaromic radiographs were taken before and after implant placement, 6, 12, and 24 months. They were analyzed by the same investigator.


   Results Top


All the patients completed the scheduled follow-up visits up to the 2-year control [Figure 2], [Figure 3] and [Figure 4]. No implants were recorded as lost during the follow-ups. No pathologic conditions in the marginal area of the implants were seen on radiographic follow-ups. After 2 years, all the implants were clinically and radiographically stable. In general, good function of implants and restorations were achieved. One patient had encountered loosening of a bridge twice, and the restoration was replaced to screw-retained system.
Figure 2: Initial radiograph of the case showing sinus pneumatization

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Figure 3: Post-surgical radiograph

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Figure 4: Radiograph showing the implant and surrounding bone at 2 years post-loading

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   Discussion Top


As the choice of the best grafting material has been questioned over the years, the search for the suitable graft material for sinus augmentations of the dental implants may be resolved in an unexpected way if successful and reliable sinus augmentations can be performed without any grafting material. [4],[5]

In the present study, all the implants, placed with the OSFE procedure without the grafting material were successfully osseointegrated after a healing time of 8-12 weeks. Hundred percent survival rate of the implants included in this study showed that the osteotome technique can be relevant when the RBH is ≤10 mm and ≥5 mm. Also, this study confirms that a graft material is not needed to promote osteogenesis and maintain the bone volume around the implants. These results are in accordance with the previous studies suggested by Shalabi et al., Nedir et al., Emmerich et al. [4],[5],[16],[17] The osteotome sinus floor elevation described by Summers involves a grafting material that is condensed in the osteotomy site to elevate the sinus membrane. [12],[13] If the Schneiderian membrane is perforated, the grafting material can migrate into the sinus and cause inflammation. [4],[18],[19] The present protocol, by eliminating use of a filling material has completely eliminated this risk as well.

From the patients' point of view, this technique is a one stage procedure; it eliminates the need for bone harvesting which is usually associated with discomfort; it eliminates concerns about using cadaver or animal derived biomaterials. [1],[4],[5] In addition, the technique is cost-effective and less time-consuming compared to the classical lateral window technique. [5],[8],[9],[10]

In the present study, we selected panoramic images to observe the changes in the volume of maxillary sinus and the bone formation around the implants. Since the present study was done retrospectively, further studies with controlled variables and 3D image procedures should be performed. However, in the present study, the OSFE without graft material was demonstrated to represent a reliable and a predictable method for implant insertion in the posterior maxilla, at sites with 5 mm or more preoperative residual bone height.


   Conclusion Top


Within the limitation of this clinical study, it can be concluded that the OSFE technique without grafting material may be predictable because the success rate was 100% in this study. Further studies are necessary in order to validate the results of the present report.

 
   References Top

1.Sani E, Veltri M, Cagidiaco MC, Balleri P, Ferrari M. Sinus membrane elevation in combination with placement of blasted implants: A 3-year case report of sinus augmentation without grafting material. Int J Oral Maxillofac Surg 2008;37:966-9.  Back to cited text no. 1
    
2.Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (II). Etiopathogenesis. Eur J Oral Sci 1998;106:721-64.  Back to cited text no. 2
    
3.Thor A, Sennerby L, Hirsch JM, Rasmusson L. Bone formation at the maxillary sinus floor following simultaneous elevation of the mucosal lining and implant installation without graft material: An evaluation of 20 patients treated with 44 Astra Tech implants. J Oral Maxillofac Surg 2007;65:64-72.  Back to cited text no. 3
    
4.Nedir R, Nurdin N, Vazquez L, Szmukler-Moncler S, Bischof M, Bernard JP. Osteotome sinus floor elevation technique without grafting: A 5-year prospective study. J Clin Periodontol 2010;37:1023-8.  Back to cited text no. 4
    
5.Nedir R, Bischof M, Vazquez L, Nurdin N, Szmukler-Moncler S, Bernard JP. Osteotome sinus floor elevation technique without grafting material: 3-year results of a prospective pilot study. Clin Oral Implants Res 2009;20:701-7.  Back to cited text no. 5
    
6.Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the sinus consensus conference of 1996. Int J Oral Maxillofac Implants 1998;13:11-45.  Back to cited text no. 6
    
7.Fugazzotto PA. Augmentation of the posterior maxilla: A proposed hierarchy of treatment selection. J Periodontol 2003;74:1682-91.  Back to cited text no. 7
    
8.Listl S, Faggion CM Jr. An economic evaluation of different sinus lift techniques. J Clin Periodontol 2010;37:777-87.  Back to cited text no. 8
    
9.Lai HC, Zhuang LF, Lv XF, Zhang ZY, Zhang YX, Zhang ZY. Osteotome sinus floor elevation with or without grafting: A preliminary clinical trial. Clin Oral Implants Res 2010;21:520-6.  Back to cited text no. 9
    
10.Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207-29.  Back to cited text no. 10
    
11.Chiapasco M, Zaniboni M. Methods to treat the edentulous posterior maxilla: Implants with sinus grafting. J Oral Maxillofac Surg 2009;67:867-71.  Back to cited text no. 11
    
12.Summers RB. The osteotome technique: Part 3-Less invasive methods of elevating the sinus floor. Compendium 1994;15:698-710.  Back to cited text no. 12
    
13.Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compendium 1994;15:152-62.  Back to cited text no. 13
    
14.Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res 1997;8:161-72.  Back to cited text no. 14
    
15.Cochran DL, Buser D, ten Bruggenkate CM, Weingart D, Taylor TM, Bernard JP, et al. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: Early results from clinical trials on ITI SLA implants. Clin Oral Implants Res 2002;13:144-53.  Back to cited text no. 15
    
16.Shalabi MM, Manders P, Mulder J, Jansen JA, Creugers NH. A meta-analysis of clinical studies to estimate the 4.5-year survival rate of implants placed with the osteotome technique. Int J Oral Maxillofac Implants 2007;22:110-6.  Back to cited text no. 16
    
17.Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotomes: A systematic review and meta-analysis. J Periodontol 2005;76:1237-51.  Back to cited text no. 17
    
18.Pikos MA. Maxillary sinus membrane repair: Update on technique for large and complete perforations. Implant Dent 2008;17:24-31.  Back to cited text no. 18
    
19.Raghoebar GM, Timmenga NM, Reintsema H, Stegenga B, Vissink A. Maxillary bone grafting for insertion of endosseous implants: Results after 12-124 months. Clin Oral Implants Res 2001;12:279-86.  Back to cited text no. 19
    

Top
Correspondence Address:
D P Senyilmaz
Department of Prosthodontics, Private Practice, ADA Dental Clinic, Atatürk Bulvari, Yat Sitesi, B Bloc, No. 4 Kusadasi, Aydin
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.94669

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