Antral Balloon Sinus Elevation and Grafting Prior to Dental Implant Placement: Review of 34 Cases Girish S. Rao, MDS1/Sudhakara K. Reddy, MDS2 Purpose: The objective of this study was to assess the antral balloon technique for sinus elevation followed by bone graft and implant placement. Materials and Methods: A total of 34 patients with atrophic edentulous posterior maxillary ridges underwent antral balloon sinus elevation followed by bone grafting (autogenous bone retrieved from the chin mixed with platelet-rich plasma) and implant placement. Results: The population consisted of 26 male and 8 female patients with a mean age of 42 years (range, 33 to 56 years). Successful sinus membrane balloon elevation was performed in all 34 patients, and 62 implants were placed. A membrane tear in one patient was managed intraoperatively by placement of a collagen membrane. Two implants failed within 6 months, and the survival rate of the other 60 implants was 100% after 3 years of follow-up. The mean inflated balloon volume was 1.96 mL and the mean elevated sinus height by balloon was 11.6 mm. An average bone gain of 7.5 mm (range, 5.2 to 10.5 mm) was observed. Conclusions: This case series demonstrates the feasibility of antral balloon sinus membrane elevation followed by bone augmentation and implant placement. This technique offers optimal assurance for membrane safety, and it is less invasive than the routine lateral window technique, safe, and associated with less postoperative bleeding and discomfort. This method is predictable, easy to learn, and associated with low complication rates. However, large comparative studies with other techniques are required. Int J Oral Maxillofac Implants 2014;29:414–418. doi: 10.11607/jomi.3075 Key words: antral balloon sinus elevation, dental implants, direct sinus elevation, lateral window sinus elevation
D
ental implants are a widely accepted viable option for the restoration of missing teeth.1,2 The edentulous posterior maxilla is unique compared with other areas in the mouth. Bone loss occurs at a faster rate,3 making the posterior maxilla a challenging area to place dental implants4,5 because of decreased bone width secondary to resorption of the buccal bone plate, loss of density because of atrophy,6 a high percentage of type IV bone,7 and a high rate of antral pneumatization. Augmentation of the sinus floor is one of the most predictable alternatives for increasing subantral bone height.8 Since the first description of subantral aug1Professor
and Head, Department of Oral and Maxillofacial Surgery, RV Dental College, Bangalore, India. 2Postgraduate Resident, Department of Oral and Maxillofacial Surgery, RV Dental College, Bangalore, India. Correspondence to: Girish S. Rao, Department of Oral and Maxillofacial Surgery, Ca-37, 24th Main, I Phase J. P. Nagar, RV Dental College, Bangalore, India. Email: [email protected] ©2014 by Quintessence Publishing Co Inc.
mentation by Tatum9 and the first publication by Boyne and James,4 various materials and techniques have been used for sinus elevation.10,11 Traditionally, there are two approaches to performing bone augmentation at the inferior aspect of the maxillary sinus: the lateral maxillary window approach (ie, hinge osteotomy) and a limited sinus elevation by osteotome.12 Various modifications of these two techniques have also been reported. In both cases, the antral membrane must be gently separated and elevated from the sinus floor to place the graft material inferiorly. In any technique, the use of sharp instruments and the presence of sinus septa can hinder elevation of the sinus membrane and greatly increase the likelihood of perforation. The use of an antral balloon for sinus membrane elevation is one modification that has been used in both approaches. This technique with the lateral approach13 was introduced in 2006. There are very few studies reporting larger patient series with this technique. The purpose of the present article, therefore, is to review the authors’ experience in sinus elevation with the balloon technique prior to placing dental implants and to determine the important aspects and advantages of this technique.
414 Volume 29, Number 2, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Rao/Reddy
Materials and Methods Patients
This prospective study involves consecutive patients, who presented between August 2006 and December 2007, with atrophic edentulous posterior maxillary ridges who needed oral rehabilitation with dental implants to restore occlusal function and who underwent surgery in the Department of Oral and Maxillofacial Surgery, R.V. Dental College and Hospital, Bangalore, India. The exclusion criteria were: the presence of any contraindicating systemic conditions such as uncontrolled diabetes, a history of radiation or chemotherapy in the head and neck region, and any active sinus infection or pathology such as sinusitis, retention cysts, polyps, root tips, etc. Included were patients with a residual alveolar crest of less than 6 mm in the atrophic posterior maxilla, in whom sinus floor augmentation for at least one of the implants was indicated. All patients were informed of the risks of maxillary sinus elevation and possible complications, and written informed consent was obtained. A complete examination of oral hard and soft tissues was conducted for each patient. Panoramic radiographs were obtained for all patients, and computed tomography scans were performed in some patients. Diagnostic casts, wax-ups, and surgical templates were also utilized as needed. The balloon used in these cases was an angled subantral membrane elevator kit consisting of a 5-mL Luer Lock syringe, a 4-mL-capacity balloon with metal shaft, and polyvinyl tubing. Sterile saline was used to expand the balloon; the amount of fluid used to inflate the balloon was equal to the amount of graft required or the amount of sinus elevation needed.
Surgical Procedure
Prophylactic broad-spectrum antibiotics for anaerobic and aerobic bacteria were prescribed preoperatively and maintained for 7 days postoperatively (amoxicillin 500 mg three times a day and metronidazole 400 mg three times a day). In all patients, the lateral window technique was used to gain access to the sinus membrane. A mucoperiosteal flap was raised via crestal and vertical releasing incisions. An osteotomy was created to visualize the dark inner lining of the sinus membrane, and a curette was used to elevate the membrane from the antral floor all the way to the medial wall of the sinus to enable insertion of the deflated balloon. Before a balloon was inserted, it was inflated with 2.5 to 4 mL of sterile saline to check for leaks. It was then emptied and placed against the sinus floor, midway between the lateral and medial walls. With the balloon in place, the Luer Lock syringe was held in a digital-palm position and the syringe plunger was slowly pressed with the thumb to expand the balloon
with 2 to 4 mL of saline and elevate the sinus membrane to the predetermined height. As the balloon expanded, the membrane was elevated. Once the desired elevation was obtained, the balloon was left inflated for 5 minutes to reduce the membrane’s elasticity. The balloon was then deflated by retracting the fluid back into the syringe, and the balloon-harboring device was removed from the osteotomy. After the balloon was removed, the sinus membrane moved with the patient’s respirations, ie, elevating on inspiration and dropping upon expiration. This oscillating movement confirmed the absence of mucosal perforation. In all the subjects, the space created by the expanded balloon was grafted with autogenous bone retrieved from the chin mixed with platelet-rich plasma, and implants were placed simultaneously. The graft was deposited into the antral void and loosely condensed. It was left loosely packed to prevent potential injury or laceration of the membrane and allow for necessary angiogenesis. The loose compaction of the graft was continued until the lateral wall of the sinus was rebuilt. The mucoperiosteal flap was repositioned and sutured to achieve primary soft tissue closure. In addition to the aforementioned antibiotics, ibuprofen (600 mg three times a day) was prescribed and patients were instructed to rinse with chlorhexidine (0.12% concentration) three times a day. The bone height obtained with the sinus elevation was calculated by measuring the postoperative panoramic radiograph. Patients were followed for 3 or more years.
Results Thirty-four patients (26 men and 8 women) participated in the study (Table 1). Their ages ranged from 33 to 56 years, with a mean age of 42 years. Of the 34 maxillary sinus elevation procedures, 19 were in the right maxilla and 15 were in the left maxilla; none were bilateral. A total of 62 implants were placed simultaneously with sinus elevation. Initial procedural success was accomplished in all 34 (100%) patients. No procedure was aborted because of membrane tear, but in one patient, the antral membrane was perforated while reflecting the window. However, the procedure was completed successfully; a collagen membrane was placed before grafting to repair the defect. In all cases, sinus membrane elevation took an average of 30 minutes. There were no major complications, and patients needed very little medical attention. Recorded minor complications included a mild self-limiting nosebleed, acute sinusitis, and hematoma (Table 2). Patients were evaluated for a mean follow-up period of 24 months. Two of the 62 implants (3.2%) failed within 6 months of placement. The survival rate of the The International Journal of Oral & Maxillofacial Implants 415
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Rao/Reddy
Table 1 Distribution of 34 Treated Patients Patient no.
Age (y)
Missing teeth (edentulous gap)*
Initial bone height
No. of implants placed
Final bone height (after 2 y)
Mean elevated bone height
1
42
26, 27, 28
3.7 mm
2
11.4 mm
7.7 mm
2
38
16, 17
4.2 mm
1
12 mm
7.8 mm
3
50
17, 18
3.2 mm
1
11 mm
7.8 mm
4
34
26, 27
3.9 mm
2
13 mm
9.1 mm
5
45
26, 27, 28
4 mm
2
9.5 mm
5.5 mm
6
42
15, 16, 17
4.8 mm
2
15 mm
10.2 mm
7
42
14, 15, 16
6.2 mm
3
12.4 mm
6.2 mm 8.6 mm
8
56
16, 17
3.6 mm
2
12.2 mm
9
33
26, 27
5.7 mm
2
13.6 mm
7.9 mm
10
48
17, 18
3.2 mm
1
9.4 mm
6.2 mm
11
40
26
4.1 mm
1
11.8 mm
7.7 mm
12
37
13, 15, 16
6.4 mm
3
14.3 mm
7.9 mm
13
55
26, 27, 28
3.4 mm
2
10.3 mm
6.9 mm
14
43
15
2.4 mm
1
9.8 mm
7.4 mm
15
54
16, 17,18
1.8 mm
2
8.5 mm
6.7 mm
16
34
17, 18
6 mm
1
13.8 mm
7.8 mm
17
35
26
5.5 mm
1
10.7 mm
5.2 mm
18
41
16, 17, 18
4.5 mm
2
10.1 mm
5.6 mm
19
47
16
3.5 mm
1
9.6 mm
6.1 mm
20
38
16
4.8 mm
1
15.3 mm
10.5 mm
21
40
26, 27
3.8 mm
2
11 mm
7.2 mm
22
45
16, 17, 18
2.8 mm
2
8.6 mm
5.8 mm
23
33
25, 26
5.2 mm
2
13 mm
7.8 mm
24
47
25, 26, 27, 28
3.3 mm
3
11.4 mm
8.1 mm
25
38
27, 28
5.2 mm
1
14.8 mm
9.6 mm
26
42
13, 15, 16, 17
3.8 mm
3
10.9 mm
7.1 mm
27
47
25, 26, 27
3.2 mm
3
9 mm
5.8 mm
28
45
26, 27
4.1 mm
2
12.5 mm
8.4 mm
29
41
17, 18
5.3 mm
1
14.7 mm
9.4 mm
30
38
25, 26
5 mm
2
14 mm
9 mm
31
40
17, 18
4.5 mm
1
11.4 mm
6.9 mm
32
45
16, 17
3.5 mm
2
9.6 mm
6.1 mm
33
44
25, 26, 28
4.1 mm
2
10.8 mm
6.7 mm
34
45
14, 16, 17
3.2 mm
3
9.4 mm
6.2 mm
*FDI tooth numbering system used.
remaining 60 implants in all patients after 2 years was 100%. Pre- and postoperative panoramic films were taken of every patient to measure and compare the result of sinus elevation with water balloon. The mean inflated balloon volume was 1.96 mL. All bone grafts were stable and integrated well with the implants after surgery. The average bone height prior to the intervention was 4.2 mm (range, 1.8 to 6.4 mm) and the average postsurgical bone height was 11.6 mm (range, 8.5 to 14.8 mm) (Table 3).
Discussion Since the first report of sinus elevation by Boyne and James,4 various surgical techniques and modifications have been reported. Each technique has advantages and disadvantages. In any technique, the major complications14 are membrane perforation, bleeding, and postoperative infection. Perforation of the sinus membrane occurs in 7% to 35% of sinus floor elevation procedures.15–18 In the present study, 1 of
416 Volume 29, Number 2, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Rao/Reddy
Table 2 Complications After Sinus Elevation and Implant Placement
Table 3 Bone Measurements After Placement of 62 Implants in 34 Patients
Complication
Measurement
No.
Amount (mm)
Antral membrane perforation
1
Mean initial bone height
Hematoma
2
Mean final bone height
Acute sinusitis
2
Average bone gain
Swelling
5
Implant success rate: 96.8% (2 implants failed and 60 were successful).
Wound dehiscence
1
Crown loosening
1
Persistent infection around the implant
1
34 (3%) patients had a sinus perforation, which was managed intraoperatively, and no procedure was aborted. This was attributed to the time spent (15 to 20 min) during initial membrane separation from the bony walls and to careful case selection. Sinus perforations can occur as a result of anatomical variations such as septa, sinus floor convolutions, or technical factors such as osteotomy design and membrane elevation technique. Subantral membrane elevation via balloon is less technically sensitive19 than other procedures, and it is less invasive than the routine lateral approach. This technique was proposed by Soltan and Smiler.20 Very few studies13,14,20–24 have documented the antral balloon elevation method. Kfir et al13 achieved procedural success in 91.6% of their initial 12 patients and 100% in a second series of 12 patients, without significant complications. In the current study, initial procedural success was 100% and an implant survival rate of 96.8% was observed after 6 months. In a recent large study by Kfir et al,22 membrane tears were reported in 3 of 109 patients who underwent minimally invasive antral membrane balloon elevation, requiring a halt to the procedure in all three cases; and an implant survival rate of 95% was observed at 6 to 9 months. Hu et al24 reported a 7% rate (2 of 28 cases) of membrane tearing during balloon sinus elevation. Mean elevated height by balloon was 10.9 ± 2.06 mm, and 1 of 26 implants failed. Another study18 showed that endoscopically controlled sinus floor elevation also did not reduce the incidence of complications such as perforations, although this approach helps to visualize perforations and eases repair. Studies25 that used piezoelectric preparation of the lateral antrostomies also showed a perforation rate of 3.6%, which was attributed to elevations using hand instrumentation. Whether the approach is manual via the lateral window approach, performed endoscopically, with piezoelectric devices, or with an antral balloon, perforation typically occurs during hand instrumentation. These techniques reduce the chances of complications after the mem-
4.2 11.6 7.5
brane is separated from the sinus floor. In comparison with other techniques, sinus membrane elevation with an antral balloon minimizes the potential for intraoperative complications. The major advantages of the antral balloon protocol are a low incidence of infection and bleeding26 and a low risk of perforation of the sinus membrane, even in anatomically complex conditions and in sinus pathology.27 A recent study by Kfir et al28 even showed successful results with subnasal elevation using an antral balloon along with antral elevation. Sinus elevation with the antral balloon eliminates the intraoperative complications, discomfort, disfiguration, and disability associated with the traditional lateral maxillary sinus approach and shortens operative time.26 It can be used to augment a severely atrophic ridge and is not dependent on the accessible ridge height, as is the crestal approach. The disadvantage of this technique is the possibility that the balloon may burst if inflated too quickly or more than 4 mL of fluid are used. Care should therefore be taken during initial insertion of the balloon, which features a pointed shape. Another possible complication may be caused by failure to expose the medial wall of the sinus. This wall must be exposed, because the viability of the graft will depend on its intimate relationship to the adjacent bone.
Conclusion The subantral balloon technique offers an almost ideal combination of a less invasive, low-complication procedure and the creation of a vertical bone bed of adequate dimensions. This technique offers optimal assurance for membrane safety and less postoperative bleeding and can be especially beneficial in difficultto-access areas when adjacent teeth are present. In addition, the blood circulation in the vascular and reticular layers remains intact, a prerequisite for subsequent vascularization of the augmented tissue. The International Journal of Oral & Maxillofacial Implants 417
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Rao/Reddy
ACKNOWLEDGMENTs The authors reported no conflicts of interest related to this study.
References 1. Misch CE, Misch-Dietsch F, Silc J, et al. Posterior implant singletooth replacement and status of adjacent teeth during a 10-year period: A retrospective report. J Periodontol 2008;79:2378–2382. 2. Adell R, Eriksson B, Lekholm U, et al. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347–359. 3. Wang HL, Katranji A. ABC sinus augmentation classification. Int J Periodontics Restorative Dent 2008;28:383–389. 4. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613–616. 5. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22(suppl):49–70. 6. Garg A. Augmentation grafting of the maxillary sinus for the placement of dental implants: Anatomy, physiology, and procedure. Implant Dent 1994;8:36–45. 7. Truhlar RS, Orenstein IH, Morris HF, et al. Distribution of bone quality in patients receiving endosseous dental implants. J Oral Maxillofac Surg 1997;55:38–45. 8. Misch CE. Maxillary sinus augmentation for endosteal implants: Organized alternative treatment plans. Int J Oral Implantol 1987;4:49–58. 9. Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–229. 10. Wallace SS. Maxillary sinus augmentation: Evidence-based decision making with a biological surgical approach. Compendium 2006;27(12):662–669. 11. Van der Bergh JPA, ten Bruggenkate CM, Disch FJM, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000;11:256–265. 12. Summers RB. Sinus floor elevation with osteotomes. J Esthet Dent 1998;10:164–171. 13. Kfir E, Kfir V, Mijiritsky E, et al. Minimally invasive antral membrane balloon elevation followed by maxillary bone augmentation and implant fixation. J Oral Implantol 2006;32:26–33. 14. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: Report of 36 procedures. J Periodontol 2007 Oct;78(10):2032–2035.
15. Shlomi B, Horowitz I, Kahn A, Dobriyan A, Chaushu G. The effect of sinus membrane perforation and repair with Lambone on the outcome of maxillary sinus floor augmentation: A radiographic assessment. Int J Oral Maxillofac Implants 2004;19:559–562. 16. Levin L, Herzberg R, Dolev E, Schwartz-Arad D. Smoking and complications of onlay bone grafts and sinus lift operations. Int J Oral Maxillofac Implants 2004;19:369–373. 17. Stricker A, Voss PJ, Gutwald R, Schramm A, Schmelzeisen R. Maxillary sinus floor augmentation with autogenous bone grafts to enable placement of SLA surfaced implants: Preliminary results after 15–40 months. Clin Oral Implants Res 2003;14:207–212. 18. Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: A preliminary prospective study. Int J Oral Maxillofac Implants 2002;17:557–566. 19. Doud Galli SK, Lebowitz RA, Giacchi RJ, Glickman R, Jacobs JB. Chronic sinusitis complicating sinus lift surgery. Am J Rhinol 2001;15(3):181–186. 20. Soltan M, Smiler DG. Antral membrane balloon elevation. J Oral Implantol 2005;31(2):85–90. 21. Kfir E, Goldstein M, Rafaelov R, et al. Minimally invasive antral membrane balloon elevation in the presence of antral septa: A report of 26 procedures. J Oral Implantol 2009;35:257–267. 22. Kfir E, Goldstein M, Yerushalmi I, et al. Minimally invasive antral membrane balloon elevation—Results of a multicenter registry. Clin Implant Dent Relat Res 2009;11:e83–e91. 23. Muronoi M, Xu H, Shimizu Y, Ooya K. Simplified procedure for augmentation of the sinus floor using a haemostatic nasal balloon. Br J Oral Maxillofac Surg 2003;41:120–121. 24. Hu X, Lin Y, Metzmacher AR, Zhang Y. Sinus membrane lift using a water balloon followed by bone grafting and implant placement: A 28-case report. Int J Prosthodont 2009;22:243–247. 25. Toscano NJ, Holtzclaw D, Rosen PS. The effect of piezoelectric use on open sinus lift perforation: A retrospective evaluation of 56 consecutively treated cases from private practices. J Periodontol 2010 Jan;81(1):167–171. 26. Raja SV. Management of the posterior maxilla with sinus lift: Review of techniques. J Oral Maxillofac Surg 2009 Aug;67(8):1730–1734. 27. Kfir E, Goldestein M, Abramovitz I, Mazor Z, Kfir V, Kaluski E. The effects of sinus membrane pathology on bone augmentation and procedural outcome using minimal invasive antral membrane balloon elevation. J Oral Implantol 2012 Mar 5. [Epub ahead of print] 28. Kfir E, Kfir V, Goldstein M, Mazor Z, Kaluski E. Minimally invasive subnasal elevation and antral membrane balloon elevation along with bone augmentation and implants placement. J Oral Implantol 2012 Aug;38(4):365–376.
418 Volume 29, Number 2, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
D
ental implants are a widely accepted viable option for the restoration of missing teeth.1,2 The edentulous posterior maxilla is unique compared with other areas in the mouth. Bone loss occurs at a faster rate,3 making the posterior maxilla a challenging area to place dental implants4,5 because of decreased bone width secondary to resorption of the buccal bone plate, loss of density because of atrophy,6 a high percentage of type IV bone,7 and a high rate of antral pneumatization. Augmentation of the sinus floor is one of the most predictable alternatives for increasing subantral bone height.8 Since the first description of subantral aug1Professor
and Head, Department of Oral and Maxillofacial Surgery, RV Dental College, Bangalore, India. 2Postgraduate Resident, Department of Oral and Maxillofacial Surgery, RV Dental College, Bangalore, India. Correspondence to: Girish S. Rao, Department of Oral and Maxillofacial Surgery, Ca-37, 24th Main, I Phase J. P. Nagar, RV Dental College, Bangalore, India. Email: [email protected] ©2014 by Quintessence Publishing Co Inc.
mentation by Tatum9 and the first publication by Boyne and James,4 various materials and techniques have been used for sinus elevation.10,11 Traditionally, there are two approaches to performing bone augmentation at the inferior aspect of the maxillary sinus: the lateral maxillary window approach (ie, hinge osteotomy) and a limited sinus elevation by osteotome.12 Various modifications of these two techniques have also been reported. In both cases, the antral membrane must be gently separated and elevated from the sinus floor to place the graft material inferiorly. In any technique, the use of sharp instruments and the presence of sinus septa can hinder elevation of the sinus membrane and greatly increase the likelihood of perforation. The use of an antral balloon for sinus membrane elevation is one modification that has been used in both approaches. This technique with the lateral approach13 was introduced in 2006. There are very few studies reporting larger patient series with this technique. The purpose of the present article, therefore, is to review the authors’ experience in sinus elevation with the balloon technique prior to placing dental implants and to determine the important aspects and advantages of this technique.
414 Volume 29, Number 2, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Rao/Reddy
Materials and Methods Patients
This prospective study involves consecutive patients, who presented between August 2006 and December 2007, with atrophic edentulous posterior maxillary ridges who needed oral rehabilitation with dental implants to restore occlusal function and who underwent surgery in the Department of Oral and Maxillofacial Surgery, R.V. Dental College and Hospital, Bangalore, India. The exclusion criteria were: the presence of any contraindicating systemic conditions such as uncontrolled diabetes, a history of radiation or chemotherapy in the head and neck region, and any active sinus infection or pathology such as sinusitis, retention cysts, polyps, root tips, etc. Included were patients with a residual alveolar crest of less than 6 mm in the atrophic posterior maxilla, in whom sinus floor augmentation for at least one of the implants was indicated. All patients were informed of the risks of maxillary sinus elevation and possible complications, and written informed consent was obtained. A complete examination of oral hard and soft tissues was conducted for each patient. Panoramic radiographs were obtained for all patients, and computed tomography scans were performed in some patients. Diagnostic casts, wax-ups, and surgical templates were also utilized as needed. The balloon used in these cases was an angled subantral membrane elevator kit consisting of a 5-mL Luer Lock syringe, a 4-mL-capacity balloon with metal shaft, and polyvinyl tubing. Sterile saline was used to expand the balloon; the amount of fluid used to inflate the balloon was equal to the amount of graft required or the amount of sinus elevation needed.
Surgical Procedure
Prophylactic broad-spectrum antibiotics for anaerobic and aerobic bacteria were prescribed preoperatively and maintained for 7 days postoperatively (amoxicillin 500 mg three times a day and metronidazole 400 mg three times a day). In all patients, the lateral window technique was used to gain access to the sinus membrane. A mucoperiosteal flap was raised via crestal and vertical releasing incisions. An osteotomy was created to visualize the dark inner lining of the sinus membrane, and a curette was used to elevate the membrane from the antral floor all the way to the medial wall of the sinus to enable insertion of the deflated balloon. Before a balloon was inserted, it was inflated with 2.5 to 4 mL of sterile saline to check for leaks. It was then emptied and placed against the sinus floor, midway between the lateral and medial walls. With the balloon in place, the Luer Lock syringe was held in a digital-palm position and the syringe plunger was slowly pressed with the thumb to expand the balloon
with 2 to 4 mL of saline and elevate the sinus membrane to the predetermined height. As the balloon expanded, the membrane was elevated. Once the desired elevation was obtained, the balloon was left inflated for 5 minutes to reduce the membrane’s elasticity. The balloon was then deflated by retracting the fluid back into the syringe, and the balloon-harboring device was removed from the osteotomy. After the balloon was removed, the sinus membrane moved with the patient’s respirations, ie, elevating on inspiration and dropping upon expiration. This oscillating movement confirmed the absence of mucosal perforation. In all the subjects, the space created by the expanded balloon was grafted with autogenous bone retrieved from the chin mixed with platelet-rich plasma, and implants were placed simultaneously. The graft was deposited into the antral void and loosely condensed. It was left loosely packed to prevent potential injury or laceration of the membrane and allow for necessary angiogenesis. The loose compaction of the graft was continued until the lateral wall of the sinus was rebuilt. The mucoperiosteal flap was repositioned and sutured to achieve primary soft tissue closure. In addition to the aforementioned antibiotics, ibuprofen (600 mg three times a day) was prescribed and patients were instructed to rinse with chlorhexidine (0.12% concentration) three times a day. The bone height obtained with the sinus elevation was calculated by measuring the postoperative panoramic radiograph. Patients were followed for 3 or more years.
Results Thirty-four patients (26 men and 8 women) participated in the study (Table 1). Their ages ranged from 33 to 56 years, with a mean age of 42 years. Of the 34 maxillary sinus elevation procedures, 19 were in the right maxilla and 15 were in the left maxilla; none were bilateral. A total of 62 implants were placed simultaneously with sinus elevation. Initial procedural success was accomplished in all 34 (100%) patients. No procedure was aborted because of membrane tear, but in one patient, the antral membrane was perforated while reflecting the window. However, the procedure was completed successfully; a collagen membrane was placed before grafting to repair the defect. In all cases, sinus membrane elevation took an average of 30 minutes. There were no major complications, and patients needed very little medical attention. Recorded minor complications included a mild self-limiting nosebleed, acute sinusitis, and hematoma (Table 2). Patients were evaluated for a mean follow-up period of 24 months. Two of the 62 implants (3.2%) failed within 6 months of placement. The survival rate of the The International Journal of Oral & Maxillofacial Implants 415
© 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Rao/Reddy
Table 1 Distribution of 34 Treated Patients Patient no.
Age (y)
Missing teeth (edentulous gap)*
Initial bone height
No. of implants placed
Final bone height (after 2 y)
Mean elevated bone height
1
42
26, 27, 28
3.7 mm
2
11.4 mm
7.7 mm
2
38
16, 17
4.2 mm
1
12 mm
7.8 mm
3
50
17, 18
3.2 mm
1
11 mm
7.8 mm
4
34
26, 27
3.9 mm
2
13 mm
9.1 mm
5
45
26, 27, 28
4 mm
2
9.5 mm
5.5 mm
6
42
15, 16, 17
4.8 mm
2
15 mm
10.2 mm
7
42
14, 15, 16
6.2 mm
3
12.4 mm
6.2 mm 8.6 mm
8
56
16, 17
3.6 mm
2
12.2 mm
9
33
26, 27
5.7 mm
2
13.6 mm
7.9 mm
10
48
17, 18
3.2 mm
1
9.4 mm
6.2 mm
11
40
26
4.1 mm
1
11.8 mm
7.7 mm
12
37
13, 15, 16
6.4 mm
3
14.3 mm
7.9 mm
13
55
26, 27, 28
3.4 mm
2
10.3 mm
6.9 mm
14
43
15
2.4 mm
1
9.8 mm
7.4 mm
15
54
16, 17,18
1.8 mm
2
8.5 mm
6.7 mm
16
34
17, 18
6 mm
1
13.8 mm
7.8 mm
17
35
26
5.5 mm
1
10.7 mm
5.2 mm
18
41
16, 17, 18
4.5 mm
2
10.1 mm
5.6 mm
19
47
16
3.5 mm
1
9.6 mm
6.1 mm
20
38
16
4.8 mm
1
15.3 mm
10.5 mm
21
40
26, 27
3.8 mm
2
11 mm
7.2 mm
22
45
16, 17, 18
2.8 mm
2
8.6 mm
5.8 mm
23
33
25, 26
5.2 mm
2
13 mm
7.8 mm
24
47
25, 26, 27, 28
3.3 mm
3
11.4 mm
8.1 mm
25
38
27, 28
5.2 mm
1
14.8 mm
9.6 mm
26
42
13, 15, 16, 17
3.8 mm
3
10.9 mm
7.1 mm
27
47
25, 26, 27
3.2 mm
3
9 mm
5.8 mm
28
45
26, 27
4.1 mm
2
12.5 mm
8.4 mm
29
41
17, 18
5.3 mm
1
14.7 mm
9.4 mm
30
38
25, 26
5 mm
2
14 mm
9 mm
31
40
17, 18
4.5 mm
1
11.4 mm
6.9 mm
32
45
16, 17
3.5 mm
2
9.6 mm
6.1 mm
33
44
25, 26, 28
4.1 mm
2
10.8 mm
6.7 mm
34
45
14, 16, 17
3.2 mm
3
9.4 mm
6.2 mm
*FDI tooth numbering system used.
remaining 60 implants in all patients after 2 years was 100%. Pre- and postoperative panoramic films were taken of every patient to measure and compare the result of sinus elevation with water balloon. The mean inflated balloon volume was 1.96 mL. All bone grafts were stable and integrated well with the implants after surgery. The average bone height prior to the intervention was 4.2 mm (range, 1.8 to 6.4 mm) and the average postsurgical bone height was 11.6 mm (range, 8.5 to 14.8 mm) (Table 3).
Discussion Since the first report of sinus elevation by Boyne and James,4 various surgical techniques and modifications have been reported. Each technique has advantages and disadvantages. In any technique, the major complications14 are membrane perforation, bleeding, and postoperative infection. Perforation of the sinus membrane occurs in 7% to 35% of sinus floor elevation procedures.15–18 In the present study, 1 of
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Rao/Reddy
Table 2 Complications After Sinus Elevation and Implant Placement
Table 3 Bone Measurements After Placement of 62 Implants in 34 Patients
Complication
Measurement
No.
Amount (mm)
Antral membrane perforation
1
Mean initial bone height
Hematoma
2
Mean final bone height
Acute sinusitis
2
Average bone gain
Swelling
5
Implant success rate: 96.8% (2 implants failed and 60 were successful).
Wound dehiscence
1
Crown loosening
1
Persistent infection around the implant
1
34 (3%) patients had a sinus perforation, which was managed intraoperatively, and no procedure was aborted. This was attributed to the time spent (15 to 20 min) during initial membrane separation from the bony walls and to careful case selection. Sinus perforations can occur as a result of anatomical variations such as septa, sinus floor convolutions, or technical factors such as osteotomy design and membrane elevation technique. Subantral membrane elevation via balloon is less technically sensitive19 than other procedures, and it is less invasive than the routine lateral approach. This technique was proposed by Soltan and Smiler.20 Very few studies13,14,20–24 have documented the antral balloon elevation method. Kfir et al13 achieved procedural success in 91.6% of their initial 12 patients and 100% in a second series of 12 patients, without significant complications. In the current study, initial procedural success was 100% and an implant survival rate of 96.8% was observed after 6 months. In a recent large study by Kfir et al,22 membrane tears were reported in 3 of 109 patients who underwent minimally invasive antral membrane balloon elevation, requiring a halt to the procedure in all three cases; and an implant survival rate of 95% was observed at 6 to 9 months. Hu et al24 reported a 7% rate (2 of 28 cases) of membrane tearing during balloon sinus elevation. Mean elevated height by balloon was 10.9 ± 2.06 mm, and 1 of 26 implants failed. Another study18 showed that endoscopically controlled sinus floor elevation also did not reduce the incidence of complications such as perforations, although this approach helps to visualize perforations and eases repair. Studies25 that used piezoelectric preparation of the lateral antrostomies also showed a perforation rate of 3.6%, which was attributed to elevations using hand instrumentation. Whether the approach is manual via the lateral window approach, performed endoscopically, with piezoelectric devices, or with an antral balloon, perforation typically occurs during hand instrumentation. These techniques reduce the chances of complications after the mem-
4.2 11.6 7.5
brane is separated from the sinus floor. In comparison with other techniques, sinus membrane elevation with an antral balloon minimizes the potential for intraoperative complications. The major advantages of the antral balloon protocol are a low incidence of infection and bleeding26 and a low risk of perforation of the sinus membrane, even in anatomically complex conditions and in sinus pathology.27 A recent study by Kfir et al28 even showed successful results with subnasal elevation using an antral balloon along with antral elevation. Sinus elevation with the antral balloon eliminates the intraoperative complications, discomfort, disfiguration, and disability associated with the traditional lateral maxillary sinus approach and shortens operative time.26 It can be used to augment a severely atrophic ridge and is not dependent on the accessible ridge height, as is the crestal approach. The disadvantage of this technique is the possibility that the balloon may burst if inflated too quickly or more than 4 mL of fluid are used. Care should therefore be taken during initial insertion of the balloon, which features a pointed shape. Another possible complication may be caused by failure to expose the medial wall of the sinus. This wall must be exposed, because the viability of the graft will depend on its intimate relationship to the adjacent bone.
Conclusion The subantral balloon technique offers an almost ideal combination of a less invasive, low-complication procedure and the creation of a vertical bone bed of adequate dimensions. This technique offers optimal assurance for membrane safety and less postoperative bleeding and can be especially beneficial in difficultto-access areas when adjacent teeth are present. In addition, the blood circulation in the vascular and reticular layers remains intact, a prerequisite for subsequent vascularization of the augmented tissue. The International Journal of Oral & Maxillofacial Implants 417
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Rao/Reddy
ACKNOWLEDGMENTs The authors reported no conflicts of interest related to this study.
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