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serious complications, and may be a relative contraindication to the use of thrombolytic agents. vent

References I. Stewart JH. Olin JW. Graor RA: Thrombolytic therapy: A review. Cleveland Clin J Med 56:189, 1989

J Oral Maxillofac 50:415-418.

2. Stewart JH, Olin JW, Graor RA: Thrombolytic therapy: A review. Cleveland Clin J Med 56293, 1989 3. Shafer KE, Santoro SA, Sobel BE, et al: Monitoring activity of fibrinolvtic agents: A therapeutic challenge. Am J Med 76: 879, 19-84 4. Del Zoppo GJ, Zeumer H, Harker LA: Thrombolytic therapy in stroke: Possibilities and hazards. Stroke 17:595, 1986 5. Sicher H, DuBrul LE: Oral Anatomy (ed 5). Saint Louis, MO, Mosby, 1970

Surg

1992

Nasal Fossa and Maxillary Sinus Grafting of Implants From a Palatal Approach: Report of a Case OLE T. JENSEN, DDS, MS,* SCOTT PERKINS, DDS, MS,* AND FRANK W. VAN DE WATER, MD*

The treatment of the highly resorbed maxilla with dental implants can require both sinus and nasal floor augmentation bone grafting. Maxillary sinus grafts are most often done through a Caldwell-Luc approach, whereas nasal grafts are usually done through the nasal aperture. By using autogenous bone, both immediate and delayed implant placement have been successfully accomplished at both sites. l-3 Iliac bone is most often used for sinus grafts, but chin cortex, coronoid process, and alveolar process bone also have been used successfully. However, when bone is obtained from oral sites, delayed implant placement is advocated.4*’ Nasal fossa grafting has been done almost exclusively using iliac bone via a Le Fort I downgraft with delayed implant placement or implant-fixed onlay/inlay grafts6“ To obtain a suitable alternative to autogenous grafting in these regions, allografts and ceramic bone substitutes have been used in an attempt to provide a simple office procedure with minimal morbidity. However, the use of these materials to facilitate osseointegration is dubious because of their much-reduced capacity to stimulate bone formation in the sinus cavity or adjacent to a titanium implant when used either alone or in combination. ‘o-‘3 Various types of allogeneic bone preparations are currently being used in the sinus membrane lift pro* In private practice, Denver, CO. Address correspondence and reprint requests to Dr Jensen: Fillmore Medical Building, 303 Josephine St, Suite 303, Denver, CO 80206. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5004-0019$3.00/O

cedure, with varying results. Demineralized, freezedried, cancellous, allogeneic bone (ethylene oxide gassterilized) has been shown to have only fair osteogenic properties in the sinus or in augmentation applications because of attenuated inductivity, whereas mineralized, radiation-sterilized (2.5 Mrad), cancellous, allogeneic bone has been shown to induce dense bone formation after 6 months in the sinus provided a barrier membrane is used over the osteotomy site.5 When the use of an iliac autograft is precluded, and immediate implantation is done, the latter grafting technique is preferred because of its twofold greater bone inductivity.‘4-‘6 In the highly resorbed maxilla, marked lateral resorption of the alveolus occurs and the jaw decreases in size in all dimensions. A sinus membrane lift antroplasty in this situation exposes a narrow anterior antrum and midalveolar placement of implants will result in penetration directly into the nasal cavity (Fig 1C). Boyne has shown in a cadaver study of elderly edentulous individuals that in the first and second premolar regions up to 80% of the implants engage the lateral nasal wall or penetrate at least in part into the nasal cavity. ” In the first and second molar areas, 50% of the implants showed penetration through the lateral nasal wall. He concluded that in highly resorbed ridges, the transverse dimension of the maxilla is so reduced that the alveolar process tends to line up in the same vertical plane as the lateral wall of the nose. When the nasal cavity is penetrated in this type of situation, the nasal membrane can most oflen be dissected from the floor of the nose through the nasal aperture. However, when the implants are placed pos-

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Suture

FIGURE 1. Diagram of grafting procedure. A, The sinus cavity is grafted with allogeneic mineralized bone after implant placement, and then the osteotomy site is covered with a ePTPE barrier membrane. B, The implants perforate into the nasal fossa but are easily visualized through the Caldwell-Luc approach. C, Either because of angulation or severe basilar bone resorption, implants can penetrate directly into the nasal fossa, where they are most easily accessedthrough a small palatal osteotomy that can later he covered with a ePTPE membrane.

teriorly in the mouth and the sinus is lateral to the implant, a palatal osteotomy must be done to provide direct visual access to lift the nasal membrane as well as facilitate bone grafting and implant placement. The medial aspect of the sinus can also be accessed through the palate

by cutting

through

the lateral

nasal wall,

which can facilitate bone grafting along the poorly accessable medial aspect of the implants. This technique is described in conjunction with a case report. Report

of Case

A 70-year-old woman had been treated for squamous cell carcinoma of the nasopharynx over an 1 l-year period. She had had 22 major operations to eradicate or reconstruct the operative sites and now presented following right hemimaxillectomy, right hemimandibulectomy with bilateral radical

neck dissections, and multiple floor of the mouth and nasal fossa excisions. She had had a deltopectoral flap rotated into the mouth, which had closed the defect but produced reduced intraoral space and limited opening. She had been edentulous and unable to wear a denture since her cancer therapy had begun several years ago. Her lower jaw was grossly deviated. The maxillary bone sites were all class D (less than 4 mm in

vertical height).‘” The surgical treatment plan included soft-tissue debulking

and scar revision in the perioral areas, to be followed by placement of osseointegratingimplants in both residual arches following allogeneic bone grafting to the sinus floor and nasal fossa. Iliac grafting was contraindicated owing to her physical status and the potential surgical morbidity. MAXILLARY IMPLANT SURGICAL PROCEDURE: The residual left maxilla was approached through a crestal incision carried around the entire arch. A full-thickness mu-

FIGURE 2.

Implant placement shown intraoperatively. The Caldwell-Luc osteotomy site is at the top of photograph and the palatal osteotomy site (arrowhead) below. The nasal ap erture is seen at letI of photograph.

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JENSEN, PERKINS, AND VAN DE WATER

FIGURE 3. The sinus and nasal cavities are bone grafted and covered with a ePTFE barrier membrane that is well adapted to the surrounding bone.

coperiosteal flap was developed that allowed exposure of the facial aspect of the maxilla and the anterior nasal fossa. A palatal flap was also reflected to expose the palatal vault. The left maxillary sinus was entered through a CaldwellLuc osteotomy. The osteotomized plate of bone was infractured and left attached to the sinus membrane, which was then lifted to expose a narrow antral cavity (Fig 1A, B). Implant sites were selected using a guide splint, but holes drilled through the midalveolus, for five implants were not all in the sinus cavity. Reflection of the nasal mucosa was accomplished through the nasal aperture, which provided adequate visualization for anterior sites but the posterior implant site access was poor. Therefore, a palatal osteotomy was done using an infracture technique and lifting of the nasal fossa lining was lifted to allow for access posteriorly (Fig 1C). The five implants were all at least in part within the nasal fossa.

FIGURE 4. Six months after implant placement, the prominence of bone generated under the ePTFE (arrow) is seen following ePTFE removal. The grafted sites were clinically firm. Ah implants integrated except for the midline implant, which dehisced medially, having been placed too close to the midpalatal hemimaxillectomy site.

FIGURE 5. A, Preoperative panoramic radiograph of highly resorbed left hemimaxilla. B, Six-month postoperative panoramic radiograph showing the grafted maxilla just prior to exposure of the osseointegrated implants. The implants extend into grafted bone in both the nasal fossa and antral areas.

The area around the implants was grafted with mineralized radiated allogeneic cancellous bone (Denver Tissue Bank, Denver, CO) through the sinus and palatal access areas (Fig 2). The sinus also was accessed through the palatal osteotomy site by cutting through the lateral nasal wall. Using these two approaches, bone was densely packed on all sides of the im-

FIGURE 6. postinsertion.

Implant-supported

prostheses in place 12 months

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NASAL AND SINUS GRAFTING FROM PALATE

plants under direct vision. A polytetrafluoroethylene barrier membrane (Gore-Tex, Flagstaff, AZ) was placed over both osteotomy sites (Fig 3) and the wound was closed primarily using resorbable sutures. The patient did well postoperatively. At the time of exposure, all implants except the most anterior one were found to be integrated. The ePTFE membranes were removed and the bone graft sites appeared clinically firm (Fig 4). A panoramic radiograph showed osseous fill (Fig 5). The patient was reconstructed with a bar-clip retained overdenture and had a markedly improved masticatory, deglutatory, and articulatory function (Fig 6). The patient’s case has been followed for 18 months with no apparent problems encountered.

Discussion The palatal aspect of the alveolar basal bone is often the final remains of decades of denture wear. The net effect is medialization of the ridge (Fig 7) accompanied

by an overall decrease in transverse maxillary dimension. The midalveolar vertical plane tends to coincide with the lateral nasal wall so that implants placed from the canine through the first molar area can sometimes be entirely within the nasal fossa. This necessitates a different approach for the grafting procedure. The palatal osteotomy described seldom will be needed but, when necessary, can be easily accomplished in the highly resorbed maxilla because of the accompanying palatal vault thinning seen in these types of cases. References 1. Boyne PJ, James RA: Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 38:6 13, 1980 2. Hall HD: Particulate bone graft of the maxillary sinus and alveolar ridge for Branemark implants. Dallas, TX, Annual Meeting of the Academy of Osseointegration, March 1, 1990 (abstr) 3. Kent JN, Block MS: Simultaneous maxillary sinus floor bone grafting and placement of hydroxylapatite-coated implants. J Oral Maxillofac Surg 47:238, 1989 4. Wood RM, Moore DL: Grafting of the maxillary sinus with intraorally harvested autogenous bone prior to implant placement. Int J Oral Maxillofac Implants 3:209, 1988 5. Jensen OT: Immediate placement of osseointegrating implants into the maxillary sinus with mineralized cancellous allograft and Gore-tex: Second stage surgical and histological findings. Proceedings of the 2nd International Symposium on Tissue Integration, Mayo Clinic, Rochester, MN, September 1990. Chicago, IL, Quintessence, 1991 (in press) 6. Keller EE, Van Roekel NB, Desjardins RR, et al: Prostheticsurgical reconstruction of the severely resorbed maxilla with iliac bone grafting and tissue integrated prosthesis. Int J Oral Maxillofac Implants 2: 155, 1987 7. Stroud SW, Fonseca R, Sanders G, et al: Healing of interpositional bone grafts aIter total maxillary osteotomy. J Oral Maxillofac Surg 38:878, 1980 8. Kahnberg KE, Nystrom E, Bartholdsson L: Combined use of bone grafts and Branemark fixtures in the treatment of severely resorbed maxillae. Int J Oral Maxillof Implants 4:297, 1989 9. Personal communication: PI Branemark, March 1988, Seattle, WA 10. Smiler D, Holmes RE: Sinus lift procedure using hydroxylapatite: A preliminary report. J Oral Implants 23:239, 1989 11. Ripamonti U, Schitzler CM, Cleaton-Jones RC: Composite allogeneic bone/alloplastic implant. J Oral Maxillof Surg 47:

963, 1989

FIGURE 7. A, Preoperative computed tomography scan showing right hemimaxillectomy and highly resorbed residual maxilla. Note first molar area (arrow) shown in cross section below. An implant placed in the midalveolus in this location penetrated into the nasal fossa. B, Preoperative cross-sectional views through second premolar and first molar areas. The midalveolus lines up with the lateral nasal wall (arrow). The nasal fossa (NF) and the maxillary sinus (sin) were both grafted.

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12. Aspenberg P, Kalebo P, Albrektsson T: Rapid bone healing delaved bv bone matrix implantation. Int J Oral Maxillofac Implants 3:123, 1988 _ 13. Kramer GM, Mattout P, Mattout C, et al: Clinical and histological response to a mixed bone/hydroxylapatite graft: Report of a case. Int J Periodont Res Dent 9:9, 1989 14. Herron LD, Newman MH: The failure of ethylene oxide gassterilized freeze dried bone for thoracic and lumbar fusion. Spine 14:496, 1989 15. Munting E, Wilmart JF, Wijne A, et al: Effect of sterilization on osteoinduction: Comparison of five methods in demineralized rat bone. Acta Orthop Stand 59:34, 1988 16. Skinner HB: Alternatives in the selection of ahogral? bone. J Orthop 13:843, 1990 17. Boyne P: Histologic and clinical investigative findings in the posterior maxilla: Implications for placement of intraosseous implants. Dallas, TX, Academy of Osseointegration, March 1, 1990 (abstr) 18. Jensen OT: Site selection for the osseointegrated implant. J Prosthet Dent 6 1:228,1989

Nasal fossa and maxillary sinus grafting of implants from a palatal approach: report of a case.

415 JENSEN. PERKINS, AND VAN DE WATER serious complications, and may be a relative contraindication to the use of thrombolytic agents. vent Referen...
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