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Table of Contents
Year : 2011  |  Volume : 1  |  Issue : 1  |  Page : 29-33

Direct sinus elevation and composite bone grafting for immediate implant placement in the posterior maxillary region

1 Department of Periodontology and Oral Implantology, S. B. Patil Dental College, Bidar, Karnataka, India
2 Department of Periodontology and Oral Implantology, Amrita School of Dentistry, AIMS, Amrita Lane, Ponekkara P.O., Edapally, Kochi, Kerala, India

Date of Web Publication2-Feb-2011

Correspondence Address:
R Sowmya
Department of Periodontology and Oral Implantology, Amrita School of Dentistry, AIMS, Amrita Lane, Ponekkara P.O., Edapally, Kochi, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-6781.76430

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An atrophied posterior maxilla is the most challenging intraoral area confronting the implantologists, requiring utmost skill for the achievement of successful results. This case report exemplifies the use of a lateral wall osteotomy approach for sinus floor elevation, combined with the composite grafting to provide the ideal milieu for placement of a dental implant.

Keywords: Composite bone graft, direct sinus elevation, implant placement

How to cite this article:
Kumar NS, Sowmya R. Direct sinus elevation and composite bone grafting for immediate implant placement in the posterior maxillary region. J Dent Implant 2011;1:29-33

How to cite this URL:
Kumar NS, Sowmya R. Direct sinus elevation and composite bone grafting for immediate implant placement in the posterior maxillary region. J Dent Implant [serial online] 2011 [cited 2023 Jan 29];1:29-33. Available from:

   Introduction Top

The posterior maxilla has been described as the most difficult intraoral area confronting the implant practitioner, requiring utmost ingenuity to achieve successful results. [1],[2] Both anatomic features and mastication dynamics contribute to the challenge of placing titanium implants in this region. [3]

Although management of the posterior maxilla presents many challenges, use of different procedures make it possible to create successful bone-anchored restorations in this region predictably. [3]

One such procedure, the sinus floor elevation technique, to facilitate implant placement in atrophic posterior maxillae was first presented in the late 1970s [4] and the first article on this subject was published in 1980. [5]

The technique of sinus elevation and simultaneous implant placement, in particular, offers the benefit of fewer surgical procedures, shorter treatment time and reduced expense. It was considered generally that at least 5 mm of bone must be present to ensure rigid fixation of the implant at the time of placement. [6]

However, there is evidence to show that it may be possible to successfully use the one-stage approach even when the residual crestal bone height is as little as 1 mm. [7],[8]

When a mature bone graft is employed for both mechanical and biologic implant stability, the use of a composite graft with an autogenous component is considered. [9] The increased volume of the mineralized bone that results from such a graft may ultimately lead to a more stable graft with greater implant-bone contact and therefore provide a more favorable prognosis for implant survival. [10],[11]

This case report presents the use of a lateral wall osteotomy approach for sinus floor elevation and the use of a composite grafting to allow placement of a dental implant in the posterior maxilla with an insufficient volume of residual alveolar bone.

   Case Report Top

A 30-year-old male patient presented with a chief complaint of difficulty in chewing food due to absence of a molar tooth in the upper right region. The patient had undergone extraction of the right upper first molar, 5 years back, due to dental caries and the medical history was non-contributory. The patient did not give information regarding any deleterious habits. Radiographic examination including orthopantomogram revealed a flat sinus floor with 4.2 mm of residual alveolar bone height which was insufficient for placement of an implant supported prosthesis [Figure 1].
Figure 1 :Preoperative radiograph

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A lateral wall approach of sinus floor elevation and simultaneous implant placement was decided upon as the final treatment plan. Informed consent was obtained from the patient.

Surgical procedure

The surgical site was anesthetized by local administration of 2% lignocaine hydrochloride (LOX, Neon Laboratories Ltd., Mumbai, India) with 1:200,000 adrenaline [Figure 2].
Figure 2 :Preoperative intraoral view

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Incision placement

A modified crestal incision, with the incision placed toward the palatal aspect of the edentulous area, was performed to achieve complete flap coverage over the site after implant placement. This incision was then continued as the crevicular incision around the teeth adjacent to the edentulous site. Vertical releasing incisions were made along the mesial line angles of the second premolar and second molar and extended beyond the muco-gingival junction to help achieve a tension-free flap with a broad base. The muco-periosteal flap was reflected and elevated to obtain direct access and visibility to the sub-periosteal surgical site.

Sinus membrane elevation using the direct technique

Osteotomy was initiated on the lateral wall of the maxillary sinus with 023-029 round steel burs (Hager and Meisinger GmbH, Dusseldorf, Germany) under cooling with sterile isotonic saline solution and a bony window was prepared with extreme caution to avoid perforation of the sinus mucosa. The sinus mucosa was then gently elevated using a sinus elevation kit (Friatech AG, Mannheim, Germany), dissected carefully and the bony wall was pushed inside carefully [Figure 3]. The space for bone grafting was thus prepared. The integrity of the sinus membrane was confirmed by observing the "in" and "out" movements of the membrane during inhalation and exhalation.
Figure 3 :Bony window pushed aside to elevate the sinus mucosa

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Autogenous block bone graft harvesting using "minimum button-hole" technique

Autogenous bone grafts are considered as the gold standard for bone reconstruction; the use of autogenous bone can be considered when the reconstructed segment is expected to be loaded with oral implants. It has been shown that in the facial skeleton, membranous bone, such as that grafted from the mandible, undergoes less resorption than endochondral bone, such as the iliac crest. [12],[13] Also, if the graft volume is sufficient for the planned reconstruction, mandibular bone is the ideal choice. [14],[15]

In the region just apical to the roots of the mandibular right incisors and canine, a minimal vestibular incision was made to create a button hole. An 11 mm diameter cylindrical autogenous block bone was harvested using a round trephine bur [Figure 4]. The block bone graft was subsequently crushed and reduced into chips and blended with bovine hydroxyapatite synthetic graft material (Bio-Oss, Geistlich Pharmaceuticals, Wolhausen, Switzerland). This composite bone graft can serve as a blend of osteogenic bone and osteo-conductive graft particles.
Figure 4 :Autogenous bone graft harvested using a bone trephine

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The composite bone graft was placed in the prepared space beneath the elevated bony wall of the sinus [Figure 5].
Figure 5 :The composite bone graft placed under the elevated sinus mucosa

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Implant placement

The implant drilling was performed under copious irrigation. An initial marking of the site was done using a round bur and subsequent osteotomies were carried out with a 2 mm drill to establish the depth and direction, and finally a 3.65 mm drill was used. A self-threaded titanium implant (4.2 mm Χ 10 mm) was inserted and covered with a titanium cover screw [Figure 6]. Adequate primary stability was accomplished by the residual host bone.
Figure 6 :Implant placement

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Membrane adaptation

The use of barrier membranes in combination with particulate grafts and implants is reported to be an effective procedure in both humans and experimental animals. [16],[17],[18]

A sterile, bio-resorbable collagen membrane (Healiguide, Advanced Biotech Products, Chennai, India) was adapted over the sinus buccal window as well as the implant, and particular care was taken to ensure that the membrane extended 2 mm all around to completely cover the sinus bony window and the implant [Figure 7].
Figure 7 :Membrane adapted over the grafted site

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Periosteal releasing incisions were finally made to ensure tension-free primary closure of the muco-periosteal flap over the membrane. The recipient and the donor sites were consequently sutured using an absorbable suture material (4-0 Vicryl, Ethicon, Inc., Johnson and Johnson, Somerville, NJ, USA)

Postoperative care

A prescription of 8 mg of betamethasone was given jointly with 2 g/day of amoxicillin for 10 days. The patient was asked to rinse with warm saltwater rinses for the first 2 weeks to promote normal flap healing without disturbing the wound. The patient was instructed to use chlorhexidine gluconate 0.12% (Peridex, Zila Pharmaceuticals, Phoenix, AZ, USA) to facilitate plaque control. [19]

The surgical site was checked every 2 weeks for a period of 2 months. After 6 months of healing, the second surgery was performed to uncover the implant for abutment connection, and subsequently, the crown was placed [Figure 8].
Figure 8 :Prosthetic crown in place orally

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The success criteria used were: the implant was immobile, no signs of pain or suppuration were present, direct implant-to-bone contact was visible on radiographs, and vertical bone resorption was less than 1.0 mm in the first year after prosthetic loading. [20] For the benefit of proper visual comparison of the preoperative and postoperative bone height in the sinus augmented region, 1 year postoperatively, the postoperative radiograph was taken after temporary removal of the crown, prior to X-ray exposure.

   Discussion Top

Studies of the long-term success of osseo-integrated implants placed in the posterior maxilla have painted a mixed picture. Implants used in the posterior maxilla showed a higher failure rate related to Type IV bone. [21],[22] However, other investigators have shown significantly higher success rates. [23],[24],[25]

A systematic review proved that the overall implant survival rate of implants placed after sinus grafting technique was 91.49%. [9] The review also supported the statement that bone-substitute materials used in combination with autogenous bone may be extremely effective compared to the use of autogenous bone alone. Bone substitutes also help to reduce the volume of autogenous bone that needs to be harvested. Finally, autogenous bone in particulate form seemed to provide better outcomes compared to block grafts, and therefore, may be the preferred choice. [9],[26]

Also, excessive resorption of autografts may be overcome by using bone substitutes that are known for their slow resorption rates and which can increase the stability of the graft during the consolidation phase. [27]

Thus, in this case report, a composite particulate graft was used to utilize the osteogenic, osteo-inductive and osteo-conductive properties of the graft particles.

The clinical findings after 1 year of implant placement showed the implant to be healthy. The radiograph confirmed this by showing very negligible amount of bone loss [Figure 9].
Figure 9 :Postoperative radiograph 1 year after implant placement

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   Conclusion Top

Dental implant placement in the posterior maxilla remains a challenge. Insufficient bone volume due to alveolar bone resorption in the edentulous maxillae and the pnuematization of the maxillary sinus makes it extremely difficult to place implants in this region.

This problem can be overcome by performing a maxillary sinus floor elevation and augmentation using various bone graft materials between the sinus mucosa and the bony floor of the sinus.

This case report highlights the use of a lateral wall osteotomy for sinus floor elevation along with the use of composite graft to allow implant placement in the posterior maxilla.

   References Top

1.Nevins M, Fiorellini JP. Placement of maxillary posterior implants. In: Nevins M, Mellonig JT, editors. Implant therapy: clinical approaches and evidence of success, Vol. 2. Chicago: Quintessence; 1998. p. 153-69.  Back to cited text no. 1
2.Zarb GA, Zarb FL, Schmitt A. Osseointegrated implants for partially edentulous patients. Dent Clin North Am 1987;31:457-72.  Back to cited text no. 2
3.Balshi TJ, Wolfinger GJ. Management of the posterior maxilla in the compromised patient: historical, current and future perspectives. Periodontology 2000 2003;33:67-81.  Back to cited text no. 3
4.Tatum OH. Maxillary sinus grafting for endosseous implants. Birmingham, AL: Presented at the Annual Meeting of the Alabama Implant Study Group; 1977.  Back to cited text no. 4
5.Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613-7.  Back to cited text no. 5
6.Nevins M, Fiorellini JP. The maxillary sinus floor augmentation procedure to support implant prostheses. In: Nevins M, Mellonig JT, editors. Implant therapy: Clinical approaches and evidence of success, Vol. 2. Chicago: Quintessence; 1998. p. 171-95  Back to cited text no. 6
7.Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol 1998;69:1397-403.  Back to cited text no. 7
8.Winter AA, Pollack AS, Odrich RB. Placement of implants in the severely atrophic posterior maxilla using localized management of the sinus floor: A preliminary study. Int J Oral Maxillofac Implants 2002;17:687-95.  Back to cited text no. 8
9.Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodont Restorat Dent 2004;24:565-77.  Back to cited text no. 9
10.Froum SJ, Tarnow DP, Wallace SS, Rohrer MD. Sinus floor elevation using anorganic bovine bone matrix (OsteoGraf/N) with and without autogenous bone: A clinical, histologic, radiographic and histomorphometric analysis: Part 2 of an ongoing prospective study. Int J Periodont Restorat Dent 1998;18:529-43.  Back to cited text no. 10
11.Valentini P, Abensur D, Wenz B, Peetz M, Schenk R. Sinus grafting with porous bone mineral (Bio-oss) for implant placement: A 5-year study on 15 patients. Int J Periodont Restorat Dent 2000;20:245-53.  Back to cited text no. 11
12.Zins JE, Whittacker LA. Membranous versus endochondral bone autografts: Implications for craniofacial reconstruction. Plast Reconstr Surg 1983;72:778-86.   Back to cited text no. 12
13.Phillips JH, Rhan BA. Fixation effects on membranous and endochondral onlay bone graft revascularization and bone deposition. Plast Reconstr Surg 1990;85:891-7.   Back to cited text no. 13
14.Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 1997;12:767-76.  Back to cited text no. 14
15.Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis graft for dental implants: A preliminary and procedural report. Int J Oral Maxillofac Implants 1992;7:360-6.   Back to cited text no. 15
16.Lundgren AK, Sennerby L, Lundgren D, Taylor A, Gottlow J, Nyman S. Bone augmentation at titanium implants using autologous bone grafts and bioresorbable barrier. Clin Oral Implants Res 1997;8:82-9.  Back to cited text no. 16
17.Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: Clinical study with 40 partially edentulous patients. J Oral Maxillofac Surg 1996;54:420-32.   Back to cited text no. 17
18.Cortellini P, Bartolucci E, Clauser C, Pini Prato P. Localized ridge augmentation using guided tissue regeneration in humans. Clin Oral Implants Res 1993;4:203-9.   Back to cited text no. 18
19.Wang HL, Boyapati L. "PASS" principles for predictable bone regeneration. Implant Dent 2006;15:8-17.  Back to cited text no. 19
20.Albrektsson T, Zarb G, Whortington P, Eriksson AR. The long term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:1-25.  Back to cited text no. 20
21.Jaffin RA, Berman CL. The excessive loss of Branemark fixtures in type IV bone: A 5-year analysis. J Periodontol 1991;62:2-4.  Back to cited text no. 21
22.Schnitman P, DaSilva J, Wohrle P, Wang H, Koch G. Influence of site on implant survival: Seven-year results (abstract 1664). J Dent Res 1993;72:311.  Back to cited text no. 22
23.Bahat O. Branemark system implants in the posterior maxilla: Clinical study of 660 implants followed for 5 to 12 years. Int J Oral Maxillofac Implants 2000;15:646-53.  Back to cited text no. 23
24.Lazzara R, Seddiqui AA, Binon P, Feldman SA, Weiner R, Phillips R, et al. Retrospective multicenter analysis of 31 endosseous dental implants placed over a five-year period. Clin Oral Implants Res 1996;7:73-83.  Back to cited text no. 24
25.Buchs AU, Hahn J, Vassos DM. Interrim clinical study report: A threaded, hydroxyapatite-coated implant- five-year post-restoration safety and efficacy. J Oral Implantol 1995;21:266-74.  Back to cited text no. 25
26.Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003;8:328-43.  Back to cited text no. 26
27.Lang NP, Lindhe J. Textbook of Periodontology and Clinical Implant Dentistry, 5th ed. 2008. 1107.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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