Utilizing the Lateral Wall of Maxillary Sinus as a Donor Site for Autogenous Block Grafts
A Case Series
Saqer M. Almutairi, DDS • Ye Shi, DDS • Wendy C. Wang, BDS, MSc • Edgar S. El Chaar, DDS, MS • Stuart J. Froum, DMD • Sang-Choon Cho, DDS
A common challenge for dental implant placement in the
posterior maxilla is the presence of large pneumatized maxillary sinus, which
results in insufficient bone volume (1). The lateral window sinus augmentation
technique is a predictable procedure aimed at increasing vertical bone volume
to enable implant placement (2,3). Similarly, in deficient alveolar ridges,
bone grafts are necessary to reconstruct alveolar bone width and/or height to
augment the ridge prior to dental implantation. A number of allogeneic and
alloplastic materials have been used for both of these purposes, but autogenous
corticocancellous bone grafts have remained the gold standard for the reconstruction of alveolar bone whether it be for a
sinus or ridge augmentation (4).
A current trend in augmentation procedures for
dental implant surgery is the use of less invasive or alternative techniques to
reduce complications and postoperative morbidity. An in-office bone harvesting
procedure performed under local anesthesia decreases the cost of the treatment
by eliminating the need for more expensive inpatient hospital care (4).
Recently, harvesting the lateral sinus wall during sinus grafting has been
described as a source of an intraoral bone graft for the reconstruction of
maxillomandibular ridge defects. The accessibility of the lateral sinus wall bone via an
intraoral approach makes it an excellent candidate for bone graft harvesting (4,5).
The purpose of this report is to describe
the use of the anterior border of the sinus wall as a donor site for block
grafting of a deficient lateral ridge in an adjacent surgical area. This
procedure can be performed alone or in combination with a sinus augmentation
Materials and Methods
Clinical data in this study were obtained
from the Implant Database (ID). This data set was extracted as de-identified
information from the routine treatment of patients at the Ashman Department of
Periodontology and Implant Dentistry at New York University College of
Dentistry. The ID was certified by the Office of Quality Assurance at NYUCD.
This study was performed in compliance with Health Insurance Portability and
Accountability Act (HIPAA) requirements.
Three partially edentulous subjects with
posterior maxillary atrophy, each of whom underwent single implant placement
using the lateral wall of maxillary sinus as a donor site for ridge
augmentation procedure from August 2009- August 2012, were chosen from the ID
and were included in this study. Selected subjects had to have had the final
implant restoration in function for a minimum of 6 months. The population
consisted of 4 female patients with a mean age of 63 years and ranged in age
from 55 to 68 (Table 1). Each subject selected conformed to the following
criteria prior to undergoing the procedure:
1. A posterior maxillary partially
edentulous area with limited horizontal bone width (i.e., 2mm to 4 mm) that
required single implant placement.
2. A healed ridge at least 3 months
following tooth extraction.
1. Presence of uncontrolled diabetes,
immunological diseases, or other systemic conditions that contraindicated
2. Periodontal diseases, or an
unwillingness to undergo needed periodontal therapy, around the subject’s remaining teeth.
3. Active sinus infection, or a history
of persistent sinus infections.
4. Cigarette smoking habit of one pack or
more per day and unwillingness to enter a smoking cessation protocol.
5. Psychological problems, which, in the
opinion of the surgeons, would have, render the delivery of comprehensive
therapy untenable. Such concerns ranged from severe manic depression for which
a patient was under professional care, to extreme nervousness or agitation,
which precluded the patient from undergoing numerous, lengthy treatment visits.
6. Unwillingness to commit to a
long-term, posttherapy maintenance program.
Prior to surgery, a complete examination
of oral hard and soft tissues was conducted on each patient, and a dental
treatment plan was formulated in conjunction with the treating restorative
dentist. Reformatted computed tomography (CT) scans were taken of the 3
patients. Diagnostic casts, waxups, and surgical templates were also utilized (Figure 1 and Figure 2). A 3D printed model
was fabricated according to dicom data, and the lateral window sinus donor site,
was designed according to the 3D model. The minimum window size was 5mm x 10mm.
In conjunction with the procedure, single
implants were placed and left submerged during healing. The time between stage
1 surgery and stage 2 abutment placement ranged from 4 to 5 months. All
implants were restored as single tooth restorations. Patients were recalled
every 3 months for supportive care and evaluation.
The criteria for implant survival
required that the implant be in function for at least 6 months. In addition, the implant had to meet the following
conditions (modifications of Albrektsson success criteria)(6), to be considered
individual, unattached implant must be immobile when tested clinically.
2. Periapical radiographs must
demonstrate no evidence of peri-implant radiolucency.
3. The implant had to be characterized by
an absence of persistent and/or irreversible signs such as pain, infection,
neuropathy, or paresthesia/anesthesia.
A standardized protocol was followed for
each of the patients:
- The patients were prescribed 2g of Amoxicillin 1 hour prior to surgery
or, if allergic, 600mg of clindamycin.
- Local infiltration anesthesia of lidocaine 2% containing epinephrine
at a concentration of 1:100,000 was used, or carbocaine 3% was administered in cases where a vasoconstrictor was contraindicated.
- A midcrestal incision between the two adjacent teeth was performed and
followed by two vertical releasing incisions from both the mesial and distal
aspects of the adjacent tooth to the mucogingival junction. A full-thickness
mucoperiosteal flap was raised, exposing the lateral sinus wall (Figure 3).
- A small, round-shaped osteotomy (2mm to 3mm in diameter) was prepared in
the lateral wall of the sinus, using a high-speed round #6 diamond bur with
copious irrigation, and followed by use of a piezosurgical tip to harvest a 5mm
x 10mm block graft. This window was created at the height of the apex of the
planned implant (Figure 4, Figure 5, Figure 6).
The window site and position was decided by the 3D printed model, and the
integrity of the Schneiderian membrane was assessed visually.
- The lateral wall of the maxillary sinus was completely separated, the
recipient site was prepared, and the graft was placed and stabilized with a
screw (Figure 7).
- A conventional maxillary sinus procedure was then completed by fully elevated sinus membrane
mesiodistally and medially over the future drilling site using a sinus membrane
elevator (SSC1, EBI implants, Kyungsan, South Korea) inserted through the
access slot on the lateral wall.
bone graft material (Anorganic Bovine Bone Matrix, Bio-Oss, Osteohealth,
Shirley, NY, USA) was placed and condensed from the lateral wall.
- Interrupted resorbable sutures were placed using 4.0 Vicryl (Ethicon,
Inc. Somerville, NJ, USA) for mid-crestal closure, and 5.0 Chromic Gut (Henry
Schein, Melville, NY, USA) for closure of the vertical incisions.
- Postoperative medications, consisting of antibiotics or Clindamycin 150
mg, were prescribed for 7 days (TID). Chlorohexidine 0.2% was prescribed
starting 24 hours after surgery and was used twice a day for 2 weeks.
Analgesics as needed for pain were prescribed (Ibuprofen 600mg q 4-6h.).
Postoperative care instructions, including a soft diet and oral hygiene
procedures, were also given to the patient.
- Follow up examinations, inclusive of periapical radiographs, were
performed 7 to 14 days postoperatively, and then at 5 months postsurgery.
- One-stage implant placement was performed 4 to 5 months following bone
grafting. Depth drilling was performed in a serial sequence under irrigation to
the final implant diameter drill. As the implant was placed, a healing abutment
was inserted. Postoperative medications were prescribed and the patient was
reappointed for implant restoration.
- After 2 to 3 months, osseointegration was assessed clinically and
radiographically; the implant had no mobility, which confirms the
osseointegration. Once it is confirmed, the final restorations were placed (Figure 8, Figure 9, Figure 10).
- The patients were recalled at 3, 6, 12, 18, and 24 months following
final restoration placement for follow-up examination and periapical
All patients were monitored with routine
follow up for all surgical and restorative implant procedures. Radiographic
parameters measured included preoperative crestal bone height, postoperative
augmented bone height, and crestal bone loss around the implant from time of
implant placement, to the final follow-up visit, and measurements were then
Four single implants were placed in 3
patients in a delayed protocol, with the lateral wall of maxillary sinus as a
donor site. All 4 implants were successful at the 6- to 24-month interval
following insertion of the final implant-supported restoration.
The mean bone gain width was 3.6 mm
(range of 3-4 mm) (Figure 7).
Buccal bone loss around the implants from time of placement to the final follow
up averaged 0.5 mm (range of 0.3mm to 0.8mm).
This technique was
designed to harvest bone from the lateral wall of maxillary sinus to augment
small- to medium-sized alveolar defects in the maxilla premolar area (4). A CT
scan is necessary to evaluate the condition and anatomy of the sinus, the
thickness of the lateral wall, the location of the maxillary artery and the
size of alveolar defect (Figure 11. Figure 12) (7). This technique can be used for bone
harvest alone or in combination with a sinus augmentation procedure.
The main advantage
of harvesting bone from the lateral wall of maxillary sinus at the premolar
site is the elimination of secondary surgery at distant intra-oral donor sites,
such as the ramus or the chin. This approach allows for one single surgical
site as the donor area is in close proximity to the recipient site. All three
implants were clinically successful during the 6- to 24-month follow-up period.
autologous grafts from the ramus has the disadvantage of potential mandible
fracture (8,9). Post operative trismus has also been reported in high frequency
(8). Grafts from the chin area carries the risks of post-operative hypesthesia
or paresthesia in the mental region (10). Altered sensation in the mandibular incisors
has been reported by 29% of the patients who underwent the procedure (10) and
some teeth have been shown to require root canal treatment after the procedure
additional surgical site requires longer procedure time and increases
postoperative morbidity for the patient. The general disadvantage of all intraoral
donor sites is the limited quantity of available bone (8). However, the
thickness of the lateral wall of the maxillary sinus bone is usually sufficient
to permit autogenous block grafting and subsequent single implant placement
into the edentulous maxillary premolar area.
graft has the potential disadvantage of resorption. Grafts from the ramus provide mainly cortical
blocks whereas grafts from the chin area have a more corticocancellous
consistency (8). Harvesting bone with similar characteristics
to the recipient site may have less bone resorption, however further study is
necessary to evaluate the long term outcome for this technique.
Autogenous block graft from the
lateral wall of maxillary sinus region with sinus membrane elevation can be
used for the regeneration of a maxillary premolar region and does not need
additional donor site.
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Simultaneous Sinus Augmentation
Particulate Graft Used
FDBA Resorbable Collagen Membrane
FDBA Resorbable Collagen Membrane
FDBA Resorbable Collagen Membrane
FDBA Resorbable Collagen Membrane