开窗植骨与闭合冲压上颌窦底提升同期种植的临床研究

目的:研究比较上后牙缺失牙槽嵴高度不足患者,根据上颌窦底牙槽嵴骨高度不同,选用开窗植骨或闭合冲压提升上颌窦底,同期种植牙的治疗效果。方法:43例(55侧)上后牙缺失患者,其中34例(40侧)窦底牙槽嵴骨高6~10 mm者行闭合冲压上颌窦底提升术,其余9例(15侧)骨高2~5 mm者行开窗植骨上颌窦底提升手术,均同期完成一期种植体植入手术。结果:所有患者术后未出现上颌窦炎症,9例行开窗植骨上颌窦底提升手术的患者,无窦膜穿孔,平均提升窦底高度5.8 mm,26颗种植体平均负载30个月,种植体稳定,骨结合状况良好。34例行闭合冲压上颌窦底提升术的患者,平均提升窦底高度4.3 mm,手术操作中有3颗发生可察觉窦膜破孔,发生率为4.1%(3/73),在73颗种植体中,有2颗种植体失败,71颗种植体平均负载23个月,种植体稳定,未见明显骨吸收,成功率97.3%(71/73)。结论:闭合冲压上颌窦底提升术是一种微创、简单、可靠用于上颌后牙上颌窦底牙槽嵴骨高度不足的种植临床技术,临床上应根据上颌窦底牙槽嵴骨高度不同,选用开窗植骨或闭合冲压提升上颌窦底。     

Maxillary Sinus Membrane Repair With Amnion–Chorion Barriers: A Retrospective Case Series

Background: Schneiderian membrane perforation is the most common complication of maxillary sinus augmentation procedures and has been associated with a variety of post‐surgical problems. Multiple techniques to repair perforated Schneiderian membranes with materials such as connective tissue, buccal fat pads, and resorbable collagen membranes have been reported in the dental literature. Although these reparative options have proven successful, they are technique sensitive and time consuming. The aim of this case series is to present a simplified method of Schneiderian membrane perforation repair with amnion–chorion membranes and results obtained from nine cases using this technique. Methods: A consecutive retrospective record review was performed of all maxillary sinus augmentation cases performed during the past 5 years by the same board‐certified private practice periodontist (DH). Results: Seventy‐seven cases were identified, with a total of 104 sinus augmentations, in which nine perforations were noted. None of the perforation cases were aborted midprocedure, and all perforations were repaired with amnion–chorion membranes. All cases were augmented with a combination of allograft and xenograft particulate bone. After an average healing time of 4.9 months, dental implants were placed in the grafted sinuses. Conclusions: This retrospective case series shows nine perforations during 104 lateral window maxillary sinus augmentation procedures. A total of 23 dental implants were placed in the augmented sinuses with perforated Schneiderian membranes, and one failure was noted according the Albrektsson success criteria. A total of 158 dental implants were placed in non‐perforated augmented sinuses, with a total of three failures noted.     

Histomorphometric Analysis of Human Maxillary Sinus Lift with a New Bone Substitute Biocomposite: A Preliminary Report

Purpose: To analyze radiographic and histological outcomes of maxillary sinus floor augmentation using a calcium-sulfate based allograft containing demineralized bone matrix particles.
Materials and Methods: Fifteen maxillary sinus lift procedures with simultaneous placement of titanium implants were performed in 12 patients of both genders aged 36–71 years. Each sinus cavity was filled by the biocomposite. After 3 months of healing, all surgical sites were uncovered and bone biopsies were retrieved for undecalcified histology and histomorphometry. The ratio between the original and the grafted sinus height (GSH/OSH) was computed using a panoramic radiography taken immediately after surgery and at 3 months of healing, and the two ratios were compared by Wilcoxon signed-rank test.
Results: By 3 months, all implants were stable without clinical and radiographic signs of infection. Significant changes in GSH/OSH during healing were seen (2.7 ± 0.6 initially vs. 2.6 ± 0.5 after healing; p  = 0.01). Histologic findings showed newly formed bone surrounding the residual grafted particles without inflammation. At 3 months, mean regenerated bone density was 33.8 ± 8.6%; marrow spaces amounted to 32.3 ± 10.3%; residual graft was 33.9 ± 9.0%. Similar histomorphometric and radiographic results were obtained independently from patient age or sex.
Conclusions: The analysed putty seems to be a safe and effective graft material for maxillary sinus floor augmentation by accelerating bone regeneration and thus reducing the healing time.     

Evaluation of the Effectiveness of a Water Lift System in the Sinus Membrane‐Lifting Operation as a Sinus Surgical Instrument

Purpose: The effectiveness of a Water Lift System in the sinus membrane‐lifting operation was examined. This investigation focused on the capability of this equipment to reduce the risk of Schneiderian membrane perforation. Materials and Methods: A preliminary clinical study on the use of the Water Lift System in sinus membrane elevation to place implants through the sinus floor was conducted. A total of 70 sinus membrane‐lifting operations were performed on patients with various bone heights ranging from 1.2 to 9.9 mm (most commonly in the range of 4–6 mm) through the lateral approach (four cases) or the crestal approach (66 cases). Results: In all of the cases performed using the lateral approach, sinus membrane perforation did not occur. In the 66 cases performed using the crestal approach, Schneiderian membrane tearing occurred in two cases. The membrane tearing occurred during elevation of the Schneiderian membrane but not when a hole was drilled to access the Schneiderian membrane. One case of membrane tearing resulted from previous inflammation in the maxillary sinus, and the other case of membrane tearing was caused by application of excessive hydraulic pressure. In addition, similar outcomes were obtained and no microbial infections were observed in a total of 68 successful cases. Conclusions: In this study, the Water Lift System was confirmed to effectively reduce the risk of Schneiderian membrane perforation during the sinus membrane‐lifting operation. We conclude that the Water Lift System deserves to be considered as a sinus surgical instrument, which ensures safety in the sinus membrane‐lifting operation.     

A method of sealing perforated sinus membrane and histologic finding of bone substitutes: a case report

To augment the atrophic posterior maxilla, a sinus bone graft has been widely used for sinus floor augmentation. Various bone substitutes have been developed and grafted in the maxillary sinus with and without membranes perforation, although autogenous bone is recommended as a gold standard of grafting materials. Membrane perforation is the most common complication associated with sinus bone graft. To repair a perforation, various methods have been developed. This case report is focused on histologic findings of 1 bovine hydroxyapatite (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland) and 2 kinds of human mineral allograft- Tutoplast cancellous microchips (TutoGen Medical GmbH, Neunkirchen am. Brand Germany), and irradiated allogeniccancellous bone and marrow (ICB; Rocky Mountain Tissue Bank, Aurora, CO) used for sinus graft in the same patient with membrane perforation after various healing periods. Mineral allograft showed favorable new bone regeneration with the repair of membrane perforation. This case report also describes a technique regarding how to repair completely perforated sinus membrane after the removal of a mucocele using human collagen membrane (Tutoplast pericardium; TutoGen Medical GmbH) and fibrin adhesive (Greenplast; Green Cross Co., Youngin, Korea) to stabilize collagen membrane.     

An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique

BACKGROUND: For many clinicians, inadequate alveolar bone height and anatomical features of the maxillary sinus complicate sinus lift procedures and placement of endosseous implants. We present a new internal crestal approach that addresses these issues. METHODS: Sinus burs and condensers of increasing width are used in conjunction with pliable atraumatic bone grafting mixture and hydraulic pressure from a surgical handpiece. The risk of a membrane perforation is minimized when the surgeon's tactile skill is administered in a two-stage process to first loosen and then graft bone particulate under the Schneiderian membrane. Threaded implants can then be placed in the same visit and secured via primary closure. RESULTS: A retrospective investigation of 1,100 cases showed that eight implants failed and 14 required longer healing periods in patients with alveolar ridge heights varying between <1 to 5 mm. CONCLUSIONS: Our experience suggests that hydraulic sinus condensing is a predictable and minimally invasive alternative for prosthetic rehabilitation of maxillary anterior and posterior regions in the presence of anatomical restrictions to implant placement.     

Combining Scaffolds and Osteogenic Cells in Regenerative Bone Surgery: A Preliminary Histological Report in Human Maxillary Sinus Augmentation

Purpose: The following case series evaluated the maxillary sinus augmentation responses to tissue-engineered bone graft obtained by a culture of autogenous osteoblasts seeded on polyglycolic–polylactic scaffolds and calcium phosphate.
Materials and Methods: Sinus floor augmentation was performed bilaterally in five patients (mean age 58.4 years) with tissue-engineered bone (test site – Oral Bone®, BioTissue, Freiburg, Germany) or calcium phosphate (control site – Biocoral, Novaxa Spa, Milan, Italy). Biopsies were harvested 6 months after sinus augmentation for histometric evaluation. Volumetric measurements were taken at baseline and 6 months after the surgical procedure.
Results: The mean of vertical bone gain was 6.47 ± 1.39 mm and 9.14 ± 1.19 mm to test and control sites, respectively. The histological sections depicted mature bone with compact and cancellous areas. All biopsies contained varying percentages of newly formed bone and marrow spaces. The mean of bone tissue in the grafted area was 37.32 ± 19.59% and 54.65 ± 21.17% for tissue-engineered bone and calcium phosphate, respectively.
Conclusion: Within the limits of the present report, the histological data in humans confirmed that tissue-engineered bone and calcium phosphate allowed newly formed bone after maxillary sinus augmentation.     

Treatment of severe sinus infection after sinus lift procedure: a case report

Maxillary sinus floor augmentation may have a variety of postoperative complications including infection, sequestration of bone, and maxillary sinusitis. Complications can also occur due to a preexisting sinus condition called ostium stenosis. This case report presents a complication after sinus lift and grafting procedure due to an unrecognized ostium stenosis. CASE REPORT: A 50-year-old male patient had sinus augmentation on his right side. However, postoperatively, his symptoms were protracted. A CT scan showed thickening of the Schneiderian membrane and scattered graft material. Management included endoscopic nasal examination and ostium enlargement, antibiotic coverage, and full enucleation of the graft and diseased tissue. CONCLUSION: Patency of the sinus ostium should be carefully evaluated before sinus lift/grafting procedure using CT technology. Radiology and otolaryngology consultations may be necessary to rule out ostium stenosis before surgery.     

The incidence of maxillary sinus membrane perforation during endoscopically assessed crestal sinus floor elevation: a pilot study

Transcrestal sinus membrane elevation is a surgical procedure performed to increase the bone volume in the maxillary sinus cavity. Because of visual limitations, the potential for maxillary sinus membrane perforations may be greater than with the lateral approach technique. The aim of this study was to macroscopically investigate ex vivo the occurrence of sinus membrane perforation during surgery using 3 transcrestal sinus floor elevation methods. Twenty fresh human cadaver heads, with 40 intact sinuses, were used for simultaneous sinus membrane elevation, placement of graft material, and dental implants. Real-time sinus endoscopy, periapical digital radiographs, and cone-beam computerized tomography (CBCT) images were subsequently used to evaluate the outcome of each surgical procedure. Perforation rates for each of the 3 techniques were then compared using a significance level of P < .05. No statistically significant differences in the perforation rate (P = .79) were found among the 3 surgical techniques. Although the sinus endoscope noted a higher frequency of perforations at the time of implant placement as compared with instrumentation or graft insertion, the difference was not statistically significant (P = .04). The CBCT readings were judged to be more accurate for identifying evidence of sinus perforations than the periapical radiographs when compared with the direct visualization with the endoscope. This pilot study demonstrated that a sinus membrane perforation can occur at any time during the sinus lift procedure, independent of the surgical method used.     

Evaluation of the capability of a new water lift system to reduce the risk of Schneiderian membrane perforation during sinus elevation

The purpose of this study was to evaluate the effectiveness of a new water lift system used as a surgical instrument in the crestal approach of the sinus membrane lifting operation and the capability of this technique to reduce the risk of Schneiderian membrane perforation in comparison with a lateral approach using piezoelectric surgery. 50 sinus membrane-lifting operations were performed. Patients were randomized in 2 groups to receive either lateral sinus elevation with piezosurgery or crestal sinus elevation using the new surgical device. Schneiderian membrane perforation was noted in 6 patients (24%) from the group undergoing the lateral sinus floor elevation approach, but no perforation was observed in the group with the crestal infiltration technique (P = 0.01). Aside from membrane perforation, haematoma was present in 3 patients (12%) from the group with lateral sinus floor elevation with no cases in the other group. No microbial infections were noted in the 50 consecutives cases. This study demonstrated that maxillary sinus floor elevation using the water lift system via the crestal approach is a predictable procedure with a low complication rate, compared with the lateral approach with piezoelectric surgery.     

Sinus Lift Using a Nanocrystalline Hydroxyapatite Silica Gel in Severely Resorbed Maxillae: Histological Preliminary Study

Purpose: The aim of this preliminary study was to evaluate histologically a nanocrystalline hydroxyapatite silica gel in maxillary sinus floor grafting in severely resorbed maxillae.
Materials and Methods: A total of 16 consecutive patients scheduled for sinus lift were recruited during this study. Patients were randomly divided in two groups, eight patients each. In both groups, preoperative residual bone level ranged between 1 and 3 mm (mean value of 2.03 mm). No membrane was used to occlude the buccal window.
Second surgery was carried out after a healing period of 3 months in Group 1 and 6 months in Group 2. Using a trephine bur, one bone specimen was harvested from each augmented sinus and underwent histological and histomorphometric analysis.
Results: Histological analysis showed significant new bone formation and remodeling of the grafted material. In the cores obtained at 6 months, regenerated bone, residual NanoBone, and bone marrow occupied respectively 48 ± 4.63%, 28 ± 5.33%, and 24 ± 7.23% of the grafted volume. In the specimens taken 3 months after grafting, mean new bone was 8 ± 3.34%, mean NanoBone was 45 ± 5.10%, and mean bone marrow was 47 ± 6.81% of the bioptical volume.
Conclusions: Within the limits of this preliminary prospective study, it was concluded that grafting of maxillary sinus using nanostructured hydroxyapatite silica gel as only bone filler is a reliable procedure also in critical anatomic conditions and after early healing period.     

Back-scattered electron imaging and elemental microanalysis of retrieved bone tissue following maxillary sinus floor augmentation with calcium sulphate

Objectives: To investigate the presence and composition of residual bone graft substitute material in bone biopsies from the maxillary sinus of human subjects, following augmentation with calcium sulphate (CaS).
Material and methods: Bone cores were harvested from the maxillary sinus of patients who had undergone a sinus lift procedure using CaS G170 granules 4 months after the initial surgery. Samples from seven patients, which contained residual biomaterial particles, were examined by field emission scanning electron microscopy and energy dispersive X-ray spectroscopy was used to determine the composition of the remaining bone graft substitute material.
Results: Residual graft material occurred in isolated areas surrounded by bone and consisted of individual particles up to 1 mm in length and smaller spherical granules. On the basis of 187 separate point analyses, the residual material was divided into three categories (A, B and C) consisting of: A, mainly CaS (S/P atomic% ratio ≥2.41); B, a heterogeneous mixture of CaS and calcium phosphate (S/P=0.11–2.4) and C, mainly calcium phosphate (S/P≤0.11; C), which had a mean Ca : P ratio of 1.63±0.2, consistent with Ca-deficient hydroxyapatite. Linescans and elemental maps showed that type C material was present in areas which appeared dense and surrounded, or were adjacent to, more granular CaS-containing material, and also occurred as spherical particles. The latter could be disintegrating calcium phosphate in the final stages of the resorption process.
Conclusions: CaS resorption in the human maxillary sinus is accompanied by CaP precipitation which may contribute to its biocompatibility and rapid replacement by bone.     

Lateral and crestal bone planing antrostomy: a simplified surgical procedure to reduce the incidence of membrane perforation during maxillary sinus augmentation procedures

This clinical report presents a simplified surgical procedure for accessing the maxillary sinus antrum via lateral and crestal approaches, which reduces the potential for sinus membrane perforation and subsequent complications when graft materials and dental implants are placed into the sinus. Due to visual limitations, perforations and associated complications can jeopardize the success rate of the graft and the implants. While there is a lack of clinical data, clinical observations suggest that the procedure, described by the authors as lateral/crestal bone planing antrostomy, can reduce the possibility of perforation of the maxillary sinus membrane during the lateral and crestal approaches to the grafting of the maxillary sinus floor. The technique involves the use of specially designed rotary instruments that plane away the bone in thinner layers, with less chance of excess bone removal and membrane perforation.     

Prospective observation of 41 perforations of the Schneiderian membrane during sinus floor elevation

Objectives: The aim of this study was to follow 41 intraoperative perforations of the Schneiderian membrane during sinus floor elevation and to identify potential differences from patients without perforations. Material and methods: Two hundred and one sinus floor elevations were performed at the department of oral and maxillofacial surgery of the University Hospital of Schleswig‐Holstein in the years 2005 and 2006. Forty‐one intraoperative perforations (20.4%) were documented and treated according to the following scheme: defects smaller than 5 mm were covered with a collagen membrane. Larger defects were additionally sutured. Particulated jawbone mixed 50 : 50 with bone substitute (25 cases) and a 50 : 50 mix of particulated iliac crest bone and BioOss^® (six cases) mainly served as graft material in the perforation group. In 12 cases, implants were installed at the time of sinus grafting, and in 27 cases, a second operation was performed. Results: Four sinus lift procedures had to be discontinued intraoperatively. Over a mean control interval of 162 days, one implant of the 93 inserted had to be replaced in the perforation group. After 1 year, the implant survival rate was 14 out of 14 in the perforation group vs. 81/92 in the control group. Conclusions: With appropriate treatment, intraoperative sinus membrane perforations did not represent an elevated risk for implant loss, infectious complications or displacement of graft material in the investigated population.     

Intrasinusal locking technique: a novel use of the ring block technique at sinus perforations for simultaneous implant placement

Ten patients who underwent sinus lift surgery with simultaneous implant placement using the intrasinusal locking technique were evaluated retrospectively. All patients were scheduled for sinus floor elevation procedures with simultaneous implant placement. Schneiderian membrane perforation occurred during the lifting procedure, and conventional methods failed to repair the perforation. Therefore, an autogenous bone ring was placed at the base of the maxillary sinus and was locked to the alveolar crest with a dental implant. Marginal resorption around the dental implants was measured on panoramic radiographs. Prosthetic rehabilitation was performed at 6 months postoperative. The overall survival rate of the implants over a mean follow-up of 24.3 months was 90%. One case failed due to resorption of the alveolar crest around the implant as a result of infection; the implant and the adjacent ring were removed at 1 month postoperative. At the time of writing, the nine implants placed using the documented technique continue to function well, without any signs of peri-implant disease. The proposed approach allows for simultaneous dental implant placement in the extremely atrophic maxilla, even if there is extensive perforation of the Schneiderian membrane.     

Complications after maxillary sinus augmentation: a case report

The maxillary sinus grafting procedure has been routinely performed with predictable results. The procedure has proven to be an acceptable modality for bone augmentation to provide a base for endosseous implant placement. Several complications have been documented in the literature. They vary from sinus membrane perforation to formation of a mucocele inside the bony graft mass. This report describes a serious complication after a maxillary sinus augmentation that resulted in obliteration of the sinus.     

The clinical significance of sinus membrane perforation during augmentation of the maxillary sinus.

PURPOSE: Augmentation of the maxillary sinus floor is a well-documented technique and is generally accepted as a pure implantology procedure to facilitate placement of dental implants in the posterior atrophic maxilla. The objective of this report was to evaluate the significance of the sinus membrane perforations on the incidence, complications, and success rate of this procedure. PATIENTS AND METHODS: Patients who received sinus floor augmentation and simultaneous placement of dental implant were included in this study. Subgroup I consisted of patients who had their sinus membrane perforated and repaired during the procedure with resorbable membrane. Subgroup II consisted of patients whose Schneiderian membrane was not perforated during the procedure. The patients were followed between 1 to 4 years after augmentation. RESULTS: All perforations were classified as class II or III. The success rate of the implants in the perforation group was 94.4%, and that for the nonperforation group was 93.9%. The difference between the 2 study groups was statistically not significant. A significant statistical correlation was found between the residual ridge height and the membrane perforation (P < .01). CONCLUSIONS: Mainly due to technical difficulties, maxillary sinus membrane perforation occurs more frequently with a small height of residual alveolar bone. In this study, no statistical difference was observed in the success rate of the immediate implants placed with sinus bone grafting in patients whose membrane was perforated versus those patients in whom an intact membrane was maintained.     

The "Dome Phenomenon" Associated with Maxillary Sinus Augmentation

Aim: This case series is aimed to report a new phenomenon, the "dome phenomenon," which was observed in infected augmented sinuses over several years.
Methods: Five patients are presented in whom sinus lift augmentation resulted in postoperative infection with inflammation and suppuration. The patients received aggressive anti-inflammatory treatment and surgical debridement of the inflamed tissue, including some grafted material performed through the lateral window of the primary procedure.
Results: The inflammatory condition was reversed, and the site healed clinically. Radiographically, a dome-shaped, radio-opaque tissue was observed at the superiormost aspect of the grafted sinus. This "dome phenomenon" was further confirmed during dental implant placement, which indicates healing potential adjacent to the maxillary sinus membrane.
Conclusions: The current report, as well as other studies and case series, suggests that there is great potential for healing and bone formation in the maxillary sinus membrane. The precise mechanism is not known. Further clinical and histologic studies are needed to understand the regenerative potential of the Schneiderian membrane.     

A clinical study of the outcomes and complications associated with maxillary sinus augmentation

PURPOSE: The aim of this study was to evaluate the rate of complications in maxillary sinus augmentation surgery and the impact of complications on subsequent implant treatment in a patient population with severe maxillary atrophy scheduled for treatment under general anesthesia. MATERIALS AND METHODS: The study population consisted of 70 patients (124 sinuses) with severe maxillary atrophy who underwent maxillary sinus augmentation. Sixteen patients were scheduled to have a unilateral procedure and 54 patients a bilateral procedure. Sinus augmentation was performed with autogenous bone alone in 93 sinuses; in 31 sinuses, a 1:1 mixture of autogenous bone and corticocancellous pig bone particles was used. Twenty-six of 124 procedures involved both sinus augmentation and autogenous block grafting for the treatment of severely atrophic maxillae. RESULTS: The most common intraoperative complication was the perforation of the sinus membrane, which was observed in 31 sinuses (25%). Seven (5.6%) sinuses in 7 patients exhibited suppuration of the maxillary sinus. Five of the 7 patients with sinus infection were smokers, showing a prevalence of complications significantly greater in smokers compared to nonsmokers. Moreover, the use of an onlay bone graft in conjunction with sinus augmentation appeared to significantly increase the rate of infective complications. Infections were treated by drainage and the administration of systemic antibiotics. Two clinical cases showing persistent signs of infection required an endoscopic inspection of the maxillary sinus. DISCUSSION AND CONCLUSION: In the present study sinus membrane perforation was not shown to be a significant factor in the rate of implant complications. However, the combination of smoking and onlay bone grafting could significantly increase the rate of postoperative infection following sinus grafting.     

Internal sinus manipulation (ISM) procedure: a technical report

Background The sinus augmentation procedure has facilitated dental implant treatment in the posterior maxilla where there is insufficient bone for implant placement. A modified Caldwell‐Luc, lateral window technique can be applied in most cases needing sinus augmentation in order to create a larger bone volume. However, treatment morbidity can be a concern, especially in the form of postoperative swelling due to surgical trauma. Vertical augmentation using osteotomes has also been selected as a choice of treatment due to less invasive surgery and less postoperative trauma. Although the osteotome technique enables the surgeon to raise the sinus membrane internally through an implant osteotomy site, the quantity and predictability of bone augmentation can be limiting due to the elasticity of the Schneiderian sinus membrane, difficulty of the membrane to separate from the floor as well as the inability to have direct tactile access to “peel” the membrane off of the floor. Purpose The objective of this report is to present a new, minimally invasive sinus augmentation technique, called the Internal Sinus Manipulation (ISM) procedure, which has been developed to facilitate sinus floor augmentation while reducing treatment morbidity and yet have direct tactile access to raise the membrane off of the sinus floor. Surgical Technique Access to the Schneiderian sinus membrane is achieved without perforation of the membrane through a conventional osteotomy drilling procedure alone or combined with osteotome technique, followed by reflection of the membrane utilizing special ISM instrumentation and bone graft procedure laterally and vertically through the osteotomy site. A planned implant is then placed. Conclusion The Internal Sinus Manipulation procedure can be used as an alternative treatment modality for sinus augmentation as compared to the external lateral window technique while reducing postoperative morbidity for the patients who need implant treatment in posterior maxillary areas.