new bone formation in max.sinus using absorb able gelatin sponge

8/3/2019 New Bone Formation in Max.sinus Using Absorb Able Gelatin Sponge

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J Oral Maxillofac Surg68:1327-1333, 2010

New Bone Formation in the Maxillary

Sinus Using Only Absorbable

Gelatin SpongeDong-Seok Sohn, DDS, PhD,* Jee-Won Moon, DDS,

Kyung-Nam Moon, DDS, MSD, Sang-Choon Cho, DDS, and

Pil-Seoung Kang, DDS

Purpose: The purpose of the present study was to evaluate the predictability of new bone formationin the maxillary sinus using only absorbable gelatin as the graft material.

Patients and Methods: Seven patients (9 sinus augmentations) were consecutively treated with sinusfloor elevation by the lateral window approach. The lateral bony window was created using a piezo-electric device and the schneiderian membrane was elevated to make a new compartment. After 18resorbable blast media surfaced dental implants were simultaneously placed, absorbable gelatin sponges

were loosely inserted to support the sinus membrane over the implant apex and the bony portion of

lateral window was repositioned to seal the lateral window.

Results: After uncovering the implants an average of 6 months after placement, new boneconsolidation in the maxillary sinus was observed on radiographs without bone graft. Two implants

were removed due to failed osseointegration on uncovering. Failures were caused by insufficientinitial stability.

Conclusion: This study suggests that placement of a dental implant in the maxillary sinus with a gelatinsponge can be a predictable procedure for sinus augmentation. 2010 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 68:1327-1333, 2010

The widespread use of dental implants for replace-

ment of missing teeth has led to complex surgicalprocedures to increase the amount of available bone.Placement of dental implants on the edentulous pos-terior maxilla could present difficulties due to a defi-

cient posterior alveolar ridge, unfavorable bone qual-

ity, and increased pneumatization of the maxillarysinus.1,2 Increased implant failure rates in the poste-

rior maxilla are related to insufficient residual height

and poor bone quality.3,4 Such problems have been

overcome by increasing the alveolar height with max-

illary sinus augmentation.5,6 The lateral window ap-

proach is a commonly used technique for maxillary

sinus augmentation, especially when the initial alveo-

lar bone height cannot ensure the primary stability

of simultaneous placement of implants.5-7 Numerous

studies have documented the technical details for the

lateral window method, and these procedures have

shown clinical predictability.6-9

The sinus augmenta-tion procedure is usually accomplished by creating a

lateral bony window followed by elevation of the

schneiderian membrane. The space created between

the maxillary alveolar process and the elevated

schneiderian membrane is typically filled with au-

tografts, allografts, xenografts, alloplasts, or combina-

tions of different graft materials to maintain space for

new bone formation.6,10-15 Several studies have re-

ported that factors such as the volume of graft mate-

rial, the kinds of bone graft, and the amount of autog-

enous bone affect the amount of new bone formation,

*Chairman and Professor, Department of Dentistry and Oral and

Maxillofacial Surgery, Daegu Catholic University Hospital, Daegu,

Republic of Korea.

Resident, Department of Dentistry and Oral and Maxillofacial

Surgery, Daegu Catholic University Hospital, Daegu, Republic of

Korea.

Private Practice, Hanbit Dental Clinic, Jeju, Korea.

Assistant Research Scientist, Clinical Assistant Professor, Depart-

ment of Periodontology and Implant Dentistry, New York Univer-

sity College of Dentistry, New York, NY.

Resident, Department of Periodontology and Implant Dentistry,

New York University College of Dentistry, New York, NY.

Address correspondence and reprint requests to Dr Sohn: De-

partment of Oral and Maxillofacial Surgery, Catholic University

Hospital of Daegu, 3056-6 Daemyung-4 Dong, Namgu, Daegu, Re-

public of Korea; e-mail: [email protected]

2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/6806-0018$36.00/0

doi:10.1016/j.joms.2010.02.014

1327
mailto:[email protected]:[email protected]


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and most of these studies have shown a correlation

between the success of the bone graft and the successof dental implants.6,10-15

Elevating the maxillary sinus membrane and graft-ing with bone substitutes has become routine treat-ment over the past 40 years, and some studies havereported successful bone formation and osseointegra-

tion in cases of performing sinus membrane elevationwithout bone grafts.16-19

The aim of this study was to verify new bone

formation by radiologic results by application of onlyan absorbable gelatin sponge (Cutanplast; MasciaBrunelli Spa, Milano, Italy) in the space between theelevated schneiderian membrane and simultaneouslyplaced implants.

Patients and Methods

PATIENT SELECTION

The present study population consisted of 7 con-secutive patients, 6 men and 1 woman, 40 to 75 years

of age (mean age, 56.1 years). All patients were in-formed about the treatment procedure and provided

written consent for participation, and this study wasapproved by the institutional review board of theCatholic Medical Center of Daegu. The patients pre-sented with a partially or fully edentulous atrophicmaxilla with sinus pneumatization. Preoperative ex-aminations with panoramic views and dental cone-beam computed tomographic scans (Combi, Point-

nix, Seoul, Korea; or Implagraphy, Vatec, Kyungi,

Korea) were performed. Available bone volume, bone

quality, and any existing sinus pathology were evalu-

ated on these radiographs. The bone height of theremaining alveolar ridge was 1.5 to 7.0 mm (average,approximately 5.0 mm; Table 1 ). Patients were con-secutively treated with sinus floor elevation by thelateral window approach.

Patients who had previous failed sinus augmenta-

tions, who exhibited pathologic findings or had ahistory of maxillary sinus diseases or operations, or

whose medical conditions might increase surgical

risks of the research protocol were excluded.

SURGICAL PROCEDURES

Prophylactic oral antibiotics (cefditoren pivoxil 300mg 3 times/day; Meiact, Boryung Pharmacy, Seoul,Korea) were used routinely, beginning 1 day beforethe procedure and continuing for 7 days. Surgery wasperformed under local anesthesia through maxillaryblock anesthesia using 2% lidocaine that includes

1:100,000 epinephrine. Flomoxef sodium (Flumarin;Ildong Pharmaceutical Co, Seoul, Korea) 500 mg in-

travenously was administered 1 hour before surgery.Maxillary sinus floor elevation by the lateral approach

was completed in all participants. The approach tothe lateral wall of the maxillary sinus was followedafter the elevation of a mucoperiosteal flap accordingto surgical needs. A piezoelectric saw (S-Saw; BukbooDental Co, Daegu, Korea), connected to a piezoelec-tric device (Surgybone; Silfradent Srl, Sofia, Italy), wasused with copious saline irrigation to create the lat-

eral window of the maxillary sinus (Fig 1). The ante-

rior vertical osteotomy was made 2 mm distal to the

Table 1. DATA ON STUDY PARTICIPANTS

PatientNo. Gender

Age(yr) Site

Mean ResidualBone Height

(mm)MembranePerforation

ImplantSystem

Implant DiameterLength (mm)

HealingTime (mo)

1 Male 75 R max second and firstmolars, L max firstand second molars

5.5 No SybronPROXRT

4.1 13 6

2 Male 40 L max first and secondmolars

3.5 No SybronPROXRT

4.1 13 6

3 Male 51 R max second and firstmolars and secondpremolar

5.0 No SybronPROXRT

4.1 13 6

4 Female 62 L max first and secondmolars

5.0 Yes SybronPROXRT

4.1 13 6

5 Male 45 R max second and firstmolars, L max firstand second molars

7.0 No SybronPROXRT

4.1 13 6

6 Male 52 R max second and firstmolars

6.5 No SybronPROXRT

4.1 13 6

7 Male 68 R max second molar 1.5 No SybronPROXRT

4.1 13 6

Abbreviations: R, right; L, left; max, maxillary.

Sohn et al. Bone Formation Using Absorbable Gelatin. J Oral Maxillofac Surg 2010.

1328 BONE FORMATION USING ABSORBABLE GELATIN


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anterior vertical wall of the maxillary sinus and thedistal osteotomy was made approximately 20 mmaway from the anterior vertical osteotomy. The heightof the vertical osteotomy was approximately 10 mm.

The anterior and inferior osteotomy line was createdperpendicular to the inside of the maxillary sinuslateral wall, and then superior and posterior osteoto-mies perpendicular to the sinus wall were performed.This design of osteotomy facilitates the precise re-placement of the bony window as a barrier over aninserted gelatin sponge in the maxillary sinus. The

bony window was detached carefully to expose thesinus membrane. The schneiderian membrane was

carefully dissected from the sinus floor walls with a

flat blunt-edged instrument. Dissection of the sinus

membrane was continued to reach the medial and

posterior walls of the sinus cavity. After elevation of

the schneiderian membrane and placement of im-

plants (SybronPRO XRT implants; Sybron Implant So-

lution, Grendora, CA), an absorbable gelatin sponge

(70 50 1 mm; Cutanplast) was divided into 3

pieces. The pieces were folded and inserted into the

new compartment of the maxillary sinus. One piece

of gelatin sponge was placed anterior to the implant

site, 1 posterior to the site, and 1 directly above theimplant apex to support the membrane (Fig 2 ). The

bony portion of the lateral window was repositioned

to prevent soft tissue ingrowth into the sinus cavity

and to promote new bone formation from the lateral

wall of the maxillary sinus (Fig 3). Flaps were sutured

using interrupted mattress polytetrafluoroethylene su-

tures (Cytoplast; Osteogenic Biomedical, Lubbock,

TX) to achieve passive primary closure. Patients were

instructed not to blow their nose for 2 weeks after

surgery and to cough or sneeze with an open mouth.

Preoperative prophylactic antibiotic therapy was con-

tinued postoperatively for 7 days, and the sutures were removed 14 days postoperatively. After sinus

augmentation, postoperative panoramic radiographs

and cone-beam computed tomographic scans were

taken immediately after surgery. An average of 6

months was allowed for the implants to integrate. The

implants were then uncovered and panoramic radio-

graphs and dental cone-beam computed tomographic

scans were obtained to assess new bone formation

around the implants. Implants were loaded with pro-

visionals for 3 months before the final prostheses

were delivered.

FIGURE 2. After elevation of the schneiderian membrane andplacement of implants, an absorbable gelatin sponge (Cutanplast;Mascia Brunelli Spa, Viale Monza, Italy) 70 50 1 mm wasdivided into 3 pieces and inserted into spaces anterior and poste-rior to the implants and below the elevated schneiderian membrane(patient 6).


FIGURE 1. A piezoelectric saw (S-Saw; Bukboo Dental Co,Daegu, Korea), connected to a piezoelectric device (Surgybone;Silfradent Srl, Sofia, Italy), was used to create the lateral window ofthe maxillary sinus in all cases (patient 4).


FIGURE 3. The lateral bony window was repositioned withoutadditional procedures (patient 6).


SOHN ET AL 1329


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Results

Postoperative cone-beam computed tomographic

scans revealed that the sinus was filled with bloodclots and voids under the elevated schneiderian mem-brane (Fig 4). No adverse events were recorded dur-ing the healing period in any patient. There were nosigns of infection. Two implants failed before loadingdue to insufficient initial stability when placed into anextraction socket. The schneiderian membrane was

perforated in 1 case. The absorbable gelatin sponge was used for managing these perforations. After un-covering the implants, on average 6 months afterplacement, new bone consolidation was observed onradiographs and cone-beam computed tomographicscans (Fig 5). The newly formed maxillary sinus floor

was observed around the implant apex in all casesincluding the failed implant sites. No apparent differ-ences were observable on imaging of the augmenta-

tion with nonperforation or perforation sites. Thepatients maintained stable implant prostheses duringtheir final prostheses (Fig 6).

Discussion

One long-term study on the clinical success of im-plants placed into the augmented maxillary sinus with

variable bone grafts, regardless of graft materials used,

has reported similar or better success than of implants

placed using a conventional protocol with no grafting

procedure.6 However, Lundgren et al16 reported suc-

cessful new bone formation and osseointegration ofimplants in cases of sinus membrane elevation with-

out bone grafts, with radiographic and in vitro histo-

logic results. Palma et al17 compared the histologic

results of sinus membrane elevation and simultaneous

placement of implants with and without adjunctive

autogenous bone grafts in primates. The results

showed no differences between membrane-elevated

and grafted sites with regard to implant stability,

bone-to-implant contacts, and bone area within and

outside implant threads histologically in animals.

Nedir et al18 reported that elevation of the sinus

membrane alone without the addition of bone graft-ing material can lead to bone formation beyond the

original limits of the sinus floor from osteotome-

mediated sinus floor elevation. Sohn et al19 reported

favorable new bone formation in the maxillary sinus

without bone graft and clinical implant success with

in vivo histologic evidence for the first time.

The absorbable gelatin sponge inserted loosely un-

der the elevated sinus membrane acted as a space

maintainer for new bone formation in the maxillary

sinus as an alternative to bone filler in this study. All

cases showed new bone formation in the new com-

FIGURE 4. Postoperative cone-beam computed tomographic scans revealed the sinus was filled with blood clots and voids under the elevatedschneiderian membrane. A, Implant corresponding to the maxillary right second molar. B, Implant corresponding to the maxillary right firstmolar. C, Panoramic computed tomogram (patient 6).




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partment of the maxillary sinus; even the elevatedsinus membrane showed repneumatization aroundthe implant apex. In cases of bone grafts into the

maxillary sinus, bone graft materials have the role offiller, resulting in space in the sinus. However, graftedbone volumes also adapt considerably in shape and

volume due to repneumatization of the maxillarysinuses, with a resorption rate of 0.4% to 54%.20-23

In the present study, 2 implants failed during theuncovering procedure due to insufficient osseointe-gration. The failed implants could not be inserted

with sufficient primary stability in the extractionsocket, and the residual bone height was shorter than2 mm in 1 of the sites. Achievement of primary sta-

bility depends on adequate preparation of the bonesite to receive the implant and demands strict adher-ence to surgical protocols.24 Implants with deficientinitial stability are susceptible to micromotion at thebone-to-implant interface, which may affect the bone-healing process and result in fibrous encapsulation.25

Previous studies have shown that implants withsurface treatment exhibit greater bone-to-implant

FIGURE 5. New bone consolidation was observed on computed tomographic scans. The former sinus floor disappeared and newly formedsinus floor and new bone formation were observed. A, Implant corresponding to the maxillary right second molar. B, Implant correspondingto the maxillary right first molar. C, Panoramic computed tomogram (patient 6).


FIGURE 6. Panoramic radiograph shows the augmented right maxillary sinus and fixed bridges in situ.


SOHN ET AL 1331


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contact mainly in the early stages of osseointegra-

tion and in areas of low-quality bone.26,27 Sybron-PRO XRT implants with resorbable blast media sur-faces were placed in the present study. Piattelli etal28 reported that the resorbable blast media sur-face could be considered more osteoconductivethan a machined surface. The study, with scanning

electron microscopy and electron spectroscopy forclinical analysis, showed that implant surface treat-ment can improve in vitro cellular adhesion and

proliferation.27 However, surface treatment pro-cesses can leave the processing material embeddedin the implant surface as residual contaminants dur-ing beading or grit blasting.29 Such a problem couldbe avoided by the use of calcium phosphate media.

Although the residual particles existed, they couldbe absorbed or attached to surrounding bone.28

The barrier membrane between graft materials andthe overlying soft tissue is necessary to prevent

growth offibrous connective tissue in the augmentedspace.30,31 The lateral bony window was replacedafter augmentation of the maxillary sinus and simul-taneous placement of implants in this study. The re-placeable bony window made by the piezoelectricsaw could be precisely repositioned because of thetilted osteotomy into the sinus, highly controlled os-teotomy, and minimal bone loss during osteotomy.Lundgren et al16 used an oscillating saw to create the

lateral window as a barrier for sinus augmentation.The application of a conventional oscillating saw increating a lateral bony window is irritating to patients

because of the loud noise during surgery. Moreover,access to the oral cavity may be limited. Hence, use ofa piezoelectric device is recommended to create alateral bony window to obtain direct visibility over

whole osteotomies, highly precise bone cut by micro-metric, and linear vibrations.19,32-36 The precisely cre-

ated bony window prevents the replaceable bony win-dow from dropping into the maxillary sinus cavity.19,34

Whether or not bone grafting is performed in themaxillary sinus, the replaceable bony window acts asa homologous barrier over the ne w compartmentunder the elevated maxillary sinus.19 Lundgren et al16

reported that there are several advantages to using a

replaceable bone window, according to the principleof guided tissue regeneration. Sohn et al19 demon-

strated that there are no clinical differences in newbone formation in the maxillary sinus between thegroup using nonresorbable membrane and the groupusing replaceable bony window to seal the lateral

window, according to histologic data in humans.However, a homologous bony window is free from

viral cross-contamination of animal or human originand saves the surgical cost of purchasing barrier mem-branes. Homologous bony windows not only prevent

soft invasion into the grafted site but also act as

osteoinductive/osteoconductive substrates for new

bone formation in the sinus, accelerating new boneformation in the grafted/nongrafted sinus.

In conclusion, elevation of the sinus membrane,simultaneous placement of implants, and insertion ofgelatin sponges demonstrate new bone formationthrough clinical and radiographic evaluations. New

bone formation was verified by stabilization of theelevated sinus membrane from the tenting effect ofplacement of dental implants and absorbable gelatin

sponge without any bone graft material. This studyshows that there is great potential for new boneformation in the maxillary sinus without the use ofadditional bone grafts. It is suggested that long-termfollow-up often is required for confirmation of thestability of this procedure.

Acknowledgment

The authors thank Dr Paul Maupin for his valuable assistance in

editing this article.

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new bone formation in max.sinus using absorb able gelatin sponge

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