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 Table of Contents  
DENTAL SCIENCE - CASE REPORT
Year : 2014  |  Volume : 6  |  Issue : 5  |  Page : 174-177  

Perforated schneiderian membrane repair during sinus augmentation in conjunction with immediate implant placement


1 Department of Dentistry, Sri Muthukumaran Medical College and Research Institute, Kotputli, Rajasthan, India
2 Department of Oral and Maxillofacial Surgery, Eklavya Dental College, Kotputli, Rajasthan, India
3 Department of Periodontology, S.R.M. Dental College, Chennai, Tamil Nadu, India

Date of Submission30-Mar-2014
Date of Decision30-Mar-2014
Date of Acceptance09-Apr-2014
Date of Web Publication25-Jul-2014

Correspondence Address:
Dr. K Hameed Fathima
Department of Dentistry, Sri Muthukumaran Medical College and Research Institute, Kotputli, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.137446

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   Abstract 

Dental implant associated rehabilitation of the posterior maxilla poses unique challenge owing to the presence of pneumatized sinuses and atrophied alveolar bone. Sinus augmentation procedure to manage expanded sinuses frequently results in membrane tear resulting in unfavorable stabilization of the graft and associated bone regeneration. Simultaneous implant placement during sinus augmentation procedures frequently requires a minimal alveolar bone height, which when not present forces clinician to defer implant placement resulting in extended treatment duration and multiple surgical appointments. The present case report is about a piezosurgery assisted lateral wall osteotomy approach for sinus augmentation associated with membrane repair with simultaneous implant placement in the posterior maxilla.

Keywords: Implant placement, membrane perforation, membrane repair, schneiderian membrane, sinus augmentation


How to cite this article:
Fathima K H, Harish V S, Jayavely P, Harinath P. Perforated schneiderian membrane repair during sinus augmentation in conjunction with immediate implant placement. J Pharm Bioall Sci 2014;6, Suppl S1:174-7

How to cite this URL:
Fathima K H, Harish V S, Jayavely P, Harinath P. Perforated schneiderian membrane repair during sinus augmentation in conjunction with immediate implant placement. J Pharm Bioall Sci [serial online] 2014 [cited 2019 Sep 22];6, Suppl S1:174-7. Available from: http://www.jpbsonline.org/text.asp?2014/6/5/174/137446

Rehabilitation of the upper posterior maxilla with implants has shown a high success in the presence of normal bone volume and density. [1],[2],[3] Prolonged edentulism of posterior maxilla is frequently characterized by ridge atrophy, pneumatization of the sinuses, low bone density and excessive occlusal loads of the dental arch, thus resulting in insufficient residual bone and complicating implant placement. [4],[5]

The most successful surgical technique to access the maxillary sinus is performed by the lateral access window (modified Caldwell-Luc technique) [6],[7],[8],[9] or a less-invasive approach through the crest of the alveolar ridge utilizing osteotomies or a combination of osteotomies and e drill.

External sinus lifting procedure enables one to place implants with a vertical height gain of up to 12 mm. [10]

Perforation of the Schneiderian membrane during external sinus augmentation is a well-documented phenomenon and is most likely to happen at sharp angle and ridge line, septa, and spines. [11] The formation of mucocele, chronic sinusitis, oroantral fistula, loss of graft material and implant nonosseointegration are other complications reported in the literature associated with membrane perforation. [12],[13],[14] Perforation of the maxillary sinus membrane were classified by many researchers and have been concluded that they were commonly treatable with the use of collagen membranes.

The present case report is about an external sinus augmentation utilizing piezosurgical techniques associated with membrane repair with simultaneous implant placement in the posterior maxilla.


   Case Report Top


A 41-year-old systemically healthy female patient presented with the chief complaint of missing teeth in the left upper posterior region for past 7 months. Patient gave a dental history of implant placement in relation to 24, 44, and 47 1 year back. Patient had undergone endodontic therapy in relation to 11, 21, 15, 16, and 17 with postendodontic restoration. A tooth supported fixed partially denture in relation to 34.35 and 36 and an implant supported fixed partial denture in relation to 44, 45, 46, and 47 region. Digital orthopantomogram (OPG) revealed a residual bone height of <2 mm in relation to 26.27 and around 4 mm in 25 region with a pneumatized sinus and horizontal bone loss on the mesial aspect of implant in 24 region.

Treatment plan of lateral wall osteotomy approach for sinus augmentation associated with simultaneous implant placement in 25, 26, and 27 region was decided upon. In spite of the literature data insisting on the minimum of 4 mm alveolar bone height for simultaneous implant placement during sinus augmentation procedures the decision of simultaneous implant placement was still considered due to the fact that implants placed creates a tenting effect resulting in excellent space maintenance for optimal regeneration. [15] Moreover such approach greatly reduces over all treatment duration and multiple surgical appointments. Considering the bone loss in 24 region a laser debridement was also planned followed by placement of splinted metal ceramic crowns involving 4 implants including implant in 24 region.

Patient was informed of the therapeutic alternatives to the sinus lift. The risk of perforating the sinus membrane and the possible complications was also explained and written informed consent was obtained.


   Surgical Procedure Top


The surgical site was anaesthetized by local infiltration with 2% lignocaine hydrochloride (1:200000 adrenalin). Two vertical releasing incisions one on the distal line angle of 24 and the other on the distal most aspect of the ridge with a para-crestal incision joining both these vertical releasing incisions was given [Figure 1]a and b. A mucoperiosteal flap was elevated exposing the lateral wall of the maxillary sinus [Figure 1]c.
Figure 1: (a) Preoperative intraoral view, (b) Placement of para - crestal and vertical releasing incisions, (c) Flap elevated exposing the lateral bony wall, (d) Preparation of bony window

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Piezo surgery assisted sinus augmentation

Using a round end piezo tip a bony window was prepared [Figure 1]d and was infractured, followed by the elevation of the schneiderian membrane using the sinus elevation tips. During sinus membrane elevation a class IIA type perforation [16] occurred [Figure 2]a, following complete elevation of the sinus membrane an implant osteotomy was performed in 25, 26 and 27 region [Figure 2]b.
Figure 2: (a) Infracture of bony window, perforation of sinus membrane encountered during membrane elevation, (b) Implant osteotomy sites prepared in 25, 26 and 27, (c) Type I collagen membrane (BioMend Extend®) placed to repair the perforated sinus membrane, (d) Sinus cavity partially packed with deproteinized bovine bone (Bio-oss®)

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Before placing the implants the perforation of the schneiderian membrane was managed by adapting a contoured guided bone regeneration (GBR) type I collagen membrane (BioMend Extend ® - Zimmer dental, 1900 Aston Avenue, Carlsbad, CA 92008-7308 USA, lot no.: 1094148) in such a way that the perforated membrane was completely shielded from the elevated sinus cavity [Figure 2]c.

The sinus space was partially packed with deproteinized bovine bone (Bio-oss ® - Geistlich biomaterials batch no. 080307) hydrated with blood [Figure 2]d followed by the placement of three wide platform tapered self-threaded titanium implants (Hi-Tec Life Care Israel for Life care devices private limited , 202 Jesia building , Jame Jamshed road , Dadar east , Mumbai - 14 - Lot No : 030610,08097,16108) [Figure 3]a. The residual spaces around the implants were further packed with Bio-oss ® graft [Figure 3]b. A type 1 collagen GBR membrane (BioMend Extend ® ) was contoured and adapted to cover the bony window and tucked under the palatal flap [Figure 3]c. The reflected flap was approximated with 4-0 vicryl (Ethicon, Inc., Johnson and Johnson, Somerville, NJ, USA) using simple interrupted sutures [Figure 3]d.
Figure 3: (a) Implant placed in prepared osteotomy sites, (b) Residual sinus cavity filled with Bio- oss ®, (c) Placement of collagen membrane (Bio mend Extend®) to cover the implants and access window, (d) Flap approximated using 4-0 vicryl suture material

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The patient was placed on amoxicillin/clavulinic acid 625 mgs 2 tablets/day for 5 days, ibuprofen/paracetomol 3 tablets/day for 5 days and Fexofenadine chloride 60 mg plus pseudoephedrine chloride 120 mg 1 tablet every 12 h, for 7 days (decongestant). Patient was advised to rinse with chlorhexidine gluconate 0.2% mouth wash twice daily for the following 4 weeks.

Patient was reviewed the next day and after 4 weeks with the postsurgical healing being uneventful at this junction laser debridement for the aligning implant in 24 region was performed. Patient was placed on periodic recall every 2 months until the 8 month during which a digital OPG and computed tomography was taken. The radiographs showed the position of implant and dense bone fill in the sinus cavity [Figure 4]a-d.
Figure 4: (a) Fully functional metal ceramic prosthesis, (b) Computed tomography shows the position of implants, (c) Preoperative radiograph shows ridge deficiency, (d) 8 months postoperative radiograph shows the augmented site with implants

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During the second stage the implant recovery was done with laser and healing caps were placed and left in place for 4 weeks. 4 weeks following healing cap placement the prosthetic abutment was screwed in with a 40 Ncm torque. The metal ceramic crown on 24 implant was retrieved and a silicone impression was taken involving implant abutments in 24, 25, 26 and 27 region. Following metal and ceramic try in, a metal ceramic prosthesis (5 units considering the mesiodistal space available) was cemented and patient was reviewed after a week during which the patient was comfortable and the prosthesis was fully functional.


   Discussion Top


Maxillary sinus augmentation is commonly undertaken to enhance otherwise inadequate bone dimension for placement of dental implants in the posterior maxilla. The most important factor is to keep the schneiderian membrane intact during sinus augmentation so that once lifted, it can become the recipient site for the bone graft and it stabilizes the graft during the healing period, constituting an important barrier for the protection and defense of the sinus cavity. Its integrity is essential to maintain the health of normal function of the sinus. Complications reported during sinus augmentation surgery are excessive bleeding during surgery, implant migration, hematoma, injury of the infraorbital neurovascular bundle and adjacent tooth sensitivity of which the most significant complication is membrane perforation which has a negative impact on graft remodeling. [17] Though piezo surgical techniques are frequently employed in sinus augmentation procedures for atraumatic osteotomy and to minimize membrane perforation, incidence of schneiderian membrane tear is not uncommon. [18] Various techniques used for the treatment of membrane tear are circumelevation technique, Loma Linda Pouch technique and the perforated membrane can be managed by using tissue fibrin glue, suturing or by covering them with a resorbable barrier membrane in case of small perforation (<5 mm), if the perforation is >5 mm larger barrier membranes, lamellar bone plates or suturing either alone or combination with fibrin glue can be advocated. In the present case report the type of perforation was a class II A and the size of perforation was larger than 3 mm so it was managed using a resorbable membrane. [16]

Various graft materials such as autogenous, allogenous, xenograft and alloplastic materials have improved the results of sinus augmentation techniques and made them more predictable. [19],[20],[21] Deproteinized bovine bone (Bio-oss ® ) as used in the present study have shown to be favorable due to its optimal resorption period, commercial availability, higher survival rate of implants and excellent handling characteristics. [22],[23],[24]

Simultaneous implant placement during external sinus augmentation requires a minimum of 4 mm of remaining alveolar bone for minimal initial stability and preventing implant migration during regeneration. [13],[14],[25],[26],[27],[28] In the present case report, implants were placed in the sites with the residual alveolar bone of lesser than 2 mm considering various advantages such as fewer surgical procedures, reduced overall treatment duration, less morbidity, less financial expense and less patient anxiety. Added advantage of the implant placed in the residual alveolar bone of lesser than 2 mm is the tenting effect of the implant on the repaired sinus membrane acting as a space maintainer.

In the present case report, implants were placed simultaneously during sinus augmentation procedure in spite of <2 mm of bone height available in 26 and 27 region and during the sinus augmentation membrane perforation occurred, which was carefully managed, postoperative healing showed optimal bone fill in the sinus region and successful ossiointegration in the implant sites. The final prosthesis was esthetic as well as functional.


   Conclusion Top


External sinus augmentation with simultaneous implant placement is a viable option even in areas with residual bone height of <4 mm as this approach reduces overall treatment duration and the stress of multiple surgical procedures for the patients.

 
   References Top

1.Albrektsson T, Zarb G, Worthington 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;1:11-25.  Back to cited text no. 1
    
2.Nevins M, Langer B. The successful application of osseointegrated implants to the posterior jaw: A long-term retrospective study. Int J Oral Maxillofac Implants 1993;8:428-32.  Back to cited text no. 2
    
3.Jemt T, Lekholm U. Oral implant treatment in posterior partially edentulous jaws: A 5-year follow-up report. Int J Oral Maxillofac Implants 1993;8:635-40.  Back to cited text no. 3
    
4.Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988;17:232-6.  Back to cited text no. 4
    
5.Lozada JL, Emanuelli S, James RA, Boskovic M, Lindsted K. Root-form implants placed in subantral grafted sites. J Calif Dent Assoc 1993;21:31-5.  Back to cited text no. 5
    
6.Lundgren S, Moy P, Johansson C, Nilsson H. Augmentation of the maxillary sinus floor with particulated mandible: A histologic and histomorphometric study. Int J Oral Maxillofac Implants 1996;11:760-6.  Back to cited text no. 6
    
7.Chiapasco M, Ronchi P. Sinus lift and endosseous implants - Preliminary surgical and prosthetic results. Eur J Prosthodont Restor Dent 1994;3:15-21.  Back to cited text no. 7
    
8.Fugazzotto PA, Kirsch A, Ackermann KL, Neuendorff G. Implant/tooth-connected restorations utilizing screw-fixed attachments: A survey of 3,096 sites in function for 3 to 14 years. Int J Oral Maxillofac Implants 1999;14:819-23.  Back to cited text no. 8
    
9.Summers RB. The osteotome technique: Part 3 - Less invasive methods of elevating the sinus floor. Compendium 1994;15:698, 700, 702-4.  Back to cited text no. 9
    
10.Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207-29.  Back to cited text no. 10
    
11.van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000;11:256-65.  Back to cited text no. 11
    
12.Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613-6.  Back to cited text no. 12
    
13.McCarthy C, Patel RR, Wragg PF, Brook IM. Sinus augmentation bone grafts for the provision of dental implants: Report of clinical outcome. Int J Oral Maxillofac Implants 2003;18:377-82.  Back to cited text no. 13
    
14.Raghoebar GM, Timmenga NM, Reintsema H, Stegenga B, Vissink A. Maxillary bone grafting for insertion of endosseous implants: Results after 12-124 months. Clin Oral Implants Res 2001;12:279-86.  Back to cited text no. 14
    
15.Lundgren S, Andersson S, Gualini F, Sennerby L. Bone reformation with sinus membrane elevation: A new surgical technique for maxillary sinus floor augmentation. Clin Implant Dent Relat Res 2004;6:165-73.  Back to cited text no. 15
    
16.Fugazzotto PA, Vlassis J. A simplified classification and repair system for sinus membrane perforations. J Periodontol 2003;74:1534-41.  Back to cited text no. 16
    
17.Chanavaz M. Sinus graft procedures and implant dentistry: A review of 21 years of surgical experience (1979-2000). Implant Dent 2000;9:197-206.  Back to cited text no. 17
    
18.Vercellotti T, De Paoli S, Nevins M. The piezoelectric bony window osteotomy and sinus membrane elevation: Introduction of a new technique for simplification of the sinus augmentation procedure. Int J Periodontics Restorative Dent 2001;21:561-7.  Back to cited text no. 18
    
19.Batista RW, Passeri LA. Sinus floor elevation and grafting for placement of dental implants. Rev Odontol Bras Cent 2000;9:54-7.  Back to cited text no. 19
    
20.Garg AK, Valcanaia TDC. Elevation of the maxillary sinus floor through graft for placement of dental implants: anatomy, physiology and procedures. Balkan Conference in Informatics 1999;6:53-64.  Back to cited text no. 20
    
21.Misch CE. Contemporary dental implants. 2 nd ed. São Paulo: Santos; 2000.  Back to cited text no. 21
    
22.Hising P, Bolin A, Branting C. Reconstruction of severely resorbed alveolar ridge crests with dental implants using a bovine bone mineral for augmentation. Int J Oral Maxillofac Implants 2001;16:90-7.  Back to cited text no. 22
    
23.Hallman M, Hedin M, Sennerby L, Lundgren S. A prospective 1-year clinical and radiographic study of implants placed after maxillary sinus floor augmentation with bovine hydroxyapatite and autogenous bone. J Oral Maxillofac Surg 2002;60:277-84.  Back to cited text no. 23
    
24.Valentini P, Abensur DJ. Maxillary sinus grafting with anorganic bovine bone: A clinical report of long-term results. Int J Oral Maxillofac Implants 2003;18:556-60.  Back to cited text no. 24
    
25.Tatum OH. Maxillary sinus elevation and subantral augmentation. Birmingham, Alabama: Implant Study Group; 1977.  Back to cited text no. 25
    
26.Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compendium 1994;15:152, 154-6.  Back to cited text no. 26
    
27.Kuabara MR, Vasconcelos LW, Carvalho PSP. Surgical techniques for obtaining autogenous bone graft. Rev Fac Odontol Lins 2000;12:44-51.  Back to cited text no. 27
    
28.Simion M, Fontana F, Rasperini G, Maiorana C. Long-term evaluation of osseointegrated implants placed in sites augmented with sinus floor elevation associated with vertical ridge augmentation: A retrospective study of 38 consecutive implants with 1- to 7-year follow-up. Int J Periodontics Restorative Dent 2004;24:208-21.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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