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DENTAL IMPLANTS

Oral Maxillofac Surg7:1098-1103, 2009

Osteotome Sinus Floor Elevation TechniqueWithout Grafting Material and ImmediateImplant Placement in Atrophic Posterior

Maxilla: Report of 2 CasesRabah Nedir, DMD,* Nathalie Nurdin, PhD,†

Serge Szmukler-Moncler, DDS, IEP, PhD,‡ and Mark Bischof, DMD§

Purpose: This case report discusses 2 patients who required implant placement in the atrophicposterior maxilla to support a fixed prosthesis with the least invasive and shortest procedure.

Materials and Methods: The reference standard of care would be to perform sinus augmentation withan autologous bone graft through the lateral approach with delayed implant placement. However, inthese cases, the posterior maxillas were treated with an osteotome sinus floor elevation procedurewithout grafting material and simultaneous placement of short, 8- and 10-mm-long, tapered implants.

Results: All implants achieved primary stability and were successfully loaded after 3.6 months ofhealing. At the 1- and 2-year follow-up visits, they were clinically stable and the final prostheses werefunctioning. The mean endosinus bone gain was 5.1 � 1.3 mm. In 1 of the patients, the implants werecompletely embedded in the newly formed bone and the sinus floor had been relocated apical to itsprevious demarcation.

Conclusions: The findings from these 2 cases suggest that the osteotome sinus floor elevation proce-dure without grafting material, and immediate placement of tapered implants, might be applied insituations for which previously only the lateral approach was considered (at the condition that implantsachieve firm primary stability). More patients and longer follow-up are warranted to investigate howreliable this technique can be when applied to the atrophic maxilla.© 2009 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 67:1098-1103, 2009

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n the posterior maxilla, tooth extraction inducesrogressive and irreversible vertical bone resorp-ion. This leads to an atrophic bone situation andimits the application of implant therapy. In suchases, the sinus lift procedure with bone augmen-ation is indicated; it is expected to facilitate im-lant primary stability, provide sufficient bone for

*Assistant Professor, Department of Stomatology and Oral Sur-

ery, University of Geneva, School of Dental Medicine, Geneva,

witzerland; Clinical Director, Swiss Dental Clinics Group, Ardentis

evey Clinique Dentaire, Vevey, Switzerland.

†PhD Scientific Collaborator, Swiss Dental Clinics Group, Arden-

is Clinique Dentaire, Vevey, Switzerland.

‡Associate Professor, Department of Stomatology and Maxillofa-

ial Surgery, UFR 068, University of Paris 6, Paris, France; Visiting-

rofessor, Galeazzi Orthopaedic Institute, Department of Odontol-

gy, University of Milano, Milano, Italy.

§Assistant Professor, Department of Stomatology and Oral Sur-

ery, University of Geneva, School of Dental Medicine, Geneva,

1098

ptimal implant osseointegration, and provide long-erm success.1

The lateral window technique was first describedy Boyne and James1 in 1980. It is the most frequentlysed procedure for vertical bone augmentation of thetrophic posterior maxilla. It requires a significantolume of bone harvested from a donor site. The

witzerland; Clinical Director, Swiss Dental Clinics Group, Ardentis

linique Dentaire, Lausanne, Switzerland.

Address correspondence and reprint requests to Dr Rabah

edir: Swiss Dental Clinics Group, Ardentis Clinique Dentaire, Rue

u Collège 3, Vevey CH-1800 Switzerland; e-mail: rabah.nedir@

wissdentalclinics.ch

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6705-0026$36.00/0

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NEDIR ET AL 1099

atter increases the patient’s postoperative discom-ort, pain, swelling, bruising, and risk of infection. Anlternative to the lateral approach is the osteotomeinus floor elevation procedure. It is less invasive andhe treatment can be achieved with a single surgery.2

The reliability of short implants with a texturedurface has been well documented.3-7 In sites withimited residual bone height (RBH), the surgical pro-edure is simpler, and the treatment duration can beeduced. For example, Renouard and Nisand5 re-orted a cumulative survival rate of 94.6% after 2ears of loading for 96 short implants placed in se-erely resorbed posterior maxilla. Recently, the needor autologous bone grafts and grafting material tochieve successful sinus augmentation proceduresas been questioned.7-10 In sites in which the meanesidual bone height was 5.4 mm, Nedir et al7 showedhat the osteotome sinus floor elevation procedureithout bone grafting material could lead to a mean

ndosinus bone gain of 2.5 � 1.2 mm. The latter wasven found to be inversely correlated with the RBHie, the lower the RBH, the greater the bone gain).7

The present report addressed the treatment of 2atients who presented with a mean RBH of 3.2 mm

n the posterior maxilla. The patients asked for theimplest and least invasive treatment. This led theractitioner to choose a surgical protocol other thanhe classic lateral window procedure. These patientsere treated by combining the osteotome sinus floor

levation procedure, without a grafting material, withhe simultaneous placement of short tapered implantsith a reduced thread pitch.

aterials and Methods

CASE 1

A 48-year-old white man came to our institution forehabilitation of his left edentulous posterior maxilla.is general health was good without a contributiveedical history. The patient was a heavy smoker (about

0 cigarettes daily) but had stopped smoking beforereatment. Despite protracted periodontal therapy, theatient had had extensive alveolar bone loss. The “re-istant periodontitis” required extraction of all theeeth from this posterior quadrant.

The periapical radiograph taken before surgery (FigA) revealed a large procident sinus cavity, extendinground the apex of the cuspids. The presence of aeptum was identified at the former position of theecond premolar. The RBH was 3.0 mm at the formerosition of the first premolar, 5.0 mm of the secondremolar, and 1.1 mm of the first molar.Prophylactic antibiotics (Amoxi-Mepha; Mepha Pharma

A, Aesch, Switzerland; 750 mg, 3 times daily) were given

he day before surgery and for 6 days after surgery. A d

id-crestal incision was performed for flap elevation;ertical and periosteal release incisions were avoided.ortical bone marking, for site positioning, was per-

ormed with 3 round burrs of increasing diametersrom 1.4 to 3.1 mm (Fig 2A). The 2.8 mm-diameterinus osteotome (Straumann AG, Basel, Switzerland)as engaged to push the sinus floor axially. The use ofsteotomes instead of drills prevented ovalization ofhe implant bed in the limited residual bone. Theinus floor was then broken by light strokes with aallet. It was then carefully pushed into the sinus

avity to a maximal height of 3 mm; the Schneiderianembrane was further elevated by implant placement.he osteotomy site was enlarged by the 3.5-mm-diame-

er sinus osteotome. The integrity of the membraneas controlled with an undersized depth gauge of 2.1m; however, microperforation of the Schneiderianembrane could not be excluded.11 No grafting ma-

erial was used. Three tapered, 8-mm-long, TE im-lants, 4.8 mm-diameter at the collar and 4.1 mm athe apex (Straumann AG), were placed in the pre-ared osteotomy sites. Implant insertion was per-

ormed without tapping. The flap was suturedround the implant neck, allowing for nonsub-erged healing (Fig 2B). The blood clot with bonearticles surrounding the implants could be clearlyeen on the postoperative radiograph (Fig 1B). Dur-ng surgery, the bone quality at the implant sites

as categorized according to Trisi and Rao:12 nor-al at the site of the first premolar and soft at the

ites of the second premolar and first molar. All 3mplants achieved primary stability.

The healing period was uneventful and lasted 3.6onths. The space delimited by the elevated Schneiderianembrane was maintained over time by the implants. The

lassic prosthetic steps were then performed, and a ce-ented porcelain-fused-to-metal prosthesis composed of 3

plinted crowns was placed. At the 1-year follow-up, allmplants were clinically stable, and the final prosthesis

as functioning (Fig 2C). All implants gained endosinusone; the mean gain was 5.5 � 1.4 mm and varied from.7 to 7.1 mm. All implants were entirely embedded inhe newly formed mineralized tissue (Fig 1C). The meanrestal bone loss was 1.1 � 0.3 mm. At 2 years, the boneevels were stable (Fig 1D).

CASE 2

A 77-year-old white man presented for rehabilita-ion of his left posterior maxilla that had been eden-ulous for several years. He was a previous smokerho was in good general health with a noncon-

ributive medical history. The RBH beneath theinus was 3.0 mm at the second premolar and 3.5m at the first molar. The surgical procedure was

imilar to that performed for patient 1. The only

ifference was that the osteotome sequence ended

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1100 OSTEOTOME SINUS FLOOR ELEVATION TECHNIQUE IN ATROPHIC POSTERIOR MAXILLA

ith the 4.2-mm diameter sinus osteotome, insteadf the 3.5-mm diameter sinus osteotome used forhe 4.8-mm diameter implants for patient 1. Thisas because larger diameter implants werelanned. The 10-mm-long tapered implants, 6.5 mm

n diameter at the collar and 4.8 mm in diameter athe apex (Straumann AG), were inserted at sites 25nd 26.

Both implants achieved primary stability. After anneventful healing period of 3.6 months, the implantsere clinically stable. Abutment screwing with a

orque of 20 Ncm did not lead to implant rotation.he final prosthesis was functioning at the 1-year

ollow-up visit. A dental computed tomography scannd panoramic and apical radiographs were per-ormed at the 1-year follow-up visit. Newly formedineralized tissue on each implant side was clearly

isible on the 1-year radiographs (Figs 3, 4). The meanone gain and crestal bone loss was 5.0 and 0.4 mmt the implant in the site of the second premolar and.6 and 0.5 mm at the implant at the site of the firstolar. Thus, the net bone gain was 4.6 mm at the

IGURE 1. Periapical radiographs of posterior area of patient 1.t 1-year follow-up visit. D, At 2-year follow-up visit.

edir et al. Osteotome Sinus Floor Elevation Technique in Atrop

mplant at the site of the second premolar and 3.1 mm e

t the implant at the site of the first molar. After 3.5ears, the implants were clinically and radiographi-ally stable.

iscussion

For the 2 patients, the available prosthetic height,easured from the bony crest of the edentulous sites

o the opposing dentition, was about 9 mm; there-ore, endosinus augmentation was indicated ratherhan crestal augmentation. The standard current clini-al practice would have required a sinus-lift procedureith autologous bone grafting and delayed implantlacement.13 This treatment would have required 6 to 8onths of healing to allow for bone formation at the

rafted area and a second healing period of 3 to 4onths after implant placement (ie, 9 to 11 months ofealing instead of 3.6 months). Furthermore, in pa-ient 1, the lateral approach would have been com-licated by the presence of a septum and might have

ed to membrane perforation.14

Both patients required the least invasive and short-

re implant placement. B, Immediately after implant placement. C,

terior Maxilla. J Oral Maxillofac Surg 2009.

A, Befo

st treatment. The osteotome sinus floor elevation

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NEDIR ET AL 1101

rocedure, although technically demanding with anBH of less than 5 mm, was minimally invasive. Be-ause the Schneiderian membrane can support eleva-ion in the sinus cavity of 4 to 8 mm,15 the requiredlevation of the sinus floor could be obtained.16

To enhance the primary stability in low-densityone, the use of osteotomes is more relevant than these of drills. By compression, the osteotomes can

IGURE 2. Clinical views of patient 1. A, During surgery. Flap elev, Immediately after surgery. Coverscrews in place and suturesrosthesis in place.

edir et al. Osteotome Sinus Floor Elevation Technique in Atrop

aterally condense bone and create a denser interface 1

t the placed implants,17 improving the initial bone-o-implant contact.18

Implant stability could be achieved despite theimited RBH down to 1.1 mm; this was because ofhe conical implant design, the threads brought upo the implant neck, and a reduced pitch of 0.8 mm.he classic parallel-walled design of the used im-lant system, with its 1.25-mm thread pitch starting

fter mid-crestal incision. Cortical bone marking for site positioning.ing to 1-stage procedure. C, At 1-year follow-up visit with final

terior Maxilla. J Oral Maxillofac Surg 2009.

ation aaccord

mm away from the neck level, would not have

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1102 OSTEOTOME SINUS FLOOR ELEVATION TECHNIQUE IN ATROPHIC POSTERIOR MAXILLA

llowed for primary stability in these demandingituations.

The osteotome sinus floor elevation procedure de-cribed by Summers19,20 involves a grafting materialhat is condensed in the osteotomy site to elevate theinus membrane. If the Schneiderian membrane iserforated, the filling material can migrate into theinus and lead to inflammation.21,22 The present pro-ocol, by avoiding use of a grafting material, has com-

IGURE 3. Dental computed tomography scan of patient 2, with oolar. A (1-9), Before implant placement; B (1-9), at 1-year follow-olar.

edir et al. Osteotome Sinus Floor Elevation Technique in Atrop

IGURE 4. Panoramic radiographs of patient 2. A, Immediatelyfter implant placement. B, At 1-year follow-up visit.

nedir et al. Osteotome Sinus Floor Elevation Technique in Atro-hic Posterior Maxilla. J Oral Maxillofac Surg 2009.

letely eliminated this risk. With this technique, un-etected perforations are likely to remain uneventfulecause the membrane can reform around �4 mm ofrotruding implants.23

The findings from these 2 cases, with a mean of 5.1m of endosinus bone gain, are also questioning theecessity of using a grafting material in sinus augmen-ation procedures. Despite the lack of grafting mate-ial, the 1- and 2-year radiographs consistently showedhe implants embedded into newly created bone andhe new apically switched demarcation of the sinus.lso, the additional bone height usually gained by therafting material placed above to the implant apex haseen shown to resorb with time, as quickly as 124 or25 years. Amazingly, it will be stabilized at the im-lant apex24 or slightly below it.25 Therefore, thatpical bone gain in this procedure is limited by themplant length should not be considered a limitationr a specific drawback of this technique without arafting material.Short implants were used in these 2 cases to mini-ize the risk of membrane perforation. This could be

ontemplated, because it has now been well docu-ented that rough-surfaced short implants, in con-

rast to machine-surfaced implants, are as reliable asonger implants.3,4,7,26-28

In summary, tapered implants with a reduced threaditch could be placed with good primary stability in thetrophic maxilla of 2 patients using an osteotomeinus floor elevation procedure without grafting ma-erial. The regenerative properties of the bone be-

coronal reconstructions of the sites of the second premolar and first. A3, B3, Site of the second premolar; and A6, B6, site of the first

terior Maxilla. J Oral Maxillofac Surg 2009.

bliqueup visit

eath the sinus floor led to high endosinus bone gain.

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NEDIR ET AL 1103

he advantages of this procedure were the avoidancef invasive surgery and permitting treatment within aingle surgical step. Before bringing this treatmentrotocol into more routine clinical practice, moreases and longer follow-up are warranted. However,hese 2 cases, successful in the short term, suggesthat room might exist to treat the atrophic maxillaith a surgical procedure other than the classic lateralindow opening for sinus augmentation.

eferences1. Boyne PJ, James RA: Grafting of the maxillary sinus floor with

autogenous marrow and bone. J Oral Surg 38:613, 19802. Toffler M: Treating the atrophic posterior maxilla by combin-

ing short implants with minimally invasive osteotome proce-dures. Pract Proced Aesthet Dent 18:301, 2006

3. Fugazzotto PA: Shorter implants in clinical practice: Rationale andtreatment results. Int J Oral Maxillofac Implants 23:487, 2008

4. Tawil G, Aboujaoude N, Younan R: Influence of prostheticparameters on the survival and complication rates of shortimplants. Int J Oral Maxillofac Implants 21:275, 2006

5. Renouard F, Nisand D: Short implants in severely resorbedmaxilla: A 2-year retrospective clinical study. Clin Implant DentRel Res 7:s104, 2005

6. Nedir R, Bischof M, Briaux JM, et al: A 7-year life table analysisfrom a prospective study on ITI implants with special emphasison the use of short implants: Results from a private practice.Clin Oral Implants Res 15:150, 2004

7. Nedir R, Bischof M, Vazquez L, et al: Osteotome sinus floorelevation without grafting material: A 1-year prospective pilotstudy with ITI implants. Clin Oral Implants Res 17:679, 2006

8. Lundgren S, Andersson S, Gualini F, et al: Bone reformationwith sinus membrane elevation: a new surgical technique formaxillary sinus floor augmentation. Clin Implant Dent Relat Res6:165, 2004

9. Winter AA, Pollack AS, Odrich RB: Sinus/alveolar crest tenting(SACT): A new technique for implant placement in atrophicmaxillary ridges without bone grafts or membranes. Int J Peri-odontics Restorative Dent 23:557, 2003

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1. Berengo M, Sivolella S, Majzoub Z, et al: Endoscopic evaluationof the bone-added osteotome sinus floor elevation procedure.Int J Oral Maxillofac Surg 33:189, 2004

2. Trisi P, Rao W: Bone classification: Clinical-histomorphometric

comparison. Clin Oral Implants Res 10:1, 1999

3. Jensen OT, Shulman LB, Block MS, et al: Report of the sinusconsensus conference of 1996. Int J Oral Maxillofac Implants13(suppl):11, 1998

4. Schwartz-Arad D, Herzberg R, Dolev E: The prevalence ofsurgical complications of the sinus graft procedure and theirimpact on implant survival. J Periodontol 75:511, 2004

5. Reiser GM, Rabinovitz Z, Bruno J, et al: Evaluation of maxillarysinus membrane response following elevation with the crestalosteotome technique in human cadavers. Int J Oral MaxillofacImplants 16:833, 2001

6. Toffler M: Osteotome-mediated sinus floor elevation: A clinicalreport. Int J Oral Maxillofac Implants 19:266, 2004

7. Hahn J: Clinical uses of osteotomes. J Oral Implantol 25:23,1999

8. Nkenke E, Radespiel-Troger M, Wiltfang J, et al: Morbidity ofharvesting of retromolar bone grafts: A prospective study. ClinOral Implants Res 13:514, 2002

9. Summers RB: A new concept in maxillary implant surgery: Theosteotome technique. Compend Continuous Educ Dent 15:152, 1994

0. Summers RB: The osteotome technique. Part 3. Less invasivemethods in elevation of the sinus floor. Compend ContinuousEduc Dent 15:698, 1994

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2. Raghoebar GM, Timmenga NM, Reintsema H, et al: Maxillarybone grafting for insertion of endosseous implants: Resultsafter 12-124 months. Clin Oral Implants Res 12:279, 2001

3. Jung JH, Choi BH, Zhu SJ, et al: The effects of exposing dentalimplants to the maxillary sinus cavity on sinus complications.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:602,2006

4. Brägger U, Hafeli U, Huber B, et al: Evaluation of postsurgicalcrestal bone levels adjacent to non-submerged dental implants.Clin Oral Implants Res 9:218, 1998

5. Hatano N, Shimizu Y, Ooya K: A clinical long-term radiographicevaluation of graft height changes after maxillary sinus flooraugmentation with a 2:1 autogenous bone/xenograft mixtureand simultaneous placement of dental implants. Clin Oral Im-plants Res 15:339, 2004

6. Buser D, Mericske-Stern R, Bernard JP, et al: Long-term evalu-ation of non-submerged ITI implants. Part 1: 8-year life tableanalysis of a prospective multi-center study with 2359 im-plants. Clin Oral Implants Res 8:161, 1997

7. Brocard D, Barthet P, Baysse E, et al: A multicenter report on1022 consecutively placed ITI implants: A 7-year longitudinalstudy. Int J Oral Maxillofac Implants 15:691, 2000

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