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MINIMALLY INVASIVE ANTRAL MEMBRANE BALLOON ELEVATION • MAZOR ET AL Flapless Approach to Maxillary Sinus
Augmentation Using Minimally Invasive
Antral Membrane Balloon Elevation
Ziv Mazor, DMD,* Efraim Kfir, DMD,† Adi Lorean, DMD,‡ Eitan Mijiritsky, DMD,§ and Robert A. Horowitz, DDS储 Posteriormaxillaryimplantplace- In the atrophic posterior max- floor. The surgical procedure was ment is often complicated by the illa, successful implant placement is performed using a flapless ap- lack of quality and volume of often complicated by the lack of proach. At 18 months follow-up, the available bone. Types 3 and 4 bone quality and volume of available implant survival rate was 100%. Ab- tend to predominate in the posterior bone. In these cases, sinus floor aug- sence of patient morbidity and satis- maxilla, generally exhibiting the least mentation is recommended to gain su- factory bone augmentation with this dense bone of the oral anatomy.1 The fficient bone around the implants. minimally invasive procedure sug- height and width of the residual ridgecan significantly be reduced or elimi- Sinus elevation can be performed by gests that minimally invasive antral nated by postextraction resorption pat- either an open lateral window ap- membrane balloon elevation should terns, use of a removable prosthesis, proach or by a closed osteotome ap- be considered as an alternative to physical trauma, periodontal disease, proach depending on available bone some of the currently used methods and pneumatization of the sinus. In the height. This case series demon- of maxillary bone augmentation. atrophic posterior maxilla, longer and strates the feasibility and safety of (Implant Dent 2011;20:434 – 438) wider implants are needed to enhance minimally invasive antral membrane Key Words: antral membrane, pos-
long-term survival. This often requires balloon elevation, followed by bone terior maxillary implants, bone
bone augmentation beneath the sinus augmentation and implant fixation augmentation, dental implants,
to increase the vertical bone height.
in 20 patients with a residual bone Tatum2 was the first to report the height of 2 to 6 mm below the sinus subantral augmentation or "sinus lift"procedure, which has evolved over thepast 25 years. A lateral window (mod- the window is gently pressed inward lary window offers an average implant ified Caldwell-Luc) approach to the and upward into the sinus cavity, survival rate of 91.8% (range, 61.7%– maxillary sinus is used. Because this which lifts the Schneiderian mem- 100%)6 but involves potential compli- has shown favorable results, the pos- brane and serves as a new sinus floor.
cations (membrane tear, bleeding, terior maxilla is often considered one The void between the elevated tissues infection, and sinus obstruction), of the most predictable regions for and the original sinus floor is filled swelling and discomfort, and relative grafting before or simultaneously with with bone graft material. Implants contraindications (sinus convolution implant placement.2–7 Basically, a may be simultaneously placed or the septum or narrow sinus and previous hinged window is created in the lateral graft may be allowed to heal before sinus surgery). Considerable surgical wall of the maxilla.8 When completed, implant placement.9–12 skills, equipment, and time are also The "osteotome technique,"13 also required. A modification of the *Private Practice, Ra'anana, Israel.
called bone-added osteotome sinus BAOSFE method is the minimally in- †Private Practice, Petach Tikva, Israel.
‡Private Practice, Tiberias, Israel.
floor elevation (BAOSFE), is an alter- vasive antral membrane balloon eleva- §Private Practice, Tel Aviv, Israel.
储Assistant Clinical Professor, Departments of Periodontics and native approach for sinus elevation tion (MIAMBE). Antral membrane Implantology, Oral Surgery, New York College of Dentistry, NY.
where a small amount of bone height elevation is performed through the os- Reprint requests and correspondence to: Ziv Mazor,
is missing. It is not suitable for pa- teotomy site (ⱕ3.5 mm) using a spe- DMD, 142 Ahuza Street, Ra'anana 43300, Israel,
tients with markedly reduced initial cially designed balloon. The use of Phone: 972-97400336, Fax: 972-97602839, E-mail:
bone height.14 BAOSFE can be com- this technique as an alternative to con- plicated by membrane perforation and ISSN 1056-6163/11/02006-434Implant Dentistry tear,15 which can be reduced with ex- Volume 20 • Number 6 Copyright 2011 by Lippincott Williams & Wilkins pert technique and specially designed Advantages of using a flapless ap- instrumentation.16 The lateral maxil- proach for dental implant placement
IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 are well known21–27— demonstratingpredictability, preservation of crestalbone and mucosal health surroundingthe implants. A flapless approach com-bined with MIAMBE has never beendescribed. In this study, a MIAMBEballoon-harboring device (MiambeLTD, Netanya, Israel) was used. This isa stainless steel tube, 3 mm in diameter,that connects on its proximal end to thededicated inflation syringe and on its Fig. 3. Underlying bony crest exposed using
distal portion has an embedded single- Fig. 1. Panoramic projection of the residual
ridge underneath the sinus floor.
a 4 mm punch.
use silicone balloon. The balloon is in-flated with diluted contrast fluid thatpushes up the Schneiderian membrane,creating the desired height for implantplacement.
The purpose of this study was to describe a case series using this newtreatment modality with its advantagesthrough a flapless approach with 18months follow-up.
MATERIALS AND METHODS
All patients were from the au- Fig. 2. CBCT axial cuts of the residual ridge
Fig. 4. Osteotomy preparation using the Pi-
thors' private practices, selected after underneath the sinus floor demonstrating ezosurgery device.
meticulous evaluation of their medical 3– 4 mm of alveolar bone height.
histories and dental examinations, in-cluding panoramic radiographs anddental cone beam CT (CBCT) scans.
Local anesthesia (infiltration of The mucosa thickness and pathology, posterior and middle superior alveolar bone height and thickness, sinus struc- nerve and greater palatine nerve) was ture, and major blood vessels were administered using 2% lidocaine (No- assessed. Patients received an oral ex- vocol Pharmaceutical Inc., Cam- planation regarding the procedure and bridge, Ontario, Canada). To obtain signed an informed consent. A prereq- platelet-rich fibrin (PRF), 40 mL of uisite included crestal bone height of 2 blood was drawn by venous puncture to 6 mm between the sinus floor and and processed. Under local anesthesia, the alveolar ridge. In 20 patients, rang- a 4-mm diameter punch was used to ing in age from 37 to 72 years (mean, remove the epithelium with connec- Fig. 5. The metal sleeve of the balloon-
49 years), a total of 24 sinuses were tive tissue and to expose the underlin- harboring device inserted into the mesial os- treated and 37 screw-type endosseous ing bone crest at the precise future teotomy, 1 mm beyond the sinus floor.
implants inserted. All patients were implant location (Fig. 3).
treated under local anesthesia in the An ultrasonic Piezoelectric (Mec- dental office.
tron S.P.A, Genova, Italy) round dia- MIAMBE osteotome. After removing mond tip drill was used in the center of the osteotome, the membrane integrity the exposed alveolar crest up to 1 to 2 was assessed by Valsalva maneuver.
The exact bone height between the mm below the sinus floor. Depth was The metal sleeve of the balloon- alveolar crest and the sinus floor was predetermined according to measure- harboring device (Miambe LTD), assessed using preoperative CBCT ments obtained from the CT scan and specifically designed for sinus aug- scans (Figs. 1 and 2). A preprocedural periapical radiographs. The ultrasonic mentation procedures, was inserted nonsteroidal anti-inflammatory agent, diamond insert was used to deepen the into the osteotomy 1 mm beyond the Augmentin (GlaxoSmith Kline, Brent- osteotomy until the sinus membrane sinus floor (controlled by Teflon stop- ford Middlesex, United Kingdom) (cla- was reached (Fig. 4). Bone graft ma- per) (Figs. 5– 8). The balloon was vulanate potassium), 875 mg, was terial and PRF were inserted into the slowly inflated with the barometric in- administered twice, 24 hours before osteotomy, subsequently enlarging the flator up to 2 atm. Once the balloon osteotomy from 2 to 2.9 mm with the emerged from the metal sleeve under
MINIMALLY INVASIVE ANTRAL MEMBRANE BALLOON ELEVATION • MAZOR ET AL Fig. 9. A mixture of xenograft grafting mate-
Fig. 6. Periapical radiograph demonstrating
rial ⫹ PRF is injected to the osteotomy sites Fig. 12. Periapical radiograph 6 months
balloon inflation in mesial site.
after balloon removal.
10). The healing abutment was con-nected to the inserted implants and aperiapical radiograph verified implantand graft positions (Fig. 11).
Patients were discharged with ibu- profen, 600 mg (single dose) for painrelief and Augmentin, 875 mg twicedaily for 7 days. At 6 months postsur-gery, patients were evaluated radio-graphically (panoramic and periapical) Fig. 7. The metal sleeve of the balloon-
Fig. 10. Self-threading implants, 5 mm in di-
before implant exposure. Clinical crite- harboring device inserted into the distal os- ameter and 13 mm long, inserted into theosteotomy sites.
ria at the time of implant exposure in- teotomy, 1 mm beyond the sinus floor.
cluded stability in all directions, crestalbone resorption, and any reported painor discomfort. Prosthetic rehabilitationwas initiated 3 weeks after implant ex-posure. Patients were monitored andfollowed-up for 18 months (Fig. 12).
All patients received the MIAMBE treatment with immediate implantplacement. Healing was uneventful,with no symptoms of pain or edema, Fig. 8. Periapical radiograph showing balloon
inflation in the distal site.
Fig. 11. Healing abutments screwed into
postsurgery. One patient, who was al- lergic to the antibiotic Augmentin(GlaxoSmith Kline, Brentford Middle- the sinus membrane, the pressure then deflated and removed. Membrane sex, United Kingdom), was prescribed dropped to 0.5 atm. Subsequently, the integrity was assessed by Valsalva ma- Clindamycin (Pfizer Pharmaceuticals, balloon was inflated with a progres- neuver and direct visualization assisted Poce Sur Cisse, France).
sively higher volume of contrast fluid.
by applying a small suction tip.
At 1 week postsurgery, patients The same procedure was applied to the A bone graft injector was filled were recalled and consequently fol- second osteotomy site.
with a mixture of bone substitute lowed up for 6 months. At 6 months, Periapical radiographs were taken (Cerabone-Botiss, Berlin, Germany) ⫹ all implants were successfully inte- to evaluate balloon inflation and mem- PRF and injected through the osteot- grated. Implants were restored with brane elevation. After the desired ele- omy into the sinus under the antral porcelain fused to metal crowns and vation (11 mm) was obtained, the membrane (Fig. 9). Screw-type im- followed-up for 18 months. The cr- balloon remained inflated in the sinus plants (Adin Touareg-Alon Tavor, estal bone height was maintained and for 5 minutes to reduce the sinus mem- Afula, Israel), 13 mm in length and 5 verified by subsequent radiographs.
brane elasticity. The balloon was mm in diameter, were inserted (Fig.
No adverse effects were noted.
IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 Dr. Efraim Kfir claims to be a Board neous implant placement in the severely Member and a consultant for Miambe atrophic maxilla. J Periodontol. 1998;69: This case series supports the prop- LTD. Dr. Adi Lorean claims to have osition that MIAMBE is a minimally 13. Summers RB. Sinus floor elevation had, in the past, "administrative sup- invasive, single-sitting procedure of with osteotomes. J Esthet Dent. 1998;10: port." The other authors claim to have maxillary bone augmentation, and im- no financial interest, either directly or plant placement can be performed 14. Nkenke E, Schlegel A, Schultze- indirectly, in any of the products or where previous conventional lateral Mosgau S, et al. The endoscopically con- companies mentioned in this article.
trolled osteotome sinus floor elevation: A window sinus augmentation had been preliminary prospective study. Int J Oral Maxillofac Implants. 2002;17:557-566.
The "osteotome technique" 15. Berengo M, Sivolella S, Majzoub Z, (BAOSFE) is minimally invasive.
1. Truhlar RS, Orenstein IH, Morris HF, et al. Endoscopic evaluation of the bone- However, if the initial height is ⱕ4 et al. Distribution of bone quality in patients added osteotome sinus floor elevation pro- mm, this method is clearly inferior to receiving endosseous dental implants.
cedure. Int J Oral Maxillofac Surg. 2004; the lateral window approach.28 The J Oral Maxillofac Surg. 1997;55(suppl 5): BAOSFE yields modest antral mem- 16. Toffler M. Staged sinus augmenta- 2. Tatum H Jr. Maxillary and sinus im- tion using a crestal core elevation proce- brane elevation and bone augmenta- plant reconstructions. Dent Clin North Am.
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19. Kfir E, Goldstein M, Rafaelov R, et cal judgment. The flapless approach al. Minimally invasive antral membrane bal- 6. Wallace SS, Froum SJ. Effect of together with the MIAMBE used in loon elevation in the presence of antral maxillary sinus augmentation on the sur- this study has several advantages over septa: A report of 26 procedures. J Oral vival of endosseous dental implants. A sys- the lateral window approach and the tematic review. Ann Periodontol. 2003;8: 20. Kfir E, Goldstein M, Yerushalmi I, et BAOSFE techniques. These include al. Minimally invasive antral membrane bal- reduced patient trauma, improved pa- 7. Peleg M, Garg AK, Mazor Z. Predict- loon elevation—Results of a multicenter tient comfort and recuperation, de- ability of simultaneous implant placement registry. Clin Implant Dent Relat Res. 2009; in the severely atrophic posterior maxilla: A creased surgical time, faster soft tissue 9-year longitudinal experience study of healing, and normal oral hygiene pro- 21. Campelo LD, Camara JR. Flapless 2132 implants placed into 731 human si- cedures immediately postsurgery.23–25 implant surgery: A 10-year clinical retro- nus grafts. Int J Oral Maxillofac Implants.
The use of preoperative CBCT mea- spective analysis. Int J Oral Maxillofac Im- surements and direct visualization of 8. Friberg B, Nilson H, Olsson M, et al.
22. Becker W, Goldstein M, Becker B, the sinus membrane through the spe- MkII: The self-tapping Brånemark implant: et al. Minimally invasive flapless implant cifically designed suction tip, as well 5-year results of a prospective 3-centerstudy. Clin Oral Implant Res. 1997;8:279- surgery: A prospective multicenter study.
as illumination, can overcome the dis- Clin Implant Dent Relat Res. 2005;7: ability to directly visualize the sinus 9. Froum SJ, Tarnow DP, Wallace SS, compartment as seen in the open lat- et al. Sinus floor elevation using anorganic 23. Rousseau P. Flapless and tradi- eral window approach.
bovine bone matrix (OstoGraf/N) with and tional dental implant surgery: An open, without autogenous bone: A clinical, histo- retrospective comparative study. J OralMaxillofac Surg. 2010;68:2299-2306.
logic, radiographic, and histomorphomet- ric analysis—Part 2 of an ongoing study.
24. Noelken R, Kunkel M, Wagner W.
When the advantages of flapless Int J Periodontics Restorative Dent. 1998; Immediate implant placement and provi- surgery are combined with MIAMBE, sionalization after long-axis root fractureand complete loss of the facial bony la- the surgeon is able to perform a pro- 10. Peleg M, Chaushu G, Mazor Z, et al. Radiological findings of the post-sinus mella. Int J Periodontics Restorative Dent.
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