Palatal window osteotomy technique improves maxillary sinus augmentation in previously insufficient augmentation case
© Ueno et al. 2015
Received: 23 April 2015
Accepted: 12 June 2015
Published: 17 July 2015
Perforation of the Schneiderian membrane is the most common complication in sinus floor augmentation (SFA). When volume of grafting is qualified to prevent enlargement of the membrane perforation, lack of bone volume may occur in optimal site.
SFA was performed in sites #24 to 26 in a 63-year-old male. However, a 10-mm size perforation of the Schneiderian membrane occurred in site #26. Although the sinus cavity was grafted with deproteinized bovine bone mineral (DBBM) after repair of membrane perforation, insufficient bone formation was observed on palatal and distal aspects of site #26 at 5 months after SFA. Although additional SFA was required for implant placement, it seemed to be difficult to elevate the membrane by a conventional lateral approach in the palatal aspect of the sinus floor (site #26). Considering the configuration of new bone formation, it was decided to perform the palatal antrostomy approach. The Schneiderian membrane was elevated without perforation, and the sinus cavity was grafted with DBBM mixed with venous blood. Two 12-mm long, 4.1-mm diameter implants were placed in sites #14 and 16. Four months after implant placement, abutment-connection surgery was successfully performed. The radiographic image indicated improved radiopacity, without obvious bone resorption in site #26.
The palatal window osteotomy technique could be considered as an alternative method for augmentation of maxillary sinus in cases where difficulty is encountered to elevate a membrane by a conventional approach (e.g., in cases in which buccal bone height is long).
Sinus floor augmentation (SFA) is the most common technique to obtain bone height for implant placement in posterior maxilla. The most common method is the classical lateral antrostomy approach; After raising a full-thickness flap on the buccal side of the alveolar ridge, a trap door is created by a round bur . The sinus membrane is dissected, and the trap door is rotated medially to push the Schneiderian membrane apically. Then the graft material is placed on the sinus floor. Although a conventional lateral window technique is known to be very predictable with good long-term success, only few reports have been introduced to evaluate the palatal antrostomy approach [2, 3]. The authors reported slight usability such as postoperative comfort compared to conventional buccal antrostomy approach . This case demonstrates significant bone augmentation using a palatal antrostomy technique in the palatal aspect of the sinus floor which makes it difficult to elevate the Schneiderian membrane by a conventional approach.
The palatal window osteotomy technique is previously described as beneficial because it has a higher postoperative comfort, especially for edentulous patients, because full dentures could be incorporated directly after surgery with an almost perfect fit [3, 5]. As another advantage, this case demonstrated significant bone augmentation in the palatal aspect of the sinus floor which makes it difficult to elevate membrane by conventional approach.
Perforation of the sinus membrane is the most common intra-operative complication in maxillary sinus floor augmentation. According to a systematic review, mean prevalence of membrane perforation was 19.5 % . Membrane perforation was usually closed by fibrin glue, suturing or, covering them with a collagen membrane. Depending on the size and location of the perforation, a sufficient quantity of bone augmentation is not possible in the optimal site. In cases of larger perforations, discontinuation of SFA, and reoperation after healing of the sinus membrane may be a more reliable method. However, the staged recovery approach requires an additional treatment period. In the present case, bone volume required for implant placement was supplemented by the first SFA. Additional SFA with the palatal window osteotomy technique was able to graft in palatal sinus cavity which is the insufficient bone volume area. A particular advantage of the palatal window osteotomy is that it can easily approach the cavity compared to buccal window osteotomy, when buccal bone in maxillary sinus is thick and long. From these findings, it may be suggested that maxillary sinus augmentation with the palatal window osteotomy approach is useful in compensation of the palatal sinus cavity. Caution should be exercised during elevation of the palatal flap and osteotomy preparation in the palatal wall to avoid damage to the greater palatine neurovascular bundle (GPB) which contains greater palatine artery, vein, and nerve. Since GPB exits through the greater palatine foramen and runs anteriorly in the bone groove of the palate, three-dimensional analysis using CBCT or CT would reduce surgical complications . Further studies are needed to confirm the efficiency of the palatal window osteotomy technique.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
TERUDERMIS, Orinpus-Termo Biomaterials, Tokyo, Japan.
Bio-Oss®, Geistlich, Biomaterials, Wolhuser, Switzerland.
Sonic Surgeon 300, Morita Corporation, Tokyo, Japan.
Stoma Tinti Sinus Lift Elevator, Stoma, Germany.
Stoma Memmingen Sinus Lift Elevator, Stoma, Germany.
Straumann® Bone Level Implant, Basel, Switzerland.
Straumann® Tapered Effect Implant, Basel, Switzerland.
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