Case report on managing incomplete bone formation after bilateral sinus augmentation using a palatal approach and a dilating balloon technique
© The Author(s). 2017
Received: 8 November 2016
Accepted: 13 January 2017
Published: 19 January 2017
Patients with resorbed edentulous alveolar ridges in the posterior maxilla often require lateral window sinus augmentation procedures prior to implant placement. Lateral window sinus augmentation procedures can produce incomplete bone augmentation as consequence of surgical and healing complications producing unusual and complex sinus anatomy. Although incomplete bone formation after sinus augmentation has been described in a previous case reports, this is the first case report that describes grafting these compromised sites prior to implant placement.
A 65-year-old male patient with no known medical conditions presented with severe chronic localized periodontitis and a combined periodontal-endodontic lesion affecting three first molars. Initial ridge preservation and lateral window sinus augmentation resulted in incomplete bone formation and complex sinus floor anatomy on both right and left sides. A dilating balloon technique on one side and a palatal approach on the other side were utilized for additional sinus augmentation using particulate allograft and resorbable collagen membranes. Healing was uneventful, and implants could be placed and restored at all sites. Periodontal maintenance was conducted every 3 months, and the implants have been in function and periodontally healthy for 2 years.
Despite initial failure of sinus augmentation to produce suitable implant sites, it is possible to rescue these sites with re-entry grafting procedures and allow successful implant placement and restoration.
Patients with severe periodontal disease often display severely resorbed ridges in the posterior maxilla. Implant therapy can be a challenge for those patients as available bone height is limited by the maxillary sinus. Although sinus augmentation using subantral or lateral window approaches are routinely used, complications occur that may limit bone augmentation in the sinus after any given procedure. The most common complication during sinus augmentation surgery is tearing of the Schneiderian membrane. This happens in 14–53% of surgeries. History of tobacco use and complex sinus anatomy are the most common risk factors for membrane tears. Membrane tears that develop during the surgery can be managed by placing resorbable membranes over the torn area [1–3]. Although piezoelectric surgery and surgical planning can reduce this complication , tears still remain a possible surgical complication and there may be incomplete bone augmentation .
One reason for this is that even though piezoelectric surgery can gently remove the overlying bone from the fragile Schneiderian membrane, sinus curettes still may be needed to manually lift the membrane from the interior walls of the sinus. As this procedure can tear the membrane, Dr. Muronoi and others developed an alternative procedure for lifting the Schneiderian membrane using a hemostatic nasal dilating balloon in 2003. For this procedure, the surgeons created a lateral window in the posterior maxilla exposing the Schneiderian membrane, slightly elevate the membrane, insert a dilating balloon, and use hydraulic pressure to inflate the balloon, which then gently separates the membrane from the underlying bone and creates space for bone grafting materials . Other clinicians refined this technique by creating successively smaller access windows and reported complications in less than 10% of cases, only minor patient discomfort and satisfactory bone formation [7–10]. Most recently, several clinicians modified the procedure by further reducing the flap size needed for the procedure, moving the access site to the ridge crest, and limit the access window to an implant osteotomy created with osteotomes [11, 12]. Significantly for our case report, this transcrestal approach reduces the chance of postgrafting complications with patients who have sinus pathology and unusual sinus anatomy while minimizing the chance of membrane tears .
Membrane tears are a significant concern as they may result in postoperative complications such as an oroantral communication as reported recently. In this case, the communication was managed by inserting a fibrin sponge, but it resulted in a cyst-like concavity within grafted bone, which was subsequently managed by re-entry and grafting of the affected site prior to implant placement . As seen in this case, incomplete bone formation can be managed with re-entry procedures, but incomplete bone formation often results in unusual sinus floor morphologies that make conventional sinus approaches difficult. A recent case report describes an unconventional palatal approach for managing sinus floor anatomy complicated by previous sinus grafting .
There is still little data on the long-term success of these unconventional re-entry procedures after incomplete bone formation, and here, we present a case with 3-year follow-up after re-entry grafting procedures using either a palatal window or balloon-dilating device for management of previously failed sinus augmentation.
All of the following surgeries were carried out under local anesthesia. The patient received one tablet of 0.25 mg triazolam the evening before the surgery appointment and was taking ibuprofen 600 mg every 6 h and amoxicillin 250 mg every 6 h for 1 week starting the evening before the surgery. Starting the second day after surgery, the patient was instructed to rinse twice daily with 0.5 oz. of chlorhexidine gluconate for 30 s after oral hygiene, and the patient was seen at least once 7 days after each surgical procedure for postoperative care and oral hygiene instruction.
Lateral window sinus augmentation was performed on each side during appointments spaced 3 months apart, following the technique developed by Tatum in 1974. For each site, a midcrestal mucoperiosteal incision with buccal releases was created, and the lateral Schneiderian membrane of the maxillary sinus exposed through an ovoid window osteotomy of about 15 mm diameter. Osteotomy was performed using a piezotome (Piezotome 2, Acteon North America, and Mount Laurel, NJ, USA). Thereafter, the Schneiderian membrane was reflected away from the inferior floor of the sinus cavity with a mushroom-shaped Piezotome insert (Sinus surgery kit, Acteon North America, Mount Laurel, NJ, USA) and Sinus curettes (Sinus surgery curette kit, ACE Surgical Supply, Brockton, MA, USA) until the inferior most 15 mm of the medial wall was felt and seen. During both surgeries, we noticed small tears of 5 mm in the mid-portion of the mobilized Schneiderian membranes and repaired those by placing a double layer of 2 cm × 2 cm × 1.5 mm thick collagen tape (RCT, cut to shape, ACE Surgical Supply, Brockton, MA, USA) over the tears, which stabilized the membrane. We then placed a 1:1:1 mixture of cancellous and cortical allograft (AlloOss, ACE Surgical Supply, Brockton, MA, USA) and bovine xenograft (NuOss, ACE Surgical Supply, Brockton, MA, USA) into the space created between the former floor of the sinus cavity and collagen tape-covered Schneiderian membrane. Buccal access windows were then covered with a resorbable collagen membrane (resorbable collagen, ConFORM, ACE Surgical, Brockton, MA, USA) as suggested by Wallace and Froum , and the surgical site closed with continuous sutures (PTFE 3-0, Cytoplast, Osteogenics, Lubbock, TX, USA). No complications were reported by the patient and only when questioned he reported a short-lived episode of postnasal drip with few embedded “sand grains” after the surgery on the left side. We waited then for 10–12 months prior to further evaluation to allow complete dissolution of allograft  and allow complete bone formation .
We conclude that incomplete bone formation after sinus augmentation can be managed successfully through a variety of re-entry procedures and that successful long-term implant placement and restoration is possible in a compliant patient of good overall health.
I would like to thank the former dental students Dr. Lily Hoang and Dr. Shirley Hsieh and their prosthodontic supervisors Dr. James Ywom, Dr. Steven Sanders, and Dr. Alessandro Urdaneta for providing this patient’s continued restorative and preventive care after the surgeries and the dental assistants of the Western University of Health Sciences Dental Center, Mrs. Cindy Morton and Mrs. Melody Palomar for the surgical assistance. I also would like to thank Dr. Bruno Correa de Azevedo for the radiology reports and the sinus balloon dilator he obtained as a sample from Osseous Technologies of America.
This work was supported by Western University of Health Sciences through no specific grant mechanism.
The manuscript was solely created by Dr. Boehm.
Tobias K. Boehm declares that he has no competing interests.
Consent for publication
Informed consent for publication of photographs and clinical data was obtained from this patient prior to treatment.
Ethics approval and consent to participate
The study was exempted for further view by the Institutional Review Board at Western University of Health Sciences (IRB 16/RFD/017). Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
The author claims to have no financial interest, either directly or indirectly, in the products or information listed in this article.
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