Is antral membrane balloon elevation truly minimally invasive technique in sinus floor elevation surgery? A systematic review
- Huda Moutaz Asmael1Email author
https://doi.org/10.1186/s40729-018-0123-9
© The Author(s). 2018
Received: 13 July 2017
Accepted: 8 February 2018
Published: 17 April 2018
Abstract
Background
Minimally invasive antral membrane balloon elevation was introduced as a less traumatic technique in sinus floor elevation surgery. This is the first systematic review to assess the results of previous studies utilizing this technique.
Aims of the study
The objectives of this study were to assess the bone gain, sinus augmentation success rate, implant survival rate, and complications with minimally invasive antral membrane balloon elevation technique in comparison with the sinus floor elevation by traditional transalveolar technique (Summers’ technique).
Materials and methods
An electronic search including MEDLINE (PubMed) and Cochrane database sites was conducted and supported by manual searching for articles on minimally invasive antral membrane balloon elevation from 1945 to 16 January 2017. Sometimes the researchers were contacted to fill the missing information which was not mentioned in their articles.
Results
The extracted articles which involved utilization of balloon technique in maxillary sinus floor elevation surgery were 27 articles, among which only 10 articles met the inclusion criteria. The average of schneiderian membrane perforation with minimally invasive antral membrane balloon elevation (MIAMBE) technique was 6.76%. The sinus augmentation success rate ranged from 100 to 71.4% with average of 91.6%. Bone gain with this technique could reach for more than 10 mm with an average of 6.96 mm.
Conclusions
Minimally invasive antral membrane balloon elevation combined the beneficial points of both lateral window approach and transalveolar approach in which it produced ≥ 10 mm of gained bone in minimally invasive manner. Anyhow, long follow-up period is needed to accurately identify the long-term success rate of dental implants placed with this technique.
Keywords
Review
Several sinus floor elevation techniques had been introduced as a minimally invasive surgical procedure. Among which, minimally invasive antral membrane balloon elevation technique was developed to achieve better results with minimal trauma to the patient also to reduce complications and intra-operative time. Conventionally, sinus augmentation procedure is performed either via lateral approach (modified Caldwell-Luc approach) [1] or through more conservative transcrestal approach (Summers’ technique) [2].
The antral membrane balloon elevation (AMBE) technique was introduced via lateral approach (direct sinus lift surgery) [3, 4].
After that, the minimally invasive antral membrane balloon elevation (MIAMBE) technique was described via transcrestal approach (indirect sinus lift) which involved utilization of balloon device through conservative 3-mm osteotomy site [5]. Since then, several articles were published utilizing this technique. This is the first systematic review for evaluation of the (MIAMBE) technique in sinus lift surgery.
Question in focus
Is the MIAMBE effective in the terms of sinus augmentation success rate, survival rate of dental implants, bone gain, and complication rate compared with the conventional sinus floor elevation by transalveolar technique (Summers’ technique)?
Materials and methods
Search strategies
This study was executed following the PRISMA criteria for the systematic review. An electronic search including MEDLINE (PubMed) and Cochrane database sites was conducted and supported by manual searching for targeted articles through the related journals and web sites from 1945 to 16 January 2017.
Inclusion criteria
- 1.
Prospective, retrospective studies and randomized clinical trials.
- 2.
Articles published in English language only.
- 3.
Human studies.
- 4.
Healthy patients without systemic or local disease that may affect the maxillary sinus health or the sinus lift procedure outcome.
- 5.
Studies which included at least six patients.
- 6.
Sinus floor elevation via the transcrestal approach only (indirect sinus lift).
- 7.
Follow-up period of at least 6 months.
Exclusion criteria
- 1.
Case reports and studies which included less than six patients.
- 2.
Studies published in other language than English.
- 3.
Experimental (animal studies).
- 4.
Sinus floor elevation via lateral approach.
- 5.
Maxillary sinus pathology or presence of sinus septa.
- 6.
Studies with follow up period of less than 6 months.
The process of extracting articles
The following keywords were involved in the electronic search:
MAILLARY SINUS AUMENATION, SINUS LIFT, INDIRECT SINUS LIFT, ANTRAL MEMEMBRANE ELEVATION, MINIMALLY INVASIVE ANTRAL BALLOON ELEVATION, ATROPHIC MAXILLA, SINUS FLOOR ELEVATION, SINUS MEMBRANE ELEVATION
Flow chart showing the search strategy
Results
The total electronic search results were 5395 articles. The reviewed articles were 400, and the extracted articles which involved utilization of balloon technique in the maxillary sinus floor elevation surgery were 27 articles. Siventen articles were excluded from this study [6–20] and only 10 articles met the inclusion criteria.
Descriptive statistics demonstrate patient characteristics and outcomes of MIAMBE technique in the selected studies
Study | Patients | Age (years) | N of sinus augmentation | Sinus augmentation success rate % | Baseline bone height (mm) | Bone gain (mm) | Antral membrane elevation (mm) | Total bone height (mm) | Inflate balloon volume | Type of graft | Membrane perforation | Test for membrane perforation | Complications | Follow-up period after operation | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N | M:F | R | M | N | PR % | ||||||||||||
Kfir et al. [5] | 12 | NM | 42 ± 9 | NM | 91.6 | 3.7 ± 1.4 | NM | > 10 | 10–17 | ≤ 2.5 mL | -PRF -ABP -Bi-Ostetic synthetic bone graft | 1 | 8.33 | Valsalva maneuver Direct visualization | 1 membrane tear 1 balloon rupture 1 implant failed | 23 months | |
12 | NM | NM | 100 | 3.5 ± 1.3 | NM | > 10 | 10–18 | 0 | 0 | 1 mild periprocedural nosebleed | 12 months | ||||||
Kfir et al. [29] | 36 | M = 18 F: 18 | 42 ± 9 | 36 | 97.2 | 3.4 ± 2.1 | NM | > 10 | 8–18 | NM | -PRF -ABP -Bi-Ostetic Synthetic bone graft -Fisiograft gel | 1 | 2.77 | Valsalva maneuver | 1 membrane tear 2 implant failed | 6–8 months | |
Hu et al. [30] | 28 | M = 143 F = 14 | 40.2 ± 12.35 | 28 | 92.85 | 4.92 ± 1.24 | NM | Mean 10.9 ± 2.06 | NM | 0.67 ± 0.17 mL | -PRF -Bio-Oss | 2 | 7.14 | Valsalva maneuver | 1 mild nosebleed after surgery 2 membrane tear and the cases aborted | 15.9 ± 2.94 months. | |
Kfir et al. [31] | 112 | M = 50 F = 62 | 44.1 ± 12.9 | NM | 97.3% initial procedural success 100% secondary procedural success | 3.8 ± 2.1 | NM | > 10 | 11–18 | NM | -PRF -Synthetic bone graft -ABP -Fisiograft gel | 12 | 10.71 | Valsalva maneuver Direct visualization | 1 infection and oroantral fistula at 4 weeks 3 membrane tear and the procedures aborted 9 micropuncture | 13 months | |
Mazor et al. [32] | 20 | NM | 37–72 | 24 | 100 | 2–6 | NM | 11 | NM | NM | -PRF -Synthetic bone substitute | 0 | 0 | Valsalva maneuver Direct visualization | 1 patient was allergic to the antibiotic | 18 months | |
Petruzzi et al. [33] | 40 | M = 16 F = 24 | 41.5 | NM | NM | 8.00 ± 2.19 | 0.6 | ≤ 20 | 14.66 ± 1.48 | 1– ml | Calcium sulphate solution | 3 | 7.5 | Microscope (KarlKaps) | 1 m acrolaceration 2 m icrolacerations 4 hemifacial edema | 1 year | |
Peñarrocha-Diago et al. [34] | 6 | M = 5 | 27–51 | 6 | 83.3% for the all 6 cases 100% for the five cases | 2.1–4.1 | 7.2–10.8 | 8.7 | NM | 11.3–14.5 | NM | -ABP -BIO-OSS bovine bone grafts | 1 | 16.66 | (Medi Pack Pal) endoscope | 1 membrane tear and case aborted | 1 year after prosthetic loading |
Gonzalez et al. [35] | 14 | M = 7 F = 7 | NM | NM | 71.4 | 5.2 | 8.5 | NM | NM | NM | BIO-OSS bovine bone grafts | 3 | 21.32 | An operating microscope | Failure of four cases due to mucosa perforation (21.32%) and balloon breakage (7.14%). 1 implant showed marginal periimplantitis which treated successfully | 1 year | |
Dhandapani et al. [36] | 9 | NM | 25–60 | 10 | 100 | 5–8 | 3–5.5 | 4.34 | ≥ 10 | 13.5–9 | 1 cc | Irradiated allogeneic cancellous bone and marrow graft | 0 | 0 | NM | No complications | 6 months |
Asmael, and Lateef [37] | 13 | M = 4 F:9 | 28–57 | 17 | 100 | 2.3–7.8 | 4.9 –10.6 | 6.70 | NM | 9.8–17.2 | 0.5–1 cc | Particulate bone grafts (βTricalcium Phosphate) | 0 | 0 | Direct vi ion Hydraulic pressure | 1 mild nasal bleeding 1 infraorbital ecchymosis | 1 year |
Total : Average Total : Range | 91.6 100–71.4% | 6.968 3–10.8 mm | 6.76 0–21.32% | ||||||||||||||
Summary of the dental implants characteristics, survival rates, and failure rates with MIAMBE technique
Study | N of patients | Baseline bone height | Total N of implants | Implants survival rate % | N of failed implants | Implant failure rate % | Implant lengths | Implant diameters | Timing of failure | Follow-up period after operation |
|---|---|---|---|---|---|---|---|---|---|---|
12 | 3.7 ± 1.4 mm | Mean ± SD 2.08 ± 0.51 | NM | 1 | NM | 13, 17.1 mm | 3.75, 5 mm | 2 weeks after procedure | 23 months | |
12 | 3.5 ± 1.3 mm Mean = 3.5 | Mean ± SD 1.91 ± 0.51 | 100 | 0 | 0 | 13, 17.1 mm | 3.75, 5 mm | 12 months | ||
36 | 3.4 ± 2.1 mm | 72 | 97.2 | 2 | 2.77 | 13, 17.1 mm | 3.75, 5 mm | 1 and 3 weeks after procedure | 6–8 months | |
28 | 4.92 ± 1.24 mm | 26 | 96.15 | 1 | 3.84 | NM | 3.8, 5.0 mm | 2 weeks after procedure | 15.9 ± 2.94 months. | |
112 | 3.8 ± 2.1 mm | 219 | 95 | 11 FR = 5% | 5 | 13, 17.1 mm | 3.75, 5 mm | At 6 months after procedure | 13 months | |
20 | 2–6 mm | 37 | 100 | 0 | 0 | 13 mm | 5 mm | 18 months | ||
40 | 8.00 ± 2.19 mm | 56 | 100 | 0 | 0 | 11.5, 13, and 15 mm | 4.00, 6.50 mm | 1 year | ||
Peñarrocha-Diago et al. [34] | 6 | 2.1–4.1 mm | 6 | 100 | 0 | 0 | 10, 11.5 mm | 4.2, 5.2 mm | 1 year (after prosthetic loading) | |
Gonzalez et al.[35] | 14 | 5.2 mm | 11 | 90 | 1 | 10 | 13 mm | NM | 1 year | 1 year |
Dhandapani et al. [36] | 9 | 5–8 mm | NM | NM | NM | NM | NM | NM | NM | 6 months |
Asmael and Lateef [37]. | 13 | 2.3–7.8 mm | 23 | 91.30 | 2 | 8.70 | 10, 12 mm | 4.2, 4.3, 4.8, and 5 mm | At 1 and 6 months | 1 year |
Discussion
Sinus floor elevation surgery with balloon is said to be a minimally invasive technique [5], but to date, no systematic review was made to clearly present the study results, authors experience, and surgical outcomes. Results of studies that utilized MIAMBE technique could be discussed under these highlighted points.
Maxillary sinus entry and elevation of sinus membrane
There are two critical points in sinus floor elevation surgery which include entry to the sinus and elevation of schneiderian membrane. Several atraumatic techniques had been developed to make transalveolar approach more predictable among which minimally invasive methods introduced like MIMBE technique [5], novel drills, and reamers to aid in atraumatic entry to the sinus [21]. Also, the Jeder-System which utilize hydraulic pressure had been introduced with predictable results [22]. Anyhow, the outcomes of these techniques need to be compared to reach to a reliable clue about the most effective method in sinus lift surgery.
Sinus augmentation and bone gain
The success of sinus augmentation procedure with MIAMBE technique was ranged from 100 to 71.4% with an average of 91.6% in these studies. Bone gain with MIAMBE technique could reach for more than 10 mm, it ranged from 3 to 10.8 mm with an average of 6.96 mm. It should be mentioned that some articles failed to report the gained bone in details.
The traditional procedure (Summers’ technique) had a limitation of allowing for only a minimal amount of bone gain which is 3–4 mm. While sinus floor elevation surgery via lateral approach produced a huge elevation ≥ 10 mm [23], it is considered as an invasive technique.
Implants survival rates
Implant survival rate associated with MIAMBE technique was ranged from 90 to 100% with an average of 96.62% as shown in Table 2. On the other hand, systematic reviews have evaluated the implant survival rate after osteotome-mediated sinus floor elevation surgery which shows an implant survival rate higher than 90% [24–26]. In most of MIAMBE studies, dental implant failure occurred early during the first 6 months after operation, some authors mentioned the cause for implant failure which was associated with infection, and others did not addressed the cause.
Surgical complications
Intra-operative complications
The most common intra-operative complication associated with sinus lift procedure was sinus membrane tear [27]. The rate of schneiderian membrane perforation with MIAMBE technique was ranged from 0 to 21.32% with an average of 6.76%. This rate was similar to the schneiderian membrane perforation rate (0–21.4%) which was reported in the systematic review of sinus floor elevation success via transalveolar approach by Tan [28].
In some of these studies, membrane perforation was treated successfully with collagen membrane and the procedure continued with successful MIAMBE technique; other studies aborted the procedure. Furthermore, some authors demonstrated the causes of sinus membrane perforation which could be due to the too rapidly inflated balloon, balloon rapture, and fracture of the sinus floor during the osteotome procedures. Anyhow, with minimally invasive methods, the accuracy in the diagnosis of sinus membrane perforation is difficult without the availability of endoscope. Therefore, the perforation rates in these studies should be interpreted carefully, and the tests utilized to detect the perforation should be addressed accurately Table 1. An important point to the surgeons who executed this procedure is to check for membrane integrity after each surgical step by endoscope, Valsalva maneuver, direct vision, and/or by aspiration with normal saline to accurately report the cause of perforation.
Post-operative complications
Complications registered with MIAMBE technique in these studies involved sinus membrane perforation, implant failure, infection, oroantral fistula, balloon rapture, mild self-limiting nose bleeding, and infra-orbital ecchymosis. All studies reported less post-operative pain, bleeding, and discomfort on the patient side. On the surgeon side, it offered short learning curve and less surgical time.
-
One study was not critical in the presentation of its results and did not include the failed aborted cases in the total sinus augmentation success rate.
-
Some studies failed to report the number of sinus augmentation procedures as it differed from the number of the patients enrolled in these studies.
-
Some did not mention the cause of membrane perforation or implant failure.
-
Some studies did not mentioned well-defined implant survival or success criteria according to which they depend in reporting the survival rate of implants.
-
Lack of long follow-up period in most of these studies.
-
Lack of randomized clinical trial (RCT) studies as shown in (Table 1).
Conclusion
MIAMBE technique is proved to be a minimally invasive procedure which is associated with low post-operative complications. The amount of gained bone with MIAMBE technique is predictable and comparable with the amount of bone achieved with the more invasive lateral window technique. Anyhow, long follow-up period is needed to accurately identify the long-term success rate of dental implants placed with this technique.
Abbreviations
- ABP:
-
Autogenous bone particles
- AMBE:
-
Antral membrane balloon elevation
- M:
-
Mean
- M:F:
-
Male:female numbers
- MIAMBE:
-
Minimally invasive antral membrane balloon elevation
- N:
-
Number
- NM:
-
Not mentioned
- PR:
-
Perforation rate
- PRF:
-
Platelets rich fibrin
- PRP:
-
Platelets rich plasma
- R:
-
Range
- RCT:
-
Randomized clinical trial
Declarations
Acknowledgements
I would like to kindly thank the authors of the original articles who responded instantly upon communication with them to complete the missing data or to clarify the unexplained points in their studies.
Funding
This research did not receive any funding from any funding resources.
Authors’ contributions
HMA performed all the aspects of this research which involved writing the research and collecting, interpreting, and analyzing data.
Ethics approval and consent to participate
This is not applicable as this research was a systematic review of the previous studies utilizing the MIMBE technique in the sinus lift surgery.
Consent for publication
Not applicable.
Competing interests
Huda M Asmael declares that she had no competing interests.
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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Authors’ Affiliations
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