JIDAM

ORIGINAL ARTICLE

eISSN 2582 - 0559

Available online

SINUS FLOOR AUGMENTATION BY SINUS-

LIFT BALLOON SYSTEM- A 1 YEAR FOLLOW-

UP STUDY

Dr. A. Archana Meenakshi

Department of Periodontology and Implantology,

Ragas Dental College and Hospital, Chennai, Tamilnadu, India.

To access & cite this article

ABSTRACT

Website: jidam.idamadras.com

A maxillary sinus floor augmentation procedure

(also known as sinus lift / sinus procedure) is

a surgical technique to augment bone mass in

the maxilla which increases the likelihood of

successful placement of dental implants. The

revolutionary concept of osseointegration is

considered highly predictable. Today the implant

supported oral restorations are among the most

updated treatment options for treating edentulous

or partially edentulous jaws opting for a fixed

prosthesis. This study aimed to assess the safety

and efficacy of a minimally invasive technique

for maxillary sinus elevation using the sinus lift

Address for correspondence:

balloon system (Zimmer Dental); followed by

augmentation of the sinus with cancellous bone

Dr. A. Archana Meenakshi, MDS.,

allograft (RMTB) and to evaluate the clinical and

Reader,

radiological outcomes of sinus floor augmentation

Department of Periodontology and

procedure using OPG, over a one-year period.

Implantology,

Ragas Dental College and Hospital, Chennai,

KEYWORDS : Osseointegration, Schneider’s

Tamilnadu, India.

membrane, pneumatization, osteotome, MIAMBE.

Received

: 26.7.2019

Accepted

: 12.9.2019

Published

: 27.12.2019

125

JIDAM/Volume:6/Issue:4/Pages 125 - 130/October - December 2019

Archana: Sinus floor augmentation by sinus-lift balloon system

INTRODUCTION:

with different carrier materials. Irradiated allogenic

cancellous bone and marrow particulate grafts

Oral rehabilitation with implant supported

randomly sized between 2-3mm have also been used

prosthesis is considered the therapeutic procedure of

as bone substitute for autogenous bone graft.

choice for partially or completely edentulous patients.

Implant success and primary stability are greatly

AIM OF THE STUDY:

affected by localized bone density, with implants

placed in areas of poorer bone quality associated with

•

1. To assess the safety and efficacy of a minimally

high failure rates¹. The posterior region of edentulous

invasive technique for maxillary sinus elevation

using the Sinus lift Balloon system

(Zimmer

maxilla frequently presents insufficient bone for

Dental); followed by augmentation of the sinus

rehabilitation by means of endosseous implants. This

with Cancellous Bone Allograft (RMTB).

might be because of alveolar bone resorption and

pneumatization of the maxillary sinus².One method

•

2. To evaluate the clinical and radiological

that makes implant placement possible in such

outcomes of sinus floor augmentation procedure

difficult situations is the augmentation of maxillary

using OPG, over a one-year period.

sinus using various graft materials. This procedure

MATERIALS AND METHODS:

involves the detachment of Schneiderian membrane

from the maxillary sinus floor, creating a space filled

The study included a total of 10 patients

with grafting material, to promote vertical bone

,7males and 3 females, aged between 25 to 60 yrs,

augmentation into the maxillary sinus cavity.

for implant placement in the edentulous posterior

maxilla. Informed written consent to participate

1994, Summers introduced osteotome

in this study was obtained from all patients, after

sinus floor elevation,

explaining the objectives and protocol of the study,

and possible side effects.

INCLUSION CRITERIA:

Patients were selected using the following criteria:

Fig 1- Osteotome sinus floor elevation technique

• With a unilateral or bilateral loss of teeth in the

maxillary premolar or molar area.

which is a minimally invasive technique that allows

for localized maxillary sinus elevation, in alveolar

• Crestal bone height greater than 5mm below the

crest with a residual bone height of 5 - 10 mm³.A

sinus floor as determined by an OPG.

minimally invasive technique for sinus membrane

• Patients with Class B, division-V

(Vertical

elevation

(MIAMBE) which is a modification of

Defect) were included (ABC classification by

osteotome technique using balloon inflator secured

Hom-Lay Wang 2008)⁵. a) The bone crest is 6

into the osteotomy site was introduced by Kfir et al

to 9mm from the sinus floor. b) The bone width

(2006)⁴.In this technique, inflation of the balloon

is 5mm or more. c) The bone crest is more than

elevated the sinus membrane, which was followed

3mm from the adjacent CEJ.

by bone augmentation and implant placement.

MIAMBE resulted in high procedural success,

• Patients with good oral hygiene and without any

satisfactory bone augmentation, implant survival

active periodontal disease were selected.

and less complication rates. Because it is minimally

EXCLUSION CRITERIA:

invasive, this technique may be used as an alternative

to the existing sinus augmentation procedures. A wide

• Systemic conditions such as uncontrolled

variety of graft materials have been used to augment

diabetes mellitus, hypertension or any other

bone volume within the sinus: demineralised freeze

contraindicating systemic complications.

dried bone allograft

(DFDBA), hydroxyapatite

preparations, calcium phosphate preparations and

• Patients with immunosuppression and bleeding

xenografts as well as growth factors embedded

disorders.

126

JIDAM/Volume:6/Issue:4/Pages 125 - 130/October - December 2019

Archana: Sinus floor augmentation by sinus-lift balloon system

• Patients with orofacial cancer, chemotherapy or

MATERIALS USED:

head and neck radiotherapy twelve months prior

to the surgery.

SINUS-LIFT BALLOON SYSTEM

• Any pathological lesion in the sinus.

• Untreated active periodontitis in neighbouring

teeth.

• Patients with long term steroid therapy or

bisphosphonate medication.

• Patients who are not current smokers.

• Pregnant women and nursing mothers.

Fig 3a & 3b - Sinus lift balloon system

• Any previous history of sinus surgery.

•

The Sinus-lift balloon system (Zimmer Dental)

• Patients with any drug abuse including alcohol.

was developed to gently elevate the Schneiderian

membrane with minimal trauma and without the

RADIOGRAPHIC EXAMINATION:

use of sharp instruments.

Preprocedural panoramic radiographs were

•

The apparatus is a pneumatic device consisting of

a 5ml syringe, polyvinyl chloride (PVC) tubing

used to assess the vertical bone height (VBH) below

and a metal shaft with the tip connected to a

the sinus lining.

latex mini balloon with an inflation capacity of

approximately 5cm³.

•

The amount of saline placed in the syringe was

determined by the number of millimeters the

sinus membrane would need to be elevated -

1cc of saline solution corresponds to 6mm (+/-

0.5mm) of membrane elevation.

BONE GRAFTS

Fig 2 - Tracing of OPG

Digital periapical radiographs were taken

before the procedure was initiated. Evaluation of

VBH from the alveolar crest (arbitrary horizontal

line joining the CEJ of the adjacent teeth) to the floor

of the sinus, was done using OPG. The following

three points were marked on the arbitrary horizontal

line joining the CEJ. • Point A- 2mm from the mesial

tooth. • Point B- Midpoint from the line joining point

A & C. • Point C- 2mm from the distal tooth. From

these 3 points mentioned above, vertical arbitrary

Fig 4 - Bone graft

lines were drawn to the floor of the maxillary sinus

and the values were recorded.

Irradiated allogenic cancellous bone and

marrow particulate bone graft

(Rocky Mountain

Tissue Bank, Denver, Co) randomly sized between 2

to 3mm has been used as a bone substitute for sinus

augmentation in this study. It is a trabecular allograft

obtained from the spinal column and treated with 2.5

127

JIDAM/Volume:6/Issue:4/Pages 125 - 130/October - December 2019

Archana: Sinus floor augmentation by sinus-lift balloon system

and 3.8 megarads of radiation.

slowly inflated with gentle inflating pressure with

SURGICAL TECHNIQUE:

Under local anesthesia, alveolar mid-crestal

horizontal incision was

Fig 7a,7b & 7c - Balloon inflation of the surgical

site done

normal saline (1cc of saline solution corresponds

to 6mm of membrane elevation). Digital periapical

radiographs were taken to assess the balloon inflation

Fig 5 - Incision placed

and the extent of sinus floor elevation at the surgical

site during the procedure. Once the desired elevation

placed in the edentulous site and connected with

(usually greater than

10mm) was obtained, the

sulcular incision of adjacent teeth. Mucoperiosteal flap

balloon was deflated. A second test of membrane

was elevated exposing alveolar crest of the bone. No

integrity was done by Valsalva manoeuvre. Irradiated

vertical releasing incision was used and the flap was

allogenic cancellous bone and marrow

(RMTB)

reflected not exceeding the alveolar ridge. Cortical

was filled under the elevated sinus membrane

perforation was done using a round bur, followed

using bone condensers.

Simple interrupted

by pilot drill reaching about 1mm short of the sinus

sutures were placed using 3-0 silk suture material.

floor

(After radiographic verification of the sinus

floor with digital periapical radiographs). Sequential

expansion of the osteotomy site was achieved

Fig 8 - Flap sutured

Fig 6a & 6b - Flap elevated and pilot drilling of the

surgical site done

Post-operative instructions and antibiotic coverage

were given. Patients were examined after a week

using a series of osteotomes (from 3.8mm to 5mm)

and suture removal was done. The grafted sinus was

in graduated diameters, to laterally condense the low

allowed to heal for 6 months.

density maxillary bone. Care was taken to gently

penetrate the sinus floor and slightly elevate the

POST-OPERATIVE RADIOGRAPHIC

Schneiderian membrane to allow 3mm of access for

EVALUATION:

the deflated balloon. Valsalva maneuver is followed.

The sinus lift balloon was anchored and secured

During the 3 months and 6 months follow-up

into the osteotomy site. Then the balloon was

128

JIDAM/Volume:6/Issue:4/Pages 125 - 130/October - December 2019

Archana: Sinus floor augmentation by sinus-lift balloon system

period, radiographic assessment

implants.

The present study was undertaken to assess

the safety and efficacy of a minimally invasive

technique (MIAMBE) for maxillary sinus elevation

using the sinus lift balloon system (Zimmer Dental);

followed by augmentation of the sinus with irradiated

cancellous bone allograft (Rocky Mountain). The

implant placement was planned after a six-month

follow-up period. It is generally preferred to delay

implant placement by several months after the

Fig 9 - post-operative IOPA

grafting phase, to allow adequate graft maturation.

In the present study, the radiographic assessment

of the vertical bone gain in the augmented sites was

was based on panoramic radiographs. Although CT

done using OPG at the three reference points (A, B,

scan is considered to be the most accurate means

C).

for the diagnosis of sinus pathologies and for the

evaluation of sinus membrane thickness, periapical

STATISTICAL ANALYSIS:

and panoramic radiographs were also frequently

used to diagnose radiodensities and mucosal cysts

The paired ‘t’ Test was adopted to evaluate

(Casamassimo PS1980)⁸. OPG can only be used

the significance of differences in the mean bone

for the assessment of bone height because it offers

height (MBH)

only a two-dimensional view, therefore volume

measurement could not be assessed. There was a

RESULTS:

significant increase in the mean bone height (MBH)

post-operatively at the 3 months follow-up period,

• Clinically, no complications were observed

which consistently increased during the 6 months

during or after the surgical procedure.

follow-up period at the 3 reference points (A, B,

• No signs and symptoms of maxillary sinus

C).This study utilized irradiated allogenic cancellous

pathology

bone and marrow graft (RMTB) for augmentation

of the sinus. It has been shown that among all

• There was a significant increase in the mean bone

available allografts, irradiated bone is most similar to

height (MBH) post-operatively at the 3 months

autogenous bone, demonstrating rapid replacement

follow-up period.

& consistent establishment of a reasonable ratio of

• Point A- 2.3mm,

new bone⁶. NS Soltan et al (2005)⁹ reported antral

membrane balloon elevation via a lateral bone

• Point B -3.2mm,

fenestration. The procedure was highly successful

• Point C- 1.8mm

and predictable. Xiulian Hu et al (2009)¹⁰ assessed

the efficacy and safety of MIAMBE followed by

• Which consistently increased during the 6 months

bone grafting and implant placement in 28 patients.

follow-up period (point A- 2.7mm, point B- 3.34

MIAMBE can be used as a predictable alternative to

mm, point C-2mm)

the invasive sinus augmentation procedures which

are currently in use.

DISCUSSION:

CONCLUSION:

First introduced by Dr. Hilt Tatum in 1974,⁶

sinus lining elevation was done using inflatable

Within the limits of this study, the following

catheters between 1975 - 1979. Boyne and James⁷

conclusions have been elucidated:

authored the first publication on the technique in 1980

• MIAMBE is safe and effective for maxillary sinus

- when they published case reports of autogenous

augmentation. The procedure yielded satisfactory

grafts placed into the sinus and allowed to heal for

bone augmentation results.

6 months, which was followed by the placement of

129

JIDAM/Volume:6/Issue:4/Pages 125 - 130/October - December 2019