Single-tooth replacement with simultaneous sinus augmentation
Generally, missing teeth in the posterior region of the maxilla span several sites. Nevertheless, single-tooth replacement with sinus augmentation does occur, and treatment protocols may in fact be deemed more complex, especially during lateral augmentation procedures where healthy roots are found nearby. Figure 5-18 shows the single-tooth replacement of a premolar with a simultaneous lateral sinus augmentation approach. Figure 5-19 demonstrates a case where bilateral missing premolars with minimal RBH were augmented using rhBMP-2. Sinus augmentations treated with rhBMP-2 are generally indicated only for cases demonstrating minimal RBH (0–2 mm) and alveolar ridge deficiency
Multiple-tooth replacement between posterior teeth
Figure 5-20 demonstrates a case where a fixed partial denture failed due to abutment-tooth failure and was replaced with implants. Following tooth extraction, the sites were grafted with a mineralized allograft (MinerOss). After a 6-month healing period, a sinus grafting procedure was then performed with simultaneous implant placement in the grafted area. Figure 5-21 demonstrates how to perform a ridge split with simultaneous sinus augmentation.While this method is tech- nically more challenging, it may be utilized as a viable treat- ment option for narrow maxillary posterior ridges
Multiple-tooth replacement with distal extension
The distal-extension edentulous posterior maxilla is the site where sinus grafting is most commonly performed and the one most recommended for the entry-level clinician. Figure 5-22 demonstrates a typical posterior sinus grafting case performed using the standard sinus graft complex composed of mineralized allograft (MinerOss) and a nonresorbable xenograft (Bio-Oss) mixed in a 1:1 ratio and L-PRF frag- ments. Because the RBH in this case was adequate and primary stability was reached, simultaneous implant place- ment was performed. Notice the excellent 4-year results, with similar bone volumes found in the sinus at 5 months and 4 years. This is the primary benefit of combining the allograft with a nonresorbable xenograft
Figure 5-23 demonstrates a more recent case performed utilizing the same protocol described in Fig 5-22 but with OD burs (as opposed to conventional burs) in order to optimize primary implant stability. Notice how in this case a crestal approach was first planned, but because of a membrane perforation a lateral approach was used to address the perforation. This case was included to highlight the necessity for clinicians to be adequately trained in lateral sinus augmentation procedures even when only a crestal approach is planned. Figure 5-24 demonstrates a second case utilizing the OD burs for a distal-extension sinus augmen- tation utilizing a crestal approach. In this case, an alloplast putty graft (NovaBone) was utilized with OD burs in order to graft apical to the implant site.
The final case in this series highlights the rare use of rhBMP-2 during sinus augmentation. I use rhBMP-2 primarily in one of only two scenarios during sinus graft- ing: (1) when a sinus is regrafted because of a complication in order to maximize the regenerative capacity in the previ- ously treated case, or (2) in cases where severe bone loss is observed and/or minimal RBH (1 to 3 mm) remains. In Fig5-25, notice the minimal RBH necessitating extensive bone gain. For such rare cases, rhBMP-2 has been utilized in order to favor maximum bone regeneration. Following a 7-month healing period, implant placement is then performed.The graft complex utilized in such cases is composed of miner- alized allograft, xenograft, and L-PRF fragments, with the addition of rhBMP-2/ACS.
Sinus augmentation in an edentulous arch
It is also common to observe completely edentulous patients who require bilateral sinus augmentations following long- term use of dentures. In Fig 5-26, bilateral sinus augmen- tations were performed. Because of the minimal RBH, a lateral approach was indicated. Notice the pathology present on the CBCT imaging. Following lateral window opening,
the pathology was removed, and the sinus membrane repair technique described later in this chapter was performed. Implants were placed at 14 months in this patient (typically a 10-month healing period is required).This case demon- strates the ability to perform sinus augmentation in the presence of pathology with excellent long-term data even when the sinus membrane is substantially perforated or absent, as discussed later in this chapter
Postoperative instructions
Following any sinus augmentation procedure, it is important to transmit the following information to patients as post- operative instructions:
• Do not blow your nose.
• Do not smoke or use smokeless tobacco.
• Do not take in liquids through a straw.
• If you must sneeze, do so with your mouth open to avoid unnecessary pressure on the sinus area.
• Take your medication as directed. You may be aware of small granules in your mouth for the next few days.This is not unusual.
Generally, missing teeth in the posterior region of the maxilla span several sites. Nevertheless, single-tooth replacement with sinus augmentation does occur, and treatment protocols may in fact be deemed more complex, especially during lateral augmentation procedures where healthy roots are found nearby. Figure 5-18 shows the single-tooth replacement of a premolar with a simultaneous lateral sinus augmentation approach. Figure 5-19 demonstrates a case where bilateral missing premolars with minimal RBH were augmented using rhBMP-2. Sinus augmentations treated with rhBMP-2 are generally indicated only for cases demonstrating minimal RBH (0–2 mm) and alveolar ridge deficiency
Multiple-tooth replacement between posterior teeth
Figure 5-20 demonstrates a case where a fixed partial denture failed due to abutment-tooth failure and was replaced with implants. Following tooth extraction, the sites were grafted with a mineralized allograft (MinerOss). After a 6-month healing period, a sinus grafting procedure was then performed with simultaneous implant placement in the grafted area. Figure 5-21 demonstrates how to perform a ridge split with simultaneous sinus augmentation.While this method is tech- nically more challenging, it may be utilized as a viable treat- ment option for narrow maxillary posterior ridges
Multiple-tooth replacement with distal extension
The distal-extension edentulous posterior maxilla is the site where sinus grafting is most commonly performed and the one most recommended for the entry-level clinician. Figure 5-22 demonstrates a typical posterior sinus grafting case performed using the standard sinus graft complex composed of mineralized allograft (MinerOss) and a nonresorbable xenograft (Bio-Oss) mixed in a 1:1 ratio and L-PRF frag- ments. Because the RBH in this case was adequate and primary stability was reached, simultaneous implant place- ment was performed. Notice the excellent 4-year results, with similar bone volumes found in the sinus at 5 months and 4 years. This is the primary benefit of combining the allograft with a nonresorbable xenograft
Figure 5-23 demonstrates a more recent case performed utilizing the same protocol described in Fig 5-22 but with OD burs (as opposed to conventional burs) in order to optimize primary implant stability. Notice how in this case a crestal approach was first planned, but because of a membrane perforation a lateral approach was used to address the perforation. This case was included to highlight the necessity for clinicians to be adequately trained in lateral sinus augmentation procedures even when only a crestal approach is planned. Figure 5-24 demonstrates a second case utilizing the OD burs for a distal-extension sinus augmen- tation utilizing a crestal approach. In this case, an alloplast putty graft (NovaBone) was utilized with OD burs in order to graft apical to the implant site.
The final case in this series highlights the rare use of rhBMP-2 during sinus augmentation. I use rhBMP-2 primarily in one of only two scenarios during sinus graft- ing: (1) when a sinus is regrafted because of a complication in order to maximize the regenerative capacity in the previ- ously treated case, or (2) in cases where severe bone loss is observed and/or minimal RBH (1 to 3 mm) remains. In Fig5-25, notice the minimal RBH necessitating extensive bone gain. For such rare cases, rhBMP-2 has been utilized in order to favor maximum bone regeneration. Following a 7-month healing period, implant placement is then performed.The graft complex utilized in such cases is composed of miner- alized allograft, xenograft, and L-PRF fragments, with the addition of rhBMP-2/ACS.
Sinus augmentation in an edentulous arch
It is also common to observe completely edentulous patients who require bilateral sinus augmentations following long- term use of dentures. In Fig 5-26, bilateral sinus augmen- tations were performed. Because of the minimal RBH, a lateral approach was indicated. Notice the pathology present on the CBCT imaging. Following lateral window opening,
the pathology was removed, and the sinus membrane repair technique described later in this chapter was performed. Implants were placed at 14 months in this patient (typically a 10-month healing period is required).This case demon- strates the ability to perform sinus augmentation in the presence of pathology with excellent long-term data even when the sinus membrane is substantially perforated or absent, as discussed later in this chapter
Postoperative instructions
Following any sinus augmentation procedure, it is important to transmit the following information to patients as post- operative instructions:
• Do not blow your nose.
• Do not smoke or use smokeless tobacco.
• Do not take in liquids through a straw.
• If you must sneeze, do so with your mouth open to avoid unnecessary pressure on the sinus area.
• Take your medication as directed. You may be aware of small granules in your mouth for the next few days.This is not unusual.
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