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Lecturer of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Azhar university1.

 –Girl BranchLecturer of Oral radiology and Diagnosis, Faculty of Oral and Dental Medicine, Azhar university2.

 –Girl Branch

 ABSTRACT.

R

ehabilitation of Posterior maxillary using dental implant is considered a problem. This

is not only for poor bone quality but also due to decrease in adequate bone height

as a result of sinus pneumatization and or alveolar ridge resorption .Reconstructionof posterior maxilla through inlay grafting of maxillary sinus can be done through open or closed

sinus lift .Closed technique is considered less invasive technique that allow upwardly displace sinus

oor lining with simultaneous implantation using osteotome .This study was done to evaluate the

success rate of closed sinus lift with simultaneous implantation at 60 months postoperatively using

both digital radiography and CT scan for grafted and ungrafted sides .Ten patients with bilaterally

missing upper six molar and atrophic alveolar ridge (only 5 to 7 mm height from crest of ridge to

sinus oor )were selected ,bilateral sinus lift in both sides were done for every case with simultaneousimplantation. one side with Frios algipore as alloplastic graft and the other without grafting .After 9

months ,xed crowns were constructed and the cases were followed up for 60 months as a long term

follow up study both clinically and radiographically At the end of follow up period one implant out of

twenty was failed ,the other nineteen implants showed proper ossoeintegration.,the bone density and

height below elevated sinus lining increased in both grafted and ungrafted sides The increase in the

Cairo Dental Journal (25)

Number (1), 43:52Janurary, 2009

LONG TERM FOLLOW UP FOR CLOSED TECHNIQUE

OF SINUS LIFT WITH SIMULTANEOUS IMPLANTATION

WITH AND WITHOUT GRAFTING USING DIRECT

DIGITAL RADIOGRAPHY AND CT SCAN

Hanan M.R Shokier1 and Naglaa Shawky2

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 Misch 1999 reported that open sinus graft procedure

has been considered the most predictable method to

grow bone height up to 20 mm compared with any other

intra oral grafting technique with graft success rate and

an implant survival rate greater than 98 %. In spite that

open technique of sinus lift has achieved high successrate but also multiple complications have been reported.

It is an invasive difcult  procedure with multiple

complications, as lining tear with graft lost inside the

sinus, injury to infra orbital neurovascular bundle with

severe hemorrhage, that can not be controlled by electro-

surgery for fear of lining necrosis with graft loss, and

difcult  access in case of multiple septa ,in which theosteotomy must be done between these septa (Bergh

et al 2000).

Other surgical techniques have been developed to

overcome the drawbacks of open sinus lift technique.

Summer 1994 introduced a less invasive alternative

for sinus oor  elevation with concurrent grafting and

immediate implantation. In this technique, he conserved

both the bone removed during implant preparation and

added additional graft material to upwardly displace the

oor of sinus through small localized area with no need

for membrane dissection or long term treatment. Closed

technique of sinus lift is indicated for patients who have

at least 5 to 6mm of bone remaining between the crest

of the ridge and oor of sinus, as the initial stability of

implant is from the pre existing bone under antral oor 

(Summer 1994).

   Rosen et al., 1999 explained that, the tips of

these osteotomes have a concave nose and sharp edge

Rosen et al 1999 Maksoud 2001 and awike 2003

reported that the most important negative factor in

closed technique of sinus lift is that it is less predictable

when there is 4mm or less of pre-existing alveolar bone

height beneath-the sinus. Another complication is the

perforation of membrane, loss of graft material inside thesinus with antrum infection, dislodging the implant or

paralleling pin into the maxillary sinus and development

of mucocele inside the bone graft mass with obliteration

of sinus (Regve et al., 1995)

Different graft materials have been used to augment

the sinus oor to increase the bone available for implant

installation. It is either Autogenous graft, Allogenic

grafts, Xenografts and Allo plastic grafts:

Frios Algipore is a alloplastic materials that is

obtained from calcium encrusted sea algae. It consists of

100% inorganic, biocompatible calcium phosphate – over

95% of the composition is in the form of apatite and is

highly analogus to bone apatite Kasperk. ,et al,1988)

Themain advantage of Frios algipore is that, it is structurally,

chemically and physiologically analogus to natural bone

with continous resorption that allow replacement of

it with bone of the host. ieniek,et al 1989 ),

Also the

high porosity of Frios Algipore result in excellent blood

absorption and coagulation behavior, that activate new

bone formation ( Hotz et al 1990 ),hence this study was

planned to make long term follow up for closed technique

of sinus lift with simultaneous implantation with and

without grafting .

MATERIALS AND METHODS.

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is at least six-millimeters of remaining alveolar height

between the oor  of maxillary sinus and the crest of

alveolar ridge at the site of osteotomy as indicated from

the diagnostic panoramic radiographs.

Each patient received 2 implants – one on each side

of maxillary dental arch at the edentulous site of missing

rst or second maxillary molar.

The osteotomy sites of each selected patient were

divided into two groups.

Group 1

The implant was installed after closed sinus liftingwithout using any grafting material. (Gel-foam was used).

Group 2

The same as in group 1, but (Frios algipore) was used

as a graft material to elevate sinus lining before implant

insertion (without using gel-foam).

Surgical procedures for implant installation

1 Presurgical preparation

Per-apical and panorama was done preoperative for

every case to determine bone length below sinus oor

A. surgical template was constructed to localize the

standard position of implant placement:

B. Implant selection :

SEMADOS Root form internally hexed pure titanium

grade 4 implants with aluminum-oxide blasted surface1

2. Surgical procedures

 First surgical phase   fxture installation)

A pyramidal muco-periosteal ap was performed in

the prepared surgical site area using No.15 surgical blade.

The surgical stent was introduced in the patient’s mouth,

to mark the xture site using round surgical bur. Then

drilling was started using a 1.6 mm diameter pilot drill

and continued to size 2.8 mm

Then the osteotome of 3-mm diameter was used to

complete the enlargement of the osteotomy site. The

osteotomy so produced was completed 2 mm shorter of

the antral oor.

The osteotomy of the other side was prepared by the

same technique. Both osteotomy sites were enlarged until

its diameter were equal to the size of the intended implant,

hence, the osteotomy site was enlarged to size 3-mm for

implant diameter size of 3.7-mm and to diameter of 4-mm

when implant diameter size was 4.5-mm.

In the osteotomy of the rst implant site the osteotomewas advanced into the osteotomy site with light malleting

using gelfoam over the concave tip of the osteotome

(Group I). While in the second osteotomy site, Frios

Algipore graft material was carried on the concave tip

of the osteotome to be inserted into the osteotomy site

before any attempt was made to raise the sinus oor

(Group II) ( Fig. 1) .

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Bone height below sinus lining along mesial part

of xtures

The mean value of bone height was 6.57 mm alongthe mesial part of xture below sinus lining one day after

closed sinus lift and become 8.01 mm at 18 months and

increased to 13 mm at 60 months postoperatively in the

side of closed sinus lift with simultaneous implantation

without grafting (Fig 3)

Group11 (grafted side)

The mean value of bone height was 7.56 mm along

the mesial part of xture below sinus lining one day after

closed sinus lift and become 9.76 mm at 18 months and

increased to 11.5 postoperatively)in the side of closed

sinus lift with simultaneous implantation with grafting.

The change in bone height over time interval along

mesial sides was statistically signicant: p value,

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gradually during follow up period for 60 months

postoperatively in both sides .

The gradual increase in bone density below sinus

lining in both gafted and un-grafted sides may attributed

to the osteogenic activity of the peri-osteal layer of

sinus lining in response to stimuli caused by closed

sinus lift with simultaneous implantation. This is in

accordance with,  Kent 1989, Burger and Veldhuijzen

1993 and Tencate 1998  who explained that intrusion

of grafts, physiologic stimuli, mild strain or even teeth

to the maxillary alveolar ridge below sinus-lining cause

reactive-bone formation below the sinus oor, where the

osteoblasts of the peri-osteal layer of sinus lining exhibita more differentiation state with an increase in alkaline

phosphatase and matrix protein production. In addition,

 Misch 1999 mentioned that surgical placement of dental

implants elicit an ostoegenic response that is largely

driven by local cytokines and growth factors.

While, the signifcant  increase in bone density in the

grafted side might be due to the effect of Frios Algipore

as grafting material below sinus lining. White et al, 1986  

described this grafting material as it is granule form

mimcs the macrostructure of natural bone with continuous

uniform channels and interconnected pores that allow for

optimal permeability that encourages tissue in growth,

vascularization ,and deposition of new bone .He added

that the bone healing around this type of bone graft

characterized by fbrovascular  invasion at frst  followed

by osteoblastic invasion, organization and completed by

lamellar bone apposition on the graft surface .

At 18 months postoperatively the bone density below

decrease in the differentiation of osteoblasts and decrease

in their production of alkaline phosphatase and bone

matrix proteins as a result of strain..

The decrease in bone density below sinus lining in

the grafted side at eighteen months postoperatively

in spite of using grafting material might occur as aresult of graft resorption or degradation . Holmes 1979 

examined the histological feature of the regenerated

bone after grafting with Frios Algipore and said that the

newly formed bone was of immature woven bone up to

two months, by six months it had matured into lamellar

bone and after 12 months bio degradation of 29% of it

occur. While Piecuch et al., 1984 explained the decreasein density of regenerated bone with loading as a result

of low compressive strength of Frios Algipore and the

ability of augmentation material to shatter under peak

load into fragments.

The increase in bone density at 60 months

postoperatively for both grafted and ungrafted sides may

be due to the maturation of newly formed bone belowlining that occurred with functioning ,also the resorption

of alloplastic (frios algipore ) and its replacement with

autogenous bone in the grafted side . (Misch 1999 )

described alloplastic graft as space ller that is completely

resorbed before replacement with autogenous bone.so the

difference in bone density between grafted and ungrafted

was not signicant .

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