The osteotome technique is more predictable with simultaneous implant placement when there is less than 5 to 7 mm of pre-existing alveolar bone height beneath sinus. Proper combination of PRF membrane, MFDBA and autogenous bone has been recommended for this situation. The purpose of this article is to describe the proper method and materials which can grow more than 10 mm bone with osteotome technique and grafting materials where the edentulous posterior maxilla radiographically showed less bone between the alveolar crest and sinus floor.

1. 462 Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015
Case Report
Address for
correspondence:
Dr. Anuj Singh Parihar,
Department of
Periodontology and Oral
Implantology, People’s
College of Dental Sciences
and Research Centre,
Bhopal, Madhya Pradesh,
India.
E‑mail: dr.anujparihar@
gmail.com
Submission: 02-06‑2014
Accepted: 15‑02‑2015
Departments of
Periodontology and
Oral Implantology and
1
Conservative Dentistry,
People’s College of
Dental Sciences and
Research Centre,
Bhopal, Madhya
Pradesh, 2
Department
of Periodontology,
ITS College of Dental
Sciences, Greater
Noida, 3
Department
of Periodontology and
Oral Implantology,
SKSS Dental College
and Hospital, Ludhiana,
Punjab, India
Modified osteotome sinus floor
elevation using combination platelet
rich fibrin, bone graft materials, and
immediate implant placement in the
posterior maxilla
Sumit Narang, Anuj Singh Parihar, Anu Narang,1
Sachit Arora,2
Vartika Katoch,
Vineet Bhatia3
Abstract:
The osteotome technique is more predictable with simultaneous implant placement when there is <5-7 mm of
preexisting alveolar bone height beneath sinus. Proper combination of platelet rich fibrin, mineralized freeze‑dried
human bone allograft, and autogenous bone has been recommended for this situation. The purpose of this
article was to describe the proper method and materials which can grow >10 mm bone with osteotome technique
and grafting materials where the edentulous posterior maxilla radio‑graphically showed less bone between the
alveolar crest and sinus floor.
Key words:
Autogenous bone, maxillary bone growth, mineralized freeze‑dried human bone allograft, osteotomes technique,
platelet rich fibrin, sinus lift
INTRODUCTION
Implant placement in posterior maxillary jaw
is more complicated because of lack available
bone compared to mandible jaw bone. Success
of implant in the posterior maxillary bone is
complex because of type III and IV bone.[1‑3]
After the extraction of the tooth residual ridge
resorption occur in buccolingual and occlusoapial
direction. There is a significant decrease in the
height of the bone available in the posterior
section of the upper arcade. Consequently,
we often end up with a residual bone height
of <3-5 mm between the alveolar ridge of
the crest and the sinus floor.[4,5]
It is difficult
to place >11 mm of implant in 2-3 mm bone
without sinus lift in posterior maxillary bone.[6,7]
As such this area requires bone augmentation
beneath sinus to increase vertical height of bone.
There are currently two principle techniques of
penetrating crestal bone and in order to elevate
maxillary sinus depending upon the availability
of bone height.[6,‑7]
The first technique is open
or lateral window technique. Second includes
close window technique. The close window
technique use variety of tools and materials such
as bone grafts, sinus elevators, balloon, sinus
condenser, sinus curettes, and collagen to lift
the sinus. Nevertheless, each technique shows
advantages and disadvantages. Lateral access
window shows a more consolidation outcome
in literature; however, it is very traumatic and
complex technique to perform. The osteotome
sinus floor elevation (OSFE) procedure,
introduced by summers may be less invasive,
less time-consuming, cost-effective, and reduces
postoperative discomfort to the patient. The
procedure consists of elevating the Schneiderian
membrane with osteotomes through a crestal
approach, placing simultaneously platelet-rich
fibrin (PRF), mineralized freeze-dried human
bone allograft (MFDBA), autogenous bone and
the implant at the osteotomy site.[8-11]
These
PRF and bone grafts are thought to provide a
cushion during membrane elevation and reduce
sinus perforation. The use of PRF and bone graft
material during simultaneous sinus lift helps
to promote natural bone regeneration.[12,13]
The
key point of this new method is to maintain
the Schneiderian membrane in the highest
possible position, increasing simultaneous
thin residual bone height >9-10 mm and width
1-2 mm.[13]
Although summers did not define
a minimum presurgical residual bone height
in the original article,[8]
other author have
made recommendations ranging from 7-9 to
6 mm.[14,15]
The aim of this case report was to
evaluate a modified OSFE technique for increased
posterior maxillary bone height and width using
PRF that is rich in growth factor, autogenous bone
that is full of live endosteal osteoblast cells and
MBDBA that has osteoinductive property.[9-12]
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DOI:
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2. Narang, et al.: Maximum bone growth observed in modified osteotome sinus floor elevation technique
Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 463
CASE REPORT
A 67-year-old female patient reported to the Department of
Periodontology and Oral Implantology with the chief complaint
of having missing teeth in right and left side of the posterior
maxilla. There was no significant medical history. On enquiring
about previous dental treatment, it was found out that the tooth
was lost because of caries and periodontal disease. Preoperative
computerized tomography (CT) scans were performed to obtain
an accurate measurement of the bone before surgery. Immediate
and 8 months postoperative CT scans were performed to check
the proper placement and success rate of the implants, bone
formation, and sinus membrane position. Patient had maxillary
posterior bone - 1.49 mm on the right side and 1.47 mm on the
left side between the alveolar crest and maxillary sinus as seen
in Figure 1a.
Presurgical preparation included medical, dental, and
computerized axial tomography (CAT) scan radiographic
evaluations and basic dental therapy to alleviate preexisting
medical-dental problems. Prior to implant surgery, informed
consent for bone graft and sinus lifting of the implant, CAT scan
consent was obtained from the patient. Patient received 625 mg
augmentin (amoxicillin and clavulanate potassium) twice in a
day before surgery. The patient was treated under oral sedation
or intravenous sedations. Patient was treated with 5 mg of
triazolam orally and then draped with sterile surgical barrier.
Before a surgical procedure start, a full mouth prophylaxis
was done on surgery patient. The posterior quadrant of the
maxilla was anesthetized via local anesthesia injection 2%
lidocaine HCL and epinephrine 1:100,000 in a 30‑gauge needle.
A direct, full thickness midcrestal incision with a #15 blade
was made through the mucoperiosteum to the crest of the
ridge. Full thickness reflection of buccal and palatal tissues
exposed the alveolar ridge. To reflect the flap, molt elevator
was used. The implant position was marked on the alveolar
crest with a small trephine drill (Ø 2.0 mm). After locating the
implant position, the preparation was widened with two sizes
internally irrigated trephine (Ø 3.5 mm and Ø 4.25 mm) drill.
Minimal pilot drilling (Ø 2.0 mm) was performed to a depth
approximately 1 mm away from the sinus floor boundary. The
osteotomy site was gently tapped with mallet and osteotome
number three or four. Intra oral radiograph of the osteotomy
site was taken to determine the position of the sinus membrane
as seen in Figure 2a.
At the same time, a 4-5 vials of blood was collected from the
patient’s vein, and blood is spun by a special machine called
a centrifuge and spun for approximately 12 min.The PRF
obtained is mixed with bone graft material. Pieces of PRF are
made with scissor. The drops of clindamycin and cefazolin
are added into the pieces of the PRF clot. These small pieces
of the membrane are placed inside the osteotomy socket as a
cushion during sinus lifting. A mixture of the MFDBA were
taken in the separate container saturated it with saline. After
10 min, the excess fluid was drained, and clindamycin and
cefazolin powder added into it. The bone particles and pieces
of membrane were placed inside the osteotomy site. The
osteotomy site with membrane and bone was gently tapped
with osteotomes and mallet. Autogenous bone grafts from
maxillary tuberosity area or bone removed during the site
preparation from trephine were used to fill out the osteotomy
site. The membrane and bone particles protect sinus membrane
from perforation. Osteotome site was packed with bone and
membrane after gradually adding bone particles and tapping
it with osteotome and mallet. Bleeding from the osteotome
site provides sign regarding the perforation of the sinus
membrane. If bleeding does not occur from the site, it shows
that perforation happened in the sinus membrane. Trial implant
is placed inside the osteotome site to check adequate width of
osteotome site. After checking with trial implant, actual size
implant was placed in the osteotomy site. All the implants
achieved primary stability. Ten to twelve small holes were
made with surgical quarter round bur on the buccal surface
of the posterior maxilla to initiate fast healing at the implant
site. Bone from the maxillary tuberosity is taken and crushed
with a bone crusher forceps. Crushed bone pieces and the rest
of MFDBA particles are placed around the implant mainly
on the buccal surface. Implant is covered with healing collar
or cover screw. Placement of healing collar or cover screw
is dependent upon occlusal clearance. Occlusal clearance
between maxillary ridge bone and mandibular teeth is <5 mm
than cover screws are placed on the implant. PRF is placed in
around healing collar for excellent healing of soft tissues. After
repositioning the soft tissues, primary closure was attained
using 4-0 chromic gut suture. The site was allowed to heal
for 3 months. After 4 months, abutments were placed on the
implants and restorative procedure was initiated.
RESULT
Patient completed the scheduled follow‑up visits up to
the 8 months. No implant failure was recorded during the
follow‑ups. No pathologic conditions in the implants site
were seen on radiographic follow‑ups after 8 months as seen
in Figure 2c. After 8 months, implants were clinically and
radiographically stable. In general, good function of implants
and restorations were achieved. Implants were stable at the
time of abutment connection which was performed after a
healing period of 3-4 months. Patient reported full satisfaction
for function, phonetics, and esthetics.
At the osteotomy site, combination use of PRF and bone grafts,
it served as a cushion below the maxillary sinus floor, reducing
the risk of perforation of the sinus membrane. The elevation of
the sinus membrane was one of the most delicate parts of the
technique, and it was performed using osteotomes, with the
PRF and bone graft itself.
Computerized tomography scan results
The CT scan carried out 8 months postinsertion showed a
dense mineralized bone surrounding the implants. In the case,
it was difficult to delineate the border line between sinus floor
and newly formed tissue. The original bone height below the
sinus floor as measured on the preoperative CT scan was 1.47
and 1.49 mm at two sites and on second CT scan evaluation
after 8 months postsurgery, the bone height achieved was of
15.42 mm and 16.94 respectively [Figures 1-4].
DISCUSSION
Summer’s osteotomes modified techniques may allow
performing a safe and effective osteotome‑related sinus
membrane elevation with simultaneous implant placement in
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3. Narang, et al.: Maximum bone growth observed in modified osteotome sinus floor elevation technique
464 Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015
posterior maxillary area, thereby drastically reducing the total
treatment time, expense and also improve healing time.[8,9]
Sinus membrane perforations using a conventional osteotomy
were reported in studies by Toffler[16]
and Ferrigno et al.,[17]
with
percentage of 4.7% and 2.2% respectively. The proposal for
using a material to weaken the impact of the sinus membrane
from perforations was suggested by Lazara et al.;(1998)
however, the type of material was not specified. Therefore, in
the present clinical case the choice was to use PRF and bone
graft materials, mainly because its biocompatibility, resilience,
and availability. The meta‑analysis conducted by Tong et al. on
bone added OSFE reported on implant survival for 18 months or
more. The survival rate was 90% when autogenous bone alone
was used, and the survival rate was 87%. When freeze‑dried
demineralized bone (FDDB) bone alone was used. The survival
98% when FDDB bone and autogenous bone were both used
together. Based on data, the authors suggested implant survival
rates can increase if the combinations of materials are used in
an appropriate way.[18]
This method has proven to be highly
predictable to gain >10 mm bone height in posterior maxillary
area. No complications have occurred in the patient treated thus
far, and no implant failures have occurred. Compare with other
technique, which requires minimum 6-9 months of healing,
this technique typically need only 3-4 months of healing. One
reason could be smaller hole is made for access in the sinus
cavity. This technique rarely compromises blood supply. Main
advantage of this technique is that implant and osteotomy
site gets blood supply from buccal, lingual, mesial, and distal
surfaces of blood vessels while in lateral window technique
implant and bone grafts gets its blood supply largely from
buccal surfaces of blood vessels. In lateral window approach
risks, the possibility of breaching the blood supply, since arteries
supplying the area are situated very close to mucoperiosteal
region of the potential window site.[14,15]
Second reason could be
PRF, which promotes bone regeneration and soft tissue healing,
improving bonding between bone and implant surface. It also
serves as protection barrier to the sinus membrane, it is much
less expensive than commercial membrane. PRF may allow
gentle elevation of membrane, and represent an excellent source
of growth factors.[12,13]
The platelets and the growth factors
included in the fluid released by membrane may locally enhance
bone regeneration as they come in contact with Schneiderian
membrane. It also has consistent regenerative power as
it combine with osteoprogenitor cells from MFDBA and
autogenous bone.[19‑21]
Third reason could be autogenous bone
graft from maxillary tuberosity area which has an osteogenic
potential related to the number of surviving osteoblasts and
potential osteoinductive effect brought about by the release of
bone morphogenic proteins and other growth factors and it also
accelerates the bone production sequence.[22,23]
Fourth reason
could be MFDBA, which gives the signal from their proteins
to neighboring mesenchymal cells and differentiate them into
bone producing cells.[24‑26]
Several studies have demonstrated that the failure rate is
higher when the bone crest is inferior to 5 mm.[16]
Nevertheless,
according to Li,[27]
the osteotomy technique can be used even
in residual ridges with heights of 3-4 mm, if primary stability
has been achieved. In the present clinical case, the height
of remaining bone was 1-2 mm, implant success rate was
higher. Further investigation is needed to establish the actual
contribution of PRF, bone graft materials at osteotomy site to
Figure 1: Preoperative computerized tomography (CT) scan was taken and
postoperative CT after 8 months of implant placement. (a) Bone height present is 1.49
mm between membrane and ridge preoperatively (b) Bone height presents 15.43 mm
between membrane and ridge after 8 months of implant placement Preoperative and
postoperative computerized tomography
ba
Figure 3: (a) Cross-sectional view of the site of the right molar showing
approximately <2 mm bone height (b) Cross-sectional view of the site of the right
molar after 8 months showing approximately >15 mm bone height
ba
Figure 2: (a) Preoperative radiograph before implant placement (b) Bone grafting
during surgery with an osteotome technique (c) Eight months after implant placement
c
ba
Figure 4: (a) Preoperative computerized tomography scan showing top view of
the sinus membrane (b) Postoperative computerized tomography scan after 8
months of implant placement showing sinus floor elevation without perforation and
bone formation Radiographic assessment of bone levels before and after implant
placement between sinus membrane and ridge
ba
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4. Narang, et al.: Maximum bone growth observed in modified osteotome sinus floor elevation technique
Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 465
the positive outcome obtained with this modified technique,
and to determine whether less residual bone height in maxilla
can be successfully achieved with this modified technique.
CONCLUSION
The use of PRF, MFDBA, and autogenous bone during
OSFE technique and implantation is a secure and reliable
option. This autologous and inexpensive material can be
considered as appropriate materials for adequate natural
bone regeneration and soft tissue healing. However, in this
technique the alveolar bone ridge height and Its width Is of
prime importance and considerations. The use of PRF during
a sinus lift, with a combination of MFDBA and autogenous
bone, may be beneficial, particularly for the posterior
maxillary bone growth. This modified method reduced
total treatment time, expense of the patients and should be
analyzed in further studies.
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How to cite this article: Narang S, Parihar AS, Narang A, Arora S,
Katoch V, Bhatia V. Modified osteotome sinus floor elevation using
combination platelet rich fibrin, bone graft materials, and immediate
implant placement in the posterior maxilla. J Indian Soc Periodontol
2015;19:462-5.
Source of Support: Nil, Conflict of Interest: None declared.
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