Sinus Floor Augmentation

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Sinus floor augmentation

Elevation and augmentation of the sinus floor is a widely accepted method of treatment. The application of Bio-Oss® alone or in combination with autogenous bone is very well documented scientifically.

Various factors influence the decision whether autogenous bone should be mixed with Bio-Oss®. The use of Bio-Oss® alone is recommended when there is adequate residual bone height (< 5 mm) and good quality of the surronding bone. With less than 5 mm of residual alveolar bone, adding autogenous bone to Bio-Oss® is recommended.

Clinical Case: Sinus Floor Elevation
Case by Dr. Stephen Wallace

Preoperative view

Outline window with #8 diamond

Window size about 15 x 10 mm for 3-4 implant graft

Free membrane with Hu-Friedy KRA-3 curette

Elevate membrane down lateral wall and across floor with larger elevator

Elevate membrane up medial wall with Hu-Friedy CS6562KB elevator

Augment narrow anterior region first

Restore buccal contour with light pressure, leaving no voids

Application of Bio-Oss® into the region to be augmented

Tension free closure

Bio-Gide® membrane placed over window and Bio-Oss® graft

Human histology demonstrates successful bone formation after using Bio-Oss^®

Histologic documentation is important to assess the biological response to any regenerative therapy. The photomicrographs below document the lack of any immunologic response to Bio-Oss®; rather new bone formation is present on the surface of the Bio-Oss® and forms bridges between the particles. In approximately six months, Bio-Oss® becomes integrated with newly formed lamellar bone; it is subsequently included in the physiologic remodeling process.

Histology - Maxillary Sinus Floor Graft
Case by Dr. Pascal Valentini, Histology by Dr. Robert Schenk; Berne, Switzerland

At 6 months postgrafting, the grafted area (coronal half of the section) consists of a dense scaffold of Bio-Oss® (*) interconnected by new bone. The orignial host bone (apical half of the section) represents a spongiosa of lower density. (Original magnification x 3.2)

At 6 months postgrafting, remodeling activity in the newly formed bone is high. Bio-Oss® (*) particles exposed to bone marrow are often lined by clear seams (arrows) partially covered by osteoclasts (arrowheads). (Original magnification x25.)

At 12 months postgrafting, the interconnecting bone in the grafted area has matured. The ongoing remodeling activity spreads out upon Bio-Oss® (*) surfaces that are exposed to bone marrow. (Original magnification x25.)

Bio-Oss® particle (*) enclosed by bone 12 months postgrafting. Particle surfaces exposed to marrow are lined by clear seams (arrows). Intensely stained lines indicate recalcification (arrowheads). (Original magnification x 50.)

At 12 months postgrafting, new bone formation is seen in a preformed canal in a Bio-Oss® particle (*). The clear seam (arrows) within the canal indicates additional osteoclastic activity and is continuous with a dark seam (arrowheads) formed underneath newly deposited, packed lamellar bone. (Original magnification x50).

Bio-Oss^® and Bio-Gide^®: Long-term implant survival

The slow resorption of Bio-Oss®results in a greater bone density and may have a
positive influence on implant stability in the augmented maxillary sinus.²

Overall survival rates at 6.5 years following maxillary sinus augmentation:¹Bio-Oss^® alone = 96.8%
Bio-Oss^® + DFDBA = 90%
Patients treated with Bio-Oss® alone show comparable survival rates using
1-stage or 2-stage procedures.¹

Comparable results with particulate autogenous bone or Bio-Oss®/Bio-Gide®.²
The resistance of Bio-Oss® to resorption is advantageous in maintaining the initial dimensions of the augmented graft.

In a meta-analysis, implant survival rates in the maxillary sinus increased by covering the lateral window with a membrane.³
*93.6% survival rate with membrane
*88.7% survival without a membrane.

*p < 0.05

The use of a membrane has a positive influence on vital bone formation and implant survival

The efficacy of membrane placement over the lateral window has been reported as both an increase in vital bone formation and as a resultant increase in implant survival. Three controlled trials (Tarnow, Tawil, Froum) show higher implant survival when a membrane is utilized. Two of these trials also show increased bone formation of 60-100% with a membrane. A comparison study (Wallace) of non-absorbable (ePTFE) and absorbable (Bio-Gide®) membranes showed similar histomorphometric and implant survival rates.

Histology - Graft with a Collagen Membrane
Histology by Dr. Stephen Wallace

Eight month lateral window core biopsy of 100% Bio-Oss® graft covered with Bio-Gide® membrane. Membrane resorbed with lateral wall (left) reformed in bone the graft (right) consists of equal parts newly formed bone (30%) and residual Bio-Oss® (30%). Original magnification x 10.

Higher magnification of internal portion of biopsy reveals intimate contact and "bridging" between Bio-Oss® particles (yellow) and newly formed bone (red). Original magnifcation x 20

Histology - Graft with an ePTFE Membrane
Histology by Dr. Stephen Wallace

Eight month lateral window core biopsy of 100% Bio-Oss® graft covered with ePTFE membrane. The graft consists of equal parts newly formed bone (30%) and residual Bio-Oss® (30%). Original magnification x 10.

Higher magnification reveals intimate contact and "bridging" between Bio-Oss® particles (yellow) and newly formed bone (red). Original magnifcation x 20

References: 1-Valentini P, Abensur DJ. Maxillary Sinus Grafting with Anorganic Bovine Bone: A Clinical Report of Long-Term Results. J Oral Maxillofac Surg 2003; 18 (4) 556-560. 2-Hallman M, Sennerby L, Lundgren S. A clinical and histologic evaluation of implant integration in the posterior maxilla after maxillary sinus floor augmentation with bovine hydroxyapatite and autogenous bone. J Oral Maxillofac Surg 2002; 60:277-284. 3-meta-analysis: Wallace S, Froum S; 2003

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