Sinus Augmentation for Implant Placement Utilizing a Novel Synthetic Graft Material with Delayed Immediate Socket Grafting: A 2-Year Case Study

Abstract

Frequently, sinus augmentation is required when replacing failing or missing molars in the maxilla due to loss of alveolar bone related to periodontal disease, pneumatization of the sinus or a combination of the two factors. Various materials have been advocated and utilized; these fall into the categories of allograft, xenograft and synthetic materials. This article shall discuss a study of 10 cases with a 2-year follow-up utilizing a novel synthetic graft material used for sinus augmentation either simultaneously with implant placement or in preparation for sinus augmentation and implant placement in the posterior maxilla. The results of the 10 cases in the study found consistent results over the 2-year study period with maintenance of the alveolar height at the maxillary sinus. A lack of complications or failures in the study group demonstrates the technique has useful applications in increasing ridge height to permit implant placement inferior to the sinus floor.

Keywords: CaSO4; beta tricalcium phosphate; calcium sulfate; crestal sinus augmentation; socket preservation; synthetic graft; β-TCP.

Figure 1

Failing endodontically treated 1st and 2nd molars (left), socket grafting with EthOss at time of extraction (middle) and following 10 weeks of healing demonstrating increased ridge height for implant placement with simultaneous crestal sinus augmentation (right).

Figure 2

Soft tissue healing with keratinized gingiva covering the ridge at the socket grafted sites at 10 weeks healing.

Figure 3

Grafted site following flap elevation and initial osteotomy demonstrating osseous fill of the grafted extraction sites.

Figure 4

Osteotomy preparation short of the sinus floor in preparation for a crestal sinus augmentation (left) and utilization of the osteotomy drill to force EthOss graft material to elevation of the sinus area (right).

Figure 5

Implant placement into the crestally elevated sinus site (left), additional EthOss graft material to fill a crestal concavity (middle) and a radiograph following implant placement and flap closure (right).

Figure 6

Exposure of the integrated implant after 10 weeks of healing (left). Screw-retained restoration placement (middle) and a radiograph to document seating of the restoration at the implant connector demonstrating conversion of the graft material to host bone (right).

Figure 7

Radiograph at 2 years post-restoration placement demonstrating stability and maintenance of the grafted area.

Figure 8

Failing 1st and 2nd molars related to periodontal bone loss (left), the site following 10 weeks of healing to allow soft tissue closure over the ridge (middle) and a radiograph demonstrating the available bone between the crest and sinus for implant placement (right).

Figure 9

Site was reentered at 10 weeks post-extraction and an implant was placed with a crestal sinus augmentation utilizing EthOss graft material at the 1st molar site and a large defect was present at the 2nd molar site (left), with a radiograph obtained to document the implant placement at the 1st molar and grafting of the defect (middle) and following crestal grafting of the 2nd molar site (right). Green line is the measurement of the height of the bone at that point between the crest and the sinus floor.

Figure 10

The keratinized gingiva at 10 weeks post-surgery (left) and following flap of the site demonstrating conversion of the osseous graft at the 2nd molar site that will allow implant placement at that site (right).

Figure 11

Radiograph demonstrating sufficient height of the ridge to allow primary stability of an implant placed at the 2nd molar with a crestal sinus augmentation at 10 weeks of graft healing (left), site preparation for the crestal sinus augmentation (middle) and implant placement into the site (right). Green line is the measurement of the height of the bone at that point between the crest and the sinus floor.

Figure 12

Radiograph following implant placement into the 2nd molar site with simultaneous crestal sinus augmentation.

Figure 13

Radiograph at 10 weeks implant integration at the 2nd molar (left) and two years following restoration of the implant at the 2nd molar showing the improved vertical regeneration between the implants (right).

Figure 14

Soft tissue at placement of the restoration on the 2nd molar (left), at 1 year post-restoration (middle) and at 2 years post-restoration (right) demonstrating maintenance of the keratinized tissue long term.

Figure 15

Radiograph of the initial site in preparation for implant treatment demonstrating minimal bone height available with a defect at the distal aspect of the site (left), of the site following EthOss grafting of the crestal graft (middle) and following 10 weeks of graft healing (right).

Figure 16

Radiograph following crestal sinus augmentation with EthOss and implant placement (left) and at uncovery and healing abutment placement after 10 weeks of implant placement demonstrating conversion of the graft material to host bone (right).

Figure 17

Healing abutment removal demonstrating noninflamed keratinized tissue over the grafted area (left), placement of the screw retained restoration (middle) and a radiograph to verify mating of the restoration to the implant at the connector (right).

Figure 18

Delayed socket grafting with flap exposure of the site (left), placement of EthOss graft to fill the defect (middle) and flap placement to achieve primary closure (right).

Figure 19

Histology of the core sample obtained following 10 weeks of graft site healing demonstrating well preserved reactive (woven) trabecular bone with intertrabecular tissue composed of uniformly collagen-rich myofibroblastic tissue and 60% of the core consisting of bone.