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| 2010-22 |
| 22-1 |
ISSN (Print) 1013-9052
EISSN 1658-3558
P.O. Box 52500,
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Composite grafting material for maxillary sinus augmentation
Khalid A. Al Ruhaimi, BDS, MSc, Dr Med Dent
This case report describes an alternative method for the use of graft
composite in maxillary sinus augmentation procedures. The graft mixture
is composed of calcium sulfate hemihydrate powder (Capsets),
demineralised xerographic bone particles; DXBP (Lattdec®), and
autogenous bone particuiates (ABP). Nine-month post-operative
radiographic follow up showed trabeculation and increase in bone
density of the grafted materia! and osseointegration to the implanted
fixtures.
The
selection of ideal bone substitute to fill osseous defects,
osseous-implant defects and in particular to graft maxillary sinus
after sinus lifting procedure is still controversial.
A
fifty-year-old male patient presented to our clinic with missing left
upper first, second premolar and first molar teeth. The patient had
expressed his desire for permanent replacements for all the missing
teeth. Radiographic evaluation showed insufficient bone height as
well as evidence of sinus pneumatization at the site of left first
molar (Fig. 1). Treatment plan, indicated the need for replacement of
the missing first, second premolar and first molar teeth. The
surgical procedure necessitated sinus lift procedure and sinus
augmentation in the area of the 1st molar. The patient was operated
for simultaneous bone augmentation and implant placement.
The surgical procedure was carried out under local anaesthesia which included infra-orbital nerve block, labial infiltration and palatal block of the greater palatine nerve. The horizontal incision of the flap was extended through the crest of the ridge distally from the upper left 1st premolar to the tuberosity of the same side. One vertical incision was made distal to root of the canine and extended to the buccal sulcus. The mucoperiosteal flap was reflected to expose the lateral maxillary wall of the sinus and the alveolar ridge of the surgical site. The exposed ridge was knife-edge shaped, therefore decision was made to flatten it by removing sharp bone edges with bone rongeurs forceps and smoothened with bone file. The chipped bone particles were collected and mixed with the other graft ingredients. The sinus lift procedure was performed using lateral window approach as described by Boyne and James2 and modified by Garg and Quinones9 for the oval osteotomy of the lateral maxillary wall. The bone window of the sinus was relieved and the maxillary sinus lining was elevated carefully. The bone window of the sinus was lifted up to act as a roof for the grafted area (Fig. 2). The height of the alveolar bone at the site of the missing first molar was approximately 4 mm. Implant size 3.75 mm in diameter and 11 in length was used for this site. Early stabilization of this implant was achieved with the remaining ridge height. Two other implant fixtures were placed in the sites of the missing second and first premolars. They measured 4 mm in diameter x 8 mm in length and 3.75 mm in diameter x 11 mm in length respectively. The bone graft mixture comprised of DXBP; Laddec®, ABP from the operated alveolar ridge and calcium sulfate power (Capset®). The mixture ratio of Laddec® to ABP was 1:1 and the total bone graft volume ratio to Capset® was 4:1 respectively (Figs. 3a & 3b). The composite graft was mixed thoroughly. Few drops of blood were placed in the bone graft composite to ease its manipulation. The bone graft was then packed and condensed to fill the sinus space. Capset® was used again to act as a graft barrier. For this application, calcium sulfate powder was mixed with sterile saline. Dough-like mixture of Capset® was applied to cover the graft for approximately 2 mm in thickness (Figs. 4a & 4b). Following placement of the barrier, the mucoperiosteal flap was returned and interrupted sutures were placed to close the flap. Immediate post-operative radiographs were taken which showed correct position of the inserted implants (Fig. 5). After 9 months of the implant placement and bone grafting, radiographs of the operated site were taken. When these radiographs were compared to the immediate post-operative radiographs, the former showed an increase in bone density in the grafted area and the implants appeared to be osseointegrated and lined with bone (Fig. 6).
The
graft mixture used in the reported case consisted of calcium sulfate
powder (Capset®)
to increase rate of bone mineralization during bone healing and to
act as a barrier to prevent ingrowth of non osteogenic cells into the
graft, with DXBP acting as osteoinductive scaffold bone filler and
ABP as osteoinductive potential to enhance bone cells differentiation
to increase rate of bone ingrowth.
Plaster of Paris is the hemihydrate form of calcium sulfate. It has a history of medical use for over a century.10 Pelteir11,12 an orthopedic surgeon could be credited with the modern surgical use of calcium sulfate for filling osseous defects. In dentistry, various forms of calcium sulfate mixtures have been used with promising results.13,14 Plaster of Paris is used also as a guided tissue regeneration barrier15-17 and as a vehicle for bone morphogenic protein.18 An advantage of mixing calcium powder with the grafting materials is that it acts as a direct source for calcium supply during osteogenesis process and also binds directly to the host bone.19 Sottosanti16 and Anson17 investigated mixing calcium sulfate to freeze-dried bone allografts and found reduced particle loss and accelerated rate of bone regeneration in periodontal defects and in exposed dental implants. Earlier Pelteir and Orn12 added calcium sulfate to autogenous and homogenous bone grafts in dogs and observed accelerated bone healing when compared to healing in the control of allogenic bone grafts without calcium sulfate. However, Pecora et al20 grafted elevated maxillary sinus with calcium sulfate alone and noted that although calcium sulfate material appeared a favorable bone filler, it failed to augment the whole of the elevated sinus space. The grafted sinuses showed bone formation in the base and center of the sinus but did not regenerate bone in the third upper part of the inserted implants. In an unpublished study, the author found that mixing calcium sulfate with different grafting materials increased the rate of osteogenesis compared to control osseous defects filled with the same graft, but without added calcium sulfate. In this unpublished study, the author also found that calcium sulfate could not be used as a bone filler alone without the presence of a scaffold grafting material. The speed of dissolution of the material, empties the osseous cavity in a shorter time than the time required for bone growth to fill in. This results in inadequate new bone ingrowth in the spaces of the resorbed material. The collapse of complete bone healing in osseous defects filled with calcium sulfate alone was due to the absence of a scaffold material that allows the bone remodeling process to take place in a gradual physiologic timing. The active bone remodeling process was centered in the middle of the defect only whereas border of the defects was empty from active bone regeneration. Shaffer and App21 have documented clinical observation which was in agreement with our conclusion. They implanted calcium sulfate material into human periodontal defects and found that defects filled with calcium sulfate alone did not induce more bone formation than the control. Pelteir12 and Frame19 have reported that although calcium sulfate enhances bone formation, it appears that the resorption rate is faster than the rate of bone growth. In conclusion, calcium sulfate cannot be used alone as a bone filling material. The composite graft of autogenous bone particles, demineralized xenography bone particles and calcium sulfate appeared to be an alternative viable grafting material for sinus grafting procedures.
1. Tatum
H. Maxillary and sinus implant reconstruction. Dent Clin North Am
1986;30:207-299.
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