Research Article

Awareness of direct procedure in implant treatment planning among dental students K. Pavithra, Dhanraj Ganapathy*

ABSTRACT

Background: Implant placement in a deficient posterior maxilla is a highly predictable treatment option due to the high rate of success of sinus augmentation techniques. Pneumatization of the secondary to posterior maxillary loss is an extremely common finding. Significant atrophy of the maxilla prevents placement in this region. Grafting the floor of the maxillary sinus has emerged as the most common surgical modality for correcting this inadequacy. Aim: Awareness of sinus lift procedure in implant treatment planning among dental students. Materials and Methods: A cross-sectional survey was initiated from a randomly chosen population of 120 undergraduate dental students. A simple random sampling technique was used to identify the samples. Inform consent was obtained from the participants and confidentiality of the records was ensured. Of the 120 samples, 84 were females and 36 were males. The distribution according to the year of study was I BDS – 9, II BDS – 21, III BDS – 33, IV BDS – 38, and CRRI – 19. The survey was conducted online using survey planet online survey tool. The survey instrument used was a pre-tested questionnaire comprising of eight questions eliciting responses pertaining to the knowledge and attitude toward direct sinus lift procedure for implant placement was elicited. Results: About 87.2% of students are aware of the sinus lift whereas 12.8% of students are not aware, 95.5% students did not have exposure of direct sinus lift whereas only 0.5% had exposure of direct sinus lift procedure while placing the implant. Conclusion: This study concludes that most of the undergraduate students are not aware of the sinus lift procedure and they want to attend training section on sinus lift procedure in dental implant placement. Bone dimensions are important for planning implant in posterior maxilla due to maxillary sinus, when there is inadequate height in posterior maxilla sinus lift has to be done in implant placement; hence, training and clinical exposure of sinus lift procedure should be conducted among undergraduate.

KEY WORDS: Implant placement, Sinus lifting, Sinus pneumatization

INTRODUCTION and dental caries are the main causes of tooth loss and the incidence of edentulous Paranasal sinuses are important anatomical structures patients varies worldwide between 7% and 69%.[1] in both medicine and dentistry. The maxillary sinus Complete or partial tooth loss is often associated with is the most relevant to dental practitioners due to its nutritional deficiencies, oral pain, and poor proximity to the posterior maxillary teeth. are psychosocial functioning. During the past 40 years, often required to make a diagnosis concerning orofacial osseointegrated dental implants have become one of pain that may be sinogenic in origin. Maxillary sinus the most used biomaterial to replace missing or lost diseases can be observed coincidentally on radiographs teeth and the treatment has been characterized by a from routine dental examinations and considered in highly successful outcome of complete, partial, or [2] the differential diagnosis. Therefore, most dentists single edentulism. Oral rehabilitation with implant- unintentionally take a look at the maxillary sinus of supported prosthesis has shown improved masticatory function and oral specific health-related quality of life their patients. compared to removable dentures.[3]

Access this article online However, placement of implants in the posterior part of the maxilla is frequently compromised or Website: jprsolutions.info ISSN: 0975-7619 impossible due to atrophy of the , poor

Department of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Science, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dhanraj Ganapathy, Department of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Chennai - 600 077, Tamil Nadu, India. E-mail: [email protected]

Received on: 19-07-2019; Revised on: 23-08-2019; Accepted on: 26-09-2019

660 Drug Invention Today | Vol 14 • Issue 4 • 2020 K. Pavithra and Dhanraj Ganapathy bone quality, and maxillary sinus pneumatization. RESULTS Therefore, vertical alveolar ridge augmentation is often necessary before or in conjunction with the installation Figure 1 shows 87.2% of students are aware of the of implants. Various surgical approaches comprising sinus lift, whereas 12.8% of students are not aware. elevation of the have been Figure 2 shows any clinical exposure of direct sinus lift proposed in order to achieve the necessary vertical procedure while implant placement; 95.5% students height of the alveolar process for the installation of did not have exposure of direct sinus lift, whereas only implants with a sufficient length including maxillary 0.5% had exposure of direct sinus lift procedure while sinus floor augmentation with the lateral window placing the implant. technique, osteotome-mediated sinus floor elevation, Figure 3 shows, students those have undergone and sinus membrane elevation without the use of training period for direct sinus lifting are 0.9%, graft material.[4] However, the treatment of choice whereas 99.1% did not undergo any training for direct for the most appropriate surgical intervention for oral sinus lift in implant placement. Figure 4 shows, best rehabilitation of the atrophic posterior maxillary ridge image modality determining bone dimension for with implants is influenced by the vertical height of placing implant is cone-beam computed tomography the residual alveolar bone, local intrasinus anatomy, (CBCT), but only 32% aware of CBCT, whereas 58% and the number of teeth to be replaced. opted for OPG and 10% intraoral periapical. Different types of biomaterials have been used Figure 5 shows Zimmer balloon kit in direct sinus lift. for maxillary sinus floor augmentation, including autograft, allograft, xenograft, alloplast, and growth Zimmer balloon kit uses an inflatable balloon to lift factors, and the selection of the ideal graft material the sinus membrane. About 17.2% was aware of the has been a subject of controversy over the years. Zimmer balloon kit, whereas 81.8% was not aware of Autogenous bone graft is considered the golden Zimmer balloon kit in direct sinus lift. standard in augmentation procedures due to its osteoinductive, osteogenic, and osteoconductive characteristics.[5] However, the use of autogenous bone Are you aware of direct sinus grafts is associated with the risk of donor site morbidity lift? and unpredictable graft resorption.[6] Therefore, various bone substitutes of biologic or synthetic origin are used increasingly to simplify the surgical procedure by diminishing the need for bone harvesting. The treatment outcome after enhancement of the vertical alveolar bone height in the posterior part of the maxilla with the different treatment modalities is well-documented and has been reported in numerous systematic reviews and meta-analysis.[7]

MATERIALS AND METHODS Yes No A cross-sectional survey was initiated from a randomly Figure 1: Awareness of sinus lift procedure chosen population of 120 undergraduate dental students. A simple random sampling technique was used to Do you have any clinical identify the samples. Inform consent was obtained from the participants and confidentiality of the records was exposure in direct sinus li ensured. Of the 120 samples, 84 were females and 36 were males. The distribution according to the year of study procedure while dental implant was I BDS – 9, II BDS – 21, III BDS – 33, IV BDS – 38, placement? and CRRI – 19. The survey was conducted online using survey planet online survey tool. The survey instrument used was a pre-tested questionnaire comprising of eight questions eliciting responses pertaining to the knowledge and attitude toward direct sinus lift procedure for implant placement which was elicited.

The data collected from these 120 dentists then No Yes statistically analyzed to generate appropriate results regarding the questionnaire study. Figure 2: Clinical exposure of sinus lift procedure

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Figure 6 Aqua Lift uses hydrostatic pressure to lift Figure 8 shows possible complications due to direct the sinus, about 20.1% aware of the aqua lift, whereas sinus lift; the most common complication includes 79.9% are not aware of the aqua lift technique. perforation of the Schneiderian membrane; other Figure 7 shows interest toward direct sinus lift among complications include rhinorrhea, acute maxillary undergraduate; almost 82.6% are keen to learn and sinusitis, and mucosal fistula. About 68.4% opted for all practices sinus lift in implant placement. the above, whereas 31.6% opted for one complication.

Have you undergone any training The system uses hydrostac period for direct sinus li pressure to li sinus procedure in dental Implant membrane? placement?

Zimmer balloon Aqua li ed None of the above Figure 6: Awareness about hydrostatic pressure to lift sinus Yes No membrane

Figure 3: Training for direct sinus lift procedure Are you interested to undergo Which imaging modality is best training for direct sinus li used in determining bone height? procedure dental implant placement?

Yes No

CBCT IOPA OPG Figure 7: Interest to undergo training for direct sinus lift procedure Figure 4: Imaging modality for bone height Possible complicaons encountered due to Are you aware of zimmer balloon kit in direct sinus li ? direct sinus li procedure?

Perforaon of Scheidarian membrane Acute maxillary sinusis Rhinorrhea Mucosal fistula Yes No All the above Figure 5: Awareness of zimmer balloon kit in direct sinus Figure 8: Complications encountered due to direct sinus lift lift procedure procedure

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DISCUSSION removable denture than maxillary sinus augmentation .[12] The maxillary sinus grows rapidly during childhood until it reaches the level of the floor of the nose. It may The need for sinus augmentation is decided according reach approximately 10 mm below the nasal floor.[8] to the size of the implant that is planned. In general, The apexes of the maxillary and molars implants are considered as short if it is smaller have a close association with the inferior border of than 8 mm in height; therefore, it is expected that the maxillary sinus. The maxillary sinus extends to there should be >8 mm of subantral bone height to the area at the anterior border and the roof is place the implants without sinus lifting.[13] Various formed by the orbital floor. methods can be used while placing the implant in this region. The important point is to decide whether The maxillary sinus volume increases continuously or not to interfere with the sinus when placing the as a person ages, which is called pneumatization. It implant. Essentially, it is important to have primary generally occurs in an inferior direction, frequently stabilization of the implant into the bone.[14] For fastens with tooth extraction, such as loss of successful , the dental implant should maxillary premolar or molars. It is reported that be attached, or at least stay immobile, in the bone at maxillary sinus pneumatization increases after tooth the initial stages of the healing process. Based on these [9] extractions. Alveolar bone loss in the region creates principles, the implant might be angulated to stay in a unique problem for implant placement following the bone or shortened and thickened to increase the extraction. The pneumatization process can eventually surrounding bony surface. result in extreme thinning of the alveolar bone and leave an inadequate amount of bone in the region The most frequently encountered surgical assigned for dental implants. The vertical bone loss complication is perforation of the sinus membrane. might occur only between the alveolar ridge crest It occurs particularly in the direct technique due to and floor of the sinus, due to the resorption process vigorous elevation, a thin membrane, sharp edges following tooth extraction. It might also occur, while and ridges, and septated or irregular topography of maintaining the level at the alveolar ridge crest with the sinus. If the perforation is missed or not properly ongoing resorption under the sinus floor, due to sealed, extravasation of the particulate graft into the increased osteoclast activity within the periosteum maxillary sinus might predispose the patient to an side of the Schneiderian membrane, or a combination infection or result in poor graft retention in the area. of both occurrences. In addition, low density of the Management of this complication is made according posterior maxillary region might contribute to all to the size of the perforation.[15] Small perforations are these resorption processes, resulting in contour or relocated in an area where the elevated mucosa folds dimensional changes. together. In such instances, there is no need for further management. For larger perforations, attempts should The aim of sinus floor elevation and augmentation be made to isolate and cover the gap with a resorbable is to create sufficient bone to house an implant with membrane to prevent loss of the graft into the sinus. adequate stability. Pneumatization of the sinus results If the perforation is sufficiently large that it cannot be in an insufficient posterior maxillary alveolus. The covered by a resorbable membrane, the procedure is adequate bone height and, thus, the moment when abandoned and a second surgery is considered after sinus floor elevation should be performed remains a 2 months. Sinus perforations also increase the rates controversial issue. Conversely, there are some other of postoperative sinusitis, infection, and graft failure. methods in which the sinus augmentation procedure is completely disregarded, such as using short implants, The other reported complication of the sinus-lifting angulated implants, or distal cantilevers. All of these procedure is significant bleeding from the posterior alternative methods are reported with long-term superior alveolar artery. In some patients, arterial successful outcomes.[10] anastomoses can superficially exist on the lateral sinus wall. The location of the posterior superior alveolar The requirement for maxillary sinus augmentation artery should be considered before every surgery. depends on the number of missing posterior teeth. Precautions must be taken to avoid massive bleeding If all premolars and molars are missing, it is more and the trajectory of this artery should be considered indispensable to perform sinus augmentation after a detailed CBCT examination. compared to a single missing or premolar tooth.[11] The patient can choose to have a dental CONCLUSION bridge restoration to replace a single missing tooth or two missing teeth. Moreover, patients missing all Maxillary sinus lift is a safe, reliable and successful premolars and molars or do not have back teeth to surgical procedure, provided that the fundamental support the bridge restoration might prefer a partial principles of the technique are strictly adhered to. The

Drug Invention Today | Vol 14 • Issue 4 • 2020 663 K. Pavithra and Dhanraj Ganapathy risks involved are small, with possible post-operative 6. Scarano A, Degidi M, Iezzi G, Pecora G, Piattelli M, Orsini G, complications managed by treatment through et al. Maxillary sinus augmentation with different biomaterials: A comparative histologic and histomorphometric study in man. medication and/or surgical interventions. This study Implant Dent 2006;15:197-207. concludes that most of the undergraduate students are 7. Lundgren S, Andersson S, Gualini F, Sennerby L. Bone not aware of the sinus lift procedure and they want reformation with sinus membrane elevation: A new surgical to attend the training section on sinus lift procedure technique for maxillary sinus floor augmentation. Clin Implant Dent Relat Res 2004;6:165-73. in dental implant placement. Bone dimensions are 8. Rodriguez A, Anastassov GE, Lee H, Buchbinder D, Wettan H. important for planning implant in posterior maxilla Maxillary sinus augmentation with deproteinated bovine due to maxillary sinus, when there is inadequate bone and platelet rich plasma with simultaneous insertion of height in posterior maxilla sinus lift has to be done endosseous implants. J Oral Maxillofac Surg 2003;61:157-63. 9. Barone A, Santini S, Sbordone L, Crespi R, Covani U. A clinical in implant placement; hence, training and clinical study of the outcomes and complications associated with maxillary exposure of sinus lift procedure should be conducted sinus augmentation. Int J Oral Maxillofac Implants 2006;21:81. among undergraduate. 10. Solar P, Geyerhofer U, Traxler H, Windisch A, Ulm C, Watzek G. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res 1999;10:34-44. REFERENCES 11. Zijderveld SA, van den Bergh JP, Schulten EA, Christiaan M. Anatomical and surgical findings and complications in 100 1. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation consecutive maxillary sinus floor elevation procedures. J Oral on the survival of endosseous dental implants. A systematic Maxillofac Surg 2008;66:1426-38. review. Ann Periodontol 2003;8:328-43. 12. Anavi Y, Allon DM, Avishai G, Calderon S. Complications of 2. Moy PK, Lundgren S, Holmes RE. Maxillary sinus maxillary sinus augmentations in a selective series of patients. augmentation: Histomorphometric analysis of graft materials Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol for maxillary sinus floor augmentation. J Oral Maxillofac Surg 2008;106:34-8. 1993;51:857-62. 13. Gupta A, Dhanraj M, Sivagami G. Implant surface modification: 3. Schimming R, Schmelzeisen R. Tissue-engineered bone Review of literature. Internet J Dent Sci 2009;7:10. for maxillary sinus augmentation. J Oral Maxillofac Surg 14. Pradeep AR, Rao NS, Agarwal E, Bajaj P, Kumari M, Naik SB. 2004;62:724-9. Comparative evaluation of autologous platelet-rich fibrin and 4. Hürzeler MB, Quiñones CR, Kirsch A, Gloker C, Schüpbach platelet-rich plasma in the treatment of 3-wall intrabony defects P, Strub JR, et al. Maxillary sinus augmentation using different in : A randomized controlled clinical trial. grafting materials and dental implants in monkeys. Clin Oral J Periodontol 2012;83:1499-507. Implants Res 1997;8:476-86. 15. Gayathri MM. Knowledge and awareness among patients about 5. Yildirim M, Spiekermann H, Biesterfeld S, Edelhoff D. dental implants. J Pharm Sci Res 2016;8:351. Maxillary sinus augmentation using xenogenic bone substitute material Bio-Oss in combination with venous blood: A histologic and histomorphometric study in humans. Clin Oral Source of support: Nil; Conflicts of interest: None Declared Implants Res 2000;11:217-29.

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