Clinical Cases

Bilateral maxillary sinus augmentation by using HAP-91 for future implant placement

Dr. William de Simone and Dr. Anderson Muller

46 years old, male patient with leukodermia shows atrophy in the bilateral alveolar ridge by pneumatization of the maxillary sinus after loss of the upper posterior elements.

Procedure

Panoramic radiography was performed where it was found atrophy of the alveolar ridge in maxillary sinus bilaterally (Fig. 1), making it impossible to place implants.

The patient was informed about the surgery he should be submitted to and the material to be used would be autogenous bone or HAP-91. The patient opted for HAP-91 because it does not require surgery for removing autogenous bone and, thus, it was possible to perform the surgery in a single site.

A relaxing incision was performed in the canine region and an incision in the alveolar ridge (Fig. 2), and displacement with removal of the periosteum until the visualization of the side wall of the maxillary sinus (fig. 3). We performed the window for access to the maxillary sinus with spherical diamond low speed drill and cooling with saline (Fig. 4).

After the maxillary sinus access through the window, the wall of the window and the sinus membrane was displaced into the maxillary sinus (fig. 5), thus generating space for placing the HAP-91 associated with platelet rich plasma (PRP). (Fig. 6).

The mixture of HAP-91 plus PRP was carefully compressed to fill the existing spaces in the maxillary sinus (Fig. 7). After filling, a hydroxyapatite membrane was placed (col.HAP-91) (Fig. 8) to seal the access window to the maxillary sinus and the suture was performed (fig. 9).

On the existing prosthesis, a relief was made for use during the waiting period of approximately 8 months. (Fig. 10)

We performed a panoramic radiography after surgery (Fig. 11), where it was found the distribution of the material used inside the maxillary sinus.

Eight months after the first surgery, we performed a new panoramic radiography (Fig. 12) and after the radiographic finding of bone formation, a surgery was performed for the implant placement.

Initially, by using a 3 mm trephine, a block was removed from the maxillary sinus for examination (Fig. 13); it was found that the fragments, on both sides of the bone tissue with bone beams, contained HAP permeating the bone beams and accumulations of amorphous basophilic material suggestive of crystals, which are sometimes incorporated into the osteoid beams.

Five implants were placed in the upper right side (Fig. 14) and four implants in the upper left side (Fig. 15); all with good stability.

After 6 months, a panoramic radiography was performed to check the quality of the bone formed around the implants (Fig. 16). It was found a doubtful image only around one implant in the tuber region in the upper right side.

Conclusion

The surgery for bilateral maxillary sinus grafting with HAP-91 associated with the use of platelet-rich plasma was effective in forming enough bone to support the placement of osseointegrated implants.