wallkamm e
6.6.2006
8:03 Uhr
Seite 1
Background information
Beat Wallkamm:
«In my practice I use the techniques originally described by Boyne and James (1) and by
Tatum (2) for sinus floor augmentation with lateral access.
To standardise it and thus improve the prognosis, I have simplified a few steps. The modifications concern mainly the incision, transmucosal implant healing and complete removal of
the bone wall in the sense of an antrostomy.»
Augmentation material
Instruments
Beat Wallkamm: «Sinus augmentation with Bio-Oss® alone can be carried out with a very good prognosis. This is shown by the literature (3 – 6). In my practice, I prefer to add a small amount of particulate autologous bone in a ratio of 0 – 50 % autologous bone
to 50 – 100 % Bio-Oss®. After opening the operation field I obtain the bone from the adjacent bone walls using a bone scraper, especially through the proposed fenestration.»
Beat Wallkamm: «I use a basic implant tray from Hu-Friedy. The instruments for elevating the membrane are from Zepf and Friadent.
They are available in different curvatures and have rounded ends.»
2. Main emphasis of this case presentation
> Clinical procedure in standard cases when there are complications with the sinus membrane
and septa.
A10 Elevating the sinus membrane with rotating movements
3. Surgical procedure on the basis of different cases
A7 Obtaining autologous bone chips with
the Safescraper®
Case A (A1 - A 18 ): Standard clinical procedure, step by step. 45 year old patient, healthy, nonsmoker.
Cases B, C, D, E: pictures from these cases to illustrate alternative situations.
Sinus membrane perforations
Beat Wallkamm: «Perforations of the sinus membrane are a frequent complication of sinus floor augmentation. According to the literature, they occur in 35 – 40 % of cases (7, 8). I distinguish between small tears, medium-sized tears and large tears. To manage these
tears, I select one of the following treatments depending on the size of the tear:
Fenestration
A1 Initial radiological situation prior to
extraction of tooth 17 because of apical
and marginal periodontitis. Tooth 16 was
lost years previously.
A2 3 months after extraction of tooth 17.
On the radiograph, residual bone thickness
of 5 mm can be seen in position 16 and
6 mm in position 17. A one-stage procedure with lateral approach to the sinus is
therefore indicated. Implant planning with
film on the OPG.
A5 Mesial releasing incision: C-shaped
mesiobuccal incision over the mesial adjacent tooth
Glue the membrane edges with Tissucol or a small piece of collagen membrane (Bio-Gide®). I do not
regard Histoacryl as suitable as the glued site becomes relatively stiff.
Medium-sized tears
(up to about 20 mm)
Glue the edges with a piece of Bio-Gide® (finer compact side towards the sinus membrane). This technique has been described in the literature as the ‹Loma-Linda Technique› (9).
If the membrane is no longer sufficient to close the tear, the operation is halted and the lateral fenestration is closed with Bio-Gide®. Repeat operation after 6 months.
After stabilisation and closure of the tear, the sinus membrane is dissected off on the side away from the tear.»
A3 Initial preoperative clinical situation
Bone septa
A8 Preparation of the lateral fenestration
with the round diamond bur (diameter
3 – 5 mm). Minimum size approx. 8 x 6 mm.
Removal of the entire bone plate.
:
A4 Free end situation: Alveolar ridge incision with V-shaped releasing incision
Small tears:
(up to 5 mm)
Large tears:
(> 20mm)
Beat Wallkamm: «Today I remove the buccal bone plate in practically every case. That way I can keep the access smaller, have more
flexibility if there are septa and the risk of sinus membrane perforation is smaller. A possible disadvantage is the lack of osteogenic
potential in the roof of the filled sinus lumen when the bone plate is folded in. Removal of the plate followed by repositioning at the
lateral fenestration brings no advantage as this bone plate becomes necrotic anyway.»
A6 Raising the mucoperiosteal flap beyond the desired extent of the lateral fenestration. Autologous blood collected in a
sterile disposable syringe.
If there is a bone septum in the region of the planned implantation site, the bony window must be removed completely in every case
(see sinus membrane, case B, page 3). The further procedure is as follows:
Sinus membrane (Schneiderian membrane)
Beat Wallkamm: «As soon as the bone wall has been removed from the sinus membrane, the thickness of this membrane and the difficulties associated with detaching it can be assessed.»
Alternative Septum in the implantation region. (case B)
Alternative Membrane preparation: 2
spaces are prepared mesial and distal to
the septum. (case B)
Alternative Implant insertion: The implant can be inserted mesially, distally or
even in the region of the septum. (case B)
Further clinical procedure
x
Alternative Offset gap situation: Alveolar ridge incision with sulcal releasing
incision mesially and distally (case C)
2
Alternative Mesial releasing incision: Cshaped mesiobuccal incision over the
mesial adjacent tooth or over the next
mesial tooth if more space is needed. The
papilla is divided at its base. (case B)
Alternative Raising the mucoperiosteal
flap. The most apical part of the maxillary
sinus (x) is located in the region of the socalled ‹red zone› . (case B)
Alternative Relatively pale appearance:
Rather thick membrane. (case B)
A9 Membrane of medium thickness appears somewhat darker. (case A)
Alternative Rather thin membrane appears
dark. (case C)
A11 Preparation with protective periosteal
elevator
3
A12 Checking with the indicator
4
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