Accepted Manuscript

Anterior sinus grafts for angled implant placement for severe maxillary atrophy as an
alternative to zygomatic implants for full arch fixed restoration: Technique and report
of five cases

Ole T. Jensen, DDS MS Mark W. Adams, DDS MS

PII: S0278-2391(14)00150-5
DOI: 10.1016/j.joms.2014.02.006
Reference: YJOMS 56214

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 3 July 2013

Revised Date: 5 February 2014
Accepted Date: 5 February 2014

Please cite this article as: Jensen OT, Adams MW, Anterior sinus grafts for angled implant placement
for severe maxillary atrophy as an alternative to zygomatic implants for full arch fixed restoration:
Technique and report of five cases, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/
j.joms.2014.02.006.

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 ACCEPTED MANUSCRIPT

Anterior sinus grafts for angled implant placement for

severe maxillary atrophy as an alternative to zygomatic

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implants for full arch fixed restoration: Technique and
report of five cases

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Ole T Jensen DDS MS, Mark W Adams DDS MS
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Abstract
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Five cases are reported, four to demonstrate the anterior sinus graft technique for angled
implant placement, and a comparison zygomatic case, all done for immediate function implant
restoration by despite severe maxillary atrophy. The sinus graft is low volume, less than 5cc of
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BMP-2/ACS/allograft in a 50% mixture, placed against the lateral nasal wall often done in
conjunction with implant placement. The importance of the technique is to simplify treatment
of severe maxillary atrophy for immediate function thus avoiding the need for zygomatic
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implant placement in the vast majority of severely atrophic maxillas.

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Key words: Zygomatic implants, sinus grafts, BMP-2, Maxillary atrophy, M-4, V-4,
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The use of zygomatic implants for the treatment of severe to extreme maxillary
atrophy is complicated by the absence of alveolar bone stock, the presence of
large maxillary sinuses and, not the least of all, inexperience of the oral-

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maxillofacial surgeon practitioner.1-3 Treatment of these types of patients is
relatively rare in most private practice settings, so that unless the practitioner is
highly familiar with zygomatic fixture placement the alternative use of sinus

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grafting may be advisable.4,5 Despite reports of success there are multiple
complications possible with zygomatic implants including oral antral fistula,

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chronic sinusitis, orbital injury and a steep learning curve when compared to sinus
grafting.6-8 Alternatively, sinus grafting with the use of BMP-2/ACS/allograft in a

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50:50 ratio will form high quality bone for osseointegration particularly in the
sinus floor.9-11 But, advocates for the use of BMP-2 have designed sinus grafts and
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augmentations that are inordinately large and not cost effective for common
patient management. 9-11 Presented here is a concept of small volume sinus
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grafting placed anterior in the maxillary sinus next to the lateral nasal wall. The
technique can sometimes be done simultaneous to implant placement.12 If a
delayed approach is used a four month healing period is followed by implant
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placement and immediate function.13

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Technique
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A crestal incision is made around the arch with a posterior releasing incision at
the first molar area continuing into the vestibule. A buccal mucoperiosteal flap
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reflection reveals the nasal fossa and lateral sinus wall. An antrostomy window
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10mm in diameter is created next to the nasal wall taking care not to enter the
nasal fossa in what can be paper thin bone. The sinus membrane is reflected off
the nasal wall and the sinus floor going posterior about 10-15mm without much
vertical membrane reflection. An implant is placed from an entry point on the
palatal side of the residual ridge traversing the anterior sinus cavity to enter into
the nasal wall. Two to four mL of BMP-2/ACS/allograft in a 50/50 ratio is grafted
around the implant and a decision is made to submerge or load the implant. This
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procedure is done bilaterally. In addition, two anterior implants usually gain good
insertion torque by entering into bone found at the nasal crest. If the four
implant scheme has a composite insertion torque of 120 NCM and there is vertical
stability of all four implants, immediate function can be allowed. When a
delayed approach is elected implants can be placed four months later and

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immediately loaded at that time. Finalization proceeds 4 to 6 months after that.

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Case Reports

1. An 64 year old edentulous patient presented with a history of 30+ years

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denture wear for rehabilitation using all on four immediate function (Figure 1).
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Her general health was otherwise unremarkable. The maxilla had severe to
extreme atrophy and was classified Class D according to the all on four site
classification.14 Due to very limited bone stock (Figure 2a,b,c,d) bilateral
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anterior sinus grafts were done through circular lateral windows adjacent to
the nasal fossa with very limited sinus membrane elevation. Three mL of BMP-
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2/ACS/allograft was used bilaterally as graft material in a 50/50 ratio (Figure

3). Posterior transsinus implants were placed simultaneous to grafting while
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anterior implants were directed into residual midline native bone at the nasal
crest forming a V-4 pattern. Anterior posterior spread was 14mm. Insertion
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torque for the posterior implants were 20 Ncm while anterior implants had
insertion torques of 50Ncm. Composite insertion torque was 140Ncm,
deemed adequate for immediate function. The findings after 18 months as
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shown on panorex were stable with maintenance of bone around all the
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implants (Figure 4). Bar cantilever was 4mm on the right side and 7mm on the
left in the final restoration.
2. An 71 year old female presented with profound atrophy classified as a Class C
maxilla (Figure 5). The posterior implants had transsinus placement with BMP-
2/ACS/allograft for grafting. Access for the graft sites was very small through a
round window less than 10mm in diameter(Figure 6). Graft volume was 2-3
mL for each side. Posterior implant insertion torques were both 25Ncm, but
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anterior implant insertion torque were 40Ncm each. The four implant total
insertion torque therefore was 130Ncm, adequate for immediate loading
(Figure 7). The patient had an immediate load provisional placed and went on
to finalization 6 months later without complication.
3. An 59 year old male patient presented with a Class C maxilla with about a

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2mm wide alveolar process from long-term denture wear. There was minimal
bone volume available for implant placement (Figure 8). Implants were placed

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trans-sinus from the palatal side into the lateral nasal wall (Figure 9 a,b) The
anterior sinuses were grafted using 2.5mL of BMP-2/ACS/allograft bilaterally

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(Figure 10). The case was immediately loaded and later proceeded to
finalization without complication.

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4. A 42 year old female maxillary edentulous patient presented with Class C
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atrophy of the maxilla treated with anterior sinus grafts with a volume of 4mL
of BMP-2/ACS/allograft bilaterally in conjunction with implants placement and
immediate loading. Relatively short length vomer-nasal crest implants were
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placed anteriorally, both with 50 Ncm insertion torques. The posterior
implants were relatively unstable with only 10Ncm of insertion torque each,
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but both implants were stable vertically. By five months after surgery
osseointegration had occurred with bone consolidation of the anterior sinus
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grafts (Figure 11a,b,c,d). Anterior sinus grafting with implant placement is

shown in Figure 12.
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5. A 47 year old female presented with a terminal dentition, minimal vertical

bone in the maxilla, anterior sinuses and a desire for fixed implant prosthetics.
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Following dental extractions five implants were placed into poor quality bone
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and immediately loaded in a fixed denture. The implant in the left maxilla
failed by three months. Removal of the implant and exposure of the area
showed a nearly absent alveolar process making anterior sinus grafting for
transsinus stabilization impossible if immediate function was desired. A 35mm
zgyomatic implant was then placed in the left posterior maxilla which was
done with a sinus elevation technique through a vertical slot (Figure 13a). The
peri-implant site was then grafted with BMP-2/ACS/allograft following
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placement of an overlying collagen membrane (Figure 13b). The grafting was

done to create an osseous seal at the alveolar/sinus floor junction as well as to
cover exposed threads. The wound was then closed water-tight around the
abutment. The implant abutment emerged in the palate due to the bone
defect. Insertion torque was well above 50Ncm and the zygomatic implant

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was immediately loaded. Finalization proceeded 5 months later Figure 13c). 8
months later the final restoration showed bone at the sinus floor and around

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the crestal portion of the zygomatic implant (Figure 13d).

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Discussion

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Reported here is a surgically conservative treatment effort contrasted with a case
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example of zygomatic implant placement to help the practitioner solve the
dilemma of severe to extreme atrophy of the maxilla decreasing risk to both
patient and practitioner.14,15 The anterior sinus graft can frequently provide
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enough bone volume for implant stabilization using 30 degree tilted implants.
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Tilted implant schemes previously reported have been designated as M-4, an “M”
shaped placement pattern when viewed on panoramic film with two implants
passing transsinus through the graft to engage the maximum available bone in
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the lateral nasal wall (M point), or V-4, a “V” shaped pattern also with posterior
implants passing transsinus through the graft into the lateral nasal wall but the
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anterior implants directed toward the midline to fix apically into the maximum
available bone within the nasal crest (V-point).16-20
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Once bone volume is present in the anterior sinus the practitioner must still
confront a flat maxilla which on occasion may even have reverse bone
architecture. This is done by inserting the implants through a palatal insertion
point near the second bicuspid zone and then directing the implants anterior if
not a little anterior-laterally. The implant placement angle is then corrected for
by angled abutments. Similarly, the anterior implants are inserted palatal of the
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absent ridge in the lateral incisor-canine zones then directed either to M point or
V point. The implants should be 12mm apart minimally for a 36mm arch span,
but can sometimes be up to 15mm apart when longer implants are used in the
posterior, enough for a 45 mm arch span.

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The use of the anterior sinus graft technique is a highly limited intervention when
compared to zygomatic placement especially if there is a need to place four
zygomatic implants which adds still another level of technical expertise if not

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greater potentional for complication.21,22

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The use of zygomatics for a nearly absent maxilla often necessitates
extramaxillary placement--so called “tuning fork” implants.23,24 Implants placed
in this way can sometimes result in soft tissue complication despite apical

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osseointegration. Depending on the residual maxillary anatomy the anterior sinus
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graft may provide enough bone stock to avoid at least two of the four zygomatic
fixtures.25,26
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The anterior sinus graft approach can also be used in the presence of posterior
zygomatic implants that are already in place as reflection of the anterior sinus
membrane is confined to implant access to the lateral nasal wall. This approach is
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sometimes needed when standard anterior implants have failed, but the posterior
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zygomatic implants persist.

In summary, the low volume anterior sinus graft using BMP-2/ACS/allograft in a

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50:50 mixture allows the practitioner to treat severe to extreme maxillary atrophy
within his or her skill set using either an immediate or delayed placement
protocol. The technique stands in contrast to the zygomatic implant approach in
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terms of technical difficulty. The anterior sinus graft is a technique that the
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practitioner can be confident will form load bearing bone as strategically placed
anterior sinus grafts make even the severely atrophic maxilla highly amenable to
angled implant support particularly for all on four immediate function.
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References:

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technology and technique.J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):161-
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systematic review. Oral Maxillofac Surg. 2013 Jun;17(2):81-93. doi:

10.1007/s10006-012-0331-z. Epub 2012 May 6.
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8. Colletti G, Valassina D, Rabbiosi D, Pedrazzoli M, Felisati G, Rossetti L, Biglioli F,

Autelitano L.Traumatic and iatrogenic retrobulbar hemorrhage: an 8 patient series. J
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9. Marx RE, Armentano L, Olavarria A, Samaniego J. rhBMP-2/ACS versus

autogeneous cancellous marrow grafts in large vertical defects of the maxilla: An
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Casap N. Experience with bone morphogenetic protein-2 and interpositional grafting

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of edentulous maxilla: a comparison of Lefort I downfracture to full ach (horseshoe)
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Legends

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Figure 1 Case 1: A panoramic view of the edentulous maxilla reveals extreme atrophy

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with very little bone stock for osseointegration suggesting the need for zygomatic
implants.

Figure 2a An occlusal view on CT Scan reveals very little bone at the level of the sinus

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floor demonstrating extreme maxillary atrophy.

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Figure 2b A cross-sectional view of the right anterior sinus indicates minimal vertical
bone and a thin pyriform rim at the point of maximum bone mass (M-point).
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Figure 2c A cross sectional view of the left anterior sinus indicates minimal vertical
bone and a thin pyriform rim at M-point.
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Figure 2d A midline periapical radiograph shows the maximum bone available in the
nasal crest (V-point) for apical implant fixation.
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Figure 3 Clinical presentation of anterior sinus antrostomies with transsinus

implantation posterior and “vomer-nasal crest” implants placement anterior.
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Figure 4 Eighteen months later a panoramic view shows well integrated implants
without bone loss and minimal cantilever in order to gain occlusal function.
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Figure 5 Case 2: Severe maxillary atrophy of the maxilla is revealed though buccal and
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lingual flaps. The ridge is approximately 2mm in width.

Figure 6. Left anterior sinus antrostomy with transsinus implant angled into the pyriform
at M point.

Figure 7 Panoramic view showing M-4 pattern for immediate loading.

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Figure 8 Case 3: A 59 year old patient presents with severe maxillary atrophy following
buccal and lingual flap reflection.

Figure 9a A right side anterior sinus antrostomy is made and the sinus membrane is
elevated minimally for placement of an angled implant and low volume BMP-
2/ACS/allograft.

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Figure 9b A left side antrostomy is made and the sinus membrane is elevated minimally
for placement of a transsinus implant and low volume BMP-2/ACS/allograft.

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Figure 10 The volume of BMP-2/ACS/allograft required is minimal when mixed in a
50:50 ratio and minimal sinus reflection is done.

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Figure 11a,b Case 4: Right sinus periapical radiographs on the day of angled implant
placement and peri-implant sinus grafting and then 5 months later showing consolidated

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graft and osseointegration.

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Figure 11c,d Left sinus periapical x-rays on the day of angled implant placement into
the lateral nasal wall in conjunction with peri-implant sinus grafting using BMP-2/ACS
and allograft, then 5 months later after graft consolidation and osseointegration.
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Figure 12: A severely atrophic maxilla may also have sinuses located very
anterior. A transsinus approach is used to place angled implants that engage the
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lateral nasal wall. Because the implants are relatively unstable BMP-
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2/ACS/allograft in a 50% ratio is used as graft material. {The case is described as a

Class C atrophy in the all on four treatment classification.}
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Figure 13a A 47 year old female had five implants placed into immediate function
after full arch dental extractions. The left posterior implant failed three months
later leaving a large defect. A zygomatic implant was placed using a slot approach
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including elevating the sinus membrane and then doing peri-implant grafting with
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BMP-2/ACS/allograft.

Figure 13b A collagen membrane is used over the implant/graft site to help
establish a water tight wound closure.

Figure 13c Finalization of the restoration as viewed on a Panorex.

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Figure 13d Bone formation at the sinus floor sealing off the sinus and oral cavities
with peri-implant bone.

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