CASE REPORT

Collagen strip technique: A novel approach for ridge preservation

and concomitant oroantral communication management
after implant explantation
Guo-Liang Cheng∗† and Dimitris N. Tatakis∗

Introduction: This case report introduces a technique for managing oroantral communication (OAC) using a collagen
membrane strip to repair the perforated sinus membrane and simultaneously graft the alveolar ridge.
Case Presentation: A 55-year old Asian male presented for a second-opinion consultation regarding an
endosseous dental implant that had been placed overly subcrestal at #13 edentulous site. The 8 mm fixture had been
placed 3 to 4 mm subcrestally with more than half the implant length into the maxillary sinus. The patient stated that
no sinus augmentation procedure had been performed. The implant was considered to be non-restorable and treatment
planned for explantation with ridge preservation. Explantation revealed a sinus perforation with OAC. A collagen membrane
strip (30 × 6 mm) was folded into a U-shape, to hold bone allograft for ridge preservation, and placed with the bottom
of the U-shape level with the sinus floor and the ends extending to the buccal and palatal, beyond the crest. A second
collagen membrane covered the graft at ridge crest level, followed by primary closure. Implant placement (4.1 × 10 mm) with
indirect sinus augmentation was performed in 6 months. The implant was uncovered and subsequently restored following a
5-month osseointegration period. The 13-month follow-up examination revealed successful outcomes, with normal clinical
and radiographic parameters.
Conclusion: This novel technique achieved the dual goals of ridge preservation and repair of a sinus membrane
perforation simultaneously after implant explantation in the posterior maxilla. It further allowed a successful implant
placement with simultaneous sinus augmentation and subsequent restoration. Clin Adv Periodontics 2020;0:1–5.
Key Words: dental implants; guided tissue regeneration; maxillary sinus; oroantral fistula; sinus floor augmentation.

Background
Oroantral communication (OAC) is a complication that
∗ Periodontology, College of Dentistry, the Ohio State University, may result from tooth extraction in the posterior maxilla.
Columbus, OH
Root apex approximation or projection in the maxillary
† Department of Dentistry, Tri-service General Hospital, Taipei, Taiwan sinus is a major risk factor for OAC occurrence.1 Other
OAC etiologies include trauma, infection, pathology and
Received August 10, 2019; accepted October 29, 2019 implant complications.2
Various approaches have been proposed for OAC
doi: 10.1002/cap.10092 management. The most accepted surgical approach for

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FIGURE 1 Initial presentation. 1a facial view, 1b occlusal view. A
soft tissue crater-like appearance was noticed at the #13 edentulous
ridge.
FIGURE 3 Surgical findings after full-thickness flap elevation. 3a
Occlusal view of the over-submerged implant. A 3-mm gap between the
implant and facial socket wall was evident after degranulation. 3b Depth
from implant platform to bone crest was measured using a periodontal
probe.

During the initial examina-

tion, a crater-like soft tissue
appearance was evident at #13
edentulous area (Figure 1). The
initial radiographic assessment
(Figure 2) revealed an 8 mm
endosseous dental implant
placed 3 to 4 mm subcrestally
with more than half the fixture
length into the left maxillary
sinus, without any sign of
bone augmentation (Figure 2b,
2c). The patient was free of
symptoms or signs of sinus
infection.

FIGURE 2 Initial radiographic assessment. 2a periapical radiograph and 2b CBCT panoramic reconstruction
revealed an apically-positioned endosseous dental implant fixture (4 × 8 mm) with approximately half of
the implant length into the sinus space; 2c CBCT coronal view further showed regional sinus membrane
thickening.
large (>4 mm) or non-resolving OAC is via either
an advanced facial or a rotational palatal flap.3,4
Autogenous grafts, for example, bone, buccal fat pad,
or platelet concentrate, are possible adjuncts to flap
alone when bone regeneration is considered.5,6 The
currently available allogeneic, xenogeneic and alloplastic
materials can successfully replace autogenous grafts in
OAC management.7–9 When selecting an appropriate
approach for OAC management, several factors should
be considered: OAC dimensions, presence of infection or
foreign body and future reconstruction plan.2
This case report introduces an OAC management tech-
nique which allows for simultaneous OAC closure, ridge
preservation, and repair of a sinus membrane perforation.
Clinical Presentation
A 55-year old periodontally and systemically healthy
Asian male presented (September 2015) to the Gradu-
ate Periodontics Clinic of the Ohio State University for
a second-opinion consultation for an implant placed at
the #13 location 3 to 4 weeks prior to presentation.
The patient reported that no sinus augmentation had
previously been performed.
Case Management
The implant was deemed
to be non-restorable.10 The
patient agreed to the proposed
treatment plan of explantation, ridge preservation, and
reconstruction followed with an implant-supported
prosthesis, and signed informed consent.
Implant explantation and ridge preservation
After administration of local anesthesia,‡ full thickness
flap elevation, and implant exposure (Figure 3), implant
stability was tested and confirmed using a surgical ele-
vator§ . Therefore, peri-implant bone was minimally and
cautiously removed using piezoelectric device until the
implant was able to be luxated with ease (Figure 4a).
Following implant explantation using forceps (Figure 4b),
an OAC was evident (Figure 4c). To manage the OAC,
which was oval with a long axis diameter of 5 mm, and
concurrently perform the needed ridge preservation and
augmentation, a collagen strip technique (CST) was imple-
mented (Figure 5). A collagen membrane¶ was trimmed
‡ 2% Xylocaine® Dental, Dentsply Sirona, Charlotte, NC.
§ 11M MacMillan elevator, Hu-Friedy Mfg. Co. LLC, Chicago, IL.
 PIEZOSURGERY® touch, Mectron s.p.a., Carasco, Italy.
¶ BioMend® ExtendTM , Zimmer Biomet Dental, Palm Beach Gardens,
FL.

2 Clinical Advances in Periodontics, Vol. 0, No. 0, xxx 2020 Socket Grafting & Oroantral Communication Repair
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FIGURE 4 Implant explantation. 4a Osteotomy was performed

using piezoelectric device to create a gap around the implant. 4b
The implant was removed using forceps. 4c An oroantral com-
munication was noticed after implant removal. 4d The explanted
implant dimensions were ≈4 × 8 mm.
FIGURE 6 Reentry for implant placement. 6a A full thickness
flap was elevated for implant placement 6 months after ridge
preservation. 6b A 4.1 × 10 mm implant was placed with indirect
sinus augmentation. 6c The baseline periapical film revealed the
“dune-shape” augmented bone covering the implant apex. 6d The
periapical film of 5-month follow-up demonstrated stable crestal
bone and augmented bone in the sinus.

Primary closure was achieved using

non-resorbable sutures (Figure 5d).∗∗
Post-operative protocol included
antibiotic (Amoxicillin 500 mg, tid
for 7 days), analgesic (Ibuprofen
400 mg, tid as needed for pain), and
antimicrobial rinse†† (0.5 oz, bid for
14 days) prescriptions, and instructions
to avoid mechanical plaque control
at the site for 2 weeks. Healing was
uneventful and sutures were removed at
2 weeks.

FIGURE 5 Collagen strip technique. 5a The collagen strip was prepared according to the socket
and OAC dimensions. 5b Bone allograft was placed to the socket for ridge preservation with the
assistance of collagen strip. 5c A second piece of collagen membrane covered across the ridge Implant placement and restoration
to secure the bone allograft. 5d Wound closure using 4-0 non-resorbable suture. 5e The baseline After 6 months, implant placement (two-
periapical radiograph showed clear bone substitute particles in the socket. 5f Particle appearance
was less evident after 5 months of healing. staged approach) was performed with
simultaneous indirect sinus augmenta-
tion at the healed edentulous ridge
into a strip (30 × 6 mm, Figure 5a) that was folded in U
(Figure 6). Briefly, after full-thickness flap elevation
shape. The width of the strip was shaped to be slightly
osteotomy was performed and bone substitute‡‡ was
wider than the diameter (or largest dimension) of the
grafted into the maxillary sinus using osteotomes.11
OAC. The bottom of the U-shaped collagen strip was
A screw-form, bone-level dental implant§§ (4.1 × 10
placed level equal to the sinus floor with the two strip ends
mm) was inserted and primary stability was achieved
folded across the socket margins in buccal and lingual
(Figure 6b). Following 5 months of healing (Figure 6d),
aspect. With this approach, the strip ends, held in place by
implant uncovery, healing abutment placement and
gentle pressure, allowed stabilization of the apical-coronal
final restoration delivery were performed (Figure 7),
position of the barrier during bone allograft# placement;
followed by maintenance visits every 4-months. Figure 8
the center of the U-shape functioned as a “basket” to
summarizes the key steps of the described technique.
hold the graft and also served as a platform for the sinus
membrane to heal. After graft placement (Figure 5b), a
second piece of collagen membrane was placed across ∗∗ 4-0CytoplastTM PTFE Suture, Osteogenics Biomedical Inc., Lub-
the ridge buccal-lingually (Figure 5c), to both secure the bock, TX.
graft in place and further stabilize the two ends of the †† Colgate® PerioGard® Rinse, Colgate Oral Pharmaceuticals, New
U-shaped strip, thus avoiding use of fixation devices. York, NY.
‡‡ OraGRAFT® Cortical Particulate - Mineralized, LifeNet Health® ,
# OraGRAFT® Cortical Particulate - Mineralized, LifeNet Health® , Vir- Virginia Beach, VA.
ginia Beach, VA. §§ Straumann® Bone Level Implant, Straumann, Basel, Switzerland.

Cheng and Tatakis Clinical Advances in Periodontics, Vol. 0, No. 0, xxx 2020 3
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FIGURE 7 Implant uncovering and functional loading. The corre-
sponding clinical (7a and 7b, respectively) and radiographic (7c and
7d, respectively) views are shown.
Clinical Outcomes
The 13-month follow-up (Figure 7d) showed successful
outcomes. Probing depths (3 to 5 mm) and periapical
radiographs revealed healthy peri-implant soft tissues and
stable crestal bone levels, with the apical implant portion
covered by augmented bone and thus separated from
the sinus cavity. The patient reported being free of any
symptoms during the entire treatment period and feeling
satisfied with the functional performance and aesthetic
aspects of the final restoration. He was advised to continue
a 4-month maintenance schedule.
FIGURE 8 Schematic diagram of collagen strip technique. 8a initial presentation; 8b oroantral communication (BEFORE); 8c U-shaped collagen
strip, bone allograft, and covering collagen membrane placed (AFTER); 8d final surgery (indirect sinus augmentation and implant placement)
completed.
4 Clinical Advances in Periodontics, Vol. 0, No. 0, xxx 2020
Discussion
This case report documents the successful application of
CST for ridge preservation and OAC closure, following
dental implant removal. The regenerated bone provided
stability for subsequent implant placement and the healed
sinus membrane was durable and allowed for a successful
indirect sinus augmentation.
Table 1 summarizes the advantages, disadvantages,
indications and contraindications of CST. As proposed,
the CST does not include autogenous grafts or rotational
flaps for coverage, thus minimizing postoperative patient
discomfort, potential vestibular depth changes, and possi-
ble alterations of existing keratinized tissue width and/or
location. Adequate strip width is key for good adaptation
in the socket, bone graft stabilization, and simultaneous
closure of OAC opening.
Generally, CST is indicated for cases where simultane-
ous ridge preservation is needed along with management
of an OAC whose size (>4 mm) precludes less elab-
orate repair methods. Such cases may typically occur
after tooth extraction or implant removal in the posterior
maxilla. Application of the CST could be expanded with
modifications, such as ridge preservation in an open-
membrane fashion12 or simultaneous guided bone regen-
eration with the assistance of space-maintaining devices.
However, CST could become technique-sensitive in cases
with irregular socket form. When residual bone height
adjacent to the OAC is very limited because of infec-
tion/trauma/pathology, this technique may not be the best
OAC management option. Systemic factors that may com-
promise outcomes of OAC management should also be
considered.13 
Socket Grafting & Oroantral Communication Repair
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TABLE 1 Indications, contraindications, advantages, and disadvantages of collagen strip technique

Indications Ridge preservation and simultaneous OAC management when OAC dimensions
(>4 mm) preclude less elaborate repair methods
Contraindications OAC resulting from severe trauma, fracture, or sizable pathology
Active sinus infection
Extremely thin residual ridge height
No intention of ridge preservation
Systemic factors: smoking, CPAP for sleep apnea
Advantages No donor site of autogenous graft (hard or soft)
Avoidance of fixation devices (e.g., tacks or screws)
Minimal flap advancement and vestibule height change
Preservation of keratinized tissue width
Predictable bone regeneration
Disadvantages Technique sensitive in cases with irregular socket form
Need for biomaterials (bone allograft, membranes)
OAC, oroantral communication; CPAP, continuous positive airway pressure.

Summary
Why is this case new  To the best of the authors’ knowledge, this case report introduces a
information? simple surgical technique for simultaneous ridge preservation, sinus
membrane repair, and oroantral communication closure.

What are the keys to successful
management of this case?
 Peri-implant osteotomy during explantation should be minimized as
much as possible.
 Collagen strip shape and dimensions should be tailored to socket and
OAC dimensions.
 A second piece of collagen membrane placed across the ridge
buccolingually is crucial for stabilizing both bone graft and collagen strip
underneath.

What are the primary limitations  Existence of active maxillary sinus infection
to success in this case?  Sites with minimal or no residual ridge height

6. Kapustecki M, Niedzielska I, Borgiel-Marek H, Rozanowski B. Alter-

Acknowledgments
The authors report no conflicts of interest related to this
case report.
CORRESPONDENCE
Dimitris N. Tatakis, Division of Periodontology, College of Dentistry, The
Ohio State University, 4121 Postle Hall, 305 W. 12th Ave. Columbus, OH
43210. E-mail: tatakis.1@osu.edu
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