Case Series

Sinus Floor Elevation Via the MaxillaryPremolar Extraction Socket WithImmediate Implant Placement:A Case SeriesShilpa Kolhatkar,* Monish Bhola,* and Tamika N. Thompson-Sloan*

Background: When immediate implant placement is con-sidered for teeth with close proximity to the sinus floor, apicalextension of the osteotomy is significantly limited, and oftena staged approach is used. Implant placement into fresh ex-traction sockets and sinus floor manipulation using bone-added osteotome sinus floor elevation with implant placementare techniques most often used independently or sequentially.Very few reports have described the combined use of immedi-ate implant placement in fresh sockets and the bone-addedosteotome sinus floor elevation technique.

Methods: We present five cases in which a maxillary premo-lar was extracted and an implant placed into the extraction sitewith simultaneous abfracture of the sinus floor using osteo-tomes. All teeth were extracted atraumatically, and socketscarefully debrided and checked for integrity of the walls. Afterideal osteotomypreparation, particulate bone graft was placedin the osteotomy and appropriately sized osteotomes wereused for sinus floor elevation. After sufficient elevation, implantplacement was completed and particulate bone was packedin the bone–implant gap when indicated.

Results: All implants were restored after a minimum healingperiod of 6 months. At the time of final restoration, bone wasseen surrounding the implants from the apical portion to themost coronal thread. All five implants healed without compli-cations and were in function for periods ranging from 6 to 12months.

Conclusions: Immediate implant placement with simulta-neous osteotome sinus floor elevation is an advantageouscombination of two successfully used techniques. This com-bined approach can significantly reduce the treatment timefor implant therapy in teeth with close sinus proximity and pro-vide the operator with the ability to place implants of desiredlength. J Periodontol 2011;82:820-828.

KEY WORDS

Bone regeneration; dental implants, immediate; grafting,bone; maxillary sinus/surgery; osseointegration; osteotomy.

The traditional approach to implantplacement, as described by Brane-mark, recommended a 12-month

healing period after tooth extraction.1

This, combined with the recommended3- to 6-month period for implant healing,often results in prolonged treatment time.To reduce this treatment interval, Lazzara2

reported on implants placed into freshextraction sites. Since then, implantplacement in extraction sockets in com-bination with bone grafts and barriershas been well documented.3-6 Duringimmediate implant placement, primarystability is achieved by preparing theosteotomy to engage the lateral wallsand the native bone apical to the extrac-tion socket. However, in many instances,apical extension of the osteotomy islimited because of the proximity of themaxillary sinus.

Sinus floor elevation (SFE) techniquesfacilitate placement of longer implants inthe presence of reduced bone height. TheSummers osteotome SFE7-9 techniquewas a modification of the traditional lat-eral approach for SFE, which offered theadvantage of reduced morbidity,10 sh-orter clinical time,11 and reduced postop-erative discomfort.12 The bone-addedosteotome SFE (BAOSFE) technique isthe addition of a bone graft into the

* Department of Periodontology and Dental Hygiene, University of Detroit Mercy,Detroit, MI.indicates supplementary video in the online Journal of Periodontology. doi: 10.1902/jop.2010.100557

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osteotomy. The addition of the bone graft is thought toprovide some cushioning during abfracture and mem-brane elevation, thereby reducing the risk for mem-brane perforation.9

When immediate implant placement is consideredfor teeth in close proximity to the sinus floor, a two-stage approach is often followed. In many instances,extraction followed by ridge preservation with or with-out SFE is the first step. Placement of an implant fix-

ture is usually attempted after asuitable healing period. Simulta-neous BAOSFE and immediateimplant placement would greatlyshorten the total treatment timewhile providing the operator thebenefit of placing longer implants.In this article, we present a case se-ries in which five implants havebeen placed in fresh extractionsockets with simultaneous SFE.We also present a decision tree(Fig. 1) aimed at helping practi-tioners determine the ideal se-quence for using this treatmentcombination.

MATERIALS AND METHODS

Five consecutive patients (threemale and two female), aged 46 to58 years, presented for implantevaluation, from June 2007 toMarch 2009. Each patient requiredextraction of a maxillary premolarfor varied reasons (Table 1; Figs.2 through 6). The prognosis ofthe specific tooth (two first pre-molars and three second pre-molars) was discussed with thepatient and the necessity forBAOSFE including risks of mem-brane perforation was thoroughlyexplained. Written informed con-sent was obtained for extraction ofthe tooth, BAOSFE, and implantplacement from all five patients.

Careful presurgical evaluationwas completed for all patients in-cluding a detailed health historyquestionnaire. All patients werecurrent non-smokers, although twoof the patients reported smokingin the past. Site-specific evaluationincluded periapical radiographs(Fig. 4A) taken using the paralle-ling axis technique or panoramicfilms. The distance between the

root apex and sinus floor was measured using a rulerand standard periapical films (Table 2). Oral prophy-laxis and scaling and root planing were completedand active carious lesions, if present, were treated.All patients were started on preoperative antibiotics3 days before the procedure, and an over-the-counternasal decongestant 1 week preceding the surgery.

All procedures were performed under profoundlocal anesthesia. Sulcular incisions were made around

Figure 1.Decision tree for determining ideal treatment sequence when using the combined techniques ofimmediate implant placement with simultaneous BAOSFE.

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the tooth with a 15C blade and extended one toothanteriorly and posteriorly when necessary (seesupplementary video in online Journal of Periodontol-ogy).Periotomeswereusedtobeginwidening theperi-odontal ligament space. Straight elevators were thenusedto further luxate the tooth,whichwasremovedus-ing gentle rotational movement. The socket was care-fully debrided and flushed with sterile saline multipletimes before initiating implant placement. A peri-odontal probe was inserted into the depth of the socketand moved in a circular fashion to confirm the integrityof the socket walls using tactile sensation. The depthof the socket was used as the working length when<1 mm of native apical bone was present. When addi-tional bone height was available, the osteotomy wasprepared to 1 mm short of the sinus floor.

Interradicular bone, when present, was preserved.Osteotomy preparation was started using a pointedtwist drill engaging the palatal slope of the interradic-ular bone and enlarged using sequentially wider drills.In single-rooted premolars, ideal bucco-palatal po-sitioning of the implant was maintained (Fig. 3B).When the osteotomy was enlarged to final dimension,a plug of bone graft (Table 2) was placed in the osteot-omy. The sinus floor was carefully abfractured usingappropriately sized osteotomes and gentle malletting.The Valsalva maneuver was performed on multipleoccasions to detect any oroantral communication,and in all of our cases, no oroantral communicationwas noted. This procedure was repeated until suffi-cient elevation of the sinus membrane was achieved.Intraoperative radiographs were taken to confirm si-

nus floor abfracture, containment of the graft material(Fig. 4B), and adequacy of elevation after which theimplant was placed (Figs. 2C, 3C, 4C, and 5B). Pri-mary stability was confirmed with tactile sensation.The bone–implant gap was measured (Fig. 4D) andwhen found to be >1.5 mm, additional bone graftwasplacedon the buccal aspectof the implant.Buccalaugmentation was required for all implants. Thebuccal and palatal flaps were then sutured with inter-rupted sutures. Healing abutments were placed atthe time of implant placement for two patients or asecond-stage procedure was completed 5 to 6 monthslater for the remaining three patients (Table 2).

Detailed written and verbal postoperative instruc-tions were given. All patients were prescribed anappropriate analgesic and antibacterial mouthrinse.Patients were instructed to refrain from vigorouslyblowing air from the nose or sneezing through thenose, and were seen for follow-up appointments at2 weeks, 2 months, and 5 months.

Before final restoration, periapical radiographsshowed increased radiopacity in the area immediatelyapical to the implant fixture. No crestal bone resorp-tion was seen. Reformation of the sinus floor (Fig.4E) with uniform increased radiodensity and absenceof any radiolucent areas around and apical to the im-plants were seen. Bone gain ranging from 1 to 4 mmwas obtained. All implants were restored by non-splinted single implant supported crowns (Figs.2D, 2E, 3D, 3E, 5C, and 6C). All patients have beenplaced in a recall program that includes regular pro-fessional oral hygiene and dental screenings.

Figure 2.A) Preoperative radiograph of tooth #5. Root apex is 2mm from the sinus floor. B) Direction indicator placed inthe osteotomy, which was prepared to the floor of thesinus. C) Immediate postoperative radiograph. D)Postrestoration radiograph showing gain in bone heightafter BAOSFE and implant placement. E) Finalrestoration of tooth #5.

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RESULTS

A total of five patients were treated with extraction ofthe first or second premolar, BAOSFE, and immediateimplant placement. All implants were stable andfunctioning well during a follow-up period of 6 to 12months, resulting in a survival rate of 100%. The vari-ous reasons for extraction, presence or absence ofradiographic periapical pathology, or smoking habit(Table 1), had no impact on the successful outcomeof the procedures. For all patients healing of the surgi-cal site occurred without any complications.

Table 2 illustrates the different bone grafting mate-rials that were used. Preoperative distance fromroot apices to the sinus floor ranged from <1 to 2mm. Implant lengths ranged from 12 to 13 mm andfour of the five implants were restored after a 6- to9-month healing period. One implant (Case 1) was re-stored at 14 months because of financial limitations.Buccal bone augmentation after immediate implantplacement was required for all implants because thebone–implant distance was >1.5 mm. In three of thefive implants a second-stage procedure for placementof healing abutments was performed at 4 to 5 monthsand the other two implants were treated as singlestage. Placement of a healing abutment at the timeof implant placement did not seem to negatively im-pact successful integration.

The radiographs taken before restoration show noevidence of crestal bone loss around the implants withdense bone extending apical to all implants. The dis-tance from the sinus floor to the apex of the teethwhen measured on the periapical radiograph was 1to 2 mm. At the time of final restoration, bone wasseen surrounding the implant from the apical portionto the most coronal thread.

Primary stability (detected using tactile sensation)was achieved atplacement forall implants.Nomobility

(detectedusing tactile sensation)waspresentwhen thefinal restorations were delivered at least 6 months afterimplant placement.

In this case series we present five cases that weretreated using the BAOSFE and immediate implantplacement techniques. In all cases, the walls were in-tact and we were able to obtain primary stability withconcurrent sinus elevation successfully.

DISCUSSION

Many reports have attested to the long-term successof BAOSFE procedures,13-16 but the amount of bonegain obtained has varied significantly. Fugazzotto17,18

reported a mean bone gain of 3.5 mm with a range of1 to 7 mm. A human cadaver study was conductedby Reiser et al.19 They used a 2-mm twist drill for os-teotomy preparation, which terminated within 1 mmof the sinus floor. The authors report predictable SFEof 4 to 5 mm and sometimes elevation of 6 to 8 mmwas observed. BAOSFE using endoscopy was con-ducted by Nkenke et al.20 The purpose of using anendoscopewas forvisualizationofmembrane perfora-tions and they recommended only a 3-mm elevationfor procedures done without the use of endoscopy.Inourcaseswehave foundSFEof3 to7mmat the timeof SFE, which eventually translated into bone gain of 1to 4 mm at the time of restoration. It is widely acceptedthat periapical radiographs provide only two-dimen-sional representationofclinicalanatomyandthereforeuse of three-dimensional radiography provides themost accurate measurement of vertical bone gain.

When SFE is attempted via extraction sites in theposterior maxilla, a two-step approach to SFE andimplant placement has been recommended by manyauthors. Fugazzotto21 reported on 109 SFE proce-dures performed in 92 patients who needed either afirst or second molar extracted. A calibrated trephine

Figure 3.A) Preoperative radiograph of non-restorable tooth #4.Note presence of periapical radiolucency. B) Implantplaced in the ideal bucco-palatal position. C) Radiographtaken at implant placement shows significant elevation ofsinus floor. D) Radiograph of final restoration of tooth #4.E) Clinical appearance of final restoration of tooth #4.

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bur, which was large enough to include the entire in-terradicular septum and 50% of the extraction socket,was used to prepare the site 1 to 2 mm short of the si-nus floor. A suitable osteotome was used to implodethe trephined core and the sinus membrane. Theextraction socket was filled with a xenograft andcovered with resorbable and non-resorbable barriers.After a sufficient healing period, 101 implants wereplaced at these sites. The author reported that thecombination of SFE and guided bone regenerationperformed at the time of extraction resulted in regen-eration of an adequate amount of bone that wouldallow the placement of implants at least 10 mm longand 4.8 mm wide. In a follow-up to the previousstudy, Fugazzotto and De22 published results of 167implants placed into sites where SFE was performedat the time of molar tooth extraction. Only two of the167 implants failed to integrate resulting in a cumula-tive success rate of 98.2%

Implant placement in fresh extraction sites is a re-cent advancement, but the success of this techniquehas been well documented. A key factor for achievingimplant success is primary stability and immobility.Early mobility of implants significantly impacts clini-cal success.23 Becker et al.24 published reports on im-plant placement in conjunction with non-resorbablebarrier membranes. After 5 years, a survival rate of

93.3% was reported. Many others have also reportedon the predictability of this technique.5,6,25-28

The presence of chronic periapical and periodontalinfection during immediate implant placement pres-ents a concern about possible infection of the implant.However, a systematic review of human and animalstudies pertaining to immediate implant placementinto sites with periapical infection was conducted byWaasdorp et al.29 and the authors concluded thatimplant survival in infected sites was consistent withthose placed in non-infected sites. Twelve publica-tions (eight human and four animal studies) were ex-amined. Implant survival in the infected sites ofhuman studies ranged from 92% to 100%. Histologicevidence from the animal studies points to similarbone–implant contact in infected and non-infectedsites. The use of antibiotics was reported in most stud-ies included in this review. Some have reported start-ing antibiotics 1 hour before surgery and continuing itfor 5 days30 postoperatively, whereas others haveused antibiotics for periods ranging from 7 to 23days.31 Implant placement in the presence of peri-odontal disease has been studied. In a report byTozum et al.,32 SFE was performed via the extractionsocket in a periodontally involved molar tooth. Theauthors presented a case in which radiographic inves-tigations revealed absence of native bone between

Figure 4.A)Preoperative radiograph of tooth #13. Note curvature of the root and proximity to the sinus floor. B) BAOSFE completed with even distribution of the bonegraft (arrows). C) Post-surgical radiograph showing ideal mesio-distal orientation of the implant. D) Occlusal view of implant placement. Note the bone–implant gap (arrow), which was filled with particulate bone graft. E) Radiograph taken 6 months after implant placement. Note increase in bone densitywith reformation of the sinus floor.

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the apical aspect of the tooth and the floor of themaxillary sinus with thickening of the Schneiderianmembrane. SFE using bovine bone and synthetichydroxyapatite was performed 4 weeks after extrac-tion through the extraction site. After a 4-month heal-ing period, two 12-mm implants were placed andrestored 6 months later. In our case series, radio-graphic evidence of periapical radiolucencies wasevident in two cases. In both cases, thorough debride-ment of the socket was conducted, and the patientswere prescribed antibiotics preoperatively and cov-ered with antibiotics postoperatively for a period of7 to 10 days. The findings of our case series are con-sistent with the systematic analyses, and we foundthat the patients with periapical pathoses had equallysuccessful outcomes as those without periapical ab-normalities.

Although both the techniques of BAOSFE and im-mediate implant placement are well established anddocumented, reports on the combined use of BAOSFEin fresh extraction sites with immediate implant place-ment are scarce. We found only two reports that havedescribed immediate implant placement in conjunc-tion with SFE.33,34 Artzi et al.33 described the place-ment of 12 wide-diameter implants in conjunction

with internal sinus lift in molar extraction sites. Theaverage preoperative residual bone height was 7.8 mm;after BAOSFE using bovine bone was performed at10 of 12 sites, a bone gain of 4.3 mm was recorded.The authors reported microperforation at three sites;however, this did not influence implant healing. Theprosthetic phase was completed 6 months after im-plant placement, and a 2-year follow-up of thesepatients revealed good stability and support of the im-plants and prosthesis. Another case series was pre-sented by Barone et al.34 Twelve patients who eachrequired extraction of a maxillary premolar and werescheduled for immediate implant placement wereincluded. Preoperative bone height, as measuredfrom the alveolar crest to the sinus floor, rangedfrom 6 to 10 mm. The length of implants ranged from10 to 13 mm, and bone gain at the end of 18 monthsranged from 3 to 5 mm. Of the 12 implants placed,one implant failed in the initial healing phase, butall other implants healed uneventfully and were func-tioning at the 18-month postoperative evaluation.The results from our case series compare favorablyto the two other studies that have described thecombined mode of treatment. We performed BAOSFEin all five patients, but did not experience any sinus

Figure 5.A)Preoperative radiograph showing recurrent subgingival decay on tooth #4. B)Radiograph taken immediately after implant placement and BAOSFE showssignificant sinus elevation (arrows). C) Radiograph of implant-supported restoration showing stable crestal bone and increased radiopacity around theimplant.

Figure 6.A) Preoperative radiograph of tooth #13, which was non-restorable because of recurrent subgingival decay. Note bone loss and significant pneumatization ofthe sinus floor on the distal aspect of tooth #13. B) Preoperative occlusal view of tooth #13. C) Radiograph of final restoration.

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membrane perforations. All implants had initial stabilityat the time of placement, and were functioning well fora follow-up period of 6 to 12 months after restoration.

There are many advantages to using a combinedapproach in patients requiring immediate implantplacement in the presence of sinus proximity. Theuse of the BAOSFE technique allows for lateraland vertical expansion of the socket and facilitatesplacement of wider and longer implants. The reduced

treatment time is another significant advantage.However, there are several clinical variables, such asintegrity of the alveolar housing, sinus proximity, pri-mary stability, and bone–implant distance, whichimpact the decision-making process. We developeda decision tree (Fig. 1) that was used for all casespresented in this series. Because this procedure isperformed in one surgical visit, the operator’s chairtime and patient visits are greatly reduced.

Table 1.

Patient Demographics, Smoking and Medical History, and Assessment of Implant Sites

Case

Age,

Sex Tooth

Reason for

Extraction Medications Smoking History

Radiographic

Periapical

Pathology

#1 (Fig. 2) 49, M #5 Severe fracture oflingual cusp

None Former smoker(17 packs per year)

Absent

#2 (Fig. 3) 50, F #4 Inadequate clinical toothstructure for crown retention

None Negative Present

#3 (Fig. 4) 54, F #13 Inadequate clinical toothstructure for crown retention

None Former smoker(30 packs per year)

Absent

#4 (Fig. 5) 46, M #4 Severe recurrent decayextending subgingivally

Oxycodone and acetaminophenfor back pain

Negative Absent

#5 (Fig. 6) 58, M #13 Severe recurrent decayextending subgingivally

Lisinopril atenolol Negative Present

Table 2.

Root Apex to Sinus Floor Distance, Type of Bone Graft, Implant Dimension, Surgicaland Restorative Time Line

Case Bone Graft

Implant Dimensions (mm)

and Date of Surgical

Procedure

Preoperative Root Apex

to Sinus Floor

Distance (mm)

Healing Abutment

Inserted at Implant

Placement

Time Between

Placement and

Restoration (months)

#1 (Fig. 2) Allograft* 3.7 · 13† 2 Second stage after 6 months 14May 2008

#2 (Fig. 3) Allograft* 4.7 · 13† 2 Single stage 6December 2008

#3 (Fig. 4) Allograft* 4 · 13‡ <1 Second stage after 6 months 8July 2008

#4 (Fig. 5) Xenograft§ 4.1 · 12i <1 Second stage after 5 months 9March 2009

#5 (Fig. 6) Allograft¶ 4.8 · 12i 2 Single stage 6June 2007

* Freeze dried bone allograft, Musculoskeletal Transplant Foundation, Edison, NJ.† Zimmer, Carlsbad, CA.‡ Prevail, BioMet, Palm Beach Gardens, FL.§ Bio-Oss, Osteohealth, Wolhusen, Switzerland.i Institute Straumann, Straumann Waldenburg, Switzerland.¶ Dynablast, Keystone Dental, Burlington, MA.

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CONCLUSIONS

In this series, we present cases in which BAOSFEwas successfully performed with immediate implantplacement in fresh extraction sites. Clinicians can fol-low the decision tree presented in Figure 1 to achievesuccessful outcomes using this combined technique.Benefits of using this combined technique include re-duction in treatment time and the flexibility to placelonger implants in the presence of sinus proximity.However, it is possible that when the ideal situationis not present, treatment modifications need to bemade that may result in delayed implant placement.

ACKNOWLEDGMENTS

We acknowledge Mr. Eric Jacobs, Media Specialist,University of Detroit Mercy School of Dentistry, De-troit, Michigan, for his assistance with videotapingand photography. The authors thank Drs. Shazia A.Haque and Leevy-Lynn Cabanilla-Jacobs, Depart-ment of Periodontology, University of Detroit MercySchool of Dentistry, for their assistance in the manage-ment of Case 4; Dr. Crystal MacIntosh, former resident,Department of Periodontology and Dental Hygiene,University of Detroit Mercy School of Dentistry, forher assistance in Case 3; and Laura Kensrud and Nel-son Wu, former dental students, University of DetroitMercy School of Dentistry, for the restoration of Cases3 and 4, respectively. The authors report no conflictsof interest related to this case series.

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19. Reiser GM, Rabinovitz Z, Bruno J, Damoulis PD, GriffinTJ. Evaluation of maxillary sinus membrane responsefollowing elevation with the crestal osteotome tech-nique in human cadavers. Int J Oral Maxillofac Implants2001;16:833-840.

20. Nkenke E, Kloss F, Wiltfang J, et al. Histomorphometricand fluorescence microscopic analysis of bone remod-elling after installation of implants using an osteotometechnique. Clin Oral Implants Res 2002;13:595-602.

21. Fugazzotto PA. Immediate implant placement and GBRin humans: A case report and histologic evaluation. IntJ Periodontics Restorative Dent 1999;19:457-463.

22. Fugazzotto PA, De PS. Sinus floor augmentation at thetime of maxillary molar extraction: Success and failurerates of 137 implants in function for up to 3 years. JPeriodontol 2002;73:39-44.

23. Ersanli S, Karabuda C, Beck F, Leblebicioglu B.Resonance frequency analysis of one-stage dentalimplant stability during the osseointegration period.J Periodontol 2005;76:1066-1071.

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27. Wagenberg B, Froum SJ. A retrospective study of1925 consecutively placed immediate implants from1988 to 2004. Int J Oral Maxillofac Implants 2006;21:71-80.

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28. Wagenberg BD, Ginsburg TR. Immediate implantplacement on removal of the natural tooth: Retrospec-tive analysis of 1,081 implants. Compend Contin EducDent 2001;22:399-404, 406, 408 passim; quiz 412.

29. Waasdorp JA, Evian CI, Mandracchia M. Immediateplacement of implants into infected sites: A systematicreview of the literature. J Periodontol 2010;81:801-808.

30. Siegenthaler DW, Jung RE, Holderegger C, Roos M,Hammerle CH. Replacement of teeth exhibiting peri-apical pathology by immediate implants: A prospec-tive, controlled clinical trial. Clin Oral Implants Res2007;18:727-737.

31. Ferreira CE, Novaes AB, Haraszthy VI, Bittencourt M,Martinelli CB, Luczyszyn SM. A clinical study of 406sinus augmentations with 100% anorganic bovinebone. J Periodontol 2009;80:1920-1927.

32. Tozum TF, Dursun E, Tulunoglu I. Sinus floor elevationfrom a maxillary molar tooth extraction socket in

a patient with chronic inflammation. J Periodontol2009;80:521-526.

33. Artzi Z, Parson A, Nemcovsky CE. Wide-diameterimplant placement and internal sinus membraneelevation in the immediate postextraction phase:Clinical and radiographic observations in 12 consec-utive molar sites. Int J Oral Maxillofac Implants 2003;18:242-249.

34. Barone A, Cornelini R, Ciaglia R, Covani U. Implantplacement in fresh extraction sockets and simulta-neous osteotome sinus floor elevation: A case series.Int J Periodontics Restorative Dent 2008;28:283-289.

Correspondence: Dr. Shilpa Kolhatkar, 2700 Martin LutherKing Jr. Blvd., Detroit, MI 48208. Fax: 313/494-6666;e-mail: kolhatsh@hotmail.com.

Submitted September 10, 2010; accepted for publicationOctober 25, 2010.

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