CHAPTER 15: ADVANCED

IMPLANT SURGERY: MAXILLA -

SINUS GRAFTING, BONE
GRAFT AUGMENTATION, AND
ZYGOMATIC IMPLANTS

Joseph Schiels, George Rubin, Farihah Khan

 BONE GRAFTING AND GRAFT
SUBSTITUTES

• Many areas have insufficient bone for implant placement

• Extraction and bone atrophy
• Sinus pneumatization
• Previous trauma
• Congenital defects
• Removal of pathologic lesions
• In all above cases bone will need to be augmented to
provide adequate support for implants
 TYPES OF BONE GRAFTING
MATERIAL

• Autogenous grafts – bone harvested from anatomic areas

• Symphysis provides best intraoral source of cortical and cancellous bone.
• Anterior iliac crest is used when more bone is required for situations such as atrophic
edentulous mandible or bilateral sinus lifts.
• Allografts – bone grafts from cadavers
• Advantages include the avoidance of an additional donor site and unlimited availability.
• Disadvantage is that a significant amount of grafted bone is resorbed.
• Xenografts – bone from genetically different species.
• Similar advantages/disadvantages to allografts

• Bone Morphogenic Proteins – protein factors that have been isolated and applied
to the reconstruction of the maxillofacial skeleton
• Have ability to enhance bone graft healing and can substitute for other grafting materials
MAXILLARY BONE GRAFT
AUGMENTATION
 BONE GRAFT AUGMENTATION

• Onlay Bone Grafting – indicated in the presence of severe

resorption resulting in absence of clinical alveolar ridge
and loss of adequate palatal vault form.
• Blocks of corticocancellous bone are secured to the maxilla
with small screws.
• Cancellous bone along with BMP contained in some type of
mesh is then packed around the grafts to improve contour.
• Implants can be placed at same time, but placement is often
delayed to allow initial healing.
ONLAY BONE GRAFTING
ONLAY BONE GRAFTING
CONTINUED
 SINUS
PNEUMATIZATION

When posterior teeth are lost,

the sinus expands inferiorly and
laterally, greatly reducing available
bone in the Maxillary region.
 SINUS GRAFT

• A bony augmentation procedure that places graft material

inside the sinus cavity but external to the membrane.
 INDIRECT SINUS LIFT

 When only a few millimeters of augmentation

are needed in conjunction with simultaneous
implant placement. Need enough bone, 4-5 mm,
for primary stability.

 Initial drill is used to locate the angulation and

position of the planned implant.

 The depth is drilled just short of the sinus floor.

 Osteotomes are then used to enlarge the site

progressively.

 The osteotome is cupped on the end and

compresses the walls of the osteotomy site, and
scrapes bone from the sides of the wall, pushing
it ahead.

 The bone of the sinus floor is pushed upward,

elevating the sinus membrane and depositing the
bone from the lateral wall and apex of the
osteotomy into the sinus below the membrane.
 O P E N A P P ROAC H S I N U S
GRAFT

• Open Approach – used when more then a few

millimeters of bony augmentation is needed.
• Opening is made in the lateral aspect of the
maxillary wall, and the sinus lining is carefully
elevated from the bony floor of the sinus.
• After elevation, the graft material is placed in
the inferior portion of the sinus, below and
external to the sinus membrane.
• Allogeneic, autogenous, xenogeneic bone, BMP,
or a combination can be used as a graft source.
• Perforations of the sinus membrane can occur
and are usually covered with a patch of
resorbable membrame material
• Usually covered up with redundancy of
elevated membrane, as well as patch of
resorbable membrane material.
• If enough bone is available to provide initial
implant stability(4-5mm) then implant
placement can be accomplished simultaneously.
• If insufficient amount of bone for initial
implant stability, wait 3-6 months for bone
to heal.
 SINUS LIFT

• Open Approach – used when more then a few millimeters of bony

augmentation is needed.
• Opening is made in the lateral aspect of the maxillary wall, and the
sinus lining is carefully elevated from the bony floor of the sinus.
• After elevation, the graft material is placed in the inferior portion of
the sinus, below and external to the sinus membrane.
• Allogeneic, autogenous, xenogeneic bone, BMP, or a combination can
be used as a graft source.
• Perforations of the sinus membrane can occur and are usually covered
with a patch of resorbable membrane material.
• If enough bone is available to provide initial implant stability(4-5mm)
then implant placement can be accomplished simultaneously.
SINUS LIFTS
 ALVEOLAR RIDGE DISTRACTION

• Trauma, congenital defects, and resection of bony pathology

often create a bone defect inadequate for immediate
reconstruction with implants.
• Distraction osteogenesis can correct these large defects
• An osteotomy is cut into the alveolar ridge. An appliance is then
screwed directly into the bone segments.
• After an initial latency period of 5-7 days, the appliance is
gradually activated to separate the bony segments. (1mm per day)
• The gradual tension produces continuous bone formation and the
adjacent tissue also expands and adapts to this gradual tension.
• The newly formed bone heals for 3-4 months at which point the
appliance is removed and implants can be placed. Additional bone
augmentation may still be required at this point,.
 ZYGOMATIC IMPLANTS

• Considered in patients for which sinus floor grafting are not feasible
• Patients with compromised health
• Patients who do not wish to undergo multiple surgeries and lengthy
treatment times
• Extremely long – 35-55 mm in length
• Posterior zygomatic implants used in combination with 4 anterior
implants to support a fixed prosthesis
• According to the position statement released in 2016 by the American
College of Prosthodontists – “A protocol has been established for the
total rehabilitation of atrophic maxillae employing four zygomatic fixtures in an
immediate loading system…The zygomatic implants will emerge within the
tooth/alveolar envelope, thus yielding a more anatomically accurate prosthesis.”
• Advantages: shortened treatment times, immediate placement of a fixed
screw-retained interim prosthesis, potentially lower cost and no need for
adjunct grafting
 PLACEMENT OF ZYGOMATIC
IMPLANTS

• Intraoral placement
• Membrane is reflected
• Implant traverses the maxillary sinus
• Tip engages the body of the zygoma
• External hex fixture emerges in the second premolar or
first molar area
• Osseointegration occurs in the portion of the implant just
medial to the alveolar crest or zygomatic bone
DIAGRAM OF ZYGOMATIC
IMPLANT PLACEMENT
A 40-YEAR OLD, DIABETIC PATIENT WITH AN
HB A1C OF 6.5 PRESENTS FOR IMPLANTS IN
THE UPPER-POSTERIOR REGION. THE
PATIENT HAS 5 MM OF AVAILABLE BONE AND
NEEDS 5MM OF BONE AUGMENTATION.
WHICH OF THE FOLLOWING PROCEDURES
SHOULD BE PERFORMED?

A. Indirect Sinus Lift w/ simultaneous implant placement

B. Indirect Sinus Lift w/ no simultaneous implant placement
C. Open Approach Sinus graft w/ simultaneous implant
placement
D. None. The patient is not a viable candidate for implants.
 IF THE SINUS MEMBRANE WAS
PERFORATED DURING A SINUS LIFT,
WHICH OF THE FOLLOWING
SHOULD BE DONE:

A. Rush the patient to the ER

B. Do nothing
C. Cover it up with redundancy of elevated membrane
D. Patch it with resorbable membrane material
E. A & C
F. C & D
 ALVEOLAR RIDGE DISTRACTION
CORRECTS LARGE BONY DEFECTS.
IT INVOLVES IMPLANTING BONE
FROM ANOTHER SITE IN THE BODY.

A. Both Statements are correct

B. Statement 1 is correct, and statement 2 is false.
C. Statement 1 is false, and statement 2 is true
D. Both Statements are false
 WHICH ANATOMIC AL SITE IN THE
BODY IS USED WHEN LARGE
AMOUNTS OF BONE IS REQUIRED
FOR A GRAFT?

A. Symphisis
B. Anterior Iliac Crest
C. Rib
D. Tibia
 IN WHICH PATIENTS WOULD YOU
RECOMMEND A ZYGOMATIC
IMPLANT?

A. A healthy patient with sound bone height and a recent

extraction of #7
B. A medically compromised patient lacking adequate ridge
height and in need of a sinus lift for proper implant
placement
C. A patient who does not wish to undergo multiple sinus lift
procedures and endure the lengthy healing time
D. B & C
E. All of the above