|Year : 2018 | Volume
| Issue : 2 | Page : 76-80
Comparative evaluation of efficacy of calcium silicophosphate putty versus particulate xenograft in maxillary sinus augmentation procedure: A clinical and tomographical study
Dushyant Malik, Mohinder Panwar, Manab Kosala, Jacqueline Jacinta Dias
Department of Dental Surgery and Oral Health Sciences, AFMC, Pune, Maharashtra, India
|Date of Web Publication||31-Dec-2018|
Dr. Dushyant Malik
Department of Dental Surgery and Oral Health Sciences, AFMC, Wanowrie, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Remodeling of bone and pneumatization of maxillary sinus posttooth extraction results in loss of residual bone height in maxillary posterior segment. Hence, maxillary sinus elevation procedure is a commonly practiced procedure for the placement of dental implant in maxillary posterior region with inadequate residual bone. Various graft materials are being used in the space created after elevation of sinus membrane to maintain sinus lining in place and formation of new bone. Aim and Objective: The aim of this study is to compare efficacy of calcium silicophosphate putty and particulate xenograft material in direct maxillary sinus elevation procedure, clinically as well as tomographically. Materials and Methods: Twenty patients with the residual alveolar bone height between 3.5 and 6.5 mm in the edentulous maxillary posterior region requiring direct maxillary sinus lift were selected for the study and divided into two groups. In Group A, calcium silicophosphate putty (NovaBone® Dental Putty) was used as graft material and in Group B, particulate xenograft (Bio-Oss®) was used. In both the groups, simultaneous implant placement was done after maxillary sinus elevation. Patients were assessed radiographically (cone-beam computed tomography) after a period of 6 months for increase in bone height and density of new bone formed. Results: The mean increase in bone height postsinus elevation was found to be statistically significant with xenograft (9.8 ± 1.21 mm). It was also found that the new bone formed postsinus elevation was much more denser than existing bone in cases where xenograft was placed in cavity postsinus membrane elevation (759 ± 211 Hounsfield unit). Conclusion: All the implants placed were successfully rehabilitated. Statistically significant difference was observed an increase in bone height and density of new bone formed with xenograft.
Keywords: Dental implant, simultaneous implant placement, sinus augmentation
|How to cite this article:|
Malik D, Panwar M, Kosala M, Dias JJ. Comparative evaluation of efficacy of calcium silicophosphate putty versus particulate xenograft in maxillary sinus augmentation procedure: A clinical and tomographical study. J Int Clin Dent Res Organ 2018;10:76-80
|How to cite this URL:|
Malik D, Panwar M, Kosala M, Dias JJ. Comparative evaluation of efficacy of calcium silicophosphate putty versus particulate xenograft in maxillary sinus augmentation procedure: A clinical and tomographical study. J Int Clin Dent Res Organ [serial online] 2018 [cited 2020 Jul 9];10:76-80. Available from: http://www.jicdro.org/text.asp?2018/10/2/76/249138
| Introduction|| |
The goal of modern dentistry is to restore normal function, comfort, esthetics, speech and health regardless of the atrophy, disease or injury of the stomatognathic system. Implant placement in edentulous ridges has regularly achieved these goals. Surgical placement of the dental implant is a technique sensitive procedure, especially in the maxillary posterior area as this region is frequently complicated by unfavorable postextraction bone patterns, pneumatization of the maxillary sinus, poor quality of the remaining alveolar bone, and higher occlusal forces. To overcome these limitations, maxillary direct sinus elevation procedure is routinely practiced in dentistry. The technique of maxillary sinus lift was first presented in 1976 by Tatum at Alabama Implant Congress in Birmingham; however, the first publication on this procedure was made in 1980 by Boyne and James. Various graft materials such as autogenous bone, xenografts, allografts, and alloplastic materials have been used for the augmentation procedure. Autogenous bone, is the preferred substitute but with the drawback of an additive surgical site and unpredictable rate of resorption, it has been replaced by different types of bone substitutes including xenografts.
Bioactive ceramics are into use as graft material in the field of Periodontology for many decades because of osteoconduction and osteostimulating effect. These are bioactive substances that is, they interact with the surrounding tissues both physically and chemically, unlike most osteoconductive graft substitutes, which are bioinert and provide only a physical scaffold for the bone to grow. Calcium Silicophosphate graft material in the form of putty is available in the market and is widely used nowadays in bone regeneration including sinus augmentation procedure because of improved handling property and ease of manipulation.
This study evaluates the efficacy of calcium silicophosphate putty in comparison to zenograft material for management of inadequate residual bone height in relation to maxillary sinus for implant placement.
| Materials And Methods|| |
This study was conducted at the Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune. Necessary clearance was obtained from the Institutional Ethical committee. Twenty patients (12 males and 8 females) requiring sinus augmentation surgery and meeting the inclusion criteria such as good general health, missing maxillary first or second molar, nonsmoker, no active periodontitis, sufficient interdental, and interocclusal space and no systemic diseases contraindicating implant placement were included in the study.
Patients were randomly divided into two groups by lottery system. Sites were assessed clinically for adequate interocclusal and interdental spaces [Figure 1]a and [Figure 2]a. The cone-beam computed tomography (CBCT) was carried out for the participants in both the groups to determine the residual alveolar bone height [Figure 1]b and [Figure 2]b as well as the density of the residual bone [Figure 1]c and [Figure 2]c. Routine blood investigations were carried out. Alginate impressions were recorded and pre-surgical casts were prepared. After correlating clinical and radiographic findings, treatment plan was explained to each patient and sinus augmentation surgery was carried out after obtaining consent. Participants in Group A underwent the sinus augmentation procedure with calcium silicophosphate putty (NovaBone® Dental Putty in syringe − 2.0cc) and in Group B, Xenograft (Bio-Oss®_2.0cc) particulate material was used.
|Figure 1: maxillary sinus lift surgical procedure with calcium silicophosphate putty (Group A). (a) Preoperative site. (b) Cone-beam computed tomography showing residual alveolar bone height of 5.4 mm. (c) Density of residual alveolar bone on cone-beam computed tomography (396 Hounsfield unit). (d) Elevation of sinus membrane by elevators. (e) Graft and membrane placement with simultaneous implant placement. (f) Cone-beam computed tomography showing alveolar bone height of 15.3 mm on sinus elevation. (g) Density of new bone formed on cone-beam computed tomography after 6 months (475 Hounsfield unit). (h) Prosthetic rehabilitation after 6 months|
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|Figure 2: maxillary sinus lift surgical procedure with particulate xenograft (Group B). (a) Preoperative site. (b) Cone-beam computed tomography showing residual alveolar bone height of 5.1 mm. (c) Density of residual alveolar bone on cone-beam computed tomography (830 Hounsfield unit). (d) Elevation of sinus membrane by elevators. (e) Graft and membrane placement with simultaneous implant placement. (f) Cone-beam computed tomography showing alveolar bone height of 15.6 mm on sinus elevation. (g) Density of new bone formed on cone-beam computed tomography after 6 months (1751 Hounsfield unit). (h) Prosthetic rehabilitation after 6 months|
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Surgical procedures in all the twenty patients were performed by one experienced surgeon. Prior to local anesthesia, mouth was rinsed with 0.2% chlorhexidine mouthwash. Direct maxillary sinus lift with simultaneous implant placement was carried out in all the cases with lateral window approach. Adequate anesthesia was obtained using 2% Lidocaine with 1:80,000 epinephrine. A full-thickness buccal flap was raised until the zygomatic buttress. The osteotomy for the lateral window was then performed using a Piezosurgical unit. The initial bone marking was done with serrated osteotomy tip. This was followed by the deepening of the mark with osteoplasty tip. Thereafter, the trumpet tip was used for scoring the sinus lining from the borders of the window. The detached window was elevated medially and superiorly (future sinus floor lining) with the simultaneous reflection of the sinus membrane with the help of elevators [Figure 1]d and [Figure 2]d. Following adequate reflection, the sinus membrane was inspected for tears. The augmentation procedure was completed with placement of graft material in the sinus cavity according to the allocated group and simultaneous implant placement [Figure 1]e and [Figure 2]e. Primary closure of the surgical site was achieved. Patients were instructed not to blow from the nose and mouth, keep the mouth open while sneezing and avoid the use of straw. Postoperatively, augmentin (1000 mg) twice a day for 7 days, combiflame (725 mg) one tablet thrice a day for 3 days, 0.12% chlorhexidine mouthwash 15 ml twice a day for 2 weeks and nasovian drops were prescribed. Sutures were removed after 10 days. All the patients were recalled every 2 months for clinical evaluation. Increase in alveolar bone height [Figure 1]f and [Figure 2]f and density of new bone formed [Figure 1]g and [Figure 2]g was assessed after 6 months on CBCT. All the cases were rehabilitated after 6 months of intervention [Figure 1]h and [Figure 2]h.
| Results|| |
In this study, a total of 20 implants were placed in 20 patients after sinus augmentation procedure. Healing was uneventful, no complication was observed in any of the patients and implant survival rate was 100% in both the groups [Table 1]. The mean age of the participants selected was 32.2 years [Table 2]. Postsinus augmentation and implant placement procedure, all the patients were successfully rehabilitated. Data collected was subjected to statistical analysis. Comparison among mean values of sinus elevation and density of new bone formed after 6 months to that of preintervention values was performed by the Mann–Whitney U-test for intergroup and Wilcoxon signed-rank test for intragroup. P < 0.05 was considered as threshold for statistical significance.
In Group A patients, the presurgical mean residual alveolar bone height assessed on CBCT was 5.9 mm and the mean density of residual bone was 494 Hounsfield unit (HU), whereas in Group B, it was 4.9 mm and 574 HU, respectively. Intergroup comparison of these presurgical values with Mann–Whitney U-test showed no statistically significant difference at baseline [Table 3].
|Table 3: Inter group comparison of residual alveolar bone height and density of residual alveolar bone at base line|
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Six months postoperative, the mean gain in alveolar bone height as assessed on CBCT was 8.0 mm in Group A and 9.8 mm in Group B. This difference was found to be statistically significant in both the groups [Table 4].
|Table 4: Intra group comparison of residual bone height and sinus elevation (6 months)|
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CBCT assessment of new bone formed showed mean density of 606 HU in Group A and 1307 HU in Group B. The mean difference in the density of new bone formed and that of residual bone was 112 HU in Group A (statistically not significant) and 759 HU in Group B (statistically highly significant) [Table 5].
|Table 5: Intra group comparison of residual bone density and density of new bone formed postintervention|
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Intergroup comparison of postsurgery variables (sinus elevation and density of new bone formed) was done using Mann–Whitney U-test and statistically significant difference was observed between the two groups [Table 6].
|Table 6: Inter group comparison of sinus elevation and difference of density of new bone formed postsinus elevation at 6 months|
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| Discussion|| |
Partially or totally edentulous posterior maxillary segment rehabilitation with implant-supported prosthesis is challenging because of the lack of bone due to alveolar ridge resorption and maxillary sinus pneumatization. Maxillary sinus augmentation is the most commonly practiced procedure for dental implant rehabilitation in the atrophic posterior maxilla, and innumerable studies have claimed success rate >90%.
Autogenous bone graft is still considered as ideal augmentation material as it combines osteogenic potential, osteoconductive property, and possible avoidance of immunological complications. Considering the limitations of autologous bone such as donor site morbidity and resorptive decrease with time, bone substitutes were introduced as alternatives.
Bone substitute materials are available in different shapes and sizes, but they may require a longer healing period in comparison to autologous bone due to the reduced biological potential, as they are cell-free. In our study, two such bone graft materials, i.e., calcium silicophosphate putty and xenograft were used successfully to augment the sinus. Xenografts undergo slow resorption during physiologic remodeling, a fact which appears appropriate for maintaining the volumetric stability of the augmented sinus and also the implant survival rate. In addition, it is an excellent osteoconductive material with hydroxyapatite content similar to the cortical bone of humans.
In our study, simultaneous implant placement was done along with sinus lift and all the cases were successfully rehabilitated. However, the amount of new bone formed and its density differed in both the groups. In our study, the height of bone obtained postsinus augmentation using xenograft was at an average of 1.8 mm more than the bone height obtained with calcium silicophosphate putty. The density of newly formed bone by using xenograft was at an average 647.4 HU more than that obtained by using calcium silicophosphate putty.
Calcium silicophosphate putty is the next generation bioactive graft material. After placing at a particular site, the smaller calcium silicophosphate particles leach or diffuse calcium and phosphorous ions into the adjacent area. The binder resorbs in 1 week exposing the larger particles to blood. Once the clot is organized, the porous network is created by the dissolution of binder and the smaller particles. Within few hours, there is the formation of calcium phosphate nodules which subsequently crystallize and a new surface apatite layer (hydroxycarbonite apatite) is formed. This apatite layer is essential for the stimulation of osteoprogenitor (undifferentiated) cells to produce transforming growth factor by the release of silicon from the surface. The surface reactions take place within 2–4 days, for the attachment of cells along with the proliferation and differentiation of osteoblasts on the surface of the bioactive material. The limitations of calcium silicophosphate putty are faster rate of resorption and poor mechanical strength which probably is the reason for formation of new bone of lesser density in Group A. The potential of bone formation in sinus without the use of bone substitutes has been proposed, but the results remain controversial and also the stability of the blood clot with sinus lifting is questionable.
| Conclusion|| |
Sinus augmentation is a technique sensitive procedure and depends on the skill of the operator, adequate preoperative planning, technique used and may be on the type of graft material used.
The success rate achieved in the present study was same with both the type of graft material used; although, radiological assessment showed improved results with xenograft in terms of gain in bone height and density of new bone formed. Further studies with large sample size are required to ascertain if xenograft has any added advantage over other type of graft materials used in maxillary sinus augmentation.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Levi I, Halperin-Sternfeld M, Horwitz J, Zigdon-Giladi H, Machtei EE. Dimensional changes of the maxillary sinus following tooth extraction in the posterior maxilla with and without socket preservation. Clin Implant Dent Relat Res 2017;19:952-8.
Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613-6.
Hallman M, Thor A. Bone substitutes and growth factors as an alternative/complement to autogenous bone for grafting in implant dentistry. Periodontol 2000 2008;47:172-92.
Anderegg CR, Alexander DC, Freidman M. A bioactive glass particulate in the treatment of molar furcation invasions. J Periodontol 1999;70:384-7.
Chiapasco M, Zaniboni M. Methods to treat the edentulous posterior maxilla: Implants with sinus grafting. J Oral Maxillofac Surg 2009;67:867-71.
Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. J Clin Periodontol 2008;35:216-40.
Sakkas A, Wilde F, Heufelder M, Winter K, Schramm A. Autogenous bone grafts in oral implantology-is it still a “gold standard”? A consecutive review of 279 patients with 456 clinical procedures. Int J Implant Dent 2017;3:23.
Sbordone L, Levin L, Guidetti F, Sbordone C, Glikman A, Schwartz-Arad D. Apical and marginal bone alterations around implants in maxillary sinus augmentation grafted with autogenous bone or bovine bone material and simultaneous or delayed dental implant positioning. Clin Oral Implants Res 2011;22:485-91.
Jensen T, Schou S, Stavropoulos A, Terheyden H, Holmstrup P. Maxillary sinus floor augmentation with bio-oss or bio-oss mixed with autogenous bone as graft: A systematic review. Clin Oral Implants Res 2012;23:263-73.
Valentini P, Abensur D, Densari D, Graziani JN, Hämmerle C. Histological evaluation of bio-oss in a 2-stage sinus floor elevation and implantation procedure. A human case report. Clin Oral Implants Res 1998;9:59-64.
Oréfice R, Hench L, Brennan A. Evaluation of the interactions between collagen and the surface of a bioactive glass during in vitro
test. J Biomed Mater Res A 2009;90:114-20.
Chen TW, Chang HS, Leung KW, Lai YL, Kao SY. Implant placement immediately after the lateral approach of the trap door window procedure to create a maxillary sinus lift without bone grafting: A 2-year retrospective evaluation of 47 implants in 33 patients. J Oral Maxillofac Surg 2007;65:2324-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]