AO Orlando preview: The sinus floor bone graft--understanding when, how, and if

Twenty years after the watershed Sinus Consensus Conference of 1996, co-chaired by Leonard Shulman, Michael Block, Vincent Lacono, and myself, we editorialized in The International Journal of Oral & Maxillofacial Implants, highlighting five areas of significant change that have occurred since that time. These five areas will be the topic of a session titled “Sinus Consensus Update Session” that I will moderate on March 17 as part of Academy of Osseointegration's (AO’s) 2017 annual meeting.

The state of the science of the sinus floor bone graft is not settled. There remains significant controvers, and, therefore, ongoing innovation as it relates to augmentation procedures to enhance osseointegration. The goal of this course will be to present key topics that have improved our understanding of when, how, and if the sinus floor procedure should be done.

One could say that the profession does not yet know what to do about aeration of the posterior maxilla with regard to tooth replacement, which is why every specialty must contribute to making treatment planning a success.

Here are five key developments that have informed our thinking:

1. Graft material: At the time of the consensus conference in 1996, the use of autogenous bone—including mandibular, iliac, tibial, and cranial—graft was championed, while alloplast and allografts were thought to be inferior (though the Consensus Conference found otherwise). Since that time, the use of xenogeneic bone has been found to be highly effective, if not the most effective, for sinus floor augmentation—a mostly space maintenance process with new bone formation migrating from the sinus floor. In fact, space maintenance without any graft material at all forms bone. Though the use of biomimetics is effective in the sinus floor and is an excellent tissue engineering advance, the use of growth factors and BMPs are generally reserved for more challenging cases.

2. Increased reports of combined alveolar and sinus floor grafting suggest that orthoalveolar form—that is, the formation of ideal shape and size of the alveolus for emergence profile restoration—is favored by clinicians even in the back of the mouth. Combined alveolar procedures done in conjunction with the addition of bone to the sinus floor gain bone mass for osseointegration as well as help to establish long-term gingivo-alveolar health.

3. Since 1996, technical advances in performing the sinus graft now involve using an alveolar approach instead of a lateral approach. Transcrestal osteotomes are used vertically to intrude the sinus floor, sometimes simultaneously alveolar splitting to gain alveolar width.

4. For the fully edentulous setting, with the advent of the All-On-4 method, sinus grafting is generally avoided even in the severely deficient patient. Implant angulation circumvents the sinus by gaining apical anchorage into pyriform, nasal crest, pterygoid, or malar bone structure, thus avoiding the need for sinus floor bone augmentation. This is a significant change in treatment prerogative since 1996.

5. Almost iconoclastic is the resurgence of the use of short implants—even ultra-short implants that avoid sinus penetration or are only minimally invasive—having been shown in three-year studies to be just as effective as sinus grafted dental implant sites using longer implants.

The overarching theme of the symposium is that ongoing clinical and basic science developments continue to strike a balance between biological efficacy and simplicity of treatment.

To view the full program guide and register to attend, CLICK HERE. Register by January 23 and save up to $250!