Minimally Invasive Subnasal Elevation and Antral Membrane Balloon Elevation Along With Bone Augmentation and Implants Placement
Atrophic edentulous anterior maxilla is a challenging site for implant placement and has been successfully treated surgically by anterior maxillary osteoplasty. This procedure is associated with considerable discomfort, morbidity, and cost—and consequently reduced patient acceptance. The efficacy and safety of minimally invasive bone augmentation of the posterior maxilla has not been extended thus far to the anterior subnasal maxilla. We present 2 representative cases in which minimally invasive subnasal floor elevation was performed along with minimally invasive antral membrane balloon elevation. Both segments underwent bone grafting and implant placement during the same sitting. Minimally invasive anterior maxilla bone augmentation appears to be feasible. Designated instruments for alveolar ridge splitting and nasal mucosa elevation are likely to further enhance this initial favorable experience.
Preoperative computed tomography reveals a narrow and low anterior maxilla ridge (underneath the nasal floor). Underneath the maxillary sinus the bone height is ∼4 mm. A polyp and septa are noted in the maxillary sinus.
Figure 2. Enlarging the osteotomy from 2 mm to 3.25 mm using a SplitMax chisel (C). The nasal floor is marked (F). Figure 3. Use of a SplitMax chisel (C) to widen the osteotomy and fracture the nasal floor (F). Note the piriform rim (P) and nasal septum (S). Various SplitMax tips are displayed. Figure 4. The first osteotomy (tooth 12) received bone substitute (B) and implant (I-12). The second osteotomy (tooth 13) was done using a SplitMax chisel (C) to lift the nasal floor (F) 4 mm. Note the anterior wall of the maxillary sinus (A) and the sinus septum (SS). Figure 5. Note the implants in area 12 (I-12) and area 13 (I-13). The implant tip extends 3–4 mm beyond the line of the original sinus floor and is surrounded by bone substitute (B). Figure 6. Sinus floor (SF) fractured with the minimally invasive antral membrane balloon elevation osteotom (O). Figure 7. Minimally invasive antral membrane balloon (M) elevation is done. Note the nasal floor (F), anterior wall of the maxillary sinus (A), and sinus septum (SS).
Figure 8. At 3 months after the procedure a new nasal floor (F) has formed. Figure 9. (a) Baseline panoramic view. (b) Panoramic view 8 months later. Figure 10. Computed tomography 8 months after the procedure. Note the implants at sites 12 (I-12), 13 (I-13), and 14 (I-14); the new nasal floor (NF); the inferior turbinate (IT); and the nasal lateral wall (LW), which is also the medial wall of the sinus (S). Figure 11. (a) Sagittal view of site 14. (b) Coronal view of site 14. Note the sinus (S) and the inferior turbinate (IT).
Figure 13. Preoperative computed tomography of the coronal plane. Figure 14. Preoperative computed tomography of the sagittal plane reveals 3 septa and 4 compartments in the left maxillary sinus.
Figure 15. Osteotomy enlargement using a SplitMax chisel (C), while splitting the nasal floor (F). Figure 16. While the first implant is placed (I-1) at area 11, the SplitMax chisel (C) is widening the osteotomy and splitting the nasal floor (F) for the second implant at area 12. Note the anterior wall (A) of the maxillary sinus and the sinus septum (SS).
Figure 17. Minimally invasive antral membrane balloon elevation (MIAMBE) performed in a maxillary sinus with 3 sinus septa (SS) and 4 compartments. The MIAMBE balloon (M) occupies the first compartment. The second implant (I-2) occupies the nasal floor (F) at area 12. Figure 18. While compartment 1 of the maxillary sinus undergoes bone grafting (B) and implant fixation (I-3), the minimally invasive antral membrane balloon (M) is inflated in compartment 2 of the maxillary sinus with 4 compartments and 3 sinus septa (SS). Figure 19. Minimally invasive antral membrane balloon (M) inflated in the third compartment (C3), while the first (C1) and second (C2) compartments undergo bone grafting and implant placement (I3 and I4). Figure 20. The 4 implants after minimally invasive antral membrane balloon elevation. Note the nasal floor (F).
Figure 21. Panoramic axial view 13 months after the initial procedure. Figure 22. Coronal section of the right side at 13 months: Note the new sinus floor (SF), sinus (S), lateral wall of the nasal cavity (LW), and inferior turbinate (IT). Figure 23. Coronal section of the left side at 13 months. Note the new sinus floor (SF), sinus (S), lateral wall of the nasal cavity (LW), and inferior turbinate (IT).
Preoperative panoramic radiograph. Note the sinus septa (SS).
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