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The International Journal of Periodontics & Restorative Dentistry
Dental implants offer a predictabletreatment modality for completelyor partially edentulous patients.1,2
After the introduction of the sinusgrafting technique,3,4 implant place-ment and prosthetic rehabilitationof the resorbed posterior maxillahave become a valid treatmentoption.5–8
Several grafting materials havebeen used to augment the antralspace, including autografts,3,4,9–13
demineralized freeze-dried bone powder,5,14–16 hydroxyapa-tite,5,8,12,16–18 xenografts,19,20 andcombinations of these.5,8,12,19,21–26
Regardless of the type of graft used, the sinus augmentation pro-cedure involves elevation of theSchneiderian membrane and place-ment of the graft material into thespace underneath the reflectedmembrane.3 The most commoncomplication during sinus graftsurgery is tearing or perforating thesinus membrane.26–28 If membraneperforation occurs, the opening canbe sealed with a piece of resorbablecollagen membrane.8,19,26–31 How-ever, to date, no study has validatedsuch repair.
The “Loma Linda Pouch”: A Technique for Repairing thePerforated Sinus Membrane
Periklis Proussaefs, DDS, MS*Jaime Lozada, DDS**
A technique, the “Loma Linda pouch,” is introduced for repairing the perforatedmaxillary sinus membrane during sinus grafting procedures. A collagen mem-brane is placed against the perforated site and subsequently covers the internalsurface of the maxillary sinus. The collagen membrane is then folded along thelateral access window to form a pouch that surrounds and isolates the graft mate-rial. (Int J Periodontics Restorative Dent 2003;23:593–597.)
**Assistant Professor, Graduate Program in Implant Dentistry, Loma LindaUniversity; and Private Practice Limited to Implant and ProstheticDentistry, Santa Clarita, California.
**Professor and Director, Graduate Program in Implant Dentistry, LomaLinda University, California.
**Reprint requests: Dr Periklis Proussaefs, Graduate Program in ImplantDentistry, Loma Linda University, School of Dentistry, Loma Linda,California 92350. Fax: + (909) 558-4803. e-mail:[email protected]
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A human study was performedat the Center for Prosthodontics andImplant Dentistry at Loma LindaUniversity, California, to evaluate theresults of sealing the perforatedmaxillary sinus membrane with aresorbable collagen membrane. Inall cases, the repair of the perforatedmembrane was accomplished byapplying a resorbable collagenmembrane against the area of theperforation (Fig 1). Biopsies weretaken during implant placement,and the preliminary data indicatedno or minimal bone formation at theperforated site. The data from thisstudy will be published elsewhere. Inmost cases, the graft materialescaped beyond the confines of theSchneiderian membrane (Figs 2 and3). As a result, the same center
developed a technique in which theresorbable membrane not only cov-ers the perforated site, but forms apouch around the entire internalsinus area to protect and isolate thegraft material in place.
The purpose of the present arti-cle is to introduce a new technique,the “Loma Linda pouch,” for repair-ing the perforated maxillary sinusmembrane. This technique may offersuperior protection and isolation ofthe graft material.
Technique
After identifying the perforated site(Fig 4), a resorbable collagen mem-brane is inserted into the maxillarysinus area (Fig 5). A curette can be
used to facilitate the insertion. Thecollagen membrane covers theentire internal maxillary sinus sur-face (Fig 6). The membrane needsto extend beyond the boundariesof the lateral window osteotomy.The graft material is inserted (Fig 7).A curette can be used to facilitatethe insertion of the graft into thesinus (Fig 8). The excess graft mate-rial is removed. The collagen mem-brane engages the graft material,forming a pouch that isolates thegraft material in place (Figs 9 and10). The lateral edges of the colla-gen membrane are folded at thearea of the lateral window os-teotomy (Figs 11 and 12). The buc-cal/palatal flaps are sutured abovethe collagen pouch.
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Fig 1 Placement of a collagen mem-brane has been proposed along the perfo-rated site to seal membrane perforation.
Fig 2 (right) By only sealing the perforat-ed membrane site, graft material can bereleased into the maxillary sinus areathrough the perforation.
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Fig 3 Escape of graft material into thesinus area. Collagen membrane placedpassively against perforated site cannotresist the mechanical forces exerted whengraft material is impacted into the sinus.
Fig 4 Large perforation of the maxillarysinus membrane can be observed.
Fig 5 Resorbable collagen membrane isinserted into the sinus area. A curette isused to facilitate the insertion.
Fig 6 Collagen membrane covers theentire internal sinus area.
Fig 7 Graft material is inserted into thepouch created by the membrane.
Fig 9 (left) Placement of the graft materi-al has been completed.
Fig 10 (right) Collagen membrane cov-ers entire internal maxillary sinus surface.
Fig 11 (left) Membrane is folded alongexternal sinus area where lateral access win-dow osteotomy has been performed. Mem-brane forms a pouch to cover and isolategraft material. Mechanical pressure duringgraft placement cannot displace membranebeyond perforation site (as in Figs 2 and 3).
Fig 12 (right) Collagen membrane isfolded along the lateral window site, form-ing a pouch that isolates the graft material.
Fig 8 Curette is used to further condensegraft material into maxillary sinus area.
Discussion
Perforation of the Schneiderianmembrane is the most commoncomplication during sinus graftingprocedures.26–28 Jensen et al28 re-port a 35% frequency of sinus mem-brane perforation, while others26 re-port a 40% occurrence when thesinus grafting procedure is per-formed for single-implant place-ment.
The use of a resorbable collagenmembrane to repair the perforatedSchneiderian membrane has beenadvocated by many authors.8,19,26–31
However, some concerns have beenreported in the literature regardingthe results of the sinus grafting pro-cedure when such a complicationoccurs. Jensen et al28 advocate theuse of bone chips around the pene-trated part of the sinus membranebecause of potential displacementof the graft material into the sinus.Others32 report that the use of par-ticulate bone graft is not predictablewhen the sinus membrane has beenperforated and recommend the useof a block graft. The describedpouch technique may offer in-creased protection and isolation ofthe graft material during sinus graft-ing procedures.
In addition, the formation of apouch in the described methodoffers the potential to cover the lat-eral access window by the same col-lagen membrane used to seal theperforated site. This may providefurther isolation of the graft material.Several authors have proposed thesinus grafting procedure without theuse of any barrier against the lateral
window.13,25,29 However, thesereports are based on the subjectiveassessment of each author. An eval-uation of histologic specimens har-vested in humans demonstratedsuperior bone formation within thegrafted maxillary sinus when a non-resorbable barrier was used to pro-tect and isolate the graft material.19
Nevertheless, other authors23 advo-cate the use of a resorbable collagenmembrane.
The Loma Linda pouch tech-nique may offer superior protectionand isolation of the graft materialduring sinus grafting procedures andwhen a perforation of the Schnei-derian membrane has occurred.However, a clinical study that wouldinclude histologic specimens de-monstrating bone formation withinthe area of the sinus is necessary tovalidate this technique.
Acknowledgments
The authors would like to thank DrsAlejandro Kleinman and Mac Ojano for theircontribution.
References
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