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The rehabilitation of the posterior sites of the maxilla with dental implants is a therapeutic procedure often influenced by the atrophy of the maxillary bone, caused by either the loss of dental elements or by the maxillary sinus pneumatization. Bone loss in the upper maxillae which prevents the placement of implant fixture, may be fixed with surgical bone regenerations techniques, such as the sinus lift, or with the placement of zygomatic and/or pterygoid implants. Although the proved effectiveness of these invasive therapeutic approaches, the biological and economic costs may be high. Also, the failure of these procedure, may further prevent the possibility of a second implant rehabilitation. In this scenario, the use of the short and ultra-short implants may be considered a valid minimally invasive alternative for the rehabilitation of the atrophic edentulous crests. Here, we describe a case of a female patient presenting with atrophic posterior maxilla which was rehabilitated with an implant of 3 millimeters in length after the failure of a previous surgical maxillary sinus lift through lateral window approach and with a total follow-up of 36 months.
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Annali di stomatologia
bone regeneration failure
Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report
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Original Article
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G. Falisi
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Department of Life Health and Environmental Sciences, University of L’Aquila,67100, l’Aquila, Italy
1971-1441
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bone regeneration failure
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Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report
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                                                                                                   Original article


Ultrashort implant in the upper jaw, an alternative
therapeutic procedure after the failure of the sinus
lift: a case report

Gianluca Botticelli 1                                      a female patient presenting with atrophic posterior
Ennio Calabria2*                                           maxilla which was rehabilitated with an implant of
Marco Severino1                                            3 millimeters in length after the failure of a previous
Giordano Foffo3                                            surgical maxillary sinus lift through lateral window
Pierpaolo Petrelli4                                        approach and with a total follow-up of 36 months.
Massimo Galli5
Calabria E6                                                Key words: ultrashort implants, sinus lift, bone re-
Giudice A7                                                 generation failure
Gatto R1
Giovanni Falisi1                                           Introduction
                                                           Implant-supported fixed prostheses represent a highly
1
    Department of Life Health and Environmental Scienc-
                                                           reliable therapeutic option and one of the most predict-
    es, University of L’Aquila,67100, l’Aquila, Italy
                                                           able dental procedures for treating partial posterior jaw
2
    Department of Neuroscience, Reproductive Sciences
                                                           edentulisms1-3.
    and Dentistry, University of Naples Federico II, Na-
                                                           The rehabilitation of posterior jaws may be clinically
    ples, Italy
                                                           challenging, especially when the residual bone volume
3
    Private practicer, L’Aquila, Italy
                                                           does not allow the proper insertion of implants with a
4
    Department of Innovative Technologies in Medicine
                                                           standard length of at least ten mm4.
    & Dentistry, University of Chieti—Pescara ‘Gabriele
                                                           In these situations, the placement of implants may pres-
    d’Annunzio’, 66100 Chieti, Italy
                                                           ent an anatomical issue due to the potential damage to
5
    Department of Oral and Maxillofacial Sciences, Uni-
                                                           noble anatomical structures such as the inferior alveolar
    versity of Rome La Sapienza, Rome, Italy
                                                           nerve or the maxillary sinus5.
6
    Private practicer, Lamezia Terme, Catanzaro, Italy
                                                           In addition, the implant rehabilitation of the posterior re-
7
    Department of Health Sciences, School of Dentistry,
                                                           gions of the upper maxilla may be even more compli-
    University of Catanzaro “Magna Grecia”,Catanzaro
                                                           cated by the volume reduction of the available bone due
    Italy.
                                                           to the loss of dental elements and the maxillary sinus
                                                           pneumatization 6-10.
*Corresponding author:                                     When the volume of the bone is inadequate for the
Elena Calabria, DDS, PhD                                   placement of standard implants, bone augmentation pro-
calabriaelena92@gmail.com                                  cedures are generally performed to provide the correct
                                                           bone volume quantity11.
Abstract                                                   According to Misch, to perform an implant rehabilitation
                                                           of the posterior maxilla in case of a width of bone < 5mm
The rehabilitation of the posterior sites of the maxilla
                                                           - category SA4, it is recommended to perform a maxillary
with dental implants is a therapeutic procedure of-
                                                           sinus augmentation procedure through a lateral window
ten influenced by the atrophy of the maxillary bone,
                                                           approach with a delayed positioning of the implant fix-
caused by either the loss of dental elements or by
                                                           ture12-13. Complications of this procedure are perforation
the maxillary sinus pneumatization.
                                                           of the Schneiderian membrane (25.7%), rhino-sinusitis
Bone loss in the upper maxillae which prevents the
                                                           (4.2%-8.4%), exposure of the bone graft (3.1%), and
placement of implant fixture, may be fixed with sur-
                                                           loss of the graft (1.6%)14-19.
gical bone regenerations techniques, such as the
                                                           Another approach in the case of maxillary atrophy is us-
sinus lift, or with the placement of zygomatic and/or
                                                           ing zygomatic implants. However, studies have demon-
pterygoid implants. Although the proved effective-
                                                           strated a higher number of complications with zygomatic
ness of these invasive therapeutic approaches, the
                                                           surgery compared to traditional sinus lift and implant po-
biological and economic costs may be high. Also,
                                                           sitioning procedures 20-21.
the failure of these procedure, may further prevent
                                                           In recent years, the use of short (5-10 mm) and ultrashort
the possibility of a second implant rehabilitation. In
                                                           implants (< 5 mm in length) has been suggested as an
this scenario, the use of the short and ultra-short
                                                           alternative therapy to such surgical options for prosthetic
implants may be considered a valid minimally in-
                                                           restoration in resorbed jawbones 4,5,22. Patients treated
vasive alternative for the rehabilitation of the atro-
                                                           with short and ultrashort implants may benefit from a
phic edentulous crests. Here, we describe a case of
                                                           rehabilitation based on fewer surgical procedures, with
Annali di Stomatologia 2020; XI (1-4): 28-32                                                                              28
     Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report

     less invasiveness and minor postoperative discomfort or              per left molar extracted (tooth 2.6- figure 1) because of a
     complication23.                                                      vertical fracture following the endodontic treatment.
     We report the case of a female patient presenting with               The patient reported that about four months following the
     severe maxillary atrophy, which was rehabilitated by in-             tooth extraction, she underwent a maxillary sinus aug-
     serting an ultra-short implant of 3 millimeters associated           mentation through the lateral window approach, with the
     with the technique of a minimal invasive crestal sinus lift          insertion of biomaterial grafting. However, she further re-
     after the failure of a previous maxillary sinus lift. 28,29,30       ported having developed acute sinusitis of the left maxil-
                                                                          lary sinus after two weeks as complications of the surgi-
                                                                          cal procedure, requiring a second surgery to remove the
     Case report
                                                                          grafting material. After 18 months, the clinical situation
     A female patient, 47 years old, a smoker with an un-                 was an atrophy degree of < 5mm - category SA4 (Figure
     remarkable medical history, was referred to the dental               2), so we first proposed the second procedure of sinus
     clinic of the University of L’Aquila (Italy) to rehabilitate         floor elevation.
     the partial posterior edentulism in the upper left maxilla.          However, the patient was looking for an alternative, less
     She reported that two years before, she had the first up-            invasive solution.




     Figure 1. OPG of the patient referring to the period when the first upper left molar was still present.




     Figure 2. OPG of the patient which highlights the absence of the dental element 2.6 and the severe maxillary atrophy.

29                                                                                            Annali di Stomatologia 2020; XI (1-4): 28-32
G. Botticelli et al.

Since the residual maxillary bone height measured 3              was prepared (with a reduced depth to that one needed),
mm, we suggested positioning an ultra-short implant              a pellet of equine collagen (Congress - Smith&Nephew)
in association with a minimal invasive crestal sinus lift.       was placed inside the prepared surgical site. Afterward,
Then, using the same implant as the residual bone com-           the implant was placed in the preparation site to deter-
paction tool along with its insertion, without performing        mine a greenstick fracture of the maxillary sinus floor.
further bone increase.                                           The implant surgical site was prepared with a diameter
An ultra-short implant of 3 mm and 5.1 mm in diameter            equal to that of the ultrashort implant; thus, the implant
was placed. The implant was made of Titanium of grade            placement was performed by giving a simple and con-
4, with a sandblasted and etched surface, and character-         trolled push to the fixture. The surgical site was sutured
ized by a conometric connection with 4° degree, with a           with VICRYL TM - Ethicon (caliber: 4/0, color: purple,
complete tubular section, hollow inside (IM Maco, Maco           shape: cylindrical, needle length: 17.4 mm, gauge: 21).
International). This fixture is characterized by a flat, self-   The sutures were removed seven days later. The patient
taping apical portion with a plateau. The coronal platform       was provided with postoperative instructions, including
is inclined with a trapezoidal section to increase the bone      antibiotic therapy as indicated, the use of non-steroidal
contact surface. The implant-abutment presents a trans-          anti-inflammatory drugs as needed, and the intake of
mucosal length of 3 mm.                                          a liquid diet for three days. In addition, the patient was
Antibiotic prophylaxis was scheduled based upon admin-           recommended to use chlorhexidine spray 0.2% for four
istering two gr/day of amoxicillin starting 1 hour before        days, cleansing with 10% hydrogen peroxide using a
the surgical intervention and continuing for the next three      sterile hydrophilic gauze to be passed over the sutures.
days every 12 hours24. Before the surgery, oral disinfec-        After about four months after the first operation, the sec-
tion was performed with chlorhexidine (0.2% solution for         ond surgical procedure was performed to expose the
one minute). Local anesthesia (OPTOCaIN®, 20 mg/m                head of the implant and remove the healing screw. A Ti-
with adrenalin 1:80,000. Molteni Dental— Italy) was ad-          tanium abutment of grade 5 was placed, and a provision-
ministered on both vestibular and palatal mucosa. First, a       al prosthesis was made in acrylic resin and then applied.
total-thickness mucoperiosteal flap was raised to reveal         After two months, the final crown in layered zirconium
the underlying alveolar bone. The protocol preparation           was cemented (Figure 3a).
phase of the implant site consisted of a first perforation       The patient attended a clinical follow-up twice a year
of the bone using a lanceolate burr, maintaining intact          as part of her routine oral hygiene program. The radio-
the cortex of the sinus floor, and proceeding sequentially       graphic follow-up at 12 and 36 months from the mastica-
by using the preparation burrs to obtain a slightly less         tory load highlights a good osteointegration of the fixture
deep implant site. Once the planned diameter of the site         (Figures 3b and 3c).  




                                                                                                Figure 3. A. Orthopanto-
                                                                                                mogram showing the defini-
                                                                                                tive crown visible in the sec-
                                                                                                ond quadrant B. periapical
                                                                                                x-ray one year after implant
                                                                                                loading. C. periapical x-ray
                                                                                                examination three year af-
                                                                                                ter implant loading.


Annali di Stomatologia 2020; XI (1-4): 28-32                                                                                     30
     Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report

     Discussion                                                         References
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