Dental News - Safe, accurate, simplified sinus-lift technique for general practitioners, Part 2: Introduction of surgical technique

Virgilio Mongalo and Jae Chang, USA

Thu. 4 April 2013

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In Part 1 of this three-part series, we presented a sinus lift technique involving hydraulic pressure to elevate the floor of the maxillary sinus. Many respected clinicians and researchers have taken the task to compare the effects as it is related to a percentage of sinus perforation using existent intracrestal sinus lift techniques.

These proven surgical techniques include the use of osteotomes (Summers — and its multiple variations), balloon lift, hydraulic sinus condensing technique (Chen and Cha) and motor-driven drilling systems.

Scientific articles published in 2012 by Loma Linda School of Dentistry (Garbacea and Lozada ) and the Department of Periodontics and Oral Medicine, University of Michigan School Dentistry (Chan and Avila), assessed crestal sinus floor elevation using cadaver heads and endoscopes to study the incidence of maxillary perforations. Both studies concluded that perforations can occur with any technique but are more likely to happen when the membrane is raised past the 10-mm mark measured from alveolar crest. A recent prospective study published in 2012 by the Division of Prosthetic Dentistry, Maxillofacial Unit in Sweden (Fornell and Johansson) presented a CBCT-guided osteotome sinus elevation technique that shows improvement over conventional techniques in that there is decrease in the percentage of perforations.

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The purpose of this article is to introduce a surgical technique that combines planning and drilling using CAD/CAM surgical guides with hydraulic intracrestal approach sinus lift. This technique is a combination of creative thinking from the authors and innovative instrumentation developed by Hiossen Implant Systems.

Four patients were treated using this technique; 20 taper-hydrophilic implants (Hiossen ET-III) were inserted and integrated over a period of six months. Two patients were partially edentulous and two were fully edentulous. A total of 12 fixtures were placed on sound residual anatomical bone and eight were placed on atrophic ridges (Misch classification SA3). The diameter of the fixtures in areas were sinus was lifted were 5 mm, and the length varied from 8.5 to 10 mm. This technique is indicated when treating patients with maxillary ridges with classification SA3 following Misch protocols for patients with 5 to 8 mm or Mongalo classification #B for ridges with 4 to 7 mm of anatomical residual ridges.

Patient No. 1 is a 55-year-old female missing posterior dentition. This case was selected to illustrate the technique, because it resembles cases that are commonly encountered in general-practitioner offices. The first step was to fabricate an all-acrylic partial with gutta-percha markers to be used as scanning prosthesis; the idea is to always keep in mind that surgeries should be guided with final prosthetics in mind (Fig. 1). The images from CBCT were converted into 3-D working models, and surgical plans (Fig. 2) were used to design and order CAD surgical guides (Fig. 3). Anterior implants not needing sinus lift were placed with the guide following flapless proven protocols (Fig. 4), and the guide was used to drill on the posterior site were lift was necessary by allowing the drills to be short 1 mm to the sinus floor (Fig. 5).

The floor of the sinus was imploded using non-cutting end drills (CAS) (Fig. 6). Three cc of saline was used to create hydraulic pressure and elevate the membrane (Fig. 7). One gram of non-ceramic synthetic bioactive crystals (Ossteogen by Implandent) was packed per implant site and fixtures were inserted at 20-30 Newtoms (Fig. 8).

All patients were scanned postoperatively to verify 360 degrees of bone spread surrounding the implant and to ascertain that sinus membrane was not perforated. Three-dimensional images revealed no perforation and excellent distribution of the synthetic bioactive material surrounding the implants placed.

Six months were allowed for bone remodeling and ossoeintegration. While this prospective study represents a very small number of cases to come to any kind of scientific conclusions, we are excited with the prospect of being able to introduce a technique that might reduce the percentage of perforations as a consequence of intracrestal sinus lifts.

Note: This article was published in Dental Tribune U.S., Vol. 8, No. 2, February 2013 issue.

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