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Simplified Sinus Lift Surgery

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Simplified Sinus Lift Surgery 56 ce ORAL SURGERY Test 168 dentalCEtoday.com Simplified Sinus Lift Surgery ental implants for edentulous a b areas of the mouth have become only D the standard of care in the United States, and the number of dentists, particu- larly general dentists, placing them is in - creasing. One challenging location for these implants, however, is the posterior Karl R. maxilla. Even with adequate crestal bone Koerner, DDS, width, implant placement may be limited MS by a lack of vertical bone height. In the past, surgical techniques to over- come this obstacle were daunting, and the use thought of approximating the maxillary Figures 1a and 1b. Crestal Approach Sinus (CAS) Kit from HIOSSEN (a). Round-ended sinus drill with blue sinus was out of the question for more con- stopper. All drills in the kit are 13 mm long. This 9 mm stopper only allows 4 mm of cutting length to be servative clinicians. With the development utilized (b). of new innovative surgical instrumenta- tion and careful case selection, more den- a b tists are now using new protocols and per- David Chong, forming at least some of these implant- DDS associated surgeries on a regular basis. This article presents brief background informa- tion and describes the surgical procedure for a crestal approach sinus graft using a predictable, minimally invasive technique. TYPES OF SINUS GRAFTS Sinus displacement/bone graft surgery in dentistry via a window made on the lateral wall of the sinus was described in the 1980s Figures 2a and 2b. Pre-op radiograph. A sinus graft and implant placement are treatment planned for a 1 2 3 maxillary first molar site (tooth No. 14). There are 5 mm of crestal bone available to provide implant by Boyne and James, Misch, and Tatum. stability (a). Post-op radiograph. The clearly defined symmetrical bone graft was placed through the implant They suggested methods to increase the site osteotomy by the technique described in this article. Graft material is ß-tircalcium phosphate alloplast amount of intra-alveolar bone in the posteri- combined with autogenous bone (b). or maxilla necessary for implants that would be long enough to support dental prostheses. addition, the sinus commonly pneumatizes olar sinus floor elevation using twist drills A less invasive way to increase vertical bone or expands closer to the oral cavity. Septa can (without ridge expansion) instead of osteo - height for implants when several millime- be found about one-third of the time in eden- tomes would, of necessity, require more bone ters of intra-alveolar bone is already present tulous patients and one fourth of the time width than 3 mm to allow for the osteotomy was proposed by Summers4 in 1994: the when the dentition is present. Such septa are plus additional bone on the buccal and lin- osteo tome sinus floor elevation technique. reported to have a mean height of 4.78 ± 1.76 gual of an implant (at least one mm on each This article presentseducational a modified and less trau- mm in length and are located 60% in the side). The original Summers technique re - matic version of the Summers technique. middle region of the maxillary sinus, 22.5% quired between 7 and 10 mm of bone be - in the posterior region, and 17.5% in the tween the bone crest and floor of the sinus. NATURE OF THE MAXILLARY SINUS anterior region.6 The ostium or drainage ori- Later, Rosen et al8 reported the implant suc- The maxillary sinus is a pyramid with its fice for the sinus is located at the extreme cess rate to be highest in cases where the pre- base facing medially (toward the nose). Its upper extent of the medial wall and averages operative vertical bone height was greater volume is approximately 15 to 20 cc. It is 28 about 2.4 mm in diameter.7 than 5 mm. Disadvan tages of this technique, to 37 mm high (vertically), 32 to 34 mm from however, can include: perforation of the anterior to posterior, and 23 to 25 mm wide CHARACTERISTICS OF THE sinus membrane, ridge fracture (especially if (bucco-lingually).5 The sinus often pneuma- SUMMERS TECHNIQUE the ridge is narrow), patient discomfort and Fortizes with age and grows larger to be in close The Summers technique as originally de - even vertigo from malleting with osteo - proximity to the roots of premolar and scribed required a minimum existing ridge tomes, complications from treating patients molar teeth. If teeth are extracted, there is width of 3 mm that could be widened with with an oblique sinus floor, and fracturing of not only alveolar ridge resorption, but in progressively larger osteotomes. A transalve- bony trabeculae. DENTALCETODAY.COM • DECEMBER 2013 MOVING BEYOND THE SUMMERS TECHNIQUE—LESS TRAUMA, FEWER COMPLICATIONS Other, newer nonosteotome sinus elevation/bone aug- mentation devices and tech- only niques are now available to more safely accomplish this procedure and lessen the problems listed above. In cluded in the various brands currently available are HIOSSEN’s Crestal Ap - proach Sinus (CAS) Kit (shown in Figures 1a and 1b and described in the use paragraphs below), Zim - mer Den tal’s Sinus Crestal The maxillary sinus is a pyramid with its base facing medially (toward the nose). Ap proach Kit, and Neobio - tech’s SCA Kit, which de - spite their differences in de - sign, all provide a mini- mally invasive trans alve - olar osteotomy and bone grafting technique for im - plant placement that can be ac complished in a short period of time. Prerequisites to be able to use these kits are that a clinician should: (1) be trained and experienced in implant placement, (2) uneducational - derstand principles of bone regeneration, and (3) have completed training that provides necessary expert- ise in doing procedures that involve the maxillary si nus, including knowing how to manage potential complications. There are Foravailable programs that meet these criteria. This procedure should not be performed if there is 58 ORAL SURGERY any disease, condition, or medication a b that might compromise healing or Table. Amount of Graft osseointe gra tion.9 A consultation with Needed* a specialist can be obtained if needed. There should be sufficient bone buccal and lingual to the proposed osteotomy Lift Height Bone Graft and at least 5 mm of vertical bone 3 mm 0.4 cc height (Figures 2a and 2b). With this system, the sinus floor does not have to 4 mm 0.5 cc be completely flat, but septa are avoid- 5 mm 0.7 cc ed if possible as they can increase the 6 mm 0.9 cc chance of membrane perforation. c d CASE REPORT *Amount will vary according to sinus A surgical case is presented that de - size. Confirm with radiograph. monstrates an intra-alveolar sinus lift only As with any implant surgery, diagnostic radiographs are of critical im portance. e f procedure with photographs and ra - si nus drills and still staying 2 mm diographs from start to finish—pre- away from the sinus (as enabled by operatively to 5 months postopera- using stoppers), the clinician progres- tively (Figures 3a to 3j). sively widens the osteotomy with the use CAS Kit drills (available sizes: Ø2.8, Surgical Procedure, Step-by-Step Ø3.1, Ø3.3, Ø3.6, Ø3.8, Ø4.1), being As with any implant surgery, diagnos- careful not to use a diameter that is tic radiographs are of critical im por - larger than the implant to be placed. tance. Panoramic radiographs have There are a total of 11 stoppers la - been commonly used in the past with beled 2 to 12 mm. The 2-mm stopper most clinicians now opting in favor of is the longest one, indicating the g h cone beam computed tomography usable length of the drill from its tip with its clarity, contrast, and image ac - to the apical edge of the stopper as 2 curacy. Intraoperatively, periodic peri- mm. Again, the speed can be about apical x-rays can be taken with drill in 1,000 rpm until closer proximity to place to confirm preoperative meas- the sinus is achieved. urements and guide the progress of Next, the stopper is set to drill (1) the procedure. one mm away from the sinus and (2) This sinus surgery is exposed to a drill to width (same size as the implant wide range of bacteria, so a broad- or the next drill size smaller than the spectrum antibiotic along with an implant) by going up the progressively antibacterial rinse is recommended. wider sizes of drills. Note, in softer i j A common protocol is: (1) amoxi- bone, some drills can often be skipped. cillin 500 mg 3 times a day starting at When this close to the sinus, the speed least one hour prior to surgery with a should be slowed to between 400 to loading dose and continuing for 5 600 rpm (the less experienced the oper- days post-op, and (2) chlorhexidine ator, the slower the speed). gluconate (0.12%), rinsing twice a Finally, the stopper is set so that day starting 2 days before surgery and the appropriate drill (in width and continuing for 7 days. length) will penetrate the last re - The first surgical step is to create maining millimeter of bone. At this a full-thickness mucoperiostealeducational flap point the speed should only be 400 ex posing crestal bone. Using a No. 6 rpm to maximize tactile feel, even round bur, a “divot” is made about slowing to 50 to 100 rpm as the drill Figures 3a to 3j. Radiograph of tooth area No. 3 showing approximately 6 mm of vertical (residual) bone height.
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