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cLINICAL Predictable Sinus Tenting with Implant Placement by Timothy Kosinski, DDS, MAGD hen evaluating edentulous and minimizing the amount of available spaces in the posterior bone. No other details were provided by Wmaxilla for dental implant the patient, therapy, practitioners are often concerned with the compromised bone CBCT scan analysis using the PaX- quantity and quantity. The maxillary i3D Green Machine Imaging system in sinus sits below the eyes, above the Figure 1 (Vatech America Inc., Fort Lee, roots of teeth on either side of the NJ) shows the axial, sagittal and coronal cheek area of the face. When teeth are planes.. The axial plane is the plane Figure 1 present, the roots help elevate the sinus parallel to the ground, thus dividing the membrane like a tent pole holds up a face from top to bottom.. The sagittal circus tent. When teeth and roots are plane is one perpendicular to the removed, the bone may shrink apically ground, dividing the face from right to and palatally, but also the sinus floor left. Finally, the coronal plane,shows may collapse, as happens to the circus the plane perpendicular to the ground, tent if the tent poles are removed. dividing the face from front to back. (Figure 2.) Most often, the maxillary bone in the posterior part of the arch is relatively The sagittal view of our preoperative CT illustrates that there is 6.6mm of Figure 2 soft, or Type IV trabecular in nature. (1) The nature of the bone allows the skull available bone height from the crest of to be lighter to be kept on the shoulders. the edentulous ridge to the floor of the In conjunction with the softer bone is sinus. (Figure 3) the fact that occclusal forces placed on When considering implant placement teeth in the posterior of the jaw are the to replace a missing maxillary second greatest. In summary, the bone is the bicuspid tooth where the sinus cavity is weakest yet the chewing forces are the large and the available bone minimized greatest. several options for treatment can be Our 51 year old female with controlled considered. An invasive Caldwell Luc Figure 3 hypertension and a sulfa allergy procedure would create a window on presented with an edentulous space in the buccal aspect of the missing tooth the maxillary left second bicuspid area. and the sinus filled with bone grafting The tooth had been extracted about 12 material of the surgeon’s choice.(2) months previously. She developed an After an appropriate healing time, the infection at the extraction site and was grafted area would convert to bone thus hospitalized to get the infection allowing implant placement. Since under control. The extraction site was there are crowns on the anterior and reportedly allowed to heal without posterior teeth to the edentulous space, grafting, thus enlarging the sinus cavity a conventional three unit bridge would Figure 4 32 T P D S P r IN g 2 0 1 6 CA) was chosen as the implant of choice not be inappropriate as an adequate in this situation. The tapered design treatment option. Our patient requested and macro and micro threads of the consideration for a single dental implant system will allow for nice initial stability which would allow easy maintenance and allow for integration of bone to the and flossing. A sinus tenting procedure body of the implant. Figure 5 shows the would allow elevation of the sinus floor 2.2mm diameter pilot drill positioned enough to place an implant and restore Figure 5 in between the first bicuspid and first with an implant retained crown. molar teeth. The intent is to visualize the The maxillary Schneiderian membrane emergence of the final implant retained can be elevated or stretched without crown prior to any surgical intervention. complication. This membrane is Once the pilot drill is shown to be ideally bilaminar in design with ciliated angled mesial-distally, the epithelium columnar epithelial cells on the internal is punched and the tissue depth side and periosteum on the osseous measured with a periodontal probe side.(3) Tearing of this membrane may (Figure 6) Next the 2.2mm diameter drill result in sinus trauma and could affect is slowly positioned to approximately the osseointegration of the implant. 1-2mm below the sinus floor. This can Figure 6 be accomplished by moving the bur in We only had 6.6mm of available 2mm or so increments. height of bone preoperatively. In my experience I am able to predictably Next a 2.8mm diameter bur is used to tent the sinus membrane about 3mm widen the osteotomy to the desired in preparation to place an immediate depth short of the sinus floor. (Figure implant. Since tenting 3mm would not 7) From this point on flat tipped allow me to predictably place at least osteotomes are used to widen the a 10mm long implant, it was decided osteotomy and compress the porous bone along the walls to help stabilize that I would not place an implant Figure 7 immediately after tenting. Rather I would the implant. The osteotome is marked attempt to lift the sinus floor first and so that the proper depth in bone can be prepare the site for an eventual implant. determined at the soft tissue level. We (4) A tenting procedure was completed chose to place the implant 11.5mm into lifting the sinus floor significantly. The bone and the tissue depth was 2mm, allograft was allowed to integrate for therefore the osteotome is set at 13.5 approximately 5 months before implant mm to soft tissue (Figure 8). The digital placement. radiograph indicated that the osteotome has created a space for the implant Figure 4 illustrates a digital radiograph 11.5 mm into bone. Figure 9 shows Figure 8 of the perceived success of the initial the preliminary osteotomy intraorally. sinus grafting.after 5 months of healing. A resorbable membrane (Cytoplast , A 5mm ball bearing is radiographed Implant Direct, Thousand Oaks, CA) is and calibrated. The new vertical height positioned into the prepared osteotomy of available bone is measured to be site (Figure 11) and allograft material 11.5mm. Thus I was able to gain nearly (Direct Gen Min Blend Allograft, 5mm of vertical height. Implant Direct, Thousand Oaks, CA) is carefully placed into the socket. A The Implant Direct Legacy 3 dental larger osteotome is used to push the implant (Implant Direct, Thousand Oaks, Figure 9 800-337-8467 TheProfitableDentist.com 33 cLINICAL membrane and allograft to the desired is removed showing a healthy pink margins at the gingiva and a Bruxzir position (Figure 13). This technique gingival cuff of epithelial tissue (Figure zirconia CAD/CAM designed implant serves to protect the schneiderian 17) An impression transfer assembly retained crown (Figure 20) The titanium membrane from perforation. , CThe is inserted into the hex designed abutment is torqued to 30Ncm. Note Implant Direct Legacy 3 is torqued implant body. I place a small piece the margins created at the gingival line to proper position to the crest of the of cotton to prevent the impression (Figure 21) ridge at 35Ncm. Radiographically the material from going into the screw implant is positioned to the floor of the hole (Figure 18) Panasil tray soft The Bruxzir crown is cemented with sinus at 11.5mm. Because the implant and Panasil initial contact vinyl Improv implant cement (Salvin Dental, is properly torqued to at least 35Ncm, polysiloxzane material provides for Charlotte, NC) and a final radiograph a 2mm tall healing abutment is placed clean, crisp impression (Kettenbach, made to insure a complete seat of both and torqued to 25Ncm (Figure 15) The Huntington Beach, CA) and the transfer the abutment and implant retained flapless procedure is atraumatic with assembly is unthreaded from the crown (Figures 22 and 23). little or no bleeding around the healing implant and placed into a lab analogue The clinical procedure completed here abutment (Figure 16) which is used to fabricate the master was done in stages. First the sinus was cast. (Figure 19) Our Lab (Glidewell elevated using a tenting technique, After approximately 4 months of Lab, Newport Beach, CA) fabricates increasing the vertical height of bone integration the healing abutment a custom titanium abutment with from 6.6mm to 11.5 mm or nearly 5mm. Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 34 T P D S P r IN g 2 0 1 6 Following integration, an implant was schneiderian membrane perforation and sinus lift graft American Society of Osseointegration. outcomes: A Retrospecitve evaluation of 359 Augmented placed ideally to the floor of the sinus. sinus. J Oral Maxillofacial Surgery. January 2014, vol. 72, He is a Fellow of the American Academy issue 1, 47-52 of Implant Dentistry and received his The surgical protocol involved using 4. Cakur, B, Akif, M et al Relationship among schneiderian Mastership in the Academy of General osteotomes to compress the available membrane, Underwood’s septa and the maxillary sinus inferior border. Clinical Implant Dentistry and related Dentistry. Dr. Kosinski has received many bone and increase initial stability of the Research. Feb. 2013 Vol 15, Issue 1, 83-87 honors including Fellowship in the American dental implant. The legitimate concerns and International Colleges of Dentists and Dr. Timothy Kosinski is an Affiliated Adjunct about placing an implant in the maxillary the Academy of Dentistry International. He is Clinical Professor at the University of a member of OKU and the Pierre Fauchard sinus are addressed by creating Detroit Mercy School of Dentistry. He is a Academy.

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