Dental Asia March/April 2019

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User Report An Elegant Transcrestal Sinus Floor Elevation Technique Using Osteo Safe ® Written by Dr. Christophe Foresti Transcrestal sinus floor elevation osteotomy is a tried and tested technique that allows compensation of the lack of bone height under the maxillary sinus. 1-2 Indications of transcrestal sinus floor elevation osteotomy are: • sinus floor bone height above 4 mm with no need for horizontal bone increase • 3D radiological examination required • single edentulism It must be noted that this procedure is absolutely contraindicated for patients with a pathologic sinus, sinus floor bone height of less than 4 mm and an inner ear disease and/or history of paroxysmal positional vertigo. 3 Moreover, this procedure is relatively contraindicated for patients with a significantly slanted sinus, intrasinus septum compared with the osteotomy 4 , large gaps and who are smokers. History In 1986, Tatum was the first to imagine sinus floor elevation via a transcrestal approach for implant placement; but it was Summers, in 1994, who described the osteotome technique as it is used today: • indication of 5-6 mm bone height associated preferably with low density bone • an osteotome is a straight, graduated instrument with a round, calibrated section, with a concave end and cutting edges, which is tapped with a mallet to create the implant site. 5-6 However, in 1996, Lazzara proposed using a sequence of osteotomes, drill burs and screw-retained implants, indicated for sinus floor height of at least 5 mm, which remains the reference. 7 Technique The initial pre-drilling measures 2-3 mm in diameter, according to the heights and stops at 1-2 mm of the sinus floor (a preoperative X-ray with a depth gauge is highly recommended). The bone ridge is cut with osteotomes, with the least possible trauma, making sure no instrument penetrates the sinus cavity during surgery. Before continuing the procedure, the integrity of the Schneiderian membrane is checked with the Valsalva manoeuvre which consists in closing the nasal airways (presence of small bubbles at the bottom of the space created) while exhaling out forcibly and observing that no air leaks through the drilling channels. If the test is positive, surgery must then be suspended and postponed for two months. 8 In order to buffer the shocks caused by the osteotomy, bone tissue must be interposed between the end of the osteotome and the sinus floor. The presence of bone on the tip of the osteotome works as a hydraulic buffer that limits the risks of perforation. However, if the residual bone height is between 6 and 8 mm, the osteotomy is made with the help of osteotomes with a concave end and cutting sides that help collect the small fragments of bone along the sides of the drilling channels. In order to do this, the diameter of the 56 DENTAL ASIA MARCH / APRIL <strong>2019</strong>
User Report initial drilling channel must be inferior to that of the first osteotome used. Thus, the addition of bone substitute is only required to further increase the volume of sinus floor obtained. If the residual bone height is between 4 and 6 mm, it may be necessary to first place a bone substitute in the drilling channel before inserting the first osteotome, which will, in this case, have a convex end. Before implantation, an X-ray is taken to view the arch obtained. Bone substitutes, like xenografts and β-TCP, seem to be as effective as autogenic bone to increase an atrophic maxillary ridge with the sinus floor elevation technique. 9-11 Advantages and disadvantages A transcrestal sinus floor elevation osteotomy is an approach most dental practitioners use because of its benefits namely: • it is considered a low invasive surgery with minimal postoperative follow-ups 13 • it does not require end drilling, thus better bone/implant interface with lower risk of heating • only a very small enlargement of the alveolar crest is made with an improved peri-implant bone density 14-15 • simultaneous implant placement is possible • reduced treatment time, as implant integration occurs at the same time as bone filling consolidation (3 to 6 months, according to residual bone height) • lower in cost because it is a single surgery with a smaller amount of biomaterial used, as the implant contributes to increase the volume of the sinus floor. Despite all of its advantages, a transcrestal sinus floor elevation osteotomy is not without its drawbacks as it is a blind technique – sinus membrane is not visible 12 , patient feels discomfort due to the shocks caused by the osteotome hammering technique and it is not suitable for treatment of extensive defects. Conclusion The essential factor to enable simultaneous implant placements seems to be the residual bone height of the sinus floor before filling. The minimal value stated varies between 4 and 6 mm, according to studies. 1-16 However, more than this value, primary stability is one of the key conditions of success, hence the importance: • of the site preparation technique with an atraumatic condensing osteotomy • of the ability to compact the filling material • of the design of the implant itself. Although this is a blind technique that carries the risk of perforating the Schneiderian membrane, in very specific cases, transcrestal sinus floor elevation osteotomy represents the most cost-effective solution for the patient. This article will focus on two clinical cases which illustrate a new transcrestal sinus floor elevation technique with Osteo Safe ® , the automatic impactor developed by Anthogyr (Fig. 1). Fig. 1: Osteo Safe ® kit Calibrated impactions enable a more precise and homogeneous progression into the bone, thereby minimising the risk of perforating the sinus membrane, while also being synonymous to higher surgical comfort for the patient. Case 1 A 59-year-old male smoker patient presented preoperative X-ray (Fig. 2) showing a sinus floor bone thickness of 4.5 mm, where we will use concave end osteotomes. As the crestal width is favourable, we placed an Axiom PX self-drilling implant measuring 4.6 mm in diameter and 10 mm in length after bone tissue development. In a standard case, drilling is initiated with a Ø2.0 mm drill up to 1 mm of the sinus floor (Figs. 3-4) but, if bone density is higher, it is preferable to place 0.5 mm, resuming the drilling in order to use a moderate impaction force, resulting in a more comfortable experience for the patient during bone perforation (Figs. 5-6). Fig. 2: Preoperative X-ray Fig. 3: Depth gauge in place. Fig. 4: Follow-up X-ray with depth gauge in place. MARCH / APRIL <strong>2019</strong> DENTAL ASIA 57
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CONTENTS MARCH / APRIL 2019 18 24 2
Page 6: First Words The New Age of Digitali
Page 10 and 11: Dental Updates New VOCO Prophylaxis
Page 12: Dental Updates AACD Welcomes 2019 C
Page 15 and 16: Periodontal Disease Bacteria Linked
Page 18 and 19: Dental Updates Henry Schein One Acq
Page 20 and 21: Under the Spotlight 18 DENTAL ASIA
Page 22 and 23: Under the Spotlight It is easy for
Page 24 and 25: Word of Mouth by Dr. Christoper Ho
Page 26 and 27: CELEBRATING DIGITAL TRANSFORMATION
Page 28 and 29: Dental Profile achieve very good re
Page 31 and 32: Dental Profile TAKING DIGITAL IMPRE
Page 33 and 34: Dental Profile The high-precision S
Page 35 and 36: Dental Profile MARCH / APRIL 2019 D
Page 37 and 38: Clinical Feature The importance of
Page 39 and 40: Fig. 8: X-ray after extraction show
Page 42 and 43: Clinical Feature Glass Ionomer Seal
Page 44 and 45: Clinical Feature Fig. 1.1: An erupt
Page 46 and 47: Clinical Feature 7 TH GENERATION AD
Page 48 and 49: Clinical Feature 1. Decay is noted
Page 50 and 51: User Report CENTION N: REDEFINING D
Page 53 and 54: User Report Amalgam GIC Cention N P
Page 56: User Report Fig. 15: Teeth 46 and 4
Page 61 and 62: User Report Fig. 16: Postoperative
Page 64 and 65: Behind the Scenes REPLACEMENT OF EX
Page 66 and 67: Behind the Scenes angles due to the
Page 68 and 69: Behind the Scenes and silanated for
Page 70 and 71: Behind the Scenes A JOURNEY THROUGH
Page 72 and 73: Behind the Scenes Fig. 11 Fig. 15 r
Page 74 and 75: Behind the Scenes The overall aesth
Page 77 and 78: In Depth With Fig. 1: Primescan - t
Page 79 and 80: In Depth With The blue light used b
Page 81: In Depth With The first set of data
Page 85 and 86: In Depth With Extending Dental Oper
Page 87 and 88: In Depth With combines the cutting-
Page 89 and 90: Product Highlight BRAVIA ® XL Spec
Page 91 and 92: Product Highlight COLTENE Unveils t
Page 93 and 94: Product Highlight 3Shape launches T
Page 96 and 97: Show Preview 9 th -12 th June 2019
Page 98 and 99: Giving Back to Society February is
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