2015-16 DIO CLINICAL CASE REPORT CONTEST 2015-16 디오임플란트 임상케이스 공모전
DIO Implant takes the dream and the future and will leap forward. We will strive to be Global Top 3 through constant progress.
Leader of healthcare solution 항
상 저희 디오임플란트의 발전과 성장을 위해 아낌없는 격려를 보내주시는 고객 여러분들에게 진심으로 감사를 표합니다.
저희 디오임플란트는 대한민국을 대표하는 임플란트 전문기업이 되기 위해 지금 이 시간에도 부단한 연구 개발과 품질 관리를 거듭하고 있습니다. 그 결과 세계 최고의 임플란트라 자부할 수 있는 UFII System과 Full Digitalized Computer Guided Surgery System DIOnavi.를 통해 대한민국을 넘어 세계 임플란트 시장을 선도하는 기업으로 발돋움하게 되었습니다. 현재 전세계 치과계는 IT 기술을 접목한 Digital 진료환경을 통해 보다 빠르고 한 차원 더 높은 수준의 진료가 가능하게 되었고, 저희 디오임플란트는 이러한 치과계 패러다임의 변화를 선두에서 이끌어 가기 위해 세계에서 가장 진화된 Digital 기술을 활용한 제품들을 출시, 고객 분들의 Digital Dentistry에 대한 꿈을
W
e, DIO Corporation, hereby express our heartfelt gratitude to your everlasting encouragement and support for the development of our company. As you know well, world dental industry is now moving rapidly toward the digital dentistry using the state-of-the-art digital devices from the traditional analogue dental environment. We are doing our utmost to provide you with the world-best digital dentistry system and dental implant being the global digital leader of the rapidly changing circumstances of the dental industry.
실현시켜 드리고자 노력해 왔습니다. 그리고 이러한 일련의 노력의 일환으로 귀하의 고견과 소중한 연구 결과가 담긴 임상 증례를 확보하여 고객과 함께 Digital Dentistry를 만들어 가는 디오임플란트의 모습을 갖추려고 합니다. 이에 금번 저희가 준비하는 디오임플란트 임상 공모전에
In order to be the world leader more quickly, we hereby politely invite you to our clinical cases contest as attached. We sincerely request you to participate in the contest and give us your valuable study reports so that you can highly contribute to our being global leader of the digital dental industry.
참여하셔서 DIGITAL DENTISTRY의 완성에 동참하시기를 정중히 부탁드립니다. 공모를 통해 수집된 귀하의 우수 임상 사례는 발전하고 있는 치과계의 현시점을 되짚어 보고, 앞으로 나아갈 방향을 모색할 귀중한 자료가 될 것입니다. 항상 저희 디오임플란트와 치과계 발전을 위해 헌신해 주시는 귀하의 지원과 협조에 무한한 감사를 표하며, 보다 발전된 모습으로 찾아 뵐 것을 약속드립니다.
Jin Cheol Kim Chairman & CEO
회장 김진철
CANDIDATE QUALIFICATIONS
- Open to all dentists REGISTRATION
Visit the official website (http://ccc.dioimplant.com) to register and submit cases
The case submitted should meet the following criteria - Originality | the case that has never been published in journals before. - The format of article must include followings. a) Title b) Introduction c) Case description d) Discussion e) Conclusion f) 3500 and 7000 words (generally 10 or 20 A4 pages) g) Written in English If requested, Chinese and Korean participants are allowed to write reports in their native languages
- The submitted data will be owned ©DIO IMPLANT for scientific and commercial purpose. - ©DIO IMPLANT and doctors will sign an agreement for further process when clinical cases win
응모자격
전 세계 치과의사 면허 소지자 응모방법 공식 웹사이트 http://ccc.dioimplant.com 로그인 후 참가신청서 작성하여 응모할 자료 업로드 응모 시 유의사항
- 국내외 저널에 게재되거나 논문으로 발표된 사실이 없는 최초 제출자료에 한함. - 논문 발표 또는 치의학 관련 저널에 투고할 수 있는 형태 및 분량 : A4 10~20page : 고해상도 이미지(1MB) 5매 이상 첨부 - 영문 작성을 원칙으로 함 : 한국, 중국 참가자의 요청이 있을 경우 예외적으로 자국어 작성-당사에서 번역 - 제출된 자료의 소유권은 당사로 귀속되며, 논문 발표 시 작성자와 Co-Work 진행
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Surface treatment analysis of UFII Implant UF II Implant
Initial stability study of UFII Implant Marginal bone loss after UFII placement Gingiva change by the kinds of abutment after UFII placement Edentulous cases by DIOnavi. Sinus lifting by DIOnavi. Solutions of free end cases
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Solution for difficult cases by DIOnavi. Comparison between conventional impression and digital impression after DIOnavi. treatment Narrow ridge cases by DIOnavi. Maxillary anterior cases Immediate loading cases Cases with a large number of metal prosthesis in oral
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” The above subtitles are DIO's suggestion for your reference. The other titles about UFII / DIOnavi. / DDS are also available.
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Comparative Study of the Osseointegration of six brands of dental implants during the first four weeks following implantation NOBEL Replace*, TS System OSSTEM*, NEO Biotech*, FX Dentium*, Seven I*, DIO* UFII November 2014
Dr. Alejandro Aguilar W. / MC Roberto B. Palma C.
Introduction Osseointegration is the key to success for the new implant systems, the most important phenomenon in implantology. Studies focus on the understanding of this process since it enables quick and in some cases immediate rehabilitation.1 Studies are currently being carried out on titanium oral implants, as well as on alloys and their effect on osseointegration, osteoconduction and osteoinduction, using different methods to modify the structure of both the bone and the implant, adding biological and chemical substances in hopes of improving their properties. The concept of osseointegration 1 is based on research conducted since 1952, starting with studies in rabbits to determine the intimate connection between fibrous tissue and bone. Titanium chambers were used for this purpose, in which integration between the bone, the tissue and the chambers was observed, because they could not be removed once the bone had healed. When the bone pieces were cut it was noted that the bone had copied the irregularities of the chamber perfectly. Further experiments focused on the repair of mandibular defects, until arriving at the idea of replacing the dental root with a screw.2 The term osseointegration is often defined as an internal and stable relationship between the anchoring of the implant and formation of bone tissue without the growth of fibrous tissue in the bone-implant interface. This implies that the osteoblasts and the mineralized matrix are in contact with the implant surface, even when occlusal loads are applied. On the other hand, the lack of osseointegration can be conceptualized as a failure in the formation of the mineralized extracellular matrix on the implant surface.1 Osteoinduction is the process by which osteogenesis is induced and is a phenomenon seen with regularity in the bone repair process. Osteoconduction refers to the growth of bone on a surface and is seen in the case of bone implants.3
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Digital Implant NO.1 DIO IMPLANT
The rate of osseointegration for titanium dental implants is related to their composition and surface roughness; this favors anchorage and biomechanical stability. Osteoconductive coatings of calcium phosphate on the implant promote healing and attachment, leading to the rapid biological fixation of the implant. Treatments of the surface include plasma spraying, abrasive blasting, acid etching, anodizing or calcium phosphate coatings, and their corresponding surface morphologies and properties. Most of these surfaces are commercially available and have demonstrated clinical efficacy.1 One of the objectives of this work is to evaluate the osseointegration of six implant surfaces from different manufacturers.
Methodology A study was carried out in more than 100 patients who received implants of the following brands: TS System de OSSTEM*, NeoBiotech*, Fx Dentium*, Seven I*, Nobel Replace* and DIO UFII. These were radiographically evaluated 40 days after placement. The intention was to observe how the bone structure was formed around the implant, to learn how osseointegration came about in the first month of implantation, as well as to observe how cancellous bone tissue is architecturally organized around the implants and compare this with bone organization around a natural tooth. Ultra High Definition Digital X-Ray equipment and densities filtration software (2010 COREL CORPORATION - PHOTO PAINT X15) was used for this study. The resolution and chromatic filtration parameters for the study are shown in table 1. Parameter Temperature Tone Saturation Brightness Contrast Highlights Shadows Halftoning
Level 7425 - 19 78 31 63 -33 17 -20
Table 1. The parameters that were used to obtain the densities of the tissue surrounding the implant.
Figure 1. Display of density of the bone structure around a tooth.
Results Images were obtained of the implants (TS System de OSSTEM*, NeoBiotech*, Fx Dentium*, Seven I*, NOBEL Replace* y DIO* UFII) as well as of natural teeth by means of Ultra High Definition Digital X-Ray and densities filtration software. Figures 1, 2, 3, 4, 5, 6 and 7 (The results were plotted according to qualitative observation)
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Digital Navigation Implant DIOnavi.
Osseointegration
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88% Longitudinal Transverse
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Figure 2. Bone density around the DIO* UFII implant and a close-up of the bone-implant interface
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FX Dentium*
Figure 3. Bone density around the FX Dentium* implant and a close-up of the bone-implant interface
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IS-II NeoBiotech*
IS-II NeoBiotech*
18% 1% IS-II NeoBiotech*
Figure 4. Bone density around the NeoBiotech* implant and a close-up of the bone-implant interface 08
Digital Implant NO.1 DIO IMPLANT
Osseointegration
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Nobel Replace*
Nobel Replace*
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Figure 5. Bone density around the NOBEL Replace* implant and a close-up of the bone-implant interface. Osseointegration
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TS III Osstem*
TS III Osstem*
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TS III Osstem*
Figure 6. Bone density around the TS OSSTEM* implant and a close-up of the bone-implant interface. Osseointegration
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25% 12% Seven*
Figure 7. Bone density around the Seven I* implant and a close-up of the bone-implant interface. 09
Digital Navigation Implant DIOnavi.
Discussion Despite the achievements of current implantology there are still several problems to be solved. One is the understanding of regeneration around the implant. How does it come about? What about osseointegration? How do different treatments of the implant surface help to accelerate union to the bone? Most importantly, how do we go about deciphering the cascade of biological reactions that come about during implantation?3 There are three different stages in bone evolution that make the bone tissue capable of regeneration. The first and most important phase, osteoconduction, is based on the construction of a base for recruitment to facilitate the migration of osteogenic cells onto the implant surface. This primary process is carried out thanks to what I call the first regeneration scaffold: the blood clot. The success of cell migration would be guaranteed if an implant has good blood wettability on its surface and the clot on the surface is uniform. The second phase of regeneration is the formation of new bone (osteogenesis). As this phenomenon develops, second and third regeneration scaffolds emerge. Collagen is first secreted by the precursor osteoblasts and subsequently the osteoblasts that are converted into osteocytes begin to secrete proteins to mineralize the collagen, constructing a bone matrix which will create a mineralized interface along the surface of the implant that would be equivalent to the cement line that exists naturally between teeth. Once these two phases are carried out the bone begins to mature increasingly and osteogenesis slowly comes about until complete bone remodeling is achieved with enough proper biomechanical strength to support the loads that are transmitted by the implant once chewing is rehabilitated. In the cascade of events that occurs once the implant is placed in its niche, the first thing the implant will have contact with is the blood, which as it clots forms a fibrin network. We consider this to be the first regeneration scaffold, and this network is of great importance to osteogenesis. Once stabilized, this fibrin network seeks to unite on tissue, or in this case on the implant surface which will form a strong and stable union. This depends on the osteoblasts being able to migrate a certain distance towards the implant to establish bone on the damaged bone or on the implant surface.3 Osborn and Newesley described the phenomenon of distance osteogenesis and contact osteogenesis by which bone can become juxtaposed to an implant surface. With the proper distance the new bone is formed both on the surface of the bone niche and around the implant. Both the endosteal and periosteal bone provide a quantity of osteogenic cells producing a new matrix that slowly invades the implant. This is because when creating the site for the implant, primarily cancellous bone is destroyed, which is easily dissolved by osteoclasts to make way for remodeling by osteoblasts.4
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Digital Implant NO.1 DIO IMPLANT
Unlike contact osteogenesis, bone is formed directly on the implant surface. To clarify, it is actually a mineralized matrix without collagenous proteins. This occurs because when creating the implant site there are active osteoblasts that secrete a number of non-collagenous proteins, such as osteopontin, that are responsible for mineralization. These proteins create the environment for a precipitation of various hydroxyapatite precursors5 (de novo formation) that subsequently grow as nodules forming what is called the cement line along the implant surface. Later these are covered with a collagen layer to make way for the next mineralization that will form the bone-implant interface. These two phenomena are influenced by biology as well as by the implant surface finishing, design and biomechanics, which is called tissue engineering. According to this, we see that with the DIO* (UFII) implant there was perpendicular bone growth similar to that which occurs in a natural tooth (see Figures 1 and 2). In the FX Dentium* implant we are able to observe few fibers towards the upper area, some in a parallel direction and only towards the apical part do we see diffuse bone density. See Figure 3. We were unable to observe bone density in the upper part of the NeoBiotech* implant; only in the apical part do we see a little perpendicular bone density. See Figure 4.
In the Seven I* implant we can observe little density of bone fiber in a parallel direction along the implant. See Figure 7. Unlike the DIO* UFII implant, in which the trabecular meshwork runs perpendicularly, in other implants parallel trabeculae are observed. The organization of perpendicular trabecular meshwork provides better biomechanics between the bonding of bone and the implant, similar to a natural tooth. According to Davies, we conclude that the DIO* UFII implant has excellent conduction as the surface achieves good anchoring at the beginning for the protein fibrin created during the bleeding that occurs during the drilling of the implant bed. This causes active osteoblasts to migrate from the alveolar bone (new bone formation by direct ontogenesis) via the network of impregnated fibrin on the implant surface and begin to secrete small nodules of hydroxyapatite according to the literature3 (see Figures 8, 9 and 10). Davies calls this surface the cement line. Once the implant surface on the bone wall adjacent to the implant is carpeted with nodules, osteoblast precursors begin to differentiate. As they differentiate, they start spreading a collagen network parallel to the implant until they make contact with the nodules (see Figure 11). Later these parallel fibers are mineralized and form perpendicular fibers that give the implant biomechanical support.3
In the NOBEL Replace* implant we are able to observe good bone density but it was parallel to the implant, and the trabecular meshwork does not join the implant thread as in the case of DIO* UFII where the entire parallel trabecular meshwork unites with the implant thread. See Figures 2 and 5. In the OSSTEM* TS implant we are able to observe few fibers towards the upper part, some in a parallel direction and only towards the apical part are there a few perpendicular fibers that connect with the implant threads. See Figure 6.
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Figure 8. Observation of the interface between the bone and the implants; the nodules of new bone which do not have a collagen matrix (cement line) can be observed.4
Figure 12. Close-up of the area of union of the collagen fibers with the nodules. Once this union is established, calcification of these fibers begins, creating new bone towards the implant.4
Our preliminary conclusions are that for the bone to form correctly and evenly all surfaces of the implant and the formation of the bone matrix must be created with a horizontal trabecular similar to that of a natural tooth: 1. Contact osteogenesis is the most important phase in the initiation of osseointegration on the implant surface.
Figure 9. Nodules on the implant surface along with a collagen layer coming from the adjacent bone.4
2. The implant surface must be homogeneous, free of any impurities or scratches in the manufacturing process. Its architectural design must enable and facilitate the collagen-free hydroxyapatite deposition (cementum) which is the first contact of bone with the implant surface. 3. During the clinical procedure the physician must work in an environment that is free from dust and microorganisms that can contaminate the implant surface. 4. The cleanliness, purity and homogeneity of the implant surface is critical. 5. The surface roughness (rugosity) has a definitive influence on the bone matrix formation.
Figure 10. . Close-up of the nodules made up principally of nanometric hydroxyapatite crystals.4
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Digital Implant NO.1 DIO IMPLANT
Natural teeth have an organization of perpendicular trabecular meshwork. This trabecular meshwork collides with the cortical plate which is in contact with the periodontal ligament which in turn is fixed with the root cement and forms a solid and biomechanically stable bond which gives it resistance to the occlusal forces that the tooth must withstand. Therefore, the implants that do not have this perpendicular development, but rather a predominantly parallel development, tend to have biomechanical problems in the future and their resistance to chewing forces will be less. The development of a parallel trabecular meshwork does not appear to have good fibrin anchorage on its surface which causes it to break, and adequate contact osteogenesis does not take place. Therefore, the collagen regeneration scaffold does not grow perpendicularly as the cement line does not exist upon which to anchor the fibers normally.
Bibliography 1. Vanegas Acosta Juan Carlos; Garzón-Alvarado Diego; Casale Martín. Interacción entre osteoblastos y superficies de titanio: aplicación en implantes dentales. Revista Cubana de Investigaciones Biomédicas. 2010; 29(1)51-68 2. Lemus Cruz Leticia María; Amagro Urrutia Zoraya y León Castell Claudia. Origen y evolución de los implantes dentales. Rev haban cienc méd [online]. 2009, vol.8, n.4, pp. 3. Davies JE. Understanding peri-implant endosseous healing. Journal of Dental Education. 2003;67(8): 932-949. 4. Chih Hsien Ko James. Investigating the Process of Cement Line Maturation on Substrate Surfaces with Submicron Undercuts. A thesis submitted in conformity with the requirements for the degree of Master of Science in Dentistry, University of Toronto Graduate Faculty of Dentistry, 2010 pp 118 5. Burr DB1, Schaffler MB, Frederickson RG. Composition of the cement line and its possible mechanical role as a local interface in human compact bone. J Biomech.1988;21(11):939-45.
During the clinical procedure the physician must work in an environment that is free from dust and microorganisms that can contaminate the implant surface. This means that the cleanliness, purity and homogeneity of the implant surface are critical. Lastly the surface roughness (rugosity) has a definitive influence on the bone matrix formation. According to this study we can initially conclude that the DIO* UFII implants have a better osteoconductive surface for the formation of perpendicular bone, as well as a surface that is adequate for fibrin anchorage at the beginning of implantation. During the year 2015, we will continue evaluating histological cuts corresponding to bone formation.
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Flapless Crestal Sinus Augmentation: Hydraulic Technique Prof. Byung-Ho Choi Department of Oral and Maxillofacial Surgery, Yonsei University Wonju College of Medicine (162 Ilsan-dong, Wonju, South Korea)
Introduction Optimization of maxillary sinus floor elevation protocols to achieve high implant success rates, minimize morbidity, shorten treatment periods, and simultaneous implant placement is a constant challenge for clinicians. In this sense, the author describes a flapless crestal sinus floor augmentation procedure using a hydraulic sinus elevation system. The minimally invasive flapless procedure significantly decreases postoperative discomfort and complications versus conventional open-flap surgery. In flapless crestal sinus augmentation surgery, both transcrestal osteotomy and sinus membrane elevation are performed via the implant osteotomy site without visual or tactile control.1 For this reason, computer-guided surgery is mandatory not just to guide drilling for implant placement but also to control the drill depth to the bony sinus floor. To achieve high success rates in the flapless crestal sinus augmentation procedure, membrane integrity is a primary condition for success. In order to keep the membrane integrity safely, it is necessary to improve the techniques and instruments. This chapter addresses the techniques and instruments for successful flapless crestal sinus floor augmentation, using a hydraulic sinus elevation system combined with computer-guided implant surgery. â– Surgical Instruments 1) Osteotomy drill 2) Dome-shaped crestal approach bur 3) Hydraulic membrane lifter 4) Bone plugger, sinus curette 16
5) Stopper 6) Digital surgical guide
1) Osteotomy drill This drill is used to drill to 1 mm short of the sinus floor. It comes with various lengths and diameters having the stop feature. The surgical guide guides the drill’s depth, direction and position. 2) Dome-shaped crestal approach bur This bur is used to eliminate the remaining bone below the sinus floor (Fig 1).
Fig. 1. Dome-shaped crestal approach burs.
The bur has round tip and vertical stop. The tip of the drill is characterized by a smooth cutting blade. This shape helps to avoid direct damage even if it comes in direct contact with the sinus membrane. The dome-shape also makes it safe to be used in either flat or steep bone walls. The bur also has a stop feature to control the drill depth through the surgical guide. To help control the drill depth precisely,
Digital Implant NO.1 DIO IMPLANT
a number of different stopper lengths are available. Using the stop feature and the stoppers, the drill depth can be controlled within 1mm range. The dome-shaped crestal approach bur has 3.2-mm-diameter, which is smaller than the diameter of implants placed in the maxillary premolar (Ø4.0mm) and molar (Ø5.0mm). 3) Hydraulic membrane lifter This is for injecting liquid into the maxillary sinus. It is comprised of a syringe, tube and a nozzle (Fig 2). Tip of the nozzle has a Fig. 2. Hydraulic membrane lifter feature that can completely close the opening to the drill hole. Thus, it has a conicalshaped sealing part and an extension part that is inserted into the drill hole. The other end of the nozzle is connected with the tube, which is then connected to the saline-filled syringe. The nozzle also has a handle feature (Fig 3).
Fig. 3. Nozzle with handle
The handle not only helps the nozzle be positioned into the hole and secured in place but it also helps the nozzle to pressure the opening area. The syringe should be a 5-ml disposable syringe. A 1-ml syringe is too tiny to apply enough pressure. In addition, if the extension part of the syringe that connects the tube to the syringe is too short, the tube can be easily separated when applying pressure. Therefore, if possible, use a syringe with an elongated connection part.
4) Bone plugger, sinus curette Bone plugger is used to insert bone-grafting material into the sinus cavity through the drill hole. Sinus curette is used to then disperse this bone-grating material in the sinus cavity (Fig 4). They have a stop feature to control the depth of insertion into the sinus cavity. Their diameters is Ø2.6mm, which will allow it to go into the Ø3.2mm hole created by the 3.2-mm-diameter, dome-shaped crestal approach bur. The head of the sinus curette has a domeshape. 5) Stopper Stopper is designed to be able to connect to any of the crestal approach bur, bone plugger or sinus curette. It also comes in varying lengths, which can help control the depth of insertion into the sinus cavity within 1mm range (Fig 5).
Fig. 5. Stoppers
6) Digital surgical guide Surgical guide guides the depth and direction of the osteotomy drill, crestal approach bur and the implant. Therefore, a highly accurate and precise surgical guide must be used – recommended the vertical error value should be less than 0.5mm. From the author’s experiments, the average vertical error value of 0.44mm was achieved if the surgical guide was digitally designed using both the CBCT image and the oral scan image taken by TRIOS (3Shape, Copenhagen, Denmark) and produced using a 3D printer. The error from the digital surgical guide might have resulted from each step of the surgical guide production including the digital impression step, the fusion of the surface scan image with the CBCT scan image, and the 3D printing process. The error value increases if the surgical guide is made with the use of stone models from alginate impressions instead of the digital impressions. If the vertical error value of surgical guide is greater than 1mm, the risk of membrane perforation increases.
Fig. 4. Bone plugger and sinus curette 17
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Technique
â– Surgical Protocol
■Preoperative Protocol The best location to penetrate the bony sinus floor is determined with the help of CBCT image of the maxillary sinus while taking into consideration both the position of the final prosthesis and the anatomy of the maxillary sinus, such as the shapes of the sinus walls as well as the presence of the septum. This location will be where the implant is placed. Once the location has been determined, the drilling depth is calculated. This is important as to avoid causing membrane perforation while drilling. CBCT’s cross-sectional image can help define the length of the osteotomy up to the sinus floor. A panoramic 2D image or dental X-rays is not appropriate for this purpose as they are not precise enough. In contrast, a CBCT image can show the anatomy of the maxillary sinus with great precision in 3D. CBCT scans and oral digital impressions are used to perform three-dimensional implant planning and to create a customized surgical guide (Fig 6).
1) Drill osteotomy Under local anesthesia with 2% lidocaine, the stereolithographic surgical guide is placed in the mouth and checked for proper seating. The guide should be positioned accurately and securely. The accurate position of the guide is extremely important for precise implant placement because minor deviations can lead to errors in drilling and implant placement. The tissue punch is the first drill in sequence. The soft tissue of the proposed implant site is punched through the guide with a 3-mm soft tissue
Fig. 7. Drilling to 1 mm short of the sinus floor
Fig. 6. Digital surgical guide designed
If immediate restoration is being per formed, the customized abutment and provisional restoration is designed and then made using the CAD/CAM milling machine. When designing the customized abutment and crown, one must consider the factors such as soft tissue profile around the proposed location of the implant and the relationship between the implant with its adjacent and opposite teeth respectively using the dental design software (Dental System, 3shape, Copenhagen, Denmark). The surgical guide, prefabricated customized abutment and crown are prepared before implant surgery.
punch. After punching the soft tissue, the crestal bone is flattened with a bone-flattening drill. After flattening the bone surface, implant osteotomy is prepared to 1 mm short of the sinus floor (Fig 7). The drilling is performed using sequential drills with increasing diameters through the guide. The implant osteotomy is prepared to the
Fig. 8. Drilling through the surgical guide 18
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appropriate final diameter according to the drill sequence. The drilling depth is controlled by the drill stop in the shank that corresponds to the sum of the implant length, the gap between the guiding sleeve and the implant, and the guiding sleeve height (Fig 8). The drill stop precludes the drill from going deeper than intended. Final drill should be about 0.7 – 1.0 mm smaller in diameter than that of the implant. For example, if Ø5.0mm implant is to be placed, use up to Ø4.3mm drill.
Fig. 9. Dome-shaped crestal approach drill eliminating the remaining bone below the sinus floor
2) Penetrating the bony sinus floor: After drilling to 1 mm short of the sinus floor, a 3.2-mmdiameter, dome-shaped crestal approach bur is used to eliminate the remaining bone below the sinus floor (Fig 9). After removing the remaining 1mm, the bur is advanced into the sinus cavity using the bur with the stop that allows it to drill down another 1mm and expand the opening on the sinus floor. The bur is used at a speed of < 10 rpm. During the drilling, upward force is applied to drill into the bony sinus floor, thus pushing the drill 1 mm beyond the sinus floor, which is controlled with drill stops and surgical guides. The bony sinus floor is perforated rather than fractured. The low-speed drilling leads to decreased friction between the bur and the membrane, when the bur comes into contact with the membrane. As a result, the technique reduces the risk of impinging on the sinus membrane attributable to the risk of subsequent membrane perforation. If the bur has no stop, stopping the drill manually at the moment of penetrating the last bone layer will come too late and the drill will still push forward and
get very abruptly drawn into the sinus cavity. This explains why this maneuver risks perforating the sinus membrane. The dome shape of the crestal burs, the low-speed drilling with upward force and the perfect drilling depth control might be crucial to remove the cortical bone of the sinus floor. 3) Membrane elevation After puncturing the sinus floor, the most reliable method should be used to elevate the Schneiderian membrane without injuring it. The most reliable one is to elevate the sinus membrane using a hydrostatic pressure because the pressure exerted is uniformly distributed across the sinus membrane to minimize membrane tearing during membrane elevation.2,3 Compared to other techniques, the hydraulic pressure generated by injecting saline into the drill hole offers the most uniform distribution of forces, resulting in uniform elevation of the sinus membrane. The step for membrane elevation is done without the surgical guide. First, the hydraulic membrane lifter’s nozzle is connected with the handle, and then the nozzle is positioned into the opening of the drill hole and secured in place. And then 0.8mL of saline is slowly injected to separate the sinus membrane from the bony sinus floor and to push the membrane upward (Fig 10).
Fig. 10. Nozzle positioned into the transcrestal osteotomy canal and secured in place
Approximately the first 0.3 – 0.4 mL will go into the drill hole without feeling pressure. As the saline enters through the hole and touches the sinus membrane, the membrane is elevated with feeling pressure. However, as soon as the membrane is elevated, the pressure is decreased. It is important not to inject too much saline as the pressure decrease as it can elevate the sinus membrane far too 19
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much. Therefore, saline should be slowly injected 0.1 ml at a time (Fig 11). If the sinus floor has not been fully penetrated, the pressure can be felt after injecting 0.3 â&#x20AC;&#x201C; 0.4
can be pushed in with the saline and some bleeding can occur as the membrane is separated from the bone. The sinus membrane is perforated if only part of the saline is sucked back up and syringe is unable to achieve negative air pressure. If this is the case, do not place bonegrafting material into the sinus cavity. It is possible that mucus can penetrate into the graft through the perforation site and affect negatively the bone formation after surgery. In addition, bone-graft can escape into the sinus cavity through the perforated area, causing sinus inflammation. If the membrane is perforated during the membrane elevation procedure, the surgery should be attempted again after about two months. During the re-attempt, the surgery is tried from a different area, away from the sinus membrane that was damaged for a better success rate.
Fig. 11. Injecting 0.8-ml of saline to separate the sinus membrane form the sinus floor and push the membrane upward.
5) Expanding opening hole of the sinus floor Prior to inserting grating material into the maxillary sinus, the opening hole of the sinus floor into the sinus cavity is expanded. The surgical guide is re-placed in the mouth and using the 3.2-mm-diameter, dome-shaped crestal approach bur, the hole is expanded by advancing it further 1mm into the sinus cavity (Fig 12).
ml of saline but no more saline can be injected. In which case, another attempt should be tried to re-inject saline after drilling an additional 1mm into the sinus cavity using the 3.2-mm-diameter, dome-shaped crestal approach bur. 4) Membrane integrity test The most reliable way to test the membrane integrity is the aspiration technique. The membrane integrity is evaluated by drawing the saline back through the drill hole. The volume of the saline that was injected is fully retrieved, suggesting that the membrane remains intact. Directly viewing the exploration, using the Valsava procedure, and probing or irrigation does not guarantee the preservation of the sinus membrane. In the authorâ&#x20AC;&#x2122;s view, retrieving and measuring the injected saline back through the drill hole is the best test to guarantee membrane integrity. Sinus membrane perforation is tested immediately after elevating the sinus membrane. Once 0.8mL of saline is injected to elevate the sinus membrane, the same syringe is used to suck back the saline. If all the saline that was just injected is sucked back up and syringe shows negative pressure, then the membrane has not been perforated. There will be some blood and bubbles that get sucked up with the saline. This is because the air that was in the hole 20
Fig. 12. Dom-shaped crestal approach drill pushed 1mm beyond the sinus floor
The bur should be advanced precisely 1mm into the sinus cavity using the surgical guide and stop on the bur. After that, the surgical guide is removed and the bone plugger is inserted to check for presence of any other bony barriers inside the hole â&#x20AC;&#x201C; making sure the opening is completely clear. The bone plugger should be restricted not to insert
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into the sinus cavity further than the additional 1 mm using a stopper. 6) Grafting procedure The bone grafting procedure is performed without the aid of a surgical guide. If Bio-Oss collagen sponge (Geistlich Pharma AG, Wolhusen, Switzerland) is used as graft material, a 1-cm3 of the sponge is cut into nine pieces and then inserted into the sinus cavity through the drill hole using the bone plugger. When inserted into the sinus cavity, the grafting material has a tendency to remain pushed upwards. Therefore, it is necessary to spread the material in the sinus cavity. Whenever approximately 0.2 â&#x20AC;&#x201C; 0.3ml of grafting material is inserted, it is dispersed using a sinus curette. The way of dispersing it is to rotate the sinus curette in the sinus cavity, both clockwise and anticlockwise, drawing largest circle possible (Fig 13).
be placed simultaneously with the grafting procedure because the implant will help disperse the grafting material as well as help keep the membrane elevated. However, if the vertical height of the residual bone is less than 2mm and the implant has no primary stability, only the bone-grafting material is inserted into the sinus cavity without placing implants. Implant stability is evaluated by resistance of the implant during insertion and via measurement of the implantâ&#x20AC;&#x2122;s insertion torque. 8) Immediate restoration or installing healing abutment Immediate restoration is performed using the customized abutment and preliminary restoration that were prefabricated pre-surgery if the following conditions have been met (Fig 14): the vertical height of the residual bone is greater than 4mm, the implant has achieved good primary stability and it has splinted with neighboring implants. For a single implant, immediate restoration is performed if the primary stability is greater than 30Ncm.
Fig. 13. Sinus curette used to spread the graft material
The amount of grafting material inserted is determined by the height of membrane elevation. When attempting to elevate the membrane by 3 mm, insert 0.3 ml; elevate by 5 mm, insert 0.5 ml; elevate by 7 mm, insert 0.7 ml. If only the grafting material is inserted into the sinus cavity without placing implants, an additional 0.3 ml is inserted. For example, when attempting to elevate by 7mm, 1 ml of graft material is inserted. 7) Implant placement Simultaneous implant placement is conducted. Before implant placement, the final drilling is performed 1mm beyond the sinus floor through the surgical guide to enlarge the sinus floor. Implants are then placed in the formed socket through the guide. It is recommended that implant
Fig. 14. Immediate restoration with prefabricated customized permanent abutments and resin temporary crowns. The occlusion and articulation of the crowns were adjusted out of contact with the opposing teeth
Fig. 15. Healing abutment is installed if the implant is unable to secure the primary stabilization. 21
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The restoration process must follow the immediate nonfunctional loading concept by adjusting the crown to avoid contact with the opposing teeth. Patients are asked to refrain from using the restored teeth for the 3-4 months. A cover screw or healing abutment is installed if the implant is unable to secure the primary stabilization. (Fig 15) 9) Radiographic evaluation The patients are scanned postoperatively with the CBCT unit to inspect and identify any sinus membrane perforations.
Advantages Compared to a lateral approach, the flapless crestal approach offers many advantages. Pain, discomfort and healing time are greatly reduced because of the absence of trauma resulting from the large sinus floor incisions that are used in lateral sinus elevation surgeries.4,5 The flapless crestal approach preserves the integrity of the bony sinus structure, except at the implant site. In addition, this is a scarless procedure, which is the result of using the punch incisions and simultaneous implant placement with the transmucosal components. The flapless crestal approach eliminates the need for a second surgical procedure to connect the transmucosal components, thereby reducing chair time. The aesthetic results are also improved compared to the lateral approach. Based on the authorâ&#x20AC;&#x2122;s experience, the average operative time for the flapless crestal approach was 17 Âą 15 minutes. The surgical procedure substantially decreased the length of the surgery, compared to the previous crestal approaches. Some possible reasons for this shortened operative time might be due to using drills with stops, using surgical guides, the effective membrane elevation system, eliminating the need for sutures, and avoiding soft tissue elevation. In addition to a short operative time, the approach is successful in anatomically difficult sinus structures. During the sinus lift surgery, problems are not encountered in the presence of antral septa or when drilling along a steep bone walls. Therefore, this procedure 22
can be highly successful in patients with septated maxillary sinuses. â&#x2013; In patients with antral septum Presence of antral septum in the sinus cavity poses an additional difficulty in a lateral approach. As a result, the lateral approach requires greater skill of the surgeon and longer operative time. Even surgeons with a lot of experience often cause sinus membrane perforation. However, with the aid of a surgical guide and hydraulic pressure, the flapless crestal approach makes the procedure simpler and faster (Fig 16). The septum can actually be utilized to aid in shaping grafting material in the maxillary sinus (Fig 17). One of the reasons for high success in patients with septated maxillary sinuses is that the dome-shaped crestal approach bur, which is used to drill
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Fig. 16. A case with antral septa. Before (A), immediately (B) and 6 months (C) after surgery
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Fig 17. A case with antral septa. Before (A) and 6 months (B) after surgery
Fig 18. Dome-shaped crestal approach bur under the septum
through the sinus floor, can be safely used in steep bone walls as well (Fig 18). Due to its round shape, the drill works whether the surface is flat or not. Bone in the septum area tends to be hard, which can help implants achieve primary stability. If the pre-surgery CBCT scan reveals presence of a septum, the surgeon must take this into consideration in determining the appropriate position and depth of initial drilling. When drilling through a steep sinus wall, depending on
Fig. 19. CBCT scans of the severely atrophic ridge with 1mm of residual bone before (A) and after (B) surgery.
the angle, the surgeon may need to drill an additional 1mm compared to when drilling through a flat wall. â&#x2013; In patients with severely atrophic maxillae Even in patients with severely atrophic maxillae (1 to 2 mm of residual bone), the implants can be successfully inserted at the same time as maxillary sinus elevation (Fig 19).6 Typically in these situations, maxillary sinus floor wall has hardened cortical bone remaining. To place implants successfully in 1 to 2 mm of bone in the posterior maxilla, the residual bone quality should be effectively used to achieve primary implant stability in the patients. The drilling and implant placement is performed without shaking their axis with the aid of surgical guide. Tapered implants are used. The osteotomy for implant placement is enlarged to 0.7 - 1.0 mm narrower than the anticipated implant diameter â&#x2013; Grafting material It is difficult to create a desirable shape of grafting material in the sinus cavity through the flapless crestal approach because the material is inserted without the ability to see inside the sinus cavity. The goal of grafting procedure using the flapless crestal approach is to simply maintain the space created by the sinus membrane elevation. In other words, keeping sinus membrane 23
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elevated to encourage new bone formation underneath the membrane. The elevated sinus membrane can act like a tent while providing rich flow of blood and take advantage of its bone regeneration ability. The environment of the sinus cavity below the lifted sinus membrane after sinus membrane elevation is quite beneficial for bone formation.7,8 This is in part because the cavity is surrounded by bone, and the primary source of revascularization of the graft originates from the adjacent bony walls. In addition, the sinus membrane has an intensely vascular network and contains mesenchymal progenitor cells and the cells committed to the osteogenic lineage.9 The periosteum of the lifted sinus membrane is another source of bone forming-cells. Accordingly, new bone formation in the newly created space can be induced by elevating the sinus membrane alone provided that the space is well-maintained. When implant is placed along with grating material, both the implant and the graft material can help maintain the elevated sinus membrane. The graft material for the flapless crestal approach must be selected on the basis of: its ability to maintain space, ability to be inserted through a small opening and ease of dispersion inside the sinus cavity. The graft material can be in either particle, gel or sponge in form. The particle type can be pushed into the sinus cavity through the drill hole using a bone carrier. However, this type can be ineffective and more timeconsuming as the small opening makes it difficult for the particles to be pushed in. Advantage for the gel type is that it can be injected into the sinus cavity through the drill hole using a syringe. However, its disadvantage is that if there is space inside the sinus cavity, the gel can shift around. In particular, in a laid-down position, the gel moves towards the back. If a thermo-sensitive gel is used instead, the gel may be able to solidify inside the sinus cavity and hold its shape. If the gel and particle types are mixed together, two things can happen. Firstly, if the ratio of particle type is greater than gel type, the mixture might not be able to be injected using a syringe. Secondly, if the ratio of particle type is less than gel type, the mixture may be absorbed too easily. In contrast, if sponge type material is inserted into the 24
sinus cavity as grafting material, the sponge can protect the membrane from the roughness of graft material and may minimize membrane tearing during the grafting procedure. The sponge type material is soft and more elastic, which makes it easier to handle. It can be cut into a size that can easily be pushed through the hole and when positioned, the sponge is able to maintain its space under the elevated sinus membrane. Bio-Oss collagen sponge (Geistlich Pharma AG, Wolhusen, Switzerland) is a commonly used sponge-type grafting material. Bio-Oss collagen sponge is made up of 90% cancellous bone from calf and 10% collagen from pig. Collagen sponge may not be suitable for maintaining space because it can be absorbed quickly. However, the Bio-Oss collagen is suitable because Bio-Oss bone particles are able to maintain its shape without being absorbed too
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Fig 20. CBCT scans taken before (A), immediately (B), and six months (C) after surgery
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References 1. Toffler M: Minimally invasive sinus floor elevation procedures for simultaneous and staged implant placement. N Y State Dent J 70:38-44, 2004. 2. Chen I, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J Periodontol 76:482-491, 2005. 3. Kao DW, DeHaven HA. Controlled hydrostatic sinus elevation: a novel method of elevating the sinus membrane. Implant Dent 2011;20:425-429.
Fig 21. View of the specimen of Bio-Oss collagen sponge. A: Low-ratio. B: High-ratio
quickly when inside the sinus cavity (Fig 20). The authorâ&#x20AC;&#x2122;s animal experiment showed that when BioOss collagen sponge was used as graft material for bone augmentation in the maxillary sinus, bone formation in the graft site was excellent and the mean osseointegration rate was more than 65 % (Fig 21).
Summary The first key factor for the success of flapless crestal sinus augmentation is penetrating the bony sinus floor using the dome-shaped crestal approach bur, the low-speed drilling with upward force and the perfect drilling depth control. The drilling depth is controlled within 1mm range. The second factor is that the hydraulic pressure is used to safely elevate the sinus membrane and check for membrane integrity. The third factor is that CBCT scan with high resolution, advanced surgical equipment and highly precise surgical guide are used for the surgery.
4. Fortin T, Bosson JL, Isidori M, Blanchet E: Effect of flapless surgery on pain experienced in implant placement using an image-guided system. Int J Oral Maxillofac Implants 2006;21:298-304. 5. Nkenke E, Eitner S, Radespiel-Troeger M, Vairaktaris E, Neukam FW, Fenner M: Patient-centred outcomes comparing transmucosal implant placement with an open approach in the maxilla: A prospective, non-randomized pilot study. Clin Oral Implants Res 2007;18:197-203. 6. Peleg M, Mazor Z, Chaushu G, Garg AK: Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. Periodontol 1998;69:1397-1403. 7. Lundgren S, Andersson S, Gualini F, Sennerby L. Bone reformation with sinus membrane elevation: a new surgical technique for maxillary sinus floor augmentation. Clin Implant Dent Relat Res 2004;6:165-173. 8. Palma VC, Magro-Filho O, Oliveira JA, Lundgren S, Salata LA, Sennerby L. Bone reformation and implant integration following maxillary sinus membran elevation: an experimental study in primates. Clin Implant Dent Relat Res 2006;8:11-24. 9. Gruber R, Kandler B, FĂźrst G, Fischer MB, Watzek G. Porcine sinus mucosa holds cells that respond to bone morphogenetic protein BMP-6 and BMP-7 with increased osteogenic differentiation in vitro. Clin Oral Implants Res 2004;15:575-580.
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Digital Navigation Implant Date of publication | April 2015 Editing | DIO Implant Marketing team Publisher | DIO Implant Headquarters
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