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Sinus Bone Grafting Technique Using Special Reamers and Microelevators Young-Kyun Kim, DDS, PhD,* and Su-Gwan Kim, DDS, PhDâ€
inus bone grafting is a procedure that is commonly performed in maxillary molar areas with insufďŹ cient bone volume, and it shows good clinical outcomes. However, sinus membrane perforation is the most common complication during sinus bone grafting, and it may occur during the formation of the lateral window.1,2 Here, we introduce a special technique for performing successful sinus bone grafting that minimizes the risk of injuring the maxillary mucosa through the use of a special reamer and a microelevator.
S
TECHNIQUE Sinus bone grafting using the sinus lateral approach (SLA) instrument (Neobiotech, Seoul, South Korea) was performed in a 62-year-old male patient. The right maxillary second molar was extracted, a ap was lifted, and the maxillary bone was exposed. Using a C-reamer (diameter, 6.5 mm and length, 3.0 mm), a lateral round window was formed in the ďŹ rst and second molar area, removed, and stored. The lateral window of the second premolar area was removed using the identical method. Nonetheless, the bone wall was thick, and thus, a bone window was formed by the *Associate Professor, Department of Oral and Maxillofacial Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea. †Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwang-Ju, South Korea.
Reprint requests and correspondence to: Su-Gwan Kim, DDS, PhD, Dept. of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, 375, SeoSuk Dong, Dong-Gu, Gwangju, South Korea 501-759, Phone: 82-62-220-3819, Fax: 82-62-228-7316, E-mail: sgckim@chosun.ac.kr ISSN 1056-6163/12/02105-387 Implant Dentistry Volume 21 Number 5 Copyright Š 2012 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0b013e31826a56c3
When residual bone height is insufďŹ cient in the maxillary posterior area, the maxillary sinus elevation and implant placement with lateral approach are oftentimes used. However, the risk of sinus membrane perforation, or tearing, is high for this procedure. This
article introduces a technique that uses a special reamer and a microelevator to minimize sinus membrane injury. (Implant Dent 2012;21:387–389) Key Words: maxillary sinus elevation, microelevator, reamer, sinus membrane injury
additional use of the LS reamer. The sinus membrane was elevated through the use of a microelevator, bone graft materials were ďŹ lled, and the removed bone window was repositioned. During the procedure, perforation of the maxillary mucosa did not occur, and successful sinus bone grafting outcomes were obtained (Figs. 1–5).
membrane does not cause negative long-term effects on sinus bone grafts and dental implants. Regardless of the controversies in the potential effect of membrane perforation on postoperative complications and implant failure, this potential for an intraoperative complication absolutely increases the surgical difďŹ culty and lengthens surgical time. Therefore, it is preferable to prevent the occurrence of a membrane perforation.4 To minimize perforation during the generation of the lateral window, various techniques and instruments have been recently developed and applied frequently in clinical practice. Wallace et al9 have reported that the perforation rate with piezosurgery was lower than with traditional rotator instrumentation during the formation of the maxillary lateral window. Sohn et al10 have reported that a bony window osteotomy could be performed in 2 to 7 minutes through the use of erbium and a chromium:yttrium-scandiumgallium-garnet laser. Nonetheless, in cases with a thick lateral wall of the maxillary sinus, it may take too long to form a bony window using a laser, piezoelectric device, or the like. Herein, the SLA instrument was used to remove the bone wall safely
DISCUSSION The incidence of perforation of the maxillary mucosa has been reported with various rates ranging from 14% to 56%.1–3 The height of the residual bones, a large edentulous area, the septum, the thickness of the maxillary lateral wall, the thickness of the maxillary mucosa, the presence of cystic lesions in the maxillary sinus, and previous allergy involving the maxillary sinus have been reported as factors increasing the risk for perforation. In addition, sinus membrane injury occurs during the process of lateral window formation via the use of surgical burs and/or drills in many cases.2,4–6 It has been reported that perforation of the maxillary mucosa adversely affected the prognosis of sinus bone grafts and dental implants.3,7 However, Oh and Kraut8 suggested that perforation of the Schneiderian
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SPECIAL REAMERS
AND
MICROELEVATORS
FOR
SINUS BONE GRAFTING
KIM
AND
KIM
Fig. 1. Panoramic radiograph of the initial diagnosis. Sinus bone grafting was planned after extraction of the maxillary right second molar, followed by the placement of implants after 4 months.
without injuring the maxillary mucosa by the application of the reamer principle. The SLA kit is a tool that connects a special reamer to the contra-angle and forms a lateral window safely without injuring the membrane, even in the absence of stoppers, by rotating the tool at 1500 to 2000 rotations per minute. Thirty-seven cases of sinus bone grafting were performed using the SLA instrument from September 2008 to December 2009 in the Seoul National University Bundang Hospital. Perforation of the maxillary mucosa occurred in 3 cases, and a perforation rate of 8.2% was determined for the procedure. The perforation area was smaller than 2 mm and was minor, and the bone graft proceeded without special treatment. Our cases showed an 8.2% perforation rate, which was relatively high compared with the rates reported in Wallace et al (7%),9 Blus et al (3.8%),11 and Toscano et al (3.6%),12 who used piezosurgery. However, the perforations in these 3 studies occurred not when a bony window was formed but when sinus mucosal elevations were conducted. The reasons for the perforation are believed to be due to a very thin mucosa, the septum, and the surgeon’s carelessness. As such, particular attention is needed when performing sinus membrane elevation after bony window formation. The advantages of lateral window formation through the application of the C-reamer and LS-reamer of the SLA kit are as follows. 1. Because a small window is formed, the formation of a minimal ap is possible, the risk of arterial bleeding is minimized, and postsurgical swelling and pain may be reduced.
Fig. 2. Formation of a lateral window using a C-reamer. A, Appearance after the formation of a lateral hole in the second molar area using a C-reamer. B, A C-reamer of 6.5 mm in diameter and 3 mm in length. C, After the removal of the lateral window, the sinus membrane was elevated using a microelevator.
Fig. 3. Formation of a lateral window using a LS reamer. A, A lateral hole was formed using a C-reamer. Nonetheless, the bone wall was very thick, and thus, it could not be removed completely. B, A LS reamer of 6.5 mm in diameter and 3.5 mm in length. C, Complete formation of the lateral window using the LS-reamer. D, Two lateral holes were formed, and the sinus membrane was elevated using a microelevator.
2. Several holes with different diameters (4–6 mm) can be formed readily without injuring the sinus membrane, and the operation time is shortened.
3. Use of the optimal microelevator ďŹ tted to the angle of approach allows the sinus membrane elevation to be performed readily and safely.
Fig. 4. A, Filled bone graft materials. B, After repositioning of the previously removed lateral window bone.
IMPLANT DENTISTRY / VOLUME 21, NUMBER 5 2012
CONCLUSION
Fig. 5. Postsurgical panoramic radiograph. Successful bone graft outcomes without tearing of the sinus membrane were obtained.
A sinus bone grafting technique using special reamers and microelevators is considered to be an effective surgical method to reduce the risk of sinus membrane perforation, and it is performed easily with anticipated surgical care.
DISCLOSURE The principle of the C-reamer is similar to that of trephine drills, and it could form lateral windows via the safe formation of a bone core. However, there is a greater possibility of perforation than that associated with the LS reamer, and the selection of the appropriate length of the reamer and formation of the bony window must be done carefully. If the bony wall is thick or if a septum exists, use in conjunction with LS reamers may be safe. The LS reamer forms a lateral hole of the desired size, and during perforation of the lateral wall, it functions to protect the membrane by forming a thin bone plate between the reamer and the sinus membrane. Microelevators are instruments of a specific shape that can elevate the membrane freely (right and left, up, and down) within a small lateral hole.
The authors claim to have no financial interest, either directly or indirectly, in the products or information mentioned in the article.
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