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Table of Contents
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 79-84

A piezoelectric surgery for direct sinus lift with immediate implant placement


Department of Prosthodontics and Implantlogy, Saveetha Dental College, Chennai, Tamil Nadu, India

Date of Web Publication15-Mar-2017

Correspondence Address:
Gopinath Vidhya
Saveetha Dental College, Chennai - 600 077, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.202158

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   Abstract 

Insufficient bone volume is a common problem encountered in the rehabilitation of the edentulous posterior maxilla with implant-supported prostheses. The bone available for implant placement may be limited by the presence of the maxillary sinus together with loss of alveolar bone height and it may be increased by augmentation. This case report presents the rehabilitation of the right maxillary molar region using direct sinus lift followed by immediate placement of the implant. It helps in reducing the treatment time and increases the patient comfort.

Keywords: Immediate implant, piezoelectric, sinus lift


How to cite this article:
Vidhya G, Nesappan T. A piezoelectric surgery for direct sinus lift with immediate implant placement. J Dent Implant 2016;6:79-84

How to cite this URL:
Vidhya G, Nesappan T. A piezoelectric surgery for direct sinus lift with immediate implant placement. J Dent Implant [serial online] 2016 [cited 2020 Aug 6];6:79-84. Available from: http://www.jdionline.org/text.asp?2016/6/2/79/202158


   Introduction Top


Implant prosthesis has become a useful and common treatment for the restoration of missing teeth. However, implant placement in the maxillary molar region requires further attention, because of potential bone quality and anatomical structure issues. In the maxillary molar area, the height of alveolar bone may be reduced due to acute or chronic periodontal disease, sinus pneumatization, or atrophy of the residual alveolar ridge after extraction.[1] Thus, implant placement in this area can be difficult or even impossible. Therefore, at the time of implant placement in the maxillary molar area, bone graft is performed using vertical alveolar bone graft, sinus lift, or onlay bone graft, of which sinus lift is simple and widely used.[2],[3] Sinus lift is generally performed before or simultaneously with implant placement using the lateral window or crestal approach.[4],[5]

Implant placement may be combined with sinus augmentation as a “one-stage” technique. Alternatively, sinus augmentation may be carried out sometime before implant placement as a “two-stage” technique, which requires an additional surgical episode.[6]


   Case Report Top


A male patient, aged 70 years reported to the hospital with chief complaint of missing upper and lower back teeth and finding difficulty in chewing. History revealed that the teeth were extracted due to caries couple of years back and wanted to replace them with the fixed option. On clinical examination, teeth no #14, #15, #16, #17, #26, and #46 were missing. The orthopantomograph and cone beam computed tomography findings showed that the bone height was insufficient [Figure 1] and [Figure 2] and so direct sinus lift was planned with the immediate placement of implant irt 14, 15, and 17.
Figure 1: Orthopantomogram

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Figure 2: Cone beam computed tomography

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Blood investigations were done, and informed consent was taken after discussing the treatment plan with the patient.

Alginate impression (Tulip, Cavex Holland) was recorded, and presurgical diagnostic casts were prepared. In the cast, the interocclusal distance was measured, and the treatment plan was discussed with the patient and the bystander.

Surgical phase

Before the surgical procedure, preparation of the patient was done. The maxillary posterior segment was anesthetized with buccal and palatal infiltration using local anesthesia of 2% lignocaine with 1:80,000 adrenaline. Once the patient was anesthetized, an incision was made using #15 surgical blade and extending from the distal surface of canine to the mesial surface of 18. A vertical incision was extended until the end of the buccal vestibule. A full thickness buccal flap was raised, and a bony window was then traced as shown in [Figure 3] using a Piezo-surgical unit (Satelec, Acteon).
Figure 3: Direct sinus lift, a window is marked

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The initial bone marking was done using tip #BS5. This was followed by the deepening of the mark using SL1 tip [Figure 4] and [Figure 5].
Figure 4: Using piezoelectric tips, a window is cut open to expose the sinus floor

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Figure 5: A window marking is deepen to remove the bony window

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The bone tracing was made until a very thin plate of buccal bone remained over the sinus lining, and then, the fractured section of the bone was taken carefully and kept aside in a sterile bowl [Figure 6],[Figure 7],[Figure 8].
Figure 6: The window can be detached or attached in one corner

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Figure 7: The bony part is removed

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Figure 8: Bone is detached completely

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This was followed by the SL3 tip to raise the lining in the vicinity of the bony window. The partially raised lining was then lifted to a greater extent using the BS4 and BS5 tips [Figure 9].
Figure 9: The sinus floor is exposed

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An osteotomy was done in the usual way, protecting the raised sinus lining from any damage with the implant drills [Figure 10] and [Figure 11]. Nobel biocare implants were then placed irt 17 (5 mm × 11.5 mm), 14 (3.5 mm × 13 mm), and 15 (4.3 mm × 11.5 mm) tapped in place using the motor driver at 25 rpm.
Figure 10: Parallelism of the drills for implant placement

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Figure 11: Implant placed art 14,15, and 17

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Once the implant-seating tip reached the crest of the bone, the implant was properly seated. The remaining space between the implant and sinus floor was again filled with bone graft (Ossifi, Equinox) and the fractured section of the bone was replaced in the same place [Figure 12] and [Figure 13].
Figure 12: Implants and cover screw are placed with bone graft

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Figure 13: The detached bone is placed in position

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This was stabilized with the membrane (PerioCol-GTR, Eucare) as shown in the picture [Figure 14].
Figure 14: Membrane is placed

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Flaps were approximated, and primary sutures were placed using 3-0 vicryl [Figure 15]. The patient was given postoperative antibiotic and anti-inflammatory coverage. After postoperative instructions were given, the patient was recalled after 10 days for reevaluation and suture removal.[7]
Figure 15: Sutures placed

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   Discussion Top


With the advancement in the field of dentistry, implant-supported prosthesis is no more a big challenge. In comparison with the anterior tooth area, the rate of tooth loss in the molar area is high due to its important role in mastication and caries or periodontal diseases caused by inferior oral hygiene practices. In addition, because bone quality of the maxilla is poorer than that of the mandible, atrophy of the alveolar ridge can be more severe in cases maxillary tooth loss. In addition, maxillary pneumatization may hinder implant placement.[8],[9]

To overcome these problems, maxillary sinus lift with an accompanying bone graft serves as a simple, widely used procedure.[7] A sinus lift for implant placement is considered one of the most predictable procedures for augmenting bone in the maxilla.[10],[11] Several approaches have been developed and are currently used. The lateral approach using a Caldwell-Luc osteotomy is historically the first main technique, where the maxillary sinus floor is grafted to provide a sufficient quantity of bone for the placement of endosteal dental implants.[6],[9] Sinus floor elevation with bone augmentation of the maxillary sinus is now well-accepted procedures which are used to increase bone volume in the posterior maxilla.[12]

In this present case, on radiographic examination, the available bone height in the right molar region was found to be only 5.47 mm from the maxillary sinus lining. Since the patient had a missing right molar and premolar for couple of years, there was atrophy of the edentulous area. This could have caused continuous loss of bone height and density and an increase in antral pneumatization.[13] Hence, direct sinus lift using piezosurgical approach following immediate implant placement was planned.[14] This technique prevents perforation of the “Schneiderian Membrane” and cause minimal postoperative complications. Oscillation frequency used in piezosurgery is designed for acting only on mineralized tissue; therefore, the cutting tip becomes inactive when it comes in contact with soft tissue. Hence, soft tissue damage is not noticed. Short- to long-term clinical studies of dental implants placed into grafted sinus demonstrate a similar or even higher survival rate than for implant placed in the maxilla without a sinus augmentation procedure.[15] Gamma irradiated cancellous bone graft was used in this case. In this case, once the bony window was prepared with piezosurgical procedures, osteotomy was widened irt #17 and #15 region protecting the raised sinus lining. Since the crestal width of bone in #17 region was 8.77 mm; a Nobel biocare implant was placed. To stabilize the implant in the maxillary sinus region and also to stimulate bone regeneration, gamma irradiated cancellous allograft was used.[16]

This technique has the advantage of not only reducing the treatment time and increases the patient comfort but also minimal soft tissue damage. Piezosurgery was performed, as it reduces the risk of damaging vital soft tissues such as nerves, dura matter, and blood vessels.[17] Using piezosurgical unit, sinus lift procedure with sinus grafting proved to be less traumatic and more successful.


   Conclusion Top


Although the placement of implants can be difficult at times due to compromised situations, by good evaluation, and utilizing the various techniques available, it is possible to provide a good treatment outcome.

Sufficient bone density is required for the placement of dental implants in nondentate areas of the maxillary posterior region. This case was challenging since there was ridge resorption, with reduced vertical bone height and pneumatization of the maxillary sinus. Hence, we planned for direct sinus lift using piezosurgical approach allowing sinus membrane integrity to be maintained during the surgical procedures when compared to conventional techniques. The success of the dental implant with sinus augmentation mainly depends on the skill of the operator, adequate preoperative planning, technique used to place an implant and the type of graft material used.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Tasoulis G, Yao SG, Fine JB. The maxillary sinus: Challenges and treatments for implant placement. Compend Contin Educ Dent 2011;32:10-4, 16, 18-9.  Back to cited text no. 1
    
2.
Nedir R, Nurdin N, Szmukler-Moncler S, Bischof M. Osteotome sinus floor elevation technique without grafting material and immediate implant placement in atrophic posterior maxilla: Report of 2 cases. J Oral Maxillofac Surg 2009;67:1098-103.  Back to cited text no. 2
    
3.
Yang JW, Park HJ, Yoo KH, Chung K, Jung S, Oh HK, et al. A comparison study between periosteum and resorbable collagen membrane on iliac block bone graft resorption in the rabbit calvarium. Head Face Med 2014;10:15.  Back to cited text no. 3
    
4.
Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, et al. Effectiveness of sinus lift procedures for dental implant rehabilitation: A Cochrane systematic review. Eur J Oral Implantol 2010;3:7-26.  Back to cited text no. 4
    
5.
Marx RE, Garg AK. A novel aid to elevation of the sinus membrane for the sinus lift procedure. Implant Dent 2002;11268-71.  Back to cited text no. 5
    
6.
Jurisic M, Markovic A, Radulovic M, Brkovic BM, Sándor GK. Maxillary sinus floor augmentation: Comparing osteotome with lateral window immediate and delayed implant placements. An interim report. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2008;106:820-7.  Back to cited text no. 6
    
7.
Cha HS, Kim A, Nowzari H, Chang HS, Ahn KM. Simultaneous sinus-lift and implant installation: Prospective study of consecutive two hundred seventeen sinus lift and four hundred sixty-two implants. Clin Implant Dent Relat Res 2014;16:337-47.  Back to cited text no. 7
    
8.
Yoon WJ, Jeong KI, You JS, Oh JS, Kim SG. Survival rate of Astra Tech implants with maxillary sinus lift. J Korean Assoc Oral Maxillofac Surg 2014;40:17-20.  Back to cited text no. 8
    
9.
Kaufman E. Maxillary sinus elevation surgery. Dent Today 2002;21:96-101.  Back to cited text no. 9
    
10.
Kitamura A. Drill device for sinus lift. Implant Dent 2005;14:340-1.  Back to cited text no. 10
    
11.
Pérez-Martínez S, Martorell-Calatayud L, Peñarrocha-Oltra D, García-Mira B, Peñarrocha-Diago M. Indirect sinus lift without bone graft material: Systematic review and meta-analysis. J Clin Exp Dent 2015;7:e316-9.  Back to cited text no. 11
    
12.
Bassi AP, Pioto R, Faverani LP, Canestraro D, Fontão FG. Maxillary sinus lift without grafting, and simultaneous implant placement: A prospective clinical study with a 51-month follow-up. Int J Oral Maxillofac Surg 2015;44:902-7. doi: 10.1016/j.ijom.2015.03.016. Epub 2015 Apr 18.  Back to cited text no. 12
    
13.
AlGhamdi AS. Management of combined ridge defect and osteotome sinus floor elevation with simultaneous implant placement – A 36-month follow-up case report. J Oral Implantol 2009;35:225-31.  Back to cited text no. 13
    
14.
Purushotham S, Raveendran AM, Kripalani BK, D'Souza ML. Direct sinus lift and immediate implant placement using piezosurgical approach - A case report. J Clin Diagn Res 2016;10:ZD20-2.  Back to cited text no. 14
    
15.
Johansson LA, Isaksson S, Lindh C, Becktor JP, Sennerby L. Maxillary sinus floor augmentation and simultaneous implant placement using locally harvested autogenous bone chips and bone debris: A prospective clinical study. J Oral Maxillofac Surg 2010;68:837-44.  Back to cited text no. 15
    
16.
Rapani M, Rapani C. Sinus floor lift and simultaneous implant placement: A retrospective evaluation of implant success rate. Indian J Dent 2012;3:132-8.  Back to cited text no. 16
    
17.
Woo I, Le BT. Maxillary sinus floor elevation: Review of anatomy and two techniques. Implant Dent 2004;13:28-32.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]



 

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