original smart lift technique for minimally invasive ... lift technique for minimally invasive...
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24 Implant Tribune Italian Edition - Novembre 2012
originalarticle
Letteratura internazionale
Smart Lift Technique for Minimally Invasive Transcrestal Sinus Floor ElevationGiovanni<Franceschetti1,<Pasquale<Minenna2,<Roberto<Farina1,<Leonardo<Trombelli1
1Research Centre for the Study of Periodontal and Peri-implant Disease, University of Ferrara, Italy, 2Private practice, Foggia, Italy
IntroductionIn the posterior maxillary sextants,
insertion of implants of desired
length and diameter is often limi-
ted by the dimensional alterations
of the residual ridge as well as the
pneumatization of the maxillary
sinus occurring after tooth loss1-4.
Transcrestal sinus floor elevation
(tSFE) represents a surgical option
to vertically enhance the available
bone in the posterior maxillary
sextant through an access crea-
ted through the edentulous bone
crest. Surgical techniques for tSFE
are mainly based on the fracture
or perforation of the sinus floor by
means of osteotomes5-7 or burs8-14.
The apical displacement of the
Schneiderian membrane obtained
by tSFE may be enhanced and bet-
ter maintained by condensing a
graft material under the elevated
sinus membrane. Pjetursson and
colleagues15 compared the outco-
mes of tSFE when performed with
osteotomes with and without the
additional use of deproteinized bo-
vine bone mineral (DBBM).
At 1 year post-surgery, periapical
radiographs at grafted sites were
more frequently associated with
a radio-opaque structure apical to
the implants compared with non-
grafted sites. After an average fol-
low- up time of 3.2 years, a signifi-
cantly greater gain in radiographic
bone height was observed in graf-
ted (4.1 mm) compared with non-
grafted (1.7 mm) sites, with a two-
fold higher probability to observe
a substantial (2 mm) gain in height
over the implant apex when a graft
material was used15.
Recently, we proposed a minimal-
ly invasive procedure for tSFE,
namely the Smart Lift technique,
which is characterized by a tran-
screstal access to the sinus cavity
by means of specially designed
drills and osteotomes16-18. The pro-
cedure represents a modification of
the technique proposed by Fugaz-
zotto10.
However, the major novelty is
that all the instruments are used
with adjustable stop devices, thus
restricting the working action of
burs and osteotomes to the vertical
amount of residual bone. This is ai-
med to prevent any accidental pe-
netration of instruments into the
sinus cavity.
Previous studies showed that the
Smart Lift technique results in a
predictable apical displacement of
the sinus floor and a limited post-
operative morbidity, when used
in association with graft biomate-
rials17. With the Smart Lift techni-
que, the vertical augmentation of
the implant site is provided by the
condensed trephined bone core
that is displaced into the sinus.
<> pagina 25
Fig. 1.a - All manual and rotating instruments of the Smart Lift technique are used with adjustable stop devices (length ranging from 4 to 11 mm).
Fig. 1.g - The trephine bur (Smart Lift Drill, Ø 3.2 mm or 4.0 mm), produces a bone core up to the sinus floor.
Fig. 1.h - The bone core is condensed to fracture the sinus floor by means of a calibrated osteotome (Smart Lift Elevator, Ø 3.2 mm or Ø 4.0 mm) that corresponds to the diameter of the trephine preparation.
Figg. 1.i, l - The Smart Lift Elevator is used under gently malleting forces to implode the trephined bone core over the sinus floor.
Fig. 1.m - The implant is inserted.
Fig. 1.b - The Locator Drill perforates the cortical bone to a depth of 3.5 mm at the site where the implant is to be placed.
Fig. 1.c - The Probe Drill (Ø 1.2 mm) is used to define the position and orien-tation of the implant. This bur is used with an adjustable stop device which is set at least 1 mm shorter than the radiographic working length.
Fig. 1.d - The “Probe Osteotome” (Ø 1.2 mm) is gently forced in an apical direction through the cancellous bone until the cortical bone resistance of the sinus floor is met. Therefore, the Probe Osteotome will provide the “surgical working length”.
Fig. 1.e - A Radiographic Pin (Ø 1.2 mm) can be used to check radiographical-ly the orientation and depth of the prepared site.
Fig. 1.f - A Guide Drill of either Ø 3.2mm or Ø 4.0mm according to implant diameter is used to create a crestal countersink, 2 mm deep, where the trephine bur will be inserted.
Fig. 1.a-m - Surgical steps of the Smart Lift technique for transcrestal sinus floor elevation.
25Implant Tribune Italian Edition - Novembre 2012
originalarticle
Letteratura internazionale
Fig. 2.a-n - A paradigmatic case of transcrestal sinus floor elevation performed with the Smart Lift technique.
Fig. 2.d - The Smart Lift Drill Ø 3.2, used at the surgical working length of 7 mm, trephined a bone core up to the sinus floor.
Fig. 2.e - The bone core created by the Smart Lift Drill. Figg. 2.f, g - Additional biomaterial (biphasic calcium phosphate composed of hydroxyapatite (60%) and beta form of tricalcium phosphate (40%)**) was inserted into the implant site, to be grafted into the sinus.
Fig. 2.c - The surgical working length was assessed at 6.5 mm throu-gh tactile perception of the sinus floor using the Probe Osteotome.
Fig. 2.a - A 53 year-old male, former smoker patient presented with an edentulous lacuna in the maxillary left quadrant. The prosthetic rehabilitation plan of the patient included the placement of one implant-supported crown in the region of the left second premolar.
<< pagina 24
This intrusion osteotomy proce-
dure elevates the sinus membrane,
thus creating a space for blood clot
formation. It is conceivable that the
contribution of the bone core to the
intra-sinusal bone formation may
relate to the amount of residual
bone at the implant site (i.e. the
more the native bone pushed into
the sinus, the more the newly for-
med bone). When a limited amount
of residual bone is present with re-
spect to the amount of bone needed
for proper implant placement, bone
formation may be implemented by
the additional use of a graft.
Scientific evidence clearly indicates
that the use of a graft biomaterial
in association with tSFE may effec-
tively sustain bone regeneration15-19.
Recently our research group20 com-
pared the clinical effectiveness of a
synthetic hydroxyapatite in a colla-
gen matrix (S-HA) and DBBM when
used in association with the Smart
Lift technique and we demonstrated
that both biomaterials may provide
a predictable elevation of the ma-
xillary sinus floor along with limi-
ted post-surgical complications and
post-operative pain/discomfort.
At present, whether and to what
extent the Smart Lift technique
may benefit by the additional use
of different graft biomaterials, and
which biomaterial is the most sui-
table to provide conditions for new
bone formation still needs to be elu-
cidated. In this context, we report
a clinical case in which the Smart
Lift technique was associated with
biphasic calcium phosphate com-
posed of hydroxyapatite (60%) and
beta form of tricalcium phosphate
(40%).
Material And MethodsRationale and indications
The Smart Lift technique was de-
veloped by the Research Center
for the Study of Periodontal and
Peri-implant Diseases, Universi-
ty of Ferrara, and the Department
of Odontostomatology, Ospedale
“Casa Sollievo della Sofferenza”, S.
Giovanni Rotondo. The technique is
characterized by a transcrestal ac-
cess to the sinus cavity by means of
specially-designed drills and osteo-
tomes. The pristine bone at sites of
implant placement is drilled up to
the sinus floor with a trephine bur,
and then used to fracture the sinus
floor by hydraulic pressure through
osteotomes. In this respect, the pro-
cedure represents a modification
of the technique proposed by Fu-
gazzotto10. The major novelty with
previously described procedures
resides in the fact that all manual
and rotating instruments are used
with adjustable stop devices which
are selected in relation to the verti-
cal amount of residual bone at sites
where implants have to be placed
(Fig. 1.a). These stop devices have a
variable length, from 4 to 11 mm,
and may be adapted to all manual
and rotating instruments. The use
of the stop device restricts the wor-
king action of burs and osteotomes
to the vertical amount of residual
bone, thus preventing the acciden-
tal penetration of instruments into
the sinus cavity. The identification
of the working length (i.e. the di-
stance from the bone crest to the
sinus floor) where the osteotome
and burs should limit their working
action is first diagnosed on periapi-
cal x-ray or CT scan, and then intra-
surgery assessed by means of a spe-
cially-designed osteotome.
The Smart Lift technique shares its
clinical indications with any other
proposed surgical procedures for si-
nus floor elevation with a transcre-
stal approach21, 22.
- indications for implant-suppor-
ted prosthetic rehabilitation,
based on accurate diagnosis and
treatment planning;
- systemic and local conditions
which are compatible with im-
plant placement and sinus floor
elevation procedures;
- residual bone height (i.e. the di-
stance from the bone crest to the
sinus floor) of at least 4 mm.
The Smart Lift technique must not
be performed when systemic and lo-
cal conditions which contraindicate
sinus floor elevation are present21, 22.
Surgical Technique
According to the prosthetic tre-
atment planning, the location for
implant placement is established,
and the residual bone height at such
locations is first diagnosed by pro-
per x-ray examination. The distan-
ce from the bone crest to the sinus
floor as assessed radiographically
will provide the “radiographic wor-
king length”. Surgical stents may be
recommended for implant positio-
ning, particularly when multiple
implants have to be inserted.
All instruments in the surgical set*
are characterized by laser marks
at 4-5-6-7-8-9-10-11 mm to allow
for a precise control of the working
length. The first drill, (Locator Drill)
is designed to perforate the cor-
tical bone to a depth of 3.5 mm at
the site where the implant is to be
placed (Fig. 1.b). A second drill (Pro-
be Drill), with a diameter of 1.2 mm
and cutting only at the top edge,
is used to define the position and
orientation of the implant. In order
to minimize the risk of sinus floor
perforation, this bur is used with an
adjustable stop device which is set
at least 1 mm shorter than the “ra-
diographic working length” (Fig. 1.c).
Then, the “Probe Osteotome” (Ø 1.2
mm) is carefully inserted into the
site prepared by the Probe Drill, and
gently forced in an apical direction
through the cancellous bone until
the cortical bone resistance of the
sinus floor is met. Therefore, the
Probe Osteotome will provide the
“surgical working length”, which is
the true anatomical distance from
the bone crest to the sinus floor in
the exact location where the im-
plant should be placed (Fig. 1.d).
Thus, the working action of all ma-
nual and rotating instruments that
will be used in subsequent surgical
steps will be now set at the “surgical
working length” by using the proper
adjustable stop device.
A Radiographic Pin (Ø 1.2 mm) can
also be used to check the angula-
tion and depth of the prepared site
by means of a periapical x-ray (Fig.
1.e). The Radiographic Pin handle
has a diameter of 4.0 mm, thus
permitting to evaluate the spatial
relationship between the prepared
site and the bucco-lingual as well
as mesio-distal dimensions of the
alveolar ridge. This will help the cli-
nicians to determine the diameter
of the implant to be placed. Then, a
“Guide Drill” of Ø 3.2 mm (implants
Ø: 3.75 ÷ 4.5 mm) or Ø 4.0 mm (im-
plants Ø: 4.8 ÷ 5.0 mm) can be used.
This drill follows the Ø 1.2 mm site
preparation and creates a crestal
countersink, 2 mm deep, where the
trephine bur (Smart Lift Drill) will be
inserted (Fig. 1.f). Such countersink
enables the trephine bur to centre
the working action of the bur accor-
ding to the desired direction. The
“Smart Lift Drill” (Ø 3.2 or 4.0), set at
the surgical working length, produ-
ces a bone core up to the sinus floor
(Fig. 1.g). Following the removal of
the trephine bur, the bone core (Fig.
1.h) is then condensed and malleted
to fracture the sinus floor by means
of a calibrated osteotome (Smart
Lift Elevator, Ø 3.2 or Ø 4.0) that
corresponds to the diameter of the
trephine preparation (Fig. 1.i, l). If
the alveolar bone core is found to be
inside the trephine, the bone core is
gently removed from the trephine
and replaced in the alveolar bone
preparation. The osteotome is used
under gently malleting forces to im-
plode the trephined bone core over
the sinus floor.
<> pagina 26
Fig. 2.b - The pre-operatory periapical radiograph showed a residual bone height (i.e. radiographic working length) of 6.5 mm at location of the second upper premolar.
26 Implant Tribune Italian Edition - Novembre 2012
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References
Figg. 2.h, i - An implant***, Ø 4.0 X 11.0 mm was positioned.Figg. 2.f, g - Additional biomaterial (biphasic calcium phosphate composed of hydroxyapatite (60%) and beta form of tricalcium phosphate (40%)**) was inserted into the implant site, to be grafted into the sinus.
<< pagina 25
In relation to the extent of vertical
bone augmentation to be achieved,
a cortical bone particulate or a bone
substitute can be further grafted
and condensed into the sinus by the
osteotome. Again, the Smart Lift Ele-
vator is used with the adjustable stop
device at the surgical working length,
thus preventing any unwanted pene-
tration of the instruments into the
sinus cavity. Provided that the resi-
dual bone may ensure an adequate
primary stability, an implant can be
inserted during the same surgical
session (Fig. 1.m). Otherwise, a staged
approach is recommended.
Clinical case report
A 53 year-old male, former smoker pa-
tient presented with an edentulous
lacuna in the maxillary left quadrant
(Fig. 2.a). Neither systemic or local
conditions contraindicating implant
surgery or sinus lift procedures were
identified at the screening visit. The
prosthetic rehabilitation included
the placement of a prosthetic crown
supported by one implant, placed
in the region of the left second pre-
molar. The pre-operatory periapical
radiograph showed a radiographic
working length of 6.5 mm at location
of the edentulous lacuna (Fig. 2.b).
Therefore, a transcrestal sinus floor
elevation was planned to allow for
the placement of an implant of ade-
quate length.
A full-thickness flap was elevated
to access the alveolar crest and the
implant site in the position 2.5 was
prepared using the Smart Lift techni-
que. First, the Locator Drill was used
to perforate the cortical bone crest
at implant sites. Then, the Probe Drill
was used with the 6-mm adjustable
stop device. The surgical working
length was assessed at 6.5 mm throu-
gh tactile perception of the sinus
floor using the Probe Osteotome (Fig.
2.c). A countersink was prepared by
the Guide Drill, then a trephined bone
core was created by the Smart Lift
Drill Ø 3.2, with the stop device set at
7 mm (Fig. 2.c). The bone core created
by the Smart Lift Drill (Fig. 2.e) was
gently malleted upwards using the Ø
3.2 Smart Lift Elevator until the sinus
floor was fractured. Additional bio-
material (biphasic calcium phospha-
te composed of hydroxyapatite (60%)
and beta form of tricalcium phospha-
te (40%)**) was grafted into the sinus
(Fig. 2.f, g). Visual inspection and Val-
salva manoeuvre did not reveal signs
of perforation of the sinus membra-
ne. One implant***, Ø 4.0 x 11.0 mm
was positioned (Fig. 2.h, i, l). At 2 years
following surgery, the implant was
clinically stable (Fig. 2.m). On peria-
pical radiographs, a radiopaque area
corresponding to the augmented
sinus floor was present around and
above the apical portion of the distal
implant (Fig. 2.n).
Discussion and ConclusionsThe present case report illustrates
a minimally-invasive procedure ai-
med at sinus floor elevation with
transcrestal approach for implant
insertion. The rationale for this tech-
nique is essentially derived from a
previously described procedure whe-
re the combined use of a trephine
bur and osteotomes was suggested10.
Briefly, this technique implied the
use of a trephine drill penetrating up
to 1 mm from the sinus floor. Then,
an osteotome was used to implode
(by the use of a mallet) the trephined
bone core to a depth of 1 mm less than
the initial trephine cut. The hydraulic
pressure exerted by the autogenous
bone core determined the fracture of
the sinus floor with vertical augmen-
tation of the implant site. Previous re-
ports with such technique showed a
cumulative success rate of 98.0% fol-
lowing 13-48 months of follow-up10.
Although proven effective, the tech-
nique proposed by Fugazzotto10 se-
ems highly technique-sensitive, par-
ticularly with respect to the control
of the working action of both trephi-
ne bur and osteotome. It may be
conceivable that, during the drilling
action of the trephine bur and the
mallet pressure onto the osteotomes,
a direct damage of the sinus mem-
brane due to instrument penetration
over the sinus floor can occur.
Recently, a systematic review23 repor-
ted an incidence of membrane per-
foration ranging from 0% to 21.4%,
and postoperative infection from
0% to 2.5% following transcrestal si-
nus elevation procedures. In an ex-
perimental evaluation of maxillary
sinus membrane response following
elevation with osteotome techni-
que in human cadavers, membrane
perforation was observed in 6 out
of 25 implants (24%), the risk being
increased with an increasing extent
of sinus floor elevation to be obtai-
ned24. An endoscopic study revealed
that the sinus floor may be elevated
up to 5mm without perforating the
sinus membrane25. However, other
endoscopic studies have demonstra-
ted the risk of membrane perforation
while performing transalveolar sinus
floor elevation26. An endoscopic eva-
luation of the bone-added osteoto-
me sinus floor elevation procedure
revealed that the surgical approach
may lead to large detachment of the
membrane over a broad area exten-
ding both apically and laterally to
the implant tip contour. However, in
2 out of 8 analyzed patients mem-
brane perforation with partial loss
of the graft particles was observed27.
Whether and to what extent mem-
brane perforation may compromise
the implant survival is still unclear.
In this respect, a preclinical study
demonstrated that implants inten-
tionally exposed for 4-8 mm into the
sinus cavity following transcrestal
sinus elevation procedures were only
partially recovered by sinus muco-
sa, the exposed part of the implant
being recovered by debris potentially
resulting in sinus infection28.
In our procedure, the working action
of the rotating and manual instru-
ments is restricted to the residual
(native) bone. The working length
is first established radiographically,
but then confirmed by the combined
use of the Probe Drill and Probe Oste-
otome. Probe Drill is provided with
a top cutting edge which can easily
proceed into the cancellous bone rea-
ching the proximity of the sinus flo-
or. Then, the surgical working length
is defined by tactile perception of the
cortical bone of the sinus floor deri-
ved from the gentle use of the Probe
Osteotome.
<> pagina 27
Letteratura internazionaleoriginalarticle
27Implant Tribune Italian Edition - Novembre 2012
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SE DICO IMPIANTO, A COSA PENSI...?
..:: DVD per la sala d’aspetto ::..
M. RONCATI, P. MARZOLA 75,00 euro + iva
CAPITOLI
1. L’IMPLANTOLOGIA È...2. CHE RISCHI CI SONO?3. CHI FUMA PUÒ FARE L’IMPIANTO?4. CON GLI IMPIANTI C’È RIGETTO?5. IN CASO DI OSTEOPOROSI?
6. QUANTO TEMPO DURA UN IMPIANTO?7. È UN INTERVENTO DOLOROSO?8. IL CARICO IMMEDIATO
9. COSTI E MODALITÀ DI INTERVENTO
10. TECNICA IMPLANTARE COMPUTERIZZATA
Questo fi lm per la sala d’aspetto informa i pazienti odontoiatrici sui vantaggidella terapia implantare. L’argomento è trattato in modo ironico e accattivanteda attori e supportato da animazioni e disegni 2D.
Obiettivo è rendere maggiormente consapevoli e preparati all’intervento coloroche stanno valutando, o hanno già optato, per questa soluzione dissipando ombre, diffusi timori e certi luoghi comuni.
DURATA: 20 MIN. CIRCA
Fig. 2.l - Periapical radiograph taken immediately after implant placement, showing radio-opaque grafted area around and above the implant apex.
Fig. 2.m - At 2 years following surgery, the implant was clinically stable. Fig. 2.n - At 2-year follow-up, a radiopaque area corre-sponding to the augmented sinus floor was still present around and above the apical portion of the distal implant.
<< pagina 26
Once the surgical working length is
established, the use of adjustable stop
devices would dictate the extent of
the working action of manual and ro-
tating instruments, thus minimizing
the risk for membrane perforation
and post-surgery infections. Other
techniques have been reported whe-
re the use of burs of variable length
and provided with a shoulder stop
have been used to perforate the sinus
floor9. Unfortunately, in such pro-
cedure the selection of the working
length of the rotating instruments is
only based on the radiographic exa-
mination, leading to potential under-
or over-estimation of the amount of
residual bone height. Extensive mal-
leting trauma during sinus floor ele-
vation with osteotomes may cause
BPPV, a benign syndrome characte-
rized by short, recurrent episodes
of vertigo, initiated by movements
of head lateralization and extension
toward the affected site29-31. In this
respect, the combined utilization
of a trephine bur in close proximity
to the sinus floor limits the need for
repeated malleting. Therefore, the
Smart Lift technique may result less
traumatic and disconcerting to the
patient with respect to the conven-
tional osteotome procedures.
Vertical augmentation of the implant
site is provided by the condensed
trephined bone core which is displa-
ced into the sinus. This intrusion
osteotomy procedure elevates the
sinus membrane, thus creating a spa-
ce for blood clot formation. It is con-
ceivable that the contribution of the
bone core to intra-sinus bone forma-
tion may relate to the amount of resi-
dual bone at the implant site, i.e. the
more native bone pushed into the
sinus, the more newly formed bone.
When a limited amount of residual
bone is present with respect to the
amount of bone needed for proper
implant placement, bone formation
may be implemented by the additio-
nal use of a graft. Grafting material is
added incrementally and condensed
into the sinus by the osteotome. Du-
ring the grafting procedure, it is the
graft biomaterial only that exerts the
hydraulic pressure to “tent” the sinus
membrane, while any direct penetra-
tion of the osteotome into the sinus
cavity is prevented by the adjustable
stop device. Previous studies seem
to suggest an enhanced osteoinduc-
tive/conductive potential with the
additional use of bone substitutes.
Pjetursson and colleagues15 compa-
red the transcrestal sinus floor ele-
vation by means of osteotomes with
and without the additional use of
deproteinized bovine bone matrix.
A gain in radiographic bone height
of 4.1 mm and 1.7 mm where obser-
ved in grafted and non-grafted sites,
respectively. Recently our research
group demonstrated that indepen-
dently from the biomaterial used in
association with the Smart Lift tech-
nique, the procedure may provide a
predictable elevation of the maxil-
lary sinus floor along with limited
post-surgical complications and
post-operative pain/discomfort20. In
conclusion, the Smart Lift technique
represents a minimally-invasive sur-
gical option for sinus floor elevation.
The technique is based on a standar-
dized, user-friendly sequence of ma-
nual and rotating instruments used
with a controlled working action ai-
med at preventing surgical compli-
cations. However, further controlled
clinical trials are needed to evaluate
the efficacy and safety of this techni-
que compared to conventional sinus
floor elevation procedures.
note* SMART LIFT; Meta CGM Spa,
Reggio Emilia, Italy.** BoneCeramic, Straumann®, Straumann
AG, Postfach, Basel, Switzerland.*** Thommen Medical AG, Waldenbug,
Switzerland.
Letteratura internazionale