art-5-ChaushuL-1-2020
ORAL IMPLANTOLOGY www.stomaeduj.com
IMMEDIATE/EARLY RADIOLOGICAL FINDINGS
Original Articles
FOLLOWING TRANSCRESTAL SINUS AUGMENTATION
USING A MINIMALLY INVASIVE IMPLANT DEVICE
Liat Chaushu 1a* , Hadar Better 2b , Nissan Joseph3c , Samuel Porphirio Xavier 4d , Adi Lorean 5e , Gavriel Chaushu 5,6f
1
Department of Periodontology and Implant Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
2
Private practice, Tel Aviv, Israel. Co Founder Maxillent LTD
3
Department of Oral Rehabilitation, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
4
Department of Oral and Maxillofacial Surgery and Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
5
Department of Oral and Maxillofacial Surgery, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
6
Department of Oral and Maxillofacial Surgery, Rabin Medical Center, Petah Tiqwa, Israel
a
DMD, MSc; e-mail: liat.natanel@gmail.com; ORCIDiD: https://orcid.org/0000-0002-5755-7526
b
DMD, MSc; e-mail: bettermed@gmail.com; ORCIDiD: https://orcid.org/0000-0001-7493-5026
c
DMD; e-mail: nissandr@gmail.com; ORCIDiD: https://orcid.org/0000-0001-7290-4357
d
DMD, Ph.D; e-mail: samuelpxavier@yahoo.com.br; ORCIDiD: https://orcid.org/0000-0001-7389-5886
e
DMD; e-mail: adilorean@gmail.com; ORCIDiD: https://orcid.org/0000-0003-4699-4330
f
DMD, MSc; e-mail: gabi.chaushu@gmail.com; ORCIDiD: https://orcid.org/0000-0001-9176-4978
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(1).art.5
Introduction Description of the immediate/early (up to one week) cone beam tomographic findings
following maxillary sinus augmentation using a minimally invasive implant device.
Methodology A self-tapping endosseous dental implant containing an internal channel that allows the
introduction of liquids through the implant body and into the maxillary sinus was used for sinus augmentation.
A periapical radiography was performed at the end of the procedure. For those cases where the periapical
radiograph could not demonstrate a clear postoperative result, a cone beam computerized tomography
(CBCT) was performed at the end of the procedure. When a CBCT device was not available an early CBCT was
performed within 1 week. Twenty immediate/early postoperative CBCT's were retrospectively evaluated for
descriptive purposes.
Results 25 immediate postoperative CBCT's were reviewed. The following radiological phenomena were
noted and described – the postoperative appearance of the Schneiderian membrane; grafting material; new
generated bone volume.
Conclusion Dental CBCT should be the gold standard for immediate/early postoperative imaging, following
transcrestal sinus augmentation using a minimally invasive implant device, to document post grafting
conditions and allow early intervention in failures.
KEYWORDS
Dental; Oral Surgical Procedures; Preprosthetic; Radiography; Sinus Floor; Augmentation.
1. INTRODUCTION ed a patient's perception of recovery after sinus-floor
augmentation [16]. The average patient should ex-
Augmentation of the maxillary sinus floor followed pect recovery within 5 days. As a result, patients may
by simultaneous or delayed placement of dental refuse the procedure due to fear, morbidity or other
implants is a well-established technique for implant- considerations. Several surgical techniques for sinus
supported rehabilitation of the partially or complete- floor augmentation were described. The classical lat-
ly edentulous patient [1-15]. Few studies document- eral window approach was described by Tatum in
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Chaushu L, Better H, Nissan J, Xavier SP, Lorean A, Chaushu G . Immediate / early radiological findings following transcrestal sinus augmentation
using a minimally invasive implant device. Stoma Edu J. 2020;7(1):35-41.
Received: November 15, 2019; Revised: January 09, 2020; Accepted: January 23, 2020 ; Published: January 28, 2020
*Corresponding author: Dr. Liat Chaushu, DMD, MSc, Department of Periodontology and Implant Dentistry, The Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
Fax: +972-86219999, Tel: +972-507821832
e-mail: liat.natanel@gmail.com
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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Original Articles
Figure 1. Immediate postoperative
view of a single implant.
1986 [17]. This surgical approach allows the clinician internal channel that allows the introduction of liq-
complete direct view of the sinus and enables sinus uids through the implant body and into the maxil-
floor augmentation to the full extent necessary. How- lary sinus. The device was approved for clinical test-
ever, it involves a significant amount of trauma to the ing by the ethical committees of the Israeli Ministry
patient [16]. The crestal approach was described by of Health following extensive preclinical and bench
Summers in 1994 [18]. This surgical procedure mini- testing. The device also has a Conformité Europée-
mizes much of the postoperative morbidity, howev- nne (CE) approval Health Canada and is allowed for
er, it limits the surgeons' direct vision and is limited in distribution in Europe, Canada and Israel. The study
its ability to augment the entire sinus floor. was approved by the ethical committee of the Tel
The hydraulic sinus membrane elevation was first de- Aviv University.
scribed by Chen and Cha in 2005 [19]. This is a variant
of the Summers' technique. The fluid pressure from 2.1. Surgical procedure
the drilling instrument is used to gently raise the si- Prophylactic antibiotics were administered (1 g of
nus membrane from the sinus floor. amoxicillin, 1 hour before the procedure). The pa-
The present study focuses on a new procedure and a tient performed a one-minute mouth wash with a
dedicated dental implant (iRaise sinus lift System by chlorhexidine gluconate 0.2% solution. Surgery com-
Herzliya, Tel Aviv, Israel) using the crestal approach menced with local anesthesia and a crestal incision,
[4,5]. This technique combines advantages of both without vertical extensions, along the maxillary ridge.
the Tatum and Summers approaches, enabling sinus Relatively small full thickness mucoperiosteal flaps
floor augmentation to the full extent necessary with were reflected. The osteotomy site was marked with a
minimum postoperative morbidity. Cone beam com- small round bur. An osteotomy was started at the im-
puted tomography (CBCT) provides a highly sophisti- plantation site with a 3.2 -mm twist drill to a depth of
cated format to precisely define the jaw structure and 3 mm. The second drill is a flat tip drill up to 1 to 2 mm
locate critical anatomic structures [20], and CBCT has below the Schneiderian membrane, as measured by
been used in diagnosis, implant treatment [21], and the preoperative radiograph. In some cases the op-
evaluation of the changes after the sinus augmenta- erator used drills stoppers in order to accurately drill
tion [6,9,12,14,21-23]. In the present study, the imme- to the planed point under the sinus floor, in other
diate and early (up to one week) tomographic find- cases the operator used a free hand drill with depth
ings following maxillary sinus augmentation using a marking only. A periapical radiograph with a depth
minimally invasive implant device will be described. guide was performed in order to verify the drilling
angulation and depth. The osteotomy site was wid-
2. MATERIALS AND METHODS ened to the desired diameter with the full drilling se-
quence for either a 4.2 or 5.0 mm–diameter implant.
The dental implant used in this trial was a self-tap- The sinus floor was opened with a drill with an active
ping endosseous dental implant [4,5]. It contains an diamond tip designed to atraumatically penetrate
36 Stoma Edu J. 2020;7(1):35-41 pISSN 2360-2406; eISSN 2502-0285
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Original Articles
Figure 2a. Preoperative CT demonstrating slight thickening of the Figure 2b. Postperative CT demonstrating moderate thickening of the
Schneiderian membrane. Schneiderian membrane.
the sinus floor under the Schneiderian membrane The bone graft syringe was subsequently discon-
with out damaging the membrane. The length of nected from the tubing port and then the applica-
the implant (ranging from 13 to 16 mm) was selected tor and tubing together were disconnected from the
based on the residual bone height: a 13-mm length implant. The implant was then fully inserted through
implant was used for bone heights of up to 5 mm, a the osteotomy into the bone graft until the coronal
14.5-mm length implant was used for bone heights aspect of the implant was aligned with the maxillary
of up to 6.5 mm, and a 16-mm length implant was alveolar crest. The gingival flaps were then sutured.
used for bone heights of up to 8 mm. The implant A periapical radiography was performed at the end
was first inserted into the osteotomy until it reached of the procedure. For those cases where the periapi-
the end of the prepared osteotomy. The implant was cal radiograph could not demonstrate a clear post-
then slowly advanced until the sinus floor was pene- operative result, a CBCT was performed at the end of
trated (approximately 1 mm). A periapical radiograph the procedure. When a CBCT device was not available
was performed in some cases in order to determine an early CBCT was performed within 1 week. Twenty
whether the implant penetrated the sinus floor. A immediate/early postoperative CBCT's were retro-
saline syringe (0.9% sodium chloride sterile saline spectively evaluated for descriptive purposes.
solution) was connected to the implant via the tub- Following the procedure the patients were instruct-
ing port. Saline solution was gently injected through ed to perform mouth rinsing for 1 minute with 0.2%
the implant and into the sinus. Slight bleeding was chlorhexidine solution, twice a day, for 10 days. Post-
noted in the retracted saline solution. This phenom- operative analgesia was used as needed. Nose drops
enon served as a further indication that the implant (topical decongestants such as oxymetazoline) were
tip penetrated the cortex. Blood was observed in the used in the relevant nostril twice a day for a week.
tubing upon stopping the injection or slightly drain- Antibiotics were prescribed at the clinician's discre-
ing fluid. Blood originated from the severed blood tion (as usually given in bone grafting procedures):
vessels connecting the Schneiderian membrane to 3 × 500 mg amoxicillin for 7 days.
the sinus bony walls. Typically, 2 to 3 cm3 of saline
were required, depending on the size of the sinus, 3. RESULTS
the number of implants, and the required elevation.
The saline solution was retracted back into the sy- 25 immediate postoperative CBCT's were reviewed.
ringe and the saline syringe was disconnected from The following radiological phenomena were noted:
the tubing port. A flowable bone graft filled syringe m Schneiderian membrane (Fig. 1)
was then connected to the tubing port. The desired A clear membrane was noted in all CBCT scans al-
volume of bone graft material was then slowly inject- lowing a distinction between the grafted area and
ed through the implant into the sinus. The amount of the rest of the sinus. The Scneiderian membrane ap-
bone graft ranged from 1 to 3 cm3, average 2.1 cm3. peared as a narrow hyperdense line.
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Chaushu L. et al.
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Original Articles
Figure 3. Immediate postoperative view of multiple implant placement. Figure 4. Immediate postoperative view of multiple implant placement.
mLack of membrane perforation (Fig. 1) superiorly, distally, mesially, palatally or any combi-
The thin line of the Schneiderian membrane is seen nation of the above.
encircling the entire new content (air, water, bone) m Membrane shape
without any perforated area. None of the included In some cases the membrane obtains a ball/balloon
materials is seen outside the membrane, within the like appearance (Fig. 1) whereas in others it may ob-
sinus. tain a completely irregular plastic shape (Figs. 3,4).
m Postoperative swelling of the sinus membrane (Fig. 2)
All cases demonstrated a slight postoperative swell- 4. DISCUSSION
ing of the sinus membrane without any signs of in-
flammation. Injectable bone substitutes are a combination of
mPalatal coverage of the membrane (Fig. 1) xenografts, allografts, alloplasts and liquid compo-
The membrane is not necessarily elevated for all the nents. Injectable alloplast proved to be very useful
bony walls. The elevation is probably proportional to when applied via a minimally invasive dental im-
the amount of residual alveolar ridge, pressure from plant device. The fluid organic components serve as
the injectable fluids and connection between the a binder for the anorganic bone substitute particles.
membrane and the bone. The organic materials prevent wash out of the par-
mFlush and compact adaptation of the grafting ma- ticles from the grafted site.[24] In order to allow op-
terial (Fig. 1) timal flow characteristics injectable grafts are further
Cases without additional implant placement dem- diluted. As a result the injected grafting material can
onstrated flush and compact adaptation of the bone easily glide between the Schneiderian membrane
graft to the sinus floor. When additional implants and the sinus floor without causing pain or injury
were inserted irregular combinations of the hyper- [25]. For clinical purposes prolonged storage of such
dense and hypodense areas were noted as a result ready-to-use injectable bone substitute materials is
fluid insertion and graft extrusion during the oste- mandatory. A neutral pH is the best solution for this
otomy preparation. (Figs. 3,4) requirement [25,26]. Their fluidity and adaptability to
mCreation of 4 layers according to molecular weight the host tissue is another mandatory requirement.
(Fig. 1) Thus, it can be speculated that the hyper dense view
Some immediate postoperative CBCT's demon- of the Schneiderian membrane is a result of the in-
strated 4 layers according to molecular weight. The creased concentration of the bone substitute macro-
most crestal is the original residual alveolar ridge. molecules adapting fast to the membrane as a result
The second is the injected bone graft. The third as of their fluidity. Sinus membrane integrity is essential
water / blood from the severed Schneiderian mem- for the success of the transcrestal sinus augmenta-
brane vessels and the most apical layer was air. The tion. Membrane perforations occur in 0-21.4% of the
layers may be arranged in either a homogenous pat- transcrestal procedures [27-28]. Ruling out in such
tern or in a completely non-homogenous one. An- cases is mandatory since there is very limited pos-
other factor is probably the additional drilling into sibility to repair such tears jeopardizing the entire
the sinus floor while adding implant, which can stir hydraulic elevation procedure. A clinical option is
the bone graft and fluid inside the space created doing a valsalva maneuver and observing the oste-
under the Schneiderian membrane. (it is possible otomy site that no air bubbles are coming out dur-
that it may take time for the layers to become homo- ing the maneuver. A dental CBCT provides conclusive
geneous as when you mix oil and water) post op information about such a perforation either
m Elevation direction (Figs. 1-4) by following the white hyperdense membrane line
There is no absolute control of the elevation amount or making sure there is no dislodged graft mate-
and direction. The membrane may be elevated either rial in the sinus beyond the Schneiderian membrane.
38 Stoma Edu J. 2020;7(1):35-41 pISSN 2360-2406; eISSN 2502-0285
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Injectable bone substitutes affect sedimentation - more fluid for elevation, to allow bony exposure and
Original Articles
the creation of precipitation layers according to the better fluidity of the bone grafting material. While
law of gravity [24-26]. This is the explanation for the membrane thickness in humans ranges from 24-
4 layers noted on CBCT – residual alveolar ridge, 350µm with a mean of 40 µm, in animals it ranges
injectable bone graft, water and blood, air. This ar- 68-318 µm [37]. Animal model studies led to the
rangement allows us to assure the intimate contact wrong conclusion that the Schneiderian membrane
of the graft to the native bone permitting good graft is elastic and responds to pressure like a balloon.
consolidation. On the other hand, this finding should The present study clearly shows that the "balloon"
also raise the question of whether studies concerning behavior is rather the exception than the rule. The
bone resorption along time represent true resorption more frequently seen behavior is plastic, obtaining
or are merely an expression of water and air content any possible shape. This is one more reason why
disappearance. Such questions should be taken in there are fewer chances for tearing the membrane
consideration in future studies allowing us to better during elevation with the hydraulic technique vs. the
understand the resorptive processes following sinus balloon technique.
augmentation [29-31]. The graft consolidation gradi- Hydraulic sinus elevation is not a new idea. Sinus en-
ent is a term describing new bone formation on the doscopy maybe an additional (albeit invasive) tech-
one hand vs. bone substitute disappearance [33]. nique to assure lack of sinus membrane perforation.
Since we are talking about a gradient, both phenom- CBCT is probably more precise but involves X-ray
ena are evaluated as a function of the distance from exposure. An additional disadvantage is the inability
either the host bone or the implant. Behavior close to to detect small rupture immediately after surgery. A
the host bone will teach us concerning the new vol- long-time comparative randomized study can give us
ume consolidation while close to the implant – con- more precise information.
cerning osseointegration. Injectable grafts are fast
resorbing materials [32]. It is known that such materi- 5. CONCLUSION
als disappear relatively fast from both sites allowing
new bone formation. Therefore, we should dedicate Dental CBCT is considered the gold standard for sinus
all our efforts to exposing the palatal site and elevat- diagnosis and surgical planning of sinus augmenta-
ing the sinus membrane. Otherwise, the palatal part tion. The present study suggests that CBCT should
of the bone will not participate in the formation of also be the gold standard for immediate or early post-
new bone. As a result, lower new bone quantity and operative imaging, following transcrestal sinus aug-
quality will be formed, lowering the biomechanical mentation, using minimally invasive implant device,
abilities of the inserted new implants to withstand to document post grafting conditions and allow early
occlusal forces [33]. Neverthless, there are reports in intervention in failures.
the literature that just tenting of the Schneiderian
membrane without bone graft may be sufficient in CONFLICT OF INTEREST
order to create new bone under the elevated and The authors declare no conflict of interest.
separated from the sinus floor Schneiderian mem-
brane. Probably blood clot is transformed into bone AUTHOR CONTRIBUTIONS
in that situation [34]. Due to Pascal's law it is difficult
CL: study design, data collection, writing the manu-
to obtain complete control of the membrane eleva- script; BH: data collection; NJ: approval of the
tion. Water will search the lowest resistant point to final version; XSP: approval of thefinal version;
detach the membrane from the sinus floor [35,36]. LA: data collection; CG: study design, data collection, writing the
Therefore, if we have any doubt it is better to use manuscript.
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40 Stoma Edu J. 2020;7(1):35-41 pISSN 2360-2406; eISSN 2502-0285
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Original Articles
Liat CHAUSHU
DMD, MSc
Department of Periodontology and Implant Dentistry
The Maurice and Gabriela Goldschleger School of Dental Medicine
Tel Aviv-University
Tel Aviv, Israel
CV
Graduated magna cum laude at Maurice and Gabriela Goldschleger school of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
Completed her MSc. Degree at Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Graduate of the periodontology
program and member of the department of periodontology and implant dentistry, the Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Graduate of the European federation of periodontology. A member
of the Israeli society of Periodondology and Osseointegration. A member of the European Federation of Periodontology.
A member of Israeli Dental Association. Lectures nationally and internationally. Published over 20 manuscripts in peer-reviewed
journals. Founder of an Israeli start-up company, Implant B, with a unique patent for the treatment of peri-implant disease.
Questions
1. How many layers were noted postoperatively?
qa. 1;
qb. 2;
qc. 3;
qd. 4.
2. Perforations can be noted easily in the postop CBCT:
qa. Yes;
qb. No;
qc. It is not possible to see perforations on CBCT;
qd. Resorbable collagen membranes should always be placed on the Schneiderian membrane.
3. The Schneiderian membrane always appears as a balloon following sinus elevation:
qa. Yes;
qb. No;
qc. It is not possible to see the Schneiderian membrane on CBCT;
qd. Only if you use a balloon for sinus elevation.
4. The 4 layers are best noted in cases of :
qa. Single implant;
qb. Multiple implants;
qc. Not relevant;
qd. Similar.
Stoma Edu J. 2020;7(1): 35-41 pISSN 2360-2406; eISSN 2502-0285 41