“Perio-Implant surgery: Expanding the Horizons”- Three lectures on “Sinus lifts- Alternative techniques and Strategies”, “Preparing PRF- What to do, what not to do” and “When not to use regenerative materials” organized by the Society of Periodontists and Implantologists of Kerala” at Kochi, India on 24/07/2016. “Sinus lifts- Alternative techniques and Strategies” and “When not to use regenerative materials”- Guest lecture as a part of Dr NTRUHS Zonal CDE programme in G Pulla Reddy Dental College and Hospital, Kurnool, India on 07/10/2016.

1. SINUS LIFTS
ALTERNATIVE TECHNIQUES AND STRATEGIES

2.  Sinus Lift encompasses the principles of
“Osteomobilization”, “Osteoelevation” and
“Osteocondensation”.*
*Cortes AR, Cortes DN. Nontraumatic bone expansion for immediate dental implant placement: an analysis
of 21 cases. Implant Dent. 2010 Apr;19(2):92-7.

3. A B
C D
Implant placement is divided into four
categories*
1. Class A, > 10 mm, classic implant protocol
could be followed.
2. Class B, 7 to 9 mm, indirect sinus lift could
be performed with simultaneous implant
placement.
3. Class C, 4 to 6 mm, a direct sinus lift
approach with delayed or immediate implant
placement.
4. Class D, 1 to 3 mm of bone, a direct sinus
lift approach with delayed implant placement
is recommended.
*Jensen OT, Shulman LB, Block MS, et al. Report of the Sinus Consensus Conference of 1996.
Int J Oral Maxillofac Implants. 1998;13(suppl):11-45.

4. 7-9 mm/ Indirect-Transcrestal Approach
Tatum, 1986
<6mm/ Direct Approach
Boyne and James, 1980

6. DIRECT SINUS LIFT
 DSL gives a better increase in height than ISL
(8.5mm vs 4.4mm).
 For ridges with 3-5 mm RBH, ISL~DSL.
 No difference between ISL & DSL in Implant stability
and bone loss during function.
Pal US et al. Direct vs. indirect sinus lift procedure: A comparison. Natl J Maxillofac Surg. 2012 Jan;3(1):31-7.

7.  5-41% perforation chances. 85% in sinusitis subjects.
 Errors in window preparation in relation to
remaining alveolus and septa.
 4.5-5.5cc~2g of commercial grafts.
Nolan PJ. Correlation between Schneiderian membrane perforation and sinus lift graft
outcome: a retrospective evaluation of 359 augmented sinus. J Oral Maxillofac Surg. 2014 Jan;72(1):47-52.
66-year-old female/10 years edentulousness/history of treated sinusitis

8. 66-year-old female/10 years edentulousness/history of treated sinusitis
 6.7% graft failure.
 11.3% required secondary antibiotics.
 30% will fail irrespective of antibiotics.
Nolan PJ. Correlation between Schneiderian membrane perforation and sinus lift graft
outcome: a retrospective evaluation of 359 augmented sinus. J Oral Maxillofac Surg. 2014 Jan;72(1):47-52.

9. 7 mm
Original sinus floor
Elevated sinus floor
“CLASSIC” INDIRECT SINUS LIFT

10. Summers, 1994
Osteotome Sinus Floor Elevation (OSFE)
Summers, 1994
Bone Added Osteotome
Sinus Floor Elevation (BAOSFE)

11. CONVEX VS CONCAVE OSTEOTOMES

12. In BAOSFE, the advantages are
Bone graft acts as cushion apically
reducing the risk of membrane perforation
and contributes to apical bone
regeneration
Vertical bone height gain results by
retention and relocation of all the
existing bone
XDisadvantages* are?
*Li TF. Sinus floor elevation: a revised osteotome technique and its biological concept. Compend Contin Educ
Dent. 2005 Sep;26(9):619-20.

13. Currently, the choice of graft material
in the apical area remains controversial.
Beirne OR. Osseointegrated Implant Systems in Principles of Oral and Maxillofacial Surgery,
Vol.II Peterson, LJ, Indresano AT, Marciani RD, Roser SM (eds) JB Lippincott Company,
Philadelphia, Chapter 44, pp 1133-1154, 1992.
No clear literature with regard to
implant-graft contact in the sinus.
Sykaras N, Iacopino AM, Marker VA, et al. Implant materials, designs, and
surface topographies: Their effect on osseointegration. a literature review.
Int J Oral Maxillofac Implants. 2000;15:675-690.
A “autologous” bony environment is best and
the blood clot can form within it.
Sbordone C, Toti P, Guidetti F, Califano L, Bufo P, Sbordone Volume changes of autogenous bone
after sinus lifting and grafting procedures: a 6-year computerized tomographic follow-up. J
Craniomaxillofac Surg. 2013 Apr;41(3):235-41.

15. Is a DSL Surgical window warranted?
Is an ISL possible?
Will you be able to achieve a dense
osseous stop/good quality bone?

16. DIRECT vs INDIRECT
Larger volumes
Better Access
Cortical stop
Easy perforation
repair
Less Invasive
Site Specific
Immediate Implant
Smaller surgical site

17. APICAL CORTICAL STOP/DENSE BONE
GOOD CORONAL BONE DENSITY
MINIMUM SURGICAL TRAUMA
*Soardi, Wang. Clinical Advances in Periodontics, Vol. 2, No. 3, August 2012
INDIRECT-DIRECT SINUS LIFT*
MINIMUM LEARNING CURVE

18. APICAL CORTICAL
STOP/ DENSE
BONE
CORONAL BONE
DENSITY
MINIMUM
SURGICAL
TRAUMA
LEARNING CURVE
DSL +++ + - -
ISL - +++ + +
Trephine core
lift
++ ++ + +
Crestal core
lift
++ + + +
Minimally
Invasive
- ++ +++ -
Pressure lift - +++ ++ -
Beirne OR. Osseointegrated Implant Systems in Principles of Oral and Maxillofacial Surgery,
Vol.II Peterson, LJ, Indresano AT, Marciani RD, Roser SM (eds) JB Lippincott Company,
Philadelphia, Chapter 44, pp 1133-1154, 1992.

19.  Cortical core at the apical area
 Delayed-Implant situation
 Lifting of membrane with cortical core
 Osteotomes increase the coronal site density
TREPHINE CORE SINUS LIFT

20. Conventional Trephine Core
Provide a cortical core at the apical area
Cortical core “tents” the membrane more effectively

21. Case #1

23. Trephines must be used with/in
 Light strokes under irrigation
 1-2mm in-and-out stroke
 Reverse direction

25. Case #2

28. “Audi ring cuts”

31. ADIN ® implant placed and primary stability
was assessed by RFA (OSSTELL®)

33. Case #3

34. *Fugazzotto,PA.ImmediateImplantPlacementFollowingaModifiedTrephine/OsteotomeApproach:
SuccessRatesof116Implantsto4YearsinFunction.IntJOralMaxillofacImplants2002;17:113–120.

36.  The technique allows for a relatively
atraumatic implosion of an autogenous
alveolar bone core and the apical displacement
of the floor of the sinus.
 Implants apically surrounded by a cortical core
have a success rate of 98.3%* in function for up
to 4 years. For BAOSFE, it is between 85%-
96%.**
*Fugazzotto, PA. Immediate Implant Placement Following a Modified Trephine/Osteotome Approach:
Success Rates of 116 Implants to 4 Years in Function. Int J Oral Maxillofac Implants 2002;17:113–120.
**Bernardello F et al. Crestal sinus lift with sequential drills and simultaneous implant placement in
sites with <5 mm of native bone: a multicentre retrospective study. Implant Dent. 2011 Dec;20(6):439-44.

37. Sinus/Alveolar Crest Tenting (SACT)

38.  CRESTAL WINDOW/CRESTAL CORE TECHNIQUE
 Less invasive than the lateral window technique
 Delayed or Immediate Implant situation
 68.9% success rate*
*Kolerman R et al. Maxillary sinus augmentation by the crestal core elevation technique. J Periodontol. 2011 Jan;82(1):41-51.

39. SACT with Delayed Implant Placement

40. Conservative osteotomy
Direct visualization
of membrane
Conservative
Flap Design
*Soardi, Wang. Clinical Advances in Periodontics, Vol. 2, No. 3, August 2012

42. Baseline 6 months

43. 3.75X8mm ADIN®

44. SACT with a Remote Palatal Flap

50. 1 week 15 days 1 month

52.  “Blind” nature of the topography.
 Risk of exceeding the elastic limits of the
Schneiderian membrane during elevation,
resulting in membrane perforation.
 In addition, the risk of injuring the posterior
alveolar artery or other vascular structures is
diminished
*Winter AA, Pollack AS, Odrich RB. Sinus/alveolar crest tenting (SACT): A new technique for implant placement in
atrophic maxillary ridges without bone grafts or membranes. Int J Periodontics Restorative Dent 2003;23:557-565.

53.  Be aware of the lower implant survival rates when pre-
implant bone height is less than 5 mm.
 Avoid lengthy, invasive, and complex sinus left
surgeries.
 Exert every effort to avoid the perforation of
Schneiderian membrane.
*Al-Dajani M. Recent Trends in Sinus Lift Surgery and Their
Clinical Implications. Clinical Implant Dentistry and Related Research, Volume 18, Number 1, 2016