Show Your Work: A Simple Approach to Crestal Sinus Augmentation by Dr. Matthew F. Bickel

The world of the general dentist has changed a lot over the years. When I graduated from the University of Medicine and Dentistry of New Jersey–New Jersey Dental School (now Rutgers School of Dental Medicine) in 1992, implant surgery was not common among GPs. We got zero exposure to implants as undergrads; I merely knew that they existed, and thanks to a sales rep at a school presentation I knew you had to use a special plastic scaler to clean one. But that was the extent of my dental school implant education.

During my Advanced Education in General Dentistry residency, also with UMDNJ, I had the privilege of being taught by Dr. Stanley Praiss, a pioneering implantologist/surgeon GP who taught the residents much more about surgery than we learned in dental school. Praiss tried very hard to get the residents to learn implant placement, but the school administration would not sanction it; it believed that GPs had no business placing their own implants. My, how times have changed! Most, if not all, GP residency programs now teach implant placement, and many older docs, myself included, have taken continuing education to learn implant placement.

My implant surgery journey began in 2013, when I took a Hiossen surgical course. Through the teaching of some great specialists and GPs (including my implant mentor, Dr. Paul Goodman), I was able to start placing implants in my office. As my experience progressed, I began taking courses in guided bone regeneration (GBR) and sinus augmentation. One of the things I enjoy most about implant surgery is that I have total control over the restorative position of my implants.

Case study
A 59-year-old patient presented with a failing implant at #4—which happened to be one of the first implants I had ever placed! The patient had disappeared from the practice for a couple of years before I could restore it, he had been a smoker, and his periodontal disease was now uncontrolled. In addition, the implant was placed without a CBCT, and it’s possible there was an osseous defect that I was not aware of.

Fig. 1 shows the CBCT images of the failing implant and the resulting osseous defect. You can also see sinus thickening because of the infection penetrating the sinus floor. The patient was now a nonsmoker, and was fully committed to treating his periodontal disease and restoring his missing teeth.

Step 1 was to remove the failing implant, completely debride the area and graft the defect. A flap was laid with a WaterLase iPlus dental laser, and the defect was thoroughly curetted as well as cleaned with the laser until we were down to clean, healthy bone. The area was grafted with Steiner Socket Putty Plus (a fully synthetic graft material containing b-TCP and osteogenic factors) and covered with a Cytoplast titanium-reinforced membrane. The membrane was removed three weeks later. Fig. 2 shows the sagittal CBCT image from the healed defect.

Fig. 3 shows the coronal CBCT image three months postop. We were able to regenerate only about 50 percent of the bone height, but we got a nice, wide ridge with resolution of the sinus thickening. The patient was aware of the amount of bone loss on #5, and knew it would most likely be replaced by an implant at some point. However, his home care had been exemplary; all his probings were at 3 millimeters or less, and he is staying on a three-month recare schedule.

At this point, the patient was ready to place implants on the UR. We would be extracting #31 because the restorative prognosis was poor, so we were looking to replace #3 and #4 with implants. Fig. 4 shows a sinus septum directly at the #3 position. The decision was made to place implants at #2 and #4, bypassing the septum (which appeared fairly high, had a sloping ridge, and was therefore more difficult to augment via crestal approach), and to make a three-unit bridge from #2 to #4.

Fig. 5 shows the implant and sinus graft treatment plan in the Anatomage software. The plan was sent to the Anatomage lab for fabrication of a surgical guide (Fig. 6).

Surgical treatment begins
On the day of surgery, the patient was anesthetized with three carps of Septocaine and rinsed with Peridex before the procedure. The surgical guide was tried in to confirm fit. A flap was laid with the WaterLase iPlus dental laser, and the surgical guide was used to make the initial pilot hole for the osteotomy position. Using the pilot holes as a guide and the CBCT measurements to gauge depth, the osteotomy was prepared with Hiossen’s Crestal Approach Sinus surgical kit. The kit uses safe-ended drills (Fig. 7) that cut a “manhole cover” of bone out of the sinus floor, and allow penetration of the osteotomy into the sinus floor with almost zero chance of a membrane perforation.

According to the kit’s instructions, after the sinus floor is penetrated, the membrane is hydraulically lifted with sterile saline using a special syringe (Fig. 8, p. 30). Bone graft is then supposed to be added into the space created after the membrane is lifted.

However, as simple as this process is, there is a way to simplify it even more. Fig. 9 shows the two syringes used for the Steiner Sinus Graft material. Steiner Sinus Graft is designed to hydraulically lift the membrane as it is injected, so we were able to skip the saline step outlined in the Hiossen CAS kit protocol.

The osteotomy was made through the sinus floor; the material was mixed, the tip placed on the syringe, and it was injected into the sinus. The tip can be trimmed to better seal the hole. As you put pressure on the plunger, the graft material hydraulically lifts the membrane while the graft is deposited (Figs. 10 and 11).

Modifying the standard technique
Besides combining two steps in one, there are three main advantages to the Steiner Sinus Graft over conventional allograft:

1. Steiner’s graft is completely resorbable, so there is no concern over particles that may not completely turn over into native bone.
2. Steiner’s graft—actually a bone cement—hardens within about 20 minutes of placement. This keeps the shape of the augmentation done at the surgery.
3. Steiner’s graft particle size is very small—small enough that it will pass through the ostium without causing a blockage if you do have a membrane perforation.

Osteotomies into sites #2 and #4 were completed into the sinus floor. Each site was lifted using one entire 2cc Sinus Graft syringe. Even though the CBCT graft-volume measurement showed that only 1cc would be needed for each site, an ultra-low-res CBCT taken after 1cc of material showed that the membrane was not sufficiently and symmetrically lifted (Fig. 12).

Because the Steiner Sinus Graft hardens after 20 minutes, it is necessary to prep the entire depth of the implant osteotomy after the graft is completed. The surgical guide was used to complete the osteotomies, and Hiossen ET3 4.5-by-8.5mm implants were placed in both sites. Implants were torqued to 35 newton centimeters. Fig. 13 shows final ultra-low-res CBCT of both implants, which were buried with cover screws.

The patient had been placed on preoperative antibiotics, which were continued for seven days because of the grafting procedure. He was given standard postop sinus graft instructions, including not to blow his nose for four weeks, and reported only very minor discomfort when he was contacted the evening of the surgery.

A complication, one-week postop
At the one-week postop suture removal visit, there was a slight exposure of the cover screws because the sutures opened. The patient was getting ready to go on a three-week vacation, and I wouldn’t be able to follow up until he got back. He also wears a temporary acrylic removable partial denture (RPD) that was relieved over the implant sites. The decision was made to remove the cover screws, place healing abutments, and drastically relieve the RPD over the implant sites.

When the patient returned from vacation, and also at his last visit (approximately three months postop) the gingival tissue around the healing caps was completely healthy with no inflammation. He will be ready for restoration of the implants in about one month (four months postop).

I hope this modification of a popular sinus lift technique has been of interest, and will drive you to investigate new materials and techniques!

Show your work in Dentaltown!
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