Crestal Sinus Lift With Sequential Drills and … Sinus Lift With Sequential Drills and Simultaneous...

Crestal Sinus Lift With Sequential Drills andSimultaneous Implant Placement in Sites

With <5 mm of Native Bone: A MulticenterRetrospective Study

Bernardello Fabio, MD, DDS,* Righi Davide, DDS,† Cosci Ferdinando, MD, DDS,‡ Bozzoli Paolo, DDS,§Soardi Carlo Maria, MD, DDS,� and Spinato Sergio, DDS¶

Implant placement is often compli-cated in the posterior upper jaw bypostextraction bone resorption,

pneumatization of maxillary sinuses,and poor quality of alveolar bone. Inthese situations, the residual verticalbone height is reduced making stan-dard implant placement difficult. Infact, studies have shown higher suc-cess and survival rates (SRs) with afixture length of at least 10 mm.1–4

The elevation of the maxillary sinusfloor is one possible solution.5 Thesinus floor augmentation techniquewas first presented by Boyne andJames6; it was based on the lateralwindow method that was a modifica-tion of the known sinus revision pro-cedure according to Caldwell-Luc.Since then and until today, the sinuslift technique using lateral access hasbeen widely documented in the litera-ture and has proved to be a safe andhighly predictable method.7–12

A crestal approach for sinus floorelevation was initially suggested byTatum.13 Summers14 later proposed the osteotome technique to place implants

in a simpler, more conservative, andless invasive manner than the lateralapproach.15 In Summers’ technique,an osteotome is inserted through theedentulous alveolar crest at the infe-rior border of the maxillary sinusfloor. This intrusion procedure pro-duces a fracture in the least traumaticway possible and the sinus floor ismoved upward. This creates a spacefor bone graft and simultaneous im-plant placement. Some years later,

some authors16–19 suggested modifica-tions to the Summers’ technique basedspecifically on the use of different bio-materials and on the expansion andcompression of the alveolar crest tolift the sinus floor of the maxilla.

In particular, Cosci and Luccioli17

presented a sinus lift 1-stage crestalapproach using a specific sequence ofdrills (Cosci’s Technique). The shapeof the drill tip prevented perforation ofthe sinus membrane and permittedgentle abrasive removal of the cortical

*Private Practice, Legnago VR, Italy.†Private Practice, Parma PR, Italy.‡Private Practice, Lamporecchio PT, Italy.§Private Practice, Caronno Pertusella VA, Italy.�Private Practice, Brescia BS, Italy.¶Private Practice, Sassuolo MO, Italy.

Reprint requests and correspondence to: SergioSpinato, Via F. Cavallotti 140, 41049, Sassuolo (MO),Italy, Phone: 0039-0536-883868, Fax: 0039-0536-400082, E-mail: [email protected]

ISSN 1056-6163/11/02006-001Implant DentistryVolume 20 • Number 6Copyright © 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3182342052

Purpose: The aim of this multi-center retrospective clinical studywas to evaluate the survival rate ofimplants placed in the posteriormaxilla with a residual bone heightof �5 mm.

Materials and Methods: Onehundred seventeen patients, recruitedfrom 6 different centers, had 134 im-plants placed below the maxillary si-nus. The patient population consistedof 52 men and 65 women ranging inage from 39 to 78 years (mean age,53.2 years). Sinus lift procedures wereperformed following a crestal ap-proach using a specific sequence ofdrills (Cosci’s technique). All implantswere submerged. Periapical radio-graphs were obtained with a parallel-ing technique and were digitized. Thepattern of bone remodeling was sub-sequently evaluated.

Results: The average (�SD)follow-up time was 48.2 months(�29.30 months; range, 24 to 120months). Of the original 134 implantsplaced, 5 implants (3.7%) failed. Theimplant survival rate was 96.3%. Theaverage residual bone height was 3.46mm (�0.91 mm) at baseline. The av-erage height of the alveolar crest inthe treated implant sites was 9.94 �2.29 mm. The radiographic bone gainwas 6.48 � 2.38 mm.

Conclusion: The investigationsuggests that this crestal drill ap-proach can be a successful sinus lift-ing procedure in a severe atrophicmaxilla with �5 mm of crestal boneheight. (Implant Dent 2011;20:1–000)Key Words: crestal approach, liftingdrills, residual bone height, sinusaugmentation, sinus graft

IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 1

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bone of the sinus floor without frac-ture. The main limitation of these cr-estal techniques is the uncertainty of apossible perforation of the sinus mem-brane. However, an endoscopic studyshowed that the sinus floor may beelevated up to 5 mm without tearingthe membrane.20 This outcome is indi-rectly confirmed by the study, whichcompared the crestal approach and thelateral antrostomy for sinus augmenta-tion: the results indicated that the os-teotome technique allowed a maximumincrease in bone height of 3 to 4 mm,whereas the lateral technique allowed anincrease of 10 to 12 mm.21

In a multicentric retrospectivestudy, Rosen et al22 evaluated the out-come of the Summers’ technique inthe placement of implants below themaxillary sinus floor: the SR was 96%when the residual bone height was 5mm or more, but dropped dramaticallyto 85% when crestal bone height was4 mm or less. Existing literature22–24

suggests that residual bone height hasa significant influence on the outcomeof crestal procedures. Specifically, thesuccess and SRs decrease with re-duced residual bone height.

The purpose of this multicenterretrospective study was to evaluate theSRs of implants placed in the posteriormaxilla with a residual bone height of�5 mm using a sequential sinus liftcrestal approach (Cosci’s technique).

MATERIALS AND METHODS

During the period from 1999 to2009, 117 patients, recruited from 6 dif-ferent centers, had 134 implants placedbelow the maxillary sinus. The patientpopulation consisted of 52 men and 65women ranging in age from 39 to 78years (mean age, 53.2 years). All of theselected patients were in a good state ofhealth, absence of diseases that affectsbone metabolism or wound healing, andno regular medications consumption for�3 months. All the authors’ patientswho underwent bone regeneration tech-niques were non-smokers.25,26 Hence,smokers were excluded from the study.

These patients presented a residualbone height of �5 mm, making implantplacement impossible without a sinuslift procedure. Pretreatment residual

bone height was determined for eachsite by using a periapical radiograph.

Radiographic Analysis

Endaural digital images (RVGKodak system & CSN system) wereobtained after implant placement(baseline) and during control examina-tions with a paralleling technique us-ing a Rinn film holder. To obtain realand accurate measurements, digitalimages were always calibrated with aspecific software application, takingthe known length of the inserted im-plant as a reference for measurement.No attempts were made for furtherstandardization.

The following radiographic linearmeasurements were made:

1. Residual bone height from the al-veolar crest (coinciding with theimplant shoulder) to the floor of themaxillary sinus mesial and distal tothe inserted implant at baseline(Fig. 1, A).

2. Distance from sinus floor to alveo-lar crest in treated sites at thefollow-up appointment (Fig. 1, B).

3. Radiographic bone gain (G) wascalculated: the distance from im-plant shoulder to the sinus floor atbaseline was compared with thedistance from implant shoulder to

Fig. 1. Linear measurements made on the periapical radiographs. A, Baseline radiograph. B,Control radiograph. Radiographic bone gain (G) is the difference between the height of thegraft (or new bone) measured from the implant shoulder to the edge of the graft (or new bone)as revealed in the control x-ray and the height measured from the implant shoulder to the sinusfloor in the baseline x-ray. G � B1 � B0 in the figures. Reduction of the graft (R) is the differencebetween the height of the graft measured from the implant shoulder to the edge of the graft(B0 � H) in the baseline x-ray and the height of the graft (or new bone) measured from theimplant shoulder to the edge of the graft in the control x-ray. R � (B0 � H) � B1 in the figures.

Fig. 2. Lifting drills with a small cutting angle of 30 degrees.

2 CRESTAL SINUS LIFT WITH SEQUENTIAL DRILLS AND SIMULTANEOUS IMPLANT PLACEMENT • FABIO ET AL

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the new sinus floor at the time oflast examination (Fig. 1, A and B).

4. Height of the graft (or new bone, inthe control x-ray image) from thefloor of the sinus to the edge of thegraft mesial and distal to the im-plant (Fig. 1, A).

5. Reduction of the graft (R) was cal-culated: the difference between theheight of the graft measured fromthe implant shoulder to the edgeof the graft in the baseline x-rayand the height of the graft (or newbone) measured from the implantshoulder to the edge of the graft inthe control x-ray (Fig. 1, A and B).

When no visible radio-opaquegrafting materials were used, it wasimpossible to measure the graft heightand therefore to calculate the reduc-tion of the graft. In these cases, onlythe radiographic bone gain was calcu-lated. Every linear measurement wasreported as a mean between the mesialand the distal measurement. A differ-ence of �0.5 mm was considered asgood interoperator agreement, ie, aclinically nonsignificant discrepancy.

At the clinical and radiographicexamination after functional loading,the following parameters were alsoevaluated: survival of implants andrestorations; pocket probing depth inmillimeters; periimplant radiographicbone loss measured from the implantshoulder to the first bone-to-implantcontact. It was calculated as an aver-age of mesial and distal bone changesfrom the preoperative values. The fi-nal value was calculated by averagingthe average bone loss per patient. Thestandard of success for implant func-tion established by Albrektsson et al27

was applied.

Surgical Procedure

All patients had been treated withimplants placed in the posterior max-illa using the specific sequence of lift-ing drills16 (Fig. 2). The set of drillsincluded 11 pieces with the same diam-eter (3.1 mm) but with increasing length(2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 mm).All patients were treated according tothe following surgical protocol. Patientsrinsed 0.12% chlorhexidine for 1 minutebefore surgery. Under local anesthesia, a

full-thickness flap was opened. If neces-sary, vertical releasing incisions weremade. The location of the implant wasmarked with a small-diameter pilot-drillof 1 mm in length working through thecortical bone. Then a larger-diameter in-termediate drill was used. An implantsite was prepared about 1 mm below thesinus floor using a lifting drill that was 1mm shorter than the height of the alve-olar crest.

A parallel pin was inserted intothe surgical site and an intraoperativex-ray revealed the exact length of thealveolar ridge below the sinus floor.The first lifting drill that was 1 mmlonger than the length of the measured

alveolar crest was then used andpushed into the site until the shoulderstop reached the ridge. With a specialrounded probe, a check was made ofthe alveolar bone to determine that itwas perforated and that the sinusmembrane was ready to be lifted: theValsalva maneuver (nose-blowingtest) showed no perforations (Fig. 3).

Then, the graft was gently pushedinto the site using a particular instru-ment called “body-lifting”; this stepwas repeated until the site was filledwith the graft. Another x-ray wastaken to check the lift and its height. Aself-tapping implant was then inserted.The type of implants placed had avariety of surfaces (microtexture andhydroxyapatite) and designs: Spline,Screw-Vent, and Screw-Vent Tapered(Zimmer Dental, Carlsbad, CA). Allimplants were submerged. The timebetween implant placement and theirexposure was approximately 6 months.Subsequent prostheses includedsingle-tooth restoration, multiple-unitimplant supported restorations, andoverdentures. All implants had to be infunction for a minimum of 24 months(Fig. 4).

Statistical Analysis

The quantitative data were ex-pressed as average � SD. The Student

Fig. 3. View of sinus membrane: the shape ofthe drill tip prevents perforation of it.

Fig. 4. A, Two implants after placement. B, Four months after the sinus lift, 1 implant wasloaded with a resin crown. The volume of added graft (Puros, Zimmer Dental, Carlsbad, CA) iseasily seen around the second implant. C, Radiographic view of the 2 splinted crowns at 2years after loading. D, Definitive restoration with fixed porcelain prosthesis.


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t test (for paired samples) was used toevaluate the statistical difference. Sta-tistical significance was set at P �0.05. Implant survival was expressedas the percentage of lost implants inrelation to the total number of im-plants inserted. The data were sub-jected to Kaplan-Meier analysis toprovide a cumulative SR.28

RESULTS

Over the 10-year period (1999–2009), 134 implants were inserted in117 patients. The average follow-uptime was 48.2 months (�29.30months; range, 24–120 months). Sixtyimplants used in this study wereSpline (Zimmer Dental); 10 implantswere Screw-Vent (Zimmer Dental);and 64 implants were Tapered Screw-Vent (Zimmer Dental). The majorityof those (50.7%) were standard im-plants with a diameter of 3.7 or 3.75mm; 18.7% were implants with a di-ameter of 4.1 mm; 20.9% were wide-body implants with a diameter of 4.7mm; 9.7% were implants with a diam-eter of 5 mm. The most frequentlyplaced implant length was 11.5 mm(placed in 46.3% of cases) followedby 13 mm implants that were placed in28.3% of cases. Ten-millimeter longimplants were used in 23.2% of cases,whereas 15-mm long implants wereused in only 2.2% of cases (Table 1).

Fifty percent of the implantsplaced with this crestal approach wereinserted in the position of the firstmolar; the second most common posi-tion was the second bicuspid in 38%of cases; and the third most commonposition was the second molar in 12%of cases. The cumulative SR of theimplants was 96.3% (95% CI) (Fig. 5).Of the original 134 implants placed, atotal of 5 implants (3.7%) failed. Fourimplants were lost before loading: 1implant was lost due to acute infectionafter 35 days. In 2 cases, the implantsdid not osseointegrate and were re-moved after approximately 2 months.The fourth implant that was lost beforeloading was removed after 6 monthswhen the implant was exposed. The fifthimplant was lost after a loading time of63 months due to periimplantitis.

The periimplant bone loss of eachof the 129 implants placed success-

fully was measured mesially and dis-tally. The range of marginal bone losswas 0 to 2 mm both mesially anddistally in 128 implants showing anaverage value of 1.07 mm (�0.40 mm)mesially and 1.20 mm (�0.51 mm) dis-tally. Only one implant showed a greatermarginal bone loss, measuring 3.5 mmmesially and 4 mm distally, due to peri-implantitis occurring during the healingperiod. The periimplantitis was treatedaccording to the implant maintenanceand treatment protocol cumulative inter-ceptive supportive therapy.29 Thirty-eight months after supportive therapy,

the implant was normally in functionwith no further bone loss. No other com-plaints or adverse effects were observedduring the follow-up time.

The average residual bone heightwas 3.46 mm (�0.91 mm) at baseline.The average height of the alveolarcrest in the treated implant sites was9.94 mm (�2.29 mm) at the time offollow-up examination. The measuredmean radiographic bone gain usingthis technique was 6.48 mm (�2.38mm) (Table 2).

In this study, 7 different types ofgrafting materials were used (autoge-

Fig. 5. Cumulative survival of 134 implants.

Table 1. Demographic Information of Implants Placed

Diameter 10 mm 11.5 mm 13 mm 15 mm

3.7 4 (1 Failed) 11 6 —3.75 5 22 (1 Failed) 18 (1 Failed) 24.1 12 (1 Failed) 10 3 —4.7 8 13 (1 Failed) 7 —5.0 2 6 4 1

Table 2. Mean Distance (mm) From Sinus Floor to Alveolar Crest in Treated ImplantSites (at Baseline and at the Follow-Up Appointment)

Baseline Follow-UpBone

Gain (G) P

Crestal bone height (mm),mean (�SD)

3.46 (0.91) 9.94 (2.29) 6.48 (2.38) �0.05

Table 3. Reduction (mm) of Grafting Materials Used in the Present Study (Only 79Implant Sites Were Evaluated)

Baseline Follow-Up Reduction (R) P

Height of the graft (mm),mean (�SD)

9.40 (1.63) 7.58 (2.03) �1.82 (1.03) �0.05


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nous bone, deproteinized bovine bonemineral, collagen, hydroxyapatite, de-mineralized freeze-dried bone allograft,tri-calcium phosphate, and mineralizedhuman bone allograft) alone or in vari-ous combinations. Because of the heter-ogeneity of the grafting materials, nocomparative statistical analysis could beperformed with regard to the 7 individ-ual materials.

It was however possible to calcu-late the reduction of the graft for 79 ofthe 129 successfully inserted implants.In these cases, a radio-opaque graftingmaterial was used. Immediately afterimplant insertion, the height of thegraft was 9.40 mm (�1.63 mm). Atthe follow-up examination, this heighthad reduced by 1.82 mm (�1.03 mm)to 7.58 mm (�2.03 mm) (P � 0.05)(Table 3).

DISCUSSION

Since their introduction into clin-ical practice, different sinus augmen-tation procedures have demonstratedtheir effectiveness regarding the en-hancement of native bone in maxillaryareas with atrophic ridges and pneu-matized sinuses. Boyne and James in1980 proposed a lateral approach forsinus lifts.6 The access to elevate thesinus floor was performed by openinga window through the lateral wall.This technique enabled a remarkableincrease in bone height of �10 mm,21

even in extremely atrophic ridges.5,8–10

However, lateral antrostomy results insignificant postsurgical morbidity andsignificantly increased risk of mem-brane tearing.30

During the 1980s, less invasiveclinical practice techniques using a cr-estal approach were introduced. Theseprocedures were based on the use ofosteotomes14–16 or sequential drills17

and allowed simultaneous implantplacement and sinus floor elevationobtained by graft insertion. Addition-ally, this drill technique eliminatedhammering and therefore proved to bemore acceptable to patients.17

Evidence available today indicatesthat crestal techniques with simultane-ous implants insertion are predictableand safe with excellent SRs.23,24,31,32

However, it is generally considered thatthe crestal approach requires a mini-

mum of 5 mm of residual bone height22

due to the risk of tearing the membraneand the difficulty of obtaining primaryimplant stability in thin ridges. For thisreason, an osteotome-staged approachwith 6 months delayed implant insertionhas recently been proposed with encour-aging results.33

Because osteotome techniques en-abled a maximum increase in boneheight of 3 to 4 mm,21,34 some au-thors35,36 proposed the use of short,porous-surfaced implants, with orwithout sinus floor elevation, in ex-tremely atrophic ridges. The resultsare undoubtedly encouraging (97%–99%) but are still based on limitedcases and supported only by short-term follow-up. In the present multi-center retrospective report, the 134implants immediately inserted intosites with �5 mm (average height,3.46 � 0.91 mm) showed an excellentSR (96.3%) (Fig. 8) calculated on asignificant follow-up period (48months).

This result is better than an anal-ogous retrospective report based on anosteotome technique that showed alower SR in atrophic ridges (85.7%).22

This result can be explained by a re-duced risk of damaging the sinusmembrane by using sequential dril-ling. This outcome is confirmed by thegain in bone height obtained in thisstudy (6.48 � 2.38 mm) (Table 2),which is greater than the increase ob-served using the osteotome technique(3–4 mm).21,34 This difference mayalso be attributed to the fact that onlynon-smokers were selected in this in-vestigation due to the fact that nicotinehas a negative impact on bone healingand sinus augmentation procedures.25,26

Another report showed 9.12 mmof bone gain but with a lower SR(91.4%) and in a shorter follow-upperiod (22 months) with localizedmanagement of the sinus floor,37 amodified osteotome technique withoutgrafting insertion. Other studies usingthe osteotome technique with no graftshowed an average gain in bone heightof between 1.7 and 3.5 mm.34,38 Theaverage length of implant used wasapproximately 11 mm and the averagediameter was 4 mm (Table 1). Thesedata confirm that the crestal sequential

drill approach enables the develop-ment of a satisfactory bone height forsimultaneous insertion of implants ofadequate length and diameter as sug-gested in the literature.1–4

Despite the heterogeneity of graft-ing materials, it was possible to calcu-late the contraction of the graft in 79of the 129 successfully inserted im-plants in which a radio-opaque graft-ing material was used. In these cases,immediately after implant insertion,the height of the graft was 9.40 � 1.63mm and, at the time of follow-up ex-amination, this height had reduced by1.82 � 1.03 mm to 7.58 � 2.03 mm(Table 3), ie, approximately 20%,which is similar to the data availablein another report.39

CONCLUSION

This retrospective investigationsuggests that the crestal sequentialdrill approach (Cosci’s technique) canbe a successful sinus lifting procedurein a severely atrophic maxilla with �5mm of crestal bone height.

DISCLOSURE

The authors claim to have no finan-cial interest in any company or any ofthe products mentioned in this article.

ACKNOWLEDGMENTS

The authors thank Dr. Luigi Vec-chi, ScD, Statistician, Mirandola (MO),Italy, for the statistical analysis.

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