Clinical experience with a new implant in a minimally invasive procedure Bilateral sinus floor elevation
and simultaneous implantation

In the following article, the author describes his clinical experience with a new implant that allows for augmentation
of the maxillary sinus floor by hydraulic elevation of the Schneiderian membrane.
When dental implants are required in the maxillary molar region, a sinus floor augmentation procedure is indicated in 50 per cent or more of cases [1] due to pneumatization of the maxillary sinus and atrophy of the alveolar ridge [2]. The common procedure in mostcases is the open sinus lift, first presented by Boyneand James [3] and subsequently by Tatum [4].
However, the open sinus elevation involves com- plications [5-9], significant trauma to the patientand usually a long recovery time involving pain,swelling and bleeding in the facial area, resulting inthe loss of a number of work days [10]. A commoncomplication is the perforation of the Schneiderianmembrane [2,8,9].
A relatively new alternative for safely elevating the Schneiderian membrane is the hydraulic sinus no connection between the prosthetic interface and elevation, or hydraulic sinus condensing [11,12]: After the duct, so bacteria from the oral cavity are blocked careful drilling into the sinus floor without damag- from reaching the bone after implantation.
ing the mucosa, the operator uses a liquid (Chen [11]uses an air/water aerosol emitted from a dental tur- Case studies
bine) to create a hydraulic pressure that detachesthe Schneiderian membrane from the floor of the This article describes two cases of bilateral sinus sinus and forms a space under it. Bone substitute is floor elevation, for a total of four sinus floor aug- inserted into the resulting space, followed by a den- mentation procedures. All four procedures were car- tal implant. Hydraulic elevation is a safer method for ried out in a similar manner. Two of the procedures detaching the membrane, as the pressure is evenly are described below in detail – one for each patient.
spread over the membrane surface [13].
The cases presented here used a new dental im - First patient
plant (iRaise, Maxillent, Israel). This implant applies The first patient was a 64-year-old woman who took the principle of hydraulic elevation using an internal metamizole for thyroid dysfunction but was other- channel within the implant, which allows for the wise healthy. Clinical and radiological examination injection of saline to accomplish the membrane ele- showed teeth 16, 17, 26 and 27 to be missing in the vation. Thereafter, the saline is removed and a bone region of the maxillary sinuses. The residual bone graft with a gel-like consistency is inserted into the height on both sides was up to 4 mm, requiring newly formed sub-Schneiderian space; finally, the bilateral sinus floor elevation as a prerequisite for implant is fully inserted into the bone. The L-shaped an implant-supported restoration. The two sinuses internal channel (Fig. 1) is designed so that there is appeared to be normal in a CT scan. Sinus floor elevation and simultaneous implant insertion at was raised by crestal incision, without release inci- site 16 and another conventional implant insertion sions. An osteotomy was prepared at site 26, and the at site 17 were carried out, and sinus floor elevation sinus floor was identified using a flat bur that pro- and simultaneous implant insertion were per- vides for tactile sensation of the hard cortical bone formed at sites 26 (sinus lift implant) and 27 (con- of the sinus floor, without any risk of rupture. After ventional implant). The method provides for aug- widening the bore, the sinus floor was weakened mentation of a whole sinus using a single implant. If using a specialized diamond bur. At this stage the additional implants are required in the treated sinus, implant was inserted into the bore. A tube connec- conventional implants of any manufacture may be tor was attached to the implant to enable the injec- placed within the elevated space that already con- tains bone graft material. In the cases described The membrane was elevated by hydrostatic pres- here, the conventional implants were iSure implants sure by injecting 3 cm3 of normal saline solution through the implant. The saline was removed from Before treatment, the patient received prophy- the sinus by withdrawing the syringe plunger and lactic antibiotics (amoxicillin and clavulanic acid, appeared to be mixed with a little blood (Fig. 4), a 875 mg) and performed a mouthwash (chlorhexidine clinical indicator for the saline having come in con- gluconate 0.12 %). A full-thickness mucoperiosteal flap tact with the Schneiderian membrane, breachingthe small blood vessels between the membrane andthe sinus floor. Next, 3 cm3 of synthetic bone substi-tute were inserted (MBCP Gel, Biomatlante, France)(Fig. 5), selected because it is easily injected throughthe implant and is fairly radiopaque, allowing it tobe identified on post-operative X-rays. The connector was removed and the implant fully inserted into the bone. Beside the sinus lift implantat site 27, a conventional implant was placed usinga standard drilling protocol. This osteotomy wasdrilled directly into the sinus, inside the bone graftbeneath the elevated membrane. Figures 6 and 7 Figs. 6 and 7 CT scan before the treatment, periapical X-ray image after the treat-ment. iRaise is the left implant in the images. show X-ray images before and after the treatment.
Figs. 8 and 9Verification ofreaching thesinus floor byperiapical X-rayimage with adepth gauge. Second patient
The second patient was a 56-year-old man who had had bypass surgery and took low-dose aspirin pro- phylactically. Clinical and radiological examination showed teeth 16, 17, 26 and 27 to be missing, with approximately 4 mm of residual bone height bilater- ally. The sinuses appeared normal in the CT scan. On the right side, sinus floor elevation was performed using the sinus lift implant at site 17. An additionalconventional implant was inserted at site 16. Onthe left side, the elevation and implantation wereperformed at site 27, and an additional conventionalimplant was inserted at site 26. On both sides, the touched the Schneiderian membrane, detaching the sinus lift implants were positioned in the distal loca- blood vessels at its bottom (Fig. 10). A connector was tions, due to the flat angulation of sinus floor, as attached to the implant, and the membrane was ele- opposed to a more angulated anatomy at sites 16 vated by hydrostatic pressure through injected saline.
The saline was drawn and fluid bone graft was insert- The procedure on the left side is described in the ed using three 1 cm3 syringes (Figs. 11 and 12).
following. The patient received antibiotic prophy- Finally, the connector was removed from the laxis before the treatment (amoxicillin and clavu- implant and the implant was fully inserted into the lanic acid, 875 mg). A flap was raised by crestal inci- osteotomy. An additional conventional implant was sion at sites 26 and 27, and preparatory osteotomies inserted at site 26. Figures 13 and 14 show a CT image were performed until the identification of the hard before the treatment and a periapical X-ray image bone of the sinus floor using a flat bur. The position immediately after it. Figures 15 and 16 show the situ- of the osteotomy with respect to the sinus floor was ation at the follow-up at four and at seven months.
confirmed by periapical X-ray image with a depth All four procedures were performed similarly to the two cases described here in detail. Pre- and post-oper- After widening the bore and weakening the sinus ative X-ray images are provided for the two remain- floor using a diamond bur, the implant was inserted.
ing cases (Figs. 17 to 22). Both patients immediately Blood was identified at the lateral opening of the resumed full activity and did not report any pain, implant, indicating that the end of the implant had Figs. 11 and 12Insertion of 3 cm3of bone graftthrough theimplant. Figs. 13 to 16 CT image before the treatment, periapical X-ray image immediately after the treatment, at four months and atseven months (from left to right). iRaise is the right implant in the images. Figs. 17 to 22 The two remaining cases in the X-ray image before and a periapical image after the treatment. Figures 17 and 18show the right side of the first patient (pre-operative CT, post-operative periapical X-ray). Figures 19 to 22 show the right sideof the second patient (pre- and post-operative periapical X-rays). Figures 21 and 22 show the situation at the follow-up atfour months and at seven months. Discussion
The cases presented in this article demonstrate a The author’s experience in the cases performed new alternative to the open sinus lift, which may show that the technique is easy to implement and potentially provide the advantages of a simpler sur- has a simple learning curve. The patients went gical technique and reduced trauma and recovery through the treatment easily and simply, with a time for the patient. It is based on a hydraulic eleva- good treatment experience, without significant dis- tion procedure, combined within a dental implant to allow a simultaneous elevation and implantation These cases, however, represent preliminary expe- rience with the surgical technique and are limitedto two patients and to four procedures. Once addi-tional patients have been treated, and with more Contact address
extensive follow-up of the patients, the efficacy of Eran Fermon, DMD
the method may be examined on a greater sample of cases and the development of bone after the Visit the web to find the list of references (
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24 de agosto de 2011 Lista Prohibida 2012 RESÚMEN de las PRINCIPALES MODIFICACIONES y NOTAS EXPLICATIVAS INTRODUCCIÓN Los miembros de la Comunidad Antidopaje deben saber que se ha prestado una meticulosa consideración a los pertinentes comentarios recibidos en respuesta a la distribución del borrador de la Lista 2012. Se hace salvedad que no todas las sugerenc


Nancy B. Davis, MDa, Ashesh B. Jani, MDb,aDepartment of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center,5841 South Maryland Avenue, MC2115, Chicago, IL 60637, USAbDepartment of Radiation and Cellular Oncology, The University of Chicago Medical Center,5841 South Maryland Avenue, MC 9006, Chicago, IL 60637, USAcThe Ben May Institute for Cancer Research, Th

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