24 Implant Tribune Italian Edition - Novembre 2012

originalarticle

Letteratura internazionale

Smart Lift Technique for Minimally Invasive Transcrestal Sinus Floor ElevationGiovanni<Franceschetti1,<Pasquale<Minenna2,<Roberto<Farina1,<Leonardo<Trombelli1

1Research Centre for the Study of Periodontal and Peri-implant Disease, University of Ferrara, Italy, 2Private practice, Foggia, Italy

IntroductionIn the posterior maxillary sextants,

insertion of implants of desired

length and diameter is often limi-

ted by the dimensional alterations

of the residual ridge as well as the

pneumatization of the maxillary

sinus occurring after tooth loss1-4.

Transcrestal sinus floor elevation

(tSFE) represents a surgical option

to vertically enhance the available

bone in the posterior maxillary

sextant through an access crea-

ted through the edentulous bone

crest. Surgical techniques for tSFE

are mainly based on the fracture

or perforation of the sinus floor by

means of osteotomes5-7 or burs8-14.

The apical displacement of the

Schneiderian membrane obtained

by tSFE may be enhanced and bet-

ter maintained by condensing a

graft material under the elevated

sinus membrane. Pjetursson and

colleagues15 compared the outco-

mes of tSFE when performed with

osteotomes with and without the

additional use of deproteinized bo-

vine bone mineral (DBBM).

At 1 year post-surgery, periapical

radiographs at grafted sites were

more frequently associated with

a radio-opaque structure apical to

the implants compared with non-

grafted sites. After an average fol-

low- up time of 3.2 years, a signifi-

cantly greater gain in radiographic

bone height was observed in graf-

ted (4.1 mm) compared with non-

grafted (1.7 mm) sites, with a two-

fold higher probability to observe

a substantial (2 mm) gain in height

over the implant apex when a graft

material was used15.

Recently, we proposed a minimal-

ly invasive procedure for tSFE,

namely the Smart Lift technique,

which is characterized by a tran-

screstal access to the sinus cavity

by means of specially designed

drills and osteotomes16-18. The pro-

cedure represents a modification of

the technique proposed by Fugaz-

zotto10.

However, the major novelty is

that all the instruments are used

with adjustable stop devices, thus

restricting the working action of

burs and osteotomes to the vertical

amount of residual bone. This is ai-

med to prevent any accidental pe-

netration of instruments into the

sinus cavity.

Previous studies showed that the

Smart Lift technique results in a

predictable apical displacement of

the sinus floor and a limited post-

operative morbidity, when used

in association with graft biomate-

rials17. With the Smart Lift techni-

que, the vertical augmentation of

the implant site is provided by the

condensed trephined bone core

that is displaced into the sinus.

<> pagina 25

Fig. 1.a - All manual and rotating instruments of the Smart Lift technique are used with adjustable stop devices (length ranging from 4 to 11 mm).

Fig. 1.g - The trephine bur (Smart Lift Drill, Ø 3.2 mm or 4.0 mm), produces a bone core up to the sinus floor.

Fig. 1.h - The bone core is condensed to fracture the sinus floor by means of a calibrated osteotome (Smart Lift Elevator, Ø 3.2 mm or Ø 4.0 mm) that corresponds to the diameter of the trephine preparation.

Figg. 1.i, l - The Smart Lift Elevator is used under gently malleting forces to implode the trephined bone core over the sinus floor.

Fig. 1.m - The implant is inserted.

Fig. 1.b - The Locator Drill perforates the cortical bone to a depth of 3.5 mm at the site where the implant is to be placed.

Fig. 1.c - The Probe Drill (Ø 1.2 mm) is used to define the position and orien-tation of the implant. This bur is used with an adjustable stop device which is set at least 1 mm shorter than the radiographic working length.

Fig. 1.d - The “Probe Osteotome” (Ø 1.2 mm) is gently forced in an apical direction through the cancellous bone until the cortical bone resistance of the sinus floor is met. Therefore, the Probe Osteotome will provide the “surgical working length”.

Fig. 1.e - A Radiographic Pin (Ø 1.2 mm) can be used to check radiographical-ly the orientation and depth of the prepared site.

Fig. 1.f - A Guide Drill of either Ø 3.2mm or Ø 4.0mm according to implant diameter is used to create a crestal countersink, 2 mm deep, where the trephine bur will be inserted.

Fig. 1.a-m - Surgical steps of the Smart Lift technique for transcrestal sinus floor elevation.

25Implant Tribune Italian Edition - Novembre 2012

originalarticle

Letteratura internazionale

Fig. 2.a-n - A paradigmatic case of transcrestal sinus floor elevation performed with the Smart Lift technique.

Fig. 2.d - The Smart Lift Drill Ø 3.2, used at the surgical working length of 7 mm, trephined a bone core up to the sinus floor.

Fig. 2.e - The bone core created by the Smart Lift Drill. Figg. 2.f, g - Additional biomaterial (biphasic calcium phosphate composed of hydroxyapatite (60%) and beta form of tricalcium phosphate (40%)**) was inserted into the implant site, to be grafted into the sinus.

Fig. 2.c - The surgical working length was assessed at 6.5 mm throu-gh tactile perception of the sinus floor using the Probe Osteotome.

Fig. 2.a - A 53 year-old male, former smoker patient presented with an edentulous lacuna in the maxillary left quadrant. The prosthetic rehabilitation plan of the patient included the placement of one implant-supported crown in the region of the left second premolar.

<< pagina 24

This intrusion osteotomy proce-

dure elevates the sinus membrane,

thus creating a space for blood clot

formation. It is conceivable that the

contribution of the bone core to the

intra-sinusal bone formation may

relate to the amount of residual

bone at the implant site (i.e. the

more the native bone pushed into

the sinus, the more the newly for-

med bone). When a limited amount

of residual bone is present with re-

spect to the amount of bone needed

for proper implant placement, bone

formation may be implemented by

the additional use of a graft.

Scientific evidence clearly indicates

that the use of a graft biomaterial

in association with tSFE may effec-

tively sustain bone regeneration15-19.

Recently our research group20 com-

pared the clinical effectiveness of a

synthetic hydroxyapatite in a colla-

gen matrix (S-HA) and DBBM when

used in association with the Smart

Lift technique and we demonstrated

that both biomaterials may provide

a predictable elevation of the ma-

xillary sinus floor along with limi-

ted post-surgical complications and

post-operative pain/discomfort.

At present, whether and to what

extent the Smart Lift technique

may benefit by the additional use

of different graft biomaterials, and

which biomaterial is the most sui-

table to provide conditions for new

bone formation still needs to be elu-

cidated. In this context, we report

a clinical case in which the Smart

Lift technique was associated with

biphasic calcium phosphate com-

posed of hydroxyapatite (60%) and

beta form of tricalcium phosphate

(40%).

Material And MethodsRationale and indications

The Smart Lift technique was de-

veloped by the Research Center

for the Study of Periodontal and

Peri-implant Diseases, Universi-

ty of Ferrara, and the Department

of Odontostomatology, Ospedale

“Casa Sollievo della Sofferenza”, S.

Giovanni Rotondo. The technique is

characterized by a transcrestal ac-

cess to the sinus cavity by means of

specially-designed drills and osteo-

tomes. The pristine bone at sites of

implant placement is drilled up to

the sinus floor with a trephine bur,

and then used to fracture the sinus

floor by hydraulic pressure through

osteotomes. In this respect, the pro-

cedure represents a modification

of the technique proposed by Fu-

gazzotto10. The major novelty with

previously described procedures

resides in the fact that all manual

and rotating instruments are used

with adjustable stop devices which

are selected in relation to the verti-

cal amount of residual bone at sites

where implants have to be placed

(Fig. 1.a). These stop devices have a

variable length, from 4 to 11 mm,

and may be adapted to all manual

and rotating instruments. The use

of the stop device restricts the wor-

king action of burs and osteotomes

to the vertical amount of residual

bone, thus preventing the acciden-

tal penetration of instruments into

the sinus cavity. The identification

of the working length (i.e. the di-

stance from the bone crest to the

sinus floor) where the osteotome

and burs should limit their working

action is first diagnosed on periapi-

cal x-ray or CT scan, and then intra-

surgery assessed by means of a spe-

cially-designed osteotome.

The Smart Lift technique shares its

clinical indications with any other

proposed surgical procedures for si-

nus floor elevation with a transcre-

stal approach21, 22.

- indications for implant-suppor-

ted prosthetic rehabilitation,

based on accurate diagnosis and

treatment planning;

- systemic and local conditions

which are compatible with im-

plant placement and sinus floor

elevation procedures;

- residual bone height (i.e. the di-

stance from the bone crest to the

sinus floor) of at least 4 mm.

The Smart Lift technique must not

be performed when systemic and lo-

cal conditions which contraindicate

sinus floor elevation are present21, 22.

Surgical Technique

According to the prosthetic tre-

atment planning, the location for

implant placement is established,

and the residual bone height at such

locations is first diagnosed by pro-

per x-ray examination. The distan-

ce from the bone crest to the sinus

floor as assessed radiographically

will provide the “radiographic wor-

king length”. Surgical stents may be

recommended for implant positio-

ning, particularly when multiple

implants have to be inserted.

All instruments in the surgical set*

are characterized by laser marks

at 4-5-6-7-8-9-10-11 mm to allow

for a precise control of the working

length. The first drill, (Locator Drill)

is designed to perforate the cor-

tical bone to a depth of 3.5 mm at

the site where the implant is to be

placed (Fig. 1.b). A second drill (Pro-

be Drill), with a diameter of 1.2 mm

and cutting only at the top edge,

is used to define the position and

orientation of the implant. In order

to minimize the risk of sinus floor

perforation, this bur is used with an

adjustable stop device which is set

at least 1 mm shorter than the “ra-

diographic working length” (Fig. 1.c).

Then, the “Probe Osteotome” (Ø 1.2

mm) is carefully inserted into the

site prepared by the Probe Drill, and

gently forced in an apical direction

through the cancellous bone until

the cortical bone resistance of the

sinus floor is met. Therefore, the

Probe Osteotome will provide the

“surgical working length”, which is

the true anatomical distance from

the bone crest to the sinus floor in

the exact location where the im-

plant should be placed (Fig. 1.d).

Thus, the working action of all ma-

nual and rotating instruments that

will be used in subsequent surgical

steps will be now set at the “surgical

working length” by using the proper

adjustable stop device.

A Radiographic Pin (Ø 1.2 mm) can

also be used to check the angula-

tion and depth of the prepared site

by means of a periapical x-ray (Fig.

1.e). The Radiographic Pin handle

has a diameter of 4.0 mm, thus

permitting to evaluate the spatial

relationship between the prepared

site and the bucco-lingual as well

as mesio-distal dimensions of the

alveolar ridge. This will help the cli-

nicians to determine the diameter

of the implant to be placed. Then, a

“Guide Drill” of Ø 3.2 mm (implants

Ø: 3.75 ÷ 4.5 mm) or Ø 4.0 mm (im-

plants Ø: 4.8 ÷ 5.0 mm) can be used.

This drill follows the Ø 1.2 mm site

preparation and creates a crestal

countersink, 2 mm deep, where the

trephine bur (Smart Lift Drill) will be

inserted (Fig. 1.f). Such countersink

enables the trephine bur to centre

the working action of the bur accor-

ding to the desired direction. The

“Smart Lift Drill” (Ø 3.2 or 4.0), set at

the surgical working length, produ-

ces a bone core up to the sinus floor

(Fig. 1.g). Following the removal of

the trephine bur, the bone core (Fig.

1.h) is then condensed and malleted

to fracture the sinus floor by means

of a calibrated osteotome (Smart

Lift Elevator, Ø 3.2 or Ø 4.0) that

corresponds to the diameter of the

trephine preparation (Fig. 1.i, l). If

the alveolar bone core is found to be

inside the trephine, the bone core is

gently removed from the trephine

and replaced in the alveolar bone

preparation. The osteotome is used

under gently malleting forces to im-

plode the trephined bone core over

the sinus floor.

<> pagina 26

Fig. 2.b - The pre-operatory periapical radiograph showed a residual bone height (i.e. radiographic working length) of 6.5 mm at location of the second upper premolar.

26 Implant Tribune Italian Edition - Novembre 2012

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Schneiderian membrane. Clinical Oral Implants Research 16: 615-621.15. Pjetursson, B.E., Ignjatovic, D., Matuliene, G., Brägger, U., Schmidlin, K. & Lang, N.P. (2009) Maxillary sinus floor

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21. Cochran D. Implant therapy I. Ann Periodontol 1996;1:707-790.22. Frizt ME. Implant therapy II. Ann Periodontol 1996;1:796-815.23. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic review of the success of sinus floor elevation and survi-

val of implants inserted in combination with sinus floor elevation. Part II: Transalveolar technique. J Clin Periodon-tol 2008;35 (Suppl. 8):241-254.

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References

Figg. 2.h, i - An implant***, Ø 4.0 X 11.0 mm was positioned.Figg. 2.f, g - Additional biomaterial (biphasic calcium phosphate composed of hydroxyapatite (60%) and beta form of tricalcium phosphate (40%)**) was inserted into the implant site, to be grafted into the sinus.

<< pagina 25

In relation to the extent of vertical

bone augmentation to be achieved,

a cortical bone particulate or a bone

substitute can be further grafted

and condensed into the sinus by the

osteotome. Again, the Smart Lift Ele-

vator is used with the adjustable stop

device at the surgical working length,

thus preventing any unwanted pene-

tration of the instruments into the

sinus cavity. Provided that the resi-

dual bone may ensure an adequate

primary stability, an implant can be

inserted during the same surgical

session (Fig. 1.m). Otherwise, a staged

approach is recommended.

Clinical case report

A 53 year-old male, former smoker pa-

tient presented with an edentulous

lacuna in the maxillary left quadrant

(Fig. 2.a). Neither systemic or local

conditions contraindicating implant

surgery or sinus lift procedures were

identified at the screening visit. The

prosthetic rehabilitation included

the placement of a prosthetic crown

supported by one implant, placed

in the region of the left second pre-

molar. The pre-operatory periapical

radiograph showed a radiographic

working length of 6.5 mm at location

of the edentulous lacuna (Fig. 2.b).

Therefore, a transcrestal sinus floor

elevation was planned to allow for

the placement of an implant of ade-

quate length.

A full-thickness flap was elevated

to access the alveolar crest and the

implant site in the position 2.5 was

prepared using the Smart Lift techni-

que. First, the Locator Drill was used

to perforate the cortical bone crest

at implant sites. Then, the Probe Drill

was used with the 6-mm adjustable

stop device. The surgical working

length was assessed at 6.5 mm throu-

gh tactile perception of the sinus

floor using the Probe Osteotome (Fig.

2.c). A countersink was prepared by

the Guide Drill, then a trephined bone

core was created by the Smart Lift

Drill Ø 3.2, with the stop device set at

7 mm (Fig. 2.c). The bone core created

by the Smart Lift Drill (Fig. 2.e) was

gently malleted upwards using the Ø

3.2 Smart Lift Elevator until the sinus

floor was fractured. Additional bio-

material (biphasic calcium phospha-

te composed of hydroxyapatite (60%)

and beta form of tricalcium phospha-

te (40%)**) was grafted into the sinus

(Fig. 2.f, g). Visual inspection and Val-

salva manoeuvre did not reveal signs

of perforation of the sinus membra-

ne. One implant***, Ø 4.0 x 11.0 mm

was positioned (Fig. 2.h, i, l). At 2 years

following surgery, the implant was

clinically stable (Fig. 2.m). On peria-

pical radiographs, a radiopaque area

corresponding to the augmented

sinus floor was present around and

above the apical portion of the distal

implant (Fig. 2.n).

Discussion and ConclusionsThe present case report illustrates

a minimally-invasive procedure ai-

med at sinus floor elevation with

transcrestal approach for implant

insertion. The rationale for this tech-

nique is essentially derived from a

previously described procedure whe-

re the combined use of a trephine

bur and osteotomes was suggested10.

Briefly, this technique implied the

use of a trephine drill penetrating up

to 1 mm from the sinus floor. Then,

an osteotome was used to implode

(by the use of a mallet) the trephined

bone core to a depth of 1 mm less than

the initial trephine cut. The hydraulic

pressure exerted by the autogenous

bone core determined the fracture of

the sinus floor with vertical augmen-

tation of the implant site. Previous re-

ports with such technique showed a

cumulative success rate of 98.0% fol-

lowing 13-48 months of follow-up10.

Although proven effective, the tech-

nique proposed by Fugazzotto10 se-

ems highly technique-sensitive, par-

ticularly with respect to the control

of the working action of both trephi-

ne bur and osteotome. It may be

conceivable that, during the drilling

action of the trephine bur and the

mallet pressure onto the osteotomes,

a direct damage of the sinus mem-

brane due to instrument penetration

over the sinus floor can occur.

Recently, a systematic review23 repor-

ted an incidence of membrane per-

foration ranging from 0% to 21.4%,

and postoperative infection from

0% to 2.5% following transcrestal si-

nus elevation procedures. In an ex-

perimental evaluation of maxillary

sinus membrane response following

elevation with osteotome techni-

que in human cadavers, membrane

perforation was observed in 6 out

of 25 implants (24%), the risk being

increased with an increasing extent

of sinus floor elevation to be obtai-

ned24. An endoscopic study revealed

that the sinus floor may be elevated

up to 5mm without perforating the

sinus membrane25. However, other

endoscopic studies have demonstra-

ted the risk of membrane perforation

while performing transalveolar sinus

floor elevation26. An endoscopic eva-

luation of the bone-added osteoto-

me sinus floor elevation procedure

revealed that the surgical approach

may lead to large detachment of the

membrane over a broad area exten-

ding both apically and laterally to

the implant tip contour. However, in

2 out of 8 analyzed patients mem-

brane perforation with partial loss

of the graft particles was observed27.

Whether and to what extent mem-

brane perforation may compromise

the implant survival is still unclear.

In this respect, a preclinical study

demonstrated that implants inten-

tionally exposed for 4-8 mm into the

sinus cavity following transcrestal

sinus elevation procedures were only

partially recovered by sinus muco-

sa, the exposed part of the implant

being recovered by debris potentially

resulting in sinus infection28.

In our procedure, the working action

of the rotating and manual instru-

ments is restricted to the residual

(native) bone. The working length

is first established radiographically,

but then confirmed by the combined

use of the Probe Drill and Probe Oste-

otome. Probe Drill is provided with

a top cutting edge which can easily

proceed into the cancellous bone rea-

ching the proximity of the sinus flo-

or. Then, the surgical working length

is defined by tactile perception of the

cortical bone of the sinus floor deri-

ved from the gentle use of the Probe

Osteotome.

<> pagina 27

Letteratura internazionaleoriginalarticle

27Implant Tribune Italian Edition - Novembre 2012

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SE DICO IMPIANTO, A COSA PENSI...?

..:: DVD per la sala d’aspetto ::..

M. RONCATI, P. MARZOLA 75,00 euro + iva

CAPITOLI

1. L’IMPLANTOLOGIA È...2. CHE RISCHI CI SONO?3. CHI FUMA PUÒ FARE L’IMPIANTO?4. CON GLI IMPIANTI C’È RIGETTO?5. IN CASO DI OSTEOPOROSI?

6. QUANTO TEMPO DURA UN IMPIANTO?7. È UN INTERVENTO DOLOROSO?8. IL CARICO IMMEDIATO

9. COSTI E MODALITÀ DI INTERVENTO

10. TECNICA IMPLANTARE COMPUTERIZZATA

Questo fi lm per la sala d’aspetto informa i pazienti odontoiatrici sui vantaggidella terapia implantare. L’argomento è trattato in modo ironico e accattivanteda attori e supportato da animazioni e disegni 2D.

Obiettivo è rendere maggiormente consapevoli e preparati all’intervento coloroche stanno valutando, o hanno già optato, per questa soluzione dissipando ombre, diffusi timori e certi luoghi comuni.

DURATA: 20 MIN. CIRCA

Fig. 2.l - Periapical radiograph taken immediately after implant placement, showing radio-opaque grafted area around and above the implant apex.

Fig. 2.m - At 2 years following surgery, the implant was clinically stable. Fig. 2.n - At 2-year follow-up, a radiopaque area corre-sponding to the augmented sinus floor was still present around and above the apical portion of the distal implant.

<< pagina 26

Once the surgical working length is

established, the use of adjustable stop

devices would dictate the extent of

the working action of manual and ro-

tating instruments, thus minimizing

the risk for membrane perforation

and post-surgery infections. Other

techniques have been reported whe-

re the use of burs of variable length

and provided with a shoulder stop

have been used to perforate the sinus

floor9. Unfortunately, in such pro-

cedure the selection of the working

length of the rotating instruments is

only based on the radiographic exa-

mination, leading to potential under-

or over-estimation of the amount of

residual bone height. Extensive mal-

leting trauma during sinus floor ele-

vation with osteotomes may cause

BPPV, a benign syndrome characte-

rized by short, recurrent episodes

of vertigo, initiated by movements

of head lateralization and extension

toward the affected site29-31. In this

respect, the combined utilization

of a trephine bur in close proximity

to the sinus floor limits the need for

repeated malleting. Therefore, the

Smart Lift technique may result less

traumatic and disconcerting to the

patient with respect to the conven-

tional osteotome procedures.

Vertical augmentation of the implant

site is provided by the condensed

trephined bone core which is displa-

ced into the sinus. This intrusion

osteotomy procedure elevates the

sinus membrane, thus creating a spa-

ce for blood clot formation. It is con-

ceivable that the contribution of the

bone core to intra-sinus bone forma-

tion may relate to the amount of resi-

dual bone at the implant site, i.e. the

more native bone pushed into the

sinus, the more newly formed bone.

When a limited amount of residual

bone is present with respect to the

amount of bone needed for proper

implant placement, bone formation

may be implemented by the additio-

nal use of a graft. Grafting material is

added incrementally and condensed

into the sinus by the osteotome. Du-

ring the grafting procedure, it is the

graft biomaterial only that exerts the

hydraulic pressure to “tent” the sinus

membrane, while any direct penetra-

tion of the osteotome into the sinus

cavity is prevented by the adjustable

stop device. Previous studies seem

to suggest an enhanced osteoinduc-

tive/conductive potential with the

additional use of bone substitutes.

Pjetursson and colleagues15 compa-

red the transcrestal sinus floor ele-

vation by means of osteotomes with

and without the additional use of

deproteinized bovine bone matrix.

A gain in radiographic bone height

of 4.1 mm and 1.7 mm where obser-

ved in grafted and non-grafted sites,

respectively. Recently our research

group demonstrated that indepen-

dently from the biomaterial used in

association with the Smart Lift tech-

nique, the procedure may provide a

predictable elevation of the maxil-

lary sinus floor along with limited

post-surgical complications and

post-operative pain/discomfort20. In

conclusion, the Smart Lift technique

represents a minimally-invasive sur-

gical option for sinus floor elevation.

The technique is based on a standar-

dized, user-friendly sequence of ma-

nual and rotating instruments used

with a controlled working action ai-

med at preventing surgical compli-

cations. However, further controlled

clinical trials are needed to evaluate

the efficacy and safety of this techni-

que compared to conventional sinus

floor elevation procedures.

note* SMART LIFT; Meta CGM Spa,

Reggio Emilia, Italy.** BoneCeramic, Straumann®, Straumann

AG, Postfach, Basel, Switzerland.*** Thommen Medical AG, Waldenbug,

Switzerland.

Letteratura internazionale