The Osteotome Sinus Lift: Placement of Long Implants Can Be Predictable

Tat Chiang, DMD; Howard J. Drew, DMD; and Barry I. Simon, DDS, MSD

Since Bränemark introduced the concept of osseointegration and its clinical application to dental implants,^1,2 excellent long-term success for restoring the fully edentulous and partially edentulous patient has been achieved. When adequate volume and quality of bone has been reported, the success rate has been shown to improve.^3-8 However, the posterior maxilla remains a challenge for implant placement because of the limited availability of bone and the poor quality of bone present (the posterior maxilla usually has type IV bone which is soft and of poor quality). The implant survival rate is lower in type IV bone than type II and type III bone. Jaffin reported the implant survival rate is only 65% in type IV bone with machine-surface implants.⁹ It is also common for the posterior maxilla to be associated with inadequate alveolar bone for implant placement. This is often because of the increased pneumatization of the maxillary sinus caused by osteoclastic erosion of the periosteal sinus floor. In addition, after the tooth is extracted without socket preservation procedures using bone graft material and membranes, rapid horizontal and vertical bone loss usually occurs.¹⁰ This results in significant loss of bone volume. The rate of resorption occurs even more rapidly in the posterior maxilla than in any other area of the mouth.¹¹ At present, sinus grafting with osteotome internal sinus-lift procedures and lateral window sinus-lift procedures are being used to regenerate and increase bone volume in the atrophic maxilla before implant placement and are considered to be safe and predictable procedures.^12-16

Lateral window sinus augmentation with clinical success was first reported by Tatum, in 1997¹⁷ and first published by Boyne in 1980.¹⁸ Since then, numerous authors using different modified techniques and bone-graft materials have reported good clinical success.^19-23 Two reviews on the survival rate of implants placed in the grafted maxillary sinus reported about 91% survival, with ranges from 61.2% to 100%.^24,25 Recently, Wallace reported a success rate of 98.6% with the use of a roughened implant surface, particulate bone-graft material, and membranes covering the osseous sinus window; this is comparable or slightly better than implants placed in native bone (95%).²⁵

Even though lateral-window sinus-lift procedures are highly predictable and successful in the regeneration of bone for implant placement in the atrophic maxilla, there are complications or medical risks commonly associated with this approach that may deter patient acceptance. Severe facial swelling, hematoma, and associated pain are not uncommon after the lateral-window sinus-lift procedure.²⁶ These are often the result of the large extensive flap design from the tuberosity to the distal of the canine or premolar. The large vertical incisions are often needed to gain access for the osteotomy of the lateral osseous window as well as to prevent the incision suture line over the large bony window. Another common complication is sinus membrane perforation. The rate of occurrence ranges from 10% to 44% even when competent clinicians performed the procedure.^27-31 This may be a result of the thinness of the Schneiderian membrane (averaging 0.3 mm to 0.8 mm),³² and partly a result of the presence of Underwood septae, which occurs approximately 24% to 31% of the time.^33,34 Typically, the sinus membrane is thinner over the area of septum and easily torn upon elevation.³⁵ Reports from the Sinus Consensus Conference of 1996 indicated that there is a direct relationship between sinus-membrane perforation and complications, and studies have found that the greater the membrane perforation, the greater the incidence of postoperative infection.^13,27

In 1994, Summers introduced the less-invasive osteotome internal sinus-lift procedure as an alternate method to regenerate bone for implant placement in the atrophic posterior maxilla.^15,36 A multicenter retrospective of 101 consecutively treated patients with a total of 174 implants with various implant surfaces and shape, using different bone graft materials (autograft, allograft, xenograft), were studied. The loading time of the implant ranged from 6 to 66 months (average 20 months) with an implant survival rate of 96% or better when pretreatment ridge height was 5 mm or higher.¹⁶ The success rate was comparable to the success rate of the lateral-window sinus-lift procedure, but the osteotome sinus-bone augmentation surgery has several advantages over the conventional lateral-window procedures.

First, the osteotome technique is, by nature, a less-invasive surgery with smaller flap design and a less extensive osteotomy. Therefore, there is less chance of postoperative complications and morbidity, and patient acceptance for surgery is greatly increased. Second, in 1996, the report of the Sinus Consensus showed that 48% of failed sinus grafts could be attributed to preoperative complications, and 38% of these were related to sinus-membrane perforation. Ferrigno and Toffler recorded that the rate of osteotome sinus-membrane perforation using the osteotome technique was 2.2% to 4.7%.^37,38 Therefore, the chance of postsurgical complications and infection associated with membrane perforation was greatly reduced. Third, the amount of graft material used in the osteotome technique is generally limited in comparison to a lateral-window procedure. A graft volume of 3.5 ± 1.33 cc is needed for placement of a 13-mm implant in sites with a pretreatment bone height of 5 mm in the lateral-window technique.³⁹ With the osteotome technique, the bone volume used to augment the sinus usually averages 1 cc to 1.5 cc instead of 4 cc to 6 cc of bone as used in the lateral-window procedure. This may be beneficial especially in a situation where the patient has a clear contraindication to sinus grafting because of space-occupying masses such as polyps, retention cysts, or mucosal thickening. This may contraindicate a lateral-wall procedure. The osteotome lift will reduce the chance of osteomeatal complex obstruction because there is a more discrete use of bone in the osteotome technique and less chance of elevating the masses to obstruct the osteomeatal complex. Fourth, as Mazor reported in a study where 10 lateral-window sinus procedures for single-tooth implants were performed in 10 patients, membrane perforation may be as high as 40%.⁴⁰ The author indicated that this might be because of the restricted access and space and the thick, overlying zygomatic thick-buttress bone. The osteotome technique may be better for single-tooth sinus augmentation because it requires a small flap design to obtain a small, localized sinus-floor elevation. There is lower rate of membrane perforation and a less complicated surgery, because osteotome surgery involves a crestal approach, which is common to standard implant surgery. Additionally, to achieve the success rate of 94% to 98% with the lateral-window approach, a resorbable or non-resorbable membrane was needed to cover the osseous lateral window.²⁵ This increased the cost when compared with internal sinus-lift procedures, which did not require the use of any membrane.

Even though the osteotome sinus-lift procedure is an easier, less-invasive and less-costly procedure, there is still concern among clinicians about the amount of the bone height that can be elevated without membrane perforation for implant placement. Unlike the lateral-window technique, the osteotome sinus technique is an internal approach where bone is added through the same channel following the osteotomy preparation for implant placement. Berengo used endoscopes to evaluate the distention pattern of the sinus membrane during the bone-added osteotome sinus-floor elevation and its relationship to membrane perforation.⁴¹ Sixteen Osseotite® implants (Biomet 3i, Palm Beach Gardens, FL) were placed under endoscopic control in eight patients. The limited report suggested that two patterns of sinus-membrane elevation can be observed relative to the area of membrane distention, one in which the elevation is restricted to the implant apices with a localized vertical augmentation pattern and another that yields a broader area of augmentation extending over the implants and lateral to the implant apical contours. Membrane perforation did occur in two of 16 implants sites, but was only observed with the vertical localized pattern of membrane distention. In terms of the amount of sinus-floor elevation, Fugazzotto indicated that no implants should be placed with a length greater than 2x minus 2 mm, with x equaling the residual alveolar bone present in millimeters coronal to the floor of the sinus at the time of therapy.⁴² According to Fugazzotto, with a pretreatment bone height of 6 mm to 7 mm, the amount of safe membrane elevation is 4 mm to 5 mm. With the use of endoscopy through the canine fossa into the sinus cavity, Nkenke was able to visualize the sinus-membrane elevation and quantify the gain in height of implant sites with 18 endoscopically controlled osteotome sinus-floor elevations.⁴³ The increases in the height of the implants by an osteotome technique alone, up to the point where the concomitant spontaneous dissection of the sinus membrane in the periphery of the elevated region stopped and the tension of the sinus membrane revealed the risk of membrane perforation, was 3 mm (range 2 mm to 5 mm). Reiser, using direct visualization of the sinus cavity through the lateral wall of the nose on 16 formaldehyde-treated cadaver heads, evaluated the sinus-membrane response in relation to perforation and elevated bone height (from 4 mm to 8 mm) with the oseotome technique. The result showed that although there were six perforations out of 25 osteotome sinus-lift procedures (24% sinus-membrane perforation rate), five of the six perforations occurred at 6-mm to 8-mm elevations and only one occurred in the 4-mm to 5-mm elevations for the osteotome technique.⁴⁴

The authors here report the technique and the following clinical cases of elevating the sinus membrane 6 mm to 10 mm with pretreatment alveolar bone heights of about 5 mm to 7 mm and placing 13-mm to 15-mm long implants routinely with the osteotome technique. According to the recent report on the relationship of implant survival rate and the length of implants placed with the one-stage osteotome sinus-lift technique (with a total of 588 implants placed in 323 patients with a mean follow-up time of 59.7 months), implants with a 12-mm length had a greater survival rate (93.4%) than 10-mm (90.5%) or 8-mm (88.9%) implants.³⁷ Therefore, it may be desirable to have implants longer then 12 mm when placing fixtures.

SURGICAL PROCEDURE

The technique employed for the osteotome sinus-lift procedure was similar to the one reported by the authors in a previous article.⁴⁵ A combination of drills and different sizes of osteotomes and countersink/pilot osteotomes is used (Figure 1). Before the surgical therapy the patient is given a thorough diagnosis and periodontal evaluation (Figure 2). A guide is fabricated for the osteotomes with precise locations for the fixtures (Figure 3). This guide also enables the authors to have the option to do site development and implant placement in two stages when necessary (in the event of perforations or if less than 5 mm of bone was initially present). Because 0.5 cc bone volume yields about 3-mm elevation of sinus membrane, the volume used is 1 cc to 1.75 cc depending on the pretreatment alveolar bone height. Slow, progressive loading of the bone graft material in small increments is very important, and the time involved to load the bone usually exceeds 30 minutes. This allows time for the membrane to relax and possibly to expand as a result of inflammation and edema created from surgical trauma, hence optimizing the deformation capacity of the sinus membrane. After 0.5 cc of bone graft is inserted into the sinus, the Valsalva maneuver is frequently used after each increment of bone graft to detect any clinical sign of membrane perforation. At the end of the procedure, the Valsalva maneuver is used again to test all of the implant sites for perforations of the sinus membrane. Radiographs are taken to verify the existence of a smooth, dome-shaped bone graft and the amount of height gained before insertion of the implant to prevent accidental perforation of the membrane by the implant.

CASE REPORTS

Case 1
The maxillary left first molar was extracted and grafted (Figure 4). After healing, precise measurements were made from the osseous crest to the floor of the sinus. Using a guide stent and the two sets of osteotomes (Summers osteotomes and countersink pilot osteotomes developed by the authors), the osteotomes were tapped and or pushed to the desired length (Figure 5). A check radiograph with parallel pins was taken. After final length was determined, osteotomes were used to move the osseous graft material apically. The osteotome always went to this final length measurement; it was the osseous graft material that elevated the sinus, not the osteotome (Figure 6). After sufficient graft material was placed a long fixture was inserted (Figure 7).

Case 2
In this patient, an otolaryngologist’s report noted focal mucosal thickening in the maxillary right sinus. The pathology contraindicated a lateral-wall sinus elevation. Using osteotomes, the sinus was elevated internally and a long fixture (13 mm) was placed. In this case, 1.75 cc of graft material was used, with approximately 6 mm of lift achieved (Figure 8).

Case 3
In this case, the maxillary right second bicuspid was extracted and grafted. After a healing period, the patient was scheduled for an osteotome procedure and immediate implant placement. In this case it should be noted that when the ridge is wide enough the authors recommend using the osteotome until a 3-mm diameter osteotomy is made. This enables more graft material to be placed at one time (Figure 9). The site was lifted and a fixture was placed and later restored (Figure 10).

Case 4
In this case, a diagnostic wax-up and guide were used to determine that three fixtures should be placed. A surgical guide was used for the radiographic data collection (Figure 11). The two anterior fixtures were placed in the conventional method with an osteotome sinus lift for the posterior implant. It should be noted that the stent and parallel pins were used for initial osteotomies to ensure parallelism (Figure 12).

Case 5
Radiographs and computed tomography (CT) with a radiograph stent were used to determine that approximately 5 mm of bone existed in the posterior implant site (Figure 13). The osteotome technique was used to more than double the amount of bone below the sinus to place an implant fixture (Figure 14).

Case 6
This case is typical of what the authors have experienced in that bilateral fixtures were placed with the necessity of sinus lifts posteriorly. Two areas on the right side (Figure 15) and one area on the left side needed osteotome sinus lifts (Figure 16). It should be noted that the initial osteotomies should be made together to ensure parallelism and allow the practitioner to make corrections.

Case 7
Both this patient’s bicuspids were extracted and grafted. The authors chose to do this in two stages to help mesialize the fixtures. Observe how the apex location differs from the tooth vs the implant (Figure 17). It should be noted that a longer posterior fixture should have been chosen. This is also true in Figure 18.

Case 8
This case depicts how the sinus lift fixture is performed in conjunction with the anterior fixture to ensure parallelism (Figure 19). The posterior tooth is being used as a temporary abutment so that the patient does not have to wear a removable transitional appliance.

Case 9
In this case, two anterior fixtures and site development of the posterior implant site were performed. Radiographs revealed approximately 3 mm of bone below the sinus in the posterior implant area. The authors used the osteotomes and graft material to develop a site for a future implant (Figure 20).

Case 10
This case involved a temporary implant used as a temporary fixed abutment. A sinus elevation using osteotomes was done, elevating the sinus both vertically and posteriorly. The temporary mini-implant allowed the patient to avoid using a removable prosthesis and prevented premature loading of the sinus-elevated fixture site (Figure 21).

Case 11
In this patient, the sinus elevation and fixture placement were done before the anterior fixtures. After healing of the site, a radiograph stent and CT were done for ideal anterior placement of fixtures. The CT revealed excellent buccal, palatal, and apical bone surrounding the posterior fixture (Figure 22).

DISCUSSION

The osteotome internal sinus-lift procedure is considered to be a predictable and safe procedure for sinus bone augmentation. It is less invasive, has less patient morbidity, and is less costly compared to a lateral-window procedure. However, because of the limited height gain of 3 mm of sinus-floor elevation generally reported by most clinicians, the procedure becomes less of a choice when the residual alveolar bone is 5 mm to 6 mm because of the concern of membrane perforation. Based on the clinical findings discussed in this article^43,44 and their own clinical experience, the authors believe membrane perforation is not necessarily a result of the large gain in height, but could be more related to a pattern of membrane distention, the presence of thin membrane (0.3 mm), and the hasty addition of large increments of graft material. To overcome this situation, the authors believe that slow increments of wet graft material over a long period of time might be important. This may allow time for the attachment of the membrane to be detached slowly from the floor of the sinus. This may also allow time for inflammation to occur and cause edema under the sinus membrane, which will help the elevation of the membrane. However, even if membrane perforation does occur, Berengo and Nkenke both showed there are no pathologic findings and complete repair of the perforation at 6 months.^41,43 Therefore small membrane perforations during the bone-added osteotome sinus-floor elevation are compatible with clinically healthy postoperative sinus conditions.

With pretreatment residual alveolar bone heights of 5 mm to 6 mm, bone-added osteotome sinus-floor elevations can gain enough bone height for placement of 13-mm to 15-mm implants. This is a viable, less-invasive alternative treatment to the lateral-window procedure.

ACKNOWLEDGMENT

The authors would like to thank Ms. Sherri Lynn Moose, management assistant, and Mr. Richard Merkel, multimedia specialist, for their work in the preparation of this article.

DISCLOSURE

The authors have received no financial support from any companies whose products are mentioned in this article.

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Figure 1 Summers osteotomes and countersink/pilot osteotomes developed by the authors. These are used intermittently to expand the osteotomy and enable subsequent osteotomes to engage the osteotomy.
Figure 2 Diagnosis, periodontal phase I therapy, and restorative temporization were done before sinus-lift procedures.
Figure 3 A diagnostic wax-up and surgical guide were made for proper osteotome location.		Figure 4 Extraction and grafting of maxillary left first molar.
Figure 5 Measurements were taken from the osseous crest to the floor of the sinus. The osteotomes and countersink osteotomes were used to the determined length.		Figure 6 After the final length was achieved, bone graft material elevated the sinus floor with the use of the osteotomes.
Figure 7 Final radiograph taken to determine optimum fixture length. Insertion of the long fixture.		Figure 8 CT scan depicting pathology. Osteotome sinus lift with fixture placement (preoperative and postoperative radiographs).
Figure 9 Initial radiograph of the second bicuspid. After healing, osteotomes and parallel pins were used to determine the final length for osteotome placement.		Figure 10 Radiographs showing sinus with placement of implant, healing abutment, and crown.
Figure 11 Radiographic surgical guide determining the optimum location for three fixtures.		Figure 12 The guide and parallel pins were used to achieve optimum implant placement.
Figure 13 Radiographic guide used to determine the optimum location of implants and need for sinus elevation.		Figure 14 Although only approximately 5 mm of bone was left below the sinus, the authors were able to elevate the sinus and place a fixture using the osteotomes.
Figure 15 Radiographs showing initial osteotomes with parallel pins. Note that the posterior fixture was corrected to maintain parallelism.		Figure 16 Radiographs showing sequence of therapy and restorations in place.
Figure 17 Radiographs depicting how the osteotomes enabled the implant locations to be mesialized.
Figure 18 Radiographs depicting excess bone graft material at the apex of the fixture. A longer fixture could have been used.		Figure 19 Radiograph showing how the initial fixture osteotomies were done together to ensure parallelism. The posterior natural tooth was a temporary abutment.
Figure 20 Radiographs depicting site development in the posterior implant area.		Figure 21 Radiographs showing internal osteotome sinus lift posterior to a temporary implant.
Figure 22 CT depicting bone around the apical, buccal, and palatal area of an implant placed using the osteotome technique.
About the Authors
Tat Chiang, DMD Clinical Associate Professor Department of Periodontics University of Medicine and Dentistry of New Jersey Newark, New Jersey Private Practice Somerville, New Jersey
Howard J. Drew, DMD Clinical Associate Professor Department of Periodontics University of Medicine and Dentistry of New Jersey Newark, New Jersey
Barry I. Simon, DDS, MSD Professor and Vice Chairperson Department of Periodontics University of Medicine and Dentistry of New Jersey Newark, New Jersey