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| CASE REPORT |
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| Year : 2016 | Volume
: 6
| Issue : 2 | Page : 79-84 |
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A piezoelectric surgery for direct sinus lift with immediate implant placement
Gopinath Vidhya, Thyaneswaran Nesappan
Department of Prosthodontics and Implantlogy, Saveetha Dental College, Chennai, Tamil Nadu, India
| Date of Web Publication | 15-Mar-2017 |
Correspondence Address:
Gopinath Vidhya
Saveetha Dental College, Chennai - 600 077, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0974-6781.202158
 Abstract | | |
Insufficient bone volume is a common problem encountered in the rehabilitation of the edentulous posterior maxilla with implant-supported prostheses. The bone available for implant placement may be limited by the presence of the maxillary sinus together with loss of alveolar bone height and it may be increased by augmentation. This case report presents the rehabilitation of the right maxillary molar region using direct sinus lift followed by immediate placement of the implant. It helps in reducing the treatment time and increases the patient comfort. Keywords: Immediate implant, piezoelectric, sinus lift
How to cite this article:
Vidhya G, Nesappan T. A piezoelectric surgery for direct sinus lift with immediate implant placement. J Dent Implant 2016;6:79-84 |
| Introduction | |  |
Implant prosthesis has become a useful and common treatment for the restoration of missing teeth. However, implant placement in the maxillary molar region requires further attention, because of potential bone quality and anatomical structure issues. In the maxillary molar area, the height of alveolar bone may be reduced due to acute or chronic periodontal disease, sinus pneumatization, or atrophy of the residual alveolar ridge after extraction.[1] Thus, implant placement in this area can be difficult or even impossible. Therefore, at the time of implant placement in the maxillary molar area, bone graft is performed using vertical alveolar bone graft, sinus lift, or onlay bone graft, of which sinus lift is simple and widely used.[2],[3] Sinus lift is generally performed before or simultaneously with implant placement using the lateral window or crestal approach.[4],[5]
Implant placement may be combined with sinus augmentation as a “one-stage” technique. Alternatively, sinus augmentation may be carried out sometime before implant placement as a “two-stage” technique, which requires an additional surgical episode.[6]
| Case Report | | |
A male patient, aged 70 years reported to the hospital with chief complaint of missing upper and lower back teeth and finding difficulty in chewing. History revealed that the teeth were extracted due to caries couple of years back and wanted to replace them with the fixed option. On clinical examination, teeth no #14, #15, #16, #17, #26, and #46 were missing. The orthopantomograph and cone beam computed tomography findings showed that the bone height was insufficient [Figure 1] and [Figure 2] and so direct sinus lift was planned with the immediate placement of implant irt 14, 15, and 17.
Blood investigations were done, and informed consent was taken after discussing the treatment plan with the patient.
Alginate impression (Tulip, Cavex Holland) was recorded, and presurgical diagnostic casts were prepared. In the cast, the interocclusal distance was measured, and the treatment plan was discussed with the patient and the bystander.
Surgical phase
Before the surgical procedure, preparation of the patient was done. The maxillary posterior segment was anesthetized with buccal and palatal infiltration using local anesthesia of 2% lignocaine with 1:80,000 adrenaline. Once the patient was anesthetized, an incision was made using #15 surgical blade and extending from the distal surface of canine to the mesial surface of 18. A vertical incision was extended until the end of the buccal vestibule. A full thickness buccal flap was raised, and a bony window was then traced as shown in [Figure 3] using a Piezo-surgical unit (Satelec, Acteon).
The initial bone marking was done using tip #BS5. This was followed by the deepening of the mark using SL1 tip [Figure 4] and [Figure 5]. | Figure 4: Using piezoelectric tips, a window is cut open to expose the sinus floor
Click here to view |
The bone tracing was made until a very thin plate of buccal bone remained over the sinus lining, and then, the fractured section of the bone was taken carefully and kept aside in a sterile bowl [Figure 6],[Figure 7],[Figure 8].
This was followed by the SL3 tip to raise the lining in the vicinity of the bony window. The partially raised lining was then lifted to a greater extent using the BS4 and BS5 tips [Figure 9].
An osteotomy was done in the usual way, protecting the raised sinus lining from any damage with the implant drills [Figure 10] and [Figure 11]. Nobel biocare implants were then placed irt 17 (5 mm × 11.5 mm), 14 (3.5 mm × 13 mm), and 15 (4.3 mm × 11.5 mm) tapped in place using the motor driver at 25 rpm.
Once the implant-seating tip reached the crest of the bone, the implant was properly seated. The remaining space between the implant and sinus floor was again filled with bone graft (Ossifi, Equinox) and the fractured section of the bone was replaced in the same place [Figure 12] and [Figure 13].
This was stabilized with the membrane (PerioCol-GTR, Eucare) as shown in the picture [Figure 14].
Flaps were approximated, and primary sutures were placed using 3-0 vicryl [Figure 15]. The patient was given postoperative antibiotic and anti-inflammatory coverage. After postoperative instructions were given, the patient was recalled after 10 days for reevaluation and suture removal.[7]
| Discussion | | |
With the advancement in the field of dentistry, implant-supported prosthesis is no more a big challenge. In comparison with the anterior tooth area, the rate of tooth loss in the molar area is high due to its important role in mastication and caries or periodontal diseases caused by inferior oral hygiene practices. In addition, because bone quality of the maxilla is poorer than that of the mandible, atrophy of the alveolar ridge can be more severe in cases maxillary tooth loss. In addition, maxillary pneumatization may hinder implant placement.[8],[9]
To overcome these problems, maxillary sinus lift with an accompanying bone graft serves as a simple, widely used procedure.[7] A sinus lift for implant placement is considered one of the most predictable procedures for augmenting bone in the maxilla.[10],[11] Several approaches have been developed and are currently used. The lateral approach using a Caldwell-Luc osteotomy is historically the first main technique, where the maxillary sinus floor is grafted to provide a sufficient quantity of bone for the placement of endosteal dental implants.[6],[9] Sinus floor elevation with bone augmentation of the maxillary sinus is now well-accepted procedures which are used to increase bone volume in the posterior maxilla.[12]
In this present case, on radiographic examination, the available bone height in the right molar region was found to be only 5.47 mm from the maxillary sinus lining. Since the patient had a missing right molar and premolar for couple of years, there was atrophy of the edentulous area. This could have caused continuous loss of bone height and density and an increase in antral pneumatization.[13] Hence, direct sinus lift using piezosurgical approach following immediate implant placement was planned.[14] This technique prevents perforation of the “Schneiderian Membrane” and cause minimal postoperative complications. Oscillation frequency used in piezosurgery is designed for acting only on mineralized tissue; therefore, the cutting tip becomes inactive when it comes in contact with soft tissue. Hence, soft tissue damage is not noticed. Short- to long-term clinical studies of dental implants placed into grafted sinus demonstrate a similar or even higher survival rate than for implant placed in the maxilla without a sinus augmentation procedure.[15] Gamma irradiated cancellous bone graft was used in this case. In this case, once the bony window was prepared with piezosurgical procedures, osteotomy was widened irt #17 and #15 region protecting the raised sinus lining. Since the crestal width of bone in #17 region was 8.77 mm; a Nobel biocare implant was placed. To stabilize the implant in the maxillary sinus region and also to stimulate bone regeneration, gamma irradiated cancellous allograft was used.[16]
This technique has the advantage of not only reducing the treatment time and increases the patient comfort but also minimal soft tissue damage. Piezosurgery was performed, as it reduces the risk of damaging vital soft tissues such as nerves, dura matter, and blood vessels.[17] Using piezosurgical unit, sinus lift procedure with sinus grafting proved to be less traumatic and more successful.
| Conclusion | | |
Although the placement of implants can be difficult at times due to compromised situations, by good evaluation, and utilizing the various techniques available, it is possible to provide a good treatment outcome.
Sufficient bone density is required for the placement of dental implants in nondentate areas of the maxillary posterior region. This case was challenging since there was ridge resorption, with reduced vertical bone height and pneumatization of the maxillary sinus. Hence, we planned for direct sinus lift using piezosurgical approach allowing sinus membrane integrity to be maintained during the surgical procedures when compared to conventional techniques. The success of the dental implant with sinus augmentation mainly depends on the skill of the operator, adequate preoperative planning, technique used to place an implant and the type of graft material used.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
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