Rupture length of the sinus membrane after 1.2 mm puncture and surgical sinus elevation: an experimental animal cadaver study

A Comparison of Elevation, Perforation Rate, and Time Spent for the Crestal Sinus Elevation Intervened by Piezosurgery, CAS-Kit, and Osteotome in a Novel Goat Model

Purpose

This study aimed to compare the differences among Piezosurgery, CAS-kit, and Osteotome regarding safe elevation, perforation rate, and time spent and to observe and analyze different sinus lifting efficacy of the three methods.

Materials and Methods

Twenty-one fresh goat heads (42 sinuses) were investigated. CBCT images confirmed the feasibility of the goat model. The maxillary sinus was successively lifted to 5, 7, and 9 mm by Piezosurgery, CAS-kit, and Osteotome until the sinus membrane was perforated or lifted to 9 mm. In the end, final elevation, sinus perforation, and time spent were recorded.

Results

Piezosurgery and CAS-kit lifted sinuses to relatively higher heights than did Osteotome (P = 0.000). Perforation rates (14.29, 21.43%) of the Piezosurgery and CAS-kit were far lower than that of the Osteotome (85.71%). In the Osteotome group, the time of lifting to 9 mm was significantly shorter than that of Piezosurgery and CAS-kit (P = 0.000). There was no statistical difference in time spent between the latter two (P = 0.115).

Conclusions

The lifting height of the Osteotome was limited, but it took the shortest time for sinus lifting. Piezosurgery and CAS-kit had higher lifting heights and lower perforation rates compared with Osteotome.

Goat Model for Direct Visualizing the Effectiveness of Detaching Sinus Mucosa in Real Time During Crestal Maxillary Sinus Floor Elevation

The procedure of crestal maxillary sinus floor elevation presents a great challenge to the field of implant dentistry. Due to the limited visualization in this procedure, the effectiveness of detaching sinus mucosa could not be assessed in real time. We recently developed an ex vivo goat sinus model by cutting the goat residual skulls along four lines determined from computerized tomography (CT) scans, extracting the maxillary premolar or molar teeth, and preparing implant socket in the maxilla. The generated ex vivo goat sinus models exposed the maxilla and the whole maxillary sinus mucosa, thus enabling real-time observation of detaching maxillary sinus mucosa via directly visualizing the working situation of sinus lift tool in the models and directly measuring the length of detached mucosa and space volume generated under the elevated sinus mucosa. One commercially available umbrella-shaped sinus lift curette was used to detach the maxillary sinus mucosa to evaluate the effectiveness of the ex vivo goat sinus models. The results showed that this curette could detach the sinus mucosa 3.75 mm in length in the mesiodistal direction and 2.81 mm in the buccal-palatal direction. Moreover, a space volume of 52.7 μl could be created under the elevated sinus mucosa in the goat ex vivo models. All the experimental results suggested that this ex vivo goat sinus model might be useful in the evaluation of improved or newly designed sinus lift tools for elevating the maxillary sinus mucosa via the crestal approach.

Histological and histomorphometric study using an ultrasonic crestal sinus grafting procedure. A multicenter case study

Background

The aim of this study was to evaluate the efficacy of a hydrodynamic ultrasonic driven transcrestal sinus grafting procedure (Intralift ®, Acteon Company, Bordeaux, France) and the use of a bovine high temperature sintered grafting material in sinus sites with less than 5 mm remaining bone height with no additional autogenous bone in order to create a sufficient recipient site for implants.

Material and Methods

12 patients (16 sinus) in this multicenter case study were included. Using a crestal approach, bone under the sinus was prepared with ultrasonic tips until the Schneiderian membrane was reached. With a trumpet shaped instrument, the Schneiderian membrane was elevated. In the new created subantral space a high temperature sintered bovine grafting material was introduced (Bego Oss, BEGO Implant Systems GmbH & Co. KG, Bremen, Germany). After 6 months biopsies were taken with a trephine bur and histologies were generated following histomorphometric analysis.

Results

The results showed new vital bone in average of 33.4% ± 17.05%, and 43.6% ± 16.70 of bone substitute material. No signs of abnormal inflammation were observed.

Conclusions

This procedure (Intralift ®) allows, using a bovine material with no additional autogenous bone, new bone formation in the sinus in order to allow place implant subantraly.

Key words:Bone regeneration, sinus, intralift ®, xenogenic bone graft

Comparison of Conventional Transcrestal Sinus Lift and Ultrasound-Enhanced Transcrestal Hydrodynamic Cavitational Sinus Lift for the Filling of Subantral Space: A Human Cadaver Study

The implant-supported prosthetic rehabilitation of the posterior maxilla may require sinus-grafting procedures due to poor quality and low volume of bone. This can be accomplished using a "lateral window" sinus augmentation or with an osteotome sinus floor elevation (OSFE). The hydrodynamic ultrasonic cavitational sinus lift (HUCSL) (Intralift) is derived from the osteotome technique and allows the reduction of some of the traumatic effects of the osteotome technique. The aim of this study was to compare OSFE and the HUCSL procedures on fresh human cadaver heads. Primary outcomes were the height and width of the grafting area in the sinus floor area. Eighty-four maxillary sinuses were selected. On each fresh cadaver head, 2 sinus lifts were done using OSFE and HUCSL in the maxillary sinuses. Computerized tomography scans were performed on each head before and after the surgeries. Measurements were done on radiologic pictures using dedicated software, and the integrity of the sinus membrane was observed after dissecting the maxillae. The use of HUCSL resulted in a significantly higher sinus floor augmentation in the mesio-distal and bucco-palatal direction compared with the osteotome technique (P < .001). There was no correlation between mesio-distal and bucco-palatal diameters of sinus floor augmentation when only the osteotome protocol was considered (r = 0.27 and P = .08). In contrast, the mesio-distal and bucco-palatal diameters of floor augmentation were correlated when the HUCSL protocol was considered (r = 0.79, P < .001). HUCSL represents a good alternative method for sinus floor elevation.

Primary implant stability in augmented sinuslift-sites after completed bone regeneration: a randomized controlled clinical study comparing four subantrally inserted biomaterials

Implant-Insertion-Torque-Value (ITV) proved to be a significant clinical parameter to predict long term implant success-rates and to decide upon immediate loading. The study evaluated ITVs, when four different and commonly used biomaterials were used in sinuslift-procedures compared to natural subantral bone in two-stage-implant-procedures. The tHUCSL-INTRALIFT-method was chosen for sinuslifting in 155 sinuslift-sites for its minimal invasive transcrestal approach and scalable augmentation volume. Four different biomaterials were inserted randomly (easy-graft CRYSTAL n = 38, easy-graft CLASSIC n = 41, NanoBone n = 42, BioOss n = 34), 2 ccm in each case. After a mean healing period of 8,92 months uniform tapered screw Q2-implants were inserted and Drill-Torque-Values (DTV) and ITV were recorded and compared to a group of 36 subantral sites without need of sinuslifting. DTV/ITV were processed for statistics by ANOVA-tests. Mean DTV/ITV obtained in Ncm were: Control Group 10,2/22,2, Bio-Oss 12,7/26,2, NanoBone 17,5/33,3, easy-graft CLASSIC 20,3/45,9, easy-graft CRYSTAL 23,8/56,6 Ncm, significance-level of differences throughout p < 0,05. Within the limits of this study the results suggest self-hardening solid-block-like bone-graft-materials to achieve significantly better DTV/ITV than loose granulate biomaterials for its suspected improvement of vascularization and mineralization of the subantral scaffold by full immobilization of the augmentation site towards pressure changes in the human sinus at normal breathing.

Schneiderian membrane detachment using transcrestal hydrodynamic ultrasonic cavitational sinus lift: a human cadaver head study and histologic analysis

PURPOSE

Recent studies have suggested the osteogenic layer of the periosteum at the base of the sinus membrane to play a key role in bone regeneration after sinus lift procedures. Thus, atraumatic detachment of the sinus membrane with an intact periosteum seems mandatory. The present histologic study of fresh human cadaver heads investigated the detachment behavior and histologic integrity of the detached periosteum after application of the transcrestal hydrodynamic ultrasonic cavitational sinus lift (tHUCSL-INTRALIFT).

MATERIALS AND METHODS

A total of 15 sinuses in 8 fresh human cadaver heads were treated using tHUCSL-INTRALIFT. After surgery, they were checked macroscopically for damage to the sinus membrane and then processed for histologic inspection under light microscopy. A total of 150 histologic specimens, randomly selected from the core surgical sites, were investigated using hematoxylin-eosin (HE), Azan, and trichrome staining.

RESULTS

None of the 150 inspected specimens showed any perforation or dissection of the periosteum from the subepithelial connective tissue and respiratory epithelium and were fully detached from the bony antrum floor. The connecting Sharpey fibers revealed to be cleanly separated from the sinus floor in all specimens.

CONCLUSIONS

The results of the present study suggest tHUCSL-INTRALIFT should be used to perform predictable and safe detachment of the periosteum from the bony sinus floor as a prerequisite for undisturbed and successful physiologic subantral bone regeneration.

Biological Principles and Physiology of Bone Regeneration under the Schneiderian Membrane after Sinus Lift Surgery: A Radiological Study in 14 Patients Treated with the Transcrestal Hydrodynamic Ultrasonic Cavitational Sinus Lift (Intralift)

Introduction. Sinus lift procedures are a commonly accepted method of bone augmentation in the lateral maxilla with clinically good results. Nevertheless the role of the Schneiderian membrane in the bone-reformation process is discussed controversially. Aim of this study was to prove the key role of the sinus membrane in bone reformation in vivo. Material and Methods. 14 patients were treated with the minimal invasive tHUCSL-Intralift, and 2 ccm collagenous sponges were inserted subantrally and the calcification process followed up with CBCT scans 4 and 7 months after surgery. Results. An even and circular centripetal calcification under the sinus membrane and the antral floor was detected 4 months after surgery covering 30% of the entire augmentation width/height/depth at each wall. The calcification process was completed in the entire augmentation volume after 7 months. A loss of approximately 13% of absolute augmentation height was detected between the 4th and 7th month. Discussion. The results of this paper prove the key role of the sinus membrane as the main carrier of bone reformation after sinus lift procedures as multiple experimental studies suggested. Thus the importance of minimal invasive and rupture free sinuslift procedures is underlined and does not depend on the type of grafting material used.