CASE SERIES 145

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Angelo Sisti, Luigi Canullo, Maria Pia Mottola, Giuliano Iannello

A case series on crestal sinus elevation with

rotary instruments

Angelo Sisti, DDS

Private Practice, Piacenza,
Italy

Luigi Canullo, DDS

PhD
Key words dental implant, sinus oor elevation Private Practice, Rome, Italy

Maria Pia Mottola

Purpose: This case series aimed to evaluate the clinical outcome of a crestal approach technique in Private Practice, Novara,
Italy
sinus oor elevation surgery with insertion of an alloplastic material.
Material and methods: A total of 50 edentulous patients received 64 implants and sinus oor eleva- Giuliano Iannello
Data Analyst, Rome, Italy
tion in posterior maxillae with residual crestal height 1.2 to 9.8 mm, and larger than 7 mm in width.
Drilling perforation was performed until the sinus oor was felt. The sinus mucosa was then lifted. Correspondence to:
Luigi Canullo
Hydroxyapatite granules were placed and implants were immediately inserted. Three months later, Via Nizza, 46
denitive crowns were cemented and patients were followed up for 18 months. Outcome measures 00198 Rome, Italy
Tel/Fax +39068411980
were implant failures, complications and radiographic bone height gain measured 18 months after Email:
prosthetic loading. luigicanullo@yahoo.com

Results: No patient dropped out and all implants were successfully osseointegrated. Only minimal
postoperative patient discomfort was reported. Only one complication occurred: a minor perforation
of the sinus membrane with no negative consequences. At the time of implant insertion, the residual
bone height mean value was 6.20 mm (2.22). After surgery and at the last follow-up, the mean
height of bone was 15.26 (3.19) and 15.40 mm (4.21), respectively.
Conclusion: The procedure was able to obtain sinus elevation and implant osseointegration.

Conict-of-interest statement: No free materials were received and the authors do not have nancial
interest, either directly or indirectly, in the products listed in the study.

remaining crestal height2. The lateral access tech-

Introduction
Sinus oor elevation is a reliable technique that
allows implant insertion in the maxillary posterior
region with either high pneumatisation or low
crestal volume1. Several surgical techniques for
sinus elevation have been studied in the literature,
with a lateral or crestal approach, based on the
nique offers a high possibility of success3, which
has contributed to its frequent use in sinus oor
elevation surgery in spite of some disadvantages
for the patients. An implant survival rate of 96% at
36 months regarding elevation with an osteotome
technique was calculated by a systematic review of
the literature4.

Eur J Oral Implantol 2011;4(2):145152

146 Sisti et al Crestal sinus elevation with rotary instruments
As well as the lateral access, Tatum studied a
sinus crestal access using osteotomes and a direct
lifting of the sinus mucosa with curettes5. The OSFE
(Osteotome Sinus Floor Elevation) and BAOSFE
(Bone Added Osteotome Sinus Floor Elevation) sinus
elevation techniques with crestal access were later
introduced6,7. Describing these procedures, Sum-
mers highlighted the importance of avoiding direct
contact between tools and sinus mucosa, which
must be dislocated with the interposition of compact
crestal bone and/or biomaterials pushed in an apical
direction. In 1998, Bruschi et al8 presented the LMSF
(Localized Management of Sinus Floor) procedure:
crestal access with a partial thickness ap allowing
sinus oor elevation as well as simultaneous horizon-
tal expansion of the edentulous crest using manual
tools and a hammer. Successively, similar techniques
were presented, utilising crestal access, osteotomes
and mallet to obtain mucosa dislocation and sinus
oor elevation9-11. Cosci in 199812 rst described
rotating tools specially designed for the sinus eleva-
tion procedure with crestal access: lifting burs with
a at extremity 1 to 8 mm long. In this technique,
the sinus cortical bone is reached with a trephine
and perforated using a lifting bur 1 mm longer than
the depth reached by the core bur. Mucosa is there-
fore exposed and elevated with an osteotome that
pushes biomaterial.
The modied trephine/osteotome approach
allowed mucosa elevation using an osteotome to
dislocate the bone cylinder obtained with a trephine
carried 1 to 2 mm from the sinus oor. The authors
concluded that implant length should not exceed
double the size of the residual crest13,14.
These techniques were the rst to utilise rotating
tools in the sinus oor elevation procedure. In the
literature, the reported mean elevation height using
a crestal approach is around 5 mm 3.
Additionally, all crestal access techniques are
recommended to be adopted in combination with
immediate implant insertion after sinus elevation,
when residual bone height is 5 to 6 mm, because of
a lack of implant primary stability9. However, Caniz-
zaro et al15 and Checchi et al16 successfully adopted
a crestal approach even with a residual bone height
lower than 6 mm.
Finally, crestal techniques, when residual crestal
bone is higher than 5 mm, report implant success
Eur J Oral Implantol 2011;4(2):145152
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ranging from 85.7 to 100%2,15-18. However, ubsome
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cases of residual bone height <5 mm or ss e n c e
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elevation >5 mm because of a high risk of mucosa
laceration3,18-20.
The aim of the present study was to evaluate,
in a prospective case series, the clinical outcome of
a crestal sinus lift technique using rotatory instru-
ments.
Materials and methods
The present study was designed as a prospective
case series on maxillary sinus elevation with a crestal
approach. From June 2007 to October 2008, in three
Italian private dental practices (Piacenza, Novara and
Rome), 50 consecutive patients were enrolled in this
study. They all presented with partially edentulous
posterior maxilla and a residual crestal height rang-
ing between 1.2 and 9.8 mm with a width more than
7 mm. An elevation technique was required to insert
implant(s) long enough to exceed the coronal/implant
ratio of 1:1 for long-term stability21. All patients were
in general good health. Exclusion criteria were:
untreated periodontitis
systemic contraindications to implant surgery
acute or chronic sinusitis
patients with a history of sinus oor elevation
smokers (>10 cigarettes/day)
pregnant or lactating women
patients treated or under treatment with intra-
venous or oral bisphosphonate therapy.
All patients were informed about the procedure
and signed a consent form. The present study was
performed following the principles outlined in the
Declaration of Helsinki on experimentation involving
human subjects.
Surgical protocol
To evaluate the possibility of sinus lift and immedi-
ate implant insertion, the crestal height at poten-
tial implant sites was measured in all patients using
orthopantomograms and standardised periapical
radiographs with the paralleling technique and a
radiographic stent.
 Sisti et al
Fig 1 Schematic drawing showing the initial implant site
preparation with a 2 mm bur up to 2 mm from the sinus
oor.
Fig 3 Schematic drawing showing the abrasion of the sinus
oor with a 3 mm rounded bur.
Before surgical procedures, a full-mouth profes-
sional prophylaxis appointment was scheduled. All
patients received 1 g amoxicillin and clavulanic acid
(Neo Duplamox, Procter & Gamble, Rome, Italy)
2 hours before surgery and 2g/day for 6 days22.
A non-steroidal anti-inammatory drug (Ketopro-
fene, 80 mg, Oki, Domp, LAquila, Italy) was given
1 hour prior surgery.
After local anaesthesia (articaine with adrenaline
1:100,000), a papilla preservation paracrestal ap
with palatal approach was raised. Buccal bone was
not exposed to maintain protection and periosteal
vascularisation of sinus lateral walls. Rotary tools
were used in the following way:
1. Preparation with a 2 mm drill up to 2 mm from
the sinus oor, following radiographic indica-
tions. In cases of a crest height less than 5 to
6 mm, this step was skipped (Fig 1).
Crestal sinus elevation with rotary instruments 147
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Fig 2 Schematic drawing showing the use of a 3 mm
chamfered/rounded bur at sinus oor level.
Fig 4 Schematic drawing showing the elevation of the
mucosa and osteotomy regularisation with a 3 mm
rounded bur.
2. Penetration until sinus oor level using a 3 mm
chamfered/rounded bur (Sweden & Martina,
Due Carrare, Padua, Italy) at 600 rpm under
profuse irrigation, controlled by stops with 1 mm
increments (Fig 2).
3. Radiographic control of reached depth.
4. Abrasion of sinus oor with a 3 mm rounded
bur at 250 rpm under profuse irrigation, control-
led by stops with 1 mm increments (Fig 3).
5. Manual check of the sinus membrane integrity
with a rounded probe for implant therapy.
6. Elevation of the mucosa and osteotomy regu-
larisation with a 3 mm rounded bur at
600 rpm, used 1 mm deeper than the previous
drill (Fig 4).
7. Insertion of an equine-collagen sponge (GINGI-
STAT, GabaVebas, Milan, Italy) in the osteotomy
site using a 3 mm bone carrier.
Eur J Oral Implantol 2011;4(2):145152
148 Sisti et al Crestal sinus elevation with rotary instruments
Fig 5 Schematic drawing showing the sinus elevation using
graft material compacted with a dedicated bone plugger.
8. Sinus mucosa elevation obtained by plugging
synthetic resorbable hydroxyapatite granules
(Sintlife 600900 m, Finceramica, Faenza,
Italy) imbued with saline solution as only graft
material using a dedicated bone plugger (Fig 5).
9. Use of bone carriers with a stop in order to pre-
vent sinus oor penetration.
10. Widening of the surgical site if necessary using a
3.4 mm or 4 mm rounded bur with depth stop
limiting insertion at crestal bone.
11. Insertion of 8 to 15 mm long implants with a
minimum torque of 25 Ncm (Premium Straight,
Sweden & Martina) (Fig 6). In cases where the
minimal torque could not be reached, a wider
implant was inserted.
12. Implants were submerged and passive closure
of the ap was achieved using twined polyester
4/0 string coated with PTHE (SOFILUM, Swe-
den & Martina).
13. Immediate cone beam computed tomography
(CBCT) (Picasso, E-WOO Technology, South
Korea) was performed after surgery to evaluate
possible dispersion of hydroxyapatite granules
in the sinus and to measure residual and aug-
mented bone.
14. Four months after implant insertion, implants
were surgically exposed, healing screws were
positioned, osseointegration was checked and
periapical radiographs were taken.
15. All implants were restored with denitive
cemented metal-ceramic crowns.
16. CBCT was repeated 18 months after prosthetic
loading to evaluate bone height (Figs 7a to 7c
and Figs 8a to 8c).
Eur J Oral Implantol 2011;4(2):145152
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Fig 6 Schematic drawing showing implant insertion.
Outcome measures
Implant failure: the stability of implants was
tested by tightening the healing screws and the
denitive abutments. At every stage (re-open-
ing, abutment connection, and last follow-up),
implant stability was radiographically tested,
analysing the possible presence of progressive
marginal bone resorption or infection.
Complications: during the postoperative healing
period, clinical symptoms of maxillary sinusitis
were investigated.
Implant prosthesis failure: planned prosthe-
sis that could not be placed due to the implant
failure(s) and loss of the prosthesis secondary to
implant failure(s).
Bone height gain: immediately after implant
insertion, a baseline CBCT was used to measure
residual crestal bone and gained bone height. An
additional CBCT exam was performed 18 months
after loading to compare the amount of regener-
ated bone. Using dedicated software (EZ-pax,
E-WOO Technology, South Korea), bone crest,
augmented height and sinus mucosa thickness
were measured on 0.1 mm sections. Bone levels
were measured using implant platform as the ref-
erence point. The following data were measured
as a mean value of distal and mesial measure-
ments parallel to the implant axis:
RC, residual crest bone height, distance from
crestal bone border (corresponding to the
implant platform) to the sinus oor
TH, total height of sinus oor elevation cor-
responding to the distance between the bone
 Sisti et al
a b
Fig 7 Preoperative (a), postoperative (b) and 18-month follow-up (c) CT scan showing 7 mm native bone elevated to 15 mm.
a b
Fig 8 Preoperative (a), postoperative (b) and 18-month follow-up (c) CT scan showing 3 mm native bone elevated to 14 mm.
crest and the radiographic appearance of sinus
oor elevation
RB, regenerated elevation height, calculated
using the RB = TH RC formula. In the CBCT
exam at 18 months after loading it was no
longer possible to distinguish the original sinus
oor and therefore the RH value used was the
value measured at implant insertion: RB (at 18
months) = TH (at 18 months) RC (at implant
insertion).
All assessments were made by an independent
examiner (MPM) and were rounded off to the
nearest 0.1 mm. Additionally, CBCT scans were
used to evaluate the thickness of the sinus mem-
brane and presence of possible sinus pathology.
To standardise the inclination of each cross sec-
tion, at the postoperative CBCT, the neighbour-
ing tooth long axis was selected as reference,
measuring apico-coronal length and repro-
ducing it in the following CT using the Image
software (EZ-Pax Plus, E-Woo Technology).
For each CT measurement, descriptive statis-
tics including mean values and standard devia-
tion were computed at the different time points
(postoperative and 18 months after loading).
Crestal sinus elevation with rotary instruments 149
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Results
Fifty patients (24 men and 26 women) were included
in this study and distributed as follows: 29 from the
Piacenza centre; 12 from the Rome centre; and
9 from the Novara centre. Patient age at time of
sinus lift ranged from 32 to 78 years (average 58.2
years). A total of 63 implants of different lengths and
diameters as summarised in Table 1 were inserted.
Thirty-seven patients received one implant and 13
received two implants. All patients were followed
up for 18 months after prosthetic loading and no
patients dropped out. All implants were clinically
osseointegrated at surgical re-opening and at 18
months after prosthetic loading.
All surgical interventions and postoperative heal-
ing periods were without any serious complication
or side effects. Only one minor mucosa laceration
occurred at drilling. This complication did not have
unfavourable clinical consequences and there was
no evidence of extruded material into the sinus at the
last radiographic follow-up. In the rst week after
implant insertion, 28 patients showed a moderate
swelling without experiencing pain. After 1 week,
no inammation symptoms were detectable. There
Eur J Oral Implantol 2011;4(2):145152
150 Sisti et al Crestal sinus elevation with rotary instruments
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Table 1 Characteristics (length and diameter) of the 63 implants included in the study. ub

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Implant diameter (mm) Implant length (mm) te n
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3.80 4.25 5.00 8 10 11 13
Number of implants 16 28 19 2 6 36 17 2

Table 2 Characteristics of the 50 maxillary sinuses included in the study pre-, post-surgery and 18 months after prosthetic
loading.

Residual crest Total height Regenerated Total height Regenerated

(RC) (TH) bone height at 18 months bone height
(RB) (TH18m) at 18 months
(RB18m)
Mean (mm) 6.20 15.26 7.73 15.40 7.86
SD 2.22 3.19 2.72 4.21 4.99
Max 9.80 24.50 13.40 25.50 20.00
Min 1.20 10.20 2.20 10.10 2.10

were no prosthetic complications during the entire
follow-up period with the exception of two abut-
ments on single implants that became unscrewed.
Crowns were removed, the abutments screws where
re-tightened, and occlusal contacts were adjusted.
The radiographic data are summarised in Table
2. The mean initial residual crest (RC) value was
6.20 mm (2.22) ranging from 1.2 to 9.8 mm, and
mean elevation of sinus mucosa (RB) obtained at
implant insertion was 7.73 mm (2.72) ranging from
2.2 mm to 13.4 mm. Eighteen months after loading,
it was not possible to see the original sinus oor on
CBCT scans. TH values ranged from 10.10 mm to
25.50 mm with a mean value of 15.40 mm (4.21).
Discussion
Traditional crestal approaches are associated with
a good implant survival rate as well as complica-
tions similar to lateral access techniques2,15,18-20.
However, crestal approach techniques studied in the
literature are usually hard to standardise. Manual
tools such as osteotomes and mallets are difcult to
handle and can create discomfort to the patient16.
Furthermore, osteotomy techniques require a long
learning process and expert handling. In fact, the
main limit of such osteotomy techniques resides in
the difculty of controlling the percussion power of
the mallet to obtain sinus oor breakage23. In addi-
tion, osteotomes, being used as well for split-crest
techniques or trabecular bone condensation, are
usually graduated only to measure distances more
than 8-10 mm. In fact, the lack of depth stop makes
the tool difcult to use. Moreover, the use of the mal-
let is often unpleasant for patients16 and a few cases
of vertigo syndrome (BPPV) or acuphenis provoked
by percussions have been reported.24 Furthermore,
traditional osteotome techniques are recommended
when at least 5 to 6 mm of crestal height is available
and for a maximum elevation of the sinus membrane
of 5 mm 1,14-16.
On the other hand, the use of burs on a low-
speed hand piece decreases patient discomfort16.
In the present study, residual crestal height ranged
from 1.2 to 9.8 mm with a mean value of 6.2 mm
with more than 20% of cases having less than
5 mm. At the same time, 51 cases out of 63 were
elevated over 5 mm, which is usually considered the
limit for elevation techniques using crestal access
in order to avoid difculties or complications3. This
data is in agreement with recently published stud-
ies15,16 that showed that this limit can be success-
fully overcome using a standardised crestal approach
with drilling burs.
In the present study, the absence of dislocated
graft material in the CBCT exam control was reported.
This suggests that the technique used in this study
seems not to incur mucosa laceration during the use
of a bur or during the mucosa elevation with bone
carriers, even in cases where limits of classic indica-
tions for elevation with osteotomes were exceeded.

Eur J Oral Implantol 2011;4(2):145152

 Sisti et al
This could be explained by the use of stops, allow-
ing perfect control of burs and avoiding membrane
perforation, according to Tilotta et al25. Additionally,
the apical shape of the burs and the sequence of
use seem to minimise the risk of membrane lacer-
ation. In cases of a small sinus membrane laceration,
which occurred once in the present study, the use of
collagen seems to be effective in preventing graft
material dislocation26. With osteotome techniques,
membrane lacerations ranging from 2 to 5%24,27
have been reported, and when the sinus elevation
exceeded 5 mm, laceration rates ranged from 10 to
over 20%28,29.
When comparing the total height at the time
of implant insertion and 18 months after loading,
measurements showed no differences (15.3 mm
at implant insertion and 15.4 mm 18 months
after loading). This data seems to be in accord-
ance with recently published studies that tested
a nano-structured hydroxyapatite graft in sinus
lift with lateral approach30 and on vertical bone
regeneration31. In fact, due to its characteristics32,
this biomimetic graft material demonstrated high
stability over time. The positive results from this
study might be inuenced by the limited number
of patients and, despite of the standardisation of
CT analysis, by the absence of individual three-
dimensional radiographic guides, which may have
resulted in minimally different inclinations of the
CT cross sections.
Within the limit of this study (short follow-up,
minimal imprecision in the measurements and small
sample size), the minimally invasive sinus elevation
(MISE) technique can be considered a simple tech-
nique alternative to osteotomes to obtain sinus oor
elevation with a crestal approach. In fact, the eleva-
tions practised in a non-invasive and quick way were
sufcient to insert implants long enough to exceed
the coronal/implant ratio of 1:1.
Conclusions
Within the limit of the study (small sample size
and short follow-up), the procedure was success-
ful in obtaining sinus elevation and implant osseo-
integration.
Crestal sinus elevation with rotary instruments 151
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Acknowledgements ub
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We highly appreciated the skills and commitment tes
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of Dr Audrenn Gautier and Dr Henry Canullo in the
supervision of the study.
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