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Implant placement in the atrophic posterior maxilla is a challenge. Bone augmentation (sinus floor elevation) is very often indicated.  When the subantral residual bone height is very limited, open sinus lift surgery or lateral window Caldwell–Luc antrostomy is the conventional therapy used by most dentists.  This is a traumatic invasive surgery with several postoperative complications for the patient and long term recovery. [2-6]
Chen was the first to introduce a hydraulic sinus lift technique, during which the surgeon lifts the Schneiderian membrane from the sinus floor using the handpiece and by spraying a liquid. The newly formed space is filled with bone grafting material and followed by implant placement.
The present case will demonstrate a novel approach to the hydraulic sinus lift technique utilising the iRaise implant system (Maxillent). The implant design includes an L-form internal channel leading to the apical portion of the implant, which allows for saline and bone grafting material to be injected into the sinus cavity. A sterile 0.9% NaCl solution is injected through the implant’s internal channel in order to detach the Schneiderian membrane from the sinus floor. Aspiration of the saline is then followed by injection of bone grafting material (in gel form) through the same implant channel, thus filling the space between the sinus floor and the membrane.
In the last step, the entire implant body is placed into the augmented bone. The hydraulic lift of the sinus membrane is performed through the alveolar crest. Once the implant has been fully inserted, the internal channel is closed by the bone and there is no communication with the implant prosthetic platform, preventing penetration of bacteria from the oral cavity to the bone graft after implant placement.
A 40-year-old healthy female patient presented to the dental office. Clinical and radiographic examination revealed that tooth #15 was missing. The residual alveolar ridge height was 5 mm. The treatment plan included placement of an endosseous implant followed by an implant-retained crown. In order to be able to realise this plan, a sinus augmentation was required.
The iRaise implant was used in this case, which allowed placing of the implant and hydraulic elevation of the sinus membrane simultaneously. Prior to the surgery, 1,000 mg amoxicillin was prescribed as a prophylactic treatment and a full-thickness mucoperiosteal flap was raised.
The exact point of implant placement was marked in region #15. Special drills were used to engage the cortical bone of the sinus floor. A diamond bur was then used to cross the cortical bone. The use of a diamond bur prevents rupture of the Schneiderian membrane. An iRaise implant of 4.2 mm in diameter and 14.5 mm in length was inserted halfway. The orifice of the internal channel reached the bone and was placed facing the buccal side. The implant connector was attached to the implant orifice, and 2 ml of NaCl was injected through the connector in order to detach the sinus membrane by equal hydraulic pressure. The Valsalva manoeuvre test was performed to confirm membrane integrity.
Aspiration of the saline followed, and a mixture of saline and blood appeared in the syringe, indicating that the Schneiderian membrane had detached and become elevated and the blood capillaries had ruptured. The next step was injection of 2 ml of a synthetic bone grafting material of tricalcium phosphate and hydroxyapatite in gel form (MBCP Gel, Biomatlante). The connector was removed and the implant inserted to its full length, to crest level.
A CBCT scan was taken immediately after treatment and showed a beautiful four-layer creation of air, water, bone grafting material and the residual alveolar ridge. The integrity of the Schneiderian membrane and a healthy sinus were also observed. The internal channel of the implant had been completely filled with the injected bone.
The surgery ended with closure of the flap by conventional suturing. The patient found the surgery easily tolerable and immediately returned to her everyday routine. No side-effects, such as swelling, pain or haematoma, were reported. Follow-up examinations at three and six months postoperatively were performed, and the periapical radiographs showed calcification, which is associated with bone formation.
The iRaise sinus lift technique is easy to perform. Two separate surgeries are combined in one short surgery to create a minimally invasive procedure that is well tolerated by the patient and allows for a quick return to normal life, as opposed to other sinus lift surgery approaches, such as the open lateral window technique, which have been shown to cause substantial side-effects, such as swelling pain and haematoma, and require longer recovery. The present minimally invasive hydraulic sinus lift technique is likely to become a routine procedure in private practices and hospitals.
Editorial note: A list of references is available from the publisher.
Thu. 29 February 2024
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