Maxillary sinus lift surgical techniques: Hammerless intra-crestal approach

Oral implantology is an ever-evolving science seeking solutions to clinical challenges. A common challenge is treating an atrophic maxillary ridge with deficiency in vertical height. In 1974, Dr Hilt Tatum performed the first sinus lift in the world. His lateral window approach has proven to be effective technique, but is invasive in nature and requires great surgical experience. The pursuit of less invasive methods led to the introduction in 1994 to a new technique using a crestal approach by Summer where osteotomes were used to “push” the floor of the sinus. In the past 20 years many variations of Summer’s technique have proven to be effective in sinus elevation.

This is a clinical case presentation where we will explore the Hammerless intra-crestal approach.

Hammerless intra-crestal lifts are those performed through the alveolar crest in a vertical direction as opposed to lateral windows. The inclusion criteria for crestal lift are: sinuses free of infection process, minimum of 3.5mm residual alveolar bone height from alveolar crest to the floor of the sinus and minimum alveolar width of 7mm.

Clinical case: X-ray reveals pneumatized sinus with 3.7mm of residual bone, full mucoperiosteal flap shows adequate bone width greater than 7mm. The hammerless kit used consists of 3 safe sinus drills, stoppers ranging from 2mm to 12mm, bone condenser, bone carrier and sinus probe (Blue Sky Bio, USA), the technique is to take a digital periapical and measure the height of bone and drill 1mm short of the floor of the sinus floor using 50 RPM and drill stoppers. Increase the length by changing stoppers until the floor has been pushed.

There are 3 possible ways to verify that the floor has been pushed and that you are in contact with the sinus membrane:
1…Patient will feel slight pain at the moment the floor is broken because innervations to the maxillary antrum comes from V1 (ophthalmic branch of the trigeminal)
2…Doctor will feel a “drop” when the floor is pushed
3…Using a round sinus probe the clinician will feel “soft-squishy” material and not hard bone.

Once it is confirmed that the floor is pushed or broken, start adding bone with an amalgam carrier until the site is filled. Condense this bone with light apical pressure and repeat this procedure 3-5 times until you are able to observe a well-defined “bone dome”. Select an implant that is self-treating, 1mm wider than your final drill to compress the walls and double the length of the stopper that broke the floor. In this case the last stopper was at 5mm so we selected a 4.5 * 10mm fixture.

Following these steps the hammerless intra-crestal lift becomes a safe and predictable surgical procedure that your patients will benefit from and that general dentists can master in short amount of time.

Thank you for reading this case and feel free to post any comments an questions. Thanks.
Virgil Mongalo D.M.D.






13 thoughts on: Maxillary sinus lift surgical techniques: Hammerless intra-crestal approach

  1. Carlo De Leo says:

    Congrats for the creativity! The analog technic you show with the hammer its called BAOSFE, Bone Aided Osteotome Sinus Floor Elevation by Dr. Summers. The hammer represents a really bad experience for the patient,
    unfortunately. Also takes autologus bones into the sinus, and Thats good…even though the technic is great!

    • virgilio says:

      Dr De Leo,
      Thank you for your response and description of Summers technique. You are 100% correct regarding patients problems with hammering, literature shows correlation with dizziness and headaches. This is why newer surgical approaches have deemed necessary.
      Virgil Mongalo

  2. CRS says:

    Very good description, I did not know about the V1 nerve anatomy of the Antrum. I would think that the local anesthesia would take care of that anyway.I like the lateral approach since I can see what I am doing and I usually perf on a crestal approach but I am learning the DASK technique for internal lifts. With this much augmentation I would use a lateral approach, I like to see what I’m doing. One comment on the “hammering ” the osteotomes need to be sharp and a light touch using the end of a elevator handle in the maxilla for example when seating a perio tome or fracturing a wall. I find that a hammer is only used when removing a mandibular Torus or in orthognathic surgery in the OR even then it is a light touch with “feel” not hammering. You can break a mandible with an osteotomes and hammer. Great post well described!

    • virgilio says:

      V1 and V2 both partially innervate the maxillary antrum. if you google innervation images to maxillary sinus you will see those nerves

      • CRS says:

        Actually did a medline search and found that the ophthalmic branch of the fifth cranial nerve does not innervate the maxillary sinus. Perhaps a bit different from Google’s information.

  3. Brian says:

    Once you’ve penetrated the sinus are you using an instrument to “tease the sinus membrane or is condensing the bobe doing the teasing.

  4. PeterFairbairn says:

    Hi CRS , Daska great choice , used both external and internal lift for about 5 years now.
    Agree in this case would have just done lateral as easier faster and can see all is good , have yet to tear a single lining in laterals since starting with Dask .

    • CRS says:

      Peter I am very happy with the DASK system even though I am on my honeymoon. It does make things easier thanks! I always learn something with these posts, keep em coming sir!

  5. ttmillerjr says:

    Virgilio my friend, nice to see you here. I have used Blue Sky Bio’s kit and it worked fine. I have to say that I like Dentium’s crestal lift kit even more, and the DASK lateral window kit has been impressive. Last week I completed a two teeth lateral window elevation in about 40 minutes (topical to final PA).

  6. GB Oral Surgeon says:

    Good case presentation. I have done fair amount of transalveolar sinus lift with conventional round ended osteotomes and had no problems so far. I agree you may not need hammer in the real sense.
    I always wonder, as others have mentioned you cannot see what is happening in the sinus cavity, what if you had a perforation? My colleagues may agree in some patients the lining is so thin and friable (you will know if you are involved in LeFort osteotomies)and never easy to predict. Just wondered if anyone can add to this technical issue. I usually pack with hemostatic collagen plugs ( a few of them ) to ensure even if you have a perforation you are somewhat ok!

  7. perioprosh says:

    It was interesting to read that V1 is innervating the maxillary sinus, something that i didn’t know. I looked it up on 38th ed. of Gray’s Anatomy and no sign of V1 innervation for maxillary antrum. However, it’s stated that Maxillary nerve is responsible for innervation the mucosa of the maxillary sinus.
    I would like to appreciate Dr Mongalo for describing the technique, and for the sake of thoroughness wanted to share this paragraph from the Gray’s anatomy.
    The posterior superior alveolar (dental) nerve leaves the maxillary nerve in the pterygopalatine fossa and runs antero-inferiorly to pierce the infratemporal surface of the maxilla (p. 1706), descending under the mucosa of the maxillary sinus. After supplying the sinus the nerve divides into small branches which link up as the molar part of the superior dental plexus supplying twigs to the molar teeth. It also supplies a branch to the upper gum and the adjoining part of the cheek.
    Dr Noohi.

  8. Wameed Saied says:

    Nice case description. Very informative explanation. Appreciate your efforts to share the case and technique.

    I want to know how to calculate the bone required for the augmentation after crystal sinus lift?

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