Using Osteotomes to Place Implants: Avoid Membrane Perforation?

Dont , the new DASK system of drills is the biggest breakthrough in both lateral and internal access. It is a system with diamond cutting surfaces with an irrigation hole at the center which keeps the lining away safely whilst the osteotomy is done simple yet effective , unfortunately taken all the edge of the seat feeling away. Now you can do these procedures without tapping through so no need for sedation , made it much easier for the patient and dentist alike . Not sure where they are from but I think Korea. Try it once and you will see.You just drill through and the saline irrigant lifts the sinus lining , after a cautious start now confident of safety.

Dr. L Prior to doing osteotome lift you should reads summers articles. That being said there are many new drill kits that allow you to lift the sinus without banging on a persons skulls. There is a great step by step article using the MIS and Megagen drill kit within the March issue of the Journal of Implant and Advanced Clinical Dentistry, you can view it online. BTI also has a a great Sinus compression kit that lifts the sinus with simpler drilling. Good luck to you.

Why an 8mm implant? If you're gonna lift, you might as well get at least a 10mm in there. I'd recommend taking a course on sinus lifts if you haven't had any formal ce on sinus augmentations. FWIW, I like the sinu-lift system.

Hi There, Can you give me an idea of the supplier of the DASK drills? Many thanks

In the UK from Implantium UK Ltd but do not know globally possibly Google , I agree as well should be a minimimun of 10 mm if lifting. Regards Peter

Funny...no one has so far answered the question of how you know if you have perforated the membrane. Having performed many sinus surgery, I have to say that the membrane is often very thin and adherant to the bone. You're only fooling yourself if you think you can preditably elevate the membrane with a 3.5 or 4 mm diameter osteotome or with a water irrigation or "hydrolic" lifting technique. The reality is there is no way of knowing whether you have perforated the membrane or not. This doesn't mean that osteotome sinus lifts don't work...it just means that you are placing your implant directly into the sinus.

With 4 mm bone I would suggest usung a lateral window approach for sinus augmentation, especially if you are placing more than one implant. You stand much less chance of perforating the sinus membrane and you would be able to graft much more effectively enabling placement of longer implants(11-13 mm fixtures). The final result is sure to be better using a sinus augmentation procedure that many consider easier to perform and is no more difficult for the patient.

drL, U ARE totally on the wrong foot here if this is ur first case dont attempt to raise more than 2to 3 mm with osteotomes. in the posterior maxilla try and avoid to use drills as there is very little bone density. and lastly u widen the osteotomy to the desired diameter 2mm short of the sinus floor and then start elevating the sinus floor the wider the diameter the wider area for dissipation of force and a better chance of getting a green stick fracture of the sinus floor. narrow diameter osteotomes tend to pierce through the floor becos of concentrated force. the case presented shows more better chances with a lateral sinus lift. prepare ur self thoroughly before u attempt a procedure for first time. the sinus complications are better avoided than treated. once there is a complication the case goes out of ur hand and comes into the hands of a OMFS and ENT and u shall be judged (by the patient) according to their comments on the procedure done. all the best.

Dr L Your case to my opinion doesn't fit to the category of osteotome lift.There is no point in creating a space for 8mm long implants in the posterior max.The min should be 10 and I usually prefer a min of 11.5. In order to achieve this goal you will need to perform either a lateral approach or a crestal minimally ivasive balloon technique as described by Kfir et al. I suggest taking a real hands on live surgery course on sinuses.I f you need details you can contact me or go to www.handsoncourse.com

Why yo dont place a Bicon implant, they are very short, they have a 5.0 x 5.0mm and a 6.0 x 5.0mm

I would strongly advise against attemting to elevate 4 mm via a crestal approach for 2 reasons. First its a stretch, especially in inexperienced hands. Second even if you are succesful in elevating it without perforation you end up with an 8mm implant which in my opinion is too short. Short implants are usually a cop out for dentists who cannot perform advanced grafting procedures. The likely scenario here is that you will perforate the sinus lining and achieve no elevation, ultimately resulting in 4mm of osseos anchorage. Do a lateral window and put in nice long implants (13-16 mm) Far more predictable. Its almost impossible to know if you perforated via a crestal approach. I find a lateral window to be less technique sensitive, and in a severely pneumatized case such as this, it should be the only technique you consider. Lastly if you want experience with a crestal approach lift try it in a case where you have 9-10 mm of bone and you attempt to get an additional 2-3 mm. Even if your elevation fails you still have a decent amount of height to work with. Use a radiopaque material such as HA in your graft material so you can assess your lift on post op x-ray.

have you tried the baloon technique?i dont know how good it is but they claim to lift the sinus directly pretty well..woukld like some comments on the same.

Even if you do perf, the bone can grow up to 4 mm. up the sides of the implant.

Richard Hughes, do you have any data to support what you just said about the bone growing up 4 mm along the side of the implant ? If this was the case, what's the point in lifting the membrane, just place it directly into the sinus and wait for the bone to grow up the implant. Also, ED, what's the point of using a radiopaque material ? Are you implying that you can somehow differentiate between the radiopaque material if its sitting outside the membrane or inside the sinus ? I wasn't aware that you can see the membrane on a conventional PO radiograph.

We always use materials that resorb 100% just leaving the patients own bone which is easier to assess by radiograph over the years , placing HA may give a denser radiograph but has no functional qualities and may affect the bone implant interface.No need for core samples as what is there is just patient bone ( which is generally more dense than adjacent bone ). I agree the lateral window is the surest way to do the augmentation but internal has a place in the right cases. I have used the Balloon a number ot times which seems to work very well ( Done Heuckmanns , hands -on) but now with Dask both these approachs have been made significantly easier and safer. As to tears in the lining utilizing synthetic graft materials that set allow the material to be stable and the epithlium merely heals around the graft material in a few days. Which gets me to Richards comment , we have done a number of cases ( some when retrieving an Implant from within the sinus )where we have had to esssentially destroy the lining the scrape the wall free of lining where we place a new implant and then pack the graft material between the implant and the wall and around the implant in a bulb. The graft material sets and we seal the window with Ca sulphate, all cases have been sucessful and scanned post-op ( we will be getting an ENT to scope as well to assess whether the new healed epithelium is stratified or ciliated ).So the body wants to heal we merely try to aid it. Regards

Mike, I will refer you to Dr. Phil Boyne's work, he did mention this in the 2005 AAID meeting.

What is the problem with short implants? If it goes wrong it just take less time when they come out by them self. So because of the less length the survivaltime when it goes wrong is less, but not the succes rate!!!! I would not try to lift more then 2 to 3 mm when it is your first time. I would not use any drills in the procedure you want to follow, except for the round bur to sign the place you want the implant. Then use osteotomes to a depth 2 mm less of the sinusfloor. When you get the diameter ( as wide as possible) for your implant then you use this to fracture up the sinusfloor. You can put in a membrane and regenration material to help you to fracture it up and preventing to perforate. It is a problem to see what you are doing and you don't know if you perforate. You can carefully do a blow through the nose test, but this can perforate the membrane further. I have once read an article in which they put implants in the sinus and watch what would happen and it seems to be that the sneiderianmembrane will growth around the implant when there is no existing sinuspathology. But they also stated that this wasn't the same as just putting the implants there without any efforts to prevent it and doing a good build up.

I use short implants all the time and they seem to do as well as others. If I have 8mm of bone I would rather use an 8mm implant vs doing a sinus lift to get more bone so I can use a longer implant. Before we did sinus lifts, we used to place the implant one or two mm into the sinus with few problems. A recent study in March J. periodontol refering to osteotome sinus lifts confirmed the success rate was the same with or without a perforation.

Mike of 25 June 2009, If you are performing a Sommers Uplift and want to determine if there is a perf of the membrane, youcan do one of two things; look for bleeding and use very delicate probing using tactile sensitive technique with a perio probe or currette, if the instrument sinks deeper than the depth of the osteotomy----you guessed it---you perfed . There may be other methods.

To test for perforation of the membrane, simply pinch the patient's nostrils and have them puff gently through their nose. If perforated,you will get blood bubbling from the osteotomy, and then an audible air hiss. If so still place the implant as it is the best plug. Whether you get only 4 mm of integration in the crestal bone or 4mm of extra bone growing on the implant is anyone's guess.

The discussion about the length of the root form implant in the posterior mand or mx is a good one. I use Bicons, AB Dental, MIS and LaminOss. If you are in doubt about the depth of osteotomy in the mx or md a Bicon 5x8 or 5x11 is just fine and will work im most situations, just give it more time to integrate. The plateau design enhances the lock of the implant into the bone and you can use a shorter implant and yet have a sufficient bone to implant interface.

Found the distributor for DASK in the USA. They are known as Dentium USA

From what I've heard, the DASK system, although effective, lacks durability. Correct me if I am wrong, I was under the impression that you have to replace the drills after 3-5 uses. There are also 2 other sequence drilling systems available: Sinus Crestal Approach (SCA Kit) and Sinus Lateral Window (SLA). Both systems are very predictable and just may be the ticket for you. Good luck!

If you are interested in elevating sinus membran without perforation then look at the pictures on this site. There is only one way. http://www.zp-aktuell.de/praxis/implantologie/story/sinprep-ein-vorschlag-fuer-die-optimierung-des-sinuslifts-teil-2.html For to determine wether there is a perforation just measure. Measure and don`t guess ! A pathophysiologic state of the sinus is not easy to determine. If such is present we are to expect problems. By measurement and documentation we at least would avoid legal ones and pursuit patient interests best. The question is how and wich of the grafting materials suit better- Mr.Dr.Peter Fairbain is somehow right. I would just prefer kollagenuos sponge on the tip of the implant. But this has to be discussed for the cases where no implant tip can be used to keep membrane lifted.

Santa-System is better then osteotomes and balloon-lift-control or even DASK System . Cheaper in the long run and more effective ! (2900€) Dask is used up relatively quick (price?), ballon lift catheter (220€) (kit 2200€) is for singular use refering one patient. You need a big lateral window only because you want to detect and treat perforation.. I personaly don`t like perforations ! Why weakening the maxilla, why refusing to use the osteocytes of the blank bone of that stability providing structure ? We learned the more walls a defect has- the safer and rapid the healing. Let`s use them ! All this systems are nevertheless a big improvement and they work more or less safe. None of them is able to determine wether there is a perforation by measurement. This is the issue, because treatment has to follow diagnostics for legal/forensic reasons.