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The transcrestal hydrodynamic ultrasonic cavitational sinuslift: results of a 2-year prospective multicentre study on 404 patients, 446 sinuslift sites and 637 inserted implants

Open Journal of Stomatology, 2013, 3, 471-485 OJST
http://dx.doi.org/10.4236/ojst.2013.39078 Published Online December 2013 (http://www.scirp.org/journal/ojst/)
The transcrestal hydrodynamic ultrasonic cavitational
sinuslift: Results of a 2-year prospective multicentre study
on 404 patients, 446 sinuslift sites and 637 inserted
implants
Angelo Troedhan1, Andreas Kurrek2, Marcel Wainwright3, Izabela Schlichting1,
Bianca Fischak-Treitl4, Martin Ladentrog5
1Center for Facial Aesthetics Vienna, Vienna, Austria 2Implantology Clinic Oberkassel, Dusseldorf, Germany 3Implantology Clinic Kaiserswerth, Dusseldorf, Germany 4Office for General Dentistry and Implantology, Mattersburg, Austria 5Office for General Dentistry and Implantology, Graz, Austria Email: Received 7 October 2013; revised 11 November 2013; accepted 23 November 2013 Copyright 2013 Angelo Troedhan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT
Keywords: Transcrestal; Hydrodynamic Sinuslift; Bone
Introduction: In 2006 an ultrasound-surgery-based
Augmentation; Implants; Ultrasound Surgery; Maxillary method to hydrodynamically detach the sinus-mem-
brane utilizing the ultrasonic cavitation effect—the
tHUCSL—was developed and a surgical protocol es-
1. INTRODUCTION
tablished. The aim of the study was to determine the
indication-range and success-rate of this novelty pro-
The basic principle of subantral bone augmentation cedure. Materials & Methods: Between 2007 and 2009,
("Sinuslift") in the lateral maxilla is a commonly ac- 404 patients were treated by 6 oral surgeons of differ-
cepted, well documented and established procedure for ent experience-levels with the tHUCSL in 446 sinus-
bone augmentation in the posterior maxilla to allow im- sites. 637 implants were inserted and then prostho-
plant insertion in the atrophic maxillary alveolar crest dontically treated and observed and documented
since the 80's of the past century. Various surgical tech- until December 2011. The subantral space was aug-
niques have been developed, described and scientifically mented via the 3 mm transcrestal approach with an
evaluated over the centuries with clinically good results augmentation volume of 1.9 ccm (+/− 0.988 ccm) and
an augmentation height of 10.7 mm (+/− 2.85 mm).
Various authors published different results and prefer- Results: Within the survey-period 15 (2.35%) of the
ences on the grafting material subantrally inserted (auto- 637 inserted implants were lost, mostly before im-
logous, heterologous, xenogenic, allogenic bone, synthe- plant loading due to postsurgical infection and non-
tic bone grafts) [11-19]. Nevertheless a survey over the osseointegration in the augmentation site. 1 implant
current literature and systematic reviews [20] suggests was lost after implant loading and prosthetic treat-
the success of sinus floor augmentation procedures to be ment within 1 year after loading. The overall success
related more to the medical history of the augmented rate with functional implants in site is 97.65% evenly
sinus and the skills of the surgeon than the used bone distributed among the participating surgeons. 86% of
graft material [21]. the patients were observed with no postsurgical swell-
The success of bone augmentation procedures espe- ing and 87% no postsurgical pain. Discussion: The
cially in sinus-floor augmentation can be considered sci- results suggest the tHUCSL to be a safe minimal-in-
entifically proven as to be more related to intact ana- vasive alternative to traditional lateral approach and
tomical and physiological structures of the periosteum transcrestal osteotome sinuslift-procedures applicable
and a sufficient blood supply of the augmentation site to all anatomical situations.
than to any specific bone graft material [22-26]. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 Diligent presurgical diagnosis, intrasurgical complica- trally inserted bone graft material and type and/or brand tion management and postsurgical patient and complica- of inserted dental implants. tion management can be considered to play a major role 2) The verification of the unrestricted applicability of in the overall success of subantral augmentation proce- the tHUCSL-INTRALIFT to every subantral anatomical dures [27-31] as well as the experience of the surgeon as surgical site from very narrow single tooth-gaps up to clinical research in other fields of oral surgery suggests bilateral endentolous upper jaws and the vastly varying [32,33]. The more bone augmentation surgery is per- anatomy of the human maxillary sinus as suggested by formed with highly invasive surgical methods, the more the experimental results [38]. postsurgical morbidity can be expected as voluminous 3) The evaluation of clinical application safety as sug- edema, pain, uncontrollable bleeding and long term fail- gested by comparative animal cadaver studies [41] when ure of the augmentation. long term experienced implantologists are compared to Proper education and training of the oral surgeon are average experienced ones. mandatory to develop the necessary skills for traditional 4) The evaluation of the procedural burdening of pa- sinuslift-procedures with lateral and/or transcrestal ac- tients such as postsurgical pain and swelling and overall cess to prevent the most feared intrasurgical complica- success-rate of the tHUC-sinuslift-technique. tion of a partial or entire rupture of the sinus-membrane. Therefore, sinuslift procedures also follow the trend 2. MATERIAL & METHODS
from massive invasive surgical protocols with a lateral approach and lateral window preparation [1-3] towards 2.1. Experience Level of Participating Surgeons
minimal invasive ultrasound surgical techniques [34] To be as close as possible to working conditions of most based on the idea of the minimal invasive transcrestal oral surgeons, 6 dentists in 5 offices were participating in approach [4,5]. The limited possible augmentation vol- the prospective study treating 412 patients in 457 maxil- ume of the classical Summers lift was partly enhanced by lary sinus sites with a subantral alveolar crest height of 1 the introduction of balloon and hydraulic pressure as- - 10 mm with the tHUCSL-INTRALIFT procedure be- sisted transcrestal sinuslift techniques [35-37]. tween February 2007 and December 2009. (Although Still these procedures are challenging the manual dili- subantral crest heights of 8 - 10 mm might be treated gence of the performing, surgeon and proper training and with short implants nowadays the authors decided the experience have to be achieved by the surgeon to per- inclusion when the protocol was setup in 2006 due to form these techniques with an acceptable success rate. lack of documented long-term success rates of short im- Above all—in case of failure—the inconveniences to the plants in the molar region of the maxilla at that time.) patient (edema, pain, costs, long term morbidity) have to One participating dentist is also specialized in oro- be kept as small as possible. maxillofacial surgery for 20 years, three dentists have To combine the advantages of a lateral approach si- long term experience in implantology and sinuslifting for nuslift (scalable augmentation area and volume) with the 5 - 10 years, one participating dentist short time experi- atraumaticity of the transcrestal approach and to avoid ence in implantology for 4 years and one dentist was at the need of the surgeon to touch the sinus membrane the beginner level in implantology with 2 years of prac- with instruments or balloons in the detachment-process tical experience, the latest two without experience in (and therewith eliminate one of the major risks of intra- surgical membrane perforation) and to utilize the well documented advantages of hydrodynamic pressure sinus- 2.2. Patients Inclusion Criteria
membrane-detachment [36,37] and atraumaticity of ul- trasonic surgery, the transcrestal hydrodynamic ultra- To be eligible for tHUC-sinuslift surgery all patients had sonic cavitational sinuslift (tHUCSL-INTRALIFT) was to fulfil the common criteria for any type of sinuslift- developed in 2006 [38-40]. procedure (no prior Caldwell-Luc-Sinus-surgery, no The significant application safety of the tHUCSL- chronic or acute maxillary sinusitis, no acute cold, no INTRALIFT compared to traditional transcrestal Sum- mucocele visible in panoramic X-ray, permission by mers- and balloon-assisted sinuslift-procedures can be General Practitioner/Internist/ENT). Smokers were con- considered as verified in animal cadaver experiments sidered as eligible since percentage of smokers in the European population is still high with an average of 30%. The aims of the current prospective multicentre study All patients requesting a sinuslift in all 5 participating performed in six implantologist's offices were: clinics/offices within the study period and fulfilling the 1) The evaluation if success-rates of the tHUCSL- common eligibility-criteria for any sinuslift procedure INTRALIFT depend on the experience-level of the per- were exclusively treated with the tHUCSL-Intralift pro- forming oral surgeon, the type and/or brand of suban- Copyright 2013 SciRes. OPEN ACCESS

A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 2.3. Surgical Protocol
The tHUCSL-INTRALIFT procedure had to be per- formed according to the strict surgical protocol with Piezotome I/II/SOLO or Implant Center I/II (Satelec- ACTEON/FR) set up by the developers of the tHUCSL- Intralift presented in their research protocol [38] and documented by pre-, post-surgical and follow-up cali- brated digital panoramic x-ray: The alveolar crest had to be revealed by either a 6 mm diameter mucoperiostal punch (Figure 1) or a minimal
invasive crestal mucoperiostal flap not or only slightly
exceeding the occlusal surface of the alveolar crest
(Figure 2).
The transcrestal approach then had to be marked with the TKW 1 diamond coated conical ultrasound tip Figure 3. TKW 1 diamond coated conical tip for Piezotome I/
(Figure 3) followed by the opening of the cortical bone
of the sinus floor with the TKW 2 tip which has a dia- meter of 2.4 mm. (Figures 4 and 5). A receptacle for
Figure 4. Opening of the bony sinusfloor with the cylindrical
and rounded diamond coated TKW 2 tip—schematic.
Figure 1. tHUCSL-INTRALIFT crestal approach via a 6 mm
gingival punch.
Figure 5. TKW 2 tip inserted to open the sinusfloor.
the hydrodynamic ultrasonic applicator TKW 5 (diameter Figure 2. tHUCSL-INTRALIFT crestal approach via a top-
3.0 mm) had to be prepared with TKW 4 tip, which has a crestal mucoperiostal flap. diameter of 2.8 mm (Figure 6).
Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 Figure 6. Preparation of the 2.8 mm receptacle with the cylin-
drical diamond coated TKW 4-tip—schematic. Figure 7. Insertion of the hollow 3.0 mm TKW 5-tip and de-
tachment of the sinus-membrane by injection of ultrasonic os- After checking the snug fit of the TKW 5-applicator in cillating saline solution creating a cavitation effect—schematic. the receptacle the hydrodynamic ultrasonic cavitational detachment of the sinus membrane had to be performed
at a power setting of the Piezotome at mode D3 with a
flow rate of 30 ml/min for 5 seconds. At these settings
the sinus membrane will be completely detached from
the entire sinus floor and provides a possible augmen-
tation volume of 2.5 ccm. (Figures 7 and 8)
The integrity of the sinus-membrane had to be check- ed visually and/or by Valsalva-test. In case of a perfora- tion of the sinus-membrane the surgeon had to decide wether to proceed or interrupt surgery for wound closure depending on the size of the perforation when visible. After widening of the transcrestal trepanation with Figure 8. TKW 5-tip inserted into the receptacle: this tip seals
TKW 3 (Figure 9) and TKW 4 diamond coated ultra-
the approach canal like a sealing ventile and enables by it's sound tips (Figure 10) synthetic, xenogenic and/or auto-
oscillations the cavitation effect. logous bone graft of the surgeon's choice was inserted under the sinus membrane with a common bone applica-
tor (Figure 11).
When available the surgeons were advised to check the augmentation area and height intraoperatively step by
step with digital X-ray to determine the case-sufficient
extension of the augmentation. (Figures 12-14)
It was also the surgeon's decision to insert one or more implants simultaneously depending on the height and quality of the subantral alveolar crest to achieve primary stability with the surgeon's common implant system. The only prerequisite towards the choice of the implant was an implant—diameter wider than 3 mm since the diame- ter of the TKW 5 tip is 3 mm. 2.4. Study Data Documented and Follow Up
Data as follows then had to be documented by the par- ticipating dentists in a web-based Excel-Sheet accessible Figure 9. After detachment of the sinus-membrane from the
Date of surgery, name of the surgeon coded by a bony floor the approach canal is widened with the cylindrical number, patient's name, age, sex, smoker y/n, diabetes diamond coated TKW 3-tip. Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 Figure 12. Intrasurgical x-ray
check of augmentation extension:
0.5 ml bone graft applied. Figure 10. Final widening and smoothing of the transcrestal
canal to 3.0 mm diameter for smooth application of bone graft. Figure 13. Intrasurgical x-ray
check of augmentation exten-
sion: 1 ml bone graft applied.
Figure 11. Application of bone graft with a common bone ap-
plicator. The amount of bonegraft applied depends on the nec-
essary extension of the subantral augmentation.
type, prior maxillary sinus surgery on sinuslift side y/n,
chronic sinusitis y/n, general medication (type);
Amount of anesthetic applied in ml, crestal mucope- riostal flap approach or gingiva-punch (f/p), mucope- riostal thickness at approach site in mm, dental socket number of INTRALIFT-approach-site, real subantral al- veolar crest height measured intraoperatively, surgeon's subjective rating of bone quality (D1-4); Perforation of the sinus membrane detected y/n, com- mercial name of inserted bone graft, amount of bone Figure 14. Intrasurgical x-ray
graft inserted in ccm, resulting subantral augmentation check of augmentation exten- height in panoramic x-ray/CAT-scan/CBCT, additional sion: 2 ml bone graft applied. Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 surgical procedures; sites with the tHUCSL-INTRALIFT-procedure. 8 pa- Noticeable swelling two, three and seven days post tients and 11 INTRALIFT-sites—although successful— surgery y/n and in case yes the severity (no swelling of had to be excluded from evaluation due to substantial lower eyelid but only the cheek, swelling of lower eyelid, lack of documentation. 404 fully documented patients swelling of lower AND upper eyelid), subjective pa- with 446 tHUCSL-INTRALIFT sites were treated with tient's report on pain after 7 days, analgetic medication 637 implants of different brands with an overall failure applied (generic substance), number of analgetic tablets consumed by the patient in the first 7 days; No significant difference (p > 0.53) in the overall Occurance of complications y/n, type of complication, failure rates between the six surgeons could be observed failure of tHUCSL-INTRALIFT (post surgical removal (Table 1).
Immediate implant insertion, delayed implant insertion 3.2. Patient Age and Sex Distribution,
date, bone quality at delayed implant insertion, implant General/Local Health State and Smoking
position(s), implant type/manufacturer, implant dimen- sions length/diameter, Immediate loading y/n, insertion The average patient's age was 52 yrs starting from 19 yrs torque at implant insertion, date of implant loading, type up to an age of 79 yrs, sex distribution resulted in 64.1% of prosthetic treatment, in case of implant loss: date, fol- female and 35.9% male patients, 3 patients were missing low up investigation 3, 6, 9, 12 and 24 months. age documentation (Table 2)
Follow up investigations included inspection of the 144 patients were smokers (35.64%; 10 - 20 cigarettes INTRALIFT-surgical site and/or inserted implant(s), per day), 252 non-smokers (62.38%), 8 patients were not calibrated panoramic x-ray radiography, percussion test documented for smoking anamnesis (1.98%). 23 patients of the implant(s) to verify osseointegration state and/or (5.7%) suffered from diabetes but had permission for prosthetic suprastructure, subjective condition of the pa- elective surgical interventions by their General Physi- tient (any inconvenience: y/n). cians. 28 patients (6.93%) underwent minor surgeries of For statistical evaluation the surgeons name was ano- their maxillary sinuses in their medical histories (mostly nymized by assigning a number (1 - 6) as well as the pa- apisectomy related interventions in the 2nd premolar or tients names by assigning running numbers from 1 - 412 1st molar region, opened sinuses after tooth extraction, with 457 tHUCSL-INTRALIFT surgeries. Statistical minor ENT-interventions) and 48 patients (11.88%) were evaluation was performed with mean-value denomina- on permanent medication, mostly for heart diseases, tion, standard deviation and p-test. Cases were only ex- blood pressure and mild anticoagulation (salicylic acid cluded from statistical evaluation when critical data were 50 mg or 100 mg/day). missing such as procedure related nominations and fol- low ups. 3.3. Amount of Local Anesthetic Applied
3. RESULTS
The mean amount of the standard local anesthetic Arti- 3.1. Comparison of Success-Rates among
cain (Ultracain dental/Ultracain dental forte) applied per Participating Surgeons
tHUCSL-INTRALIFT-site-surgery was 4 ml (min. 1.00 ml, max. 8.00 ml, Stand. Dev. 1.26), 8 patients were Six surgeons treated 412 patients in 457 maxillary sinus treated with INTRALIFT in general anesthesia.
Table 1. number of patients per surgeon1, tHUCSL-procedures per surgeon2, inserted implants per surgeon3, case exclusions due
to lack of documentation4 and failure rates per surgeon5.
4Exclusions (Pat/OPsite 5Overall failure rate (count 3Inserted implants per tHUCSL-sites/surgeon) Failure rate difference between surgeons Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485
Table 2. Age1 and sex2 distribution of patients treated with
tHUCSL.
Number of females2 Age Max 79 Age Min 19 64.1% Number of males2 Figure 15. Intraoperatively measured heights of the subantral
alveolar crest at the tHUCSL-INTRALIFT site. 3.4. Types of Surgical Approach
In 144 tHUCSL-sites the crestal gingiva was opened by a 6 mm gingival punch (32.29%), in 300 cases by a top crestal mucoperiostal flap with a size between 8 × 8 mm to 10 × 10 mm (67.26%). 2 cases (0.45%) were not docu- mented for the gingival approach (flap or punch). The gingiva thicknesses measured intraoperatively varied from 2 to 5 mm with an average thickness of 3 mm. (Stand. Dev. 0.69) 3.5. Intrasurgical tHUCSL-INTRALIFT Sites
Related Results
The mean subantral alveolar crest height at the tHUCSL- INTRALIFT-approach site measured intraoperatively Figure 16. "Two hole approach" to sinus floor: membrane
and scaled to full mm-values was 4 mm starting at 1 mm detachment is carried out first via one single hole approach. up to a subantral alveolar crest height of 10 mm (Figure
After membrane detachment a second trepanation is prepared 15), the bone quality mostly D2, followed by D3 and
for subantral filling of bone graft. The intact sinus-membrane only rarely D1 or D4. is well visible. The transcrestal approach sites were chosen case spe- cific and by the extension/pneumatization of the maxil-
lary sinus from the first premolar area to the 2nd upper
molar area both as "single hole approach" (entire aug-
mentation performed via a single transcrestal trepanation)
or as a "dual hole approach" (augmentation performed
via two transcrestal trepanations; Figure 16). One site
was not documented exactly for approach location (Fig-
ure 17).
3.6. Implant-Insertion Related Data (Single and
Two Stage)
Figure 17. Denomination of tHUCSL subantral approach sites
A total of 637 implants were inserted into the augmented and number of transcrestal trepanations. sites of which 302 implants (47.41%) were inserted si- multaneously after the tHUCSL-INTRALIFT and suban- was 7.92 months (max. 16.80 months, min. 3, 72 months, tral augmentation and 335 implants (52.59%) in a second Stand. Dev. 0.22) with 68 implants inserted after less than 6 month (20.3%), 192 implants inserted after less The mean value of time elapsed between tHUCSL and than 9 months (57.31%), and 75 implants (22.39%) after insertion of the 335 implants in a second stage surgery more than 9 months. Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 3.7. tHUCSL-INTRALIFT Perforation
Occurrence and Implant Loss Correlation
In 25 sites (6%) of all 446 tHUCSL-surgical sites the surgeon detected—visually or by Valsalva-test—a perfo- ration of the sinus membrane. Nevertheless, all surgeons decided to proceed with subantral grafting backed by experimental suggestion [41] and only 2 implants (0.31%) were lost in these cases with an insignificant correlation (p > 0.83) compared to the overall failure rate. 3.8. Grafting Materials and Achieved
Augmentation Heights and Volumes
Figure 19. Achieved augmentation heights.
As grafting materials "easygraft" (SUNSTAR-Degrad- able/CH), "Nanobone" (Artoss/GER), "BegoOss" (Bego/ Table 3. Brands and implant types inserted into tHUCSL-IN-
Ger), "Cerasorb" (Curasan/CH), "BioOss" (Geistlich/CH) TRALIFT sites1 and brand related loss rates2. and other brands were applied (Figure 18).
The achieved average augmentation volume was 1.9 Implant Brands and Types 2Implants lost per brand ccm starting at 0.4 ccm up to 7.0 ccm in very vast and Q2/QK (Trinon GmbH) highly pneumatized maxillary sinuses with an average achieved augmentation height of 10.7 mm starting at 4 3i Certain/Nanotite (BIOMET 3i) mm height up to 17 mm (Figure 19). In 14 cases (3%)
autologous bone was added to the synthetic bone graft, in BEGO S/RI (BEGO) 432 cases (97%) no autologous bone was added to the synthetic or xenogenic bone graft. Alphatech (Alphatech) 3.9. Implant Brands, Implant Success-Rates and
Prosthetic Treatment
Ankylos (DentSply) The 637 implants inserted were from different brands and manufacturers, the overall loss was 15 implants Misc (Straumann. Nobel‐Biocare. n/a etc.) (2.35%) in the 2-year survey-period with no significant difference in brands and manufacturers (p > 0.4) (Table
The loading of implants and prosthetic treatment took place after a mean period of 8.6 month (max. 18 months, min. 5.76 months, Stand. Dev. 0.28) after implant inser- tion both for single stage as well as two-stage implant insertions. 623 implants out of 637 inserted implants were eligi- ble for prosthetic treatment starting after less than 6 months (145 implants; 23.27%) with smaller augmenta- tions of less than 1 ccm, between 6 and 9 months (344 implants; 55.22%) with average augmentation volumina of 2 ccm, up to a prosthetic treatment after more than 9 months (134 implants, 21.51%) when augmentation volumina were greater than 2 ccm and/or unforeseen causes delayed the prosthetic treatment. Unforeseen causes delaying the prosthetic treatment after a 12 month healing period were—according to written comments by the participating surgeons—mostly: Acute general deseases of patients older than 65 yrs Figure 18. Bone grafting materials applied.
(acute cardial, gastrointestinal, gynocological, skeletal Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 deseases) preventing prosthetic treatment due to general desease-specific rehabilitation, financial reasons (job- loss/savings-loss due to general economic state) and in some cases organizational delays on patient's or sur- geon's side (job related, pregnancy etc.). Overall implant loss before prosthetic treatment was 14 implants (2.2%) of which 12 implants (1.88%) showed no stable osseointegration (dull percussion sound, no rotational stability and visible micromovement) and had to be removed. Two simultaneously inserted im- plants (0.31%) were lost due to postsurgical infectious complications, one implant (0.16%) was lost 1 year after loading within the observation period due to periimplan- Figure 20. Swelling score.
3.10. Patient tHUCSL-Intralift Related
Morbidity Data
344 patients (85%) received a peri- or postsurgical anti- biotic shielding with Clindamycin or Amoxicillin for 3 - 5 days, 60 patients (15%) were not shielded with an anti- biotic. A highly significant (***) number of this patient- group (84%) suffered from postsurgical infectious com- plications whereas only 8% suffered from postsurgical infection when shielded with an antibiotic (p = 0.001). Overall postsurgical complications occurred in 3%: 84% of all complications were related to post-surgical infections in the patient group that was not shielded with an antibiotic. One patient suffered from a postsurgical infection although shielded with an antibiotic. One pa- Figure 21. Patient case I: facial situation 2 days after IN-
tient lost the bone graft transnasal with an accompany- TRALIFT in the right maxillary sinus: no swelling can be de- ing stronger bleeding maybe caused by the intake of an unknown dosage of Acetyl Salicylic Acid the evening before surgery which the patient did not report to the surgeon upon inquiry. 97% of all patients did not suffer from any postsurgi- cal complication. The average postsurgical analgetic intake (ibuprofen/ dexibuprofen 400 mg) was 1.7 tablets with a maximum of 12 tablets and a minimum of zero tablets in the first 14 days after surgery (Stand. Dev. 0.43). Postsurgical pain also showed a seasonal distribution: in winter, early spring and late autumn exogenic acquired secondary vi- ral infections such as colds led to a higher consumption Figure 22. Patient case I: post surgical X-ray of the patient in
of analgetics than in the rest of the year (p < 0.05). Figure 16 with a substantial subantral augmentation with easy-
Postsurgical visible swelling on day two, three and graft (SUN-STAR-Degradable/CH). seven post tHUCSL was reported for 58 patients (14%) of which 49 patients (84%) showed only mild swelling pression of postsurgical pain: 13 % declared to have ex- (no edema of the corresponding lower lid), 8 patients perienced postsurgical pain, 87% declared not to have (14%) medium swelling (edema of lower eyelid) and 1 experienced any postsurgical pain (Figure 23).
patient (2%) strong swelling with edema also of the up- 4. DISCUSSION
per eyelid on the surgery-side. 346 patients (86%) were
reported free of visible swelling (Figures 20-22).
The overall results of this study suggest the tHUCSL- All patients were asked to score their subjective im- INTRALIFT to be a minimal-invasive alternative not Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 dardized and calibrated detachment forces provided by the Piezotome-device. The tHUCSL-INTRALIFT-procedure can be trained with a small investment of time by the dentist and be
applied by every dentist with a basic training in implant-
tology with almost the same success-rate as long-term
experienced oral surgeons as the study results suggest. It
is applicable to every anatomical situation (Figures
24-32) and achieves an equal overall success rate as
Figure 23. Pain score.
only to traditional transcrestal sinuslift techniques but also to lateral approach sinuslift-procedures and is appli- cable to all common sinuslift indications. In cases of narrow interdental gaps—when other transcrestal sinus- lift-techniques cannot be applied due to lack of approxi- mal space—it revealed it's applicability as an alternative to lateral approach sinuslift-techniques. The achieved augmentation volumina with a mean value of 1.9 ccm correspond to results achievable with the lateral approach sinuslift technique if necessary but inhere the minimal invasiveness of transcrestal proce- dures. The risk of sinus-membrane perforation is low with 6% compared to lateral approach sinus-lift procedures Figure 24. Patient case II: presurgical situation.
performed with rotating instruments with a reported per- foration rate of 14% - 56% [42] due to the use of dia- mond coated ultrasonic instruments which are known to be highly safe on soft tissues [43-46]. Since all surgeons —backed by experimental results published [41]—de- cided to proceed with subantral grafting even in these reported cases of sinus-membrane-perforation, only 2 implants (0.31%) were lost in these cases, suggesting a perforation as described by Jank et al. [41] not to be a reason to interrupt the procedure. The preparation of the transcrestal approach and the hydrodynamic detachment of the sinus-membrane grants a minimum risk of procedural perforations and seems to avoid complete ruptures of the membrane in the detach- ment process since the surgeon need not touch the sinus membrane with instruments [36]. The standardized hydrodynamic pressure described in the surgical protocol [38] combined with the ultrasound cavitation effect distributes the detaching forces equally between the sinus membrane and the bony antrum of the sinus. The tHUCSL-INTRALIFT thus excludes the high- Figure 25. Patient case II: situation 6 month post INTRALIFT
est risk-factor in the detachment process—the surgeons with easygraft (SUNSTAR-Degradable/CH) prior to implant hand [27-33]—by the non-contact procedure and stan- insertion of 2 Q2-implants (Trinon/GER). Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 Figure 26. Patient case II: final prosthetic treatment after 8.5
Figure 28. Patient case IV: INTRALIFT with "easygraft"
(SUNSTAR-Degradable/CH) and simultaneous insertion of 2 single-stage Q1-implants (Trinon/GER) and pseudo-imme- diate-loading (infraocclusal resin provisional). Figure 27. Patient case III: INTRALIFT with Nanobone (Ar-
toss/GER) simultaneous single tooth implant insertion (Q2-Im- Figure 29. Patient case V: INTRALIFT with
plant, Trinon) and prosthetic loading after 5 months. BEGO-OSS (BEGO/GER) and simultaneous implant insertion (IMZ-Implant, Dentsply- other transcrestal sinuslift techniques [47-49] but is not Friadent/USA) in a narrow dental gap (4 limited by a minimum subantral alveolar crest height and achievable augmentation volumina. With tHUCSL the indication for a transcrestal approach can be extended after surgery and thus accept sinus lifting to a higher compared to traditional transcrestal procedures and ap- plied to indications which were reserved for lateral ap- The overall implant-loss rate of 2.35% is not related to proach sinuslift-procedures until now. the experience of the dentist and complications are Patients experience very little postsurgical pain and mostly related to postsurgical infections when no antibi- swelling and mostly are able to work within 3 - 5 days otic shielding is prescribed. In the rare case of a complete Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 Figure 30. Patient case VI: loosened old
dental implant has to be removed.
Figure 32. Patient case VI: prosthetic treat-
ment after 7 months.

enables simultaneous bilateral augmentations of the si-
nus-floor without major surgical trauma thus widening
the indication spectrum to a wider and older base of pa-
tients with remaining subantral alveolar crest heights of 1
mm or less and proves the osteogenic capacity of the
atraumatically detached sinus membrane independent
from age [50] (Figures 33-36).
The indication for a sinuslift procedure might be ques- tionable at subantral crest heights of 8 mm or more since a high reliability of short implants is discussed. Never- theless, the results of this study clearly show that two thirds of patients in need of implants in the lateral max- illa presented equal or less than 4 mm subantral alveolar crest-height thus being not eligible for treatment with short implants (Figure 15).
Figure 31. Patient case VI: immediately af-
ter implant removal INTRALIFT was carried
5. CONCLUSION
out with Nanobone (Artoss/GER) and simul- taneous implant insertion of 2 Q2-implants The tHUCSL-INTRALIFT is compatible to all implant- systems with an implant—diameter of more than 3 mm and—most of all—applicable to all anatomical condi- rupture of the sinus-membrane or loss of the bone graft tions of the alveolar crest and the maxillary sinus which the procedure did not cause major inconveniences on the can be considered a major advantage. Compared to other patient's side and can be repeated after 3 - 5 months. transcrestal instrument sets, balloon- or hydraulic-as- The success-rate of the tHUCSL-INTRALIFT is in- sisted sinuslift systems or "sinuslift"-implants that de- dependent from the type and brand of used bone-graft- mand a minimum mesio-distal distance of the dentition material as well as the type and brand of inserted im- gap and/or a subantral alveolar crest height of more than plants as already generally described by Del Fabbro et al. 4 mm, the results of this prospective study suggest the for transcrestal sinus-floor elevation in a systematic re- tHUCSL-INTRALIFT to be a safe and predictable alter- native also to lateral-approach sinuslift-techniques. It can Especially in older patients the tHUCSL-INTRALIFT be applied beginning with maxillary dentition gaps of a Copyright 2013 SciRes. OPEN ACCESS
A. Troedhan et al. / Open Journal of Stomatology 3 (2013) 471-485 minimum of 3.5 mm up to the entire edentulous maxilla with remaining subantral alveolar crest heights of 1 mm or less. Thus it might fulfil the demand of the ever grow- ing community of dentists confronted with the demand of a highly safe and minimal invasive sinuslift-procedure in the growing number of cases with little or no remnant subantral alveolar crest and highly pneumatised maxil- lary sinuses with the least risk of failure and procedural patient morbidity. Figure 33. Patient case VII: 78 yrs old female with edentulous
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