Crestal Sinus Lift With Sequential Drills and

Simultaneous Implant Placement in Sites

With <5 mm of Native Bone: A Multicenter
Retrospective Study
Bernardello Fabio, MD, DDS,* Righi Davide, DDS, Cosci Ferdinando, MD, DDS, Bozzoli Paolo, DDS,
Soardi Carlo Maria, MD, DDS, and Spinato Sergio, DDS
I
mplant placement is often compli-
cated in the posterior upper jaw by
postextraction bone resorption,
pneumatization of maxillary sinuses,
and poor quality of alveolar bone. In
these situations, the residual vertical
bone height is reduced making stan-
dard implant placement difficult. In
fact, studies have shown higher suc-
cess and survival rates (SRs) with a
fixture length of at least 10 mm.
14
The elevation of the maxillary sinus
floor is one possible solution.
5
The
sinus floor augmentation technique
was first presented by Boyne and
James
6
; it was based on the lateral
window method that was a modifica-
tion of the known sinus revision pro-
cedure according to Caldwell-Luc.
Since then and until today, the sinus
lift technique using lateral access has
been widely documented in the litera-
ture and has proved to be a safe and
highly predictable method.
712
A crestal approach for sinus floor
elevation was initially suggested by
Tatum.
13
Summers
14
later proposed the
osteotome technique to place implants
in a simpler, more conservative, and
less invasive manner than the lateral
approach.
15
In Summers technique,
an osteotome is inserted through the
edentulous alveolar crest at the infe-
rior border of the maxillary sinus
floor. This intrusion procedure pro-
duces a fracture in the least traumatic
way possible and the sinus floor is
moved upward. This creates a space
for bone graft and simultaneous im-
plant placement. Some years later,
some authors
1619
suggested modifica-
tions to the Summers technique based
specifically on the use of different bio-
materials and on the expansion and
compression of the alveolar crest to
lift the sinus floor of the maxilla.
In particular, Cosci and Luccioli
17
presented a sinus lift 1-stage crestal
approach using a specific sequence of
drills (Coscis Technique). The shape
of the drill tip prevented perforation of
the sinus membrane and permitted
gentle abrasive removal of the cortical
*Private Practice, Legnago VR, Italy.
Private Practice, Parma PR, Italy.
Private Practice, Lamporecchio PT, Italy.
Private Practice, Caronno Pertusella VA, Italy.
Private Practice, Brescia BS, Italy.
Private Practice, Sassuolo MO, Italy.
Reprint requests and correspondence to: Sergio
Spinato, Via F. Cavallotti 140, 41049, Sassuolo (MO),
Italy, Phone: 0039-0536-883868, Fax: 0039-0536-
400082, E-mail: albispina@tiscali.it.arrey
ISSN 1056-6163/11/02006-001
Implant Dentistry
Volume 20 Number 6
Copyright 2011 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e3182342052
Purpose: The aim of this multi-
center retrospective clinical study
was to evaluate the survival rate of
implants placed in the posterior
maxilla with a residual bone height
of 5 mm.
Materials and Methods: One
hundred seventeen patients, recruited
from 6 different centers, had 134 im-
plants placed below the maxillary si-
nus. The patient population consisted
of 52 men and 65 women ranging in
age from 39 to 78 years (mean age,
53.2 years). Sinus lift procedures were
performed following a crestal ap-
proach using a specific sequence of
drills (Coscis technique). All implants
were submerged. Periapical radio-
graphs were obtained with a parallel-
ing technique and were digitized. The
pattern of bone remodeling was sub-
sequently evaluated.
Results: The average (SD)
follow-up time was 48.2 months
(29.30 months; range, 24 to 120
months). Of the original 134 implants
placed, 5 implants (3.7%) failed. The
implant survival rate was 96.3%. The
average residual bone height was 3.46
mm (0.91 mm) at baseline. The av-
erage height of the alveolar crest in
the treated implant sites was 9.94
2.29 mm. The radiographic bone gain
was 6.48 2.38 mm.
Conclusion: The investigation
suggests that this crestal drill ap-
proach can be a successful sinus lift-
ing procedure in a severe atrophic
maxilla with 5 mm of crestal bone
height. (Implant Dent 2011;20:1
000)
Key Words: crestal approach, lifting
drills, residual bone height, sinus
augmentation, sinus graft
IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 1
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bone of the sinus floor without frac-
ture. The main limitation of these cr-
estal techniques is the uncertainty of a
possible perforation of the sinus mem-
brane. However, an endoscopic study
showed that the sinus floor may be
elevated up to 5 mm without tearing
the membrane.
20
This outcome is indi-
rectly confirmed by the study, which
compared the crestal approach and the
lateral antrostomy for sinus augmenta-
tion: the results indicated that the os-
teotome technique allowed a maximum
increase in bone height of 3 to 4 mm,
whereas the lateral technique allowed an
increase of 10 to 12 mm.
21
In a multicentric retrospective
study, Rosen et al
22
evaluated the out-
come of the Summers technique in
the placement of implants below the
maxillary sinus floor: the SR was 96%
when the residual bone height was 5
mm or more, but dropped dramatically
to 85% when crestal bone height was
4 mm or less. Existing literature
2224
suggests that residual bone height has
a significant influence on the outcome
of crestal procedures. Specifically, the
success and SRs decrease with re-
duced residual bone height.
The purpose of this multicenter
retrospective study was to evaluate the
SRs of implants placed in the posterior
maxilla with a residual bone height of
5 mm using a sequential sinus lift
crestal approach (Coscis technique).
MATERIALS AND METHODS
During the period from 1999 to
2009, 117 patients, recruited from 6 dif-
ferent centers, had 134 implants placed
below the maxillary sinus. The patient
population consisted of 52 men and 65
women ranging in age from 39 to 78
years (mean age, 53.2 years). All of the
selected patients were in a good state of
health, absence of diseases that affects
bone metabolism or wound healing, and
no regular medications consumption for
3 months. All the authors patients
who underwent bone regeneration tech-
niques were non-smokers.
25,26
Hence,
smokers were excluded from the study.
These patients presented a residual
bone height of 5 mm, making implant
placement impossible without a sinus
lift procedure. Pretreatment residual
bone height was determined for each
site by using a periapical radiograph.
Radiographic Analysis
Endaural digital images (RVG
Kodak system & CSN system) were
obtained after implant placement
(baseline) and during control examina-
tions with a paralleling technique us-
ing a Rinn film holder. To obtain real
and accurate measurements, digital
images were always calibrated with a
specific software application, taking
the known length of the inserted im-
plant as a reference for measurement.
No attempts were made for further
standardization.
The following radiographic linear
measurements were made:
1. Residual bone height from the al-
veolar crest (coinciding with the
implant shoulder) to the floor of the
maxillary sinus mesial and distal to
the inserted implant at baseline
(Fig. 1, A).
2. Distance from sinus floor to alveo-
lar crest in treated sites at the
follow-up appointment (Fig. 1, B).
3. Radiographic bone gain (G) was
calculated: the distance from im-
plant shoulder to the sinus floor at
baseline was compared with the
distance from implant shoulder to
Fig. 1. Linear measurements made on the periapical radiographs. A, Baseline radiograph. B,
Control radiograph. Radiographic bone gain (G) is the difference between the height of the
graft (or new bone) measured from the implant shoulder to the edge of the graft (or new bone)
as revealed in the control x-ray and the height measured fromthe implant shoulder to the sinus
floor in the baseline x-ray. GB
1
B
0
in the figures. Reduction of the graft (R) is the difference
between the height of the graft measured from the implant shoulder to the edge of the graft
(B
0
H) in the baseline x-ray and the height of the graft (or new bone) measured from the
implant shoulder to the edge of the graft in the control x-ray. R (B
0
H) B
1
in the figures.
Fig. 2. Lifting drills with a small cutting angle of 30 degrees.
2 CRESTAL SINUS LIFT WITH SEQUENTIAL DRILLS AND SIMULTANEOUS IMPLANT PLACEMENT FABIO ET AL
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the new sinus floor at the time of
last examination (Fig. 1, A and B).
4. Height of the graft (or new bone, in
the control x-ray image) from the
floor of the sinus to the edge of the
graft mesial and distal to the im-
plant (Fig. 1, A).
5. Reduction of the graft (R) was cal-
culated: the difference between the
height of the graft measured from
the implant shoulder to the edge
of the graft in the baseline x-ray
and the height of the graft (or new
bone) measured from the implant
shoulder to the edge of the graft in
the control x-ray (Fig. 1, A and B).
When no visible radio-opaque
grafting materials were used, it was
impossible to measure the graft height
and therefore to calculate the reduc-
tion of the graft. In these cases, only
the radiographic bone gain was calcu-
lated. Every linear measurement was
reported as a mean between the mesial
and the distal measurement. A differ-
ence of 0.5 mm was considered as
good interoperator agreement, ie, a
clinically nonsignificant discrepancy.
At the clinical and radiographic
examination after functional loading,
the following parameters were also
evaluated: survival of implants and
restorations; pocket probing depth in
millimeters; periimplant radiographic
bone loss measured from the implant
shoulder to the first bone-to-implant
contact. It was calculated as an aver-
age of mesial and distal bone changes
from the preoperative values. The fi-
nal value was calculated by averaging
the average bone loss per patient. The
standard of success for implant func-
tion established by Albrektsson et al
27
was applied.
Surgical Procedure
All patients had been treated with
implants placed in the posterior max-
illa using the specific sequence of lift-
ing drills
16
(Fig. 2). The set of drills
included 11 pieces with the same diam-
eter (3.1 mm) but with increasing length
(2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 mm).
All patients were treated according to
the following surgical protocol. Patients
rinsed 0.12% chlorhexidine for 1 minute
before surgery. Under local anesthesia, a
full-thickness flap was opened. If neces-
sary, vertical releasing incisions were
made. The location of the implant was
marked with a small-diameter pilot-drill
of 1 mm in length working through the
cortical bone. Then a larger-diameter in-
termediate drill was used. An implant
site was prepared about 1 mm below the
sinus floor using a lifting drill that was 1
mm shorter than the height of the alve-
olar crest.
A parallel pin was inserted into
the surgical site and an intraoperative
x-ray revealed the exact length of the
alveolar ridge below the sinus floor.
The first lifting drill that was 1 mm
longer than the length of the measured
alveolar crest was then used and
pushed into the site until the shoulder
stop reached the ridge. With a special
rounded probe, a check was made of
the alveolar bone to determine that it
was perforated and that the sinus
membrane was ready to be lifted: the
Valsalva maneuver (nose-blowing
test) showed no perforations (Fig. 3).
Then, the graft was gently pushed
into the site using a particular instru-
ment called body-lifting; this step
was repeated until the site was filled
with the graft. Another x-ray was
taken to check the lift and its height. A
self-tapping implant was then inserted.
The type of implants placed had a
variety of surfaces (microtexture and
hydroxyapatite) and designs: Spline,
Screw-Vent, and Screw-Vent Tapered
(Zimmer Dental, Carlsbad, CA). All
implants were submerged. The time
between implant placement and their
exposure was approximately 6 months.
Subsequent prostheses included
single-tooth restoration, multiple-unit
implant supported restorations, and
overdentures. All implants had to be in
function for a minimum of 24 months
(Fig. 4).
Statistical Analysis
The quantitative data were ex-
pressed as average SD. The Student
Fig. 3. Viewof sinus membrane: the shape of
the drill tip prevents perforation of it.
Fig. 4. A, Two implants after placement. B, Four months after the sinus lift, 1 implant was
loaded with a resin crown. The volume of added graft (Puros, Zimmer Dental, Carlsbad, CA) is
easily seen around the second implant. C, Radiographic view of the 2 splinted crowns at 2
years after loading. D, Definitive restoration with fixed porcelain prosthesis.
IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 3
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t test (for paired samples) was used to
evaluate the statistical difference. Sta-
tistical significance was set at P
0.05. Implant survival was expressed
as the percentage of lost implants in
relation to the total number of im-
plants inserted. The data were sub-
jected to Kaplan-Meier analysis to
provide a cumulative SR.
28
RESULTS
Over the 10-year period (1999
2009), 134 implants were inserted in
117 patients. The average follow-up
time was 48.2 months (29.30
months; range, 24120 months). Sixty
implants used in this study were
Spline (Zimmer Dental); 10 implants
were Screw-Vent (Zimmer Dental);
and 64 implants were Tapered Screw-
Vent (Zimmer Dental). The majority
of those (50.7%) were standard im-
plants with a diameter of 3.7 or 3.75
mm; 18.7% were implants with a di-
ameter of 4.1 mm; 20.9% were wide-
body implants with a diameter of 4.7
mm; 9.7% were implants with a diam-
eter of 5 mm. The most frequently
placed implant length was 11.5 mm
(placed in 46.3% of cases) followed
by 13 mm implants that were placed in
28.3% of cases. Ten-millimeter long
implants were used in 23.2% of cases,
whereas 15-mm long implants were
used in only 2.2% of cases (Table 1).
Fifty percent of the implants
placed with this crestal approach were
inserted in the position of the first
molar; the second most common posi-
tion was the second bicuspid in 38%
of cases; and the third most common
position was the second molar in 12%
of cases. The cumulative SR of the
implants was 96.3% (95% CI) (Fig. 5).
Of the original 134 implants placed, a
total of 5 implants (3.7%) failed. Four
implants were lost before loading: 1
implant was lost due to acute infection
after 35 days. In 2 cases, the implants
did not osseointegrate and were re-
moved after approximately 2 months.
The fourth implant that was lost before
loading was removed after 6 months
when the implant was exposed. The fifth
implant was lost after a loading time of
63 months due to periimplantitis.
The periimplant bone loss of each
of the 129 implants placed success-
fully was measured mesially and dis-
tally. The range of marginal bone loss
was 0 to 2 mm both mesially and
distally in 128 implants showing an
average value of 1.07 mm (0.40 mm)
mesially and 1.20 mm (0.51 mm) dis-
tally. Only one implant showed a greater
marginal bone loss, measuring 3.5 mm
mesially and 4 mm distally, due to peri-
implantitis occurring during the healing
period. The periimplantitis was treated
according to the implant maintenance
and treatment protocol cumulative inter-
ceptive supportive therapy.
29
Thirty-
eight months after supportive therapy,
the implant was normally in function
with no further bone loss. No other com-
plaints or adverse effects were observed
during the follow-up time.
The average residual bone height
was 3.46 mm (0.91 mm) at baseline.
The average height of the alveolar
crest in the treated implant sites was
9.94 mm (2.29 mm) at the time of
follow-up examination. The measured
mean radiographic bone gain using
this technique was 6.48 mm (2.38
mm) (Table 2).
In this study, 7 different types of
grafting materials were used (autoge-
Fig. 5. Cumulative survival of 134 implants.
Table 1. Demographic Information of Implants Placed
Diameter 10 mm 11.5 mm 13 mm 15 mm
3.7 4 (1 Failed) 11 6
3.75 5 22 (1 Failed) 18 (1 Failed) 2
4.1 12 (1 Failed) 10 3
4.7 8 13 (1 Failed) 7
5.0 2 6 4 1
Table 2. Mean Distance (mm) From Sinus Floor to Alveolar Crest in Treated Implant
Sites (at Baseline and at the Follow-Up Appointment)
Baseline Follow-Up
Bone
Gain (G) P
Crestal bone height (mm),
mean (SD)
3.46 (0.91) 9.94 (2.29) 6.48 (2.38) 0.05
Table 3. Reduction (mm) of Grafting Materials Used in the Present Study (Only 79
Implant Sites Were Evaluated)
Baseline Follow-Up Reduction (R) P
Height of the graft (mm),
mean (SD)
9.40 (1.63) 7.58 (2.03) 1.82 (1.03) 0.05
4 CRESTAL SINUS LIFT WITH SEQUENTIAL DRILLS AND SIMULTANEOUS IMPLANT PLACEMENT FABIO ET AL
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nous bone, deproteinized bovine bone
mineral, collagen, hydroxyapatite, de-
mineralized freeze-dried bone allograft,
tri-calcium phosphate, and mineralized
human bone allograft) alone or in vari-
ous combinations. Because of the heter-
ogeneity of the grafting materials, no
comparative statistical analysis could be
performed with regard to the 7 individ-
ual materials.
It was however possible to calcu-
late the reduction of the graft for 79 of
the 129 successfully inserted implants.
In these cases, a radio-opaque grafting
material was used. Immediately after
implant insertion, the height of the
graft was 9.40 mm (1.63 mm). At
the follow-up examination, this height
had reduced by 1.82 mm (1.03 mm)
to 7.58 mm (2.03 mm) (P 0.05)
(Table 3).
DISCUSSION
Since their introduction into clin-
ical practice, different sinus augmen-
tation procedures have demonstrated
their effectiveness regarding the en-
hancement of native bone in maxillary
areas with atrophic ridges and pneu-
matized sinuses. Boyne and James in
1980 proposed a lateral approach for
sinus lifts.
6
The access to elevate the
sinus floor was performed by opening
a window through the lateral wall.
This technique enabled a remarkable
increase in bone height of 10 mm,
21
even in extremely atrophic ridges.
5,810
However, lateral antrostomy results in
significant postsurgical morbidity and
significantly increased risk of mem-
brane tearing.
30
During the 1980s, less invasive
clinical practice techniques using a cr-
estal approach were introduced. These
procedures were based on the use of
osteotomes
1416
or sequential drills
17
and allowed simultaneous implant
placement and sinus floor elevation
obtained by graft insertion. Addition-
ally, this drill technique eliminated
hammering and therefore proved to be
more acceptable to patients.
17
Evidence available today indicates
that crestal techniques with simultane-
ous implants insertion are predictable
and safe with excellent SRs.
23,24,31,32
However, it is generally considered that
the crestal approach requires a mini-
mum of 5 mm of residual bone height
22
due to the risk of tearing the membrane
and the difficulty of obtaining primary
implant stability in thin ridges. For this
reason, an osteotome-staged approach
with 6 months delayed implant insertion
has recently been proposed with encour-
aging results.
33
Because osteotome techniques en-
abled a maximum increase in bone
height of 3 to 4 mm,
21,34
some au-
thors
35,36
proposed the use of short,
porous-surfaced implants, with or
without sinus floor elevation, in ex-
tremely atrophic ridges. The results
are undoubtedly encouraging (97%
99%) but are still based on limited
cases and supported only by short-
term follow-up. In the present multi-
center retrospective report, the 134
implants immediately inserted into
sites with 5 mm (average height,
3.46 0.91 mm) showed an excellent
SR (96.3%) (Fig. 8) calculated on a
significant follow-up period (48
months).
This result is better than an anal-
ogous retrospective report based on an
osteotome technique that showed a
lower SR in atrophic ridges (85.7%).
22
This result can be explained by a re-
duced risk of damaging the sinus
membrane by using sequential dril-
ling. This outcome is confirmed by the
gain in bone height obtained in this
study (6.48 2.38 mm) (Table 2),
which is greater than the increase ob-
served using the osteotome technique
(34 mm).
21,34
This difference may
also be attributed to the fact that only
non-smokers were selected in this in-
vestigation due to the fact that nicotine
has a negative impact on bone healing
and sinus augmentation procedures.
25,26
Another report showed 9.12 mm
of bone gain but with a lower SR
(91.4%) and in a shorter follow-up
period (22 months) with localized
management of the sinus floor,
37
a
modified osteotome technique without
grafting insertion. Other studies using
the osteotome technique with no graft
showed an average gain in bone height
of between 1.7 and 3.5 mm.
34,38
The
average length of implant used was
approximately 11 mm and the average
diameter was 4 mm (Table 1). These
data confirm that the crestal sequential
drill approach enables the develop-
ment of a satisfactory bone height for
simultaneous insertion of implants of
adequate length and diameter as sug-
gested in the literature.
14
Despite the heterogeneity of graft-
ing materials, it was possible to calcu-
late the contraction of the graft in 79
of the 129 successfully inserted im-
plants in which a radio-opaque graft-
ing material was used. In these cases,
immediately after implant insertion,
the height of the graft was 9.40 1.63
mm and, at the time of follow-up ex-
amination, this height had reduced by
1.82 1.03 mm to 7.58 2.03 mm
(Table 3), ie, approximately 20%,
which is similar to the data available
in another report.
39
CONCLUSION
This retrospective investigation
suggests that the crestal sequential
drill approach (Coscis technique) can
be a successful sinus lifting procedure
in a severely atrophic maxilla with 5
mm of crestal bone height.
DISCLOSURE
The authors claim to have no finan-
cial interest in any company or any of
the products mentioned in this article.
ACKNOWLEDGMENTS
The authors thank Dr. Luigi Vec-
chi, ScD, Statistician, Mirandola (MO),
Italy, for the statistical analysis.
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6 CRESTAL SINUS LIFT WITH SEQUENTIAL DRILLS AND SIMULTANEOUS IMPLANT PLACEMENT FABIO ET AL
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