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Minimally Invasive Implant and Sinus Lift Surgery With Immediate Loading
DENTAL IMPLANTS J Oral Maxillofac Surg 64:1635-1638, 2006
Minimally Invasive Implant and Sinus Lift Surgery With Immediate Loading Kenneth L. Halpern, DDS, MS, PC,* Emily B. Halpern, DDS,† and Salvatore Ruggiero, DDS, MD‡ As 1-stage dental implants continue to gain significantly in popularity, the adaptation of surgical protocols specifically geared to single-stage implants should be considered. Because this type of implant is transgingival at the time of placement, it is now practical to perform implant surgery as well as sinus elevation surgery using minimally invasive techniques without the need for flaps or sutures. The basic concept involves the use of a 5- or 6-mm dermal tissue punch that permits access to the osteotomy site as well as to the sinus, when an elevation procedure is indicated. This technique allows for excellent esthetics in immediate load situations, forming a natural and predictable interdental papilla at the time of surgery. © 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:1635-1638, 2006
Single-Stage Implant Placement Using a Minimally Invasive Technique
to 0.5 to 1 mm above the gingival crest. Care is taken to avoid impingement on the soft tissues.
PROCEDURES
IMMEDIATE LOADING
This simple surgical technique obviates the need for raising a full-thickness flap and enables the surgeon to create a precise, stable, interdental papillae at the time of surgery. Under local anesthesia, a 5-mm disposable dermal tissue punch is used to make a circular incision through the attached gingiva and periosteum at the proposed implant site (Fig 1). A 6-mm punch is used if a wide body fixture is to be placed. The handle of the punch may be removed when access is limited. The gingival tissue core is removed and preserved in saline in the event that a free gingival graft is subsequently required in the procedure (Fig 2). The endosseous implant site is then prepared using the conventional sequence of implant drills and the implant is placed 2 to 4 mm apical to the gingival height depending on the soft tissue thickness and esthetic requirements. At this point an appropriate healing abutment is secured to the implant and should emerge
If the implant is to be used for immediate loading, an appropriate standard final abutment is torqued to 35 Ncm or until the implant begins to rotate (Fig 3). The abutments are generally retorqued to 35 Ncm following osseointegration, before the final impression, following an appropriate healing time. An acrylic coping previously fabricated on an implant analog in the laboratory serves as a base for a temporary crown. It is temporarily seated onto the abutment and a temporary restoration is usually fabricated within 24 hours (Fig 4). It is imperative that all temporary restorations are kept out of occlusion for 6 to 8 weeks. Patients
Received from the Department of Oral and Maxillofacial Surgery, Long Island Jewish Medical Center, New Hyde Park, NY. *Associate Attending. †Assistant Attending. ‡Chairman. Address correspondence and reprint requests to Dr Halpern: 70 Glen Cove Road, Suite 304, Roslyn Heights, NY 11577; e-mail: [email protected] © 2006 American Association of Oral and Maxillofacial Surgeons
0278-2391/06/6411-0011$32.00/0 doi:10.1016/j.joms.2006.04.043
FIGURE 1. Incisions made with tissue punch. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
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MISL WITH IMMEDIATE LOADING
FIGURE 2. Gingival cores removed. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
FIGURE 4. Prefabricated acrylic copings to be used as a foundation for temporary restorations. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
are typically instructed to chew on the contralateral side during that period of time (Fig 5). This procedure is indicated only in patients with an adequate width of attached gingiva. It should be considered in situations where the esthetics and interdental papilla morphology is of extreme importance. A predictable interdental papilla should result consistently. The technique is also advantageous for patients who present with a coagulopathy. Because a mucoperiosteal flap is not required, the risk of postoperative subperiosteal hematoma formation does not exist. Capillary oozing, although rare, is a potential complication in this patient population. In addition, the avoidance of mucoperiosteal flap reflection minimizes the potential for postoperative ischemic changes at the alveolar crest and averts early crestal bone loss, especially in thin ridges.
Postoperative edema is generally eliminated and patient discomfort is significantly diminished. Reduced healing time is observed because stage II gingival healing is not required, as opposed to a 2-stage technique. Finally, because the punches correspond to the implant sizes, they can be used to predict the exact distance between implants. This orientation is lost when a flap is raised. Minimally invasive implant procedures are contraindicated in patients exhibiting significant bony irregularities. This includes patients with thin or knifeedge ridges or those with significant depressions of the buccal alveolus (Table 1). MINIMALLY INVASIVE SINUS LIFT SURGERY
This procedure is a modification of a technique originally described in an article by Summers in
FIGURE 3. Implants placed with abutments torqued to 35 Ncm.
FIGURE 5. One week postoperatively: patient is wearing temporary crowns that were fabricated immediately following implant placement.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1637
HALPERN, HALPERN, AND RUGGIERO
Table 1. ADVANTAGES AND DISADVANTAGES OF MINIMALLY INVASIVE IMPLANT AND SINUS LIFT SURGERY
Advantages 1. Minimal swelling and postoperative discomfort 2. No risk of wound dehiscence 3. Sinus precautions less critical; pressure unlikely to disturb graft 4. Decreased operative time 5. Decreased potential for crestal bone resorption 6. Eliminates postoperative subperiosteal hematoma formation 7. Formation of stable and predictable interdental papilla
Disadvantages 1. Relies solely on tactile sense (clinical visualization not possible) 2. Significant perforation may require conversion to conventional technique 3. Osteotome and mallet use may be disconcerting to patient
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1994.1 Similar to conventional sinus lift surgery, this technique can be performed at the time of implant placement provided that there is a minimum of 3 to 4 mm of alveolar height. If there is not sufficient bone for initial stabilization, implants are typically placed 6 months following minimally invasive sinus lift surgery and the punch is sutured back into place. After administration of local anesthesia, a 5- or 6-mm dermal tissue punch is selected in accordance with the diameter of the implant that will be placed. The attached gingival core is removed, exposing the osteotomy site. A pilot hole is made to a depth that is approximately 2 mm inferior to the sinus floor. The correct depth is established both by radiographic analysis and by the use of calibrated instrumentation. The osteotomy is then widened to its final diameter using a series of incrementally larger twist drills. At each step, care is taken to avoid perforation of the Schneiderian membrane. Next, the widest diameter concave sinus osteotome is used to upfracture the floor of the maxillary sinus with a mallet (Fig 6). An attached stop is positioned to allow the osteotome to penetrate to a depth 2 mm
greater than that of the osteotomy. This allows the membrane to be lifted along with an attached disc of bone, minimizing the chance of perforation. Next, an approximately 8 ⫻ 8 mm resorbable membrane is introduced through the osteotomy and placed against the slightly elevated Schneiderian membrane. This serves to diffuse the pressure exerted on the membrane, minimizing the chance of perforation during the membrane elevation. Secondly, the resorbable membrane minimizes the possibility of graft extravasation if a small perforation exists. A 3- to 4-mm diameter convex (rounded) depth tool is then inserted into the osteotomy and the membrane is gently teased in every direction to allow elevation of a discrete portion of the Schneiderian membrane. An additional height of 5 to 10 mm can be achieved by this technique (Fig 7). A tent-like effect may be accomplished by lifting this localized region of the sinus membrane. When placing multiple adjacent implants, the sinus elevations can sometimes be inadvertently connected, allowing elevation of the entire inferior aspect of the sinus. It is important to rely on tactile sensation to
FIGURE 6. Calibrated osteotome demonstrating osteotomy depth of 6 mm.
FIGURE 7. After sinus elevation, depth gauge measures 12 mm.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1638
MISL WITH IMMEDIATE LOADING
FIGURE 10. One year postinsertion with excellent gingival health. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
FIGURE 8. A, Periapical radiograph demonstrating excellent immediate bone fill around adjacent implants. B, Panoramic radiograph exhibiting implants and minimally invasive sinus lift in the immediate postoperative period. (Note the dome-shaped graft, which is typical.) Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
ensure that the membrane is not perforated at any point in the procedure. Resistance of the membrane must be delicately verified with use of the instrumentation at all times. If at any point, resistance is no longer appreciated, the technique is aborted and a conventional sinus lift is performed instead. The graft materials are now prepared and introduced through the osteotomy and into the elevated sinus cavity. The depth tool can be used to gently pack the graft superiorly. Alternately, the graft material may be inserted into a syringe and injected through the osteotomy site. It is helpful to mix a small amount of radiopaque graft material such as hydroxyl apatite to facilitate intraoperative and postoperative radiographic interpretation. The graft should exhibit a dome-shaped radiographic appearance (Fig 8). If a sinus perforation has occurred, it is usually represented by an irregular or nonrounded appearance of the bone graft on a postoperative radiograph. In this situation, the patient must adhere strictly to sinus precautions and success of the graft will be determined after 6 months (Figs 9, 10). The implant is now placed and an appropriate abutment is secured.
Discussion Although there are distinct advantages in using minimally invasive implant techniques, these procedures must be reserved for the highly experienced implant surgeon. Anatomic considerations are of extreme importance, especially in the esthetic zone. It is recommended that initial cases be anatomically straightforward. FIGURE 9. Periapical radiograph taken 6 months following minimally invasive implant and sinus surgery. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
Reference 1. Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compend Contin Educ Dent 15:152, 1994
Minimally Invasive Implant and Sinus Lift Surgery With Immediate Loading Kenneth L. Halpern, DDS, MS, PC,* Emily B. Halpern, DDS,† and Salvatore Ruggiero, DDS, MD‡ As 1-stage dental implants continue to gain significantly in popularity, the adaptation of surgical protocols specifically geared to single-stage implants should be considered. Because this type of implant is transgingival at the time of placement, it is now practical to perform implant surgery as well as sinus elevation surgery using minimally invasive techniques without the need for flaps or sutures. The basic concept involves the use of a 5- or 6-mm dermal tissue punch that permits access to the osteotomy site as well as to the sinus, when an elevation procedure is indicated. This technique allows for excellent esthetics in immediate load situations, forming a natural and predictable interdental papilla at the time of surgery. © 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:1635-1638, 2006
Single-Stage Implant Placement Using a Minimally Invasive Technique
to 0.5 to 1 mm above the gingival crest. Care is taken to avoid impingement on the soft tissues.
PROCEDURES
IMMEDIATE LOADING
This simple surgical technique obviates the need for raising a full-thickness flap and enables the surgeon to create a precise, stable, interdental papillae at the time of surgery. Under local anesthesia, a 5-mm disposable dermal tissue punch is used to make a circular incision through the attached gingiva and periosteum at the proposed implant site (Fig 1). A 6-mm punch is used if a wide body fixture is to be placed. The handle of the punch may be removed when access is limited. The gingival tissue core is removed and preserved in saline in the event that a free gingival graft is subsequently required in the procedure (Fig 2). The endosseous implant site is then prepared using the conventional sequence of implant drills and the implant is placed 2 to 4 mm apical to the gingival height depending on the soft tissue thickness and esthetic requirements. At this point an appropriate healing abutment is secured to the implant and should emerge
If the implant is to be used for immediate loading, an appropriate standard final abutment is torqued to 35 Ncm or until the implant begins to rotate (Fig 3). The abutments are generally retorqued to 35 Ncm following osseointegration, before the final impression, following an appropriate healing time. An acrylic coping previously fabricated on an implant analog in the laboratory serves as a base for a temporary crown. It is temporarily seated onto the abutment and a temporary restoration is usually fabricated within 24 hours (Fig 4). It is imperative that all temporary restorations are kept out of occlusion for 6 to 8 weeks. Patients
Received from the Department of Oral and Maxillofacial Surgery, Long Island Jewish Medical Center, New Hyde Park, NY. *Associate Attending. †Assistant Attending. ‡Chairman. Address correspondence and reprint requests to Dr Halpern: 70 Glen Cove Road, Suite 304, Roslyn Heights, NY 11577; e-mail: [email protected] © 2006 American Association of Oral and Maxillofacial Surgeons
0278-2391/06/6411-0011$32.00/0 doi:10.1016/j.joms.2006.04.043
FIGURE 1. Incisions made with tissue punch. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1635
1636
MISL WITH IMMEDIATE LOADING
FIGURE 2. Gingival cores removed. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
FIGURE 4. Prefabricated acrylic copings to be used as a foundation for temporary restorations. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
are typically instructed to chew on the contralateral side during that period of time (Fig 5). This procedure is indicated only in patients with an adequate width of attached gingiva. It should be considered in situations where the esthetics and interdental papilla morphology is of extreme importance. A predictable interdental papilla should result consistently. The technique is also advantageous for patients who present with a coagulopathy. Because a mucoperiosteal flap is not required, the risk of postoperative subperiosteal hematoma formation does not exist. Capillary oozing, although rare, is a potential complication in this patient population. In addition, the avoidance of mucoperiosteal flap reflection minimizes the potential for postoperative ischemic changes at the alveolar crest and averts early crestal bone loss, especially in thin ridges.
Postoperative edema is generally eliminated and patient discomfort is significantly diminished. Reduced healing time is observed because stage II gingival healing is not required, as opposed to a 2-stage technique. Finally, because the punches correspond to the implant sizes, they can be used to predict the exact distance between implants. This orientation is lost when a flap is raised. Minimally invasive implant procedures are contraindicated in patients exhibiting significant bony irregularities. This includes patients with thin or knifeedge ridges or those with significant depressions of the buccal alveolus (Table 1). MINIMALLY INVASIVE SINUS LIFT SURGERY
This procedure is a modification of a technique originally described in an article by Summers in
FIGURE 3. Implants placed with abutments torqued to 35 Ncm.
FIGURE 5. One week postoperatively: patient is wearing temporary crowns that were fabricated immediately following implant placement.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1637
HALPERN, HALPERN, AND RUGGIERO
Table 1. ADVANTAGES AND DISADVANTAGES OF MINIMALLY INVASIVE IMPLANT AND SINUS LIFT SURGERY
Advantages 1. Minimal swelling and postoperative discomfort 2. No risk of wound dehiscence 3. Sinus precautions less critical; pressure unlikely to disturb graft 4. Decreased operative time 5. Decreased potential for crestal bone resorption 6. Eliminates postoperative subperiosteal hematoma formation 7. Formation of stable and predictable interdental papilla
Disadvantages 1. Relies solely on tactile sense (clinical visualization not possible) 2. Significant perforation may require conversion to conventional technique 3. Osteotome and mallet use may be disconcerting to patient
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1994.1 Similar to conventional sinus lift surgery, this technique can be performed at the time of implant placement provided that there is a minimum of 3 to 4 mm of alveolar height. If there is not sufficient bone for initial stabilization, implants are typically placed 6 months following minimally invasive sinus lift surgery and the punch is sutured back into place. After administration of local anesthesia, a 5- or 6-mm dermal tissue punch is selected in accordance with the diameter of the implant that will be placed. The attached gingival core is removed, exposing the osteotomy site. A pilot hole is made to a depth that is approximately 2 mm inferior to the sinus floor. The correct depth is established both by radiographic analysis and by the use of calibrated instrumentation. The osteotomy is then widened to its final diameter using a series of incrementally larger twist drills. At each step, care is taken to avoid perforation of the Schneiderian membrane. Next, the widest diameter concave sinus osteotome is used to upfracture the floor of the maxillary sinus with a mallet (Fig 6). An attached stop is positioned to allow the osteotome to penetrate to a depth 2 mm
greater than that of the osteotomy. This allows the membrane to be lifted along with an attached disc of bone, minimizing the chance of perforation. Next, an approximately 8 ⫻ 8 mm resorbable membrane is introduced through the osteotomy and placed against the slightly elevated Schneiderian membrane. This serves to diffuse the pressure exerted on the membrane, minimizing the chance of perforation during the membrane elevation. Secondly, the resorbable membrane minimizes the possibility of graft extravasation if a small perforation exists. A 3- to 4-mm diameter convex (rounded) depth tool is then inserted into the osteotomy and the membrane is gently teased in every direction to allow elevation of a discrete portion of the Schneiderian membrane. An additional height of 5 to 10 mm can be achieved by this technique (Fig 7). A tent-like effect may be accomplished by lifting this localized region of the sinus membrane. When placing multiple adjacent implants, the sinus elevations can sometimes be inadvertently connected, allowing elevation of the entire inferior aspect of the sinus. It is important to rely on tactile sensation to
FIGURE 6. Calibrated osteotome demonstrating osteotomy depth of 6 mm.
FIGURE 7. After sinus elevation, depth gauge measures 12 mm.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
1638
MISL WITH IMMEDIATE LOADING
FIGURE 10. One year postinsertion with excellent gingival health. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
FIGURE 8. A, Periapical radiograph demonstrating excellent immediate bone fill around adjacent implants. B, Panoramic radiograph exhibiting implants and minimally invasive sinus lift in the immediate postoperative period. (Note the dome-shaped graft, which is typical.) Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
ensure that the membrane is not perforated at any point in the procedure. Resistance of the membrane must be delicately verified with use of the instrumentation at all times. If at any point, resistance is no longer appreciated, the technique is aborted and a conventional sinus lift is performed instead. The graft materials are now prepared and introduced through the osteotomy and into the elevated sinus cavity. The depth tool can be used to gently pack the graft superiorly. Alternately, the graft material may be inserted into a syringe and injected through the osteotomy site. It is helpful to mix a small amount of radiopaque graft material such as hydroxyl apatite to facilitate intraoperative and postoperative radiographic interpretation. The graft should exhibit a dome-shaped radiographic appearance (Fig 8). If a sinus perforation has occurred, it is usually represented by an irregular or nonrounded appearance of the bone graft on a postoperative radiograph. In this situation, the patient must adhere strictly to sinus precautions and success of the graft will be determined after 6 months (Figs 9, 10). The implant is now placed and an appropriate abutment is secured.
Discussion Although there are distinct advantages in using minimally invasive implant techniques, these procedures must be reserved for the highly experienced implant surgeon. Anatomic considerations are of extreme importance, especially in the esthetic zone. It is recommended that initial cases be anatomically straightforward. FIGURE 9. Periapical radiograph taken 6 months following minimally invasive implant and sinus surgery. Halpern, Halpern, and Ruggiero. MISL With Immediate Loading. J Oral Maxillofac Surg 2006.
Reference 1. Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compend Contin Educ Dent 15:152, 1994