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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Inadequate vertical bone dimension managed by indirect sinus grafting technique and simultaneous implant placement</title><author><name sortKey="Nandal, Shikha" sort="Nandal, Shikha" uniqKey="Nandal S" first="Shikha" last="Nandal">Shikha Nandal</name><affiliation><nlm:aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</nlm:aff></affiliation></author><author><name sortKey="Ghalaut, Pankaj" sort="Ghalaut, Pankaj" uniqKey="Ghalaut P" first="Pankaj" last="Ghalaut">Pankaj Ghalaut</name><affiliation><nlm:aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</nlm:aff></affiliation></author><author><name sortKey="Nandal, Deepika" sort="Nandal, Deepika" uniqKey="Nandal D" first="Deepika" last="Nandal">Deepika Nandal</name><affiliation><nlm:aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28356698</idno><idno type="pmc">5357917</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357917</idno><idno type="RBID">PMC:5357917</idno><idno type="doi">10.4103/0975-5950.201355</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">001F46</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001F46</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Inadequate vertical bone dimension managed by indirect sinus grafting technique and simultaneous implant placement</title><author><name sortKey="Nandal, Shikha" sort="Nandal, Shikha" uniqKey="Nandal S" first="Shikha" last="Nandal">Shikha Nandal</name><affiliation><nlm:aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</nlm:aff></affiliation></author><author><name sortKey="Ghalaut, Pankaj" sort="Ghalaut, Pankaj" uniqKey="Ghalaut P" first="Pankaj" last="Ghalaut">Pankaj Ghalaut</name><affiliation><nlm:aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</nlm:aff></affiliation></author><author><name sortKey="Nandal, Deepika" sort="Nandal, Deepika" uniqKey="Nandal D" first="Deepika" last="Nandal">Deepika Nandal</name><affiliation><nlm:aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</nlm:aff></affiliation></author></analytic><series><title level="j">National Journal of Maxillofacial Surgery</title><idno type="ISSN">0975-5950</idno><idno type="eISSN">2229-3418</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Implant placement into the posterior maxilla often creates a challenge due to inadequate bone height because of close sinus proximity. This article presents a case report of indirect sinus lift technique involving hydraulic pressure to elevate the floor of the maxillary sinus.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Sato, T" uniqKey="Sato T">T Sato</name></author><author><name sortKey="Hara, T" uniqKey="Hara T">T Hara</name></author><author><name sortKey="Mori, S" uniqKey="Mori S">S Mori</name></author><author><name sortKey="Shirai, H" uniqKey="Shirai H">H Shirai</name></author><author><name sortKey="Minagi, S" uniqKey="Minagi S">S Minagi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chanavaz, M" uniqKey="Chanavaz M">M Chanavaz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ulm, Cw" uniqKey="Ulm C">CW Ulm</name></author><author><name sortKey="Solar, P" uniqKey="Solar P">P Solar</name></author><author><name sortKey="Krennmair, G" uniqKey="Krennmair G">G Krennmair</name></author><author><name sortKey="Matejka, M" uniqKey="Matejka M">M Matejka</name></author><author><name sortKey="Watzek, G" uniqKey="Watzek G">G Watzek</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Albrektsson, T" uniqKey="Albrektsson T">T Albrektsson</name></author><author><name sortKey="Dahl, E" uniqKey="Dahl E">E Dahl</name></author><author><name sortKey="Enbom, L" uniqKey="Enbom L">L Enbom</name></author><author><name sortKey="Engevall, S" uniqKey="Engevall S">S Engevall</name></author><author><name sortKey="Engquist, B" uniqKey="Engquist B">B Engquist</name></author><author><name sortKey="Eriksson, Ar" uniqKey="Eriksson A">AR Eriksson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tan, Wc" uniqKey="Tan W">WC Tan</name></author><author><name sortKey="Lang, Np" uniqKey="Lang N">NP Lang</name></author><author><name sortKey="Zwahlen, M" uniqKey="Zwahlen M">M Zwahlen</name></author><author><name sortKey="Pjetursson, Be" uniqKey="Pjetursson B">BE Pjetursson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Esposito, M" uniqKey="Esposito M">M Esposito</name></author><author><name sortKey="Grusovin, Mg" uniqKey="Grusovin M">MG Grusovin</name></author><author><name sortKey="Rees, J" uniqKey="Rees J">J Rees</name></author><author><name sortKey="Karasoulos, D" uniqKey="Karasoulos D">D Karasoulos</name></author><author><name sortKey="Felice, P" uniqKey="Felice P">P Felice</name></author><author><name sortKey="Alissa, R" uniqKey="Alissa R">R Alissa</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sotirakis, Eg" uniqKey="Sotirakis E">EG Sotirakis</name></author><author><name sortKey="Gonshor, A" uniqKey="Gonshor A">A Gonshor</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hernandez Alfaro, F" uniqKey="Hernandez Alfaro F">F Hernández-Alfaro</name></author><author><name sortKey="Torradeflot, Mm" uniqKey="Torradeflot M">MM Torradeflot</name></author><author><name sortKey="Marti, C" uniqKey="Marti C">C Marti</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nandal, S" uniqKey="Nandal S">S Nandal</name></author><author><name sortKey="Ghalaut, P" uniqKey="Ghalaut P">P Ghalaut</name></author><author><name sortKey="Shekhawat, H" uniqKey="Shekhawat H">H Shekhawat</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chugh, A" uniqKey="Chugh A">A Chugh</name></author><author><name sortKey="Nandal, S" uniqKey="Nandal S">S Nandal</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nandal, S" uniqKey="Nandal S">S Nandal</name></author><author><name sortKey="Ghalaut" uniqKey="Ghalaut">Ghalaut</name></author><author><name sortKey="Shekhawat, H" uniqKey="Shekhawat H">H Shekhawat</name></author><author><name sortKey="Nagar, P" uniqKey="Nagar P">P Nagar</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Natl J Maxillofac Surg</journal-id><journal-id journal-id-type="iso-abbrev">Natl J Maxillofac Surg</journal-id><journal-id journal-id-type="publisher-id">NJMS</journal-id><journal-title-group><journal-title>National Journal of Maxillofacial Surgery</journal-title></journal-title-group><issn pub-type="ppub">0975-5950</issn><issn pub-type="epub">2229-3418</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28356698</article-id><article-id pub-id-type="pmc">5357917</article-id><article-id pub-id-type="publisher-id">NJMS-7-213</article-id><article-id pub-id-type="doi">10.4103/0975-5950.201355</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Inadequate vertical bone dimension managed by indirect sinus grafting technique and simultaneous implant placement</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Nandal</surname><given-names>Shikha</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Ghalaut</surname><given-names>Pankaj</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Nandal</surname><given-names>Deepika</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib></contrib-group><aff id="aff1">Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Shikha Nandal, H. No. 159/12, Gulmarg Ice Cream Factory, Delhi Byepass Road, Rohtak - 124 001, Haryana, India. E-mail: <email xlink:href="drsnmds@gmail.com">drsnmds@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jul-Dec</season><year>2016</year></pub-date><volume>7</volume><issue>2</issue><fpage>213</fpage><lpage>216</lpage><permissions><copyright-statement>Copyright: © 2017 National Journal of Maxillofacial Surgery</copyright-statement><copyright-year>2017</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.</license-p></license></permissions><abstract><p>Implant placement into the posterior maxilla often creates a challenge due to inadequate bone height because of close sinus proximity. This article presents a case report of indirect sinus lift technique involving hydraulic pressure to elevate the floor of the maxillary sinus.</p></abstract><kwd-group><title>Key words</title><kwd>Bone graft</kwd><kwd>hydraulic pressure</kwd><kwd>implant</kwd><kwd>sinus lift</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>I<sc>NTRODUCTION</sc></title><p>Once the loss of the natural dentition occurs, the lack of occlusal forces transferred to the alveolar bone activates a series of bone remodeling processes that cause pressure threshold-regulated bone atrophy.[<xref rid="ref1" ref-type="bibr">1</xref>] Apart from the resorption of the buccal plate of the residual ridge after tooth extraction, increased osteoclastic activity of the periosteum of the maxillary sinus floor leads to the enlargement of the sinus. This pneumatization occurs at the expense of alveolar ridge height beneath the maxillary sinus.[<xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref>] Inadequate height, width, and density of the alveolar process are considered some of the common limiting factors for dental implant placements in the posterior maxillary regions. Compromised quality and quantity of bone in the posterior edentulous maxilla can adversely affect the clinical outcomes of dental implant treatments with higher incidences of implant failure rates and complications.[<xref rid="ref4" ref-type="bibr">4</xref>]</p><p>Various intra-crestal sinus lift techniques include the use of osteotomes (summers – and its multiple variations), balloon lift, hydraulic sinus condensing technique (Chen and Cha) and motor-driven drilling systems.</p><p>The surgical approach, known as sinus floor elevation (SFE), can dramatically increase the height of bone available for implant placement. In general, two main SFE approaches for dental implant placement can be used – indirect and direct.</p><p>Indirect sinus grafting technique a transalveolar approach can be utilized to condense bone grafting materials beneath the Schneiderian membrane in the presence of at least 5 mm of residual bone, this approach can gain approximately 3–5.0 mm in height within the sinus with a simultaneous implant placement option.[<xref rid="ref5" ref-type="bibr">5</xref>]</p><p>Direct sinus grafting technique, sinus lifting through a lateral window approach, is recommended as the treatment of choice where the height of residual bone is <5.0 mm. This approach provides clinical outcomes of increased height of bone >5.0 mm but usually requires a 6–9 months delayed staged approach of implant placement.[<xref rid="ref6" ref-type="bibr">6</xref>]</p><p>This article presents a case report of indirect sinus lift technique involving hydraulic pressure to elevate the floor of the maxillary sinus.</p></sec><sec id="sec1-2"><title>C<sc>ASE</sc> R<sc>EPORT</sc></title><p>A 35-year-old male patient reported to the Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak for the replacement of his missing tooth [<xref ref-type="fig" rid="F1">Figure 1</xref>]. After a thorough history taking, clinical and radiographic examination, the treatment options were explained to the patient, and it was decided to place an implant with respect to missing 16. Since the available bone height in this region was only 5 mm, hence, it was decided to perform an indirect sinus lift and bone grafting with simultaneous implant placement.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Preoperative intra-oral view (missing #16)</p></caption><graphic xlink:href="NJMS-7-213-g001"></graphic></fig><sec id="sec2-1"><title>Procedure</title><p><list list-type="bullet"><list-item><p>The crestal approach sinus kit (CAS-KIT, Hiossen) was used in this case to provide a convenient sinus grafting surgery and to enhance maximum safety while easily providing the lift of the membrane in a controlled manner for the maxillary sinus [<xref ref-type="fig" rid="F2">Figure 2</xref>]</p></list-item><list-item><p>After anesthetizing the patient, the crestal incision was given [<xref ref-type="fig" rid="F3">Figure 3</xref>] and flap was reflected</p></list-item><list-item><p>The CAS-drills were used in a sequential manner to prepare the osteotomy site. Due to the inverse conical drill design of the CAS-KIT, the conical bone chips in between the cutting blades create an auto-lifting function to elevate the membrane safely. The atraumatic design of the drill tip allows the user to perform sinus surgery even if the sinus floor is flat, incline, or septum. The unique stopper system also prevents membrane perforation and excessive drill penetration [<xref ref-type="fig" rid="F4">Figure 4</xref>]. Thus, progression of 1.0 mm increments could be accomplished until penetration was achieved in a controlled manner</p></list-item><list-item><p>The hydraulic lift system was used to elevate the sinus membrane by hydraulic pressure of saline injected through a syringe [Figures <xref ref-type="fig" rid="F5">5</xref> and <xref ref-type="fig" rid="F6">6</xref>]</p></list-item><list-item><p>The bone carrier was used to deliver bone graft material (Ostofom) [<xref ref-type="fig" rid="F7">Figure 7</xref>] into the space created by sinus lift [Figures <xref ref-type="fig" rid="F8">8</xref> and <xref ref-type="fig" rid="F9">9</xref>]. Graft material required is in direct proportion to the amount of fluid used to inflate the balloon: 1cc of fluid will require 1cc of graft material</p></list-item><list-item><p>After delivering the bone graft material in the osteotomy site, the bone condenser [<xref ref-type="fig" rid="F10">Figure 10</xref>] was used to compact the bone material. Using a slow speed (50 rpm), the bone spreader was used to evenly spread the material within the cavity. This step was repeated until the desired height and volume of the sinus cavity was filled and was ready for implant insertion. This was followed by placement of Implant (3.75 mm × 10 mm, Osstem) and the site was sutured [<xref ref-type="fig" rid="F11">Figure 11</xref>].</p></list-item></list></p><fig id="F2" position="float"><label>Figure 2</label><caption><p>Crestal approach sinus kit</p></caption><graphic xlink:href="NJMS-7-213-g002"></graphic></fig><fig id="F3" position="float"><label>Figure 3</label><caption><p>Crestal incision</p></caption><graphic xlink:href="NJMS-7-213-g003"></graphic></fig><fig id="F4" position="float"><label>Figure 4</label><caption><p>The unique stopper system of crestal approach sinus kit</p></caption><graphic xlink:href="NJMS-7-213-g004"></graphic></fig><fig id="F5" position="float"><label>Figure 5</label><caption><p>Hydraulic lifter securely fitted in osteotomy site</p></caption><graphic xlink:href="NJMS-7-213-g005"></graphic></fig><fig id="F6" position="float"><label>Figure 6</label><caption><p>Hydraulic sinus lift by injecting saline</p></caption><graphic xlink:href="NJMS-7-213-g006"></graphic></fig><fig id="F7" position="float"><label>Figure 7</label><caption><p>Bone graft material</p></caption><graphic xlink:href="NJMS-7-213-g007"></graphic></fig><fig id="F8" position="float"><label>Figure 8</label><caption><p>Bone carrier being loaded with bone graft material</p></caption><graphic xlink:href="NJMS-7-213-g008"></graphic></fig><fig id="F9" position="float"><label>Figure 9</label><caption><p>Bone carrier delivering bone graft into the space created by sinus-lift</p></caption><graphic xlink:href="NJMS-7-213-g009"></graphic></fig><fig id="F10" position="float"><label>Figure 10</label><caption><p>Bone spreader</p></caption><graphic xlink:href="NJMS-7-213-g010"></graphic></fig><fig id="F11" position="float"><label>Figure 11</label><caption><p>Postoperative orthopantomography (implant placed)</p></caption><graphic xlink:href="NJMS-7-213-g011"></graphic></fig></sec></sec><sec sec-type="discussion" id="sec1-3"><title>D<sc>ISCUSSION</sc></title><p>Sotirakis and Gonshor[<xref rid="ref7" ref-type="bibr">7</xref>] proposed an elevation of the maxillary sinus floor with hydraulic pressure. This technique involves elevation of the sinus floor by injecting normal saline solution under hydraulic pressure beneath the Schneiderian membrane with a suitably fitted syringe. This procedure achieves simultaneous detachment and elevation of the sinus membrane.</p><p>The indirect sinus elevation technique is less invasive, less time consuming with decreased postoperative patient morbidity, and discomfort. Lack of direct visualization of the membrane and the use of osteotomes may lead to a risk of membrane perforation as high as 26%.[<xref rid="ref8" ref-type="bibr">8</xref>]</p><p>Hiossen's CAS-KIT makes the sinus lift procedure easy and predictable, combining the advantage of high volume bone placement of the lateral window approach, with the simplicity of the crestal approach without any fear of membrane perforation. Use of non-invasive technique minimizes the crestal bone loss, which is otherwise inevitable and is upto 0.5 mm in first 6 months of implant surgery[<xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref10" ref-type="bibr">10</xref>] and hence ensuring the long term implant success.[<xref rid="ref11" ref-type="bibr">11</xref>]</p></sec><sec sec-type="conclusions" id="sec1-4"><title>C<sc>ONCLUSION</sc></title><p>This article presents a novel technique for indirect sinus elevation using the CAS-KIT followed by bone graft and simultaneous implant placement.</p><sec id="sec2-2"><title>Declaration of patient consent</title><p>The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. 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