The Crestal Core Sinus Elevation: An Alternative to the Lateral Window.
Periapical radiograph reveals 4 mm subantral bone #3 and 7 mm subantral bone #4. Tooth #2 will be extracted and tooth #5 will be retained temporarily to support a fixed prosthesis along with #6
At site #3, a 5 mm diameter crestal core prepped to depth of 3 mm, at site #4, a 4 mm diameter core has been prepped to a depth of 6 mm. This is the working depth at both sites, 1 mm coronal to the sinus floor.
The 5 mm diameter core at site #3 has been imploded to a depth of 4 mm. The 4 x 6 mm core at site #4 has been removed from the osteotomy and the sinus floor infractured directly with an osteotome.
At site #3, the osteotomy was grafted with mineralized freeze-dried bone (MFDB). At site #4, the sinus was grafted with MFDB and the 4 x 6 mm core was replaced in the osteotomy. Both sites were covered with an Osseoguard membrane and the tissues primarily closed.
The immediate postoperative radiograph clearly shows the apically displaced core at #3 and the sinus graft at #4.
5 months later, the graft has consolidated and now there is approximately 8 to 10 mm of subantral bone.
The ridge has completely healed with no evidence of either osteotomy.
Placement of a wide neck Straumann implant at #3 and a regular neck Straumann at #4.
Immediate post placement radiograph shows 4.8 x 10 mm implant #3 and 4.1 x 10 mm implant #4.
3.5 months later #s 3 and 4 support the temporary prosthesis and #5 extracted with immediate implant placement (3.3 x 10 mm regular-neck Straumann) with osteotome-mediated sinus floor elevation (OMSFE) using platelet-rich fibrin (PRF) plugs. An Osstell pin was inserted into the implant to measure implant stability quotient (ISQ) at 78.
BioOss placed in facial gap #5
Graft covered with BioGide and PRF membrane. PRF membrane is shown.
Postoperative radiograph shows a 3.3 x 10 mm regular neck Straumann immediate implant.
8 weeks later, the patient was referred for a splinted implant-supported restoration #s 3,4 & 5.
( Restorative Dentistry-Dr David Sirois, New York, NY)
© 2008 Journal of Implant and Advanced Clinical Dentistry. Privacy Policy | Terms & Conditions
Comments
Short Implants
I am not trying to plug a particular implant manufacturer but I have found that the BICON 5X8 to be a work horse in my practice. In particular the posterior mand and max. The engineering behind this implant lends it to use in sites without a lot of vertical bone height and bruxers. In fact, I have not had any failures with said implant.
Narrow BTI and Extra-Wide Short Megagen add VERSATILITY!
As was mentioned previously on this board by Dr. Salama and others, short implants and narrow implants are becoming a routine part of our toolbox to treat specific situations with less surgical trauma, healing time and cost to the patient.
In my hands the BTI TINY and the Megagen Extra wide and short options are very unique and have worked very well in narrow ridges and spaces for BTI and for Molar areas, below the Sinus and above the mandibular nerve for Megagen. Other more popular systems do not provide you with this versatility.
Sam
CCE
The incorporation of the core osteotome into the procedure to prepare the apical 1 to 2 mm of subantral bone reduces the risk of perforation tremendously. One should not attempt to elevate the core 15 mm into the sinus and it is certainly easier to perform in sinus floors that are 8 to 13 mm wide rather than a broad flat sinus where a lateral approach is indicated.
Why not post a video on XP??
Dr. Toffler; It would be great if you could put a video of this technique onto www.dentalxp.com. I am a Premium member of this site and it is fantastic. Makes it much easier to learn from videos of a technique than from static images in a powerpoint or an article?? Just inquiring.
Sam
Dr. Toffler Read your article But...........
Dr. Toffler well written article and very innovative technique but isnt this a pretty risky procedure?
Isnt there a high perforation rate?
Tom
Crestal Core Sinus Elevation
Nice case and creative thinking!
CCE
Thank you Richard, appreciate it.
Always impressed with your suggestions, analysis and clinical experience
Best
Michael
splinted implant case
xrays seem to indicate that 3,4,and 5 are individual as the metal framework is not contiguous. I have not seen crowns splinted by porcelain alone. Are they in fact splinted and what is the technological base if so? nice presentation and well documented very instructional Charles
Crestal Core Sinus lift: Can you do this at extraction
Very nice case. Can you do this technique at extraction to site develop lets say a number 3 or 14 site?
Maria
Impressive Case by Dr. Toffler: When would you do this?
Dr. Toffler excellent well documented case. However, looking at the radiograph this is a pretty predictable lateral window sinus lift. Why would you choose the crestal core (which to me looks complicated) over a lateral window with a piezo?
Thanks
Chace
Dr. Toffler Bravo and a question
Well documented case. What is your indication for tapping up the core vs. removing and replacing the core??
Dr. Toffler Great case, how do you handle perfs in your practice
Dr. Toffler Great case, how do you handle perfs in your practice?
This technique could result in a high degree of tears so I have some concerns on how to avoid this complication.
Perfs
Thank you for your comments Logan
By using an instrument called a core osteotome to infracture the sinus floor along the periphery of the crestal core, perforations are minimized.The technique and instrumentation will be featured in the July issue of JIACD. A large perf with CCE requires elevation of a lateral window or cessation of the procedure and a return in 3 to 5 months. All of my perfs for lateral windows are treated with platelet rich fibrin and a collagen membrane.
DR TOFFLER VERY WILD CASE AND QUESTIONS
I got tight just looking at this case. WOW.
Very impressive skills.
Will you ever place an implant at the same time as a crestal core case? Or is it always two staged?
What is your indications for placing and implant at the same time?
Staged implant placement
CCE is always a staged procedure. The smallest core has an outer dimension of 6mm allowing the use of only wide, Megagen-like implant. I have never done it as a simultaneous procedure as I would have to elevate the core too far into the sinus, increasing the risk for a good size perf which would then require a lateral window to manage. A clear understanding of the limitations to a crestal approach using osteotomes is essential otherwise you will experience alot of perfs and have an increased incidence of infection. These same limitations might not apply to a balloon-mediated crestal approach which could be used to treat more atrophic cases without a lateral window.Thank you also for your kind comments
Michael
BTI Short Implants article and a question for Dr. S and Toffler
Dr. S,
Very timely comments in that this months JIACD issue had an article on BTI short implants:
http://www.nxtbook.com/nxtbooks/specops/jiacd_201006/#/20
I myself have never used a short implant system. I fear placing anything less then 11mm for risk of failure. There are many articles out there to show implants 10 mm or less leads to failure.
My question to you and the forum is:
When do you feel comfortable placing short implants? What clinical parameters must be present? Amount of native bone, Biotype etc?
Is there 1 system that is more benefical over the other?
For Dr. Toffler. Impressive case, how do you avoid perfing the membrane with the trephine. Is there any precautions you take?
Thanks,
Shaz.
Membrane perf with CCE
Dear Shaz
There is an instrument called a core osteotome which is used to prepare close to the sinus membrane as a trephine will always give you a large tear in the membrane. In an earlier post there were publications mentioned in 2002 and 2004 that show the technique, but in next month's JIACD there will be a featured article and many photos to explain.Thanks for your interest.
Michael
Crestal Core Elevation
Dear Brooke and OMFS Guy
Thank you for your kind comments.
In next month's issue of JIACD I will have an article that reviews the technique as well as its indications and complications. It will also show dedicated instrumentation to make the procedure easier. You are correct, it is not a simpler procedure but a less invasive alternative to a lateral approach at sites that meet the specfic requirements.
CCE is traditionally performed at maxillary premolar and molar implant sites with a residual subantral bone height (RSBH) of 3 to 6 mm and a residual ridge width (RRW) ≥ 7mm to retain at least 0.5 to 1.0 mm of crestal bone facial and palatal to 5 mm or 6mm core preps which have external diameters of 6 mm and 7 mm respectively. . If multiple sites are treated, then sites with as little as 2 mm RSBH may be treated but I prefer a lateral window approach here. CCE is especially useful a single tooth sites where a lateral window is technically more difficult due to restricted access, limited size of the antrostomy, increased thickness of the lateral sinus wall and the presence of adjacent teeth.
Also note that the extent of elevation with CCE is usually limited by the height of the preexisting crestal bone unless the core(s) are intruded well beyond the level of the original sinus floor which increases the risk of membrane laceration.
For an older review please see:
1. Practical Procedures and Esthetic Dentistry 2002;14(9):767-774.
2. New York State Dental Journal November 2004 - reviews osteotome procedures
Hope this info is helpful
Michael
How about 3 splinted SHORT implants here instead of Sinus Lift?
Michael;
Nice case and nice to see you in Boston at the Quintescence Meeting this weekend. I like the creative surgical approach and have performed it myself.
BUT, in light of some of the NEW info regarding SHORT implants, would you or anyone here in the Forum be comfortable or confident in approaching this case with 2 SHORT implants splinted together with the standard length at the extraction site of #5??
I have recently been placing some BTI and Megagen SHORT implants to avoid Sinus grafts and they have performed very well especially when splinted together in a series. In as little as 4mm of Bone we have options that may be less expensive, less risky, and involve less time for the patient. I have seen and personally spoken with Eduardo Anitua and Samuel Lee who have many cases and experience with these approaches with extremely high success rates.
Eduardo recently published 5 year data with 99% success rate!!
Anyway, your case seems to fall into this category where it is "on the fence" as to which way to go. Obviously, your approach worked and is classically performed BUT wouldn't a less complicated approach be more attractive to the patients when less time, risk and cost are involved??
4mm or less Bone at the crest with substantial vertical ridge loss and a probable poor crown-implant ratio would be a clear indication for Sinus Augmentation.
4mm or more would be an area of MANY Options.
regards
Dr. S
couldn´t agree more. José
couldn´t agree more.
José Rosa
www.jose-rosa.com.pt
Short Implants: A viable treatment option.
Maurice
Nice to see you in Boston as well. I must compliment you on your willingness to share, your energy and commitment to what we do.......That said;
I could not agree with you more on the value of short implants. I have had great success with Straumann 6 to 8 mm implants in the atrophic mandible where vertical augmentation is a great challenge and nerve lateralization is too great a risk. I have also used the wide Straumann 8s and Neoss 5.5 x 9mm implants in the posterior maxilla with great predictability avoiding lifts or at least minimizing them (both lateral and crestal). In addition by utilizing PRF as my sole graft material for osteotome lifts and taking Osstell measurements I believe I can more predictably treat sites with 4 mm of subantral bone with an osteotome and simultaneous placement of an 8 mm wide diameter implant. An economically-challenged environment and an older patient population make less invasive alternatives so much more attractive. There are too many potential implant patients who go untreated because they are not offered proven alternatives that are less invasive and less costly. I wrote about this in Inside Dentistry in January of 2009. There is a great presentation in here somewhere (as I have repeatedly stated to Straumann) and alot of patients just dying to be treated with less cost and less pain.
Thanks for sharing your thoughts Maurice
All the Best
Michael
Dr Toffler very impressive case and a question
Very impressive and well documented case. My question is as an oral surgeon I would tend to do these in a open sinus lift fashion.
What is the advantage of doing this technique over a lateral window sinus lift?
Dr. Toffler excellent case: A sinus question for you?
Dear Dr. Toffler,
This case is well documented and shows some great results. The technique looks very difficult to me. I dont know if I have the surgical ability to pull this off.
When do you decide to do the crestal core lift vs a osteotome lift vs a lateral window?
What complications have you seen with the crestal core?
Do you offer any training courses in this technique?
Brooke.