The Efficacy of Different Techniques of Crestal Sinus Lifting to Place Dental Implant Into Prosterior Maxilla of Deficient Height: Randomised Clinical Trial
Phase: NA
Conditions: Maxillary Sinus Augmentation
Sponsor: Al-Azhar University

 
Placement of dental implant into posterior maxilla of deficient 
height applying different techniques  
A protocol submitted in Partial fulfillments of the requirements for Doctor   Degree 
in Oral Medicine, Periodontology, Oral Diagnosis and Oral Radiology 
BY 
Ahmed Halim Hassan Hashem  
BDS, 2011 faculty of dental medicine (Boys, Cairo) Al-Azhar University 
MSc D, 2018, faculty of dental medicine (Boys, Cairo) Al-Azhar University 
Ass. Lecturer, Department of Oral Medicine, Periodontology, Oral Diagnosis and 
Oral Radiology   
Department of Oral Medicine, Periodontology, Oral Diagnosis and Oral Radiology 
Faculty of Dental Medicine, Boys, Cairo 
 Al-Azhar University  
                                                      Supervisors 
Dr. Mohamed Fekry khedr                            Dr. Mahmoud Taha  Eldestawy  
Professor and head of department of                Ass.professor of oral medicine 
Oral Medicine, Periodontology                        periodontology, diagnosis and oral  
Oral Diagnosis and Oral Radiology              radiology,  Faculty of Dental Medicine 
Faculty of Dental Medicine                            (Boys, Cairo) Al-Azhar University.                          
(Boys, Cairo)  Al-Azhar University.                                                                                                                 
 
Faculty of Dental Medicine, (Boys, Cairo) 
 Al-Azhar University  
                                                      1441 H- 2019 G 

Introduction 
Treatment for edentulous patients is either removable complete or partial 
dentures. However, the use of removable dentures reduces taste perception and 
chewing capacity. (1) Dental implants have become a predictable treatment option 
for applicable patients. (2) The success rate of dental implants is associated with 
bone quality and quantity. (3)  
Most implant failures occur in the maxillary molar region with poor bone 
quality. (4,5) Other factors that may cause failure and difficulty in implant placement 
in the posterior maxilla are limited visibility, reduced inter-arch space, and sinus 
pneumatization due to atrophy of the alveolar ridge. In such cases, sinus 
augmentation is required to create sufficient vertical bone volume for implant 
placement with adequate stability. (6)  
Numerous methods have been proposed to treat a vertically deficient, 
edentulous, posterior maxillary ridge of poor bone quality. Traditionally, two 
techniques are employed, namely, the direct sinus elevation procedure using a 
lateral window approach and the indirect sinus elevation procedure using a crestal 
approach.(7) The lateral window approach has been reported to yield predictably 
favorable clinical results.(8) Nonetheless, the degree of invasiveness and patient 
morbidity, risk of severing the alveolar antral artery, risk of perforating the sinus 
membrane, delay in healing, and increased risk of postsurgical infection are major 
drawbacks of this procedure.(9) Conversely, the transcrestal indirect sinus elevation 
techniques are less invasive, less time-consuming, and reduce patient morbidity. 
However, the risk of membrane perforation may be as high as 24% due to lack of 
direct visibility and access. (10) 
 
 

Many surgical techniques have been developed to lift the sinus membrane 
indirectly, Summers in 1994 had described a technique; the Osteotome sinus Floor 
Elevation (OSFE) wherein an osteotome is used to fracture the sinus floor and to 
lift the sinus membrane, then grafting materials and implants can be inserted in the 
subantral space through the osteotomy site. (11)    This technique also is not without 
its drawbacks, namely, explosive force to the maxilla with poor control, 
unintentional displacement or fracture, membrane perforation, benign paroxysmal 
positional vertigo and patient discomfort. (12) 
Vercellotti et al presented the use of piezoelectric ultrasound as a new 
alternative in performing osteotomies in maxillary sinus lifting surgeries. (13) An 
important feature of the piezoelectric device is the selective cutting of only 
mineralized structures, without damaging soft tissues. (13, 14) No perforations of the 
Schneiderian membrane occurred during the piezoelectric preparation of the lateral 
antrostomies.(15) Piezosurgery was used to expose the maxillary sinus mucosa 
through the alveolar crest pathway in maxillary sinus floor elevation with hydraulic 
pressure for the graft and simultaneous implant placement. Some potential 
advantages of the method are reduced trauma and a reduced rate of sinus 
membrane perforation during surgery, no malleting, and shorter surgery time. 
Although all of these advantages, membrane perforation by high hydraulic pressure 
may happens. (16)   
An additional technique of bone instrumentation called osseous densification 
was introduced.  It is a biomechanical osteotomy preparation technique that 
preserves bone through a non-excavating drilling process utilizing specially 
designed drills with a tapered geometry and specially designed flutes to 
progressively expand the osteotomy while compacting bone into its walls and 
apex. In this manner, this bone densification method enhances implant primary 

stability due to an elastic “spring-back” effect created in the prepared osteotomy by 
the compaction autografting.(17) 
         In view of this, it would be of value to assess the effect of these different 
techniques which have been used in crestal sinus lifting compared to each other. 
Such comparison may aid toward further clarification of this, with aspect to 
overcome one of the most perplexing phenomena which is weak implant stability 
and low bone level associated with sinus pnuematization. 
 
 
 
 
 
 
 
 
 
 
 
 
 

Aim of study 
The aim of the present study is to evaluate and compare the efficacy of different 
techniques for implant placement in deficient posterior maxilla 
Objective 
 Evaluation of implant primary and secondary stability, bone gain and density 
using different techniques (Osteotome technique, Densah drills technique, 
Piezosurgery) in crestal sinus lifting. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Patients and Methods 
Study design  
Comparative study   
Study setting and population 
Twenty one patients will be included from those attending at the Department of 
Oral Medicine, Periodontology, Oral Diagnosis and Oral Radiology, Faculty of 
Dental Medicine,   (Boys ,Cairo) Al-Azhar University. 
Eligibility criteria of population:  
A. Inclusion criteria: 
 (1) Young and adult patients of both sexes.  
(2) Patients exhibit class C residual bone height according to ABC sinus 
augmentation classification.(18) 
(3) The edentulous ridges are covered with mucoperiosteum free from signs of 
inflammation, ulceration or scar tissue. 
(4) Remaining natural teeth have good periodontal tissue support. 
(5) Occlusion showing sufficient inter-arch and intra-arch spaces for future 
prosthesis. 
B. Exclusion criteria: 
(1) Patients with systemic conditions that could influence the outcome of  the 
therapy as: Pregnancy and Heavy smokers  
  (2) Patients with systemic disease that may affect bone quality. 
(3) Uncooperative patients 

(4) Patients with active periodontal disease. 
(5) Patients with neglected oral hygiene. 
(6) Patients with limited mouth opening and unfavorable intermaxillary arch 
space. 
(7) Patients with maxillary sinus disease or previous sinus surgery. 
     C. Ethical consideration: 
      All participants will be verbally informed about the nature of the study, and 
written informed consent will be collected for participation in the study.  
Sample size calculation 
According to analyses of the post- operative bone height (16, 19-20), sample size 
calculation was undertaken via G power version 3.1 statistical software based on 
the following pre-established parameters: an alpha-type error of 0.05, a power test 
of 0.95, a total sample of at least 21 subjects (7 subjects for each group) appeared 
to be sufficient. 
.                  
Intervention   
The patients will be randomly divided into 3 equal groups: 
1) Group 1(controlled group): 7 patients will be treated by traditional closed sinus 
lift (osteotome) with bone grafting (xenograft) and implant placement.  
2) Group 2:  7 patients will be treated by densah drills(Versah, Jackson, MI, USA) 
sinus lift with bone grafting (xenograft) and implant placement.    
3) Group 3: 7 patients will be treated by piezoelectric (Piezotome; Satelec) crestal 
sinus lift with bone grafting (xenograft) and implant placement.                              

Pre-surgical Therapy:  
       
Before the surgery, each patient will be given careful instructions in proper 
oral hygiene measures. A full mouth supragingival and subgingival scaling and 
root planning procedure will be performed under local anesthesia using ultrasonic 
as well as hand instrumentation.  
-Cone-beam computed tomography (CBCT) will be taken to estimate the height 
and width of the bone crest and bone density. 
Surgical Procedure: 
     Patients will be asked to use 0.12% chlorhexidine digluconate rinse, and 
Povidone iodine solution will be used to perform extraoral antisepsis. After 
administration of local anesthesia at the implant site, a full thickness flap will be 
elevated to expose the crest of alveolar ridge.  A pilot drill will be used to start the 
osteotomy preparation, which should be ended 1mm short of sinus floor.              
In group 1; (closed sinus lifting with Osteotome): The drills can be sequentially 
used to widen the osteotomy site to the same level (1 mm short of the sinus floor), 
an osteotome of diameter a little less than the planned implant body, will be 
inserted in the prepared osteotomy site and gently tapped to reach the same level, 
the osteotome will be tapped gently to fracture up the sinus floor.              
  In group 2; (closed sinus lifting with densah drills): Change the drill motor to 
reverse-densifying Mode (counterclockwise drill speed 800-1500 rpm with copious 
irrigation), Begin with the densah bur (2.5mm) until 1 mm short of the sinus floor, 
use the next wider Densah Bur (3.0mm) in the same mode and advance it into the 
previously created osteotomy with modulating pressure and a pumping motion. 
When feeling the haptic feedback of the drill reaching the dense sinus floor, 

modulate pressure with a gentle pumping motion to advance past the sinus floor in 
1 mm increments, the next wider densah drills advance in the osteotomy. 
In group 3: The initial osteotomy will be performed with a 2-mm twist drill to 
remove the cortical bone, then the intralift tips (Intralift; TKW1, TKW2, TKW3, 
TKW4, TKW5; Satelec). TKW1 to TKW4 tips have diameters of 1.35 mm, 2.1 
mm, 2.35 mm, and 2.8 mm and will be used to gradually widen the access canal to 
the Schneider membrane, gentle pressure will be applied on the tips to deepen the 
pathway, and a sterile spray (80 mL/min) cooling the tips to avoid heat injury.   
The TKW5 tip will be then inserted into the access canal, and the ultrasonic 
activation for 5 seconds with internal irrigation of 40 mL/min and repeated at 50 
mL/min and then 60 mL/min. The sinus membrane will be pushed upward by the 
hydraulic pressure, the floating of the sinus membrane will be evaluated, and then 
the TKW4 (Ø 2.8 mm) will be used again to widen the access canal to the sinus 
membrane before plugging the bone graft. 
 For all groups:  Clinical check for membrane still intact, blocking the patient’s 
nostrils and asking the patient to blow through his or her nose. Xenograft will be 
added as the grafting material and pushed to the sinus through the osteotomy site 
until the desired height of sinus elevation will be gained, the implant fixture will be 
inserted. Smart peg will be placed on implant and Ostell will be used to record 
ISQ. Cover screw will be placed on implant and flab will be sutured. Sutures will 
be removed after 10 days. 
 
 
 
 
 
 

Evaluation  
 Patients will be evaluated clinically and radio graphically as follows:  
1. Clinical parameter including: 
i. Implant primary stability will be evaluated by resonance frequency 
analysis (RFA) (21) at base line.  
ii. Implant secondary stability will be evaluated by resonance frequency 
analysis (RFA) (21) at 6 months (immediately before loading). 
2. Radiological assessment:  
i. 
Preoperative Cone beam computerized tomography (CBCT) 
will be taken for assessment of bone height and thickness 
(implant treatment plan) and at time of loading (6 months) to 
evaluate vertical bone gain, ridge width, crestal bone loss and 
bone density.  
 
 
 
 
 
 
 
 
 
 

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