Sie sind auf Seite 1von 8

CASE SERIES 145

pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
te n ot

n
ss e n c e
fo r
Angelo Sisti, Luigi Canullo, Maria Pia Mottola, Giuliano Iannello

A case series on crestal sinus elevation with


rotary instruments

Angelo Sisti, DDS


Private Practice, Piacenza,
Italy

Luigi Canullo, DDS


PhD
Key words dental implant, sinus oor elevation Private Practice, Rome, Italy

Maria Pia Mottola


Purpose: This case series aimed to evaluate the clinical outcome of a crestal approach technique in Private Practice, Novara,
Italy
sinus oor elevation surgery with insertion of an alloplastic material.
Material and methods: A total of 50 edentulous patients received 64 implants and sinus oor eleva- Giuliano Iannello
Data Analyst, Rome, Italy
tion in posterior maxillae with residual crestal height 1.2 to 9.8 mm, and larger than 7 mm in width.
Drilling perforation was performed until the sinus oor was felt. The sinus mucosa was then lifted. Correspondence to:
Luigi Canullo
Hydroxyapatite granules were placed and implants were immediately inserted. Three months later, Via Nizza, 46
denitive crowns were cemented and patients were followed up for 18 months. Outcome measures 00198 Rome, Italy
Tel/Fax +39068411980
were implant failures, complications and radiographic bone height gain measured 18 months after Email:
prosthetic loading. luigicanullo@yahoo.com

Results: No patient dropped out and all implants were successfully osseointegrated. Only minimal
postoperative patient discomfort was reported. Only one complication occurred: a minor perforation
of the sinus membrane with no negative consequences. At the time of implant insertion, the residual
bone height mean value was 6.20 mm (2.22). After surgery and at the last follow-up, the mean
height of bone was 15.26 (3.19) and 15.40 mm (4.21), respectively.
Conclusion: The procedure was able to obtain sinus elevation and implant osseointegration.

Conict-of-interest statement: No free materials were received and the authors do not have nancial
interest, either directly or indirectly, in the products listed in the study.

remaining crestal height2. The lateral access tech-


Introduction
nique offers a high possibility of success3, which
Sinus oor elevation is a reliable technique that has contributed to its frequent use in sinus oor
allows implant insertion in the maxillary posterior elevation surgery in spite of some disadvantages
region with either high pneumatisation or low for the patients. An implant survival rate of 96% at
crestal volume1. Several surgical techniques for 36 months regarding elevation with an osteotome
sinus elevation have been studied in the literature, technique was calculated by a systematic review of
with a lateral or crestal approach, based on the the literature4.

Eur J Oral Implantol 2011;4(2):145152


146 Sisti et al Crestal sinus elevation with rotary instruments
pyrig
No Co

ht
t fo
rP

by N
As well as the lateral access, Tatum studied a ranging from 85.7 to 100%2,15-18. However, ubsome

Q ui
li a
sinus crestal access using osteotomes and a direct clinical protocols recommend the lateral approachcin ti
tein cases of on
ot

n
lifting of the sinus mucosa with curettes5. The OSFE cases of residual bone height <5 mm or ss e n c e
fo r
(Osteotome Sinus Floor Elevation) and BAOSFE elevation >5 mm because of a high risk of mucosa
(Bone Added Osteotome Sinus Floor Elevation) sinus laceration3,18-20.
elevation techniques with crestal access were later The aim of the present study was to evaluate,
introduced6,7. Describing these procedures, Sum- in a prospective case series, the clinical outcome of
mers highlighted the importance of avoiding direct a crestal sinus lift technique using rotatory instru-
contact between tools and sinus mucosa, which ments.
must be dislocated with the interposition of compact
crestal bone and/or biomaterials pushed in an apical
direction. In 1998, Bruschi et al8 presented the LMSF Materials and methods
(Localized Management of Sinus Floor) procedure:
crestal access with a partial thickness ap allowing The present study was designed as a prospective
sinus oor elevation as well as simultaneous horizon- case series on maxillary sinus elevation with a crestal
tal expansion of the edentulous crest using manual approach. From June 2007 to October 2008, in three
tools and a hammer. Successively, similar techniques Italian private dental practices (Piacenza, Novara and
were presented, utilising crestal access, osteotomes Rome), 50 consecutive patients were enrolled in this
and mallet to obtain mucosa dislocation and sinus study. They all presented with partially edentulous
oor elevation9-11. Cosci in 199812 rst described posterior maxilla and a residual crestal height rang-
rotating tools specially designed for the sinus eleva- ing between 1.2 and 9.8 mm with a width more than
tion procedure with crestal access: lifting burs with 7 mm. An elevation technique was required to insert
a at extremity 1 to 8 mm long. In this technique, implant(s) long enough to exceed the coronal/implant
the sinus cortical bone is reached with a trephine ratio of 1:1 for long-term stability21. All patients were
and perforated using a lifting bur 1 mm longer than in general good health. Exclusion criteria were:
the depth reached by the core bur. Mucosa is there- untreated periodontitis
fore exposed and elevated with an osteotome that systemic contraindications to implant surgery
pushes biomaterial. acute or chronic sinusitis
The modied trephine/osteotome approach patients with a history of sinus oor elevation
allowed mucosa elevation using an osteotome to smokers (>10 cigarettes/day)
dislocate the bone cylinder obtained with a trephine pregnant or lactating women
carried 1 to 2 mm from the sinus oor. The authors patients treated or under treatment with intra-
concluded that implant length should not exceed venous or oral bisphosphonate therapy.
double the size of the residual crest13,14.
These techniques were the rst to utilise rotating All patients were informed about the procedure
tools in the sinus oor elevation procedure. In the and signed a consent form. The present study was
literature, the reported mean elevation height using performed following the principles outlined in the
a crestal approach is around 5 mm 3. Declaration of Helsinki on experimentation involving
Additionally, all crestal access techniques are human subjects.
recommended to be adopted in combination with
immediate implant insertion after sinus elevation,
Surgical protocol
when residual bone height is 5 to 6 mm, because of
a lack of implant primary stability9. However, Caniz- To evaluate the possibility of sinus lift and immedi-
zaro et al15 and Checchi et al16 successfully adopted ate implant insertion, the crestal height at poten-
a crestal approach even with a residual bone height tial implant sites was measured in all patients using
lower than 6 mm. orthopantomograms and standardised periapical
Finally, crestal techniques, when residual crestal radiographs with the paralleling technique and a
bone is higher than 5 mm, report implant success radiographic stent.

Eur J Oral Implantol 2011;4(2):145152


Sisti et al Crestal sinus elevation with rotary instruments 147
pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
te otn

n
ss e n c e
fo r

Fig 1 Schematic drawing showing the initial implant site Fig 2 Schematic drawing showing the use of a 3 mm
preparation with a 2 mm bur up to 2 mm from the sinus chamfered/rounded bur at sinus oor level.
oor.

Fig 3 Schematic drawing showing the abrasion of the sinus Fig 4 Schematic drawing showing the elevation of the
oor with a 3 mm rounded bur. mucosa and osteotomy regularisation with a 3 mm
rounded bur.

Before surgical procedures, a full-mouth profes- 2. Penetration until sinus oor level using a 3 mm
sional prophylaxis appointment was scheduled. All chamfered/rounded bur (Sweden & Martina,
patients received 1 g amoxicillin and clavulanic acid Due Carrare, Padua, Italy) at 600 rpm under
(Neo Duplamox, Procter & Gamble, Rome, Italy) profuse irrigation, controlled by stops with 1 mm
2 hours before surgery and 2g/day for 6 days22. increments (Fig 2).
A non-steroidal anti-inammatory drug (Ketopro- 3. Radiographic control of reached depth.
fene, 80 mg, Oki, Domp, LAquila, Italy) was given 4. Abrasion of sinus oor with a 3 mm rounded
1 hour prior surgery. bur at 250 rpm under profuse irrigation, control-
After local anaesthesia (articaine with adrenaline led by stops with 1 mm increments (Fig 3).
1:100,000), a papilla preservation paracrestal ap 5. Manual check of the sinus membrane integrity
with palatal approach was raised. Buccal bone was with a rounded probe for implant therapy.
not exposed to maintain protection and periosteal 6. Elevation of the mucosa and osteotomy regu-
vascularisation of sinus lateral walls. Rotary tools larisation with a 3 mm rounded bur at
were used in the following way: 600 rpm, used 1 mm deeper than the previous
1. Preparation with a 2 mm drill up to 2 mm from drill (Fig 4).
the sinus oor, following radiographic indica- 7. Insertion of an equine-collagen sponge (GINGI-
tions. In cases of a crest height less than 5 to STAT, GabaVebas, Milan, Italy) in the osteotomy
6 mm, this step was skipped (Fig 1). site using a 3 mm bone carrier.

Eur J Oral Implantol 2011;4(2):145152


148 Sisti et al Crestal sinus elevation with rotary instruments
pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
te ot n

n
ss e n c e
fo r

Fig 5 Schematic drawing showing the sinus elevation using Fig 6 Schematic drawing showing implant insertion.
graft material compacted with a dedicated bone plugger.

8. Sinus mucosa elevation obtained by plugging Outcome measures


synthetic resorbable hydroxyapatite granules
(Sintlife 600900 m, Finceramica, Faenza, Implant failure: the stability of implants was
Italy) imbued with saline solution as only graft tested by tightening the healing screws and the
material using a dedicated bone plugger (Fig 5). denitive abutments. At every stage (re-open-
9. Use of bone carriers with a stop in order to pre- ing, abutment connection, and last follow-up),
vent sinus oor penetration. implant stability was radiographically tested,
10. Widening of the surgical site if necessary using a analysing the possible presence of progressive
3.4 mm or 4 mm rounded bur with depth stop marginal bone resorption or infection.
limiting insertion at crestal bone. Complications: during the postoperative healing
11. Insertion of 8 to 15 mm long implants with a period, clinical symptoms of maxillary sinusitis
minimum torque of 25 Ncm (Premium Straight, were investigated.
Sweden & Martina) (Fig 6). In cases where the Implant prosthesis failure: planned prosthe-
minimal torque could not be reached, a wider sis that could not be placed due to the implant
implant was inserted. failure(s) and loss of the prosthesis secondary to
12. Implants were submerged and passive closure implant failure(s).
of the ap was achieved using twined polyester Bone height gain: immediately after implant
4/0 string coated with PTHE (SOFILUM, Swe- insertion, a baseline CBCT was used to measure
den & Martina). residual crestal bone and gained bone height. An
13. Immediate cone beam computed tomography additional CBCT exam was performed 18 months
(CBCT) (Picasso, E-WOO Technology, South after loading to compare the amount of regener-
Korea) was performed after surgery to evaluate ated bone. Using dedicated software (EZ-pax,
possible dispersion of hydroxyapatite granules E-WOO Technology, South Korea), bone crest,
in the sinus and to measure residual and aug- augmented height and sinus mucosa thickness
mented bone. were measured on 0.1 mm sections. Bone levels
14. Four months after implant insertion, implants were measured using implant platform as the ref-
were surgically exposed, healing screws were erence point. The following data were measured
positioned, osseointegration was checked and as a mean value of distal and mesial measure-
periapical radiographs were taken. ments parallel to the implant axis:
15. All implants were restored with denitive RC, residual crest bone height, distance from
cemented metal-ceramic crowns. crestal bone border (corresponding to the
16. CBCT was repeated 18 months after prosthetic implant platform) to the sinus oor
loading to evaluate bone height (Figs 7a to 7c TH, total height of sinus oor elevation cor-
and Figs 8a to 8c). responding to the distance between the bone

Eur J Oral Implantol 2011;4(2):145152


Sisti et al Crestal sinus elevation with rotary instruments 149
pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
te n
ot

n
ss e n c e
fo r

a b c

Fig 7 Preoperative (a), postoperative (b) and 18-month follow-up (c) CT scan showing 7 mm native bone elevated to 15 mm.

a b c

Fig 8 Preoperative (a), postoperative (b) and 18-month follow-up (c) CT scan showing 3 mm native bone elevated to 14 mm.

crest and the radiographic appearance of sinus Results


oor elevation
RB, regenerated elevation height, calculated Fifty patients (24 men and 26 women) were included
using the RB = TH RC formula. In the CBCT in this study and distributed as follows: 29 from the
exam at 18 months after loading it was no Piacenza centre; 12 from the Rome centre; and
longer possible to distinguish the original sinus 9 from the Novara centre. Patient age at time of
oor and therefore the RH value used was the sinus lift ranged from 32 to 78 years (average 58.2
value measured at implant insertion: RB (at 18 years). A total of 63 implants of different lengths and
months) = TH (at 18 months) RC (at implant diameters as summarised in Table 1 were inserted.
insertion). Thirty-seven patients received one implant and 13
All assessments were made by an independent received two implants. All patients were followed
examiner (MPM) and were rounded off to the up for 18 months after prosthetic loading and no
nearest 0.1 mm. Additionally, CBCT scans were patients dropped out. All implants were clinically
used to evaluate the thickness of the sinus mem- osseointegrated at surgical re-opening and at 18
brane and presence of possible sinus pathology. months after prosthetic loading.
To standardise the inclination of each cross sec- All surgical interventions and postoperative heal-
tion, at the postoperative CBCT, the neighbour- ing periods were without any serious complication
ing tooth long axis was selected as reference, or side effects. Only one minor mucosa laceration
measuring apico-coronal length and repro- occurred at drilling. This complication did not have
ducing it in the following CT using the Image unfavourable clinical consequences and there was
software (EZ-Pax Plus, E-Woo Technology). no evidence of extruded material into the sinus at the
For each CT measurement, descriptive statis- last radiographic follow-up. In the rst week after
tics including mean values and standard devia- implant insertion, 28 patients showed a moderate
tion were computed at the different time points swelling without experiencing pain. After 1 week,
(postoperative and 18 months after loading). no inammation symptoms were detectable. There

Eur J Oral Implantol 2011;4(2):145152


150 Sisti et al Crestal sinus elevation with rotary instruments
pyrig
No Co

ht
t fo
rP

by N
Table 1 Characteristics (length and diameter) of the 63 implants included in the study. ub

Q ui
lica
tio
Implant diameter (mm) Implant length (mm) te n
ot

n
se nc e
s15 fo r
3.80 4.25 5.00 8 10 11 13
Number of implants 16 28 19 2 6 36 17 2

Table 2 Characteristics of the 50 maxillary sinuses included in the study pre-, post-surgery and 18 months after prosthetic
loading.

Residual crest Total height Regenerated Total height Regenerated


(RC) (TH) bone height at 18 months bone height
(RB) (TH18m) at 18 months
(RB18m)
Mean (mm) 6.20 15.26 7.73 15.40 7.86
SD 2.22 3.19 2.72 4.21 4.99
Max 9.80 24.50 13.40 25.50 20.00
Min 1.20 10.20 2.20 10.10 2.10

were no prosthetic complications during the entire techniques or trabecular bone condensation, are
follow-up period with the exception of two abut- usually graduated only to measure distances more
ments on single implants that became unscrewed. than 8-10 mm. In fact, the lack of depth stop makes
Crowns were removed, the abutments screws where the tool difcult to use. Moreover, the use of the mal-
re-tightened, and occlusal contacts were adjusted. let is often unpleasant for patients16 and a few cases
The radiographic data are summarised in Table of vertigo syndrome (BPPV) or acuphenis provoked
2. The mean initial residual crest (RC) value was by percussions have been reported.24 Furthermore,
6.20 mm (2.22) ranging from 1.2 to 9.8 mm, and traditional osteotome techniques are recommended
mean elevation of sinus mucosa (RB) obtained at when at least 5 to 6 mm of crestal height is available
implant insertion was 7.73 mm (2.72) ranging from and for a maximum elevation of the sinus membrane
2.2 mm to 13.4 mm. Eighteen months after loading, of 5 mm 1,14-16.
it was not possible to see the original sinus oor on On the other hand, the use of burs on a low-
CBCT scans. TH values ranged from 10.10 mm to speed hand piece decreases patient discomfort16.
25.50 mm with a mean value of 15.40 mm (4.21). In the present study, residual crestal height ranged
from 1.2 to 9.8 mm with a mean value of 6.2 mm
with more than 20% of cases having less than
Discussion 5 mm. At the same time, 51 cases out of 63 were
elevated over 5 mm, which is usually considered the
Traditional crestal approaches are associated with limit for elevation techniques using crestal access
a good implant survival rate as well as complica- in order to avoid difculties or complications3. This
tions similar to lateral access techniques2,15,18-20. data is in agreement with recently published stud-
However, crestal approach techniques studied in the ies15,16 that showed that this limit can be success-
literature are usually hard to standardise. Manual fully overcome using a standardised crestal approach
tools such as osteotomes and mallets are difcult to with drilling burs.
handle and can create discomfort to the patient16. In the present study, the absence of dislocated
Furthermore, osteotomy techniques require a long graft material in the CBCT exam control was reported.
learning process and expert handling. In fact, the This suggests that the technique used in this study
main limit of such osteotomy techniques resides in seems not to incur mucosa laceration during the use
the difculty of controlling the percussion power of of a bur or during the mucosa elevation with bone
the mallet to obtain sinus oor breakage23. In addi- carriers, even in cases where limits of classic indica-
tion, osteotomes, being used as well for split-crest tions for elevation with osteotomes were exceeded.

Eur J Oral Implantol 2011;4(2):145152


Sisti et al Crestal sinus elevation with rotary instruments 151
pyrig
No Co

ht
t fo
rP

by N
This could be explained by the use of stops, allow- Acknowledgements ub

Q ui
lica
ing perfect control of burs and avoiding membrane tio
We highly appreciated the skills and commitment tes
n ot

n
perforation, according to Tilotta et al25. Additionally,
se nc e
fo r
the apical shape of the burs and the sequence of of Dr Audrenn Gautier and Dr Henry Canullo in the
use seem to minimise the risk of membrane lacer- supervision of the study.
ation. In cases of a small sinus membrane laceration,
which occurred once in the present study, the use of
collagen seems to be effective in preventing graft
material dislocation26. With osteotome techniques, References
membrane lacerations ranging from 2 to 5%24,27 1. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation
have been reported, and when the sinus elevation on the survival of endosseous dental implants. A systematic
review. Ann Periodontol 2003;8:328-343.
exceeded 5 mm, laceration rates ranged from 10 to 2. Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P,
over 20%28,29. Alissa R, Worthington H, Coulthard P. Effectiveness of sinus
lift procedures for dental implant rehabilitation: a Cochrane
When comparing the total height at the time
systematic review. Eur J Oral Implantol 2010;3:7-26.
of implant insertion and 18 months after loading, 3. Pjetursson BE, Rast C, Brgger U, Schmidlin K, Zwahlen M,
measurements showed no differences (15.3 mm Lang NP. Maxillary sinus oor elevation using the (transalve-
olar) osteotome technique with or without grafting material.
at implant insertion and 15.4 mm 18 months Part I: Implant survival and patients perception. Clin Oral
after loading). This data seems to be in accord- Implants Res 2009;20:667-676.
4. Emmerich D, Att W, Stappert C. Sinus oor elevation using
ance with recently published studies that tested osteotomes: a systematic review and meta-analysis. J Peri-
a nano-structured hydroxyapatite graft in sinus odontol 2005;76:1237-1251.
5. Tatum H Jr. Maxillary and sinus implant reconstructions.
lift with lateral approach30 and on vertical bone Dent Clin North Am 1986;30:207-229.
regeneration31. In fact, due to its characteristics32, 6. Summers RB. Sinus oor elevation with osteotomes. J Esthet
Dent 1998;10:164-171.
this biomimetic graft material demonstrated high 7. Summers RB. Staged osteotomies in sinus areas: preparing for
stability over time. The positive results from this implant placement. Dent Implantol Update 1996;7:93-95.
8. Bruschi GB, Scipioni A, Calesini G, Bruschi E. Localized
study might be inuenced by the limited number
management of sinus oor with simultaneous implant
of patients and, despite of the standardisation of placement: a clinical report. Int J Oral Maxillofac Implants
CT analysis, by the absence of individual three- 1998;13:219-226.
9. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman
dimensional radiographic guides, which may have RH, Marks MH, Fugazzotto PA. The bone-added osteotome
resulted in minimally different inclinations of the sinus oor elevation technique: multicenter retrospective
report of consecutively treated patients. Int J Oral Maxillofac
CT cross sections. Implants 1999;14:853-858.
Within the limit of this study (short follow-up, 10. Davarpanah M, Martinez H, Tecucianu JF, Hage G,
Lazzara R. The modied osteotome technique. Int J Peri-
minimal imprecision in the measurements and small odontics Restorative Dent 2001;21:599-607.
sample size), the minimally invasive sinus elevation 11. Nocini PF, Albanese M, Fior A, De Santis D. Implant place-
ment in the maxillary tuberosity: the Summers technique
(MISE) technique can be considered a simple tech- performed with modied osteotomes. Clin Oral Implants
nique alternative to osteotomes to obtain sinus oor Res 2000;11:273-278.
12. Cosci F, Luccioli M. A new sinus lift technique in conjunc-
elevation with a crestal approach. In fact, the eleva- tion with placement of 265 implants: a 6-year retrospective
tions practised in a non-invasive and quick way were study. Implant Dent 2000;9:363-368.
13. Vlassis JM, Fugazzotto PA. A classication system for sinus
sufcient to insert implants long enough to exceed
membrane perforations during augmentation procedures
the coronal/implant ratio of 1:1. with options for repair. J Periodontol 1999;70:692-699.
14. Fugazzotto PA. Treatment options for augmentation of the
posterior maxilla. Implant Dent 2000;9:281-287.
15. Cannizzaro G, Felice P, Leone M, Viola P, Esposito M. Early
loading of implants in the atrophic posterior maxilla: lateral
Conclusions sinus lift with autogenous bone and Bio-Oss versus crestal
mini sinus lift and 8-mm hydroxyapatite-coated implants.
Within the limit of the study (small sample size A randomised controlled clinical trial. Eur J Oral Implantol
2009;2:25-38.
and short follow-up), the procedure was success- 16. Checchi L, Felice P, Antonini ES, Cosci F, Pellegrino G,
ful in obtaining sinus elevation and implant osseo- Esposito M. Crestal sinus lift for implant rehabilitation: a
randomised clinical trial comparing the Cosci and the Sum-
integration. mers techniques. A preliminary report on complications and
patient reference. Eur J Oral Implantol 2010;3:221-232.

Eur J Oral Implantol 2011;4(2):145152


152 Sisti et al Crestal sinus elevation with rotary instruments
pyrig
No Co

ht
t fo
rP

by N
17. Fugazzotto PA. Immediate implant placement following a ubof oxi-
26. Jeschke MG, Sandmann G, Schubert T, Klein D. Effect

Q ui
modied trephine/osteotome approach: success rates of dized regenerated cellulose/collagen matrix on dermalliand
ca
116 implants to 4 years in function. Int J Oral Maxillofac epidermal healing and growth factors in an acute wound. tio
Wound Repair Regen 2005;13:324-331. t e
otn

n
Implants 2002;17:113-120.
18. Del Fabbro M, Testori T, Francetti L, Weinstein R. Sys-
s e nc e
27. Ferrigno N, Laureti M, Fanali S. Dental implantssplacement
fo r
tematic review of survival rates for implants placed in the in conjunction with osteotome sinus oor elevation: a
grafted maxillary sinus. Int J Periodontics Restorative Dent 12-year life-table analysis from a prospective study on 588
2004;24:565-577. ITI implants. Clin Oral Implants Res 2006;17:194-205.
19. Zitzmann NU, Schrer P. Sinus elevation procedures in the 28. Reiser GM, Rabinovitz Z, Bruno J, Damoulis PD, Grifn
resorbed posterior maxilla. Comparison of the crestal and TJ. Evaluation of maxillary sinus membrane response fol-
lateral approaches. Oral Surg Oral Med Oral Pathol Oral lowing elevation with the crestal osteotome technique in
Radiol Endod 1998;85:8-17. human cadavers. Int J Oral Maxillofac Implants 200;16:
20. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic 833-840.
review of the success of sinus oor elevation and survival of 29. Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW,
implants inserted in combination with sinus oor elevation. Part Wiltfang J. The endoscopically controlled osteotome sinus
II: transalveolar technique. J Clin Periodontol 2008;35:241-254. oor elevation: a preliminary prospective study. Int J Oral
21. Salvi GE, Brgger U. Mechanical and technical risks in implant Maxillofac Implants 2002;17:557-566.
therapy. Int J Oral Maxillofac Implants 2009;24:69-85. 30. Canullo L, Patacchia O, Sisti A, Heinemann F. Implant restor-
22. Esposito M, Grusovin MG, Loli V, Coulthard P, Worthing- ation 3 months after one stage sinus lift surgery in severely
ton HV. Does antibiotic prophylaxis at implant placement resorbed maxillae: 2-year results of a multicenter prospec-
decrease early implant failures? A Cochrane systematic tive clinical study. Clin Implant Dent Relat Res 2010 Oct 21
review. Eur J Oral Implantol 2010;3:101-110. [Epub ahead of print].
23. Berengo M, Sivolella S, Majzoub Z, Cordioli G. Endoscopic 31. Canullo L, Sisti A. Early implant loading after vertical
evaluation of the bone-added osteotome sinus oor eleva- ridge augmentation (VRA) using e-PTFE titanium-reinforced
tion procedure. Int J Oral Maxillofac Surg 2004;33:189-194. membrane and nano-structured hydroxyapatite: 2-year
24. Pearrocha M, Garcia B. Benign paroxysmal positional ver- prospective study. Eur J Oral Implantol 2010;3:59-69.
tigo as a complication of interventions with osteotome and 32. Gotz W, Gerber T, Michel B, Lossdorfer S, Henkel K-O,
mallet. J Oral Maxillofac Surg 2006;64:1324. Heinemann F. Immunohistochemical characterization of
25. Tilotta F, Lazaroo B, Gaudy JF. Gradual and safe technique nanocrystalline hydroxyapatite silica gel (NanoBone) osteo-
for sinus oor elevation using trephines and osteotomes genesis: a study on biopsies from human jaws. Clin Oral
with stops: a cadaveric anatomic study. Oral Surg Oral Med Implants Res 2008;19:1016-1026.
Oral Pathol Oral Radiol Endod 2008;106:210-216.

Eur J Oral Implantol 2011;4(2):145152