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Minimally invasive hydraulic elevation of the Schneiderian membrane and insertion of bone graft material using a novel self-tapping implant system: Radiographic and prosthetic aspects

September 20, 2016 / Categories: Digital Dentistry, Implant Dentistry

Tallarico, Marco

Xhanari, Erta

Paglia, Paolo

Meloni, Silvio Mario

The objective of this article was to report the clinical and radiographic performance of a novel implant system that allows for hydraulic Schneiderian membrane elevation and simultaneous bone graft augmentation.

Introduction

In the posterior sextants of the maxilla, tooth loss is generally associated with alveolar bone loss and sinus pneumatization.1Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review.
→ Ann Periodontol. 2003 Dec;8(1):328–43.
In addition, poor bone quality may have a negative influence on the survival rate of implants.2Salimov F, Tatli U, Kürkçü M, Akoğlan M, Öztunç H, Kurtoğlu C. Evaluation of relationship between preoperative bone density values derived from cone beam computed tomography and implant stability parameters: a clinical study.
→ Clin Oral Implants Res. 2014 Sep;25(9):1016–21.

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There is no consensus on treatment for the atrophic posterior maxilla, with the dilemma of whether to place short implants3Srinivasan M, Vazquez L, Rieder P, Moraguez O, Bernard JP, Belser UC. Efficacy and predictability of short dental implants (< 8 mm): a critical appraisal of the recent literature. → Int J Oral Maxillofac Implants. 2012 Nov-Dec;27(6):1429–37.4Sun HL, Huang C, Wu YR, Shi B. Failure rates of short (≤ 10 mm) dental implants and factors influencing their failure: a systematic review. → Int J Oral Maxillofac Implants. 2011 Jul-Aug;26(4):816–25. or tilted implants5Peñarrocha-Oltra D, Candel-Martí E, Ata-Ali J, Peñarrocha-Diago M. Rehabilitation of the atrophic maxilla with tilted implants: review of the literature.
→ J Oral Implantol. 2013 Oct;39(5):625–32.
6Menini M, Signori A, Tealdo T, Bevilacqua M, Pera F, Ravera G, Pera P. Tilted implants in the immediate loading rehabilitation of the maxilla: a systematic review.
→ J Dent Res. 2012 Sep;91(9):821–7.
or to augment the floor of the maxillary sinus.7Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation.
→ J Clin Periodontol. 2008 Sep;35(8 Suppl):216–40.
8Meloni SM, Jovanovic SA, Lolli FM, Cassisa C, De Riu G, Pisano M, Lumbau A, Lugliè PF, Tullio A. Grafting after sinus lift with anorganic bovine bone alone compared with 50:50 anorganic bovine bone and autologou bone: results of a pilot randomised trial at one year. → Br J Oral Maxillofac Surg. 2015 May;53(5):436–41.In a recent review of the literature, Pjetursson et al. reported that the placement of dental implants in combination with maxillary sinus floor elevation using a lateral approach is a predictable treatment option showing high medium-term implant survival rates and low incidences of complications.9Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation.
→ J Clin Periodontol. 2008 Sep;35(8 Suppl):216–40.
However, the lateral approach to the sinus entails elevation of a large mucoperiosteal flap that affects postoperative recovery of the patient and the additional expense of the augmentation procedure.10Geminiani A, Weitz DS, Ercoli C, Feng C, Caton JG, Papadimitriou DE. A comparative study of the incidence of Schneiderian membrane perforations during maxillary sinus augmentation with a sonic oscillating handpieceversus a conventional turbine handpiece.
→ Clin Implant Dent Relat Res. 2015 Apr;17(2):327–34.
Schneiderian membrane perforations, nose bleeding, postoperative pain and swelling could be considered major risks.11Katranji A, Fotek P, Wang HL. Sinus augmentation complications: etiology and treatment.
→ Implant Dent. 2008 Sep;17(3):339–49.
The elevation of the maxillary sinus floor through the alveolar crest (transalveolar) was first described by Tatum11 and modified by Summers.12Summers RB. A new concept in maxillary implant surgery: the osteotome technique. → Compendium. 1994 Feb;15(2):152, 154–6, 158 passim; quiz 162.
Subsequently, various modifications to the original technique have been reported, in order to improve the predictability and safety, such as the use of atraumatic lifting drills,13Cosci F, Luccioli M. A new sinus lift technique in conjunction with placement of 265 implants: a 6-year retrospective study.
→ Implant Dent. 2000 Winter;9(4):363–8.
membrane elevation via inflation of a balloon catheter,14Soltan M, Smiler DG. Antral membrane balloon elevation.
→ J Oral Implantol. 2005 Apr;31(2):85–90.
and the use of hydraulic15Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique.
→ J Periodontol. 2005 Mar;76(3):482–91.
or negative pressure.16Suguimoto RM, Trindade IK, Carvalho RM. The use of negative pressure for the sinus lift procedure: a technical note.
→ Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):455–8.

The aim of this clinical report was to present a novel self-tapping endosseous implant system (iRaise, Maxillent, Herzliya, Israel) developed for sinus augmentation. The advantage of this system is the ability to perform major sinus lift augmentation via a minimally invasive transcrestal approach and to simultaneously place an implant, with minimal patient discomfort and shortened treatment time.

Case presentation

Fig. 1
Preoperative panoramic radiograph.

Fig. 2
Alveolar ridge before implant placement (occlusal view).

Fig. 3
Preoperative CBCT scan.

Fig. 4
The iRaise sinus-lift system (Maxillent, Herzliya, Israel).

Fig. 5
CBCT scan immediately after implant placement.

Fig. 6
CBCT scan six months after implant placement.

A 63-year-old female patient presented with compromised fixed dental prostheses supported by failing teeth in her posterior maxilla (Figs. 1 & 2). The patient reported esthetic concerns and impairment of her masticatory function; consequently, she desired replacement of the prostheses. A cone beam computed tomography (CBCT) scan was performed to evaluate the amount of residual bone. On the right side, conventional implant placement was planned. However, on the left side, the distance from the maxillary crest to the sinus floor was 3.2 mm, requiring a bone augmentation procedure. After detailed consultation, various treatment options were discussed with the patient. Closed major sinus floor augmentation with a transcrestal approach using the iRaise implant system was planned for the maxillary left first molar position to support a screwretained fixed dental prosthesis. An adjunctive implant was planned for the maxillary left first premolar position.

The day before the implant placement, the patient underwent intranasal spray therapy (thiamphenicol glycinate acetylcysteinate, 810 mg/4 mL) b.i.d. One hour before surgery, a single dose of antibiotic (2 g of amoxicillin and clavulanic acid) was administered prophylactically. A 0.2% chlorhexidine mouthwash was administered for 1 min prior to the implantation procedure.

Local anesthesia was administered (articaine with 1:100,000 epinephrine) and a small fullthickness mucoperiosteal flap was elevated. A 2 mm diameter round bur was used to mark the implant site. The osteotomy was prepared with a 2 mm twist drill 1 mm below the sinus floor. A periapical radiograph with a depth guide was performed in order to verify the drilling angle and depth, as well as the distance to the sinus floor. The implant recipient site was widened to allow the placement of a 5 mm diameter implant, according to the drilling protocol suggested by the manufacturer and reported in a previously published paper.17Better H, Slavescu D, Barbu H, Cochran DL, Chaushu G. Minimally invasive sinus lift implant device: a multicenter safety and e icacy trial preliminary results.
→ Clin Implant Dent Relat Res. 2014 Aug;16(4):520–6.
The length of the implant was selected beforehand based on the residual bone height, measured using the preoperative CBCT scan, from the bone crest to the sinus floor, along the implant’s planned axis. A 14.50 mm length implant (iRaise, Maxillent, Herzliya, Israel) was used according to a residual bone height of 3.21 mm (Fig. 3). The implant was first inserted into the osteotomy until it reached the end of the prepared site. The implant was then slowly advanced until the sinus floor was penetrated for approximately 1 mm. A periapical radiograph was performed in order to determine whether the implant had penetrated the sinus floor. A saline syringe with 2–3 cm3 of a 0.9% sterile saline solution was connected to the implant through the tubing port. With this system, the tube connector is easily assembled on the implant, allowing injection of fluids with a standard Luer lock connector. Saline solution was gently injected through the implant and into the sinus and slight bleeding was noted in the retracted saline solution upon stopping the injection. A syringe containing 2 cm3 of a flowable bone graft material (MBCP Gel, Biomatlante, Vigneux-de-Bretagne, France) was subsequently connected to the same port. The material was slowly injected through the implant into the sinus (Fig. 4).

Fig. 7
Definitive prostheses on the cast (occlusal view)

Fig. 8
Definitive prostheses on the cast (frontal view).

Fig. 9
Metal-free framework.

Fig. 10
Right lateral view of the definitive prosthesis taken one year after loading.

After the grafting procedure had been completed, the hydraulic system was disconnected from the implant, and the implant was inserted to its entire length into the osteotomy and the grafted sinus cavity and left to heal according to a submerged protocol.An additional implantwas placed after completing the iRaise surgical sequence. A postoperative CBCT scan was taken with reduced voxel size, field of view and milliampere settings
(Fig. 5). After surgery, intranasal spray therapy (thiamphenicol glycinate acetylcysteinate, 810 mg/4 mL) was continued for ten days, an antibiotic (1 g of amoxicillin and clavulanic acid b.i.d.) for six days and a 0.2% chlorhexidine mouthwash (1 min b.i.d.) for two weeks. A soft diet was recommended for one week, while 1 g of paracetamol was prescribed in case of pain. The sutures were removed after one week, and oral hygiene instructions were emphasized.

Six months after implant placement, a CBCT scan was taken with the same parameters used for the postoperative scan, and the healing abutments were connected. The bone gain was 18.5 mm (Fig. 6).

Fig. 11
Frontal view of the definitive prosthesis taken one year after loading.

Fig. 12
Left lateral view of the definitive prosthesis taken one year after loading.

Definitive screwretained metalfree restorations were delivered eight months after implant placement (Figs. 7–9). The occlusion was carefully checked. Recall appointments for oral hygiene maintenance and oral hygiene instructions were set for every four months after loading. The occlusion was evaluated at each visit. CBCT scans were performed one year after implant loading (20 months after implant placement) and compared with the previously taken CBCT scans (Figs. 10–16).

Fig. 13
Panoramic radiograph taken one year after loading.

Fig. 14
CBCT scan one year after loading (sagittal view).

Fig. 15
CBCT scan one year after loading (coronal view).

Fig. 16
Superimposition of the CBCT scans taken six months after implant placement (red) and one year after loading (gray) showing stability of the grafted material over time.

Discussion

The present case report is one of the first aimed at evaluating a novel implant system that allows for minimally invasive major sinus floor elevation at the time of implant placement. According to a recent Cochrane systematic review, if the residual alveolar bone height is 3–6 mm, a transcrestal approach to lifting the Schneiderian membrane and placing 8 mm implants may lead to fewer complications than would a lateral window approach and placing implants at least 10 mm long.18Esposito M, Felice P, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus.
→ Cochrane Database Syst Rev. 2014;5:CD008397.

In the case presented, the patient experienced minimal discomfort and was functionally restored in a shorter period than are patients treated with a twostage sinus grafting technique. In investigating the transcrestal osteotome technique for sinus floor augmentation, some researchers have recorded high rates of patient satisfaction.19Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation.
→ J Clin Periodontol. 2008 Sep;35(8 Suppl):216–40.
20Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, Schmidlin K, Lang NP. Transalveolar maxillary sinus floor elevation using osteotomes with or without grafting material. Part II: radiographic tissue remodeling.
→ Clin Oral Implants Res. 2009 Jul;20(7):677–83.
21Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S. Implant survival rates after osteotome-mediated maxillary sinus augmentation: a systematic review.
→ Clin Implant Dent Relat Res. 2012 May;14 Suppl 1:e159–68.
Maxillary sinus floor elevation with a transcrestal approach is advocated as a minimally invasive procedure, owing to the minimal surgical flap required. Moreover, the lateral sinus wall remains intact, reducing postoperative morbidity.22Chan HL, Oh TJ, Fu JH, Benavides E, Avila-Ortiz G, Wang HL. Sinus augmentation via transcrestal approach: a comparison between the balloon and osteotome technique in a cadaver study.
→ Clin Oral Implants Res. 2013 Sep;24(9):985–90.
23Bruschi GB, Crespi R, Capparè P, Gherlone E. Transcrestal sinus floor elevation: a retrospective study of 46 patients up to 16 years.
→ Clin Implant Dent Relat Res. 2010 Oct;14(5):759–67.
This technique is widely documented in the literature and supported by several longitudinal studies that attest to an average implant survival rate close to 92% in the medium term.24Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation.
→ J Clin Periodontol. 2008 Sep;35(8 Suppl):216–40.
25Meloni SM, Jovanovic SA, Lolli FM, Cassisa C, De Riu G, Pisano M, Lumbau A, Lugliè PF, Tullio A. Grafting after sinus lift with anorganic bovine bone alone compared with 50:50 anorganic bovine bone and autologous bone: results of a pilot randomised trial at one year.
→ Br J Oral Maxillofac Surg. 2015 May;53(5):436–41.
26Nkenke E, Stelzle F. Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review.
→ Clin Oral Implants Res. 2009 Sep;20 Suppl 4:124–33.
Recent publications have shown that transalveolar sinus floor elevation is a reliable method for implant placement in the posterior maxilla, even at sites with ≤ 4 mm of residual alveolar bone height.27Better H, Slavescu D, Barbu H, Cochran DL, Chaushu G. Minimally invasive sinus lift implant device: a multicenter safety and e icacy trial preliminary results.
→ Clin Implant Dent Relat Res. 2014 Aug;16(4):520–6.
28Ahn SH, Park EJ, Kim ES. Reamer-mediated transalveolar sinus floor elevation without osteotome and simultaneous implant placement in the maxillary molar area: clinical outcomes of 391 implants in 380 patients.
→ Clin Oral Implants Res. 2012 Jul;23(7):866–72.
29Tallarico M, Meloni SM, Xhanari E, Pisano M, Cochran DL. Minimally Invasive Sinus Augmentation Procedure Using a Dedicated Hydraulic Sinus Lift Implant Device: A Prospective Case Series Study on Clinical, Radiologic, and Patient Centered Outcomes.
→ Int J Periodontics Restorative Dent. 2016. doi:10.11607/prd.2914.
Nevertheless, implant survival rates may decrease with reduced residual bone height.30Tallarico M, Better H, De Riu G, Meloni SM. A novel implant system dedicate to hydraulic Schneiderian membrane elevation and simultaneously bone graft augmentation: An up-to 45 months retrospective clinical study. → J Craniomaxillofac Surg. 2016;44:1089–94. doi:10.1016/j. jcms.2016.05.016. 31Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH, Fugazzotto PA. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients.
→ Int J Oral Maxillofac Implants. 1999 Nov/Dec;14(6):853–8.

The main concerns related to the transcrestal approach, compared with the lateral surgical approach, are the absence of direct visualization of the sinus cavity and Schneiderian membrane, the limited amount of bone augmentation achieved and the high risk of inadvertent perforation of the Schneiderian membrane during fracture of the sinus floor with osteotomes, or burs, with or without stop drills, without the possibility of repairing the torn membrane. Nevertheless, in an eight-year retrospective study on 1,100 participants with 1–5 mm of residual bone height who received 1,557 implants with minimally invasive hydraulic elevation of the Schneiderian membrane, an incidence of membrane perforation of less than 0.5 % was reported.15
The iRaise implant system is a uniquely designed implant housing an L-shaped channel separate from the prosthetic connection and the oral cavity, thereby eliminating the possibility of bacteria migrating into the bone. Through this channel, saline is introduced to elevate the Schneiderian membrane. The iRaise system allows the clinician to perform a minimally invasive sinus augmentation procedure immediately. The hydraulic elevation of the Schneiderian membrane and the insertion of bone graft material are performed through the implant itself, resulting in fewer complications, shorter treatment time and greater comfort for patients, compared with the open sinus lift procedure.

Closed major sinus floor augmentation with a transcrestal approach can be accomplished using a novel system that allows for hydraulic elevation of the Schneiderian membrane, injection of a flowable bone graft material and simultaneous dental implant placement, with minimal patient discomfort. Long-term clinical studies on larger cohorts of patients are needed to confirm these preliminary results.

Competing interests

This was an investigator-initiated trial. The trial was supported partially by Maxillent.

Acknowledgments

The authors wish to thank Maxillent (Herzliya, Israel) for its partial support of this trial and provision of the implants and prosthetic components. The authors also wish to thank the sta of the dental laboratory (Odontotecnica Paglia & Moretti, Rome, Italy) who manufactured the definitive prostheses.

Tallarico Marco

Interview

with Dr. Marco Tallarico

Why did you conduct the research reported on in this paper?

To report the clinical and radiographic performance of a novel implant system that allows for hydraulic Schneiderian membrane elevation and simultaneous bone graft augmentation.

For what reasons could others cite your paper?

Although this is a case presentation, hydraulic elevation of the Schneiderian membrane using the iRaise sinus lift system (Maxillent, Herzliya, Israel) can be considered a valuable treatment option for the rehabilitation of atrophic edentulous posterior maxillae.

How could your study’s findings have an impact on dentistry?

While this is only a case presentation, the results could have a high impact on dentistry in that it was clearly demonstrated that sinus floor elevation can be performed using a minimally invasive approach.

What is the relevance of your study’s findings to the daily practice of a dentist?

This technique could be used in the daily practice by dentists. Both the patient and the dentist will benefit from a safe and minimally invasive procedure. Furthermore, complications may be reduced.

What are your recommendations for further investigation of the topic of your article?

To compare the proposed technique with the gold standard approach to elevating the sinus membrane (lateral approach).

References   [ + ]

1. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review.
→ Ann Periodontol. 2003 Dec;8(1):328–43.
2. Salimov F, Tatli U, Kürkçü M, Akoğlan M, Öztunç H, Kurtoğlu C. Evaluation of relationship between preoperative bone density values derived from cone beam computed tomography and implant stability parameters: a clinical study.
→ Clin Oral Implants Res. 2014 Sep;25(9):1016–21.
3. Srinivasan M, Vazquez L, Rieder P, Moraguez O, Bernard JP, Belser UC. Efficacy and predictability of short dental implants (< 8 mm): a critical appraisal of the recent literature. → Int J Oral Maxillofac Implants. 2012 Nov-Dec;27(6):1429–37.
4. Sun HL, Huang C, Wu YR, Shi B. Failure rates of short (≤ 10 mm) dental implants and factors influencing their failure: a systematic review. → Int J Oral Maxillofac Implants. 2011 Jul-Aug;26(4):816–25.
5. Peñarrocha-Oltra D, Candel-Martí E, Ata-Ali J, Peñarrocha-Diago M. Rehabilitation of the atrophic maxilla with tilted implants: review of the literature.
→ J Oral Implantol. 2013 Oct;39(5):625–32.
6. Menini M, Signori A, Tealdo T, Bevilacqua M, Pera F, Ravera G, Pera P. Tilted implants in the immediate loading rehabilitation of the maxilla: a systematic review.
→ J Dent Res. 2012 Sep;91(9):821–7.
7, 9, 19, 24. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation.
→ J Clin Periodontol. 2008 Sep;35(8 Suppl):216–40.
8. Meloni SM, Jovanovic SA, Lolli FM, Cassisa C, De Riu G, Pisano M, Lumbau A, Lugliè PF, Tullio A. Grafting after sinus lift with anorganic bovine bone alone compared with 50:50 anorganic bovine bone and autologou bone: results of a pilot randomised trial at one year. → Br J Oral Maxillofac Surg. 2015 May;53(5):436–41.
10. Geminiani A, Weitz DS, Ercoli C, Feng C, Caton JG, Papadimitriou DE. A comparative study of the incidence of Schneiderian membrane perforations during maxillary sinus augmentation with a sonic oscillating handpieceversus a conventional turbine handpiece.
→ Clin Implant Dent Relat Res. 2015 Apr;17(2):327–34.
11. Katranji A, Fotek P, Wang HL. Sinus augmentation complications: etiology and treatment.
→ Implant Dent. 2008 Sep;17(3):339–49.
12. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. → Compendium. 1994 Feb;15(2):152, 154–6, 158 passim; quiz 162.
13. Cosci F, Luccioli M. A new sinus lift technique in conjunction with placement of 265 implants: a 6-year retrospective study.
→ Implant Dent. 2000 Winter;9(4):363–8.
14. Soltan M, Smiler DG. Antral membrane balloon elevation.
→ J Oral Implantol. 2005 Apr;31(2):85–90.
15. Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique.
→ J Periodontol. 2005 Mar;76(3):482–91.
16. Suguimoto RM, Trindade IK, Carvalho RM. The use of negative pressure for the sinus lift procedure: a technical note.
→ Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):455–8.
17, 27. Better H, Slavescu D, Barbu H, Cochran DL, Chaushu G. Minimally invasive sinus lift implant device: a multicenter safety and e icacy trial preliminary results.
→ Clin Implant Dent Relat Res. 2014 Aug;16(4):520–6.
18. Esposito M, Felice P, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus.
→ Cochrane Database Syst Rev. 2014;5:CD008397.
20. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, Schmidlin K, Lang NP. Transalveolar maxillary sinus floor elevation using osteotomes with or without grafting material. Part II: radiographic tissue remodeling.
→ Clin Oral Implants Res. 2009 Jul;20(7):677–83.
21. Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S. Implant survival rates after osteotome-mediated maxillary sinus augmentation: a systematic review.
→ Clin Implant Dent Relat Res. 2012 May;14 Suppl 1:e159–68.
22. Chan HL, Oh TJ, Fu JH, Benavides E, Avila-Ortiz G, Wang HL. Sinus augmentation via transcrestal approach: a comparison between the balloon and osteotome technique in a cadaver study.
→ Clin Oral Implants Res. 2013 Sep;24(9):985–90.
23. Bruschi GB, Crespi R, Capparè P, Gherlone E. Transcrestal sinus floor elevation: a retrospective study of 46 patients up to 16 years.
→ Clin Implant Dent Relat Res. 2010 Oct;14(5):759–67.
25. Meloni SM, Jovanovic SA, Lolli FM, Cassisa C, De Riu G, Pisano M, Lumbau A, Lugliè PF, Tullio A. Grafting after sinus lift with anorganic bovine bone alone compared with 50:50 anorganic bovine bone and autologous bone: results of a pilot randomised trial at one year.
→ Br J Oral Maxillofac Surg. 2015 May;53(5):436–41.
26. Nkenke E, Stelzle F. Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review.
→ Clin Oral Implants Res. 2009 Sep;20 Suppl 4:124–33.
28. Ahn SH, Park EJ, Kim ES. Reamer-mediated transalveolar sinus floor elevation without osteotome and simultaneous implant placement in the maxillary molar area: clinical outcomes of 391 implants in 380 patients.
→ Clin Oral Implants Res. 2012 Jul;23(7):866–72.
29. Tallarico M, Meloni SM, Xhanari E, Pisano M, Cochran DL. Minimally Invasive Sinus Augmentation Procedure Using a Dedicated Hydraulic Sinus Lift Implant Device: A Prospective Case Series Study on Clinical, Radiologic, and Patient Centered Outcomes.
→ Int J Periodontics Restorative Dent. 2016. doi:10.11607/prd.2914.
30. Tallarico M, Better H, De Riu G, Meloni SM. A novel implant system dedicate to hydraulic Schneiderian membrane elevation and simultaneously bone graft augmentation: An up-to 45 months retrospective clinical study. → J Craniomaxillofac Surg. 2016;44:1089–94. doi:10.1016/j. jcms.2016.05.016.
31. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH, Fugazzotto PA. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients.
→ Int J Oral Maxillofac Implants. 1999 Nov/Dec;14(6):853–8.

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