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TRANSCRIPT
Evaluation of the Effectiveness of a Water LiftSystem in the Sinus Membrane-Lifting Operationas a Sinus Surgical Instrumentcid_292 1..10
Dae Y. Kim, BDS;* Yusaku Itoh, BDS;† Tae H. Kang, BDS‡
ABSTRACT
Purpose: The effectiveness of a Water Lift System in the sinus membrane-lifting operation was examined. This investigationfocused on the capability of this equipment to reduce the risk of Schneiderian membrane perforation.
Materials and Methods: A preliminary clinical study on the use of the Water Lift System in sinus membrane elevation toplace implants through the sinus floor was conducted. A total of 70 sinus membrane-lifting operations were performed onpatients with various bone heights ranging from 1.2 to 9.9 mm (most commonly in the range of 4–6 mm) through thelateral approach (four cases) or the crestal approach (66 cases).
Results: In all of the cases performed using the lateral approach, sinus membrane perforation did not occur. In the 66 casesperformed using the crestal approach, Schneiderian membrane tearing occurred in two cases. The membrane tearingoccurred during elevation of the Schneiderian membrane but not when a hole was drilled to access the Schneiderianmembrane. One case of membrane tearing resulted from previous inflammation in the maxillary sinus, and the other caseof membrane tearing was caused by application of excessive hydraulic pressure. In addition, similar outcomes wereobtained and no microbial infections were observed in a total of 68 successful cases.
Conclusions: In this study, the Water Lift System was confirmed to effectively reduce the risk of Schneiderian membraneperforation during the sinus membrane-lifting operation. We conclude that the Water Lift System deserves to be consideredas a sinus surgical instrument, which ensures safety in the sinus membrane-lifting operation.
KEY WORDS: Schneiderian membrane perforation, sinus membrane-lifting, sinus surgical instrument, Water Lift System
INTRODUCTION
Sinus floor elevation is an internal augmentation of
the maxillary sinus that allows for the placement of
implants.1,2 The Schneiderian membrane (maxillary
sinus membrane) must be elevated to place implants
through the sinus floor.3 The Schneiderian membrane,
which is attached to the bordering bone of the maxillary
sinus and is characterized by a periosteum overlaid with
a thin layer of pseudociliated, stratified respiratory epi-
thelium, constitutes an important barrier for the protec-
tion and defense of the sinus cavity.4 The integrity of this
membrane is essential for the maintenance of healthy
sinus function. The efficacy and predictability of maxil-
lary sinus elevation surgery has been previously deter-
mined in numerous studies. Since the technique was
first introduced by Boyne and James,5 and then Tatum6,
an increasing number of articles have been published on
this type of surgery.2,7–15
Perforation of the Schneiderian membrane is a
common problem of the sinus-lift procedure that occurs
during placement of implants through the floor of
the sinus.3,16 To minimize or circumvent the risk of
Schneiderian membrane perforation, many instruments
designed especially for sinus membrane lifting have
been proposed. For example, a Piezosurgery® system
was developed to reduce membrane perforation during
window-making, which uses ultrasonic vibration unlike
*Doctor, KwakGyeongHwan Dental Clinic, Incheon, Korea; †doctor,Osseo Skarp Institute, Osaka, Japan; ‡doctor, Skyopen KangLimKang-Jung Seoul Dental Clinic, Seoul, Korea
Reprint requests: Dr. Tae Hyun Kang, Skyopen KangLimKangJungSeoul Dental Clinic, Room 523-524, fineApple Store, LLL’s Apart-ment, 19, Jamsil-dong, Songpa-gu, Seoul 138-916, Korea; e-mail:[email protected]
© 2010, Copyright the AuthorsJournal Compilation © 2010, Wiley Periodicals, Inc.
DOI 10.1111/j.1708-8208.2010.00292.x
1
rotary instruments.17 However, this instrument
occasionally creates membrane perforations during
membrane elevation.18
The Water Lift System is a recently introduced sinus
surgical instrument. According to the manufacturer’s
instructions, the Water Lift System is specifically
designed for the safe operation of sinus lifting and
includes the following sinus surgical set: an artificially
intelligent (AI) drill, which is a resistance-sensitive drill,
and an aqua system, which is a sinus membrane eleva-
tion instrument capable of providing evenly distributed
hydraulic pressure on the Schneiderian membrane
during sinus membrane elevation. The AI drill was
designed to stop drilling upon contact of the drill bit
with the Schneiderian membrane.
In this study, we investigated the capability of the
Water Lift System to reduce the risk of perforating the
Schneiderian membrane in the sinus membrane-lifting
operation.
MATERIALS AND METHODS
Sinus Surgical Instrument
The Water Lift System (Naturallaw, Seoul, Korea) was
used as a surgical instrument in the sinus membrane-
lifting operation. There are two Water Lift Systems:
a crestal approach system (Figure 1A) and a lateral
approach system (Figure 1B). The Water Lift System for
the crestal approach was composed of a void remover,
a compaction drill, an AI drill, an aqua-lifter, an
aqua-injector, an expanding drill, and a spread drill. The
Water Lift System for the lateral approach was composed
of an AI drill, an aqua-lifter, an aqua-injector, and a
burin drill. All drills in the Water Lift System are hand-
held. The diameter (1.5 mm) of the aqua-lifter is similar
to the AI drill diameter, which allows for synchroni-
zation with AI drilling. In addition, the AI drill was
designed to drill at angles up to 65°, which results in
accurate drilling of most of the bone during the dental
implant surgery without significant difficulties.
Case Studies
A total of 70 sinus membrane-lifting operations were
performed on patients with various bone heights
ranging from 1.2 to 9.9 mm, and most frequently in the
range of 4 to 6 mm, through the lateral approach (four
cases) or the crestal approach (66 cases). The decisive
criterion for sinus floor augmentation in this study was
less than 10 mm of residual bone height. The crestal
approach was the first choice for sinus membrane eleva-
tion in this study because the extent of elevation of
the sinus membrane can still be easily examined in the
crestal approach using the Water Lift System (ie, the
crestal approach using the Water Lift System is not a
blind technique). Information on sinus floor augmenta-
tion patients is presented in Table 1. Sinus floor aug-
mentation was performed on these patients using the
Figure 1 A schematic view of the Water Lift System for thecrestal approach (A) and the lateral approach (B). A schematicview of the disassembled artificially intelligent (AI) drill (C).(A) (a) Void remover, (b) compaction drill, (c) AI drill, (d)aqua-lifter, (e) aqua-injector, (f) expanding drill, and (g) spreaddrill. (B) (a) AI drill, (b) aqua-lifter, (c) aqua-injector, and (d)burin drill. (C) (a) Shaft, (b) center drill, (c) peripheral drill,(d) cover, and (e) rotation indicator. The digitized images werereduced at different image scales. 250 ¥ 409 mm (72 ¥ 72 DPI).
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2010
TABLE 1 Patient Information
Case No.Age
(years) SexNo. ofTeeth
Residual BoneHeight (mm)
Distance SinusMembrane-Lifted (mm)
1 51 M 16 1.2 9.3
2* (Figure 4) 35 F 15 1.5 10.3
3* 63 M 16 2.0 9.0
4 42 M 17 2.0 6.8
5 58 M 27 2.1 9.9
6 58 M 26 2.3 9.6
7 57 M 16 2.3 8.6
8* 63 M 17 2.3 8.7
9* 35 F 16 2.4 8.5
10 51 M 17 2.5 9.2
11 57 M 16 3.1 7.0
12 57 M 26 4.2 4.8
13 57 M 26 4.2 4.8
14 52 M 27 4.4 5.1
15 59 F 16 4.7 8.3
16 29 F 16 4.8 6.9
17 59 F 17 4.8 7.6
18 54 F 26 4.8 5.8
19 53 F 17 4.8 8.3
20 46 F 27 4.9 4.2
21 48 M 26 5.1 6.0
22 47 M 26 5.2 3.6
23 69 F 26 5.2 3.6
24 54 F 25 5.2 4.3
25 38 F 16 5.2 7.6
26 51 M 15 5.2 5.3
27 42 M 16 5.3 4.2
28 69 M 17 5.5 3.9
29 54 M 27 5.7 3.7
30 54 M 26 6.0 3.9
31 38 F 26 6.0 3.9
32 38 F 26 6.0 3.9
33 57 M 25 6.1 4.1
34 57 M 25 6.1 4.1
35 57 M 15 6.5 3.6
36 35 F 25 6.5 6.3
37 28 M 26 6.8 8.4
38 47 F 26 6.8 4.3
39 46 M 27 7.1 3.9
40 29 F 26 7.2 5.2
41 42 M 18 7.3 1.6
42 43 F 16 7.3 4.3
43 62 M 26 7.3 2.1
44 38 F 27 7.3 5.8
45 62 M 27 7.5 5.3
46 64 M 27 7.6 6.6
Water Lift System in Sinus Membrane-Lifting Operation 3
lateral approach with a superior curving maxillary sinus
floor (two cases) or sinus membrane thickening (two
cases). In each approach, the corresponding Water
Lift System was used according to the manufacturer’s
instructions. The radiographic contrast medium Iobrix
300 (647 mg/mL iohexol; TAEJOON PHARM, Seoul,
Korea) served as the fluid for the aqua system. The
radiographic contrast medium was injected at a rate of
one click per 10 seconds. After each use, the AI drill was
disassembled and sterilized for the next use according
to the manufacturer’s instructions. Some images illus-
trating the operation steps were captured using the
dental fluoroscopy instrument DreamRay™ (Dream-
Ray, Busan, Korea). In this study, lifting of the sinus
membrane was considered successful according to the
following parameters: (1) no occurrence of sinus mem-
brane perforation and (2) presence of a dome shape on
the elevated Schneiderian membrane as visualized via
standard X-ray or panoramic imaging.
Lateral Approach
The procedure for the lateral approach using the Water
Lift System is presented in Figure 2. A door in the lateral
maxillary sinus wall was first prepared using the AI
drill (Figure 2A). The Schneiderian membrane was then
separated from the lateral wall of the sinus using the
aqua system (Figure 2, B and C). After sufficient eleva-
tion of the Schneiderian membrane, the window for
the sinus lateral approach was prepared using the burin
drill (Figure 2D). The bone replacement material filling
TABLE 1 Continued
Case No.Age
(years) SexNo. ofTeeth
Residual BoneHeight (mm)
Distance SinusMembrane-Lifted (mm)
47 35 F 26 7.6 3.5
48 68 M 16 7.7 2.4
49 27 M 15 8.2 4.6
50 25 M 26 8.3 3.4
51 36 M 16 8.3 3.5
52 58 M 27 8.3 4.6
53 58 M 27 8.3 4.6
54 67 M 26 8.5 3.6
55 (Figure 5) 48 M 15 8.6 6.8
56 64 M 26 8.6 7.0
57 31 F 26 8.7 2.3
58 57 M 25 8.9 2.5
59 65 M 26 8.9 3.8
60 47 F 16 8.9 3.1
61 53 F 26 8.9 2.1
62 50 F 15 9.0 3.2
63 25 M 14 9.2 3.3
64 69 F 25 9.2 2.0
65 48 M 27 9.3 3.6
66 63 F 14 9.6 3.3
67 61 M 27 9.7 2.8
68 60 F 26 9.8 2.0
69 60 F 27 9.8 2.0
70 48 M 26 9.9 2.4
Avg (50.4) – – Avg (6.3) Avg (5.1)
Max (69) – – Max (9.9) Max (10.3)
Min (25) – – Min (1.2) Min (1.6)
*Lateral approach.M = Male; F = Female; Avg = Average; Max = Maximum; Min = Minimum.
4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2010
(Figure 2, F and G) and implant placement (Figure 2H)
were then performed through the window.
Crestal Approach
The crestal approach procedure using the Water Lift
System is presented in Figure 3. The superior cortical
bone layer was drilled through first, using a conventional
drill (ie, lindeman drill, lancet drill, or round bur) to
prepare the hole (Figure 3A). Next, the bone void was
removed using a void remover (Figure 3B). The residual
spongy bone was then removed, and the remaining bone
was compacted using the compaction drill (Figure 3C).
Preparation of the hole was completed by drilling the
residual bone with the AI drill (Figure 3D). The aqua-
lifter was placed into the hole to access the Schneiderian
membrane (Figure 3E), followed by elevation of the
Schneiderian membrane. Using the aqua-injector,
the radiographic contrast medium was injected into the
hole to elevate the Schneiderian membrane (Figure 3F).
After sufficient elevation of the Schneiderian mem-
brane, which can be determined on a standard X-ray or
panoramic imaging, the hole was expanded using a
spread drill (Figure 3G). Through this expanded hole,
bone replacement material filling was performed using
the spread drill (Figure 3H). Finally, placement of the
implant was performed (Figure 3I).
RESULTS
The effectiveness of the Water Lift System for sinus
membrane elevation was verified in a total of 70 sinus
membrane-lifting operations performed on patients
with various bone heights ranging from 1.2 to 9.9 mm
(most frequently in the range of 4–6 mm), which
were subjected to sinus floor augmentation and dental
implant placement. In total, four cases were per-
formed using the lateral approach and 66 cases were
Figure 2 A schematic diagram of the lateral approach. (A) Preparing a door in the lateral maxillary sinus wall using the artificiallyintelligent drill, (B) placing the aqua-lifter into the prepared door, (C) lifting the Schneiderian membrane with the radiographiccontrast medium using the aqua system, (D) preparing an oval window for the sinus lateral approach with the burin drill, (E) liftingthe Schneiderian membrane using a sinus curette, (F) filling with bone replacement material through the prepared window, (G)covering the window, and (H) placing the implant. 250 ¥ 179 mm (72 ¥ 72 DPI).
Water Lift System in Sinus Membrane-Lifting Operation 5
performed using the crestal approach with the corre-
sponding Water Lift System. The exemplary lateral
approach case is presented in Figure 4, while the crestal
approach is presented in Figure 5.
Sinus membrane perforation did not occur in any
of the lateral approach cases. However, two instances
of Schneiderian membrane tearing occurred in the 66
crestal approach cases. The Schneiderian membrane
tearing occurred during hydraulic pressure-based sinus
membrane elevation, but not when a hole was drilled to
access the Schneiderian membrane. One case of mem-
brane tearing resulted from previous inflammation in
the maxillary sinus. The other case of membrane tearing
was caused by application of excessive hydraulic pres-
sure; however, the membrane tear occurred at an early
stage when the appropriate procedure for using the
Water Lift System was being established. Therefore, this
was a rare occurrence based on the final established
procedure, which did not result in tearing of the
Schneiderian membrane during use of the Water Lift
System. From these results, it was concluded that drilling
a hole to access the Schneiderian membrane and eleva-
tion of the Schneiderian membrane using the Water Lift
System reduced the risk of lacerating the Schneiderian
membrane to a minimum.
In addition, similar outcomes were obtained and
no microbial infections were observed in a total of 68
successful cases.
DISCUSSION
Perforation of the Schneiderian membrane is a common
problem of the sinus-lift procedure that occurs during
implant placement through the sinus floor. In this study,
the use of the Water Lift System for sinus membrane
elevation reduced the risk of perforating the Schneide-
rian membrane. Perforation of the sinus membrane
occurred in 2.9% of total cases using the Water Lift
System. Generally, perforation of the sinus membrane
Figure 3 A schematic diagram of the crestal approach. (A) Lancet drilling, (B) void removal, (C) compacting, (D) preparing a holeto access the Schneiderian membrane, (E) placing the aqua-lifter into the hole, (F) lifting the Schneiderian membrane with theradiographic contrast medium using the aqua system, (G) broadening the hole using the spread drill, (H) filling with bonereplacement material using the spread drill, and (I) placing the implant. 259 ¥ 190 mm (72 ¥ 72 DPI).
6 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2010
occurs in 10 to 35% of sinus-lift procedures,19–21
although membrane perforation is reduced to 7% when
osteotomy is performed using the piezoelectric tech-
nique.22 Within the limitation of sample size, the pre-
sent results confirmed that the Water Lift System could
reduce the risk of perforating the sinus membrane.
The ability of the Water Lift System to reduce the
risk of perforating the Schneiderian membrane is most
likely due to two primary reasons. The first reason is that
the Water Lift System utilizes a resistance-sensitive drill
(AI drill) that is designed to only function when the drill
bit meets solid tissue, such as bone. The AI drill stops
when the drill bit meets soft tissue, such as the Schneide-
rian membrane because of the drill control mechanism.
The resistance applied to the bit controls the AI drill.
When resistance is applied to the drill bit, the center drill
[(b) in Figure 1C] moves down and is connected to the
shaft [(a) in Figure 1C]. Immediately after the center
drill is connected to the shaft, the center drill turns on.
The center drill moves to the original position as soon
as the resistance disappears due to contact with the
Schneiderian membrane. The center drill is then discon-
nected from the shaft, which stops the drilling due to the
lack of resistance, and the center drill is pushed ahead by
0.5 mm. Consequently, the center drill moves forward
by 0.85 mm to stop drilling because the length of the AI
drill tip is 0.35 mm. This relatively short movement will
not result in perforation of the Schneiderian membrane.
Furthermore, when drilling is stopped due to the lack of
resistance, the bone chip in the bone chip reservoir at the
tip of the center drill springs off in the direction of the
Schneiderian membrane. This results in contact between
Figure 4 A case report of the lateral approach. (A) Preparing a door in the lateral maxillary sinus wall using the artificially intelligentdrill, (B) placing the aqua-lifter into the door with an aqua-lifter placer, (C) DreamRay™ image of Schneiderian membrane liftingwith the radiographic contrast medium using the aqua system, (D) preparing the window for the sinus lateral approach using theburin drill, (E) filling with bone replacement material through the window, (F) preop panoramic view, and (G) postop panoramicview. Filling with bone replacement material was performed at the site of the missing maxillary right second premolar (tooth 15).The patient had a superior curving sinus floor (protrusion into the sinus at the sinus inferior wall). 259 ¥ 200 mm (72 ¥ 72 DPI).
Water Lift System in Sinus Membrane-Lifting Operation 7
the bone chip and the Schneiderian membrane prior
to contact with the drill tip. Simultaneously, the
Schneiderian membrane can be slightly elevated by the
bone chip, which prevents the drill bit from contacting
the Schneiderian membrane directly. These factors
reduce the potential for Schneiderian membrane perfo-
ration. Therefore, the AI drill of the Water Lift System is
more suitable for drilling while maintaining the integ-
rity of the Schneiderian membrane. To our knowledge,
the AI drill used in this study is the first resistance-
sensitive drill to be utilized in the dental profession.
The second reason is that the Water Lift System uses
a sinus membrane elevation system (aqua system) that
provides evenly distributed hydraulic pressure on the
Schneiderian membrane during sinus membrane eleva-
tion. The aqua system is comprised of an aqua-lifter and
Figure 5 A case report of the crestal approach. (A) DreamRay™ image of void removal, (B) DreamRay™ image of residual bonecompaction, (C) DreamRay™ image of artificially intelligent (AI) drilling, (D) AI drilling, (E) DreamRay™ image of Schneiderianmembrane lifting with the aqua system, (F) DreamRay™ image of filling with bone replacement material, (G) DreamRay™ image ofimplant placement, (H) placing the implant, (I) preop panoramic view, and (J) postop panoramic view. The implant was placed atthe site of the missing maxillary right second premolar (tooth 15). The patient bone height was 8.6 mm with D3 bone.259 ¥ 250 mm (72 ¥ 72 DPI).
8 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2010
an aqua-injector. The elevation of the Schneiderian
membrane using the aqua system can be explained by
Pascal’s principle, which states that “a change in the
pressure of an enclosed incompressible fluid is conveyed
undiminished to every part of the fluid and to the
surfaces of its container.” Therefore, the aqua system can
be used to safely elevate the Schneiderian membrane
without resulting in damage. Based on the capability
of the Water Lift System to elevate a greater section of
the Schneiderian membrane to a greater degree around
the implant compared to conventional sinus-lift instru-
ments, a larger amount of the bone replacement mate-
rial can be filled through the crestal approach with the
Water Lift System compared to the conventional crestal
approach with conventional sinus-lift instruments.
Filling with a larger amount of bone replacement mate-
rial may result in improved implant stability over a
longer time period.
The Schneiderian membrane elevation technique
that utilizes the aqua system differs from other reported
techniques that are based on fluid injection (hydrodis-
section).23 In the technique proposed by Chen and Cha,
the force is applied to only one part of the Schneiderian
membrane. Therefore, the even distribution of tension
is not possible, and premature rupture (bursting) of the
Schneiderian membrane may occur. Moreover, excess
pressure cannot accumulate in the cavity due to the risk
of Schneiderian membrane perforation because the use
of a fluid jet causes pressure peaks at those sites where
the jet impacts the Schneiderian membrane.
The use of the Water Lift System is also relatively
easy, because the AI drill operation depends on a
mechanical control system instead of on an operator.
Therefore, a similar outcome may be obtained among
experienced operators and surgeons who are unfamiliar
with the Water Lift System or even novices to dental
implantology.
A precaution to using the AI drill is that the type of
bone encountered in the crestal approach differs from
that encountered in the lateral approach. Whereas only
cortical bone is involved in the lateral approach, a mul-
tilayer bone structure composed of spongy and cortical
bone is encountered in the crestal approach. Therefore,
drilling with the AI drill in the crestal approach should
be performed after removal of the bone void to prepare
the hole for access to the Schneiderian membrane. If
the AI drill is used to drill spongy bone without void
removal, the control mechanism of the AI drill may not
work properly due to the absence of sufficient resistance
by the spongy bone. Therefore, void removal is necessary
to create a suitable environment that will ensure proper
functioning of the AI drill.
Any fluid (eg, saline or whole blood) can be selected
for use in the aqua system. However, the radiographic
contrast medium is recommended to determine the
extent of Schneiderian membrane lifting by standard
X-ray or dental panorama X-ray examination. The
amount of bone replacement material required can be
easily determined based on the volume of radiographic
contrast medium that is injected. Additionally, the use
of radiographic contrast medium can facilitate visual-
ization of any Schneiderian membrane perforation.
Perforation did not occur if the elevated Schneiderian
membrane has a dome shape on a standard X-ray or
panoramic imaging. However, perforation did occur if
the elevated Schneiderian membrane has a collapsed
shape and the radiographic contrast medium diffuses to
the inside of the sinus.
Aside from Schneiderian membrane tearing, infec-
tions present another considerable risk of this dental
surgery.3,24,25 No microbial infections were observed in
the 68 successful cases during this study. The simple
disassembly of the AI drill and components allows
for easy sterilization (refer to Figure 1C), which may
reduce the risk of microbial infections during the next
operation.
Due to the many advantages of using the Water Lift
System for sinus membrane elevation, the Water Lift
System should be considered as a surgical instrument for
sinus membrane lifting.
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