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1
 
Samuel
 
Lee,
 
DDS
*
,
 
Grace
 
Kang
‐
Lee,
 
DDS
†,
Kwang
‐
Bum
 
Park,
 
DDS,
 
MS,
 
PhD
‡
,
 
Thomas
 
Han,
 
DDS,
 
MS
 
§ 
Abstract
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Background:
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The placement of dental implants in posterior maxilla is often a challenge due to pneumatization of maxillary sinus. Dental surgeons have predictably overcome these obstacles by performing bone grafting proceduressuch as lateral window technique (modified Caldwell-Luc). But, mobidity has been a concerned due to postoperativebrusing, pain, and swelling. To reduce the mobidity, many internal (crestal) approaches to sinus grafting wereintroduced using osteotome, reamers, tapping drills, piezo, ISM, HSC, etc. But still, all these internal techniques forsinus grafting are difficult to predict their results because of lack of visibility when opening sinus floor and manipulatingSchneiderian membrane.
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Purpose:
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Presenting a new sinus grafting technique that is systematic and predictable. This system utilizes crestalapproach to reduce morbidity. Unlike the other crestal approaches to sinus grafting, the uniqueness of this system is thatit is not a blind technique and the result of membrane elevation is comparable to that of lateral approach.
U
Conclusion:
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The new systematic approach to internal sinus grafting is simple, predictable, without morbidity associatedwith lateral window technique.
U
KEY WORDS:
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Sinus, grafting, Lift, dental implants, lateral window, crestal window, internal sinus lift, crestal sinus lift,sinus elevation, osteotome, Schneiderian, sinus membrane, minimally invasive sinus surgery
 
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Introduction
 The treatment of posterior edentulism has been achallenge for dental physicians due to poor bonequality and quantity (due to pneumatization of maxillary sinus). We have overcome theseobstacles by bone condensing and bone grafting intomaxillary sinus under Schneiderian membrane.
1-18
 Bone grafting into sinus have produced predictableresults enabling clinicians to place longer implant formore stable prosthesis with better and long termoutcome.
3
However, morbidity associated withlateral window grafting procedure has beenconcerned.
5, 6, 7, 15, 17, 18
Severe brusing, swelling,and pain are the common postoperativecomplications due to flap elevation beyondmucogingival junction.
5, 6, 7, 15, 17, 18
Theintraoperative complication that arises from therupture of intraosseous branch of posteriorsuperiorior artery (branch of maxillary artery) ispanic-striken
15
. Moreover, the technical nature of lateral window procedure is easily accompanying thepossibility of Schneiderian membrane perforationwhile opening an window and elevating sinusmembrane. Therefore, nowadays, many internal(crestal) approaches to sinus grafting have beenintroduced such as osteotome
5, 6, 7
, reamers
17
, tappingdrills
18
, piezo, ISM
17
, HSC
15
, etc. Nevertheless, allthe internal techniques for sinus grafting to this dateare unpredictable for average clinicians, because of lack of visibility when opening sinus floor andmanipulating Schneiderian membrane.Standard diameter implant (4.0mm) has been a greatsolution for premolar area, but it has somelimitations in the molar area resulting pooremergence profile
21
, fracture of implants
20
, crestalbone strain
19
, and narrow occlusal table. Minimumof 5mm to 8mm implants in diameter willovercome poor bone quality by increasing bone toimplant contact surface as well as making superioremergence profile
21
. Such diameter of implants inmolar area also decreases the fracture rate of implants, crestal bone stress, and allows fabricationof natural occlusal table
20
.Use of wide diameter implant, which is moreappropriate for molar restoration as described above,opened a new door to sinus grafting. Crestalwindow, instead of lateral window, is made with
“Crestal
 
Window
 
Sinus
 
Lift,”
 
minimally
 
invasive,
 
predictable,
 
and
 
systematic
 
approach
 
to
 
sinus
 
grafting.
 
 
2
 
trephine bur to elevate sinus membrane and graftbone into sinus with direct visualization (not a blindtechnique like previous crestal approach techniquespublished). The new innovation in sinus graftingdescribed in this paper makes sinus grafting easy andpredictable, without the cost of morbidity associatedwith lateral window technique.
UU
Description of the Innovation/Method
 Flap ElevationIncision design that is at least 2 mm more palatalthan implant position and flap elevation that does notopen beyond mucogingival junction is recommended(figure 1). This type of incision design allowsminimal pain, prevention of oral antralcommunication in case of perforation, unilateralretraction of flap, and option of doing one or twostage implant placement without losing keratinizedtissue.
Figure 1. Palatal incision for minimal pain, prevention of oralantral communication in case of perforation, unilateralretraction of flap, and allows option of doing one or two stageimplant placement without losing keratinized tissue.
 Location of crestal windowLowest point is located by aid of panoramicradiograph (figure 2). It is more favorable if thisposition coincides with implant position. If implantplacement on #2, 3, and 4 are anticipated and #3 siteis the lowest sinus floor, #3 site is used to lift sinusmembrane. The rationale behind this method is thatthe elevation is done from the bottom to up. Thatbeing the case, this approach is easier to elevatefrom lowest point.
Figure 2. Internal sinus lift initiated from lowest location.
 Crestal window with set of specially designedtrephine burs
#
 Round windows is made on the crestal bone with setof specially designed trephine bur which is 1 mmsmaller in diameter than final implant size. Forexample, if 6 mm implant is anticipated, 4.0 mminner diameter and 5.0 mm outer diameter is used.Unlike the conventional trephine that uses 700-1000rpm with ample amount of irrigation, this techniqueutilizes lower speed, 40-50 rpm without irrigation,for that reason it is called “Waterless technique.
18
”Waterless technique has many advantages of notusing saline irrigation. For instance, a patient ismore comfortable during waterless procedure, asurgeon is able to collect more autogenous bone,and this technique is more friendly to vital structuresuch as sinus membrane, lingual plate, buccal wall,arteries, and nerves. Moreover, this techniqueenables implant position and angulation more precisebecause it is performed at lower speed
18
.Trephining at precise location can be challengingdue to drifting nature of trephine bur. In order tominimize heating of bone and to maximizevisualization and precision of trephine bur, a newlydesigned “pointed trephine
#
” is used at the speed of 50 rpm without irrigation (figure 3). The pointedtrephine is used to mark the location for crestalwindow, and penetrates only cortical bone of crest(figure 4).The second step of this system utilizes the trephinethat has adjustable stopper
#
. One millimeter shortof sinus floor from crestal ridge is estimated with aidof radiograph, and the “stopper trephine” is used toset that length inside the trephine. For example, if 6 mm of bone height is anticipated, then stopper isset at 5 mm within trephine. Using 50 rpm speed,
 
3
 
the “stopper trephine” is used to take bone core out(figure 5). If the sinus floor is weak and relativelyflat, the sinus floor will fracture off and exposeSchneiderian membrane (figure 6). However, if sinus floor is dense or in incline plane, it will leaveabout 1 mm of cortical bone (floor of sinus).
Figure 3. Pointed trephine to mark precise location of crestalwindow position.
 
Figure 4. After use of pointed trephine. Pointe trephine isused to mark the position of implant not penetrating more than2 mm.
 
Figure 5. Stopper trephine used at 50 rpm 1 mm short of sinusfloor.
 
Figure 6. Flat sinus floor will be taken out with trephine burleaving just sinus membrane most of time.
 If cortical bone is still intact after the use of the“pointed trephine” bur, then the “sinus diamondbur
#
” is used to open the sinus floor withoutperforating the sinus membrane (figure 7 and 8).This is done very predictably because of the formulabelow:Pressure = Force / AreaThe force is minimized by utilizing stopper at theshoulder of the diamond bur. The diamond surfacewill grind out bone rather than cutting it. Thesefine bone particles will act as buffer between sinusmembrane and diamond bur creating larger surfacecontact, which in turn reduces pressure on themembrane. In addition, large diameter of diamondbur is used, rather than small one to increases surfacearea, which in fact, also decreases pressure onScheiderian membrane. This concept is similar to
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