More Predictable Osteotomy

When using implants in the posterior maxilla, the sinus is often a frequent anatomical restriction. Two basic techniques have been used since the 1980’s to elevate the sinus floor. Tatum and Misch first reported on the lateral wall (Caldwell-Luc) procedure and Tatum also tried a crestal approach. In 1994 Summers reported on a less traumatic and invasive crestal approach using osteotomes to elevate the sinus.

The problem that I have found with osteotomes (on the market) is that as the clinician increases the diameter of the osteotomy with subsequent osteotomes the osteotome does not fit into the osteotomy. Using the rationale of pilot drills (Fig. 1) for conventional drilling of the osteotomy led to the development of the Salvin/Drew osteotomes (Fig. 2). These “pilot/countersink” osteotomes are made to be used in conjunction with tapered osteotomes (Fig. 3). With conventional tapered osteotomes, a significant vertical depth (approximately 10 mm) had to be achieved before the next osteotome could be inserted into the cortical crest osteotomy. The problem is that subsequent osteotomes may not necessarily follow the initial path, so crestal cortical bone could be compromised. In addition, when ridge expansion is also needed, the crestal bone is often destroyed instead of widened.

It should be noted that these osteotomes diverge for ridge expansion and that the tip is concave to introduce graft material and push bone apically from the sides of the osteotomy walls. This design compacts the osseous layer around the osteotomy and creates a denser bone interface with the fixture (Fig. 4).

The following schematic sequence represents the Salvin/Drew osteotomes.

1. Initially accurate radiographic measurements are made from the crestal bone to the base of the sinus floor (Fig. 5).

 

1. Next using a surgical guide the Drew 1.8 is tapped approximately 1 mm to 2 mm coronal to the floor of the sinus (Fig. 6). This countersink pilot osteotome has now widened the osteotomy to accept the Salvin osteotome.

 

1. With the surgical guide in place, the 2.6 osteotome is tapped to the desired measurement
   (Fig. 7).

 

1. At this point a radiograph is taken with parallel pins (directional indicators) in place. If necessary modifications can be made by cutting parallel pins in half. This will increase pin stability (Fig. 8).

 

 

5. The entrance of the osteotomy is widened and compacted with the use of the Drew 2.6 countersink/pilot osteome (Fig. 9). The osteotome widens the entrance of the osteotomy to accept the Salvin 3.1 osteotome. This osteotome is now tapped or pushed to the final length. This final length never changes (Fig. 10).

 

5. The osseous graft material is now placed in the osteotomy and the 3.1 osteotome is tapped or pushed to the final depth measurement, (Fig. 11) with the addition of graft material the elevation progresses to the desired final depth (Fig. 12).

 

5. In (Fig. 13) a radiograph is taken to take a measurement and choose the proper fixture size.

Depending on the crestal coritical bone, a subsequent Drew osteotome (3.1, 3.8, etc.) can be used to expand the entrance of the osteotomy (Fig. 14). It should be noted that since the osteotomes range from 1.8 to 5.0 mm you can use a sequence for narrow or wide fixtures. Also realize that drills can be used with the osteotomes for select shaping of the osteotomy. In (Fig. 15) the implants have been selected and placed in the osteotomy.

CASE REPORT 1
In this case, the patient was taken through a periodontal and prosthetic workup. Temporization was completed to restore vertical dimension (Fig. 16). Following healing, (post extraction and osseous grafts), the patient was scheduled for implants in the maxillary left first and second molar areas (Fig. 17). Using the modified osteotome technique described above, the sites were prepared (Fig. 18). The Salvin and Drew osteotomes enabled the operator to elevate the sinus, compact the osteotomy, maintain parallelism, and preserve crestal cortical bone (Fig. 19).

CASE REPORT 2
The patient was taken through a periodontal/prosthetic evaluation (Fig. 20). The patient was temporized with full arch provisionals (it should be noted that only the cuspids in the maxilla were retained in the final prosthesis). At this time a CT scan was taken with the patient wearing acrylic temporaries with radiographic locators (Fig. 21). (Fig. 22) indicated that osteotome ridge expansion was necessary. Using Salvin and Drew osteotomes the ridge was slowly expanded to accept fixtures in the lateral incisors areas (Fig. 23).

CONCLUSION
The Salvin/Drew Osteotomes can be used for sinus elevation, site development, and ridge expansion/augmentation. These osteotomes will aid the clinician in cases where vertical and horizontal bone is limited.

Note: Figure 3 &16 through 23 reprinted from: Inside Dentistry: Drew HJ, Chiang T, Simon BI. The osteotome technique: modifications to the original approach. 2007;3(10): 58-65. Copyright 2007. With permission from AEGIS Publications, LLC.”