the new york state dental journal
Volume82 Number 4
June/July 2016 20 In Love with His Profession and His Football Team A conversation with NYSDA President Richard F. Andolina, D.D.S.
25 Clinical and Radiographic Examination of Endoscopically Controlled Indirect Sinus Lift Shefali Phogat, M.D.S.; Reshu Madan, M.D.S.; Harish Yadav, M.D.S.; Anil Yadav, M.D.S.; Puja Malhotra, M.D.S. Study undertaken to quantify gain in height of bone at implant sites by endoscopically controlled osteotome sinus floor elevations with simultaneous implant placement and to record number of sinus membrane perforations determined technique is a safe and well-controlled procedure that is more acceptable to patients. An in vivo study.
30 Eagle Syndrome
Cover: For Rick and Molly Andolina, home is the small village of Arkport, population 800. The small town life suits the couple just fine.
2 Editorial Emergency preparedness 5 Attorney on Law Employment law undergoes changes 8 Letters 10 Perspectives A veteran’s take on millennials 14 Association Activities 59 Component News 69 Read, Learn, Earn 72 Books 73 Classifieds
David Whiting, D.D.S.; Louis Mandel, D.D.S. Both an elongation of the styloid process and ossification of the stylohyoid ligament, Eagle syndrome is best diagnosed through imaging, as subjective symptomatology is varied or can be absent. Case report.
32 A Comparison of Three Camera Systems for Intraoral Photography Lawrence Parrish, D.D.S., M.S.; Ruben Sagun, D.D.S., M.S.; Stephen J. Hess, M.S., D.D.S.; Gene Gaspard, D.D.S.; Chol Chong, D.D.S., M.S.; Scott Gruwell, D.D.S., M.S. A single lens reflex camera, a prosumer camera and a smartphone camera were compared for their ability to produce digital intraoral images. Sharpness, depth of field, exposure, white balance and image composition were considered.
38 Effect of Molding Technique on Two Physical Properties of Acrylic Resin Specimens Jafar Gharechahi, D.D.S.; Nafiseh Asadzadeh, D.D.S.; Foad Shahabian, D.D.S.; Maryam Gharechahi, D.D.S. Study was conducted to compare dimensional changes and flexural strength of specimens processed by conventional and injection-molding techniques.
46 Resective or Regenerative Periodontal Therapy: Considerations during Treatment Planning Rajbir Singh, B.D.S., M.D.S.; Srinivas Sulugodu Ramachandra, B.D.S., M.D.S. Successful long-term management of molars with advanced periodontal disease with secondary endodontic involvement is challenge to periodontist. Effective treatment of patient with deep periodontal pocket on right mandibular first molar and bone loss extending to apex of mesial root, forms discussion of factors to be considered when choosing regenerative over resective periodontal therapy. Case report.
50 Oral Jewelry and Piercing: Risks to Health Ronald I. Maitland, D.M.D.; Jeffrey S. Blye, D.D.S. What appears to be a decorative fad, pursued by people of all ages, is, for the most part, an invasion of the body by poorly trained individuals.
75 Index to Advertisers 80 Addendum The New York State Dental Journal is a peer reviewed publication. Opinions expressed by the authors of material included in The New York State Dental Journal do not necessarily represent the policies of the New York State Dental Association or The New York State Dental Journal. EZ-Flip version of The NYSDJ is available at www. nysdental.org and can be downloaded to mobile devices.
Use your smartphone to scan this QR Code and access the current online version of The New York State Dental Journal.
editorial
What if it’s an Emergency?
A
If a patient in pain calls your office and you’re out of town, have you made arrangements for someone to cover for you?
friend of my wife’s had a tooth extracted by her dentist. Over the next few days, she developed severe pain in the region of the extraction. I told my wife to tell her friend to contact the dentist who extracted the tooth to tell him about this. My wife related her friend had tried to do this, but when she called the office, she was told the dentist was out of town and unavailable. My wife’s friend asked what she should do about the pain and was told to wait until Monday and call the office back for an appointment. Since she was in excruciating pain, this option was really no option at all. I advised her to call the hospital, which has a dental residency program, to see if she could get help there. Because it was Saturday, the clinic was closed, and she was told to call back on Monday. I then suggested she call an oral surgeon to see if he could help her. Again, she was told to see her dentist on Monday, that the oral surgeon would not see her as she was not a patient of record. I could understand why the oral surgeon would not see a patient he did not know. With all the emphasis on opioid abuse, it’s possible he thought she was searching for pain medications and was not really in trouble. I don’t agree with that assessment, but it’s possible that was his thought process. What I 2
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don’t understand is how a dentist can leave the area and not have someone covering the practice in his absence. When I leave town, I always make sure there is another orthodontist available to cover any emergencies that may arise with my patients. It is just the proper thing to do. It is also the ethical thing to do. The ADA Code of Ethics and Professional Conduct states: “Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record. Dentists shall be obliged when consulted in an emergency by patients not of record to make reasonable arrangements for emergency care. If treatment is provided, the dentist, upon completion of treatment, is obliged to return the patient to his or her regular dentist unless the patient expressly reveals a different preference.” And the NYSDA Code of Ethics states: “Emergency Service. Dentists shall be obligated to make reasonable arrangements for the timely emergency care of their patients by a licensed dentist. Dentists are obligated, when consulted in an emergency by persons who are not their patients, to recommend reasonable arrangements for emergency care. Should a dentist undertake emergency treatment of a new patient, the patient will have the choice of where to receive subsequent dental care.”
THE NEW YORK STATE DENTAL JOURNAL
EDITOR Kevin J. Hanley, D.D.S.
ASSOCIATE EDITOR Chester J. Gary, D.D.S.
MANAGING EDITOR Mary Grates Stoll
ADVERTISING MANAGER Jeanne DeGuire
ART DIRECTORS Kathryn Sikule / Ed Stevens
EDITORIAL REVIEW BOARD Frank C. Barnashuk, D.D.S. David A. Behrman, D.M.D. Michael R. Breault, D.D.S. Ralph H. Epstein, D.D.S. Daniel H. Flanders, D.D.S. Joel M. Friedman, D.D.S. G. Kirk Gleason, D.D.S. Brian T. Kennedy, D.D.S.
It really can’t be clearer. You must make arrangements for emergency coverage when you are away from the practice. This woman’s dentist failed to do this. To be told by the practice that she had to suffer through the weekend with what was possibly a dry socket is truly unconscionable. Any patient in pain should be seen as soon as humanly possible. As we all know, dental discomfort can be among the worst pains a patient can experience. Her dentist should have had a contingency plan for covering his emergencies while out of town. The oral surgeon also should have done something to help alleviate the patient’s pain. At the least, he should have offered to see the patient to determine if there was anything he could do to help. If it was a dry socket, there are steps he could take to alleviate the patient’s pain without prescribing drugs. If it wasn’t a dry socket, he could at least reassure the patient that the pain should diminish over the weekend and that she should continue to take the medication prescribed by her dentist and see him on Monday. However, that didn’t happen and the patient was left in pain and with the feeling that no one would help her in her time of need. Is that the conclusion we want our patients to have? That we really don’t care about them or that we won’t go the extra mile when they need our help most? I don’t think so. In my practice, I carry a pager when not in the office. I am available 24 hours a day for my patients if the need arises. I have been called at all times of the day and night by patients who have an emergency. Of course, my emergencies are a bit less dramatic than those confronting most dentists. However, there are times when a patient has been involved in a sports accident and braces have become embedded into lips and cheeks. Parents call with great concern for their child and want to know what can be done to help them. I dutifully go to the office to see the patient, to address the emergency. It may be inconvenient for me to see the patient at that particular time, but, I think, what would I do if this were my son
Stanley M. Kerpel, D.D.S. Elliott M. Moskowitz, D.D.S., M.Sd Francis J. Murphy, D.D.S. Eugene A. Pantera Jr., D.D.S. Robert M. Peskin, D.D.S. Georgios Romanos, D.D.S., D.M.D., Ph.D., Prof.Dr.med.dent Pragtipal Saini, B.D.S., D.D.S., M.S.D. Robert E. Schifferle, D.D.S., MMSc., Ph.D.
PRINTER Fort Orange Press, Albany NYSDJ (ISSN 0028-7571) is published six times a year, in January, March, April, June/July, August/September and November, by the New York State Dental Association, 20 Corporate Woods Boulevard, Suite 602, Albany, NY 12211. In February, May, October and December, subscribers receive the NYSDA News. Periodicals postage paid at Albany, NY. Subscription rates $25 per year to the members of the New York State Dental Association; rates for nonmembers: $75 per year or $12 per issue, U.S. and Canada; $135 per year foreign or $22 per issue. Postmaster: Please send change of address to the New York State Dental Association, Suite 602, 20 Corporate Woods Boulevard, Albany, NY 12211. Editorial and advertising offices are at Suite 602, 20 Corporate Woods Boulevard, Albany, NY 12211. Telephone (518) 465-0044. Fax (518) 465-3219. E-mail info@nysdental. org. Website www.nysdental.org. Microform and article copies are available through National Archive Publishing Co., 300 N. Zeebe Rd., Ann Arbor, MI 48106-1346.
The New York State Dental Journal • JUNE/JULY 2016
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or daughter? I would want immediate treatment to solve the problem. I don’t know why the dentist involved had not set up emergency coverage for his practice. Maybe he thought it was not necessary, as he would only be gone over the weekend. Maybe he tried, but none of his colleagues would or could cover for him. However, Murphy’s law is bound to come into play when proper arrangements are not made. And, I don’t know why the oral surgeon would not see the patient. Maybe he was apprehensive about seeing a patient he had never seen before because he was fearful of a lawsuit. With all the talk about opioid addiction, he may have thought the patient was doctor shopping and didn’t want to get involved. Therefore, it was just easier to tell the patient there was nothing he could do to help and leave it at that. But the dental profession failed this patient. She had a tooth extracted, developed severe pain, and no one was there to help her. This is not the profession I have come to know and love.
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When we earn our dental degrees and licenses, we assume the duty to provide the best care possible to our patients. That includes delivering emergency care in a timely manner. It does not mean providing emergency care when it is convenient for us. It means if we are not available to offer such care, we have a system in place to take care of our patients in our absence. It also means we should be available for our colleagues when they are out of town to cover their emergencies. Some emergencies are simple affairs, as are most of mine. Some, however, are not. We have to be available for our patients when they need us, not just when it is convenient for us. Our patients deserve nothing less.
D.D.S.
Lynne Brennan Photography
In Love with His Profession and His Football Team A Conversation with NYSDA President
Andolinas at home in Arkport. Rick and wife, Molly, are joined by sons, from left, Nick, Mitch, Rick Jr.
Richard F. Andolina, D.D.S.
All you really need to know about Rick Andolina is contained in his own admission that he has a hard time saying “no” when asked to take on yet another responsibility. The consequence is that while filling the office of president of the New York State Dental Association, he’s also serving as chairman of the ADA Political Action Committee. While some might see this as an excess of responsibility, Rick counters that it’s a marriage of his two loves: dentistry and advocacy. He says he has always felt it necessary that he work to help protect his profession from political foes and regulatory measures that threaten to damage or alter the livelihood of his colleagues. It’s also essential to know that Rick is an unabashed Ohio State Buckeye fan. What follows is more information about Rick, gleaned from a recent conversation.
Mark Bauman, DDS
Rick Andolina, who will take over next year as chair of the ADA political action committee, at ADA Washington Leadership Conference earlier this year with Chuck Norman of Greensboro, NC, ADA 2013-2014 President.
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Where did you grow up? I’m a small town boy. I grew up in Stannards, a hamlet of around 400 people at the time, in New York State’s Southern Tier, 70 miles south of both Rochester and Buffalo. The closest town, Wellsville, population of 8,000, was a couple of miles away. Stannards was best known for producing George “Gabby “ Hayes, the cowboy sidekick of the Wild West movie days. There were sightings of him around town whenever he came from Hollywood to visit.
Lynne Brennan Photography
Avowed fans of The Ohio State University Buckeyes, Andolina clan can be found on weekends during football season cheering their team on.
What about your family? My parents were hard working people who ingrained the importance of a college education in me and my two sisters. While an undergraduate education was an absolute requirement, my parents felt it should lead to a postgraduate education. My father was a university professor teaching hematology and nursing at a small college, Alfred State University. My mother was employed in banking, working in the consumer credit division of a local community bank. One of my sisters, Pam, worked in the medical division of Kodak, while my other sister, Patty, became an optometrist. After graduating from Wellsville High School in a class of around 140, I attended the largest, single campus university, The Ohio State University. While there was a huge discrepancy between the population there and where I grew up, I adjusted quickly and immediately became an avid Buckeye fan. I then attended the State University of New York at Buffalo School of Dental Medicine, receiving my dental degree in 1980. Following graduation, I completed a one-year general practice residency at Millard Fillmore Hospital in Buffalo. I returned to my small town roots, establishing my practice in Hornell, a small city of fewer than 9,000 people in Steuben County, 27 miles from where I grew up and 60 miles south of Rochester. It was there that I met my wife, Molly. We were married in 1982, and we have been blessed with four wonderful children—three boys and a girl. While my practice is in Hornell, we live in Arkport, a village of 800 residents.
Rick and daughter, Jill, at Ohio State for game. The Andolinas lost their daughter three years ago to leukemia. Rick calls her his “hero.”
If there was one thing I expected from my children it was that they love sports—and they had to be Buckeye fans. We attended Ohio State football games every year, and they quickly learned “the thrill of victory and the agony of defeat.” Fortunately for us, we felt the thrill more often than the agony. My eldest son, Rick Jr., followed my educational path by attending The Ohio State University and then obtaining his dental degree at the University at Buffalo School of Dental Medicine three years ago. I am fortunate that he decided to join me in my practice, along with my partner, Ryan Batte, a 1989 University at Stony Brook School of Dental Medicine graduate. My second son, Nick, attended Alfred University, where he played basketball on the college team. He continued his studies at the New York Chiropractic College and now practices chiropractic medicine in Virginia. He and his wife, Jessica, also a chiropractor, are expecting their first child and our first grandchild, a son, this September. My youngest son, Mitch, graduated from Alfred State University. He is a self-employed computer technician, working and living in Arkport. Our daughter, Jillian, graduated from the State University at Geneseo in 2011. Shortly thereafter, she was diagnosed with leukemia. Sadly, we lost her two and a half years later, at the age of 26. She was a true inspiration not only to us, but to everyone who ever met her or followed her during her courageous fight against the dis-
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Lynne Brennan Photography
Rick and his other “family,” his office staff. Deb Bossie to his right. Mary Valentine to his left. Standing, left to right: Donna Woolever, Pam Sniffen, Eileen St. James, Starla Williams, Sara Paul. In back: dental partner Ryan Batte and son, Rick Jr., who joined the practice three years ago.
Best of friends after all these years. Members of the UB School of Dental Medicine Class of 1980. From left: Rick Andolina, Jeffrey Baumler, Frank Barnashuk, David Bonnevie, Jonathan Gellert, Andy Vorrasi.
Rick and Molly at ceremony honoring Rick, 2004 recipient of UB Alumni Association Humanitarian of the Year Award.
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Rick was on TV once, along with his 1921 Ritter open cathode ray tube dental X-ray unit, which he purchased at auction for $25. The two appeared on History Channel’s “American Restoration.”
ease. I can never thank all of my friends in the dental community enough, both statewide and nationwide, for the love and support they gave during her illness. Jill will always be my hero. As she struggled with her disease, she was more worried about others than she was about herself. Jill was a lover of animals and a frequent visitor and volunteer at the Hornell Area Humane Shelter. They recently built a dog park in her memory next to the shelter. And while I’m discussing my family, I need to recognize the staff at my dental office. They, too, are my family. Two of them have been with me for over 30 years, while, until recently, the shortest serving person had been with me for more than 15 years. This year, we added another staff member. These are very experienced people, dedicated to our patients’ well-being. Without their help and understanding, it would have been almost impossible for me to take on the voluntary positions I have over the years. Many dentists say they disliked their time in dental school. What is your recollection of those days? I can honestly say those four years of dental school were some of the best years of my life. I love my classmates and am proud to be a member of the UB Dental Class of 1980. It was a very interesting class, with the average age of the students a little older than those in other classes. The Vietnam War was over, and we had several veterans in our class. But the best thing I can say about the class was that we were supportive of one another and united as
Rick’s 1975 fully restored Camaro is his personal time machine. It’s the car that got him through dental school and his residency.
a group. I was, and continue to be, extremely honored that they voted me their representative to ASDA and an officer all four years of school, then supported me as president of the UB Student Dental Association my senior year. It seems that even early in your career you were involved at various levels of organized dentistry. How did that come about? Perhaps it was because I have always been willing to speak up and have always had a hard time saying no. Anyway, whenever a volunteer was needed, I jumped in to help. Maybe it was related to my involvement with ASDA as a student. It was a total surprise when I was asked to join the Board of the Seventh District Dental Society a few years into my career. Other positions within the organization quickly followed, and soon I was asked to participate at the state and national levels. Even with that, my home within organized dentistry has been and always will be in the Seventh District. There is a culture of inclusion and involvement within the organization. The support and encouragement of my fellow district members and mentors, such as Fred Halik, Bill Calnon, Warren Shaddock and Andy Vorrasi, are responsible for my success. You have received acknowledgements in dentistry. Are there any that stand out in your mind? The greatest honor for me has always been to serve alongside my colleagues in organized dentistry. However, as far as honors bestowed, it would have to be receiving the University at Buffalo Alumni Association Humanitarian of the Year Award in 2004 and, more recently, being selected to deliver the commencement address at the 2016 UB School of Dental Medicine graduation ceremony.
Lynne Brennan Photography
If you could make a career choice again, would you still choose dentistry? Would you recommend it to others? Absolutely to both questions. I love what I do, and I feel fortunate to be a dentist. Recently, US News and World Report released its list of the best professions and jobs. I was not surprised that dentistry was listed at number one. I have the opportunity every year to visit UB dental school and address the students, along with other colleagues, on ethics and professionalism. I tell them that what defines dentistry as a profession and not a job is that its members must abide by a strict code of ethics. I firmly believe that the future of the dental profession is bright. If I didn’t believe that, I wouldn’t have encouraged my son to pursue a dental career. Is there an area of concern you have for the profession, and how would you address it? This question goes directly to the core of what has concerned me for years and that is advocacy. Every day, decisions are being made by outside organizations and government agencies that can have a profound impact upon our profession, our livelihood and our patients. Often it is an inadvertent consequence of legislation that causes detrimental effects. We have to be ever vigilant. And we must respond to these intrusions with a united voice. Individuals often say they don’t want to be involved in politics. If we fail to get involved, we rely upon others who may not have any knowledge of our profession. I’ve been active with EDPAC, NYSDA’s political action committee, in the past as an officer. I currently serve as chair-elect of the ADA political action committee, ADPAC. I believe our members must do better at the grassroots level, else we may go down the same road that other medical professions have. At the ADA level, a dentist who is a constituent is assigned to every member of Congress and the Senate and given the title of Action Team Leader. That person
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Rick’s commencement address to 2016 graduates of his alma mater, UB School of Dental Medicine, stressed ethics in practice and the need to engage with organized dentistry.
and his or her team is our conduit to their assigned legislator. I strongly believe we need to replicate this system with the members of our state Assembly and Senate. Our lobbying efforts have been extremely effective because of our experienced lobbyist, Roy Lasky, and EDPAC. Now it’s time for dentists to take a more active role. Expressing the importance of advocacy and involving more dentists, young dentists and dental students in the process is one of my goals during my year as president. Every year, I go to student events to discuss advocacy. As dentists, we must never forget that the decisions made today will affect the profession and its future members. We need to get our younger members actively involved. Do you have any concerns about serving as NYSDA President? While I welcome the opportunity to serve, I wouldn’t be telling the truth if I said I didn’t approach this position with a little trepidation. But, as I think about it, I realize I have a tremendous support group in Albany—our seasoned, dedicated and knowledgeable staff, led by Executive Director Mark Feldman. They are unquestionably the best. And I will rely upon them throughout the year. In addition, I will look for support from my fellow officers and the entire Board of Trustees. The components have selected extremely qualified individuals to represent them on the Board. Additionally, I look forward to continue working with the NYSDA House of Delegates. You were involved in youth sports for over 25 years, even after your children were past playing ages. What did you gain from that? First of all, there’s no better way to spend your time than with our youth. By being involved, you can have the opportunity to positively influence them. Some of my fondest memories are of my children and their friends growing up and learning to play team sports, especially baseball, softball and basketball, and of the time I spent as a coach and as president of the local Little League. Years later, former players still thank me for my involvement. It’s satisfying to know that, perhaps, I made a difference in their lives.
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Rick answered call for volunteers to staff first-ever Mission of Mercy, sponsored by NYSDA and New York State Dental Foundation in 2014 in Troy.
What are your memories of the time your children were growing up? In addition to watching and coaching them in sports, my lasting memories are of the family vacations and the individual trips I took with one or more of my children. While multiple ski trips out West, a tour of Europe, trips to Cancun, the Dominican Republic or other places overseas or in the United States were wonderful, the one trip my children and I enjoy the most is a simple one—our yearly, two-week fishing trip in Canada, now in its 17th year. Do you have any hobbies? Delivering dentistry is a hobby to me. As far as what I enjoy outside of dentistry, I used to be very active in the outdoors. I grew up fishing, snow skiing, hunting, playing and coaching baseball and basketball with my sons and their friends. I still love to fish, but to do so, I have to force myself from home, my office and my computer. If following and attending college sports, particularly college football, is a hobby, I guess I’m guilty of that too. You have been involved in your community, serving on various boards (bank, hospital, Chamber of Commerce, Little League, YMCA, Humane Society and others) while running a dental practice. What made you do that? Is there one community board that you enjoy most? I’ve always felt that service is the cornerstone of community. As professionals, we have an obligation to be involved and give back to not only our profession and our patients, but also to our community. While it does consume personal time, it is gratifying when you see an organization improve during the time you are serving. The most rewarding, but by far the most challenging board— with tremendous potential liability—I have served on has been the Board of a bank. I’ve been involved in banking for 20 years, first in an advisory capacity for a large bank and for the past 14 years, as a Board member of a federally chartered community bank. I became Chairman of the Board six years ago. As I’ve told many of my dental colleagues, dentistry is heavily regulated, but it pales in comparison to banking. Bankers have a tremendous responsibility to their depositors and shareholders. After all, it’s their money! p
implantology
Clinical and Radiographic Examination of Endoscopically Controlled Indirect Sinus Lift An In vivo Study Shefali Phogat, M.D.S.; Reshu Madan, M.D.S.; Harish Yadav, M.D.S.; Anil Yadav, M.D.S.; Puja Malhotra, M.D.S.
ABSTRACT It was the aim of this study to quantify the gain in height of bone at implant sites by endoscopically controlled osteotome sinus floor elevations (ECOSFE) with simultaneous implant placement and to report the number of sinus membrane perforations. An indirect sinus lift was done in 10 patients under endoscopic control with an osteotome technique. The average residual height of the alveolar crest in the posterior maxilla was 5.625 mm. Elevation of the sinus floor was done using conventional sinus floor elevation instruments. A mean elevation of 5.205 mm was achieved. Twenty implants ranging in length from 10 mm to 13 mm (mean implant length 10.65 mm) were placed. As augmentation material, platelet-rich fibrin and autogenous bone were used. The sinus membrane could be visualized throughout the procedure and revealed no perforation. This technique is a safe and well-controlled procedure that allows immediate implant placement following sinus augmentation. It is more acceptable to patients, and can be applied to any implant system.
Endoscopy allows a surgeon to perform adequate surgical procedures with minimal injury to the human body. Endoscopy has long been used in the field of medicine but only lately has gained popularity in the field of dentistry. Implant restoration of the posterior maxilla poses a significant challenge to the clinician because of the anatomical location of maxillary sinuses and the poor quality and quantity of bone. Thinner cortical plate, larger marrow spaces and lesser density make the bone quality poor, which, in turn, leads to faster resorption subsequent to tooth extraction.1 Unlike the mandible, here bone loss occurs not only from the crestal side, but also from the apical side of the socket due to pneumatization of the maxillary sinus, leading to poorer bone quality.2-4 As a result, poorer success of implants has been reported in the maxilla as compared to the mandible.5 In order to attain long-term success of implants, the clinician needs to augment the bone whenever it is below the critical level. Sinus augmentation techniques of grafting and implant placement are accomplished as either a one-step or two-step surgical procedure.6 The one-step procedure should be reserved for patients who have at least 5 mm of alveolar bone in the posterior maxilla to stabilize the implants.7 Less than 5 mm of available host bone is considered insufficient to mechanically maintain the endosteal implants. Thus, the two-step procedure, like onlay grafting, has been recommended in these patients.8,9 Among one-step procedures, the lateral window approach direct sinus lift and the crestal approach indirect sinus lift are the
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Figure A. Preoperative IOPA X-ray. Sinus lining is marked with red line.
Figure B. Endoscope and osteotome in position.
Figure C. Clinical & endoscopic view of green stick fracture of bone at sinus floor.
Figure D. Last view of implant seen through membrane before suturing.
Figure E. Implants placed.
Figure F. Six-month postoperative IOPA radiograph of patient. Red line depicts preoperative level of sinus lining and blue line postoperative level.
most popular. The direct sinus lift procedure was first described in 1977 by Tatum.7,8,10,11 In 1980, Boyne and James introduced the lateral osteotomy. Indirect sinus lift (osteotome technique) was introduced by Summers in 1994.12 Using the elasticity of the bone, Summers started floor dilatation of the sinus, thus increasing the length of his implants. The disadvantages of this technique are its limited indications with only 1 mm to 2 mm gain in the height of bone and the absence of direct visual control of the state of the sinus membrane.13 The osteotome technique has been reported to improve the survival rate of implants in the residual bone of the posterior maxilla.14 The osteotome sinus floor elevation has been carried out with an implant survival rate higher than 95%.15 However, when osteotome sinus floor elevation is applied without endoscopic control, a direct inspection of the sinus membrane is not possible.16 And during preparation of the implant site, a perforation might not be recognized. This study was performed to quantify the gain in height of bone at the implant site by endoscopically controlled osteotome sinus floor elevation and simultaneous implant placement. Materials and Method Patients were selected from the Outdoor Patient Department of the Department of Prosthodontics & Implantology, S.G.T College of Dental Sciences and Research, Gurugram, India, irrespective of socio-economic status, religion, age or sex. A total of 20 implants were placed in the posterior maxillary region, two in each patient.
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Prior to beginning implant surgery, a detailed history of the patient was carefully recorded to check for eligibility based upon set inclusion and exclusion criteria. Routine blood investigations were carried out before the surgery to rule out any systemic disease or bleeding disorders. A thorough clinical and radiographic assessment was done to decide the implant dimensions (Figure A). Subsequently, the diagnostic wax up of the cast was completed, and the surgical template was prepared to guide the implant location and angulation during placement. The diameter and length of the implants used in the study ranged from 3.75 mm to 5 mm and 8 mm to 13 mm, respectively. The surgical procedure was performed using a standardized technique under local anesthesia. After a mid-crestal incision, a full thickness mucoperiosteal flap was elevated. A pilot drill was used to reach the cancellous bone, stopping 1 mm below the floor of the sinus. Simultaneously, a stab incision was made in the region of the canine fossa, and the maxillary sinus was punctured without flap retraction with progressive osteotomes of 2 mm, 3 mm and 4 mm. A 70-degree bevelled endoscope was used with a second-generation highdefinition endoscopic camera to visualize the sinus membrane. Using larger diameter, concave-tipped osteotomes, the osteotomy was successfully widened, and lateral and apical condensation was done. Each osteotome was retained in place for one minute before the next, greater diameter was used to ensure elastic deformation. The final osteotome with the widest concave tip was used, and the sinus floor elevation was performed under
endoscopic control (Figure B). The cortical plate was punched out of the sinus floor with the adherent membrane, and a tent-like formation was created (Figure C). The height of the residual alveolar bone was measured with a depth gauge as the distance from the sinus floor (endoscopic control) to the crest of the alveolar ridge. The cortical plate was lifted with the osteotome until no further concomitant spontaneous dissection of the sinus membrane from the sinus floor occurred in the periphery of the elevated region and visible tension of the sinus membrane revealed the risk of rupture. At this point, the height of the elevation was measured again with the depth gauge. Subsequently, the endoscopic view was used to control the dissection of the mucosa from the sinus floor, which was performed with a blunt elevator. At the end of the procedure, all implant sites were tested for perforations of the sinus membrane using the Valsalva maneuver. For the sinus augmentations, particulated autogenous bone from the osteotomy site was applied. The largest osteotome was reinserted to position the grafting material in the newly formed space between the sinus membrane and the sinus floor. Subsequently, the implant was placed (Figure E). The last view of the implant was captured using a digital camera before
suturing (Figure D). The muco-periosteal flap was repositioned and sutured. A single suture was also placed at the canine fossa region, from where the endoscope was inserted. On follow-up appointments of one, three and six months, sinus complications were assessed clinically. Periapical radiographs were taken to evaluate the gain in bone height (Figure F). Stability of all implants was checked clinically on the day of second-stage surgery, which was done six months after implant placement. All patients were suitably rehabilitated with a cement-retained prosthesis. Results The bone was measured preoperatively on intraoral periapical radiographs (IOPA) from the crest of the ridge to the sinus lining. Postoperatively, the value was measured from the top of the implant head to the elevated sinus lining, since the implant was placed at the preoperative crest level. The selected patients had a minimum of 5 mm bone height in the posterior maxillary region (Table 1). The mean preoperative height for 20 implant sites was 5.625 mm. The bone height at postoperative baseline was 12.225 mm, achieved through membrane elevation and graft material.
TABLE 1
Intraoperative and Follow-up Data Patient No.
Region of Implant
Vertical dimension of Bone (mm)
Implant Length (mm)
Baseline Bone HeightImmediate Postoperative
Sinus Elevation (mm)
Valsalva Maneuver
Pathologic Findings 6 Months Postop
Loss of Implant
Pt 1
27
5
10
11
6
Negative
None
No
26
5
10
11
6
Negative
None
No
Pt 2
15
6
11.5
12.5
6.5
Negative
None
No
17
5
10
11
6
Negative
None
No
Pt 3
16
6
11.5
12.5
6.5
Negative
None
No
17
6.5
11.5
13.5
7
Negative
None
No
26
6
11.5
12.5
6.5
Negative
None
No
25
5
8
10
5
Negative
None
No
Pt 4
Pt 5
Pt 6
Pt 7
Pt 8
Pt 9
Pt 10
27
5
10
11.5
6.5
Negative
None
No
25
5
10
11.5
6.5
Negative
None
No
27
6
10
12
6
Negative
None
No
26
6
10
12
6
Negative
None
No
17
6
11.5
13.5
7.5
Negative
None
No
16
6
13
14
8
Negative
None
No
26
5
10
11
6
Negative
None
No
15
6
10
12
6
Negative
None
No
26
5
10
11
6
Negative
None
No
16
5
10
11
6
Negative
None
No
17
7
13
14
7
Negative
None
No
15
6
11.5
13
7
Negative
None
No
The New York State Dental Journal • JUNE/JULY 2016
27
nificant (Table 3). The change from preoperative bone height to six-month postoperative bone height was highly significant (p # 0.001). In two out of 10 patients, the implant was clearly visible. In eight patients, only blanching was observed. No perforation was recorded in any patient. There was no delayed post-treatment complication observed clinically. Four out of 10 patients had nose
After correction of the magnification factor, a statistical analysis was done (Table 2). A slight decrease in bone height was observed at six months on the mesial side (10.827) and distal side (10.834 mm) because of dissolution of graft material and bone remodelling. A mean increase of 5.205 mm (mesial=5.201; distal=5.208) was achieved. The difference between the means was calculated by a pair-difference t-test; a p-value
