evaluation of the effectiveness of a water lift system … of the effectiveness of awater lift ......

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.


(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).


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).


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).


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).


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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evaluation of the effectiveness of a water lift system … of the effectiveness of awater lift ......

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