Densah Bur, What Can Go Wrong

60 Rating(s).


Posted on By Salah Huwais In Sinus Augmentation

The patient is 61 years old presented 3 m post extraction of # 14. Significant maxillary sinus pneumatization with sinus floor at 5 mm from crest. Tx plan was to perform Densah lift and immediately place a 6/11.5 mm implant.
Procedure Complication:
Maxillary sinus membrane crestal perforation was caused by the pilot drill at 5mm depth.
Complication Management:
1- I used Densah Burs with vertical stop at 4 mm depth, which was 1 mm below the perforation level.
2- New sub-floor was established below the perforation utilizing Densah Burs in OD mode to compact autogenous bone and gradually seal the perforation.
3- The new working depth stayed at 4 mm at all times
3- Additional allograft was propelled into the sinus to facilitate additional membrane lift.
4- 6/11.5 mm implant was placed.

Membrane perforation at 5 mm
Densah Bur densifying new sinus sub- floor at 4mm

Perforation seal by osseodensification
Propel allograft and fixture placement


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24 Comments

Salah. Great case and documentation! I also have used the Densah burs in a similar way with and without allograft. These burs are indeed a versatile instrument. The ability to obliterate and displace the sinus floor apically in a controlled manor is impressive. Once a NEW SINUS FLOOR is established, an intact sinus membrane may not be critical for healing and/or repair apically. IMO ANOTHER POTENTIAL PARADIGM SHIFT PERHAPS EXCLUSIVE TO THE DENSAH BURS!. However, it is important to note other parameters (bone quality,timing after extraction,sinus anatomy,diameter of osteomy ect.) need to be considered as part of the equation. GREAT CASE! Personally given the magnitude of the healing it would be justified to dedicate an additional post of more comprehensive and sequential CBCT images (hint hint). Congratulations! Thank you for sharing my friend. Chuck


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Great case. how does OD plug the membrane? do the bone particals link together and form a solid mesh? is this what stops their being pushed into the sinus?
do you always put allograft into initial osteotomy prior to lifting the sinus floor?
is the floor lifted with pressure from the larger densah bur or with an osteotome?

but great to see possible complications and their management.
would an option for a less experienced operator, who perforated with pilot bur simple be to close up for say 6 weeks?




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Thank you, John:

IMO, The DB does underline the membrane with autogenous bone paticulate then lift the floor with the underlined membrane.
In this case, with 1.7 mm perforation.
1- I was able to densify a "new sub-floor" that was 3X wider than the perforation (5.2mm) and 1 mm occlusal to perforation level. This new sub-floor has an intact underline membrane surrounding the perf. Then, when the wider DB lifted this new subfloor, it lifted up the underline membrane with it including the perforated area.
2- I do not think that the perforation was completely sealed. It was reduced in size to clinically insignificant diameter. Also, The compacted autogenous bone in the apex has contributed to some extent to the perforation reduction.
3- In these cases I tend to use a particulate graft of 50/50 FDBA and DFDBA. I used the same final Densah Bur to propel the graft into the sinus. The Bur must not advance beyond the new sub-floor level at all times. The allograft can create the additional cushion that ultimately helped in closing the perforation and allowing additional membrane lift to the desired depth.
4- When the perforation is too wide, I tend to graft socket and return in 12 weeks for a 2nd attempt.
The Key is to create a new densified sub-floor that is 3X wider than the perforation so it will provide enough elasticity to lift the new floor without further membrane perforation.

Salah


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Thank you Chuck!
You are absolutely right. In this case, several factors have played a positive role:
1- It is a healing socket, so the bone has a higher plasticity. You can still see the outline of the buccal roots in slide #2.
2- The sinus floor, in this case, has multi levels that has caused the perforation to start with, but also helped later in lifting the new sub-floor.
3- The diameter of the osteotomy in relation to the diameter of the perforation is the most important factor. IMO, it is important to establish a new sub-floor that is 3X wider in diameter than the perforation. So if the perforation is >3 mm, I graft the socket without pushing bone into the sinus and allow it to heal for three months because it is impossible to establish a new 9mm sub-floor within 9 mm osteotomy and still place a 6 mm implant.

Salah


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Salah,
this a great case and quite a solution for a possible common complication.
It is quite difficult, IMO, once membrane is perforated, to find viable solution,on the crestal approach, considering low visibility and limited maneuver possibilities.
The healing seems, on X-ray, excellent, with a thin healthy mucosa above sinus elevation.
Thanks for sharing this topic application of densah burs.
Armando


Reply

Armando:
Thank you. I agree, membrane perforations are always challenging to manage due to the control issue. The Burs allow a haptic feedback that may provide the needed control. It is all about bone and collagen plasticity my friend. I am a believer that better bone instrumentation will help us to optimize the outcome.

Salah


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Wow ! Salah, this is incredible stuff. I have not used Densah burs, and had no i idea something like this was possible. I cannot wait to start using them really.

My questions are similar to John's, so ill await your answer. Congratulations on an excellent result and documentation here.

Thanks for sharing my friend

Ehab


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Salah

A great case by an experienced clinician. Recently I was teaching a surgical course with AIE Seminars in Mexico and a student who had never performed a crestal lift repaired her mistake under my supervision just as you have demonstrated.

If the protocol is strictly followed successful results will occur.



A repair by a novice


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Is the allograft placed at 4mm?
how do you go from allograft to the full 11.5mm implant?


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Frank:
In this case I used a particulate graft of FDBA and DFDBA. I used the same final Densah Bur to propel the graft into the sinus. The Bur did not advance beyond the new sub-floor level of 4 mm at all times. The allograft did create the additional cushion that ultimately helped in closing the perforation and allowed for the additional membrane lift to the desired depth of 12 mm. For every filled socket with Allograft expect to get about 1-2 mm lift.
see link below for a case with more detailes
http://forum.dentalxp.com/case/details/densah-sinus-lift-the-4mm-ridge/5255

Salah


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thank you
i just received the burs and my brother will be my first sinus lift using these
previously i have been using hiossen cas-kit
i'm excited to try this!


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Frank:
Below is a video detailing the Densah lift procedure without a Perf. You may have seen it already. I am including the link just in case. Good luck with your surgery. Keep us posted.

http://forum.dentalxp.com/video/details/densah-sinus-lift-utilizing-osseodensif/5042

Salah


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Great Case and documentation Salah!
I loved the idea of restoring a perforated sinus membrane with the aid of the Densah Burs. Seemed imposible...but you have done!
Thanks for the idea, and we now have to re-think our believes on crestal sinus lift.
Thanks,
Jorge


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Jorge:

Thank you. This approach is reproducible. There are three key elements to this procedure:

1- Perforation has to be less than or equal to 2 mm and in the center of the osteotomy; otherwise it would be difficult to create enough plasticity around it to lift it up with equal pressure.
2- The new subfloor/ the osteotomy needs to be 3X wider than the perforation.
3- Densah Burs are to be used in large increments. After the 1.7 mm pilot perforation at 5 mm depth, I used the densah bur that is VT2535 (3mm) to the 4 mm level. Then I used the Densah Bur VT3545 (4mm), and then Densah Bur VT4555 (5mm) and the final was VS5258 (5.5mm) all in OD mode (CCW). The significant jump in diameter to start is to provide enough autogenous bone shaving at the tip to densify the new Sub-floor. If small increments approach was used, the shavings would become too small and turn into powder and will not create the densified subfloor. I hope this will help.
Salah


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Salah, your imagination surprises me! Ha, ha.
Very good respons my friend! Now, sounds logical.
Thanks for sharing
Jorge


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Great case Salah, compliments. What a simple ledging principle, enjoyed it. In Endo, the same ledge will block the root canal and gives a negative result, but here the same ledge will save the perforated membrane and gives a positive result. Very effective technique. Thanks for sharing.

Do you have any delear in India, so that i can contact them to procure these burs or else, i have to do lot of exercise to smuggle it from U.S, lol,


Reply

Ashok:
Thank you. Your endo parallel is great. You are right on. This concept is creating a ledge to seal an apex perforation, then it is lifting the new ledge with the underlining membrane.

I am sorry, No dealer in India yet. We are working on it. If you are aware of a good option, please let me know.

I hope you are attending DentalXP conference 2016 in Florida. You can stop by and see us.

Salah


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Salah. Thank you for the explanation. If this reproducible and a 6x10mm diameter implant is planned, why not employ this protocol intentionally? That way you accurately identify the sinus floor and insure a perforation to be less than 2mm. It couldn't be easier. Very interesting. Warm regards. Chuck


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Chuck:

You are always thinking outside the box, my friend. I agree with Armando though. We have better and safer ways to identify the level of the sinus membrane. The procedure protocol is simple and may predictably allow the lift without perforation. Most of my perforations are usually happen with the pilot drill, so I now skip the pilot drill in any ridge that is less than 6 mm and start directly with Densah Bur VT1525 (2mm) in OD mode instead of the pilot. I stop with it at the floor level, and then I start pushing up into the sinus with the wider DB according to protocol.

Salah


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Salah. I agree with both you and Armando. However, I don't believe 2mm is wide enough to ensure against a sinus perforation, as I have had a perforation with the 2mm bur when crystal bone was less than 6mm. I believe once you establish a channel of 3mm in depth, you should work your way to the sinus floor with the widest diameter bur that that can displace bone apically. Do you have any experience with this approach? Many possibilities still to explore. Best regards from "outside the box". Maybe some of us just have larger boxes than others :-). Chuck


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Chuck,
your "lateral" thought could be an interesting conclusion if 3D planning was not available: right now you can predict in advance the range depth to reach. Healing pattern of sinus perforation could be challenging at time and with many variable: for instance on the case shown by Salah the sinus is in an healthy initial state and possible sterile. The air pressure can push mucosa to heal over a clot but the configurstion of defect could be an issue.
But I did enjoy your creative thought to improve a new way of doing things: shift on knowledge and other instrument/procedure technology.
Thanks Chuck.
Armando


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Nice case Salah,

I can't wait to start using system.

I would like to meet you and John some afternoon or evening.

Matt Lark


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Very innovative way to handle a sinus perforation. I've been using your Densah burs for a few months now exclusively for my osteotomies with amazing results. Now you've given me another use for them. Excellent innovation and bone growth around the implant in the sinus.


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Loyd:
Thank you. I am happy to hear that the Densah burs are instrumental in your hands. I know that you have been considering early loading with osseodensification sites. Any update with that?

Salah


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