Crestal Sinus Approach with Hydrodynamic and Densah protocols

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Posted on By Maurice Salama In Sinus Augmentation

Patient presents with wide ridge >5mm and 6-7mm of remaining crestal bone for implant placement. Crestal approach was utilized with hydrodynamic lift, Densah osseodensification drills and PRGF Fibrin. No Bone Graft was used a la Professor Dong Sohn. Excellent bone density and lift achieved with minimally invasive approach and low risk. Thoughts. Dr. Salama

Depth Stop with Sinus drill
Preop PA

Crestal Reamer from Salvin Sinus kit
Densah Drill on Osseodensification mode

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Wet Gauze utilized to push Fibrins into sinus...

Wet Gauze technique
Sinus access after Fibrin inserted


placement of implant at 45 NCM....
This technique will be reviewed in detail during the Hands-on in Houston this April. Dr. Salama

Implant insertion
Torque reading


Mo. I like this protocol very much. Especially if the ridge is wide and there is less than 7mm of crestal bone. However, I think when there is 7mm or more crestal bone, Densah burs alone can get the job done. Currently I feel if the site is narrow with less than 3mm crestsl bone I prefer HISPE with injectable bone putty. However, if site is wide and 3-6 I use wet gauze and/or Densah burs with injectable bone putty and/or particulate allograft. For me, lateral windows are rarely necessary for single sites. So many new options with current technology. Great case. Thank you for sharing. Florida is going to GREAT! Best regards. Chuck


Thank you for sharing! Do you have a final X-ray? What type of implant did you use? Gregory


Zimmer 6.0mm wide by 11.5mm....Post op soon...but without bone not much change radiographically expected so soon?



This is an excellent case. The Densah Burs will help maintain all bone tissue after a minimum width pilot, and deposit bone apically. The piezo tips are useful and more gentle than a standard pilot drill but maybe still sacrificing bone tissue because of their width. Do they come in less than 2mm width?

I would agree with Chuck, The Densah Bur alone may get the job done after a "Narrow Pilot". I also agree that maybe the "Lateral Window Approach" will remain mainly for large cases with complications. Optimized and minimally invasive implantology is here.

Thank you for sharing and welcome to osseodensification. See you in Florida.



I am so glad to know about your Densah burs Dr. Huwais, I have not seen you with Dr. Koussa for more than 3 years. I am so impressed about your system and studies. My only question about this system, why do you use high speed not low speed with Densah burs during bone condensation?, Have you noticed any implant failures due to bone necrosis with your Densah system?. Thank you so much and wish you all the best. My best regards, Ahmad Hawasli


The question is indeed to bone graft or not in cases when the implant will lift the Schneiderian membrane as a tenting screw. If a micro tear of the membrane is present and undetected in those crestal sinus lifts, the bone graft will be in contact with whatever `Junk`there is in the sinus and will be at risk of getting infected and treated as a foreign body. In this case I saw last week, I lifted the membrane with Neobiotech burs then Hydrodynamic further lift then 4 PRF Plugs before inserting 0.50cc of bone. I felt the plugs would seal any undetected tear of the memrane and èncapsulate`the bone graft. But as I was grafting, I was asking myself what does that added bone add to the success and outcome of the case ?????


Laurent; A very very very good question indeed. Thanks Dr. Salama


Laurent, generally speaking the sinus is considered sterile, So, in an healthy state no bacteria reside on the sinus and that is due to the acitiviaty of ciliate cells, the mucous and the air stream and pressure. So, it is dental procedure affecting the sinus rather than the opposite. IMO, fact of placing some 'solid'material' is mainly beacuse of air pressure over the Scheinderian membrane that could progressively narrow the space created for bone regeneration. Implant is acting as a 'tent effect' but pressure around it may not allow sufficient bone growth sustaining the apical implant body. Armando


Mo ...this seems to be a very interesting technique that i would compare it with the intralift piezo hydrodynamic technique that i have been using. Thank you for posting ...see you soon.


Maurice; Very nice and clean sx! I also have stopped over the past few years adding bone graft in small sinus lifts as per Dr.Sohn research results. I dont see any difference so far in the outcomes, it works fine with less risk. In this case the diificulty is avoiding a perf due to the sinus slobe, so i think the hydrolift was important.



This below is the Densah protocol for Sinus lifting.
In comparison, the sinus auto-grafting protocol (the Densah Lift) calls for an earlier decortication of the sinus floor. In your case example, the determined working length is 5 mm which is the bony height below the sinus floor. The Densah lift protocol is as follow:
1- 1.7 mm pilot to 4 mm.
2- DB VT1525 CCW rotation to decorticate the floor without going into the sinus. (to 5 mm)
3- DB VT2535 CCW rotation to modulate the sinus floor and go to (7-8 mm) depth (3mm beyond the working length)
3- DB VT3545 CCW rotation to further widen the osteotomy and modulate the sinus floor and go to (8 mm) depth.
4- DB VT4555 CC Rotation to additionally widen the osteotomy and to modulate the sinus floor and go up to (8 mm). AT anytime the Densah Bur must not enter into the sinus more than 3 mm.
5- Place the implant.

The early decortication will allow the Hydrodynamic wave to lift the membrane and deposit autogenous bone that is shaved off the osteotomy walls with the sequencing burs.

In cases with less than 5 mm bone height below the sinus floor, I tend to skip step 1 and 2 and start with wider DB (VT2535) to decorticate the sinus floor and follow it with wider DBs to lift the membrane and deposit the autograft.

The DB will produce up to 3 mm lift only with autogenous graft deposit. If more than 3 mm lift is required, an allograft is needed.


Great case with beautiful documentation as usual Dr Salama. I have wanted to try HPISE but have not had access to the Piezo tips. So I started using a regular piezo diamond tip to access the floor, followed by using a plastic narrow tip syringe, to generate pulsations a of sterile water to lift the membrane. And it has been working well for me. Obvious radiographic change needs time, but l have sometimes seen the tenting effect on the immediate PA (photo). Just wanted to share this thought with the group :) :)

Thank you for generating the discussion as always.

See you all soon,



Have you guys tried CAS kit from Hiossen ? It comes with vertical stops and the non cutting end of burrs acts to lift membrane . It is my go to kit for any cases 4mm and up of residual Height .



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