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ePaper created 2017-05-12, 09:42:21 | version 1.38.0
| case report Fig. 3a Fig. 3b Fig. 3c Fig. 3d Fig. 3e Fig. 3f ment (Fig. 1b). This high-speed 1,100 rpm drill is used with external water irrigation and has a cutting edge at the apical portion. The pilot osteotomy should be 1 to 2 mm shorter than the calculated RBH measured on the periapical xR. The following steps are achieved with latch reamers at 50 rpm without water irriga- tion. The reamer consists of two vertical cutting edges, which stops 2 mm before the apical portion. The apex is tapered and without a cutting edge to avoid Schneiderian membrane perforation. A 2.5 mm latch (mechanical) reamer was inserted to start the widening of the crestal cortical bone and to deepen the bur with finger pressure towards the cortical bone of the sinus floor. The pressure allows the non-cutting edge to be pressed through the smooth cancellous bone but stops at the hard tissue of the sinus floor (Fig. 2d). With this 2.5 mm latch reamer, an X-ray was taken to determine the reaming final length before sinus floor (Fig. 2f). The RBH was mea- sured to determine the final drilling length and the latch reamer series with 0.5 mm diameter improve- ment were inserted until the 4.5 mm implant diame- ter was reached. The following step describes the microfracture technique of the sinus floor. With the 3.5 mm hand reamer that has a single vertical cutting edge and ends with a knife-edge at the apex of the reamer, we tapped the sharp tip of the hand reamer at four dif- ferent points along the buccopalatal and mesiodistal axis to facilitate the microfracture of the sinus floor cortical bone. The first fracture point was the lowest RBH on the periapical. We started the fracture at the distal aspect of the osteotomy. The second and fourth fracture points are always the buccal and the palatal because of their higher pneumatisation towards the buckle. The third point in this case is the mesial aspect (Figs. 3a–c). A synthetic and bacteriostatic grafting material (Synthograft, -TCP, size 50–500 m) was mixed with the collected blood until getting a putty consis- tency and no liquid was obvious in the mixture. A 4.0 mm bone graft syringe was used to place a bone graft material into the apical portion of the oste- otomy (Figs. 3e & f). Once resistance against the Schneiderian membrane was detected, a slow retrac- tion of the syringe while continuously injecting was done. After bone graft material was injected, a 3.5 mm Summer osteotome was used to gently push the material into the osteotomy. With the graft ma- terial in place, the osteotome was advanced via gen- tle tapping until the cortical bone was fully fractured, and lifted with the sinus mucosa (Figs. 3a–f, 4a–c). Fig. 3: a) Schematic illustration of the microfracture points along the cortical zone performed with the 3.5 mm hand reamer. First microfrac- ture at distal, second microfracture at mesial, third microfracture at buccal and the fourth microfracture was performed at distal; b & c) clinical picture showing the 3.5 mm hand reamer when performing microfrac- tures; d) schematic representation of the grafting material inside the cavity; e) clinical picture of the grafting material being injected; f) the 3.5 mm osteotome first insertion into the cavity. 22 implants 2 2017