Abstract
Purpose
Maxillary sinus augmentation using the lateral bone window approach has been well documented and studied, with the advent of many newer techniques and instruments. It is prudent that operators make a choice based on scientific evidence and feasibility guided by each case. The purpose of this study is to analyze whether a combination of more than one method could prove beneficial when compared to any one method alone.
Materials and Methods
Radiographic and clinical data from 48 augmented maxillary sinuses in 42 male and female patients was collected and the clinical outcome analyzed based on different clinical parameters. Data collected from 48 augmented maxillary sinuses was divided into 4 groups based on the osteotomy method used. A comparison was made between rotary diamond bur (Group 1), the piezosurgical device (Group 2), a hand-held bone scraper (Group 3) and a combination of method 1 and 3 (Group 4). Mean wall thickness for the maxillary Bucco-facial wall was measured for all cases. Clinical parameters measured included time taken to complete the osteotomy, membrane perforation, operator fatigue, anastomotic vessel damage and autogenous bone collected.
Results
Mean time taken for Group 1 was 17.33 min, Group 2 was 34.83 min, Group 3 was 38 min, Group 4 19.5 min. Membrane perforations were highest in Group 1 & 2 at 16.66%. Groups 2 and 4 showed the least chances of damage to the vessel at 16.66%. Significance of operator fatigue was highest at 16.66% in Group 4.
Conclusions
It was concluded that there may be an advantage in selecting a combination of surgical protocols in accordance with the lateral wall thickness. The advantages may extrapolate to safety, simplicity and ergonomics of surgical approach compared to any one technique alone.
Keywords: Maxillary Bucco-facial wall, Sinuslift, Bone scraper, Piezosurgery
Introduction
The maxillary sinus ‘aka’ Antrum of Highmore is a pyramid shaped structure located in the maxilla with its apex extending into the zygomatic bone. It is of importance in dentistry and otorhinolaryngology. In the past a greater number of procedures of the sinus via lateral wall access used to be undertaken by otorhinolaryngology specialists compared to dentists. This included the well described ‘Caldwell-Luc approach for surgical treatment of maxillary sinusitis. With the advance of endoscopic procedures this protocol is near redundant and now antral access through the lateral wall is mostly undertaken by dental specialists for the purpose of bone augmentation for implant placement [1, 2].
The loss of bone in the posterior maxilla occurs from both vectors, alveolar loss related to periodontal disease and sinus pneumatization after tooth extraction [3].
To overcome the clinical situation of deficient bone height in the premolar and molar region dentists have turned to either one of two protocols- (A) Graft-less solutions which comprise the use of short or tilted implants or (B) Maxillary sinus augmentation [4–6].
The number of cases requiring augmentation of posterior maxillary bone volume prior to dental implant placement is increasing with time due to more clarity of surgical protocols lending better predictability to the outcome. There are two basic approaches (1) Lateral wall access and (2) Crestal access, with all other sub-categories being modifications of these two [7].
The lateral wall access utilizes an osteotomy in the Bucco-facial wall of the maxilla corresponding to the region of interest. Thickness of this Bucco-facial maxillary wall makes the surgical procedure more demanding and time consuming [8].
Large anastomotic vascular canals (of up to 2-3 mm diameter) are seen in 7% individuals as reported by Mardinger (2007). The likelihood of such canals in thicker walls is higher and visualization of the same in thicker walls more difficult. Further consideration may be required when preparing an osteotomy in thick Bucco-facial walls to avoid any unexpected injury to vascular anastomosis.
Lim et al. [9] reported a mean thickness of the maxillary buccal wall at 4 vertical tangents from the orbital floor in three different ethnic groups.
Clinicians have the option of rotary, piezoelectric and manual devices alongside hard tissue lasers, to prepare an osteotomy in the lateral maxillary wall. Depth-controlled island burs have been used, highlighting their safety over conventional rotary devices (Garg et al. July 2nd 2019; Oral Health, online feature article). Each of these have their attending pros and cons related to time consumed, costs involved, learning curve and surgical skill sets [10].
The bone window may be separated completely or hinged inwards and rotated upwards. In cases with a thick bone wall a piezosurgical ‘elephant foot’ tip may be required to shatter any remaining bony adhesions.
The Schneiderian membrane is known to vary in thickness and tenacity with little correlation to age and sex [11], but till date the most common intra-operative complication is membrane perforation. Authors have reported a range of 10–30% perforations during lateral window access [12, 13].
Piezosurgical devices and rotary burs have been reported to show insignificant difference in outcome when used for lateral window osteotomy, except in very thick walls where the time taken is significantly higher [14–16].
Barone et al. compared the use of piezosurgery with conventional methods for surgical access to the sinus membrane [17].
Lozada et al. reported the use of a bone planning diamond drill to reduce the thickness of the maxillary lateral wall till proximity to the Schneiderian membrane is achieved [18].
Use of a bone scraping device for osteotomy preparation has been described as a viable, safe and simple option for lateral window access [19]. An added advantage reported is the simultaneous collection of autogenous bone for use as a graft.
The objective of this study was to analyze how the thickness of maxillary Bucco-facial wall if at all, influences the surgical outcome and whether a combination of more than one methods proves beneficial compared to any one protocol alone.
Material and Methods
The study was designed to assess whether maxillary lateral wall thickness, measured on pre-operative scans has any influence on lateral window osteotomy.
Retrospective 5 year data from 48 augmented maxillary sinuses in 42 male and female patients between 29 and 63 years of age (operated between January 2014 and January 2019) was collected and organized to assess the clinical outcome based on instrumentation used. Cases with any attending co-morbidities affecting bone quality such as osteoporosis, bone metabolic disorders were not included. Cases that underwent indirect sinus augmentations were excluded.
Selection criteria included partially and completely edentulous operated sites missing two or more maxillary posterior teeth and requiring unilateral or bilateral sinus augmentation.
Data collected was divided into 4 groups based solely on the osteotomy protocol.
Group 1—protocol used, rotary diamond burs (Meisinger, Germany) (Fig. 1).
Fig. 1.
Osteotomy using a Rotary diamond bur
Group 2—protocol used, piezosurgical device with a diamond insert (Surgibone, Italy) (Fig. 2).
Fig. 2.
Osteotomy using a Piezoelectric insert
Group 3—protocol used, bone scraper (Safe scraper, Geistlich, Wolhusen, Germany) (Fig. 3).
Fig. 3.
Osteotomy using a Bone Scraper
Group 4—protocol used, combination of group 1 + 3 (Fig. 4).
Fig. 4.
Buccal wall after a scraper has reduced the thickness
Records collected included duly signed consent forms, treatment records and preoperative 3-dimensional cone beam computed tomography (CS9300 Carestream Dental, France) with view sections in coronal axial and sagittal planes at a slice thickness of 0.075 to 0.250 µm.
Measurements were made using the digital caliper in the CD3D software at a vertical height of 2 mm and 10 mm, respectively, above the sinus floor, because the osteotomy most likely would traverse these locations. Clinical photographs were procured wherever available to assess the actual location of lateral window osteotomy. A mean wall thickness was extrapolated from the two values measured for each case (Fig. 5).
Fig. 5.
Thick Bucco-facial wall
All osteotomies had been performed by a single operator, thereby reducing the error due to variation in surgical skills. Since all cases selected required replacement of two or more maxillary posterior teeth all osteotomies measured ≥ 1 cm in antero-posterior dimension.
Intraoperative parameters taken into account were as under:
Time taken to complete the osteotomy and gain access to the sinus membrane.
Damage to the sinus membrane if any during osteotomy preparation.
Trauma to the anastomotic vessel.
Ability to procure any autogenous bone during osteotomy.
Ergonomic parameters such as operator fatigue.
Time elapsed between start to completion of osteotomy was recorded on a digital timer being counter-checked by more than 1 operating room staff.
Results
Parameters recorded were tabulated for statistical analysis (Table 1).
Table 1.
Parameters from data records with wall thickness and surgical methodology
| Case no. | Time taken (min) | Lateral wall thickness (mm) | Method | Membrane perforation | Anastomotic vessel trauma | Autogenous bone procured | Operator Fatigue |
|---|---|---|---|---|---|---|---|
| 1 | 18 | 1.35 | Rotary Bur | None | Anastomotic vessel damage | Yes-suction bone trap | None |
| 2 | 15 | 2 | Rotary Bur | None | Anastomotic vessel damage | None | None |
| 3 | 14 | 1.8 | Rotary Bur | None | None | None | None |
| 4 | 16 | 2.15 | Rotary Bur | None | Anastomotic vessel damage | None | None |
| 5 | 17 | 2.4 | Rotary Bur | None | None | None | None |
| 6 | 18 | 2.75 | Rotary Bur | Perforation < 2 mm | Anastomotic vessel damage | None | None |
| 7 | 25 | 1.4 | Rotary Bur | None | None | Yes-suction bone trap | None |
| 8 | 18 | 2.25 | Rotary Bur | None | Anastomotic vessel damage | None | None |
| 9 | 16 | 1.65 | Rotary Bur | None | None | None | None |
| 10 | 14 | 1.3 | Rotary Bur | None | None | None | None |
| 11 | 12 | 1.2 | Rotary Bur | None | None | None | None |
| 12 | 20 | 3.15 | Rotary Bur | Perforation < 2 mm | Anastomotic vessel damage | None | Significant |
| 13 | 32 | 2.2 | Piezosurgery | None | Anastomotic vessel damage | None | None |
| 14 | 28 | 1.1 | Piezosurgery | None | None | None | None |
| 15 | 22 | 1.4 | Piezosurgery | None | None | Yes-suction bone trap | None |
| 16 | 34 | 2.4 | Piezosurgery | Perforation < 2 mm | None | None | None |
| 17 | 30 | 1.85 | Piezosurgery | None | None | None | None |
| 18 | 35 | 1.35 | Piezosurgery | None | None | None | None |
| 19 | 37 | 2.75 | Piezosurgery | Perforation < 2 mm | None | None | Significant |
| 20 | 30 | 2.4 | Piezosurgery | None | None | None | Significant |
| 21 | 32 | 1.1 | Piezosurgery | None | None | None | None |
| 22 | 38 | 2 | Piezosurgery | None | None | None | None |
| 23 | 35 | 1.8 | Piezosurgery | None | Anastomotic vessel damage | None | None |
| 24 | 38 | 2.1 | Piezosurgery | None | None | None | Significant |
| 25 | 35 | 2.2 | Bone scraper | None | None | Yes-Smart scraper | Significant |
| 26 | 40 | 2.15 | Bone scraper | None | None | Yes-Smart scraper | Significant |
| 27 | 35 | 1.6 | Bone scraper | None | Anastomotic vessel damage | Yes-Smart scraper | Significant |
| 28 | 25 | 1.1 | Bone scraper | None | None | Yes-Smart scraper | None |
| 29 | 18 | 0.6 | Bone scraper | None | None | Yes-Smart scraper | None |
| 30 | 45 | 2.8 | Bone scraper | None | None | Yes-Smart scraper | Significant |
| 31 | 36 | 2.25 | Bone scraper | None | Anastomotic vessel damage | Yes-Smart scraper | Significant |
| 32 | 38 | 2.4 | Bone scraper | None | Anastomotic vessel damage | Yes-Smart scraper | Significant |
| 33 | 24 | 1.2 | Bone scraper | None | None | Yes-Smart scraper | None |
| 34 | 32 | 1.8 | Bone scraper | None | None | Yes-Smart scraper | Significant |
| 35 | 34 | 2.15 | Bone scraper | None | Anastomotic vessel damage | Yes-Smart scraper | Significant |
| 36 | 24 | 1.25 | Bone scraper | None | None | Yes-Smart scraper | Significant |
| 37 | 20 | 2.4 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | Significant |
| 38 | 21 | 2 | Bone scraper + Rotary Bur | None | Anastomotic vessel damage | Yes-Smart scraper | None |
| 39 | 18 | 1.8 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
| 40 | 22 | 2.25 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | Significant |
| 41 | 18 | 1.8 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
| 42 | 20 | 2 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
| 43 | 18 | 1.6 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
| 44 | 19 | 1.65 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
| 45 | 18 | 1.4 | Bone scraper + Rotary Bur | Perforation < 2 mm | None | Yes-Smart scraper | None |
| 46 | 16 | 1.45 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
| 47 | 18 | 2.65 | Bone scraper + Rotary Bur | None | Anastomotic vessel damage | Yes-Smart scraper | None |
| 48 | 16 | 2.4 | Bone scraper + Rotary Bur | None | None | Yes-Smart scraper | None |
Time taken to complete the osteotomy was measured in all groups by dividing them into two sub-groups, those with mean lateral wall thickness < 2 mm and those ≥ 2 mm.
For Group 1 the mean time taken for osteotomy in < 2 mm walls was 16.50 min, in ≥ 2 mm walls was 17.33 min.
For Group 2 the mean time taken for osteotomy in < 2 mm walls was 30.33 min, in ≥ 2 mm walls was 34.83 min.
For Group 3 the mean time taken for osteotomy in < 2 mm walls was 26.33 min, in ≥ 2 mm walls was 38 min.
For Group 4 the mean time taken for osteotomy in < 2 mm walls was 17.83 min, in ≥ 2 mm walls was 19.50 min.
Membrane perforations were highest in Group 1 & 2 at 16.66%, noteworthy to mention that all perforations occurred in subjects where the lateral wall dimensions were 2.4 mm and higher. Where a combination of bone scraper and rotary burs were used one membrane perforation was recorded which (in operative records) had been attributed to the presence of a septum.
Autogenous bone was possible in all subjects where the bone scraper was used.
In two cases in Group 1 and one case in Group 2 bone had been collected using a suction trap. In Groups 3 & 4 all cases demonstrated sufficient bone collection.
Damage to the anastomotic vessel was highest in Group 1 at 50%, while Group 3 was at 33.33%, while Groups 2 & 4 showed the least chances of damage to the vessel at 16.66%.
Ergonomic parameters by way of operator fatigue recorded as grip strength and pinch strength recorded at the end of osteotomy preparation were analyzed.
Though a dynamometer is best deployed to measure grip strength here we looked at the ability to firmly grip the surgical handpiece without muscle cramps in palmar and pen grasp positions [20].
Significance of operator fatigue was 8.33% in Group 1, 25% in Group 2, 75% in Group 3 and 16.66% in Group 4.
One parameter that was not accounted for in this analysis but deserves mention as it was duly noted under ‘special concerns’ in patient postoperative records, was psychological trauma felt by two subjects in Group 3 due to the scraping sounds transmitted by the hollow maxilla which they felt was distressing through the procedure.
Statistical Analysis
Data was analyzed using Statistical Package for Social Sciences (SPSS) version 21.0. Chi-square and Independent samples ‘t’ tests were used for univariate analysis. Multivariate analysis was performed using Binary logistic regression.
A total of 48 cases were enrolled. A total of 12 (25%) each were managed using Bone scraper, Piezosurgery, Rotary bur and combination of Bone scraper with rotary scraper, respectively. Time taken for procedure ranged from 12 to 45 min with a mean of 25.08 ± 8.81 min. A total of 19 (39.6%) cases were managed within 20 min, 13 (27.1%) in 20–30 min, while 16 (33.3%) took > 30 min. Lateral wall thickness ranged from 0.60 to 3.15 mm. Mean lateral wall thickness was 1.89 ± 0.54 mm. Maximum (n = 15; 31.3%) had lateral wall thickness in 2.0 to 2.5 mm range followed by those having lateral wall thickness < 1.5 and 1.5 to 2.0 mm range (n = 14; 29.2%). A total of 5 (10.4%) had lateral wall thickness > 2.5 mm. As far as different intraoperative events and outcomes were concerned ability to procure autogenous bone was most common (n = 27; 56.2%) followed by operator fatigue (n = 15; 31.2%), traumatic anastomotic vessel damage (n = 14; 29.2%) and Schneiderian membrane perforation (n = 5; 10.4%), respectively (Table 2).
Table 2.
Surgical profile and clinical outcome (n = 48)
| SN | Variable | Statistic |
|---|---|---|
| 1 | Type of Procedure | |
| Bone scraper | 12 (25.0%) | |
| Piezosurgery | 12 (25.0%) | |
| Rotary Bur | 12 (25.0%) | |
| Bone scraper + Rotary bur | 12 (25.0%) | |
| 2 | Mean time taken for procedure ± SD (Range) in min | 25.08 ± 8.81 (12–45) |
| < 20 min | 19 (39.6%) | |
| 20–30 min | 13 (27.1%) | |
| > 30 min | 16 (33.3%) | |
| 3 | Mean Lateral wall thickness ± SD (Range) in mm | 1.89 ± 0.54 (0.60–3.15) |
| < 1.5 mm | 14 (29.2%) | |
| 1.5–2.0 mm | 14 (29.2%) | |
| 2.0–2.5 mm | 15 (31.3%) | |
| > 2.5 mm | 5 (10.4%) | |
| 4 | Schneiderian membrane perforation | 5 (10.4%) |
| 5 | Traumatic anastomotic vessel damage | 14 (29.2%) |
| 6 | Ability to procure autogenous bone | 27 (56.2%) |
| 7 | Operator fatigue | 15 (31.2%) |
On univariate analysis, no significant association was observed between type of procedure and outcomes Schneiderian membrane perforation and anastomotic vessel damage. However, autogenous bone procurement was significantly associated with use of bone scraper either alone or in combination with rotary motor (p < 0.001), whereas Operator fatigue was significantly associated with use of bone scraper alone (75%) as compared to other procedures (8.3% to 25%) (p = 0.002). Mean time taken for procedure did not have an association with the outcome of Schneiderian membrane perforation, anastomotic vessel damage and autogenous bone procurement; however, it was significantly associated with operator fatigue. Mean lateral wall thickness showed a significant association with all the intraoperative events and outcomes (p < 0.05) except ability to procure autogenous bone (p = 0.292). On evaluating the association between different intraoperative events and outcomes, the association was not found to be significant (p > 0.05) (Table 3).
Table 3.
Univariate analysis for different outcomes
| SN | Predictor | Outcome | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Schneiderian membrane perforation | Anastomotic vessel damage | Autogenous bone procurement | Operator fatigue | ||||||
| Yes (n = 5) | No (n = 43) | Yes (n = 14) | No (n = 34) | Yes (n = 27) | No (n = 21) | Yes (n = 15) | No (n = 33) | ||
| 1 | Type of procedure | ||||||||
| Bone scraper | 0 | 12 (100%) | 4 (33.3%) | 8 (66.7%) | 12 (100%) | 0 | 9 (75.0%) | 3 (25.0%) | |
| Piezosurgery | 2 (16.7%) | 10 (83.3%) | 2 (16.7%) | 10 (83.3%) | 1 (8.3%) | 11 (91.7%) | 3 (25.0%) | 9 (75.0%) | |
| Rotary bur | 2 (16.7%) | 10 (83.3%) | 6 (50.0%) | 6 (50.0%) | 2 (16.7%) | 10 (83.3%) | 1 (8.3%) | 11 (91.7%) | |
| Bone scraper + Rotary bur | 1 (8.3%) | 11 (91.7%) | 2 (16.7%) | 10 (83.3%) | 12 (100%) | 0 | 2 (16.7%) | 10 (83.3%) | |
| Statistical significance | χ2 = 2.456; p = 0.483 | χ2 = 4.437; p = 0.218 | χ2 = 37.5; p < 0.001 | χ2 = 15.03; p = 0.002 | |||||
| 2 | Mean time taken for procedure ± SD (min) | 25.40 ± 9.32 | 25.05 ± 8.87 | 25.29 ± 8.93 | 25.00 ± 8.90 | 25.00 ± 8.49 | 25.19 ± 9.43 | 32.40 ± 7.66 | 21.76 ± 7.21 |
| Statistical significance | ‘t’ = 0.084; p = 0.933 | ‘t’ = 0.101; p = 0.920 | ‘t’ = 0.073; p = 0.942 | ‘t’ = 4.651; p < 0.001 | |||||
| 3 | Mean lateral wall thickness ± SD (mm) | 2.49 ± 0.66 | 1.82 ± 0.49 | 2.19 ± 0.46 | 1.77 ± 0.53 | 1.82 ± 0.53 | 1.99 ± 0.57 | 2.24 ± 0.47 | 1.73 ± 0.51 |
| Statistical significance | ‘t’ = 2.776; p = 0.008 | ‘t’ = 2.612; p = 0.012 | ‘t’ = 1.067; p = 0.292 | ‘t’ = 3.329; p = 0.002 | |||||
| 4 | Schneiderian membrane perforation | ||||||||
| Yes | – | – | 2 (40%) | 3 (60%) | 1 (20%) | 4 (80%) | 2 (40.0%) | 3 (60.0%) | |
| No | – | – | 12 (27.9%) | 31 (72.1%) | 26 (60.5%) | 17 (39.5%) | 13 (30.2%) | 30 (69.8%) | |
| Statistical significance | – | χ2 = 0.317; p = 0.573 | χ2 = 2.980; p = 0.084 | χ2 = 0.199; p = 0.656 | |||||
| 5 | Anastomotic vessel damage | ||||||||
| Yes | – | – | – | – | 7 (50.0%) | 7 (50.0%) | 5 (35.7%) | 9 (64.3%) | |
| No | – | – | – | – | 20 (58.8%) | 14 (41.2%) | 10 (29.4%) | 24 (70.6%) | |
| Statistical significance | – | – | χ2 = 0.314; p = 0.575 | χ2 = 0.183; p = 0.669 | |||||
| 6 | Ability to procure autogenous bone | ||||||||
| Yes | – | – | – | – | – | – | 11 (45.8%) | 13 (54.2%) | |
| No | – | – | – | – | – | – | 4 (19.0%) | 16 (81.0%) | |
| Statistical significance | – | – | – | χ2 = 3.24; p = 0.072 | |||||
As univariate analysis showed that except for the outcome operator fatigue, none of the other intraoperative events/outcomes showed association with more than one variable. It was seen that operator fatigue showed a significant association with type of procedure, lateral wall thickness and operative time, respectively. Hence, a multivariate binary logistic regression was performed to find out whether operator fatigue had a significant association with independent variables type of procedure, operative time and lateral wall thickness, respectively. However, the analysis revealed that out of the three independent variables, only one, i.e., lateral wall thickness played a significant role in influencing the dependent variable operator fatigue (Table 4).
Table 4.
Multivariate analysis for outcome operator fatigue
| Independent predictors | B | S.E | Wald | ‘p’ | Exp(B) | 95.0% C.I.for EXP(B) | |
|---|---|---|---|---|---|---|---|
| Lower | Upper | ||||||
| Rotary Bur | −3.791 | 3.186 | 1.416 | .234 | .023 | .000 | 11.616 |
| Piezosurgery | −6.518 | 4.766 | 1.870 | .171 | .001 | .000 | 16.845 |
| Bone Scraper | 6.257 | 4.259 | 2.159 | .142 | 521.912 | .124 | 2,202,409.506 |
| Time taken for procedure (min) | .504 | .314 | 2.581 | .108 | 1.656 | .895 | 3.063 |
| Lateral wall thickness (mm) | 7.584 | 3.847 | 3.885 | .049 | 1965.593 | 1.044 | 3,701,971.110 |
| Constant | −28.204 | 13.359 | 4.457 | .035 | .000 | ||
Discussion
This retrospective analysis of 48 subjects highlights the difference in intraoperative parameters.
Lim et al. in 109 cone beam CT measurements reported a mean maxillary lateral wall thickness was 3.3 mm at the 1st and 2nd maxillary molar region [9].
All perforations in our study in Groups 1 and 2 possibly occurred as the end cutting tip of the bur or the piezoelectric insert got locked into the deep recess causing destabilization of the handpiece. This happened due to the bone wall being thicker than the diameter of the cutting tip or the bur. Another factor which may influence the perforation rate is the depth of the osteotomy cut which makes it difficult to visualize the color change as the osteotomy approaches the sinus membrane.
Garg et al. (2019) reported the use of novel island shaped rotary burs with depth stops to create a lateral window.
Atieh et al. in their systematic review of 178 lateral window preparations comparing piezoelectric devices with rotary burs. Operating time, membrane perforation and implant failure rates were looked at. They concluded that within pooled estimates there was no significant difference between the two methods of osteotomy [14].
Wallace et al. evaluated piezoelectric cutting devices for lateral window osteotomy and reported low perforation rates of 7%. In 87 of their cases the Bucco-facial wall was > 1 mm thick, while 13 cases included had wall thickness < 1 mm [15].
Piezoelectric devices have been reported by some as safer than conventional methods for osteotomy preparation, but in thick Bucco-facial wall cases the time taken is significantly more than conventional methods.
Additionally, piezoelectric devices have shown comparable results to conventional methods when used for osteotomy preparation for sinus augmentation [16].
Lozada et al. described a method where a modified rotary diamond bur was used to plane the lateral or crestal bone and thin it out. This protocol increases the simplicity of the procedure in thick Bucco-facial wall but does not allow for simultaneous harvest of any autogenous bone that may be used to graft the sinus [18]. The diameter of the diamond bur used could range from 1 mm diameter onwards with some of the island burs (Garg et al. 2019) measuring as large as 8 mm in diameter.
Use of a suction bone trap utilizing a separate dedicated suction unit has been reported by many as a method to collect bone debris during drilling though bone obtained therein has been shown to be possibly contaminated in 82.70% cases. Species isolated included aerobes (Streptococcus salivarius) and anaerobes (Bacteroides, Peptococcus, Veillonella and Peptostreptococcus) [21–23].
While the use of a bone scraper alone serves the purpose of autogenous bone collection, but time taken, another parameter that deserves mention here is operator fatigue is due to the repetitive push–pull action [19].
Conclusions
The results obtained hint towards lateral wall thickness playing an important role in determining the intraoperative course and operator fatigue. As such, none of the techniques could be stated to have an edge over the other when used alone. In cases with Bucco-facial wall thickness ≥ 2 mm it may be good practice to use a bone scraper to reduce the thickness followed by a rotary diamond bur to complete the osteotomy. The possibility of using a combination of bone scraper with piezoelectric devices should be explored.
This may prove as a safe, simple, economic and ergonomic approach rather than the use of any one technique alone. The increased cost of a disposable scraper could be offset against the reduced cost of biomaterials due to significant volume of autogenous bone procured.
Limitations
Authors agree that a number of confounders such as demographic and clinical profile of patients and operator skill level could also play an important role in affecting the outcome. Moreover, sample size limitation also restricts the generalization of results. Further multi-center studies with inclusion of more independent variables are recommended.
Acknowledgements
The author would like to thank Mr. Varun Arora (Research Consultant and Visiting Fellow, Epidemiology and Biostatistics, University of Lucknow) for his help with the statistical analysis in this study.
Compliance with ethical standards
Competing interests
None.
Consent for publication
The author hereby provides consent to publication. Informed consent for sharing of clinical pictures was obtained from patients at the time of surgery.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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