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Year : 2021  |  Volume : 25  |  Issue : 5  |  Page : 451-456  

A dynamic surgical navigational approach for immediate implantation and transcrestal sinus augmentation

Chief Dental Surgeon, Dr Jain's Dental Care, Honorary Consultant, KEM Hospital, Pune, Maharashtra, India

Date of Submission22-Aug-2020
Date of Decision19-Dec-2020
Date of Acceptance20-Jun-2021
Date of Web Publication01-Sep-2021

Correspondence Address:
Akshita Solanki
501, Platinum Towers, Near Zambre Palace, Mukund Nagar, Pune - 411 037, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_581_20

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Real-time dynamic navigation shows various advantages over static guides in the placement of dental implants. The goal of this article is to highlight a safe and alternative approach for transcrestal sinus augmentation and immediate implantation by dynamic navigation. It elaborates and defines numerous advantages of the trace and place workflow over the fiducial technique in dynamic navigation. The usage of osseodensifying burs were shown to have higher bone-implant contact, stability, and insertion torque. Their application allows drill-tip calibration that can thus be used for dynamic navigation allowing a real-time surgical evaluation for the implant placement. This article describes a novel technique for transcrestal sinus augmentation during implant placement with osseodensifying burs using dynamic navigation.

Keywords: Immediate implants, osseodensifying burs, real-time dynamic navigation, transcrestal sinus augmentation

How to cite this article:
Jain S, Solanki A. A dynamic surgical navigational approach for immediate implantation and transcrestal sinus augmentation. J Indian Soc Periodontol 2021;25:451-6

How to cite this URL:
Jain S, Solanki A. A dynamic surgical navigational approach for immediate implantation and transcrestal sinus augmentation. J Indian Soc Periodontol [serial online] 2021 [cited 2022 Aug 19];25:451-6. Available from:

   Introduction Top

Lazzara placed implants into fresh extraction sites to inhibit the delay between implant surgery and implant prosthetic restoration.[1] Research has shown that during immediate implant placement, primary stability is achieved by engaging the implant threads to lateral walls and the native bone apical to the extraction socket. However, in many instances in a posterior atrophic maxilla apical extension of the osteotomy is limited because of the proximity of the maxillary sinus.

The most commonly used bone augmentation technique in the posterior maxilla is the sinus floor elevation technique (SFE) from a lateral window approach, which was first presented in 1977 by Tatum[2],[3] and first published in 1980 by Boyne and James.[4] Tatum changed his initial technique of SFE from a complex crystal access to a more versatile and practical technique of a lateral access.[5] Summers later invented a less invasive approach for sinus augmentation with immediate implant placement.[6] The Schneiderian membrane was elevated using these osteotomes from a crestal approach without the preparation of a lateral window. The use of osteotomes should produce a higher bone density and a higher primary implant stability.[6],[7] The osteotome technique has been useful in SFE but the most sensitive aspect involves the tapping force that should be sufficient enough to in fracture the sinus floor but restrained enough to prevent the osteotome tip from traumatizing the Schneiderian membrane. Densah burs that were introduced by Huwais in 2013, are another treatment alternative for internal transalveolar approach of SFE. In densifying mode, the Densah burs breach the sinus floor with autografting without causing any perforation.[8] These osseodentification burs work on a nonsubtractive fashion and condense the soft bone laterally and apically leading to higher bone density and implant stability.[9] A review by Tan et al. in 2008 shows that the survival rates of implants placed in transalveolar sinus floor augmentation sites are comparable to those in nonaugmented sites.[10]

Dynamic surgical navigation uses real-time tracking technology that tracks the dental drill and patient position throughout the implant placement procedures by integrating surgical instruments, three-dimensional images, and optical positioning devices. The dynamic navigation systems display those images on the computer. The dynamic navigation allows to view the drill trans-alveolarly or through any anatomical structure. It, therefore, disables any iatrogenic trauma to the anatomical structures and allows alteration in the intraoperative surgical treatment plan. Unlike static computer-guided surgery where 3D stents guide the implant placement, the dynamic navigation does not need any stents resulting in its application on individuals with reduced mouth opening. Dynamic navigation application can be done with any implant or drill system.

A novel approach to do transcrestal sinus augmentation during an immediate implant placement was done by the osseodensifying burs with the application of dynamic navigation.

   Case Report Top

A 39-year-old female with a noncontributory medical history presented with a fractured maxillary first molar. Dental history revealed that the patient had a root amputation of the root canal treated tooth 5 months ago. Intraoral periapical radiographic evaluation revealed that the mesiobuccal root of the maxillary first molar was amputated [Figure 1]. Clinical photographs [Figure 2] and a cone-beam computerized tomography (CBCT) scan were taken [Figure 3] (Kavo, OP 3D Pro, KaVo Kerr, India). The CBCT data revealed adequate healing in the mesiobuccal socket of 16 [Figure 3]. The DICOM data was transferred to navigation stystem, Navident (Navident R2.0, ClaroNavInc, Toronto, Canada).
Figure 1:Intraoralperiapicalradiographshowingmesiobucaalrootoffirstmolarwas amputated

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Figure 2: Clinical photograph showing missing missingmesiobuccal cusp

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Figure 3: Cone beam computed tomography showing adequate healing in mesiobuccalsocket

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Part I-Trace and place workflow for dynamic navigation

Presurgical workflow

As there is no fiducial in the scan, the jaw (maxilla) and the area (16 regions) where implant surgery was going to be performed was located by dragging the red line to the occlusal plane approximately and pressing the button for the upper arch [Figure 4]. The jaw centerline curve that is required for the generation of the panoramic view was marked [Figure 5]. The prosthecially driven implant planning was carried out on the navident software taking into account the anatomical landmarks, tissue irregularities, the available bone and the adjacent and opposing teeth. The crown's buccolingual, mesiodistal angulation, and placement for the region of interest was chosen according to sagittal, coronal, and axial views on the navident software. The implant length (10.5 mm), diameter (4.6 mm), and angulation along with its mesiodistal, apico coronal, buccolingual placement were selected according to the prosthetic outlines [Figure 6]. Trace registration was done on both sides of the region of interest[11] from right to left, to mark landmarks that were easily identifiable locations on buccal sides of teeth [Figure 7].
Figure 4: The jaw (maxilla) and the area (16 region) where implant surgery was going to be performed was located by dragging the red line to the occlusal plane

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Figure 5: The jaw centre line curve that is required for the generation of the panoramicviewwasmarked

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Figure 6: The implant length (10.5 mm), diameter (4.6 mm) and angulation along with its mesio distal, apico coronal, bucco lingual placement was selected according to the prosthetic outlines

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Figure 7: Trace registration was done on both sides of the region of interest

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Intraoperative dynamic navigation workflow

The intraoperative dynamic navigation involves the drill tip to be accurately guided into the desired position into the bone as per the pre surgical planning. The navigation tool must map the drill tip to a CBCT scan of the jaw.

Registration is the process to map the CBCT image to the patient's physical jaw structures. Instillation of the head tracker was done to allow the tracking of the patient's maxilla during navigation by the micron-tracker that uses stereoscopic vision in real-time. It involves protective eyeglasses and tracer tag that are placed on the patient's head with support from ear hooks and nose pads [Figure 8]. By holding the tracer tool [Figure 9] that is fixed to the tracer tag [Figure 10], on the dimple of the jaw tag that was used as a calibrator, the calibration of tracer tooltip was done. This was done at a distance of 50 cm from the camera. The tracer tooltip and tracer tag were identified by the navigation systems camera (MicronTracker) and calibration of the tracer tooltip was completed. The tracer tooltip was placed on the buccal aspect of the first tooth that was selected for obtaining landmarks [Figure 11]. The tracer tooltip was identified by the Navident. Tracing was done by holding the tip constantly in contact with the tooth and sliding (scoring) it on the buccal, palatal, proximal, and incisal part of the tooth. Tracing was done until a score of 100 was achieved for each selected tracer site on the navident software [Figure 12]. Tracing was followed on the next tooth, adjacent to the landmark registered earlier. When all preselected landmarks had been traced an identifiable sound was heard and the tracing was registered. This tracing step registers the head Tracker position to the CBCT scan images in the Navident software. Navident could map the patient's actual anatomical structures to the CBCT scan images, maintaining this mapping accurately during the surgery regardless of the patient's possible movement. Accuracy check was done. The drill tip calibration related the axis and tip of the drills to the drill tag. The DrillTag was first attached to the surgical contra-angled 20:1 hand-piece, then the chuck of the handpiece was placed on a pin on the calibrator (jaw tag) and rotated around this pin. This identified the axis of the handpiece. The drills to be used were inserted into the handpiece, and the drill tip was placed in the dimple on the jaw tag in the same manner as how the tracer tool was calibrated. The location of the drill tip and its axis were now set in relation to the DrillTag [Figure 13].
Figure 8:HeadTrackerwithearhooksandnosepads

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Figure 9: Tracer tool

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Figure 10: Tracer tag

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Figure 11:Landmarkswereobtainedforaccuratenavigation

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Figure 12: In-situ photo of tracing and registration

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Figure 13: The location of drill tip and its axis were set in relation with the drill tag

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Part II-The transcrestal sinus augmentation during immediate implantation

Local anesthesia was administered to the patient. The first molar was extracted atraumatically with the help of carbide tooth splitting bur (Strauss and co.) bur no FG-ZEKRYA28. In order to save the interradicular bone for immediate implant placement, the roots were split at the furcation level and then with the help of DE3 luxator (SS White) individual sectioned tooth pieces were extracted. The dimensions of the extracted palatal root and distobuccal root were measured with a Williams graduated probe and were found to be 12 mm and 10.5 mm in length respectively. The distobuccal and palatal socket walls were evaluated and were found to be intact. The buccolingual distance of the socket was measured based on the CBCT cross-sectional image and correlated with the clinical intraoral measurements. Using these criteria, the diameter of the implant was selected to maintain a 3 mm gap between the buccal plate of the socket and the implant. A full-thickness mucoperiosteal flap was raised bucally and palatally. The implant length of 10.5 mm, diameter of 4.6 mm, and the implant angulation were predetermined on the navident software earlier. The available bone height to the sinus floor was 8 mm therefore a sinus augmentation of 5.5 mm was needed as the 10.5 mm implant had to be placed at least 3 mm subcrestally in immediate implant placement. This was achieved by transcrestal sinus approach using versah burs (Densah burs). After the calibration of handpiece, each drill was calibrated before being used for osteotomy as explained earlier in the tracing procedure. Starting with the 2 mm Densah drill instead of the pilot drill. The drilling for osteotomy preparation was done after drill tip calibration, with copious irrigation at a speed of 1200 rpm in a clockwise direction through the interradicular bone to 1 mm below the sinus floor [Figure 14]. The 3 mm versah drill was the next to be used following drill tip calibration, at a speed of 1,200 rpm in anticlockwise direction to 3 mm past the sinus floor [Figure 15]. The 4 mm versah drill was used under copious irrigation following the drill tip calibration at a 1200 rpm speed in a densifying mode (anticlockwise direction) 3 mm above the sinus floor. The Rocky Mountain tissue autograft (Rocky Mountain Tissue Bank, USA) was used for sinus augmentation. The grafting was done with the help of a 4.3 mm versah drill was used at a speed of 600 rpm in an anticlockwise direction without irrigation 3 mm above the sinus floor [Figure 16]. The implant was calibrated and placed 3 mm subcrestally [Figure 17]. Healing abutment was placed and 4-0 silk sutures were placed.
Figure 14:Twommdrillwasdrilled1mmbelowthemaxillarysinusfloor

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Figure 15:Threemmdrillwasdrilledtillthesinusfloor

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Figure 16:Threemmdrillseenat2.2mmabovesinusfloor

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Figure 17:4.3mmburat600rpmseen3.9mmbeyondthesinusfloor.Thegraftedbone can be appreciated on the navigation software

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Postoperative prosthesis

After a healing period of 4 months, implant level impressions were made and screw-retained prosthesis was fabricated in the lab, which was torqued up to 30Ncm2. The abutment screw access was then sealed with Teflon tape and composite.

   Discussion Top

Dynamic navigation has shown to be equivalent to static guides in relation to accuracy however they are both better than freehand implant placement. The dynamic navigation system however has a learning curve associated with it.[12],[13],[14] Studies have shown that an appropriate hands-on training and guidance enhances the ease and accuracy of surgeries done by dynamic navigation.[15] The advantages of dynamic navigation over static guides are that it features real-time intraoperative guidance allowing alterations in surgical plan, does not require special instrumentation, can be used in individuals that have less mouth opening, and appreciates the slightest alterations when compared to the preoperative plan intraoperatively. In this case report a new registration method known as “Trace and place” has been applied. This is different from the conventionally used fiducial method as observed in other navigation techniques. In the fiducial method, a CBCT scan with a custom-made stent attached to a radiographic marker known as fiducial needs to be taken. The Trace and place registration has the following advantages when compared to the latter technique. (1) A additional CBCT scan with fiducials is avoided, therefore there is no added patient cost and radiation exposure. (2) Avoidance of inaccuracy due to placement of stent during CBCT scanning and intraoperatively. (3) Avoidance of fabrication of custom stent reduces the treatment cost. (4) Intra-operative ease for doctor.

Osseodensification by application of densah burs allows a greater implant stability and insertion torque due to the spring back effect.[16] In addition, the compacted bone that lies in contact to the implant allows physical interlocking between bone and implant surface, it acts as a nucleation site for new bone formation.[11] The transcrestal sinus augmentation and immediate placement of dental implants widely accepted procedures. The survival rates are comparable to implants inserted according to conventional treatment protocols.[17],[18] Huwais in 2018 stated that osseodensification can be used to obtain higher bone to implant contact in both transalveolar sinus augmentation and immediate implant placement. The densah burs unlike other sinus augmentation tools can be calibrated and guided by navigation to the preplanned surgical position while doing transcrestal sinus augmentation. Therefore with the added application of navigation, the densah burs can be seen in real-time on the laptop screen approaching towards the sinus wall and elevating the maxillary sinus membrane. This added benefit cannot be obtained by any other technique of sinus surgery. Further research and long-term studies need to be done on this novel technique.

   Conclusion Top

Real-time feedback using digital imaging, tracking systems, tracing, and registering to navigate is a well-documented science in medicine and surgery. Safer and less invasive protocols are the way ahead in dentistry. Real-time Dynamic navigation is proving to be the pilot in this. Improvement in stereoscopic cameras, optical markers, and software will herald an unprecedented level of accuracy in all dental procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:332-43.  Back to cited text no. 1
Smiler DG, Johnson PW, Lozada JL, Misch C, Rosenlicht JL, Tatum OH Jr, et al. Sinus lift grafts and endosseous implants. Treatment of the atrophic posterior maxilla. Dent Clin North Am 1992;36:151-86.  Back to cited text no. 2
Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207-29.  Back to cited text no. 3
Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613-6.  Back to cited text no. 4
Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the sinus consensus conference of 1996. Int J Oral Maxillofac Implants 1998;13 Suppl: 11-45.  Back to cited text no. 5
Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compendium 1994;15:152, 154-6, 158 passim.  Back to cited text no. 6
Davarpanah M, Martinez H, Tecucianu JF, Hage G, Lazzara R. The modified osteotome technique. Int J Periodontics Restorative Dent 2001;21:599-607.  Back to cited text no. 7
Kumar BT, Narayan V. Minimally invasive crestal approach sinus floor elevation using Densah burs, and Hydraulic lift utilising putty graft in cartridge delivery.Clinical Oral Implants Research. 28; (Suppl 14). (Huwais S. Inventor; Fluted osteotome and surgical method for use. US Patent Application US2013/0004918; 3 January, 2013)  Back to cited text no. 8
Almutairi AS, Walid MA, Alkhodary MA. The effect of osseodensification and different thread designs on the dental implant primary stability. F1000Res 2018;7:1898.  Back to cited text no. 9
Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Part II: Transalveolar technique. J Clin Periodontol 2008;35:241-54.  Back to cited text no. 10
Trisi P, Berardini M, Falco A, Podaliri Vulpiani M. New osseodensification implant site preparation method to increase bone density in low-density bone: In vivo evaluation in sheep. Implant Dent 2016;25:24-31.  Back to cited text no. 11
Stefanelli LV, DeGroot BS, Lipton DI, Mandelaris GA. Accuracy of a dynamic dental implant navigation system in a private practice. Int J Oral Maxillofac Implants 2019;34:205-13.  Back to cited text no. 12
Block MS, Emery RW, Lank K, Ryan J. Implant placement accuracy using dynamic navigation. Int J Oral Maxillofac Implants 2017;32:92-9.  Back to cited text no. 13
Block MS, Emery RW, Cullum DR, Sheikh A. Implant placement is more accurate using dynamic navigation. J Oral Maxillofac Surg 2017;75:1377-86.  Back to cited text no. 14
Koch AD, Ekkelenkamp VE, HaringsmaJ, Schoon EJ, de Man RA, Kuipers EJ, et al. Simulated colonoscopy treatment leads to improved performance during patient based assessment. GastrointestEndosc 2015;81:630-6.  Back to cited text no. 15
Huwais S, Meyer E. Osseodensification: A novel approach in implant osteotomy preparation to increase primary stability, bone mineral density and bone to implant contact. Int J Oral Maxillofac Implants 2016;32:27-36.  Back to cited text no. 16
Barone A, Toti P, Quaranta A, Derchi G, Covani U. The clinical outcomes of immediate versus delayed restoration procedures on immediate implants: A comparative cohort study for single-tooth replacement. Clin Implant Dent Relat Res 2015;17:1114-26.  Back to cited text no. 17
Tarnow DP, Chu SJ. Human histologic verification of osseointegration of an immediate implant placed into a fresh extraction socket with excessive gap distance without primary flap closure, graft, or membrane: A case report. Int J Periodontics Restorative Dent 2011;31:515-21.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]


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