II. Methods
A new sinus curette has been designed with the purpose to be used through the alveolar ridge. The devices consist of a handle with a detachable curette. The 4 mm diameter curette slides into the handle and is rotated into the desired position adjustable to full 360 degrees. Once the curette is in the desired position, the fixation screw of the handle is tightened to fix the position. Three interchangeable tips at different angles, all of which can rotate 360 degrees, has been designed to allow the operator choose the more convenient design that conforms to the geography of the Antrum. Access to the membrane is achieved in different ways including the implosion of ridge with summer’s osteotomes or with a round bur. Once the membrane is elevated, graft material can be introduced inferior to the membranes, implant placement can also be attempted if primary stability can be assured.

III. Results
The micro adjustable sinus elevator has proven to be an effective and convenient device specifically designed to elevate the sinus membrane through the alveolar ridge. The rotational component replaces the need for a large stock of sinus curettes with different angles.

IV. Conclusion
ISM procedures are being used as an alternative to the traditional lateral window. The limitation created by the lack of available instruments to perform this procedure raise the need to develop more ergonomic devices that will simplify this technique.

POSTER PRESENTATION ABSTRACTS

P-148
Dome Shape Resorbable Membranes for Internal Sinus Elevation, 2 Years Later.
A. Ordonez, B. Rojas, Y. Kim, R. Kimsey, F. Briceno Coral Gables, FL

I. Introduction
Schneidarian membrane manipulation or sinus elevation is a procedure performed with the intention to gain vertical height in the maxillary sinuses, for the placement of longer Dental Implants. It usually requires tactile ability of the operator to avoid rupture of this delicate membrane. Different techniques for sinus elevation have been postulated to gain access and elevate this membrane. The most common complication in all of them is the perforation of the sinus membrane. In 2006, Dr. Ordonez, Briceno and Kim postulated a technique to repair perforations of the Sinus membrane in internal sinus manipulation procedures. Utilizing a three-dimensional fast resorbing membrane made of porcine collagen and shaped as a dome.

II. Methods
The porcine Dome Shaped membrane postulated by Ordonez, Bericeno and Kim has very specific rigidity and physical characteristics that allow proper manipulation and placement through the Antrum. This membrane is designed to resorb in seven (7) to fifteen (15) days which allows enough time for the formation and repair of the Schneidarian membrane. Bone Graft is placed inside the dome membrane and the graft will nourish from the newly repaired Schneidarian membrane, forming the necessary bone for eventual implant placement. Some perforations were performed without the existence of any kind of manipulation of the Sinus.

CLINICAL INNOVATIONS ABSTRACTS

CI-9
Bone Condenser for Immediate Implant Placement
R.D. Kimsey, A. Ordonez, B.Rojas Coral Gables, FL

I. Introduction
Immediate implant placement is performed routinely and with increasing frequency in implant dentistry. Frequently these implants fail to engage bone throughout their body when first placed. This requires the surgeon to attempt to graft bone into these voids. These voids are of particular concern in the molar and maxillary premolar regions. When attempting to graft these voids the surgeon may graft prior to placement of the implant of graft immediately after placement. If a mineralized graft is placed into the socket prior to the insertion of the implant then the hard particles may prevent proper seating of the implant body. If the surgeon elects to graft the voids between the bone and the implant after seating the implant the surgeon faces a challenge of getting the graft particles into sites that are frequently between 1 to 3 mm.

II. Methods
In order to condense osseous graft materials into the voids along the implant body a new bone condenser has been designed. The immediate placement bone condenser is a doubled ended hand instrument fabricated from titanium. The tips are rods 1.5 and 2.0 mm by 20mm long. The tips are at a ninety degree angle to the handle and have marks at five, ten, and fifteen millimeters length. The tip of the condenser is concaved. The concaved tip allows for greater control and more rapid placement of the osseous graft. The five and ten millimeter marks provide the surgeon a guide in evaluating the depth of the void between the implant body and the native bone. After placement of the implant the bone condensing instrument may be used as a probe to evaluate both the diameter and depth of the osseous void. The osseous graft material is then introduced to the surgical site and placed apically and adjacent to the implant body with the implant bone condenser. Once the surgeon has filled in the gaps he can close the site as usual knowing that there are no large gaps between the implant body and bone without adversely affecting the implant surface.

III. Conclusion
With the advent of immediate implant placement combined with bone grafting techniques there has been a lack of a proper instrument to adequately place and condense bone into the smaller voids between the implant body and bone without adversely affecting the implant surface. The immediate placement bone condenser solves this dilemma.

CLINICAL INNOVATIONS ABSTRACTS

CI-11
Trephine-assisted Osteotome Sinus Floor Elevation for Simultaneous Implant Placement
J.Y. Kim, A. Ordonez Garden Grove, CA

The osteotome sinus floor elevation technique originally introduced by Summers in 1994, has the advantages of not only gaining the vertical bone height for longer implant placement, but of obtaining increased bone density immediately surrounding the site. However, this technique has two major potential drawbacks: (1) the risk of sinus membrane tear, and (2) the concern of over-preparation at the crestal area, as tapered osteotomes are utilized, trephines have been utilized in sinus floor elevation in various capacities. Generally, large trephines have been used to prepare precisely controlled osteotomy, whereby the cut portion of the alveolar bone would be lifted with the sinus floor, leaving a relatively large alveolar bone defect that would be grafted. By utilizing smaller trephines of defined dimensions that correspond to about a millimeter smaller than the implant diameter, sinus floor elevation and simultaneous implant placement is possible. Trephine is introduced into the alveolus within millimeters of the sinus floor. A non-tapering osteotome corresponding to slightly smaller diameter than the trephine is introduced to condense the core of bone just prepared in a superior direction. Flat or concave end has worked equally well. The condensed bone would expand the floor of the sinus and ultimately fracture the floor upwards. Bone graft particles may be introduced into the osteotomy site. When tapered implant body are to be utilized, the osteotomy site can be further condensed laterally with tapered osteotome. The size of the trephine, depth of the trephine osteotomy, and selection of appropriate implant size is dependent on the density and topography of existing alveolar bone. This innovative technique has been utilized by the authors on numerous cases, including one involving immediate implant placement in a molar site. Clinical cases as well as a detailed description of the technique, its potentials, complications and its limitations will be presented.

CLINICAL INNOVATIONS ABSTRACTS

CI-15
Atraumatic Sinus Floor Elevation by Compression
A.J. Ordonez, A. Garg, J.Y. Kim, R. Kimsey Coral Gables, FL

Repeated malleting in sinus floor elevation procedure utilizing osteotomes has been regarded as one of the most distressing procedures performed on dental implant patients. In patients that are not sedated, malleting is usually the most traumatic aspect of the surgery. A new technique is being proposed to elevate the sinus floor and simultaneously improve density in the immediate surrounding bone through compression. An initial pilot hole allows the use of a series of screws that expand and condense the bone, thus providing space to place the vertical expanders, which consist of three screws of varying diameters and an inner screw, allowing an internal screw to pass apically through the anchorage screw. The internal screw is designed to turn superiorly, and to apply controlled forces in the superior direction, while the anchorage screw is firmly anchored, in the resident alveolar bone. The controlled forces then condense and deform the bone towards the sinus floor, effectively expanding the bone superior to the device towards the sinus floor. This ultimately greenstick fractures the sinus floor portion of the bone, and thus elevates the floor of the sinus. The increased height available for implant placement allows wider and longer implants to be placed in better quality bone with excellent stability. Furthermore, traumatic malleting can be eliminated by utilizing this technique. Clinical cases as well as detailed description of the technique, its potentials, complications and its limitations will be presented.

CLINICAL INNOVATIONS ABSTRACTS

CI-09
Utilization of Dome-Shaped Resorbable Membrane in Internal-Lift Sinus Perforations
Ordonez, F. Briceno, J.Y. Kim Gainsville, FL

I. Introduction
Techniques in maxillary sinus floor elevation have been considerably modified during the last several years. Newer, less invasive techniques have been suggested since Summers introduced the osteotome elevation technique, in what is known as the “internal-lift”, as opposed to the lateral window technique. They include modified techniques utilizing trephines (Kim & Ordonez 2005), and atraumatic elevation with expander devices (Ordonez 2005). These methods, however, suffer in that they are largely blind procedures, relying almost entirely on tactile senses of the operator. The most common complication is the perforation of Schneiderian membrane.
Repair of membrane tear during lateral window approach using collagen-based membranes have been suggested by a number of clinicians. However, in internal lift, flat piece of membrane serves no more than a plug o dressing as its physical form cannot be maintained in the narrow bone defect.

II. Methods
Utilizing a dome shaped resorbable collagen membrane that contains bone graft material, implant placement can be achieved in cases of Schneiderian membrane tears that would have otherwise led to an abortion of simultaneous implant placement. The unique shaped resobable collagen membrane is made with collagen extracted from cultivated pig gut. Material is isolated and exposed to a chemical bath, then dehydrated a laminar flow cabin on a prefabricated bullet shaped mole. These are manufactured in different dimensions simulating the degrees of bone/membrane defects. These are shaped with extensions from the dome to assist in clinical handling of the material. Sterilization is achieved with ethylene oxide.
The rigidity of this dome-shaped membrane allows secure placement into the narrow osteotomy which has a communication to the antrum. The dome is securely placed with the aid of winged extensions. It is placed with the domed portion protruding into the antrum. Bone graft material can now be introduced inferior to the membrane. Implant placement can also be attempted at this stage is primary stability can be assured.

III. Results
Animal studies have suggested satisfactory repair of sinus membrane over the dome membrane. The dome membrane is also proven to be as a true barrier in various laboratory and in vivo animal studies.

IV. Conclusion
Preliminary human clinical cases have been performed on limited number of cases to date, where satisfactory clinical outcomes have been documented.