Bilateral Maxillary Sinus Lifts with Bone Augmentation: How Long To Wait Before Implant Placement?

In my opinion he's being too cautious. Depending on the type of graft material he uses, after 6 months the new bone that has formed will already begin to resorb. He may be using some type of sintered bovine material or even an alloplast which would take longer to resorb, but isn't necessary for this type of procedure. He can get vital bone which is more conducive to placing an implant in 4-6 months if he uses an allograft.

The healing period following sinus bone grafting depends on the amount of pneumatization, residual bone below the sinus, patient factors and type of graft material used. If autogenous bone is used the healing time can be shortened (~4 months). If bone substitutes are used then longer healing periods would be prudent. You can estimate the sinus graft incorporation at about 1.0 millimeter/month with bone substitutes. Greater vital bone formation will occur with greater time. If you started with 3.0 millimeters of bone then at 6 months you should have adequate bone formation to place the implants (~9.0 mm). The bone graft will still be healing but the implants can heal with the graft at this point. The implant healing is related to the bone quality. At six months the graft is often softer (D3) so a six month implant healing period could be considered before uncovery. This would result in at least a 12 month overall healing period at the earliest. Additional time will result in more bone formation. If the surgeon waited 9 months then a shorter implant healing may be considered (ie. 4 months) as the bone should be better quality. As you can see the overall treatment length is similar with either approach. Twelve months graft healing is probably longer than necessary before implant placement.

with Bovine material 6 months is the minimum time, 8 is better. with Allograft like Puros for example that i use i go back at 4 month and the half.

As Serge says the time is mainly dependant on the graft material and he possibly used a Xenograft which takes time , trust his judgement as if it goes wrong he will be held to re-do the implants. Allografts and alloplasts can be placed at 4 to 5 months.

The period of time to safely re-enter a sinus graft with 3mm of bone between the sinus floor and crest of the residual ridge is usually around 6 months when all synthetic/allograft materials are used or around 4 months when autograph is also added to the graft. The larger the sinus mesial-distal size, the longer the waiting time and the smaller width sinus shortens the time. This time period may also be affected by sinus pathology after the graft (i.e. infection). The time period should start after the infection is resolved.

Dear Anon, 3mm of residual bone height is sufficient for doing a simultaneous sinus augmentation with implants placement. Ther is enough data in the literature to support it including our group publications. As to the waiting period- we usually wait 6 months for graft consolidation.with bovine material only i would go to 8 months. With allografts or composite grafts it will reduce the time to 6 months.Adding PRF will be a benefit to all types of grafts.

Dear Anon, I would follow the instructions of the oral surgeon. It is easy to guestimate how much time is required based on the type of grafting material used. One important factor not mentioned by any of the above experts, is what was the quality of the blood circulation in the antrum. The only person to answer this question is the oral surgeon who did the work. It is always better to wait longer in these situations when you know the chances of success are greater. Gerald Rudick dds Montreal, Canada

It is conservative to not place implants when there is only 3 mm of bone.... Some implant surgeons place the implants at the same time they graft, if they have 3 or more mm of bone to stabilize the implants. This does require a good technique in placing the implants, to obtain at lease 35 Ncm of stability for the implants being placed. Being conservative in this matter is not a bad thing. A couple of bad experiences tend to make us more conservative.... It is very conservative to wait 9 to 12 months for the graft to heal. A good average is about six months with most materials... Some graft materials, especially, autogenous iliac crest grafts need placement around 4 months, or sooner, to avoid loss of grafted bone, to atrophy. As soon as bone starts to mature, and there is no function for the bone, it begins to atrophy. As Carl Misch stated, if you have infection, the time always starts after the infection is cleared up. I won't use all bovine HA in a graft, but if you do, 9 to 12 months waiting shouldn't hurt. It takes years for all the bovine HA to convert to the patients own bone. (If it ever does completely convert). My experience is, that a bovine HA graft is hard and brittle when mature, and many of the HA partials stay around, and around, and around, seemingly forever. I maintain that LD HA added to other graft material works well to strengthen the grafted "new" bone.

Anon, Listen to your OS

Dear all,I graduated 2yrs ago with an MSc in Implantology from the Eastman in London. I have placed around 200implants, mostly Nobel. I am looking for good thorough courses on Sinus Lifts and Block bone grafts. I know the theory but have no practice. Any of you can recommend a good centre to learn this?? Regards from sunny Malta

Hi Dr Jp, Ziv Mazor is your man , he works in the Med area as well , contact him about his next course. Also look into the Dask system for window preparation it sure makes life easier. Peter

Dr. JPDemajo(Malta), You may consider to following for a good source of information/courses. Tatum Surgical in sunny St. Petersburg Florida USA. at 1-888-360-5550 and Joel Rosenlicht's courses in Manchester Conn. USA. Both will give you an excellebt understanding. Also the American Acaemy of Implant Dentistry has a DVD lecture series about sinus augmentation etc. I hope this helps.

Anon, 9-12 months is definitely a long time to wait to re-enter after bilateral sinus lift. However, it is possible that your oral surgeon ran into some sinus pathology at the time of grafting and that is his reasoning for waiting this long. Therefore, ask him why he is waiting this long. On average, 6 months is an okay time frame to wait after sinus augmentation to go ahead with implant placement..but again this depends on the type of bone graft material used, as well as if pathology is present or not. I would NOT even think about bilateral sinus lift and immediate placement of implant with only 3mm of bone. You would need at least 5-6mm of bone in order to even consider this. Good luck with your case

Allen, If you go over the literature starting in 1998(J.Perio) you will be surprised to see that implants can be placed simultaneously with sinus augmentation even in 1-2 mm of residual bone height.Since 1998 many articles have proven the same.In 2006 we published in IJOMI 9 years of retrospective study of 731 sinuses with more than 2000 implants performed simultaneously regardless of the residual bone height.There is no change in implant survival rate or integration. Stating"I would NOT even think about bilateral sinus lift and immediate placement of implant with only 3mm of bone" is subjective and not evidence based.

Ziv Thank for your comment, and I understand that there is literature that supports placing implants simultaneously with 2-3mm of bone height. However, how predictable is this treatment is the question, in comparison to grafting and waiting. If you speak to many of the world leaders in implant education, you will see that such a treatment plan is not recommended. Why risk, inadequate initial stability, or having an implant pushed into the sinus...as these are the types of things that can occur often with push the limit in such situations. We all want something that shows very high success rate and great long term success, and if you look at the literature, it will tell you that when having 5mm or less of bone, it is recommended to graft the sinus and return in 4-6 months. Read Carl Misch's text...that is just one example

I actually consider Dr. Carl Misch as a great teacher for all of us, but in this particular case, I have to admit that Dr. Mazor is right. I learnt this technique from Dr. Ady Palti at kraichtal, Germany who taught me how to place implants while grafting the maxillary sinus simultaneously.Before that, we used to do our sinus liftings then wait for a time lapse of four to six months -depending on wether it is a viable autogenous bone graft or a biomaterial- and then re-enter the site to place our implant(s).From then on, we have been placing our implants and at the same time grafting our maxillary sinus floor, no matter how thick the bone between the alveolar crest and the sinus floor might be.In some cases, this bone was so thin that we had to take advantage of certain bone fixation plates as implant stabilizers.After the passage of years, I dare say that I am very satisfied with the results, and as Dr. Mazor has mentioned before, There is a very good literature support for this method.

To Dr. Mazor and Jafari I dont disagree that this technique works. I have used what both of you have suggested and it does work. It is just that it is not necessarily as predictable of a technique compared. However, If both of you use it and have had great success with it, then that is great.

I always based my decision on principles,to decide wether to do simuletanous implant & sinus lift .the principle is,assure a good implant stability & donn't gain implant stability by the grafting material.so I have done cases with sinus lift & simulatenous implant pacment ,with sinus floor 2-3mm,but implant stability is gained through surgical technique&implant type.in addtion to one important factor in primary stability in sinus lift which is the engament of cortical plate of sinus floor.finaly add your bone graft to gain addtional bone during healing period to get sufficient bone for the function of the implant.if the addtion height needed is 3mm or less,we don't use any kind of grafting material.

Dear Drs Fairbairn and Hughes. Thankyou for the info. I will look into it. I am realizing that my implant planning is being limited by the sinuses and often I have to compromise the positioning. Back in London most of my tutors wouldn't dare risk doing a lift themselves because of the max sinus artery so they wouldn't show us how its done, just theory, all because of 1death due to haemorrage in 2007. Have you had any sinus lift related emergencies ? regards Jean Paul

Dear Jean Paul, things can happen in all surgery but it is not the Carotid or femoral artery , Piezo can help to isolate the possible buccal wall artery but as I use the Dask system now I suppose a scan ( which you should always do in sinus augmentation if possible) can reassure you as well. We use the lateral (Cauldwell Lac ) approach mostly as it allows you see the site clearly and the smaller Dask is great here. Biggest issue is infection and again with bacterio-static alloplasts that is not an issue. Spurs another issue again Scan and as for tears in the lining again with Dask much less of an issue. Treatment planning without sinus augmentation is very limiting. If London based occasionally come to ADI Forum in November . Regards Peter

Dear Jean Paul Giving a treatment plan to your patient without being able to place implants in the sinus area is not giving a proper solution to the patient's needs. Using tilted implants or doing all on 4 in the maxilla was invented in order to give economical solutions to populations who could not afford the ideal treatment. Sinus augmentation is one of the most predictable procedures for augmenting bone in the posterior maxilla with a very high success rate.I'm amazed with your comments about the situation in England... You are always invited to get on board and do a hands on live surgery course on sinuses www.handsoncourse.com Learning how to deal with complications is a must before you start on your own.

With due respect to all the big names who have posted on this blog, Doing a Sinus lift procedure simultaneously with Implant placement in a residual crest of 3mm could be analysed as under: 1)The Implant is placed within a 'graft'mixture and not within good healthy bone 2)The generation of Osteoclasts,Osteobalsts and their promotion of the Inflammatory phase (as predicted and described by Dumont & Cruess, 1975 Lippincott., in their famous and still quoted "Healing graph") is unlikely to happen. 3) The posterior maxilla is already compromised by a severe lack of vertical height as the resorption pattern leaves a reverse ratio as far as Implant :Crown is concerned 4)To be placing an Implant within the graft mixture simultaneously (in the sinus) would leave the most distal area (the 'periapical'-Load bearing segment of the Implant) encased in graft rather than bone even after bone has turned over in the proximal areas closer to the residual Maxilla. 5) Lekholm & Zarb , Cawood & Howell et al, have over the years demonstrated that resorption patterns in the posterior Maxilla take away all of the alveolar component leaving behind residual basal maxillary bone. Bone that is not so accepting of Occlusal load (like the Alveola bone was when the tooth it supported transferred Occlusal load). This being the case, the Implant would therefore ideally be supported by bone rather than a graft mixture whose rate of turnover and conversion into native bone is speculation at best at any given point of time! Therefore, simultaneously placing Implants within a Sinus augmented posterior maxilla is like expecting two "miracles" to happen at the same time !! The 'miracle' of Osseointegration being big enough as it is, toexpect it to happen alongside the 'miracle' of Osteogenesis is when "PREDICTABILITY" becomes more and more "UNPREDICTABLE" !!

If bilateral sinus lift is to be done- why not a full arch prosthetic on Disc /BOI (basal osseointegrating implants) using trans sinus technique. Safe enough even for immediate loading. Predictable and immediate benfit for Patient. What is decisive in that particular case - mastication and function or esthetics. Many things work.

Ditto on Dr. Richard Hughes!! There is no advise that can be given on an open blog like this one that will give you the training and experience you need to make decisions like this one on a daily basis. Go to AAID and enroll in the fresh cadivar course that will be given next year; taught by Dr. Jim Rutkowski. Then go to Tatum Surgical, and Dr. Joel Rosenlicht to get more training and be clear about pre-operative, surgical, and post-operative protocols. Tim Hacker DDS, Diplomat ABOI/ID

Recommendations: Sinus lift and forensics are an issue. The maintanace of the integrity of the sinus membrane is of crucial physiologic and legal importance in the sinus-lift procedure-no matter if performed as described by Summers or Tatum. As it is absolutely not easy to determine the status quo of the sinus prior to elevation complication may arrise. Spurs/latent chronic infects/patented hiatus/granuloma and so on might lead to problems as occasionaly reported by unhappy patients. Grafting as therapy has to follow prooved surgical diagnostics. Therefore the surgeon might get confronted with the reproach of having caused damage that was not present to the patient before. I would like to invite all collegues and especially the more experienced to evaluate and discuss following approach to sinus-lift for conclusivity. Starting from a biological modell (egg-shell) over a simulation modell (egg-shell in gips) up to the presented experimental patient case preparation was done on a fluidic basis and prooved by a "modified" tensiometer. If you see an improvement in quality of treatment and legal/forensic security of the medícal provider by using such device/technique for preparation,diagnostics and documentation wich decission would you take as the treatment provider in case. 1) membran integrity can be/is secured and prooved would you perform sinus lift and grafting on a patient with known chronic allergic sinusitis ? 2) would you graft with extraneous, alloplastic, xeno- or autologuous bone material ? why ? 3) if sinus membrane integrity was maintained would it be sufficient to keep the membrane lifted- for example by a kollagen-sponge around implant- tip ? A device for a controlled progressive and atraumatic preparation of the Schneiderian membrane capable to determine if integrity of the prepared tissue is present does not exist yet. Would it be usefull ? Your oppinon ?

Anon, talk to your OS and ask him to try this technique (sin-prep) placing simultaneously implants and provisory superstructure in non-occlusion. Beware of parafunction. If there is less then 3mm use 2 piece implants and wait 5 months. Start with progressive loading and use al least 3 provisory adjustments over 6 months before final prosthetics. Use body`s own tissue engineering. http://www.zp-aktuell.de/praxis/story/sinprep-ein-vorschlag-fuer-die-optimierung-des-sinuslifts-teil-2.html

To Prof.Dr.Hossam Barghash would you like to contact me. Thanks, even if not roland.balan@gmx.de