Can I Avoid a Maxillary Sinus Lift?

Sir, in your case, if you really need to avoid the sinus floor lifting operation, then the best choice would be referring the patient to an oral and maxillofacial surgeon.He will do the job in a perfect manner and then the patient will be back to you to insert the implants after four months.

Dear colleagues ,still the quesion is there what oral maxillofacial surgeon will do? since the implant dentist he would like to avoid the sinus floor lifting. thanks

i place 3 implant to substitute lower right 5,6,7.after 3 monthes i load on the implants by athree units bridge.after one month i found that there is a mobility .i take an x-ray there is no bone loss or infection.what is the solution?

refix bridge- if there is no implant mobility (Cementum-temporry bonding)! Biological answer is binary- either yes or no. You are the surgeon and dentist ! Far advised suggestions are usualy post/ante perspectives and not of real use. No ailing no removal- wait and see !

And do it !

the abutments may be loose and not the implants.

Elsayeid, Please respect the forum guidelines by starting your own thread with your question instead of asking in somebody else's thread. This is called "hijacking" a thread and I am sure you did not mean to do that. Dr. A Even though you have not stated your reasons for avoiding a sinus lift, here are my suggestions: Five millimeters of bone is adequate to obtain fixation of the implant whether you choose a lift or not. Many dentists use short implants in the posterior area such as Bicon for that same reason. You may also select the appropiate size implant and do an osteotome elevation with or without a bone graft. Obtaining three additional millimeters of length this way is easy. Evaluate your options and choose based on proven principles and you should be fine. Good luck!

If you have 5 mm between the floor of the sinus and the ridge crest,I'd suggest to approach the site following the standard procedure with drills but drill up to 3 mm and then proceed manually with osteotomes,once you break the cortical bone of the floor you can place bone graft and place a 5x8 implant. Do not use 5x5 Innova implants,they are not forgiging if the beads are left exposed!

the first question should be is it the patient who doesn't want the sinus augmentation or the clinician. I can speak from personal experience in saying that when I was not undertaking these procedures, I would routinely avoid them and tailor my conversations with patients with this prejudice. Once I had obtained good training, and had the appropriate equipment, I realised that it is no more invasive than a conventional implant placement when handled with care. I agree with the comments above that 5mm is adequate for an internal sinus floor elevation, providing the osteotomy is not over prepared. I prefer to use the MIS bone compression kit for these procedures, as it reduces the likelihood of concussion injuries which have been associated with osteotome and mallet procedures. Less than 4mm and I will open a sinus window with a piezo surgical unit. This is a very conservative and elegant way to undertake this procedure, and patients experience minimal morbidity, particularly with some dexamethasone premed. I would recommend doing some additional training, expecially with cadavers, to widen your comfort zone with sinus procedures, and more cases will be managable in your practice.

Totally agree with BriaN. The use of the MIS os Meisenger expanders will elevate the sinus floor crestally after you break through the sinus floor with your pilot. Osteotomes are way more traumatic with less control. Additinally you will get much better bone quality with the compression for great stability of the implant .

I avoid sinus lifts in my practice in two ways: 1) Using BOI (Basal Osseo Integration) implants introduced by Dr.Ihde Dental Germany - the basal implants are inserted laterally and not crestally. A portion of the implant can very well go in trans-sinus without creating any problems, whatsoever. 2) Using Bicortical Screw implants anterior to and posterior to the sinus (in the maxillary tuberosity - pterygoid regions). These are single piece implants which provide excellent support. For more information please copy paste the following link on your browser: http://sites.google.com/site/onepieceimplantscom/no-more-sinus-lifts You will reach a page "No more sinus lifts" on which an article by Dr. Stefan Ihde has been loaded in downloadable PDF format.

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You should find a way for the patient to do a sinus lift: lern on eggs :) or refer. 5mm is to small for the closed sinuslift. You would create yourself a trouble. And for the sake of all planet don't consider BOI implants - a man-made disaster from the past.

I had more complictions with implant insertion in hard bone than in soft bone with limited hight as it is in lateral maxilla! Don't scare patients with touching the sinus with minimal invasive procedures and explain that in most cases there is no need for classical lateral window approach (Caldwell-Luc.) The only thing that you have to decide is weather you intentionaly perforate cortical bone of the sinus with undersized drill or perform crestal sinus lift both for short tapered implants. Avoid engaging sinus only in the cases of sinusitis history.

hai all those sirs can we use a endopore implants for this case in which we can place 5 x5 or u prefer bicon or do an indirect sinus lift using mis kit or osteotomes

I see that adverse comments have been posted about BOI implants. Now, I have placed several implants by now in the maxilla - sinus regions and they are all working fine. Dr.Ihde Dental has done extensive research on the topic and several articles have been published concerning BOI implants in the maxillary sinus regions.

Bicon 5 >

One can also perform a unilateral subperiosteal implant, with the right conditions........

Richard Hughes, I am amazed at what knowledge makes you want to place subperiosteal implant. They fibrointegrate, are traumatic to place, and destroy remnants of the bone.

If concept BOI is so good why it is not used by large players of the market or simply is not bought entirely.

Andryi, One can place a subperiosteal in such a way that it will osseointegrate. The maxillary unilateral cub is a workhorse in the posterior maxilla. In general subs are far more demanding for the doctor, because you need superior surgical skills and a deeper understanding of prosthetics and occlusion. Sinus lifts can be just as invasive.

Dear Dr A, I guess you are another fictitious Doc with an alphabet. Nevertheless, it is an interesting question. If you do not want to do a sinus lift, any reason will do though it might not be a good one. I myself once did not want to do it because I hated having to make a large opening into the sinus! And if I can avoid it, I did. So I tried crestal lifts invented by Summers. Works, but often found myself having to spend more time than if I just did a lateral window which is more sure and definitive. There are various ingenious ways nowadays, the latest seem to be the "hatch" technique with a special off centre drill. However, if you want to avoid all these, there are several ways to avoid a sinus lift altogether:- * Do a conventional bridge on adjacent teeth. Use the tooth in front and the tooth behind the edentulous space. Or a cantilever might work. * Place an implant in the tuberosity where there is usually more than enough bone and join it to the natural tooth just anterior to the edentulous space. * Or use MINIs! Do a tripod. 3 minis with the tips cut off at 5mm length, and build a crown on it. * 2 or 3 Minis carefully threaded into the walls of the sinus on the buccal and the palatal where there is usually 3-5mm thickness of bone. These technique requires a lot of skill and experience though. * Use short large diameter fixtures from Bicon, Endopore or some of these Korean makers that come in diameters up to 8mm! * Or like Dr Richard Hughes suggest.... place in a subperiosteal. Now all of the above require quite a lot of skill and experience.....maybe you might just want to learn to do a lateral window sinus lift which actually, once you get the hang of it may be actually simpler and surer in results! Cheers.

Richard, I take it you are a man of skill. How did you last make sure your subperiosteal OSTEO-integrated and not just hooked up there? Is it Resonance Frequency Analysis ? If the vestibular thread of a root-form implant is without bone and covered with periost do you think it will last?

Dr Chow - Three questions. 1} Never thought of "cutting off the tips" at 5mm on a mini. How do you do that? 2.}How do you get it to "catch" the threads if the tip is cut off? 3.}I have built several crowns on tripod minis, but I haven't seen clinical techniques discussed on how to "fix" the parallel problem. Your suggestions?

Andryi, I do not understand your questions as per the vestibular thread or resonance frequency analysis. However, I will describe how to make the subperiosteal implant integrate. First, in the maxilla place a two stage root form or blade and let them integrate or use a sound natural tooth (cuspid or bicuspid with copings) as anterior abutments. Next on the cast generated from the ct or made from the impression, countersink the primary cross over struts. Next cut the portion of a root form implant that houses the abutment and have one welded/soldered to the primary strut where you want your abutments to protrude. You may have to uplift the sinus in some areas. Also countersink the distal peripheral crossover strut and plase dense HA over the bone prior to placing this strut. Place the implant and remove boney undercuts on the buccal and cut a shallow retention groove on the palatal to lock in the palatal peripheral strut. Plase over the struts a particulate graft mixed with prp. Place prf membranes over the abutment post areas and use alloderm to assist with tension free primary closure. You need for the opposing arch a balanced occlusion. On the other side of the maxillary arch you need a full complement dentition and do not restore till you have a full complement dentition. This is a little of what you have to know and do. If is a bit involved, but you can help alot of people with this method. PLACING THESE COUNTERSINKS AND ANTERIOR NATURAL/IMPLANT ABUTMENTS HEPLS TO REDUCE ANY ANTERIOR POSTERIOR ROCK-THIS IN MOST IMPORTANT! PRIMARY CLOSURE IS MOST IMPORTANT. USING TITANIUM OR VITALLIUM IS MOST IMPORTANT. Other important surgical points are: Do not dissect the hamular process- YOU WANT TO STAY AWAY FROM THE LIGAMENT (VERTIGO) AND DON'T ELEVATE THE POSTERIOR MUCOSA OFF THE BUCCAL BONE WITH THE ELEVATOR ON THE BONE , GET THE ELEVATOR IN AND PULL IT OFF. tHE OTHE KEY POINT IS TO POUR A MODEL IN SUCH A WAY SO THAT YOU DO NOT DIDTORT THE IMPRESSION (EDGES OF THE IMPRESSION ARE VERY THIN, SO PAINT THE IMPRESSION WITH DIE STONE-LET DRY AND KEEP ON PAINTING IN THIS LAYERS.

Hi Ken, Since we have only 5mm bone height, we can reduce the threaded part of the mini-implant to 5mm by cutting of 5mm of a 10mm thread. Use a sterile orthodontic cutter. Grip the mini by the collar with a sterile orthodontic pliers or even a tweezer.... and then cut! With experience, you can just cut off 3mm and leave a 7mm threaded part. As you screw it in, it will do a Summers sinus lift. Always make sure your drill hole is about 0.8 to 1.0 mm in diameter smaller than your mini diameter. If you are using a 2.5mm diameter mini, your last drill should be 1.5mm diameter or even less if your bone is soft. If the drill hole diameter is smaller than your implant diameter, then even if you have cut off the tip, the remaining threads should still bite into the side of the hole and draw in the implant as you clockwise it. Lastly, you have rightly observed that our current prosthodontic solutions for the minis for both removable and fixed prostheses are still less than satisfactory in terms of simplicity and ease of maintenance. As such, I have developed a system called "THE BUDDY SYSTEM" to try to address the current shortcomings. I will post the sequential write-up in my smalldentalimplants.blogspot.com and will appreciate yours and others advice for any possible improvement. Hopefully, the problem of parallelism can be resolved with a moulding device and that of maintenance of fixed prostheses can be resolved with the use of "cleaning grooves" which I will describe. Warmest regards and cheers.

Ken, The tripoding issue is not new. Check out the literature on pin implants, inclusive of some of Dr. Linkow's cases, which may give you an idea as per managing said situations.

In looking at the question I need some more information... how many teeth are being replaced? What is the density of the bone? What are the 5 patient force factors? What is the implant design? It is possible for a 4x9 mm implant of optiumial functionial surface area(i.e. square thread design with many threads) can support a premolar crown with no lateral forces or parafunctional loads in centric.

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I agree with Dr Carl Misch; "It is possible for a 4×9 mm implant of optiumial functionial surface area(i.e. square thread design with many threads) can support a premolar crown with no lateral forces or parafunctional loads in centric." However I also am certain that a wide enough (and therefore strong enough) implant of 8, 7, 6 and even 5mm can successfully support a premolar crown - whatever the thread design - hell even if it has no threads at all (Endopore or Bicon). I also know they can support molar crowns just fine - I do them often enough and have done so for long enough to know if they didn't. There is now such an overwhelming amount of CURRENT literature (please don't quote me anything more than 7 years old on this - it's out of date!) that shows that once integrated, short implants work exactly as well as longer ones. Even the very slowest to catch on must be now gradually seeing the light. Times move on and the definition of a "Short" dental implant changes over time. At one time a "short" implant used to be anything less than 14mm but that time passed a long while back. Then we went to less than 12mm, then 10mm, then 8mm (it always seems to be even numbers!) and more recently "short" tends to be described as 6mm or less. This literature shows short implants from many different systems and thread designs - or no threads at all - all working in exactly the same successful manner. So the one thing we can be fairly sure about is that thread design is not a particularly important factor in short implant success. Kind Regards, Bill Schaeffer

I just can't trust my eyes nowadays.I really admire Dr. Carl Misch as a real scientific phenomenon,a great teacher and a grand master.But, isn't he full of surprises? The questioner says that he has only 5 mms of bone and does not intend to do any floor lifting or bone grafting in order to insert a 9mm long implant, and guess what,he receives his blessing from Carl Misch The Great.Now,I understand that I am losing my eyesight and I have to do something about it.

Ah Dr Jafari, I'm afraid you need to read Dr Misch's post again - he says that; “It is possible for a 4×9 mm implant of optiumial functionial surface area(i.e. square thread design with many threads) can support a premolar crown with no lateral forces or parafunctional loads in centric.” Not much blessing for a 5mm long implant there! Kind Regards, Bill Schaeffer

Dr. Schaeffer, I agree with you. I would suggest to Dr. Jafari to do an uplift with the Abrahammi kit. It is simple to use.

Dear Dr Hughes, I think you misunderstand me. I think a 5mm long implant will work fine. I also think a 6, 7, 8 or 9mm implant with internal (osteotome) lift will work fine. I also think a 9, 10, 11, 12, 13, 14 or more implant with a lateral sinus graft (Caldwell Luc) will work fine. I've done all of these options and if you do them correctly, they all work extremely well. Pt doesn't want a graft. I HEAR THIS ALL THE TIME. After all, who does "want" a bone graft?! Sometimes I'll feel a graft is the only way to go and I explain this to the patient. Sometimes the use of short or narrow implants can avoid a graft and they get their way. I'm very lucky in that I use a number of different implant systems - each of which has their own advantages and disadvantages. I can then choose the most appropriate one for the case presenting itself. If all you have is a hammer, everything looks like a nail! Kind Regards, Bill Schaeffer

Bill, I do not think I misunderstood you. There are times when we have to step back and look at all the options/literature/marketing and then think! You are a thinking man. I would be reluctant to use a single coventional (screw-in) eight mm implant in some patients to tx a single tooth the mx posterior. I do not have faith in the real shot Bicons in this area. I stop at the 5x8. I have had failures with rootforms with aggressive threads etc. These failures were due to oclusal parafunction. So, due to my experience, the patient will do it my way or hit the highway and let another doc have the problems! You have to look at the size of the pts. mouth, interocclusal space, neck and physical stature, wear marks, periodontal status and willingness to cooperate. Even doing all this you can get fooled.

dear Doctor The question you have placed has received more horses than courses as answers. My advice to you is why are you doing implants at all? Bicon/endopore/ tripod minis??? Human mind has a tremendous potential to create disaster. AS LONG ITS NOT IN HIS backyard. If a sinus lift scares you, you'd be better off referring the patient. Or make a flipper. 5mm bone is more than sufficient. Listen to the guru misch. Regards Lanka 55

Bill, You miss the point regarding threads. It's related to surface area. Bicon's threads are called fins...they serve to increase surface area. Endopore increases surface area with the pores. FWIW, I would much rather have threads or fins than pores. The FUNCTIONAL surface area is more with threads or fins. Don't you lecture for Bicon? I'm surprised you don't know this. Surface area matters. If you think it doesn't, try placing smooth implants and see what happens. Carl is spot on when he recommends an implant with increased surface area. Implant design matters!

Actually Paul, I think you've missed the point I was making. The argument presented by Misch was that short implant survival was related to thread design. Endopore has one of the very few 10 year follow-up RCTs in implant dentistry and shows excellent results. Endopore doesn't have threads. Bicon has great long-term success with short implants and it doesn't have threads. As you point out they are fins. So if two non-threaded implants have some of the best survival rates of all short implants, then the one thing you can take from that is that thread design is perhaps not the most important issue in short implant survival. You are of course correct in that surface area plays a role - but once again, it is only one of many factors that determine short implant success. Finally, although I lecture widely on implants I have never been paid to lecture for any implant company (i.e. I am not a paid consultant or lecturer for any company) and I use multiple implant systems. If you want to learn more about short implants you can hear me lecture on short implants in Denmark at the DSOI national conference in 3 weeks time. Kind Regards, Bill Schaeffer

Surface area, force distribution, and bone-to-implant contact; these are the factors that determine implant success. With regard to Endopore, great idea in theory but terrible clinical results. As stated on this website by Duke Heller from the Midwest Implant Institute, and a beta tester for Innova, he had an extremely high failure rate of this type of architecture. This was from peri-implantitis, NOT a failure of physics. While Bicon has far fewer issues in this realm, any bone loss around a short implant has dramatic negative consequences. When they work, they they are great, but when they start to develop problems, they all meet the same fate. Extremely difficult to repair and almost all are lost. You have then converted a patient from minimal bone volume to one of virtually no bone volume. Not a great strategy to employ. RJM

Bill, Re-read what Carl said you you'll see you missed the point. "optimal functional surface area" was what he wrote. He gave square threads as an example. Bicon would be another example of an implant with increased functional surface area. Endopore has a lot of surface area IN THEORY but it doesn't translate well to clinical success because the bone quality isn't as good. Once again, I think you should already know this as a lecturer for Bicon. One of Bicon's selling points is that the bone quality is better between deep wide fins (or threads) than small, closely spaced threads. This is a vastly different (and, imo, superior) design than endopore. There's a reason why short implants have deep threads/fins. Design matters.

Dear Paul, As one studies more and more in-depth about this topic, you will discover that not everything you initially think you know about implants is true. I will repeat, the design on the thread, and even whether the implant has threads or not, is only one factor affecting success of short implants. The surface area, is only one factor affecting short implants. Please take a moment to look at disc implants (AKA Basal Osseointegrated Implants). These work great and yet have no threads at all. In fact they are the shortest of all short implants! Believe me Paul, I do understand this topic reasonably well, and there are many more important factors in short implant success than whether the implant has a "square thread design with many threads" or not. Kind Regards, Bill Schaeffer

Hi Robert - you are clearly not a lover of short implants and that's fine. But to dismiss them as a treatment modality is becoming untenable with current research showing better crestal bone levels around short implants and equal or better clinical results compared with bone grafting and longer implants. If you want to keep grafting so you can get longer implants in, that's fine. But I'm comfortable placing short implants, and that's fine too. Kind Regards, Bill Schaeffer

On the contrary Bill, I do use short implants. I especially like them in mandibular second molar positions where the IAN or submandibular fossa prevents placement of a longer implant. I take exception, however, to the profligate use of short implants as an excuse not to learn more advanced grafting procedures in the aesthetic zone (which includes bicuspids and molars in visible buccal corridors), or where biomechanical forces are excessive. A growing part of my practice is implant case revisions. An increasing number of those cases involves failed short implants, with the majority of them placed in posterior maxilla without a sinus lift/graft. I go back to the previous statement I made; when they work they are great, but when they fail they leave a defect that is significantly more difficult to retreat. Short implants should be used for what they were designed for: site specific where all other factors are close to ideal. RJM

Ah well Robert we will have to agree to disagree on this one. Like you, I teach bone grafting and I am extremely comfortable with grafting sinuses. However, I am equally comfortable avoiding sinus grafting by using short implants. Like you, I am in full-time implant practice and have placed enough implants over enough time that if what I was doing didn't work I would have started seeing it by now. Like you, I also get sent a lot of other people's failures, and they cover every aspect of implant dentistry - long implants that have failed, short implants that have failed and bone grafts that have failed. I completely agree that fixing a case that has failed is far harder than starting from scratch - and yet I am still happy to place short implants in the posterior maxilla. In my hands they work just fine. have a great evening. Kind Regards, Bill Schaeffer