Concurrent sinus lift and graft: thoughts on approach?
I have treatment planned a patient for a sinus lift via lateral window, bone graft for vertical and horizontal ridge augmentation and implant installation in #14 area [maxillary left first molar; 26]. The implant site has a deficiency in vertical and buccal bone. Do you think my plan to do all of this at the same time is a sound plan with high chance of success? What bone graft material would you recommend for this procedure? I would appreciate and feedback regarding this approach.
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20 Comments on Concurrent sinus lift and graft: thoughts on approach?
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Leal
2/15/2013
Well, it depends whether you can or can't have vestibulo-lingual natural bone to embrace the implant. If you have it or if you can manage to have it by osteotomes then Bio-oss for vertical augmentation and Bio-oss for buccal filling fits just fine.
If you don't have enough width to place a decent implant (by decent I mean at least 4,5mm understanding you don't plan to place an implant on the 2nd molar) then you might consider bio-oss for vertical and BTCP for horizontal or BTCP for both horizontal and vertical, wait 6mths and place implant.
I would also place an implant at 2nd molar and splint them. Also 1st left mand molar is crucial. Also 2nd right max molar is compromised.
Good luck
Fins
3/14/2013
I would perform this in this manner:
1. Ramus graft to improve width and vertical in area of 14. Wait 4-6 months.
2. Lateral window sinus graft (sa3 immediate) with immediate implant placement (5mm bone +) 14.
If you do both at same and the patient has an incision line opening (#1 complication), you may have serious sinus complications and lose all the bone. 2 stages reduces sinus complications from a possible incision line opening.
If you combine 2 procedures like this into one, you can save the patient time. If you combine them and complications occur, you lose time/ money/ patients bone / patient confidence.
CRS
2/15/2013
It depends on where you plan to place the implants and how much width you have. I would place an implant at the first molar area with a simultaneous lift and add bone over the implant to gain some height with PRGF and allograft with a tented membrane.. If you graft for alveolar height with a rigid membrane you won't need a lateral lift just a crestal lift since you will get the implant length you need . Sinus lift will give you implant length but the abutments will be long. The mandibular second molar is supra-erupted with a furcation involvement which will need to be removed in the future. I would place a mandibular first molar implant to occlude with the top implant. I add a little Bio oss in my lifts as a radiographic marker it gives a grainy feel so I don't like drilling through it for an implant osteotomy so I use allograft. Nice case.
Richard Hughes, DDS, FAAI
2/16/2013
You can place an angled STR implant. Without a sinus lift and perhaps no buccal graft. You will have to prep the second bi and abut with a provisional on the vary same appointment. YOU can obtain the implant from Pacific Implants.
CRS
2/17/2013
Abutting a natural tooth to a angled implant may not be the treatment of choice when grafting is available . I would present both options to the patient . In my experience most patients would go with the grafting when you weigh the options . I am assuming this is the plan since you would not place a provisional in a submerged healing molar implant. I have found that a great majority of patients go with the conservative options. Thanks for reading.
Richard Hughes, DDS, FAAI
2/18/2013
CRS in all due respect. Do you know what I am talking about? Do you know anything about the STR implants? The STR is far more conservative that any grafting procedure. The patient is definitively restored in no more that a couple of months and at a fraction of the cost. Pacific Implants in Rio Del Ca manufactures said implant.
I know we are in the era of root forms, but root forms do not meet all the patients needs, unless you can graft like crazy. Blades and subs and disks are there for the strophic needs. They came to soon. The younger docs don't know or appreciate them. They tell a patient that they are not a candidate for dental implants. When these people can be restored, if that doc knew how!
CRS
2/18/2013
As I said in previous posts I 'm old enough to have removed blades and subs, and have seen the damage they cause when they fail. I have chosen not to go there. I feel that this is a very nice case for augmentation and probably an internal lift. Let's just say I agree to disagree with you and leave it at that. Grafting is just not that big of a deal especially with a team approach, I like to set up my docs for success with a more mainstream approach. I 've even placed mandibular staples and blck HA in the olden days when regenerative products were not available. I like to move forward as we learn more about restoring what was lost vs just using what is available. My patients respond well to this philosophy and it is very rewarding to see their reactions. I just have a different practice philosophy and I try to follow basic surgical principles. These older techniques have fallen to the wayside since it is possible with expansion, grafting etc to prepare the site adequately for a root form. I do see that with each new generation of practitioners there is a new market for the older techniques until they decide what works for them. I feel that it would be a shame not to offer patients what I feel is optimal for them. Let's just agree to disagree! Thank you for reading.
Plike to move forward as we learn more about restoring and reconstructing lost bone and anatomy. I think the patient benefits with restoring what was lost vs using what is available
Richard Hughes, DDS, FAAI
2/19/2013
CRS, I will admit that I have semoved subs, blades and root forms that failed not all mine. The subs require a far higher level attention to many details that root forms do not require. That said they are still more reliables and far less costly than extensive and expensive grafting. There have been some significant changes with sub designs lately.
As per the STR implant, they come straight and angled. They are essentially a one piece blade, except for the coping. The angled on is perfect for this site in question. It was designed for the post maxilla. It is to be abutted to a natural tooth or implant ASAP.
In closing "I would rather have a mind open by wonder, that closed by belief."
CRS
2/19/2013
I see this type if case a lot and that's how I treat it. In my practice we try to make the cost reasonable and to fit the patient's budget. You would be surprised how creative patients would be in financing their healthcare especially older patients who really enjoy eating( their world is smaller) I try not to make money an issue in my treatment plans even giving deep discounts and pro bono work. That said I try to create value in my work that the patient will appreciate. I know we don''t work in a perfect world and I really appreciate your honesty. I sincerely hope we will run into each other at one of the implant meetings, I always value other's experience another's expertise and knowledge , it needs to be passed along. Thanks for reading.
Timothy Hacker DDS D-ABOI
2/19/2013
There is nothing more stable than resident alveolar bone. Both CRS and "D" implants will work well in this case. For the screwologists in the crowd; a lateral window approach with crestal expansion; grafting both with irradiated cancellous bone. I use a mono cortical block supplied by Rocky Mountain Tissue bank for the crestal expansion. If your patient is esthetically demanding in the posterior area and willing to undergo another procedure, then you can do a vertical vascularized osteotomy to gain the vertical required. Then place the implants that are at least 4.5mm in width in 4-6 months.
Choosing not to do a certain implant modality because you have seen failures is inappropriate and shows need for more training in that modality.
CRS
2/19/2013
I really like the "d" implants and the screwologist comment.. I will add the cortical block as an expander/and vascular osteotomy to my arsenal We have Ole Jensen speaking at our local society in March. Thanks for sharing I never know hoe to say things politely.
Richard Hughes, DDS, FAAI
2/19/2013
Jensen's book on the Maxillary Sinus has some very interesting approaches that are appropriate for the above case.
Again the angled STR is a great implant in this situation. It is a very rigid implant that goes in by the osseocompresson technique.
Sb oms
2/19/2013
Are there any online resources for me to learn about str implants?
Ramus implants?
I agree with you on this Richard Hughes. I watched my father place root form implants in the early 80's. he has more experience than just about anyone I know. He tells me over and over again how the blades and other types of non-grafting implants never got their chance in the world of implants and people who used them were labeled as quacks.
Yes I would graft this case and do what CRS said. I've done hundreds like this. In well trained hands It works, it's expensive but reliable.
I'd love to be able to offer an alternative to patients.
I also place zirconium implants and do lots of all on 4 cases.
But I'd like to know more about this.
We need to be open minded and offer options.
Richard Hughes, DDS, FAAI
2/20/2013
Sb OMS. You could travel to RioDel Ca. Dr Roberts would be delighted to show you. He might even know your father. Dr Roberts is a great person and loves to teach about implants.
We all can learn from each other, if we keep our minds open!
Richard Hughes, DDS, FAAI
2/20/2013
The D implant is a plateau implant, designed by Tatum. The implant is placed with a bone expansion and compression protocol. They are for the maxilla only.
Dr Hacker is also discussing a vital segmented osteotomy procedure, which is a nice tool to have in your tool box. This too by Tatum.
It is interesting, that we are in an age where doctors are very proficient with root forms and the various procedures and products to make them work. It is interesting that they either have not heard about blades, disk and subs or they are blinded by the propaganda from the implant companies or docs with less skill. I see this over and over again.
Timothy Hacker DDS D-ABOI
2/20/2013
Ditto, Dr. Hughes.
Tatum has a fresh cadaver course in Atlanta this summer. You can find out more about it online. I also know Dr. Roberts as a wonderful teacher. Keep your mind open.
CRS
2/22/2013
I honestly don't think it is a matter of skill but choice. I like to rebuild what was lost and place things ideally. I don 't think it is propaganda but philosophy. In my neck of the woods blades, subs etc are not mainstream, but nostalgic. I would hate to see newer practitioners going down that learning curve. Anyway don't mean to offend and my mind is open! Just like a firm foundation with site preparation, I feel in the long run it is worth it. I see the subs as a last resort , when they need to be removed it is bad.
Baker Vinci
2/23/2013
Without a scan, every suggestion is speculative. This is why cbct technology is soon to be "standard of care". Bv
Peter Fairbairn
2/24/2013
Agreed BV especially now as the CBCT limited area and new Kavo scan have a much reduced exposure regime.
An Israeli Friend has some very convincing work with STR Implants.
BUT with newer techniques , DASK and synthetic grafts that set you can now do safe patient sympathetic sinus procedures with no post op pain the following day .
Keep it safe and simple for the patients sake.
Peter
Richard Hughes, DDS, FAAI
2/24/2013
Yes, the STR implants are quite nifty. Dr Roberts takes care of many issues in an accurate and simplistic manner. To ignore this implant is doing patients and oneself a disservice. For those of you that say blades etc are bad because of limited exposure, I ask you to be honest with yourself and recollect how many root forms you have placed or restored have failed. I have rerestored blade and sub cases that had over 24 yrs of service because the prosthesis was worn out. Yes, I have removed blades and subs. These cases had decades of service. The required skill set for these modalities subs and blades is much higher. Root forms are very easy to place. The extensive augmentation is where the level of difficulty changes. If I had a case that I could not treat, I would refer for augmentation. Each modality has its own standard for success and failure.
Again, with blades and subs, I can side step the extensive augmentation. I wish we had disk implants in the USA.
You will never grow with a mind closed by blind belief.
