Crestal sinus lift or lateral approach: any thoughts?

I think that in this case a lateral approach would be safer and more predicable. In my hands, a summers bump is good for gaining 3mm or so, any more is pushing it a bit. With a lateral window you will have much more control.

I would do a simultaneous lateral lift with implant placement. Cover it with nothing and restore in six months. I use bottle bone with a growth factor of choice and a little Bio OSS as a radiographic marker. What makes me nervous are the implants splinted to the failing endo teeth and the pier implant abutments on the other side. I don't like using endodonticaly treated third molars in bridges. So keep a close watch on these teeth, hope the bridge is screw retained if it need be removed in future when the endo teeth fail I don't see the point in splinting these iffy teeth to new implants but I honestly can't tell for sure on just the film. No harm in using the endo teeth as spacers on staged treatment that's why I like not splinting them to the implants it gives you an easy retrieval vs cutting off the prosthesis. A totally implant supported bridge would have been my choice on the lower right. Good luck.

i agree with the above comments. a lateral window sinus lift is the proper way to treat this type of case.

I like to use a mix of cortical cancellous Demineralized two products are Allosorb and Maxxeus, good quality and price. Other brands are Puros, I like human in my techniques but other colleagues like synthetic and they can advise better on this. I use PRGF but it is technique sensitive, I have heard good things about PGF and I have had good success with PRP but the kits are very expensive. In the sinus many things work but I try to be cost conscious the fibrin holds the bone together nicely and the growth factor produces a predictable result. The Bio OSS stays around forever and marks my post op film! I just wanted to advise the poster on the treatment plan on the right side and to carefully monitor those implants. I respectfully like to build in the possibility of old endo failure and retrievability of prosthesis for future, I see this in my practice.

Agreed CRS , Lateral window is easier and safer as placing 2 implants and can be done by a window between the two placement sites . I use Dask as again safe fast and reliable ( Have not torn a lining since May 2000 when I first used it ....... may have been lucky !!! ) I use Synthetics and feel they need to be fully bioabsorbed as the X-ray will not be a real reflection of the Bone status long term. Early loading ( 10 weeks ) is helpful but always use Osstell to check the ISQ . Yes CRs a eye on the other Implants will do no harm Peter

A very nice 2D film. A tatum lateral wall approach is predictable for your case. It is unlikely that there are zero bacteria associated with the retained root so extract it and after healing 8wk+ take a CT and this will help you comment/asess the PAR on upper right molar root and the dome shaped radioopacity in the right antrum (mucocoele likely) as well as image the left antrum. Materials choice for grafting can be a personal choice bases on experience and training but we know synthetics require a longer healing time. But this will not be so significant for your case as there is good initial (living) bone height. If you want to add a little biological factor, simply spin some whole blood and add the platelet rich fraction to the lateral wall prior to closing up. Looks like you can call time on the failing wisdom tooth bridge abutment and section to extract this for the sake of eliminating pathology (and these days to avoid any risk of being accused of ignoring treatment issues prior to embarking on a restorative programme!). You have a very nice case here and it should go well, best wishes.

Hi Reg like cars all synthetics can vary hugely , our cores often show up the 40 % new bone at 10 weeks in clinical cases ... hence a far more rapid turnover due to their up-regulatory effects ( See Zhao and Watanabe et al 2013 , Bone ) where host Genetic response in measured or our recent Animal study published in the current Implant Dentistry ( ICOI )journal .. But as you say a nice case with decent host bone ... Peter

Peter, are using LPRF as well?

when your looking to only gain 5-6mm of height the crestal approach is easier and less problematic then a lateral approach and gentler on the patient. There are some nice crestal kits that have been developed and Hiossen (CAS-Kit) has a nice one that has safe end drills with stoppers that virtually eliminate membrane tearing. I have published on this kit if you want an article let me know.

I would also like a copy of the research. Also would bicon implant be suitable here? You'd sill need a lift but much less of one.

Hi Larry no not but have seen many good internal cases with PRF that a friend has done . I feel more comfortable with the lateral approach although do internal ( crestal) as well , here as two are planned lateral is best .. Peter

I usually graft w/lateral window then implants 6 months later. Curious on decision framework? How do you decide to do do graft versus graft+implant? Does age play a factor? Bone height (3mm v 5mm v 1mm)? Hows the surgical workflow look like? - Open lateral window, reflect membrane, make osteotomy, place implants, pack bone, cover and suture everything. Also what is your typical final drill size for a 4.0mm implant in a D3 bone like this? 2.8mm? 2.0mm? Spreaders?

^^^Did i miss anything? Also what torque do you place in implant in conjunction w/graft? 30N torque? Machine torque half way, then hand-torque the rest of the way (ala difficult split-ridges) ?

My suggestion is in these sinus lift cases or even any implants being placed into the posterior maxilla due to the lower quality (density) of the bone to after using a pilot drill to then go to osteotomes to laterally condense the bone and improve the quality/density using the implant as the final osseocompressor