Implant in Upper Right quadrant: Can I avoid an open sinus lift?

You can but much faster safer and easier just doing lateral window using DASK and you can optimise the Implant position ( Where the residual bone is thin ). The premolar site just change angulation to to optimise bone ... Peter

Great advice, that's a very long span the space of at least two molars. The distal tooth is in the third molar position. I the patient would best benefit with a lateral lift.

Age old question. If it were your loved one? why comprise the treatment? Do the lateral wall sinus lift.

First get a CBCT to identify sinus anatomy and the radiopacity.

Lateral approach for a sinus lift is your best bet.......don't be frightened, it is a relatively easy procedure, and you can see what you are doing and where your graft material is going. Doing a PRF procedure when you start your operation is a good idea, so that in the case of a Schneiderian membrane perforation....you have an autologous sticky patch to repair the membrane. Good luck you will do fine

What is your treatment plan?

That got away before I was finished. What is the treatment plan for the rest of the case. A couple of implants in the upper right quadrant with nothing to occlude against, along what appear to be a number of other problems, doesn't make much sense, other than some kind of exercise in grafting and placing implants. Will the patient really be any better off.

Hi I agree with previous posts. However I have to say CBCT helps you decide where and how much bone is present. I have used crestal/osteotome approach and definitely works. I would't recommend if this is your first case and you do not have any surgical expertise in general. Lateral window is not the only option and in fact depending on your skill level and indemnity it can be more demanding . Get yourselves a mentor before you go further. Best wishes

Agree with all of the above but IMHO you cannot attempt a closed sinus lift without being able to do a lateral window lift. If you get into difficulties with a closed lift such as a tear, you have to be able to revert to a lateral lift to deal with the complication. Better still do this in the first place where the bone height is so limited. If you are not confident then as GB suggests get a good mentor.

I'm not too sure how many easy lateral wall sinus lifts I've done in the last 25 years. Honestly it's one of maybe two procedures I am aware of a risk of arterial perforation that could lead to uncontrollable bleeding. ( the other being perforation of the lingual branch of the carotid) My humble advice to you is, if you haven't been taught this technique in a residency based program and you don't own a piezo drill, don't try this on your own. It could end in a big disaster. (Never mind understanding how to deal with various size years)

I may be wrong but from the limited information available this looks like a case for a Tatum lateral wall sinus graft. Male patient (Guess), high occlusal forces (inferred), good mandibular bone opposing lightweight posterior Mx would indicate a requirement to provide enhanced implant suport in maxilla. As our colleagues have already stated, you are doing a sinus graft so the only querie is approach. Can you justify the restricted crestal approach? Yes it is possible but of course limited and what are you left with if there is a complication? You won't "need" a piezo or even a DASK to begin with , just the relevant CE and mentoring/referral. Maxilla can then have longer/more numerous implants with higher bone implant contact compared to coping with compormised bone. Treatment plan as Robert stated is paramount and as our longterm metors would say what is your plan if you had the unlimited bone (and unlimited funds help also!)? You or a colleague can provide the bone for this case to be a great success which would be preferable to revisiting it later on with potential prosthetic or bone maintanence issues to cope with. Good luck with the case and thanks for sharing.

An "open" sinus lift, which is the only way implants can or should be attempted here, can be avoided. The patient can have a removable partial denture fabricated.

We've used Floor Transports with Bicon Short 6x6 implants where the ridge width is adequate to put friction on the window. Of course, one needs to be able to treat possible sequalae.

Dr. Manuel is right, a 6x6 Bicon will be ideal for this case, at the same time I can say the same for a Quantum 6x6.. Regarding Dr.G comments of the need for a piezo instrument and the needi of a residency training, is way out of the main stream. Lets not forget who developed the sinus elevation Technic. Regarding Dr. Flanagan posting, In my opinion is safe and very well founded advice. Regards Raul

I agree with Raul the piezo isn't needed. For 20 years I used a large round diamond and a high speed handpiece. And for 99 out of 100 cases that's all I'll need, but for that 100th case man what a lifesaver. How many of us have dissected out the maxillary branch of the of the external corotid artery will a round but? Very scary situation indeed. With a piezo it's no effort and very safe. (Everyone remember SALFOPS Max?) Fortunately a good CBCT can give you a heads up on where that artery is located in the wall of the sinus. Sometimes not knowing what lurks ahead is what is the real danger in dentistry. The way we overcome this is through diligent education ie residency. Oscar Hilt Tatum did in fact perform the first sinus lift, you learn that history in your residency as well as all the supporting studies that document his trials and errors. And all surgeons are thankful for his expertise and the patients who underwent this experimentation, but that in now way justifies a non formally trained Dentist in 2015 to "try one". Dentistry is a funny business there are a large number of Jack of all Trades practitioners out there. The question they need to ask is why? If they do it all better than individual specialists then there is the answer. But if it's for ego or greed or keeping the schedule full then shame, shame, shame.

There is no doubt that the doctor needs to be well trained before he does any procedure. And I totally agree Anatomy and Surgical knowledge are required before doing any sinus treatment, my point is that a Residency is not a requirements. Dr.Mohamed Sharaway offers a great training course in dental anatomy, I strongly recommend his course. Raul

I agree completely this is exactly the type of course one needs to learn to place implants and perform sinus lifts! "Dr. Sharawy, through the AAID, was one of the initiators and developers of the MAXI course in the USA. The course provides over 300 hours of instructions that include 50 hours of surgical anatomy for implantologists. The Maxi course is in its 14th year at MCG. He is also a significant contributor to the Maxi Course at Howard University and at the University of Irbid, Jordan. Dr. Sharawy has participated in the Perceptorship Program in Implantology at San Antonio School of Dentistry for the past 13 years. He also presents an advanced course in bone graft and implants at the same institute. He is a visiting Professor at Misch International institute for Implants since its inception and the course director for the surgical anatomy course. Dr. Sharawy was the past interim dean and one of the initiators and developers of the School of Dentistry at King Abdul-Aziz University at Jeddah, Saudi Arabia. "

Actually, a Piezo is contraindicated for the floor transplant procedure since the kerf would cause friction loss on the moving window. Partial cutting and careful chiseling provide a stable floor reposition. Bicon has several sizes of sinus lift abutment stabilizers which control position of the implant itself.

I have been lucky enough to perform these surgeries with Dr Tatum and have hands on with Dr Sharawy and in no way are their procedures "experimental" as mentioned above. The Maxi courses are extensive in their didactic and hands on training and far more in depth than residency programs when it comes to the specifics of Implants. That being said they are not the only education programs that provide extensive training on Implant science and procedures. I am all for encouraging non initiated doctors to enrol in advanced training programs well before they enter into a sinus but I don't think using scare tactics such as external carotid bleeds help advance the education process. There is a lot of research and information on when and when not to do verticals Vs Laterals. I do believe that if you are asking a question such as the one above, "Can I avoid an open sinus lift?" you may be in need of some education and hands on to help with making these decisions and treating them. Thats not a bad thing. recognizing what you don't know is an excellent first step and much better than not knowing what you don't know.

Once you tried a closed lift method (baloon or other ) for those cases , and gain a reasonable degree of self-confidence, you NEVER go back to open lifts no matter how experienced you are, unless there is a complication ! Stress free, a lot safer, much better accepted and unbelievably gentle for the tissues.

1)The first requirement in surgery is to be able to see what we are doing and the crestal approach is a blind approach 2) There are several techniques for the crestal approach ( osteotomes , saline , balloon , special drills, etc..) for all those techniques no documentaion in the scientific litterature ,no RCTs , no multi center studies, etc...

The answer is " Yes " if you really want to . Will I personally avoid a lift ..... NO. I will do exactly as other have suggested. However if you are really intent on avoiding the sinus , than this is what I would do : 1: Extract the upper right wisdom tooth, curette the socket of granulation tissue which is evident on the x ray and then do a socket graft . 2: Plan an angulated implant with a platform that will allow the screw access to be correct/ vertical. Check out Southern Dental implants . 3: Used Guided surgery. Place a straight implant in the second premolar , angulated in the posterior to exist around your second molar and then make a 3 unit screw retained bridge.