Internal sinus lift immediately thru the palatal root socket?

I have not done it, but I have had to restore them. You are more likely to perforate the membrane trying to elevate it when it is the highest point than when it is level with the adjacent bone at the floor of the sinus. You can restore it adequately with a custom abutment and crown (can show you pictures), but you would be doing a surgically driven instead of a prosthetically driven restoration. In your mouth, which would you prefer?

It is not done very frequently these days, but have you offered a distal root amputation to allow the patient to keep his crown if the rest is in good shape?

We have been doing a lot of these over the last three years, so much so it is now relatively routine, and I am pleased to say, successful. The one thing I would not attempt to do is to place the implant down the palatal root space, it's often quite angled and outer bone plate can be quite thin. The problem with maxillary molars is that the labial and palatal bone about the residual roots is thin, often fenestrated and receded as well. It’s no wonder there is so much collapse of the alveolus following the extraction. It’s possible to fill the root spaces with bone graft following the extraction and this is the key to an effective Socket Regeneration procedure. The question then comes to be one of whether it is possible to place an implant at the same time. The key to success lies in whether the implant can be stabilized adequately in the residual bone. When the tooth is removed, which we do by removing each root individually, a triangular core of bone can generally be seen in the central part of the socket, this is supported on webs of bone from the adjacent sockets. Often it’s possible to generate a starter channel down into this central core with an ultrasonic instrument or a trephine. Care has to be taken because the central core can be very shallow. Generally we get through the cortical bone to some softer cancellous bone. This can be expanded outwards and upwards with osteotomes. Usually, this will be the start of a Sinus Lift as well. Once we know we are into the sinus, we add bone graft into the region and then osteotome this up by hand. It’s possible to get good stability in a relatively small amount of bone because the outer rim of the region is cortical bone. Then it is a matter of placing the implant. We use a tapered system which does not have an aggressive thread pattern. The platform of the implant is placed down below the surrounding bone line. We place a 4.0mm gingivaformer in the implant and then bring additional bone graft up and around that gingivaformer. We cover the graft, implant and region with a thicker and tougher membrane than usual. Instead of two or three surgical procedures (extraction + socket regeneration, Implant placement 3 - 6months later, second stage exposure finally) this is all done in a single procedure. You can get Primary Stability for the implant in the web of bone and in the sinus floor. Secondary Stability comes with healing in the Socket Regeneration region. We never place a provisional restoration at the outset as this would break the Primary Stability. Usually these can be restored in 4-6 months.

Why not just place the implant into the palatal socket immediately following extraction and be done with it?

Because: 1. The implant will be considerably off axis. 2. The augmentation will be all to the labial: greater bulk leads to greater shrinkage in the region of greatest bulk. 3. Placement of the implant may mean the thin walls of the palatal socket become fractured.

hello. all roots look real far apart. why not go right thru the middle; at its best position. just my thought

i agree with peter hunt. im doing them now with the versah burs. i could share some really cool sinus cases demonstrating it if interested.

in regards to your original concern. if there is a root tip fracture of buccal roots, you can find them thru buccal and not effect placement of central, ideally placed implant in great healthy most solid bone. also, i often use mallet and periotome (assistant pressing in forehead) to sever pdl all around tooth. to facilitate extraction. i dont have physic forceps and some extractions wouldn’t allow them anyways. what do you do yaron miller before taking tooth out? did a cool lift yesterday also along with digging out root tips left behind years ago on a #13. molar #14 taken out and a 5x11.5 placed. versah in transport to there symposium as we speak, lol cool stuff

I always section the roots and take them out individually. To date I have never had an issue with fracture of the buccal plate. I guess I will see you at the symposium then- safe travels.

There is the Fugazzotto technique. Using an appropriate trephine, cut through the inter-radicular pyramid of bone and carefully elevate the cut pyramid superiorly so as not to tear the sinus lining. Introduce particulate mixed with CaSO4. If there is enough bone the implant can be placed. If there is inadequate bone then graft and cover with a collagen barrier and suture.

the adjacent teeth are already crowned. Just do a 3 unit bridge

Peter Hunt is right on. I've been doing immediate maxillary molar implants for 7-8 years. About 95% of cases are great candidates for this AND you get a prosthetically driven implant position. The sinus floor provides nice primary stability.