Penetrate Maxillary Sinus or Sinus Lift?

Your best option is the sinus graft followed by implant placement after graft heals. With 3mm of bone to work with you may not be able have your implant fixated.

We place at the time of the lift with as little as 1mm of bone due to the use of sythetic graft materials that "set" hard thus further stabalizing the implant and stabilize the graft site allowing for better oseteogenic activity. It means 1 procedure and thus 1 trauma for the patient. the patients never have post traumatic pain (max One asprin a few hours after the procedure) due to the stability and as it is synthetic there is no reaction to the graft. Even in case where the sutures have torn 2 days later the graft site is not compromised. No membrane is needed which allows the blood supply from the periosteum to aid improved healing.. Some implants allow for better stability in their design in these situations..

What is this mystery material that allows a "hard set." From what I have seen, the only thing osteogenic has been autogenous bone. Everything else seems akin to a scaffold in my experience and in the sinus requires at least 8 to 10 months for dense structure. I have placed implants in less time and been less than happy with the feel of the grafting site in the sinus. I am interested to learn what you have found. What is this material?

We have only been using it for 5 years so early days , but it has been used in a different form for 20 or more years. It is Beta Tri Ca Phosphate but what helps is that it is in Ca Sulphate matrix which enables it to set thus stabilizing the graft site. Sure Autogenous is the "gold standard" but results with these materials are exceptional and the reduced pain to the patient is the bonus. Having used all the other materials (barring Bio oss) this how I would do it on myself.

First I think your doing a great diservice by thinking of placing a 7mm long implant for a molar. Evaluate ridge width, can it support a 4.5 or 5 mm implant?, you will be happier with the emergence profile and periodontal health in the long run and so will the patient. Make the effort and do a wax up. Where is the ridge versus the implant osteotomy? I see more guys get in trouble because the implant is 2 or 3 mm displaced to the lingual and you end up with an esthetic failure and perio compromise. DO NOT forget crown to root ratio. I have seen very few ridges that have not had some buccal collapse and troughing mesial to distal so you are not in the ideal unless you have performed socket grafting at the time of extraction. Gotta have at least 1:1. I do not consider anything less than a 10 mm implant for molars. Show me the LONG term studies of the 7 and 8 mm implants, ie 10+ years....can't find any can you. They have not been out in the US for a long time and they are over marketing them. Implant patients can be your best referal or your worst, so give them the best chance at long term success What is the shape of the sinus floor, is it deep and narrow or deep and long in the area. Deep and narrow you can consider an osteotome technique sinus lift. I typically will do it only if I have 7 - 9 mm of bone and I wish to place a 10 - 11.5 mm implant. There is a limit to the envelope I will push for this. THe goal is to get 3 mm of bone above the implant! Deep and wide traditional sinus lift Place no Implant before its time....let the bone heal. Are you using PRP??? The studies are mixed on the value of PRP but IMHO you cant beat the healing power. It jump starts the healing process and vascularization. I typically re enter sinuses at 8 months and find solid bone formation. I recently started to take trephine samples for eval so we'll see. Just remember your basic Prosthodontic principles as a guide and it will let you decide what will be best. I would love to see what the "hard set" material is. Synthetic and you have to consider whether you have an actual bond. Everything is a foreign body once it is placed. The issue becomes recognition as a foreign body.

DR M is right. That is real treatment planning. I am not questioning fairbain's integrity,but is it not real heroic to place implant in 1 mm of bone? Even if "HARDSET" material may be hard set in the begining but it has to resorb and so be "SOFT" to be replaced by patient's bone.Where do you get implant stability then?,from 1 mm of bone? And if "HARDSET" material stays HARDSET all the time like a concret cement(asphalt),it may hold implant tightly but there will not be real osseo-integration. As far as I know:without providing space, osteogenesis will not happen.very few kind of trees can grow in the rock. Where is the source of mesenchymal cells for osteogenesis? PLEASE CORRECT ME IF I AM WRONG. I WILL BE GLAD TO BE EDUCATED IN THIS MATTER.

Dr. M is right on the money. I have had to remove the short fat implant that was not properly treatment planned. All of the factors Dr. M said are true. If he were a restorative doc , i would want to work with him.

I have had patients bite on something just right and push a non-restored, threaded implant almost into the sinus despite 5mm of bone and a simultaneous sinus life graft. Do yourself a favor and do the graft first.

Obviously, if you ask what to do, it means you do not have experience with the sinus. Be cautious. There are many techniques to deal with lack of bone in the molar area. If you feel comfortable with sinus lift,the best alternative. Any bone is good (European consensus and AO lastest report). The only thing it will not make a difference is using PRP (proven). If you are familiar with Summer techniques and all variants, try one o f them. Place a patient on antibiotics (Augmentin at least) They will need antihistaminics too. Nose bleeding can happen the day of surgery. Use a conical implant to prevent placement of implant into the sinus. Have all consent form signed. Be honest with patient. Tell him or her that they are more trained people than you but you would like to do it. Have a back up plan. Somebody to call in case you run into trouble. This way you are well covered. Short (10 mm) or long implant (more than 13mm) work the same in the grafted sinus. Hope it helps my answer to your question. Dr. vergara Houston Periodontist

If you do not know the right answer to this question, you probably should not be placing implants into the sinus.

Please remember, one of the purposes of this blog is to learn. Remarks such as the above - criticizing a doctor's questions only shows one's ego and are certainly not helpful.

I would evaluate the ridge width and after waxup etc as Dr, M suggested. Upon eposure of the location elevate the flap create a receptor site with ostetomes 2mm deep. lift the sinus, push in graft as much as I can (physiologic limits of health) and close. After 4-5 month redo the similiar procedure but the osteotomes go deeper. Life the sinus again and push in graft and may be place 13-15 mm length implant. As the receptor is made with manipulation it mat be a 5mm diameter or more depends on the case It will be a sinus lift and not sinus augmentation Dr. Narkhede CA Prosthodontics

I would like to share my experience with the balloon sinus lift system produced by Meisinger. The amazing thing is that it works very easy. The best is that you can do sinuslift from the lateral side of the bone ridge, even then when molars are still there. This is a very good alternative when you know that due to periodontic reasons you cannot leave the molars for long. The balloon allows you to determine the height of the augmentation depending from the volume of liquid which you inject into it. If you want to save money, just buy the balloon without the expensive equipment around. With a cost of about $ 250 you have a phantastic instrument in your hands. I could show many cases in which I have implanted conical screws in a bone of 3 mm with a simultanious sinus lift. it is obvious that a conical implant will have a better initial stability and lower tendency of moving into the sinus. We use onepart implants and very often link them one to each other with a temporary bridge without occlusion. Dr. Thomas Veigel Germany

i have seen cases working with as little bone as 3mm with the endopore system. the advantage being that there are numerous elevated ball like structure around the implant and thus increasing the surface area --- as good as of a 13mm implant. an 4.1 x 7 mm should be a good option.

The only long term study of sinus lift materials was published in Dec 2005 Journal of Oral and Maxillofacial Surgery - Ewers This looks at over 15 years of follow up and references a number of articles. Bottom line was to use a material that has porosity, is absorptive and eventually resorbs. Still use the 6 month wait prior to implants with less than 4-6 mm of residual bone and place a long ie at least 10mm, preferably 13 mm implant.

This situation will require a sinus graft followed by implant placement. The D-4 bone in this area will not give adequate stability if it is only 3mm. If you are measuring this on a radiograph, it's probably less than 3mm. I would explain the procedure to the patient and tell them why they need the sinus procedue. i would not place anything less than 4.5 mm diameter in this area or less than 10mm length. I prefer 6.0-5.7mm diameter for first molar teeth in the maxilla. In situations like this, evaluate the adjacent teeth. if they are full of restorations or already crowned, do the patient a favor and give them a bridge as a second option.

3mm of residual alveolar bone height is enough to secure a tapered Implant with a simultaneous sinus augmentation.In the pat 14 years i've done only 4-5 cases of a two step approach where I had almost no bone.In an article published in IJOMI 2006 we have reported 9 years with more than 730 sinuses done at the same way. Placing a 7mm Implant will not serve the benefit of the patient.

has anyone tried using an endopore implant in such a situation

I really don't like endopores, I have had a lot of long-term failures with them 2-3 years out. Once the beads are exposed - game over - must be removed period.

Dr.S ?

Dr Peleg wrote an interesting article last year about implant success in sinuses with limited bone. Basically, a one stage approach is possible as long as you can stabilize the implant. 1mm of bone is pushing it but if you can do it predictably in 3mm of bone than more power to you. Personally, I stage it with less than 5mm of bone. That's how I would want it if I needed it.

Dear Dr P: The honest answer to your question is that everyone who answered you is advising you from his or her experiences and from their understanding of the research that they have been exposed to! I too will try to advise you as best I can from the point of view of someone who lectures and conducts a surgical residency for one of the implant companies that was previously mentioned. Dr. Leo is talking about the need for having the implant “fixated”(?). This is true primarily for a screw. Dr. Fairbairn is using a product which may not be available to us in the U.S. unless he is considering “mixing his own” ala Sotosani…and why has he never tried BioOss with such positive long-term results? Dr. M has great “Standard of Care” treatment planning type suggestions but is mistakenly suggesting we employ crown to root ratio standards developed for teeth with periodontal ligaments for the much different attachment system found in the “ligament-less” anklylosed implant. In the case of the implant, one should more appropriately consider crown to surface area ratio…and if one compares the different implant systems, their surface treatments and the resultant surface area calculations, the Innova Endopore has more than sufficient surface area (in fact, the highest percentage) to support a free standing, individually restored molar. In addition, because of the design of this implant (tapered truncated cone with a unique porous surface), and the proprietary protocol and osteotomes which may be used to simultaneously lift the sinus while compressing type 3 and 4 bone into type 2 bone, placement and successful long-term osseointegration of a 7mm implant in the region you are considering (even with as little as 3mm of bone) is predictable in the hands of a surgeon trained in, and experienced with the technique. As for “long term studies” all one has to do is Google: “Ten year study with 7mm dental implants” and up will pop:Douglas Deporter DDS, PhD, Philip Watson DDS, MScD, Michael Pharoah DDS, MSc, Reynaldo Todescan DDS, PhD, George Tomlinson PhD (2002) Ten-Year Results of a Prospective Study Using Porous-Surfaced Dental Implants and a Mandibular Overdenture Clinical Implant Dentistry and Related Research 4 (4), 183–189. Just try it yourself…it will be first on the list! But remember, training and experience here is the key! Before you try it on a patient, get training in the technique, get some help from a mentor and make sure you properly treatment plan for the ridge and sinus shape in relation to the occlusion or you will suffer the same consequences as one of the Docs who have had problems with a screw failure from an inadvertent mis-directed bite or bead exposure and implant loss a couple years out.

The product ( Fortoss Vital) is FDA approved and will be available in the US soon. There have been 5 year core samples done at the Unversity of Liverpool which show very favourable results. There seems to be some confusion in some responses we have NEVER placed less than a 10mm by 4.5 mm in the sinus lift procedure and have always used the lateral window aproach. All the material does is effectively creates a stable blood clot with nutrients CA, Ph and sulphate which can upregulate the bodies response and then let the body do what is does which is heal and create new bone. Why not Bio-Oss well I suppose always followed Hilt procedure and used Rocky mountain with great results until the more recent issues and noe take a more patient friendly approach. Now Vital is here and it is a future

Dr. Fairbairn: Am anxious to hear more about Vital!

Dear Dr.P try doing a sinus lift & simultaneous implant placement. A good way to determine primary stability of the implant is to drill & tap th bone and leave the tap after disengaging it from the handpiece if the tap stands firm the implant would have primary stability n would survive well. Remember the rule to success is primary stability. If not stable it will never survive. The best graft is 50% BIOSS 50% autogenous mixture

5mm residual bone is the minimal height according to Lekholm, Vital or non-vital bone is the question (Wallace,Tarnow)...xenograft and particulate bone is a good option.The best option is autologous bone. And the very best is to respect the "speed limits"....beleive me!

I was at the last Greater New York Meeting and I saw the implant work of a Dr Serafaty from France. His work was astounding. He was placing 10-12 mm implants in the sinus with as little as 3mm of bone to work with. He had the three and five year x-rays to back up the bone climbing all over the implants. No bone grafting no nothing just great clinical technique. He made me feel like I was back in the two stage surgical technique impant placement era.

Sir, will you please let us know how he was able to get the primary stability by having only three millimeters of bone and then what bone was supposed to withstand the biting forces applied to the rest 9 millimeters of bared titanium threads? It seems that France,nowadays,is full of surprises.

It would be great to know what is the special surgical technique used wherein no bone grafting n bone grows over the implants?

One may assume that the French surgeon may have taken advantage of implant stabilizers to gain the primary stability for his implants. These are a special kind of titanium rigid fixation plates that are laid sub-periosteally on the ridge and attach the implants together. What remains the primary concern to a surgeon though, is what would be done for the naked titanium threads still suspending in the Antrum of Highmore without being covered by any grafting bone particle.

It is known that slight sinus membrane perforation due to implant placement can heal spontaneously. Looking into some research studies provided no evidence that the length of implant penetration could inhibit the spontaneous recovery of membrane perforations after implant placement. In one study, when implants penetrated the mucosa of the sinus floor less than 2 mm, spontaneous covering of the implants with the sinus mucosa occurred. On the other hand, when implants penetrated the mucosa of the sinus floor more than 4 mm, the apical parts of the implants extending into the sinus cavity were not covered with the growing antral membrane. Therefore, we might expect that implants protruding into the sinus cavity could act as foreign bodies and become a source of inflammation and sinusitis. However, no signs of pathologic findings were observed in this study in any of the maxillary sinus cavities in both the 4-mm or 8-mm sinus-penetrating implant sides. These results suggest that implant exposure to the sinus cavity is not related to the development of sinus complications. It has been reported that implant extension into the nasal cavity can give rise to rhinosinusitis. The most likely explanation for this complication is that altered nasal airflow could induce irritation of the nasal mucosa. In addition, nasal clearance could be disturbed by implant blockage of the mucociliary pathway, giving rise to inflammation. It is possible that implant extension into the maxillary sinus cavity may alter the normal function of the maxillary sinus mucosa and make it vulnerable to complications. In one study, debris accumulated on the exposed surfaces of the implants extending into the sinus cavity that were not covered with the antral membrane. The antral membrane around the implants did not show any sign of inflammation. This may be explained by the direct attachment of the membrane to the implants, forming a barrier to the sinus cavity. As for the parts that were not covered with the antral membrane, we may expect an increase in debris accumulation over time.

We started to sell in EC a new surgical implant navigation system. With ultra sound 3D a clear vision of the bone is possible without opening tissue with an 0,2mm accuracy. Placement of the implant in 3D will be made with the GPS system with or WITHOUT (simple Xray)Ct scanner. simple case and complex could be done with or without guide . The all planning could be done on stone cast or directly in the mouth no need for complex steps in the software. This is a real advance in non invasive technology for implant procedure without surgery , less Xray doses , bone volume graft peroperative and endondic surgery. We will be pleased to keep you with more update on your demand. Dr Raymond DERYCKE President Haptitude

can fragments of an implant accidentally end up in one's sinus? can any fragment end up there? i had 3 implants removed and now a white shaped kidney bean is showing up on xray. i will go to ENT tomorrow. please let me know. thanks

Dear colleagues, the problem is not whether an implant penetrates in the maxillary sinus "just 1,0 mm" or more. Basically the problems are: 1.Possible recurrent infection, staying along the uneven, rough implant surface (if sinusitis occurs-from e.g.common cold post op, bacteria will attach to the porous implant surface and may stay there for a long time,causing chronic inflammation) 2.Loss of implant stability, due to the lack of suppport in the apical implant area Remember a perfect exam of implants placed through the maxillary sinus intentionally, withot complications?- the Zygoma implant by Nobel. You perform an antrotomy to monitor the implant`s insertion in the zygomatic bone, and to avoid it going into the orbit. This way the implant GOES ALL THE WAY THROUGH the maxillary sinus. Although I am curious to see a long term follow up study on those Zygoma cases.

I am a patient that has had 2 root canals, an apicoectomy and then finally an extraction of Molar # 14. A pyros bone graft was placed at the time of extraction. It has been 4 months since the extraction. I only have one third of the bone needed for my implant. It has been suggested that I have an open maxilla sinus lift using jaw bone to graft the area. This would be followed by a 6 month waiting period for further evaluation of the appropriateness of the implant. My dilemma is that I continue to have a chronic ache in the tissue above the extraction site. Xray revealed that the area has healed from the infection. The surrounding teeth look healthy. My oral surgeon and dentist are not sure why I am still uncomfortable. Are there any cases of patients whose bodies reject the materials used in these grafts? Would you recommend giving the site more time to heal before doing the open maxilla sinus lift? Would a bridge be a better option? Any thoughts on the subject would be appreciated.