Sinus Lift in Two Stages?

Why not do an open sinus lift and accomplish your goal in a single surgery? If you cannot do an open sinus lift, refer the open sinus lift and place the implants later. You don't have to do everything yourself...

Do not forget the option of learning how to do open technique yourself. There are some really good CE's out there for this. Why only go for 3mm using closed technique? Using Summers technique I routinely go 4 to 5mm of lifting with out trouble.

The first question is: 1. What is the height of bone from the crest to the sinus floor? 2. Can you stabilize the implant to at least 45 NCM with the apex of the implant in the sinus? 3. Is the sinus compartmentalized? 4. Can you do a crestal or lateral window? From my experience of doing both ways, it is best to place the implant at the time of grafting. If you do a lateral windo it is more predictable to mix your graft of choice with PRP. I use Curasan. If you do a crestal approach you can get drifting of the osteotome as it glances off the medial wall or a spine. Good Luck and do what you feel comfortable with.

Summers technique is sometimes ok for up to 4 mm. A shorter implant, ie 11 mm might be the answer. I have never tried a two stage Summers technique. The idea makes me nervous. Your success rate would probably be best to place implant and do sinus lift at the same time, using a lateral window and lifting the membrane. This is a slam dunk, with a little training. Use some Colla Tape for the top of the graft, a good graft material all around the apex of the implant and only drill your implant osteotomy to one size smaller than the implant body, for stabalization. Don't get all upset if the membrane tears, just get it off the bone. It should work fine. This will save the patient time and trauma, assuming primary stability of the implant is possible, (at least 4 mm of bone in the floor of the sinus. You can do this if you want to.

As far as I can imagine, you must have at least maybe 4-5 mm of height, maybe you should think of using endopore implants and save yourself the trouble of grafting, if you have 4mm, you can place 5x5 implants and do free standing crowns, with a very small lift if any. The placing technique can be done completely with the osteotomes and guides, hence minimal perforation risk and really great sorrounding bone and awsome initial stability. If you have 3mm , the same aproach but with a summers sinus lift attached in the same surgery. best of luck

If you do not know the answer to this I would suggest referring the sinus lift case and let someone else do this for you. If you are not comfortable with the knowledge to answer to this question, you should not be doing a surgery.

There is always a shower bag that answers as if he knew everything.... "If you do not know the answer to this I would suggest referring the sinus lift case and let someone else do this for you. If you are not comfortable with the knowledge to answer to this question, you should not be doing a surgery" HA! I think that you could place the fixtures at the time of the lift if you gain initial stability.

You can use the Pecora technique (use calcium sulfate based bone graft like DentoGen and apply it in the defect layer by layer). Compress and harden every layer with guaze and fast setting solution. You should be able to complete entire grafting process in one visit, not need for 2 visits. Implant can be placed at the same visit or at 4 months after there is good bone growth.

If you are going to open the sinus you are better off grafting all at one time. One can also place the implants in a severely atrophic maxilla at the same time as grafting by way of using orthopaedic plates and screws. However you are better off to take your time and see how the graft works out. You may want to consider a Sommers technique, if you have enough vertical bone.

If this was you, would you want to have 2 sinus lift surgeries or would you prefer one that takes care of the entire problem. Once a lateral window is open, you can graft the site for future 12-13 mm implants. There is nothing wrong with sinus lifts and almost anything will work as long as the site is maintained to allow for bone fill. If doing Summers technique, make sure the patient is sedated as they will not appreciate being pounded with a hammer.

As I have said I always try to do a one stage procedure now as we have synthetic graft materials that set thus sealing the lateral window. We have one staged sucessfully with as little as 1 mm (primary stability vital) of bone and have used these materials for about 4 years. You can look at biocomposites.com and go to news and then sinus lift to see the grafting. Regards

where can I look up summers tech.?

You can do lateral window and graft, place implants all at the same time. You can also do summer/ Chen's technic and lift 10mm+ place implants at the same time. Why do you want to do it in two stages?

By 2 stage sinus lift I assume you mean sinus lift as separate procedure with delayed placement of the implants. I'm not familiar with a 2 stage sinus lift technique. As stated previously, one would have to know howmuch bone there is between floor of the sinus and the crest of the ridge, i.e., whether or not the implants could be stabilized by the available bone concurrently with implant placement. If 5 mm-3 mm bone height, I would be more comfortable with lateral window and concurrent placement, if stabilization is obtained. Less than 3 mm of bone height, or inability to stabilize implants (stable=zero mobility), then 2 stage protocol. Some cowboys might consider that overly conservative.

Sommers technique can be found in various texts : Misch, Cranin, Jensen and various articles from the Journal of Oral implantology. One can also yplift the entire sinus floor, graft, place implants with the use or orthopaedic plates and have tension free closure. The uplift is alot easier.

Have you told your patient that you are going to post a question on a internet site on how to do a technique that if it goes bad may cost her time, money, let alone sufering. I fear for this industry. I may go back for law school. It may be more promising than dentistry. I'm not a specialist. Pick up the phone. Send her to someone who has done it before. For her sake as well as the dental profession.

Dear Anon, I think my and your patients deserve the optimal treatment concerning both quality and time.It makes no sense in doing staged closed sinus lift.For what you've presented I strongly recommend doing an open lift .We have demonstrated almost 10 years ago in the JP that there is no minimal bone height which is required for doing a one stage sinus approach. If you want to get experience and knowledge in open sinus lift you are invited to take our hands-on live patient sinus lift course.The next one will be at the end of october at the university of Belgrade (Details can be found in here.

DearAnon: Be wise and know when to refer. In assuming the proceedure be certain you also know how to deal with the complications which may occur. Do you feel compelled to ALSO state that you are also doing 3 PFM's that are free standing as part of your surgicaL QUESTION? I am not sure what that means at this juncture? Why not type 2 gold surfaces and join the units? The overall question is just a dot in the whole concerning the patient. We need to work on ourselves and note that we are not step workers, but doctors. By the way Sommers got the technique from the origional Hilt Tatum. Be guided with some caution and advanced education is a powerful tool.

Hi there, 1.If u got >4mm bone SA2 type place screw rootform implants same stage u'll get 30Ncm avg. 2.If SA3 or 4 then graft n wait 4-9 mnths depending on what the graft is. Anyways u will nevr need to graft twice if yr technique is good. Read the ITI treatment guide or Misch's book or do a CDE. please feel free to ask for any queries. All th best

The rule of 4mm residual bone height for placing simultaneous implants while doing sinus lift is ancient history.It is agreed today that there is no such a thing as minimal height today for a simultaneous approach.It seems bone width is a factor.A narrow ridge will dictate doing horizontal augmentation prior to a sinus augmentation.

Hi there Ziv, I have placed implants many a time in almost no residual bone with a simultaneous sinus lift but couple of cases had almost no initial stability. Would'nt that be of concern considering that there have been case reports of implants slipping into the sinus when placed in next to no redidual ridge bone height? How would you address the situation where a screw type root form implant outstrips the osteotomy at just 15Ncm, would you leave it to integrate?

I guess that Dr. J and Dr. J Peter said it all....you can´t make does questions at that level of pratice....that´s irresponsable and shows how unprepared you are in the implant´s field. jose rosa, Lisbon Portugal

Hi Dr Gandhi, I have no concerns as long as I take away all partials and full dentures from the sinus augmented patients.Sometimes I use mini Implants such as Dentatus to construct a temp bridge. As for the initial stability- I leave them to integrate and again when there are no biting forces due to a temp bridge on mini implants or hopeless teeth there is a minimal concern for disintegration.

During residency I watched a non-surgeon literally spray blood on the ceiling while attempting a lateral maxillary sinus lift. We had to intervene and ultimately needed to embolize a rare branch of the I. Max. Artery. Really, really atypical...... However, The patients don't trust our profession because of we can handle the 99 cases that go without complication..... They trust us because we can handle the one that goes bad. Please show caution and do a few of these under supervision before you try such an invasive intra-bony surgery alone.

Again, I am not saying I know everything. However, this should be a rather simple question for an experienced surgeon. If you do not know the answer, how can you do the procedure with confidence. I recommend referring the case, learn more, watch some cases, you don't have to do everything contrary to what the implant companies such as Nobel tell you that you can do and learn in a weekend course. Ask yourself, would you let someone with your knowledge work on your mother? That should give you the answer to if you should do the surgery right there. Would you trust an internal medicine doctor to do surgery on you if he posted a question on how to do the procedure on the web? I doubt it.

Everyone- lets just address the question. he asked about doing a two stage lift to avoid a lateral window. yes, it can be done. personally, in my opinion, your patient deserves the least invasive procedure with the best proven clinical results. sounds like the patient may be better off with a lateral lift with simultaneous implant placement. one surgery, proven outcome.

Eric why do you feel it necessary to bring us back to the question when posters on these threads bring up other issues that are important to the questions. Doctors obviously need to be warned of the risks as many of us are turning into cowboys with no training other then some CE. Remember we as Doctors should be bound by doing no harm. To me being a good surgeon is not just being able to do alot of procedure well. Its about knowing what your limitations are, knowing the risks and complications, knowing when your over your head and knowing when to refer. As emperical medicine brought up, there are complications with any and all surgical procedure and while some are rare, "surgeons" need to be prepared. I use the word surgeon in quotes because anyone doing the procedure will be held to that standard of care.

Thanks Ziv

mainoralsurgeryman - i think we are on the same page, just asking to remain focused. read my response again. obviously implant dentistry as a whole is in danger by folks asking questions like this. our loaded chit -chat is not going to solve the problem, answering the questions with our knowledge as specialists is the best solution.

If you're asking these questions you and more importantly your patient would benefit from a referral to an oral surgeon.If you like ,get together with the surgeon and perhaps go over to observe.I'm placing implants for 9 years .I much prefer to assist the doctor that does the lateral window for me, the patients are ready to go in 8 months and everyone wins.If you have enough bone to get stability,as mentioned above in previous posts you could place simultaneously and do the case together.Again,this isn't cooking,you can't throw out the meal and start all over.Get the training or get someone with the training to render the service .You'll be doing the patient and yourself a favor.

Two stage tx is out of the question! Perform the lift, then graft, give it time. If not enough bone one can fixate the implants with orthopaedic bone plates. Always give the patient the best of care and do not expose them to excessive procedures. Your question is interesting. If you really want to learn these procedures - check out Tatum, Pikos and or Rosenlicht. They are all excellent. Remember we all start out as beginners, so don't feel bad about the question. Seek help from good teachers, not hateful critics.

I routinely graft and place the implants in one surgery. If you are concerned about the sinus floor being too thin, then graft more autogenous bone. There is no reason to open the lateral window twice.

Anon I'd love to know how things went.Do email me at tailor7793@rogers.com htailor

Why subject your patient to two surgeries? Would you want this? Do it right the first time out.

Dear Doc, There are some illustrious names that have posted replies to your question and I have read them all. I still felt, there was a perspective to the issue that was left unaddressed, and hence , as impertinent as it might sound, I thought I would go ahead and post it anyway! I am an OMF Surgeon in exclusive (almost) Implant practice for the last 7 years. have had the privilege of training with some good, big names. During the time when I started doing Sinus lifts (did my first one as an OMFSurgeon and then later as an "Implantology-educated OMFSurgeon", and realized what a world of difference there is to both. Having routinely practiced Implant placement simultaneously with Sinus-Lift procedures in the past (with reasonable adherence to a 'minimum-residual-bone' protocol, which actually vary from author to author); I was fairly convinced that it was the way to go. At a dinner a few months ago, where my close friend an Implantologist of repute, had the honor of being at the same table as the master Hilt Tatum himself, he heard from the Professor himself, that there was only one way to go.... do the sinus Lift (Lateral window) and then wait for the graft to heal and place Implants as a second stage procedure. His justification for the radical change in thinking apparently stemmed from a more intimate understanding of bone behaviour and tissue response under load. The posterior maxilla is predominantly Cancellous and a resorbed posterior maxilla is almost aways, really Type IV (Misch) bone which is poorly mineralized and lacks a cortical component. From our knowledge of "Bone Die-back" (or the phenomenon of early osteoclastic activity leading to loss of bone to almost 0.2 to 08mm in the BIC area in the immediate post Implant period.. Ref Amler et al, Extraction Socket healing., 1983, Extraction Socket Healing vs. Implant healing.,1994) we are so dogmatic about Initial insertional stability or Primary stability, which is necessary to offset this very phenomenon of Bone Die-back. Consider that placing an Implant in an area devoid of optimal bone (as in the case of a resorbed posterior maxilla) in the first place would be subjecting it to an element of very plausible instability in the initial weeks ensuing insertion. In addition, the fact that even if we did place autogenous bone around the Implant within the Sinus after the Lift, it would be bone (graft) that would be subjected to the negative influence of the Osteoclastic response and with no primary vascularity, have to overcome the phase to go ahead and regenerate and remodel sufficiently to be able to turn over bone of quality that is good enough to sustain loading (Posterior compressive load) in the near future. Seems like a lot of variable that have to fall in place ( to me a recipe that is fraught with long-term risks, as the patients in this category are usually over 45-50 years old). It therefore seems safe to be able to predict better longevity , based on this rationalization (as the big man himself authenticates), and do it as a 2-stage procedure, when the bone that is regenerated after the Sinus Lift has established its own vascularity and is therefore better enanbled to sustain load.

Very interesting discussion, now for my two cents worth...Lateral access access unavoidable with poor bone volume and quality, bit Summers closed lift a very kind and conservative approach. Excellent grafting course run by the legend Danny Buser out of the uni of Berne three crammed days of beautiful, predictable, evidenced based training. Best of luck.

In residency I saw only one situation that did call for the use of Summer's technique twice. The CT showed a complicated system of septa and only 1-2mm residualy bone. Rather than attempting a Lateral approach and almost certainly perforating the membrane, the Summer's technique was used to elevate the membrane and graft 3-4mm of bone. 2-3 months later the surgeon returned to the site repeated the Summer's technique and placed the implants. I can't think of any other situation where a repeated Summer's technique woould be appropriate and I concur that if you must post this type of question that you should refer the case or get further training.