Summers Lift Technique: Am I Pushing This Technique Too Far?

What is the point in putting an implant 2-3mm into the sinus?You will not gain additional bone at the apex...I do think you push the technique too far. I will be giving a two day course in Atlanta at dentalxp and in NYC focusing on state of the art in sinus augmentation.I will discuss all three approaches to sinus augmentation: creatal,lateral window and balloon.

Ok - upto 4mm into the sinus using summers is fine - you lift the membrane - remember though it very much depends on experience and bone density. I have placed implants at the same time at using the lateral window approach and find the bone condensers or osteotomes move a breakage of bone laterally/and up with the implant - I completely disagree with the previous statement that 3mm is to much - wheres the evidence - oh sorry there isnt any !! - 3mm is fine in fact you create a tent and bleeding is from highly bone-forming cells so bone does form around the implant apex along the body.

It all depends on how much crestal bone you have. You really need about 5mm of bone to start out with in order to get enough primary stability. So it will ultimately depend upon what legth implant you plan to place. Do I think a summers apporach is indicated if you want an 11mm implnt and you only have 5mm of bone- NO. If you have 7mm of bone and you want to place a 9-11mm implant- YES. Ultimately it will all come down to what you start with. If I am faced with having to get 4 or more mm of bone height- I will do a lateral approach. Anything under that, grafting will done through the osteotomy(Summers).

Crestal Osteotome technique works very dependably if good implant stability is achieved in native bone. The sinus augmentation is achieved via introduction of grafting material through the osteotomy and lifting the sinus membrane. This is followed by an implant placement done together as a single surgery. Lifting of 2 to 3 mm. is very predictable and will reliably generate the development of bone about the implant apex. I have seen experienced operators use this technique to elevate even beyond 5 mm and have done so myself on numerous occasions. However, the further up you attempt to elevate the membrane the greater risk you will have perforating it and there comes a point where the lateral window approach become more suitable and less risky.

I guess Dr Mazor has not read your comment guidelines regarding marketing/promotional comments. Transalveolar sinus lift is a predictable and minimally invasive procedure in my opinion, and can be used to elevate the sinus floor up to five millimeters. There are many parameters to consider in any and all implant cases. A cook-book approach is inappropriate and a solid understanding of bone physiology, anatomy, and general implantology concepts are imperative for high success rates and happy patients.

I have done 2 cases with only 3 to 4 mm bone with endopore 4.1x7 mm implants. In one I replaced # 2, and #3 with separate crowns. That was 2 and 1/2 yrs ago. They are doing good so far. Dr deporter ( uni of Toronto ) has reported couple of cases with 3 mm bone and using separate crowns. Endopore has a good taper preventing it from loosing it into the sinus. I would avoid using cylindrical implants when bone hight is limited. I have heard from 2 dentists that they lost the implant into the sinus. I think Endopore works great when i have less than 5mm bone bellow sinus. Dr Deporter suggest that we should have at least 2 mm bone on both baccal and palatal side of the implant.

I believe when Hilt Tatum first discovered the idea of being able to regrow bone in a pneumontized sinus years after teeth were extracted, his approach was the lateral wall sinus lift. An edentulous posteror maxilla has very much the engineering principles of an elephant standing on a glass cup... you can put remendous weight on it providing all the walls are intact. I have had the experience, years ago, of placing two implants in minimal bone ( just enough to secure the implants) and instead of cover screws, used titanium washers to prevent the implants from possibly slipping into the sinus ( the implants had straight walls in those days). A lateral window was cut into the buccal wall and the sinus was stuffed with grafting material......so far so good..... However,shortly thereafter, the patient bit into something very hard, and fractured the entire tuberosity area. He lived out of town,did not get back to me, and instead of having a surgical repair, the local prosthodontist made him a maxillary partial denture with an obturator to close the hole.....a huge oral-sinus passage. From a practical point of view,a "Summer's Lift Technique" works well, keeps the anatomy of the tuberosity in tact, and there is no hard and fast rule that states how far into the sinus an unloaded implant can protrude. I have many cases using 16mm implants, which were fixed in 4mm of crestal bone, and after a reasonable healing period, a halo of bone can be seen over the apex of the implants. The lateral approach is excellent because you can estimate more accurately where the grafting is needed and the volume as well.....but remember until good bone growth is achieved, the tuberosity is at risk of fracture.

Dr Leon Chen developed a technique to lift the sinus lining and graft the sinus floor through the osteotomy. The length of the implant can then be as much as 13mm or so. I have had success with this technique. It then allows restoration of the implant within 6-8 months.

I have no hard stats on the summers approach, but it works well for me. Reason tells me that if the anatomy of the sinus to be lifted is that of pneumatization where the base of the sinus is cupped rather than flat, you can lift higher. It is because there are more bone cells surrounding the lift site as opposed to a flatter anatomy. There are variables, too, such as technique, health concerns, graft composition and post op patient care that can affect the best of efforts. I have found that an upfracture of 5-6mm lifts a segment of bone that fosters a better graft placement and allows for more autogenous bone on the superior aspect that is attached to the membrane. It makes sense to me. Mind you, you still lose some of that bone over time. If you lift 5mm, you may end up with 3. JMHO. Bill

There are many papers published on the crestal approach to sinus augmentation. Dr. Wise has shown, on cadavers, a greater perforation rate with elevation of 5mm or more. There is always a risk of perforation with the lateral approach, however it is easier to repair as you can visualize the site. You must also choose the type of bone graft that will give you the kind of BONE you are comfortable with in the regenerated or just grafted site. Many courses are available that will assist you in learning the various techniques and material choices available to you. These range from pure lecture to hands-on model and cadaver to live surgery with participation by the student.

dr.charles gave the best explanation.i agree with u.

Each technique crestal or lateral has limitations.The crestal approach is fine for elevating 3-4mm.Elevating more than that involves higher potential for perforation of the membrane as demonstrated in several studies.Success rate is very high yet the procedure has some drawbacks: 1) Sloped sinus floor 2) Presence of septa 3)Potential concussion due to our instrumentation. Lateral approach gives better visibility and ability to deal with membrane repair yet the post ops are almost inevitable. Balloon approach eliminates the post ops and reduce the chair time by half.

The Balloon lift has alot of promise. I encourage you all the read the balloon articles published in JIACD and JOI.

I guess our colleagues have not forgotten about one of the most serious complications of sinus floor lifting by osteotomes, which is benign paroxysmal positional vertigo (BPPV).The best prevention is avoiding that technique.

Thank you for your post. It's always nice topic for discussion since there are som many ways to approach it. When you say that you always use osteotome technique I wonder how can you do it in cases of SA4 (Misch classifiction) when the sub antral wall is less then 5 mm? regarding the question of placing the implants 2-3mm in the sinus there are some papers mentioning that even WITHOUT GRAFT success/Survival rates are comparable to osteotome technique + graft. It is worth to mention Dr. Jafari when he talks about BPPV.

As an Oral surgeon and ENT, BPPV is a risk factor for concussive trauma to the labyrinth. However, well over 99% recover spontaneously and the rate of BPPV is less than 1%

Ask yourself this, what other methods do you have that can used to restore this area and what is most acceptable method for treatment. Explain this to the patient. Proceed within your comfort zone and move on

the classic indication for summers technique is at least 5 mm left and straight sinus floor, in this case you can insert an 8 mm implant. as soon as you decide to do this technique to the right case, you can lift the sinus 2-3 mm safely.

BPPV can be completely avoided using a powered bone expansion kit like the MIS Bone Compression Kit. Excellent control, precise manipulation of the bone without the percussion. Just buy one.

Ah Brian - you wouldn't by any chance work for MIS?!

No Bill, just your common garden variety periodontist. :)

I have used the MIS kit and a number of other minimally invasive sinus augmentation systems. I have had good and bad experiences with each. No magic bullet here, but i have had success with summers with no graft with 8mm or more bone.

Lifting of 2 to 3 mm. is very predictable and will reliably generate the development of bone about the implant apex.