Patient does not want sinus lift: options for implant placement?

This patient wants to replace #3 and #4 [maxillary right first molar and second remolar[ 16, 15] with 2 free standing implants with single crowns.  Patient does not want sinus lift.  Should I extract and attempt a Summer’s lift and install implants at the time of extraction?  Should I extract and socket preservation and allow for osseointegration and install implants later?

Bitewing Xray

20 thoughts on “Patient does not want sinus lift: options for implant placement?

  1. Assuming that something’s wrong with the molar apart from the distal caries and the mesial apparent poor adaptation of the restoration and assuming for some reason you can’t / won’t redo the endo on the 15 and do a crown with post core, I think you should first exo nr. 15 and 16 and graft with probably 50% TCP 50% CaSO4 and go back 3 or 4 months later to install implants with no need to lift the sinus, just anchor them within the sinus floor. The reason I’m telling you not to do immediate implant placement is because of the curvature of tooth nr 14 and even if you trisect the molar you probably won’t be able to securely place the implant to the desired and correct place (the implant’s apex can fall down to the distal socket and you would have a deficient prosthesis or it could fall down to the mesial socket and you woudn’t have the minimum 3mmdistance between implants), even though it is possible.
    Oh and by the way, splint the crowns.
    Good luck!

  2. I would extract the premolar measure the root for implant length and graft then place the implant. I would see if molar is treatable with root canal, if not then extract measure root for implant length graft an place implant. If you do a good job in the grafts with a quality allograft, primary closure and perhaps a membrane you will get decent bone height and not need any type of lift. Site preparation is key, I consider it part of the implant procedure. Not sure why you don’t want to save the molar. Nice post good luck

  3. I would immediate place the implant after extraction of the premolare , but i will not risk with the molar , because it may be a traumatic extraction , as well as the tip of the distal root tip may be in the sinus . Try to save the molar by root canal treatment ,crown lengthening and good post and core +crown . Otherwise good luck .

  4. I would say that you really don’t need a lift, just go with expansion and place the implants, graft as needed and you are done.
    Luck

  5. Dr. Hughes is correct. This is a very simple case and will give you some good experience in treatment planning. Endo and crown the molar; tooth #3. Atraumatic extraction of tooth #4 using perio-tomes or a subluxator. This will preserve the buccal bone. If the buccal plate breaks, or comes out with the tooth root you must graft the socket and wait 4 months to place the implant. If you get the tooth root out without compromising the buccal bone; curette the socket with a small molt and place the implant at least 3mm beyond the apex. You will be close to the sinus floor but not in it. Place allograft around the coronal areas that the implant is >1mm gap from the bone. Gently suture. Restore in 4 months. Good luck.

    • I think that you need to think of crown lengthening if you wish to consider retaining the tooth look at mesial of the 16 ( first molar). The tooth will need endo crown lengthening then crown . And this is all dependent on the amount of residual coronal dentine. I would not rule out the implant in the 16 without checking this first.

  6. Great advice so far. I’d also advise you have an endodontist with scope check out that molar for fracture lines, etc., while performing Endo therapy. I’m good at Endo tx, but there’s a lot riding on the condition of those molar roots, and a specialist is the best way to avoid having to extract a broken root or leaking canal down the road.

    Do what you do best and send the crazy stuff to the “Big Boys”. That was the advice of my old mentor and, a few times, I have certainly regretted not having followed it. I have never regretted referring a complicated procedure to a specialist. The trick is selecting cases you can reliably handle and sending the others out. We work well as a team in most cases.

  7. I would extract # 3 and #4 and place 2 …4.5 X 6mm Bicon implants with grafting Synthograft (making sure it is mixed with the patient’s own blood)…no sinus lift should be necessary…looking at this e-xay…if it is consider a internal sinus lift.

    Should be fairly straight forward….

    One point …I hope this is not you first implant case!!!

  8. While a Bicon short implant is great for this type of case, the more ideal size for the molar is a 6.0 x 5.7 mm. We just put one on this morning with an internal lift.

    One would need to know the ridge more closely to decide about 4.5 x 6.0 mm or 5.0 x 6.0 mm, either one of which would easily bear the load grafting not likely needed unless a Buccal under cut or such.

  9. You can use whatever system you want without doing sinus lift. All systems have 8-9 mm implants which are ideal for this case. I prefer to do extraction, wait 2 months then place your implants. You need to do socket preservation only if the extraction site is missing walls.This is an elementary case as somebody said.

  10. First of all we need to check the restorability of molar then if not restorable we will go for exo. of molar and premolar and if the buccal plate is sound we can do immediate implant with conture augmentation,if the plate is not sound we can waite six weeks then we can start implant

  11. IF you decide that you must extract GET A CBCT SCAN FIRST. That will help you determine the actual position of the roots to the sinus floor and if you need to do lift or not.

  12. I know this is not necessarily answering your direct question, but how a bout a 3 unit bridge? Both adjacent teeth need full coverage restorations. I you feel the need to do the implant I agree with the prior posters its a straightforward immediate implant.

    • Dr G, THANK YOU!. A 3 or 4 unit FPD is an excellent treatment. The patient can be restored quickly, easily and at a lower cost.
      I always suggest a FPD to the patients, just to clear the air. I also mention the maintenance/responsability issues with implants and fixed prosthetic treatment.
      A point to mention about #3, it will need crown lengthening to obtain adequate margination and future periodontal health.

  13. It is very difficult to get an accurate diagnosis wether a sinus lift is needed or not BEFORE the extraction. If it was my case I would do the extraction, wait two months and do a TAC scan and then you will have the exact diagnosis of how much bone you have and if you need the sinus lift that I presume you will, then look at the patient eyes and say: you need a sinus lift done.
    So far I have done more than 400 sinus lift since I started in the year 2000 and let me tell you that besides a 10 infections that I have controlled with changing the antibiotic most of them (just on three cases I had to re enter and re graft, take a microbial sample and antibiogram) on the overall rate I have been able to place the implants in all cases. one hundred per cent!. As peridontist I can’t say of one procedure better than this one.

  14. just extract the root and place the implant into the extraction socket without sinus elevation.
    key points-

    1. measure the root dimensions after extraction and use the implant with the adequate diameter which can be engaged along the socket walls to achieve the adequate stability.
    2. submerge the implant 1-1.5 mm apical to the crest and close the flap for submerge healing.
    3. uncover the implant after 4 months and restore

    that’s it.

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