Sinus Lift: First Case Recommendations?

Last Updated: Jan 24, 2013

I have placed probably 100 implants and have taken several bone grafting courses including cadaver training for sinus lift surgery. I am currently working up a treatment plan on a health 38 year old non-smoker who lost several teeth at a early age in her country of origin. She presents with significant bone resorption on the UR area. Tooth 2 has already been removed, the intention is also to remove tooth number 4 and place 3 implants after bone augmentation/sinus lift. My question is as follows. I have observed several surgeries and I have studied the technique however have yet to perform sinus or onlay surgery on a live person. Do you consider this a good first case? Do you think a sinus lift alone will be adequate or do you think onlay graft is also neccessary? I have surgical handpieces, but no ultrasonics, thoughts on this? Augmentation material recommendations. I was planning on lifting (lateral window) and then returning for implant placement later due to the total lack of bone support, thoughts? Thanks in advance for your thoughts, comments, advice.

(click images for larger views)

![]pan1_0123](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/01/pan1_0123-e1359060203632.jpg)

![]pa2_0123](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/01/pa2_0123-e1359060240657.jpg)

10 Comments on Sinus Lift: First Case Recommendations?

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CRS

01/24/2013

I hope you grafted the socket of tooth #2 so you have a base. Tooth number 4 needs a socket graft also. Once these areas have healed I'd do the lift since you'll have a scaffold of bone to work between. What's going on with the sinus radio-opacity do you have a CT scan? This is a challenging first time case with a high likelyhood of a sinus floor perforation with such thin bone. If you get an O-A communication it may be difficult to manage. Not an easy first time case. I'd use PRGF or PRP with the graft to prevent migration and be sure you know how to manage a tear, see Pikos technique on repair. Good luck, you're pretty brave.

Richard Hughes, DDS, FAAI

01/25/2013

CRS gave you great advice! Take care of the sockets first. When you do graft, use PRP and PRF to consolidate your graft and close any perforations with the PRF. I suggest using OsteoGen as a graft material. It does work. Stay away from BioOss, it will not resorb and will yields an insufficient BIC. OsteoGen resorbs and does help the body ake lamellar (mature) bone.

CRS

01/25/2013

Since the sinus has pneumatised down to the level of the remaining teeth which is actually somewhat helpful you don't need vertical augmentation the bone gained in the lift will replace that. However you may require some lateral augmentation depending on how thick the buccal plate and if It is collapsed. That can be augmented at implant placement with expanders and an onlay graft. I would be careful to make the lateral window about 4-5mm above the sinus floor, if you have a breakdown at least the O-A communication will be to the side and more favorable to close. You also could place the implants exactly where the roots were with a ct guided stent and avoid the sinus issue altogether, but in a young patient if would be better to restore the lost maxillary bone now. This is a challenging case but with careful planning and staging the result will be great if you are willing to devote the time to the treatment planning, perhaps working with an experienced colleague. Best wishes.

Peter Fairbairn

01/25/2013

Hi CRS in first again with great advice ........ For a first try another less complicated case , funny thing whenevr helping dentists I am mentoring they always bring challenging cases in with great optimism. Make life easier ,maybe refer this one Peter

Tyler

01/26/2013

Good points above. Make sure the inferior cut of your window is not at the inferior border of the sinus, this will give you flexibility when (not if) you perf the membrane. You would have significantly less chance of perforation if you use piezosurgery. It really is amazing how great of a tool Piezo is for sinus surgery. Something nobody else mentioned is if you're right handed, it will be significantly easier to do this then the same case on the left side. Make sure you have the correct retractors and sinus elevators etc. I use a 1:1 mix of Bio-Oss Cortical and FDBA. We have great bone fill shown by CBCT, and very low (no) failure of implant placement. I use this mixture when I place implants at the same time as open sinus augmentation as well. I would urge you agains't trying a lateral ridge augmentation and open sinus at the same time. It seems that these cases are more prone to problems due to flap dehisscence etc.... One miracle at a time! Tyler

Michael Stanley

01/29/2013

Does that look like about 10 mm of sinus membrane thickening? If so, that's a contraindication until resolved.

Carlos Boudet DDS

01/29/2013

The severely thickened sinus membrane is consistent with mucositis at the least and possibly sinusitis and sinus disease. If you are considering a sinus graft you should get a conebeam CT and get a radiology report. Sinus disease affecting the osteomeatal complex you would not see in two dimentional films, but if present, is a contraindication unless treated. Good luck!

Gerve ,msc

01/29/2013

I see now mucositis in sinus.

Terence Lau

01/30/2013

The mucositis is probably caused by the failing rct's and will most likely clear up after extraction of these teeth. If not, best to get an ENT cons as a precaution.

Frank

02/15/2013

This "thickening" of the the membrane may represent a chronic sinusitis. Consider treating the patient with a course of nasal corticosteroids like Flonase and nasal decongestants or refer to ENT for clearance. If there are problems later you will have a leg to stand on. In the mean time remove the roots and graft if necessary. Do not assume that this thickening represent solid tissue. It may be edematous, inflammed with the potential for increased bleeding and friable which could mean keeping the membrane intact is more difficult not less. Perhaps not the best case to start with. Good luck though.

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