Sinus lift or no sinus lift?

We apologize for any confusion with your post. Obviously, our intent was not to distort your narrative, but simply to actually make the narrative read more clearly. Anyway, we have reposted your question exactly as you sent it to us without any editing. There doesn't seem to be that much difference in the two versions, quite frankly, but hopefully with your original unedited question now posted the intention of your narrative is clearer.

Peter, please elucidate little bit more re: graftless option of placing angled implants. I am a big friend of guided surgery and I could take advantage of that. Thank you.

Richard I have a question, I like to have the crestal height as close as possible to the natural teeth for emergence profile and hygiene, is that a safe assumption? And if both implants although shorter and both osteointrgrated and parallel why would one splint? I think the hygiene is tougher and if one implant fails the prosthesis is not retrievable. I feel that splinting implants is borrowed from natural teeth with PDLs I would really appreciate your thoughts. I feel that sometimes like crown/ root ratio, cementing and splinting are indiscriminately applied to implants which are not teeth. I've even seen implants deliberately tilted without cross arch stabilization. I don't restore so I need some help here. Thanks

From mechanical point of view, it makes sense to splint short or narrow implants to a bridge for added stability. This would be a workaround for narrow or short ridges avoiding major graftings.

I agree with Richard Highes regarding the implants. Ankylos has a system where you would place the implant in at an angle. The abutment system called SmartFix will allow you to correct the implant insertion angle by 30 degrees. It is their prosthetic solution on angles implants. However, I do not understand what Richard meant by abutting to the anterior teeth with FPDs. (I apologize to Richard if I misunderstood his post.) If he meant making a bridge with an implant as one abutment and a natural tooth as the other abutment, I would advise against that. Natural teeth have a PDL that allows a tooth to move. Implants do not. It is my opinion that the implant will fail due to micromovements.

Dr. Hughes, Thanks for your info. Learn something everyday. One question....Why would you NOT place an implant between natural tooth abutments? (I am assuming you mean removing the bridge and replacing it with an implant between the two natural teeth that were supporting the bridge)

Dr Wong, The reason is as you stated about the PDL. The implant is mobile but not as much as a tooth. So in this case you would have problems. On the otherhand, an implant as a terminal abutment is ok. If one does combine teeth and implants, then place coping a over the natural teeth while performing the bridge work. I suggest reading Misch book on implant pros and some text on copings. Use a very hard cement for cementing the coping and a softer cement for the bridge. An implant supported bridge is ideal but not an absolute.

The mobility I'm referring to is insignificant when compared to a periodontally involved tooth. Carl Misch makes this point in his text books. However, when implants and teeth are mixed, certain combinations are not suitable for long term success. Again, this is in his Implant Prosthetics text. You are correct in assuming that a healthy implant does not have mobility like a periodontally involved tooth.

In all respect to Dr Misch and I have both his textbooks, my background in bone has the perspective of working with anklylosed teeth, very rare, fractures with plating and orthognathic surgery so here goes. The osteointrgrated implant is fused to the bone. Forces on the implant can be transmitted to the live bone which can remodel causing the mobility. I think what is missing is what happens when implants are splinted to natural teeth I think there are many factors involved so I stick to simple rules of avoiding this, keeping the implants parallel to the forces since I often can augment the bone to allow this. I think one can get into trouble confusing an implant with a natural tooth however all our backgrounds are important and sharing info respectfully is key I don't want to divulge how long ago I placed a crown and Tempbond makes me break out in a sweat!