What bio-material to choose for sinus lift?

I have treatment planned a patient 2 implants in the maxilla and need to do a Summer’s technique sinus lift.  Which bone augmentation material is better to use: Cerabone (Botiss, Germania) or Bio-Oss (Geistlich, Elvetia)?  Do you recommend any other material? Any other thoughts?

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25 thoughts on “What bio-material to choose for sinus lift?

    1. Thank you for your feedback.
      Yes, the pictures correspond to the actual digital treatment planning.
      One more mention, I forgot: bone density for both sites is category IV, according to Leckholm & Zarb classification. In this case the material is needed?
      The implants will be Straumann Bone Level SLActive, Φ4.1mm, L10mm

      1. For those implants and for that IV bone I would “pinch” the bone with the lance drill and use 2; 2,5 and 3mm convex osteotomes; then the 3mm concave osteotome to fracture the sinus floor and finally place the implant. Don’t expect high insertion torques.
        A 5 X 10mm (that is actually 9mm) Megagen Anyridge (placed 1mm infraosseous as per manufacture instructions) would be my choice here. In this case the last osteotome would be a 3,5 and you should expect at least 25N.cm insertion torque.

        Thanks

  1. I would clinically feel if my pilot drill was at or below the sinus floor (hard bone encountered, or perforation, but delicate feel so minimal membrane damage. . If not, no added bone. If so, I would enlarge my prep to accommodate the implant to a few mm below the sinus floor, then osteotome up the last few mm. Then add Puros (I like real human bone) into the prep (transalveolar graft) a few times and condense it to implant length. Repeat a few times. Then place implant.
    If say > 3mm into sinus I would consider a lateral sinus window at same time as prep, and then place implant and then Puros graft. If > 5mm I do an open sinus graft first, then place the implant a few months later. I’m still working with >99% success, and no failures to date with these sinus grafting techniques. (I have had two cases the membrane was so very thin there was no way to infracture the wall without tears.) I have found those patients with a history of sinus issues have a much thicker sinus membrane and less chance of a tear.

  2. This is a slam dunk case for using versah burs. Through Osseodensification, you will densify the existing bone as well as push the existing bone towards the sinus floor- so no extra bone would be needed. Forget about using osteotomes- that’s like iPhone 2 technology. Any 5×10 or even 5×11.5 implant will work here. All titanium integrates, some just more expensively than others. Good luck this should be a fun case.

    1. Yaron
      Recent research shows that osseodensification does not increase bone density, primary stability or secondary stability.

      Effects of Condensation on Peri-implant Bone Density and Remodeling.

      1. Hi Greg, love your products btw. I know that you are a researcher and I, am certainly not qualified to debate this issue with you, however, some of the most respected names in implant dentistry namely- Mazor, Pikos, Salama, Gluckman etc are all recommending the use of this technology backed by research that they, and many others presented at the last Dental XP meeting. There is a correct method to using these burs and certainly in my practice I have had great success with them especially in posterior molar areas where the bone height is 6-7mm. Please forward the link to the research as I would be interested to read it. Thanks

        1. Yaron Thank you for your business and I have no interest in debating this issue. I am just relaying what I read in the literature. The clinicians you cite are respected and very good but they don’t know anymore about bone than the average dentist which is not intended to be any type of insult of anyone but just a fact. Please look below as I have listed the reference in another post.

        2. I second the the use of Densah burs, I have had great success with them in less than ideal situations, both for ridge expansion and internal sinus lifts using the patients own bone and propelling it upward lifting the membrane. I like using them with Verban drill stops for an extra margin of control. They also have to potential to greatly reduce the need for lateral sinus lifts. Osteotomes are good but traumatic to the patient. A lot of products come and go in dentistry but these burs seem like they are the real thing, at least clinically if not histologically. Dr Mark Lubitz

    1. J Dent Res. 2017 Apr;96(4):413-420. doi: 10.1177/0022034516683932. Epub 2017 Jan 3.
      Effects of Condensation on Peri-implant Bone Density and Remodeling.

      Wang L1,2, Wu Y2,3, Perez KC2, Hyman S2, Brunski JB2, Tulu U2, Bao C1, Salmon B2,4, Helms JA2.

      The lead author Jill Helms who is a periodontist who also has a PhD and has published extensively in the field of bone biology. She is a full time academic and professor at Stanford. The authors refute the claims being made about osseodensification but if you use this device you should read the article.

  3. I believe the question is what graft material do you recommend. In this case, the biomaterial used is inconsequential. Since the loading zone for the implants planned is in existing bone, graft material will not contribute to secondary stability. Let’s pose a different question. What if the sinus floor was only 2-4 mm from the crest. Of the graft materials mentioned, xenograft is the worst of all of the possibilities. If you use Bio-Oss alone, you will end up with approximately 35% vital bone. In D4 bone at the crest, this is insufficient for function in high loading zones in posterior maxilla. I have seen the worst failures of implants in this scenario. The choice should always be what graft will give you the highest percentage of vital bone after turnover. Allografts are OK. But low or non crystalline CaPO4’s give a higher percentage. If you mix autologous biologics with calcium phosphates, you can actually get up to 75% vital bone. This is my choice in sinus grafts. RJM

    1. Robert,
      Would you mind sharing your recipe for autologous biologics mixed with calcium phosphates?

      Over the past 1-2 years, I have had mixed success with the TCP products and would love to know how to get better and more consistent success with synthetic graft materials.

      I switched to TCP products for most of my grafts in efforts to increase vital bone formation, but have found inconsistent results, most commonly the synthetic particles have not integrated and can be curretted out of the socket after 4 months healing. In these cases, I have covered the graft material with PTFE membranes, cytoflex resorb membranes.

      Thank you for your advice, Ethan Moulton

  4. Robert has summed it up very well . If you want a nice “white looking ” x-ray then HA is the best , especially xenograft . So when you show your case in 5 years it will still look white and “bone like ” but it is all about the quality of the bone over the long term , as it is living tissue and needs to be able to turn over .
    So the best materials will be ones that are fully turned over to host bone …
    With BTcP in all our histological studies both clinical and Animal studies there is consistently over 50% new host bone at 10 weeks which is line with the research .
    Greg I must read that research ..makes sense , logic is always most important

  5. Thank you all for your feedback.

    I’m just a patient trying to find out best choice in this case and maybe I didn’t understand well:

    @Peter Fairbairn: “Robert has summed it up very well . If you want a nice “white looking ” x-ray then HA is the best , especially xenograft”
    But, Robert J Miller said that “Of the graft materials mentioned, xenograft is the worst of all of the possibilities”

    So, in my case xenograft (Bio-Oss/Cerabone) will help? or no matter xenograft will be used, there is no difference in bone quality for long term?

    1. A white radiograph does not necessarily mean that there is dense, living bone present. It may look good, but is it adequate to support an implant? So Drs. Robert and Peter are saying pretty much the same thing, just differently and being polite.

  6. Thanks Dr JL for clarification.

    After reading all your replies (some of them are confusing me as I’m not specialist) it’s worth to mention the surgical technique used in my case as stated by my surgeon dentist: 3D Stereo-lithographic CAD-CAM surgical guide based on CBCT, using flap-less technique.

    Is this technique suitable for my case?

    Thank you again for your support!

  7. Excellent advice already given. I would recommend visiting Intra-Lock’s website and research Platelet Rich Fibrin (PRF). Cheap and easy to produce, it can be combined with any graft material or even used alone as a graft. I have been very impressed with the results I’ve had using it in both hard and soft tissue procedures. My preferred particulate is a cortico-cancellous bone mix, 50:50, with particles of 250-1200 um, with iv metronidazole solution (by patient) incorporated into the graft. Prayers and Best Wishes for your practic and patient.

    1. Wesley
      PRF inhibits bone formation. We all know what you have been told by Choukroun and company but my suggestion is that you do some research on your own and look at the clinical studies published on PRF. Go to Pubmed and input PRF bone. Virtually every study shows PRF provides no benefit compared to no grafting.

        1. Apologies, Greg; when I left that answer, I was not totally focused here. I am going to check PubMed. You do make a good point: PRF does not grow bone. Nothing does. New bone must grow into a biologically acceptable graft material from existing bone. Research not withstanding, it has served well in my hands as a graft binder, occlusive membrane, and soft tissue dressing and graft supplement; I have never felt confident in using it as a sole grafting material.
          I leave the decision to use it to any practitioner who cares to research and actually use it. PRF is not equal from all sources and methods. My purpose is not to distract from the thread owner’s question, and I leave quietly at that. Thank you, and to the doctor who asked the question, the only other graft material I can recommend is the addition of an appropriate antibiotic, i.e. metronidazole, to reduce the chance that the avascular graft material will serve as a focus of bacterial colonization. Thank you for the opportunity to respond.

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