Can I use the osteotome technique for this case?

You could get more usable bone depth by slanting more parallel to the palatal bone surface, maybe not totally parallel. The teeth and implants do not have to be in a strictly vertical position. Also, why not consider a shorter implant such as 4.5 or 5.0 by 6.0 mm length Bicon. You could avoid the need for a lift this way or encounter less risk by keeping the internal lift at or below the width of the implant body. Just by using a 6.0 length, you'd eliminate the need for 3.5 mm of sinus lift, even if you kept the implant vertical. John

Also, the tapered top surface of the Bicon implant would avoid interference with that short palatal wall on emergence.

I guess people like using the Implants they are used to , and develop skills with them . Bicon is a great system but possibly requires a different set of skills as the placement protocol is very different. So the average Dentist likes to work in a comfort zone of using techiniques they are fimiliar with. Could use a B 8 and use a one of the Korean systems like Dask for safe crestal entry , then if not totally comfortable with internal lifting use a balloon to lift the lining . As to closure the Ankylos system is sub-crestal so closure will not be an issue. Although I have placed Ankylos I do not use them regularly. Peter

Correct CT analysis: antagonist included.

Sorry maybe would use a thinner A Implant as ridge with may be an issue but hard to see on this CBCT. Peter

Would suggest do pilot drill to 2mm short of sinus floor, then use osteotomes to widen the ridge and laterally condense the bone, place granular graft material in do you can laterally condense this taking the width to 1mm short of the implant diam to be placed. then can use Summers to gain more height then the implant does final lateral compression thus converting say a D4 bone to a D3 or D2

Implant selection is one thing but most implants will work well. Why are bicom people afraid of sinuses and prefer putting a weaker implant just to avoid a procedure. This case clearly shows a ridge width deficiency. Possibilities, numerous. One to consider is slight vertical ridge reduction to achieve a decent bone width. Once there, do the osteotome and let the area heal. But, do not compromise the area vertically if the adjacent teeth (mesial and distal) would not allow for a favorable esthetic and hygienic restoration. Need to consider that you are trying to achieve and work backwards to get it. I've done osteotome regularly with as little as 3mm vertical bone with no issues. It's all technique - controlled preparation with osteotomes. Also, do not go with a really small diameter osteotome, do one size smaller than your final implant drill.

I doubt that neither Bicom nor Bicon operators are "afraid of the sinus". I know that Bicon is very sinus lift friendly. The surface area of an implant has more variables than length. The volume of the implant's central core can reduce thread or fin loading area, for instance. Bicon implants are fin-like and placed passively, so there is no significant initial bone resorption stage. They are immediately invaded by a cortical-like, laminar bone. Placed in soft bone, they are invaded by the harder, laminar bone, creating stronger bone connection than the softer, surrounding medullary bone. The question arises as to why an operator would insist that 13-18 mm implants are the first choice, "go to" best plan before considering the well reasearched, shorter designs which have proven to be, not weaker, but equal to or stronger than the longer designs. And, to consider that research has shown that the shorter designs stimulate bone formation over the top of the implant body in reliable, predictable fashion. You will have more bone two years from insertion than at insertion. Is that a problem to avoid?

All the comments have value, but at the end of the day, you will be responsible for the result. Using the Ankylos implant you will usually not lose bone around the implant, therefore a 9.5mm implant is effectively a 9.5 not 7.5 as with most systems. Go for it. Do the lift even with the prospect of a perforation.

Why are people so afraid of doing lateral windows? Once you get the hang of it, they are much easier to do than an osteotome. Sometimes I would rather have a 1-2mm of the implant perforate into the sinus. I have less swelling and I still get primary stability and proper healing. I know it sounds taboo, but it works well in my hands. I find it that when I do osteotomes, sometimes in my hand, i have more post operative sequelae and swelling than with a lateral window. Besides, with a lateral window technique I can place longer implants versus tiny little short implants. This has been my experience with patients thus far in my career.

BTW, you realize according to the CT scan slice, you don't have enough palatal bone for a wide implant. So in all seriousness, do a lateral window. Take your time doing it if you know how to do it. Let the sinus heal, and then put a nice long 11.5-13 mm wide diameter implant.

Why do you think you need primary closure? Bv

This seems to be an ideal situation for a classic sinus lift! Bv

Dear all my colleagues, Thank you very much for your all comments! They're very useful for me, a beginner in implantology. In my case, I don't want to use lateral sinus lift because it seems much discomfort for patient after surgery, also, I have no experience in this technique. I'll try maybe in this patient. I need primary closure of the flap because I have GBR graft at palatal wall, I don't want my GBR will be failed. Best regards, Tri Dung.

Gbr palatal wall? Sinus lift is far more predictable and less technique sensitive. Don't do palatal gbr.

Dear Dr. Dan, Thank you for your comments. I just worry some threads of implant will be exposed and need to be grafted with bioss and collagen membrane in palatal wall. Certainly,I only graft a little, not so much graft in palatal. Also, I will do the sinus lift. How do you think?

And do lateral wall. If you want this prosthetic position and not angle the implant buccally, then do lateral wall and after it heals place the implant deeper. Much easier and less technique sensitive

Thank you for your all useful comments. I really appreciate about this. In my case, the lateral wall is still good, no need any graft. So can I graft in palatal side and make releasing incision at buccal flap to get primary closure? I hope Dr. Dan will agree with me about this. Best regards, Tri Dung.

If we are comparing implants and sinus lifts to miracles, then maybe the task is a bit "tall". Why do you feel the need to get primary closure on a traditional lift. Some of the latest literature suggest no need for primary closure, even with bioss. Bvinci. Vinci Oral and Facial Surgery. Baton Rouge, La.

No palatal graft. It won't work

Hi, everybody! Thank you very much for your all comments. I'll see my patient in next month. I'll report the result later. Best regards, Dr. Tri Dung.