Crestal vs Lateral Sinus Lift?

This case involves a 47-year old healthy female who wants an implant in the #3 area. Consideration is between crestal vs lateral sinus lift. Sloping sinus floor with 4 mm bone distal and 6 mm bone mesial. I would need at least 6 mm of sinus augmentation to allow a 9mm long 5mm width implant. I would be more comfortable in this case with a lateral sinus lift. I would like the opinion of other expert surgeons. Thank you. LG




27 Comments on Crestal vs Lateral Sinus Lift?

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rk
5/13/2020
intracrestal at time of placement. Unloaded
Brian Toorani DDS
5/13/2020
This is a great great question. For me, if i have 5mm of bone, my preference is a vertical (internal) sinus lift with implant placement. I am also old school in that i prefer the old school osteotome with Mallet technique. In a case like this, i would plan the implant to do the Osteotomy fully guided and position implant about 0.5mm short of the floor and would use the guide to just accurately drill to this depth to avoid perforation. Then i would compact and fracture and lift the bone internally and slowly lift by 1mm increments and verify no perforation gently (when you do the test for perforation, DO NOT HAVE PATIENT PLUG RIGHT NOSTRIL AND BLOW AS THAT WILL INCREASE CHANCES OF PERFORATION. BEST TO HAVE PATIENT BLOW OUT AIR THROUGH BOTH NOSTRILS OPEN). I personally like leaving an ISLAND bone above the bone graft as it will act a ROOF on top of your graft and IMO, will spead up healing. I also would collect the osteotomy bone (after pilot hole at 800 RPOM with irrigation, i would drill rest at 80 RPM and collect the bone on the drill and mix it with allograft and PRF for internal graft). With all that said, one could easily do a lateral here and do an immediate placement and a guide would not really be needed as you will Clearly see the site. I would advise to eval bone density and undersize the osteotomy for good stability). Also, there are times where a perf can happen, and you will have to open up the sinus laterally and patch and graft (have had to do that a few times). BTW, I see a slight Sinusitis (mild) at the site, so consider placing pt on Mucinex and Nasal rinse for 2 wks prior to the sinus lift. Hope this helped. Good luck and great case!
Joseph Kim, DDS, JD
5/13/2020
In this case, where the site presents with a gentle slope, no septa, and no potential to "pinch off" an area of the maxillary sinus, an internal lift is preferable due to lack of postoperative pain and bleeding compared to a lateral approach. If you don't have a crestal sinus kit (I use the Hiossen CAS and Hiossen Guised CAK kits), the next simplest, and perhaps significantly faster, approach is to us a Versah drill to slowly erode and perforate the bone of the floor, while preserving the integrity of the Schneiderian membrane. It is possible to accomplish this step in as little as 1 minute with the Versah drills, and anywhere from 5-10 minutes with the crestal lift kit. On a significant slope, I will sometimes use my parallel walled, round tipped, offset ostetotome with an adjustable depth screw, to enlarge the bony perforation and to advance the graft particulate. I suggest anorganic bovine or b-TCP, preferably mixed with prf. It is important to have the osteotome make contact with the walls of the osteotmy, in order to achieve a true hydraulic lift, which will transfer the force from the small osteomy to gently raise the Schneiderian membrane off of the bone. If you are going to use a crestal approach kit, remember to run the specialized, soft tissue sparing, final drill at a low RPM (500 to start, but not above 1000), to avoid tearing the Schneiderian membrane. Hope this helps. (disclosure - I receive financial and material compensation for providing lectures and cases to related to Hiossen's crestal approach sinus kit)
Bruce Smoler
5/14/2020
Just for the sake of completeness, what is your reason for anorganic bovine or TCP vs DMFDB ?
Joseph Kim, DDS, JD
5/14/2020
Both materials are completely free of any organic tissue. With anorganic bovine, it is heated high enough to turn any cells or tissues into ash, leaving just the minerals behind. Being synthetic, b-TCP contains zero living tissue, yet has an excellent resorption profile and long term data to justify it’s use. Both of these materials require FDA registration and have been shown to be safe in humans. For optimal results, it is best to pair a ptfe membrane with the b-TCP. I have used both 4+ month resolvable xenograft membranes and ptfe for bovine with excellent results. Allografts, by comparison, will heal differently than the grafts mentioned above, something that I didn’t notice until approximately 10 years after apparently successful grafts. In patients who were experiencing periimplantitis around implants in grafted bone, radiographs would show strange patterns of resorption in allograft sites. Upon surgical entry, it it notable that the the periimplantitis around allograft is markedly different than around sites that had no grafting (native bone), or bone grafted without allograft, which would appear as a traditional saucerization in an intraoral radiograph. Instead, the allograft bone would still be present, but in clumps and chunks. At last year’s AAID meeting (the first AAID conference I’ve attended), I happened to run into Greg Steiner, a periodontist who also runs SteinerBio. He graciously took the time to present his theory of why it seemed that this strange pattern of clumpy, necrotic bone was present in allograft sites. In short, the allograft seems to elicit a long term foreign body type of reaction which histologically shows as what appears to be sclerotic bone encapsulating allograft particles that appear to be unchanged, meaning they have not turned over. Instead, over he years, the bone around these particles turns relatively solid, with no vascularization to the deeper areas of the sclerotic bone. In fact, he showed me clinical and histological pictures of several cases where the pattern of clumpy bone was present, and only in sites where allograft was present. He explained that b-TCP and anorganic bovine do not result in the sclerotic bone, as evidenced in many citations, while the claims associated with allograft are not overseen by the FDA, since allografts qualify as human transplants, and are not subject to FDA approval. While his claims seem a bit conspiratorial, I have, so far, found no opposing research, and clinically, his theory of sclerotic bone is the only one that fits the pattern of destruction that I only see around sites that were grafted with allograft. Having said that, these were problem sites were all medium and large size grafts, which is why I never seem to see this phenomenon around sites with minor allograft use. Also, it is unclear is mixing the allograft with autogenous or bovine results in any different than allograft alone. Another interesting phenomenon, is that I don’t seem to see this problem in sites where irradiated cancellous bone was used, whether blocks or particulate, at least the material from Rocky Mountain Tissue Bank, which leads me to believe that not all allografts are biologically equivalent. In summary, currently, I only use allograft blocks (irradiated cancellous), and mostly anorganic bovine for GBR. Until more research becomes available to explain the phenomenon I described above, I am avoiding freeze dried allografts in all sites. Hope this helps.
Timothy Hacker DDS FAAID
5/13/2020
You are asking a good question about a situation that every implant surgeon should be able to navigate. A good rule is 5mm minimum crestal bone height for primary implant stability. Your algorithm should include not only how much sinus membrane lift you can safely predict, but also a short implant modality. Several manufacturers are providing short implants in the wider 5mm-6mm diameters for cases like this. Also, will you use the Summers Technique, add particulate bone with L-PRF, or an Osseodensification technique using special bur protocols for that? Both require training, a learning curve, and specific armamentarium. The fact that you are asking the question leads me to believe that you would be wise to get training in all of the above modalities before starting this case and becoming frustrated because you back yourself into a complication you can't navigate. You could even use this patient in one of those courses. Thank you for posting this nice case.
John Hoar
5/13/2020
Good advice, Tim.
Alejandro Berg
5/13/2020
This a no contest, internal sinus floor elevation, hopefully you could choose an equalized hidro pressure system with no real contact between the instruments and the membrane. with that base you can easily place a 4,2 x13 or 5 x13. With very little or no post op issues. cheers
Dr. Gerald Rudick
5/13/2020
The problem with the documentation given is that the CT Scan was done at a low level, and it is impossible to see the patency of the Ostium; and not having this information would restrict me from making a decision how to proceed.
Louis
5/13/2020
Thank you. Can you please tell me how the patency of the ostium restricts you from making a decision. I appreciate your comments. LG
PerioG
5/13/2020
LG: with all due respect here, the question you ask should be known before performing any sinus lift surgery. If you honestly were about to perform this surgery and don't understand the risk of sinus lift complications including the knowledge of a patent ostium, then please do not attempt this case. This is the problem, everyone wants to be a surgeon but not everyone should be one. I feel so sorry for patients nowadays, have no idea what they're getting themselves into anymore.
ST
5/13/2020
No need to be snobby and unprofessional PerioG. The fact that he is asking these questions indicate he is honestly trying to do what’s best for his patient and improve his knowledge. Don't forget, you where in his position once and im sure your first few lifts left a lot to be desired. We need to support each other not try to scare others from evolving.
PerioG
5/13/2020
ST: I was waiting for someone to give me a reply like yours. This female is at risk, I don't really give a crap if I hurt someones feelings here. My interest is the patient. When I started performing a sinus lift surgery, I knew the risks. To ask about the significance of a patent ostium tells me this doctor is not ready to perform this surgery. Period.
Joseph Kim, DDS, JD
5/14/2020
For a large lift, I agree that imaging a patent osteum is preferable, but for a minor lift, as seen here, I don’t think it is necessary. Judging by the minor thickening of the membrane at the floor of the sinus, and the location of the proposed augmentation and implant length, it seems highly unlikely that any harm could be done. While I don’t want to encourage poor imaging technique, these straightforward cases were routine in my practice many years before we had a CBCT. Seeing the osteum in a panoramic radiograph was basically impossible, yet patients received predictable, safe care.
Louis
5/14/2020
Dear PerioG: I hope your chairside manner with your patients is better than your obnoxious demeanor towoard colleagues on this forum. FYI - am a Board Certified Oral & Maxillofacial Surgeon AND a BOARD CERTIFIED OTOLARYNGOLOGIST. 35 years experience. I am well aware of the sinus anatomy including the ostium. I was asking, in a case like this where minimal grafting and no risk of ostium encroachment, how was that information pertinent in the question at hand - crestal vs lateral sinus lift. Thank you. Louis Gallia MD, DMD, FACS
Richard Hughes, DDS, FAAI
5/13/2020
If the patient presents with at least 4mm of vertical bone , without a septum and a the sinus floor is not oblique, then perform an internal lift. If less than 4mm. vertical bone, then a lateral sinus graft. Both are very predictable.
Peter fairbairn
5/13/2020
Yes all points to internal lift with whatever you are comfortable with , DASK or Versah . Was using more and more Versah .
Neil Zachs
5/13/2020
I guess I am in the minority here. From the Literature, especially Pikos and Misch, the sinus membrane can really only be lifted 3 mm max on an internal lift. I look at it this way...why go through an internal lift just to put in a short implant. Pt has between 4 and 6 mm of bone. Do a nice lateral window lift so a long 10-12 mm implant can be placed. You should be able to do an immediate implant into the site at the same time as the lift. Just a thought. I only do internal lifts if I have 7 mm of bone minimum so at least a 10 mm implant can be done. Just the way I practice. Best of luck! Neil Zachs DMD, MS Periodontist, Scottsdale AZ
ST
5/13/2020
PerioG, your reply speaks volumes. The last thing you care about is the patient, what you are really showing is bravado. My impression was that this forum, which I have followed for many years, is to try and share knowledge and with courtesy point others in the right direction, but i guess you "don't give a crap".
PerioG
5/13/2020
ST: No the problem here is I am the only one that does give a crap here! Continue to remain diplomatic, that's fine. Give this doctor a sense of security that everything is going to be alright. And how's that helping him or the patients?
JP
5/13/2020
Your message may be harsh but I agree with your sentiment. The success of a surgeon lies within the knowledge of complication risks and anatomical understanding as much as the skillset.
Dr Zoobi
5/13/2020
In performing any internal sinus lift with immediate implant placement you should be able to handle any complication by being able to perform lateral wall technique to correct any complication. I would start this case by performing internal sinus lift. If membrane is perforated, go for lateral wall to correct. You need to locate the Ostium and make sure you will not be blocking it with your lift. If ostium is occluded, will lead to major sinusitis and a non starter. Seems like a typical 1st molar case but always good to consult with mentors as a beginner. If you need any help you can always email me. Good case and thanks for posting.
Raul Mena
5/13/2020
PerioG, Using your own words, you are the only one that gives a Crap, You are giving a arrogant, egomaniac answer to a colleague that is asking an honest question and trying to learn. You must be one of those that treat your referrals like if you own them. By the way When someone gives such a Macho Man answer should sign with your full name and not hide behind Perio What? i am wandering if when you have a sinus complication you handle it yourself or you have to ask your friendly OS or ENT to take care of your patient.
PerioG
5/13/2020
This isn't about being Macho Man, this is about causing no harm to patients. If you want to perform a procedure then know the risks. If no one brought up patency of the ostium, this doctor would be going in oblivious, not even knowing that was a thing. So go ahead and think this is about ego, I personally don't care what you think of me. I care about what's happening to our industry. Doctors performing surgeries when they have no business doing so. This isn't about me not being busy either, I am busy taking care of the crap from doctors that don't understand the surgeries they are about to perform. And don't let the name fool you.... From PerioG
David Anson
5/13/2020
In my opinion, the easiest and most predictable way is with an internal sinus lift with Versah burs. Check out their website (I have no financial relationship with the company besides being a customer). Very easy to raise the membrane rapidly and predictably way more than 3mm.
Natan Guzner
5/14/2020
1: Try to get the set belongs to iRaise 2: Try to get the ossix bone 3: Use valsalva after going through the sinus floor. 4: Any kind of implant is good. Good Luck
Larry J Meyer
5/17/2020
I would use Versah burs and you will get an autograft as well as nice placement. Be sure to be in densification mode at a slow speed and use copious irrigation with pumping action when going through the sinus floor and when adding any graft material before placing implant. Go to the website and learn protocol before doing it.

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