Grafting Combinations: Which Would Yield the Best Results?

This is a composite defect (two dimesional). You have to look at each dimension individually. First address the vertical issues: You have a native bone height of 6-7 mm. A summer's type of sinus bump will rarely gain more than 3mm height in a controlable fashion. Are you comfortable with 10 mm implants in the maxilla? sometimes yes, sometimes no. you need to answer this question for your self. I would do a small lateral window with simultaneous implant placement. You will get a lot of different answers, but you must do what works in your hands. Remember, the goal is long term stability. Your real issue here is the horizontal dimension. Your width is approx 3.5mm and you want to place 4.2 mm implants. You will want at least one and 1/2 mm of bone on both sides of your implant. Your choices are ridge split vs. onlay with a huge variety of variations. What are you comfortable with??? I try to address the issues one at a time, or as they say "one miracle at a time." While it may take longer, it helps me sleep at night. You can do a sinus lift, place the imlants, and graft all at once. There is alot that can go wrong with this type of combined procedure. It sounds like you are a general DDS with good training and experience. If I were you, this is what I would do: 1. Lateral window sinus lift. Use the lateral window and other autogenous scrapings to augment laterally. Cover site with resorbale membrane and make sure you have good tension free closure. Leave for 5-6 months. 2. Plan for implant placement and be prepared to do a minor ridge split or buccal grafting.Allow implants to heal in a submerged fashion. Allow 4-5 months for osseointegration depending on primary stability. 3. Uncovering / second stage surgery. My goal is to always try and optomize bone conditions PRIOR to placing implants. I'm sure you will get some replies telling you that this can be done in a single surgery. Just remember that the more things that you try and accomplish during a single procedure, the more that can go wrong.

As far as which combinations of grafts to use is concerned, combination of irradiated cancellous bone and DentoGen would be a great choice.

You need to graft the ridge so you have about your implant width + 2mm circumferentially about 7-8 mm. Also check for verticle resorption. A word to the wise: it doesnt take much to mess up a sinus so if your doing more than a 3 mm addition to the sinus via crestal lift and with 2 implants you need a CT scan to verify ostealmedial patentcy and rule out any sinus path. If your sinus floor height is RAP. Let taht graft mature 6 mos. An Essex appliance is a good temp since it places very little pressure over the graft. Better yet if your in so much doubt maybe you should get some more education like an ICOI or AAID sponsored fellowship program. Theyre expensive and time consuming but are the best!They will give you some credential also. There's lots of Vultures and Predators out there who would love to go after you if something goes wrong!!! Myself NOT included!!! Just my 2 cents worth.

I am a general dentist as well and I just restored a case almost identical to the one described. I placed two implants in sites 4 and 5. I performed a lateral window sinus lift and expanded the osteotomies with expansion drills, covered buccal aspect with FDBA and placed resorable membrane. The case turned out fine. I got a CT scan before restoring. But, what I will tell you is that I have another one coming up in two weeks and this time I will do all my grafting and return 4-6 months to place my implants. It is a lot of work to augment vertically, horizontally and place the implants all at once. I have placed hundreds of implants and the more grafting and implants I place the more conservative I have become. Most patients dont mind waiting an extra 4-6 months for a more predictable outcome. The question you need to ask is do you want to have the conversation with the patient about how their graft/implant failed and you are going to have to do it all over? If this happens who is going to cover the expense, you or the patient? Hope this helps!

Dr.sb, thanks that was the answer I was looking for. ended up doing a lateral window, with infuse and medpore membrane for the width augmentation. will wait 6 mo. for the infuse graft to mature.

I've had good success in the past with BMP-2 / Bio Oss/RCM 6 membrane. Graft maturation varies widely with patients. I've waited on average 9 mos. before placing implants into the sinus graft and an additional year if I got a "spinner" or immature bone prior to loading. Select your patients carefully with their ability to tolerate treatment plan changes.

Couldn't agree with sb oralsurgeon more on all the points made. have had to encounter the situation where horizontal deficits in the posterior maxilla accompany the usual vertical deficits several times. Going by the classifications of Ridge resorption patterns given by Cawood & Howell or Lekholm and Zarb previously, the situation you are in represents extended ridge resorption (severe or delayed stages of edentulousness). In such cases (as in other regular cases as well), it is best to seek recourse to the Prosthetic wax-up (which simulates the final Prosthesis as closely as possible), to assess the amount of deficiency that exists, volumetrically. A wax-up would tell you just by how much you are deficient in the bucco-lingual(palatal) dimension, that will therefore enable you to have na idea of whether to go in for a Split and either a Sandwich graft in between (Hom Lay Wang technique) or whether an Onlay graft (Michael Pikos) is the best way to go about recoonstructing the defect. In my mind (as it is with several others who have done a fair bit of grafting and lived to observe its effects over 5 years or more), it is best to create an ideal implant recipient site before you go about placing an implant, rather than placing implants simultaneously with graft procedure (unless you are one of those wizards who manage predictable vertical gain simultaneous with implant placement). As mentioned by sboral surgeon above, go for either procedure (Split-expansion or Onlay) after you have assessed the defect and choose carefully between the Indirect an Direct sinus lift as the Indirect Sinus Lift is best for smaller quantum of vertical gain (3-4mm at the best) predictably, and for more gain, it is besxt to choose the Direct Sinus Lift method! Cheers Jeevan

I don't think that everyone here understood my question. The question was not related to the material to be used for the procedure but rather to the surgical techniques. Also the asessment of the amount of deficiency was and the waxup were done before posting the question. The amount of grafting needed could be achieved by both procedures to increase height(lateral window or osteotome assisted sinus lift) and also by both procedures to increase width(onlay graft or ridge split). The question was refering to: witch procedures to use in combination, to achieve both height and width. I am aware that I have both options, the question was exactly that, which one would offer a better result. Thank you to all of you who responded to my question.