Is a Sinus lift needed?

Well, this is a very very generic question. Don't you plan to do a CT scan? BASED ON THIS IMAGE, I would say that sites #14 and #15 won't need sinus lifting; #24 probably yes; #36 probably no bone graft needed

No Doc I don’t think you need a sinus lift .

CT first then ask the same question :)

Without CBCT it is impossible to make any recommendations. Then based on height of available bone and type and size of implant, you may choose to either do sinus lift and implant in 2-satages, or single stage, or do internal sinus lift using osseodensification, or simply not need it.

This panoramic X-ray is not enough for planing of implantologic treatment. You need to receive CT

Possible perio upper molars, conical root. If so treat first

This is only 2 dimensional wiew. For bone widthening you can use visual inspection, palpation, measuring the width of the bone without the thickness of the gum, or simple make cbct. But you do not need sinus lift.

I am not sure. CT scan first

Two short implants dimeter 3,5-4/8 -9 mm with agressive thread design should work just fine . Go ahead with the bone quality in mind and flapless.

I would not think it would be necessary.

I agree with some of the other comments. A Pano is not diagnostic enough to make a determination whether implants can be placed. A CBCT would be a far superior diagnostic tool. I would also be asking what the width of the bone is in the areas in question. I would also diagnose and treat the Periodontal issues present BEFORE placing any implants. What is the overall treatment plan?

One final observation regarding many of the posts on this site. If a clinician has to ask for answers to some of the questions, then perhaps they should refer the cases to someone who knows the answers already. Wouldn't that be in the patients best interest?

I have a cone beam in my office. I use it a few times a year. I do not need it for implants. The panorex gives me 2D, and my exam completes the 3D. Using the real M-D of a molar 11 mm, and comparing it to the panorex measurements, you can do basic math to measure vertical from the panorex in other areas. Your fingers will tell you of width of the ridge, undercuts in the implant area. I also will take a PA of my pilot a few mm short of any area (nerve or sinus) I am concerned about. Great way to check angulation also. In this case, measuring off this pan provided, there is about 8mm of bone above #4 and 15mm above #5. Likely will need to do a transalveolar graft or simultaneous open sinus graft when the implant is placed. #5 can accept a 13 mm implant. Area #12 needs a graft to level the ridge and likely widen it. Then a 10-13 mm implant with transalveolar graft if needed. #19 needs to increase vertical and I'm very sure width. A graft is indicated. I'm sorry I do not feel CTs are necessary. And expense and radiation can be avoided. I truly do have a 99% success rate these last 20 years, but admittedly conservative with avoiding immediates if possible, and adequate time for bone graft and implant healing.

If an American trained dentist went to Nepal and had to perform a procedure like implant placement, would he refuse because he has no excess to a scanner? In my opinion that would be embarrassing. Dentists and physicians volunteer treating people all over the world in very primitive condotion with success. Only those that are inexperienced or poorly trained require s multitude of tools to be able to carry out their services. A pano in this case gives one a perfect picture of the general condition. A peri-apical x-ray with a guide pin to about 5 mm will allow a person to calculate the distance to the sinus knowing the actual lenght of inserted pin portion vs. the length of the pin represented on the radiograph. The rest of the information in a bucco-palatial direction can be asserted from palpating. The answer should be easy from this point forward. When implants started to be placed cbct was not available.

Is your patient a flat piece of wood, or a 3D person? 3D imaging (CBCT) will answer your questions about the need for bone augmentation/ sinus lift. I have 30 years of experience and have placed thousands of implants, but would not plan an implant case without 3D imaging or place an implant without a guide. We are not living in 1984. We have the technology to allow us to provide better patient care. We should use it.

All comments and advice are valid - Eric has a good point that you don't always need a cone beam - it does however appear from your intiall questions that you could do yourself a good turn - listen to drphil and Jr -- call a colleague who has some experience and get some advice and assistance - remember the basics - the 5P's that Ziv Simon talks about. Proper Planning Prevents Poor Performance. And to my more experienced colleagues out there - remember there are no stupid questions but there can be stupid answers.

In the upper right two tooth space I would recommend a radio opaque surgical guide when you get CBCT to determine placement. The other single sites are probably okay if you are experienced and confident enough to place by lining up with adjacent teeth. The width determination is key unless you have several implants in stock for variation in bone quality and width. A sinus lift may not be required but I don’t hamstring myself in with the patient I leave that option open depending on clinical parameters.

This is a great case for short Bicon implants. With Bicon and Ankylos short implants there are very few cases like this where you aren't sure. Yes, I am a fan of CBCT, but with Bicon especially there are few cases you can't treat. Make sure your patient has good Vit D and Ca++ levels, and does not have problems with hyperlipidemia and/or hypercholesterolemia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617053/

no not required if you are doing basal implants otherwise you may have to have cbct is required to evaluate.

Based "on this image", I think 14 (#5, UR 1st premolar) no, 15 (#4, UR 2nd premolar) maybe, but maybe you can just tease up the membrane at implant placement and add (but since you've asked this question, you may not have the experience required, no offense intended). Upper left 24, 25 (1st and second premolars) probably need some grafting. Lower left molar (36, #19) probably not. You may not NEED a CBCT, but if you have any doubts then you SHOULD use one. 3D treatment planning software isn't required, but it makes life a whole lot easier. my 2 cents

Implants have become the industry standard, over RPDs and "bridges". CBCT may not be the industry standard, but it is becoming such. May as well learn to use it now. It will be helpful. NOT using one could end with a legal issue, and most OS' will fault you for failure to use one if it goes to court. Not worth the risk, IMHO.

Interesting comments on CBCT. While nobody can deny that CBCT is extremely useful, it's really only gone mainstream in the US, in the last decade or so. Obviously, if you can use one, you should, but I wonder if the success rates of implants in the last 10 years vs prior has actually increased due to CBCT? Were there more failures in prior years without CBCT? I suspect the answer to both these questions are negative. But I'm not aware of any large scale studies that compare implants placed in prior years without CBCT and implants placed nowadays with CBCT. My general feeling is that this trend towards making CBCT standard of care has been driven by lawyers, not by any actual clinical evidence that CBCT has improved the success rate of implant placement in a statistically significant way. If I'm wrong, please let me know. Anyway, I think many people here comment based on the assumption that the rest of the world looks like the US where cost and availability of the latest technologies, like CBCT, are not issues. Unfortunately, not everyone (even some places in the US) necessarily has easy access to CBCT, nor is it always cost effective for the patient. So telling someone to just get a CBCT is really not all that helpful particularly since many clinicians got along fine without it for decades.

No I don’t think this case need sinus lifting.

Agreed with some doctors you don't need sinus lifting but yes before proceed must have one scan .

The statement that CBCT is in anyway the standard of care will make the manufacturers of the units delighted. CBCT is with our doubt an extremely useful tool,and there are definite situations where it’s use is benificial. There are other cases were it is just an added expense and an unwarranted exposures to radiation. I am particularly concerned about the current trend for scans in Orthodondtic offices and their routine use in Endodontics. As a long practicing OMS I regret the assertion than OS is an adversary in a litigation. Failure should not be litigated. We all have failures, a well informed consent and an educated patient goes a long way in preventing legal problems. Bottom line is there a many cases that don’t require a CBCT. 2D and experienced hands of are sufficient.

As usual, there are a number of opinions here that are reasonable. The sinus issue is the least consequential issue discussed here. If I perforated into the site #4 I wouldn't do anything but place the implant. Phillip Boyne at Loma Linda showed many years ago that bone will grow 2 to 3 mm. on a perforated implant even without bone grafting. You would be at greater risk to try to lift the sinus after a perforation as your bone particles might migrate and potentially clog the sinus osteum which is the biggest reason for sinus infections. But in this case if a 10 mm implant was placed, I doubt it would perforate very far. If you elected to do an internal sinus lift(I usually just use hollow point osteotomes and collaplug and fracture the floor of the sinus then slowly place my bone..but I have used the Densah Versah burs the last year and a half . Had one sinus I over-densed and lost the implant at one week but not since then so I now only use that for large vertical lifts but that is a whole separate concept). The use of the CBCT or not is the most interesting part of this discussion. I began placing my own implants in 1986. Obviously all we had was Panoramic views. Put in 1000's of them that way including on my own Mom(toughest case of my career!)28 years ago. But today I do use CBCT on every case and I do consider it the standard of care. I have seen so many anatomic anomalies that I could not view by feeling or palpating well particularly the mandibular lingual. The cost of a CBCT in my area is about $250 or less. I first bought Simplant over 20 years ago but at the time the CT scans were $1400 an arch. I did talk quite a few into doing it but a lot of my patients balked at paying that. Those days are over. So although you can use a Panorex to place implants...why would you? Today I would feel blind without a CBCT.

Great comments, lots of expecting this group. Width is sites essential to dx and plan. Some grafting should be needed at least in 24 site for coronal Implant Health. Type of implant chosen will affect fate of 36. I️ personally use Bicon in 36 site to get robust molar without grafting in this case. Great multi-site challenge as no two sites are the same!

Regarding sinus lift and its necessity: In the posterior maxilla with typically D4 bone, it is best to over engineer: Longest and widest implant possible for both integration, as well as design of proper abutment and crown form for emergence phenomenon. Short and wide implants are options in first molar sites if sinus lift is not possible and there is adequate width (which you won't know without a CBCT). A minimum of 10 mm implants is generally recommended in the posterior maxilla which would require about 2 mm of apical bone. This can be achieved very predictably using osseodensification technique through implant site preparation (it also converts D4 bone to D2 or D1 for additional primary stability). The treatment plan needs to consider bone quality, patient's occlusion, anticipated occlusal forces, and tissue architecture. A note on sinus perforation: if the perforation is though the membrane, no bone forms in that site! Regarding CBCT and its necessity in implant dentistry, may I raise the following questions: 1. We are 3-dimensional and have 3-dimentional anatomy. Why wouldn't we diagnose and plan in 3-D? 2. The decision to recommend CBCT is best made based on evidence-based dentistry and not on 'what I do or what works for me'. This goes for choice of any technique, tools, or materials! If you look at evidence-based dentistry and extensive amount of literature on CBCT, you will never do any implant cases again using a panorex and palpation (which has been proven to lead to poor decisions and outcomes). 3. Every clinician recognized as an expert in implant dentistry who lectures and publishes on implants, usees CBCT and now digital planning for their cases. This is among the many internationally respected leaders in our field. I think you would agree that there are no better and more skilled clinicians than these leaders. If they think it's vital, what does that say to you? 4. Our patients come to us for solutions and put their trust, time, and money in our hands. Don't we owe it to them to do EVERYTHING we can to deliver predictable treatments and desired outcomes? Why take a chance? Why increase risk of mishaps? Why loose that trust when things go wrong? For $250 cost of a CBCT and one time exposure to slightly more radiation, isn't it worth it to deliver the best and most predictable treatments we can? The exposure to radiation never stops a neurosurgeon, a general surgeon, an orthopedic surgeon, etc. from getting 3-D diagnostics (CT Scan) on their patients. They would not dare making decisions let alone performing critical surgeries without seeing and knowing with absolute certainty what is happening. 5. It is well recognized that 90% of dental implant complications are due to poor planning and lack of proper diagnostics (and the rest from inexperience and poor execution). Such complications are completely preventable through comprehensive diagnostics and planning. If you have doubts about the necessity of 3-D diagnostics and planning for dental implant therapy, I invite you to attend the next dentalXP symposium, Academy of Osseointegration meeting, AAOMS implant meetings, and other perio and prosthodontic conferences and see why it is so vital to this field. I also suggest to read this article by Dr. Gordon Christensen (I know we all love and respect him as one of the greats in our field): http://www.dentaleconomics.com/articles/print/volume-102/issue-8/practice/do-you-need-cone-beam-radiography.html Lastly, we just held a 2-day course on dental implant complications with discussion of dozens of cases and their etiologies. I will be happy to share the recorded version which will be available soon Thank you all for participating in this important and relevant conversation. It is only through understanding and questioning that we can learn.

Is a CT scan necessary for this case? Not unless you run into a problem, then you would have wished you had one. Certaintly in the maxilla, you can use Pan, bone mapping/sounding and intraop PA's as there are no vital strucutes to irreversibly damage. On the lower however, we all know that there are nerves and concavities that are essential to avoid to prevent serious complications. You really need to judge what your risk tolerance is and decide if CBCT is necessary to deliver the desired result. In the US, if a lawsuit arises, and I do not mean because of failure but rather due to nerve damage, or other avoidable surgical complication, you can be guaranteed that one of the first questions asked will be.......did you have a pre op CT scan. If not, why didn't you? You can be sure there will be a post op scan. Remeber, standard of care issues only arise when there is a problem or lawsuit. Protect yourselves, and at the same time arm yourselves with the most comprehensive information to deliver the best treatment you can. I have found personally that CBCT has improved my diagnostic capabilities and raised my implant game pre operatively, which has led to less complications and failures post operatively.

What do you charge for CBCT?

$320 if I read it also, 270 If not read, just sent on to another dentist.

on my opinion ,he/she a young patient , here if your going to do 8 mm length implant ..sure you dont need sinus lifting..but i prefer at less 10 mm implant ...as mentions in some comments before you need to do cbct for accuracy .. or at lest a periapical image with good angulation .. if you r going for 10mm yes almost you need it at site # 13.23...with internal approach and without bone graft , just use Osteotome tech....regard