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Sinus lift or no sinus lift?

Last Updated: Jan 14, 2019

This pleasant 61 y.o. female patient presents to my office wishing to replace all the missing teeth. Her medical history is unremarkable. For the sake of this post, we will focus on the Maxilla only. Analysis of study models and radiographs indicates that if this lady had her posterior Maxillary teeth replaced with implants, the crown height of the crowns on those implants would be in a range of 15mm. Provided the patient has about 1.5 – 3.5mm of bone in the area of the fist Maxillary molars, if we were to graft those sinuses, in order to keep crown/implant ratio to at least 1:1 the implants placed would have the length in the range of 16mm. That translates into about 15-17mm elevation of the sinus membrane. Please review my case and provide an input on the handling of this case. Thank you in advance for everyone’s input.


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32 Comments on Sinus lift or no sinus lift?

CRS

01/15/2014

I don't think the natural teeth look that bad on the film why are you removing them?

Mark

01/15/2014

Im not removing ANY teeth. The editor distorted my original narrative beyond recognition

OsseoNews

01/15/2014

We apologize for any confusion with your post. Obviously, our intent was not to distort your narrative, but simply to actually make the narrative read more clearly. Anyway, we have reposted your question exactly as you sent it to us without any editing. There doesn't seem to be that much difference in the two versions, quite frankly, but hopefully with your original unedited question now posted the intention of your narrative is clearer.

peter Fairbairn

01/15/2014

Depends a bit on what your patients needs are and the funding available . Taking the lower dentition and age etc you could place only 1 Implant on either side slightly angled forward and restore with a single tooth but make a first molar size tooth on effectively the second pre-molar site . Hence you could avoid Sinus augmentation if the patient so desires . Best senario would be bi-lateral sinus augmentation with lateral windows , I always one stage even on the side with only 2 mm of residual bone . Could restore with two separate crowns on 5 Implant and 6 Implant or place more in the 7 area and have 3 unit bridges . Final option is place in the 5 area and the second in the tuberosity both angled to optimise the bone , personally this is the least desirable option but the patient makes the final decision .. Regards Peter

Mark Dankowski

01/15/2014

Peter, please elucidate little bit more re: graftless option of placing angled implants. I am a big friend of guided surgery and I could take advantage of that. Thank you.

CRS

01/15/2014

If it were me, I would build up a few mm of height and place implants in the second premolar area doing a small lift to avoid the septa present. Probably a 11.5-13mm immediate placement with lift. depending on the bone height an internal lift would also work.

Richard

01/15/2014

I think that crown to implant ratio 1:1 is not necessary. According to this article in JOI Online and this article in Dental CE Today an similar articles you can put 8 mm implant. I would do a small lift, place shorter implants and splint crowns.

CRS

01/19/2014

Richard I have a question, I like to have the crestal height as close as possible to the natural teeth for emergence profile and hygiene, is that a safe assumption? And if both implants although shorter and both osteointrgrated and parallel why would one splint? I think the hygiene is tougher and if one implant fails the prosthesis is not retrievable. I feel that splinting implants is borrowed from natural teeth with PDLs I would really appreciate your thoughts. I feel that sometimes like crown/ root ratio, cementing and splinting are indiscriminately applied to implants which are not teeth. I've even seen implants deliberately tilted without cross arch stabilization. I don't restore so I need some help here. Thanks

Kambiz

01/23/2014

From mechanical point of view, it makes sense to splint short or narrow implants to a bridge for added stability. This would be a workaround for narrow or short ridges avoiding major graftings.

Richard Hughes, DDS, FAAI

01/15/2014

Preangled Single Tooth Replacement plate form implants can be used to bypass the sinuses and they can be abutted to the anterior teeth with FPDs. Therefore there will not be a need for sinus grafting.

Doug Wong

01/21/2014

I agree with Richard Highes regarding the implants. Ankylos has a system where you would place the implant in at an angle. The abutment system called SmartFix will allow you to correct the implant insertion angle by 30 degrees. It is their prosthetic solution on angles implants. However, I do not understand what Richard meant by abutting to the anterior teeth with FPDs. (I apologize to Richard if I misunderstood his post.) If he meant making a bridge with an implant as one abutment and a natural tooth as the other abutment, I would advise against that. Natural teeth have a PDL that allows a tooth to move. Implants do not. It is my opinion that the implant will fail due to micromovements.

Peter Fairbairn

01/16/2014

Hi Mark agree with Richard those days are long gone with the extensive research on shorter Implants now. Firstly the left hand side use a 10-12 mm long taper type , width 3.8 or so ( no scan to assess the ridge width ) and angle it into the space between the sinus and the root of the first premolar . Then place another distal to the sinus again angling to optimise the bone then restore with a 3 unit bridge . On the right the same protocol but the distal bone has less height so aim to place a shorter Implant ( 8 mm ) at the area of the greatest height ( about the area of the septum ) again a small angle will optimise things ) Again as Richard said you could use a Southern Angled head implant for improved restoration . Regards Peter

Alex Zavyalov

01/16/2014

I would restore the mandible first to see how functional it is, and based on it I would choose a quantity of maxilla implants with adequate surgical approach. The jaws are interrelated and cannot be separated even for the sake of this post.

Mark Dankowski

01/16/2014

Alex, I am not sure I am following you when you say "restore maniblle first..."

Alex Zavyalov

01/17/2014

Mark, I've meant any type of prosthesis financially affordable for the patient, including implant supported.

Barrow

01/22/2014

Doug et al, Do you feel that connecting an implant to a natural tooth is is always a poor solution. If you are connecting to several natural teeth,there is little to no movement. What has ben the experience of the rest of you?

Richard Hughes, DDS, FAAI

01/22/2014

Dr Wong, There is no hard proof that abutting natural teeth to implants is improper. There is just theory. However, do not abut to mobile teeth or even place and restore an implant adjacent to mobile teeth. I usually do not abut to Endo treated teeth with the exception of sound cuspids. Also, another point is do not place an implant in between natural tooth abutments. The implant I was referring to for treatment of this situation is a one piece implant that has a predetermined abutment post of 22.5 or 45 degrees, and is bendable. It is used as a distal terminal abutment when the bone is of sufficient width but not height. It has a load bearing area of at least 50 mm square.

Doug Wong

01/22/2014

Dr. Hughes, Thanks for your info. Learn something everyday. One question....Why would you NOT place an implant between natural tooth abutments? (I am assuming you mean removing the bridge and replacing it with an implant between the two natural teeth that were supporting the bridge)

Richard Hughes, DDS, FAAI

01/22/2014

Dr Wong, The reason is as you stated about the PDL. The implant is mobile but not as much as a tooth. So in this case you would have problems. On the otherhand, an implant as a terminal abutment is ok. If one does combine teeth and implants, then place coping a over the natural teeth while performing the bridge work. I suggest reading Misch book on implant pros and some text on copings. Use a very hard cement for cementing the coping and a softer cement for the bridge. An implant supported bridge is ideal but not an absolute.

CRS

01/25/2014

I'm confused how can an osteointrgrated implant be mobile?

Richard Hughes, DDS, FAAI

01/26/2014

The mobility I'm referring to is insignificant when compared to a periodontally involved tooth. Carl Misch makes this point in his text books. However, when implants and teeth are mixed, certain combinations are not suitable for long term success. Again, this is in his Implant Prosthetics text. You are correct in assuming that a healthy implant does not have mobility like a periodontally involved tooth.

CRS

01/26/2014

In all respect to Dr Misch and I have both his textbooks, my background in bone has the perspective of working with anklylosed teeth, very rare, fractures with plating and orthognathic surgery so here goes. The osteointrgrated implant is fused to the bone. Forces on the implant can be transmitted to the live bone which can remodel causing the mobility. I think what is missing is what happens when implants are splinted to natural teeth I think there are many factors involved so I stick to simple rules of avoiding this, keeping the implants parallel to the forces since I often can augment the bone to allow this. I think one can get into trouble confusing an implant with a natural tooth however all our backgrounds are important and sharing info respectfully is key I don't want to divulge how long ago I placed a crown and Tempbond makes me break out in a sweat!

Barrow

01/26/2014

Could my colleagues further elucidate their feelings on combining implants with natural teeth it seems to me in this case you have fairly sound anterior teeth why not consider a roundhouse with distal implant abutments. To me, this would avoid a great deal of surgical intervention and probably would be cosmetically appealing.

Barrow

01/26/2014

In addition to the roundhouse you can also consider a distal cantilever on each side this would be more than sufficient for the patient both cosmetically and functionally. I anxiously await comment from my esteemed colleagues.

Kambiz

01/26/2014

As a daring solution for bypassing lateral sinus lifts, I would consider angulated placement of implants on positions 15, 18,25,28 and bridges.

Mark Dankowski

01/26/2014

Unfortunately I would have to reject the idea of roundhouse: Emax is planned for the anterior teeth and I do not believe it is suitable to do Emax roundhouse. Let alone hygiene issues associated with it.

Dr. Ahmed Tarek

02/04/2014

two distal implants in premolar area....8mm is more than enough for 61 year of female.. Full arch bridge pfm, cantilever 1st molar...

John L Manuel, DDS

02/04/2014

The side with less than 2.0 mm bone over the sinus would do fine with a floor transport and two simultaneously placed Bicon Implants. They have webcasts on their site. The other side with about 3 mm (2.7) could use a wide, short Bicon 6.0 x 5.7 with an internal lift posteriorly and a 4.5 x 6.0, 5.0 x 6.0 or 4.0 x 5.0 in the first bi area. These could all be done in one appointment with minimal soft tissue trauma and loaded 4 - 5 months later.

John L Manuel, DDS

02/04/2014

correction, 2nd bi area for the small implant without grafting. Note that Bicons do well with high crown-root ratios since they are "rotationally" loaded via fin like structures which transmit lateral forces down one side, across the botttom and back up the opposite side of the implant. The 6.0 x 5.7 is "ball shaped" and extremely good at this.

manosteel

03/11/2014

I'm not sure why you couldn't just graft both sinuses up to the 12-14 mm level via lateral window. Then in six months put in implants in the 2nd bi and first molar positions as large a one as can be accommodated and just restore the 2 units splinted so the patient has a 1st molar occlusion which should be satisfactory against a lower with 1st molar occlusion. Of course a CT verifying osteomedialpatentcy, lack of pathology, bone volume and orientation would help before and after the grafts. The short wide body "fat boy" implants would also be a good consideration in the molar areas. Am I wrong???

Mark Dankowski

04/13/2014

I think you are right

Pantelis Bochlogyros

05/28/2017

I believe that the best solution is a zygoma implant in the area of the first molar together with a regular one replacing the second premolar.In any case we do need a CBCT to estimate bone dimentions.Remember that Zygoma implants are the best alternative to bypass sinus lift problems or complications, present high percentage of success ,less morbidity,less complications.

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