Summers Lift Case: Is There a Contraindication in this Situation?

Interesting case ,placing implants in a Bio-Oss sinus site at 3 months is a little adventourus , thus better to wait.The sinus can bleed a bit when lifting the lining but unless a clear tear not sure about the membrane "under" the lining . Do not do a Summers type approach then as it can cause an issue if there is to much force. Use of a Scan before complex sinus cases also helpful to assess and check for pathology. Anyway patience will help here..

I agree with DR Fairbairn. a summers lift works well when you have a definite cortical shell to your sinus. with your sinus lift, you have changed the situation. bio-oss will not likely "bend" or behave predictably as would alveolar bone in a summer's technique as to your situation, you most likely have an anterior perforation in the membrane and the bio-oss particles are migrating into the sinus. the particles will be transported to the osteum and into the nose. as bio-oss is radio-opaque, a scan would show you what is happening. pre-op scans are standard of care in sinus cases. post-op scans are standard of care in diagnosis and managing complications. i am not calling this a complication. however, you should always know the results of what you have done. if you can't clear things up 100%, you owe it to your patient to involve someone who can. always put yourself in the chair. what would you want at this point?? I assume the answer is: 1. A clear explanation of the radiographic findings 2. the clinical ramifications of these findings 3. A good solution or definitive treatment plan. If you cannot provide these, involve someone who can.

Thanks for the advice. I was thinking along the same line myself that there will not be a normal cortical plate. I scanned and simplanted the scan before the graft so I was fully aware of anatomy. I do agree with you both that 3 months is rather short for this case before placing. Is there a justifiable need to scan this patient again before placing.. I would probably think so.. Do you agree. What do you think of doing a DASK system internal lift if I need to gain a few extra mm. I think you have used this before Peter . This way I would not be putting. Lot of pressure on the graft

I advise to place longer implants. Study show that when doing Summer Lift, it is better to place the longest implants available. This will allow more bone to regenerate around it. For example, if you place 18mm implants, you may be able to gain maybe 10 mm more bone. This is my experience. It always works.

Couple of things on this case......... 1. When doing a lateral sinus approach even if doing just a single fixture elevate the entire floor and graft larger then you need. This minimizes settling issues and is easier when placing the fixtures. 2. Most of the time I think there are tears in the membrane often we dont notice them at surgery so place a collagen membrane in on the medial wall. to co ver all sinus membrane. 3. biggest failure during a lateral window approach is failure to elevate up the medial wall and this leaves a possible lack of graft and bone after healing on the medial aspect of the fixture which one can not appreciate on standard radiographs as they ar 2D. 4. You have to wait a sufficient time to allow the graft to organize and convert to bone. so depending on what graft material is used time will vary. 3 months is too short with almost all materials. BioOss takes a minumum of 6 months sometimes longer. I prefer a blend of materials for different reasons. I usually use Grafton as the base because of its texture (like wet shredded wheat) it is not easily dislodged from the sinus should the patient sneeze or cough. I will mix in bovine material (BioOss or similar) its a good stretcher volume wise and usually mix in some Pepgen P-15 granules mostly because it is very obvious on the inital radiograph so you can see where the graft is and identify if any migrates elsewhere in the sinus. 5. One can gain typically 5mm with a summers approach. In this case I think on healing your going to need more then that. I would suggest renter in a lateral approach and elevate, place the graft then at same time do your osteomty and place the fixrure and allow to heal for 6 months.

Do you think part of your problem is the 2 very different radiographs? The focal point and the angulation of the head in the second radiograph is very different to the first, thereby causing distortion.I would try another radiograph first before I jumped to any conclusion.

good point dr berne

Whilst the DASK system is a breakthrough in sinus entry I think here the hydrolic pressure may be an issue if used on a Bio-0ss site at 3 months . As I use only synthetics it is not my area of knowledge but give the site more healing time then scan to get a true picture of where you are. Then you can plan the way forward , there is no problem at all with 10mm implants that is more than sufficient in the sinus as the bone (grafted site) is generally better than adjacent maxillary bone. Peter

Dear Dr A, If the patient is generally healthy, after 3 months, the membrane will have healed very well. The sinus has always been very forgiving towards our abuses and have a high ability to heal itself and regenerate bone at the slightest provocation. In fact, the sinus is a very active site of the body where the membrane and bone is constantly regenerating and remodeling itself because of its peculiar functions in not only managing all the forces of mastication, it also manages the constant flow of air with its accompanying microbes and foreign particles. Three months is very adequate for you to proceed to put the implants in. The Bio-oss will still be there and have a soft consistency. All you have to do is drill a hole through the cortical plate. Use a bone spreader and create an osteotomy for your chosen implant and screw it in. Summers Lift of going all the way to the membrane and lifting it is usually unnecessary. The bone spreader with a rounded end will actually lift up the membrane in a sort of modified Summers Lift. It is amazing how well the body, especially the maxillary sinus can repair itself despite our challenges to it. Like Peter Fairburn said.....patience helps. All the best.

Dr. A,I totally agree with the above statements that you can`t judge for the success or complication of the procedure by a 2D image as the panoramic. However it gives some idea of the situation. I would recommend that you wait at least 6 months (better eight), because the graft you used is only a scaffold for the new tissue (Biooss has only osteoconductive properties not osteoinductive ones). After 6-8 months do a CBCT scan and see how your graft site looks like (hight and width of the graft). Also observe it`s density (in Hounsfield units), and check for voids (next to the mesial sinus wall or within the graft itself). Voids are most often associated with delayed healing, caused by membrane rupture and infection. Voids+low Housfield values=problem with sinus graft. This is the worst that might happen and will lead to the need of cleaning the sinus and repeating the graft. I totally concur that 10 mm in height can be enough (if you are planning to place 5 mm wide fixtures. Even if they need to be narrower, you can always follow the "gradual loading concept". You train he bone-after you place your 10mm fixtures, wait for their osseointegration, then you make a metal reinforced resin provisional, wait another 2 months,then X-ray check all and deliver the final bridge. If you are not confortable with 10mm implants,try a Summers at the time of implantation. But don`t push too much, you`ll be able to place, let`s say 12 or 13mm max. Don`t worry, best of luck, Dr Dimitrov

Sir, When you have used Bio-Oss to lift the antral floor, there won't be much difference between six or eight months, because in neither of them you will finally find any formation of sound an intact bone at the same place.Actually,Bio-Oss' resorption and replacement by sound and dependable bone may take ten years or more(or even never).So, an old man like me, will never recommend it in such cases.I guess for those practitioners who have been doing this procedure for decades, the best choice is always a mixture of autogenous viable bone and a synthetic fast resorbing biomaterial.Ecoutez toujours a les vieillards.

I agree completely with Dr. Jafari with his comments about Bio-Oss but must take exception with his comments on the use of autogenous bone for sinus grafting. In our retrospective studies, the use of autogenous bone has produced the smallest volume of bone production as compared to only alloplast or allogaft. Autogenous bone seems to resorb too quickly in the sinus and, as a result, is the most unpredictable. If your mixture is primarily alloplast with a small amount of autogenous for BMP, this formula may be best. But simply stating that you mix both without giving relative percentages will often result in less than spectacular results. S'il vous plait etre precis. RJM

Dr. Miller: You are most correct.