How to use Summers technique exactly? What sequence?

I have treatment planned this patient for a Summer’s lift to place a Straumann Tissue Level WN 4.8 of 8mm implant in the maxilla in the right second molar site.  I have 7mm of bone.  I have a kit with 5 convex and 5 concave osteotomes as pictured.  The osteotomes are 4.2mm in diameter, all angulated.  I’d like to know what the correct sequence is? After I drill the osteotomy, what sequence of osteotomes should I use?  When should I use the convex osteotomes and when should I use the concave? Should I use only the concaves?

27 thoughts on “How to use Summers technique exactly? What sequence?

  1. Merlin P. Ohmer, DDS, MAGD says:

    Not answering your question directly, but if you are going to lift 1mm, why not do 3mm and use a longer implant? I do not use osteotomes.

  2. Gregori Kurtzman, DDS, MAGD, FACD, FPFA, DICOI, DADIA says:

    Pilot drill used to 2mm from the sinus floor, then use the pointed osteotomes to the same depth to widen and condense the site to a 4.0 mm width then a 4.0mm wide concave osteotome is introduced into the osteotomy that has been half filled with a granular graft material. gently tap it up to up the sinus floor to 6mm depth from the crest and take a PA to check now use the same osteotome and gently tap it on 3mm more take an other PA when you see the floor tenting as evidenced by the graft material on the radiograph then place the implant in to do final lifting and your done As Merlin Ohmer indicated I too would use an 11mm long implant

  3. perioprosth says:

    if you want to raise the floor for 1 mm or 3 mm, have you thought how much bone Graft you would like to have above and circumferentially around the implant? that will tell you how much you need to lift?
    if you perforate the membrane, which many do at the first couple of attempts, do you have a plan B how to proceed?
    i think you should think it through and trouble shoot the procedure before attempting to do it. it might not be as easy as you think it is, if you have never done it under supervision of someone who knows the technique well.

  4. Howard Abrahams says:

    I recommend you refer to Louis Al-faraje page 54 in his book on implant complications. It is a pretty good illustration of the technique.
    Sounds like a hands on course would be very helpful to you as well.
    Take your time. Set aside a lot of clinic time for yourself. You will hopefully finish early and have time to sit back and enjoy a coffee.

  5. val says:

    Do it as Dr.Gregory Kurtzman adviced ,gently slowly .For 1 or 2 mm membrane raise the risk is minmal . May be a good idea to consider Densa Bur approach as well . Who dares wins .
    Good luck .

  6. Wesley Haddix says:

    The only guidance I can offer may not provide the most immediate help. In my hands, closed sinus elevation osteotomies proved frustratingly unpredictable compared to a lateral window approach. The time it takes to reflect/tie back a flap, make a lateral window, and have direct visualization is about the same for me as using multiple osteotomes. Angulation was more difficult to properly control the farther posterior the implant site was. One patient, a heavy bruxer, had bone so dense in the first/second molar area that my osteotomes actually bent; add to that the issues of potential concussive injury, and osteotomes were relegated to the back of my surgical table. Many here perform these procedures successfully, speaking to their skills, but my greatest recommendation for you in these cases is to deepen your skill set (if you havn’t already) and add the lateral approach window technique. Prayers and best of everything to your practice and your patient.

  7. ilker says:

    you can place an 8mm implant without lifting by placing the implant palatinally inclined and finish the prothesis with angulated abutment..

  8. Robert Moxom says:

    Wesley,
    At present,I employ a maxillo-facial surgeon to perform lateral window sinus lifts.Having over 30 years of experience he is happy to use a Toller bur to expose the membrane.Myself,if I were to attend a course,would prefer a Piezo approach which,I understand is unlikely to perforate the membrane.
    Are there many negatives with Piezo surgery?I expect it takes longer to cut the bone.
    My worry with trans crestal techniques is as above,unseen perforation.
    My surgeon colleague described a terrible consequence of getting it wrong whereby particulate bone granules were forced into the sinus resulting in infection and combined ENT/max fax surgery.What I hadn’t realized is that the celia of the membrane distribute the granules throughout the sinus and into the nose making it almost impossible to remove them.Please bear this in mind.

    • Wesley Haddix says:

      Robert: in truth, over 50% of subantral augmentions involve some degree of perforation, pinholes to outright blowouts. I got my training from Carl Misch and Mike Pikos, and learned how to recognize when tears are likely to occur, how to minimize and mange them. If Mike Pikos is still teaching, take his courses. Poor technique leads to poor outcomes as you describe. Training and experience teach is how to know exatly where to open the antrum & how high to pack the graft. Infections and graft migration are part of this surgery’s risks and need to be in tje consent. The surgeon needs to be confident in managing infections, early and late. I’ve experienced both and successfully treated all of them. Again, this is my personal opinion. You will experience graft failure if you do enough of these procedures, so the risks/benefits of controlling placement and size of implant needs to be weighed. As far as piezo, it is very precise, but for me slower than a bur, and there are issues of access to consider. I started with a #2 round bur and stuck with it – I remove the bone over the window anyway. It is as easy for a surgeon to perforate a sinus with a piezo as it is with a bur, it depends on the surgeon, the patient, and the moon phase.

      Preoperative chlorhexidine rinsing AND scrubbing along with intraoperative chlorhexidine irrigation, pre/post surgical antibiotics and antibiotics in the graft along with rigid aseptic technique, careful planning including preop/postop CBCT are de rigeur. Learning this surgery dispelled the notion that the sinus is the “black hole of death” and opened up other methods and techniques for me, and I count it as one of the most valuable tools in my skill set. I have retrieved lost roots, improved my extraction technique, and learned how to manage OA fistulas from extractions. I very humbly ask one question: if you perform a closed elevation, introducing a graft through a contaminated access, and there is a tear and an infection, do you manage your patient, or do you ask an oral surgeon to clean up after you? Again, I feel if we are to treat the sinus, we must be ready to treat it with reopening, irrigation, drains, and IV antibiotics as quickly as we are ready to treat them with implants. If not, perhaps we should not be treating the sinus ourselves at all. How well trained would you want your surgeon to be?Apologies for misspelling and verbosity, but I feel this is one of the greatest privileges a dentist can have, but it has to be earned, not taken. Respect to all here and your efforts, this is my opinion such as you find it, and I stick by it.

      • DrG says:

        I couldn’t agree more. Unfortunately the world of specialty dentistry has rapidly disappeared. Dentist are trying more advanced procedures and taking greater risks every day. It usually takes just one major screw up to question their motives, but the lesson is a terrible price to pay for the victim.

  9. Angela says:

    Use Bicon Implants, and you do not have to go through any of these problems. You can easily place 6×5 Integra CP Bicon implant there. do not even deal with any of these issues.

  10. J says:

    I’m the author of the trend. I have received lots of critiques and I want to explain myself. I AM taking a course. I’m a beginner in the implant field, I read lots and lots of articles and I study really really hard. In my course I have placed dozens of implants and I have already performed both lateral window sinus lift and summers technique. Regarding this trend’s specific question, I asked because I never find a specific guideline for how to perform summers technique, I think it is because the technique changed lots of times and each one has a specific way to do it. Summer’s original paper doesn’t describe the convex osteotomes, only the concave ones. Many doctors don’t use any grafts for small lifts (like this one, 1mm), many do use graft regardless the case. That’s why I asked this here.

    To all of those who told me to take a course. You all suddenly start doing great surgeries from one day to another? You’ve never had thoughts and doubts about any procedures? Never asked for advice for anyone? Today we have internet, which is a great way to make friends and discuss. I’m sorry, I just wanted a few opinions.

    • docphil says:

      Just ignore the people who simply criticize. Fact is, there are various techniques, instruments etc. for sinus lift, and it can get confusing, especially as different courses may recommend different things. There are new studies all the time comparing different techniques. Your question was a fair one. Ultimately, it’s better to raise questions about the procedure than pretend to be a “know it all”. I think the best teacher is experience (not just courses), and you never get anywhere without trying and asking questions.

      As an aside, I do agree with one of other posters here to shelve the osteotomes in favor of new instrumentation and/or a new technique. You may want to take a look at the SCA Kit for example, if you plan on doing more of the crestal approach.

      • J says:

        Thank you for your comment. Your comment reminded me of another important issue. I’m from a poor country. I don’t have access to all the technology available. I have to work with I have. Many recommend densah burs and etc and i just took a look at this SCA kit and it’s very expensive to me.

    • Wes Haddix says:

      I sincerely hope that none of my comments came across as critical. That is certainly not my intention. Merely recommendations based on my 25 years of experience in the field as someone such as yourself, a doctor with good intentions, desiring to improve himself for the sake of all he is responsible to: Patients, Practice, Family, Self.

      The electronic age has given us great access to information. It is up to us how we use it. Weigh criticisms for what they are worth; don’t dismiss them outright because of the seemingly harsh tone. In my career, I was chastised by specialist and GP alike for only trying to learn new skills. I’ll leave the reasons for those motivations to reader’s own speculations.

      Doubts, absolutely! First surgery, every surgery. Mostly over small things. With time and experience, they become less and less. Even Hilt Tatum had his first surgery, and all the giants in the field were subjected to intense criticism and scrutiny. Imagine having the stones to criticize Carl Misch and Mike Pikos. Think of that when it happens to you, but don’t dismiss criticism out of hand. It can be a guide.

      Your skills will develop over time. In the beginning, live surgical course, preferably ones you can participate in, are the best start. I don’t know the particulars of the case you are performing; I only offer an insight into a possible path of future study based on my own experience as a general dentist who made some lucky choices along the way that enabled me to develop and advanced skill set. You can never know enough, and you likely already have found that advanced knowledge and skills in one spill over into other areas as well. The skills in flap management for implants and sinus elevations potentially translate into surgical extractions, periodontal care, crown lengthening, and other areas. A comment was made that there is a trend for GPs to rush into advanced areas without adequate training. That may be so in some cases, but it should not discourage you from broadening and deepening your skill set.

      I wish you and your patient all the best in their upcoming treatment, and a long and prosperous future in dentistry.

  11. perioprosth says:

    if you want to learn the technique, here is an excellent article by P Rosen and R Summers himself. you can learn how to improve your skills.
    As i mentioned in my previous comments,in mu humble opinion and experience it is important to use the technique for the first few times with someone who is well familiar with the technique. This way your potential mistakes will be mentioned to you as you do it and also the risks of complications is minimized. it is just a reality of advanced procedures. it is like doing root canals by just reading a Endodontic Book and no previous experience. Don’t be discouraged but be aware those who do it well didn’t learn it by just taking a few weekend course or reading some articles. what is being thought in several months cannot be crammed in a few days.

    The Bone-Added Osteotome Sinus Floor Elevation Technique: Multicenter Retrospective Report of Consecutively Treated Patients.
    Volume 14 , Issue 6
    November/December 1999
    Pages 853–858

    Hope it will help.

  12. JJ says:

    An Implant guru once said in a podcast like this:
    “you aint earning money with that, you will be losing money with that.”

    I think it was Dr. Carl Misch but not sure….
    Do not dive in serious and adacious case without basic knowledge.

  13. Paul says:

    Hiossen has a kit dedicated to the technique. I my opinion it is well worth the expense and utilization because it assures great success without unnecessary risk. In the world of dental gadgets the Hiossen kit which is presented on their website and instructional video is one of instruments that assures precision and removes the unpredictability.

  14. Denture Guy says:

    the Hiossen kit and SLA kit are great and fairly easy The main thing I would suggest is that if you are going to do these cases then use the proceeds to fund the instruments for the case . Also I would not introduce a graft material first The issue with lifts is getting graft material through the membrane into the sinus If your do a lift it can be difficult to know if you have a tear Get a PRF set up and introduce the membrane first so if there is a tear this can help cover , cushion and heal the membrane and protect it from the graft An alternative would be a collplug then the graft material

  15. Paul says:

    Denture Guy,
    Perforation of the membrane is very obvious and there are methods to confirm that. One of them is the nose blowing with pinched nose (cannot recall the name of this technique) and the other is the probing with a mushroom instrument that one needs for that procedure. Obviously there is nothing wrong with the suggested methods you propose. Injection of saline to lift the membrane will also provide clues of perforation.

  16. Denture Guy says:

    That is true that there are many ways to determine perforations prior to introducing the graft material. There are very few ways to know if there is a peforation after you have introduced the material . Packing sharp biomaterial and using this to lift the membrane can be the cause of a perforation itself. Personally I like a barrier there and PRF will protect , cover and heal any opening I might have missed

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