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Sinus Lift or No Lift?
Dr. Meniga asks:
Recently, we had a discussion in my dental implant study club about the placement of a 10 mm dental implant fixture in 9 mm wide bone under maxillary sinus.
Some of my colleagues think that a crestal sinus lift should be preformed first. Some of my other colleagues (including myself) prefer the stabilisation of a dental implant in the sinus floor in spite of possible laceration of Schneiderian membrane. In other words, no sinus lift. What are your experiences? What are your protocols?
November 13, 2006 in Sinus Lift | Permalink
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Comments
I have to solve the same case as soon as possible.My opinion is without sinus lift,but I'll be glad to be shared and other protocols.
Posted by: d-r ivo | Nov 13, 2006 12:52:29 PM
Well unless you want your patient to be a human rattle, do the sinus lift
Posted by: | Nov 13, 2006 2:30:22 PM
When you said 9mm wide bone, I assume you mean 9mm deep. If my assumption is right, then use a self trading implant and prepare the hole 1 to 2 mm short of the sinus. Screw in the implant and then there will be an infracture towards the end. An infracture this way up to 3mm is quite safe. The Schneiderian membrane has great powers of osseogenesis and after 2 months an Xray will show that bone will have formed over the end of your fixture.
Posted by: | Nov 14, 2006 8:11:57 AM
whether you infracture bone with osteotomes or IMPLANTS or bone taps outcome is same,CRESTAL SINUS FLOOR LIFT".
then why not use better approach where you can place graft material between your implants and membrane with traditional crestal approach with osteotomes.
instead of expecting bone fill from membrane only YOU CAN PLACE REAL BONE GRAFT.
Also inadvertent exposed part of implant in sinus cavity, particularly rough macro surfaced can be a source of chronic sinusitis.
BY NO MEANS I STATE OTHER APPROACH IS NOT ACCEPTABLE.
Posted by: satish joshi | Nov 14, 2006 9:33:56 AM
Why don't you just perform a sinus lift with osteotomes?
Posted by: | Nov 14, 2006 9:55:49 AM
I would place the implant without the sinus lift, if the implant is 10mm long and you've got 9mm of bone. Protruding the implant by 1-3mm into the sinus isn't going to make any difference, the sinus membrane will just heal over the top of the implant again. The membrane obviously has a great potential to heal. It is my belief that most so-called 'sinus lifts' make a break in the membrane anyway and this seldom causes a problem.
Don't let anyone telll you taht the patient is going to rattle - this is just nonsense!
Posted by: MS | Nov 14, 2006 10:26:46 AM
Last post advocates leaving 1 mm of implant protruding in sinus with membrane cover( Again I am not against this approach). So in sense only 9 mm of implant is supported by bone- implant contact.Then why not place 8.5 mm implant, .5 mm deeper to engage cortical plate of floor of sinus and get better anchorage for implant and not to worry about sinus involvement at all.
Posted by: satish joshi | Nov 14, 2006 10:42:58 AM
I agree completely with Mr. Joshi's previous comment - use a shorter implant and avoid the problem altogether.
The question is, what do you do when you have, say 6mm of bone under the sinus (with good width)? Personally I would use an 8mm implant (of ample girth),protrude it 2 mm into the sinus, ensure that I have primary stability and probably do it 2-stage. And only in patients with no history of sinus pathology.
Posted by: MS | Nov 14, 2006 10:56:29 AM
Dr Meniga:
Maybe instead of debating wether to do or not the sinus lift just by pass it and use an endopore implant that will work perfectly for a molar or premolar with as little as 5mm (in a 5x5 format) or 7mm (7x4.1). Isnt it much simpler?.
By the way no real sinus needed in the case you mentioned.
Posted by: Alejandro Berg | Nov 14, 2006 3:04:55 PM
I have cases that are going on five years where I had 8 mm of bone or even 7 mm of bone, using osteotomes and following through with irradiated cancellous bone or DFDB into this same opening then placing my implant into this.It gave me a beautiful result time and again.If you think you could place these little mushroom implants that are quite wide and stumpy short to solve your problem you're being misled.I have had excellent results for the past seven years of placing and restoring and just restoring for the past 13 years. I always adhered to the basic protocols based on sound dental principles you learned in dental school ie:crown to root ratio etc.These osteotome cases work great if not abused.
PS. It should be required of anyone posting to put their name where they put their wise remarks otherwise it undermines the integrity of the discussion.
Posted by: Dr. R Mosery | Nov 14, 2006 4:54:37 PM
It appears that these comments are form individuals that don't have the sound principles of implant surgery. How could one make an assumption that bone is surrounding the 1 to 2 mm of exposed implant into the sinus? I think that we should focus on evidence base treatment modalities for our patient's.
Posted by: | Nov 14, 2006 7:57:17 PM
Having bone around the 1-2mm of implant that protrudes into the sinus is not important - the sinus membrane effectively seals it off from the sinus cavity with the advantage that the implant has bi-cortical stability. I do not believe that so-called internal sinus lifts will produce bone around the part of the implant protruding into the sinus in most cases. Membrane coverage - yes. Bone - no.
It is the integrity of the bone that surrounds that rest of the implant that is important-the bone to implant contact area. As we all know, some implant designs have a fantastic surface area due to their design (Bicon for instance)whereas others (Straumann and copies) do not. An 8mm Bicon, I have heard has the same surface area as an 11 or 12mm Straumann of the same diameter. Added to this, the large fins on Bicon and similar implants designs allow cancellous bone growth between the fins to provide a further mechanical advantage.
These are not just principles of "sound implant surgery", but also common sense!
Posted by: MS | Nov 14, 2006 11:46:08 PM
I would do an osteotome sinus lift. You can easily get 3mm and with experience get 5 to 8mm of sinus floor elevation in certain cases. The key is not to tear the sinus membrane in the drilling phase of the osteotomy. I often use osteotomes in the maxilla (type 3 and 4 bone) to replace the final drill diameter or to elevate the membrane a few millimeters. A bone graft showing elevation of the sinus floor can easily be performed through the osteotomy that can clearly be seen on a radiograph.
Posted by: Gary D Kitzis, DMD | Nov 15, 2006 2:17:29 AM
As an oral and maxillofacial surgeon I perform many sinus grafts and simultaneous implant placements. (We work in the sinus all the time in many procedures.) It is a standard procedure graft simulaneously when there is enough bone to stabilize the implant. Some times a separate staged graft is needed. Exposing the sinus floor to the implant is also not a problem. we expose much more than that with our zygoma implants with no infection issues. remember we must keep in mind evidence driven techniques based on science and not anecdotal experience and speculation!!!
Posted by: | Nov 15, 2006 2:23:38 AM
Thank you very much to the OMS from the last post. I can't agree more and I think the most important is the primary stability of an implant in relation to the sinus.
Posted by: Andrej Meniga, DDS,PhD | Nov 15, 2006 9:59:35 AM
Why not just place a 9mm or 7mm long endopore implant instead with better long term results proven over 10-12 year studies?
Posted by: Terence Lau | Nov 15, 2006 10:35:48 AM
I am not an oral surgeon,and I do not place zygoma implants but I do know each and every implant exposed in sinus does not cause problem.
I leave in NEW YORK city.In NY there is one group called 'POLLAR BEAR'GROUP people in sixties and seventies.Those people in midwinter in single digit temperature go to Coney Island beach and dive into ice cold Atlantic ocean in only underwears, after bathing, come out smiling.Does it mean every NEW YORKER can do that. I do not think so.I may end with hypothermia or severe cold or may be pnuemonia.
If I am sailing in same ice clod water in a boat, and if there is a fire on a boat, and I have no option but to jump in water.Will I do it.You bet.
But if boat is large enough and fire can be contained,and I have a option of staying on boat.Would I still jump.
Of course not.
Zygoma implant is a must expose case.
this discussion is about a case with 9 mm bone height.
not a must expose case.
Then why one should play Hero?
Violate sinus?
Does it make sense?
I HAVE WITNESSED A CASE WHERE AN EXPOSED IMPLANT WAS THE SOLE CAUSE OF CHRONIC RECURRENT SINUSITIS WITH FRQUENT EPISODES OF ACUTE SYMMPTOMS AND PATIENT WAS TREATED MULTIPLE TIMES WITH DIFFERENT ANTIBIOTICS AND ENT VISITS ANS FINALLY AFTER MANY MONTHS PROBLEM WAS RESOLVED.
When you have option not to violate sinus, why would you do it?
ANSWER
USE SHORTER IMPLANT.PERIOD.
Posted by: satish joshi | Nov 16, 2006 5:20:42 AM
I have no problem with sinus graft with crestal approach and place longer implants if needed.
By stabilizing 10 mm implant with 9 mm of implant in bone and let 1 mm implant left in sinus covered with membrane will still be a 9 mm implant for crown /root ratio not 10.mm.
Posted by: satish joshi | Nov 16, 2006 9:19:37 AM
I don't believe that crown/root ratio is as important as implant-bone surface area/root ratio. Surface area of integration is in IMO more important than implant length. What do you think?
Posted by: MS | Nov 16, 2006 12:20:31 PM
to MS
You are right.
The point I am making is different.
There won't be much difference in using 10mm implant with 1 mm protruding in the sinus and 8.5 mm w/o violating sinus or using Endopore 7mm which can provide much more implant/root surface.
Posted by: satish joshi | Nov 16, 2006 12:32:05 PM
So it's agreed. Avoid the sinus if possible by using shorter large surface area implants. However protruding by a mm or two into the sinus isn't going to cause much trouble, and in 9mm of bone, fiddling around with some sort of sinus lift procedure probably isn't necessary if using a 10mm implant and stability is good.
Posted by: MS | Nov 16, 2006 12:41:29 PM
There seem to be a few "issues" here in the UK with Endopore (www.adi.org.uk) Numerous recent studies seem to indicate that length of implant is not as critcal as the top 4 to 5 threads cope with the majority of the load stress. The crestal plate is vital, so 8mm, supracrestally placed should be good especially if the system has good bio-mechanical properties (stress breaking).Repneumatization can lead to the appearance of the implants being "in " the sinus but if you scan the full picture looks different. There are rarely problems if the lining is raised ,as the osteotomy site is sealed with the implant.
Posted by: peter | Nov 16, 2006 1:32:04 PM
I can't remember the reference but there was a study done using an intra-sinus camera to look at the floor of the sinus while implants were being placed.
40% of the implants had burst through the membrane unknown to the operator but the % of complications in this 40% was the same as the 60% which had not perforated. I am quoting from memory but I think the study was roughly what I've said. So this study at least, suggests that we shouldn't be paranoid about accidental perforations.
Posted by: Peter Gilfedder | Nov 17, 2006 10:41:01 AM
All we're doing is perforating the membrane and then filling the hole up with an inert object -the implant. The membrane will just heal itself over the top.
Posted by: | Nov 18, 2006 7:51:04 AM
I just had a sinus lift for implants. What are you guys saying? I spent 7 grand for no reason?
Posted by: | Nov 18, 2006 6:30:01 PM
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