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Placing implant Position #4 and cantilever to #3 - Courtesy ROOTS

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credited for the individual posts where they are - www.rxroots.com
From: Jose
To: implants
Sent: Tuesday, November 24, 2009 10:12 PM
Subject: [implants] sinus lift

Here is a sinus lift I performed yesterday, pt is a smoker, the treatment plan is to place
one implant is the position of # 4 and cantilever to # 3. The space will fit two premolar teeth.
I decided to place the implant in the position of #4 due to the amount of bone available and
relying on the strong internal conection of the morse taper that the Ankylos implant provides.
Midcrestal incision was done with small vertical releasing, buccal and palatal, both to the
mesial and distal of the area. The osteotomy was prepared initially with the pilot drill and
then a sinus lift was performed using Xive osteotomes. No sinus perofation were suspected base
on the Valsalva test. Bone grafting material was added into the osteotomy, this one being
Pep-Gen putty, to take advantage of its consistency to prevent any particles from migrating
into the sinus in case there was any small perforation on the membrane.

Then an A/11 Ankylos implant was placed, subcrestally, the mount removed, and the flap
repositioned.  Sutures were taken with polyglicolic acid. Reason to leave the implant submerge
was due to the patient's smoking. - Jose

Or a shorter implant with no sinus lift? - Dan Shalkey Dan, that was another alternative, but I prefer to place implants that are in similar length, if at all possible, to the adjacent teeth, and specially with this type of procedure that is minimally invasive or traumatic, why not place a longer implant. But you are right, the prosthesis could have been done with a shorter implant without a sinus lift. By the way, when I do this implant placement that requires a sinus bump, there is no charge for the sinus tap, it is included as part of the placement - Jose Since it is my opinion that tears in the membrane are way under reported in the literature, and since I know of nothing that says it hurts anything, what I teach for osteotome sinus lifts is to take a piece of collagen (collacote, collatape, gtr collagen membrane) about twice the diameter of the osteotomy, slit it in four corners half way to the center, and push this up first. It folds up into a cup shape and contains the graft material passing through the osteotomy, and when it clears the osteotomy, it springs back out, and blocks any potential tear. I’ve had very good success doing this for many years - Gary Henkel
Interesting question............Kendo This is exactly how my surgeon placed an implant in an area that should have not been possible to place one. I’ll try to post a picture of it…radiograph - Guy I was talking to our local oral surgeon that we refer to who is an MD/DMD with a dual degree in facial plastics. I was asking him about how he handles sinus lifts in people that are congested and he said he does not worry about it. He said the sinus membrane in someone who has a congested maxillary sinus is irritated by the congestion and tough like shoe leather and you really don't have to worry about tearing those. He said its the membranes in the clear sinuses you have to worry about- they are the ones that can tear. Like in the picture Gary posted. He has also done ~ 300 hip graft cases with Dr. Kline from our office. And those cases look great with little morbidity from the donor site - ie the pts are not using any type of support to walk post op - Arturo Gary, thanks for the advice and I also use the same technique that you just described, like you say it does not hurt. My only question is sometimes when we are tenting so much as in the case that you just posted, how do I know that the membrane is going to where the perf is, if there is one, or that it is covering the whole area? But like you said, what do we lose! - Jose Such a modest lift is justified and the surgical skills shown appear excellent, the length of the implant is appropriate in my practice. I would question the intention of a cantilever and my eye was first drawn to the mesio-angular molar. I would be interested in seeing either photos of the teeth or models in occlusion, as uprighting the molar and a second implant would probably have been my first choice. No doubt the patient would have expressed concern about cost, but the load on this implant would appear to be more than I am comfortable with - Scott Davis Scott, thanks for your comments. In response to your question, the decision to place the implant on the area of # 4 was due to the available bone and the financial situation of the patient. I also would have prefer to see a second implant placed on the # 3 area with another sinus bump, and also the uprighting of the molar, but if I had pushed the treament, the patient would have never done anything about the space. In regards to the load, I have seen cases coming from Frankfurt University where they have restored heavy bruxers with distal cantilevers and shown recalls 8 years later with no bone loss around the implant. I'll try to dig out the x-ray later on. Take care - Jose Hi Jose, I have seen such pictures in the mandible, but I am still nervous about such load myself. Especially in the maxilla where the apical third is in either low density bone or graft becoming bone. Let me suggest a compromise, I would approach the next patient with a similar situation as follows: "After examining your mouth, the plaster casts and your x-rays we have discovered it is possible to replace those teeth that you lost on the upper right. Unfortunately the back tooth has drifted forward, see on this x-ray and the model? So, we will first place an implant in the #4 site, that is just here. This will improve your smile a lot and help you with chewing. When money allows we can also replace the #5, first we would attach a little wire to the #4 and a spring and push the #6 back to where it should be, you will hardly see it, much more discreet than full braces. Then place the second tooth. Doing it this way allows for an ideal result and within your budget. What do you think, Mrs so and so?" You would be surprised how many people agree to a staged plan where they can spread the cost over a year or two. For moving the molar, I like to plan a screw retained crown on #4, so when the ortho phase is required, remove the crown and place an interim resin crown to attach the appliance too. Easy and cheap, you don't have to be an orthodontist to do that, and perfect anchorage. The best new implant patients we have in out practice is the ones we have already treated, because you don't need to convince them how good implants are, they already know and want to have more, when they can afford it - Scott Davis Scott, great point and a magnificent way to present the treatment plan. Going by what you said, the only thing I can think of is trying to suggest to the patient and dentist is if they would agree to temporize # 5, see if the pt can get $ for an implant on # 4, and then try to square things out. If they do not go for that, I will certainly tell the dentist to do progressive loading on the implant to mature the bone around it prior to the final restoration. I really appreciate your input - Jose Jose, My pleasure. If they intend to temporize for any length of time they really should consider a lab made temporary, smoother and kinder to the tissues than most of the chair side ones I have seen - Scott Davis
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