Lecture 7 (sinus lifting)

The area of upper posterior teeth is challenging because.

1. Sustains greater bite force compared to anterior area
2. Difficult and challenging access
3. Commonly reduced inter-arch space
4. Post extraction resorption that leads to extensive tissue loss over time
5. Sinus pneumatization
6. Poor bone quality (type IV)
Firstly classified according to Leckholm and Zarb in 1985

Then classified into 6 classifications;

Then Carl Misch classified according to available bone into;

SA-1  there’s available bone under the sinus, implant Can be placed (10-12mm)
SA-2  10 – 9 mm of available bone
SA-3  5-7 mm
SA-4  1-2 mm
Anatomy of maxillary sinus:
 Develop embryonically and begin as a mucosal invagination that grows laterally
from the middle meatus of the nasal cavity at approximately the seventieth day
of gestation. At birth the sinus cavity is still somewhat less than a centimeter in
any dimension
 After birth the maxillary sinus expands by Pneumatization into the developing
alveolar process and extends anteriorly and inferiorly from the base of the skull,
closely matching the growth rate of the maxilla and the development of the
dentition.
 As the dentition develops, portions of the alveolar process of the maxilla,
vacated by the eruption of teeth, become pneumatized
 By the time a child reached age 12 or 13, the sinus will have expanded to the
point at which its floor will be on the same horizontal level as the floor of the
nasal cavity
 Expansion of the sinus normally ceases after the eruption of the permanent
teeth but will, on occasion, pneumatize further, after the removal of one or more
posterior maxillary teeth
Some say that the sinus membrane has osteogenic property, and only by lifting it
and placing the implant bone will form.
To test the osteogenic properties of the Schneiderian membrane, it was proposed to
transplant the membrane in another area and see it there will be bone deposition or
not  there was evidence of bone formation
Other said to remove the membrane completely and place the implant  still bone
was formed, due to the presence of the periosteum.

Complex surgical procedures

1- Avoid the sinus and place implant anteriorly, posteriorly or medially
PROS:
 Avoid the surgical complications that may arise from management of sinus
pneumatization.
 Simple procedure
 Can be used with old age or medically compromised patients
 More time and cost effective
CONS:
 Compromise prosthetic options
 May require use of angled abutment
 Require guided surgical implant placement
 Risk of penetrating into the sinus and failure
Short implants can be used, it has the same PROS and CONS above
Zygomatic and pterygoid implants
PROS :
1- Avoid the surgical complications of sinus perforation
2- Viable option in severe ridge atrophy in both horizontal and vertical
dimensions
CONS:
1- Requires extremely high surgical skills and knowledge of the technique
2- Very complex procedure and may yield multiple complications
3- Compromised aesthetics and prosthetics
4- Not suitable for single unit implant
Subperiosteal implants
PROS:
1- Theoretically avoids the sinus perforation and its complications
CONS:
1- Obsolete line of treatment that requires a very heavy surgery and flap
elevation
2- Usually yield fibro-osseous integration rather than osseointegration that
leads to poorer biomechanics and longevity
3- Screw used for its fixation may still perforate the sinus or other vital
structure
2- Crestal approach for sinus lifting
We reach the sinus from the socket after simple drilling in the bone, classified into;
 Sinus elevation with osteotomes without bone
 Sinus elevation with osteotomes with bone
 Sinus elevation with osteotomes with other material other than bone
 Crestal approach without osteotomes (implant approach)
 Sinus balloon or any other adjuncts to help with crestal approach
Sinus elevation with osteotomes without bone.
Summers suggested that; we have very soft bone in the upper posterior area, so
suggested initial drilling with pilot drill than use osteotomes with the tap to compact
bone laterally and at the same time I form a place for implant placement.
Osteotomes have circular outline but not larger that implant size to be placed.
There’s modification to its shape now it have a concave end to avoid perforating the
sinus membrane.
Pros:
1. Avoid use of bone graft that adds an extra factor that may lead to failure
2. More time and cost effective
3. Less chance of sinus membrane perforation
Cons:
1. Still a blind technique
2. Use of osteotome by itself may be an unpleasant experience to some
patients
Sinus elevation with osteotomes with bone.
Summers then suggested the addition of bone, in this paper they found addition of
bone lead to higher success rate
Pros:
1. Avoid complex surgical procedures of Open sinus elevation
2. Allows placement of implant simultaneously
Cons:
1. Blind technique
2. Requires use of bone substitute materials
3. Failure due to bone dispersion around the implant
They stated that the use of osteotome with bone might cause perforation and lead
to displacement of bone into the sinus and there was evidence on that but resulted
in the end in healing on the membrane and the displaced bone didn’t cause any
problem.
Sinus elevation with osteotomes with other material than bone.
Suggested the withdrawal of blood and the use of growth factors instead of bone to
not increase expenses on the patient and found that the results are acceptable
Crestal approach without osteotomes (Implant Approach).
Here they use the implant instead of osteotome. Basically, I use the implant to push
the membrane, the design of the implant must be blunt to not injure the membrane.
Causing the tent effect that will then be filled by bone. Used when the buccolingual
dimensions it not huge.
Pros:
1. Graftless technique that is minimally invasive
2. Spares the patient both the discomfort of the osteotomes and lateral
approaches
3. Less time and cost for the patient
Cons:
1. Still a blind technique
2. Requires a special design of implant
3. Requires minimum bone height to guarantee implant stability
Sinus balloon or any other adjuncts to help with crestal approach.
I drill normally just before the sinus by a couple of mm the I use a special sinus
lifting kit, then to avoid perforating the membrane I place the balloon and inflate it
so it raised the sinus
3- Lateral approach for sinus lifting
I open a window from the buccal surface, and I raise the sinus. It is more invasive
than crestal but used when the crestal approach can’t be used like in case the
residual bone is less than 4 mm.
 Open sinus elevation with bone
 Open sinus elevation using guided surgery
 open sinus elevation and bone without implants (staged approach)
 Open sinus elevation with bone and other material or other material alone.
Open sinus elevation with bone.
Pros:
1- Open technique that allows actual vision of the membrane and so checking
physically its integrity
2- Allow bone grafting
3- Can place the implant simultaneously
Cons:
1- High chances of perforation of the membrane while removing or drilling the bony
window
2- More time consuming if it’s a staged approach
3- Requires high surgical skills and considered a complex surgical procedure
4- Requires a large amount of bone graft to fill the gap of raised membrane
Open sinus elevation using guided surgery.
Used to guide the sinus elevation to avoid injury to vital structures and can be used
also for placement of the implant simultaneously
Staged approach.
I have 1 or 2 mm of bone so I can’t have primary stability during implant placement.
Thus, I open and elevate the sinus and place bone for up to 9 months then after
healing implant placement is done.
We can use different bioactive materials:
 Growth factors
 Platelets rich plasma
 Platelet rich fibrin
 Bone morphogenic protein
 Hyaluronic acid
 Lecture 8(Introduction to placement approach)
Immediate here means the time of placement and not loading
Marco Esposito classified the timing of implant placement into 3 categories.
1- Immediate  extraction socket, I extract and place the implant immediately,
usually will be used in case of central incisors. I target esthetics, position,
emergence profile and
2- consider the type of retention of the prosthesis.

3- Early or immediate delayed  usually I curettage all the granulation tissue

than I drill for implant placement, usually used when there’s insufficient
keratinized tissue and I need to increase its length, thickness and contour
before implant placement, mainly concerned in case of esthetic area

4- Delayed  (3-6ms) placed in a fully healed socket, if there’s no enough bone

than bone grafting should be done.

According to a systematic review and meta-analysis found that.

IIP  Immediate implant placement PI Plaque index

PES  Pink esthetic zone EIP  Early implant
placement
MBL  Marginal bone loss
Which means that the 3 approaches have similar outcomes, but when addressing
the esthetic zone immediate have better outcomes.
Chen & Buser, they developed a larger classification. Which is considered more
accurate
How can I choose the suitable approach (immediate, early or delayed)?
Many factors have to be considered, like bone quality, soft tissue, esthetic demands,
patient desire, implant stability, optimum peri-implant health.
We should always think about the end in mind, which means I think about the
prosthodontics part before the surgical part.
Healing of the extraction socket
 In anterior region usually the buccal bone is thin after extraction almost 1-2
mm thick. Histologically, its bundle bone
 Bundle bone has periodontal fibers, the periodontal fibers need 1-2 mm to
attach the bundle bone, so all socket is bundle bone.
 So we have bundle bone theory: after extraction we lose the periodontal
fibers so we lose the bundle bone. So the anterior is critical zone.
Bone modeling & remodeling
Modeling  apposition of bone that is responsible for osteointegration and stability
Remodeling  it is an ongoing process.

In this paper the author extracted the teeth of a dog and monitored the healing over
a period.
After 1 week  socket is healed and still has the bundle bone + granulation tissue
After 2 weeks  bone apposition begins and granulation tissue
After 8 weeks -> may not have enough bone.

Conclusion:
We must distinguish between healing phases and osteointegration
Importance of esthetic value of treatment planning and different surgical techniques
 Lecture 9 (dr abo el fettouh part 1)

Those are the steps to restore the anterior tooth.

Single tooth replacement is very difficult as I have a reference that should be mimic,
want to fit the implant in the actual position in all aspects

After the extraction we anticipate some structure changes, we had a root supporting
the soft tissue after extraction we lost this support so collapse would occur. We aim

to maintain this relation to avoid the collapse of the bone structure.

Basal bone: bone doesn’t undergo resorption
Alveolar bone: attached to the tooth
No digital planning will give me anticipation of the bone or soft tissue that will occur.
Anticipation is from your experience, knowing the anatomy and applying it on cases.
There’s no one single technique that can result in the same result. One technique
can’t fit all.

When I encounter a case that didn’t achieve the end result I wanted, I should ask
myself?
1) Was it the implant position?
2) Was it soft tissue support?
3) Should I have placed connective tissue?
4) Was it hard tissue support?
5) Should I have opened a flap and constructed the whole ridge?
6) Should I have chosen a delayed approach?
What is the challenges in anterior implants? 18 reasons as follows

All these failures are emergency profile problems.

In the implant we don’t have emergency profile we create it (built in)
How to make a good emergency profile?
The tooth has 3 planes, between the first and the second is the maximum contour
We must restore the tooth according to these 3 planes and ensure that our lab
follows them.
How to shape the first plane?
Firstly, we should know the Supra-implant structure complex.
What do they all have in common?
They are all concave toward the soft tissue.
Never go for convex structure toward the soft tissue,
as our natural emergence profile of our natural teeth
is straight.
If convex profile is made it will cause apical migration
of the soft tissue and cause recession as our soft
tissue is viscoelastic in nature and has linear
deviation.

we have 2 levels of emergence:

 First: the titanium part usually is concave by default or straight according to the
manufacture.
 Second: level is straight or concave and can be in a different level as the pic.
The components of emergency profile;1- implant fixture position, 2- soft tissue
contour, 3- crown profile.
Case #1:

There was 5 mm soft tissue present, they were supported by the root and the bone.
Thus, I anticipate that ST will collapse even though its thick and I will make CTG.
So some will say to do convex profile to support the present soft tissue
But take care any pressure application on the ST will result in apical migration of the
ST (recession)
Lessons learnt from clinical practice:
Case #2:
In this case ST contour is good but the problem was the convex profile of the
implant side that made the crown appear longer
In this case also, CL was done to expose the 1 st plane of the tooth that was covered

by soft tissue
Case #3:
This is a ST defect, so CT graft and correction and new crown should be done.
So, this photo should be in your mind and with your lab that the hidden profile
should be concave.

Lesson #1: (No convex emergency profile)

Case #4:

Implant was placed in a wrong position with placement of bone graft and collagen
membrane, that occurred due to the thin part of cortical bone that deviated the
drill, thus we need to remove this cortical part to avoid it from occurring again.
Thus here we have to use angled abutment, with angled abutment we cant use
concave profile as it will lead to fracture of the abutment.

Case #5:

After I see this case, I’ll decide to make CT graft but no wait and analyze the case.
After seeing the crown, it has a convex emergency profile.
After analyzing the CBCT and fusion it before and after, we noticed that the implant
was in the wrong position apico-coronally, just 2 mm and this is not enough to
create emergency profile, we need 5mm from gingival margin, his doctor should
have placed the implant in deeper position.
So, what is your reference?
In immediate implant it is the gingival margin is my reference and should place my
implant 5mm deeper than it.
Will CT Graft solve the problem? No, implants need to be removed and placed
correctly.
Lesson #2: (implant position affects the emergence profile):
Case #6:

In this case we planned it digitally and used surgical guide.

Implant should be placed palatal to the incisor edge, so wrong planning led to
improper placement of the implant which resulted in the use of angled abutments
with convex profile  apical migration.
Here we did CL to give some illusion to the teeth.

We have 3 types of abutments:

 Straight abutment I can reduce it by only 9 degrees and not more, more will
lead to convex profile
We have to palatal to the incisor edge when placing the implant, but sometimes I
have to go labially to place the implant or create what’s called a “Implant driven
gap”, then I have to compensate the bone and soft tissue and avoid placement of
angled abutment as much as possible.
If you don’t have one, create an incisal edge.
The incisal edge is the determinant point of occlusion, so virtual crown must be
placed all the time

The safe angle concept:

We have incisal root angle “straight line from the incisal edge and the root”.
When we use straight abutment, we have much better space but the angle
decrease the space so ST will elevate as no space
Correlation between incisal root angle, increasing in angle 40 degree and more you
can used straight abutment and has a good case
If decreases than 40 that means you will put angled abutment
In virtual planning you must have virtual crown and after that put the abutment
When thinking about this case
1) I think the position of incisal edge
2) ST, how far I will go deeper to give 5mm space to the ST
3) safe angle and 3D position
4) bone quality and decide whether I will put bone or not
 Lecture 10 (dr abo el fettouh part 2)
You should always document your work to be able to watch your progress and learn
from your mistakes.
Recap from last lecture;
1) We cannot have convex profile of anterior region, mainly single anterior teeth
2) Incorrect implant planning will result in the use of convex profile
Lesson # 3: (the collateral awareness):

In this case back then we used to extract the tooth right away, upon opening the
flap this defect was observed then extraction was done, after 2 months the clinic

situation was as follows

Observing the space of the central incisor, it is different WHY? The lateral angulation
changed due to loss of contact between the teeth as our teeth tend to move
towards the midline. It will move depending on the sagittal position of the root in
the arch. The teeth movement didn’t only affect the present space but also affected
the present interdental papilla. Knowing this information in this case splinting of the
teeth should be done; might be done using Maryland bridge.
Implant placement was done using bone graft and collagen membrane, followed by
temporization.

In the 2nd temporization we gave the illusion of the interdental papilla, however
viewing from the occlusal view showed the soft tissue volume deficient but also the
adjacent tooth has only 2 planes in other words means that the cervical portion of
the adjacent tooth is covered by tissue. So I have 2 options either do a crown

I must consider the collateral tooth structure,

to decide whether there’s loss in soft tissue
volume in relation to the adjacent tooth that
may need CTG. Or there’s maxillary excess and
lengthening of other teeth OR design the implant crown to be designed on 2 planes
with CTG to repair the loss in the volume.
Lesson #4 (check the arch form and look for the neighbors):

In this case the patient experienced trauma at a young age resulting in ankylosis of
the central incisor, there was an infection and CBCT showed a defect, extraction
was done to the tooth.

After 3 months of healing, the implant was placed with bone graft and membrane,
here no soft tissue graft was needed.
This case is similar to the one before but here the patient already had an extraction
and restored the missing tooth using Maryland bridge but wanted to place an

implant.
This patient bone was better, but need a little of bone graft on the labial surface

However, on placement of the temporary, the tooth didn’t look right, upon further
investigation it was found that that occurred due to change in the arch form which
can occur due to stress.
When we look at the second picture it should the basal bone and the alveolar bone
in the upper one they are on the same line while in the lower picture they are not,
the alveolar bone is supported by the soft tissue that’s why although both cases are
similar in this case CTG is needed.
Lesson #5 (interdisciplinary restorative soft tissue management is

mandatory):

In this case the ortho finished its work and said that the maximum that they can do
and the pt want to restore the lateral , however there’s difference between the MD
dimensions of both laterals. So here we can either restore with bridges from canine
to canine and distribute the dimensions to reach the best esthetic outcome. The
second one is implant and to reach the desired emergence profile I have to place it
more apical at least 3 mm to the crest of the bone.
We place the implant in 2 positions; apico-coronal and labio-palatal, if we placed it
too coronal I cant create the desired emergence profile

So here we removed 3 mm of the cortical bone while preserving the interdental

papilla, now im able to place my implants
still UR 2 is 9.2mm while UL2 is 7.4mm
which can be resolved using line angle, as if we approximate the line angles of the
crown it will appear narrower while if they’re distant appear wider. But care should
be given as if one line angle is more prominent than the other, it will result in over
contoured

after fabricating of temp, it showed soft tissue volume deficient, thus CTG was done
lesson #6 (The physical support is not a consistent solution):
the physical soft tissue support in immediate implant placement
In case #1:
In the cross section the soft tissue is supported with bone and root. After implant
placement and final crown the was soft tissue recession
In case #2:
The same protocol was used but a temporary abutment was placed and customized
to support the tissues, and the results was accepted showing no signs of recession.
In Case #3:
We used guided implant placement and placed a customized abutment however
here was 2.5mm recession
Thus, The physical support is not a consistent solution
Even after support after time there might be loss in soft tissue volume
lesson #7 (how to analyze peri-implant tissue):
The mean gingival thickness around maxillary anterior teeth is usually 1.2-1.3mm,
we don’t need more than this because we have biological attachment around the
natural tooth
Soft tissue around the implant firstly might appear thick but when compared to
adjacent tooth it looks thin, and after placement of the crown it will appear thin.
In the implant it’s the volume not the thickness
In anterior implants tissue thickness is considered enough if it restores the overall
volume
lesson #8 (angulated abutment should be eliminated in the anterior

implants):