Timing of extraction and sinus augmentation???

Challenging case, Henry.

My overall objectives would be to eliminate the offending and problematic teeth/infection, augment vertically the ridge (horizontal looks decent) and place implants at the # 02, 03 and 04 sites with subsequent restoration ofthe fixtures.

To accomplish that I would:

1) Plan for provisionalization - while I prefer fixed in most casses, removable may be unavoidable here. Impress for and fabricate an acrylic RPD. If adequate bone is available at the # 01 site, an implant here to act as a vertical stop for the RPD would help protect the grafted areas.
2) Extract # 02 (the curent distal bridge abutment) and extract # 04 (a very poor candidate to maintain/utilize as even a single crown abutment) and decorticate/graft the # 02, 03 and 04 sites for minimization of continued bone loss and to attain as much vertical and horizontal augmentation as possible. I would use allograft with tenting of membranes (bone pins +/or Titanium reinforced), biologics...
3) If practical (based upon clinical presentation and operator assessment/comfort), a simultaneous lateral window sinus elevation (# 02 - 03) would be optimal. If appropriate to delay, this could be performed three - four months following the initial ext/graft Sx. I would utilize allograft and BioOss with biologics, whether simultaneous or delayed.
4) 6 - 9 months post lateral window, I would place implants at the # 02, 03 and 04 sites, of appropriate dimension. Length and diameter should not present a problem as per scan and anticipated graft outcome. Very important to relieve/soft reline RPD throughout the post graft period.
5) restorations at 2-3 month post implant placement.

There is an alterntative to consider (pending adequate available bone and WNL intermaxillary clearance...) - it would take some finessing, but it would allow for fixed provisionalization and protect the graft sites:

1) Extract # 02 and # 04 and place an implant in the # 01 area (sub-antral elevation llkely required) and place an immediate implant # 04, decorticate and graft the # 02, 03 ridge, place a fixed provisional # 01 - 04 (out of occlusion and without any right sided function or mastication) .
2) Subsequent lateral window sinus elevation # 02, 03 with simultaneous implant placement # 02, 03 (if adequate alveolar primary stabilization is attainable) or delayed implant palcement 02, 03 if indicated.
3) Restore defintively # 02, 03 and 04 implants. Maintain/restore or remove/leave dormant # 01 implant as per clinical dictates.

I am interested to hear your take on this case.

Jeff

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