Sinus elevation ; grafts

Sinus Elevation and
Bone Grafting in
Implantology
Dr. Bhuvanesh Kumar.D.V
D.V.BHUVANESH KUMAR 1

Contents
•Introduction
•Anatomy of the maxillary sinus
•Classification of Bone
• Amount of Available Bone
• Misch Classification on Bone Density
• CT Classification
•Classifications of the Posterior Maxilla
• Misch Classification
• Chiaspasco Classification
•Indications and Contraindications
•Sources of Graft material
•Techniques

•Prosthetic Management of the Sinus
Graft Patient
•1st Stage Provisional Prosthesis
•2nd Stage Provisional Prosthesis
•Definitive Prosthesis
•Complications
•Review of Literature

Introduction
A common problem
encountered while
placing implant fixtures
in the posterior maxilla
region is the lack of bone
required for successful
implant therapy
This problem led to the
development of the sinus
elevation procedure by
Tatum, James and Boyd
in the 1950s.

•Grafting of the sinus floor increases the vertical height
of the posterior maxillary bone prior to implant
placement
•The reports of implant survival under functional
loading vary from 36% to 61.7% and the overall
success rate is 91.6% for implants with a rough surface
and 92.3% for particulate bone grafts.
The 1996 Sinus
Consensus
Conference deemed
this therapeutic
modality highly
predictable and
effective

Anatomy of the maxillary sinus

•Is approximately 15ml in
volume air space although
the actual size depends on
the amount of resorption
that has taken place
•Formation begins in the
second to third year of life
and is nearly complete by
8 years of age
•It has a non-physiologic
drainage port high on the
medial wall that drains
into the middle meatus of
the nose.D.V.BHUVANESH KUMAR 7

•The bony walls are thin, except for the anterior
wall and the alveolar ridge in the dentate patient.
•Is lined with a pseudostratified columnar
epithelium – “Schneiderian Membrane”
•Beneath the surface epithelium , is a highly
vascular thin tissue which Is followed by
periosteum D.V.BHUVANESH KUMAR 8

•Area of sinus surgery is mainly supplied by branches
from the internal maxillary artery.
•Other arteries supplying the sinus are:
• Infraorbital artery
• Superior labial artery
• Anterior ethmoidal arteryD.V.BHUVANESH KUMAR 9

Classification of Bone
Division A Bone (Abundant Bone)
Division B Bone (Barely Sufficient Bone)
Division C Bone (Compromised Bone)
Division D Bone (Deficient Bone)
Bone Density
D1 Dense Cortical Bone
D2 Thick dense to porous cortical bone
on crest and coarse trabecular bone
within
D3 Thin porous cortical bone on crest and
fine trabecular bone within
D4 Fine trabecular bone
D5 Immature, non-mineralized bone
D1: >1250 Hounsfield units
D2: 850-1250 Hounsfield units
D5: <150 Hounsfield units

Classifications of the
Posterior Maxilla

•Misch Classification
•Chiapasco Classification

Misch
Classification
(1999)Treatment
Option
Residual
Bone
Height (mm)
Treatment Procedures Healing Time
1 >12 Division A implant placement Implant Osseointegration:
4-6
2 10-12 Sinus graft; simultaneous
division A implant placement
Implant Osseointegration:
6-8
3 5-10 Lateral wall approach sinus
graft; delayed division A
implant placement
Graft consolidation: 2-4
Implant Osseointegration:
4-8
4 >5 Lateral Wall approach sinus
graft; delayed division A
implant placement
Graft consolidation: 6-10
Implant osseointegration:
4-10

Option 1 Option 2

Option 3 Option 4

Chiapasco Classification (2003)
•Modification of the existing classifications with the aim
of correlating morphology with current surgical
reconstructive protocols.
•Classification is based on 3 variables:
• Width
• Height of the residual alveolus
• Inter-ridge relation
•The variables are used to define 9 types of sinus-
posterior maxillary alveolar morphologies according to
their treatment needs
•Classes A to D address height and width, and the
remaining classes define crown height space.

Class A
•Residual alveolar ridge height of 4 to 8mm
•Residual alveolar ridge width of at least 5mm
(i.e. absence of significant horizontal
resorption and maintenance of acceptable
horizontal intermaxillary relationships)
•Absence of vertical resorption of the
alveolar ridge with maintenance of
acceptable vertical intermaxillary relationship
•Suggested Surgical Protocol:
A. Sinus Elevation with osteotome
technique
B. Sinus Elevation via lateral approachD.V.BHUVANESH KUMAR 24

Class B
•Residual alveolar ridge height of 4 to 8mm
•Residual alveolar ridge width of 5mm(i.e. presence
of horizontal resorption and unfavorable
horizontal intermaxillary relationship)
•Absence of vertical resorption of the alveolar
ridge with maintenance of acceptable vertical
interarch distance
A. Sinus Elevation and lateral bone grafting
B. Sinus Elevation and guided bone
regeneration

Class C
•Residual alveolar ridge height of less than 4mm
•Residual alveolar ridge width of at least 5mm (i.e.
absence of significant horizontal resorption with
maintenance of acceptable horizontal
intermaxillary relationship)
interarch distance
•Sinus Elevation via lateral approach

Class D
•Residual alveolar ridge height of less than 4mm
•Residual alveolar ridge width of less than
5mm(i.e. presence of horizontal resorption and
unfavorable horizontal intermaxillary relationship)
interarch distance
A. Sinus elevation via lateral approach with
lateral bone grafting
B. Sinus Elevation and guided bone
regeneration D.V.BHUVANESH KUMAR 27

Class E
•Same characteristics as Class A except with increased
crown height space
A. Vertical onlay grafts with autogenous bone block
B. Interpositional alveolar bone graft
C. Vertical guided bone regeneration
D. Vertical distraction osteogenesis
•The sinus graft is associated with one of these procedures
but only if correction of the vertical intermaxillary
discrepancy is insufficient to obtain adequate bone
volume for implant placement

Class F
•Same characteristics as Class B except with
increased vertical crown height space
A. Simultaneous vertical and horizontal onlay grafts
with autogenous bone blocks
B. Interpositional bone graft without sinus grafting
C. Simultaneous vertical and horizontal bone
regeneration
•Vertical distraction osteogenesis is not indicated
because the technique does not correct the
horizontal defect

Class G
•Same characteristics of Class C except
with increased vertical crown height
space
A. Sinus graft via a lateral approach
combined with vertical autogenous
block onlay graft
B. Sinus graft with vertical guided bone
regeneration D.V.BHUVANESH KUMAR 31

Class H
•Same characteristics as class D except with
increased vertical crown height space
A. Sinus graft via a lateral approach with
simultaneous vertical and horizontal onlay
block grafts
B. Sinus graft with simultaneous vertical and
horizontal guided bone regeneration

Indications
and
Contraindicati
ons

Indications
•Pneumatization of the sinus
•Poor bone density
•Strong occlusal forces

Pneumatization of the Sinus
•The maxillary sinus retains
its overall size when teeth
remain in function, but it
expands when posterior
teeth are lost.
•The antrum expands both
inferiorly and laterally
potentially invading the
canine and lateral piriform
regions.
•After the loss of teeth, the
amount of teeth in the
posterior maxilla is greatly
reduced. D.V.BHUVANESH KUMAR 39

•A major criterion for successful implant treatment is the
amount of available bone. Height of the bone is a
consideration for predictability of implant treatment
•Because of periodontal disease, tooth loss, and sinus
expansion, there is often less than 10mm of bone
between the maxillary sinus floor and the alveolar crest
ridge.
•Removal of teeth in patients
with “pneumatic trifurcation”
can leave only 4 to 5mm
of bone remaining

Poor Bone Density
•Bone mineral density is critically important for
implant survival under a load. Implants are at the
greatest risk of failure under conditions of poor
mineralization.
•The bone density of the maxilla is often 5 to 10
times lower than that of the anterior mandible
and the quality of bone in the posterior maxilla
is poorer than in any other intraoral region
•Deficient osseous structure jeopardizes not only
the initial implant stability but also load bearing
capacity.

Strong Occlusal Forces
•The bite force in the molar region for a dentate
individual ranges from 1,378 to 1,723 Pa.
•Natural molars have a 200% more surface area
than premolars and a significantly wider
diameter. Both these factors reduce bone strain.
•Following this natural model, implant support
should be greater in the posterior molar region
than in any other area of the mouth.

•In addition, the posterior maxilla opposes
natural teeth or implant supported
restorations contributing greater force to
soft tissue-borne restorations.
•Therefore decreased bone quality and
quantity as well as increased bite force
should be considered in the treatment of this
region of the mouth.

Contraindicatio
ns
•A grafting procedure generally does not
interfere with sinus function when performed
on a healthy sinus. However when performed
on an unhealthy sinus, the same procedure will
contribute to fluid stagnation and bacterial
overgrowth, leading to exacerbated sinusitis
•The presence of space occupying masses such
as polyps, tumors and hyperplastic mucosa
represent obstacles to the elevation of the sinus
mucosa.

Contraindications
•Local contraindications
•Potentially Irreversible (relative) contraindications
•Irreversible (absolute) contraindications
•Intraoral contraindications
•General medical conditions of concern

Potentially Irreversible, Relative Contraindications
•Some anatomic and/or structural alterations of the
nasomaxillary complex may interfere with the normal
ventilation and mucociliary clearance of the maxillary
sinus
•Compensation may occur over time, leaving such
conditions clinically silent or with only mild to moderate,
sometimes intermittent symptoms
•Sinus grafting in these settings decompensate a
compromised sinus, causing mucus stasis, suprainfection
and subacute sinusitis.
•Elevation of the sinus floor and/or modification of the
sinus anatomy may on occasion lead to better sinus
drainage in the presence of mild sinus membrane
dysfunction D.V.BHUVANESH KUMAR 46

Irreversible, Absolute Contraindications
1. Severe (noncorrectable) deformities of the maxillary sinus
2. Scarred and hypofunctional sinus mucosa following
trauma of previous operation
3. Radiotherapy of the head and neck area (dose above
45Gy)
4. Chronic recurrent sinusitis with or without polyposis, that
disrupts mucociliary clearance and is unresponsive to
medical or surgical treatment
5. Local expression of a systemic granulomatous disease
such as Wegener Granulomatosis or midline idiopathic
granuloma
6. Sarcoidosis
7. Benign but locally aggressive tumor (amelobastoma,
myxoma)
8. Malignant tumor, both primary and metastatic, deriving
from epithelial, connective, or odontogenic tissue
(squamous cell carcinoma, adenoid cystic carcinoma)D.V.BHUVANESH KUMAR 50

Intraoral Contraindications
1. Grossly inadequate oral hygiene or inability to
perform or maintain appropriate oral hygiene
2. Untreated periodontal disease of adjacent
dentition
3. Gross malocclusion and insufficient freeway
space for restoration
4. Severe pathologic parafunctional habit
(clenching or bruxism)
5. Fulminant mucosal disease (desquamative
mucosal disease, erosive lichen planus)
6. Severe Xerostomia

Sources of graft
material

Terms
• Autograft / autologous graft: a graft of tissue derived from
another site in or on the body of the organism receiving it.
• Allograft: graft taken from one human and transplanted into
another
• Alloplastic graft: a graft consisting of an inert material
• Xenograft: a graft taken from a donor of another species
-Glossary of Prosthodontic Terms 8

Autografts
•The advantage of using autologous bone
in sinus grafts offers the following
advantages:
1. Increased bone formation
2. Shorter healing time requirements than
for bone substitutes
3. Possibilities for simultaneous lateral
augmentation
4. Low operator costs
5. No risk of disease transmission

Disadvantages
•Need for a second operative site
•Difficulty in obtaining a sufficient amount of
graft material in some cases (especially in
intra-oral sites)

Maxillofacial Donor
Sites
•Maxillary Tuberosity
•Zygomaticomaxillary buttress
•Zygoma
•Mandibular symphysis
•Mandibular body
•Ramus of the mandible

Other Sites…
•Tibial Bone Grafts
•Iliac Grafts
•Calvarial Grafts

Graft form & Maximum volume
available from autogenous bone
donor sites
Donor Site Form Available Maximum Volume (ml)
Extraoral
Posterior Iliac Crest Block / particulate 140
Anterior Iliac Crest Block / Particulate 70
Tibia Particulate 20 to 40
Cranium Dense cortical Bone 40
Intraoral
Ascending Ramus Block 5 to 10
Anterior Mandible Block / particulate 5
Tuberosity Particulate 2-4
Misc (suction traps) Particulate Varies

Maxillary Tuberosity and Buttress
•Approximate Resorption time: 3-6
months
•Can be used for small reconstructions
with low or moderate osteogenic
potential
•hyperpneumatized unilateral maxillary
sinuses or
•bilateral sinuses in conjunction with other
graft materials

Maxillary Tuberosity and Buttress

Mandibular Symphysis
•Approximate Resorption time: 4-8
months
•Can be used for small reconstructions
with low or moderate osteogenic
potential
•hyperpneumatized unilateral maxillary
sinuses or
•bilateral sinuses in conjunction with other
graft materials

Mandibular Symphysis

Mandibular Ramus and Bone Shavings from
Adjacent Areas of Surgical Site
•Approximate Resorption time: 3-7 months
•Can be used for small reconstructions with
low or moderate osteogenic potential
•hyperpneumatized unilateral maxillary sinuses
or
•bilateral sinuses in conjunction with other graft
materials

Mandibular Ramus

Bone Suctioned while Drilling Osteotomies
•Approximate Resorption Time: 1-3
months
•Very small defects such as exposed
implant threads

Alloplasts for Grafting
•Hydroxyapatite
•Bioactive Glass
•Beta-tricalcium Phosphate

Advantages
•Ready availability
•Elimination of the need for a patient
donor site
•Reduced anesthesia and surgical time
•Decreased blood loss
•Fewer complications

Hydroxyapat
ite
•Hydroxyapatite in its various permutations has
demonstrated excellent osteoconductive capacity.
•Marorana et al compared the degree of marginal
bone resorption and implant longevity when HA or
xenograft was used in sinus augmentation and found
no significant difference in terms of bone resorption
around implants or osseointegration success rates in a
4-year follow-up study.
•They reported a 97% success rate for treatment of 34
patients with 26 sinus grafts and 37 implants placed,
with 1 implant lost.

•Silva et al used HA in the form of solid
bioceramic discs to treat critical-sized
defects in rat craniums that were
allowed to heal primarily. They found
that the ceramic achieved better results
than autogenous grafts alone.

Bioactive Glass
•Bioglass is a silicon dioxide material that
contains calcium, phosphate and sodium ions
(45% SiO2, 24.5% CaO, 24.5% Na2O and 6%
P2O5) in particle sizes ranging from 90 to 710µm
•When bioglass particles come into contact with
tissue fluid, hydroxycarbonate (HCA) forms on
their surface, making them highly conducive to
osteoblast attachment via chondroitin sulfate
and glycosamine protein bonds.
•Mineralization progresses rapidly under these
conditions, resulting in dense bone formation.

•Bioactive glass bonds directly to bone.
•Through osteoconduction, glass becomes
wholly incorporated and is then resorbed
and replaced by bone.

Beta-tricalcium Phosphate
•β-TCP is a highly biocompatible, resorbable,
osteoconductive grafting material that has been tested
in many animal studies and used extensively for repair
of bone defects and to expand autograft for sinus
grafting.
•Artzi et al placed β-TCP and bovine bone in critical sized
defects in dog mandibles. Both showed excellent bone
bridging, but the β-TCP had entirely resorbed by 24
months and was completely replaced by lamellar bone.
•Engelke et al used β-TCP to place sinus-directed
implants and reported that 200 implants
osseointegrated for a 95% success rate.

• 100% synthetic and fully Resorbable.
• It is composed of calcium phosphosilicate (CPS) particles in a bimodal size
distribution combined with
• polyethylene glycol and glycerine binder.

•Upon implantation, the water soluble binder is
•absorbed within 24 to 72 hours, creating a 3-
dimensional porous scaffold that facilitates
diffusion of blood and tissue fluids through the
matrix
•After implantation, surface reactions result in
absorption of the graft material, a controlled
release of Si, Ca, and P ions, and concurrent new
bone formation.
•These surface reactions result in an
osteostimulative effect, defined as the stimulation
of osteoblast proliferation in vitro as evidenced by
increased DNA content and elevated osteocalcin
and alkaline phosphatase levels

Techniques

Sinus Allograft
Procedures
•Allogenic bone is placed using any of
the three generally accepted
procedures:
•The osteotome technique
•The simultaneous sinus elevation and
implant placement technique
•A two stage lateral approach to sinus
elevation and implant placement

Osteotome Technique
•Was developed to
compress soft maxillary
bone
•Improved initial fixation
obtained from bone
compression of the
osteotomy walls leads
to better primary
stabilization.
•Healing is rapid and
uneventful

•Requires a two-person team
•Involves inserting a series of osteotomes of successful
larger diameter until full depth is reached, if possible.

•Surgeon positions and guides the instrument
with both hands – one hand creates a rest
and maintains stability while the other hand
gently rotates and applies pressure with the
osteotome
•The assistant will apply gentle malleting
technique to the osteotome.
•Osteotome is roated after every stroke to
prevent binding to the bone.
•Osteotomes are to be kept lubricated but
irrigation is not required.

•To form a round osteotomy, side to side
movement of the instrument is to be avoided.
•Each strike of the mallet is applied to the
osteotome in exactly the same path that it is held.
Off-angled malleting causes the osteotome to
migrate and creates an elliptical osteotomy,
which comprimises initial fixation
•The surgeon places restraining pressure on the
osteotome to prevent it from advancing more
than 1mm with each impact of the mallet
•A drill can be used at any step to increase the
diameter of the osteotomy or deepen the
preparation as needed.

Bone Added Osteotome Sinus
Floor Elevation

Staged Sinus Floor
Elevation
•A technique for sinus floor augmentation with
delayed implant placement
•Introduced by Tatum in 1977
•Large sized osteotome is used to infracture the
crest after limited use of drills or trephines
•Grafting is done without disturbing the sinus
membrane. A collagen membrane is used to
close the sinus membrane
•The crestal entry creates a “socket” that heals
rapidly.
•Implant fixture is placed 6 months later

Lateral Wall Approach for Sinus
Elevation
•Is used for both delayed and simultaneous
implant placement
•Autogenous bone is harvested from the
lateral wall of the antrum for use in
conjunction with the allograft
•The full extent of the sinus wall is made
visible by thinning out of the lateral wall
•Osteotomy is performed using a multifluted
finishing bur.
•Infracture and membrane elevation are
accomplished and the graft procedure is
performed. D.V.BHUVANESH KUMAR 119

a. Delayed sinus elevation with 1 to 4mm of residual bone. A partial thickness
Flap is bevelled to the palate
a. Elevation of Buccal and Palatal flaps & osteotomy made in the lateral wall
of sinus D.V.BHUVANESH KUMAR 120

Simultaneous Sinus Elevation
and Implant Placement

Prosthetic
Management of the
Sinus Lift Patient

Diagnosis and Treatment Planning
•Verify the maxillomandibular relationship
using mounted casts
•Duplicate the casts and fabricate a wax
mockup to determine the prospective
occlusal plane, occlusal scheme and
esthetics
•Make impression of the mockup to create
surgical template and a provisional
prosthesis and to aid in the creation of both
the second stage screw-retained provisional
restoration and the definitive prosthesis.

First Stage Provisional Prosthesis
•Removable Partial Denture
•Used to replace teeth distal to the canine
•Must have maximum stability and cross
arch transmission of occlusal forces
• Retaining system should include shallow occlusal or
incisal rests as well as retaining and bracing arms
• A combination clasp system provides stress relief and
also permits easy adaptation and subsequent
adjustment of the retainer system to the abutment
teeth
• Provide relief over the edentulous areas

•Pressure from the transitional CPD may cause
micromovement of the implants – the patient
should be instructed not to wear the
prosthesis for 3 weeks following implant
surgery. At the time of insertion, the denture
flange must be kept away from the graft area
•The prosthesis will be worn for at least 9
months. Following 1st stage surgery, it will be
refitted and the tissue treatment material will
be replaced weekly until the surgical site has
healed.

Second Stage Provisional
Prosthesis
•Following implant uncovering and abutment
installation, a screw-retained fixed-detachable
prosthesis is fabricated.
•The prosthesis is fabricated as soon as it is
feasible following installation of the preselected
abutments
•It permits loading of the grafting material and
surrounding alveolar bone without going directly
to the final restoration
•Provisional loading allows the graft and native
alveolar bone to remodel in response to bone
strains transmitted to through loadingD.V.BHUVANESH KUMAR 127

•The provisional prosthesis is worn for at
least 6 months
•When anterior implant(s) are in ungrafted
alveolar bone and posterior implants are in
the sinus graft, the definitive prosthesis is
constructed approximately 6 months after
placement of the second-stage provisional
prosthesis.
•If the prosthesis is supported only by
implants placed in a graft material, the
provisional is worn for 1 year prior to the
fabrication of the definitive prosthesis to
allow for maturation of the graft.

Advantages
•The advantages of using a second-stage single
screw-retained provisional prosthesis are:
•Acts a template for the definitive prosthesis
•Allows the patient to wear a fixed prosthesis after
second-stage surgery
•Allows the patient to learn how to function with
and maintain a screw-retained fixed detachable
prosthesis
•Is retained by the patient after completion of the
definitive prosthesis, and may be used if
alterations to the final prosthesis are ever
required

Definitive Prosthesis
•Is a fixed-detachable screw retained restoration
constructed from type IV gold alloy with a heat-
cured acylic resin veneer
•For shock absorption, acrylic resin occlusal surfaces
may be employed to reduce forces on the
underlying graft and implants.
•When < 5mm of residual bone remained beneath
the sinus before grafting use acrylic resin occlusal
surfaces
•When > 5mm residual bone was present beneath
the sinus, gold occlusal surfaces are used.

Complications

Complication Possible Cause
Intraoperative
Bleeding Osteomeatal complex obstruction
Buccal flap tear Inadequate graft fill
Infraorbital nerve injury Alveolar ridge fracture
Membrane perforation Damage to adjacent dentition
Early Post Operative
Incision line opening Acute infection
Bleeding Graft loss (partial or complete)
Barrier membrane exposure Implant failure
Infraorbital nerve parasthesia Oroantral fistula
Late Postoperative
Graft loss/failure Soft tissue invasion over access window
Implant failure Maxillary cyst
Oroantral fistula Chronic sinus disease
Implant migration Chronic infection
Inadequate graft fill sequelae Chronic painD.V.BHUVANESH KUMAR 143

Membrane Perforations and Tears

Dehiscense of Graft Site
Epithelial Cyst
Oro-Antral Fistula in Smoker

Review of Literature

Tarnow DP, Wallace SS, Froum SJ. Histologic and clinical
comparision of bilateral sinus floor elevations with or without
barrier membrane Int J. Periodontics Restorative Dent 2000
A controlled trial by Tarnow et al, Tawil and Mawla and Froum
et al showed that there is a higher implant survival rate with
membrane use.
Study Survival Rate with Survival Rate
without
Tarnow et al
(2001)
100%; n =28
implants
92.6%; n = 27
implants
Tawil et al (2001) 93.1%; n = 29
implants
78.1%; n=32
implants
Froum at al (1998) 99.2%; n= 133
implants
96.3%; n=82
implants

Tepper G. et al: Effects of sinus lifting on voice quality: a prospective
study and risk assessment. Clin. Oral Impl. Res. 14, 2003; 767–774
•No changes were detected in any of the commonly
evaluated parameters.
•These were rated subjectively by patients and their
friends or relatives and objectively with
instrumental tools under isolated phoniatric lab
conditions.
•They concluded that, sinus lift surgery appears to be
a safe, predictable evidence-based method for
regenerating the highly atrophic posterior maxilla,
which does not jeopardize the individual
characteristic voice pattern of high-profile patients
critically dependent on their voices for their
livelihood

Dec-2013
There were 197 implants placed and mean age of the group
was 40.2 ± 10.7 years. There was a slight male predilection
(54.3%).
The gain in bone height as expressed in percentage after a
year was 134.6%. On comparing the length of residual alveolar
bone (RAB) at start and end of study, ISAT had a mean
preoperative height of 7.88 mm while postoperative
height was 13.22 mm.
For DSAT, the mean height at start of treatment was 3.94
mm while at the end it was 10.13 mm. Themean increase in
height was 6.19 mm

•Age, gender, and period of edentulism did
not influence the outcome.
• The alveolar width appears to differ and
influence the outcome.
•When alveolar width increases, wider
diameter implants can be placed by
compromising height.
•Thus it is a clinical experience that would be
extremely helpful to gauge the outcome of
the condition.

• Jenson OT: The Sinus Lift Procedures. 2° Edition, Mosby Co. 2007
• Misch CE: Contemporary Implant Dentistry. Mosby Co. 1997
• Garg A: Bone: Harvesting Biology and Grafting.
• Babbush CA: Implant dentistry – the art and science.

Thank You

Sinus elevation ; grafts

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