Implant Placement with Internal Sinus Lift – Tooth #16
Surgical Procedure

Chief Complaint
Missing upper right molar (#16) requiring implant rehabilitation.
Clinical Findings
Edentulous site at #16
Adequate ridge width for implant placement with requirement for internal sinus lift
CBCT confirmed appropriate anatomy for crestal approach sinus elevation
Treatment Plan
Implant placement at #16
Internal sinus lift (crestal approach)
Sinus augmentation with collagen xenograft
Buccal bone grafting
Healing abutment placement
Post-operative CBCT for verification
Pre-operative Assessment
Pre-op CBCT reviewed
Risks and surgical steps explained
Implant position planned
Patient understood and agreed
Informed consent obtained for implant placement with sinus lift and augmentation
Anesthesia
Local anesthesia.
Surgical Procedure
Patient cleaned and draped
Incision made; buccal flap raised
Osteotomy prepared using implant drills and osteotomes
Internal sinus lift performed via crestal approach
Sinus augmented with Dentium Osteon II Collagen xenograft (6.0 × 10.0 mm)
Megagen AnyOne Implant (5.0 × 7.0 mm, plasma-blasted) placed at #16
Healing abutment 7.5 mm (M) attached
Buccal bone grafting performed using additional Dentium Osteon II Collagen xenograft
Flap released and advanced
BSS × 4 placed for primary closure
Hemostasis achieved; POI given

Post-operative Assessment
Pre-op CBCT reviewed
Risks and surgical steps explained
Implant position planned
Patient understood and agreed
Informed consent obtained for implant placement with sinus lift and augmentation
