Abstract
BACKGROUND: This case report involves a 38-year-old male who presented to the clinic after experiencing complications from a tooth extraction, including a dislodged root segment in the sinus, a sinus wall fenestration on the palate, a residual bone height (RBH) of 3 mm, and inadequate healing of the soft tissue. He presented for implant placement. METHODS: Recombinant human platelet-derived growth factor-BB (rh-PDGF-BB) was applied to a wound dressing material and placed in the sinus cavity alongside a 4.8 × 10 mm dental implant (Straumann SP, Straumann, Andover, MA, USA.). As documented in the literature, a graftless sinus lift via a lateral window was performed using a split-thickness flap technique to elevate the sinus membrane, re-establish its integrity, and restore its barrier function. RESULTS: An 8-month cone beam computed tomography assessment showed a 6.2 mm vertical bone gain and complete implant coverage. CONCLUSION: This approach provided a successful alternative to shorten treatment duration and achieve favorable radiographic outcomes during early healing. KEY POINTS: The use of rhPDGF-BB and a collagen matrix in a sinus lift procedure emerges as a practical therapeutic option when grafting might lack predictability and notably consume more treatment time, while also achieving the desired bone height when used with a simultaneously placed implant.