After extraction, osteotomes are used to create osteotomy (bone being solid) and sinus lift, followed by insertion of tap (Fig.2: 4.5x20mm).  Arrowheads indicate the upper border of the sinus floor.  It appears that instrument is intruded too much into the sinus.  Clinically the sinus membrane is perforated, as shown by nose blowing.  The next bone manipulation instruments (taps 5-7 mm in diameter) are shortened (17 mm).  

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Xin Wei, DDS, PhD, MS 1st edition 01/12/2013, last revision 01/12/2014