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This case combines several advanced surgical techniques

  • bone split and ridge expansion on both ends of lower jaw
  • extraction and immediate implants with simultaneous vertical sinus lift
  • wide lateral sinus lift for later implants

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A) Bone split and ridge expansion on both ends of lower jaw

First day of surgery. I place implants on the left jaw.

Many years without teeth have left a collapsed, atrophic ridge, both in width and height.

The inverse “V”  shaped ridge is not wide enough as to place the narrowest 3.25” implants.

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So, I use a radial saw to slit the bone, working the expansion to the spongeus with chisels.

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Then, I use a set of expanders, switching them in progressive widths

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I place a short 11.5×3.75” at the back , a 13×3.25” and a 15×3.25” angled towards liguo-mesial in order to avoid the mentonian hole and allow for bigger implant length.

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Then, it’s time to fill the gap between corticals and implants with Bio-Oss bone graft and cover it with a Bio-guide resorbable collagen membrane fixed by the healing screws.

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On the right side there is even a shorter ridge. That means the leverage forces will be greater. I repeat the bone split process an drill carefully with an angle towards lingual, allowing the mentonian nerve to pass by vestibularly. A 3.75×13” implant at the back, and two 3.25×15” in the front.

B) Extraction and immediate implants with simultaneous vertical sinus lift

The second surgery is on the upper right jaw. There is a “one-and-a-half- tooth” space. Too narrow for two regular teeth. Too wide for just one.

Besides, there is a low sinus. The little bone support, even with sinus lift bone graft (less dense), could be a challenge for long term expectancy. So, my decision is to place two implants, with two small crowns in the end.

I first extract a decayed root with a periapical granuloma.

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I open up the flap and start the vertical sinus lift with osteotoms, on both 15 and 14 places, starting by the narrowest one.

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Note the damaged, thin cortical layer at 14.

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Through the perforation, I apply small pieces of collagen sponges mixed with bone graft. Then, I place a 3.25×11.5 on 15, and a 3.75×13 on piece 14.

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I cover the defect with Bio-Oss bone graft and a Bio-guide resorbable collagen membrane fixed by the healing screws.

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C) Lateral sinus lift for later implants

The upper left jaw needs a wide sinus lift in order to lace implants at a later stage. There is a no residual bone left at all.

I extract the damaged root and open a wide flap.

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I drill quite a wide lateral “window” carefully, not to perforate the membrane. At first touch one can appreciate the extreme thinness of the bone here.

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While separating the membrane a perforation occurs. I keep separating, since we’ll need a big volume graft to allow the future implants to hold on to.

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Then, I cover the perforation with a resorbable Bio-Guide collagen membrane, fill the sinus with almost two grams of Bio-Oss bone graft

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and cover the graft laterally with another Bio-Guide membrane, closing the flap on top.

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Again, the before and after panorex. Now we need to wait at least six months to place the implants on the left sinus graft.

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