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
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.
So, I use a radial saw to slit the bone, working the expansion to the spongeus with chisels.
Then, I use a set of expanders, switching them in progressive widths
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.
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.
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.
I open up the flap and start the vertical sinus lift with osteotoms, on both 15 and 14 places, starting by the narrowest one.
Note the damaged, thin cortical layer at 14.
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.
I cover the defect with Bio-Oss bone graft and a Bio-guide resorbable collagen membrane fixed by the healing screws.
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.
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.
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.
Then, I cover the perforation with a resorbable Bio-Guide collagen membrane, fill the sinus with almost two grams of Bio-Oss bone graft
and cover the graft laterally with another Bio-Guide membrane, closing the flap on top.
Again, the before and after panorex. Now we need to wait at least six months to place the implants on the left sinus graft.