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lateral sinus lift, bone split and impacted cuspid extraction

lateral sinus lift, bone split and impacted cuspid extraction

This is a complex case of first-stage bone regeneration in order to set two implants in the next phase.

There is also an impacted 13 cuspid, at 45º angle, on the vestibular side, that needs to be extracted.

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Sinus lift and Bone Split

More than ten years edentulism in this 28year old patient have left an atrophic ridge “V”shaped, with not enough height as to fix implants simultaneously to the sinus lift.

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I open a large flap and drill a lateral window on the bone, setting its lower limit at the estimated height from the ridge I calculate from the X-ray.

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I push the window into the sinus and press the sinus membrane up. I measure the crestal bone with from the inside with a probe or curettes to confirm weather the implants can be fixed at this stage or not, depending on factors (bone height, width, density).

I estimate that the with and height are not sufficient for now, and with will be narrow for the future, also. So I split the crestal bone with a disk saw and chisels .

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I fill the sinus and the ridge crack I opened with 1gr. Bio-Oss and cover the whole graft with a resorbable Bio-Guide collagen membrane. Stitching this flap section back in place, as I will continue with the cuspid extraction.  6 months will be needed to approach the next phase, which is the placement of the implants. Further ridge augmentation may be needed, depending on the bone stabilization.

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Impacted cuspid extraction

The cuspid lays at a 45º angle, on the vestibular side, as I have made sure by touch. With a round bur I open a window on the bone at the estimated position I calculate from the X-ray and finger relief touch.

I soon feel the different hardness of the enamel compared to the bone. I widen the window until I see there could be enough space for the crown to come out.

I cut the crown using the same bur and pull it out with pliers and leverage forces.

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If the root is not hardly anchored, It can be pulled out by using a large endodontic round section file, #60 in this case.

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The patient will have a bridge done in this section. So there is no need for bone graft to prevent resorption.  Stitches are used to close the flap in place over the gum.

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Mandibular bone split, lateral sinus lift and other immediate implants

Mandibular bone split, lateral sinus lift and other immediate implants

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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Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla. Single tooth.

Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla. Single tooth.

 

This case shows how to place an implant in a narrow ridge after several years without teeth. This patient lost the two premolars, but we will only replace one, a little distally, for a fellow doctor to retrude the cusp with orthodontics, anchored on the implant.

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The two corticals have collapsed transversally, leaving a ridge much narrower than what I need to place a 3.2mm standard (hollow) where to screw abutments for the ortho treatment as a well as the final prosthesis.

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Once I open the flap I find a ridge even narrower than I expected. This is not unusual. Soft tissue often keeps volume rather normal, while the bone undergoes a grater resorption.

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We can’t do any drilling here. It would remove the little spongeus bone left in between the two inner and outer corticals. The first approach is to do a puncture and try to expand it. This gives me an idea of the bone density and elasticity. The more spongeus there is, the more malleable the bone is.

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This section of the bone presents both corticals closely collapsed together. The bone doesn’t accept further expansion, it doesn’t flex. So I need to split the bone. I use a radial mini-saw to open the ridge and a set of chisels to enlarge the opening.

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Then, I use more expanders until I reach the necessary width to insert the thinnest implant available.

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Note that the direction may not always be the best. The concavity of the external bone forces the direction of the implant to be not straightly vertical, as it would provoke exposition of the end part of the implant threads.

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This is the final position. The bone expansion can be appreciated. Sometimes there is a remaining gap along the ridge, both in front and behind the implant. In those cases we need a membrane to cover it, but this is not that case.

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Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla with resorbable membrane. Single tooth. (2).

Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla with resorbable membrane. Single tooth. (2).

This case shows how to place an implant in a a narrow ridge after several years without teeth, same as case “bone splitting (1)” This patient lost the two premolars, but we will only replace one, a little distally, for a fellow doctor to retrude the cusp with orthodontics, anchored on the implant. The difference is that in this case I will need to use a resorbable membrane.

An abscess is growing since long around the root we need to pull out.

I decide to extract the root and let the abscess cure before placing the implant. It is safer than placing the implant immediately, but there is a counterpart, too.

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The exterior cortical layer is normally damaged by an existent bone loss, through which the abscess has being draining. So we could expect great collapse during the healing time. 3-4 months, as it happened in fact.

The two corticals have collapsed transversally, leaving a ridge much narrower than what I need to place a 3.2mm standard (hollow) where to screw abutments for the ortho treatment as a well as the final prosthesis.

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We can’t do any drilling here. It would remove the little spongeus bone left in between the two inner and outer corticals. The first approach is to make a puncture and try to expand it. This gives me an idea of bone density and elasticity. The more spongeus there is, the more malleable the bone is.

This bone doesn’t accept further expansion, it doesn’t flex. So I need to split the bone. I use a radial mini-saw to open the ridge and a set of chisels to enlarge the opening.

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Then, I use more expanders until I reach the necessary width to insert the thinnest implant available

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Note that the direction may not always be the best. The concavity of the external bone may cause the direction of the implant to be not straightly vertical, as it would provoke exposition of the end part of the implant.

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But in this case the axis is almost vertical and the bone can be split to insert a 3.75mm regular implant. The outer cortical shows a deep crack.  You have to be careful to expand but not to break the cortical. We want to gain bone, but not to lose it. If we cannot expand wide enough as to insert the implant in that surgery, we may need to fill the gap with bone graft and cover it with a membrane. Wait a 3-4 months and then repeat the operation.

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The collagen membrane, Bio-Guide, is cut to fit in place and perforated to let the healing screw enter the inner thread of the implant

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I always start fixing the membrane from the far end, while filling the vestibule with graft (Bio-Oss). Stitches are applied to close the flap in place.

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Stitches should be kept as long as possible, since the has been a considerable increase in volume that makes complete closure difficult.

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A tetracycline gel can be used to prevent infection. Tetracycline is preferred over hexetidines because these have been reviewed to affect the collagen regeneration the area.