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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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Impacted cuspid, palatal extraction

Impacted cuspid, palatal extraction

This case shows the extraction of a maxillary canine, impacted  in the palate.

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I open a flap in the palate, preserving the papilla, so I can stitch the flap back again. I calculate the position by the x-ray and start drilling the bone with a hand-piece until I touch the tooth. I know that because of its different hardness.

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I remove as much bone as I need to see the crown and I cut it with a high speed turbine drill. I keep removing bone until I can pull out the crown split part of the cuspid.

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I work my way to remove the root end of the tooth, the soft tissue capsule, and I stitch the palate flap back in place.

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Literature speaks of swallowing or difficult, painful bonding of the palate flap over the bone. It is convenient to prepare a Hawley-type splint, or simpler, a silicone cast that the patient can bite on intervals. This applies enough compression on the palate to minimize swallowing, conducting to adequate healing.

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Delayed implants after total extractions. Impacted cuspid extraction.

Delayed implants after total extractions. Impacted cuspid extraction.

This case presents severe periodontal disease. The only logical treatment plan is full extractions and new denture.

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The bone ridge is very damaged and there too many irregularities as to approach immediate implants after extractions. I prefer having the teeth extracted and wait until the bone ridge is in better, safer shape.

In addition, an impacted upper right cuspid will leave a big hole in the bone in an area that I will need to use for implantation.

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So,  I proceed to extract the cuspid and fill the bone defect with Bio-Oss graft, covering it with a resorbable Bio-Guide membrane.

Then, all the teeth are extracted by his general dentist, who places a removable denture while waiting for the bone to heal.

CEFERINO_02 Four months later, the bone ridge is more regular

Then, I place six implants on each jaw.

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Note the unexpected, deep bone defect that laid after previous extractions of the upper right molars, which was filled up with soft tissue.

I use Bio-Oss bone graft and Bio-Guide resorbable membrane to cover the cavity and place the last implant on the front side of the defect.

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This is the final result after 6 months, ready for his general dentist to initiate the fixed prosthesis.