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