First of all, Happy New Year to all the Engel Alumni and fellow colleagues. 2018 has come and gone but lets look forward to a prosperous wonderful 2019. Last week , on my last working day of 2018 my patient that had a fixed bridge from 12-15 that had decay under #12. This bridge was in for 10 years, and her previous bridge was in for 10 years, which was a bridge from 13-15. #13 had decay and was lost to non restorability. The second time around on the four unit bridge, the patient was offered to get two implants on the area 13 and 14 instead of doing a bigger bridge. The patient declined due to the cost.
10 years later deja vu and now the patient was in the same boat. If this was your patient how would you of handled this? Lets look at the clinical photos.
Clinically the tissue did not look bad, but on the Xray you can clearly see the ring of decay around #12. The patient was given options and the plan was to extract 12, immediately place an implant in #12, and to do an implant in the area of #14 with a coronal sinus lift. Prior to the surgery, an impression was made to make a removable Engel temp for the area 12-14..
Cone beam was taken to study the areas prior to surgery. Using my Vatech I was able to come up with a game plan prior to surgery.
To all Alumni, if Surgical Implant Dentistry is what you want to do then an investment in a cone beam must be considered. If you planning on picking and choosing your cases, then the calibration technique taught in M1 will work.
When planning your cases remember tooth first, implant second. Do the measurements and see what will be the size of the tooth you will be replacing. If you are going to be replacing a 7mm premolar and have width in the jaw to place a 4.1 mm implant, you place a 3.3 not a 4.1. Its about the tooth, not the width of the bone when deciding to the implant.
The patient was numbed, and the bridge was sectioned to look at surgical area.
My work flow was to place the implant in the 14 area first before taking #12 out. I did a full thickness flap, and tied it back with silk suture. I took my surgical 2 round bur to mark the area to start my osteotomy. According to my cone beam I had 6 mm from crest to sinus. My pilot drill went in very easy. I had a thin cortical plate and then the bone was soft. It was definitely a D3 bone so instead of drilling I went right for my osteotomes. I took my 2.6 osteotome and I couldnt have been in 4 mm and I was able to tap up and feel the break at 6 mm.
(DENTAL PEARL) Just because you were taught to try and drill .5 mm from the crestal portion to base of the sinus doesnt mean that you cant stop sooner. In this case it was 2 mm form the sinus floor. Doing more and more of these will give you the experience and tactile sensation that no guided surgery can give you. You need to feel the bone!
I used my osteotomes and widened to the 3.8 osteotome. I used a 4.5cc mixture of Straumann Allograft with a Xenograft.
Since the Cortical plate was thin I did check the width with the countersink drills to see what width I was at since I was placing a 4.8 x 10 mm implant. Implant was placed, 35ncm was achieved.
From here I proceeded to extract tooth #12. I split the tooth mesio-distally to so I could remove the roots separately. After removal, I cleaned the area and proceeded to start drilling my osteotomy.
I placed the loxim in on 14 to use as a guide while drilling my osteotomy. A 3.3mm implant was chosen. Implant was placed. Remember on immediates to place 1 mm below the crest to allow for remodeling.
Covercaps were placed. #12 area was grafted then protected with BioXclude membrane. Area was sutured with PTFE sutures. Temp was tried in an adjusted. Patient was instructed to only where the temp if she was going out. She said she wasnt and she wouldnt wear it until she saw me in two weeks.
Final Xray of placement. I had great torque on both implants and Healing caps could of been used. As I have said before on all immediates I place and sinus lifts I perfer to bury the implants. Just a personal preference.