Ridge Splitting and Internal Sinus Graft Part 2

513 Rating(s).


Posted on By Maurice Salama In Bone Grafting

Patient presents with horizontal deficiency and limited bone below sinus in Maxillary Right Quadrant. Ridge Split and internal Sinus Lift performed rather than GBR and Lateral Window approach. Comments? Thoughts? Dr. Salama

PRGF and Veneer bone graft
Fibrin PRGF Membrane

Dermis with Horizontal Mattress suture
Tension Free Closure


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22 Comments

Dr. S.
During the splitting, the vertical limit of the chisel is the actual size until the floor of the sinus measured in the CT or some mm before and complete with the atraumatic elevators?
Thanks for share your knowledge!
Sormani.


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Great case Dr Salama !

A great service to the patient, with expedited treatment time while maintaining an excellent outcome.

What are your thoughts on using Piezo Vs small round bur for the split?

Thanks,

Ehab


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Thank you Dr. Salama for your elegant cases. What (if any) soft tissue procedure did you use to restore the mucogingival position/vestibule? Did the technique involve a split thickness vestibuloplasty followed by placement of a CT graft that was left exposed?


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Carl; Good Question, on the photo #4 above you will notice that I utilized Dermis ACDM underneath the flap at the time of closure connecting it to the flap within my horizontal mattress suture. This allowed me to comeback at uncovering "stage 2" and utilize a palatal crestal incision and reposition the MGJ and apically position the flap with KT on the buccal aspect. See the 6 year post op of KT and reestablished MGJ and vestibule.
thanks Dr. Salama


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great job.1 question:Why did you remove the crown after 6 years?


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Neamat; good question. The patient had the temp bridge and never returned for 6 years because they could not afford final ceramic bridge.
Next time, we should not make such good provisionals? Real world.....Dr. Salama


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Dr.Maurice,
Amazing case, just the art and science of implant dentistry framed by skillful hands.
Was the distal molar part of the temporary bridge For few years ?
If it is, this is a very good example of a successful tooth to implant attachments in long term, when the biomechanical principles properly applied. As, there was one recent post discussing that issue.

Omar


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Omar; Interestingly, the implants were connected to the distal tooth against my wishes by the restorative dentist. They did this thinking that the patient would return quickly for final bridge? What she found after "6 years" is complete wash out of cement in molar area with some decay but no tooth intrusion!
Dr. Salama


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Maurice. Great case as always. My question is: do you think is possible to achieve the same result without PRGF and dermis, only using a colagen membrane?
Thanks for sharing. Ramón


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Ramon; I do not believe i would have had as much tissue thickness on Labial without Dermis. As for PRGF/PRF etc. impossible to really compare without a blinded study with histology. My feelings are that it speeds up healing.
regards Maurice


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Thank you


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Any bone graft was placed in the internal sinus lift technique with BTI motor expanders?


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Yes e chan. Mineross and PRGF.
Dr. Salama


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Maurice,

I have found similar when provisional is too nice! saw a patient yesterday- 4 years teeth 5-12- wont get final-

Being that the implants were splinted to natural teeth and posterior implant is "short" would you advise splinting implant crowns when restored?

Cheers,

Richard


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Rich; We prefer splinting posterior implants in general.
Maurice


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thanks!


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Maurice,
that is a beautiful case!
I have been doing ERE for many years and it is my most favorite technique when it can be applied.
I always do full thickness flap and place veneer graft to further augment.

Three points that I have observed:
1. If the facial plate expanded is less than 2mm thick then the % of implants with exposed the coronal facial part (1-2mm) increases. Thus, if the plate is less than 2mm thick, I go into two stages
2. Almost always the mesial part of the ERE, close to the tooth/root achieves less ridge width gain compared to midle and distal part
3. when the bone quality is 4 at the apical part of osteotomy, bellow the ERE, I had cases that the implant at uncovery had slightly different angulation compared to initial placement. The latest I have over-comed with different implant macro-geometries.

What are your guys observations and thoughts on the above?

Yiannis


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Maurice, I'm curious why ACDM used in this case as opposed to additional layer(s) of autologous fibrin? Also when Dr Swimer says "soften the site", is he meaning at the intended apical border (hinge ) of the graft? Dale Probst DMD


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Dale. When I mentioned "softening the bone" I was referring to ridge expansion not ridge split. Usually needed in posterior mandible not maxilla. Chuck


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Thanks Dr Schwimer, I'm understanding the softenning makes cortices more pliable and better vascularized and expansion is a more localized result compared to a ridge split which may modify a broader area. Dale


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Dr.Salama, Simply put, It's a great dentistry!
My observations, what was the restorative dentist's rational for splinting the temp bridge on implants to the distal tooth especially it was delayed loading? wouldn't the implants have had been completely osseointegrated and ready for loading at stage 2 surgery?
If the reason was the short distal implant, why didn't you place longer implant since you already performed sinus lift?

Thanks for posting such cases.


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Bassam; The case is not splinted to distal natural molar? This molar required a crown and was treated simultaneously. Transitional appliance was an Essix Vacuformed matrix. A 16mm implant in mesial site and 8mm in distal sinus site. Not longer implant since we did Sinus Lift immediately at time of ridge split. Thank you Maurice Salama


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