41 year old Causasian male. Patient’s chief complaint is swelling and pain to touch lasting 2 months. Oral examinations reveals localized marginal/ papillary inflammation between tooth #’s 26 and 37. Occlusal check reveals hyperocclusion at MIP on both teeth. Radiographic findings revealed a localized bony defect on the mesial aspect of #37 and a widening of the PDL on the mesial root of #36.
DIAGNOSIS AND TREATMENT PLANNING:
Treatment options were discussed with the patient and he consented to the extraction of the teeth if a root fracture was detected as well as grafting of the sockets with particulate allograft and plateletrich fibrin (PRF) for future implant placement.
An intra sulcular incision was made on the distal aspect of #37 and carried forward to the MB line angle of tooth #35. Once the flap was reflected, a buccal bony defect on the MB root of #36 was evident. The granulation tissue was removed and the MB root fracture was clearly visible (Fig 1).
An interproximal bony defect between #36 and #37 was also noted (Fig 2). The teeth were sectioned and extracted. Both sockets were debrided using surgical curettes and a large round carbide bur in a surgical handpiece using copious saline irrigation and subsequently further decorticated with a hard tissue laser (at 30hz-120mj of energy) promoting bleeding and sterilizing the sites. Both sockets’ buccal and interproximal bony defects were packed with particulate allograft. A long lasting resorbable RTM cytoplast™ 1 collagen membrane was shaped and placed over the buccal defect (#36) to protect and stabilize the graft. The top of the grafted sockets were overlaid with two PRF membranes and a non-resorbable Cytoplast PTFE membrane which was secured using x-mattress and single, interrupted sutures.
STAGE 1 IMPLANT SURGERY #’S 36, 37:
Four months post extraction, socket grafting, and buccal defect repair, a CBCT was taken with the patient wearing an acrylic stent that included the Inliant Fiducial™ to aid in the surgical treatment. Soft tissue had healed very well and the CBCT revealed good socket healing. The patient had been informed of Inliant Clinical Dental Navigation System’s2 purpose – helping clinicians plan and place implants in a safe, efficient, and ideal position based on both clinical and CBCT evaluation. Since the patient had a technology background he was very excited about this advancement in dentistry. The Inliant stent and tracker were placed in the patient’s mouth and verified again for good stable fit. The Inliant navigation was initiated (Fig 3) and the Hiossen lance drill was used to penetrate the soft tissue down to the level of the of the bone in both implant sites followed by a tissue punch creating a soft tissue channel consistent with the preplanned implant size and position.
The soft tissue plugs were removed and a gingival height of 3mm was measured in both sites. The Inliant system was used throughout the sequence of Hiossen osteotomy drills. After the Initial 2.0x11.5mm drill was used it was determined that the bone was of D2-D3 quality. As such both osteotomies were fully prepared to the final diameter and length of 5.0 x 11.5mm. The implants were then placed and hand torqued to crestal level. Implant mounts were removed and anatomically profiled healing abutments placed. No soft tissue closure was necessary and the patient was given post-operative instructions. The patient was seen two weeks post-op. He reported minimal planning post-operative discomfort on the day of the surgery and nothing thereafter. He was then scheduled for final implant impressions four months post Stage 1 surgery (Fig 4). Following fixture level planning impressions, two screw retained porcelain fused to metal crowns were inserted. The occlusion was verified and the esthetics and comfort approved by the patient (Fig 5, 6).
Dr. Jim Yeganegi received his Bachelor of Science degree from the University of British Columbia in 1991 and his DMD from the Tufts School of Dental Medicine in Boston, Massachusetts in 1995. Upon returning to Vancouver and successfully completing the Canadian Board examinations he began associating with Dr. Arthur Ross. He purchased the practice in 2001 planningand continues to provide a complete range of dental services. He began his education and training in implant dentistry in 2007. Dr. Yeganegi’s training included guidance under the VOISSCI Surgical Study Group, Bites Institute, and Kois Learning Center. His passion for Implant Surgery has led him to become the first adopter of the Inliant Clinical Surgical Guidance System in Canada.
(1) Cytoplast is a trademark of Osteogenics Biomedical, Inc.
(2) Inliant has received a Medical Device License for sale in Canada.
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