Dental Implants. Flapless Surgery and Immediate Loading

Cesar Luchetti

Department of Implant Dentistry. National University of La Plata. Argentina

Implant dentistry is pushing their limits towards less invasive procedures and with results in a day.

Although this is a valid approach, an adequate diagnosis is necessary to perform these cases in a secure way.

Flapless surgery is usually faster and gives more postoperative comfort to the patient. However, the adequate tridimensional position of the implants must not be sacrificed just to avoid a flap, especially in cases when bone reconstruction is needed.

Long term prognosis is influenced by a good tridimensional positioning of the implants which is determined by the biomechanical requirements of the teeth being replaced.

Immediate loading is useful because the patient retrieves the function instantaneously, but it must be done just in cases with a good initial fixation.

The following video shows a case with a flapless approach.

Implant site development was made with threaded expander in order to increase bone density allowing a better initial fixation.

The implant used, B&W CIH (Argentina), has an implant carrier who can be adapted as an abutment. A provisory crown was made over it a few moments after surgery.

To see the video in full screen, please click in the link below (opens in a new window). Then, click in the lower right square of the screen.

Dental Implants. Flapless Surgery and Immediate Loading

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Bone Expansion by means of Ridge Splitting

Cesar Luchetti and Alicia Kitrilakis

Department of Implant Dentistry. National University of La Plata. Argentina

Ridge splitting is a procedure used to expand the bone by separating the buccal and palatal plates.

It is normally performed in the maxilla using chisels, osteotomes and a mallet.

It could be done also in the mandible, but is a little bit more complicated due to the denser bone. In this case, is recommended to use a cutting disk or piezoelectric devices and threaded expanders, because these are less traumatic.

It is indicated when:
-The bone is less than 3 mm wide. (If we have more we normally can expand it just by means of osteotomes or expanders)
-The bone is enough to place an implant but we want to expand it for esthetics reasons.

Typically, the procedure is initiated by thin chisels, followed by wider ones and then osteotomes.

Residual spaces are filled with a bone graft.

A clinical case is showed below.

Preoperative x-ray.

Preoperative situation. A fistula is

observed at canine level due to a

root fracture.

Flap raised. A longitudinal fracture of

the canine root is observed.

View of the narrow ridge after the extraction.

Start of the ridge splitting with thin chisels.

Ridge splitting with chisels.

Initial ridge splitting.

Continuation of the procedure by means of

osteotomes to prepare the implants sites and

to get the final expansion.

Continuation of the procedure by means of

osteotomes to prepare the implants sites and

to get the final expansion.

Final expansion.

Comparison between the initial aspect of the

ridge and the situation after the expansion.

Implants placed.

Bone graft filling the residual spaces.

Suture.

Abutments in place.

Definitive crowns.

Pre and post operative comparison.

Post operative x-ray.

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Restoring a Natural Tooth Adjacent to a Dental Implant

Cesar Luchetti

Department of Implant Dentistry. National University of La Plata. Argentina

One of the most challenged situations we must face regarding esthetics results is when we must do a crown over a natural tooth adjacent to a crown over a dental implant.

The differences between natural tooth and implant anatomy make difficult to harmonize the two emergency profiles.

Over the last years, slopped implants have proposed to be the solution to this problem. Although this could be true regarding the anatomy, there were some difficulties of some clinicians for the correctly implementation of its use.

We are presenting a case where we must restore a natural upper lateral incisor adjacent to an implant in upper central incisor area.

Pre-operative situation. An acrylic restoration

was present over the lateral with an extension

to the central incisor.

Pre-operative situation after the bridge was

retired. A depression is noticed in the buccal

area together with a loss in papilla height in

the mesial aspect of the lateral.

Implant placement. Incision was made to the

palatal and implant was placed in one stage

approach to maximize the soft tissue in the

buccal aspect and to avoid future

soft tissue manipulation.

Once the implant was integrated, a combined

transfer – natural tooth impression was made.

Note that the implant is slightly placed to the

palatal to achieve better force distribution and

also to allow a bigger amount of soft tissue

in the buccal area.

Metal substructures try in.

Definitive crowns in place.

Pre and post-operative comparison.

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Maxilary Sinus Lift and Sinus Membrane Reparation with Simultaneous Ridge Augmentation

Cesar Luchetti

Department of Implant Dentistry. National University of La Plata. Argentina

Sinus lift procedures are common in the atrophic posterior maxilla. However they are more or less complicated depending in what approach we decide to use.

In great atrophies, the lateral window approach is often the most indicated, usually associated with ridge augmentation. Although this is a predictable procedure, sometimes we must face some problems. One of the most common is the perforation of the Schneider membrane.

Here we can have basically three scenarios:

1- Small perforation. In this cases, it is normally occluded itself by just raising it.

2- Medium perforation. Here we can manage it by using collagen membranes or membranes made of PRP.

3- Large perforation. In these situations, there are usually no possibilities of reparation. The recommendable approach is to clean out the affected Schneider membrane, irrigate the sinus a lot and close the flap. Then, wait at least 3 months and re-enter to do the sinus lift.

In this work we will describe and show how to manage a medium perforation during sinus lift together with a ridge augmentation.

Preoperative situation.

Preoperative situation 15 days after

teeth extractions.

Ridge defects are showed after raising the flap

.

Access to the maxillary sinus and Schneider

membrane elevation.

A perforation is noticed at the center part.

Membrane perforation in a closer view.

Collagen membrane.

Collagen membrane placed to cover

the perforation

.

Graft placed into maxillary sinus and in the

ridge defects.

In both cases we use Beta Tricalcium Phosphate

(spherical in sinus and irregular particles

in the ridge)

PRP covering the graft and collagen membrane

over the access window. This is not really

necessary in our experience, but we decided to

do it just to help this difficult case in particular.

Suture

Postoperative picture, prior to implant

placement, showing good bone regeneration.

Implants in place following a triangular

distribution to improve load distribution of the

future crowns. Also, a small graft was done to

achieve a better contour in the posterior area.

Suture

Healing abutments 10 days after the

uncover surgery.

Definitive abutments in place.

Metal substructure try in. Notice the depression

created in the anterior implant to achieve better

esthetics. This was done by compression with

the provisionals.

Definitive crowns.

Definitive crowns from a more lateral view.

Definitive crowns from an occlusal view.

Pre and postoperative comparison.

Nasal Cavity Lift

Cesar Luchetti and Alicia Kitrilakis

Department of Implant Dentistry. National University of La Plata. Argentina

Nasal cavity lift associated with implant placement is not a common procedure. However, is useful in some cases with ridge atrophy and a low nasal floor. In this case we describe the technique to do the nasal lift. The surgery was performed by Dr. Luchetti and crowns were made by Dr. Kitrilakis.

The nasal cavity lift is some times easier than maxillary sinus lift. The pituitary mucosa is often more resistant than Schneider membrane and there is not need to make an access window.

The technique is simple. Once the incisions were made, the flap must be raised to reach the nasal cavity. Then, the mucosa is detached using the same curettes we use to use for sinus lift procedures and a bone graft is placed below the pituitary. Implant placement can be done simultaneously or in a two stage approach. The main difference with sinus lift is that is not recommendable to make a lift bigger than 3-4 millimeters.

Preoperative situation.

Flap raised. An old failing implant is present

and must be extracted.

Curette doing the pituitary lift before the final

placement of the implants.

Implants in position. Due to limitations in the

ridge anatomy, there were placed in the areas

where we achieved the best initial fixation.

The blue arrows point the nasal cavity.

Graft in nasal cavity placed.

In this case we use a bovine hidroxyapatite.

Graft placed in the ridge irregularities.

Polilactic Acid polimerizable membrane is

placed to protect the graft.

Suture.

Seven days postoperative.

Abutments in place.  

Metal substructure try in.  

Final ceramic crowns.

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