Peri-implant Bone Lesions and Re-osseointegration

César Luchetti

Article published in the December 2010 issue of Maxillaris (Spain). Article in Spanish.

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Ridge Splitting, Nasal Cavity Lift and Simultaneous Dental Implants Placement

Cesar Luchetti

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.

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 use both approaches together, in order to have the possibility to place the implants.

Preoperatory situation.

Flap raised. An extremely atrophied ridge is observed. 
Also, the nasal cavity is shown. (Black arrows)

Doing the pituitary membrane lift using a curette.

Doing the pituitary membrane lift using a curette. 

Diamond disk used to perform the cut of the ridge to initiate

the splitting.

Making the cut using the disk.

Initial ridge split.

Ridge split after using the chisels.

Final expansion using threaded expanders.

Surgical sockets.

Implants placed.

Graft placed in the nasal cavity. (Black arrows)

Graft placed between the expanded plates.

Suture.

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Maxillary Sinus Lift in a Case with a Complete Partition Wall and Simultaneously Placement of Dental Implants

Cesar Luchetti

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

Maxillary sinus usually presents partition wall inside, but normally they are incomplete. When a complete partition wall is present, the sinus lift procedure could be more difficult. In such cases, the lateral wall must be taken out (because it is impossible to move it medially inside the sinus) and create two different access at both sides of the partition wall.

In the following case the technique to do this is showed.

Preoperatory situation

Flap raised.

Maxillary sinus access, after the lateral wall

was retired, showing the partition wall.

First load of the bone graft into the medial

part of the sinus.

Implants placement.

Bone graft is completed.

Suture.

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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

...

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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Bone Expansion Using Threaded Expanders

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

In the previous post, a group of instruments for bone expansion was analyzed.

Bone atrophies must be treated adequately to allow the implant placement in optimal position, according to the biomechanical requirements, and also to achieve better esthetics of the future crowns.

Here we are presenting a case, where there is bone atrophy and a low insertion of the frenulum. 

The therapeutic approach was to make a bone expansion together with a frenectomy.

Bone atrophy and a low insertion of the frenulum.

After raising the flap, the bone atrophy is

observed, which is more important in the

anterior part.

Expander number 3 in position.

Expander number 4 in position. With this one

is enough to place a 4 mm diameter implant.

Bone expansion achieved.

Implants in place.

Implants in place from another view.

Suture of the flap.

In the buccal aspect the suture associated

with the frenectomy is observed.

Pre and post operatory 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.