8-Year Result of a Lateral Window Opening using an LS-reamer with a Small Vertical Incision

Situation

A 56-year-old male

His medical condition was normal and non-smoker.

The residual bone is about 4mm at #15 and 16 area. 6mm at #27

Pre-operative Panorama

Maxillary right second premolar and the first and second molars were missing. The alveolar ridge had enough bone and sufficient attached gingiva. The first premolar needed RCT and crown.

Flapless implant placement surgery with SLA technique using LS- reamer through a small vertical incision was planned.

A lateral hole was made by Ф7.5mm LS-reamer using 2000 rpm with copious saline irrigation. A large lateral hole can allow easy elevation of the membrane from the anterior to the posterior.

A lateral hole was formed and the sinus mucosal membrane was elevated with the microelevators in the SLA kit. The residual bone height of #17 area was about 9mm. This did not need a bone graft, just membrane detachment to make a Class II CMI fixation.

10mm vertical incision was done above the second premolar. The second premolar area was chosen for the best location of a lateral hole, which should be at the most anterior and most inferior area from the most anterior implant.

The flap was retracted for inserting the LS-reamer. Lateral wall of the maxillary sinus was seen from the small opening. To elevate the membrane for 3 implants, the reamer should be the largest one (Ф7.5mm).

A lateral hole was made by Ф7.5mm LS-reamer using 2000 rpm with copious saline irrigation. A large lateral hole can allow easy elevation of the membrane from the anterior to the posterior.

Simple interrupted sutures were made. Simultaneous implant placement was planned with a punching technique because there was sufficient attached gingiva and a wide ridge.

Punching the midcrestal attached gingiva with Ф5mm tissue punch. At least 2mm attached gingiva around the implant should exist for tissue punching technique.

3 positions were prepared for punching and the round tissue was detached for simultaneous implant placement.

Three CMI EB (Neobiotech, Seoul Korea) fixtures were placed: #15: EB4511, #16: EB510, #17:EB5010. The bone densities and ITV (insertion torque value) were D320 with 35 Ncm, D320 with 40 Ncm, and D342 with 35 Ncm for #15, 16, and 17 respectively.

Healing abutments were connected. There were more than 2mm of attachment gingiva around the healing abutments.

Panoramic view after the sinus graft and implant placement in the right side. Sufficient bone grafting was done at #15, and 16 area. At #17, only membrane was elevated and the implant was placed without bone grafting.

After 10 days, the incision area was completely healed. The patient felt almost no pain or swelling. That is the big advantage of the SLA technique with minimal vertical incision.

A periapical radiograph after 3 months healing. ISQ values were 75-80. Final impression was made at the visit.

A definitive 3-unit PFM FPD (SCRP) was fabricated.

Occlusal surface of the SCRP. Its design had screw holes but metal chimneys were not formed in order to enhance the esthetic aspect.

Finally, the SCRP superstructure was cemented with a permanent resin cement in the mouth.

The whole unit SCRP was removed from the fixtures by unscrewing. Access cement was removed and crown margins were polished at the outside of the mouth. The SCRP has many advantages: crown margin can be positioned at the sub-gingival area and emergence profile can be reproduced by crown contour.

The occlusal screw holes were filled with a permanent composite resin. It is a retrievable prosthesis like a screw retained one.

Buccal view after delivery of the prosthesis.

Periapical radiograph after delivery of the final prosthesis.

Panoramic view after delivery of the prosthesis.

8 years of follow-up panoramic view. All implants were well maintained without any noticeable bone loss.

8 years of follow-up periapical view. Bone levels were well maintained at the bioseal level.