Patient information A 64-year-old male, hypertension, diabetes, and previous myocardiac infarction. Hypertension and diabetes were controlled with exercise and diet, but he had a stent in his heart, and had taken aspirin. He had poor oral hygiene and generalized periodontitis. treatment plan:· General periodontal treatment before surgery· Sinus bone augmentation with SLA technique· Implant placement in #16 and 17 right after extraction of #17 at the time of sinus graft (Class IV CM/C fixation)
Preoperative observation
Initial panoramic view: severe pneumatization of right maxillary sinus and periodontally compromized teeth #17, 12, 46 and 47 were observed.
A picture before surgery (after anesthesia). It shows abundant keratinized gingiva. Deep periodontal pockets existed in the buccal (7mm) and lingual (8mm) sides.
#17 was extracted and thoroughly cleaned up.
Full thickness flap with papilla preserving incision was made. For autogenous bone collection from maxillary tuberosity, flap was extended to the posterior part with No. 12 blade.
Horizontal incision was slightly inclined to the palatal side so as not to disturb drilling.
Ø6.5mm LS-reamer was located at the lowest area of the sinus floor between #16 and #17 so that it was easy to elevate the membrane from the bottom of the sinus. It is better to hold the hand piece firmly as the reamer tends to wobble during drilling.
A bony window was made about 5mm superior to the crestal part of #16,17. The Schneiderian membrane was clearly seen with some piece of thin bony wall. Even though the membrane was contacted by the reamer directly during drilling with more than 2000 rpm, it was still safe from membrane tearing. The membrane was elevated with microelevators from the SLA kit.
Sufficiently hydrated syringe type RegenOss (Cellumed, Seoul Korea) was grafted under the elevated membrane. The posterior area of the sinus was filled first, the anterior part second, and the center last. There can be a void at the anterior part because the patient is in a supine position. It can be helpful to push the bone graft material to the anterior direction to prevent void formation.
Initial stability of #16 and 17 implant was about 40 Ncm. The bone defect around implant #17 is observed.
Autogenous bone collected from a maxillary tuberosity was filled between extraction socket and implant after healing abutment connection.
A clinical view after surgery. The one-stage approach was performed. The extraction socket was completely closed by management of soft tissue.
A panoramic x-ray after surgery. Well-grafted, dome-shape bone graft material around #16 and #17 implant can be observed.
A periapical x-ray at the delivery of a definitive prosthesis (2 unit PFM SCRP) 4 months after the surgery.
While waiting for the healing time, implants in the #12 and 47 area were placed and delivered at the same time. A panoramic x-ray at the delivery of a definitive prosthesis (2 unit PFM SCRP).
Buccal view of left side in centric occlusion.
Radiograph after 2 years. Bone graft material seemed to have matured well, and remodeling of the sinus floor is clearly seen.
8 year follow-up radiograph after the surgery. The sinus floor has been modified by remodeling. No other specific change can be seen.