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JEREMY BEWLEY
Hard to see on my phone Chuck, but it looks like
a case where fixture placement and simultaneous
grafting would work well for me. You’d probably have to graft
even with the 4.1.
FARHAD BOLTCHI (FACULTY)
I agree with Jeremy’s comments above: I think
this is a very predictable and easy implant place-
ment, with simultaneous bone grafting case, doing it as Daniel
has suggested above.
Regarding ridge splitting/ridge expansion: not a big fan.
You can try all sorts of fancy splitting and expansion tech-
niques, but you are still going to need to graft, so why not just
place the implant and graft the couple of exposed threads..
One tip: if you place a Straumann Bone Level implant,
don’t place a cover screw. Rather, place an RC 4.5 mm x 2 mm
conical healing abutment, then submerge the implant with it
instead of with a cover screw. You will thank me at the uncov-
ering appointment.
CLIVE DICKINSON
Farhad, I know, is generally left as the last word,
but I would like to suggest a ridge split method.
Charles, when you went to Boston and did the three courses
back-to-back, Ridge Splitting was one of the topics listed and
Professor Shadi Daher would have run you through this.
I did purchase the Mectron Piezosurgery last year, and
just love it for those difficult extractions cases; but I followed
Shadi’s technique for ridge splitting: cutting the rectangle
from the crest down on the buccal, and leaving it a month
before another crestal incision. Then, finding the crestal
split and chiselling it apart, drilling osteotomy past the lower
buccal horizontal cut (the buccal segments flaps against the
drill piece, but the periosteum and gingiva are attached),
in-filling the space with graft (likely TcP ) and close.
If it is a standard implant, you have fixation, but it’s totally
applicable toBicon aswell. Allowa little deeper placement—say
1.5 mm because of crestal resorption. It sounds like a busy tech-
nique—and the treatment gets spreadout—but at the endof the
day youwill have teased out that buccal wall that was sloping in,
and allowed keratinisation-type healing of the split on top.
Charles, in your case, if you don’t do the above, perhaps
drop to a 3.3 Roxolid BL. I must say, I felt very comfortable
with Piezo cutting through the cortical plate to “free” it up,
and the bloodless field and the inability to cut soft tissue has
much merit; eliminating the rotary cuttings methods via
Piezo has advantages as well.
DAVID HONEY
I would use the Densah burs on that. I’ve gotten
great results just from the expansion in that area.
May need to graft it, but I haven’t had to yet.
KIRSTEN ANDREWS
In the suggestions of placing the graft at
implant, what is the best suggestion for keeping
the membrane in place? Can you place the membrane —
partially over the implant and put the cover screw through
it? In the past, I have had difficulty keeping it from moving
everywhere.
Thanks Chuck for posting this case. I love what I can learn
on this site.
EMIL VERBAN
I would second the suggestion from David.
CHARLES LOGIUDICE
I want to thank everyone for their responses. I
have a lot of surgery experience, but very little
implant surgery/bone grafting experience.
Perio and I haven’t been a good fit. I have a very difficult
time fathoming how the Densah bone expanding osteotomy
drills would give the amount of ridge expansion necessary for
this case. Possibly by drilling a little deeper than planned? I
amconsidering referring this one for the bone grafting, letting
it heal five or six months, and then placing the implant.
KARL SCHNECK
Did you try planningwith a Bicon? They like being
buried and might fit well without any grafting.
The sloping shoulder and a taller abutment post might work.
