Extraction, Internal Sinus Lift, Immediate Implant, and Final Restoration – Without Ever Taking An Impression

Let’s walk through a case from start to finish.  I’ll put more emphasis on the surgical phase and just outline the restorative phase.

Tammy is like many of our patients.  She is fearful of dentists and only visits when things are hurting.  Tammy came to our office for limited exam (emergency visit) to evaluate her broken upper left first molar (#14).  Our brief exam revealed a significant fracture of the mesiolingual cusp #14 and heavy calculus buildup. 

Preoperative closeup of severely fractured tooth #14

Preoperative closeup of severely fractured tooth #14

Based on the clinical finding our treatment plan was for the removal of #14 to deal with her chief complaint.  I also expressed concern regarding her overall gum health and recommended full mouth scaling and root planing.

Tammy’s first question was how long would she have to go without a tooth and how many visits this would take.  My answers were that I could complete her care in two visits about 4 months apart and she would only be without a tooth for that time period.

Her next question was how do you do this and make me comfortable.  To this I answered that we offer oral sedation.

Her final question was how much and how does she pay for it.  To this, I invited our treatment coordinator into the room and went over the details of our visit and Melinda put together a written plan and written financial arrangements for Tammy.

Tammy agreed to treatment and selected our in office no interest 6 month payment plan.  Her first visit would be full mouth scaling and root planing with our hygienist and then extraction/implant with myself in a single visit.

Between her emergency visit and her treatment visit, I finalized her implant plan and ordered a surgical guide for implant placement.

3D slice showing location of sinus and root divergence allowing adequate bone for stability

3D slice showing location of sinus and root divergence allowing adequate bone for stability

occlusal view of CEREC integrated data

occlusal view of CEREC integrated data

digital surgical guide

digital surgical guide

Her implant planning showed sufficient bone to allow for immediate placement. I recognized that we were going to be close, if not into, the sinus so we were prepared for a minor sinus bump.

Immediate placement is predicated upon removing the tooth ‘atraumatically’ and not damaging the bone.  My preferred method of extraction for immediate placement is to section the tooth and remove each root individually.

'Atraumatic extraction involves cutting off crown and sectioning root

‘Atraumatic extraction involves cutting off crown and sectioning root

extraction complete maintaining buccal plate and septal bone

extraction complete maintaining buccal plate and septal bone

Once the tooth is removed and the site debrided, the surgical guide is placed and the ostotomy completed.  In the case of maxillary molars (softer bone), I will purposely undersize the osteotomy to preserve bone and gain stability.  This concept is predicated on using an active implant that is self tapping and condensing.

surgical guide seated in place

surgical guide seated in place

undersized osteotomy completed

undersized osteotomy completed

Since we were quite close to the sinus, I removed the surgical guide, flushed the osteotomy to remove any debris. I gently ‘up fractured’ the floor of the sins with an osteotome.  I then went ahead and placed particulate bone into the extraction sockets and into the osteotomy. 

particulate graft material inserted into socket and osteotomy

particulate graft material inserted into socket and osteotomy

The surgical guide is then placed back into the mouth and the implant is driven into place.

implant being inserted through surgical guide

implant being inserted through surgical guide

implant achieving stable torque

implant achieving stable torque

implant immediately after placement

implant immediately after placement

My preferred implant is the NobelActive.  I prefer this implant because it is end cutting and condenses the bone.  I find that I can almost always attain primary stability with this implant.  It will also divert the particulate bone into the nooks and crannies of the site.  In this case it also drove the graft material slightly into the sinus for my internal sinus lift.

radiograph immediately after placement

radiograph immediately after placement

A collagen plug was used to cover the site and several sutures were placed to hold it all together.

site immediately after completion

site immediately after completion

Patient returned for a brief check at the 2 week mark.  At this visit we also went ahead and scheduled Tammy for a single visit implant restoration visit at the 6 month mark.  This would also coincide with one of her perio maintenance visits.

site at 2 weeks for post op evaluation

site at 2 weeks for post op evaluation

At her six month visit, prior to beginning restorative treatment the site is evaluated clinically and radiographically.

site at 6 months

site at 6 months

radiograph at 6 months

radiograph at 6 months

Since there is a large band of keratinized tissue – a benefit of immediate placement with ‘gap’ grafting is the preservation of the site dimensions.  A punch was used to uncover the implant.  A slight amount of lidocaine is given directly to the crystal tissue and the surgical guide is used to punch the tissue.

surgical guide used to allow for tissue punch uncovery

surgical guide used to allow for tissue punch uncovery

tissue punch uncovery

tissue punch uncovery

A digital impression post is placed onto the implant and scanned with CEREC to fabricate the idealized screw retained implant restoration.

digital impression post in place at time of uncovery

digital impression post in place at time of uncovery

digital implant restoration design

digital implant restoration design

After the restoration is milled and stain/glazed it is bonded to the TiBase and delivered to the patient.

final restoration at delivery completed on same day as uncovery

final restoration at delivery completed on same day as uncovery

About the Author Tarun Agarwal

Dr. Tarun Agarwal represents the next generation of leadership for the dental profession. As a respected speaker, author and opinion leader, he is changing the way general dentists and their teams practice.

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  • Michael Gagaoudakis says:

    Nice case, great documentation. Thanks for sharing.

  • Harris Siegel says:

    Great case, Tarun! As always, thanks for sharing!!

  • That is a beautiful case example!

  • Sean Mooring says:

    Wonderful case Tarun! Thanks for sharing and inspiring us.

  • Excellent case | presentation | care and expertise. Bravo

  • Tarun, please confrim you place your particulate graft into the osteotomy and then place your implant …. Do you not find that you will get less autogenous bone engaging with your implant from the osteotomy ?

    • i place the allograft into the extraction socket and into the osteotomy. The material in the osteotomy is gently pushed into the sinus (internal lift) with the osteotome. The implant is then driven into place.

  • Great case and very nice photos showing the procedure.
    I found the blog helpful with my work.
    many thanks

  • Mickey says:

    Great case and presentation. Thanks.
    Did you place the implant into the palatal root position?
    Also, my Pan x ray unit has a severe oil leak and repair is $12,000. I was thinking of upgrading to a sirona CT scan so can integrate with my cerec. I am new to placing implants, although been restoring them for over 10 yrs(not with my cerec omnicam as I never managed to learn to do it properly….)
    Do you think this is a good move?
    Thanks
    Mickey
    London
    Uk

    • T-Bone says:

      Mickey… we did not place this into the palatial root. We actually guided it into the interseptal bone as that was the most ideal restorative driven position.

      You will absolutely love the integration capabilities. The key is dedicating the time to master and learn the possibilities.

  • Mickey says:

    Thanks
    Uk

  • Mickey says:

    Thanks Tarun
    Do you have any training for cerec implants and for the ct integration I can purchase from you?

  • choong chai says:

    Nice case Tarun as always

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