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case report I I 23implants4_2015 healed bone. In addition, concave inserts during the breaking of the last sub-sinus millimetre enable lat- eralbonerecoveryofthis"bonesocket"whileproject- ing it apically. During sinus progression PRF mem- branes (or native collagen membranes) are placed in the osteotomy opening to fill the intra-sinus space thatistherebygained(theyalsoprovideprotectionof the sinus membrane). The Erbium laser is again passed through the os- teotomysockettovaporisethebonedebrisandsludge along the walls of this osteotomy. The implant is placed according to the manufacturer's recommen- dations, but with an even slightly higher torque if the titanium grade allows doing so. A healing screw that fits the diameter and height of the residual gap to be closed is carefully chosen (Fig. 6). If the healing screw does not enable primary clo- sureofsofttissue,PRFmembranesareusedtofillthe gap. If this gap is too big, a mucoperiosteal detach- ment of 6 to 10 mm and then a horizontal incision of theperiosteumof6to8mmaremade.Thistechnique serves to pull the gum around the healing screw by maintaining it with two sutures. The control X-rays clearlyshowedgoodosseointegrationoftheimplant, significant filling and regeneration in only three months, and then perfect filling and regeneration four months after surgery. The bone remodelling around and above the im- plantneckalsoseemedtobewellexecuted.Thecone- beam3-Dimaginginthefirstplaceshowedahealthy sinus without inflammation or infection as well as boneremodellingattheapexandaroundtheimplant (Figs. 7–8). In the case of a trans-alveolar sinus lift combined withtheplacementofanimplantbyboneexpansion, convex-tipped inserts should be used first to enable lateralexpansion,andthenconcaveinsertsforscrap- ing of the bones of the lateral walls of the osteotomy toenableapicalprojectionafterbreakingthelastmil- limetre under the sinus floor. If a maxillary implant is tobeplacedcompletelyinnativebone,convexinserts suffice. The last insert that is placed is smaller in di- ameter than the implant that is chosen. The advan- tage of this technique was noted starting in 1996 by Summers himself with the use of conical osteotomes asopposedtocylindricalosteotomes,whichwerethe only ones available up until then. The idea was actu- allytoenablelateralperi-implantbonecondensingin order to increase notably, primary stability and com- pensate for the lack of vertical dimension of the sub- sinusnativebone.Theobjectiveofthistechniqueisto maintain, if possible, the entire maxillary bone by lat- erally pushing back the bone with minimum trauma whilecreatingapreciseosteotomythatbreaksthelast millimetre of the sinus floor while protecting the si- nus membrane. The consequence is the notable in- creaseinperi-implantbonedensitywithahigheleva- tion of BIC (Bone Implant Contact) and therefore, bone stability. _Case 2 The patient presented with a fracture of tooth number24withsignificantperiapicalinfection(Figs.9 and 10.) It was decided that an extraction would be performed with immediate placement and loading of an implant after complete decontamination of the extraction socket using lasers (Figs. 11 and 12). Next, OsteoSafe®wasused(Fig.13)toenablegentletrabec- Figs. 7a–d_Panoramic views: a) Pre-op.; b) Per-op.; c) at three months, d) follow-up at one year. Fig. 8_Control at six months. Fig. 9_Preoperative view— fistula on 24. Fig. 10_Panoramic view with gutta- percha cone inserted in the fistula that reaches the apex. Fig. 11_Laser decontamination. Fig. 12_Laser degranulation. Fig. 10 Fig. 12Fig. 11 Fig. 7 Fig. 9Fig. 8 a b c d