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ePaper created 2016-03-24, 17:16:09 | version 1.38.0
| case report 32 implants 1 2016 Fig. 6: Re-implant placed flapless. Fig. 7: Panoramic radiograph, restoration Table 1: Technical data. sion resulted from the fact that the mesio-distal length of the bridge required to accommodate three teeth was 18 mm and not 21 mm. The height of the extracted implant and the available bone was 8 mm when the panoramic im- age was evaluated (Fig. 4). As the available diag- nosis information did not provide data regarding the desired diameter and angulation of the implant to be placed, the patient’s consent for CBCT (plan D) was obtained and added to the contractual treatment plan. Only then, the radiograph of the molar region of the right mandible was performed. CBCT (Planmeca ProMax 3D s, Planmeca Oy, Hel- sinki, Finland, Table 1) and the measurements in millimeters of the bone height and angulation us- ing tools of the Planmeca software (Romexis 2.5.1.R), in the most representative CBCT transver- sal slice demonstrated the possibility of placing a 13 mm implant (853213 – 3.2mmD, 13mmL Implant Direct Legacy3, Implant Direct, CA, USA) with 35 degree lingual angulation to avoid SF (Fig. 5). Treatment timeline The timeline detailing the entire treatment was as follows: –– 31 March 2014 Diagnosis and treatment plan- ning –– 2 April 2014 quality control (QC) phone call with no patient response, possibly due to disappoint- ment over many changes in treatment plan –– 6 April 2014 implant placement 3.2 x 13 mm im- plant direct (Fig. 6), –– 15 April 2014 QC with positive response, –– 14 June 2014 uncovering and impression using open tray technique, –– 17 June 2014 QC with positive response, –– 21 June 2014 prosthesis 2 unit bridge PFM ce- mented with Temp Bond (Fig. 7), –– post-operative one-year maintenance visit on 10 August 2015 showed healthy functional re- sults as recorded (Fig. 8). Analysis of patient images 1. Axial CBCT slice in which the angle required (35 degree) to bypass SF corresponding to longest necessary length (13 mm) and diameter (3.2 mm) was measured (Fig. 9). 2. Coronal CBCT slice in which the openings cor responding to the lingual 1.9 mm and buccal 2.5 mm bone thickness, was measured respec- tively (Fig. 10). 3. Transversal CBCT image from lingual wall demonstrating the severe SF depression (Fig. 11). 4. Axial CBCT slice shows the height of the ex- traction socket as 8 mm (Fig. 12). Panoramic radiography, in which images of the right and the left inferior alveolar nerves are clearly seen below the opaque mylohyoid line, demonstrate that the right and the left SFs are seen as clear ra- diolucent areas, with the IAN giving the illusion of sufficient length to place a regular size implant. Discussion The use of a wider diameter implant with the same height was the alternative solution if CBCT was not available. CBCT occlusal images (Fig. 10) indicated that a wider implant diameter would have destroyed the lingual plate of the bone in that area.12 The surgery was performed without raising Fig. 6 Fig. 7 Anode voltage 60–90 kV Anode current 1–14 mA Focal spot 0.5 mm, fixed anode Image detector Flat panel Image acquisition Single 200 degree rotation Scan time 7.5–27 s Reconstruction time 2–25 s 12016