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ePaper created 2016-06-21, 09:24:47 | version 1.38.0
| case report use of CBCT 06 cone beam 2 2016 Fig. 6: Re-implant placed flapless. Fig. 7: Panoramic radiograph, restoration. Table 1: Technical data. tient’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 man- dible was performed. CBCT (Planmeca ProMax 3D s, PlanmecaOy,Helsinki,Finland;Table1)andthemea- surements in millimeters of the bone height and angulation using tools of the Planmeca software (Romexis 2.5.1.R), in the most representative CBCT transversal slice demonstrated the possibility of placinga13mmimplant(853213–3.2mmD,13mmL ImplantDirectLegacy3,ImplantDirect,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 planning, – 2April2014qualitycontrol(QC)phonecallwithno patient response, possibly due to disappointment over many changes in treatment plan, – 6 April 2014 implant placement 3.2x13mm 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), – postoperative one-year maintenance visit on 10August2015showedhealthyfunctionalresults 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 (13mm) and diameter (3.2mm) was measured (Fig. 9). 2. Coronal CBCT slice in which the openings cor- responding to the lingual 1.9mm and buccal 2.5mmbonethickness,wasmeasuredrespectively (Fig. 10). 3. Transversal CBCT image from lingual wall demon- strating the severe SF depression (Fig. 11). 4. AxialCBCTsliceshowstheheightoftheextraction socket as 8mm (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 therightandtheleftSFsareseenasclearradiolucent 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 thelingualplateoftheboneinthatarea.12 Thesurgery was performed without raising a flap for better postoperative healing.13 Traditionally, we do not re- quire CBCT images for a single implant placement.14 However, this case signifies the importance of 3-D imaging in certain situations like deep SF (Fig. 11). When the bone width is narrow, periosteal elevation is recommended to be able to safely observe the os- teotomic drills as they reach to the final depth. This procedureisonlyadvisedwhenapanoramicimageis the only diagnostic tool we have as it adversely causes further bone loss during the healing phase.13 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 22016