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ePaper created 2016-09-14, 10:12:26 | version 1.38.0
| industry 22 implants 3 2016 sue grafts from the palatal flap or tuberosity can be harvested and sutured under the buccal flap. Alter- natively,anallograftconnectivetissueorathickcol- lagenmaterialcanbeusedtothickenthebuccalflaps when necessary. Surgical appointment The patient was pre-medicated with oral sedation (triazolam 0.25 mg), amoxicillin, a steroid dose pack and chlorhexidine gluconate (CHG) rinse, all starting onehourpriortosurgery.Thepatient’schinandnose were marked with indelible marker, and the OVD was measured using a sterile tongue depressor with simi- lar markings while the patient’s mouth remained closed. The patient was then given full mouth local anaesthesia. Starting with the maxillary arch, full-thickness flaps were raised and sutured to the buccal mucosa with4-0silktoprovideimprovedsurgicalaccessand vision. The teeth were removed with the goal of buccalplatepreservationusingthePIEZOSURGERY® (Mectron:Columbus,OH)forbonepreservation(tips EX 1, EX 2, Micro saw: OT7S-3). The sockets were de- granulated with PIEZOSURGERY® (tip: OT4) and irri- gated thoroughly with sterile water. With the anatomically correct surgical guide in position and firmly held in place by the surgical assistant, measurements were made from the mid- buccal of each tooth. Surgical cuts were made going from the anticipated cantilever of site #3 (FDI: #16) to site #14 (FDI: #26) using the PIEZOSURGERY® saw(tip:OT7).Ourteamgoalwastocreatethepros- thetic room necessary for a hybrid restoration i.e. 10–12 mm. The cuts were intentionally extended be- yondtheanticipatedcantileverlengthtocreateade- quate strength and thickness of the final prosthesis intheseunsupportedcantileverareas(Figs.5–6).The mandibular arch was treated in a similar manner. Additionally, bilateral mandibular tori reduction was accomplished with the aid of the PIEZOSURGERY® saw (tip: OT7) after the extractions and prior to the verticalbonereductionofthemandibularridge.Sub- sequently, the implants were placed. Theimplantsiteswerepreparedperthemanufac- turer’s protocol (except for bone tapping) for the Straumann® BLT implant. The implants were placed usingthesurgicalguidetemplatewiththefollowing insertion torques measured: site: FDI: #15, #12, #11, #21, #23, #25, #34, #32,#42/US: #4, #7, #8-9, #11, #13, #21, #23, #26. All torques were >35 Ncm with #28 (FDI: #44) recording 20 Ncm insertion torque values. All implants were 4.1 mm in diameter and 14 mm in length except FDI: #12, #11, #21, and #23/US: #7, #8–9, and #11, which were 12 mm in length(Fig.7).All17and30degree-angledimplants Fig. 6 Fig. 5 Fig. 7 Fig. 8 Fig. 9 Figs. 5 & 6: Extension of the cuts beyond the anticipated cantilever length to create adequate strength and thickness of the final prosthesis in unsupported cantilever areas. Fig. 7: All implants were 4.1 mm in diameter and 14 mm in length except FDI: #12, #11, #21, and #23/US: #7, #8-9, and #11, which were 12 mm in length. Fig. 8: Placement of tall protective healing caps. Fig. 9: Application of bite registration material to confirm there was no contact. 32016