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Dental Tribune Middle East & Africa Edition | 3/2017 ◊Page 12 mCME 13 Fig. 12. Laser degranulation Fig. 14. Positioning of the implant Fig. 15. Immediate implant placement with tempo- rary crown Fig. 16. Control panoramic view at two months Fig. 13. Use of OsteoSafe® in the extraction socket after debridement and decontamination of a self-tapping conical implant (Axiom PX®- Anthogyr). this In case, where bone re- covery along the osteotomy walls was not necessary, only convex inserts were used. The palatal and subcrestal position of the implant is respected (Fig. 14). The gap between the implant and the vestib- ular cortical bone is not filled. Care- ful choice of the implant abutment enables an ideal emergence both in terms of hard tissue and soft tissue. The temporary crown is thereby shaped in such a way that it closes the gap by slightly compressing the marginal gum (Fig. 15). teotomes, which were all that were available up un- til then. The idea was actu- ally to enable lateral peri- implant bone condensing in order to increase nota- bly, primary stability and compensate for the lack of vertical dimension of the sub-sinus native bone. The objective of this technique is to maintain, if possible, the entire maxillary bone by laterally pushing back the bone with minimal trauma while creating a precise osteotomy that breaks the last millimeter of the sinus floor while protecting the si- nus membrane. The consequence is the notable increase in peri-implant bone density with a high elevation of BIC (Bone Implant Contact) and, therefore, bone stability. Case 2 The patient presented with a fracture of #24 with significant periapical in- fection (Figs. 9,10). It was decided that an extraction would be performed with immedi- ate placement and loading of an implant after complete decontami- nation of the extraction socket using lasers (Figs. 11, 12). Next, Osteo Safe® was used (Fig. 13) to enable gentle trabecular expansion and placement It is mounted out of functional oc- clusion. Of course, the patient was advised to avoid voluntary chewing on this implant and only use local cleaning with cotton soaked in Chlo- rhexidine. Following verification of the osse- ointegration (Fig. 16), the impression was made eight to 10 weeks after sur- gery, followed by placement of the permanent prosthesis (Fig. 17). Conclusion The implant placement technique with the use of osteotomes is not a new concept. On the other hand, using an automatic osteotome pro- vides a better view of the site and makes it possible to practice flapless surgery, to position more precisely and obtain more homogeneous progression, in comparison to us- ing bone taps with a surgical mallet. From the patient's perspective, sur- Fig. 17. Permanent crown at three months to be well executed. The cone beam 3-D imaging in the first place showed a healthy sinus without inflamma- tion or infection as well as bone re- modelling at the apex and around the implant (Fig. 7-8). In the case of a trans-alveolar sinus lift combined with the placement of an implant by bone expansion, con- vex-tipped inserts should be used first to enable lateral expansion, and then concave inserts enable scrap- ing of the bones of the lateral walls of the osteotomy to enable apical projection after breaking the last millimeter under the sinus floor. If a maxillary implant is to be placed completely in native bone, convex inserts suffice. The last insert that is placed is smaller in diameter than the implant that is chosen. The advantage of this technique was noted starting in 1996 by Summers himself with the use of conical oste- otomes as opposed to cylindrical os- ◊Page 11 Fig. 6a: An immature tooth that was laterally luxated, as can be seen by the empty socket space around the apex on the radiograph. Fig. 6b: The tooth was repositioned and splinted for two weeks. Fig. 6c: At the six-month recall there is good evidence that the apex is ma- turing and the pulp responds normally to cold. At the three-year recall the pulp chamber is completely calcified; however, the tooth responds normally to EPT and there is no apical pathology. Fig. 7: Ankylosis or re- placement root resorp- tion, in which the root structure lost and replaced by bone. Note that no apparent PDL space is seen. is pal necrosis, root resorption and/or arrested root development are con- firmed. In the case of a closed apex, revascu- larization is not expected. Therefore, endodontic treatment must be initi- ated two weeks after the tooth is re- implanted, and prior to removal of the splint. Treatment should not be initiated earlier because any further manipulation of the tooth prior to or immediately after reimplantation can cause further damage to the PDL. In addition, it has been shown that placing calcium hydroxide as an in- tracanal medicament immediately after reimplantation will promote inflammation that can lead to PDL damage.30 If the tooth had been kept dry longer than 60 minutes, per- forming root canal treatment prior to replantation is indicated.31 After the emergency situation has been managed and the tooth/teeth stabilized, the second phase begins, in which the pulpal condition and likelihood of root resorption have to be carefully evaluated and the patient followed over a period of months, if not years. Fig. 8a: Inflammatory root resorption second- ary to pulpal necrosis and infection in the pulpal space after avulsion. If diagnosed in time, it is pos- sible to arrest the root resorption and maintain the tooth. Extensive inflammatory root resorp- tion on a tooth that was avulsed and reimplant- ed, but no further treatment done for six weeks. Fig. 8b_Calcium hydroxide was placed in the tooth for three months. Apparent healing of the peri-root lesions and some reconstitution of a normal looking PDL. A follow-up timeline is essential to allow for intervention if signs of complications appear. In such cases, the expertise and training of endo- dontists become important. Diag- nosing, preventing and treating any pulpal complications are an integral part of endodontic training as are performing pulp regenerative pro- cedures and treating inflammatory root resorption (Figs. 8a & b). gical comfort is significant and very noticeable. It should be borne in mind that if you want to avoid using filling materials, tissue must be conditioned to enable its regeneration. For immediate post- extraction implant placement, lasers are of unrivalled usefulness, because they enable socket decontamination and induce bone regeneration. If the basic principles of this bone regen- eration are respected, the conditions are adequate enough to enable bone growth without the use of biomate- rials. These advantages are decisive dur- ing preparations such as alveolar si- nus lift as well as "split crest" where the buccal cortical bone is generally very fragile. Vital importance is attributed to the closure of soft tissue during implant placement, either by carefully choos- ing the healing screw (the height and diameter) or the implant abutment, enabling slight compression of soft tissue and providing the implant/ prosthetic connection system with a 'barrier' that enables the regenera- tion of the two families of tissues. These minimally invasive tech- niques still require many improve- ments and more wide-spread valida- tion. However, for ethical and safety reasons, the practitioner should al- ways suggest the least invasive tech- nique that contributes to, guides and induces this tissue regeneration for which, most of the time, we have the matrix around these traumatized zones. References 1. The utility of the electric mallet. Crespi R, Bruschi GB, Capparè P, Gh- erlone E. J Craniofac Surg. 2014 May; in 25(3): 793-5. 2. Electrical mallet implants placed in fresh extraction sockets with simultaneous osteotome sinus floor elevation. Crespi R, Capparè P, Gherlone EF. Int J Oral Maxillofac Implants. 2013 May-Jun; 28(3): 869- 74. 3. Electrical mallet provides essential advantages in split-crest and imme- diate implant placement. Crespi R, Capparè P, Gherlone EF. Oral Maxil- lofac Surg. 2014 March;18(1): 59-64. Editorial note: The full list of referenc- es available from the publisher. Dr Gilles Chaumanet Dr. Gilles Chau- manet graduated from the University of Nantes in 1983. He has worked in more than 15 dif- ferent countries on four continents. Since 2000, the practice of laser in his field has revolutioned his procedures. His prac- tice is limited to oral surgery and implan- tology in Paris and Verona, Italy. He holds different masters and post-grad- uates in laser, periodontology, implant therapy, oral surgery, anatomy and radiol- ogy. He is president of SOLA France (Socie- ty for Oral Laser Application), ambassador of Global Oral Implant Academy (GOIA), active member of CENALOS, member of French Society of Medical Laser (SFLM), member of International Academy of Per- iodontology (IAP), member of Italian So- ciety of Oral Surgery (SICO) and member of AGLZ Academy. He lectures widely in Europe, America and the Middle East. He is in private practice in Villeneuve-Loubet (France) and Verona (Italy). Visit www.drchaumanet.com. Conclusion Traumatic dental injuries present difficult challenges for both patients and their dentists. Current evidence allows the dental health care provid- er to manage situations that, in the past, often resulted in crippled den- tition and unsightly appearance. Ap- propriate treatment can turn what at first glance looks like a hopeless situation into a very satisfactory out- come for patients. The endodontic specialist can play an important role in the team approach to treating pa- tients with traumatic dental injuries. References 1. Diangelis AJ, Andreasen JO, Ebel- eseder KA, Kenny DJ, Trope M, Sig- urdsson A, et al. International As- sociation of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012;28:2-12. 2. Andreasen JO, Ahrensburg SS, Tsil- ingaridis G. Root fractures: the influ- ence of type of healing and location of fracture on tooth survival rates - an analysis of 492 cases. Dent Trau- matol 2012;28:404-409. 3. Bucher K, Neumann C, Thiering E, Hickel R, Kuhnisch J. Complications and survival rates of teeth after den- tal trauma over a 5-year period. Clin Oral Invest 2013;17:1311-1318. Editorial note: Reprinted with permis- sion from the American Association of Endodontists, ©2014. A complete list of references is avail- able from the publisher. Asgeir Sigurdsson, DDS,MS He was a full-time faculty member at UNC School of Dentistry from 1992 until 2004, first as an assistant professor and then associate professor with tenure beginning in 2000. He was appointed as the gradu- ate program director of endodontics (spe- cialty training) in 1997 and served in that position until 2004. From 2004 to 2012 he was in a private endodontic practice in Reykjavik, Iceland, and London, England. He is active in many professional organi- zations and is past president of the Inter- national Association for Dental Trauma- tology (IADT). He received the Edward M. Osetek Educator Award from the Ameri- can Association of Endodontists in 1998.