logo 19 • CAMLOG Partner Magazine • December 2018 13 the implant neck should be developed or preserved to a thickness of approximately 2 mm. For this reason, it is necessary to align the implant position in the sagittal dimension towards palatal and to build up a distance of approx. 2 mm [3;4] (“jumping distance”) between the facial bone wall and the buccal implant neck. The cavity between the implant and the bone lamella should be filled with modern bone substitute materials to ensure safe filling of the gap with bone. Implant surgical intervention To avoid postoperative wound infections, the patient was given antibiotic cover preoperatively. 1000 mg amoxicillin three times a day for one week was given as preventive treatment. First, the teeth were extracted gently using a periotome to preserve the bony structures and the alveoli were cleaned of inflammatory tissue residues using a bone curette. Implant positioning was performed using the 3D implant positioning system [5]. To preserve the buccal bone wall, the sagittal orientation was aligned palatally. The vertical positioning depends on the buccal bone margin level and the implant hardware and is determined by measuring the biological width of the adjacent tooth. The distance between the gingival margin to the bone was 3 mm in each case. The expansion of the sleeves corresponds to the most common implant diameters (3.3; 3.8 and 4.3 mm), taking into account the required distance of 2 mm to the adjacent tooth or 4 mm between two implants. First, the implant positions in region 12 and 21 were determined by placing the 2 mm extension of the sleeve against the buccal wall of the alveolus (Figs. 7 and 8). Pilot drilling for the exact 3D alignment was performed centrally through the sleeve. The implant sites were prepared for the insertion of two implants (tapered internal implant Ø 3.8 mm/L 11 mm, BioHorizons, Birmingham, AL) with the appropriate system drills. The implants were inserted with primary stability and the “Jumping Distance” of approx. 2 mm was filled with bovine bone substitute material (MinerOss® X Granulate/BioHorizons) to stabilize the bone wall. Subsequent augmentation of the alveolar bone in region 11 to reconstruct the buccal wall was performed with the alveolar protector (KLS Martin, Tuttlingen). The shape of the protector made of resorbable poly-D-L lactide allows the threedimensional construction of the alveolar ridge with a minimally invasive procedure. [6]. The protector is dimensionally stable and the degradation process begins after about 4 months. Bone augmentation is essential to create an anatomically shaped alveolar ridge and to maintain a natural mucogingival margin. After the minimally invasive preparation of a mucoperiosteal flap, the alveolar protector was inserted into the prepared pocket (Fig. 9). Owing to this flap formation, the protector could be inserted exactly, so that the system-inherent fixation using a pin with ultrasound (Sonic Weld) became unnecessary. Augmentation was performed with MinerOss X (BioHorizons). The bone substitute material is well suited for alveolar management. With a particle size of 250 to 1000 µm, it can easily be inserted into the defect site. The bimodal pore structure leads to rapid blood uptake of the material (Fig. 10). The natural consistency and the complex trabecular framework promote ideal new bone formation. Slow resorption rate provides the required stability for the buccal wall. Fig. 4: The alveoli on 12 and 21 were intact, but partial bone loss was visible on the facial lamella in region 11. Fig. 5: The sectional view of tooth 21 showed congested root filling material and the fractured root tip. Fig. 6: The sectional view shows the loss of facial lamella and root resorption of tooth 11. Fig. 7: After gentle extraction of the teeth, the implant positions were determined using the 3D implant positioning system. Fig. 9: To create an anatomically shaped alveolar ridge, an alveolar protector was inserted into the prepared mucoperiosteal pocket. Fig. 8: To preserve the buccal bone wall, the sagittal orientation of the implants was aligned palatally. CASE STUDY
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