PMC3886442_01
Initial X-ray examination.
CRIM.DENTISTRY2013-612108.001.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.001.jpg
fig1
A 51-year-old male patient (R.R.), with good general health (ASA 1), nonsmoker, was referred to our department for rehabilitation of the first molar (Figure 1).
X-ray examination after first extraction: residual root and insufficient bony support.
CRIM.DENTISTRY2013-612108.002.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.002.jpg
fig2
Bone lesion occurred trying to retrieve the residual fragment before sinus lift approach.
CRIM.DENTISTRY2013-612108.003.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.003.jpg
fig3
To avoid a higher bone loss and oroantral communication (Figure 3), it was decided to leave the last apical fragment in the alveolus.
((a), (b)) Radiographic exams (paraxial images) also revealed not only the residual root apex in the palatal side, but also insufficient bone volume.
CRIM.DENTISTRY2013-612108.004.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.004.jpg
fig4
As for any other sinus floor elevation case, reformatted computer tomography (CT) scans were required to examine insufficient bony support (Figure 4).
Surgical site.
CRIM.DENTISTRY2013-612108.005.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.005.jpg
fig5
An intrasulcular and crestal incision was performed and a full-thickness mucoperiostal flap was reflected to expose the maxillary and palatal wall (Figures 5 and 6).
Alveolar bone exposed.
CRIM.DENTISTRY2013-612108.006.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.006.jpg
fig6
An intrasulcular and crestal incision was performed and a full-thickness mucoperiostal flap was reflected to expose the maxillary and palatal wall (Figures 5 and 6).
Antrostomy on the lateral maxillary wall.
CRIM.DENTISTRY2013-612108.007.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.007.jpg
fig7
(a), (b): Intra-operative images during retrieval of residual root apex through the antrostomy.
CRIM.DENTISTRY2013-612108.008.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.008.jpg
fig8
The residual was removed without difficulty with hemostatic clamps (Figures 8(a) and 8(b)).
(a) Insertion of graft material; (b) collagen membrane positioned.
CRIM.DENTISTRY2013-612108.009.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.009.jpg
fig9
Particulate graft material (Geistlich Bio-Oss) was inserted between Schneiderian membrane and sinus floor and also between implant and vestibular tissue to fill the gap (Figure 9(a)).
Reopening after 3 months.
CRIM.DENTISTRY2013-612108.010.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.010.jpg
fig10
After three-months, the second-stage operation was carried out to expose the fixture and cover screw was placed (Figure 10).
X-ray control after 3 months.
CRIM.DENTISTRY2013-612108.011.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.011.jpg
fig11
Radiograph examination showed (Figure 11) correct osteointegration, displaying good bone filling and the successful fractured apex retrieval (Figure 12).
Retrieved residual root fragment.
CRIM.DENTISTRY2013-612108.012.jpg
PMC3886442_01_CRIM.DENTISTRY2013-612108.012.jpg
fig12
Radiograph examination showed (Figure 11) correct osteointegration, displaying good bone filling and the successful fractured apex retrieval (Figure 12).