I’d Hit That: Mallet Driven Sinus Lift with Legacy 4 Implant

Here is a fun case using the Legacy 4 implant with the new fixture mount and healing collar.  #14 healed for 3 months post graft with DFDBA and a collagen membrane. Previous fractured tooth at the bone level.  I started wanting to do a CEREC Guide, and yes its my own damn fault, the thermoplast really got under the rotated #13 and #1. I could get it off my Mach 2 model, but could not get it into the mouth.  Drilling on Thermoplast is about as easy as herding chickens so I could not get it to seat and did not have time to go back and block out the model so I punted.

 

I have about 8mm of bone above the sinus and a somewhat narrow ridge for a molar.  I planned a 10mm 4.7 by 10 Legacy 4 and we will bump the sinus and graft ahead of the implant.  The tough part will be the tipping of #13 and #15, especially without a guide.

 

Used a large punch, this is an early prototype of my punches that I rejected as it was too short.  Although we are not using a Guide, I could use some drill stops.  In this case I used the Zosseo stops.  They function as a bumper laterally as they are quite a bit larger that the implant and just barely got in between the M and D contacts of 13 and 15.  And of course they regulate depth as well.

 

 

You can see how wide the yellow stop is and its really keeping me centered.  Per the Curve of Wilson we know that #14 tips slightly buccal.  You can see the funky angulation mesio distally I had to place the implant to get centered in the edentulous space with the tip of #15

 

 

 

 

We have a bone height of about 8 and a tissue height of about 3 so I placed the stop at 15mm so I could gain about 3mm.  One or two hits with the mallet and I was up.

 

In this case the stop of the Osteotome engaged the tissue, if you were doing a flap you would want to set it to the bone level.  Felt around with the ball ended probe and we had a nice hard lifted floor, so no need to lay a membrane down on the sinus membrane.  Packed DFDBA into the osteotomy with my new graft packing tool, note the IME blue color ;}

 

 

 

 

There is about 3-4mm of graft in the osteotomy so we placed the implant in and advanced it up.  Warn your patient that they will feel pressure.  Obviously do this dry to keep blood on the implant and to not wash away your graft.

 

 

 

Final, I think we got a good result.  This is the new freebie healing collar that comes with the Legacy 4.  Too narrow a space for a Contour Healer, but I may try a pre molar sized one later.  From a restorative standpoint I may do some “Porcelainectomy” on #13 distal and #15 medial in 4 months.