f DT page 2A was too shallow; b) it was too close to perfora- tion and c) the peri-radicular dentine was insufficiently strong to sup- port a permanent restoration. These critical factors, in my opinion, rendered the tooth non- restorable. A cotton pellet and Cavit were placed in the access cavity and a follow-up call with the referring dentist was conducted in order to update him on the condition of his patient and to determine what recommendations should be given regarding the tooth. It was recommended to the patient that the tooth be extracted and the socket preserved through a minor grafting procedure. This would allow for an ideal amount of bone to receive a dental implant approximately four to six months later. It was also recommended that he receive some orthodontic treat- ment prior to the placement of the implant so that all the diastemas would be closed and the dentition properly aligned for this proce- dure. The patient clearly understood the concept and the logistics of the orthodontic treatment recom- mended but expressed no interest in this approach. The bigger picture It is very important in evaluating treatment using implants to con- sider the entire dentition and not just the space or tooth in question. It should be borne in mind that implants, unlike teeth, do not move, so if there are any mis- alignments in the dentition, orth- odontic treatment prior to implant therapy is imperative should the patient proceed with the dental implant at a later stage. If the treatment plan is not in this sequence, the dental implant could become a challenging obsta- cle during the orthodontic treat- ment. The patient was prescribed 500 mg Amoxicillin (one every six hours, beginning two days before the next appointment) and Chlorhexidine rinses (three times a day, also beginning two days before the next appointment). The use of tartar-control tooth- paste was also recommended in order to avoid staining of teeth. On the day of surgery, the patient’s blood pressure was 119/73 with a heart rate of 76. Under local anaesthetic (Lido- caine 2 percent HCl with epineph- rine 1/50,000 x 2 cpl) and using a dental rubber dam, magnification loupes and supplementary illu- mination, the tooth was sectioned into three pieces. The rubber dam was removed, and using PDL-Evator elevators (Salvin) all three roots were extracted without any complica- tions. Spoons were used to curette the socket in order to clean any granulation tissue and engage the cancellous bone. This crucial step results in some bleeding and thus promotes angio- genesis. The crest of the inter- radicular bone was engaged with the socket cupped part of a XiVE osteotome (DENTSPLY Friadent), and a sinus lift was performed using the Summer’s technique. There were no signs of a sinus perforation based on the Valsalva test. The sockets and sinus-lift area were then grafted with a mixture of DBX and MCP using a marshmallow technique. This grafting mixture helps the site produce its own bone in terms of mineral and collagen from the DBX, and it provides a better scaf- fold effect from the MCP. The area was covered with a PTFE mem- brane, slightly tucked under the periosteum (not more than 2 mm). Sutures were done with polygly- colic acid using a criss-cross four- x corner technique (Fig. 3). Removing the sutures The sutures were removed two weeks later. Two weeks after suture removal, the patient was seen again for the removal of the membrane. This was done by gen- tly picking at the membrane with cotton pliers and exerting pull on it — there is often no need for anaesthesia. The benefit of using this allograft cocktail is that the waiting period for re-entry was approximately four to six months versus six to nine had a xenograft been used. The quantity and the quality of the bone appeared to be much better with the use of this allograft cocktail. At the time of re-entry, the patient’s blood pressure was 113/69 with a heart rate of 64 (Figs. 4, 5). Under local anesthetic DENTAL TRIBUNE | April 2010 Clinical 11A AD Fig. 2: Bitewing X-ray after decay has been removed. Fig. 3: Grafted socket following extraction. Fig. 4: Peri-apical film showing heal- ing of grafting material after four months. Fig. 5: Pre-op film on the day of sur- gery. g DT page 12A (Lidocaine 2 percent HCl with epi- nephrine 1/50,000 x 2 cpl), a tissue punch access was done using a 3.8 tissue punch XiVE drill (DENT- SPLY Friadent). The pilot drill from the ANKY- LOS implant system (DENTSPLY Friadent) was then used to drill 6 mm, just short of the sinus floor (Fig. 6). A series of XiVE osteo- tomes, from size 2.0 up to 3.4, were used to perform a sinus lift using the Summer’s technique. The osteotomy was prepared to a depth of 11 mm (Fig. 7). A Valsalva test was performed to ensure that the sinus had not been perforated. An ANKYLOS implant A11 (3.5 mm x 11 mm) was placed and primary stability was obtained. The density of the bone perceived as D-3 during the drilling stage, likely changed to D-2 with the use of the osteotomes. The implant-transfer mount was removed, as was the cover screw that came pre-mounted inside the implant, and a 1.5 mm sulcus former (healing abutment) was placed into the implant (Figs. 8, 9). Conclusion This case clearly demonstrates one of the reasons that endodon- tists are becoming increasingly involved in implant dentistry. They are able to provide a com- prehensive evaluation of the tooth in question, and they are able to

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