This document summarizes a clinical study on using the zygomaticomaxillary buttress as a donor site for bone grafting to augment maxillary alveolar defects for dental implant placement. It describes the anatomy of the zygomaticomaxillary buttress and reviews its advantages as a donor site, including good bone quality and quantity while avoiding complications from other sites. It then presents a case study where bone was harvested from the buttress to graft a maxillary defect and allow successful implant placement, with follow-up showing osseointegration and no complications. The conclusion is that the zygomaticomaxillary buttress is a viable donor site for limited bone grafting for dental implants.
Fixed prosthodontic treatment can offer exceptional satisfaction for both patient and the dentist. Fixed Prosthodontics can transform an unhealthy, unattractive dentition with poor function into a comfortable, healthy occlusion capable of giving years of further service while greatly enhancing esthetics.
Nothing is more important in the construction of fixed partial dentures than an adequate diagnosis and a well-devised treatment plan. Although these two subjects are usually considered together. Astute dentists must recognize their subtle differences. Diagnosis is an evaluation of the condition of the patient when he presents for treatment. Treatment planning concerns the treatment procedures by which the dentist will restore the patient to an optimum state of dental health.
Fixed prosthodontic treatment can offer exceptional satisfaction for both patient and the dentist. Fixed Prosthodontics can transform an unhealthy, unattractive dentition with poor function into a comfortable, healthy occlusion capable of giving years of further service while greatly enhancing esthetics.
Nothing is more important in the construction of fixed partial dentures than an adequate diagnosis and a well-devised treatment plan. Although these two subjects are usually considered together. Astute dentists must recognize their subtle differences. Diagnosis is an evaluation of the condition of the patient when he presents for treatment. Treatment planning concerns the treatment procedures by which the dentist will restore the patient to an optimum state of dental health.
Is a dental condition that is commonly seen in patients with a completely edentulous maxilla and partially edentulous mandible with preserved anterior teeth
Neutral Zone
In dentistry, the neutral zone refers to that space in the oral cavity where the forces exerted by the musculature.of.the tongue are equal and balanced with the.forces exerted by the buccinators.muscle of the cheek.laterally and the orbicularis.oris muscle anteriorly
One of the objectives in complete denture prosthetics is to produce a harmonious appearance of the denture when in the patient’s mouth.
A denture usually perceived as esthetics when the teeth and bases are in harmony with the facial musculature as well as the size & shape of the head.
The selection of artificial teeth & their arrangement to meet esthetic requirements demand artistic skill in addition to scientific knowledge.
Is a dental condition that is commonly seen in patients with a completely edentulous maxilla and partially edentulous mandible with preserved anterior teeth
Neutral Zone
In dentistry, the neutral zone refers to that space in the oral cavity where the forces exerted by the musculature.of.the tongue are equal and balanced with the.forces exerted by the buccinators.muscle of the cheek.laterally and the orbicularis.oris muscle anteriorly
One of the objectives in complete denture prosthetics is to produce a harmonious appearance of the denture when in the patient’s mouth.
A denture usually perceived as esthetics when the teeth and bases are in harmony with the facial musculature as well as the size & shape of the head.
The selection of artificial teeth & their arrangement to meet esthetic requirements demand artistic skill in addition to scientific knowledge.
by - dr. sheetal kapse, 2nd year p.g. student, dept. of oral & maxillofacial surgery, RCDSR, Bhilai, C.G. please contact for any question...email id - sheetal.kpse@yahoo.com
[Dr. Suh's thesis in International journal SCI]
“A Novel technique for short nose correction”
The nominated thesis is about A Novel technique for short nose correction; Hybrid septal extension graft that have acquired the favorable reputation internationally based on the advanced clinical experiences.
Interproximal tunneling with a customized connective tissue graft a microsurg...MD Abdul Haleem
Journal Club Presentation - Interproximal Tunneling with a Customized Connective Tissue Graft A Microsurgical Technique for Interdental Papilla Reconstruction.
omfs journal club ppt on bone ridge augmentationAkhil Sankar
This is a journal club to start with for new omfs pgs . This is correctly criticized and cross-checked ppt. Also, it is a relevant topic in day to day preactise
The denture-wearing history should provide information on the age of existing dentures, the frequency of denture replacement, the patient's experiences and expectations. It is important to identify whether any previous dentures have been successful as it may be suitable to copy features from a previously successful set. It will be important to manage expectations for those patients with a history of denture intolerance, yet technically satisfactory prostheses.
Clinical examination
Clinical examination should fully evaluate both the patient's anatomy and previous dentures to anticipate challenges and the potential to improve upon retention, stability, support, appearance and/or other factors. This should be undertaken in a systematic manner and would typically involve assessment of anatomy followed by an assessment of any existing dentures. This should follow a diagnostic process to determine if the patient presents with:
Technically adequate dentures on a favourable tissue base
Technically adequate dentures on an unfavourable tissue base
Technically inadequate dentures on a favourable tissue base
Technically inadequate dentures on an unfavourable tissue base.
Split ridge and expansion techniques are effective for the correction of moderately resorbed edentulous ridges in selected cases.
Transverse expansion is based on osseous plasticity obtained by corticotomy. It progressively allows for an adequate transversal intercortical diameter large enough to insert one or several dental implants.
The gap created by sagittal osteotomy expansion undergoes spontaneous ossification, following a mechanism similar to that occurring in fractures.
Journal Club On Pre-extractive Interradicular Implant Bed Preparation: Case P...Shilpa Shiv
Journal Club On Pre-extractive Interradicular Implant Bed Preparation: Case Presentations of a Novel Approach to Immediate Implant Placement at Multirooted Molar Sites, IJPRD 2013.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. A CLINICAL STUDY AND REVIEW OF
LITERATURE
Guided by DR. SUNIL C DUTT, Prof. & HOD
DR. M. SATISH, Reader
DR. DEEPAK THAKUR, Reader
DR. MANISH PANDIT, Senior Lecturer
Presented by –
DR. SHEETAL KAPSE
2ND YEAR P.G. STUDENT
2
3. INTRODUCTION
AIM & OBJECTIVE OF STUDY
ANATOMY
CLINICAL PRESENTATION
DISCUSSION WITH REVIEW OF LITERATURE
CONCLUSION
RESOURCES
3
4. • Augmentation of maxillary alveolar bone defects
for placement of implant still poses a clinical
challenge for the surgeons.
• In addition to autogenous bone & alloplastic
materials, synthetic bone substitutes as well as
denatured bovine bone & coral structures, are all
possible alternatives available for use as
augmentation material.
4
5. • But the use of autogenous bone graft
still remains the ‘gold standard’ for
both cancellous & cortical bone
grafting applications.
5
6. Maxillary Tuberosity
• After bone harvesting from this
area, postoperative trismus as well as injury
to the adjacent soft tissues with profuse
hemorrhage can occur.
Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann
KH. Alveolar Zygomatic Buttress: A New Donor Site for Limited
Preimplant Augmentation Procedures J Oral Maxillofac Surg
.2007;65:p275-280.
6
8. Osteodistraction
• This method might be
considered by some
clinicians and patients
alike to be a rather
involved and timeconsuming alternative.
Schlegel KA, Neukam FW:
Augmentationen, Knochenersatzmaterialien, Membranen, in
Reichart PA, Hausamen J-E, Becker J, Neukam FW, Schliephake
H, Schmelzeisen R (eds): Zahnärztliche Chirurgie I.
8
13. • Vase shaped
• Boundaries Inferiorly- alveolar process and roots of teeth
medially - roots and sinus
superiorly joins the zygoma
posteriorly infratemporal fossa
• Bone quality – cortical & cancellous
• Intramembranous ossification
• Function - Provides pressure absorption and
transduction in the facial skeleton.
• Pathologies and variations not known
13
15. • Subsulcular
or
Extended crestal incision
• Elevation…superiorly
till the ZM suture
• These designs will expose the entire buttress.
15
16. • The minimum donor site surface area
should be approximately 10 mm X 15 mm
and accessible with the instrument at an
angle between 5° and 50°.
Peleg M, Garg AK, Misch CM, Mazor Z. Maxillary sinus and
ridge augmentations using a surface-derived autogenous bone
graft. J Oral Maxillofac Surg. 2004 Dec;62(12):1535-44.
16
17. Technical note
• Use of ultrasound based dissection with
piezosurgery causes no trauma to sinus
membrane.
Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH. Alveolar Zygomatic
Buttress: A New Donor Site for Limited Preimplant Augmentation Procedures J Oral
Maxillofac Surg .2007;65:p275-280.
17
18. 1. Accessibility to site & excellent visibility.
2. Same morphology & Same architecture.
3. Good quality & adequate quantity.
4. No muscular or neurovascular injury.
5. Less prone to resorption.
6. 1.5 to 2 cm - not compromise the strength of the
lateral midface frame.
18
19. •
•
•
•
Damage to maxillary sinus membrane.
Damage to tooth root.
Limited volume of graft.
Contraindicated in patients with sinus problem
Montazem A, Valauri D, St-Hilaire H, Buchbinder D. The mandibular symphysis
as a donor site in maxillofacial bone grafting: a quantitative anatomic study. J Oral
Maxillofac Surg 2000: 58: 1368–1371.
Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant
placement. Int J Oral Maxillofac Implants 1997: 12: 767–776.
Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with mandibular or iliac
19
crest bone grafts: a comparative study. J Oral Maxillofac Surg 1990: 48: 554–558.
21. • A 26 year old male visited us for rehabilitation
of lost teeth following RTA, Was treated in
2010 for pan facial fractures by ORIF.
21
22. Treatment plan
• Following clinical, radiological and model
assessments Maxillary rehabilitation was planned
using implants supported prosthesis bridge .
22
23. • Bone height was found satisfactory except in the
canine region where a crater of about 1cm was
present.
• Zygomaticomaxillary buttress grafting under local
anesthesia.
23
34. • To achieve a good esthetic result and long-term
functional stability, positioning of the implant is
crucial.
• Alveolar crest defects have been particularly
scrutinized because they are the limiting factor in
optimal implant positioning.
• If the bony recipient site does not fulfill the later
implant- based prosthodontic requirements, failure of
the whole treatment is likely to occur.
34
36. Peleg et al in 2004
Michael Peleg, Arun K. Garg, Craig M. Misch, Ziv
Mazor, Maxillary Sinus and Ridge Augmentations Using a
Surface-Derived Autogenous Bone Graft. J Oral Maxillofac
Surg. 2004; 62:1535-1544.
Gellrich et al in 2007
Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH.
Alveolar Zygomatic Buttress: A New Donor Site for Limited Preimplant
Augmentation Procedures. J Oral Maxillofac Surg .2007;65:p275-280.
36
38. References
1.
Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH.
Alveolar Zygomatic Buttress: A New Donor Site for Limited Preimplant
Augmentation Procedures J Oral Maxillofac Surg .2007;65:p275-280.
2.
Schlegel KA, Neukam FW: Augmentationen, Knochenersatzmaterialien,
Membranen, in Reichart PA, Hausamen J-E, Becker J, Neukam FW,
Schliephake H, Schmelzeisen R (eds): Zahnärztliche Chirurgie I. Berlin,
Quintessenz, 2002, pp 434-459
3.
Michael Peleg, Arun K. Garg, Craig M. Misch, Ziv Mazor, Maxillary
Sinus and Ridge Augmentations Using a Surface-Derived Autogenous
Bone Graft. J Oral Maxillofac Surg. 2004; 62:1535-1544.
4.
Kainulainen VT, Sàndor GK, Oikarinen KS, Clokie CM. Zygomatic
bone: an additional donor site for alveolar bone reconstruction. Technical
note. Int J Oral Maxillofac Implants. 2002 Sep-Oct;17(5):723-8.
38
39. References
5.
Montazem A, Valauri D, St-Hilaire H, Buchbinder D. The mandibular
symphysis as a donor site in maxillofacial bone grafting: a quantitative
anatomic study. J Oral Maxillofac Surg 2000: 58: 1368–1371.
6.
Misch CM. Comparison of intraoral donor sites for onlay grafting prior to
implant placement. Int J Oral Maxillofac Implants 1997: 12: 767–776.
7.
Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with
mandibular or iliac crest bone grafts: a comparative study. J Oral
Maxillofac Surg 1990: 48: 554–558.
39
Implant site was exposed through crestal incision and grafting site exposed through a Sub-sulcular incision extending from 2ndpremolar to the distal of 1stmolar mucoperiosteal flap raised
Implant site was exposed through crestal incision and grafting site exposed through a Sub-sulcular incision extending from 2ndpremolar to the distal of 1stmolar mucoperiosteal flap raised
Implant site was exposed through crestal incision and grafting site exposed through a Sub-sulcular incision extending from 2ndpremolar to the distal of 1stmolar mucoperiosteal flap raised
Implant site was exposed through crestal incision and grafting site exposed through a Sub-sulcular incision extending from 2ndpremolar to the distal of 1stmolar mucoperiosteal flap raised