Implants with ball retainers an Locator attachments on the lower jaw are an efficient solution to avoid the instability of a total prosthesis, especially for those patients with a big tongue (macroglosia) and little bone ridge retention.
Actually, the tongue tends to grow as we grow old, and even more when we lose teeth, because the leave more place for the tongue itself.
With the tongue movements, the prosthesis comes loose easily and that is usually uncomfortable for the patients because of the lack of confidence on the prosthesis while eating or speaking.
The lower jaw keeps normally enough bone on the anterior region, even in very atrophic cases. This case, from a 77 year-old male, shows more than enough bone kept. So 3 ICX implants, all three 15” x 3,75” were easily set on the most conveniet places of the lower anterior region.
The remainig lower left wisdom tooth was left in place. At 77 years of age and without sympoms and no influence on the therapie, it can as well stay in place.
So, after two months the healing caps are changed by ball retainers and the old prosthesis is relined in order to fit the new conectors.
The prosthesis is marked below, exactly where the contact points are.
Then comes the drilling until the prosthesis rests freeely on the gums.
Reline resin is added under the prosthesis. The patient bites in the normal position and the resin selfcures in the mouth.
The rubber rings inside the stainless steel structure can be chosen in three differente degrees of hardness and retention. They wear out like every rubber component and can be therefore easily changed.
After a few minutes cure time the retainers are already fixed and the retaining force can already be appreciated, as the prosthesis stays in the right position although the tongue and the cheeks exert the same force as before.
In this case, the three ball retainers proved not to be retentive enough for the patient. Normally a four implant solution provides a more retentive, more stable, four-point trapezoidal support. Nut the patient was running on a low budget and we had to go for a three implant display, with the central implant close to the mandibular synfisis.
By changing the three ball retainers into Locator attachments and just placing the softer plastic rings under the metal matrixes, we achieved a good degree of confort for the patient.
In this post I want to show the bone regenerating effect from the narrow threads around the neck of an implant, brand ICX, 8” long, 4,8” wide. You can see the one-year evolution control on this following post
Day O: a second molar on the left upper jaw was extracted on May 9, 2011 due to a tooth fracture. The X-ray was taken after the extraction. The wisdom tooth is kept behind to minimite the alveolar resortion.
Three months later, on August 16, 2001 the ICX 4,8″x8″ was set with 35 N primary stability, by means of a punch technique and small vertical sinuslift, using a collagen membrane and autogenous bone. The implant was set further distal to the center space, counting already on the future extraction. The wund is sealed with a platform-switch healing screw.
Two months later, on October 18, 2011, I make another X-ray check, test the stability of the implant.The bone has grown around the narrow neck threads. The bone is condensed around the apex and the impact sound is excellent, showing a good integration.
I insert the closed-impression post. Now has come the moment of the extraction of the third molar (wisdom tooth), because it is no longer necessary and, furthermore, interferes with the plastic cap that goes over the post. The impression is taken therefore after the extraction.
Nine days later, on October 27, 2011, the abutment is screwed in with 35 N torque and the crown is cemented with temporary cement until the 6-moth control.
* To see the the one-year evolution control go this post
This is a simple case with plenty of bone, plenty of attached gingiva and quite good prosthetic space. So we might as well expect some esthetic results.
However, it’s interesting to notice the difference in healing following the two different techniques chosen while stitching the flaps back in place.
On the right side I simply faced both parts of the wound and sewed them up with simple and double stitches. The picture sequence is as of 0, 5 and 22 day period.
On the left side I removed part of the gum prior to sewing both ends in place, letting the screws exposed. The healing, as we can see, is apparently healthier, no second surgery was needed to expose the healing screws, but the final result was the same on both sides. Basically, because the attached gingiva was generous on both, the gum biotype was thick and there was no need to lift up the flaps during surgery, as the bone was wide enough, too.
These are the radiographic details. External hexagon 3.75 x13 and 10mm, . Front implant overlapped radiographically due to the pantomographic angle of exposure.
All except for the stump on 24, are screwed. 24 was done on stump because the intermaxillary gap was short. The antagonist 35 was also reduced in height, as you may see. When the occlusion is so well defined, I take partial casts, as they are more comfortable to obtain.
The three screw chimneys are filled up with glass ionomer cement for this final result
I placed an overnight acrylic splint to prevent bruxism, too.
this is a quite complicated case, as for the degree of bone destruction, the esthetic demand, and the surgical-prosthetic procedures involved in the process. View full processe here…
Initial phase: extractions and healing
Old metal-ceramic crown work over devitalized incisors. Periodontal abscess, retracted alveolar front wall, frontal gingival recession, central incisor presenting endo-periodontal injury around root apex.
Extractions are done and an immediate removable prosthesis is placed during the healing period. Acrylic relines are successively done to keep contact between the resin and the gum, in order to prevent further resorption.
One thing should be taken into consideration: a different approach could be done by filling the sockets with bone graft and covering them with a membrane. With the existing endo-perio pathology it may be a safer play to let it heal by itself. Second, there is short soft tissue over the central incisor as to cover the resorbable membrane.
Surgical phase: implant placement, bone augmentation
The two implants are placed along the convenient axis, already expecting exposure of a few threads. The Bio-Guide membrane is cut to fit in the edentulous gap, holes are poked to screw the implants’ healing screws throw it, acting as fixation.
Enough membrane margin is left to fit under the palatal flap and several holes are poked on the apical end of the membrane. First, to drill through the pin retention. Second, to nail the pins through.
Once the pin holes are drilled with no tension on the membrane (it should be baggy enough as to allow for sufficient graft volume), a little blood is extracted, mixed with Algipore
, and placed over the implant’s threads and the bone concavity.
The resorbable pins are nailed carefully fitting them through the membrane holes and into the previously drilled socket retentions.
Periosteal cuts are done under the full thickness flap. This permits further elongation of the flap in order to close the wound over the increased volume base.
Implant osseointegration phase: 6 months
The acrylic removable prosthesis is immediately relined to fit over the suture and checked up periodically for later relines in order to keep contact with the gum.
Prosthetic phase: Procera veneers and metal-ceramic crowns over angled pillars
During the try-on, the left central incisor doesn’t fit precisely. Maybe due the tooth migration, maybe due to impression accuracy. So the cuspid’s veneer is cemented and second impressions are taken for the final result, incorporating pink ceramic to disguise the implants’ high emergence.
This a long, multidisciplinary case, involving peridontics, endodontics, resin restorations, orthodontics, implants and venners.You can view the full process here…
Orthodontics & Implants on 12, 35
Removal of orthodontics, bleaching & retainer
Prosthetic Phase & retainer
results: 5yrs post implantary phase, 10yrs from restoration
This is a quite long, combined case of orthodontics, implants, esthetic ceramic crowns and fillings, substituting the old metal ceramic and amalgam restorations for a more esthetic overall result.
At first stage, I want to use orthodontics in order to close the space of the missing upper second bicuspid, move the mid lines to the left and reduce protrusion. So I cut the 24-25 bridge, apply full Roth .022″ ceramic braces and start moving the pieces with elastics and springs on .016″ round wire.
The movements on the left side are attempted gradually, with springs and/or elastics, as well as ligature anchorage when possible
When the turn comes to the 11-22 bridge, I cut it in between 21-22 to liberate 22 for motion with springs.
I used elastics on 21 to prevent from rotating, since the spring force will act with high leverage on 11.
Now it’s time to move the central incisors and the midlines to the left, also progressively, one tooth at a time. When the upper incisors reach the symmetric position, I close the gaps with chained elastics.
When the space is crated for 41, I bring it into the arch and do a little stripping.
Final adjustments on the lower incisors after stripping.
Midlines aligned with the nose. Finishing inter-arch elastics for maximum intercuspidation, and opening spring to back-tip 37 and allow for implant placement.
Now the spaces are not at their final size, but they are enough as to place the implants.
I place two Alpha Bio implants. 36 is a 3.75×15″ external hexagon, and 21 is a 3.75×16″ internal hexagon. I needed to cut the 11-21 bridge, do some ridge widening with osteotoms, and hang the loose 21 crown on the wire.
When healing takes place, I set the gums with future esthetic tooth proportions. I use electric scalpel for the gingivectomy.
I used the spring after the implant placement to continue opening the space for a molar. That rotated the premolar forward. I cut the implant transporter as to allow occlusion and attach a premolar band with Dura-Lay resin in order to de-rotate the premolar back in place. The final corrections are accomplished with elastics from either the labial bracket or the lingual button.
When everything is in its final place, I remove the braces, cut the 11&22 crowns, carve the 11,22&24 preparations and apply two retraction threads together with vase constrictor. I take a two-step silicone impression.
Temporary resin crowns are used during color and shape trials. Several were done until a good esthetic result was accomplished.Notice the compressed, isquemic gum on 21 right after placement. The crowns are made of Procera ceramic.
Placement of the 36 crown is achieved in several days. This was due to the unavoidable tendency of the molar and premolar go close the space. Despite the use of the band-resin maintainer, a small width difference was enough not to allow the crown to fit in place at the first moment. The crown was screwed in, little by little, in the following days.
I substituted the old amalgam restorations by composites and placed a .060″ clear retainer on the lower arch. Notice the slight rotation of 41 during this phase. Upper retention was not needed. The implant on 21 may have acted as a retainer. No motion was observed before or after this phase on the upper teeth.
Final result, at right and left laterality
Before, intermediate and final stages of the front crowns.
Final result on maximum intercuspidation.