This is the case of a 50 year old male, smoker, with severe periodontal disease and ongoing periapical pathology in some of his teeth.
I extract all the teeth, place a temporary removable prosthesis, and wait three months until the sockets are healed and the bacterial flora has hopefully changed.
I place, then, the 8 + 8 implants, but the two last ones in the upper right sector fail, and I have to wait a little longer to replace them. The rest work osseointegrate themselves fine.
after six months from the re-placement of the last two implants, I start with the prosthetical procedures.
This is the trial model, to test size, shape, color, and smile line
This are the final prosthesis on the cast, the upper one divided in four sections 7-4, 3-1, 1-3, 4-7 and the lower one in three 7-5, 4-4, 5-7
The two upper front sections are cemented over gold abutments and the rest are screwed.
Oclusal view with the chimneys filled up
This is a complex case of first-stage bone regeneration in order to set two implants in the next phase.
There is also an impacted 13 cuspid, at 45º angle, on the vestibular side, that needs to be extracted.
Sinus lift and Bone Split
More than ten years edentulism in this 28year old patient have left an atrophic ridge “V”shaped, with not enough height as to fix implants simultaneously to the sinus lift.
I open a large flap and drill a lateral window on the bone, setting its lower limit at the estimated height from the ridge I calculate from the X-ray.
I push the window into the sinus and press the sinus membrane up. I measure the crestal bone with from the inside with a probe or curettes to confirm weather the implants can be fixed at this stage or not, depending on factors (bone height, width, density).
I estimate that the with and height are not sufficient for now, and with will be narrow for the future, also. So I split the crestal bone with a disk saw and chisels .
I fill the sinus and the ridge crack I opened with 1gr. Bio-Oss and cover the whole graft with a resorbable Bio-Guide collagen membrane. Stitching this flap section back in place, as I will continue with the cuspid extraction. 6 months will be needed to approach the next phase, which is the placement of the implants. Further ridge augmentation may be needed, depending on the bone stabilization.
Impacted cuspid extraction
The cuspid lays at a 45º angle, on the vestibular side, as I have made sure by touch. With a round bur I open a window on the bone at the estimated position I calculate from the X-ray and finger relief touch.
I soon feel the different hardness of the enamel compared to the bone. I widen the window until I see there could be enough space for the crown to come out.
I cut the crown using the same bur and pull it out with pliers and leverage forces.
If the root is not hardly anchored, It can be pulled out by using a large endodontic round section file, #60 in this case.
The patient will have a bridge done in this section. So there is no need for bone graft to prevent resorption. Stitches are used to close the flap in place over the gum.
This case combines several advanced surgical techniques
- bone split and ridge expansion on both ends of lower jaw
- extraction and immediate implants with simultaneous vertical sinus lift
- wide lateral sinus lift for later implants
A) Bone split and ridge expansion on both ends of lower jaw
First day of surgery. I place implants on the left jaw.
Many years without teeth have left a collapsed, atrophic ridge, both in width and height.
The inverse “V” shaped ridge is not wide enough as to place the narrowest 3.25” implants.
So, I use a radial saw to slit the bone, working the expansion to the spongeus with chisels.
Then, I use a set of expanders, switching them in progressive widths
I place a short 11.5×3.75” at the back , a 13×3.25” and a 15×3.25” angled towards liguo-mesial in order to avoid the mentonian hole and allow for bigger implant length.
Then, it’s time to fill the gap between corticals and implants with Bio-Oss bone graft and cover it with a Bio-guide resorbable collagen membrane fixed by the healing screws.
On the right side there is even a shorter ridge. That means the leverage forces will be greater. I repeat the bone split process an drill carefully with an angle towards lingual, allowing the mentonian nerve to pass by vestibularly. A 3.75×13” implant at the back, and two 3.25×15” in the front.
B) Extraction and immediate implants with simultaneous vertical sinus lift
The second surgery is on the upper right jaw. There is a “one-and-a-half- tooth” space. Too narrow for two regular teeth. Too wide for just one.
Besides, there is a low sinus. The little bone support, even with sinus lift bone graft (less dense), could be a challenge for long term expectancy. So, my decision is to place two implants, with two small crowns in the end.
I first extract a decayed root with a periapical granuloma.
I open up the flap and start the vertical sinus lift with osteotoms, on both 15 and 14 places, starting by the narrowest one.
Note the damaged, thin cortical layer at 14.
Through the perforation, I apply small pieces of collagen sponges mixed with bone graft. Then, I place a 3.25×11.5 on 15, and a 3.75×13 on piece 14.
I cover the defect with Bio-Oss bone graft and a Bio-guide resorbable collagen membrane fixed by the healing screws.
C) Lateral sinus lift for later implants
The upper left jaw needs a wide sinus lift in order to lace implants at a later stage. There is a no residual bone left at all.
I extract the damaged root and open a wide flap.
I drill quite a wide lateral “window” carefully, not to perforate the membrane. At first touch one can appreciate the extreme thinness of the bone here.
While separating the membrane a perforation occurs. I keep separating, since we’ll need a big volume graft to allow the future implants to hold on to.
Then, I cover the perforation with a resorbable Bio-Guide collagen membrane, fill the sinus with almost two grams of Bio-Oss bone graft
and cover the graft laterally with another Bio-Guide membrane, closing the flap on top.
Again, the before and after panorex. Now we need to wait at least six months to place the implants on the left sinus graft.
This case shows the substitution of four periodontally damaged lower incisors by four 3i implants 3.75×15” and 3.25×15”, one of which failed in the following weeks after insertion.
The patient had annoying mobility in the incisors and wanted to replace them. She didn’t want to hear about extracting the other teeth for a 6-implant fixed denture, for example.
Normally, four lower incisors can be replaced by two implants and four crowns on top. She just wanted four implants as replacement, which is very critical surgery as we will see.
I extract the teeth and analyze the ridge. I find insufficient width in the central as to place the narrowest 3,25”implants.
So, I expand the ridge to the limit of its elasticity with a set of expanders, gradually bigger and simultaneously on either central alveolus.
It’s a very critical maneuver. You need to stop when either the bone starts to crack a little or you reach enough with before that happens.
Then, it’s time to place the implants. 3i 3,25” implants are very delicate.
They have many narrow threads. They need many turns to be screwed.
If you drill or expand too much, the implant may be loose. If you drill or expand too little, they may need too much torque, with the risk of bone heating and failure.
3,75”implants are easier to handle. They are more “self-tapping”.
Still, the error margin is close to none with such little space.
Healing takes place with increasing pain in the 42 area. Maybe bone heating, maybe lack of hygiene… implant on 42 failed and I had to remove it. I healed with great resorption, so I abandoned the though of placing another one, since three are more than enough.
These are the impression pillars and the prosthesis by Dr. Jon Igaralde
three dental implants in the lower incisor region
And the final panorex, before fixing the prosthesis.
This case shows the placement of four implants immediately after extractions, and the final rehabilitation with a denture over an Ackermann bar.
Several years’ edentulism has left ridge bone collapsed.
The only places where the implants can be set are exactly where the four remaining teeth are.
But it even in these places the cortical layers are very thin and concave. There are even bone defects after the extractions, too.
On the left side, I fill the gaps between corticals and implants with Bio-Oss bone graft and cover it with a Bio-guide resorbable collagen membrane fixed by the healing screws.
On the patient’s right side, more of the same. Thin, almost transparent, concave corticals, leaving groove defects after extractions. Same procedure, as before. Graft and membrane.
Two week’s healing, prior to removal of stitches, and Ackermann bar screwed over the implants.
Clamps under the denture hold onto the bar.
Prosthesis by Dr. Jon Igaralde, DDS
This case shows the placement of several implants, immediately after extractions. Establishing the setup for a following othodontic treatment consisting of maxillary front teeth retrusion.
The patient is a severe bruxist
. You can tell bi the extremely closed goniac mandible angle, wide jaw branches and high bone density.
Extreme abrasion and deep Spee curve overbite that is damaging the palate gingiva behind the upper incisors.
Lack of upper and lower molars that led to further bite collapse.
Due to the muscular strength, bone density and extreme degree of occlusal plane distortion, we discard orthodontics in the lower jaw. Rather, we go for a full makeover, full extractions and fixed prosthesis over implants.
On the upper jaw the treatment plan is:
removing destroyed molars,
place two implants on both sides with simple sinus lift,
wait for healing
bring back front teeth to
correct tooth inclination to vertical
establish new bite for lower rehabilitation
extract one premolar on each side if further retraction is needed
Nothing is easy in this particular case. Decayed roots have plenty granulation tissue
that leave wide open spaces after being removed and the sinus is a bit low as to place a short implant with this hyper-strong occlusion. Moreover, the patient is under anticoagulation treatment the we need to suspend. I would have preferred to approach the implant surgery after a period 3-4 moths after extractions, but the patient chose immediate implants, is possible, to minimize the number of surgeries and coagulation risks.
I accomplish the upper left surgery by lifting the sinus vertically with osteotoms, Bio-Oss bone graft and collagen sponges, leaving several threads non-screwed as to level up with the crestal bone.
Then I fill up the gaps with Bio-Oss bone graft and cover it with a Bio-guide resorbable collagen membrane fixed by the healing screws.
I stitch the flap back in place using gum portions for maximum closure and wait for second intention healing.
Upper right surgery is accomplished two weeks later. A decayed root of molar 16 and molars 17-18 need extraction for periodontal reasons. The steps are similar. Vertical sinus lift with Bio-Oss bone graft and collagen sponges. The alveolus is not so damaged, but I still use bone graft and membrane as on the left upper side.
Panorex after upper upper surgeries. Two 5×15” on the right, 5×15” and 4×15” on the left.
As for the lower surgery, we face the same problems. Wide alveolus, irregular ridge bone, plenty of granulation periodontal tissue.
I extract the teeth, place implants as wide, long and parallel as possible using the alveolus as insertion guides.
I place the implants a little under the crestal bone, providing margin for ridge resorption.
I cover the gaps with Bio-Oss bone graft and pieces of Bio-guide resorbable collagen membranes fixed by the healing screws.
And I stitch the flaps back in please, using wide, second phase, healing screws for maximum closure.
I prevent the patient from using the temporary denture as little as possible during the first weeks. Her extreme bruxism might affect primary stability on any of the implants.
Now it is time to start ortho treatment in the upper jaw…