This is a simple case of an included, not erupted, lower third molar extraction.
Incision is done down the line and around the preceding molar, as well as the vertical discharge in the middle of the vestibular side.
The flap is open and the periostium is peeled off the bone
A round drill is used with physiologic serum irrigation to remove the covering vestibular bone until the molar can be pulled off.
Luckily the molar comes out intact together with the surrounding inflammatory process.
Stitches are used to place the flap back in place.
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 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…
This case shows the placement of two individual implants, each with different characteristics.
The upper one must be placed in the 15 bicuspid area. The bone has collapsed during resorption, although, externally, it doesn’t seem so.
The lower one must substitute a damaged 46 molar,which presents periapical abscess in both rots, bone loss in the septum and fistula draining to vestibule.
I start always by the easier part of each surgery. Which, in this case, is the upper implant.
After opening the flap I find a concave vestibular bone, with a ridge of about 4”, insufficient for placing a 3,75” with safety margin ridge bone on either side of the implant.
A smaller diameter implant could have been used, but this is a heavy duty area for chewing, and for me, the wider and longer the implant is, the better.
So, I expand the ridge to the limit of its elasticity in the desired angle. Again, I could have chosen another angle for insertion, but the more vertical, the better long term expectancy, especially in single, heavy loaded implants. You can appreciate the vestibular groove due to the concavity, angle of insertion and elasticity limit.
I place a 4×15” 3i implant and proceed to cover the bone defect with Bio-Oss bone graft and Bio-guide resorbable collagen membrane fixed by the healing screw.
The lower molar, after extraction, leaves a wide crater, wide septum resorption, as expected by x-rays, and a thin, cracked by the extraction, vestibular wall, through which the fistula was draining out.
I prefer to postpone the implant placement for a second phase. By now, I clean the alveolus thoroughly, removing all soft tissue, fill it up with Bio-Oss bone graft and Bio-guide resorbable collagen membrane, and try to close it as much as possible with the flap.
Four months later we check X-rays and see the shadow of the new generating bone in the alveolus.
Ridge preserved in height and width, the placement is now simple.
This case shows the extraction of a maxillary canine, impacted in the palate.
I open a flap in the palate, preserving the papilla, so I can stitch the flap back again. I calculate the position by the x-ray and start drilling the bone with a hand-piece until I touch the tooth. I know that because of its different hardness.
I remove as much bone as I need to see the crown and I cut it with a high speed turbine drill. I keep removing bone until I can pull out the crown split part of the cuspid.
I work my way to remove the root end of the tooth, the soft tissue capsule, and I stitch the palate flap back in place.
Literature speaks of swallowing or difficult, painful bonding of the palate flap over the bone. It is convenient to prepare a Hawley-type splint, or simpler, a silicone cast that the patient can bite on intervals. This applies enough compression on the palate to minimize swallowing, conducting to adequate healing.
This small surgery is done to remove the frenulum, a small fold of tissue that prevents an organ in the body from moving too far.
Strongly inserted frenulums may cause awkward mobility of the lip or tooth separation.
Another surgical technique is the Z-plasty, normally used for bigger frenulums.
gently passing the electrode over the frenulum while pulling off the lip allows the tissues to shape up differently.
The electro-scalpel both cuts and coagulates as needed. So, healing is fast and without stitches.
This is the healing a week after surgery.