Select Page
Delayed implants after total extractions. Periodontal disease.

Delayed implants after total extractions. Periodontal disease.

This case presents severe periodontal disease. The only logical treatment plan is full extractions and new denture.

maria_delia_00

The virulence of the periodontal affection and the severe bone ridge damage, with too many irregularities, suggest a prudential approach for the implant surgery. I prefer having the teeth extracted and wait until the bone ridge is in better, safer shape and the bacteria in the mouth have cleared up.

IMGP1244 IMGP1243 IMGP1245

So, the patient is sent to her general dentist for full extractions and temporary denture placement.

maria_delia_1

We wait 4 1/2 months, with periodical checks to prevent from a sudden ridge collapse. The longer the wait, the safest the implant surgery (more regular bone and healthier flora), but you have to be ready for an eventual fast bone resorption that may be the signal to program an immediate implant surgery, not to lose much bone height or width.

The ridge is amazingly flat, but extremely deceiving for its concavity. The earlier thrust of a macroglosic tongue left an alveolar protrusion in both maxillas. IMGP1248

In order to prepare an optimal fitting and esthetic prosthesis. I place the implants as parallel as possible, taking care not to perforate the vestibular bone, but sometimes, it happens.

 IMGP6196 IMGP6197

If the space is limited, bone graft and membrane should be used to cover the vestibular defect and still keep the implant in the same place. But in this case there is plenty of space to insert the implant somewhere else.

IMGP0025IMGP4108

  maria_delia_2

Two weeks later I proceed to the upper maxillary implant surgery. The bone has a more rounded ridge and not as much concavity, but enough as to need a change in placement. The higher the number of implants, the bigger need for their parallelism. But, the angle that works fine in one bone section may not be as good in another portion of the bone. And perforations can happen. This could be prevented by CAD-CAM designed surgery, but it is also costly. It can be done with a little personal 3D view and surgical resources.

IMGP3761 IMGP3764 IMGP3760

IMGP3766 IMGP4109

This is the final result after 6 months, ready for his general dentist to initiate the fixed prosthesis.

Extractions, immediate implants, and sinus lift (lateral approach) for later implant placement

Extractions, immediate implants, and sinus lift (lateral approach) for later implant placement

Sinus lift surgery is done when there is not enough bone height to fix one or several implants in the upper rear sections of the mouth.

Placement of the implants can be done:

  • simultaneously: remaining bone height over 4-6mm, good primary stability of the implants
  • six months after the sinus lift surgery: the remaining bone height doesn’t stabilize the implants well enough (under 4-6mm, depending on bone density and with)

This case shows the placement of two implants on the upper left side, immediately after the extraction of two damaged roots that helped supporting an old bridge.

Simultaneously, I proceed to lift the sinus. Six months will be needed for the second stage implant on the graft, 26 area.

IMGP3799 IMGP3797

I remove the bridge and prepare to extract two bicuspid roots.

IMGP3801 IMGP3800

I open a flap, place the first implant on 24, carefully drill a lateral window on 26 and break it open into the sinus, pushing the membrane as far up as possible.

IMGP3802 IMGP3805

I place the bio-oss bone graft inside the sinus, cover it with a lateral collagen resorbable bio-guide membrane .

Then, I insert the second implant on the groove of 25, now that the sinus membrane has been lifted and I can reach maximum height with the implant.

IMGP3806 IMGP3807

To end with, I fill the small hollow spaces around the implants with more bone graft. I cover them with another piece of membrane and apply stitches to close the flap back in place.

IMGP3808 IMGP3809

This is the result after the surgery. Implant 24 and the cuspid overlap on the X-ray, but it’s just an effect of the panorex. The healing screws are not completely screwed in place because they have been used to fix the second membrane and cannot fit further in, but it s sufficient.

After a few weeks’ resorption, the screws can be adapted more deeply.

BETTY-DAM-3

Six months later, the graft will have enough density as to place the third implant.

Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla. Single tooth.

Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla. Single tooth.

 

This case shows how to place an implant in a narrow ridge after several years without teeth. This patient lost the two premolars, but we will only replace one, a little distally, for a fellow doctor to retrude the cusp with orthodontics, anchored on the implant.

IMGP4098IMGP4442

The two corticals have collapsed transversally, leaving a ridge much narrower than what I need to place a 3.2mm standard (hollow) where to screw abutments for the ortho treatment as a well as the final prosthesis.

IMGP4099 IMGP4440

Once I open the flap I find a ridge even narrower than I expected. This is not unusual. Soft tissue often keeps volume rather normal, while the bone undergoes a grater resorption.

IMGP9950

We can’t do any drilling here. It would remove the little spongeus bone left in between the two inner and outer corticals. The first approach is to do a puncture and try to expand it. This gives me an idea of the bone density and elasticity. The more spongeus there is, the more malleable the bone is.

IMGP9951

This section of the bone presents both corticals closely collapsed together. The bone doesn’t accept further expansion, it doesn’t flex. So I need to split the bone. I use a radial mini-saw to open the ridge and a set of chisels to enlarge the opening.

IMGP9952 IMGP9954

Then, I use more expanders until I reach the necessary width to insert the thinnest implant available.

IMGP9955 IMGP9956

Note that the direction may not always be the best. The concavity of the external bone forces the direction of the implant to be not straightly vertical, as it would provoke exposition of the end part of the implant threads.

IMGP9957

This is the final position. The bone expansion can be appreciated. Sometimes there is a remaining gap along the ridge, both in front and behind the implant. In those cases we need a membrane to cover it, but this is not that case.

IMGP9959IMGP9960

Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla with resorbable membrane. Single tooth. (2).

Bone splitting and widening of a narrow jaw ridge in the edentulous maxilla with resorbable membrane. Single tooth. (2).

This case shows how to place an implant in a a narrow ridge after several years without teeth, same as case “bone splitting (1)” This patient lost the two premolars, but we will only replace one, a little distally, for a fellow doctor to retrude the cusp with orthodontics, anchored on the implant. The difference is that in this case I will need to use a resorbable membrane.

An abscess is growing since long around the root we need to pull out.

I decide to extract the root and let the abscess cure before placing the implant. It is safer than placing the implant immediately, but there is a counterpart, too.

IMGP1620 IMGP1622

The exterior cortical layer is normally damaged by an existent bone loss, through which the abscess has being draining. So we could expect great collapse during the healing time. 3-4 months, as it happened in fact.

The two corticals have collapsed transversally, leaving a ridge much narrower than what I need to place a 3.2mm standard (hollow) where to screw abutments for the ortho treatment as a well as the final prosthesis.

IMGP9965 IMGP9967

We can’t do any drilling here. It would remove the little spongeus bone left in between the two inner and outer corticals. The first approach is to make a puncture and try to expand it. This gives me an idea of bone density and elasticity. The more spongeus there is, the more malleable the bone is.

This bone doesn’t accept further expansion, it doesn’t flex. So I need to split the bone. I use a radial mini-saw to open the ridge and a set of chisels to enlarge the opening.

IMGP9969 IMGP9966

Then, I use more expanders until I reach the necessary width to insert the thinnest implant available

IMGP9970 IMGP9971

Note that the direction may not always be the best. The concavity of the external bone may cause the direction of the implant to be not straightly vertical, as it would provoke exposition of the end part of the implant.

IMGP9972 IMGP9973

But in this case the axis is almost vertical and the bone can be split to insert a 3.75mm regular implant. The outer cortical shows a deep crack.  You have to be careful to expand but not to break the cortical. We want to gain bone, but not to lose it. If we cannot expand wide enough as to insert the implant in that surgery, we may need to fill the gap with bone graft and cover it with a membrane. Wait a 3-4 months and then repeat the operation.

IMGP9974 IMGP9976

The collagen membrane, Bio-Guide, is cut to fit in place and perforated to let the healing screw enter the inner thread of the implant

IMGP9977 IMGP9978

I always start fixing the membrane from the far end, while filling the vestibule with graft (Bio-Oss). Stitches are applied to close the flap in place.

IMGP9979 IMGP9980

Stitches should be kept as long as possible, since the has been a considerable increase in volume that makes complete closure difficult.

IMGP9982

A tetracycline gel can be used to prevent infection. Tetracycline is preferred over hexetidines because these have been reviewed to affect the collagen regeneration the area.

Lower, free-end, posterior implants

Lower, free-end, posterior implants

This case shows the placement of four implants on the left side, upper and lower,  simultaneous to the sinus lift. This is reviewed in another article.

NURIA CABRERA 2 NURIA CABRERA 3

A flap is opened to expose the recipient bone.IMGP7621 Drills are done to the length and with the implants need. In this case two 3.75”x 15” implants are easily placed a little under the bone margin, to let space for the crown placement, since the occlusal plane is so damaged, due to the lack of teeth for so long.

IMGP7622 IMGP7624

I decide to cover the implants with long healing caps, to prevent the bone from growing over the implants. Now there is extra volume compared to the previous situation… so I take off some gum tissue in order to adapt the flap and close it with stitches.

IMGP7625 IMGP7626IMGP7628

This case will need orthodontic treatment to put the left teeth back in place, using the implants for anchorage. Once the occlusal plane is aligned, the crowns over the implants will be built.

IMGP7614

Sinus lift (Lateral approach), simultaneous to implant placement

Sinus lift (Lateral approach), simultaneous to implant placement

Sinus lift surgery is done when there is not enough bone height to fix one or several implants in the upper rear sections of the mouth.

Placement of the implants can be done:

  • simultaneously: remaining bone height over 4-6mm, good primary stability of the implants
  • six months after the sinus lift surgery: the remaining bone height doesn’t stabilize the implants well enough (under 4-6mm, depending on bone density and with)

This case shows the placement of four implants on the left side, upper and lower,  simultaneous to the sinus lift. the placement of the lower implants is reviewed in another article.

Several years without teeth on this side has completely altered the occlusal plane compared to the other side .

IMGP7613 IMGP7614

IMGP7617 IMGP7615 NURIA CABRERA 2

I open a flap on the gums big enough to approach the bone I want to treat.IMGP7629

The first approach is to drill and expand the crestal bone. Ostetoms are pushed carefully in to prevent the thin membrane that covers the inner side of the from breaking.  This gives to signals. One is the bone density. The other is the bone height to the maxillary sinus.

IMGP7630

If height, width and density are estimated to be enough as to stabilize the implants, as well as the bone graft, the graft can be introduced through these drillings and no further surgery is needed other than placing the bone graft and the implants.

In this case I estimated:

  • Stability was good enough to place 4mm implants
  • the leverage forces the implants would receive after load would be high, since the implants were to placed high up compared to the occlusal plane
  • the amount and extension of the graft should be big enough as to provide support to these implants

So, I decided to lift the sinus membrane also laterally and insert the maximum bone graft material.  A lateral window is open by drilling extremely carefully, not to break the membrane. The implants are placed and their stability is checked. IMGP7633 

Thanks to the window I opened on the bone, the thread of the implants can be seen laterally.

IMGP7632

I place the graft around the screws inside what used to be just air a few minutes before. The graft is made of lyophilized animal bone and some minerals. The body uses these graft material to crate self bone progressively. It takes about six months for this new generated bone to have enough strength to support load.

IMGP7635

The lateral wall of the sinus is now folded up and above the implant threads, becoming the “ceiling” of the graft. Now we need another “wall” to close the “window” I opened and avoid the graft falling out and being reabsorbed without creating new bone. This is done by placing a resorbable collagen membrane over the lateral side. IMGP7636

Then, the flap is put back in place and stitches are used to close. They will be removed after 10-14 days, but the longer, the better, since the flap won’t stick to the membrane as it will stick to the bone.IMGP7637

The lower left implants are easily placed a little under the bone margin, to let space for the crown placement, since the occlusal plane is so damaged.

NURIA CABRERA 3   NURIA CABRERA 4dibujo

This case will need orthodontic treatment to lift the left teeth back in place, using the implants for anchorage. Once the occlusal plane is aligned, the crowns over the implants will be built.