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.
Ceramic inlays are the best way to restore posterior teeth. The round contact point in between the teeth can be prepared by the dental technician in the best way, as compared to a direct, ordinary class II filling restorations. Also, patients who present allergy to metals and who desire a highly esthetic restoration might benefit from ceramic inlays because these restorations are extremely biocompatible (ceramics are among the most compatible biomaterials) and can mimic the appearance of the natural tooth, when properly made.
Ceramic inlays are tooth-colored glass-based restorations used as fillings in back teeth (molars and premolars). These fillings are made of dental porcelain in a dental laboratory using a copy or model of the tooth preparation obtained from a mold made by the dentist. After being completed, the inlay is cemented in the tooth preparation with composite cement.
The X-Ray shows interproximal caries in between the lower right molars and inaccurate edge -to-edge termination of the class II fillings in between the molar and the premolar.
The preparation of the teeth needs to be totally extrusive, so that the ceramic inlays can be set in place easily. The retention is obtained by means of the cement composite and the adhesives. In order to obtain a good silicone impression, the papilla can be cauterized with an electro scalpel. The papilla will grow back again after the ceramic inlays are definitely set in place. The displacement of the papilla can also be achieved by using retraction threads.
The provisories for the ceramic inlays are made with a soft, light cured composite. These are the views at the moment of setting and one week after. The provisories should be easy to remove with a probe, for example, and they hold themselves in place without cement.
This are the views of the preparation in cast, and the set-up display in mouth prior to cementation. A rubber dam is used for isolation of the desired teeth, with the help of one or two clamps. Correct rubber dam isolation and correct use of adhesives are both vital for a long lasting result.
This is the final mimetic result of the ceramic and a check X-ray in order to control the contact points where the eye doesn’t reach. A small excess composite still needs to be removed from the contact point in between the molar and the premolar.
Thomas Hirsch, Zahntechnikermeister, Langobardenstrasse 35/1a, 1220 Wien, Österreich
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.
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 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