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 presents severe periodontal disease. The only logical treatment plan is full extractions and new denture.
The bone ridge is very damaged and there too many irregularities as to approach immediate implants after extractions. I prefer having the teeth extracted and wait until the bone ridge is in better, safer shape.
In addition, an impacted upper right cuspid will leave a big hole in the bone in an area that I will need to use for implantation.
So, I proceed to extract the cuspid and fill the bone defect with Bio-Oss graft, covering it with a resorbable Bio-Guide membrane.
Then, all the teeth are extracted by his general dentist, who places a removable denture while waiting for the bone to heal.
Four months later, the bone ridge is more regular
Then, I place six implants on each jaw.
Note the unexpected, deep bone defect that laid after previous extractions of the upper right molars, which was filled up with soft tissue.
I use Bio-Oss bone graft and Bio-Guide resorbable membrane to cover the cavity and place the last implant on the front side of the defect.
This is the final result after 6 months, ready for his general dentist to initiate the fixed prosthesis.
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.
I remove the bridge and prepare to extract two bicuspid roots.
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.
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.
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.
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.
Six months later, the graft will have enough density as to place the third implant.
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.
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.
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.
Then, I use more expanders until I reach the necessary width to insert the thinnest implant available
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.
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.
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
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.
Stitches should be kept as long as possible, since the has been a considerable increase in volume that makes complete closure difficult.
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.