The width of the buccal wall of a dental implant is becoming more and more important for its long term durability.
Placing the dental implant with 1,5 to 2 milimeters away from the buccal wall provides the bone wall with enough blood supply.
Opposite to teeth, whose surrounding bone receives plenty of blood support from the periodontal ligament, the implant have no ligament and no surrounding blood circulation. Thus the buccal wall blood support comes only from the periosteum and the transeptal blood vessels.
Providing the buccal bone wall with a good thickness allows the internal bone blood vessels to supply nutrients to the buccal bone.
The X-ray shows two edentulous spaces on a 60 year-old man, non-smoker. Thick biotype.
Preoperatory diagnostic measures. Control of the soft tissue quantity and quality
as well as a2D X-ray measurement with 5″ balls.
- Implant placement surgery
Regular split flap with two vertical discharges mesial and distal of the spot. Bone condensing carried out to finally place a 3,75×12,5″ ICX-Templant (internal hexagon) insertion after bone spreading.
The implant is placed 1mm under the bone level. This allows some typical crestal bone resorption while still keeping the internal cone properties of the implant. Notice the concavity of the buccal wall under the ridge level.
Bio-Oss and Bio-Guide GBR material protecting the buccal bone wall. This increases the initial volume and adds extra hard tissue substance to the buccal wall.
Panoramic post-operatory X-ray, after placing two 3,75×12,5″ ICX-Templant internal hexagon dental implants.
Suture with 4/0 Prolene.
and healing sequence after 2, 5 and 9 weeks
- Implant exposure surgery after 9 weeks
a regular exposure surgery, with a minimal incision from the palatinal side, and the tissue buccally displaced. Healing abutment over a 3,75×12,5″ ICX-Templant (internal hexagon)
3 weeks after the exposure surgery, with the healing abutment.
Impression transfer for a closed tray.
3,75×12,5″ ICX-Templant (internal hexagon) abutment on cast lab modell showing the platform switch, with the corresponding crown
3,75×12,5″ ICX-Templant (internal hexagon) abutment emerging. Screwed at 30Ncm torque.
Metal-ceramic crown placed on the 3,75×12,5″ ICX-Templant (internal hexagon) abutment. Notice the metal line at the gum level, due to slight gingival retraction
7 weeks after insertion. The metal-ceramic crown placed on the 3,75×12,5″ ICX-Templant (internal hexagon) abutment. Notice that the metal line at the gum level has dissapeared, due to gingival re-growth
occlusal mirror view of the final result
this is a quite complicated case, as for the degree of bone destruction, the esthetic demand, and the surgical-prosthetic procedures involved in the process. View full processe here…
Initial phase: extractions and healing
Old metal-ceramic crown work over devitalized incisors. Periodontal abscess, retracted alveolar front wall, frontal gingival recession, central incisor presenting endo-periodontal injury around root apex.
Extractions are done and an immediate removable prosthesis is placed during the healing period. Acrylic relines are successively done to keep contact between the resin and the gum, in order to prevent further resorption.
One thing should be taken into consideration: a different approach could be done by filling the sockets with bone graft and covering them with a membrane. With the existing endo-perio pathology it may be a safer play to let it heal by itself. Second, there is short soft tissue over the central incisor as to cover the resorbable membrane.
Surgical phase: implant placement, bone augmentation
The two implants are placed along the convenient axis, already expecting exposure of a few threads. The Bio-Guide membrane is cut to fit in the edentulous gap, holes are poked to screw the implants’ healing screws throw it, acting as fixation.
Enough membrane margin is left to fit under the palatal flap and several holes are poked on the apical end of the membrane. First, to drill through the pin retention. Second, to nail the pins through.
Once the pin holes are drilled with no tension on the membrane (it should be baggy enough as to allow for sufficient graft volume), a little blood is extracted, mixed with Algipore
, and placed over the implant’s threads and the bone concavity.
The resorbable pins are nailed carefully fitting them through the membrane holes and into the previously drilled socket retentions.
Periosteal cuts are done under the full thickness flap. This permits further elongation of the flap in order to close the wound over the increased volume base.
Implant osseointegration phase: 6 months
The acrylic removable prosthesis is immediately relined to fit over the suture and checked up periodically for later relines in order to keep contact with the gum.
Prosthetic phase: Procera veneers and metal-ceramic crowns over angled pillars
During the try-on, the left central incisor doesn’t fit precisely. Maybe due the tooth migration, maybe due to impression accuracy. So the cuspid’s veneer is cemented and second impressions are taken for the final result, incorporating pink ceramic to disguise the implants’ high emergence.
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 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