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Maxillary bicuspids on both sides. Esthetic treatment with four implants.

Maxillary bicuspids on both sides. Esthetic treatment with four implants.

This is a simple case with plenty of bone, plenty of attached gingiva and quite good prosthetic space. So we might as well expect some esthetic results.

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However, it’s interesting to notice the difference in healing following the two different techniques chosen while stitching the flaps back in place.

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On the right side I simply faced both parts of the wound and sewed them up with simple and double stitches. The picture sequence is as of 0, 5 and 22 day period.

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On the left side I removed part of the gum prior to sewing both ends in place, letting the screws exposed. The healing, as we can see, is apparently healthier, no second surgery was needed to expose the healing screws, but the final result was the same on both sides. Basically, because the attached gingiva was generous on both, the gum biotype was thick and there was no need to lift up the flaps during surgery, as the bone was wide enough, too.
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These are the radiographic details. External hexagon 3.75 x13 and 10mm, . Front implant overlapped radiographically due to the pantomographic angle of exposure.

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Prosthetic phase
All except for the stump on 24, are screwed. 24 was done on stump because the intermaxillary gap was short. The antagonist 35 was also reduced in height, as you may see. When the occlusion is so well defined, I take partial casts, as they are more comfortable to obtain.
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The three screw chimneys are filled up with glass ionomer cement for this final result
I placed an overnight acrylic splint to prevent bruxism, too.
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Combined implant and ortho treatment in a severe bruxist with posterior occlusal collapse and closed bite

Combined implant and ortho treatment in a severe bruxist with posterior occlusal collapse and closed bite

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.

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The patient is a severe bruxist. You can tell bi the extremely closed goniac mandible angle, wide jaw branches and high bone density.
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Extreme abrasion and deep Spee curve overbite that is damaging the palate gingiva behind the upper incisors.
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Lack of upper and lower molars that led to further bite collapse.
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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:
  1. removing destroyed molars,
  2. place two implants on both sides with simple sinus lift,
  3. wait for healing
  4. Ortho treatment
    1. bring back front teeth to
      1. correct tooth inclination to vertical
      2. close spaces
      3. establish new bite for lower rehabilitation
    2. extract one premolar on each side if further retraction is needed
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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.
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I stitch the flap back in place using gum portions for maximum closure and wait for second intention healing.
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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.
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Panorex after upper upper surgeries. Two 5×15” on the right, 5×15” and 4×15” on the left.fabiola-esther-2
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.
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I place the implants a little under the crestal bone, providing margin for ridge resorption.
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I cover the gaps with Bio-Oss bone graft and pieces of Bio-guide resorbable collagen membranes fixed by the healing screws.
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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.
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Now it is time to start ortho treatment in the upper jaw…