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Esthetic treatment combining ortho, implants and Procera®

Esthetic treatment combining ortho, implants and Procera®

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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.
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after
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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.
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The movements on the left side are attempted gradually, with springs and/or elastics, as well as ligature anchorage when possible

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When the turn comes to the 11-22 bridge, I cut it in between 21-22 to liberate 22 for motion with springs.
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I used elastics on 21 to prevent from rotating, since the spring force will act with high leverage on 11.
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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.
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When the space is crated for 41, I bring it into the arch and do a little stripping.
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Final adjustments on the lower incisors after stripping.
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Midlines aligned with the nose. Finishing inter-arch elastics for maximum intercuspidation, and opening spring to back-tip 37 and allow for implant placement.
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Now the spaces are not at their final size, but they are enough as to place the implants.
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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.
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When healing takes place, I set the gums with future esthetic tooth proportions. I use electric scalpel for the gingivectomy.
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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.
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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.
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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.
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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.
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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.
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Final result, at right and left laterality
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Before, intermediate and final stages of the front crowns.
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Final result on maximum intercuspidation.

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Mandibular bone split, lateral sinus lift and other immediate implants

Mandibular bone split, lateral sinus lift and other immediate implants

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

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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.

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So, I use a radial saw to slit the bone, working the expansion to the spongeus with chisels.

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Then, I use a set of expanders, switching them in progressive widths

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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.

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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.

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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.

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I open up the flap and start the vertical sinus lift with osteotoms, on both 15 and 14 places, starting by the narrowest one.

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Note the damaged, thin cortical layer at 14.

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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.

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I cover the defect with Bio-Oss bone graft and a Bio-guide resorbable collagen membrane fixed by the healing screws.

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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.

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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.

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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.

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Then, I cover the perforation with a resorbable Bio-Guide collagen membrane, fill the sinus with almost two grams of Bio-Oss bone graft

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and cover the graft laterally with another Bio-Guide membrane, closing the flap on top.

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Again, the before and after panorex. Now we need to wait at least six months to place the implants on the left sinus graft.

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Two implants, one with ridge expansion and membrane, the other with osseous regeneration and delayed placement after abscess healing.

Two implants, one with ridge expansion and membrane, the other with osseous regeneration and delayed placement after abscess healing.

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.

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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.

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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.

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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.

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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.

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Four months later we check X-rays and see the shadow of the new generating bone in the alveolus.

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Ridge preserved in height and width, the placement is now simple.

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Single implants and orthodontics in lower jaw

Single implants and orthodontics in lower jaw

This case shows a treatment combination of orthodontics, implants and prosthesis.
The patient lacks teeth on the lower jaw, pieces 47, 46, 45, 36, 42 and carries a one-pillar bridge over 42, 41. Due to previous crowding, she had a lower incisor extracted.
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I used a quick ortho treatment lo help alignment and. After extracting the lower left wisdom tooth (48), I corrected the first molar (46) angle, tilted forward after several years edentulous space.
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Implants are placed easily on the rear ends. But the space available on the incisors is always more critical. So, first I cut the bridge and, then, I open the flap.
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I run a set of expanders, since the ridge is rather narrow.
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The bone’s concave shape in this region forces the implant to be inserted in a different angle than the adjacent teeth in order to avoid thread exposure of the implant.
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The implant is set in place, to the limit of bone elasticity for a 3.75x15mm implant. I prefer not to use 3.25mm of 3i brand, if possible.The thread is too small. Too many threads probably heat the bone a little too much and failure happens more often than with regular thread implants. For me, the wider the thread, the better.
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I put the flap back in place with stitches and let the implants heal.
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I remove the braces and use a thin, temporary clear splint for retention, to prevent the spaces from collapsing,  while a fellow doctor works on the fixed prosthesis.
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When the prosthesis are finally fixed, I substitute the clear retainer for a new, thicker one, including the implant crowns.
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Final result. Note the different level of the gingiva in the incisors. Fortunately, This effect can’t be seen while talking. Now it would be time to start treatment in the upper jaw, to get better esthetics.
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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.

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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.

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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.

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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.

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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.

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

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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.

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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.

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