Select Page
Fixed ceramic oral rehabilitation on 16 implants

Fixed ceramic oral rehabilitation on 16 implants

0019630H0019630M0019630Q00196322001963290019632B0019632K00196313

This is the case of a 50 year old male, smoker, with severe periodontal disease and ongoing periapical pathology in some of his teeth.

0019630H 00196302 00196305 00196304

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.

00196306  0019630I

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.

0019630M 0019630K

after six months from the re-placement of the last two implants, I start with the prosthetical procedures.

0019630T 0019630Q
0019630R 0019630S

This is the trial model, to test size, shape, color, and smile line

0019630W 00196322

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

001963230019632400196325 00196326 00196327 00196328

The two upper front sections are cemented over gold abutments and the rest are screwed.

00196329 0019632J 0019632B 0019632C

Oclusal view with the chimneys filled up

0019632K 0019632L 00196313 …and final smile
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.

 fabiola-esther-1  fabiola-esther-3
The patient is a severe bruxist. You can tell bi the extremely closed goniac mandible angle, wide jaw branches and high bone density.
 IMGP2059  IMGP2060
Extreme abrasion and deep Spee curve overbite that is damaging the palate gingiva behind the upper incisors.
 IMGP2063  IMGP2064
Lack of upper and lower molars that led to further bite collapse.
 IMGP2061  IMGP2062
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
IMGP5878 IMGP5880
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.
IMGP5881 IMGP5882
I stitch the flap back in place using gum portions for maximum closure and wait for second intention healing.
IMGP5883 IMGP6212

IMGP6412

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.
IMGP6414IMGP6417 IMGP6419
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.
IMGP8010 IMGP8012
I place the implants a little under the crestal bone, providing margin for ridge resorption.
IMGP8013 IMGP8015
I cover the gaps with Bio-Oss bone graft and pieces of Bio-guide resorbable collagen membranes fixed by the healing screws.
IMGP8017 IMGP8018 IMGP8016
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.
 IMGP8021 fabiola-esther-3
Now it is time to start ortho treatment in the upper jaw…
Delayed implants after total extractions. Periodontal disease.

Delayed implants after total extractions. Periodontal disease.

This case presents severe periodontal disease. The only logical treatment plan is full extractions and new denture.

maria_delia_00

The virulence of the periodontal affection and the severe bone ridge damage, with too many irregularities, suggest a prudential approach for the implant surgery. I prefer having the teeth extracted and wait until the bone ridge is in better, safer shape and the bacteria in the mouth have cleared up.

IMGP1244 IMGP1243 IMGP1245

So, the patient is sent to her general dentist for full extractions and temporary denture placement.

maria_delia_1

We wait 4 1/2 months, with periodical checks to prevent from a sudden ridge collapse. The longer the wait, the safest the implant surgery (more regular bone and healthier flora), but you have to be ready for an eventual fast bone resorption that may be the signal to program an immediate implant surgery, not to lose much bone height or width.

The ridge is amazingly flat, but extremely deceiving for its concavity. The earlier thrust of a macroglosic tongue left an alveolar protrusion in both maxillas. IMGP1248

In order to prepare an optimal fitting and esthetic prosthesis. I place the implants as parallel as possible, taking care not to perforate the vestibular bone, but sometimes, it happens.

 IMGP6196 IMGP6197

If the space is limited, bone graft and membrane should be used to cover the vestibular defect and still keep the implant in the same place. But in this case there is plenty of space to insert the implant somewhere else.

IMGP0025IMGP4108

  maria_delia_2

Two weeks later I proceed to the upper maxillary implant surgery. The bone has a more rounded ridge and not as much concavity, but enough as to need a change in placement. The higher the number of implants, the bigger need for their parallelism. But, the angle that works fine in one bone section may not be as good in another portion of the bone. And perforations can happen. This could be prevented by CAD-CAM designed surgery, but it is also costly. It can be done with a little personal 3D view and surgical resources.

IMGP3761 IMGP3764 IMGP3760

IMGP3766 IMGP4109

This is the final result after 6 months, ready for his general dentist to initiate the fixed prosthesis.

Delayed implants after total extractions. Impacted cuspid extraction.

Delayed implants after total extractions. Impacted cuspid extraction.

This case presents severe periodontal disease. The only logical treatment plan is full extractions and new denture.

CEFERINO_01

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.

IMGP4222 IMGP4223 IMGP4224

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.

CEFERINO_02 Four months later, the bone ridge is more regular

Then, I place six implants on each jaw.

IMGP3779 IMGP4412

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.

IMGP4413 CEFERINO_03

This is the final result after 6 months, ready for his general dentist to initiate the fixed prosthesis.