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Bone regeneration around the neck threads of an ICX implant. One-year control.

This post is the continuation of this last year’s post. It shows how the ridge bone grows and remodels itself around the thin neck threads of an internal hexagon ICX implant with cone-connection.

 

000-X-rays-1-2-3

 

The upper second molar was extracted and the implant was placed three months later with a simultaneous internal sinus lift under low primary stability conditions. Finally, the third molar was extracted at the moment of taking the impressions for the implant crown.
 ICX internal hexagon cone dental implant crown one year X-ray evolution
Once again, you can see the beginning of this case on this post.
The case was indeed very favorable regarding the amount and quality of the soft tissue, although the circumstances were right the opposite regarding the bone. Relatively good width, but scarce height and density, three months after the extraction.
This X-ray was taken on October 9, 2012, a year after setting the crown and 14 months after placing the ICX implant.

ICX internal hexagon cone dental implant crown one year X-ray control



It shows how the crestal bone has remodeled itself, growing vertically around the neck threads of the implant.
The soft tissue is really healthy after one year, although the hygienic conditions surrounding the implant are certainly not the best.

ICX internal hexagon cone dental implant crown one year after buccal view

ICX internal hexagon cone dental implant crown one year occlusal view

ICX internal hexagon cone dental implant crown one year lingual soft tissue view
General anesthesia in dentistry

General anesthesia in dentistry

Although the majority of the dental surgery procedures and general dental treatments can be done with the only help of local anesthetics, sometimes general anesthesia  is strictly necessary in order to carry out long , extensive surgeries, such as orthognatical surgery, or neoplassical surgery.

dentist general anesthesia dental office treatment
General anesthesia at the dental office allows to provide a confortable better dental treatment.

In other cases it is just a matter of patient’s comfort or a patient’s requirement because of his great fear to the dentist, or fear to the dental treatment.
In some cases the use of general anesthesiaallows to carry out a long, extensive, integral multiphase treatment in just one long appointment, which would be perhaps too much for the patient to handle without general anesthesia.
monitoring parameters non-deep general anesthesia
monitoring parameters for a non-deep general anesthesia

Some countries’ laws require that general anesthesia is carried out in a hospital. In other countries it is a popular method in normal dental offices, where the anesthetist brings his own equipment by the dental chair.

This allows to have all dental equipment, instrument and materials –wich are many more as an ambulatory general anesthesia unit, including accessories- right on the spot in order to provide a better dental treatment.  
The way the general anesthesia is carried out depends on the anesthetist’s preferences and likes.
Nasal Oral intubation general anesthesia dental treatment
nasal vs. oral intubation

Some anesthetist prefer deep anesthesiasessions no longer as 3-4 hours, without local anesthetics.

Some others carry out not so deep general anesthesia, combined with the help of local anesthetics placed on the treated areas. This has the advantage of allowing longer ambulatory treatment sessions with short recovering periods.
monitoring parameters non-deep general anesthesia
Monitoring parameters

The anesthetist controlls then oxygen, carbon dioxide curve and uses light amounts of anesthetical to induce sleep but on a superficial level, so that the patient can almost breath by his own, while still beign assisted by artificial respiration.

The recovering period is obviously related to the anesthesia duration, The longer the session, the longer the recovering phase. But the depth of the anesthesia influences also the recovering period.
A normal recovering phase would be around 30-40 minutes for 3-4 hours general dentistry anesthesia, 60-90 minutes for 6-8 hours .
After that, the patient can already walk home with a companion’s supervision. 
Another technical difference is the way the intubation for breath support is done.
Oral intubation general anesthesia dental treatment
oral intubation

Oral intubation is quicker and easier for the anesthetist, leaves less soreness, but it leaves less space in the mouth for the dental surgeon to work in. Obviously, the mouth cannot be closed. It mostly used for surgery not needing occlusion references, such as third molar extractions, or neoplassical surgery. 

Nasal intubation general anesthesia dental treatment
nasal intubation

Nasal intubation is slightly more complicated to carry out , can eventually leave some soreness in the nasal mucosa, but, on the other hand, it provides free space for the dental surgeon to work comfortably in the mouth. It is used to carry out orthognatical surgeries, fracture correction surgeries, prosthetical treatments, or extensive cavity restorations involving large occlusal surfaces. In this cases the dental surgeon needs to close the patient’s jaw in order to test the occlusion or to splint both jaws after they are set in the new place. Obviously, this could not be done with an oral intubation technique.

roll-up soft tissue enhancement around dental implants

roll-up soft tissue enhancement around dental implants

Soft tissue enhancement around dental implants is becoming more and more important in the daily dental practice.
soft tissue management enhacement dental implant neck crown roll-up technique
soft tissue enhancement around a dental implant crown

At the beginning of the dental implants era, we thought that just placing the dental implant on a prosthetically convenient place and achieving a proper osseointegration was already a success. Today the success criteria have been raised in the dental implantology, based on the continuous research.

The amount and quality of the gingival soft tissue around the dental implant neck is one of those success criteria being considered nowadays in dental implantology
After years of experience, it has been demonstrated that the more soft tissue there is around a dental implant, the better its long-term prognosis is.

 

This is because the dental implant has no micro blood vessels around it like a tooth has. The blood support for the bone around a dental implant needs, therefore, to come extra from the soft gingival tissue, since the internal bony circulation is quite limited.
Thus, surgical techniques have been developed to provide the dental implant neck with more surrounding soft tissue.
The buccal soft tissue can be of three kinds, free gingival tissue, attached gingival tissue and alveolar mucosa.
    The free gingiva is made of non keratinized tissue. It surrounds the neck of teeth and implants and its inner side forms the gingival sulcus.
    The attached gingival tissue is made of keratinized fibers and it is associated to masticatory function. It lays between the alveolar mucosa and the gingival groove. It has a characteristic orange-peel stipplings in a healthy state.
    The alveolar mucosa is the non keratinized continuation of the attached gingiva towards the cheeks and lips. It is movable, too. Between this two there is a characteristic line, limiting what is attached and what is movable.
The attached gingiva has proved to be the most deciding part in the long-term preservation of the ridge bone around the dental implant neck. You want to have as much of this tissue around your dental implant as possible. Obviously it cannot be augmented infinitely beyond the anatomical boundaries and the surrounding soft tissue limits. There is an intimate relationship between the bone ridge laying underneath and the soft tissue above it.

In this clinical case we see how a unitary dental implant is placed on the extraction site of a lower first molar that had severe periodontal damage due to an insufficient root canal treatment.

 

This is the resulting state of the attached gingiva after the healing phase, prior to the dental implant exposure surgery.

 

In this exposure surgery, a roll-up soft tissue enhancement technique is employed. This roll-up surgery pursues to increase the attached gingiva thickness on the buccal side around the dental implant neck.
Since the external layer of the flap will be submerged between periosteum and the attached gingiva, this external layer -which served as mastication surface on the edentulous space- needs to be de-epithelized.
De-epithelization is the removal of the thin outer most layer of keratinized cells, so that the flap quickly bonds itself to the inner tissues where it is laid. This is done with a sharp scalpel blade or with a diamond drill.
After rolling in the flap towards the side pouch, it is fixed by means of a 6/0 nylon micro suture, that can be removed after seven days.


The roll-up technique deals with the inside folding of the attached, keratinized gingiva covering the implant, which is moved to the side and rolled in between the periosteum and the outer attached gingiva while creating a pouch for it.

The prosthetical phase starts with the impressions, in this case, with open tray abutments. 
The next step is the design and construction of abutment and crown for the ICX implant on the cast model. This implant model provides platform switch, internal hexagon and cone.
The abutment is screwed onto the implant with 30Ncm torque-control
And the crown is inserted over the abutment. Due to its rounded shape, it pushes somehow the gums while it slides in place, producing temporary ischemia -compromised blood support-, as seen on this pale shade around the crown.
The gums are a flexible tissue and they adapt themselves to the new situation in a matter of minutes or some hours at the most.

The result is a new thicker keratinized attached gingival band around the dental implant neck.

 

Distalizing a molar to correct mesial tipping with implants and no orthodontics

Mesial tipping behind an extraction site is a normal phenomenon that can be corrected using a simple acrylic wedge and some patience, from both patient and dentist.
Here I show how to distalize a tooth in order to correct the mesial tipping without using orthodontics.
 
 
distalization molar implant mesial tipping third molar extraction X-raydistalization molar implant mesial tipping wedge design
distalization molar implant mesial tipping third molar extractiondistalization molar implant mesial tipping crown

*this is the continuation of the previous post, which shows the surgical soft tissue management phase

First make your design and explain it to the patient and to your dental technician.
The goal in this case was to fit a longer disto-mesial crown on the back implant that tilts the second molar back to a more upright angle. 
Notice that is is reciprocal. The crown won’t fit in the place unless the gap is made somehow bigger before the insertion.
distalization molar implant mesial tipping wedge design cast model
For that we need a simple aid. That is, for example, a chairside made acrylic wedge that you make over the future crown abutments on the cast model or directly in the mouth.  It can also be done in the lab, if you prefer.
There are, however, two ways to approach the solution at this point:
  1. You make the acrylic wedge with the actual size, then you add acrylic distal increments
    1. This is more precise, but it requires a second impression and thus, more time.
  2. You take some cast material from the mesial side of the tooth to be tipped back, then you build the acrylic wedge on the model.
distalization molar implant mesial tipping wedge design cast modeldistalization molar implant mesial tipping wedge design cast model
    • This allows to prepare the final crown and to have it ready as soon as the molar tips back and lets the crown in.
    • But not valid for screwed crowns if the gap opening is more than 1″ on average.
abutment implant ICX
abutment implant ICX
distalization molar implant mesial tipping third molar extraction

In this clinical case I chose the second way and I gave the patient both the edge and the crowns, instructing her to take them in and out until the crowns fit in.

 A second molar can hardly be tipped back if there is a wisdom tooth behind it. So I extracted the third molar and inserted the acrylic wedge on the same day. 
On the hand design you may see I planned to insert the front crown and only a wedge on the back implant, but the I tested it and realized that the wedge was more stable with a double post retention. But it could have been also done with one abutment.
 
distalization molar implant mesial tipping wedge design

The wedge must adapt passively on the front and ut must have an inclined rear surface that pushes the molar back while the occlussion keeps the wedge in place.

distalization molar implant mesial tipping third molar extractionThere will be subsequently an increased bite heigth, resulting in no front contacts and premature contact on the wedge and the implants underneath.
 
 
 
Caution:
  • You may want to allow the implants a longer healing period just to assure full osseointegration
  • You need to tell the patient that he/she should not overload the implants by bitting hardly on them, and that the molar will move back gently in a few days or a few weeks, depending on different factors (bone density, extraction distally, degree of tipping vs. amount of distal movement).
  • You may need to schedule some control appointments, checking how the molar moves back and the bite closes down. If that doesn’t happen, you may need to introduce some changes in your wedge design or confirm that the patient carries it at all times. 
distalization molar implant mesial tipping wedge design open bitedistalization molar implant mesial tipping wedge design open bite

 

There will be a moment, days or weeks later, when the crown can be placed on the abutment and fits in with more or less pressure. This can be done by the dentist or also by the patient at home, providing he/she was properly instructed on this task. Normally it is the crown itself that pushes the tooth back the last tenths of millimiter and falls right in place.

abutment implant ICXabutment implant ICX crown
abutment implant ICX crownsoft tissue management abutment implant ICX crown
Soft tissue management around two mandibular implants

Soft tissue management around two mandibular implants

Soft tissue enhancement around dental implants is becoming more and more important in the daily dental practice.
soft tissue management enhacement technique dental implant neck
soft tissue enhancement around a dental implant crown

At the beginning of the dental implants era, we thought that just placing the dental implant on a prosthetically convenient place and achieving a proper osseointegration was already a success. Today the success criteriahave been raised in the dental implantology, based on the continuous research.

How soft tissue protects the implant

The amount and quality of the gingival soft tissue around the dental implant neck is one of those success criteriabeing considered nowadays in dental implatology

After years of experience, it has been demonstrated that the more soft tissue there is around a dental implant, the better its long-term prognosis is.
This is because the dental implanthas no micro blood vessels around it like a tooth has. The blood support for the bone around a dental implantneeds, therefore, to come extra from the soft gingival tissue, since the internal bony circulation is quite limited.
Thus, surgical techniques have been developed to provide the dental implant neck with more surrounding soft tissue.
The buccal soft tissue can be of three kinds, free gingival tissue, attached gingival tissue and alveolar mucosa.
  • The free gingiva is made of non keratinized tissue. It surrounds the neck of teeth and implants and its inner side forms the gingival sulcus.
  • The attached gingival tissue is made of keratinized fibers and it is associated to masticatory function. It lays between the alveolar mucosa and the gingival groove. It has a characteristic orange-peel stipplings in a healthy state.
  • The alveolar mucosa is the non keratinized continuation of the attached gingiva towards the cheeks and lips. It is movable, too. Between this two there is a characteristic line, limiting what is attached and what is movable.
The attached gingiva has proved to be the most deciding part in the long-term preservation of the ridge bone around the dental implant neck. You want to have as much of this tissue around your dental implant as possible. Obviously it cannot be augmented infinitely beyond the anatomical boundaries and the surrounding soft tissue limits. There is an intimate relationship between the bone ridge laying underneath and the soft tissue above it.
soft tissue management around dental implants occlusal view
soft tissue management around dental implants diagnose X-ray
soft tissue management around dental implants lateral view

Clinical soft tissue management case

In this clinical case we see how two dental implants are placed on the left lower jaw, after a long term period without teeth. 50 year-old woman, non smoker, thick biotype.

Diagnose

By clinical examination we appreciate light vertical bone resorption, mid horizontal resorption -thanks to the thick biotype pattern- but indeed a remarkable recession of the attached gingiva. The mesio-distal gap between adjacent teeth is 23mm.


control diagnose soft tissue management around dental implants lateral viewcontrol diagnose soft tissue management around dental implants lateral view


The 5″ diameter measurement balls show panoramic 2D X-ray show enough bone depth for two 12,5″ ICX-Templant implants on both sides. We will discuss the left side on this post only.

soft tissue management around dental implants diagnose X-ray

Implant surgery

The purpose of this surgery is not only to place the implants, but also to enhance the attached gingiva on the spot. This means a partial thickness epithelial flap -leaving the periosteum on the bone-, displacing the flap buccally (to the side) and apically (downwards), and open healing.

Incision

Contrary to a normal implant surgery, where the upper incision is done right on the ridge, in this case we want to displace as much keratinized epithelium from the lingual side and fix it bucally. we need also two vertical discharges along which the flap will be moved.

soft tissue management surgery around dental implants lateral view

Implant placement

Two 3,75×12,5″ ICX-Templant internal hexagon conus implants are placed with no complications. The buccal bone wall appears to be thick enough so as not to need bone graft protection, regarding especially the fact that there will be supposedly less bone loss by not detaching the periosteum
soft tissue management surgery around dental implants lateral view parallelsoft tissue management surgery around dental ICX implants lateral viewsoft tissue management surgery around dental ICX implants lateral view
soft tissue management surgery around dental ICX implants lateral view bone level

 

The implants are place at bone ridge level and, due to the periosteum thickness, they appear to be more submerged.

Suture of the flap

soft tissue management surgery around dental ICX implants lateral view bone level healing abutmentsNow it is time to screw the healing abutments (3″ hight in this case) and to reposition the flap bucally with 6/0 Prolene stitches on the periosteum.

soft tissue management surgery around dental ICX implants lateral view bone level healing abutments



soft tissue management surgery around dental ICX implants lateral view bone level healing abutments

Removing the suture stitches

The gum tissue needs now quite a few week to re-epithelize the area, while the implants complete the osseointegration phase. The stitches can be removed one or two weeks after the surgery, but in this it was done 4 weeks later, because the patient leaves a few hours away from the office and cannot come so easily. I try to adapt the appointments to other work stages on the right side, ceramic inlays and other conservative general dentistry therapies.
soft tissue management surgery around dental ICX implants lateral view bone level healing abutments


At this stage an enhancement of the attached gingiva can already be seen buccally.

This is the resulting state of the attached gingiva after the healing phase. 14 weeks in this case, but it could have done by the 8th week or even earlier.  The benefit os this first surgery technique is that it needs dental implant exposure surgery at this second stage.
The result is a new thicker keratinized attached gingival band around the dental implant  necks.
soft tissue management surgery around dental ICX implants lateral view bone level healing abutments

Impressions

Two impression abutments are fixed on the implants and the plastic tray is perforated conveniently to let the abutments thorugh.
 
soft tissue management surgery around dental ICX implants impression abutmentssoft tissue management surgery around dental ICX implants impression abutments
The impression is taken with Impregum, polyether material.
dental ICX implants impression abutmentsICX implants impression abutments tray

Prosthetical phase

In the next post I will explain how I corrected the mesial inclination of the second molar and placed a wider crown on the 36 implant.
distalization molar implant mesial tipping  third molar extraction
distalization molar implant mesial tipping  third molar extraction wedgedistalization molar implant mesial tipping  crown wedge