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.
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.
The movements on the left side are attempted gradually, with springs and/or elastics, as well as ligature anchorage when possible
When the turn comes to the 11-22 bridge, I cut it in between 21-22 to liberate 22 for motion with springs.
I used elastics on 21 to prevent from rotating, since the spring force will act with high leverage on 11.
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.
When the space is crated for 41, I bring it into the arch and do a little stripping.
Final adjustments on the lower incisors after stripping.
Midlines aligned with the nose. Finishing inter-arch elastics for maximum intercuspidation, and opening spring to back-tip 37 and allow for implant placement.
Now the spaces are not at their final size, but they are enough as to place the implants.
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.
When healing takes place, I set the gums with future esthetic tooth proportions. I use electric scalpel for the gingivectomy.
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.
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.
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.
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.
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.
Final result, at right and left laterality
Before, intermediate and final stages of the front crowns.
Final result on maximum intercuspidation.
This case shows a treatment combination of orthodontics, implants and prosthesis.
The patient lacks two molars on the lower jaw. She has moderate to advanced periodontal disease, occlusal plane with a deep Curve of Spee and produces an incredible amount of calculus in a short time. She is experiencing the effects of tooth loss and periodontal disease. These are rear occlusal collapse, mesial tilting of the remaining molars and gap opening due to lack of bone support and tongue thrust.
The molars could have been also extracted, but we decided to give them a chance. With the help of nearby implants and at a correct angle, their life expectancy will be extended and depending only on the evolution of the patient’s hygiene and the periodontal disease.
The lower incisors almost out of the bone and have a high degree of mobility. The decision was to replace them by implants after ortho. I used ortho treatment to flatten the occlusal plane, close the spaces and tilt the molars to vertical.
I didn’t use braces on the incisors for three reasons:
- They would be extracted
- No intrusion or further bone remodeling was needed
- I could afford crowding during the treatment because this would mean less space to cover with two implants.
Note that the upper occlusal plane flattened by itself, without ortho.
Implants are placed easily on the rear ends. 5×10” on the right and 4×11.5” on the left, brand 3i.
Regarding the incisors, I pulled them out and placed the implants immediately. Waiting for the gum to heal after extraction often produces great ridge collapse in these periodontal cases.
The with of the bone was enough for two 3.25×15” 3i implants.
I prefer not to use 3.25mm of 3i brand, if possible. The thread is too short and too many threads probably heat the bone a little too much. Failure happens more often than with regular thread implants. For me, the wider the thread, the better.
But I prefer not to try expansion in this case, as there is risk of fracture in any of the alveolus walls.
A removable, acrylic, partial denture is used as temporary and space retainer, while a fellow colleague works on the ceramic crowns.