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