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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.

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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.

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

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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.

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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.

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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.

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

Single implants and orthodontics in lower jaw (II), with periodontal disease.

Single implants and orthodontics in lower jaw (II), with periodontal disease.

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.

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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.

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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:

  1. They would be extracted
  2. No intrusion or further bone remodeling was needed
  3. I could afford crowding during the treatment because this would mean less space to cover with two implants.

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Note that the upper occlusal plane flattened by itself, without ortho.
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Implants are placed easily on the rear ends. 5×10” on the right and 4×11.5” on the left, brand 3i.
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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.
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The with of the bone was enough for two 3.25×15” 3i implants.
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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.
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A removable, acrylic, partial denture is used as temporary and space retainer, while a fellow colleague works on the ceramic crowns.

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.

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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.

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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.

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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.

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

Veneers on tainted teeth with periodontal disease

Veneers on tainted teeth with periodontal disease

This case shows the procedure to make a smile make over with a combination of periodontal treatment and prosthetics.

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The patient arrives with moderate periodontal disease, lack of hygiene, severe stains due to excessive Fluor in the water he drank during childhood,  and, of course, smoking.

Exploration with probe shows bleeding and periodontal pockets over 3-4mm. So, first, we clean the gums thoroughly and watch the evolution of new hygienic habits for several weeks. Teeth should be rather taller than wider, in a proportion of 2(width) to 3 (height). This case is the other way around.

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Then, I do a gingivoplasty. This is the surgical removal of gum tissue (gingiva), reshaping around teeth to a more proportional, healthy and esthetic shape.

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Now we have a healthier, more esthetic look, 2 by 3 in proportion, that even shows the effect of smoke. The light band of previously covered neck section of the teeth vs… the smoked front section.

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Stains cannot be removed by bleaching or whitening, since they are too dark and deep in the enamel. Plus, there are open spaces. So I proceed to carve to teeth with a controlled depth of 0.5mm on the front side, up to the gums.

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Then, I remove the incisal edge of the teeth to let space for the veneers that will fit on top. Otherwise they would be so thick that the bite would only touch on the veneers, breaking them.

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A set of two thin threads are placed in the gun pocket. This phase would have been impossible to carry out without the convenient periodontal treatment explained before.

The ultimate purpose is to get a healthy gum tissue that doesn’t bleed when a silicon impression is taken. Bleeding gums provoke bubble distortions in the silicone impression, and an inaccurate cast.

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A precision cast is made out of the silicone impression. The cast is scanned by a in-office CAD-CAM system called Procera. The scanned data are sent to the Procera headquarters in Sweden, where they make the inner part of the veneers.

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Temporary acrylic veneers are bonded while waiting for laboratory working times. Several layers of ceramic colors are placed over the Procera nucleus to reach the final translucent color.  After we test a perfect adaptation and convenient color match, we bond the ceramic veneers.

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In this case we only substituted the four front teeth. If the veneers had been more as to cover 6,8 or 10 teeth, the color could have been completely changed into a new one. But in this case we tried to camouflage the veneers with color and little white stains of the nearby teeth.

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Are they strong? Do they come off?

Well, here is a good example.

Three years after, the patient hit himself with the edge of the pool, and here is what happened.

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Only a slight ding on the color ceramic covering . No cracks in the under structure. So I repaired it easily with a combination of composite resin colors, to match the ceramic.

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You can chew on these veneers as much as you can. They will not come off. The bonding used is the same as for regular fillings, but the bonding force is huge thanks to the large area of bonding, compared to the reduce leverage.

Risk of fracture is minimized by controlling the depth of the carving, and allowing enough thickness to the nucleus and cover not to break upon load.