this is a quite complicated case, as for the degree of bone destruction, the esthetic demand, and the surgical-prosthetic procedures involved in the process. View full processe here…
Initial phase: extractions and healing
Old metal-ceramic crown work over devitalized incisors. Periodontal abscess, retracted alveolar front wall, frontal gingival recession, central incisor presenting endo-periodontal injury around root apex.
Extractions are done and an immediate removable prosthesis is placed during the healing period. Acrylic relines are successively done to keep contact between the resin and the gum, in order to prevent further resorption.
One thing should be taken into consideration: a different approach could be done by filling the sockets with bone graft and covering them with a membrane. With the existing endo-perio pathology it may be a safer play to let it heal by itself. Second, there is short soft tissue over the central incisor as to cover the resorbable membrane.
Surgical phase: implant placement, bone augmentation
The two implants are placed along the convenient axis, already expecting exposure of a few threads. The Bio-Guide membrane is cut to fit in the edentulous gap, holes are poked to screw the implants’ healing screws throw it, acting as fixation.
Enough membrane margin is left to fit under the palatal flap and several holes are poked on the apical end of the membrane. First, to drill through the pin retention. Second, to nail the pins through.
Once the pin holes are drilled with no tension on the membrane (it should be baggy enough as to allow for sufficient graft volume), a little blood is extracted, mixed with Algipore
, and placed over the implant’s threads and the bone concavity.
The resorbable pins are nailed carefully fitting them through the membrane holes and into the previously drilled socket retentions.
Periosteal cuts are done under the full thickness flap. This permits further elongation of the flap in order to close the wound over the increased volume base.
Implant osseointegration phase: 6 months
The acrylic removable prosthesis is immediately relined to fit over the suture and checked up periodically for later relines in order to keep contact with the gum.
Prosthetic phase: Procera veneers and metal-ceramic crowns over angled pillars
During the try-on, the left central incisor doesn’t fit precisely. Maybe due the tooth migration, maybe due to impression accuracy. So the cuspid’s veneer is cemented and second impressions are taken for the final result, incorporating pink ceramic to disguise the implants’ high emergence.
This a long, multidisciplinary case, involving peridontics, endodontics, resin restorations, orthodontics, implants and venners.You can view the full process here…
Orthodontics & Implants on 12, 35
Removal of orthodontics, bleaching & retainer
Prosthetic Phase & retainer
results: 5yrs post implantary phase, 10yrs from restoration
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 the procedure to make a smile make over with a combination of periodontal treatment and prosthetics.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.