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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.

 

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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
Bone regeneration around the neck threads of an ICX implant

Bone regeneration around the neck threads of an ICX implant

In this post I want to show the bone regenerating effect from the narrow threads around the neck of an implant, brand ICX, 8” long, 4,8” wide. You can see the one-year evolution control on this following post

Day O: a second molar on the left upper jaw was extracted on May 9, 2011 due to a tooth fracture. The X-ray was taken after the extraction. The wisdom tooth is kept behind to minimite the alveolar resortion.
Three months later, on August 16, 2001 the ICX 4,8″x8″ was set with 35 N primary stability, by means of a punch technique and small vertical sinuslift, using a collagen membrane and autogenous bone. The implant was set further distal to the center space, counting already on the future extraction. The wund is sealed with a platform-switch healing screw.
 
Two months later, on October 18, 2011, I make another X-ray check, test the stability of the implant.The bone has grown around the narrow neck threads. The bone is condensed around the apex and the impact sound is excellent, showing a good integration.
I insert the closed-impression post. Now has come the moment of the extraction of the third molar (wisdom tooth), because it is no longer necessary and, furthermore, interferes with the plastic cap that goes over the post. The impression is taken therefore after the extraction.
 
 
Nine days later, on October 27, 2011, the abutment is screwed in with 35 N torque and the crown is cemented with temporary cement until the 6-moth control.
* To see the  the one-year evolution control go this post

 

lateral sinus lift, bone split and impacted cuspid extraction

lateral sinus lift, bone split and impacted cuspid extraction

This is a complex case of first-stage bone regeneration in order to set two implants in the next phase.

There is also an impacted 13 cuspid, at 45º angle, on the vestibular side, that needs to be extracted.

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Sinus lift and Bone Split

More than ten years edentulism in this 28year old patient have left an atrophic ridge “V”shaped, with not enough height as to fix implants simultaneously to the sinus lift.

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I open a large flap and drill a lateral window on the bone, setting its lower limit at the estimated height from the ridge I calculate from the X-ray.

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I push the window into the sinus and press the sinus membrane up. I measure the crestal bone with from the inside with a probe or curettes to confirm weather the implants can be fixed at this stage or not, depending on factors (bone height, width, density).

I estimate that the with and height are not sufficient for now, and with will be narrow for the future, also. So I split the crestal bone with a disk saw and chisels .

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I fill the sinus and the ridge crack I opened with 1gr. Bio-Oss and cover the whole graft with a resorbable Bio-Guide collagen membrane. Stitching this flap section back in place, as I will continue with the cuspid extraction.  6 months will be needed to approach the next phase, which is the placement of the implants. Further ridge augmentation may be needed, depending on the bone stabilization.

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Impacted cuspid extraction

The cuspid lays at a 45º angle, on the vestibular side, as I have made sure by touch. With a round bur I open a window on the bone at the estimated position I calculate from the X-ray and finger relief touch.

I soon feel the different hardness of the enamel compared to the bone. I widen the window until I see there could be enough space for the crown to come out.

I cut the crown using the same bur and pull it out with pliers and leverage forces.

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If the root is not hardly anchored, It can be pulled out by using a large endodontic round section file, #60 in this case.

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The patient will have a bridge done in this section. So there is no need for bone graft to prevent resorption.  Stitches are used to close the flap in place over the gum.

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Mandibular bone split, lateral sinus lift and other immediate implants

Mandibular bone split, lateral sinus lift and other immediate implants

This case combines several advanced surgical techniques

  • bone split and ridge expansion on both ends of lower jaw
  • extraction and immediate implants with simultaneous vertical sinus lift
  • wide lateral sinus lift for later implants

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A) Bone split and ridge expansion on both ends of lower jaw

First day of surgery. I place implants on the left jaw.

Many years without teeth have left a collapsed, atrophic ridge, both in width and height.

The inverse “V”  shaped ridge is not wide enough as to place the narrowest 3.25” implants.

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So, I use a radial saw to slit the bone, working the expansion to the spongeus with chisels.

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Then, I use a set of expanders, switching them in progressive widths

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I place a short 11.5×3.75” at the back , a 13×3.25” and a 15×3.25” angled towards liguo-mesial in order to avoid the mentonian hole and allow for bigger implant length.

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Then, it’s time to fill the gap between corticals and implants with Bio-Oss bone graft and cover it with a Bio-guide resorbable collagen membrane fixed by the healing screws.

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On the right side there is even a shorter ridge. That means the leverage forces will be greater. I repeat the bone split process an drill carefully with an angle towards lingual, allowing the mentonian nerve to pass by vestibularly. A 3.75×13” implant at the back, and two 3.25×15” in the front.

B) Extraction and immediate implants with simultaneous vertical sinus lift

The second surgery is on the upper right jaw. There is a “one-and-a-half- tooth” space. Too narrow for two regular teeth. Too wide for just one.

Besides, there is a low sinus. The little bone support, even with sinus lift bone graft (less dense), could be a challenge for long term expectancy. So, my decision is to place two implants, with two small crowns in the end.

I first extract a decayed root with a periapical granuloma.

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I open up the flap and start the vertical sinus lift with osteotoms, on both 15 and 14 places, starting by the narrowest one.

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Note the damaged, thin cortical layer at 14.

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Through the perforation, I apply small pieces of collagen sponges mixed with bone graft. Then, I place a 3.25×11.5 on 15, and a 3.75×13 on piece 14.

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I cover the defect with Bio-Oss bone graft and a Bio-guide resorbable collagen membrane fixed by the healing screws.

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C) Lateral sinus lift for later implants

The upper left jaw needs a wide sinus lift in order to lace implants at a later stage. There is a no residual bone left at all.

I extract the damaged root and open a wide flap.

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I drill quite a wide lateral “window” carefully, not to perforate the membrane. At first touch one can appreciate the extreme thinness of the bone here.

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While separating the membrane a perforation occurs. I keep separating, since we’ll need a big volume graft to allow the future implants to hold on to.

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Then, I cover the perforation with a resorbable Bio-Guide collagen membrane, fill the sinus with almost two grams of Bio-Oss bone graft

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and cover the graft laterally with another Bio-Guide membrane, closing the flap on top.

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Again, the before and after panorex. Now we need to wait at least six months to place the implants on the left sinus graft.

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Combined implant and ortho treatment in a severe bruxist with posterior occlusal collapse and closed bite

Combined implant and ortho treatment in a severe bruxist with posterior occlusal collapse and closed bite

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.

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The patient is a severe bruxist. You can tell bi the extremely closed goniac mandible angle, wide jaw branches and high bone density.
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Extreme abrasion and deep Spee curve overbite that is damaging the palate gingiva behind the upper incisors.
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Lack of upper and lower molars that led to further bite collapse.
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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:
  1. removing destroyed molars,
  2. place two implants on both sides with simple sinus lift,
  3. wait for healing
  4. Ortho treatment
    1. bring back front teeth to
      1. correct tooth inclination to vertical
      2. close spaces
      3. establish new bite for lower rehabilitation
    2. extract one premolar on each side if further retraction is needed
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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.
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I stitch the flap back in place using gum portions for maximum closure and wait for second intention healing.
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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.
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Panorex after upper upper surgeries. Two 5×15” on the right, 5×15” and 4×15” on the left.fabiola-esther-2
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.
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I place the implants a little under the crestal bone, providing margin for ridge resorption.
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I cover the gaps with Bio-Oss bone graft and pieces of Bio-guide resorbable collagen membranes fixed by the healing screws.
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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.
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Now it is time to start ortho treatment in the upper jaw…