Extraction, implant placement and immediate loading

C
CLINICAL CASE
Extraction, implant placement and
immediate loading
Dr. Francis BAILLY
> Doctor of dental surgery.
> Graduate from the Medical Faculty of Lyon (France).
> University Degree in Oral and Maxillo-facial Implantology.
> Training in advanced and bone-graft surgery with Prof. Khouri
at Schellenstein in Germany.
> Formerly attached to Lyon hospitals.
38200 Vienne - France
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Immediate loading is a surgical and prosthetic technique that
ensures immediate function of dental implants by means of
a fixed prosthesis in occlusion.
The success of this technique depends on two factors :
> The first is surgical: obtaining primary stability of the
implants (biomechanical aspect).
> The second is prosthetic: maintaining this stability despite
immediate function of the implants.
Presentation of the case
The patient is 59 years old, in good health, not taking any
treatment, and is a non-smoker.
She is experiencing great difficulty chewing because of the
absence of many teeth and the mobility of certain teeth.
She feels very uncomfortable when she smiles.
Diagnoses
At present, the new C implant, available in lengths of
16 and 18 mm, is perfectly adapted to this situation.
It is self-tapping and self-penetrating, which facilitates its
anchorage in a low-density bone.
Depending on the bone density encountered, we may decide
to sub-drill in order to obtain a minimum anchorage of
35 Ncm (standard clinical value), which is necessary for
immediate function of the implant.
The treatment will thus be done in two separate stages in
order not to subject the patient to excessively long surgeries.
We shall start in the upper jaw, where the bone density is
weakest.
The temporary bridges are placed using a direct technique,
with no reinforcement or extension.
We waited 4 months after placing the lower jaw implants to
do the upper and lower screw-retained bridges at the same
time.
Dental diagnosis :
> absence of teeth 14, 15, 16, 17, 25, 26, 27, 36, 37, 46, 47.
> temporary tooth on 13.
Periodontal diagnosis :
> healthy periodontium.
Occlusal diagnosis :
> vertical dimension normal,
> supraocclusion.
Aesthetic diagnosis :
> gummy smile.
Treatment plan
Pict. 1 - Analysis of the smile line.
First surgery: Upper jaw treatment
To remove the gummy smile, a significant coronal elongation
would be incompatible with the very weak bone anchorage of
the remaining upper maxillary teeth.
The bone, at the pre-maxillary level, allows us to consider
placing 6 G implants according to an all-on-6
protocol, i.e., implants slightly angled at the level of the
second premolar.
Regularisation of the bone crest will remove the gummy
smile.
Second surgery: Lower jaw treatment
In the lower jaw, 4 implants, using the all-on-4 technique, will
be sufficient to support a screw-retained bridge of 12 resinbonded teeth.
Pict. 2 - Patient’s gummy smile.
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CLINICAL CASE - DECEMBER 2011
Pict. 3 - The clinical view shows us a supraocclusion..
Pict. 7 - Planning of the upper jaw using Simplant® software produced
by Materialise®.
Pict. 4 - Edentulousness in left sector.
Pict. 8 - 3D reconstruction.
We observe numerous fenestrations in the apices.
Pict. 5 - Edentulousness in right sector.
Pict. 6 - The panoramic X-ray shows the weak bone anchorage of the
residual teeth.
Pict. 9 - Loss of the buccal shelf at the level of 14.
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Pict. 13 - Same view without teeth.
Pict. 10 - Palatal view showing the bone craterization.
Pict. 14 - The operating field is detached by a wide flap, of full
thickness, with no discharge incision, which enables crestal osteotomy
to be performed.
Pict. 11 - The virtual extraction of the teeth allows the cavities to be
seen.
Pict. 12 - Positioning of implants in occlusal view in relation to the
remaining teeth.
Pict. 15 and 16 - Concordance between the clinical view and the 3D
image reconstructed from the X-ray.
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CLINICAL CASE - DECEMBER 2011
Pict. 17 - View of the bone after thorough curettage of the cavities and bone
remodelling.
Pict. 20 - Before suturing, PRF membranes were added to facilitate
healing.
Pict. 18 - A mixture of half Cerabone (bovine bone) and half Maxgraft
(allogeneic human bone) is applied around the 6 G implants.
Straight and inclined conical abutments, as well as temporary copings, are
fixed on the implants.
Pict. 21 - 6 G implants with diameter 4.0 and length 14 mm.
Pict. 19 - A Jason collagen membrane covers the whole.
Pict. 22 - Patient’s smile with the temporary bridge just after the
surgery.
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Pict. 23 and 24 - Start of the second surgery with extraction of the teeth
at the lower jaw.
Pict. 28 - Temporary copings in place. The same mixture as in the upper
jaw is added around the implants.
Pict. 25 - Flap of full thickness without discharge incision.
Pict. 29 - Jason collagen membrane.
Pict. 26 - The first implant in distal position is inclined at 45º.
It is positioned above the mental foramen.
Inclining the distal implants makes greater lengths possible.
The distal exit can be made at the level of the second premolar and the
distal extension at the level of the first molar.
The orientation of the conical abutment inclined at 30º is facilitated by
the surgical guide.
Pict. 30 - PRF membrane.
Pict. 27 - Two 4.0 x 18 mm C implants, with conical
abutments inclined at 30º distally, two 4.0 x 16 mm C
implants with two straight conical abutments in the anterior sector.
Pict. 31 - Panoramic X-ray at end of the surgery.
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CLINICAL CASE - DECEMBER 2011
Pict. 32 - Check of frames.
Pict. 33 - The healing of the soft tissues is excellent.
Pict. 34 - Final upper and lower bridge.
Pict. 35 - Patient’s final smile.
The transition line between the artificial gum and
the gum is not visible.
Conclusion
This technique reduces the duration of treatment and the number of surgeries compared with the conventional protocol.
The screw-retained bridges satisfy functional and aesthetic demands.
Thanks to the Bienfait Laboratory (Av. des Ifs, 69340 Francheville - FRANCE) for its work on the prosthetic restoration part.
T!
N
A
L
P
NEW IM
Promise of eXpertise
Unique and innovative A concept :
1 SINGLE morse tapered connection !
1 common prosthetic range.
1 G E surgical kit.
F*
*A REGULAR
CC2PXGB-2011-11
2237 Avenue André Lasquin
74700 Sallanches - France
Phone : +33 (0)4 50 58 02 37
Fax. : +33 (0)4 50 937860
www.anthogyr.com
C an ideal complement :
w Indications of immediate post-extraction
implant placement and low-density bone.
w Conical design, self-drilling and
self-tapping thread.