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What problems can tooth implantation solve?

• Single tooth missing. In this case there is no need to remove the neighbor teeth nerves and turn-process these neighbor teeth for tooth crown attachment
• A few teeth missing in a row. Tooth implantation provides a possibility to place a stationary dental prosthesis instead of a removable dental prosthesis.
• All teeth missing

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Tooth Implantation History

In 1965 professor Ingvar Branemark was a head of research group at the University of Goteborg (Sweden) and his studies finally resulted in osteo-integration discovery (titanium prosthesis integration into tissue). Branemark’s researches were aimed at jaw bone healing and regeneration after injury. The most remarkable thing about this is that osteo-integration phenomenon was discovered accidentally.

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Clinical Case 7

Teeth extraction, installation of implants on each jaw, restoration of the alveolar ridges, splitting of the upper jaw, bone grafting with a block and open sinus lift in the area of teeth # 16 and 17.

1. When the patient came to the clinic she was diagnosed with a partial mandibular edentulism and complete maxillary edentulism.

2. It was suggested to remove the remaining teeth and install up to 10 - 12 implants on each jaw. Also, the method of treatment by reducing the volume of the alveolar ridges was explained to the patient. Splitting of the maxillary alveolar ridge (in several quadrants), bone grafting with a block (in the third quadrant) and open sinus lift in the area of teeth # 16 and 17 were planned.

3. Periapical X-rays of the anterior mandible. All planned interventions were suggested to be performed in one or two surgical procedures (depending on the conditions for the initial stability of implants).

4. The patient has an old denture on the upper jaw which we plan to use after surgery as an immediate denture with a soft template. On the lower jaw we have already begun to remove old metal-ceramic crowns. On the crowns we can see “Kvarotti” clasps from the old denture.

5. Oral cavity condition without the dentures.

6. Hollows and thinning of the alveolar ridge in the upper jaw are visible to the naked eye.

7. …as well as the "quality" of the alveolar ridge and the mucous membrane as in the prosthetic bed area...

8. …and marginal gingiva surrounding the metal-ceramic structures. On the lingual surface the mucous is macerated, there are sores (due to a permanent denture in the mouth). If we blow air between the crown and the mucosa with a puster, a pocket with the depth of at least 3 mm will be exposed.

9. View of the anterior mandible after removal of the old metal-ceramic interconnected crowns. Some cast metal cores got unfixed when we were removing the crowns.

10. After removal of the lower incisors we see the contour of the bone that forms teeth sockets and the interdental septa.

11. With the help of a disk the surgeon carefully cuts away bone exostosis and thin edges of teeth sockets, and puts them in a separate container with blood plasma obtained after centrifugation (thereby producing another batch of autobone).

12. View of the alveolar ridge in the anterior area after using the disk.

13. Pieces of autolbone soaked in blood plasma (exostosis and thin edges of teeth sockets).

14. Autobone can be retrieved from the bone collector.

15. Temporary plastic crowns were planned to be placed on the lower jaw. They were scheduled to be made after the removal of sutures. Due to good primary stability of implants in the bone at the time of operation we can install healing caps immediately and replace them with temporary abutments at the orthopedic stage.

16. Tooth # 47 was removed in the lower jaw and an implant was installed in its place. It was installed with excellent primary stability. This group of implants will support a non-removable temporary structure.

17. Collecting of a bone block is carried out with a piezo surgical instrument in the retromolar area of the fourth quadrant.

18. Horizontal and vertical cuts in the retromolar area before collecting the bone block.

19. The block is on the right in a separate container together with the exostosis soaked in blood plasma.

20. Donor site after collecting the bone block.

21. A surgeon with certain skills and experience can easily get the block split in half lengthwise. A through bed for the screw should be formed in the block to avoid excessive pressure and cracking of the block when the screw will pass through the block. There should be special proper screws for this.

22. From these two parts of the bone a formwork is built, which is then fixed with screws and a mechanical screwdriver.

23. The same line up formwork which is located in the area of teeth # of 35, 36 and 37. In this area there will be a delayed implantation.

24. View of the formwork from above.

25. All the empty space we got as the result of building the formwork is filled with a mixture of bone material (synthetics (OSTEON2), biomaterials, bone autobone). Autobone has the best osteoinductive properties.

26. Part of planned implants with healing abutments is installed in the lower jaw. Teeth sockets without implants are filled with a mix of synthetic material and autobone. View of the wound before suturing.

27. View of the wound after suturing. Prolene 4.0.

28. A full surgical template placed on gums (as usual full dentures) allows the surgeon to verify the interproximal distance between implants with relative accuracy.

29. An incision is made in the first quadrant along the alveolar ridge 0.5-1mm closer to the palate. We can measure the space we are interested in using intraoral calipers.

30. If we work in a loose bone on a narrow ridge and we are not ready to create deficit of bone when forming the implant bed, we must adhere to the osteotome technology of forming the bed.

31. Skills of our surgeons allow them to use trephine for simultaneous autobone sampling and formation of the implant bed (of a smaller diameter than the bed which is formed by the final drill).

32. With the help of a diamond hemisphere from the sinus lift DASK kit we form a lateral window for access to Schneider membrane.

33. If the extent of your involvement (amount of maxillary sinus) is large, it is not necessary to create a large lateral window. We would recommend to create two holes of a small diameter. A big window should be covered with a membrane and fixed with pins.

34. Also with the help of a set of DASK curettes Schneider membrane is detached from the bottom, the medial and lateral walls of the maxillary sinus.

35. A resorbable membrane folded into a hemisphere is introduced into the lateral window. It straightens and serves as a roof for the formed space which in its turn will be filled with a certain amount of implants and artificial bone.

36. First portion of the artificial bone is introduced. It is a mix of alloplant and synthetic bone material OSTEON 2. Condensation of the material with a special plugger. Particles of synthetic bone material will act as an X-ray contrastor.

37. Two implants are installed simultaneously with sinus lift in the area of teeth # 16 and 17.

38. Splitting of the alveolar ridge and simultaneous installation of implants were planned in the area of teeth # 14-11. A horizontal cut is made on the top of the ridge with a disk. Cooling with physical solution is used in the process.

39. After the vertical cuts on the vestibular surface of the ridge we move along the horizontal cut and immerse the osteotome to the desired depth. IMPORTANT: osteotome moves 2 mm apical to the future implant.

40. Next, following the osteotome technique we install convex osteotomes where we are going to install implants. In good (large) set of osteotomes minimum diameter of drills starts with the diameter of awls. There is a graduated scale on the top of osteotomes.

41. That’s how primary (thinnest) osteotomes look. They are used to work in a small volume of bone. It must be understood that the convex osteotomes while passing in the thickness of the bone expand and seal the walls of the bone bed. Concave osteotomes while passing in the thickness of the bone extend and collect the bone from the bone bed which they move in the process. This feature should be taken into account when performing closed sinus lifting.

42. That's how concave osteotomes look. There is a graduated scale on the surface.

43. Note the clear separation of the vestibular and palatal areas of the ridge. In the places where osteotomes were installed great beds for the implants are formed.

44. Implants are installed accurately in the splitting line and closed with cover screws.

45. All the free space formed between the vestibular and palatal alveolar wall and between installed implants is filled with a mixture of bone material (biomaterials, autobone, Osteon 2).

46. The working zone is covered with a fibrin clot membrane and a resorbable membrane.

47. We can form the bed with the help of a trephine and immediately set the future direction of the axis of the implant. Thus we get an additional portion of autobone. Trephine plunges to the depth and stops before reaching the bottom of the maxillary sinus by 1-2 mm.

48. We can seal the walls of the bed and "buckle" the roof of the bed (bottom of the maxillary sinus).

49. With a special set of curettes for sinus lift DASK we elevate the mucosa from the bottom of the maxillary sinus in a circular motion through the created hole. Thus we perform closed sinus lift.

50. After installing implants in the area of 26th and 27th teeth we move to the front and side parts of the second quadrant. We form a longitudinal section along the top of the ridge with the help of piezo surgical tools.

51. As in the first quadrant the osteotome passes to the depth greater than the length of the implant by 2 mm.

52. After vertical cuts on the vestibular surface we begin forming beds for the implants with the help of osteotomes. With the passage of an osteotome through the sick of the bone splitting of the vestibular wall occurs simultaneously by a "green branches" principle.

53. Osteotomes by Dentium also have graduation on the surface. The use of osteotomes should alternate from small to large.

54. Implants are installed in the line of the splitting. We must remember that thickness of the bone around the implant should be at least 1 - 1.5 mm.

55. All the space between the area of splitting and the area of removal is covered with artificial bone and then with a resorbable membrane.

56. View of the sutured wounds on the upper jaw, Prolen 5,0.

57. Control OPG shot after the operation. We can see the following areas: 16, 17 open sinus lift, from the 14th to 25th splitting of the alveolar ridge, 26, 27 closed sinus lift, 35, 36, 37 fixation of the bone block by the sandwich technique using titanium screws. Donor site, where the bone block was taken from (retromolar area, tooth 48).

58. Two weeks after the stitches are removed we unscrew healing abutments, measure the depth of the gingival bed with a depth gauge and choose temporary abutments. In this case we chose double abutments DAB.

59. There is no need to bury the abutment ledge under the gum at all or only a little bit.

60. Protective caps are fixed on the abutments. We can place temporary crowns on them.

61. We added 26th and 27th teeth to the old denture (instead of extracted teeth). We chose plastic with excess inside to form a space for the pud.

62. Full denture in the upper jaw with a pud. View of the lateral department.

63. Full denture in the upper jaw with a pud. View of the front department.

64. Full denture in the upper jaw with a pud in habitual occlusion with plastic crowns on the bottom jaw. A side view.

65. Occlusal surface of the temporary crowns of the lower jaw.

66. The patient came to the clinic to continue her treatment plan. We installed four more implants (in the area of 15th, 35th, 36th and 37th teeth).

67. Bite templates for an edentulous jaw should look similar to this in our view. Two or three implants are selected for better stability (the analog to the working model), they should be as parallel as possible (for the smooth introduction and removal of the rigid structure.) You can take two or three transfers (which will remain attached to the polymerized basis) and shorten them to the thickness of the base and the height of the wax cylinder. We need to use screws for securing abutments as they are short.

68. If we do not use the facebow we should stick to the classic definition of the parameters of the centric relation. Tragi-nasal line to determine the occlusal plane, and pupillary line for the front area. Central line, fang line and smile line are made on the wax model, which will help to choose the size of the teeth in the anterior area.

69. We made a composite template for the processed abutments to check they are in place.