Abstract ::This article describes the stages of treatment in solving a patient with the loss of the dental implantation at the majority of maxillary teeth in one period of time with BCS type implants without sinus lift, bone addition, augmentation and without an intermediary period of healing and without wearing of a mobile prosthesis.
INTRODUCTION: The patient,aged 32, clinically healthy, shows himself for troubles concerning the mobility of the
lower front group and of the upper teeth. Clinically, we can notice a III class occlusion, which led to the loss of the bony support through the functional trauma to which was added the lack of oral hygiene having as a result the formation of bacterial plaque and tartar which increased the occlusion trouble, probably even a periodontitis of an unknown ethiology.
The patient shows himself with an increased mobility of the lower front group, which enables us to notice the same problem to all his upper teeth except for 22, 23, 24.
a) The extraction of the teeth with advanced mobility and also of the included teeth and the mobile prosthetic.
b) The possibility that in time the prosthesis may be replaced by multi-phasic implants and bone addition, and the sinus lift of the side zone.
c) The extraction of all teeth and their replacement with 10 basal BCS type implants, immediately post extraction and a fixed metal-plastic prosthetic construction with composite teeth.
THE MANDIBLE: a) The extraction of the front lower incisors and the placing of a metal-ceramic construction by polishing teeth 33, 34, 35, 36 and 43, 44, 45, 46
b) The extraction of the front lower incisors and their replacement with 3-4 basal BCS type implants with immediate loading and a metal ceramic construction.
c) The extraction of the front lower incisors followed by a mobile prosthesis until healing 6-9 months and the use of 2-3 multi-phasic implants for a fixed metal ceramic final prosthesis.
For a start, the patient agrees only with the mandible prosthesis ( pct. a ), wishing to ask for another medical opinion concerning the upper part..A month after the lower prosthesis execution the patient agrees that for him the best solution is the one with basal BCS type implants and he agrees with the intervention.
MATERIALS AND THE METHOD OF TREATMENT:
The disinfection of the mucosa ,of the teeth and tongue is done with Betadine 5%, followed by plexal anesthesia in the left half of the maxilla and the extraction of teeth 26, 27, the curettage of the granulation tissue and the execution of a flap which should give access to the odontectomy of tooth 28 and the further covering of the edentulous area 26-28. After the extraction of tooth 28 through the alveolus formed by means of a BCD X1 mill fixed on hand-grip the inner and external cortical side of the jaw bone is drilled and that of the Pterygoid plate of the sphenoid bone. The direction of insertion is found by palpating the hamulus and it lies between medial pterygoid lamina si lateral pterygoid lamina. The drilling is performed by hitting the hand- grip with the handle of an elevator and the turning of the mill manually until the drilling of the slots .Then it is replaced by a twist drill 2.0/30 and the operation is repeated. After that a BCS 3.5-23 implant is inserted with the hand grip until the last whirl gets through the bone. In this case the tip of the implant also gets into the side pterygoid muscle approximately 1-2 mm, this fact not affecting the functioning of the muscle; the patient did not complain about any inconveniences when opening and shutting his mouth. The second implant will be placed in the zone of the palatal root of tooth 2, the hand grip and the two drills will be used in the same succession. This time it is drilled through lamina cribrosa, the spongy bone and the inner cortical side of the maxillary sinus is pierced in the palatal zone. After insertion the flap is relieved and pulled over the heads of the implants. In the contact area a perforation in the mucosa is done through which it glides over the neck of the implant. The suture is performed with 3.0 silk.
Next,the anesthesia for the group of teeth 24-14 is given followed by their extraction. We enter with a twist drill mill 2.0/30 obliquely from the distal towards the mesial through the alveolus of premolar 2. While touching the nasal cortical side we can sense the resistance and the characteristic sound of a rock. We measure the length at that moment and we choose an implant 1-3 mm longer. The nasal cortical side is drilled and a BCS 3.5/20 mm Implant is set. Then, through the alveolus of canine 23 comes a BCS 3.5/20 mm implant and through the one of the midmost 21 a BCS 3.5/20 implant. The insertion is performed identically, mention should be made that the implants are not introduced simultaneously, but from different angles. For the canine we choose a more palatal insertion, and for the midmost one slightly vestibular. We insert in the same order a BCS 3.5/17 in alveolus 11 and a 3.5/20 in alveoli 13 and 14.After insertion the implants are parallelized by bending using the key for the implants insertion KOS and an adapter. The plexal anesthesia comes next followed by the extraction of 16-17, a flap with the uncovering of 18 and extraction. Through the alveolus towards 18 in the same way like for the opposite side a tubero pterygoid 3.5/23 implant is introduced. The flap is brought over the head of the implant like for the opposite side. During the intervention, after each extraction, the alveolus is checked to remove the granulation tissue, and the implants are introduced in Betadine 5% before insertion.
At the lower prosthesis construction effectuated a month previous to the implants we notice canine 33 cu 2 canals and 2 roots . The implants are parallelized by bending them in the front zone and those in position 23-24 will be shortened so as to adapt the occlusion.
The tooth print is taken with addition semisolid silicon without using a supra printing with fluid silicon. In order to obtain the fidelity of the head of the implant we use plastic printing heads, and the dental technician uses transfer abutments of the implants.
On the second day, the patient comes for the testing of the metal structure and for the removing of the suture strings. The local disinfection is done with Betadine, and before the testing of the metal structure, this one is also dipped into Betadine 5% solution. Thus the bacterial insemination is prevented in the junction area of the implant with the mucosa or the blood clot. We recommend the patient a lymphatic drainage due to the edema in the part of the face corresponding to 18.
On the third day the testing of the construction is performed and its cementation with Fuji plus cement. Any testing of the construction is preceded by its disinfection and of the mucosa with Betadine 5% solution, this one being the best bactericide, fungicide and virucide acting in no longer than 2 minutes, and without any allergic reactions.
We notice in the 17-18 area the covering of the flap over the implant with pterygo maxillary insertion. We did the same procedure for the 27-28 area.
The prosthesis construction is executed according to Camper plan, Wilson curve and Spee curve. The length of the construction extends from tooth 16-26, and the height at premolar-molar level is of maximum 6 mm. At the level of the last implants the zone 17-18, 27-28 the crowns are undersized at minimum, thus being taken out from the occlusion and allowing a better sanitation. We make sure that there is no leading function at the level of the frontal zone 13-23 a malocclusion of 1-2 mm being normal. In the side movement the leading is on the occlusal sides of the premolars and of the molar on the same side with malocclusion on the opposite and front side. Thus all masticatory forces will be inscribed in a polygon in the inner side of the implants insertion..
INSTRUCTIONS GIVEN TO THE PATIENT : To have a semisolid diet in the first 3 months, a normal oral hygiene and once a week to use the oral lavage with Betadine 5%, to come for the readjustment of the occlusion at fortnight and after that every month. Regular check-ups every three and six months and panoramic X-ray after a year. The patient comes for check-up after two weeks. At clinical examination the alveolar mucosa is healed with a slight gum retraction.
Final rehabilitation – we can notice a good aesthetic by the positioning of the upper front group slightly vestibular so as to
compensate for the III class occlusion.
OCCURING TROUBLES AND THEIR SOLUTIONING:
Although the patient was explained that after the replacing of the natural teeth with a prosthetic construction this would not look the same in shape and size, after 24 hours he asked to have it replaced with a ceramic one without gum mask. This fact emphasized the fact that these patients who had a complete set of teeth and a satisfactory physionomy and mastication up to the moment of extraction needed special psychological guidance so as to understand the healing process after the extraction including the use of artificial models of study which could show them the purpose and the finality of these procedures. This patient made a parallel between the colour of the prosthetic mask and the mobilizable prosthesis. We agreed that the construction would be replaced with a ceramic one after 9 months, while the bony and gum tissue would be stable, and completion in the area of the right tuberosity with another implant. . Another problem which occurred and which was partially solved in 2 weeks was that of phonation. In the future it is necessary that in the case of classes 2 and 3 the implants in the front area should be limited to the skull level if possible , maximum on sides, so as to allow the technician to perform a correct gearing and a width and shape of the bridge body which should not disturb speech.
One last problem should be the extraction of the 3 lower molars, the patient not agreeing with that in a first stage, these being extracted at a further appointment. The necessity of the extraction is given by the fact that that area is blocked for a good functioning of the osteon, leading to atrophy due to inactivity and to a zone susceptible to bacterial infections.
CONCLUSIONS: The treatment by the use of oral implants with immediate loading shortened the treatment period of the patient from 1-1,5 years to a week ; from minimum 3 surgical procedures: bone addition , prosthetic abutment for only one and most importantly for this patient he did not have to go through the phases of total edentulous jaw, bearer of mobile prosthesis until final rehabilitation.
After 12 months pacient comes back to change the upper metal to plastic bridge with metal ceramic bridge
I put two implants for safety, place 17 and 11
I finish the ceramic bridge in 3 days and after one week I make the extractions 38 and 48 also.