Sinus graft complications & management

The following clinical case shows several minor complications and management during different dental implant surgical stages. 

This is the case of a  28 years old healthy male who came to our clinic for dental implant rehabilitation of the posterior left maxillary area. After clinical and radiographic evaluation, the need for vertical and horizontal ridge bone augmentation was determined. Vertical augmentation was treatment planned to be obtained through lateral window sinus lift surgery accompanied by horizontal ridge augmentation using particulate bone grafting material and membrane. 

Two dental implants were placed 8 months post sinus lift surgery. During the osteotomy for the molar site implant, a small membrane perforation was identified, managed and controlled through the osteotomy site. Dental implants were placed and primary stability was obtained for both. 

Upon dental implant uncovery, 3 months after surgical placement,  bone loss was found on the molar site implant. We reduced the exposed implant threads with Implant-plasty using a fine diamond bur and a layer of HA xenograft bone grafting material was used to graft the facial aspect of the implant. 

The 3 year follow up X-ray shows good bone stability around the implants.

Ioannis

Gingival recession treatment with connective tissue graft

Patient presented to our clinic with the chief complaint of: "Increased and persistent sensitivity on upper left central, lateral, canine and first premolar teeth (21, 22, 23, 24)"

After clinical and radiographic evaluation our Diagnosis given to those teeth was: Class I Miller recession on 21, 22, 23, 24

Etiology: Traumatic forces (applied with a hard toothbrush) over a thin tissue biotype.

Treatment plan: Connective tissue graft with a coronally positioned flap

Prognosis: Excellent (90-100% root coverage is anticipated in class I miller recessions)

Some post operative instructions given to the patient included but were not limited to: 

- Oral hygiene modification: modified Bass toothbrusing technique was instructed

- Recommended the use of a soft toothbrush 

Ioannis

Excision of a Fibroma with the use of a Nd-Yag Laser

Clinical diagnosis:
- Trauma induced Fibroma

Treatment protocol:
1. Occlusal adjustment of the uneven cusps of the teeth involved
2. Complete excision of the lesion for histologic evaluation

The excision of the lesion was performed using a Nd-Yag Laser.
Settings used: 4W, 200mJ, 20Hz

GBR at the time of Immediate Implant Placement

Factors to consider after reviewing a similar case to the one presented in this video:

1. In the presence of an edentulous space next to a tooth that is treatment planned to be extracted, you should evaluate the width of the crest at the edentulous site. This might give you an idea of how much resorption the extraction socket would have if not grafted or immediately place an implant.

2- If not planning on horizontally graft the edentulous site, place your dental implant in the extraction site 2mm lingually to the facial wall of the edentulous site. This is irrespective of the gap between the implant body and the facial wall of the socket. This way you will have a predictable result. If this case scenario would compromise the prosthetic rehabilitation of the implant, then perform GBR and place the implant at second stage.

3. Place the immediate dental implant 2mm sub-crestally to the lingual wall of the extraction socket to accommodate for height resorption, to provide space for establishment of proper emergence profile of the restoration and to establish adequate thickness/height of soft tissue around your implant for the uncovery stage.

Ioannis

Replacement of a broken dental implant

This patient was referred in our clinic for evaluation of an implant that was previously placed by another dentist.

Upon clinical and radiographic evaluation, our diagnosis was:

- Broken dental implant collar associated with occlusal parafunctional habits (bruxism)

Our treatment plan was as follow:

- Dental Implant removal & guided bone regeneration
- Placement of a new dental implant 4-6 months later
- Restoration + delivery of a biteguard for night use: 2-3 months later

Tips: A wider diameter dental implant would be preferable but the limited space mesio-distal and the triangular shape of the desired final restoration would not allow for the use of it. In order to overcome the above, the final prosthesis was kept out of contacts on lateral excursions and protrusion movements.

Ioannis

Dental implant uncovery with simultaneous free gingival graft procedure to augment keratinized gingiva

Diagnosis:
- Movable muccosal tissue around dental implant

Treatment plan for this case:
- Free gingival graft upon uncovery of the implant

Why is stable keratinized tissue important?

1. Keratinized attached tissue around a dental implant minimizes the chance of future recession and possible bone loss on the facial surface of the implant

2. Oral hygiene practices could be performed with minimal discomfort on the area and plaque removal is more predictable if done correctly.

3. Reduction on discomfort related to mastication of hard foods on that site.

Immediate implant placement

Treatment plan:

1. Extraction of teeth #22 and #12 and immediate implant placement with GBR
2. Restoration of the implants 4-6 months later r

Tips:

1. Due to the presence of a very thin buccal plate of the socket as well as on the edentulous area adjacent to the extractions (sites: #11, and 21) we anticipated more bone resorption despite the use of GBR.  An estimation of approximately 1.5-2mm vertical bone loss is expected, therefore the dental implants were placed 2mm sub-crestally.

3. The smooth collar of the implant won't be able maintain the height bone. For that reason it is better to utilize implants with full rough surface treatment in such cases.

4. We used these specific implants as requested by the restorative dentist

5. The open margins of the restoration are located far away from the crestal bone and 0.5mm subgingivally. Thus the environment is relatively aerobic and can be maintained clean with oral hygiene.

I posted this case to point out some factors that could be done better and optimize the result. It will be interesting to see how this case will hold on with time. I will keep you updated as the time passes.

Ioannis

Cosmetic crown lengthening procedure for teeth restored with full ceramic veneers and crowns

Diagnosis:
- Short clinical crown of the central incisors (old crowns present)
- Gingival asymmetry in the anterior sextant
- Malposition in the arch of the lateral incisor (#22)

Treatment plan:
1. Orthodontic treatment to align teeth (patient declined)
2. Temporary prosthesis (crowns / veneers) to establish final incisal edge position of the anterior teeth
3. Crown lengthening surgery
4. Final full ceramic crowns and veneers on anterior sextant 3 months after surgical procedure

Esthetic crown lengthening

Esthetic crown lengthening

Key points to the technique

1. Identify pre-op the location of the CEJ
2. Remove exostosis and festoon the bone for better soft tissue adaptation
3. Establish the 2mm biologic zone around the teeth
4. Apically position the flap to desired position, if necessary perform gingivectomy
(gingivectomy can be performed if zone of attached gingival is adequate)
5. inform the patient prior to the procedure that a secondary minor gingivectomy/plasty might be needed

Ioannis

Immediate implant placement with 4.5 years follow up (Legacy 1 dental implant)

The case presented is an extraction with immediate implant placement of an upper right first premolar. Patient has been followed up for 4.5 years. Radiographic evidence of inter-proximal bone stability has been consistent through out the years.

In our clinical practice, we have found true that with the proper prosthetic management of soft tissues, adequate quality and quantity of hard tissues and appropriate periodontal maintenance, we could expect long term hard and soft tissue stability, even in periodontally controlled patients.

Key points of the techniques used:

Surgical
- Maintain facial wall intact
- Disinfection of the socket thoroughly
- Surgical removal of the coronal portion of the inter-radicular septum to get a more stable grip of the initial drill in the socket
- Extend 3mm apically to the existing socket to obtain adequate primary stability (therefore, extra 3mm of bone apical to the existing socket)
- Place your implant towards the palatal socket allowing at least a 4mm space between the facial wall to the implant platform and fill in the gap with bone graft material
.
Prosthetics
- Screw retained restorations to prevent the retention of cement apically towards the implant body where it would be harder able to detect.
- Torque crown to 30N/cm or as per manufacturer's recommendation to minimize microgap and micro movement
- Protected occlusion