A. Systemic phase: none
B. Preparatory phase: Phase 1
- Patient education to the etiology and pathogenesis of periodontal disease
- Oral Hygiene instructions: demonstration of the use of the rubber tip and tooth brush and dental floss.
- Endodontic consultation and re-evaluation of #3,4,9,14
- Root planing and polishing
- In the preparatory phase: extraction of distal root of #31
- Prosthodontical evaluation.
- Caries control.
- Occlusal splint therapy and occlusal adjustment to correct occlusal interferences
- There is a need for additional radiological exams for a complete diagnostic evaluation of the implant sites. A prosthetic consultation resulted in impressions for study models and diagnostic wax-up. On the basis of this wax-up, a radiological stent was fabricated for new orthopanthomographic radiographs and tomograms. The same stent was used at the time of surgical implant procedures . Guttapercha has been used as radiopaque material to identify implant locations in the stent fabrication.
- Radiological Report
- Upper Left Surgery: teeth #14-15
- Implant Therapy: region of teeth #30-31
- Crown lengthening: teeth #2-3
- Purpose of the surgery: Direct access to the overhang, and root surface. Goals of the surgery: Elimination of the overhang , root surface treatment, pocket elimination and re-establishment of "biological width".
- Surgical procedure: Anesthesia. Topical anesthetic.
- Infiltration anesthesia: 4x 1.8ml carpule 2% Lidocaine 1:100000 Epinephrine
- Probing and bone sounding revealed a possible bone defect interproximally and a suprabony pockets distally; minimum buccal furcal involvment.
- Buccal Incision: Sulcular
- Palatal incision : Sulcular # 14. Reverse bevel scalloped incision about 1.5 mm apical to gingival margin tooth#15.
- Vertical incision placed on mesial line angle #14.
- Distal wedge incision: Two parallel distal incision were placed about 3mm apart and extending 6 mm distally
- Full thickness flap elevation
- Soft tissue degranulation
- Exam revealed overhanging gold pin. No root fracture or perforations could be seen adjacent to the pin. Examination of the bone morphology presented an osseous defect classified as a Class I crater (less than 2-3mm deep;); Pin smoothed down with rotary instruments; Diamond burr and white stone.
- Osseous recontouring: Osteoplasty and minimum ostectomy. A completely palatal approach was preferred to reduce the interproximal lesion. Defect was eliminated completely from the palatal side. An attempt to create a 10 degree slope was performed. Minimum osteoplasty and ostectomy of the buccal furcation region.
- Scaling root and planing performed after osseous resection.
- Suture: 4-0 silk with a FS-2 needle. Continuous sling anchored and with vertical mattress interproximal palatal . Single interrupted to suture the distal and vertical incisions. Dressing was placed ( Coe-Pack). Post operative instructions were given to the patient.
- Amoxicillin 500 mg , 21 caps, 1 T.i.d, Diflunisal 500 mg, 8 tabs, 1 tab q 8hrs, p.r.n.
- Post operative: 1 week: Healing very well. Distal incision healing by second intention
- At subsequent checkup visit after 3 weeks: clinically completely healed
- Probing depths after 18 months revealed a residual depth of 4 mm palatal interproximal #14-15 and no bleeding on probing.
- Oral hygiene has been re-enforced.
- Premedication with 1 gr. of Amoxicillin 1 hour before surgical incision
- Presurgical rinsing with 0.12% chlorhexidine for 30 seconds.
- Anesthesia: Alveolar nerve block with 1 carpule 2% Lidocaine 1:100,000
Lingual nerve block with 1 Carpule 2% Lidocaine 1:100,000
Local infiltration with 2x carpule 2% Lidocaine 1:100,000
- Incision: Crestal linear incision , Distally divergent towards the buccal. Vertical incisions placed buccal and lingual with preservation of distal papilla of #29.
- Full thickness flap reflected and minimum ridge preparation with round burr under copious irrigation. Surgical stent placed to assess ideal positioning of the implants.
- Implant site preparation with the stent aiding in implant positioning. Round burr, 2mm drill , 3mm pilot, 3mm drill , countersink. Extreme care was taken to continuously irrigate during surgical procedures. Partial tapping was needed for distal implant because of high bone density. Last 3-4mm of implant were not tapped. Mesial implant was not tapped. In both cases self tapping Nobelpharma titanium implants were used. A 15mm implant was placed mesially and 13mm implant was placed distally. Both implants were placed in ideal prosthethic angulation both buccal -lingually and mesial-distally according to surgical stent direction.
- Periosteal release on the buccal flap to allow tension free suture and closure.
- Before cover screw placement, the internal aspect of the implant was rinsed with sterile saline physiologic solution.
- Sutures: 3-0 Plain-gut with FS-2 needle. Horizontal mattress sutures were placed to evert flap margins. Single interrupted to facilitate primary intention healing.5-0 Plain-gut with P-3 needle to close vertical incisions.
- Post operative instructions.
Amoxicillin 500mg 21caps,1 T.i.d.
Chlorhexidine rinse twice per day for 3 weeks
Pain medication: Diflunisal 500 mg, 8 tabs, 1 tab q 8hrs, p.r.n.
Healing proceded uneventful: - Check up: 1 week, 3 weeks, 6 weeks
- 4 months after implant placement:
- Anesthesia: Infiltration with 1 Carpule 2% Lidocaine 1:100,000 Epinephrine.
- Incision: Paracrestal lingual incision extending about 4mm distal to the distal implant. Vertical Incison was placed buccal mesial of the mesial implant. Distal papilla of tooth # 29 was preserved.
- In the attempt of elevating a split thickness flap some osseous denudation could not be prevented.
- Flap was sutured at the base of the split preparation with 5-0 Gut sutures.
- Examination of the implants revealed no mobility and clinical osseointegration . After abutment placement a periapical xray was taken: no evident pathology could be seen.
- Because the minimal vestibular depth and the minimum amount of keratinized tissue a free gingival graft was harvested from the right region of the palate.
A third rationale for a soft tissue graft procedure was to avoid bone exposure. - Postoperative instructions.
Chlorhexidine rinses twice per day, for 3 weeks.
Pain Medication: Diflunisal 500 mg, 8 tabs, 1 tab q 8 hrs, p.r.n.
- Healing proceded uneventful.
- After final healing the patient was instructed in oral hygiene procedures and explained about the importance of the home care for the long term duration of the implants. Patient instructed to use interproximal brush around the implants.
- Radiographic examination of the implant at the time of second stage surgery and six months after second stage revealed no apparent changes in bone height. Final impressions and prosthetic provisionalization were performed 10 weeks after second stage surgery.
- Oral hygiene around the implants is good. No signs of inflammation are clinically detectable.
- A provisional restoration was placed.
- Need for crown lenghtening palatal and distal. Pocket elimination and osseous defect reduction; elimination of overhang on # 2.
- Anesthesia. 3x 1.8 carpule 2%lidocaine 1:100000.
- Incision: Buccal: Crestal incision; Palatal: Scallop 2-3mm around # 2 and 3; vertical incision on distal line angle# 5. Distal incision: Two separate distal incision 2mm apart were placed extending about 7 mm distally
- Full thickness flap elevated. Degranulation of soft tissue. Examination of osseous architecture.
- Osteoplasty and ostectomy to provide positive architecture .Overhanging amalgam was smoothed down with a white stone.
- Scaling and root planing.
- Care was taken to allow the maintenance of a "biologic width space" and to avoid to compromise the furcation region especially on the distal furca of #2.
- 4-0 Silk sutures were used. Continuous sling and horizontal mattress on the palatal.
Single interrupted for the distal incision.
- Post operative instructions.
Chlorhexidine rinses twice per day, for 3 weeks.
Pain medication: Diflunisal 500 mg, 8 tabs, 1 tab q 8 hrs, p.r.n.
- Healing;1 week. Healing very well on the buccal. Minimum healing for secondary intention on the distal of #2.
- Final Healing: Excellent.
- Oral hygiene still not as desired. Re-enforced at each appointment.
- At last appointment, 1 and 1/2 year after first visit OH is improved. Still margin for improvement.
- Oral hygiene instructions and demonstration of the use of rubber tip. Provisional restoration placed.
- Dental Chart
- In the region of marker #1, there is approximately 2cm from the superior border of the alveolar ridge to the superior border of the mandibular canal. In the region of marker #2, there is approximately 18mm from the height of alveolar ridge to the superior border of the mandibular canal. Examination of the panoramic radiograph reveals the possibility of periapical disease associated with the apice of #3, and 4. All tomographic images are magnified 1.7X
- The endodontic consultation did not suggest any need for additional endodontic therapy.
C. Surgical treatment:
- Periodontal surgical treatment:
Upper Left surgery : #14-15
- Implant Surgery:
Stage 1:
- Crown lenghtening: #2,3
Do you wish to take this course for continuing education credit? Yes
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