injerto en bloque, sutura en rampa, implantes dentales, elevacion de seno, Khoury´s technique, elevacion de seno, regeneracion osea guiada.
Referral
The patient was received at the maxillofacial surgery service (Foz do Iguazu, Brazil).
Patient Complaint
« The patient complained that she had much pain in her mouth. »
History of presenting complaints
When performing an X-ray and oral examination, it was seen that apart from having active periodontal disease, she had excellent mobility of the teeth 3.7, 3.8 and 1.7.
Social history
Age: 64 years old.
Married: 30 years.
Occupation: Nurse.
Do not smoke or drink alcohol.
Medical history
Actual diseases: High hypertension.
Past illnesses: COVID-19 in February of 2020.
Allergy: Aspirin.
Family conditions: Morbid obesity and type 2 diabetes predominate in her family.
Dental history
Oral hygiene technique: The patient has inadequate hygiene.
Dental visits: She fears the dentist; she had a bad experience with her child.
Reason for loss of teeth: Due to periodontal disease.
Habits: Anything relevant.
Evaluation:
1. Health
2. Function
3. Aesthetics
The maximum aperture was 40 mm in the anterior zone.
Dental treatments performed before surgery
1. Cleaning and applying airflow are carried out.
2. Perio chart to know the hard and soft tissue conditions:
A. Bleeding and plaque generalised.
B. The patient has generalised gingival recessions, being Miller type 1 and 2 (Pini-Prato, 2011)in the anterior incision and length of 3 mm.
C. Gingival biotype thin.
D. Deep pockets in the mandible are 4 mm on average, although 3.6 and 3.7 have 9 mm p pockets.
In the maxilla, the average is 4 mm, but teeth 2.7 and 1.7 have 7 and 10 mm of deep pocket average, respectively.
E. Tooth 2.7 has an involved- furcation type 2C(Rasperini et al., 2020) according to Rasperini et al. 2020.
F. Lack of keratinised gingiva from 3.4 to 3.8 and from 1.4 to 1.8
3. The patient was taught the instructions and good brushing and flossing techniques.
4. Extraction of 3.6, 3.7 and 1.7 were realised.
5. General dentistry.
Attitudes Towards Previous Treatment
Good attitude
Systematic orofacial examination
The face:
Mixed race patient with strong chewing muscles with brachyfacial features.
Mouth:
1. without swelling.
2. Sufficient saliva, good tongue mobility, and good mucosa hydration.
O.P.G before the extractions and perio-treatment:
O.P.G after two months of extractions, perio-treatment and general dentistry:
Diagnosis
1. Severe periodontitis, molar-incisive distribution with potential for additional tooth loss and a moderate rate of progression(G. Caton et al., 2018), stadium 3, because the patient was 64 years old if she was 40, it could be a rapid degree of progression.
2. Mobility of teeth 3.7, 3.8 and 18 grade 2-3(Aminoshariae et al., 2020).
3. Presence of wisdom tooth included in 4.8.
4. Maxillary atrophy in the first and third quadrants horizontally and vertically.
Differential fixed treatments
- Vertical augmentation with an autologous bone graft, Khoury technique and sinus lift.
- Vertical augmentation with Gore-Tex membrane, autologous bone and xenograft.
- Vertical augmentation with a metallic membrane and a mix of autologous bone and xenograft material.
- Makes a computerised prosthesis that already contains the implants and is fixed to the bone using micro-screws.
Treatment
- Resective periodontal surgery in both maxillas.
- After controlling the periodontal disease, the treatment has been to extract the included tailpiece of 4.8 with the piezoelectric to take advantage of the vestibular table to make an autologous cortical bone graft. However, it was not removed because the vestibular table was more than 4 mm thick, so the included window was not seen. This table was cut with discs, polished with the safe scraper, and fixed vertically in the third quadrant. It was filled with autologous bone, and another sheet was placed by buccal to make the formwork of the Khoury technique(Khoury and Hanser, 2019).
- In the upper part of the first quadrant, a sinus lift(Silva et al., 2016) was performed with a collagen membrane, and Microdent screws were placed to achieve the tent-pole technique. It has waited five months for the regeneration, and in the lower part, it has waited four months for the placement of the implants, as Khoury recommends(Khoury and Hanser, 2019).
Options
conveniences
1. It is an effective treatment that works overtime(Al-Moraissi et al., 2020).
2. This treatment let me put on a long implant and get good stability.
3. It allowed to improve the patient’s aesthetics and avoid the realisation of a fixed prosthesis with teeth that are too long, which would affect pronunciation and hygiene.
4. As it is performed mainly with autologous bone, the possibility of rejection decreases, and regeneration times are shortened
Inconveniences
1. Requires more manual skill. If there is any complication in the surgery with manipulating the alveolar dental nerve, I could alter the nerve’s sensitivity (Abayev and Juodzbalys, 2015).
2. Using intravenous anaesthesia has risks(Manso et al., 2019). First, the patients need help to help us. Second, working is complicated because the patient is in a deep stage.
3. If the regeneration is exposed or goes wrong, we can produce a more extensive defect than we initially had.
Surgery/Treatment details:
1. Anaesthesia local: Adrenaline 4%, infiltrative in the buccal zone; lidocaine 2% was used to block the dental alveolar nerve.
This case was realised under intravenous sedation.
2. From 3.4 to 3.8, a crestal incision was made with a 3.4 hockey stick-style shock.
A total mucoperiosteal detachment was performed, and the area was cleaned and scraped with the safety scraper to activate the recipient’s bone.
3. After dividing the cortical bone into two parts, a table was placed vertically, marking the necessary height for regeneration. Next, lined autologous bone was placed in the middle and covered horizontally with another table.
All of this was fixed with screws.
4. a crestal incision of 1.4 to 1.8 in the upper part was made in the first quadrant, with a distal discharge of 1.4.
5. The mucoperiosteal flap was separated, around the hand bur was used, a window was made at the and 1.6, the Schneiderian membrane was separated, filled with autologous bone, and a xenograft was placed in the vestibular part.
6. To perform vertical regeneration, micro screws were used, which would be used to achieve vertical rejuvenation and mark the desired height. Then, with a layer of autologous bone and another layer on top of the xenograft, everything was covered with a collagen membrane and fixed with pins.
Oral medication:
The patient was premedicated with 500 mg amoxicillin and 125 clavulanic acids every 8 hours for ten days.
It was administered every 8 hours for seven days, starting two days before
Ibuprofen 400 mg, 3 times per day for 4 days.
X-rays control of regeneration:
O.P.G after upper implants:
Periapical X-ray after four-month post-implants:
Photos after four months of bone regeneration
Note how the regeneration has not been entirely complete on the vestibular part. The patient does not have keratinised gum, and an apical displacement flap will have to be performed, plus a free gum graft to gain keratinised tissue or a ramp mattress suture with a connective tissue graft.
Photo with implants essential cone 0.7 from Klockner:
Photo of autologous bone obtained from fresh biologic drill set on the buccal side:
Ramp mattress suture:
The ramp mattress suture was published by Tinti & Benfenati in 2002(Tinti, C., & Benfenati, 2002). They described the technique:
“Ramp mattress suture applies pressure and tearing forces on the flap in an apical-coronal direction at the vestibular site and opposite traction in a coronoapical order at the palatal site. The ramp mattress suture seems capable of pulling the flap in an apical-coronal direction in the vestibular area and in a coronoapical direction in the palatal site, making it possible to obtain a more coronal gingival margin.
After an adequate healing period of approximately five weeks, a vestibular scalloped gingivectomy is performed around the vestibular surface of the abutment to create either a scalloped gingival margin or interproximal papillae only in the vestibular area. Thus, forming a gingival ramp in a palate-vestibular direction to reasonably reduce the residual increased vestibular depth and optimise the aesthetic result”.
Photo of Ramp mattress suture in 1.6 and 1.7 implants after two months:
Evolution and prognosis:
The evolution and prognosis of this case have been favourable; no more teeth have been extracted in the three years I reviewed this patient.
Managing hard and soft tissues has allowed this result to be maintained over time.
Overall
In this case, it was learned to perform the tent pole technique for vertical regeneration. It was interesting to observe how sometimes the regeneration with autologous bone is not perfect, but thanks to the biological drilling, the clinical appearance of the implants could be improved. Carlo Tinti’s ramp suture helped achieve keratinised gingiva and placed it where needed. The patient attends her check-ups once a year and has not had any complications.
Implantología
Rehabilitación oral
Cirugía oral
Periodoncia