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| case report 24 implants 2 2016 have compromised the patient’s quality of life sig- nificantly, the remaining teeth would have been weakened and bone loss accelerated. In the mandi- ble, an insufficient temporary bridge of 33–45 had been established. Extraorally, a negative lip line, the typical symptom of a vertical loss of occlusal plane, was detected. A CMD-test, in which the maximum jaw movements and symmetries were evaluated at opening and closing, revealed an age-appropriate finding with no evidence of pathological changes of the temporomandibular joints. Oral inspection re- vealed residual dentition not worth retaining with a mobility of 2 to 3. Toestimatetheriskforimplantinsertionbyperi- odontal pathological bacteria, a bacteria risk test andInterleukin-1testwastakenfromgingivalfluid on all teeth using sterile paper points. The pan- oramic X-ray (Fig. 1a) confirms the already known clinical dental report. Neither for the surgery, nor foranadvancedtreatmentplan,digitalvolumeto- mography would optimise the final result and was thereforenotperformed.Intheposteriorregionof the maxilla, due to massive horizontal and vertical boneresorption,implantationisnotpossiblewith- out expanded augmentation on both sides. The lower jaw, however, provides sufficient vertical bone volume, so we can fulfil the desire of the pa- tient of a fully loaded and functional lower jaw by inserting implants and horizontal reconstruction using alloplastic synthetic bone. In the upper jaw, nine implants were planned. To determine the possible implant length on OPG, a 5 mm reference sphere was used (Fig. 1b). The bacterial diagnosis showed a greatly increased bacterial count (>1 million)ofdenticolaforsythus andtreponema denticola. Preprosthetic treatment and surgery Inordertoreducethepreviouslyidentifiedbacte- rialload,thepatientstartedtwodaysbeforesurgery with the antibiotic treatment by Clindamycin per os and a professional dental cleaning. When selecting the antibiotic, we followed the recommendation of thelaboratorytestresults,whichrecommendedthe use of Metronidazole or Clindamycin. We see Metro- nidazole as much more prone to possible side ef- fects. We especially followed the recommendations of the American Heart Association with Clindamy- cin. We have very good experiences with Clindamy- cin due to its bone penetration ratio. The patient’s own medication was maintained. Impressions and bite registration followed for the production of removable temporary prostheses. In general anaesthesia, all teeth were extracted, fol- lowedbytheexcisionofgranulationtissue.Intheup- per jaw, bilateral external sinus lifts were performed with accretion of hydroxyapatite (Ostim®, Heraeus- Kulzer) and membrane (Cerasorb®, Curasan) and a total of nine implants (Alpha bio TEC) were inserted. In the lower jaw, twelve implants and three tempo- raryimplantswereinsertedtostabilisetheprosthesis (immediate provisory implant, Nobel Biocare). Bone edges were smoothed, bone defects filled with alloplastic bone substitute material (Ostim®, Heraeus- Kulzer). Tension-free wound closure and the fitting of the temporary prostheses ended the surgery. The patient received inpatient care in the hospital. The postoperative panoramic X-ray was inconspicuous (Fig.1c).Postoperatively,inadditiontotheantibiotic, ibuprofen and nose decongestants (Otriven®) were prescribed. Eleven days postoperatively, sutures were removed. All wounds were completely closed, which should allow a good prognosis for hard and soft tissue consolidation. The patient was in a good general condition. Implant exposure followed four months after im- plantation.Whenexposing,thetemporaryimplantin region 32 was extracted due to lack of space. Implant imprints After two weeks of healing time after the expo- sure, the patient presented a well-healed gingiva (Fig. 2a). The prosthesis on the two temporary im- plants in the lower jaw have fulfilled their function asstabilisers,nowtheyhadtoberemovedbeforethe upcomingimpression.Theresultingdefectwasfilled with alloplastic bone substitute material. The open impression (pick-up technique) of many close-set implants with laboratory-manufactured individual impression trays is difficult from our perspective. Fig. 2a: Situation after implant exposure after two weeks. Fig. 2b: Impression with individualised foil tray with additional retentions. Fig. 2bFig. 2a 22016