15: Case Presentations

CHAPTER 15 Case Presentations

Management of Complications

Management of Failed Immediately-Loaded Zygomatic Implants

A 64-year-old woman presented with no restorable mandibular dentition and an ill-fitting maxillary full denture. The clinical and radiographic studies demonstrated multiple periodontally involved and nonrestorable teeth. The panoramic study demonstrated advanced resorption of the maxillary alveolar bone and residual alveolar bone in zone I only. The patient’s priority was treatment of the mandibular arch. After fabrication of a full mandibular denture, the mandibular teeth were removed; mandibular implants were placed immediately and the mandibular denture was converted into an immediate-load mandibular provisional, implant-supported bridge. After 3 months of osseointegration, the mandibular implants were checked for the presence of osseointegration and the final profile prosthesis was fabricated and delivered (Figures 15-1 to 15-3).

FIGURE 15-1 Preoperative panoramic radiograph with evidence of nonrestorable mandibular teeth and presence of zone I alveolar bone only in the edentulous maxilla.

FIGURE 15-2 Removal of the mandibular teeth and simultaneous placement of mandibular implants.

FIGURE 15-3 Radiograph taken 5 years after surgery with the completed mandibular profile prosthesis and the existing edentulous maxilla.

Five years after treatment of the mandible, the patient requested treatment of her maxillary arch with an implant-supported fixed bridge. Because of the presence of zone I bone and an inadequate volume of zones II and III bone, the zygomatic treatment method was used. Using the protocol for the zygomatic method, two premaxillary implants and two zygomatic implants were placed and the patient’s full maxillary denture was converted to a provisional, immediate-load prosthesis (Figures 15-4 to 15-7).

FIGURE 15-4 Placement of the maxillary implants using the zygoma concept for the posterior maxilla and placement of two premaxillary implants.

FIGURE 15-5 Placement of abutments and completed soft tissue closure.

FIGURE 15-6 Indexing the implant positions on the intaglio surface of the full maxillary denture.

FIGURE 15-7 Completed conversion of the full maxillary denture into an immediate-load maxillary provisional prosthesis.

Six months after the maxillary procedure, the patient presented for phase II with stable occlusion and without any complaints. Osseointegration was confirmed and fabrication of the final profile prosthesis was planned. After removal of the provisional prosthesis, osseointegration was checked by applying the torque driver to each implant. The right zygomatic implant rotated on its axis, demonstrating a lack of osseointegration. The remaining premaxillary and left zygomatic implants were stable without any rotation or symptoms during torquing of their abutment screws. The decision to replace the right zygomatic implant was made.

In preparation for replacement of the failed zygoma implant, reformatted views of the patient’s cone beam radiographic study demonstrate the availability of bone above the existing implant. The intention of the procedure was to remove the failed implant, with immediate placement of a new zygoma implant with the apex in the os zygomaticus and above the failed implant apex (Figures 15-8 to 15-16).

FIGURE 15-8 When 20 Ncm of torque is applied to confirm osseointegration, the right zygomatic implant demonstrates rotation.

FIGURE 15-9 Cone beam radiographic study demonstrates availability of bone in the body of the zygoma immediately above the existing failed implant.

FIGURE 15-10 A full-thickness mucoperiosteal implant demonstrates coverage of the previous osteotomy into the maxillary sinus by the re-established Schneiderian membrane.

FIGURE 15-11 The yellow arrow points to the depth gauge instrument placed in the new osteotomy. The green arrow demonstrates the inferior position of the removed failed implant.

FIGURE 15-12 Placement of the new zygomatic implant at 40 Ncm or more.

FIGURE 15-13 To prevent soft tissue breakdown over the crestal bony defect, a resorbable membrane is placed over the implant platform.

FIGURE 15-14 The membrane is tailored over the defect and stabilized using 1.5-mm fixation screws.

FIGURE 15-15 Closure of the soft tissues after connection and torquing of a new multiunit abutment at 35 Ncm.

FIGURE 15-16 Immediate postoperative radiograph demonstrating the new right zygoma implant and the fixation screws of the membrane.

To reconnect the immediate-load provisional prosthesis to the new implant, the existing right posterior maxillary titanium cylinder was removed. The provisional prosthesis was connected to the existing three implants by their retention screws and the new implant was “salt and peppered” to the new titanium cylinder. The patient was discharged with the corrected prosthesis. An additional 6 months of osseointegration was allowed prior to checking the right maxillary implant for osseointegration. After osseointegration of all four implants was confirmed, the final metal-based profile prosthesis was fabricated (Figures 15-17 to 15-22).

FIGURE 15-17 The existing temporary titanium cylinder is removed f/>

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Tags: Implant Treatment Planning for the Edentulous Patient

Jan 7, 2015 | Posted by mrzezo in Implantology | Comments Off

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