24
Multidisciplinary Cases: Implants
24.1 TADs to Intrude Upper Molars
Fig. 24.1 Initial intraoral view.
Diagnosis
A 27‐year‐old woman with hyperdivergent skeletal Class II presented with constricted dental arches, Class II division 1, posterior crossbite of 25, severely extruded 26, and missing 36 and 46. They had a left‐side deviation of the lower midline, slight labial incompetence, retruded chin and a gummy anterior smile of 3 mm.
Treatment Plan
Maxilla:
- Symmetrical expansion and intrusion of 26 using TADs: one labial, one in mesial and another distal to the tooth
- During the refinement, once the implant for 46 could be placed the TADs could be removed and the intrusion of 26 assisted by a provisional crown at 46
Mandible:
- Expansion and arch form coordination
- Centre lower midline with upper midline
Fig. 24.2 Pretreatment extraoral and intraoral views.
Fig. 24.3 Initial: teleradiograph, cephalometry and panoramic X‐rays.
Fig. 24.4 Initial occlusal contact point.
Requirements for the Technician
Maxilla
- Symmetrical expansion of the upper arch with attachments to control the molar torque in the first premolar and first molars during expansion.
- For 26 intrusion, an attachment is not necessary but attachments on adjacent teeth (25 and 27) will assist the intrusion, helped by the occlusal contact between 27 and 47.
- In order to be able to intrude the 26 space is opened between the molar and the premolar and between the first and second molar of 0.25 mm so that the first molar would have enough room for the intrusion.
Mandible:
- Use the expansion to open 10 mm of space for future implants of 36 and 46
- Use the expansion space to centre the lower midline with the upper midline
Fig. 24.5 Occlusal ClinCheck views.
Fig. 24.6 Lateral ClinCheck views.
Fig. 24.7 Interproximal reduction was not planned in the ClinCheck, but was made mesial and distal to 26 during the intrusion to provide space for the movement.
Fig. 24.8 Initial frontal Clincheck view.
Treatment Summary
- Total treatment time was 13 months.
- The patient wore 27 aligners in the first phase with 10‐day change intervals; during that phase she used crisscross elastic on the left‐side with a class II component, and class II elastic on the right, both with full‐time wear.
- Two microscrews placed mesial and distal of the 26 and a Powerchain from a button in 26 were used to assist the 26 intrusion.
- After these 27 aligners, a set of additional aligners were requested to complete the intrusion of 26, in that moment the implant of 36 and 46 had already been placed with provisional crowns.
- Occlusal contact between the provisional crown in 46 and the extruded 26 completed the correction.
- The TADs and the final provisional crown in the 46 over the implant were critical to the success of the intrusion of the 26.
- The smile of the patient improved considerably as a result of the transversal development of the arches, a bilateral class I was achieved with normal overjet and overbite and with both midlines centred.
Fig. 24.9 Situation before additional aligners. Results after the first set of 27 aligners and the use of two microscrews to intrude 26.
Fig. 24.10 Initial (upper) and final (lower) occlusion. Final result after refinement and provisional crowns on 36 and 46 implants.
Fig. 24.11 Initial (left) and final (right) occlusals.
Fig. 24.12 Initial and final smile.
Fig. 24.13 Final panoramic and lateral X‐rays.
24.2 Upper Midline Shift
24.2.1 Opening Space for Implant of 23
Fig. 24.14 Initial intraoral view.
Diagnosis
A 31‐year‐old woman with a normodivergent skeletal Class III presented with constricted upper arch, unilateral Class III on left side, a missing 23 and left‐side deviation of the upper midline.
Treatment Plan
Maxilla:
- Symmetrical expansion 5–5
- Opening space for implant for 23
- Crown of 24 and 25 were separated in a previous orthodontic treatment when she was a child. However, as the roots of 24 and 25 were convergent, it was decided to open a space for the missing 23 instead and distalize 24 to place it in its normal position
Mandible:
- Expansion and arch form coordination
Fig. 24.15 Pretreatment extraoral and intraoral views.
Fig. 24.16 Initial occlusal contact.
Fig. 24.17 Panoramic and lateral X‐rays. Cephalometric analysis.
Requirements for the Technician
Maxilla:
- Symmetrical expansion of the upper arch with attachments to control molar torque in first premolar and first molars during the expansion
- Open a space of 8 mm for the missing 23 and provide mesial‐tipping to the root of 22 and distal‐tipping to the root of 24 to ensure space for the future implanting of the canine
Mandible:
- Coordinate arches and make IPR 3–3 to provide a final overjet of 1.5 mm
Fig. 24.18 Opening space for missing 23.
Fig. 24.19 interproximal reduction 3 to 3 to allow lower incisors retraction and create positive overjet.
Fig. 24.20 Initial lateral ClinCheck views.
Treatment Summary
- Total treatment time was 16 months.
- The patient wore 34 aligners in the first phase with 7‐day change intervals; during that phase she used class II elastic on the left‐side to move 24 to distal, and triangular elastics on right side.
- After these 34 aligners, a set of 16 additional aligners were requested to complete opening space for implant of 23.
- The smile of the patient improved considerably as a result of the transversal development of the arches; a bilateral class I with normal overjet and overbite, and with both midlines centred was achieved and the surgeon was able to place the implant for 24.
- Retention was provided by fix retainers and Vivera retainers for night use.
Fig. 24.21 Powerarm to make roots of 25 and 24 closer.
Fig. 24.22 Evolution at 12 months.
Fig. 24.23 Evolution after using additional aligners.
Fig. 24.24 Final views with implant for 13.
Fig. 24.25 Initial (left) and final (right) occlusal.
Fig. 24.26 Initial and final overjet.
Fig. 24.27 Evolution of the patient’s smile (from left): initial, before additional aligners and final result.
Fig. 24.28 Final panoramic X‐ray with implant for 23.
Fig. 24.29 Final teleradiograph with overjet corrected.
24.3 Posterior Bite Collapse
Fig. 24.30 Initial left intraoral view.
Diagnosis
A 39‐year‐old woman with skeletal class I presented with dentoalveolar protrusion, posterior bite collapse owing to missing lower molars, severe extrusion of the upper molars with posterior gummy smile and TMJ disorder; her upper midline was centred. She had attrition of the edges of upper and lower incisors (occlusal wear) as a result of the anticlockwise mandible rotation that happened when she lost her lower molars, with a consequent edge to edge situation in the anterior incisors.
Treatment Plan
- The oral surgeon made a mock‐up to estimate the vertical dimension needed
- In order to have anchorage to intrude the upper molars and to retract the proclined incisors, the surgeon placed the implants on the lower arch with temporary crowns. With the occlusal contacts, the aligners would be able to provide an effective intrusive force
- With the help of lower arch implants and provisional crowns, the plan was to intrude upper molars, level the upper occlusal plane and provide anchorage to retrude the lower incisors and create positive overjet
Fig. 24.31 Pretreatment extraoral views.
Fig. 24.32 Pretreatment intraoral views.
Fig. 24.33 Initial panoramic X‐ray, teleradiograph and cephalometry.
Requirements for the Technician
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