Multidisciplinary Cases: Implants

24
Multidisciplinary Cases: Implants

24.1 TADs to Intrude Upper Molars

Photo depicts initial intraoral view

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

Photos depict pretreatment extraoral and intraoral views

Fig. 24.2 Pretreatment extraoral and intraoral views.

Photos depict initial: teleradiograph, cephalometry and panoramic X-rays

Fig. 24.3 Initial: teleradiograph, cephalometry and panoramic X‐rays.

Photos depict initial occlusal contact point

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
Schematic illustration of occlusal ClinCheck views

Fig. 24.5 Occlusal ClinCheck views.

Schematic illustration of lateral ClinCheck views

Fig. 24.6 Lateral ClinCheck views.

Schematic illustration of 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. 24.7 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.

Schematic illustration of initial frontal Clincheck view

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.
Photos depict situation before additional aligners. Results after the first set of 27 aligners and the use of two microscrews to intrude 26

Fig. 24.9 Situation before additional aligners. Results after the first set of 27 aligners and the use of two microscrews to intrude 26.

Photos depict initial (upper) and final (lower) occlusion. Final result after refinement and provisional crowns on 36 and 46 implants.

Fig. 24.10 Initial (upper) and final (lower) occlusion. Final result after refinement and provisional crowns on 36 and 46 implants.

Photos depict initial (left) and final (right) occlusals

Fig. 24.11 Initial (left) and final (right) occlusals.

Photos depict initial and final smile

Fig. 24.12 Initial and final smile.

Photos depict final panoramic and lateral X-rays

Fig. 24.13 Final panoramic and lateral X‐rays.

24.2 Upper Midline Shift

24.2.1 Opening Space for Implant of 23

Photo depicts initial intraoral view

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

Photos depict pretreatment extraoral and intraoral views

Fig. 24.15 Pretreatment extraoral and intraoral views.

Schematic illustration of initial occlusal contact

Fig. 24.16 Initial occlusal contact.

Photos depict panoramic and lateral X-rays. Cephalometric analysis.

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
Schematic illustration of opening space for missing 23

Fig. 24.18 Opening space for missing 23.

Schematic illustration of interproximal reduction 3 to 3 to allow lower incisors retraction and create positive overjet

Fig. 24.19 interproximal reduction 3 to 3 to allow lower incisors retraction and create positive overjet.

Schematic illustration of initial lateral ClinCheck views

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.

Photos depict powerarm to make roots of 25 and 24 closer

Fig. 24.21 Powerarm to make roots of 25 and 24 closer.

Photos depict evolution at 12 months

Fig. 24.22 Evolution at 12 months.

Photos depict evolution after using additional aligners

Fig. 24.23 Evolution after using additional aligners.

Photos depict final views with implant for 13

Fig. 24.24 Final views with implant for 13.

Photos depict initial (left) and final (right) occlusal

Fig. 24.25 Initial (left) and final (right) occlusal.

Photos depict initial and final overjet

Fig. 24.26 Initial and final overjet.

Photos depict evolution of the patient’s smile (from left): initial, before additional aligners and final result

Fig. 24.27 Evolution of the patient’s smile (from left): initial, before additional aligners and final result.

Photo depicts final panoramic X-ray with implant for 23

Fig. 24.28 Final panoramic X‐ray with implant for 23.

Photo depicts final teleradiograph with overjet corrected

Fig. 24.29 Final teleradiograph with overjet corrected.

24.3 Posterior Bite Collapse

Photo depicts initial left intraoral view

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

Photos depict pretreatment extraoral views

Fig. 24.31 Pretreatment extraoral views.

Photos depict pretreatment intraoral views

Fig. 24.32 Pretreatment intraoral views.

Photos depict initial panoramic X-ray, teleradiograph and cephalometry

Fig. 24.33 Initial panoramic X‐ray, teleradiograph and cephalometry.

Requirements for the Technician

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Feb 27, 2022 | Posted by in Orthodontics | Comments Off on Multidisciplinary Cases: Implants

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