The patient was a 60 year old female with an unremarkable medical history. She presented with a worn dentition and general neglect; her main concern was the mobility of the upper left four unit bridge (fig 1) from the upper left canine to the upper left first molar. She also wanted to improve the aesthetics and oral health. The patient also has a very strong gag reflex and made it clear that she would not be able to wear a partial denture during her treatment which
could compromise the outcome of her treatment.
The CT scan revealed a very large area of radiolucency around the root of the upper left canine and upper left lateral, which extended right through to the upper left central and upper right central. There was also notable bone loss around the roots of the upper left first molar.
Following atraumatic extraction of the upper right central, upper left central, lateral, canine and first molar, the granulation tissue was removed (fig 2). The buccal bone, as expected, was destroyed over the upper left canine and lateral. The area was curetted aggressively to ensure that all granulation tissue had been removed. This defect needed to be augmented to prevent even further bone loss.
Immediate implants (Bti implants) were placed at a torque of 35Nm, slightly lingual in the upper right central, upper left central, leaving a gap between the implants and the buccal bone which were filled with Mineross, and a membrane that was formed making use of PRGF endoret, and upper left second premolar (fig 3). Multi-im abutments were fitted on the implants. The defect of the upper left canine, lateral and first molar was filled with allograft material (Mineross), and the clot formed making use of PRGF(plasma rich in growth factors) Endoret (fig 4) and then covered with PRGF Endoret membrane. The area was closed with 5-0 Cytoplast sutures tension free. A temporary screw retained bridge was fitted to the immediate implants.
Three days following the surgery the patient showed hardly any swelling (figs 5 and 6) or bruising and had very little discomfort. Two weeks post op showed uneventful healing was taking place.
After six months (usually after four months but the patient has not been able to come back earlier) a CT scan was taken which showed sufficient volume and quality of bone in the upper left canine area (figs 7 and 8) and upper left first molar area, and that the large defect was completely filled. It also showed good buccal bone at the upper right and left centrals.
Healing was uneventful and both the dimensions and attached gingiva were retained . A flap was needed to access the area to be able to place implants in the upper left canine and first molar region. A site specific flap was raised. On exposure it confirmed the image of the CT scan and showed a good volume and quality of bone. An osteotomy was performed and Bti implants were placed in both the canine and first molar’s positions (fig 9) at 35Nm. The buccal area over the canine was augmented with Mineross and the PRGF clot then covered with a PRGF membrane. The flap was sutured with 5-0 cytoplast and the screw retained temporary bridge re-fitted.
After a six month healing period the upper left canine and first molar implants were exposed (fig 10) and multi-im abutments fitted. The temporary bridge was again re-fitted. Two weeks after exposure the final impressions were taken. The patient wanted to improve the aesthetics and appearance of her smile and requested veneers which were prepared on the same-day. Figure 11 shows healthy gingiva around the multi-im abutments. A metal try in was done before the final fit appointment.
Two weeks after the final impressions and one year after the initial surgery the final screw retained bridge was fitted. The screw holes were filled with PTFE tape and covered with composite. The veneers were also fitted at the same appointment (fig 12). Figure 13 shows where the journey started and figure 14 the end. The preservation and
restoration of the supporting hard tissue for the implants and the ridge profile were achieved reducing the swelling and bruising of the patient making use of PRGF Endoret. The procedure described the benefits to both patients and surgeons that will lead to increased acceptance to the treatment protocol making use of PRGF Endoret.
References available on request.