Clinical Case of STRATEGIC IMPLANT.

ORAL REHABILITATION WITH FIXED PROSTHESIS ON MAXILLARY IMPLANTS.
VERY ATROPHIC WITH BASAL IMPLANTS AND MONOPHASIC IMPLANTS.

Author: Dr. Miguel Alvarado Pastor

SUMMARY

Clinical Case with Strategic Implant ®.

This article shows how to solve the case of a patient with very advanced alveolar atrophy in both jaws with “Immediate Load” implant treatment, applying the rules of Strategic Implantology developed by Dr. Stefan Ihde and Cols. at the International Implant Foundation (IF). In this case it is decided to place “Strategic Implants ®” in the upper jaw of the BCS ® model of Ø 3.5 and lengths 17,14,14 and 10 mm and the ZSI ® model zygomatic Ø 4.6 and length 50 mm. In the lower jaw it is decided to place single-phase implants KOS ® and KOS B ® of Ø 3,0 – 3,2 – 3,7 and 4,1 of lengths of 12, 15, 10 and 6 mm. Implants all of them manufactured in Ti6AI4V (Ihde Dental AG). The use of these types of implants allows the rehabilitation of patients with very atrophic jaws.

Following the rules of “Strategic Implantology” it was possible to rehabilitate the patient without having to perform sinus elevations, bone grafts or lateralizations of the tooth. In addition to restoring the patient’s teeth immediately, thus restoring the masticatory, phonetic and aesthetic function on the same day with provisional resin, for 4 days to place the definitive zirconium prosthesis, the patient not having to wait 9 months or more if a treatment had been performed with a traditional approach.

The speed of the treatment, not having to go through bone graft interventions, sinus elevations, lateralization of the tooth and a high aesthetic was greatly appreciated by the patient.

INTRODUCTION:

Rehabilitations of patients with very atrophic jaws imply treatments of a high degree of difficulty to rehabilitate with traditional biphasic implants, in addition they are patients who have been evicted for implants in most of the occasions (they have been told that implants cannot be placed due to lack of bone) or who have to undergo long and painful interventions, such as block bone grafts, sinus elevations or lateralizations of the tooth, with the risks that these entail.

Patients are demanding more and more immediate solutions, as painless as possible and with the least morbidity, as well as being able to optimise costs.

In this article I intend to show the countless advantages of following the philosophy of work with Strategic implant ® that breaks with rules and dogmas powerfully established in oral implantology, improving what exists, innovating and as not replacing. In summary these are the concepts of the Strategic Implant ® :

Discipline and protocol in the confection of the prosthesis:

The prosthesis must follow some very easy but strict parameters, such as; splinting of the implants as soon as possible by means of a rigid structure, shape of the rounded prosthetic pieces without very marked edges and, of course, a very stable occlusion, leaving the posterior areas free or in nanocclusion. And all this in record time…

Surgery as the basis of the main work:

All surgery, whatever it may be, must always be very well planned, but with Strategic Implant® we must also be aware that we are working with atrophied jaws and basal bone, where the measurements of the implants and their location are fundamental to the success of the treatment. In addition we must have a high anatomical knowledge of the jaws; to look for in the implants an anchorage in 2as or 3as corticales and also to arrive at these in a safe way, creating between the implants placed a structural polygon for the posterior support of the forces that exert the prosthesis.

CLINICAL CASE

Female patient, 43 years old, without systemic diseases who asks us for a rehabilitation with implants. In the exploration the patient presents the 1st and 3rd edentulous quadrant, fixed prosthesis from piece 12 to 28 and another fixed prosthesis bridge from 34 to 45 and then 3 biphasics with cemented crowns in the shape of premolars up to the height of 47-48.

Ortopantomografía preoperativa

Fig. 1 Preoperative orthopantomography

In orthopantomography there is a great bone atrophy, root remains and infectious processes in some parts. The patient manifests to be very dissatisfied with the aesthetics of her prosthesis, in addition to the discomfort caused by the filtrations of the prosthesis and the bad smells that emanate from it, she also confesses that she is unable to wear the two removable ones because they caused nausea. All this makes her request treatment with implants.

The patient had previously consulted different professionals who had told her that she was not a candidate for rehabilitation with implants or that she had to undergo interventions prior to implants (bilateral sinus elevation, block bone grafts and possible lateralization of the 3rd quadrant tooth), another solution that was given was to place 6 implants in the upper jaw and 4 in the lower jaw, rehabilitating with two hybrid prostheses, which the patient immediately discarded because of their characteristics.

It is decided as treatment: exodontia of all the dental pieces and root remains, since almost all the pieces are very deteriorated by leaks, use the 3 biphasic implants that are currently well, and place Basal Implants following the rules of Strategic Implant ® in the upper jaw (BCS ® and zygomatic ZSI ® – Ihde Dental AG) and in lower jaw single-phase implants (KOS ® and KOS B ® – Ihde dental AG). Plus an immediate provisional prosthesis of resin and later one of definitive zirconium.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 2. Post-operative orthopanoramic, shows the strategic implants placed (basal BCS ® and zygomatic ZSI ®) in the upper jaw and the monophasic KOS ® implants in the lower jaw as well as the three biphasic implants previously carried by the patient.

METHOD AND MATERIALS

The patient has an upper and lower CT, study models and records are taken to make the provisional ones, so that they are available on the day of surgery.

On the day of the surgery, the teeth are exodonted and 7 strategic BCS ® implants are placed in the anterior group, 5 of them looking for anchorage in the floor of the nostrils and 2 of them in the canine eminences.

4 zygomatic ZSI ® strategic implants are placed (2 on the right side and 2 on the left side), and in the 2nd quadrant at the height of the tuberosity a BCS ® strategic implant with anchorage in the cortical floor of the sinus and tuberosity, while in the 1st quadrant at the height of the tuberosity a KOS ® single-phase implant was placed looking for anchorage in the wings of the pterygoid.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 3 Radiographic aspect where the strategic BCS® implants can be seen in the anterior group and in the canine eminences.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 4 and 5. Radiographic slices of the scanner where ZSI strategic zygomatic implants are observed on both sides.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 5 and 7. Radiographic slices of the scanner showing the most distal implants, one with anchorage in the sinus floor cortex and the other in the pterygoid cortex.

ZSI® strategic zygomatic implants have a totally polished surface, a Ø 4.6, and lengths ranging from 35 to 55, these characteristics allow us to place implants looking for anchorage in the zygoma, through the breast without causing major destruction of it, causing minimal inflammation, thus facilitating a rapid recovery and also get with these implants a very strong and secure anchorage to fully rehabilitate the patient with his fixed prosthesis.

In the lower jaw, we proceeded to perform the exodontia of the teeth and took advantage of the 3 biphasic implants already carried by the patient. First, 6 KOS ® implants were placed in the anterior group and then another 2 in the 3rd quadrant and 1 more in the 4th quadrant.

Once all the implants had been placed, the abutments were carved to leave them as parallel as possible. The impressions and registers were taken to make the fixed prosthesis.
The provisional prosthesis was then passed, the occlusion was adjusted and cemented. In the rest of the remaining 4 days, the cap, sponge, occlusion adjustments, finished and cemented tests of the definitive zirconium prosthesis were carried out, with the occlusion following the rules of Strategic Implantology. Afterwards, the appropriate radiographic controls are carried out, as well as possible occlusion adjustments.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 8. Radiological image of the lower jaw in which the placed KOS® implants and the 3 biphasic implants carried by the patient can be seen.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 9 View of the patient before being operated on. Fig. 10 View of the patient after the exodontia of the teeth and placement of the implants. The abutments are carved, note that there is very little edema and bleeding. The impressions are taken and the provisional ones are restored.

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 11 View of the patient with the final prosthesis in place
Fig. 12 View of the occlusal adjustment and the adjustment on the gums

CASO CLÍNICO STRATEGIC IMPLANT

Fig. 13 Control orthopantomography at 18 months.

DISCUSSION

It is evident that one does not get up one morning and begin to perform upper and lower rehabilitations with strategic implants (basal and zygomatic) in patients with atrophied jaws, this is a long road, in which one learns from their mistakes and especially from our patients, but following the steps of Strategic Implant ® I am totally convinced that through this new didactic and pedagogical approach to rehabilitate with implants, always looks ahead, that everything we can imagine ends up becoming reality in a simple way: implants that the neck can be bent to facilitate the axis of insertion of the prosthesis, implants long enough to be able to take advantage of the best bone available, anchoring even to cortical of difficult access. In addition, the fact that your body can be bent allows us to take better advantage of anatomical repairs or avoid them so as not to damage them. This without forgetting its totally polished surface, which makes it impossible for bacteria to adhere to the implants.

In Strategic Implantology it is necessary to be clear where to place the implants, actively looking for the best available bone, the best and most stable anchorage areas for the 2nd and/or 3rd cortical, thus improving the areas of load transmission, by creating a support polygon in which the slopes of the occlusal faces of the prostheses are part of the load transmission together with the implants and their position in the bone, all of which closely form strategic positions (hence the meaning of the term “strategic implantology”) that favour successful treatment. The combination of all these fragments are designed to adapt to a living form that constitutes a whole, such as bone, the forces of mastication and how they are transmitted by the implants and in turn to the skeletal architecture of the jaws.

When I sit down with the patient to plan everything, after seeing all the possibilities and listening to his expectations, I like to explain that we are going to carry out a living geometric rehabilitation that actively adapts to his conditions, in an autonomous way, guided and in a very simple and direct way.

SUMMARY

The evolutionary step to “Immediate Load” is to perform the rehabilitation of our patients with the guidelines of Strategic implant ®, which guarantee and minimize the risks, increasing the success and satisfaction of our patients in a safe and quiet way, it is evident that leads to a path of learning long and hard but not impossible, and in any case similar or simpler than others (eg: grafts). The philosophy and systematics of Strategic Implant ®, is based on the scientific evidence of Immediate Load implants carried out by Dr. Stefan Ihde y Cols. in the International Implant Foundation (IF), counting for it with a long biography and with innumerable cases and research works carried out all over the world, which provide a high content of clinical experience and scientific knowledge, which has greatly simplified the technique and has organized the pedagogy to transmit it to the scientific world of health.

Perhaps the most important change is to be able to change our heads as health professionals, that all our patients can have implants and that it is not necessary to perform bone grafts on our patients, it means breaking rules and principles that are deeply rooted in our daily lives.
Strategic Implant ® provides us with the necessary tools to be the number 1 or 2 in our area to be able to give the best service to our patients and also be able to differentiate ourselves from the rest of the professionals.

One cannot forget its beginnings, always with mists, with caution, with fear and learning a lot from our failures, until one day someone comes and clears the horizon completely. Strategic Implant ® revolutionized my way of rehabilitating my patients, eternally grateful to everything it teaches me, but who I think should be much more grateful are my patients to whom without the guidelines of Strategic Implant ® I could never have rehabilitated them in a way so satisfactory for them, making rehabilitations that adapt to each of them actively, autonomously and fully guided in an easy and direct way.

Living geometric rehabilitations so we feel them patient and a server, one more step of Strategic Implant ®.

Bibliography

  • Ihde & Ihde. Introduction to Working with Strategic Implant 1.
    International Foundation Publishing. 2015.
  • Ihde & Ihde. Book of Chewing Recipes 4.
    International Foundation Publishing. 2015.
  • Ihde & Ihde. Laboratory Work on Strategic Implants 6.
    International Foundation Publishing. 2016.
  • New Systematic Terminology of Cortical Bone Areas for Osseofixed Implants in Implantology.
    Stefan Ihde, Antonina Ihde, Valeriy lysenko, V. Konstantinovic, Lukas Palk.