TOTAL REHABILITATION WITH 27 INDIVIDUAL CROWNS PLACED OVER 27 OSEOINTEGRATED IMPLANTS IN ONE PATIENT Dr. E. Topete Arรกmbula President of the Mexican Council of Oral Implantology (M.C.O.I.) ICOI Board of Directors In the past it used to talk about individuals crowns only, placed it over implants just when it used to try to replace only one tooth separatly lost, generally it used to think in this way of rehabilitation only for the upper maxilla, in the anterior area. This describe for the first time the posibility of a total rehabilitation in the mandibule and the maxilla with individual crowns over individual implants. Since memorial times man has been trying to replace their dental lost pieces with different kinds of implants, however, the first evidence of one dental implant we fouded at the Mayan Civilization, developed near to Cancun, Mexico, in the year 600 A.C. since that time, man dreamed with the realization of the first individual implants and they made it with pearl shell, shaping to give a root and crown form of the three anterior incisors, which were found in their place and with the evidence of have been permanence in the mouth virtually osteointegrated and without any infection or strange body reaction, which means, demostrate in the skull found in the Palenque zone, in Mexico (this skull can be seen in the University of Harvard). In this time the Mayan Civilization has a great development in the medicine and physics studies and probably discovered that the position and inclination of teeth respect to the sagital axis it is not the same for any of them, due to length, width and distribution of their roots it is variable, we know today the dimentions of the apical surface of each tooth; it would be ideal to make it equal in each replacement implant and us much as bone can permit it (talking of a optimun bone), to make equal the number of roots that got lost and replace them with individual implants, in this way we will obtein a bone with less reabsortion posibilities, an implants with a long success time and an excelent osteointegration of the sames, that could last trought the years, as the skull found in the Palenque zone in Mexico.
We also know, that the inferior anterior teeth have an inclination with the sagital plane that could change from 0 to 20 bucal inclination degrees, that the first bicuspid is the only one that has a zero inclination degrees, the second bicuspid with 7 degrees respect to the sagital plane to the tongue direction, the first molar 15 and the second 20 degrees of inclination to lingual in the jaw and therefore, the upper pieces have different inclinations as well; as the incisors and canines, that could change from 0 to 40 degrees bucal inclination, the first bicuspid has from 0 to 20 of bucal inclination degrees, the second bicuspid and the first molar in an inclination that could change from 0 to 15 degrees and the second molar from 0 to 20 bucal inclination degrees.; if we get in an individual form to reproduce these inclinations, with implants, at the length and wide maxillary and mandibular bone, in each one of the different alveolar zones, we could distribute in a better and more natural way the masticatory forces trought the implants, that would have the original alveolar direction and inclination that the lost pieces had, the periapical zone would react favorable trought the years, avoiding no wishes reabsortions, provoked for no balance oclusal forces distributions on the poor balance united prosthetics over implants, these prosthetics could suffer some fractures in the porcelain and poor adjustment specialty in the jaw, cause for the normal flexion that suffers the mandibule when the masseter muscles make a strong oclusion. The main function of the alveolus consist in being a tooth soport and admit the masticatory forces or deglution transmited to the bone by the dental forces. The masticatory system when it is completely health and in total function, maintain the normal balance between the reabsortion and the bone formation. As soon as the pieces get lost, the balance change in the corresponding place. The osteoblast lose their function, while the osteoclast show an activity increase; since
a clinical point of view, it could say that start an atrophy process of the alveolar bone. The non physiological pressure over the alveolar bone without teeth, applied for the partial or total prosthesis could in fact acelerate even more the procces of bone degeneration. Niedermeier demostrated that under the bases of the prothesis generally increase the general inflamation sintoms in the infiltrade form of cilindrical cells and vasculars changes. From there he figure it out that these fenomenos must considerate as the expression of an increase reaction of the tissue defense. On the other hand, Menkes, Mazel and Redmont, in his study of middle and advance age man, could determinate that as grater tensional effort over the bone, grater bone formation would be. Determine that the excercise of a grater effor over the bone and the frecuency which is ejecuted this effort, are determinates to the bone estructural adaptation. The author development his filosophy and his concept of treatment after have been watched this physiological body reaction respect to the charge non physiological imposed by a prothesis, which means, due to the abscence of physiological efforts over funcional teeth and the deteriorate consequences in some of the patients that has been loss the teeth during a long period, with the almost next total lose of alveolar bone. The author tried to copy as mayor grade possible the human dentition by individual crowns soported by implants, making a physiological prophilaxis, of the alveolar structure bone, root by root in the right places, by the placement of intraoseuos implants of root form. English told, the implants in a screw form have a surface of 20 to 30% grater than the cylindrical implants. Without taking in count that the longest implants when they have a mayor diammeter, they have a mayor surface as well, the author try to get a surface as big as possible and a great quantity of bone deposit at the sides of the implant, using long implants of screw kind Pitt-Easy Bio-Oss, with a maximun
E. Topete Arámbula
racional diammeter. The anatomy of the crown is select in a way that every masticatory forces get an axial directions, which means, vertical corresponding, over the implant crown. The flanks relatively planes (maximum six of ten inclination grades), contribute also to the horizontal friction forces ocurr extremely low. The distance between the upper maxillar and the mandibule in the case of the individual crowns soported by implants, must be dimentioned in a way that the proportion root-crown would be minor of one. In the cases which the atrophy of the alveolar bone be unfavorable, in a way that the anatomic structures make it imposible the length and wide enough to the implants, as well as the right angulation of these, it would required special techniques to increase the bone, sames that should apply. The advantages and disadvantages of the individual crowns placement over implants for total or partial rehabilitations are the next:
elements. 5. It could make a perfect cleanning interteeth . 6. The patient experiment a mayor confort, segurity and esthetic.
Advantages: 1. To Maintain the alveolar bone. 2. Eliminate the need of a cement, removal or total prothesis. 3. To Avoid the chafe of a healthy neighbors pieces to the portion without teeth that requires a cement prothesis. 4. To Avoid complicade connexion
REFERENCES -BENDER, M. F.; Individual Crowns in the Molar Region: a new method of Treatment Int. “J. Dental Symposia”, 2: 65-68, 1994. -ENGLISH, C. E.; Beware the Premaxilla. “J. Tenn. Dent. Assoc.”, 72(3): 16-18, 1992. -ENGLISH, C. E.; Implant-supported Versus Implant-natural-tooth Supported Fixed
1 Fig 1: Mayan Dental Implants year 600 A.C
Disadvantages: 1. Mayor costs 2. Intesive explanation work. CONCLUSION The filosophy of the presented treatment, is based in the natural carateristics of the human dentition, of this way, we try to give to the patient an endosteal implant, even after of been lost one simple tooth or after of been lost his 28 dental pieces, this is with the objetive on maintain the alveolous intact and young ( in the case of inmediate implants), until a old age, maintaining the activity of the osteoblast. At the end, this means also the analoge reposition of every places wich any dental piece has been lost in the maxilla and the mandibule.
3 2 Fig 2: Panoramic X Ray before Fig 3: Panoramic x Ray with the realization of the total the implant and porcelain implant rehabilitation (1991) crowns (1992)
5 Fig 5: 13 Post and a natural piece in mandibule
Partial Dentures. “J. Dent. Symposia”, 1(1): 65-66, 1993 -LANEY, W. R.; JEMT, T.; ZARB, G. A., et al.: Osseointegrated Implants for Singletooth Replacement: Progress Reports from a Multicenter Prospective Study after 3 Years. “Int. J. Oral & Maxillofac. Impl.”, 1: 49-54, 1994. -MEIJER, H. J.; KUIPER, J. H.; STAR-MANS, F. J. ; BOSMAN, F. ; Stress Distribution Around Dental Implants ; Influence of Superstructure, Length of Implants and Height of Mandible. “J. Prosthet Dent.”, 68(1): 96-102, 1992. -MENKES, A.; MAZEL, S.; REDMONT, R. A.; et al.; Stregh Trainning Incrases Regional Bone Mineral Density and Bone Remodeling in Middle-aged and Older Men, «Appl. Physiol.”, 74(5); 78-2484,, 1993. -NIEDERMEIER, W. Et al.: Physiological Reactions of the Denture Bearing Mucosa Following Mechanical Stress. “Dtsch. Zahnarztl Z.”, 4588): 443-448, 1990. -SCHUH, E.: SCHUMIED, R.; VOGEL, G.: Anatomic Limits of Endosseous Dental Implantation. “Z. Stematol.” 81(2): 81-90, 1994. -SCHMITT, A.: ZARB, G. A.: The Longitudinal Clinical Effectiveness of Osseointegrated Dental Implants for Single-tooth Replacement. “Int. J. Prosthodontics”, 6(2): 197-202, 1993.
6 Fig 6: Maxillary view a year after (1993)
7 Fig 7: Mandibular view a year after (1993)
4 Fig 4: 14 Posts over 14 maxillary implants
8 Fig 8: Front view of the upper and lower total Rehabilitation.