Ortho & Provisional
A 48-year-old lady has lost the tooth #3 with mesial shifting and tilting of the tooth #2 (Fig.1). One month and a half since installing open coil spring between the tooth #2 and an implant at #4, the long axis of the tooth #2 improves (Fig.2 black line). The distance between #2 and 4 at the crest increases slightly (compare red lines in Fig.1,2).
Fig.3a is an illustration of the upper right sextant (occlusal view) with placement of premolar and molar bands (black and blue squares) and segmental arch wire (brown). At the tension of an open coil spring (Fig.3b green), the tooth #2 is being distalized (straight arrow, as expected) and rotated (curved arrow, unexpected and unwanted). To prevent further rotation, an implant will be placed at the edentulous area with placement of an immediate provisional (Fig.3c red square, good proximal contact, off occlusion). With the guidance of the provisional, the tooth will continue being distalized (Fig.3d open arrow) without too much rotation (curved arrow). It is also easy to determine the amount of the movement when the provisional is in place.
Use #15 to start bone expansion, followed by bone scalpels and bone blades, microosteotomes, DIO Sinus Master Kit and bone expander kit. Initial depth will be 7-8 mm. It appears that UF implant (Fig.4) can be adapted to more varieties of abutments than SM (narrow and regular) or Tatum (Fig.5) if ortho treatment can increase the edentulous space to normal mesiodistal width. Place the implant slightly more distal. Bone graft (.5-1 mm) will be used for sinus lift (red circles).
Prior to implant placement, change the segmental wire to 16x16 and check occlusion with articulating paper to decide whether #2 has premature contact. The latter may interfere with ortho movement. In fact, the tooth seems to be more intruded while being distalized.
After 2 mm initial drill at 3 mm and 2.8 mm round drill until 5 mm, allograft and Osteogen are mixed and placed for sinus lift (Fig.6 *, 3 months post banding). A 4x8.5 mm implant is placed with insertion torque <50 Ncm. A 4.5x4(2) mm abutment is placed and more graft is placed around the crest at #3 and 4. An immediate provisional is postponed due to limited space until wound heals. The provisional is fabricated (as shown in Fig.3c) 20 days postop. Three months postop (6 months of orthodontic treatment), the root of the tooth #3 is parallel to the implant at #3 (Fig.7, compare Fig.6). There is a 2 mm space distal to the provisional (Fig.8 #3). The excessive distal space (Fig.9 D) can be corrected by using an angled abutment next appointment. For this aspect, the implant should have been placed after distalization. To alleviate the problem, the wire and open coil spring are removed. The distal contact is established with less contact buccally so that the tooth #2 may de-rotate.
Two months later, the tooth #2 does not seem to have been self mesialized, probably because of lack of occlusal clearance. An angled abutment is placed (Fig.10: 4.5x15°B(3mm)) in an attempt to bissect mesiodistal dimension. A more useful benefit of using the angled abutment is the exposure of the mesial margin of the abutment (easy for impression).
Two months post (temporary) cementation, the distal contact is loose. The crown is going to be removed after taking pick up impression. Find the old temporary crown or remake one. Tell the lab to apply a lubricant around the crown (inside) before pouring for a model. Add porcelain to the distal surface of the permanent crown.
There is formation of cortex-like bone mesial to the tooth #2 6 months post cementation (Fig.11).
Return to Upper Molar Immediate Implant,
Posterior Immediate Provisional,
Implant & Ortho
Xin Wei, DDS, PhD, MS 1st edition 03/12/2016, last revision 04/30/2017