To give back

To give back!

“And at the end, when he said thank you, Dr. Chen, I said thank you for helping me in the past. I tried to give my best to honor the moment.”

I am in the Kingdom of Saudi Arabia, just finished my lecture for the dentists at the Saudi Arabia Medical Hospital in Riyadh. I’m in the VIP hall at Turkish Airlines, waiting for my flight to Istanbul, and then, from Istanbul, going home. I was just reminding myself of the case we did on Thursday.

Dr. A. was one of the most important pregnancy echographers that we had in Lisbon. There was no important pregnant woman who wasn’t proud to go to his office to do the morphological exam. I still remember that one had to wait almost one full day for the appointment. Normally, when you go to a doctor, you have a timeframe: they say you go at 10, or 11, or 12. But with Dr. A., what happened was that the nurse called you in the morning and said, you have an appointment today. When we are ready, we will call you to come in. So there was no schedule, and you had to wait all day.

Because he was one of the best, sadly, when it came to dental treatment, I think he chose the wrong team to be treated. And so he appeared for my appointment, and when we looked at the case, we saw an awful prosthetic procedure. I mean, it was just amazing.

How can a person or a team do such bad work? That’s the type of thing that gives a bad reputation to dentistry, either in Portugal or anywhere in the world.

So I received the case, and I chatted with Dr. A., and I told him that my sons — my sons — they all had their morphological exams with him 14 years ago. But 14 years ago, he was a younger doctor. Now he seems older, and completely forgotten about things. So it was time for me to give back the favor that he did 14 years ago, when he looked after my children inside Elena’s belly.

The first thing that we did was to schedule an appointment to remove the implants that he had on the upper arch, because they were just impossible to rehabilitate. They had peri-implantitis, disease, infection, and the prosthesis was one of the worst prostheses I have ever seen, accumulating every kind of debris and every bit of food that Dr. A. ate. At this point, João placed a removable prosthesis so Dr. A. could wait in a socially acceptable way, but as with any removable prosthesis in a healing site… it is a pain in the …

Second, we waited about six weeks (a technique of early implant placement ) to allow some tissue healing and coverage. Between those two appointments, we had to treatment-plan the implants. I used a dual-scan protocol, placing barium markers on the prosthesis that João made and sending Dr. A. to the CBCT room, so we could scan both the prosthesis and the prosthesis in the mouth. Then Sofia merged these two datasets in coDiagnostiX so I could start planning the implants.

After that, we selected the implants. We were — Sofia, Margarida, and I — deciding where to place them. And even when you have the most difficult case in front of you, you should never forget the principles of full-mouth rehabilitation. You need good primary implant stability, a good A–P spread, an adequate cantilever, sufficient interocclusal distance, and a stable occlusion. These prosthodontic principles should always, always, always be in your mind.

The first step , as always is medical history and patient médica control, to control anesthesia and measure the patient’s blood pressure to ensure he was calm.

He was very calm indeed.

I anesthetized with four cartridges, two on the right and two on the left, all articaine 1:100,000, plus half a cartridge on the palatal side, left and right, towards the anterior palatine canal, and a small amount in the nasopalatine area. I also anesthetized the palatal sites near the canine region, because the literature shows that accessory canals may be present there, and patients can feel discomfort in that area. This also helps with hemostasis during flap elevation.

Then came the trickiest part: the crestal incision and elevation of the buccal flap. This was a heavily compromised area, with multiple infections and previous implant failures. You need strong fingers — stiff enough to elevate the tissue, but gentle enough not to tear it. It’s a balance. You need to be somewhere between a good periodontist and a good oral surgeon, because in cases like this, that balance makes all the difference.

I always say start as a perio gentle , move to a surgeon and finish as a perio ! Open - do - suture !

The periosteum was extremely adherent to the bone and the infected tissue, making elevation difficult. After the mid-crestal incision, I made two vertical releasing incisions in the posterior area. I elevated first from the right side towards the midline, then from the left side towards the center, until the entire flap was elevated.

You have to go with low speed and a big bur, normally a big cylindrical one, but a big round one is also possible, and perform bone reduction and decontamination, removing all the remnants and debris attached to the bone.

The palatal flap was then elevated, and the nasopalatine bundle isolated. This is a thick neurovascular bundle and is very difficult to damage during normal elevation. Even light contact with a low-speed bur during bone resection often causes no injury.

Once everything was prepared, the implant surgery began. The provisional prosthesis that was going adapted to the implants and was left open on the palatal side (where the implants will come out). The prosthesis was positioned, finger pressure was applied on the palate, and a hole was drilled along the 2-mm midline osteotomy to ensure a screw-retained position and proper midline orientation. In this case, the nasal midline was shifted due to a significant nasal deviation visible on CBCT, so the goal was to remain as close to the clinical midline as possible.

The first implants placed were the two anterior ones: TLX NT 3.75 × 10 mm implants, which are effectively 12 mm in length when the 2-mm polished collar is included.

These implants were placed parallel to the midline position pin. Due to vertical defects, parts of the implants would be exposed. In such cases, you either regenerate with biomaterial and a resorbable membrane, or you intentionally leave the 2-mm polished collar supracrestal, allowing the biological width to form around the smooth surface and avoiding rough surface exposure.

Number 21 was exposed. We could have tried to bury the rough surface by changing to an 8-mm implant, but that would have made it too buried, compromising the prosthesis and the emergence profile, even with the 2-mm machined collar. So we placed a resorbable membrane around the implant. We made a small hole in the membrane, gently squeezed it in so it adapted to the SRA abutment, and filled the defect with xenograft bone substitute.

The posterior implants were easier. We had good bone in the tuberosity, especially on the right side. Tilted implants at 30° were planned. During drilling, it is essential to avoid entering the sinus. If the drill suddenly drops or enters a hollow space, the osteotomy must be redirected according to the bone morphology. With this very soft bone, wide implants can be placed in a 2-mm osteotomy while still achieving good primary stability. In this case, BLX implants of 12 mm length were used.

It is crucial to ensure that the rough surface collar is fully inside the bone. Because of the curvature of the tuberosity, the distal portion may sometimes remain slightly supracrestal, which is undesirable. On the left side, the implant was anchored deeper to engage the pterygoid wall. This is not a true pterygoid implant, as the plate was not perforated, but the BLX apical design allows partial engagement of the pterygoid bone.

Moving to the premolar region, the right side was straightforward. The internal sinus wall was identified, and bicortical anchorage was achieved to ensure primary stability. This implant was tissue-level, leaving the rough surface supracrestal. On the left side, a TLX NT 3.75 × 12 mm implant was used, which is effectively a 14-mm implant.

The most difficult implant was number 24 because we wanted a good balance between pontics and cantilever. The available bone that allowed a simple placement was near number 22, but it was so close that the implants could end up very near to each other. I didn’t like that position, so I decided to perform an external sinus elevation with simultaneous implant placement.

This was the tricky part, because the anterior wall of the sinus was too pneumatized towards the anterior region. The idea was to create a triangular window to elevate the membrane towards the distal and allow the implant to engage the anterior wall without tearing the membrane. Unfortunately, the membrane was extremely thin, and when I touched it, it tore. I had significant difficulty repairing it.

I ended up attempting a tenting technique using the damaged membrane and xenograft. This was the worst scenario of the intervention, as a proper sinus elevation could not be completed. In the end, only limited graft containment was achieved.

The implant will integrate mainly in the 5 mm of residual bone, while the apical portion will have less vital bone and therefore lower osseointegration potential. However, because this is a full-mouth rehabilitation, all implants will be ferulized and protected once the prosthesis is in place. The implant used here was a TLX NT 3.75 × 12 mm.

All implants achieved very good primary stability. I then selected the appropriate transepithelial abutments (SRA): the posterior abutments were 4.5 mm high with 30° angulation, the premolar abutments were 4.5 mm high with 17° angulation, and the two anterior implants received 3.5-mm straight intermediate abutments.

Moving to the mandible

This was also a bone-driven treatment plan made by the dentist …., since the prosthesis was completely off the tooth axis from the beginning.

I placed the BTI extractor kit to see if tooth number 45 would respond to this extraction technique. The ratchet popped at 200 N/cm. Normally, I would stop and proceed with a trephine, but in this case I went a bit further, like my friend La Grange does, and pushed a little more… and it popped out. Normally, I hate to do this because in slim mandibles you risk a mandibular fracture, which can become a serious problem.

After that, I performed a mid-crestal incision and a central incision to reflect a full-thickness mucoperiosteal flap. To remove the two implants in the middle, I used a Lindemann bur to create a sulcus on the buccal and distal aspects of the implants. Implant number 42 was easy, because once the bone was released, the retriever did the job. However, implant number 32 had a fractured screw with torque still inside the implant.

This case also presented a deviation from the normal inferior alveolar nerve anatomy, with a large loop at the mental foramen. The inferior alveolar nerve was very close to this implant, so extreme caution was required with the Lindemann bur, limiting its use to the distal and buccal aspects. After this, a small sulcus was created on the distal lingual area, and an elevator was used to luxate the implant. Remember that this is not a tooth — it will not come out with an elevator alone. Once mobility is achieved, you must use a 150 forceps and rotate counterclockwise to retrieve the implant like a screw.

After removing the implants, the two new implants in the middle had to be placed more lingually, so as not to repeat the same mistake made previously. One implant had to be placed mesial to the previous position of implant 32, because the inferior alveolar nerve loop did not allow a distal position. Implant number 42 had to be placed slightly distal compared to the previous position.

Both implants were BLX implants, 3.5 mm in diameter and 10 mm in length. The drilling protocol consisted of using the 2.8-mm drill to full depth and the 3.5-mm drill only for the first 4 mm. The implants were inserted with very good primary stability. A collagen sponge was placed in the remaining implant sockets.

To finalize, implant number 45 was placed distal to the previous site using a 2.8-mm drill, and a BLX implant 3.5 × 11 mm was inserted. SRA abutments were placed, and the wounds were closed.

All sutures, both upper and lower, were Gore-Tex sutures.

At the end of the day, this case was not about implants, membranes, or prostheses. It was about closing a circle. Fourteen years ago, Dr. A. took care of my family at one of the most important moments of our lives, when he looked after my children before they were even born. Today, it was my turn to take care of him. And when he said thank you, Dr. Chen, I could only answer honestly: thank you for what you did for us back then. This was simply about giving back — with respect, responsibility, and the best I could offer. This doctor especially did not deserve the below-average dentistry that was applied to him. It was totally unfair, considering what he has given to the medical field and to the hundreds of patients he correctly diagnosed.

Give it back !

Have a nice week !!! Merry Christmas 🎁