Ragasztható fémkerámia körhíd implantátumokon
A female patient, 55 reported to our clinic with the following complaints:
- Tooth sensitivity and loose teeth
- She was looking to have her rear teeth replaced which were extracted long ago
- She was prepared to have all her teeth removed, but wherever possible she desired to have them replaced with a fixed solution secured by implants
- Restoration of aesthetics and masticatory function were equally important for her
First treatment session (3 workdays)
A panoramic radiograph was recorded at the first session and the condition of teeth was thoroughly examined. Unfortunately her teeth proved beyond repair and had to be removed due to a large extent of horizontal and vertical bone resorption. Most of her natural teeth were affected by chronic periodontitis and became dental foci. Had her periodontal disease been treated several years earlier and had sub- and supragingival tartar (tartar beneath and over the gum) been removed at least twice a year her gums, teeth and jawbone would not have fallen into such a state of disrepair.
During the first treatment session all her upper teeth and all her lower teeth except for 4 were extracted and her mouth was cleansed of dental foci. The gums were sealed with sutures, the removal which was due 7 to 10 days after the intervention. An immediate denture was prepared at the chairside for the patient to have teeth, be able to smile and eat, and have self-confidence without his quality of life being compromised during the healing period of at least 3 months.
- Thorough oral hygiene is also important with immediate dentures. The denture should be removed after each meal and cleaned with a denture brush and food remains stuck beneath should be removed. link: For further information please click our article on cleaning dentures
- Patients are advised to remove dentures overnight, and on any other occasions when not required to meet people and talk, clean them and store them in a well-ventilated area ensuring that the wound in the mouth can “breathe” and heal.
- In the course of healing the anatomic relations are constantly changing. A few weeks on the denture will no longer align well, it may wiggle or go loose. If the patient is disturbed by the wiggling the denture may be relined at our clinic to ensure a seamless, stable fit. link: navigating to the article on reline
- If wearing the denture causes your gum to crack see our clinic immediately as this may easily be helped.
- The treatment may continue after 3 to 4 months’ healing once the bone is healed and the continued treatment can be designed using a CT scan.
Panoramic radiograph of the initial condition
Follow-up panoramic radiograph after the removal of teeth
Second treatment session (3 workdays)
Following 4 months’ healing a CBCT (Cone beam computed tomography) scan was made to examine resdual bone mass prior to the implant surgery. The CT scan demonstrated that the bone mass was appropriate and even well suited for the insertion of implants. It was within our patient’s means to have the missing teeth replaced by as many implants as required for a fixed replacement.
The missing lower molars were replaced by 2 implants on each side which would support an implant bridge. 7 implants were installed for the replacement of upper teeth which would retain a full-arch cement-retained implant bridge following healing time (a fixed replacement requires a minimum of 6 implants in the maxilla and mandible each in case of complete edentulism).
Implant stability exceeded 30 Ncm at installment and could therefore be closed with gingiva formers. In such cases no additional surgery is required one month prior to the placement of the final replacements. With worse implant stability the implants would have to be uncovered one by one to replace the cover screws initially installed with gingiva formers.
The exposed gums were sealed with sutures due for removal in 10 days.
The immediate denture is relined as per the altered anatomic relations to ensure a comfortable and seamless fit.
Please see that the implanted/bone grafted area is not exposed to pressure and that the provisional denture does not “wiggle” on the implants. Pressure exerted by the denture decreases blood circulation, hinders healing and may cause cracking, infection or, worst of all, the rejection of the implant, however well the implant was installed.
CT scan picturing the residual bone mass of the mandible in 3 dimensions, based on which the location and dimensions of the implants are designed.
CT scan picturing the residual bone mass of the maxilla in 3 dimensions, based on which the location and dimensions of the implants are designed.
Follow-up panoramic radiograph after the instalment of implants. It is readily visible in the scans that the implants were sealed with gingiva formers.
Third treatment session (10 workdays)
Following 6 months’ healing the instalment of the final tooth replacements was due. Metal-ceramic cement-retained bridges were fabricated to be supported by natural teeth and implants. Often this is the most time consuming session of all the treatment sessions. Precision impressions were taken of the implants with special closed tray impression copings. Then the remaining natural teeth were prepared (filed) to accommodate crowns, and impressions were taken thereof. Following impression taking a gnathological treatment was performed and several trial fittings were necessary as the dental technician proceeded with the fabrication of crowns. Framework test fitting allows us to verify the trueness of the impressions, the precision of the framework prepared, and whether all tooth replacements seamlessly fit the master cast. Occlusion, the length of the framework and the teeth, the central position of the 2 large incisors and the proper backward curve of the teeth, etc. are checked again. At the preliminary test fitting the crowns are almost finished, the ceramic is sintered onto the metal framework. At this trial fitting the occlusion (function), the shape and colour of the crowns and the middle line and smile lines (aesthetics) can be verified with even better accuracy. Several days may elapse between the different trial fittings during which the dental technicians are working at full tilt in the background. Also, between the test fittings the remaining teeth underwent a root canal treatment.
Our patient weighed the situation and opted for the final cement-retained crowns to be attached with a provisional cementing material, taking the trouble of returning to the clinic and having her crowns fixed whenever the provisional cement gives way. In this manner any issues can be addressed by removing the tooth replacement and fixing it. Also, the implants provide easier access without the crowns on, which facilitates cleaning.
The finished tooth replacement needs to be checked regularly, which is also a condition for warranty. It is often thought that tooth replacements need not undergo a professional tartar removal but this is a misbelief. Tartar may also deposit on tooth replacements as well and regular cleaning and tartar removal once or twice yearly are equally important in this case too at least.
Follow-up panoramic radiograph of the closed tray impression copings inserted into the implants.
Gnathological session, Artex (Rotofix) face-bow transfer
Cement-retained implant abutments and the preps (filed natural teeth stumps) on the master cast.
The metal framework of the cement-retained metal-ceramic full-arch bridge fabricated for upper implants on the master cast
The metal framework of the cement-retained metal-ceramic full-arch bridge fabricated for upper implants in the mouth
The final metal-ceramic bridges for implants and natural teeth
The final metal-ceramic bridges in the front region complemented with flesh-coloured ceramic
The final metal-ceramic bridges for 7 implants, complemented with flesh-coloured ceramic and a special artificial gum shown on the master cast too
Cement-retained implant abutments on the upper implants
The finished cement-retained metal-ceramic crowns in the mouth
Follow-up panoramic radiograph with the final metal ceramic crowns