Full-arch metal-ceramic bridges supported by 16 implants
Our female patient (52 years old) presented to our clinic with the following requests:
- She lost all her teeth despite her young age and had a hard time dealing with this.
- She wanted to regain her smiling self of old she lost together with her teeth.
- She was not happy with her removable dentures and wanted a fixed cement-retained solution borne by as many implants as possible to ensure the utmost stability.
- She was tremendously disturbed by her cheeks that looked sunken without teeth making her look way older than her age.
Some photographs taken before and after:
Panoramic radiograph recording the initial condition (completely edentulous mouth)
First treatment, 3 workdays
Since we were looking to install implants a CBCT (Cone beam computed tomography) scan was recorded for a 3 dimensional examination of residual bone mass prior to implant surgery. The CT scan demonstrated adequate residual bone mass for installing implants. Nor was bone graft indicated. Furthermore the jawbones were even suited for the insertion of 8 implants each (A fixed replacement required a minimum of 6 implants).
Since the primary stability of the implants was adequate, Dr. Suba decided to seal the exposed gums directly with gingiva formers (healing abutments). When the implant’s primary stability is less than 30 Ncm a flat cover screw is placed inside the implant and the gum is completely sealed for complication-free healing. Once the gums over the implants are completely sealed, an additional surgery is due in 3 months’ time to locate the implants and place in gingiva formers (healing abutments) protruding from the gums to ensure an ideally shaped gum contour for the permanent abutments.
The patient’s old denture was in a sound condition, it only required to be relined for a comfortable fit to be worn even during healing time.
It is important to minimise the wearing time of the provisional removable denture following bone graft and/or the installation of the implant. Patients are advised to only wear their provisional dentures at work or at places where they are required to talk or smile. When at home, please immediately remove the denture. Also make sure you keep your denture and mouth clean, that no pressure is exerted on the denture/implanted area and that the denture does not “wiggle” on the implants. Undue pressure exerted by the denture restricts blood circulation, hinders healing and may cause cracking or infection, or worst of all, the rejection of the implant, however successful the implant surgery may have been. A failing denture may result in the loss of an implant.
A CBCT scan displaying the maxilla and the maxillary sinus allowing bone height and width to be examined in 3 dimensions. The lower 3 pictures evidence a bone height of 11.7 mm, suitable for the installation of implants.
Follow-up panoramic radiograph of the 16 implants following installation (the good stability of the implants justified the insertion of gingiva formers (healing abutments) into the implants.
Second treatment, 10 workdays
Following 6 months’ healing the permanent tooth replacement was ready to be installed. Metal-ceramic cement-retained bridges were fabricated for the implants. Luckily both the patient’s financial means and residual bone mass made it possible for fixed/cement-retained permanent replacements to be mounted on the 16 implants.
The fabrication process of the finished tooth replacement is the most time-absorbing of all. In the present instance the permanent replacement required 10 workdays to complete. Precision impressions were taken of the implants by means of special closed tray impression copings. In the gnathological treatment an Artex facebow was used to determine the accurate axial angle of the upper jaw and the patient’s gypsum sample was inserted into a customised Artex CR articulator in the appropriate joint position. Henceforth the articulator would simulate the patient’s oral cavity in the dental laboratory. Following impression taking several test fittings would take place while the dental technician is proceeding with the preparation of the crowns. The frame test fitting allows us to verify the accuracy of the impressions and the trueness of the frame of the tooth replacement since all tooth replacements must seamlessly fit the master cast. This is also when the length of the frame and the teeth are verified, and the middle line of the 2 central incisors and the appropriate rearward curve of the denture, etc. are checked. At the preliminary test fitting the crowns are almost finished, the ceramic is already sintered onto the frame (with a matte finish), and the patient’s bite (function), the shape and colour of the crowns, the middle line (aesthetics) and smile line can be verified with even better accuracy. Although several days elapse between the different test fittings, the dental technicians are working at full tilt in the meantime. In M.Z.’s case the dental technician also modelled pink artificial gums from ceramic to achieve the best aesthetic results.
Follow-up panoramic radiograph with lower closed tray impression copings.
Our patient was supremely satisfied with the result. As per her expectations, we succeeded in preparing a fixed replacement, namely, a full-arch metal-ceramic bridge. Her face no longer looks old and sunken, but is round and filled thanks to her new teeth.
One of the first smiles with the newly installed teeth
Panormaic radiograph of the finished prosthetic replacement with cement-retained full-arch metal-ceramic bridges secured on 8 implants in each arch.
Full-arch metal-ceramic bridge mounted on 16 implants in the mouth. The pink flesh coloured ceramic was prepared by the dental technician to achieve lifelike results.
Upper full-arch metal-ceramic bridge secured on 8 implants.
Full-arch metal-ceramic bridge secured on 8 implants and the abutments on a gypsum cast.
