Upper combined denture, lower full-arch metal-ceramic bridge

Our female patient aged 49 presented to Suba Dentál’s clinic with the following complaints:

• She had lacked the courage and financial means to visit the dentist for years and presented to our clinic on her friends’ recommendation.
• She wants to have her mastication restored and beautiful teeth again.
• She is aware that some of her teeth need to be extracted since they are apparently loose.
• She does not debar the possibility of an implant, but is against a major bone graft. If a major bone graft was indicated she would rather go with a removable solution.

 

Before

After

 

At the first examination it became evident that the upper and lower incisors and the upper right first premolar had to be removed due to the extent of bone decay around tooth’s root canal.

At the first treatment a CBCT (Cone beam computed tomography) scan was performed in order to examine residual bone mass in 3 dimensions and assign the exact location of the implants. The CT scan demonstrated that in the area of the upper molars bone height was inadequate on both sides indicating a bone graft called sinus lift for the implants to be retained securely. Since our patient was against a bone graft we recommended her conventional prosthodontics, namely, a combined tooth replacement.

What does combined tooth replacement mean?

A combined replacement is the combination of two different kinds of tooth replacements. It is usually applied with free-end edentulism with available natural front teeth but missing rear teeth missing. In such cases natural teeth receive a fixed metal ceramic bridge, which is a fixed cement-retained tooth replacement onto which the hidden-clasp removable denture substituting the rear teeth is attached.
Having examined the mandible we established that the edentulism in the left rear position no. 6 (first molar) could be perfectly restored with an implant seeing as the residual bone mass was adequate for a tooth implant. Following consultation and drawing up a treatment plan the implant was inserted. Teeth beyond repair were removed and provisional dentures were provided for the healing period.

What to know about provisional dentures?

• Thorough cleaning is also all-important in case of provisional dentures! The denture should be removed following each meal and thoroughly cleaned with a denture brush removing food remains stuck underneath. The oral cavity should also be rinsed thoroughly exercising caution.
• It is advisable to remove the dentures overnight, clean them and store them in a dry place so that the the fresh wound in the mouth can “breathe” and heal.
• During healing the anatomical relationships between the jawbone and gums constantly change. A couple of weeks on, the denture may start to wiggle, become loose and go out of alignement since the initial swelling recedes in a few days’ time.
• If the denture waggles too much and its wearing results in cracking, please come to our clinic since this can be helped with a simple reline.
• If it can be helped, wear the provisional dentures only if you have to leave home or meet others. When at home, always be sure to remove the denture so it does not hinder the healing process.

The treatment can be continued after 3 to 4 months’ healing, once the tooth extraction sites have healed completely and the implants have integrated into the bone (osseointegration).

First panoramic radiograph presented by the patient

Follow-up panoramic radiograph following the installation of the lower implant and the extraction of teeth as required

 

Second treatment (10 workdays)

Following 3 months’ healing a longer 10-day treatment ensued.

First, precision impressions were taken of the implant using closed-tray impression copings. The natural teeth were than prepared for the placement of crowns, and impressions were also taken thereof.

In a gnathological treatment the appropriate position of the temporomandibular joints and bite height were determined.

During the framework trial fitting the accuracy of the impressions and the trueness of the metal framework of the tooth replacement were verified. At this time all tooth replacements must seamlessly fit the master cast.

During the denture try-in the bite, the length of the framework and the replacement teeth, the middle line and smile line were checked once again

At the preliminary test fitting the crowns are almost finished, the ceramic is already sintered onto the frame, the metal plate of the denture is complete, yet the teeth are still embedded in wax to allow for adjustments as required. At this test fitting 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.

Between the different test fittings root canal treatments are performed as required.

Once the bite and aesthetics are perfect, the crowns receive a glaze layer to sport a natural look. Although several days elapse between the different test fittings, the dental technicians are working at full tilt in the background.

On completion on the treatment our patient was content and left with a broad smile. Her self-esteem is now restored and she feels at ease to smile again.

Do not forget that if a tooth replacement is complete it does not mean we can stop visiting the dentist. Think of the new denture as a new car that has just rolled out of the dealership: besides brushing and grooming, our teeth also require regular servicing and inspection much in the same way as our car does. Annual inspection and professional tartar removal are warranty conditions.

Upper combined denture on a gypsum cast. The front crowns are readily visible to which the removable denture attaches with so-called hidden retainer clasps.

The upper combined denture removed from the gypsum cast

The fixed part of the upper combined denture (metal ceramic bridge), which is cemented onto the prepared natural teeth (preps)

The removable part of the upper combined denture, that is, the removable denture with the rear teeth and metal butterfly wings to ensure better stability.

Upper combined denture dismantled. The front metal ceramic bridge, which is the fixed cement-retained part and the removable denture with the rear teeth and butterfly wings to ensure better stability

Metal ceramic full-arch bridge designed for natural lower teeth and implants, on a gypsum cast

Instruction of the patient on the importance of home care, dental care devices and brushing techniques. Cleaning of the finished metal ceramic bridge by means of an interdental brush and Super Floss (Oral B)

Panoramic radiograph of the finished metal ceramic bridges following permanent cementing

 

Before

After