Tooth extraction, fabrication of bar denture secured on 4 implants

Our male patient, aged 57, reported to our clinic with the following complaints and requests:

  • Although he had neglected his teeth before, he finally made up his mind to have his teeth fixed.
  • He wanted to have his missing teeth replaced.
  • He has no objection against implants, but is totally against a bone graft surgery.
  • He does not insist on a fixed solution at all costs, he would also be satisfied with a stable denture.
  • He would be pleased if aesthetics and masticatory function could be restored too, taking into account his means.

Before

After

First treatment session: complete elimination of dental foci in the mouth, fabrication of provisional dentures (3 workdays)
At the first consultation, a digital panoramic radiograph was taken and the condition of the teeth and periodontium was thoroughly assessed.

The first panoramic radiograph of the severely periodontitis-ridden teeth and root remains

The examinations revealed that the patient’s teeth were afflicted by chronic periodontitis and were beyond repair. Had his periodontal disease been treated several years earlier and the sub- and supragingival tartar removed at least twice a year, his gums, teeth and jawbone would not have fallen into such a state of disrepair, and his teeth could have been salvaged.

Upper right teeth densely covered in tartar

The lower teeth with immense amounts of tartar and receded gumline

During the first treatment session all his teeth were extracted and his mouth was cleansed of dental foci. The gums were sealed with sutures for better healing, the removal of which was due 7 to 10 days after the intervention, provided that non-absorbable sutures were used. An immediate provisional denture was fabricated for the patient to have teeth with which to smile and eat, without his self-esteem and quality of life being compromised over the healing period of at least 3 months.

What to know about provisional dentures?

  • Careful and thorough cleaning is crucial with provisional dentures too. The denture should be removed after each meal and cleaned with a denture brush and food remains stuck beneath should be removed. The oral cavity should also be rinsed gently but thoroughly.
  • Patients are advised to remove dentures overnight, 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 not fit as snugly, it may wiggle or go loose since the initial swellings recede in a few days with the denture going loose. This may necessitate a reline at our clinic as the denture is also at a risk for breakage.
  • If your gums develop pressure sores due to wearing the denture (denture sores), see our clinic immediately as this easily may, and should, be helped.

The treatment may continue after 3 to 4 months’ healing, once the bone and gums at the site of the tooth extractions have healed.

Second treatment phase, implant surgery, reline of provisional denture (3 workdays)

Following 3 months’ healing time, we were ready to resume the treatment with the installation of implants. A CBCT (Cone beam computed tomography) scan was recorded for the 3 dimensional examination of residual bone mass prior to the intervention.

CT scans which allow the bone mass of the jawbones to be examined in 3 dimensions and the precise assignment of the location and size of the implants:

Taking into account our patient’s requirements and financial means, we opted for 4 implants to be fixed in the lower and upper arch each, which would support bar dentures. Besides stability, bar dentures also have the great benefit that implants can be aligned with the bone mass, and axial discrepancies can be remedied with implant bars, which eliminates the necessity of a bone-graft.
It is important to minimise the wearing time of removable provisional dentures following implant surgery. Patients are advised to wear provisional dentures only to work or at places where they are required to talk and smile. When at home, provisional dentures should be removed immediately. Please keep the denture and the mouth clean and see that the implanted area is not exposed to pressure and that the provisional denture does not “wiggle” on the implants/gingiva formers. Pressure exerted by the denture compromises blood circulation, hinders healing, may cause denture sores and infection, or, worst of all, the rejection of the implant, however well the implant was installed.

Follow-up panoramic radiograph following implant surgery

Third treatment phase: The fabrication of permanent tooth restorations (10 workdays)

Following six months’ healing time the final and lengthiest treatment phase could ensue. Thanks to gingiva formers (healing abutments) precision impression taking can be performed in a simple and almost painless way. Following the removal of the gingiva formers, so-called impression copings are screwed in, which give the dental technician exact information as to the location and axial position of the dental implant installed. A follow-up panoramic radiograph is made to verify the seamless fit of the impression copings in the implants.

Follow-up panoramic radiograph of the open tray impression copings screwed into the upper implants

Photograph of the open tray impression copings screwed into the upper implants, giving the dental technician exact information as to the exact location and axial position of the dental implants installed.

Open tray impression copings on the master cast placed into a custom-moulded tray with a view to achieving the perfect precision of the impression

The custom-moulded tray prepared specifically for the present instance by the dental technician for precision impression taking

The finished upper precision impression taken with the custom-moulded tray

Following impression taking a gnathological treatment (viz. an instrument-aided bite registration) is due for the technician to see the exact position of the jawbones in the articulator to ensure the correct position of the temporomandibular joint on occlusion.

Articulator: a dental instrument reproducing the movement of the mandible and the maxilla in the correct position of the temporomandibular joint. The movements of the articulator are as follows:

  • opening-closing movements
  • lateral movements
  • forward (propulsion) + backward movements

Gnathological treatment, facebow transfer

The placement of the upper plaster cast into the articulator for the dental technician to see the precise position of the maxillary arch in relation to the temporomandibular joint

With dentures, not to mention bar dentures, several crucial trial fittings are performed for the dentures to seamlessly fit and to achieve perfect aesthetics. During the trial fittings of the framework and bar the finished bar is screwed into the implants to verify the trueness of the framework of the tooth restoration. The trial fitting of the teeth focuses on aesthetics and correct occlusion. During the trial fitting of the teeth, aesthetics can be improved in the event of individual requests as to the position and shape of the teeth.

At handover, the bars are screwed onto the implants with the appropriate torque on which the new denture will seamlessly sit.

The bipartite bar intended for 4 upper implants on the master cast:

Intraoral view of the bipartite bar intended for 4 upper implants

Bar supported by 4 lower implants on the master cast

Intraoral view of the bar supported by 4 lower implants

Upper bar denture on the master cast:

Bars offer such a degree of stability that dentures sit firmly even without the support of the roof of the mouth, making it an ideal solution for those unable to wear palate-supported dentures.

Bottom view of the finished bar-retained denture featuring dolder bars

Lower bar denture on the master cast:

Bar mounted on 4 lower implants on the master cast

Bar mounted on 4 lower implants on the master cast and bottom view of the finished lower bar denture featuring dolder bars

Intraoral view of the finished bar dentures following handover

Follow-up panoramic radiograph of the lower and upper bars following handover in which the seamless fit of the bars can be verified

A few weeks on, the patient’s ability to eat, speak and smile would be perfectly restored and his self-confidence regained, and he would feel free to mingle with people. The first 8 days following hand-over of the finished work is a difficult period during which the patient should read out aloud, talk and eat so that the natural function of the muscles, tongue and the temporomandibular joint is restored as soon as possible. This process usually lasts two months.

Our patient was content with the treatments and comes for regular check-ups, oral hygiene treatments and professional tartar removal, which constitutes a condition for warranty.

It is supremely important to keep the denture clean. Patients are advised to remove it after each meal and clean it thoroughly with a denture brush. The implants and the bar must also be cleaned thoroughly with a tooth brush, toothpaste, and beneath the bar, with Super Floss and an interdental brush.

Follow-up panoramic radiograph at the first annual follow-up examination

Before

After

Before

After

Further pictures of the finished dental restoration: