Our female patient aged 74 reported to the Suba Dentál clinic with following complaints and requests:
- She has lost some of her upper teeth and had a clasp denture fabricated which she could not get accustomed to.
- She desired to have a more aesthetic fixed replacement.
- She sought to have whiter teeth.
- She did not keep aloof from an implant surgery, but disliked the idea of a bone graft surgery.
First treatment session (3 workdays)
At the first consultation we thoroughly examined the condition of teeth. A CBCT (Cone beam computed tomography) scan demonstrated that residual bone mass was suffiecient for the missing lower right molars to be substituted by implants. However, in the upper left region substitution by implants was only practicable by means of a bone graft surgery the idea of which our patient abandoned altogether.
At the first treatment session tartar removal and in-office Zoom whitening was performed and two implants were installed at the site of the missing molars on each side.
Panoramic radiograph brought along by the patient to the first consultation
Our patient requested no temporary replacement for the time of healing as she had had no tooth replacements whatsoever below, and she could easily do without one for the next 3 months to come.
Her old overdenture which she could never come to terms with
Second treatment session (10 workdays)
After 3 months’ healing time the instalment of the permanent crowns was due. Metal-ceramic crowns and bridges were fabricated for natural teeth and the lower implants. For this patient we fabricated a half-arch combined tooth replacement in order to bypass bone graft.
When is a combined tooth replacement indicated?
It is generally applied in the restoration of free-end edentulism, with natural teeth present but rear teeth missing. A fixed metal-ceramic bridge is fabricated to be secured on natural teeth to which a hidden-clasp removable denture attaches which substitutes rear missing teeth.
For the most part, it is the permanent tooth replacement that requires the longest treatment session of all the sessions. Precision impressions are taken of the preps (filed natural tooth stumps) and the implants with the help of closed tray impression copings.
Follow-up radiograph picturing the closed tray impression copings inserted into the implants
Following impression taking 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. At this trail fitting, 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. can be checked with even better accuracy. 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 teeth in need undergo a root canal treatment/repeated root canal treatment.
Our patient is fully pleased with her new teeth. She is glad that her upper dental arch has been restored with a good looking fixed replacement with only a small removable part. Her old denture is but a bad memory now.
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 making regular cleaning and tartar removal is indispensable at least once or twice yearly in this case too.
Lower metal-ceramic crowns for natural teeth and cement-retained implant crowns on the master cast
Lower cement-retained implant abutments with the screw driver required for installation
Upper combined restoration with the metal-ceramic crowns to which the removable denture attaches with hidden clasps at the rear
Upper combined restoration on a master cast with the front crowns to which the removable denture attaches with hidden clasps (MK1)
Upper full-arch metal-ceramic bridge on a master cast
Follow-up panoramic radiograph of the metal-ceramic crowns designed for natural teeth and implants
Keywords: Metal-ceramic crown, metal-ceramic bridge, removable denture, overdenture, implant, cement-retained implant crown, combined restoration, hidden clasps, denture trial fitting, MK1