Periodontitis-related anterior edentulism restored with a metal-ceramic arch bridge (Case presentation) (56 )

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Periodontitis-related anterior edentulism restored with a metal-ceramic arch bridge

Our female patient aged 33 reported to our clinic with the following requests and complaints:

She suspected problems with her front teeth. She had a greatly receded gum line and complained of cervical sensitivity and loose teeth.
She is greatly disturbed by the black gaps between her teeth.
Although she is afraid of dentists, she thinks she can no longer procrastinate the intervention.
What with her being a young lady, restoration of aesthetics was a top priority so she could feel at ease to smile again.
First off, she wanted to have her front teeth to be taken care of, and only wanted to deal with the lower ones later down the line.

Before

After

First treatment session (3 workdays)

At the first session a panoramic radiograph was recorded to examine the condition of the teeth and the periodontium. The first examination revealed that her remaining upper molars were beyond repair due to the extent of the inflammation having formed around the root canals and could only be helped by removal. These inflammations were dental foci that could not go untreated as they may give rise to a number of other non-dental problems (such as hair loss, dermatological issues and cardiological complications). The upper front teeth were also marked removal due to progressive horizontal and vertical bone resorption. Our patient was fairly alarmed at this as she hoped she could “steer clear” of a drastic intervention. She was against dental implants, and would have been in favour of having her edentulism restored with a bridge. This is feasible with upper teeth, but if a fixed restoration is intended for the mandible, implants cannot be avoided.

In case of edentulism, restoration of the masticatory function requires the first molar to be replaced as well in order to enable the patient to properly chew and prevent gastroenterological disorders arising in the wake of inadequately chewed bits of food.

As a matter of course a CBCT (Cone beam computed tomography) scan was recorded prior to the implant surgery for the bone mass to be examined in 3 dimensions for the thorough planning of the intervention. Since the stability of the implant exceeded 30 Ncm, healing abutments aka. gingiva formers were installed right away to allow the gums to heal to the perfect shape for the permanent abutment.

Follow-up panoramic radiograph with the implant installed at the site of the lower left molar

The treatment continued with the removal of the teeth. The patient was provided with a removable provisional denture for the time of healing with a view to preserving her self-esteem.

Photos of the teeth prior to extractions

Photos after extractions. The wound was sealed with a few stitches for better and faster healing

Provisional denture for the replacement of front teeth with clasps imitating aesthetic gums for better aesthetic results.

Provisional denture in the mouth offering an aesthetic solution for the time of healing

Smile with the provisional denture substituting the 4 front teeth

Second treatment session (workdays, following 3 months’ healing time)
Following the mandatory 3 months’ healing time we could set about finishing the permanent tooth restorations, that is the crowns/bridges.

The healed gums following tooth extractions and the healing time

Our patient sought to have her missing teeth replaced with zirconia crowns, but the dental technician confirmed our decision that bridges with such a large span and cantilever units on both sides cannot be suitably replaced with a zirconia arch bridge, so we opted for a conventional metal-ceramic arch bridge. It rarely happens that we cannot accommodate the patient’s request, but this was one such case. She talked over the possibilities with her treating specialist and dental technician, and accepted the arguments, so metal-ceramic crowns were fabricated for the maxilla and screw-retained crowns were mounted on the lower implants.

The placement of a gingival retraction cord around the tooth prior to preparation of the tooth allowing the technician to see the actual rim of the tooth and fabricate accurate crowns

The staff of a dental clinic must work in a well-coordinated fashion where everyone is an expert in their respective field, in order to provide patients with the best custom-tailored solutions. To this end, our colleagues regularly participate in trainings and confer with one another.

The DIO implant installed at the site of the lower molar with the healing abutment on top, following healing

The DIO implant installed at the site of the lower molar following removal of the healing abutment. As can be seen, the gums have beautifully healed into the shape of the permanent abutment.

Follow-up panoramic radiograph of a closed tray impression coping, taken prior to precision impression taking

Until such time as the permanent crowns are finished, provisional (plastic) crowns are fabricated for the prepared teeth to protect them. Impression taking is followed by several trial fittings as the technician is making progress with the crowns. At the trial fitting sessions, the plastic provisional crowns can be removed and glued back on.

Since our patient has always desired slightly whiter teeth, professional tartar removal was performed using Zoom 2 in-office LED teeth whitening, in a bid to match the colour of the crowns with that of the natural teeth to achieve a perfect and white smile.

During the trial fitting of the framework the impressions are checked for trueness and the accuracy of the framework is verified (for the length of the teeth) and all tooth restorations must seamlessly fit the master cast. Thus, if need be, timely measures can be taken to rectify any issues rather than being faced with problems when the crown is finished when rectification is a lot more complicated, if not downright impossible.

The metal framework of the upper arch bridge on the master cast

The tooth preps filed to form shoulders

The framework of the upper metal ceramic arch bridge on the master cast

Intra-oral view of the framework of the upper arch metal ceramic bridge (trial fitting of the framework)

At the trial fitting of the matte teeth the crowns are almost complete with the ceramics already sintered onto the framework with a matte finish. At this trial fitting the patient’s bite (function), the shape and colour of the crowns and the centre line and smile line can be checked again (trial fitting for aesthetics). At this phase aesthetics can still be improved, if required. If correction is required, the trial fitting of the matte teeth is repeated to achieve perfect aesthetics.

Intraoral view of the trial fitting of the matte teeth

Finally, the dental technician burns a glossy layer onto the crowns (glaze), which makes the teeth deceivingly life-like. The crowns are now ready to be glued on.

The finished metal ceramic arch bridge on the master cast. For better aesthetics the dental technician uses pink ceramics between the teeth, matched to the colour of the gums and covering up black gaps between the teeth. The black gaps (black triangle effect) forming between the cervices can look rather unappealing.

Front view of the finished metal ceramic arch bridge, taken off the master cast

Bottom view of the finished metal ceramic arch bridge off the master cast

A few hours to several days elapsed between the different trial fittings. These are procedures of varying length demanding painstaking attention to detail, if we are to achieve perfect results.