The replacement of neglected, decayed and missing teeth with implants and metal-ceramic arch bridges
Our male patient, aged 40, reported to Suba Dentál’s clinic with the following requests and complaints:
- He had neglected his teeth for a very long time due to financial and psychic reasons.
- In his own account, he had never been more afraid of anything than a dentist, stemming from a childhood trauma suffered at a dental clinic.
- He was resolved to have his teeth repaired both in terms of function and aesthetics.
Panoramic radiograph of the initial situation.
First treatment phase (3 workdays): consultation, removal of teeth as required
Our patient showed up at the first consultation with a panoramic radiograph based on which, and following a clinical examination, a treatment plan and quote was drawn up. According to the treatment plan all teeth beyond repair would be removed and replaced with implants which would support fixed restorations, crowns and bridges so as to prevent the patient from wearing an overdenture at such an early age.
Photograph taken of the upper teeth (initial condition)
Follow-up panoramic radiograph following removal of the teeth
Tooth extractions are followed by 3 months’ healing time before implant surgery can be resumed.
Second treatment phase: the installation of dental implants (3 workdays)
Following 3 months’ recovery a CBCT (Cone beam computed tomography) scan was taken of the healed bone to examine the bone mass in 3 dimensions. The upper arch could accommodate longer and thinner implants, whereas the lower arch could only support short and thicker ones. We were vainly trying to persuade our patient to have more implants installed given that his lower jaw would only allow for short implants: this would have been beyond his means. Finally, a total of 9 implants were installed. Following implant surgery his provisional denture was relined at the chairside so he would be able to wear it over the next 6 months’ healing period.
Follow-up panoramic radiograph following installation of the implants
Third treatment phase (1 workday): the exposure of the implants and the mounting of healing abutments
Since short implants were installed and the patient insisted on wearing his removable denture, the implants were sealed with cover screws and the gums were sutured. Following the osseointegration of the implants (fusion of the bone and the implants) another surgical intervention is required during which the gums are exposed and healing abutments are placed inside the implants. Due to the altered anatomical relations the provisional dentures need to be relined on mounting gingiva formers (healing abutments) in order to ensure ease of wear over the remaining one month.
Fourth treatment phase (10 workdays) the fabrication of permanent crowns for natural teeth and implants
6 months after implant surgery we are ready to set about the fabrication of crowns for natural teeth and the implants installed. Our patient opted for cement-retained crowns on account of its reasonable price and aesthetics.
Since multiple teeth need to prepared, one day is devoted to one arch and another one to the other arch and precision impressions are taken of the tooth preparations.
Following the shoulder margin preparation of the teeth, the precision impressions, photographic documentation and the patient’s aesthetic requests are forwarded to the dental laboratory.
Until the completion of the permanent crowns immediate crowns are fabricated (with the Scutan method) to cover and protect the tooth preparations. The provisional crowns are fabricated at the chairside right after the treatment so that the patient does not leave with tooth stumps in their mouth. With the impressions taken a gnathological treatment (viz. an instrument-aided bite registration) is due with the use of an Artex face bow. This device helps the dental technician examine the mutual position of the jawbones and the tooth preparations and see that the temporomandibular joints are in a correct occlusal position with the new permanent crowns on.
With metal-ceramic crowns, the framework is trial-fitted first during which the impressions and framework (metal framework, in the present instance) are verified for accuracy. This is when the length of the framework (i.e. the length of the future replacement tooth) is verified along with the middle position of the central incisors and the rearward curve of the teeth. This serves as the basis for aesthetics, since, for instance, if the framework is too long, the tooth will also be too long with the ceramic coating sintered on, which is unappealing. If all is found in order at the trial fitting of the framework, the trial fitting of the matte teeth may ensue at which the teeth are almost ready, having received their ceramic coating (with ceramics already sintered on). This trial fitting allows a closer verification of occlusion (function) and the shape, colour and centre and smile lines (trial fitting for aesthetics). The trial fitting of the matte teeth clears the way for handover, when the crowns are permanently glued in place. At handover the patient is shown the particulars of home cleaning and tools with which to thoroughly cleanse his teeth, implants and parts beneath the bridges of food remains.
At handover our patient was moved to tears when he saw the results. He travelled an arduous path during which he overcame most of his dental fears too. It took great courage to achieve all this.
Follow-up panoramic radiograph of the cement-retained metal ceramic crowns borne by implants and natural teeth
The finished metal-ceramic crowns (designed for natural teeth and implants) on the master cast