Patient Case 7

I. Pre-operative: 1. Main Complaint

The patient presents to the practice with a mutilated dentition requesting to have all his teeth removed.

2. Dental History The patient had for a very long time not seen a dentist for any treatment or maintenance. He is a smoker with the intention to have all his teeth removed. He claims that all teeth that have been previously treated ended in failure. It is visible on the OPG that this may well be the case. Following a lengthy discussion considering different treatment modalities, we agreed that the implant rout may well be his best option. The risk, time and financial implications were clearly put to him, whereby he decided to have the implant based option.

3. Medical History No Medical conditions were reported.

4. Photographs of study models in left and right sides in occlusion and left and right sides of the individual upper and lower models.            

                       

                                         

5. Photographs of the wax up and surgical stent.

                                                                 

6. Photographs of the section plane showing the bone profile after bone mapping at the implant sites The patient was sent for Cone beam CT to determine amount and quality of bone for the placement of implants.

7. Clinical pre-operative photographs with the following views:

8. Radiographs: a. Adequate OPG (panorex)

b. CT Scan, Simplant or NobelGuide (optional)

9. Treatment plan

a. Restorative treatment plan

The plan is to remove all the maxillary teethe and place 8 implants to make a screw retained fixed maxillary prosthesis. In the mandible, the 45 and 46 will be removed and replaced by implant supported crowns.

The anterior component will be cleaned up and bleached to the desired shade. In an extreme view, the anterior lower teeth may be veneered with CAD/CAM milled veneers of maximum 500 Micron in thickness. Replacement of the 35and 36 with implant supported crowns

b. Implant treatment plan The implant plan consists of the immediate placement of 8 implant in the maxilla with an immediate loading protocol. The mandibular implants will be done later due to financial considerations.

c. Follow up an maintenance plan During the initial phase of treatment , the base lines regarding oral hygiene and subsequent maintenance of such an extensive prosthetic will be firmly entrenched. I soft surface Night guard will follow to protect the porcelain of the crowns during nocturnal parafunction.

II. Intraoperative: 1. Open site

A Clearance of the maxilla was performed and sutured with an immediate placement of 8 implants

. Confirmation of the thickness of the buccal wall was done with these callipers  

Placement of the positioning stent to determine tooth position with regards to screw directions and exit angles in the restorative space.

2. Position of implant prior suturing

    The implants were placed with flapless surgery with the help of a implant positioning stent and the CBCT to determine the implant position prior to stent manufacture.

3. Situation prior / after grafting if any  

The immediate situation following the implant placement with the impression tray in place for the manufacture of the immediate provisional fixed bridge. This will act as a splint as well as an intermediate dentition.

     A  bar  substructure  for  the  provisional  was  constructed  allowing  for  all  the  implant  to  be  fixed  within  the  structure.  The  implants  were  however  selectively  connected  to  the  bar  due  to  the  status  of  primary  stability.  All  the  implants  that  were  not  torqued  in  at  25  N.cm  were  left  out.

The immediate provisional was functional but aesthetically compromised. The desired soft tissue scallop was now already being created by the position of the crown margins and ovate pontics.

No grafting procedures were done and implant placement was a straight forward process, without any complications. Primary stability was achieved in all but one implant. That was the implant in the area of the 26.

Notwithstanding the fact that the patient managed to destroy the immediate provisional as well as the metal reinforced provisional, the implants integrated and the soft tissue have adapted very well to give an acceptable gingival morphology. The process to manufacture the final restoration was now due.    

                                                                   

III. Post operative:

1. Radiographs

a. Immediate post-operative periapical radiograph b. One month follow up radiograph c. Radiograph at second stage surgery and provisionalisation if relevant d. Radiograph of final restoration treatment.

2. Photograph after 12 weeks of healing      

The implant on the 26 that was initially not stable failed and was removed. An implant was placed in the pontic site between 24 and 26 and the punch out attached gingiva used to close the void

   

               

 

 

                                 

 

The implant information was transferred to the models via primary and then final impression. Models were casted and abutment fixtures custom made. Intra oral positioning stents accompanied the substructure.

   

The abutments were fitted and torqued in to the manufacturer’s specification    

                                     

 

A Bisque bake try- in was done. Good pressure on the soft tissue to enforce the “SOFT TISSUE CARE” concept was achieved.

The restoration on the final day of placement, with the promise of a good result to follow.

THE FINAL ONE WEEK LATER

                                                                                                                         

 

The final Panorex  

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Treatment rationale:

This relatively young patient opted to have the implant treatment option due to the predictability of the treatment. He has already changed his oral maintenance ways and is much improved. He finally has some self respect and can socialise with confidence. He is very eager to continue with the mandibular treatment. He is acutely aware of the projected improvement in function once the posterior component is in full occlusion. The screw

retention makes access and retrieveability simple. The quality of the bone should for good reasons remain good for many years and the patient will not lose critical amounts of bone. The facial volume around the implants should also be predictably stable.