The lovely patient presented with loose upper front teeth which she had trauma in her teenage years and had been root canal treated and crowns previously. The four upper front teeth were deemed to be of poor long term prognosis and were extracted. Two implants were placed and a four-unit implant-retained bridge was constructed.
We also did some teeth whitening, reshaping of the teeth and a couple of white filling material to the canines helped to achieve a pleasing smile.
Before
Extraction and immediate denture
The patient is of low esthetic risk as she has a low smile line but as the lips which were well supported earlier, lost support
We knew from the beginning the restorative space was very constricted, so we planned to use noble-biocare as the stack height minimum we would need from implant head to occlusal plane was 5mm, with about 2 mm sub-crestal placement we decided we could get a reasonable result without opening the OVD.
Mockup
We used a trial denture without a buccal flange. This is a very important stage as the denture with a flange gives patients lip support which an implant bridge will not give, and it is important to make sure the patient and we are happy with the result. At this appointment, the patient requested teeth whitening which was planned to be done close to the definitive bridge stage.
Stage 1 - Implant placement
We copied the trial denture in clear acrylic we used the same for a CBCT as a radiographic stent in the mouth with temp-bond on them, we also used the same as a surgical stent to help aid during surgery.
Checked the angulation and the placement with the stent in place ( the guide pins should really be flossed !!)
Nobel biocare - Regular Platform, 10 mm implants were placed 2 mm sub crestal in the UR1 and UL1 position to aid in stack height and good emergence. Some bone grafting was also done to aid in buccal contour. The implants covered with a cover screw and covered for 4 months with the denture as a temporary.
Stage 2 - Exposing implants and healing abutments
Please ignore the little flap of tissue mesial to the UR1, this was only my second ever stage 2, and my was hand only still becoming steady with a 15 scalpel !! a wide healing abutment places so I have a good emergence profile, so the blanching - but the patient did not report much post-operative pain although I warned of pain for 1 week !!! phew!
Stage 3 - Impressions
The impression coping modified with flow composite into the gap between impression coping and gum, as I used a large healing abutment. Impression using impregum ( poly ether) and open tray technique.
Provisionals
Teeth whitening completed, shade taken and provisional screw-retained completed in PMMA at abutment level. ( Multi-unit abutment selected by the lab ).
Definitive impression and Verification Jig
Definitive impressions done with abutment impression copings and open tray with impregum, then the next stage is to use a verification jig, this is usually done to double-check if the impression was accurate, this is made in duralay and if this breaks on tightening, we will need new impressions.
Definitive Restorations
The definitive restoration, a 4-unit screw-retained implant bridge. It has a milled co-chrome framework, with pink and white composite added for esthetics. With 2 implant screw-retained abutments and 2 single cantilevers to either side, the screw access holes were covered with PTFE tape and composite. There was no occlusion / occlusal guidance on the cantilevers.
Needless to say, the patient was indeed very happy with her smile.
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