Implant Case study
No quick fix
Case description
Patient arrival
After a horse-riding accident, Charlotte attended a free implant assessment at TIC to have a second opinion; her own dentist having judged that there was little that could be done to help her attain the smile she wanted.
The TIC and CDL multidisciplinary technical and surgical team met with Charlotte to talk through the look that she wanted, what might be possible from a surgical and technical perspective and what she might expect from the treatment. Charlotte was clear that she wanted to regain her old smile and her confidence. She was open to options to deliver this.
The team explained that we would discuss a number of options internally and create study models for her to visualise her treatment before committing to a course of action. The outline treatment plan sounded good and she chose to move forward with CT scans and primary impressions for the lab to make study models for a case discussion.
This case presents technical challenges and is aesthetically demanding. The patient has a broad high smile and a high lip line. Lip support and palatal contour had been given careful consideration to enable correct phonetics. Surrounding teeth had also been traumatised which needed to be taken into account for her long term future.
Process
1. Case Planning Meeting
The case was presented and discussed between lab and surgical teams to decide the most appropriate course of action.
As Charlotte hadn’t lost much bone, implants were a good option to explore. The non-vital misaligned 21 tooth would have to be removed as this would
compromise future restorations. As a team, we determined that a 3 unit bridge secured on 2 implants would be the optimal solution for Charlotte. The exact shape and form of the restorations would be gradually determined with the patient over time to enable her to fully participate in the design of the final restorations, also to ensure that soft tissue could be contoured to match her high smile line. We designed a temporary bridge for Charlotte to leave the surgery with to give her an immediate impression of the end result.
2. Pre surgery laboratory work
We designed and manufactured a printed drill guide using a scan of the wax up for predictable placement to guide the surgeon in the placement of the implants.
The design process is collaborative with the surgeon visiting the lab and talking through the planned surgical approach; the technician working with the surgeon to ensure that the angle and depth of implant placement would support the optimum restoration and deliver the results which Charlotte expects.
We manufactured a temporary immediate denture ready for surgery and post surgery, this was designed to be as close as possible to the end result
3. Surgery
The 21 was extracted and the implants placed using the drill guide in 11 and 22 site, the flap was closed and a new implant level impression taken along with an opposing alginate impression. The patient left wearing the denture and the surgery was absolutely successful, leaving us as a team a solid foundation from which to plan the most aesthetic and functional restorations.
A three unit temp bridge was designed and milled in PMMA to fit after the sulcus formers are removed, this temporary bridge also acts as a diagnostic for patient preferences and more importantly for custom contouring of the soft tissues to help restore the interdental papilla and establish correct phonetics as we knew that the bulky denture gave Charlotte problems.
Temp bridge to create soft tissue shape
Ready for impression
Custom contouring with temp bridge
Definitive Zirconia ceramic bridge
4. Refinement and adaptation
Charlotte was invited back into surgery to meet with the multidisciplinary team for a number of appointments where we added/ removed composite to give the perfect tissue contouring and refine the exact shape and position of the restorations. This allowed Charlotte to live with the new teeth, speak, chew and really understand what she liked and didn’t like. It is critical that patients are full design partners in the end outcomes.
Once we had established that the tissues were now stable and healthy a custom impression jig was made in the lab to copy exactly the profile that the team had worked on to create. The final design was agreed at a clinical case review meeting and agreed between restoring surgeon and technician.
FINAL RESULT
At CDL/TIC, we review all implant cases one year later to ensure that the intervention has been successful and still meets the clients’ needs. Charlotte is still delighted and has in fact referred friends and family to us.
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