Transforming a life with staged full mouth rehabilitation
Featured Products Promotional FeaturesPosted by: Dental Design 18th May 2022
Presentation
A 61-year-old female patient presented in July 2019 with a large failing bridge in the upper jaw and some failing teeth in the lower jaw. Her motivation for attendance was to change her smile and gain confidence with eating and smiling. She was interested in a smile makeover, having just retired and starting a new phase of life.
Examination revealed
The upper bridge spanned from UR5 to UL5, with 6 abutment teeth – all of which had a hopeless prognosis. In addition to the upper failing bridge, the patient also presented with a failed lower bridge from LR2 to LR6. This was held in position by just LR3 and LR6, which also both had a hopeless prognosis. Further still, the patient had already had a traumatic extraction of LL4 by another dentist, which had created significant bone loss as well.
The patient’s oral hygiene was fair, but showed mild to moderate signs of chronic periodontitis. She had also recently been afraid of attending for hygiene visits because of the loose-fitting bridge and the fear of losing it in the cleaning process. Otherwise, the patient had been a regular dental attender at her previous practice.
She also had presented in good general health, only taking medication for high blood pressure, and she had no history of smoking or drinking. She was a well-motivated, positive patient with realistic expectations. She depended on her daughter to drive her to dental appointments, but was financially stable and could afford treatment if costs were spread over at least a year.
Treatment plan
All possible treatment options were presented to and discussed with the patient. In terms of fixed solutions, the only viable solution for the upper arch was an implant-supported bridge. A delayed implant approach was indicated for treatment of the upper jaw. A total of 6 upper implants were planned. Bilateral sinus lifts with sequential extractions would be required, as well as extraction of all the anterior teeth, leaving the two molars in the first quadrant to provide a vertical stop. A denture would be provided while the soft tissue was healing for an estimated three months. Oral hygiene visits with the hygienist were scheduled to stabilise the periodontitis prior to commencing any restorative treatment.
The clinical procedures, benefits, risks and limitations of treatment were conveyed to the patient in detail, who provided informed consent to proceed.
Upper arch
The planned extractions were performed as atraumatically as possible in September 2019. Immediate partial acrylic dentures were provided for the patient to wear during the healing phase.
She returned to the implantologist in January 2020, after successful hygiene treatment. Upon review, the soft tissue had healed well and was presenting as pink and healthy. Conditions were ideal to proceed to the surgical implant stage of the upper jaw.
At the first implant surgical session, four implants were placed in the upper anterior region – three AxiomÒ Bone Level (BL) 3.4mmx10mm and one AxiomÒ BL 3.4mmx12mm, all from Anthogyr. The implants were buried and cover screws fitted to help reduce the risk of periodontal disease interfering with implant healing. All remaining sockets were grafted using Ethoss synthetic grafting material to preserve alveolus architecture. A sinus lift in the upper right quadrant was performed using a lateral approach with Geistlich Bioss Collagen and granules using a Piezotome. The sinus lift in the upper left region was planned for March 2020, but due to COVID-19 restrictions, treatment was delayed.
The sinus lift was only performed six months later in July 2020. During the same session, the upper right distal implant – another AxiomÒ BL 3.4mmx10mm – was placed and the last two molars removed. The patient had adapted well to the temporary denture and a note was made about the vertical dimension.
The final upper left distal implant was placed in August 2020 and left to integrate for three months. The patient was wearing a denture throughout all of this, so she was quite comfortable.
The prosthetic phase was completed in February 2021. This consisted of a Simeda-milled CAD/CAM zirconia bridge based on the InLinkÒ system from Anthogyr. The bridge was designed and finished by Jon Dolding from Ceramic Designs Brighton. The process consisted of a primary open tray impression at tissue level with InLink abutments in place, Verification of the implant positions was completed with a stone jig. A wax try-in of the mock-up bar and teeth was tried in the mouth so vertical dimensions and occlusion could be checked and confirmed. The final bridge was delivered and the patient was very pleased with the outcome.
Lower arch
In October 2020, five AxiomÒ BL implants were placed in the lower jaw. This presented some challenges in the distal region LR5,6 due to the lack of bone height available above the inferior alveolar canal. Short implants were placed and angled to make maximum use of available bone. Even though it was prosthetically planned, the screw access channels of the final prosthesis could only be achieved by using a specific Anthogyr InLinkÒ connection. A cement-retained bridge was considered but decided against due to long-term maintenance issues. The patient was keen to avoid further bone grafting, and given that vertical and horizontal grafting in the mandible is costly and far less predictable, another solution was sought. The unusual angulations for implant placement allowed for primary stability and good anchorage in the existing bone.
One of the only implant systems that can do this, is the Anthogyr AxiomÒ implant system. It uses a flat connection, which enables the clinician to mould the bridge with different angulations and makes it possible to design the restoration with opposing screw angulations, all without compromising function, strength or aesthetics. AxiomÒ Tissue Level (TL) abutments were chosen because they wouldn’t interfere with the final restoration and would facilitate cleaning. The flexibility this affords is unique to this implant system.
A similar restorative protocol was followed for the lower arch as in the upper. The lower prosthesis was manufactured by Kevin McKeeman Dental Laboratory in Sevenoaks, Kent. Treatment was completed in April 2021.
Outcome
The patient was delighted with the final result in this case. A significant transformation was achieved, restoring function and aesthetics, while ensuring easy maintenance.
This case shows that by delaying and staging treatment, full-arch treatment can be predictable in less-than-ideal cases and more affordable for the patient. It also shows the flexibility of this particular implant system. AxiomÒ from Anthogyr is a surgeon friendly implant and it allows for predictable restorative treatment in more complex cases.
Images
Anthogyr solutions are available through the Straumann Group. For more information, please visit https://www.straumann.com/group/ca/en/home/our-brands-and-partners/technical-partners/anthogyr.html
Author:
Dr Werner Slabbert
BChD (Stell), MClinDent Oral Surgery (London), Dipl.Implants (UWC), Dipl.Sedation (Kings), MJDF RCS England
Dr Slabbert is the owner of Sussex Implant Centre and Advanced dentistry in Brighton East Sussex UK. He has a passion for Advanced dentistry and, in particular, Implantology, Oral Surgery and Sedation. He has extensive experience in oral surgery and implants and regularly accepts referrals from other dentists. He is a key opinion leader of the Anthogyr implant system and has lectured locally and internationally.
