Implant case study Continued »
no regular dental care over many years, but brushed three times daily and used a mouthwash. Her partial upper denture was worn on a full-time basis and cleaned once a day. She was working as a full-time community occupational therapist, was single, a non-smoker and did not drink alcohol.
Examination Examination revealed that there was no tenderness around the temporomandib- ular joints or muscles of mastication. She had an average lip line. Intra-oral, there was evidence of
palatal erythema on the denture-bearing area (Fig ı). Her oral hygiene was deficient of BPEs (Table ı.) She had generalised reces- sion and pocketing. She also had extensive caries in her remaining teeth (Fig 2). The upper ridge was irregular and also thin anteriorly. The lower ridge was atrophic posteriorly and there was a chronic abscess related to 27. She was wearing a partial upper acrylic
denture which was ill-fitting. A cone beam CT scan showed generalised moderate to advanced bone loss; there was limited bone support around her remaining upper teeth; there was adequate bone volume of good quality for the All-On-4 technique in the lower jaw. The prognosis for all of CK’s teeth was
poor. We discussed all of the treatment options including clearance, construction of conventional upper and lower dentures, construction of a conventional upper denture and an implant-retained lower overdenture or implant-retained bridge work, construction of an upper overdenture or upper implant-retained bridge work. The advantages and disadvantages
of all treatments were fully discussed. Agreement was reached to carry out a clearance, construct an upper imme- diate denture, to place four implants in the lower jaw and to construct an immediate implant-retained bridge followed by construction of a long-term bridge in titanium and acrylic. Primary and master impressions were
taken and a wax try-in was carried out for the upper teeth and the lower posterior teeth. CK was very particular in relation to the position, size and shape of the teeth and, after two adjustments, a complete upper denture and complete lower denture was constructed. The surgery was carried out under local anaesthetic and intravenous sedation on ıı December 20ı2. The remaining upper teeth (ı7 and 27) were extracted and all lower teeth were extracted. A mucoperiosteal
Complete upper denture and lower bridge work in place Fig 5
flap was raised; the lower ridge was evened and smoothed with a burr. The mental nerves were identified and protected; four implants and multi-unit abutments were placed in the lower jaw with the two posterior implants angled (Fig 3). The implants were stable; the holes were
cut in the complete lower denture which was located using temporary cylinders (Fig 4). An impression of the multi-unit abutments was also taken to allow the technician to construct a master cast and allow adjustment and accurate finishing of the undersurface of the bridge work. The provisional bridge work was screwed in place later on the same day. The patient was given full post-operative instructions, including use of chlorhexidine mouthwash. She was followed up in the healing period, during which time she was seen by our hygienist who gave her appropriate and precise oral hygiene instruction. After a period of approximately three weeks, she was instructed in the use of a water jet. After a period of healing of approximately
four months, master impressions were taken of the implant abutments using multi- unit fixture head impression copings in a special tray. A verification jig was tried on the next visit to ensure accuracy of the master cast. A full wax try-in was then completed for the complete upper denture and the
lower implant-retained bridge prior to construction of the titanium framework. A full wax try-in was then again completed prior to processing of the complete upper denture and the implant-retained lower bridge, which was delivered on 2 May 20ı3. Our hygienist saw CK again for further oral hygiene instruction and emphasised the importance of optimal plaque control.
Discussion Implant therapy has changed the way in which we approach treatment planning. Many patients are very aware of implant techniques and will come in requesting,
Continued » ABOUT THE AUTHOR
Arshad Ali is clinical director of Scottish Centre for Excellence in Dentistry, a centre for dentistry, implantology and face and body rejuvenation. He has been involved in implant treatments since 1986. Arshad was the winner of the Creative Circles Award at the 40th Anniversary Nobel Biocare World Converence in Las Vegas in 2005 and the Crown and Bridge and Implant Award at the Nobel Biocare World Tour Conference in London in September 2006. He is committed to postgraduate education and has been involved in teaching and training at all levels. He has given more than 250 lectures and courses in the UK, Europe, North America, Hawaii and the Far East. He is currently providing lectures and hands-on courses in crowns, bridges and implants.
Scottish Dental magazine 63
Fig 3 Lower arch implants
Fig 4 Immediate bridge work
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