CHIEF COMPLAINT:
Patient was not satisfied with aesthetics…
DIAGNOSIS: Female patient, 52 years old, non-smoker.
Initial status:
• Metal-ceramic fixed partial denture (FPD) (11-15) supported by three dental implants in 11, 13 and 15.
• Metal-ceramic FPD over teeth 21-22-23-25
• Small exposure of the implant neck in 11 position.
• Significant root exposure on teeth 21 and 22.
• In the lower jaw, patient had edentulous spaces in 46 and 36, and tooth 47 is tilted mesially.
TREATMENT PLAN:
Maxilla: periodontal plastic surgery to increase gingiva thickness and reduces root exposures. Ceramic FPD in the 1st and 2nd quadrants.
Mandible: dental implant in tooth 36 with a screw-retained crown and a FPD in teeth 47-45-44 (overlays in teeth 47, 45 and 44, allowing the closure of the edentulous space of tooth 46).
TEAM PLAY ‘DENTIST – DENTAL TECHNICIAN’ NOTES: After a careful clinical observation together with the dental technician, the laboratory phase was initiated with the study models mounted in a semi-adjustable articulator. Then, a diagnostic wax-up was constructed and discussed inside this team. After approval, a silicone index was used to fabricate the provisional FPD. In the 1st quadrant, a screw-retained FPD. In the 2nd quadrant, an egg-shell provisional FPD to rebase over the natural re-prepared tooth abutments.
The provisional FPD were placed in the maxilla and were used to remodel soft-tissue architecture and test the aesthetic concept achieved with the diagnostic wax-up.
In the mandible, a transparent silicone index was done to allow a direct provisional FPD in the 4th quadrant.
In the meanwhile, a dental implant was placed in tooth 36. After the healing phase, an impression with an open-tray technique was done, and the dental technician constructed an implant-supported screw-retained crown. The framework of this crown was designed with a modification (“a platteau”) in the interproximal spaces to better support the ceramic veneering.
After it, dental/implant impressions in the 1st, 2nd and 3rd quadrant were done. The inter-maxillary relations were recorded by removing the provisional FPD separately. This was the relation tolerated by the patient while using the provisional restorations.
Then, a digital image of the diagnostic wax-up was used to guide the development of the zirconia frameworks.
Then, a new inter-maxillary recording was done by removing the provisional FPD separately, to do fine occlusal adjustments during the ceramic veneering.
The overlays in the 4th quadrant were bonded in the same day that the zirconia frameworks were tested.
In the bisque-bake try-in step, the dental technician was presented in the dental office to observe and register ‘in vivo’ the modifications that needed to be done, mainly concerning dental anatomy.
DENTAL LABORATORY: DentalMaia, Castelo da Maia, Portugal.