CHIEF COMPLAINT:
Patient was unhappy about having “recessed upper teeth”, and wanted “fixed teeth”.
DIAGNOSIS:
Female patient, 47 years old, non-smoker. Bearing a partial, removable, skeletal upper prosthesis. Missing teeth 1.8/1.7/1.6/1.4/2.1/2.3/2.6 and 2.8. Teeth 1.5/1.3/1.2/1.1/2.2/2.4 and 2.5 presented endodontic treatment, intra-radicular posts and extensive restoration. Good oral hygiene was observed, as well as good gingival health. The patient presented a Class III, and the maxillary edentulous areas were compatible with implant placement.
TREATMENT PLAN:
After clinical analysis and imaging, a rehabilitation of the maxilla was suggested to the patient, including:
• 4 element bridge with Zr infrastructure and ceramic, using teeth 1.5/1.3 and 1.2 as abutments and tooth 1.4 as pontic.
• 6 element bridge with Zr infrastructure and ceramic, using teeth 1.1/2.2/2.4/ and 2.5 as abutments and teeth 2.1 and 2.3 as pontic.
• Placement of both implants, on the locations of teeth 1.6 and 2.6. Implant rehabilitation with two screw-retained crowns.
A prosthetic rehabilitation of the Class III would also be attempted, should the patient approve this procedure after a preliminary mock-up.
TREATMENT NOTES:
After the initial impressions, models assembled on semi-adjustable articulator facilitated a diagnostic wax-up, to simulate the desired rehabilitation. This steered the correction of the patient’s Class III. A Putty silicone matrix was shaped from this wax-up, enabling the production of a mock-up using dual polymerization composite resin. After mock-up polishing and cleanup, the patient accepted the aesthetic impact of the suggested rehabilitation with enthusiasm. A provisional bridge was then made in the lab, in auto-polymerizable acrylic and with the inclusion of a reinforcement. The provisional bridge consisted of a single, ten-element block. After dental preparation this provisional bridge was realigned in-mouth, at first with auto-polymerizable acrylic, and later with composite resin. After eight weeks of use, to allow for the settling of soft tissues, as well as aesthetic and functional evaluation, the provisional bridge was removed for final impression. A triple-viscosity double impression technique was used. This impression provided a working model, digitally scanned in the lab. The waxed model scan was overlaid onto the working model scan, so that the CAD-CAM infrastructures could be built in accordance with the intended specifications, and towards the desired result. Two parts were obtained, one composed of four elements and another comprising six elements, both clinically tested and validated. They were returned to the lab, for ceramic coating (according to initial wax-up), and finally sent back to the clinic for definitive placement. One month later, two implants were placed, on the locations of teeth 1.6 and 2.6. The implants were scanned directly in-mouth after two months of osseointegration. The scan yielded two screw-retained crowns, placed over the implants, in a fully virtual workflow. Finally, the crowns were installed, completing the patient’s upper jaw rehabilitation.