DIAGNOSIS:
Female patient, 48 years old, non-smoker. Presented to the clinic with the aim to do a fixed rehabilitation. The clinical examination revealed the necessity to recover the occlusion vertical dimension, the placement of two dental implants in the 2nd quadrant associated with extensive tissue regeneration and correction of the occlusal plan.
TEAM PLAY ‘DENTIST – DENTAL TECHNICIAN’ NOTES:
Diagnostic wax-up was done in study models gathered by addition silicone impressions. Then, they were mounted in a semi-adjustable articulator through a face-bow and an intermaxillary record. Dental anatomy was recreated from anatomical, esthetic and functional criteria. Tooth repositioning in the 2nd quadrant deserved a special attention regarding their relations with the antagonist. The discrepancy observed between the dental arch and the alveolar ridge was covered with a gingival epithesis in wax.
Using this diagnostic wax-up, a transparent acrylic prosthesis with teeth and a gingival epithesis was executed to enable a direct mock-up in the patient’s mouth. This mock-up allowed the patient to realize the need for the regeneration of hard and soft tissues as well as their limitations.
Once accepted the treatment plan, the diagnostic wax-up enable the creation of a transparent acrylic template in which radiopaque composite cylinders were placed on the buccal and palatal tooth surfaces, to serve as a radiological guide. Based in these elements, the implants virtual planning was done in specific software.
The diagnostic wax-up allowed the construction of two acrylic-reinforced provisional bridges, and also an acrylic gingival epithesis. After preparing the teeth, these bridges were rebased, adapted and cemented. The patients wear the provisionals for 8 weeks to assess the aesthetics and function of this ‘project’.
After it, we have advanced with the surgical part, by transforming the radiological guide into a surgical guide, placing the implants under the virtual planning. Tissue regeneration was done according to the volume and shape of the epithesis. Three months for complete healing and maturation of soft tissue were required.
Final impressions were done with an addition silicone, one-phase technique, in a open-tray. The working models were mounted in a semi-adjustable articulator using the provisional bridges:
the maxillary position was captured with a face-bow register, and the inter-maxillary relations were recorded with a silicone bite registration material placed over the provisional bridges.
then, the provisional bridges were screwed to the maxillary working model, and with the face-bow record, this model was mounted in the upper arm of the articulator.
after it, the silicone bite registration material was placed over the inferior provisional bridge, and this cast was mounted in relation to the upper model.
finally, the bridges were removed from the models and screwed again in the patient’s mouth.
Then, a metallic framework was done, based on the initial wax-up that was assessed in the patient’s mouth. Ceramic build-up had to include dental and gingiva components. Tissue regeneration in the 2nd quadrant was satisfactory but could not recreate the interdental papillae as expected. This was compensated using gingiva-shade ceramics to rehabilitate these areas.
This work shows that careful planning is essential in major oral rehabilitations, being teamwork essential to achieve the best results.
Dental Laboratory:
DentalMaia, Castelo da Maia, Portugal.