CHIEF COMPLAINT:
The patient complained that the "bridge was shaking” and “had pain in the tooth that held the bridge".
DIAGNOSIS:
Male patient, 30 years old and non-smoker. Had a two-element metallic ceramic bridge, with the tooth 2.1 as pillar and tooth 2.2 as cantilever pontic. Tooth 2.1 had an endodontic treatment and had extensive root reabsorption. Cervical level of the bridge teeth was 2 mm apical in relation to the adjacent teeth. The bridge had slight mobility. With indicated extraction on tooth 2.1, the bridge was compromised. Reasonable oral hygiene and periodontal health.
TREATMENT PLAN:
Suggested treatment included removing the bridge, regeneration of soft and hard tissues, and placement of an implant at the site of tooth 2.1 that would support a two-element screwed bridge. This bridge would have a metal infrastructure. The use of gingival shade ceramic was not decided beforehand, depending on what would be achieved with tissue regeneration.
TEAM PLAY “DENTIST – DENTAL TECHNICIAN” NOTES:
After impression for production of an immediate acrylic removable prosthesis carried out in the lab, removal of the bridge on tooth 2.1 was performed with root extraction. The prosthesis was placed after thorough curettage of the area. Eight weeks later, surgery was performed with a chin autograft, fixed with osteosynthesis screws that sought to recover the lost bone volume. Twelve weeks after autograft, an implant was placed at the site of tooth 2.1, the screws for osteosynthesis were removed and new regeneration was performed with bone substitute and connective tissue graft. Despite the two surgeries performed with the intention of recovering the bone volume, made by an experienced professional, overlapping the models before and after regeneration revealed significant increase in vestibular volume and little or no vertical increase. Three months after implant placement, the second surgical phase was performed, for implant exposure and healing screw placement. The incision was made to mobilize more soft tissue to the vestibular area. With the healed tissues around the healing screw, an impression was made with open tray technique for confection of a screwed provisional bridge. The provisional bridge was bolted to release the patient from the removable prosthesis and begin work on the emergency profile of the implant and the pontic. Placement of the provisional bridge allowed aesthetic visualization of the lack of soft tissues in the interdental papilla. Along with the patient, this led to the possibility of using gingiva shade ceramic. Once gingival architecture was stabilized, the definitive impression was made using the emergency profile of the provisional bridge, for transfer individualization. A metal infrastructure was built in the lab, and later tested in the mouth. Work was finished with placement of coronary and gingiva shade ceramic. Having been approved by the patient, after a long treatment period, the bridge was definitively screwed.