CHIEF COMPLAINT:
The patient suffered trauma and the fracture of the teeth caused him to be urgently rehabilitated with a skeletal prosthesis. What brought him to the consultation was the desire to have fixed teeth in the anterior sector and abandon the removable prosthesis. Initially teeth 1.2 and 1.1, which were in very poor condition, were not in the patient's rehabilitation plan. Subsequently, with a new trauma to these teeth, the patient chose to rehabilitate the 4 incisors in a fixed manner.
DIAGNOSIS:
Male patient, 64 years old, non-smoker, came to my consultation after trauma in the anterior sector. Teeth 2.1 and 2.2 had extensive infra-osseous fractures. Teeth 1.2 and 1.1 were sintered with a composite resin in the inter-proximal area. Tooth 1.1 had poor endodontic treatment and an intra-radicular post. Tooth 1.2 was vital and had extensive composite resin restoration. Being splintered, it was not possible to assess the degree of tooth mobility of each one of the teeth, but the set had no mobility. After clinical and imaging examination, it was concluded that the roots of teeth 2.1 and 2.2 had indicated extraction. The patient was provisionally rehabilitated with a 3-tooth removable skeletal prosthesis. He had some periodontal involvement and his teeth showed worn occlusal and incisal surfaces. Reasonable oral hygiene.
TREATMENT PLAN:
Extraction of the roots of teeth 2.1 and 2.2 was proposed. and placement of 1 implant in the location of tooth 2.1 that would support a screwed bridge with 2 elements. Tooth 2.1 over the implant and 2.2 in extension. If in periodontal terms the 1.2 and 1.1 zones continue to mature without problems and if good support without mobility is guaranteed, it would be proposed to redo the 1.1 endodontic treatment and perform the 1.2 endodontic treatment. Afterwards, after placing intra-radicular posts, the teeth would be rehabilitated with a bridge with 2 elements. After placing the 2-element bridge over the implant placed in the 2.1 site, the patient suffers a new trauma that compromises the viability of teeth 1.2 and 1.1. At that time, it is proposed to place a new implant in the location of tooth 1.1 and make a 4-element bridge with teeth 1.1 and 2.1 over the implants and teeth 1.2 and 2.2 as extension pontics.
TREATMENT NOTES:
First Phase.
Root extractions from teeth 2.1 and 2.2 were done because they were bothering. After 3 months of healing, the imaging examination and implant study were performed to place the implant in the 2.1 site. An implant of 4.1mm in diameter and 10mm in height was placed, placed at the bone level. Two months after the implant surgery, the second surgery was performed to place a healing screw. The impression was made to the implant using the open tray technique with double-viscosity silicone one month later. In the laboratory, a metallic infrastructure was made for a 2-element bridge screwed to the implant. This infrastructure featured 2 palatal supports to help stabilize teeth 1.1 and 2.3 recovering from trauma. Once the teeth were recovered, the supports could be removed. This piece had an internal connection to the implant with an anti-rotational system. The proof of the infrastructure was made in the mouth and its correct adjustment was verified with imaging control. In the covering of the infrastructure, ceramics of coronal and gingival shades were used. After being checked in the mouth and approved by the patient, the bridge was definitively tightened and the access hole filled.
Second Phase
6 months after placement of the bridge, the patient suffers a new trauma compromising the viability of teeth 1.2 and 1.1. A removable acrylic prosthesis was performed to provisionally rehabilitate the patient while teeth 1.2 and 1.1 were extracted and the implant was placed in the location of tooth 1.1. After 3 months, an impression was taken of the implant placed in 1.1 and, simultaneously, the bridge of teeth 2.1 and 2.2 was dragged. For this purpose, in implant 2.1, a one-piece transfer screw was used. In this way, it was possible to correctly impress the gingival architecture of the antero-superior sector. The objective was to simultaneously correctly impress this area and take advantage of the metal structure of this bridge to build the new 4-element bridge. A healing screw was placed on implant 2.1 and teeth 2.1 and 2.2 were added to the removable prosthesis. With laboratory expertise, a new 4-element metallic infrastructure was created based on implants 1.1 and 2.1 and with suspended pontic elements 1.2 and 2.2. In implant 2.1, the internal connection to the implant was maintained in implant 1.1, an intermediate piece was chosen, facilitating the insertion of the infrastructure. The new infrastructure was verified by mouth. As there may have been some change in the gingival architecture with the removal of the bridge and placement of the healing screw in 2.1, a silicone key was made to allow a drag impression of the metallic infrastructure. A new artificial gingiva was performed on the working model according to this drag print. Coronary and gingival shade ceramic was placed. The prosthetic piece was slowly screwed into the mouth to allow soft tissue adaptation. After correct placement and imaging verification, the bridge was definitively tightened in the mouth and the access holes filled. Regardless of the misfortunes the patient had, I could have the satisfaction of seeing him happy with this rehabilitation.