CHIEF COMPLAINT:
The first reason that brought the patient to the consultation was the lack of the canine and the 1st P.M. of the first quadrant. In a second phase, after the rehabilitation of 13 and 14 with an implant bridge, tooth 12 was lost. An extensive caries irreparably destroys this tooth, leading the patient to simultaneously want to solve this problem and rehabilitate the missing teeth 24 and 25.
DIAGNOSIS:
Male patient, 55 years old, non-smoker. He was missing teeth 17/14/13/26 and 27 in the upper jaw and 37/45/46 and 47 in the lower jaw. Tooth 25 presents with endodontic treatment and extensive coronary destruction. It has a moderate and generalized periodontal bone loss. In the edentulous zone of the 1st Quadrant, there was a marked vestibular depression. Satisfactory oral hygiene and average gingival biotype.
TREATMENT PLAN:
According to two different clinical situations that arose at different time points, two treatment plans were proposed:
1. Initially, it was proposed to place two implants in the place of teeth 14 and 13, to be rehabilitated with a metal-ceramic bridge of 2 elements 14 and 13.
2. In a second phase, with the loss of tooth 12, it was proposed to place an implant in the place of 12. The objective would be to make a bridge of 3 elements 14/13 and 12. The implant placed in the area of 13, at that time had bone loss in its coronal portion, however without inflammatory or infectious manifestations. This treatment plan would be prepared for two scenarios. The first, in which it would be possible to keep the implant at 13 and the second in which this implant would have to be dispensed with. In this scenario, a 3-element bridge could be maintained, but fixed at 14 and 12. In the 2nd Quadrant, it was proposed to place 2 implants in place of 24 and 25 with a 2-element bridge.
TREATMENT NOTES:
Two implants were placed at the sites of 14 and 13. The first was 3.3 mm in diameter and 10 mm in height and the second was 4.1 mm in diameter and also 10 mm in height. During implant placement, guided bone regeneration was performed with the intention of reducing buccal bone deformation. After 3 months, an impression was made on the implants with an open tray technique and a metal-ceramic bridge was made. This bridge had a hybrid fixation, screwed at 14 and cemented at 13. Two different intermediate pieces were used, in 14 a multibase was used, in 13 an individualized stump was used. The metallic infrastructure was tested in the mouth and its seating was checked by imaging. The bridge was placed in the mouth, and the screws were screwed during the cement setting time. 7 years after the first rehabilitation, tooth 12 was submitted to an endodontic treatment and later reconstructed with an intra-radicular post.3 Years later, in a routine consultation, an extensive caries that irreparably compromised the tooth is detected. Simultaneously, bone loss was detected in the implant placed at the site of the 13. As an emergency treatment, tooth 12 is extracted and a composite resin tooth is bonded with a metal mesh to the adjacent teeth. In the same consultation, the metal-ceramic bridge was unscrewed and cemented to make an impression on the implants 14 and 13. This impression gave rise to a screw-retained metal-acrylic bridge of 3 elements, 14/13 and 12, with a metallic palatal support nº11. The provisional bridge was placed to rehabilitate the missing tooth 12. Subsequently, an implant was placed at the site of 12 and two implants at the site of 24 and 25. During the osseointegration period, the patient used the screw-retained provisional bridge. As a final rehabilitation, 2 bridges were placed. One in the 1st quadrant with 3 elements and one in the 2nd quadrant with two elements. The two bridges had a screw-retained fixation and coronal and gingival ceramics were used. After approval by the patient, they were screwed and the final torque was given with 35 N.