CHIEF COMPLAINT:
Patient expressed a strong desire to change his appearance. While reporting no functional limitations, the intention to improve phonetics was manifested.
DIAGNOSIS:
Male patient, 24, non-smoker. Operated as a child to a cleft palate, subsequently subjected to orthognathic surgery. This surgery aimed to correct maxillary retraction retrusion through slow bone distraction technique. Patient was afterwards referred for oral rehabilitation completion. Despite a successful surgery and a marked correction made with bone distraction, the patient still suffered significant jaw disharmony. On maximum intercuspidation ,only two teeth made contact. Several deciduous teeth and atypical anatomical shapes were present in the arcades. Teeth arrangement of the upper jaw was severely irregular. Oral hygiene was sufficient but not expected, and gingival tissues showed some signs of inflammation. The upper lip presented an aspect compatible with cleft palate correction.
TREATMENT PLAN:
Patient was proposed full oral rehabilitation. Treatment for the lower jaw included confection of two bridges, with Zr infrastructure, featuring coronary and gingival hue ceramic coating, to correct the occlusal plane with minimally invasive surgery. The anterior -inferior sector, if necessary, would be aesthetically corrected with ceramic veneers. For the upper jaw, total rehabilitation would be fixed on teeth and implants , to preserve all dental pieces that would prove viable. On the one-piece top, a Zr infrastructure would be used and subsequently coated with coronary and gingival hue ceramic.
TREATMENT NOTES:
Treatment began with thorough analysis of information gathered by the dentist and dental technician. Based on models mounted on semi-adjustable articulator, a basic diagnostic wax-up of the jaw was performed, to allow a first inner and outer oral assessment. It was deemed necessary to raise the incisal edge and increase the size of the teeth. Once performed, these changes were evaluated and validated by the patient and team. This basic fixed wax-up originated the final diagnostic wax-up, already waxed on the teeth to keep and on the alveolar ridge. This wax-up was doubled in plaster models that were digitally scanned. After these procedures the abutment teeth were prepared on the plaster models, and teeth that were to be extracted were eliminated. Through CAD-CAM techniques, 3 temporary bridges were prepared: an upper, one-piece structure reinforced with glass fiber, and two lower bridges. A minimally invasive tooth preparation was performed on the abutment teeth, and non-viable teeth were extracted. After thorough relining, the temporary bridges were cemented. During four months, post-extraction areas healed and the new inter-jaw relation was successfully integrated, as well as the patient's new look. During the healing period, we took the opportunity to prepare a ceramic feldspathic veneer for aesthetic rehabilitation of tooth 4.1. Virtual planning of implant placement in the upper jaw was informed by the overlap of diagnostic wax-up and CT-Scan, taking advantage of this information to prepare a prosthetic guided surgery. This virtual planning yielded a surgical guide for implant placement. Contrary to initial planning, and prosthodontic conditions, we ended up building a guide aimed at placing a single implant on the anterior zone. The surgical guide would be supported by prepared pillars. Placement of 5 implants was made with the surgical guide, without flap opening, for a minimally invasive surgery. The osseointegration period ran for two months, during which the patient carried a fixed temporary bridge. After osseointegration the final prints were taken, first in the lower jaw and then the upper. In the lower jaw, using CAD-CAM technology and based on diagnostic wax-up, two bridges were prepared, with Zr infrastructure and coated with coronary and gingival ceramic. The inner infrastructure featured ceramic coating, to be bonded to the enamel of prepared teeth. After rehabilitation of the lower jaw, definite impression of the upper jaw was made, using an open tray technique. The provisional bridge was divided into two parts, in order to register the inter-maxillary relationship provisionally validated. Intermediate parts were selected, and an infrastructure was designed by CAD-CAM techniques based on the diagnostic wax-up. A plastic replica of this structure was tested in the mouth, allowing further assessment of the upper jaw relationship with the skull base, using the face bow. The top-piece was finished, and placed on the Zr ceramic infrastructure with coronary and gingival hue. After approval by the patient, treatment was definitely cemented in the mouth.
COLLABORATION:
Previous Orthognathic Surgery) - Dr. Carlos Monteiro
Virtual Planning - Dr. Ivo Lopes