Aesthetically demanding full-arch rehabilitation

rehabilitation caseJessica Maguire and Pav Khaira discuss how a complex full arch implant rehabilitation case led to Evodental’s entire surgical and technical team coming together to ensure the best outcome for a patient.

JB is a 60-year-old woman who was a previous smoker. She was referred to us by her dentist in Wales after he had visited Evodental’s Heathrow clinic as part of an ‘Evoexperience’. Her motivation for coming to see us was interest in a fixed solution. She was fed up with her removable prosthesis. A panoramic radiograph was sent alongside the original referral from her dentist. 

Figure 1 shows the radiograph, which appears to show suboptimal dentition, pneumatised maxillary sinuses, and severely super-erupted maxillary anterior teeth. 

Figure 1: Preoperative radiograph submitted by referring dentist

At her full clinical assessment (FCA), it became apparent that her aesthetic needs were quite complex, with significant excess gingival display in the aesthetic zone. Figure 2 shows the photographs taken on the day of JB’s FCA.

JB was diagnosed with vertical maxillary excess, dentoalveolar compensation and an ill-fitting existing removable partial denture. This, combined with a desire for fixed teeth, led to a treatment plan involving significant alveoplasty (26mm). Also, immediate placement of implants in the maxilla and mandible; including pterygoid implants. 

Appropriate alveoplasty would be critical to the success in treatment for JB. An inadequate alveoplasty would result in a visible transition line and aesthetic failure.  

Figure 2: Patient at initial presentation

Treatment

JB’s case was discussed at a multi-disciplinary team (MDT) meeting (as are all cases at Evodental) a week prior to her surgery. 

At the MDT meeting, Evo’s clinical and technical teams sit and discuss each case in detail to finalise the aesthetic and biomechanical requirements for success. The digital case work-up permits us to refine the proposed occlusion and aesthetic design to a high level of precision. No impressions or prostheses were made prior to the day of surgery. It was agreed, during the MDT meeting, as to where the alveoplasty line should be placed in order to avoid a visible transition. It is important for surgical and prosthetic planning to take place together, prior to surgery. 

Figure 3: Imetric photogrammetry in use

Surgery was performed by Dr Pav Khaira, utilising the data discussed from the previous week’s MDT to undertake accurate alveoplasty and ensure the implant positions were correct for the proposed design. Mucoplasty was performed to remove excess hypertrophic tissue and to ensure adequate keratinised tissue around the implants that is dimensionally stable during the healing process. 

The day-of-surgery prosthesis required no occlusal adjustment in centric or excursive movements. Accuracy of fit was ensured by the use of Imetric photogrammetry for implant position capture (Figure 3).

Figure 4 shows the postoperative CBCT implant positions. The use of photogrammetry allows the positions of the implants to be captured digitally and integrated into the digital workflow to design and manufacture a prosthesis with ideal contour and mechanical strength straight after surgery. 

This prosthesis is monolithic PMMA and is milled directly to the multi-unit abutment interface using a prosthetic screw specially designed for use in polymers that do not loosen or break through the PMMA housing. This process compares favourably to retro-fitting a pre-made prosthesis on titanium cylinders. 

Figure 4: JB’s post-op CBCT

Review

The patient then attended for her three-week review. At this appointment, no occlusal adjustments or re-articulation of the prostheses were required; nor was a soft tissue capture needed due to the stability of tissue shape during the healing phase. 

A prescription for a definitive prostheses was issued to the lab which were then fit three weeks later. Figure 5 shows the patient on the day of surgery (DOS) with her first set of prostheses.

Figure 5: JB with her DOS prostheses

Outcome

JB had been a denture wearer for many years. This had dramatically damaged her self-confidence over time. She felt overwhelmed with emotion at the difference this treatment had made to her life. She said she had avoided social situations for many years. JB was excited to finally have meals out with friends again without having to worry about her teeth. 

We should not underestimate the effect of oral rehabilitation on the patient’s health and life. This is evident every day at Evodental.  

Figure 6: JB’s photos taken preoperative vs at her three-week review

Spend a day with Evodental, free of charge, to see the life-changing work it does in person. www.evodental.com/idt

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