Case 37 | Prosthodontic Award 2015 | Chile
Dr. Sebastian Bravo
52 years old male patient, with severe marginal bone loss and decreased gingival tissue support due periodontal desease sequelae.
After periodontal treatment, it was decided to maintain all mandibular teeth, and rehabilitate the maxilla with an Implant supported fixed prothesis. Teeth 1.4, 1.3, 1.2, 1.1, 2.1, 1.2 and 2.3 had moderate to severe bone loss and also presents mobility, all this resulting uncomfortable to the patient and from a prosthetic point of view a bad prognosis.
The treatment was planned with STAGED APPROACH, which in these case involves strategic extractions of teeth 1.4, 1.2, 2.1 and 2.3 along with immediate implant placement in the correspondent sites and flap less implant in the 2.4 zone. Teeth 1.6, 1.3, 1.1 and 2.2 were used as abutments for a fixed provisional prothesis during the osseointegration phase.
On the first clinical session, a silicone matrix of the superior arch is taken; the preparation of selected teeth was made and registered with an impression that was sent to the technician for the confection of a provisional prothesis that would be installed the same day of the surgery. Also teeth 1.6, 1.3, 1.1 and 2.2 were milled and individual provisionals were made up from the silicone matrix previously taken.
In the second session, extractions and immediate implant placement were performed in 1.4, 1.2, 2.1 and 2.3; all gaps were regenerated with bovine xenograft, also a flapless implant in the zone of tooth 2.4. A fixed provisional was installed on the abutment teeth, customizing pontic areas with resin flow to maintain contours of extraction sites.
After 4 months of healing, the second stage surgery was performed making a little punch to access the implant cover screws and change it for a healing abutment.
Two weeks later, the provisional was changed from teeth support to implant support, to create the emergency profiles around implants. The imprint in the pontic zones were captured with resin flow to the temporary abutment and then it was hand adapted and polished.
4 weeks later, with stable emergency profiles, we started the surgical management of the pontics.
First, on teeth 8 and 10, it was planned the root submerged technique with a pedunculate CTG, both teeth vitals. With this technique, we want to maintain tissue volume, contours and esthetic. Tooth number 6, was managed with ridge preservation technique but trying to gain in vertical , with soft and hard tissue autograft taken of the left maxilla tuberosity, after two weeks the patient lost the soft tissue graft, so we waited 6 weeks to do a pedunculate connective tissue graft to increase the volume.
6 weeks later, after the pontic areas were healed and stable, we used the provisional to copy the emergency profiles and the pontic sites to transfer it to the impression copings and maintain the soft tissue architecture that we achieved.
The impression was taken and a verification splint was made to check the master cast accuracy, then an aesthetic resin proof was made to check the future teeth shape and contours, after that the metal framework was built and try to check the passive seating, then we ask the final ceramics screw retains crowns.
An occlusal splint was indicated to the patient and after 18 month the implant safe test was performed, resulting in negative outcome, the implant safe test is an indicative of the aMMP-8 enzyme for tissue destruction in the context of periodontitis or perimplant tissue destruction.