Case 58 | Prosthodontic Award 2015 | Italy
Dr. Luca Sighel | DT Stefano Petreni
68 years old patient.
Medical history negative. He comes to our observation with previous metal ceramics reconstructions of upper and lower jaw.
The patient reports recurrent toothache to the fourth and sixth sextant and the presence of diffused cold hypersensitivity because of several carious infiltrations under the crown margins and gum recessions with exposure of vital dental tissue. The 38 will be extracted in the first visit. He also reported to have problems in chewing due to the poor functional rehabilitation and the absence of the molars teeth in the third sextant. He was truly unsatisfied about the aesthetics of his rehabilitation: presence of inadequate prosthetic crowns shape and proportions, visibility of carious lesions and exposed metal margin while smiling. He also reports that halitosis is a big problem in interpersonal relationships.
He wishes an adequate masticatory function without pain and hypersensitivity and an aesthetic smile: for this reason he is strongly determined to cooperate and to undertake the dental treatment that can significantly improve his dental situation and his lifestyle.
We observe the exposure of the incisors and canines during the forced smile while we appreciate only the lower incisors and canines during speaking and natural smile.
The aesthetics analysis shows that the II sextant is composed of eight prosthetic elements four of which lateral incisors.
The absence of the molar in the third sextant and the inadequate occlusal anatomy creates discomfort to the patient.
In the radiographic status we appreciate a thick periodontal biotype and good preservation of periodontal support without angular defects, confirmed by periodontal probing. Thoot 36 presents a first degree lesion of buccal and lingual furcation. Thoot 47 presents a second degree vestibular and first grade lingual furcation lesion. We can also note the absence of dental elements 16, 26, 27 and 46. The tooth 38 has a destructive decay. The endodontic treatment of dental elements 17, 22, 23, 36 and 47 do not present periapical lesions. We appreciate caries infiltration under the crown margins of teeth 37, 36, 35, 33, 32, 31 and 41.
- Inadequate Metal-ceramicrestorationsin aesthetics,biology and
- Decay under the crown marginsof teeth37, 36, 35, 33, 32, 31 and41;
- Destructivedecayof dental element 38;
- Cyclic periodontalabscessestovestibular furcation47;
- Absenceof teeth16, 26, 27 and
- Prognosis of teeth 17,15, 14, 13, 12, 11, 21, 22, 23, 24, 25, 37, 35, 34, 33, 32, 31, 41, 42, 43, 44, 45 is positive subject to causal therapy success, osteo resective and implant surgery, congruous and balanced prosthetics reconstructions.
- The 36 element will be extracted: the biomechanical weakening and the difficulty to vouch for a sufficient ferrule effect to the future prosthetic crown make low predictable the therapies; moreover the carious lesion under the metal fused pin is too much close to the furcation.
- The 47 will be extracted: the tooth presents a mesial stripping on distal root, cause the toothache and the cyclic periodontal abscesses associated to very deep probing values in the furcations.
- Extraction of 36 and 47 elements.
- Endodontic retreatment of 17, 22, 23,37 elements.
- Preprosthetic reconstructions of 17,37,35,33,32,31,41.
- First provisional shells 17-x-15-14-13-12-11-21-22-23-24-25 and 37-x-35-34-33-32-31-41-42-43-44-45-x-47.
- Osteo resective surgery on the upper jaw and implant surgery in 26, 27 and 46, 47 position.
- Second provisional crowns: 17-16 and 46, 47 crowns on implant, splinted. Single crowns on 34, 33, 32, 31, 41, 42, 43, 44, 45.
- Second periodontal evaluation
- Definitive Prosthetic finalization. Upper jaw: zirconia ceramic bridge on 17-x-15, zirconia ceramic single crowns on 14, 13, 12, 11, 21, 22, 23, 24, 25. Zirconia ceramic splinted crown 26-27 on titanium customized abutments. Lower jaw: zirconia ceramic bridge 37-x-35, zirconia ceramic single crowns on 34, 33, 32, 31, 41, 42, 43, 44, 45, zirconia ceramic splinted crown 46-47 on titanium customized abutments.
- Night guard.
- Periodontal maintenance program.
Operative prosthetic sequence
- Impression for study cast models and registration wax in R.C. position.
- Preprosthetic composite reconstructions on 17-22-23-37-35-33-32-31-41-42.
- First provisional shells on elements 15-14-13-12-11-21-22-23-24-25-X-27 and 37-X-35-34-33-32-31-41-42-43-44-45-X-47.
- Impressions, facebow transfer and occlusal registrations in R.C. position for the second provisional crowns.
- Periodontal and implant surgery on the upper and lower jaw.
- Final Precision impressions.
- Facebow transfer and occlusal registrations of centric relation position.
- Zirconia frameworks try-in with pattern jig and revealing paste.
- Bisque bake try-in with aesthetic and occlusal check.
- Position impression and facebow transfer for the reassembly in articulator.
- Occlusal check post cementation and night guard.
The old metalceramic crowns were disassembled and the provisional preprosthetic reconstructions were performed, then the provisional shells, derived from the analysis preliminar wax up, was rebased and cemented.
After the initial periodontal preparation and hygiene instructions, 36 and 47 dental elements were extracted, the elements 17, 22 and 23 were endodontically treated. Also the 37, because of a post preparation pulpitis, was endo treated. The cervical decay of the teeth 35,33,32,31,41,42, were treated and the preprosthetics reconstructions in 17,22,23,37 were performed.
The osteoresective surgery will recreate the correct periodontal relation and will allow to have an adequate height of prosthetic abutments. The implant teraphy, guided by surgery and radiographic dime, will restore the masticatory function in 26-27 and 46-47 position.
Clinical situation 90 days after the osteo resective and implant surgery. A precision impressions, the facebow tranfer, the R.C. position wax, the alginate impressions of the first provisional shells, were performed to create adequate second provisional crowns.
The second provisional crowns were built taking care about occlusal details and complying with marginal tissues and the hygiene maintainability of interdental spaces. The occlusal and funtional situation will be similar to the occlusal and funtional situation of the final rehabilitation. We can appreciate a well balaced smile with the new provisional.
A new radiographic status and the periodontal exam, that shows <3mm probing sites, no mobility, plaque index <20% and bleeding index <10%, confirm an healty periodontal situation before precision impressions.
Double retraction cords were inserted in the sulcus of every teeth in upper and lower jaw. The transfer of implant position was performed using a double dimes that are built with impression copings splinted with orthodontic ligatures and pattern resin. Were also sent to the dental technician the facebow transfer, the alginate impressions of the second provisional crowns, the R.C. position wax between the upper second provisional crowns and the inferior abutments and a R.C. position wax between the upper and lower abutments, to correctly assemble the articulator and obtain the right informations for the analysis wax up.
Some evidence points are drawn for the alignment between master cast models and second provisional cast models.
Scan of cast models (Master cast model- second provisional cast model). Images alignment process (provisional cast model – master cast model). The image of the second provisional crowns is used how a prosthetic project.
After the alignment the file was cleaned. The teeth coronal anatomies are lightly modified and the occlusal relationship was improved.
Tridimensional version of crowns digital cut-back.
Tridimensional view of zirconia frameworks in master cast models.
We can appeciate a good relationship between zirconia frameworks and marginal tissues.
The bisque bake try-in shows a good aesthetic integration between the new crowns, with an adequate teeth shape, and the marginal tissues. During this check is evaluated the hygienic mantenibility of the new prosthetic reconstruction using floss and interdental brush. The occlusal balance in statics and dinamics and the aesthetic integration are optimized during this session.
We have an good periodontal healt before the cementation.
In this situation of periodontal healt can be appreciated a good aesthetic and functional integration of the definitive zirconia ceramic prosthetic rehabilitation.
A good occlusal balance in the static and dinamic movements give to the patient a remarkable masticatory confort.
The definitive prosthetic rehabilitations have a good balance with the smile and a natural integration with the oro-facial relationship.
Stomatologic exam: the restoration of the masticatory function without ATM sintomatology, the confort without toothache, the integration of the prosthetic reconstruction with the gingival tissue, are the demostration of a general stomatologic healt.
Occlusal exam: the prosthetic rehabilitation interact, in static occlusion with a cuspid- marginal crest dental relation in first Angle class in posterior sectors. In dinamic occlusion we appreciate a incisal guide supported by central and lateral incisor, in lateral movements a canine guide.
Periodontal exam: the vigorous aspect of marginal tissues, confirmed by a periodontal probing <3mm, by plaque index < 20% and bleeding index <10%, undeline the periodontal healt.
Radiographic exam: the final radiographic status shows the precision of the prosthetic reconstruction in a patient with healty periodontal support and without endodontic lesions.