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Clinical case
Patient with no relevant medical history, smoker of 10 cigarettes a day, comes to the consultation due to multiple missing teeth in the upper arch and poor anterior aesthetics in the remaining teeth, the result of a long-standing periodontal disease.
The patient's expectations were to improve her masticatory ability and, above all, her upper aesthetics, since in addition to the fanning of the upper anterior teeth, these were extruded and the patient had a gingival smile component.
After making the diagnosis and evaluating the prognosis of all remaining teeth, the extraction of all the teeth in the upper arch, placement of 4 implants and placement of a complete fixed implant-retained rehabilitation were recommended.
Procedure
Prior to surgery, periodontal treatment was performed on the remaining teeth, including those to be extracted, to provide a favorable bacterial environment.
For the impressions and intermaxillary relationship, a slightly modified duplicate of the patient's removable upper prosthesis was made, where the central incisors and tooth 22 were virtually extracted and printed with resin for intraoral use (Nexdent SG). In cases of total rehabilitations with extractions and immediate placement, we usually make a duplicate of the patient's removable prosthesis that allows us to take the intermaxillary record at the same time as the impression with closed-tray copings. In this way, the arch to be treated can be referenced in relation to the antagonist in a more reliable way and the usual occlusion adjustments can be reduced during immediate loading.
The intervention was performed under local anesthesia, 5% bupivacaine with 1:200000 adrenaline.
After making an occlusal crest incision, a full-thickness mucoperiosteal flap was raised, complementing it with intrasulcular incisions in the anterior area and two distal discharges in areas 17 and 27, in order to obtain good visibility of the alveolar processes.
Bone regularization was then performed with vertical reduction of the alveolar process to eliminate the gummy smile, using a handpiece and acorn bur. Once bone regularization was completed, the canines were extracted.
Two 4x10 mm Avinent Ocean IC endosseous implants were placed in zones 16 and 26, and two 3.5x11.5 mm Avinent Ocean IC implants were placed in zones 12 and 22, the latter post-extraction.
No regenerative treatment was required and straight transepithelial abutments were placed in the molar area and angled ones in the anterior area in the same surgery.
Once the closed-tray copings were placed, the tissue side of the duplicate prosthesis tray was hollowed out to provide the necessary space for the closed-tray copings, and the impression was taken with Afinis (Coltene TM) addition silicone in its putty and regular consistencies, while guiding the jaw to be closed in the position marked by the duplicate tray.
The provisional prosthesis was placed 48 hours after the intervention.
After 6 months of osseointegration, the prosthesis was removed to take the final impression, checking the good condition of the tissues.
In parallel, the patient's prosthesis was used to mount models on a semi-adjustable articulator. This allowed us to respect the vertical dimension, lip support and anterior aesthetics, since in general terms it was to our liking (with discrete corrections in the midline, occlusal plane and length of the central incisors).
Following the completion and validation of a PMMA test, the Aurora framework was produced. This prosthetic solution consists of a titanium metal framework with optimal surface roughness and a shoulder design that facilitates the cementation of the individual Vita Enamic crowns. The process of cementing the crowns and staining the hybrid prosthesis is carried out in the laboratory.
Finally, the definitive prosthesis was placed, achieving satisfactory aesthetics and function, as well as good stability and maintenance of the soft tissues.
The patient is currently undergoing periodontal maintenance since the treatment was performed in 2020.
Conclusions
This prosthetic solution offers a successful and predictable result, exceeding the patient's aesthetic expectations, giving her back a correct function that she had not enjoyed for a long time.
From a clinical point of view, having individual crowns allows for a simple approach to repairing the hybrid prosthesis in the event of a crown fracture, since it can be managed as a single crown on a natural tooth, and therefore it is not necessary to dismantle the prosthesis to fix it, avoiding long clinical times or discomfort for the patient by having to wear their provisional prosthesis again.
