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Before starting on any treatment, it is important to do a full examination and diagnosis for the patient. Radiographs are very helpful in this regard because they let us assess the location and position of the existing dental implants. They also give an indicator of the health of the implants and their surrounding bone. This radiograph shows some implants placed in a classic “all-on-4” design where they are angled steeply in the back.
Upper arch; pre-rescue. This patient had a treatment plan for full mouth implant restorations in another dental office. Implants were placed at the time of his extraction but the positions were not ideal. He was left without teeth for a few months before he arrived at our office looking like this.
Lower arch, pre-rescue.
Upper arch; day of uncovering/ investigation.
The first clinical procedure was to uncover and assess the existing implants. As predicted, the implant on the upper left side was too shallow and too severely angulated to be useful in his definitive restoration. This implant was cut short and bone was allowed to grow over it. In addition, two new implants were placed in the upper left side to provide additional support.
Closer view of the very poorly placed implant. When we inherit these cases we are often astonished when we see implants placed that simply cannot be restored. This is a perfect example of a dentist who went to an implant course for a short time and attempted to execute a surgical procedure before he was far enough along in his learning curve.
Upper arch, frontal view. This is an assessment of the angulation of the implants after multi-unit abutments were attached. Note how the implants in the front project outward and seem to come out the mouth. This is a good example of how radiographs can be deceptive. Sometimes, the angle of the implants can be surprisingly severe, even when they look straight on the radiograph.
Upper arch, lateral view.
Lower arch, frontal view. Another picture depicting the shocking lack of understanding of the surgical procedure from previous dentist. This dentist had no earthly idea what he or she was attempting to accomplish.
Lower arch, lateral view.
A set of provisional restorations were then made for the patient. These provisionals are handmade in the office by one of our prosthodontists so the patient can leave with a restoration that is functional and esthetic.
This radiograph shows the shortened implant that was left in the bone, as well as the two new implants in the upper left side.
After three months with provisional restorations, the patient returns for re-evaluation and to begin the final restorations. A well-shaped provisional and good home care were key to ensuring the health and ideal contours of the soft tissue.
Upper soft tissue development.
Lower soft tissue development.
The patient is asked to smile as large as possible. This is one picture that helps us determine overall aesthetics to include tooth shape, length and position.
Prototype, frontal. Using the provisional restorations as a guide, the dental lab then makes a prototype out of acrylic and wax.
Prototype, right lateral.
Prototype, left lateral.
The prototype is tried in the patient’s mouth to assess esthetics. We are particularly critical at this stage to ensure the teeth are positioned and shaped exactly how we like them.
Prototype try-in, portrait, full smile.
Final, zirconia prostheses – frontal view. The lab then uses the wax prototypes to fabricate definitive zirconia prostheses. These restorations are hand-finished by a team of talented dental technicians to ensure a beautiful, life-like result. The teeth are characterized, producing different zones of translucency and opacity, as opposed to making them look like a single monochromatic block. In this particular case, some of the implants’ trajectories were angled too steeply to correct, even with special angle-correcting screws. We had to overcome this by having the screw access holes come out from the front of the tooth and sealing them after with a tooth-colored filling material.
Final, zirconia prostheses – right lateral view.
Final, zirconia prostheses – left lateral view.
Upper zirconia prosthesis.
Lower zirconia prosthesis.
Upper intaglio. Special care is taken for the undersides of the prostheses, even though these areas are not usually seen. Smooth, convex contours allow them to be easily cleaned on a daily basis and the highly glazed material resists plaque.
Lower intaglio.
Upper soft tissue health – occlusal. When the patient returns for the final delivery appointment, his tissues were in a fantastic condition. We can see the little depressions where the provisionals sat to provide positive tissue pressure, allowing an ideal combination of function, esthetics, and hygiene.
Remember, this is the tissue after the patient wore the provisional restorations for 3+ months.
Upper soft tissue health – frontal.
Lower soft tissue health – occlusal.
Lower soft tissue health – frontal.
Final upper prosthesis, mirror view.
Final lower prosthesis, mirror view.
Final prostheses, right lateral view.
Final prostheses, left lateral view.
Final prostheses, frontal view.
Final prostheses, smile.
Final prostheses, portrait front.
Final prostheses, portrait, side.
Conclusion: It is far better to begin treatment with a well-qualified dentist but if you are one of the unlucky, there is a reasonable chance we can salvage a good result.