Multiple implant support crowns

Patient was referred by his general dentist for implant supported crown replacement of missing teeth: 46, 45 & 44.

Implants placed on the right side of the lower jaw holding abutments are screwed in place to house the proposed implant supported bridgework. This simple procedure requires approximately two hours in a dental chair with normal local dental anaesthetic used for tooth removal or dental filling.


Multiple implant support crowns

Missing teeth: 44, 45 & 46.

Patient was referred by his general dentist for implant supported crown replacement of missing teeth: 46, 45 & 44.



General prosthodontic assessment confirmed;

1. Normal range of craniomandibular movements. CR-CO slide =0.5mm. Anterior guidance and posterior disclusion.

2. Presence of porcelain veneers on teeth 12,11,21,22 in situ for the last 15 years requiring replacement. Teeth 24 & 15 could also benefit from full crown coverage, especially tooth 24 to improve the structural integrity

3. Symmetrical lips at rest and at full smile. Good lip thickness and outline.

4. Moderate Smile line, the lower gum ridge is not visible during normal smile and speech dynamics, Minimal soft /hard tissue loss at site 44-46.

After discussion regarding all modalities and risks of implant therapy, consent was obtained in writing. Implants placed at sites 44, 45 & 46.

Implants placed on the right side of the lower jaw holding abutments are screwed in place to house the proposed implant supported bridgework. This simple procedure requires approximately two hours in a dental chair with normal local dental anaesthetic used for tooth removal or dental filling.

Multiple crowns

Tooth 44 was lost recently. Well healed ridge form and outline. Note how the lower right lip and cheek collapses into the mouth due to loss of teeth support. Teeth and supporting bone provide the scaffolding for peri‐oral regional function. Teeth and supporting bone provide all those important muscle attachments for our facial expression, our youthfulness to exist. Graceful aging means that our face has not atrophied. That is, we have maintained all the important facial features in the oral region to maintain our youthfulness.




Dental implants require careful assessment and planning. Therefore, please do not be surprised when Dr Nalbandian takes time for his diagnosis, assessment and planning. This will involve X‐rays (CBCT‐Cone Beam Cat Scan) study models, functional, phonetic and aesthetic assessment. Good diagnosis and treatment planning takes time and expertise.



Recently healed ridge: generally, it is advisable to wait 3 months, ready for implant placement. Implants can also be placed immediately after tooth removal. Missing teeth: 46, 45 & 44.



Implants placed and healing with the bone 4 months later.

Healing has been uneventful.



Laboratory constructed implant crowns. You see the screw section that is used to bolt the implant crown into the implant, which is fused (Osseointegrated with the bone). Note the threads in the implant head section.



These implant‐crowns are very carefully constructed by our laboratory and custom made for the patient. These crowns are made in Australia, by our technical experts.





Sequential placement of implant crowns: screw tightening and final torque to establish idea; screw tightness for implant‐crown stability during normal function.







Summary views:
Implants assessed and implant at site 44 uncovered, all fixtures have integrated. Direct to fixture head impressions were taken and three individual implant supported crowns constructed and issued on 14 Jan 2011. Screw torque at 32 Ncm + cotton+ composite screw access coverage.

Patient is delighted with the final result. He has been an excellent patient and it was a pleasure treating him.



Initial Presentation

Implants have fused with the bone (Osseointegration)




Osseointegration) Final implant supported crowns (implanted teeth) in place.


Laboratory stage (note the screw access via the crown: this is important, as cementing crowns can leave access cement in the abutment/implant interface)


Direct implant crown screw access to the implant seems to create a better biological seal compared to cementing the implant crowns.



Restoring: function, comfort, chewing efficiency and aesthetics. These are linked together.

Patients want teeth and not implants! Patient was grateful to the referring dentist Dr. Adamou for referring him to our practice. I thank both the dentist and the patient for the opportunity to perform the treatment.

Candidature: There is no such thing as an ideal case to treat. However, given the right conditions, the treatment prognosis is enhanced. This we refer to as risk assessment.

Patients who are or who have:

1. Non bruxer (do not grind or clench their teeth at night).
2. Lost Teeth from Caries.
3. Ideal ridge form shape angle and bone dimensions H+V
4. Optimal Periodontal (gum) health.
5. Attends for regular maintenance visits.
6. Inter implant papilla is usually 3mm from the bony crest.
7. Non smoker and healthy
generally pose less risk for optimal outcome of the implant therapy.

This lovely patient has all these factors She wishes to replace her upper removable partial denture with implant supported crowns and bridgework.The general discomfort and unsatisfactory aesthetics (especially the metal clasp) and incorrect bite was a major concern.

Note how the implant‐crowns emerge from the gums as if they belong to the patient. This is called emergence profile. In implant dentistry we try to get as




close as possible to the natural tooth. In an ideal situation this is possible. However, unfortunately this may not be in every case, where we use pink porcelain to match the gums and lost bone tissue.



During the process of implant therapy: prosthodontic treatment, we also corrected the bite (anterior cross bite) to improve the facial height (VD)‐vertical dimension of occlusion) that helped to improve overall smile line: arch shape, position: Dentofacial aesthetics. The images below are six years post op.


Summary



Six years post op. Full oral rehabilitation was carried out.



Laboratory Procedures

Models produced to construct the porcelain implant supported bridgework

Completed Porcelain bridgework on the modelCompleted Porcelain bridgework





Total treatment time for implant placement to final restoration is three to six months: implant placement ‐ three months connection of abutments – two weeks for final bridgework in place.

Congenitally Missing Teeth

Case study: Missing upper lateral incisors and upper left second premolars causing “smile disharmony” shifted midline to the right narrow upper arch. Another difficulty is the patient has a slightly protruding (overshot) lower jaw.



Solution: Orthodontics repositioning of teeth in ideal sites to allow optimal placement of implants especially at missing upper lateral incisors. In most cases, patients with congenitally missing teeth have a lack of bone at these sites requiring bone augmentation grafting with or without simultaneous implant placement. In this patient, no bone augmentation was needed.

Optimal spaces created using orthodontics treatment time 12 months, followed by optimal implant placement.



Ideal gum architecture achieved to simulate and replicate natural teeth. Final crown placement on osseointegrated implants.



Final definitive implant crowns bolted to the implant surface.

Improved patient confidence, comfort and aesthetics.

All above procedures were performed by Dr Sarkis Nalbandian.

Education and Experience are everything.

Designer Smiles® is a one stop shop for most implant, surgical and reconstructive (prosthodontic) oral rehabilitation solutions.