CASE 4 “I want implants!”

Age: Over 50

Sex: Female

Chief complaint: “I don’t like my upper denture and want implants!”

Medical history: Non-contributory health history

Periodontal assessment: AAP type III, Grade A with minimal inflammation

Function/TMJ: No clicks or joint sounds

Tooth structure: Many large restorations

Esthetics: Chipped and discolored teeth, poor esthetics, missing teeth, evidence of tooth wear, large embrasure spaces

Clinical scenario: This patient presented with a desire to improve her smile by replacing her partial upper denture with dental implants (Figs. 1.25–1.27)

Problem list:

1. Unhappy with esthetics

2. Maxillary partial denture

3. Multiple missing teeth

4. Discolored teeth

5. Failing prostheses

6. Gingival recession

7. Large embrasure spaces

8. Lack of posterior occlusal stops

9. Misaligned teeth

Treatment plan: Six implants were planned in the maxillary arch to replace teeth 4, 7, 10, 11, 12 and 13. Individual non-splinted crowns were planned on the implants to enable the maintenance of oral hygiene [29]. Full coverage restorations were planned on teeth 5, 6, 8 and 9. A cast partial denture was planned to replace the posterior missing teeth of the mandibular arch

Summary of treatment performed: Because of the less than ideal positioning of the implants in the locations of teeth 10, 11, 12 and 13, the implant crowns were splinted to optimize the esthetics. Full coverage restorations were placed on teeth 5, 6, 8 and 9. A cast partial denture was made to replace the bilateral missing posterior teeth in the mandibular arch (Figs. 1.28, 1.29)

Treatment analysis: Limited communication between the surgeon, restorative dentist and lab technician was the major reason for suboptimal implant placement

[30], which resulted in the display of metal collars (Figs. 1.30, 1.31) and necessitated splinting of the implants (in the locations of teeth 10, 11, 12 and 13). The implant positions were more cervical compared with the remaining teeth because of bone resorption (Fig. 1.32). The unavailability of CBCT at that time made implant planning and placement very challenging. As a result, the implant restorations were not predictable and had suboptimal esthetics. However, the patient’s low lip line covered the display of the unesthetic areas when she smiled. There was a step in the occlusal plane after treatment which was not a concern to the patient (Fig. 1.33).

Dental practitioners must decide the type and design of the restoration prior to implant placement and plan the implant position and angulation based on the design of the definitive restoration [30]. A thorough clinical examination must be performed along with mounted diagnostic casts and interocclusal records. A diagnostic wax-up incorporating the proposed missing teeth should also be made. Surgical guides should be fabricated for optimal implant placement [30]. A CBCT scan should be taken to assess and plan the optimal implant positions [31]. It is important to educate surgeons to place implants not only based on the location of the bone but also based on the design of the definitive prosthesis [30]. After developing an appropriate treatment plan, it is prudent to convey the restorative goals to the laboratory and the surgeon. It is also critical to discuss the surgical or restorative concerns with the patient before initiating treatment [32]